Every finding on record at Denton Nursing and Rehab

Based on observations, interviews and record reviews it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety in the kitchen and the resident refrigeration units. This practice had the potential to affect all residents that eat food prepared by the facility's kitchen and stored food in the refrigeration units. The findings include:1. During a tour of the kitchen with the Kitchen Manager on 3/10/2026 at 7:14 AM the following items were found:A box of fully cooked mostly dark meat chicken had been opened and did not have an open date in the walk-in freezerA clear bag of unlabeled food identified as chicken nuggets by the KM in the walk-in freezerA box of open diced carrots not wrapped or labeled with an opening date in the walk-in freezerA box of vegetable blend not labeled with an opening date in the walk-in freezerA box of southern style biscuit dough was opened and not dated in the walk-in freezerA box of chicken meatballs had an opened bag and was not dated in the walk-in freezerA gallon bottle of [NAME] Mayonnaise opened and not labeled in the walk-in refrigeratorAn Arby's drink was in the walk-in freezer without a labelSeveral trays of cut pieces of cake were uncovered in the walk-in refrigeratorDuring an interview with the Kitchen Manager on 3/11/2026 at 7:29 AM she reported that [NAME] mayonnaise should have been labeled with an open date and then would be good for 30 days. She advised the cake should have been covered when in the refrigerator. She stated they had run out of the cart covers and advised she would cover the cake with sheet paper. She reported the Arby's shake should not be in the unit without a label. She reported items should be labeled with an opening date after being opened. During a review of the facility's Food Receiving and Storage on 3/12/2026 at 11:23 AM policy it was discovered that All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).2. During an observation of the resident refrigeration unit with the Infection Control and Prevention (ICP) nurse on 3/10/2026 at 10:53 AM. She confirmed the refrigeration unit was for Residents to store their food and it was labeled as the being in the Breezeway. The refrigeration unit was for Residents on the 100, 200, 300 and 400 units. The freezer of the Unit was found to have a build up of brownish colored and whitish colored frost built up on the interior roof, both sides and the bottom.During an interview with the Infection Control Prevention Nurse on 3/10/2026 at 10:54 AM she confirmed that the freezer needed to be cleaned.During the observation of the refrigerator of the unit it was found to be very full, and the following items were found:A temperature of 54 degrees Fahrenheit inside the refrigerator according to the facility thermometer inside the refrigerator.A disposable container labeled for Resident #75 with no date labeledA divided Tupperware container that was not labeled with a name or dateAn unlabeled salad that was not labeled with a name or date.Containers of Chinese food for Resident #47 not labeled with a dateAn opened Cloverland 2% Reduced Fat Milk carton with a Sell by date of 3/03/2026A Cloverland 2% Reduced Fat Milk Carton with a Sell by date of 3/08/2026.During an interview with the ICP nurse on 3/10/2026 at 10:59 AM she reported that Resident's food in the refrigerator must be dated and is taken out after 3 days if not eaten. She confirmed that the temperature in the refrigerator was 54 degrees Fahrenheit and that the expired items should be thrown away. She agreed the freezer and refrigerator needed to be cleaned and the temperature was too warm.During an observation of the refrigeration unit in the Breezeway on 03/10/2026 at 2:03 PM it was revealed that the temperature showed 49 degrees for the refrigerator. The Maintenance Director adjusted the temperature to be cooler.During an observation with Licensed Practical Nurse (LPN) #13 on 3/11/2026 at 6:11 AM the temperature of the refrigerator in the breezeway was 44 degrees Fahrenheit, she confirmed that the refrigerator was above the expected temperature and advised that sometimes the door doesn't shut all the way.During an observation with the Maintenance Director of the refrigerator in the breezeway on 3/11/2026 at 6:20 AM it was discovered that the temperature of the refrigerator was 48 degrees Fahrenheit which he confirmed was still too high.During an observation of the refrigeration unit in the breezeway on 03/11/2026 at 8:11 AM now has an out of order do not use sign.During a review of the facility's Use and Storage of Food Brought in by Family or Visitors policy on 3/12/2026 at 11:12 AM it stated, All food items that are already prepared by the family of visitor brought in must be labeled with content and dated and The prepared food must be consumed by the resident within 3 days. If not consumed within 3 days, food will be thrown away by facility staff.During a review of the facility's Food Receiving and Storage policy on 3/12/2026 at 11:16 AM it was discovered that 'All food items to be kept below 41 degrees Fahrenheit must be placed in the refrigerator located at the nurse station and labeled with a use by date. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines.3. During an observation of the Resident's refrigerator on the 500 unit with the ICP nurse on 3/10/2026 at 11:07 AM it was discovered that the freezer and refrigerator did not have a thermometer inside to monitor the temperature.During a repeat observation of the Resident refrigerator on the 500 unit on 3/10/2026 at 12:45 PM it was discovered that the refrigerator and freezer now have thermometers. The refrigerator temperature showed 50 degrees Fahrenheit.During an interview with the ICP on 3/10/2026 at 12:48 PM she reported the kitchen brought thermometers to the refrigerator and freezer for the Resident refrigerator on the 500 Unit.During an observation of the refrigerator in the memory unit on 03/10/2026 at 2:05 PM with the Maintenance Director it was revealed that the temperature showed 48 degrees for the refrigerator. The Maintenance Director adjusted the temperature to be cooler in the refrigerator.During an observation of the 500 unit refrigerator on 3/11/2026 at 6:18 AM it was discovered that the temperature of the refrigerator was 40 degrees Fahrenheit.During an interview with LPN #14 on 3/11/2026 at 6:41 AM she reported that the memory care unit refrigerator hasn't had any thermometers in the refrigeration unit since they got a new one about three weeks ago. She advised the thermometers went with the old refrigeration unit.During a review of a receipt provided by the Maintenance Director on 3/11/2026 at 11:46 AM it was discovered that the refrigerator for the memory unit was delivered on February 11.4. During an observation of testing for the sanitizer sink on 3/11/2026 at 9:36 AM the Kitchen Manager used test strips from above the sink and reported those were the strips used for testing the sanitizer concentration in the sink. The sanitized water was tested three times and all 3 tests resulted below the expected 200 as advised by the Kitchen Manager.During an observation of the test strip bottle used to test the sanitizer level on 3/11/2026 at 9:41 AM it was noted to have a worn label and the expiration date for the strips was listed as Expired 09/2024.During an interview with the Kitchen Manager on 3/11/2026 at 9:41 AM she reported they test the sanitizer water every time they do dishes and advised the test strips shouldn't be used since they expired.5. During an observation of the kitchen dishwasher on 3/11/2026 at 10:32 AM with the Kitchen Manager on it was discovered that there was no documentation of the sanitizer levels for the dishwasher.During an interview with the Kitchen Manager on 3/11/2026 at 10:34 AM she reported that the staff does not test the sanitizer in the dish washing machine and added we don't have any testing strips for it. She advised the staff maintains a temperature log for the dishwasher, but they do not maintain a sanitizer log.During an interview with the Regional Maintenance Director on 3/12/2026 at 11:54 AM he confirmed the kitchen should have a test kit and log for documenting sanitizer testing. During a review of the facility's Dishwashing Machine Use Policy on 3/12/2026 at 12:36 it was revealed that A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution and Concentrations will be recorded in a facility approved log. The policy adds, Corrective action will be taken immediately if sanitizer concentrations are too low. If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or Parts Per Million are adjusted.

Based on observations, interviews and record reviews it was determined that the facility failed to ensure essential equipment was in safe operating condition. This was found to be evident in the kitchen. This practice has the potential to affect all residents. The findings include:1. During a tour of the kitchen on 3/10/2026 at 7:24 AM it was discovered to have a reach-in refrigerator that had tape around a hole on the left side door where the embedded handle was previously located. The rectangular area had tape surrounding all four sides and the inside of the door was exposed. There was no handle on the left door.During an interview with the Kitchen Manager on 3/10/2026 at 7:24 AM she reported the handle on the reach-in refrigerator had been missing for a long time.During an interview with the Maintenance Director on 3/10/2026 at 11:23 AM he reported attempts had been made to fix the refrigerator handle. He advised the previous Maintenance Director had tried to secure the handle with duct tape. The Maintenance Director reported he has been unable to find a refrigerator handle for the unit.During a review of the facility's Sanitation policy on 3/12/2026 at 11:32 AM it reported that The food service area shall be maintained in a clean and sanitary manner. And All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning.2. During a tour of the kitchen on 3/10/2026 at 7:33 AM the sink used to sanitize dishes after washing was found to have a fast and steady leak. There was a large black bin sitting under the sink catching the leaking water. A wet floor sign was near the sink.During an additional observation on 3/10/2026 at 8:12 AM the sink was noted to still be leaking and had overfilled the black bin spilling water into the floor.During an interview with the Kitchen Manager on 3/10/2026 at 7:32 AM she reported that the sink had been leaking for a while. She advised that when the staff is doing dishes they have to continue refilling the sanitizer sink to complete the task due to the water draining out of the bottom of the sink.During an interview with the Maintenance Director on 3/10/2026 at 11:35 AM he advised the leak is at the base and I need a new sink, he added, I have fixed it a few times the past few months and it leaks again. He reported he's waiting on corporate to buy a new sink.During an interview with the Maintenance Director on 3/11/2026 at 9:14 AM he reported that he was able do a temporary fix on the leaking sink with a new rubber seal and liquid sealant. He also advised that a replacement sink had been ordered.During a review of the facility's Sanitation policy on 3/12/2026 at 11:32 AM it reported that The food service area shall be maintained in a clean and sanitary manner. And All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning.3. During a tour of the kitchen on 3/10/2026 at 7:47 AM the walk-in freezer was found to have white towels lying under the freezing unit. After removing the towels an icicle was found coming from the rear of the freezer unit. There was leakage under the icicle with a wet spot noted on top of a box of Chef [NAME] Pumpkin Pies. There was also a big chunk of ice under the food rack.During an interview with the Maintenance Director on 3/10/2026 at 11:36 AM he advised the freezer had a leak a few months ago and reported the ice cycle and block of ice on the floor was from that.During an observation on 3/10/2026 at 2:23 PM a contractor, EMR, was servicing the freezer.During a review of a Service Report from EMR dated 3/10/2026 on 3/11/2026 at 11:32 AM it reported, Inspected unit and replaced section of insulation on back of evaporator. One icicle hanging down from condensation from bad insulation but replaced4. During a tour of the kitchen on 3/10/2026 at 8:21 AM the ice machine was noted to have a whitish brown leakage between the machine and the ice bin on both sides of the machine.During an interview with the Kitchen Director on 3/10/2026 at 8:21 AM she reported that maintenance and an outside service provider handled the service of the ice machine.During an interview with the Maintenance Director on 3/10/2026 at 11:20 AM he reported the ice machines are maintained by a subcontractor that comes every couple of months. He advised he was not sure when they were here last to service the ice machines.During a review of a Service Report on 3/11/2026 at 10:32 AM it showed the ice machine was installed on 8/04/2025.During a review of a Service Report provided EMR on 3/11/2026 at 10:34 AM it was revealed that EMR serviced the ice machine on 3/10/2026 and they Found filter is very old and needs replaced. Two water filters were ordered to replace the current filter and one was ordered as an extra.5. During an observation of the Dish Washing Machine on 3/10/2026 at 2:26 PM several observations revealed dishes were being washed with the temperature gauge at 118 degrees Fahrenheit during the wash cycle.During an interview with the kitchen manager on 3/10/2026 at 2:30 PM she reported the temperature for the Dish Washing Machine should be at least 120 degrees Fahrenheit during the washing cycle. She advised the Dish Washing Machine was serviced last year.During a repeat observation of the Dish Washing Machine on 3/11/2026 at 9:50 AM it was noted to continue to show a temperature of 118 during the wash cycle.During an interview with the Kitchen manager on 3/11/2026 at 9:50 AM she advised the only way to check the temperature for the dishwasher was the gauge attached to the machine. She denied performing any other checks to confirm the dishwasher temperature was accurate.During a review of a Kitchen Service Report from the contractor Cleanslate on 3/11/2026 at 11:22 AM it was discovered that the dishwasher was last serviced on 10/09/2025 and the report identified Gauges Needs Attention.During an interview with the Kitchen Director on 3/11/2026 at 11:22 AM she reported that she was not aware of the dishwasher needing any work for the gauges.During a review of the facility's Dishwashing Machine Use Policy on 3/12/2026 at 10:48 AM it was revealed that, The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. The policy added that The supervisor will check the calibration of the gauge weekly by: Running a secondary thermometer through the machine to compare temperatures; or Using commercial temperature test strips following manufacturer's instructions. If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or Parts Per Million are adjusted.During an interview with the Maintenance Director on 3/16/2026 at 6:23 AM he reported that the contractor Cleanslate was here yesterday to work on the dishwasher and they would be back today to repair the gauge.

Based on medical record reviews and staff interview, it was determined that the facility failed to ensure that residents were offered written information regarding advance directives. This was evident for 4 (Residents #8, #10, #47, and #86) out of 6 residents reviewed for advance directives during the recertification and complaint survey process. The findings include: An Advance Directive is a legal document in which a person specifies their wishes regarding medical treatment in situations where they may no longer be able to express informed consent. It can include instructions about end-of-life care and may appoint a healthcare proxy (someone to make medical decisions on their behalf). On 03/10/2026 at 6:29 PM, a review of medical records revealed no written documentation indicating that the facility offered advance directives or provided education regarding advanced directives to Residents #8, #10, #47, and #86 or their resident representatives.On 03/13/2026 at 1:15 PM interview with Regional Social Worker (LMSW) reported that residents or their responsible party are asked upon admission whether an advance directive is in place. If an advance directive is not in place, the facility provides the Maryland Attorney General's Office Advance Directive packet. On 03/13/2026 at 1:30 PM the LMSW reviewed the medical records of Residents #8, # 10, #47, and #86 with the surveyor and confirmed there was no written documentation indicating that advance directives were offered or that education regarding advance directives had been provided to the residents or their responsible parties. She further stated that the Interdisciplinary Team (IDT) recently discussed incorporating advance directive discussions into care plan meetings, particularly for long-term care residents.

Based on observation, record review, and interview, it was determined that the facility failed to ensure services were provided in accordance with professional standards for quality of care. This was evident for 6 (Resident #28, #5, #47,#90, #91, and #44) out of 6 Residents reviewed for professional standards during the medication administration facility task conducted as part of the annual/complaint survey. The findings include: 1) Medication is considered unnecessary if it is administered without a valid medical indication, is continued longer than clinically needed, or is not properly monitored or evaluated for effectiveness and safety. On 03/11/2026 at 10:23 AM during an unnecessary medication review, the surveyor noted that Resident #28 had an active physician's order for Bacitracin External Ointment 500 UNIT/GM (Topical) to be applied into both nostrils twice daily for dry/irritated nostrils, with a start date of 09/03/2025. Further review of medical records revealed that the order for Bacitracin External Ointment 500 UNIT/GM (Topical) for Resident #28 had been active for over six months with no documentation of reassessment, evaluation of ongoing need, or clinical justification for continued use. On 03/12/2026 at 9:12 AM review of Resident #28's Medication Administration Record (MAR) revealed that nursing staff documented administration of Bacitracin External Ointment 500 UNIT/GM (Topical) from September 3, 2025, through March 12, 2026. On 03/12/2026 at 9:20 AM an interview was conducted with the Director of Nursing (DON) regarding topical antibiotics use. She stated that all topical antibiotic orders should include a stop date. On 03/12/2026 at 9:30 AM an interview was conducted with the Medical Director (MD) regarding the use of topical antibiotic ointment. The MD stated that antibiotic ointments are normally used to treat skin tears or minor skin issues for approximately 5–7 days or until the wound is healed, depending on the condition of the skin and physician discretion. He further stated that orders should include a stop date. The surveyor brought the concern regarding Resident #28's prolonged Bacitracin order to the MD's attention. The MD acknowledged the oversight and confirmed, that is a mistake on our part, I will discontinue the order. Further review of the medical record revealed that following the surveyor's intervention, the order for Bacitracin External Ointment 500 UNIT/GM (Topical) for Resident #28 was discontinued on 03/12/2026. 2) Enteral feeding is the delivery of liquid nutrition directly into a resident's stomach or intestines through a tube when they are unable to eat or swallow safely, but their digestive system still works. The process involves preparing the feeding formula, connecting it to the feeding tube, and administering it at the prescribed rate. All feeding bottles and water flush bags must be properly labeled with the resident's name, date, time, and feeding rate and changed every 24 hours to ensure safety and prevent infection. On 03/10/2026 at 11:40 AM during rounds in Resident #5's room, the surveyor observed an enteral feeding bottle and water flushing bag hanging with no start date or time labeled to indicate when the feeding was initiated. The Kangaroo water bag had no date and was labeled Levity. The enteral feeding bottle was labeled exp 48 hrs, indicating the expiration time, but without a documented start date and time, staff cannot determine when the 48-hour period began. On 03/10/2026 at 11:47 AM interview with Registered Nurse (RN) #5, regarding the process for enteral feeding administration. She stated that before hanging the feeding, the feeding bag and water bag must be labeled with the date, name of the feeding, resident's name, rate, start time of the feeding, and flushing schedule. She further stated that the expectation is for labeling to be accurate and complete. The RN #5 confirmed that the eternal feeding bottle and water bottle observed had no date or start time documented. During an interview conducted with the Director of Nursing (DON) on 3/11/2026 at 1:30 PM regarding expectations for enteral feeding administration, the DON stated that nursing staff are expected to properly label the feeding bottle and water flush bag with the date, time, resident's name, and feeding rate. She further stated that enteral feeding bottles and water flush bags must be changed every 24 hours. 3) During 400-unit rounds on 03/10/2026 the following were observed by the surveyor: 11:34 AM Resident #28, the surveyor observed oxygen tubing in use had no date or label. 11:34 AM Resident #47, the surveyor observed a nebulizer treatment machine placed on a plastic container on the floor. The tubing and mask were lying on top of the resident's clothes on the floor, and the tubing had no label. 11:38 AM during observation of Resident #90, the surveyor observed a nebulizer treatment mask, tubing, and oxygen tubing without a label. On 03/10/2026 at 11:55 AM during an interview, Registered Nurse (RN) #5 stated that the expectation is for staff to label oxygen tubing and humidifier bottles. RN #10 confirmed that Residents #28, #44, and #90's oxygen tubing was not labeled. On 03/11/2026 during 400-unit rounds the surveyor observed the following: 07:56 AM Resident #47's nebulizer treatment machine was placed on a plastic container on the floor, and the tubing and mask were lying on top of the resident's clothes on the floor. Additionally, the tubing had no label. 08:01 AM Resident #90, the surveyor observed the resident receiving oxygen therapy. The oxygen tubing in use had no label. Additionally, a nebulizer treatment mask, tubing, with no labeling sitting on resident's bed. 08:05 AM Resident #91, the surveyor observed the resident lying in bed with oxygen tubing lying on the floor. Lead Geriatric Nursing Assistant (GNA) #7 entered the room to assist the resident, picked up the oxygen tubing from the floor and placed it back on the resident's nose. At 08:56 AM, the surveyor observed Resident #44 lying in bed with oxygen in use and noted that the oxygen tubing had no label. On 03/11/2026 at 12:10 PM The surveyor conducted rounds on the 400-unit with RN #5 and confirmed the above concerns. On 03/11/2026 at 1:35 PM an interview was conducted with the Director of Nursing (DON) regarding the facility's expectations for oxygen tubing and nebulizer treatment equipment. The DON stated that oxygen tubing, nebulizer tubing, and masks are expected to be labeled and stored in a plastic bag when not in use.

Based on record reviews and interviews, it was determined that the facility failed to ensure Staff were competent in their skills. This was found to be evident for 4 (GNA #1, #2, #8, & #9) out 5 Geriatric Nursing Assistants reviewed for skill competency evaluations during the recertification and complaint survey.The findings include:During a review of employee files conducted on 03/16/26 at 9:12 AM for Geriatric Nursing Assistants (GNA) #1, #2, #8, & #9 it was discovered that there were not any current records of skills competencies.During an interview conducted on 03/16/26 at approximately 9:45 AM, the Director of Nursing (DON) reported that the facility conducted skills clinics that included return demonstrations. She further stated that she would obtain the records for the GNAs.On 03/16/26 at approximately 10:15 AM, the DON returned and reported that the facility failed to conduct the skill competency clinics for 2025. She also reported that she had 2026 skill competency clinics scheduled for May and June of 2026.

Based on record review and interview, it was determined that (1) the facility failed to ensure residents were offered and educated on COVID-19 vaccinations and (2) the facility failed to maintain staff documentation of COVID-19 screening, education, offering, and current vaccination status. This was evident for 5 of 5 residents reviewed (Resident #15, #5, #47, #7, and #81) and 5 of 5 staff reviewed (Geriatric Nursing Assistants #1, #2, #6, #7, and Registered Nurse #10) for COVID-19 immunization status.The findings include:(1)On 03/11/2026 at approximately 12:00 PM, this surveyor conducted a record review of electronic health records for Resident #15, #5, #47, #7, and #81 to determine COVID-19 vaccination status. The review revealed that Resident #15 had not been offered the COVID-19 vaccine since 04/12/2025, Resident #5 since 12/03/2024, Resident #47 since 02/18/2025, and Resident #81 since 12/05/2024. Resident #7, admitted in February 2026, had no documented evidence of being offered the COVID-19 vaccine.On 03/11/2026 at 3:12 PM, an interview was conducted with the Infection Control Preventionist (ICP), who reported starting in the role on 02/05/2026 in a part-time capacity. She stated that prior to her, the Assistant Director of Nursing (ADON) had served as ICP.On 03/11/2026 at 3:50 PM, a joint interview was conducted with the ADON and ICP. During the interview, the ADON reported that there was a transition period toward the end of 2025 when the ICP position was vacant. She stated that during this time, ensuring residents were offered vaccinations may have been missed and some residents may not have been accounted for. The ADON reported that the expectation is for nursing staff to offer vaccinations upon admission, including providing education, obtaining consent, and documenting this in the electronic health record. She further stated that residents should be offered influenza, COVID-19, RSV (Respiratory Syncytial Virus), and pneumococcal vaccines as appropriate on admission. On 03/11/2026 at 4:10 PM, during continued interview, the ICP reported that after the previous ICP left (approximately November 2025), there were no designated staff responsible for monitoring and ensuring residents were offered vaccinations. The ADON confirmed that no staff member had been assigned to oversee this responsibility during that time. It was communicated that this lack of oversight resulted in residents not being offered COVID vaccines, as evidenced by record review of Residents #15, #5, #47, #7, and #81. It was further explained that Resident #7's recent admission without any documented COVID vaccination offer demonstrated a continued gap in practice. The ADON and ICP acknowledged that responsibilities associated with the ICP role were not consistently maintained during the transition period. On 03/13/2026 at 10:48 AM, this surveyor conducted an interview with the Director of Nursing (DON). The DON confirmed awareness of the identified concerns and reported that a Performance Improvement Plan (PIP) had been initiated to address the issue. The DON stated that the facility had begun conducting a vaccination audit, and documentation of the audit and PIP was provided to the surveyor. (2)On 03/13/2026 at approximately 1:30 PM, this surveyor conducted a record review of COVID-19 immunization records for GNA #1, #2, #6, #7, and RN #10. The review revealed that the last COVID-19 vaccination dates were: GNA #1 - 02/27/2022, GNA #2 - 01/16/2022, GNA #7 - 05/28/2021, and RN #10 - 05/02/2022. GNA #6 had a COVID-19 vaccine declination statement, but it was incomplete and undated. No recent documentation was found demonstrating that these employees had been offered, educated about, or provided the opportunity to receive the COVID-19 vaccine.On 03/13/2026 at approximately 3:35 PM, this surveyor interviewed the Infection Control Preventionist (ICP) and Assistant Director of Nursing (ADON). They confirmed that no active process has been in place for offering COVID-19 vaccinations to staff, providing education, or obtaining declination forms. They presented a document including COVID-19 vaccine education and a declination section, which they reported will be used moving forward. When asked if documentation existed showing staff had previously been offered the vaccine, received education, or completed declination forms, they reported none was available. It was communicated that this lack of process and documentation represents an infection control concern. The concern is further supported by the record review of the five employees (GNA #1, #2, #6, #7, and RN #10), which showed no evidence of screening, offering, or education regarding COVID-19 vaccination. The ICP and ADON acknowledged and confirmed understanding of the concern.

Based on interviews, observations and record reviews it was determined the facility failed to ensure a functioning call bell system was available for all residents. This was found to be evident for 4 (Resident's #75, #51, #58 and #98) of 18 Residents review for call bell access during the recertification survey.The findings include:1. During an interview with Resident #75 on [DATE] at 9:06 AM he/she reported that his/her call bell had been broken for a year and it comes on without the Resident activating the bell.During an observation of the call bell alerts on [DATE] at 9:15 AM it was revealed that the call bell for Resident #75 was actively alerting.During an additional observation of the call bell system on [DATE] at 11:15 AM it was discovered that the call bell for Resident #75 was again alerting.During an interview with the Infection Control and Prevention nurse (ICP) on [DATE] at 11:16 AM she reported that Resident #75 doesn't want anything, maintenance is working on getting his/her call bell fixed.During an interview with the Maintenance Director on [DATE] at 11:17 AM he reported that he has made attempts to fix the call bell for Resident # 75 and still had problems. He advised he was now going to reprogram the call bell for the Resident to see if that works.During an interview with GNA #11 on [DATE] at 11:31 AM she reported that she didn't answer the call bell for Resident #75 earlier because it's broke and he/she usually calls on his/her phone.During an observation on [DATE] at 6:11 AM it was discovered that the call bell for Resident #75 was alerting.During an interview with GNA #16 on [DATE] at 6:31 AM she reported she didn't answer the call bell for Resident #75 because it's broke, it's been broken.During an interview with Resident #75 on [DATE] at 6:46 AM he/she reported they did not ring the call bell and did not need anything.During an observation on [DATE] at 8:30 AM it was revealed the Maintenance Director was in the room of Resident #75 to repair the call bell. During a review of the maintenance repair requests from the TELS system on [DATE] at 11:16 AM it was discovered that the request to repair the call bell was placed on [DATE] and it reported the call bell won't go off.During an interview with the Maintenance Director on [DATE] at 6:24 AM he reported there have been problems with the call bell for Resident #75 for a while and the problems have been off and on. He reported he replaced the cable for the call bell.During a review of the facility's Call Lights: Accessibility and Timely Response policy on [DATE] at 10:38 AM it was discovered that Staff will report problems with a call light or the call system immediately to the supervisor and /or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. 2. During an observation of Resident #51 on [DATE] at 9:54 AM it was revealed that the Resident did not have a call bell or another device to call for assistance from the facility staff. His/her roommate, Resident #77 had a call bell.During an interview with Resident #77, the roommate for Resident #51, on [DATE] at 9:57 AM he/she reported that Resident #51 uses my bell, he/she tells me to call and I ring mine. He/she advised Resident #51 had not had a call bell since moving into the room with Resident #77 about 3 months ago and confirmed that he/she has had to use their own call bell to ring for Resident #51.During an interview with Licensed Practical Nurse (LPN #4) on [DATE] at 9:58 AM she reported he/she should have a call bell and if not a hand bell to alert for help. She confirmed that Resident #51 did not have his/her own call bell and reported that she would notify maintenance.During an observation of the Maintenance Director on [DATE] at 10:04 AM it was revealed that he was replacing the single wire call bell going to resident #77 with a dual wire call bell device designed for two residents.During an interview with the Maintenance Director on [DATE] at 11:21 AM he reported that the facility did room changes and they didn't notify me.During an interview with the Director of Nursing on [DATE] at 8:28 AM she reported that Every resident should have a call bell. She advised the rooms were single rooms and the rooms were turned into a room for two Residents.During a review of medical records for Resident #51 on [DATE] at 7:45 AM it was discovered that he/she was admitted to his/her room on [DATE]During a review of the facility's Call Lights: Accessibility and Timely Response policy on [DATE] at 10:38 AM it was discovered that The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet and the Call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.3. During an observation of Resident #58 on [DATE] at 10:06 AM it was revealed that the Resident did not have a call bell or another device to call for assistance from the facility staff. His/her roommate Resident #36 had a call bell.During an observation with the Maintenance Director on [DATE] at 10:07 AM he confirmed that Resident #58 did not have a call bell. He advised the call bell in his/her room was only a single wired call bell going to Resident #58 roommate. He would replace it to a double.During an interview with Resident #58 on [DATE] at 10:08 AM he/she reported that he/she would catch the nurse when they go by or have his/her roommate use his/her call bell to get help if needed.During an interview with the Director of Nursing on [DATE] at 8:28 AM she reported that Every resident should have a call bell. She advised were single rooms and the rooms were turned into a room for two Resident.During an interview with the Maintenance Director on [DATE] at 11:21 AM he reported that the facility did room changes and they didn't notify me.During a review of medical records for Resident #58 on [DATE] at 7:45 AM it was discovered that he/she was admitted to his/her room on [DATE].4. During an observation of Resident #98 on [DATE] at 10:10 AM it was revealed that the Resident did not have a call bell or another device to call for assistance from the facility staff. His/her roommate Resident #81 had a call bell.During an interview with the Director of Nursing on [DATE] at 8:28 AM she reported that Every resident should have a call bell. She advised were single rooms and the rooms were turned into a room for two Resident.During a review of medical records for Resident #98 on [DATE] 11:12 AM it was discovered that he/she was admitted to his/her room on [DATE].During an interview with the Maintenance Director on [DATE] at 11:21 AM he reported that the facility did room changes and they didn't notify me.During a review of the facility's Call Lights: Accessibility and Timely Reponse policy on [DATE] at 10:38 AM it was discovered that , Staff will report problems with a call light or the call system immediately to the supervisor and /or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. All staff members who see or hear an activated call light are responsible for responding.

Based on record reviews and interviews it was determined that the facility failed to ensure that residents remained free of neglect. This was evident for 1 (Resident #75) of 1 Resident reviewed for neglect during the recertification survey. The findings include:During a review of Facility Reported incident #2730935 on 3/10/2026 at 8:35 AM it was revealed the incident was submitted to the Office of Health Care Quality on 1/30/2026. The incident reported an allegation was made by Resident #75 that no staff provided care to him/her during the 11p - 7a shift.During a review of the facility incident folder for incident #2730935 on 3/11/2026 at 10:46 AM a Follow-Up Investigation form was discovered that validated the allegation and reported it was confirmed that Geriatric Nursing Assistant (GNA) #12 did not go into the room of Resident #75 to provide care during the 11p - 7a shift on the shift of 1/29/2026. The facility noted the concern was a Verified allegation and that GNA #12 was disciplined.During a review of the GNA tasks documentation on 3/11/2026 at 11:32 AM it was revealed that there was no documentation for Bathing, Bed Mobility, Oral Hygiene, Toileting, Barrier Cream after incontinence care, Bowel Elimination, Urinary Incontinence or Foam Ankle Boots on in bed as tolerated being completed on 1/29/2026 for the 11p - 7a shift.During an interview with the Director of Nursing on 3/12/2026 at 8:28 AM she stated that care provided during the shift should be documented by the GNA. She confirmed that there should not be blank spaces on the GNA tasks documentation, she added refusals and anything related to the care the GNA provided should be documented. She reported that if the task wasn't documented she advised we don't have the support to show it was completed. She confirmed that if care was provided to Resident #75 on the night shift of 1/29/2026 then it should have been documented and not left blank.

Based on record reviews and interviews, it was determined that the facility failed to thoroughly investigate allegations of neglect. This was evident for 1 (Resident #75) of 1 Resident reviewed for neglect during the recertification survey.The findings include:1. During a review of medical records for Resident #75 on 3/16/2026 at 9:25 AM a Hospital Consult Report had been uploaded into the medical records for Resident #75 on 12/13/2025. Upon reviewing the consultation report it was discovered that Resident #75 had went to the Emergency Department on 12/13/2025. The Emergency Department Provider Note stated the resident had complained that Resident #75 reported that he/she constantly has been getting neglected by the night shift 11p - 7a shift at the nursing facility and He/she frequently sits in his/her urine and says that they purposely ignore his/her call bell. This time, he/she called 911 for help.During an interview with the Administrator on 3/16/2026 at 9:38 AM he reported that he was not aware of the complaint that Resident #75 had made to the Emergency Department. He also advised that he was not aware of an investigation being conducted for this complaint. He confirmed that the Emergency Department Note found in the medical records for Resident #75 had been uploaded by staff from the nursing facility. He confirmed that the Administrator should be made aware of any reports of neglect and those concerns should be investigated.During an interview with the Director of Nursing on 3/16/2026 at 9:50 AM she reported that when a Resident returns from the hospital the admitting nurse would screen the resident and review discharge paperwork for discharge information and orders. She confirmed that the nurse that admitted Resident #75 should have reviewed the discharge paperwork and should have noted the resident's complaint of neglect.2. During a review of Facility Reported Incident #2690114 on 3/16/2026 at 9:56 AM it was discovered that Resident #75 had reported an allegation of neglect to the facility and being left in soiled conditions for an extended period.During an interview with the Director of Nursing (DON) on 3/16/2026 at 10:17 AM she reported she could not find the investigation file for incident #2690114 concerning Resident #75. She was able to provide documentation of the initial incident report that was submitted to the Office of Health Care Quality on 12/10/2025 at 5:15 PM. She was unable to find any additional files or documentation related to the incident.During an interview with the DON 3/16/26 at 10:58 AM she reported that a file would be kept containing any interviews or evidence that was obtained during an investigation of a Facility Reported Incident. She confirmed that Resident #75 should have an investigation folder for incident #2690114 but they were unable to find the investigation folder.During an interview with the Administrator on 3/16/26 at 10: 58 AM he confirmed the investigation notes and interviews from a facility reported incident would be kept in a folder which would be kept in a file cabinet. He advised the previous DON handled the investigation for incident #2690114 and confirmed that they were unable to find the investigation file.

Based on interviews and medical record reviews it was determined that the facility failed to ensure 1) quarterly care plan meetings with the interdisciplinary team were held and 2) a Residents care plan intervention was implemented. This was found to be evident for 2 (Resident #75 and #1) out of 18 Residents reviewed for care plans during the recertification and complaint survey. The findings include: 1) A Care Plan is used in nursing facilities to summarize a resident's health conditions and care needs. It is used to ensure resident's needs are met and consistent care is provided to the resident based on those needs. Care Plan meetings are meetings with a team of care providers (attending physician, a registered nurse with responsibility for the resident, nursing assistant with responsibility for the resident, dietary services, the resident, and the resident's representative if applicable) to ensure the plan is continually adjusted to meet the changing needs or concerns of residents. Care Plan meetings are required to be held quarterly. During an interview with Resident #75 on 03/10/2026 at 12:15 PM he/she denied having regular care plan meetings. During a review of medical records for Resident #75 on 3/11/2026 at 11:07 AM it was discovered that he/she had care plan meetings held on 12/04/2024, 9/17/2025 and 1/16/2026. There were no additional care plan meetings documented between the meetings held on 12/06/2024 and 9/17/2025. During an interview with the Regional Social Worker on 3/11/2026 at 12:52 PM she reported there were no care plan meetings held for Resident #75 between the care plan meetings that were held on 12/04/2024 through 9/17/2025. She confirmed meetings were missed and should have been held in March and June of 2025. 2) During a review of Resident #1's progress notes conducted on 03/11/26 at 9:15 AM, it was discovered that the Resident had multiple occasions where he/she displayed inappropriate sexual behavior. During a review of the Resident #1's Care Plan conducted on 03/11/26 at 9:22 AM, it was discovered that the Resident had a Care Plan for inappropriate sexual behavior with an intervention for a 1 to 1 supervision. During an observation of Resident #1 conducted on 03/11/26 at 10 :33 AM, the Resident was observed on the unit without 1 to 1 supervision. During an interview conducted on 03/10/2026 at 10:42 AM, The Surveyor asked Registered Nurse (RN) #10 if Resident #1 continued to have inappropriate sexual behavior. The RN reported that the Resident continued to display inappropriate behaviors with other Residents. When asked if the Resident had 1 to 1 supervision, the RN replied not presently. When asked when the last time the Resident had 1 to 1 supervision the RN stated that it had been a while maybe 2 months ago. When asked if the Resident had displayed inappropriate behaviors in the last 2 months the RN replied that the Resident had those behaviors daily. During an interview conducted on 03/13/26 at approximately 11:00 am, the Director of Nursing (DON) acknowledged that Resident #1 displayed inappropriate sexual behavior and did not presently have a 1 on 1 supervision as noted in the care plan.

Based on observations, record reviews and interviews it was determine that the facility failed to provide Residents with quality of care. This was found to be evident for 5 (Resident #88, #39, #41, #47 and #90) out of 18 Residents reviewed for quality of care during the recertification and complaint survey. The findings include: 1) On 03/11/2026 at 10:02 AM, this surveyor observed Licensed Practical Nurse (LPN) #4 administer medications to Resident #88. When administering medications, LPN #4 did not explain the medications to the resident or offer the opportunity for the resident to be informed. On 03/11/2026 at 10:58 AM, this surveyor observed LPN #4 administer medications to Resident #40. LPN #4 did not explain the medications or offer the resident the opportunity to be informed. On 03/13/2026 at 8:42 AM, this surveyor observed Registered Nurse (RN) #5 administer medications to Resident #39 in a shared room with Resident #41 present. RN #5 did not provide privacy during the medication administration, as the privacy curtain was not drawn and Resident #41 was able to observe the process. On 03/13/2026 at 8:57 AM, record review of the facility's medication administration policy under Policy Explanation and Compliance Guidelines indicated Provide Privacy. On 03/13/2026 at 10:40 AM, this surveyor conducted an interview with the Director of Nursing (DON), who reported that staff are expected to offer residents the opportunity to be informed about their medications during administration, as this supports resident choice and the ability to refuse medications if desired. During the interview, the DON was informed of the above concerns, including failure to explain medications and failure to provide privacy during medication administration. The DON acknowledged and confirmed understanding of the concerns. On 03/16/2026 at 8:46 AM, this surveyor conducted an interview with the Administrator and communicated the concerns related to medication administration practices. The Administrator acknowledged and confirmed understanding. 2) On 03/10/2026 at 12:05 PM the surveyor observed two urinals filled with urine on top of the nightstand in Resident #47's room. The resident stated, Some of the aides empty it for me, and some don't. It depends on who is working. This happens all the time. On 03/10/2026 at 12:10 PM during room rounds, the surveyor observed a urinal filled with urine and a trash can sitting on the bed in Resident #90's room. During room rounds in 400-411 on 03/10/2026 at 12:15 PM, the surveyor observed a trash can under the sink that was approximately one-quarter full of coffee-colored water and trash. Resident #47 stated, Don't worry, it has been there for a couple of days. On 03/10/2026 at 12:44 PM during an interview, the Lead Geriatric Nursing Assistant (GNA) stated that GNAs empty residents' urinals during rounds, conducted every two hours and as needed. She confirmed that, while some residents may empty their own urinals, it is the responsibility of GNAs to ensure all urinals are emptied during the shift. During room rounds on 03/11/2026 at 1:59 PM in room [ROOM NUMBER]-411, the surveyor and the Director of Nursing (DON) observed a trash can under the sink approximately one-quarter full of coffee-colored water and trash. The DON stated that it was 'probably left there to prevent water from leaking on the floor,' but acknowledged it was not supposed to be there and indicated that a work order was being placed immediately.

Based on observations, interviews and record reviews it was determined that facility failed to ensure a Resident was provided with supervision. This was found to be evident for 1 (Resident #1) out of 1 Resident reviewed for supervision during the recertification and complaint survey.The findings include: During a review of Resident #1's progress notes conducted on 03/11/26 at 9:15 AM, it was discovered that the Resident had multiple occasions where he/she displayed inappropriate sexual behavior. A Care Plan is a formalized, personalized, and actionable document developed by healthcare professionals in collaboration with patients and families to manage specific health conditions. It acts as a roadmap for care, outlining goals, necessary interventions, and timelines. These plans are constantly updated based on patient progress. During a review of the Resident #1's Care Plan conducted on 03/11/26 at 9:22 AM, it was discovered that the Resident had a Care Plan for inappropriate sexual behavior with an intervention for a 1 to 1 supervision. During an observation of Resident #1 conducted on 03/11/26 at 10 :33 AM, the Resident was observed on the unit without 1 to 1 supervision. During an interview conducted on 03/10/2026 at 10:42 AM, The Surveyor asked Registered Nure (RN) #10 if Resident #1 continued to have inappropriate sexual behavior. The RN reported that the Resident continued to display inappropriate behaviors with other Residents. When asked if the Resident had 1 to 1 supervision, the RN replied not presently. When asked when the last time the Resident had 1 to 1 supervision the RN stated that it had been a while maybe 2 months ago. When asked if the Resident had displayed inappropriate behaviors in the last 2 months the RN replied that the Resident had those behaviors daily. During an interview conducted on 03/13/26 at approximately 11:00 am, the Director of Nursing (DON) acknowledged that Resident #1 displayed inappropriate sexual behavior and did not presently have a 1 on 1 supervision as noted in the care plan.

Based on interviews and record reviews it was determined that the facility failed to ensure that the individual designated as the Kitchen Manager was certified for food service management and safety. This had the potential to affect all residents. The findings include: During an interview with the Kitchen Manager on 3/10/2026 at 7:14 AM she reported she was the kitchen supervisor and managed the Kitchen. She advised she was not currently certified and did not currently hold a Certified Dietary Manager Certification (CDM). She reported she had completed her training and took the test in October; however, she needs to retake the test. She advised she's waiting for approval to retake the test. She advised the previous Kitchen Manager left about a year ago and she took over for him. She advised the facility does have a dietician that comes to the facility every Wednesday.During an interview with the Administrator on 3/10/2026 at 2:16 PM he reported the facility has a Dietician and she comes in every so often. He confirmed the Dietician was not full time. He advised he would check on the Kitchen Manager's certification.During a follow-up interview with the Administrator on 3/11/2026 at 11:16 AM he confirmed the Kitchen Manager did not have a current CDM certification. He advised she took the test for the CDM certification and needed to retake the test. He advised when the previous Kitchen Manager left we hired from within the facility and she would get her certification.During a review of documents provided by the Administrator on 3/11/2026 at 1:26 PM it was revealed that the Kitchen Manager had completed Nutrition and Foodservice Professional Training Pathway I with the University of Florida on 8/05/2025. The document notes that this is a Pre-certification course for CDM's.

Based on observation and interview, it was determined that the facility failed to ensure 1) measures were in place to prevent and monitor the growth of Legionella and other opportunistic waterborne pathogens in the building water system. This deficiency has the potential to affect all residents who utilize the facility's water system and 2) staff perform appropriate hand hygiene. This was found to be evident for 1 Licensed Practical Nurse (LPN #4) of 2 LPNs observed for infection control during the recertification and complaint survey.The findings include: 1) Legionella (and other opportunistic waterborne pathogens) is bacteria that can grow in building water systems and cause illness when exposed to contaminated water. TELS is a web-based building management and maintenance software solution specifically designed for senior living and healthcare facilities. On 03/11/2026 at 2:55 PM, this surveyor conducted an interview with the Maintenance Director. When asked whether the facility has measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens, or a system to monitor such measures, the Maintenance Director reported that the facility follows a water management program. The Maintenance Director further stated that the facility conducts in-house water testing for Legionella approximately once per year, a practice in place since around September 2022. He reported that test results are photographed and uploaded into the TELS system. When asked whether the facility has had any known cases of Legionella, the Maintenance Director reported that there have been no reported cases since his employment began in September 2022. On 03/13/2026 at 9:05 AM, the Maintenance Director reported that he was unable to locate documentation of the in-house Legionella testing results. He stated that he believed the results had been uploaded into the TELS system; however, he was unable to verify this and could not determine their location. The Maintenance Director confirmed that he did not have any additional documentation or evidence to demonstrate that in-house testing for Legionella or other opportunistic waterborne pathogens had been completed. It was then asked if the facility had any measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. The Maintenance Director reported that the facility utilizes mixing valves and confirmed that the water is heated and passes through mixing valves prior to reaching resident rooms. On 03/13/2026 at 9:08 AM, this surveyor and the Maintenance Director conducted a joint observation of the boiler room. It was observed that a mixing valve was in place and that heated water was being delivered from the water heaters through the mixing valve and then distributed to resident rooms. A thermometer on the outgoing water line to the resident rooms read 112 degrees Fahrenheit. The Maintenance Director was asked what temperature the water reaches in the tanks prior to passing through the mixing valve. He reported that he was not sure. It was observed that there were no thermometers present to monitor or display the temperature of the water within the tanks. When asked what the expected water temperature should be to help prevent the growth of Legionella and other opportunistic waterborne pathogens, the Maintenance Director stated that he believed it should be approximately 140 degrees Fahrenheit. On 03/13/2026 at 9:33 AM, this surveyor observed the Maintenance Director obtain a water temperature reading directly from a hose connected to the water heater tank. The temperature measured 108.5 degrees F. The Maintenance Director reported that he had consulted with the Regional Maintenance Director, who confirmed that thermometers should be present on the exterior of the water heater tanks to monitor water temperature. He also reported plans to install thermometers on the water heater tanks to monitor water temperatures moving forward. It was communicated that the facility was unable to verify that water temperatures were being maintained at levels expected (140 degrees F) to prevent the growth of Legionella and other opportunistic waterborne pathogens. Additionally, the inability to provide documentation of in-house water testing further indicated a lack of evidence demonstrating active monitoring or prevention measures. The Maintenance Director acknowledged the concern and confirmed that, without documented test results, the facility cannot verify that Legionella testing had been performed. On 03/13/2026 at 10:12 AM, the Maintenance Director reported that he would conduct a Legionella test to assess the facility's water system. At 10:25 AM, this surveyor observed the test being completed using water directly from a sink in an unoccupied resident room; the results were negative. While this confirmed no active Legionella in the water, the surveyor noted that the facility still lacks a documented, ongoing prevention and monitoring system for Legionella and other opportunistic waterborne pathogens. The Maintenance Director acknowledged and understood this concern. On 03/16/2026 at 8:46 AM, the surveyor discussed this concern with the Administrator, emphasizing that, despite negative test results and no reported cases of Legionella, the facility does not have active preventive or monitoring measures in place. The Administrator confirmed understanding of the concern. 2) Hand hygiene is mandatory before putting on gloves and immediately after removing gloves to prevent cross-contamination, as gloves are not a substitute for hand hygiene. Health care workers must change gloves and perform hand hygiene when moving from a soiled to a clean body site on the same patient, or between patient contacts On 03/13/2026 at 1:42 PM, LPN #4 was observed providing wound care for Resident # 11. LPN #4 changed gloves between the cleaning of the wound and placing the clean dressing. LPN #4 failed to perform hand hygiene between changing gloves. When LPN #4 finished applying a dressing on one wound, they again changed gloves and failed to perform hand hygiene before putting on another pair of gloves to apply a clean dressing to a second separately located wound on Resident #11 sacrum. On 03/13/2026 at 1:45 PM, an interview with LPN #4 confirmed that they should have performed hand hygiene between changing gloves.

Based on record review and interview, it was determined that the facility failed to provide influenza and/or pneumococcal immunizations as required or appropriate for residents. This was found to be evident for 4 (Resident #15, #47, #7, and #81) out of 5 Residents reviewed for influenza and pneumococcal immunizations during the Infection Control facility task conducted as part of the annual/complaint survey. The findings include:On 03/11/2026 at approximately 12:00 PM, this surveyor conducted a record review of residents' charts (Resident #15, Resident #5, Resident #47, Resident #7, and Resident #81) to determine influenza and pneumococcal vaccination status. The review showed no documentation that these vaccines were offered during the 2025-2026 season for the residents listed, with the exception of Resident #5, who was offered the influenza vaccine on 10/01/2025 and refused. Additionally, for Resident #7, admitted in February 2026, there was no documentation of vaccination status or that influenza or pneumococcal vaccines were addressed upon admission.On 03/11/2026 at 3:12 PM, this surveyor conducted an interview with the Infection Control Preventionist (ICP), who reported she began working in the role on 02/05/2026 in a part-time capacity. She stated that prior to her assuming the role, the Assistant Director of Nursing (ADON) had been serving as the ICP.On 03/11/2026 at 3:50 PM, a joint interview was conducted with the ADON and ICP. During the interview, the ADON reported that there was a transition period toward the end of 2025 when the ICP position was vacant. She stated that during this time, ensuring residents were offered vaccinations may have been missed and some residents may not have been accounted for. The ADON reported that the expectation is for nursing staff to offer vaccinations upon admission, including providing education, obtaining consent, and documenting this in the electronic health record. She further stated that residents should be offered influenza and pneumococcal vaccines as appropriate, and that influenza vaccines should be offered annually during the flu season (October 1 through March 31).On 03/11/2026 at 4:10 PM, during continued interview with the ICP and ADON, the ICP reported that after the previous ICP left (approximately November 2025), there were no designated staff responsible for monitoring and ensuring residents were offered vaccinations. The ADON confirmed that no staff member had been assigned to oversee this responsibility during that time. It was communicated that this lack of oversight resulted in residents not being offered required immunizations, as evidenced by record review of Residents #15, #47, #7, and #81. The ADON and ICP acknowledged that responsibilities associated with the ICP role were not consistently maintained during the transition period.On 03/13/2026 at 10:48 AM, this surveyor conducted an interview with the Director of Nursing (DON). The DON confirmed awareness of the identified concerns and reported that a Performance Improvement Plan (PIP) had been initiated to address the issue. The DON stated that the facility had begun conducting a vaccination audit, and documentation of the audit and PIP was provided to the surveyor.

Based on complaint, reviews of a closed and active medical record, reviews of all pertinent administrative records, and staff interviews, it was determined that the facility failed to have a system in place to ensure clinical records were complete and accurately documented. This was found to be evident for 2 (Residents #8, #9) of 9 residents reviewed during the complaint survey.The findings include:Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication errors and more prone to changes in condition that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles.Late documentation is a form of inaccurate documentation and is worsened if the documentation does not document when medications were given. 'Late administration' is defined as giving medication greater than 1 hour after a medication is due. 'Late documentation' is defined as not documenting immediately after administration.A review of the facility Pain Management policy revealed a section named Pain, Management and Treatment, which included: #1 - Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission.1) Resident #8 was admitted to the facility on [DATE] with diagnoses that included but limited to: anxiety, dementia, and atrial fibrillation. The facility initiated a comprehensive care plan for pain management on 10/17/2023. The goal of the pain management care plan was: The resident will be free of any discomfort or adverse side effects from pain medication the review date. The Pain Management care plan was last revised/updated on 06/23/25. Nursing interventions included but were not limited to administering analgesic medications as ordered by physicians and monitor/document side effects and effectiveness every shift.Review of Resident #8's closed medical record on 12/01/25 revealed a controlled medication utilization record that was issued by the facility pharmacy on 10/27/25 for the pain medication, Morphine Sulfate 100 mg/5 ml, give 0.25 ml orally once a day, and give 0.25 ml orally as needed every 2 hours. A review of Resident #8's Morphine Sulfate controlled medication utilization record revealed 34 doses of Morphine Sulfate had been signed out in November 2025. A review of Resident #8 November 2025 medication administration record (MAR) revealed that only 26 doses had been signed off as being administered to Resident #8 in November 2025. The dates the nursing staff failed to document administering a dose of Morphine Sulfate to Resident #8 on the MAR Included the following:11/08/25 at 12 noon11/08/25 at 5 pm11/11/25 at 1 pm11/19/25 at 6 pm11/22/25 at 11 am11/22/25 at 3 pm11/22/25 at 6 pm11/23/25 at noonA further review of Resident #8's November 2025 (MAR) and the nursing progress notes failed to reveal any nursing documentation of a nursing assessment indicating these doses of Morphine Sulfate were effective or not.In a telephone interview with staff nurse #1 on 12/04/25 at 3:38 PM, staff nurse #1 stated that s/he was not aware of not signing off administering doses of Morphine Sulfate to Resident #8 in November 2025. Staff nurse #1 also stated that Resident #8 had a standing order (once a day) and a as needed order for Morphine Sulfate.2) Resident #9 was admitted to the facility on [DATE] with diagnoses that included but limited to: lumbar back pain, chronic pain, repeated falls, and muscle wasting and atrophy. Resident #9 started Hospice services on 10/09/25. The facility initiated a comprehensive care plan for chronic pain on 10/31/23. The goal of the pain management care plan was: The resident will verbalize adequate relief of pain or ability to cope with pain through the review date. The Chronic Pain care plan was last revised/updated on 01/29/24. Nursing interventions included but were not limited to anticipating the resident's need for pain relief and responding immediately to any complaint of pain.Review of Resident #9's closed medical record on 12/03/25 revealed a controlled medication utilization record that was issued by the facility pharmacy on 10/14/25 for the pain medication, Morphine Sulfate 100 mg/5 ml, give 0.25 ml every 4 hours as needed for restlessness. A review of Resident #9's Morphine Sulfate controlled medication utilization record revealed 35 doses of Morphine Sulfate had been signed out from 10/14/25 through 11/30/25. A review of Resident #9's October and November 2025 medication administration records (MAR) revealed that only 14 doses had been signed off as being administered to Resident #9 between 10/14/25 and 11/30/25. The dates the nursing staff failed to document administering a dose of Morphine Sulfate to Resident #9 on the MAR included the following:10/27/25 at 3 pm10/28/25 at 1 pm10/29/25 at 9 pm11/02/25 at 8 pm11/03/25 at 12 noon11/07/25 at 10 pm11/11/25 at 11 am11/12/25 at 2 pm11/15/25 at 10 am11/17/25 at 2 pm11/19/25 at 9 am11/19/25 at 6 pm11/20/25 at 11 am11/22/25 at 9 am11/25/25 at 11 am11/26/25 at 1 pm11/28/25 at 6 pmA further review of Resident #9's October and November 2025 (MAR) and the nursing progress notes failed to reveal any nursing documentation of a nursing assessment indicating these doses of Morphine Sulfate were effective or not.In a telephone interview with staff nurse #1 on 12/04/25 at 3:38 PM, staff nurse #1 stated that s/he was not aware of not signing of administering doses of Morphine Sulfate to Resident #9 in November 2025. Staff nurse #1 also stated that Resident #9 was able to inform the nursing staff if s/he was in pain.

Based on a review of a complaint, medical record review, facility documentation review, and staff interviews, it was determined the facility failed to keep a dependent resident free from injury while transferring the resident from the bed to the chair via a Hoyer lift, which resulted in actual harm to Resident (R) #11. The failure of facility staff to follow the plan of care while transferring a resident resulted in bilateral sacral fractures and a L2 fracture. This was evident for 1 (#11) of 3 residents reviewed for falls. The findings include:A Hoyer lift is a mechanical device that uses a sling to safely lift and move a resident who is unable to transfer themselves between surfaces like a bed, wheelchair, or toilet. The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the care.On 8/27/25 at 10:35 AM complaint 295983 was reviewed and alleged that an aide put Resident #11, who was an amputee and paralyzed, in a Hoyer lift and dropped the resident onto the floor which resulted in Resident #11 being transferred to the hospital.A review of Resident #11's medical record was conducted and revealed Resident #11 was admitted to the facility in June 2024 with diagnoses that included, but were not limited to quadriplegia, anxiety, and acquired absence of left leg above the knee.Review of a 12/16/24 at 15:00 (3:00 PM) nurse's note documented, GNA (geriatric nursing assistant) came to get me stating resident fell. Resident states that [his/her] back is hurting mostly on the left side. The note stated, is requesting to go to hospital.A 12/17/24 at 8:55 AM Nurse Practitioner (NP) progress note documented, patient returned from hospital s/p fall with bilateral sacral fractures and L2 compression fracture. Patient with complaints of pain. Patient is alert and responsive but does not appear at full baseline at this time, frequently falling asleep. However, patient spent the night in the ER and has not slept. The assessment was, bilateral fractures to bilateral sacrum and L2 compression.A 12/17/24 at 10:12 AM IDT (interdisciplinary team) note documented, IDT met today to discuss resident's witnessed fall on 12/16/24. Intervention initiated is staff re-education on Hoyer transfers.A 12/18/24 physician's note documented, is being evaluated following a fall while in a harness, landing on the buttock region. [He/she] was sent to the emergency department, where a CT scan revealed a bilateral sacral fracture and a mild L2 compression fraction. The patient reports experiencing mild pain with movement, which occurs even with assistance, as [he/she] is quadriplegic and requires help for mobility. The note documented the resident had quadriplegia after acute trauma after an MVA (motor vehicle accident) in 2009. The plan documented that a neurosurgery consult was placed. Tylenol was ordered every 6 hours for pain relief as the resident preferred not to take Oxycodone, but had it ordered if needed.Review of GNA #16's witness statement documented that Resident #11 wanted to get up. I grabbed one of the two slings placed in [his/her] chair. I placed the smallest sling under [him/her] while crossing the bottom of it. As I lifted [him/her] and proceeded to move [him/her] from the bed to chair. I hit the end of the bed with the wheel of the Hoyer, and [he/she] slipped through the sling and fell to the floor, bottom first. The GNA documented that she placed pillows under the resident and went to get the nurse.Review of Resident #11's 10/14/24 MDS assessment documented in Section GG0115 that the resident had impairment on both sides, upper and lower; dependent for all ADLs (activities of daily living.)Review of R #11's care plan, has an ADL self-care performance deficit r/t paralysis, that was initiated on 1/25/24, had the intervention, the resident requires Hoyer Lift with 2 staff assistance for transfers with a date initiated of 4/30/24.Review of the actual nursing schedule for 12/16/24 documented that there was 1 nurse (LPN #15) and 2 GNAs (GNA #16, and another GNA) for the 300 unit, the unit where R #11 resided. It was noted that GNA #16 was assigned to unit 300 and unit 400, therefore GNA #16 had a split assignment.On 8/28/25 at 8:10 AM an interview was conducted with LPN #15 who stated, I remember them coming to get me that [he/she] fell out of the Hoyer lift. I called the doctor and 911 and had [him/her] sent to the hospital. LPN #15 stated that they told her GNA #16 was transferring the resident by herself. I think we were short staffed that day. We worked short a lot. It happened at the end of day shift. I thought it was a lot taking care of people for the GNAs when short staffed. When I went in there the resident was on the floor. I can't remember if [he/she] was in pain. It was so busy, crazy that day and I was the only nurse on those 2 hallways.On 8/28/25 at 9:25 AM an interview was conducted with Staff #17, the previous Director of Nursing (DON). Staff #17 stated, one of our aides was transferring [him/her] by herself without a second person and she said the leg hit the bed and the resident slid out of the sling and fell on the floor. It was the right size sling. It was [his/her] sling. Staff #17 stated, We let her (GNA #16) go for transferring without a second person that resulted in the resident being hurt. On 9/2/25 at 3:02 PM GNA #22 was interviewed and stated that Resident #11 was totally dependent on staff for all ADLs. GNA #2 stated that Resident #11 was transferred with a Hoyer lift. I was working the morning shift. It happened at the end of the shift, and I was actually leaving. I was at the desk charting. I did hear a yell and then I went down to see what happened and I went and got the nurse. GNA #2 stated, the aide that was taking care of the resident at the time was in the room. When I went in there she was the only one in there when I walked in. All she said was that she was transferring [him/her] back into the bed and it was a split body sling, and [he/she] had fallen through it. I was on the 300 hallway. The groups on that hall changed a lot and I did not have [him/her.] We must have had a split hallway. Sometimes if we are short we have a split hallway. We did work short last December. On day shift I usually take care of 11 or 12 residents. That day we only had 3 aides on day shift. That is about 15 to 16 people that we would have had to take care of. That is a lot for day shift because most of them are total care. I can say sometimes I have transferred people by myself, but after that incident I have not transferred by myself using the Hoyer lift. During that time the nurse would try her best to help with transfers or a unit manager or someone but if they were too busy I'd have to do it myself, especially if it were 3 of us having 15-16 residents a piece. Prior to the fall I would see other GNAs transferring with the Hoyer by themselves. When I went in the room the resident was lying flat on [his/her] back. [He/She] was saying that [he/she] was in pain. I don't recall if [he/she] was crying but I do remember [him/her] saying [he/she] was in a lot of pain. There was a wound on [his/her] bottom and I believe it was bleeding after the fall. We got [him/her] back in bed with the Hoyer. It was 4 of us that got [him/her] back in bed. [He/She] was saying [he/she] was in pain when we were putting [him/her] back to bed. On 9/3/25 at 9:00 AM an interview was conducted with Physician #31. He stated he remembered the incident and stated, it was a big deal. Why was one person transferring the resident?On 9/4/25 at 11:30 AM the Nursing Home Administrator (NHA) and the interim DON were informed of the concern.

Based on medical record review, facility documentation and interview, it was determined the facility failed to provide a safe and functional environment resulting in psychosocial and physical harm to a resident (Resident #9). This was evident for 1 of 79 residents in the facility on 1/24/25 and reviewed during the complaint survey.The findings include:Review of facility documentation provided by the Administrator on 8/27/25 revealed the Office of Health Care Quality (OHCQ) conducted a Life Safety Code complaint survey on 1/29/25 and found the facility was cited for not maintaining temperature in the attic to prevent pipes from freezing causing the pipes to rupture. During interview with the Director of Maintenance (DM) on 9/2/25 at 11:05 AM, The DM stated the pipes were not insulated and the broken pipes caused the ceiling to collapse on Resident #9 who was in room [ROOM NUMBER] on 1/24/25. The DM stated no other residents were affected. The DM stated the facility has implemented their plan of correction, the pipes have been insulated, and he is doing temperature checks in the attic regularly.Review of Resident #9's medical record on 8/27/25 revealed the Resident was admitted to the facility in November 2022 with a diagnosis to include quadriplegia. Quadriplegia is a severe medical condition characterized by the partial or total loss of function in all four limbs and the torso. The facility staff assessed the Resident on 12/15/24 to have a BIMS (Brief Interview for Mental Status) out of 15 which indicates the Resident has a fully intact cognitive function.Further review of Resident #9's medical record revealed a Change of Condition Assessment on 1/24/25 that stated: Pipe burst above resident room causing ceiling to collapse on top of resident and resident to be covered in water, insulation and drywall.During interview with Resident #9 on 8/27/25 at 10:45 AM, the Resident stated on 1/24/25 he/she heard water sounds and then saw water dripping from the ceiling by his/her feet and he/she called the front desk to get help. Resident #9 stated staff did come in, but it was too late, and the ceiling crashed on me and water was pouring on me. He/she stated I felt like I was drowning and was coughing. I couldn't move myself and it took them a few minutes to get me out of the room. The resident also stated that every time it rains; he/she is afraid it is going to happen again. Further review of the Resident's medical record revealed the Resident was sent to the emergency room on 1/24/25 and the triage note stated: Patient arrives after a piece of dry wall fell on him/her. A pipe burst in the ceiling and water was pouring on him/her for approximately 5 minutes until staff arrived to move him/her to another bed. The Resident received a CT scan of the head which showed no acute intracranial hemorrhage. The discharge instructions included lots of fluids, Tylenol or Motrin for pain and fever, follow-up with your primary care and the Resident was sent back to the facility on 1/24/25.Further review of Resident #9's medical record revealed the Resident was seen by the Physician (Staff #31) on 1/27/25 who diagnosed the Resident with cervical spine and lumbar strain. The Physician documented that the Resident was complaining of neck and back pain. The patient reports that baclofen, Tylenol, a short course of Flexeril, and ibuprofen (Motrin) as needed have not alleviated his/her symptoms. At that time the Physician ordered Oxycodone 5 mg every 6 hours as needed for pain for 14 days for the Resident.Review of Resident's Medication Administration Records (MAR) for January, February, March, April and May 2025 revealed the Resident was administered Oxycodone 5 mg twice a day from 1/27 through 1/31/25; at least once a day from 2/2 through 2/28/25; at least once a day in March 2025 except 3/9 and 3/22/25; at least once a day in April 2025 except 4/9, 4/15, 4/20, 4/29 and 4/30/25; and in May 2025 received Oxycodone 5mg on the following days: 5/1, 5/2, 5/6, 5/7, 5/11, 5/12, 5/15, 5/16, 5/17, 5/18, 5/19 and 5/21/25.Review of the Neurologist consultation on 5/16/25 revealed the Neurologist documented patient reports lower back pain since an incident on 1/24/25 when a ceiling fell on him/her. An MRI conducted on 5/6/25 showed a mild disc bulge at L5-S1. Mild disc bulge may be due to injury. The Resident is scheduled for a follow up Neurologist appointment 9/16/25. At that time the Neurologist recommended to continue physical therapy and may increase Oxycodone for better pain control.Review of Resident #9's physician orders revealed the Oxycodone 5 mg was discontinued on 5/22/25 and the Resident was ordered Suboxone film 4-1 mg every 24 hours as needed for pain. Further review of Resident #9's pain medication orders on 9/2/25 revealed the Resident is currently ordered Buprenorphine-Naloxone 2-0.5 mg 3 tablets every 24 hours as needed for pain with the last dose received on 9/2/25. Review of a psychiatric evaluation and consultation note dated 1/30/25 revealed it stated: seen for psych follow-up per facility request following a flood on the 300 unit. The patient is currently relocated to a new room. He/she reports the roof fell on him/her, and this has worsened his/her PTSD (Post Traumatic Stress Disorder).Review of a psychological services progress note dated 3/13/25 revealed it stated: He/she discussed the flood that occurred in his/her room and the ceiling falling. He/she discussed having PTSD triggers. Resident #9 was seen by psychological services on 4/8/25, 4/24/25 and 6/11/25.Review of psychological services progress note dated 7/2/25 revealed it stated: Patient did share that he/she would like to begin regular psychotherapy services because I want to talk about my trauma. Clinician reminded patient that these services are what this clinician provides, however, patient declined, expressing a preference for provider who is not affiliated with the facility.Interview with Staff #18 on 9/2/25 at 11:47 AM stated she was working that day when saw dripping from the ceiling in Resident #9's room by his/her feet. Staff #18 stated she and Staff #20 went to try to remove the Resident from the room when all of the sudden the ceiling crashed on the Resident. Staff #18 stated the size of the ceiling that fell was about the size of the Resident's bed. Staff #18 stated when the ceiling came down it was dry wall, insulation and water was all over the Resident. Staff #18 stated water was just pouring down. Staff #18 stated the Resident was mad and upset. Staff #18 stated she went to see the Resident later that day after the Resident was moved to a different room and the Resident was all shook up.During interview with Staff #19 on 9/2/25 at 12:20 PM, Staff #19 stated he/she wasn't here the day the ceiling fell on the Resident but cares for the Resident regularly. Staff #19 stated the Resident has stated he/she doesn't want to go back to that room because the Resident was traumatized, and the Resident will complain of low back pain to her. During interview with Staff #20 on 9/2/25 at 1:22 PM, Staff #20 stated he/she saw the water dripping from the Resident's ceiling and went in with the GNA (Staff #18) to remove the Resident from the room when all of the sudden the ceiling fell on the Resident. Staff #20 stated it was approximately a 4 ft by 6 ft section, then water rushed out and the water was all over the Resident. Staff #20 stated she got hit on the head by the drywall herself, so other staff took over removing the Resident from the room. Follow up interview with Resident #9 on 9/2/25 at 2:00 PM, the Resident stated he/she has had low back pain since the incident that he/she didn't have before, and he/she would also like to get counseling and physical therapy from someone not affiliated with the facility. Resident #9 states he/she feels unsafe at the facility and the incident on 1/24/25 has made his/her PTSD worse.Interview with the ADON (Assistant Director of Nursing) on 9/2/25 at 2:10 PM, the ADON was advised of Resident's request for outside counseling and therapy services. The ADON stated she was not aware the Resident wanted outside counseling and therapy services and would follow up with the Resident.Interview with the Resident's physician on 9/3/25 at 8:45 AM, the Surveyor advised the Resident's physician Resident #9 would like outside counseling and therapy sessions. The Physician stated he was unaware of the Resident's request, and he would talk to the ADON about looking into for the Resident. The Physician stated he is aware of the MRI results, and the Neurologist consult note on 5/16/25 stating the mild disc bulge may be due to the incident on 1/24/25. The Physician stated he is aware the Resident has an appointment with the Neurologist this month and he would follow up with what the Neurologist recommends.The Surveyor reviewed the concern of physical and psychosocial harm of Resident #9 on 9/3/25 at 10:45 with the ADON and Interim Director of Nursing related to the ceiling collapse on 1/24/25 due to the facility not maintaining temperatures in the attic to prevent pipes freezing and rupturing.

Based on observation, interview, and medical record review, it was determined the facility failed to ensure that the resident's call light was within reach, per the individualized care plans, to allow access to assistance when needed. This was evident for 1 (#13) of 14 residents reviewed during a complaint survey. The findings include: On 9/3/25 at 10:00 AM observation was made of Resident (R) #13 lying in bed. R #13 asked the surveyor to hand him/her the hair brush that was on the night stand. At that time observation was made of the call bell lying on the floor in front of the oxygen concentrator. R #13 was asked how he/she called the nurse. R #13 stated that the call bell was usually on the top of the bed, but [name] took it away from him/her because he/she was ringing it too much. At that time the surveyor showed Certified Medicine Aide (CMA) #23 the call bell that was lying on the floor. CMA #23 placed the call bell on the bed.Review of R #13's medical record revealed an ADL (activities of daily living) care plan related to hemiplegia (paralysis or weakness on one side of the body) that was initiated on 10/21/24. The intervention on the care plan stated, encourage the resident to use bell to call for assistance.A second care plan, at risk for falls had the intervention, be sure the resident's call light is within reach on [his/her] right side and encourage the resident to use it for assistance.On 9/3/25 at 10:55 AM the acting Director of Nursing (DON) and Assistant DON were informed of the observation. They stated that they were made aware and they were investigating the incident.

Based on medical record review, facility documentation and interviews, it was determined the facility staff failed to notify a physician promptly when a resident had a change of condition (Resident #12) and failed to notify a resident's representative when a resident had medication changes (Resident #6). This was evident for 2 of 14 residents reviewed during a complaint survey.The findings include:1.Review of Facility Reported Incident 295918 on 8/27/25 revealed the facility reported to the Office of Health Care Quality (OHCQ) that on 11/28/24 the facility staff reported to the Resident's nurse (Staff #34) that Resident #12 was declining, and Staff #34 failed to assess the Resident timely. Review of Resident #12's medical record on 8/27/25 revealed the Resident was admitted to the facility in 2015 had diagnosis to include traumatic brain injury, heart and renal failure. Further review of Resident #12's medical record revealed Staff #34's nurse's note on 11/28/24 at 12:04 PM that stated: patient noted as difficult to arouse, lethargic, plan of care ongoing. Further review of Resident #12's medical record revealed Staff #8's nurse's note on 11/28/24 at 12:28 PM that stated: was called to resident room by another staff member to collaborate with another nurse on resident due to change in condition. Resident was cool to touch, difficult to palpate radial pulse, sternal rub-unable to rouse resident. 15 Liter NRB (non-rebreather) mask applied while EMS enroute to facility. EMS arrived and transported resident to the hospital. Interview with Staff #8 on 8/27/25 at 2:35 PM, Staff #8 stated she received a message that Staff #34 wanted her to come up the hall. Staff #8 stated when she arrived on the unit Staff #34 stated since I was the RN (registered nurse) on duty she wanted me to look at the Resident who was unresponsive. Staff #8 stated I asked for the vital signs and Staff #34 had not gotten them, so we got vital signs. The Resident blood pressure was in the 60s over 30s, it was hard to get a oxygen reading and I said the Resident needs to go to the hospital and I put him on 15 Liters NRB mask. During interview with Staff #12 on 8/27/25 at 2:44 PM, Staff #12 stated a GNA (geriatric nursing assistant) asked me to come look at Resident #12 because the GNA couldn't get the Resident to respond, had told Staff #34 and Staff #34 had not checked on the Resident. The GNA thought I might be able to get the Resident to respond. I also couldn't get the Resident to respond to me and Staff #34 was sitting at the desk and I asked her is she knew about the Resident, she said she knew, and I told her if she didn't do something I was going to report her to the State. It was about lunchtime. During interview with Resident #14 (Resident #12's roommate) on 9/3/25 at 10:20 AM, Resident #14 asked if he/she remember the day Resident #12 left the facility in November 2024. Resident #14 stated he/she did remember and the last time the Resident spoke to him/her was the night prior. Resident #14 stated he/she remembered staff bringing in the Resident's breakfast, but the Resident was not talking, and he/she was breathing heavy and fast. The Resident stated it wasn't until after lunch that they did anything. That is when people came in and they put oxygen on him/her and then sent the Resident out. During interview with Staff #23 on 9/3/25 at 10:31 AM, Staff #23 stated she was working on a different unit and 2 GNAs asked me to come and look at Resident #12. I went to see Resident #12 and shook him/her and tried a sternal rub but he/she was not responding. I went and told Staff #34 and she stated she had been in there and the Resident was okay. I think it was about 11 AM. Review of Staff #34's employee file revealed Staff #34 was a LPN (licensed practical nurse) and on 12/10/24 Staff #34 was terminated with the reason documented due to on 11/28 several staff members reported issues with Resident (#12) immediate action was not taken. Interview with the Assistant Director of Nursing on 9/3/25 at 10:45 AM confirmed Staff #34 did not notify Resident #12's physician timely on 11/28/24 when the Resident had a change in condition. 2.On 8/28/25 at 11:50 AM a review of complaint 295977 alleged there was no communication with the RP when there were medication changes. On 8/28/25 at 11:50 AM a review of Resident (R) #16's medical record was conducted. R #16 was admitted to the facility in August 2023 with diagnoses that included but were not limited to non-rheumatic aortic (valve) stenosis, hyperlipidemia, dementia, hypertension, atrial fibrillation, and heart disease. Review of physician's orders revealed on 3/6/25 the anti-psychotic medication Risperdal was changed from 0.25 mg every day to twice per day. There was no RP notification found in the medical record. On 3/19/25 there was a new order for the anti-anxiety medication Buspar 5 mg. twice per day. There was no RP notification found in the medical record. On 4/16/25 the Risperdal dose increased to 0.5 mg twice per day. There was no RP notification found in the medical record. On 4/25/25 the Buspar frequency was increased from twice per day to three times per day. There was no RP notification found in the medical record. On 4/30/25 the Risperdal does was increased to 0.75 mg. twice per day. There was no RP notification found in the medical record. On 9/4/25 at 9:48 AM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she thought it was an issue before she started working at the facility but was not currently an issue. The ADON reviewed the medical record and confirmed there was no documentation related to RP notification.

Based on medical record review, it was determined that the nursing staff failed to promptly notify a physician of a resident's change in condition in three (Resident #82, #5, #77, ) of 35 sampled resident records in the Stage 2 Review. The findings included: 1. The nursing staff failed to promptly notify a physician of a resident's abnormal laboratory results. Resident # 82 was admitted to the facility with multiple [DIAGNOSES REDACTED]. The resident did require assistance from staff for her care, comfort, and safety. By way history on 01/11/2014, this resident was assessed by nursing to have a nonproductive cough and abnormal lung sounds. The physician was called and ordered a chest X-ray which revealed pneumonia. In response to the resident having pneumonia, the physician ordered a decongestant and an antibiotic. During the next several days the resident's appetite was poor and the resident experienced several episodes of diarrhea. On 01/20/2014, the resident was seen by her physician and was assessed to have chest congestion again. In response to this resident's chest congestion the physician ordered another chest X-ray and laboratory tests. The chest X-ray was performed on 01/20/2014, and revealed improvement in her lung status. The physician was made aware of the chest X-ray results that same day, and gave no new orders. On 01/21/2014, the ordered laboratory tests were drawn, specifically a complete blood count (CBC) and a basic metabolic panel (BMP). The CBC sample was not analyzed by the laboratory due the specimen being clotted. A CBC is a laboratory test obtained by blood sample. This is a series of tests that provides a tremendous amount of information about the hematologic system and many other organ systems. A BMP is a laboratory test obtained by blood sample. This is a series of tests that provides a tremendous amount of information about the blood's composition. This test evaluates four electrolytes, (sodium, potassium, chloride, and [MEDICATION NAME]) blood urea nitrogen (BUN), creatinine and glucose. On 01/21/2014 at 3:00 p.m., the BMP was made available at this facility. The BMP revealed the following results: Sodium: 155 (normal range 135 -145). [MEDICAL CONDITION] is an electrolyte disturbance that is defined by an elevated sodium level in the blood and a deficit of water in the body. Water is lost from the body in a variety of ways such as perspiration, vomitus, feces or urine. If the amount of water ingested consistently falls below the amount of water lost, the plasma sodium level will rise, leading to [MEDICAL CONDITION]. [MEDICAL CONDITION] is often synonymous with dehydration. BUN: 42 (normal range 10 -26). BUN measures the amount of urea nitrogen, a waste product of protein metabolism, in the blood. Urea is formed by the liver and carried by the blood to the kidneys for excretion. Because urea is cleared from the bloodstream by the kidneys, a test measuring how much urea nitrogen remains in the blood can be used as a test of renal function. A resident who is severely dehydrated may also have an elevated BUN due to the lack of fluid volume to excrete waste products. Creatinine: 0.7 (normal range 0.5 - 1.5). Creatinine is a substance formed from the metabolism of [MEDICATION NAME]. The kidneys filter out most of the creatinine and dispose of it in the urine. Creatinine is also an indicator of kidney function and is an excellent indicator to determine hydration status. On 01/21/2014 at 6:00 p.m., according to nursing documentation the BMP laboratory test results were faxed to the physician. There is no evidence that the physician received these results. Review of the nursing notes revealed the following: 01/21/2014 at 8:00 p.m.: "Appetite poor, refused mech (mechanical) soft diet ordered, < (less than) 10% taken. ...". The next day on 01/22/2014 (time unknown), the physician was called and made aware of this resident's laboratory results. The physician ordered for the resident to be transferred to the hospital and left the facility at 1:30 p.m. with a [DIAGNOSES REDACTED]. Upon arrival to the emergency room the resident was assessed to be obtunded and did not withdrawal from noxious stimuli, her blood pressure was low at 90/48 and oral cavity was dry; all physical signs of dehydration. Laboratory results revealed a sodium level remaining elevated at 153 and a critically elevated 2.7 Creatinine level. The resident's admitting [DIAGNOSES REDACTED]. The nursing staff failed to promptly notify a physician of a resident's abnormal laboratory results that contributed to the worsening of this resident's dehydration and leading to mental confusion and acute [MEDICAL CONDITION]. 2. The nursing staff failed to notify the physician of ongoing pain and swelling of the left elbow for Resident #5. Resident #5 was admitted to the facility on [DATE] following a hospitalization for weakness, dehydration and falls at home. Review of the medical record revealed a nursing admission assessment dated [DATE] that identified swelling of the left elbow. Review of the physician's admission History and Physical dated 04/29/14 revealed no mention of swelling of the left elbow. Review of the medical record revealed documentation of the resident complaining of pain and swelling of the left elbow from 05/06/14 to 05/22/14. Further review of the medical record revealed that the nursing staff administered 5mg of [MEDICATION NAME] IR (an immediate release narcotic pain medication) and elevated the left elbow on pillows as needed to alleviate the pain The pain medication was effective in relieving the pain. Further review of the medical record revealed that the nursing staff failed to notify the physician of the ongoing swelling and pain of the left elbow until 05/22/14 when the swelling increased to the left elbow and forearm. Upon notification, the physician ordered an x-ray to rule out a fracture. The x-ray was done on 05/22/14 and showed a [MEDICAL CONDITION] elbow. The physician was notified of the fracture and ordered an orthopedic consult. A sling was applied to help immobilize the arm to facilitate healing. The nursing staff's failure to notify the physician of the ongoing complaints of pain and swelling of the left elbow delayed the assessment, [DIAGNOSES REDACTED]. 3. The nursing staff failed to notify the physician, in a timely manner, of a pressure ulcer. A pressure ulcer (also known as pressure sore or decubitus ulcer) is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. A pressure ulcer can range from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater) or Stage IV ( full thickness skin loss with extensive damage to muscle, bone, or tendon). Resident #77 is totally dependent on the staff for all care. Review of the medical record revealed that on 07/07/14 a Geriatric Nursing Assistant (GNA) notified the nurse of an open area in the skin on the resident's "bottom". Further review of the medical record on 07/09/14 revealed no nursing assessment, no physician notification or treatment orders for the Stage 2 pressure ulcer on the resident's "bottom". During an interview at 11:00AM on 07/09/14, nurse #2 stated that she was aware of the pressure ulcer and that she had made the decision to keep the resident in bed positioning her from side to side and to continue using [MEDICATION NAME] ointment on the skin. [MEDICATION NAME] is an ointment used as a moisture barrier to prevent and promote healing of skin irritation. Further interview with nurse #2 revealed that she thought the area was healed. This surveyor and nurse #2 observed the resident's "bottom" and found a Stage 2 pressure ulcer. Upon surveyor intervention on 07/09/14, nurse #2 notified the physician and the wound nurse of the Stage 2 pressure ulcer that was first identified on 07/07/14.

Based on medical record review and interviews, it was determined the nursing staff failed to notify the physician of skin breakdown in two (residents #213 and #38) of 19 sampled resident record reviews. The findings included: 1. The nursing staff failed to notify the physician, in a timely manner, of a pressure ulcer. Resident #213 was admitted to the facility on [DATE] after a hospitalization . Review of the medical record revealed that nurse #6 identified a pressure ulcer on the resident's sacrum (lower back) on 08/26/14. A pressure ulcer (also known as pressure sore or decubitus ulcer) is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. A pressure ulcer can range from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater) or Stage IV ( full thickness skin loss with extensive damage to muscle, bone, or tendon). Review of the note written by nurse #6 on 08/26/14 revealed the following assessment of the pressure ulcer: "area on sacrum is partial thickness wound. Dark SDT (suspected deep tissue injury) with slough in center. Area 2x1.3x0.1. Edges very jagged. periwound red and inflamed. Dressing with santyl and CDD (clean dry dressing) to cover. Change daily." A SDT presents as a purple or very dark area that is surrounded by profound redness, [MEDICAL CONDITION], or induration suggesting that deep tissue damage has already occurred and additional deep tissue loss may occur. This deep tissue damage could lead to the appearance of a Stage III or IV pressure ulcer or progression of a Stage I pressure ulcer to an ulcer with eschar or exudate within days after admission. Eschar is described as thick, leathery, frequently black or brown in color, necrotic (dead) tissue. Exudate (drainage) is any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury. Slough is necrotic/avascular (dead) tissue in the process of separating from the healthy tissue and is usually light colored, soft, moist and stringy. Further review of the medical record revealed that nurse #6 did not notify the physician until 08/27/14, one day later. As stated, a SDT can very quickly progress to a Stage III or Stage IV pressure ulcer and therefore, prompt treatment is essential. Further review of the medical record revealed that a physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) revealed the first treatment was done on 08/28/14. See Cross Reference CMS 2567, F314. 2. The facility nursing staff failed to notify the physician of a wound on the sacral area in a timely manner for resident (#38). Review of resident #38 medical records on 9/3/13 at 10am, revealed a weekly skin integrity review dated 8/20/14 and 8/27/14. The weekly skin integrity review is one of the assessment tools used by the facility to determine if a resident has a change in skin integrity. On 8/20/14, the weekly skin integrity review was blank but signed by the nurse indicating the skin assessment was completed. On 8/27/14 the weekly skin integrity review indicated, the resident had an wound on the sacrum. Further review of the medical record revealed the physician was not notified until 8/28/14 at that time a treatment order was obtained. During interview with nurse # 2 on 9/4/14 at 2 pm, the finding was verified.

Based on review of the medical record, administrative documents and staff interview, it was determined that the nursing staff failed to provide safe and effective nursing care to a dependent resident. This failure resulted in multiple fractures of the resident ' s legs and was evident in one sampled resident. The findings included: Resident #1 was a [AGE] year old male admitted to the facility with multiple [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool used by the interdisciplinary team, completed on 01/04/2012, revealed this resident as totally dependent requiring two person physical assistance for bathing, dressing, elimination, bed mobility and transfers. This resident was also non ambulatory. Interview with the Director of Nursing on 02/09/2012 at 9:50 a.m., and record review revealed that this resident was in his usual state of health until 2:30 p.m. on 01/01/2012. At that time the resident was assisted back to bed a Sit to Stand mechanical lift. The resident remained in his bed for the remainder of the day on 01/01/2012 till the morning of 01/02/2012. During this time the nursing staff provided all of his care needs. A Sit to Stand mechanical lift is equipment used to assist a resident in transfers from one location to another. Resident ' s must be able to physically assist and comprehend how to participate safely in the transfer. On 01/02/2012, a nursing assistant was performing morning care for this resident when the resident had complaints of pain in his legs. The nursing assistant reported this resident ' s complaint of leg pain to the nurse. Review of the medical record revealed the following nursing note: 01/02/2012 at 8:45 a.m.: "Pt (patient) noted to have increased [MEDICAL CONDITION] R (right) foot & ankle & L (left) foot & ankle, on shin of L leg has a hard lump. His R foot is misshapen (abnormal alignment). Pt stated legs hurt. Called (physician), Xray's ordered. ...". Review of the X-ray reports revealed this resident had bilateral distal tibia and fibula fractures with slight displacement. The tibia and fibula are the two bones located in the lower leg. The facility conducted an investigation into the possible etiology of multiple fractures in this resident who was dependent on the nursing staff for his care and safety. The facility staff concluded that the fractures likely occurred as a result of the transfer on 01/01/2012, using the Sit to Stand lift. While the facility ' s conclusion regarding the likely cause of the fractures may be correct, one cannot conclusively determine the exact cause. What is clear is that any movement of the resident was done by the facility ' s nursing staff and ultimately the development of bilateral leg fractures is inconsistent with safe and effective nursing care.

Based on medical record review and interview, it was determined that the nursing staff failed to follow a speech language pathologist recommendations and physician ordered diets in two of 25 sampled resident records in the Stage 2 review. Also, the nursing staff failed to accurately define a Level 3 dysphagia diet for one resident. A speech-language pathologists (SLP) assess, diagnose, treat, and help to prevent speech, language, communication, and swallowing disorders. Speech language pathologists are college educated and specially trained to use a variety of diagnostic skills to assess an individual's ability to swallow safely. Dysphagia is an abnormal condition, characterized by difficulty in swallowing. Interview with the administrative and nursing staff on June 9 and 10, 2011, revealed that despite speech language pathologist recommendations and physician ordered diets, the nursing staff provided foods that was not a part of the prescribed diet. The nursing staff's decision not to follow prescribed diets placed residents in jeopardy of choking and/or aspiration of food, fluid. Aspiration occurs when foreign substances are inhaled into the lungs increasing the risk of pneumonia. These findings constituted an Immediate Jeopardy situation at 1:30 p.m. on June 10, 2011. A plan of correction was submitted, with new policy development and training conducted with the staff. The Immediate Jeopardy was abated at 4:35 p.m. on June 10, 2011. The findings included: 1. The nursing staff failed to follow the speech language pathologist recommendation and physician ordered NPO (nothing by mouth) status putting this resident at risk for choking and/or aspiration. Resident #9 was admitted to the facility with multiple [DIAGNOSES REDACTED]. By way of history, this resident resided in the community and in March 2011, was hospitalized for [REDACTED]. As a result, the resident had an inability to chew and swallow food, fluids, or medications safely. A gastrostomy tube was placed. A gastrostomy tube is inserted surgically through the abdominal wall to the stomach. A gastrostomy tube is used as an alternate method to administer food, fluid and medication. After this resident's hospitalization the resident was transferred to this facility and was treated by a speech language pathologist. The resident progressed and was transitioned from receiving his food, fluids and medications through the gastrostomy tube to being able to accept them orally. On 05/23/2011, the resident was prescribed a dysphagia II diet. This is a transitional diet of moist, soft textured foods with pureed meats. Pureed meat is blenderized to a smooth consistency similar to that of baby food. A dysphagia II diet is indicated for those residents who have difficulty swallowing and to decrease the chance of choking and/or aspiration. Review of the medical record revealed the following speech language pathologist note: 06/08/2011 at 10:30 a.m.: "Pt (patient) presents this a.m. c (with) significant (change in) status: labial droop R (right) > L (left), anterior loss saliva & dramatic (change in) swallow status. Pt demonstrates (decrease) labial seal for adequate oral prep, (decrease [MEDICATION NAME] manipulation, (decrease) A (anterior) P (posterior) transit, c anterior loss R > L. Suspected freespill over. Turbulence via cervical auscultation on all consistencies, which places pt at high risk for choking & aspiration. SLP (speech language pathologist) recommends physician consider NPO (nothing by mouth) status c alternate nutrition source. Nsg (nursing) (name of charge nurse #7 and unit manager #6) notified immediately." Interview with the SLP on 06/09/2011 at 10:00 a.m. revealed that she observed this resident with "a significant change in status, I observed the resident right greater than left lip drooping and he was drooling". This observation prompted her to complete the above assessment. Based on her assessment she recommended for this resident to receive nothing by mouth. The SLP went on to state that her assessment and recommendations were communicated to the charge nurse (#7) and unit manager (#6). The medical record also revealed the following "REHABILITATION COMMUNICATION form: 06/08/2011: "SLP recommends physician consider immediate NPO status 2 (secondary to) (change in) swallow function. Thank you." Interview with the charge nurse (#7) on 06/10/2011 at 9:30 a.m. revealed that the SLP did communicate her assessment and recommendations to her. The charge nurse (#7) stated she promptly contacted the physician and received the following orders at 10:00 a.m. on 06/08/2011: "Pt NPO status. Restart tube feeding as previously ordered until seen by dietician." Though charge nurse (#7) stated she did not write the orders until 6:00 p.m. on 06/08/2011, she did communicate the new physician orders to the nursing assistants, the medication aide (#9), and unit manager (#6). The SLP later that day performed another assessment of the resident and documented the following: 6/08/2011 at 12:00 p.m.: " Pt reassessed prior to lunch for possible (change in) status. Pt. presents c no (changes in) oral phase. Pt now demonstrates (increased) turbulence via cervical auscultation on all consistencies c suspected pharyngeal pooling & lack of protective cough reflex, followed by wet breath quality. SLP continues to recommend NPO status for basic safety. Nsg (name of charge nurse (#7) and unit manager (#6)) aware)." Interview with the medication aide (#9) on 06/10/11 at 9:55 a.m. confirmed that the charge nurse (#7) instructed her that the resident was not to receive anything by mouth to include food, fluid, or medication. The medicine aide (#9) went on to state that this resident's lunch tray arrived to the nursing unit and asked the unit manager (#6) and assistant director of nursing (#2) what to do with the resident's lunch tray. The medicine aide (#9) stated that she reported to the unit manager (#6) and assistant director of nursing (#2) that as far as she was aware the resident was not allowed to eat. The medicine aide (#9) stated she was instructed by the unit manager (#6) and assistant director of nursing (#2) to feed the resident and to let them know if there were any problems. The medicine aide (#9) reported that she fed the resident and he consumed 75% of the meal tray. Interview with the unit manager (#6) on 06/09/2011 at 11:00 a.m. revealed that she was made aware of the resident's NPO recommendation by the SLP and physician order obtained by the charge nurse (#7) for NPO. The unit manager (#6) stated she was asked by the charge nurse (#7) to assist in the assessment and monitoring of this resident. The unit manager (#6) stated she reviewed his vital signs (temperature, blood pressure, heart and respiration rate) and performed neurological testing (pupil response to light and hand grasp strength). This basic assessment the unit manager (#6) stated to be normal for this resident. However, at no time was a swallowing assessment performed by this nurse. The unit manager (#6) further stated she was not qualified to perform such an assessment. The unit manager (#6) went on to state that she did communicated to the assistant director of nursing the SLP recommendation of NPO and the charge nurse (#7) had obtained an order for [REDACTED]. Interview with the assistant director of nursing (#2) revealed that she was asked to assist with the assessment of this resident. The assistant director of nursing (#2) stated that her assessment revealed that the resident was alert and able to speak and she used her nursing judgement and felt the resident was safe to eat. Despite the SLP's determination and the physician ordered status of NPO (nothing by mouth), the nursing staff made the decision to feed this resident thereby putting him at extreme risk for choking and/or aspiration. 2. The nursing staff fed a resident chicken that was not at the consistency recommended by the Speech Language Pathologist and ordered by the physician putting this resident at risk for choking and/or aspiration. Aspiration occurs when foreign substances are inhaled into the lungs increasing the risk of pneumonia. Speech-language pathologists (SLP) assess, diagnose, treat, and help to prevent speech, language, communication, and swallowing disorders. Speech language pathologists are college educated and specially trained to use a variety of diagnostic skills to assess an individual's ability to swallow safely. Resident #47 was admitted to the facility on [DATE] for continued rehabilitation following a stroke. Review of the medical record revealed that the resident was deemed incapable of making an informed healthcare decision by two physicians, by the first physician on 04/26/10 and the second physician on 08/11/10. Further review of the medical record revealed a physician's order dated 11/18/10 for a dysphagia II diet of nectar thickened liquids, mechanical soft vegetables and pureed meats. A pureed diet is the consistency of baby food. Thickened liquids include water, juice, milk, coffee, etc that have been thickened to a safe consistency based on the individual's ability to swallow. The pureed diet and thickened liquids were ordered by the physician based on the evaluation and treatment by the SLP. SLP determined that meat at a pureed consistency was the safest texture for this resident to decrease the chance of choking or aspirating. Review of the medical record revealed the following SLP note dated 01/20/11: "SLP informed this day that patient was given regular texture chicken legs for pleasure and that it was tolerated well. Thus, patient was re-screened to determine whether patient may be a candidate for diet upgrade. Pt (patient) seen (with) green beans and pizza. Pt demonstrates impulsivity & compromised oral phase, placing him (at) high choking risk. Pt able to maintain safety (with) current diet (with) 1:1 (supervision) as previously recommended, but is not a candidate for diet upgrade & should not be offered anything outside current prescribed diet (secondary to) high safety risk. Team aware & to monitor". On 06/09/11 at 1:40PM, an interview with the SLP revealed that she was asked to re-evaluate the resident on 01/20/11 after the nursing staff fed the resident a chicken leg despite the SLP recommendations and physician orders. On 06/10/11 at 10:50AM, an interview with the Director of Nursing (DON) revealed the following recollection of the events on 01/20/11: "Lunch was a resident choice lunch which was chicken. The staff was serving the chicken to the residents in the dining room and Resident #47 asked for a chicken leg. A Geriatric Nursing Assistant (GNA) told a nurse that the resident was asking for a chicken leg and the nurse said it was OK to give him one because it was his resident right. The nurse (GNA unable to recall name of nurse) told the GNA to sit with him and feed him. The GNA went to the DON and stated that the resident did really well. The DON asked SLP for a re-evaluation for possible diet upgrade. The re-evaluation was done and the resident was found to require same dysphagia diet which was pureed meats". On 06/14/11 at 2:30 PM, an interview via telephone with the DON revealed that on 01/20/11 the DON removed the meat from the bone, cut it up into small pieces and mashed the meat with a fork. The DON stated, "I didn't alter his diet or upgrade his diet. The meat was well-cooked and soft so that I was able to cut it and mash it with a fork". The DON also provided a written statement stating that "the meat was removed from the bone, cut into very fine pieces and fed one piece at a time via spoon". The resident's diet was for pureed meats. A pureed diet is the consistency of baby food. SLP had determined that meat at a pureed consistency was the safest texture for this resident to decrease the chance of choking or aspirating. Despite the SLP's (a trained healthcare professional) determination and the physician's order for pureed meats, the nursing staff made the decision to feed Resident #47 chicken that was not the proper consistency thereby putting this resident at risk for choking or aspiration. 3. The nursing staff failed to accurately define a Level 3 dysphasia diet. The facility's Level 3 dysphasia diet is a soft-solid diet of easy to cut meats, fruits, and vegetables. The meats are cut into soft, bite size pieces. Staff #9 was interviewed on 06/10/11 at 12:40 p.m., while she was feeding a resident. The resident's meal ticket documented that the resident required a dysphasia level 3 diet. When this staff member was asked what a dysphasia level 3 diet was, she replied that she did not know and "that was something for the kitchen department." Staff #10 was interviewed on 06/10/11 at 12:57 p.m., while she was feeding a resident. The resident's meal ticket documented that the resident required a dysphasia level 3 diet. When this staff member was asked what a dysphasia level 3 diet was she replied that she did not know. Staff #11, was interviewed 06/10/11 at 1:00 p.m., When asked about the different diets, this staff member stated that she got confused about the difference between the dysphasia diets and would have to look up the information. Interview of the DON on 06/10/11 at 1:15 p.m., revealed that she incorrectly defined the level 3 dysphasia diet. The nursing staff failed to accurately define a level 3 dysphasia diet. The nursing staff's inability to accurately define a level 3 dysphasia diet limits their ability to determine if the residents are receiving the correct diet.

Based on medical record review and interviews with staff, it was determined the nursing staff failed to apply a seat belt to a resident while in her wheelchair resulting in a fall from the wheelchair striking her face on the floor causing a fracture to her nose, swelling around right eye, and generalized pain. This occurred in one of 25 residents reviewed in Stage 2. Review of the facility's investigation, inservices, and action plan related to this incident resulted in this deficiency being cited as past non-compliance. The findings included: Resident #63 has multiple [DIAGNOSES REDACTED]. Resident has a history of multiple falls. Review of the medical record revealed a physician's orders [REDACTED]. A seat belt is used to remind the resident to ask for assistance before standing and for maintaining a safe position in the wheelchair. Review of the medical record revealed a nurse's note dated 03/15/11 noted, "resident was sitting up in w/c (wheelchair) in hall, fell forward out of chair, states she fell on face. Nose was bleeding and appeared dislocated, c/o (right) shoulder pain and (right) hip (pain)...". The physician was notified and the resident was sent via 911 to the hospital for evaluation. The resident's nose was fractured and she sustained extensive swelling and bruising to her right eye. Review of the facility's investigation of the fall and interview with the Director of Nursing (DON) at 11:00 a.m. on 06/10/11 revealed that a Geriatric Nursing Assistant (GNA) failed to apply the seat belt around the resident after transferring the resident from her bed to the wheelchair. The GNA's failure to apply the seat belt to the resident resulted in the resident leaning forward and falling out of the wheelchair causing an injury to the resident.