Every finding on record at Elmwood Manor Nursing Home

Based on observation, record review, and interview, the facility failed to date and label stored food in 2 of 3 freezers sampled for food storage. The DON identified 36 residents received food from the kitchen. On 07/28/26 at 10:05 a.m., a brief initial tour of the kitchen and storage area that contained two stand up refrigerator/freezers and two chest type freezers was completed. The following observations were made: a. a package containing a meat-like substance was not labeled or dated;b. a package labeled roast beef was not dated; andc. a package of vegetables was not labeled or dated. A policy titled, Food Receiving and Storage, dated 11/2022, read in part, 1. All foods stored in the refrigerator or freezer are to be covered, labeled and dated (use by date). On 07/28/26 at 10:36 a.m., the dietary manager stated all food in refrigerators and freezers should have been dated and labeled when received. On 07/31/26 at 11:26 a.m., Dietary #1 stated food is normally unpacked, broken down into smaller bags or containers, dated, and labeled when it arrived. They stated all food containers in freezers and refrigerators should have been labeled and dated when it was received. On 07/31/26 at 12:44 p.m., the administrator stated all food received by the facility, including freezers and refrigerators, should have been labeled and dated when received at the facility.

Based on observation, record review, and interview, the facility failed to ensure resident urinary catheter bags were covered for 1 (#3) of 2 sampled residents reviewed for dignity. The administrator identified three residents with urinary catheters. On 07/28/26 at 2:12 p.m., Resident #3 was observed lying in bed asleep. Resident #3 was observed to have a urinary catheter bag hanging from the bedside that was not covered. On 07/30/26 at 2:43 p.m., Resident #3 was observed with a urinary catheter bag hanging from the bedside that was not covered. An undated diagnoses tab in the electronic record for Resident #3 showed the resident had a diagnosis of neuromuscular dysfunction of the bladder. A facility policy titled Dignity, dated 10/2025, read in part, Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident keep urinary catheter bags covered. On 07/31/26 at 9:06 a.m., the DON stated Resident #3's catheter bag should have had a privacy cover.

Based on observation, record review, and interview, the facility failed to ensure soiled wound supplies were not placed with clean wound supplies during wound care for 1 (#3) of 1 sampled resident reviewed for wound care. The administrator identified four residents received wound care. Findings: On 07/30/26 at 2:43 p.m., wound care for Resident #3 was observed. LPN #1 gathered supplies and prepared a clean field for the care. LPN #1 utilized gauze soaked with wound cleaner to clean the wound. LPN #1 placed the gauze used to clean the wound on the clean field with the clean supplies. LPN #1 used a cotton tip applicator to apply a wound medication to the wound. LPN #1 placed the used applicator on the clean field with other clean supplies. A facility policy titled Wound Care, dated 04/2026, read in part, Establish a clean field on resident's overbed table .Place disposable cloth next to the resident to protect the bed linen and other body sites.Loosen tape and remove the old dressing.Pull one glove over the dressing and discard into appropriate receptacle. An undated diagnoses tab in the electronic medical record for Resident #3 showed the resident had a diagnosis of pressure ulcer. On 07/30/26 at 2:56 p.m., LPN #1 stated they should not have placed used wound care supplies back on to the clean field. On 07/31/26 at 9:06 a.m., the DON stated LPN #1 should not have placed the soiled dressing supplies on the prepared clean field. The DON stated it was an infection risk.

Based on record review and interview, the facility failed to ensure a resident did not fall from a mechanical lift during a transfer for 1 (#2) of 5 sampled residents reviewed for dependent transfers using a mechanical lift.The administrator identified 19 residents were dependent for transfers using a mechanical liftFindings:A Safe Lifting & Mechanical Lift Policy, dated 01/01/25, read in part, General Safety Rules .Use proper sling and equipment .Two trained staff required .Follow manufactures instructions.Resident #2's care plan for activities of daily living, dated 10/30/25, showed the resident required a mechanical lift for transfers.A hospital imaging report, dated 11/13/25 at 11:57 a.m., showed Resident #2 had an x-ray exam of the right knee with two views. The report showed Resident #2 had a nondisplaced fracture deformity of the distal femur.A late entry nursing progress note, dated 11/13/25 at 4:12 p.m., showed on 11/13/25 licensed practical nurse #2 observed Resident #2 on the floor under the mechanical lift. The note showed Resident #2 complained of pain all over and was sent to emergency room for further evaluation. An administrator progress note, dated 11/14/25 at 9:46 a.m., showed the administrator noted Resident #2 stated they went to the doctor and the doctor told them their leg was broken. A facility incident report, dated 11/14/25, showed the facility failed to ensure residents were free from falls during a transfer on 11/13/25. The report showed Resident #2 fell from a mechanical lift while being transferred by CNA #5 and CNA #6. Resident #2's care plan for falls, dated 11/17/25, showed the resident was up in a mechanical lift when the sling loop came off of the lift causing the resident to fall to the floor towards the right lower corner of the sling. The care plan showed Resident #2 was sent to the hospital for evaluation and treatment.Resident #2's quarterly resident assessment, dated 12/31/25, showed the resident had a brief interview for mental status score of 15, which indicated the resident's cognition was intact. The assessment showed the resident was dependent on staff for mobility.There was no documentation quality assurance was involved in the process. On 01/23/26 at 10:40 a.m., CNA #2 stated they were to inspect the lift before use, ensure the resident was in the sling correctly, and ensure the hooks were secured.On 01/23/26 at 10:48 a.m., CNA #3 stated they inspected the lift before transferring Resident #2 and ensured the resident was hooked properly with the straps. On 01/23/26 at 11:00 a.m., CNA #5 stated they inspected the lift before use on Resident #2 and ensured the hooks of the sling were on correctly and were assisted by another trained staff member. On 01/23/26 at 12:33 p.m., Resident #2 stated they thought CNA #5 and CNA #6 had them secured correctly and did not know what happened.On 01/23/26 at 12:55 p.m., the administrator stated CNA #5 and CNA #6 were both in-serviced, passed a quiz on how to use the mechanical lift, and both passed a lift safety checklist observed by the director of nursing.

On 10/29/25, an immediate jeopardy (IJ) situation was determined to exist the facility failed to ensure Resident #1 was free from sexual abuse and psychosocial harm from Resident #2. The incident resulted in Resident #2 raising Resident #1 shirt up and inappropriately grabbing their breast in the front lobby.On 10/29/25 at 4:45 p.m., OSDH was notified and verified the existence of the IJ situation.On 10/29/25 at 5:25 p.m., the administrator was notified of the IJ situation and was provided the IJ template. On 10/30/25 at 10:56 a.m., an acceptable plan of removal was approved by the OSDH. The plan of removal, read in part, Plan of Removal of IJ 10/29/202510/29/2025 [staff name withheld], General Manager completed the Process for Completion of a State Reportable given by [name withheld], [staff name withheld], Administrator has also completed training from [business name withheld] on Abuse and Neglect and from [business name withheld] on Conducting an Abuse Investigation.In-service was provided to [staff name withheld], Administrator and [staff name withheld], Corporate Nurse on Abuse investigation, Reporting, Completion, Conducting and the updated abuse policy 10/29/25.10/29/2025 All staff was educated on abuse, neglect, and exploitation by [staff name withheld], Administrator.10/29/2025 Resident #2 was educated on abuse and resident's rights by [staff name withheld].10/29/2025 All staff was educated on the reporting structure and be provided contact information for the administrator of record by [staff name withheld], Administrator.10/29/2025 Resident #2 was put on one on one monitoring with direct care staff or designee when out of resident's room for 30 days to monitor for agitation, under stimulation and overstimulation.10/29/2025 Resident #2 medications will be reviewed by Psych [staff name withheld] NP and Dr.[staff name withheld] MD, to assist with potential reduction and behaviors due to side effects if applicable.10/29/2025 All findings and audits will be reviewed the[sic] Director of Nursing, Administrator and/or designees daily for 30 days.10/29/2025 A review of residents will be done to list any [gender withheld] resident that are at risk for inappropriate unwanted behavior. This list will be done by the Director of Nursing.10/29/2025 All at risk [gender withheld] resident will be not placed near Resident #2.10/29/25 All at risk [gender withheld] residents will be care planned with interventions of maintaining placement when out of room away from resident #2.10/29/2025 All [gender withheld] at risk residents who are at risk for unwanted behavior will be added to the shift monitor report so that the charge nurse and staff are aware to maintain distance from resident #2.10/29/2025 Facility will continue to work with active family member to restructure visit times to be scheduled during high aggressive times once identified during the 30 days of monitoring.10/29/2025 Resident #1 will be monitored daily by the charge nurse for 60 days for any psychosocial alterations.10/29/2025 All staff and currently in facility residents was interviewed to rule out abuse, neglect or exploitation using a safe survey. There were no other residents affected. This was completed by [staff name withheld], Administrator.10/29/2025 The abuse, neglect and exploitation policy was updated by [staff name withheld], General Manager to include specific verbiage inappropriate sexual behaviors in the screening component, training component, prevention component and identification component.10/29/25 A QA was created and implemented pertaining to the inappropriate behaviors of Resident #2 with interventions.10/29/25 A monitoring form for interventions for resident #2 was created and implemented.10/29/2025 Education was provided to activities/social services staff to do 1:1 activities with Resident #2 after lunch. This was done by [staff name withheld], Administrator.10/29/2025 The care plan for [resident name withheld] was updated to include the interventions put into place.10/29/2025 The care plan for [resident name withheld] was updated to include the psych-social monitoring and an order was placed in the emar to be monitored daily by nurses.10/29/2025 [resident name withheld] was seen on 10/28/2025 by [staff name withheld] NP and Dr. [staff name withheld]. [gender withheld] medication was reviewed and the Prevera [sic] was increased from 10mg to 20 mg. The diagnosis for the Prevera [sic] is SOA, which s sexually inappropriate behaviorDescription of #5 for non-verbal residents----Residents that identify as non-verbal/incapacitated were interviewed on 10/29/2025 using the following process: a direct care staff member accompanied administrator to conduct interviews. Resident are asked each question with a 2 minute timed response window time: Residents are observed for the following by both person [sic] present. Administrator and the CMA watched for facial expressions, gestures, and emotional cues/reactions also, anything noted outside of baseline is documented. A summary of the observation is recorded. Unless the responses are clear and observable, the question is not answered yes or no.Description of #9----line of sight---all staff were instructed via (elect. Inservice) to keep resident #2 away from all [gender withheld] residents who have been identified as vulnerable or at risk of inappropriate behavior. When resident #2 is out of [gender withheld] room, staff was instructed to move [gender withheld] away from all [gender withheld] residents who have been identified in public areas and this was assigned to ALL staff and to document on the daily monitoring form by the charge nurse. Inservice was done on implemented 10/15 still ongoing as of 10/29/2025 and beyond. Documentation will be completed on exception if behavior occurs in the nursing notes and behavior record. (Behavioral management in-service) This documentation will be completed by the charge nurses. The IJ was lifted, effective 10/31/25 at 6:05 p.m., when all components of the POR had been verified as completed.a. clinical staff were interviewed regarding in-services for abuse and monitoring Resident #2's sexual behaviors and incidents:b. in-service documentation on 10/29/25, showed 26 clinical staff attended in-person and 28 staff were trained via telephone by the administrator over the facility's abuse policy. Abuse Policy documentation, dated 10/29/25, was reviewed for POR updates; c. Resident #2's care plans, dated 10/28/25, showed 1:1 intervention were added, and medications dosages were increased to reduce behaviors; Resident #2 physician orders, dated 10/29/25, showed Resident #2's Prevera (hormone) dosage was increased;d. Resident #2 was observed to ensure 1:1 intervention by clinical staff; Residents #1, 4, and #5 were observed to ensure they maintained a safe distance away from Resident #2. A list for residents with unwanted behaviors was observed at the nurse's station. The listed showed 5 residents at risk; ande. QA documentation, dated 10/29/25, showed the facility had a meeting where they addressed the abuse incident. On 10/29/25 the general manager documentation for in-service completion for state reportable training was reviewed.The deficiency remained at an isolated level with the potential for more than minimal harm.Based on record review and interview, the facility failed to protect residents from inappropriate sexual behaviors for 3 (#1, 3, and #4) of 8 residents sampled for sexual abuse.The corporate nurse identified 39 residents resided in the facility.Findings:A facility policy titled Abuse Prevention Program, revised August 2006, read in part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion.#1. An undated diagnoses report showed Resident #1 had diagnoses which included bipolar, Alzheimer's and dementia with a moderate cognitive impairment with decision making with daily events, with a BIMS of 12.#2. An undated diagnoses report showed Resident #2 diagnoses which included Alzheimer's, dementia and severe depression with a staff assessment that indicated a severe cognitive impairment for daily decision making with daily events.A behavior note, dated 01/12/24, for Resident #2 showed, Resident #2 followed Resident #3 and #4 making them uncomfortable, and Resident #2 kissed Resident #4. Resident #2's care plan, dated 02/05/25, showed a focus for inappropriate talking/asking questions to [opposite sex] residents included the following interventions for sexual behaviors directed towards staff and residents:a. Pristiq (antianxiety) 50 mg, one time daily,b. Provera (hormone regulator) 20 mg, twice dailyThe care plan did not address any other interventions for sexual behaviors.A behavior note, dated 05/21/25, for Resident #2 showed Resident #2 was moved away from an unidentified resident, due to inappropriate language and expression of physical contact. Resident #2's quarterly assessment, dated 09/25/25, did not show any behaviors.A revised physician's order, dated 10/16/25, Provera (hormone regulation) 10 mg, oral tablet twice a day.A revised physician's order, dated 10/17/25, Pristiq(anti-anxiety) 25 mg, 1 oral tablet 24 hour extended release once a day.A behavior note, dated 09/09/24, read in part, This morning while walking down the hallway a resident [Resident #3] reported to me this resident is saying vulgar comments to them. #3. A quarterly assessment for Resident #3, dated 09/27/25, showed a BIMS of 00 and diagnoses which included modified independence for decision-making skills for daily events, schizophrenia and mild neurocognitive disorder.On 10/29/25 at 2:07 p.m., Resident #3 stated they felt violated by Resident #2 and they did not know if the facility ever investigated the incident. #4. On 10/29/25 at 2:00 p.m., Resident #4 was observed seated in a wheelchair playing bingo with Resident #3. Resident #4 was observed to show a communication deficit of slowed speech and struggled to find words.Resident #4's quarterly assessment, dated 09/25/25, showed they were unable to participate and had a BIMS score 00. The assessment showed Resident #4 had diagnoses which included cerebral infarction, other paralytic syndrome, and cerebrovascular disease affecting the left dominant side.On 10/29/25 at 2:00 p.m., Resident #4 stated they felt bad when Resident #2 kissed them.An incident report, dated 10/14/25, read in part, It was reported by the charge nurse that [Resident #2] was touching [Resident #1] inappropriately. [Resident #1] were [sic] moved away from [Resident #2] and put on 15 min monitoring and one on one when in the area that [Resident #2] is in. Staff was notified. The inappropriate touching was [Resident #2] had [Resident #1's] shirt up and was touching their breast.On 10/29/25 at 1:29 p.m., CNA #1 stated Resident #2 was always saying nasty and perverted things to residents and staff.On 10/29/25 at 1:36 p.m., the general manager stated they did not complete safe surveys regarding abuse.On 10/29/25 at 2:04 p.m., the administrator was asked for documentation for the alleged sexual abuse incident which occurred on 10/14/25. The administrator stated they had not conducted an investigation over the abuse incident on 10/14/25.

On [DATE], an IJ situation was determined to exist when the facility failed to ensure Resident #8 was monitored and received assistance while eating in their room. The incident resulted in the death of Resident #8. Resident #8 had a care plan intervention which included assist to dine.On [DATE] at 1:00 p.m., the OSDH was notified and verified the existence of the IJ situation.On [DATE] at 1:30 p.m., the administrator was notified of the IJ situation and was provided the IJ template.On [DATE] at 10:55 a.m., an acceptable plan of removal was approved by the OSDH. The plan of removal, read in part, POR [DATE] for IJ cited on [DATE] @ [at] 1:30pmSummarized Statement of Deficiency (Problem Identified):Staff failed to provide required meal supervision for a resident with two prior choking incidents and an established care plan requiring Immediate Removal Actions Taken:All residents nutritional care plans and diets were reviewed for choking risk, non-compliance with diets, therapeutic diets, and assisted feeding needs on [DATE]. 2 Residents that are at risk of choking or non-compliance with diet orders/ diet recommendations or residents who require assistance with feeding were identified on [DATE].4 Residents were identified as a choking risk4 Residents were identified that require feeding assistance5 were identified as non-complaint 3. All residents that had a therapeutic diet were identified on [DATE] residents were identified as having therapeutic diets 4. All residents identified as choking risk received nutritional care plan update by Clinical staff on [DATE] Residents were identified and received nutritional care plan updates 5. A quick reference chart (diet reference list) was created on [DATE] for all clinical staff and dietary staff to utilize, the chart includes:The resident's meal location(s) preference, the resident's diet (including consistency), portion, and protein supplements to be added to meals The quick reference chart was placed at the nurse's station in the nurse shift book on [DATE]The quick reference chart was placed in the kitchen on the bulletin board on [DATE]The quick reference chart was placed at the nurse's station in the cna shift report book on [DATE] 6. On [DATE] a policy addendum on choking or dietary non-compliance was created and added to the assistance with meals policy, to reflect the following changes and implemented:Key personnel to contact regarding a choking or dietary non compliance event to allow early interventionKey personnel to contact regarding residents who are non-compliant with diet and dietary interventions Assessment of the resident to determine the need for treatment such as the Heimlich 7. On [DATE] CPR policy and procedure was created and implemented to reflect the following changes: When to initiate CPR Training and competency -All clinical staff must maintain valid CPR/BLS certification. -Newly hired staff are required to obtained[sic] CPR certification within 90 days of hire -CPR recertification is required every 2 years - A 45 day grace period is permitted for staff to renew an expired certification - proof of certification shall be maintained in personnel files 8. [DATE] and [DATE] Inservice educations were provided, completed, and implemented to all clinical staff by the administrator, Director of nursing, and Corporate nurse on the following topics:Topic: Supervision during meals plans -all clinical staff were educated on procedures for meals supervision. Staff will stay with resident 1:1 until entire meal is completed during any mealtimes for all residents who require feeding assistance or are choking risk. Trainers: administrator, Director of nursing, and Corporate nurse (completed on [DATE])how to locate/follow care plan-all clinical staff were in serviced where to locate the residents care plan in the resident's electronic health record. Staff were also educated if they cannot access the information needed in the care plan, they are to notify the charge nurse, and he/she will retrieve the information. Trainers: Administration, Director of nursing, and Corporate nurse (completed on [DATE])Procedure related to a choking event- all clinical staff and dietary supervisor were educated on who were choking risk, who to report choking events to, and how to report dietary compliance issues. Trainers: Administrator, Director of nursing, and Corporate nurse (completed on [DATE])CPR and Heimlich- all clinical staff were CPR trained on [DATE] unless training had been provided prior. Trainers: Administrator, Director of nursing, and Corporate nurse (completed on [DATE]) 9. Quality Assurance PIP was conducted and completed on [DATE] to address assisting and monitoring residents named as choking risk and 1:1 supervision of residents during mealtimes until meal is completed. 10. Quality assurance monitoring was created and implemented on [DATE].Monitoring will be completed for Resident at risk for choking by DON/Designee 3 times weekly for 90 days and as needed thereafter. The IJ was lifted effective [DATE] at 2:53 p.m., when all the components of the POR had been verified as completed.a. all clinical staff were interviewed and were able to communicate regarding services for care plans, non-compliance, therapeutic diets, and assisted feeding needs in-service that was conducted on [DATE];b. in-services documentation completed on [DATE] identified four choking residents, four residents that required feeding assistance, five non-compliant and therapeutic diets documentation showed a total of 21 residents with therapeutic diets;c. care plan documentation, dated [DATE], showed four residents identified with choking risk nutritional updates;d. quick reference chart, dated [DATE], showed resident meal locations, preferences, resident's diet (including consistency), portion, and protein supplements to be added to meals. The quick reference chart was observed nurse's station in the shift report book and on kitchen's bulletin board;e. CPR policy and procedures, dated [DATE], showed the following changes were made; when to initiate, training and competency, clinical staff certification, newly hired staff CPR requirements, grace period and maintaining personnel files;f. in-services documentation, dated 11/0425 and [DATE], showed education was provided, to all clinical staff by the administrator, DON and corporate nurse on supervision of meal plans, monitoring residents with 1:1, residents who required feeding assistance or residents who were at risk of choking;g. CPR and Heimlich documentation, dated [DATE], showed all clinical staff were trained on CPR and Heimlich; andh. QA documentation, dated [DATE], showed PIP was conducted to address monitoring of residents who were identified a choking risk and in need of 1:1 supervision.The deficiency remained at an isolated level with the potential for more than minimal harm.Based on record review and interview, the facility failed to provide supervision to prevent a resident from choking during a meal for 1 (#8) of 3 sampled residents reviewed for accidents.The corporate nurse identified 39 residents resided in the facility.Findings:A policy facility titled Assisting the Impaired Resident with In-Room Meals, revised [DATE], read in part, The purpose of this procedure is to provide appropriate support for residents who need support with assistance with feeding. A policy facility titled Assisting with Meals, revised [DATE], read in part, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. An undated Diagnosis Report showed Resident #8 had diagnoses which included of hemiplegia and hemiparesis following the cerebral infarction affecting the left non-dominant side. Resident #8's quarterly MDS assessment, dated [DATE], read in part, showed they were cognitively intact with BIMS of 15. Resident #8's care plan, dated [DATE], read in part, Diet order was changed on 10032023[sic] to regular diet with chopped meats. ST approached this nurse and charge nurse RD [registered dietician] regarding their visit on 10172023[sic] d/t [due to] [them] picking up the cake with [their] hand and placing more than half of the piece in [their] mouth. ST recommended having a mechanical soft diet with chopped meats. Ordered was updated Date Initiated: [DATE]. Resident #8's nursing note, dated [DATE], read in part, During lunch resident got choaked[sic] on a piece of ham, [they] were able to cough it out. Staff has reported that [they] had been coughing alot [sic] while [they] is eating. Resident also reported [they] will 'get strangled' on tough meat. Resident #8's nursing note, dated [DATE], read in part, CN [charge nurse] requested assistance with [Resident #8] c/o [complain of] of 'something in throat', upon inspection [Resident #8] had a visibly large chunk of meat in throat. Resident #8's nursing note, dated [DATE], read in part, [Resident #8] was getting choked on meats. Resident #8's physicians order, dated [DATE], read in part, Regular diet, Chopped Meats texture, Regular/Thin consistency. Resident #8's care plan, dated [DATE], read in part, Eating: Assist with meal set up and feeding. Resident #8's nursing note, dated [DATE], read in part, Called to residents [sic] room d/t [due to] resident choaking [sic]. Upon entering [CNA #3] was doing the Heimlich on resident. Resident #8's incident note, dated [DATE], read in part, The call light was initiated, and a nurse aide entered the room. [Resident #8] pointed to [their] throat showing choaking [sic]. CNA #3's witness statement, dated [DATE], read in part, I [CNA #3] came to answer to [Resident #8] light and when I walked into the room, they were sitting up in bed eating. Resident #8 had they arms up waving me towards them when I noticed they were choking. I ran over to Resident #8 and called for [CNA #4] to help sit them up, [CNA #4] could not get their arms around Resident #8. LPN #3's witness statement, dated [DATE], read in part, At 5:28 p.m., I saw [CNA #3] running down the hallway and yelled '[resident name withheld] is choking.' [LPN #3] ran to the room upon entering [CNA #4] was standing next to [Resident #8] bed. EMS [emergency medical services] at 5:50 p.m. pronounced time of death. On [DATE] at 11:27 a.m., the corporate nurse stated staff should have been monitoring Resident #8, but staff were passing out meal trays for dinner in the hallway. On [DATE] at 12:44 p.m., the activities director stated they worked on [DATE] and when Resident #8 was in bed eating and no staff was in the room when Resident #8 started choking. On [DATE] at 1:18 p.m. the maintenance supervisor stated LPN #3 asked them to come help with the Heimlich because they were too small to perform the maneuver on Resident #8.

Based on observation, record review and interview, the facility failed to ensure 1 of 1 treatment cart was locked when not in use.The corporate nurse identified 39 residents resided in the facility and had one treatment cart.Findings:On 11/03/25 at 2:39 p.m., the treatment cart was observed [NAME] of the nurse's station unlocked and unsupervised with insulin pens and vials in the top drawer.On 11/03/25 at 2:40 p.m., LPN #1 was observed walking to the South end of the hallway and away from the treatment cart.On 11/06/25 at 1:29 p.m., the treatment cart was observed [NAME] of the nurse's station unlocked and unsupervised.On 11/06/25 at 1:30 p.m., LPN #2 was observed standing in dining hall out sight of the treatment cart, which was unlocked and unsupervised.A policy titled Security of Medication Cart, revised April 2007, read in part, 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 4. Medication carts must be securely locked at all times when out of the nurse's view.On 11/04/25 at 2:41 p.m. LPN #1 stated the treatment cart was unlocked and unsupervised. LPN #1 stated it was their responsibility to ensure the treatment cart was locked.On 11/04/25 2:45p.m., the corporate nurse stated the facility had two medication carts and one treatment cart that sat by the nurse's station. On 11/04/24 at 3:11 p.m., the corporate nurse was asked what items were stored in the treatment cart. They stated the treatment cart contained insulin and peg tube supplies.On 11/06/25 at 1:31 p.m., LPN #2 stated they were supposed to supervise the treatment cart and lock it.

Based on record review, and interview, the facility failed to thoroughly investigate allegations of abuse for 1 (#1) of 8 residents sampled for abuse.The corporate nurse identified 39 residents resided in the facility.Findings: A facility policy titled, Abuse Investigations, revised October 2009, read in part, All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The individual conducting the investigation will, as a minimum: Interview any witnesses to the incident; .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; . Interview the resident's roommate, family members, and visitors; .Review all events leading up to the alleged incident.5. Witness reports will be obtained in writing. Witness will be required to sign and date such reports.An incident report dated of 10/14/25, showed [Resident #2] was inappropriately touching [Resident #1] and had [Resident #1's] shirt up and touching their breast.On 10/29/25 at 1:35 p.m., the general manager was asked if the10/14/25 allegation abuse witness statements were completed. They stated I should have done a full investigation for 10/14/25 abuse incident.On 10/29/25 at 2:04 p.m., the administrator stated they had no witness statements from the 10/14/25 incident of abuse on Resident #1 and Resident #2.

Based on record review and interview, the facility failed to track and monitor choking incidents for 1 (#8) of 3 sampled residents reviewed for choking incidents for quality assurance.The corporate nurse identified 39 residents resided in the facility.Findings:A policy titled Safety and Supervision of Residents, revised December 2007, read in part, QA & A reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization.A nursing note for Resident #8, dated 01/18/24, read in part, called to residents room D/T [due to] resident choaking [sic], . At 5:50 p.m. Paramedic staff pronounced time of death.The quality assurance notes, dated 02/29/24, did not show any documentation for monitoring and tracking related to Resident #8's choking incident on 01/18/24 which resulted in Resident #8's death in the facility.On 11/04/25 at 1:07 p.m., the corporate nurse stated they did not QA or document the 01/18/24 incident involving Resident #8.

Based on record review and interview, the facility failed to ensure the physician responded to a pharmacist MRR and failed to ensure physician rationale was documented related to a declination of a GDR for two (#6 and #26) of five sampled residents reviewed for unnecessary medications. The BOM identified 38 residents who resided in the facility. Findings: A Drug Regimen Review policy, dated 2020, read in parts, .The consultant pharmacist drug regimen reviews are processed as follows: The physician provides a written response of the report to the facility within one month after the report is sent . 1. Res #6 had diagnoses which included dementia, schizophrenia, unspecified psychosis, and insomnia. A physician order, dated 06/08/23, documented to administer ramelteon (hypnotic medication) 8 mg at bedtime for insomnia. A physician order, dated 06/21/23, documented to administer Trintellix (antidepressant medication) 20 mg in the morning for depressive disorders. A physician order, dated 06/21/23, documented to administer desvenlafaxine (antidepressant medication) 100 mg in the morning for depressive disorders. A physician order, dated 07/27/23, documented to administer Vraylar (antipsychotic medication) 6 mg daily for schizophrenia. A physician order, dated 11/10/23, documented to administer olanzapine (antipsychotic medication) 10 mg at bedtime for schizophrenia. An annual assessment, dated 04/01/24, documented the resident was moderately cognitively impaired, had no depression symptoms, had no behaviors, and received hypnotic, antidepressant, and antipsychotic medication. A MRR report, dated 05/07/24, documented the resident was due for consideration of a gradual dose reduction of Trintellix, ramelteon, Vraylar, olanzapine, and desvenlafaxine. There was no documented response from the physician on the MRR report. On 10/24/24 at 9:15 a.m., the DON stated they did not have anything to do with the MRR process and was not familiar with the policy. The DON stated the MDS coordinator was responsible for this task. On 10/24/24 at 9:20 a.m., the MDS coordinator stated the physician had not responded to the pharmacist's request for a gradual dose reduction for Res #6's medication. 2. Res #26 was admitted with diagnoses which included dementia, depression, and insomnia. A physician order, dated 02/02/22, documented to administer trazadone (antidepressant medication) 150 mg at bedtime for insomnia. A physician order, dated 06/20/23, documented to administer Lexapro (antidepressant medication) 20 mg daily for depression. A physician order, dated 06/20/23, documented to administer Remeron (antidepressant medication)15 mg daily for depression. A physician order, dated 06/21/23, documented to administer lamotrigine (anticonvulsant medication) 150 mg twice daily for physical debility. A physician order, dated 08/08/23, documented to administer Invega (antipsychotic medication) 234 mg intramuscularly every 21 days for unspecified dementia. An annual assessment, dated 01/11/24, documented the resident was severely cognitively impaired, had no depression symptoms, had no behaviors, and received antipsychotic and antidepressant medication. A MRR report, dated 01/12/24, documented the resident was due for consideration of a GDR for Lexapro, lamotrigine, Remeron, Invega, and trazadone. The physician documented they disagreed with the request. There was no physician documented rationale for the declination of the GDR request on the MRR report. On 10/24/24 at 9:30 a.m., the MDS coordinator stated the physician should have documented a rationale for the declination of a GDR request for Res #26. On 10/24/24 at 11:45 a.m., the corporate nurse consultant stated the physician did not provide rationale for the declination of a GDR request for Res #26, but should have.

Based on record review and interview, the facility failed to administer medication as ordered for one (#3) of six sampled residents whose medication records were reviewed. The BOM identified 38 residents who resided in the facility. Findings: Res #3 had diagnoses which included schizophrenia, auditory hallucinations, and bipolar disorder. A Release of Responsibility for Medication record, dated 12/11/23, documented the facility received 125 tablets of clozapine (antipsychotic medication) 100 mg upon Res #3's admission. A physician order, dated 12/11/23, documented to administer two tablets of clozapine 100 mg at bedtime for schizophrenia. A physician order, dated 12/11/23, documented to administer one tablet of clozapine 100 mg twice daily for schizophrenia. A care plan, dated 12/14/23, documented Res #3 received psychotropic medication for schizophrenia and to administer clozapine 100 mg at 8:00 a.m. and 4:00 p.m. The care plan documented to administer clozapine 200 mg at bedtime. A December 2023 MAR documented Res #3 received a total of 83 tablets of clozapine 100 mg. A pharmacy log, dated 01/26/24, documented the facility received 56 tablets of clozapine 100 mg for Res #3. A January 2024 MAR documented Res #3 received a total of 124 tablets of clozapine 100 mg for the entire month. A pharmacy log, dated 02/19/24, documented receipt of 56 tablets of clozapine 100 mg for Res #3. A February 2024 MAR documented Res #3 received a total of 116 tablets of clozapine 100 mg for the entire month. Pharmacy record review documented the facility had received a total of 237 tablets of clozapine 100 mg for Res #3 during the months of December 2023, January 2024, and February 2024. Res #3's medication records documented the resident had received 323 tablets of clozapine 100 mg during the months of December 2023, January 2024, and February 2024. On 10/24/24 at 10:23 a.m., CMA #1 was asked about the discrepancy in the number of clozapine tablets available in relation to the number of tablets documented as given for Res #3. CMA #1 stated Res #3 had received a total of 4 tablets of clozapine 100 mg daily during the months of December 2023 through February 2024. They stated having only been responsible for administering one of the three tablets during their shift. CMA #1 stated CMA #2 would have been responsible for administering the other three tablets in the afternoon and at bedtime. They stated CMA #2 may have been administering a discharged resident's leftover clozapine after Res #3's supply of tablets ran out. CMA #1 stated giving Res #3 some other resident's medication was against the rules and should not have happened. On 10/24/24 at 10:40 a.m., the BOM stated CMA #2 was unavailable for interview due to a medical leave absence. Attempts to interview CMA #2 via phone call were made with no success. On 10/24/24 at 11:27 a.m., the administrator was made aware of the medication count discrepancy for Res #3. The administrator stated the concern was never brought to their attention by staff. They stated staff should not have borrowed medications from another resident and there was no way to prove Res #3 had received the medication according to physician orders. On 10/24/24 at 11:43 a.m., the corporate nurse consultant stated Res #3's clozapine had not been administered per physician order.

Based on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for one (#32) of one sampled resident reviewed for bed rails. The corporate nurse consultant identified four residents whose beds were equipped with a bed rail of any type. Findings: An undated Maintenance policy, read in part, .This facility will conduct preventative maintenance checks periodically and as needed for facility equipment and facility property. This facility will maintain preventative maintenance records pertaining to equipment and facility property . Res #32 had diagnoses which included fusion of the cervical spine, central cord syndrome, and muscle weakness. An admission assessment, dated 09/26/22, documented the resident was cognitively intact, required extensive assistance with bed mobility, and had one fall without injury. A physician order, dated 06/28/23, documented the resident could have half rails to their bed for repositioning purposes. A care plan, dated 09/28/23, documented the resident was able to use side rails for repositioning and rolling in bed. On 10/21/24 at 9:56 a.m., Res #32 was observed lying in bed. Bilateral half bed rails were observed on the upper half of the bed in the up position. Res #32 stated the bed rails were used to aide in turning and repositioning. On 10/22/24 at 1:35 p.m., the administrator was asked to provide documentation of regular bed rail inspections for Res #32. On 10/22/24 at 2:05 p.m., the administrator stated maintenance routinely checked bed rails, but had not maintained records of the inspections.

Based on observation and interview, the facility failed to ensure food was stored in accordance with professional standards for food service safety. The BOM identified 38 residents resided in the facility. Findings: On 10/21/24 at 8:12 a.m., the initial tour of the kitchen was conducted. The following was observed: a. in the two door silver refrigerator a clear gallon bag containing six raw, pre-formed, hamburger patties was observed in a white plastic tote on top of a clear gallon bag containing pre-cooked and sliced sandwich meat labeled Ranch Packs dated 10/03/24, b. in the two door silver refrigerator a clear gallon bag labeled deli-sliced ham was on top of the bag containing raw hamburger patties, c. in the two door silver refrigerator a gallon pour top jug containing a brown liquid was not dated or labeled, d. in the two door silver refrigerator a gallon pour top jug containing an orange liquid was not dated or labeled, e. in the dry storage area an undated and unlabeled blue bag was observed with the top tied in a knot, the staff identified the contents as raisins, f. in the white Frigidaire refrigerator zucchini was observed to have a grey and white fuzzy substance covering the surface of the vegetables, and g. the floor in the kitchen had debris and food particles. On 10/21/24 at 8:16 a.m., [NAME] #1 stated the raw meat should not have been stored with the cooked meat. They stated food should be labeled and dated when they were prepared, stored, or opened. On 10/21/24 at 8:46 a.m., the DM was made aware of the above observations.

Based on record review and interview, the facility failed to ensure a resident who received psychotropic medications had an acceptable diagnosis/indication for the use of an antipsychotic medication for one (#26) of five sampled residents reviewed for unnecessary medications. The corporate nurse consultant identified 16 residents who received antipsychotic medications. Findings: Res #26 was admitted with diagnoses which included dementia and depression. A physician order, dated 06/20/23, documented to administer cariprazine (antipsychotic medication) 3 mg once daily for unspecified dementia without psychotic or behavioral disturbance. A physician order, dated 08/08/23, documented to administer Invega (antipsychotic medication) 234 mg intramuscularly every 21 days for unspecified dementia. An annual assessment, dated 01/11/24, documented the resident was severely cognitively impaired, had no depression symptoms, had no behaviors, and received antipsychotic medication. On 10/24/24 at 9:30 a.m., the MDS coordinator stated Res #26 should not have antipsychotic medications ordered for a diagnosis of dementia. On 10/24/24 at 11:45 a.m., the corporate nurse consultant stated dementia was not an appropriate diagnosis for the use of antipsychotic medications.

Based on observation, record review, and interview, the facility failed to ensure informed consent was obtained prior to the utilization of bed rails for one (#32) of one sampled resident reviewed for bed rails. The administrator identified four residents whose beds were equipped with a bed rail of any type. Findings: A Proper Use of Side Rails policy, revised December 2016, read in part, .Consent for side rail use will be obtained from the resident . Res #32 had diagnoses which included fusion of the cervical spine, central cord syndrome, and muscle weakness. An admission assessment, dated 09/26/22, documented the resident was cognitively intact, required extensive assistance with bed mobility, and had one fall without injury. A physician order, dated 06/28/23, documented the resident could have half rails to their bed for repositioning purposes. A care plan, dated 09/28/23, documented the resident was able to use side rails for repositioning and rolling in bed. On 10/21/24 at 9:56 a.m., Res #32 was observed lying in bed. Bilateral half bed rails were observed on the upper half of the bed in the up position. Res #32 stated the bed rails were used to aide in turning and repositioning. There was no documentation of informed consent for bed rails found in the medical record. On 10/22/24 at 2:00 p.m., the corporate nurse consultant stated informed consent was not obtained prior to use of bedrails.

Based on observation, record review, and interview, the facility failed to ensure a care plan was updated to include an order for oxygen for one (#5) of one sampled residents reviewed for oxygen. The corporate nurse consultant identified two residents required oxygen. Findings: 1. Res #5 had diagnoses which included COPD. A physician order, dated 08/15/24, documented Res #5 was to receive oxygen at two to three liters per minute via nasal cannula to maintain oxygen saturation above 90%. On 10/21/24 at 9:57 a.m., Res #5 was observed in bed in their room. The oxygen concentrator was observed at bedside delivering oxygen at two liters per minute via nasal cannula. Res #5's care plan did not document they received oxygen. On 10/24/24 at 10:40 a.m., the MDS coordinator stated oxygen should be on the care plan. Upon review of Res #5's care plan they stated the oxygen was not documented, but should have been.

Based on record review and interview, the facility failed to ensure the resident's treatment and care was in accordance with professional standards and the person centered care plan for one (#1) of three resident reviewed for neglect. The Resident Census and Conditions of Residents form documented 41 resident resided in the facility. Findings: Res #1 had diagnoses which included diabetes mellitus, hyperlipidemia, and HTN. A physician order, dated 09/01/21, documented to administer Cozaar (an antihypertensive every day for HTN. A care plan, edited 12/20/21, documented the resident was at risk for impaired cardiac status related to anemia, HTN, history of COVID 19, and hyperlipidemia. The care plan documented to obtain blood pressure prior to administering medication. A physician order, dated 01/20/22, documented to administer amlodipine (a calcium channel blocker) one every HS for HTN. A MAR, dated March 2022, revealed the resident's blood pressure had not been documented prior to the administration of Cozaar one time March 19th, 2022 and six times for the amlodipine on March 11th, 13th, 14th, 16th, 18th, and 19th of 2022. On 02/27/23 at 12:25 p.m., CMA #1 stated the system the facility is currently using will not let you proceed if you do not enter the blood pressure. She stated she thought the old system was also that way. She stated she normally worked the days shift and would give the medication between 7:00 a.m. to 9:00 a.m. She stated she had worked one night the blood pressure had not been documented on the MAR. On 02/27/23 at 2:21 p.m., RN #1 stated the blood pressure should have been obtained before blood pressure medication was administered. The RN was asked about the days on the MAR without documentation of blood pressures. RN #1 stated looks like the staff had not documented the blood pressures.

Based on record review and interview, the facility failed to ensure resident medical records were complete and readily accessible for one (#1) of three residents whose records were reviewed. The Resident Census and Conditions of Residents form documented 41 resident resided in the facility. Findings: Res #1 had diagnoses which included diabetes mellitus, hyperlipidemia, and HTN. On 02/24/23, at approximately 1:00 p.m., the corporate nurse stated she did not have the MDS assessments for the closed records. The MDS for resident #1 was not available during the survey. On 02/27/23 at 3:15 p.m., the administrator stated she had requested the MDS assessments for Res #1 but had not received them.

Based on record review, observation, and interview, the facility failed to ensure residents were free from abuse for three (#1, 12, and #18) of three residents reviewed for abuse. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: An Abuse Policy and Procedures, dated 2019, read in parts, .Each resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property . Abuse shall include physical harm, pain, mental anguish, verbal abuse derogatory terms, sexual abuse, photographs and/or videos, or involuntary seclusion from any source . Resident care and treatment shall be monitored by all staff on an ongoing basis to assure residents are free from abuse, neglect, or mistreatment . It is the responsibility of all staff to provide a safe environment for the residents . The director of nursing or designee will complete an assessment of the resident or residents involved and document finding in the medical record and interdisciplinary care plan as needed. 1. Res #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 05/11/22, documented the resident was cognitively intact and was independent with most activities of daily living. Res #19's quarterly assessment, dated 07/08/22, documented the resident was cognitively intact and was independent with most activities of daily living. The assessment documented the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An incident report, dated 09/20/22 at 7:15 p.m., read in parts, .This adm was notified by the nurse around 5:45 p.m. that an altercation occurred between these two residents. (Res #12 name deleted) removed another resident's hall tray out of the hot cart. The tray was for a resident that refused the meal .A verbal altercation that also included a scratch on (Res #12's name deleted) arm. (Res #12 name deleted) has double portions and can request more food as desired but has been homeless so they may explain the getting the tray out of the hot cart .Residents on 30 min monitoring 72 hrs. (Res #12 name deleted) was assessed and the area cleaned. Residents were spoken to by staff about behaviors. (Res #12 name deleted) diet order will be changed to triple portions & (Res #12 and Res #19 name deleted) reminded this is not acceptable behavior. A nurse note, dated 09/20/22 at 11:47 p.m., read in part, .1725 nurse noticed (Res #12 name deleted) took untouchable tray from cart to eat & another (Res #19 name deleted) was there & ordered this (Res #12 name deleted) to place this food back. This (Res #12 name deleted) didn't listen then another (Res #19 name deleted) hit this (Res #12 name deleted) on his R forearm scratched till blood. They started loud with each other try to hit. Nurse & CNA barely separated (Res #12 and Res #19 name deleted) from each other. (Res #12 and Res #19 name deleted) placed on Q 30 minute observation during 72H. DON, ADM, and (physician name deleted) notified. (Res #12 name deleted) has been told if this accident will be repeated nurse will call to police. 09/26/22 at 12:58 p.m., Res #12 was observed sitting outside in smoking area smoking a cigarette. Res #12 reported an altercation with another resident about a week ago resulting in a scratch on the right forearm. A reddened scabbed area approximately two inches in length was observed on res #12's right forearm. On 09/26/22 at 4:00 p.m., Res #19 was observed propelling down hall in wheel chair towards smoking area exit door. Res #19 stated he stayed to himself most of the time and avoided Res #12. Res #19 denied further incident with Res #12 since the incident in question. On 09/27/22 at 2:37 p.m., Res #12 was observed sitting in a chair in the common area hallway. Res #12 stated he avoided Res #19 most of the time. Res #12 denied additional altercation with res #19 since the incident in question. On 09/28/22 at 3:55 p.m. through 4:30 p.m., five staff members which included a LPN, housekeeper, and three CNAs were asked if additional abuse prevention training occurred after an incident of abuse in the facility. All staff members denied additional in-services or training after an incident of abuse. On 09/28/22 at 3:56 p.m., LPN #1 stated any incident of abuse should have been reported to the charge nurse immediately. She stated residents were separated immediately, assessed for injuries, and the administrator, physician, and family were notified. LPN #1 stated the incident was documented in the progress notes and an incident report was completed. She stated this incident should have been documented in the progress notes of the medical record. On 09/29/22 at 10:20 a.m., the administrator stated a facility incident report and state reportable incident report was completed. The administrator stated that both residents were educated to never touch another resident and to always remove themselves from any situation that might result in harm or abuse in the future. She stated verbal and physical abuse occurred and assessment of the resident or residents involved was not documented in the medical record or interdisciplinary care plan but should have been according to the policy. On 09/29/22 at 10:25 a.m., the corporate nurse stated the plan of care was not revised with interventions to prevent abuse. On 09/29/22 at 2:03 p.m., CNA #2 stated that after an abuse incident occurred no additional training was provided to staff. 2. Res #18 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 07/13/22, documented the resident was cognitively intact and independent with most activities of daily living. An incident report, dated 09/12/22, read in parts, .It was reported to this administrator on 09/12 at 7:10 p.m., by the corp. nurse. She reported that (Res #18 name deleted) came to her office and reported what (staff member name deleted) said while she was assisting in weighing residents fat ass. (Res #18 name deleted) stated he was tired of her saying things like this to him .(Staff member name deleted) was suspended pending an investigation .The investigation is completed and in the opinion of (facility name deleted) the allegations of inappropriate language and inappropriate comment verbal abuse was substantiated . No documentation of the alteration was found in the progress notes or interdisciplinary care plan. On 09/28/22 at 8:50 a.m., Res #18 was observed sitting on the bed in room. Res #18 stated the staff member who committed the verbal abuse was lazy, rude, and never responded to needs in a timely manner. The resident stated that the staff member was fired immediately after the incident and felt the situation was handled appropriately by administration. On 09/28/22 at 3:20 p.m., the administrator stated the incident was reported within two hours and was investigated. She was asked why the staff member who witnessed the event did not come forward and report it to administration. The administrator stated that the witness stated at the time when the incident occurred she thought it did not upset the resident because he is very [MEDICATION(S)] and sarcastic and always joked and spoke to the staff in a harsh way. The witness stated she realized the resident was upset when she was brought in for the investigation. The administrator stated no in-service or training was provided to the staff after the incident occurred because the staff should have known better and not let it happen in the first place. On 09/28/22 at 3:30 p.m., the corporate nurse stated any allegations brought to her attention were immediately sent to the administrator. She denied additional abuse training for staff or revision of resident care plans after incidents of abuse occurred. On 09/28/22 at 3:50 p.m., the DON stated she did not complete documentation of interventions or implementation of additional safety interventions on the plan of care after incidents of abuse in the facility. 3. Res #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An incident report, dated 03/04/22, documented Res #23 swatted at Res #1 while they were in the lobby and Res #1 kicked back at Res #23. The incident report documented the residents were separated by the administrator and the corporate nurse and were placed on 30 minute monitoring for 72 hours. The incident report documented staff were made aware. No other steps to prevent recurrence of resident to resident altercations was documented on the incident report. An incident report, dated 05/26/22, Res #1 observed an unidentified resident, who was no longer in the facility, while the unidentified resident was striking and yelling at staff members. The incident report documented Res #1 attempted to strike the unidentified resident who then spit in Res #1's face. The incident report documented Res #1 then spit back at the unidentified resident and attempted to hit her. The incident report documented four staff members held the residents apart while Res #1 was taken to the break room then to his room. The incident report documented Res #1 sustained a skin tear to his hand and a small abrasion to the left side of the face. No steps to prevent recurrence was documented. An annual MDS assessment, dated 06/22/22, documented Res #1 was moderately impaired in daily decision making, had no behaviors, and required supervision to limited assistance with ADLs. An incident report, dated 08/15/22, documented Res #1 entered another a second unidentified resident's room and struck the unidentified resident in the stomach. The incident report documented neither resident was injured and both were place on 72 hour monitoring. The incident report did not document any other interventions to prevent the recurrence of Res #1 from striking other residents. A care plan for Res #1, dated 09/07/22, documented the resident had an alteration in coping, mood, or behavior related to [CONDITION(S)], depression. The care plan documented a goal of Res #1 would have no increase or change in behaviors. The care plan documented the resident had harmful behaviors to others with a goal to remain free from accidents. Interventions included to assess the resident's behavior pattern daily, to implement behavior modification activities, and gently redirect as necessary. The care plan did not document the resident's previous altercations or steps to prevent recurrence for each incident. A quarterly assessment, dated 09/22/22, documented Res #1 was moderately impaired in daily decision making, had no behaviors, and required supervision to limited assistance with ADLs. On 09/29/22 at 4:39 p.m., the administrator was asked about intervention to prevent recurrence for the 03/04/22 incident. The administrator stated Res #23 was experiencing a manic episode, was running into things, and was not easy to redirect. She stated Res #23 was sent to a geriatric psychiatric hospital for evaluation and treatment and she was not like that anymore. On 09/29/22 at 4:44 p.m., the administrator was asked about interventions to prevent recurrence for the 05/26/22 incident. The administrator stated she had been told Res #1 had been in the military and she felt the resident was trying to protect the staff members from the unidentified resident. She stated the unidentified resident was the aggressor in this incident and she subsequently went home with family. On 09/29/22 at 4:47 p.m., the administrator was asked what steps were put in place to prevent Res #1 from entering another residents' room and striking them. She stated there were no other interventions put in place for Res #1 other than 72 hour monitoring. The administrator was asked if an investigation had been conducted to ascertain what may have precipitated the event, she stated she did not document an investigation. She stated Res #1 had walked into the second unidentified resident's room through the adjoining bathroom. The administrator stated they placed a lock on the unidentified resident's bathroom so it could be secured to prevent a resident from entering from the adjoining room. On 09/29/22 at 4:54 p.m., the administrator was asked if the facility had put any new interventions in place to prevent Res #1 from becoming aggressive with other residents or to prevent him from becoming a target for aggression. She stated other than putting a new doorknob with a lock and the resident in the second incident leaving the facility she did not put any new interventions in place to prevent resident to resident abuse for Res #1.

Based on observation and interview, the facility failed to ensure a a safe, clean, comfortable, and homelike environment for residents, visitors, and staff. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: On 09/29/22 at 2:01 p.m., a tour of the laundry room was conducted. Water was observed leaking from the piping below the hand sink and standing water was observed in containers below the sink. A accumulation of lint and dust was observed on the washer and dryer. A plastic/material was observed peeling off the walls. Dirt and other debris was observed on the floor around the equipments and along the baseboards. On 09/29/22 at 2:15 p.m., a laundry staff #1 stated they cleaned the physical environment and equipment when they had a chance. The laundry staff stated the leak below the sink and the material peeling off the walls had been like that since they had worked at the facility. On 09/29/22 at 2:20 p.m., Res #7's wheelchair was observed to have brown residue on the chair tag and on the metal areas on the frame of the wheelchair. At that time, the resident was asked how often their wheelchair was cleaned. Res #7 stated it used to be cleaned every two weeks but not so often anymore. The resident stated they would like to have their wheelchair cleaned. The wood flooring at the threshold of the resident's room was observed to be broken, missing a section, and not secured to the floor. On 09/29/22 at 2:23 p.m., a gap and daylight was visible around the window air unit in Res #20's room. The resident stated bugs came in the gap. On 09/29/22 at 2:55 p.m., RN #1 and CNA #1 stated maintenance were responsible to clean the wheelchairs at least once a week and the CNAs cleaned them as needed. They Res #7 was out of the building the last time the wheelchairs were cleaned and had let them know they needed their wheelchair cleaned. On 09/29/22 at 3:00 p.m., RN #1 stated if there was a maintenance issue they verbally reported the issue to maintenance or there was a book to document the issue in. On 09/29/22 at 3:02 p.m., the maintenance supervision and administrator were asked about the threshold of Res #7's room. They stated they were working on getting materials which would be sturdy but allow easy access for the residents into their rooms. They were asked about the gaps around the window air units and stated they would be replacing the areas with wood around the windows. They were made aware of the gap where daylight was visible around the window unit in Res #20's room. They stated they were aware of the above findings in the laundry room.

Based on record review, observation and staff interviews, it was determined the facility failed to: a) Assess, monitor and provide interventions to prevent multiple stage II pressure sores for one (#6) sampled resident, which resulted in harm to the resident. Four residents with pressures sore were sampled. b) Assess and monitor the condition of a stage II pressure sore for one (#4) of four sampled residents with pressure sores. No other residents were identified by the facility with pressure sores. Findings: 1. A policy titled, Pressure Ulcer Risk Assessment, documented the following: "... Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately, report any signs of a developing pressure ulcer to the supervisor...Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Monitoring: a. Staff will maintain a "skin alert," performing routine skin inspections daily or every other day as needed. b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes...The following information should be recorded in the resident's medical record...Wound appearance, including wound bed, edges, presence of drainage...All assessment data (i.e., wound bed color, size, drainage,etc.) obtained when inspecting the wound." A policy titled, Pressure Ulcer Treatment, documented, "...The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the pressure ulcer(s)...Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, boggy, warmer or cooler as compared to adjacent tissue...Documentation...5. Any change in the resident's condition. 6. The condition of the resident's skin (i.e., the size and location of any red or tender areas.)" Resident #6 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission nurse's note, dated 07/04/11, documented, "New admit, has been here before. Brought to facility by our van & our driver per her request. Resident is blind. soft spoken. States she just got out of the hospital this am. She was in there because of her Gout & is not able to walk right now. Will order PT. OT to eval & tx as indicated. She is incont of B&B at times requires total assist c all ADLs including feeding. [AGE] year Indian female ....No distress noted. Resident has been at home s much help from family. She is no longer able to be by herself. She is on Bactrim for 3 more days for her gout. No S/S of distress noted at this time." The above note did not identify any skin problems upon admission. No head to toe assessment had been documented upon admission to the facility. An admission assessment had not been completed for the resident. A care plan, dated 07/04/11, documented, "Problem Potential for alteration with nutrition Goal For resident to have ADQ (adequate) food and fluid Approach Have staff feed and assist with fluids D/T [MEDICAL CONDITION] Monthly wts Nursing to document in meal book Do not rush resident with eating or drinking Notify physician with any changes." A Monthly Vital Sign sheet, dated 07/04/11, documented no admission weight for the resident. A Nutritional Assessment, dated 07/05/11, documented, "...Poor intake reported @ meals Rec. Health shake @ meals." The Food Intake Record for July 5th through July 13th was reviewed. There was no documentation the Health Shakes were being offered with meals. The nurses' notes documented the following: 07/05/11 at 10:30 a.m., "...Resident with poor appetite only ate 5 bites of hot cereal this AM. Encouraged to drink replacement without success. 3/11 Refused supper..." 07/06/11, "7/3 shift, Dr, (Name deleted) here to see Resident c N.O. [MEDICATION NAME] ES 650mg one tsp q day x 60 days due to Cachexia of dementia..." On 07/12/11 at 11:20 a.m., CMA #1 was asked to see the MAR for the resident. The MAR indicated [REDACTED]. At that time, CMA #1 was asked if the she had given the [MEDICATION NAME] at 8:00 a.m., as ordered. She reported she had been off for a few days and couldn't find the [MEDICATION NAME] to give. She looked through the medication cart and found the [MEDICATION NAME]. The [MEDICATION NAME] bottle was full. She then reported she thought it was a one time order. The [MEDICATION NAME] had only been given once from 07/06/11 to 07/12/11. The nurse's notes documented the following: 07/07/11, "7/3 shift,...Poor appetite Drank health shake 50 % & water & OJ & refused to eat any food. cont c poor appetite noted..." 07/08/11, "(7/3)...Resi cont c poor appetite..." 07/11/11, "0900...Also noted open areas very superficial to R buttocks N.O's Recd 1200, Staff attempted to spoon feed resident c very little success. Ate 25% for both meals Resident drank 1/2 of Health Shake. 3/11 resi c poor appetite noted." A physician's telephone order, dated 07/11/11, documented, "Cleanse open areas to buttocks c wound cleanser Pat dry apply [MEDICATION NAME] Q shift till resolved." The above pressure sores were not assessed as to the stage, type of wound, length, width, depth, any tunneling or drainage or description of the wound bed. On 07/11/11 at 3:30 p.m., the resident was observed in her room sitting in a W/C. There were no pads or cushions in the W/C. On 07/12/11 at 10:45 a.m., LPN #1 was asked about the open areas. She reported there were two open areas on the resident's buttocks. She was asked if the areas had been measured. She reported she did not measure the areas, but the DON was supposed to measure the areas. The LPN was asked to notify the surveyor when she provided the treatment on the next day. On 07/12/11 at 11:35 a.m., the DON was asked if the two open areas had been measured. She reported she had just found out about the areas earlier in the day and had not measured the areas. She was then asked if she had completed a head to toe assessment. She reported she had not completed a head to toe assessment. On 07/13/11 at 9:30 a.m., LPN #1 reported more open areas had been found, when the resident's skin had been viewed earlier in the day. At that time, the resident's skin was observed with 5 stage II pressure sores in the coccyx area. [MEDICATION NAME] ointment was administered to the areas. LPN #1 was then asked to view the resident's heels. A reddened, mushy area with a defined border was observed to cover the resident's left heel. At that time, LPN #1 was asked if she knew about the residents left heel breakdown. She reported she had not seen the area. She was then asked to have the multiple open areas on the residents coccyx, buttocks and heel assessed and measured. The following measurements were documented on a Wound Progress Note/Weekly Skin Assessment sheet: "7/12/11 R upper buttock Stage II O Eschar type of wound Pressure/sheer Length 2.0 Width 1.5 Depth less than 0.1 Undermine Tunnel - Drainage O Initial date of wound 07/11/11 Shallow open ulcer c red/pink moist wound bed. 7/13/11 New skin breakdown areas noted surrounding previously noted wound. ...Coccyx-superior gluteal cleft Stage II O Eschar type of wound Pressure/sheer Length 2.0 Width 0.5 Depth less than 0.1 Undermine Tunnel - Drainage O Initial date of wound 07/13/11 red/pink moist wound bed. Coccyx-superior gluteal cleft inferior to #2 Stage II O Eschar type of wound Pressure/sheer Length 0.8 Width 0.4 Depth less than 0.1 Undermine Tunnel - Drainage O Initial date of wound 07/13/11 red/pink moist wound bed. Rt upper buttock superior to #1 Stage II O Eschar type of wound Pressure/sheer Length 0.6 Width 0.6 Depth less than 0.1 Undermine Tunnel - Drainage O Initial date of wound 07/13/11 red/pink moist wound bed. Rt upper buttock inferior to #4 Stage II O Eschar type of wound Pressure/sheer Length 1.8 Width 1.2 Depth less than 0.1 Undermine Tunnel - Drainage O Initial date of wound 07/13/11 red/pink moist wound bed. Rt upper buttock medial to #5 Stage II O Eschar type of wound Pressure/sheer Length 0.2 Width 0.2 Depth less than 0.1 Undermine Tunnel - Drainage O Initial date of wound 07/13/11 red/pink moist wound bed. L heel Stage I O Eschar type of wound Pressure Length 3.5 Width 6.0 Depth- Undermine Tunnel - Drainage - Initial date of wound 07/13/11 Skin intact c slightly reddened defined line mushy heel area. Dr notified by chg nurse, orders rec'd for [MEDICATION NAME] to all open areas. [MEDICATION NAME] ordered for heel, cushion ordered for W/C." The nurses notes, dated 07/13/11, documented "7/3 Pat dry apply [MEDICATION NAME] to all open areas q shift 2. Cushion to wheel chair while up. Tx book updated. 9:45 While in Room noted L heel to have discolored area Area non blanchable 3.5 x 6 cm. Also noted corn L little toe was bleeding. Dr (Name deleted) notified c N.O. 1. Heel protectors to bilat feet. 2. [MEDICATION NAME] Spray to L heel q shift. 3. Clean corn to L little toe Apply bandaid q day & PRN. Tx book ^ dated." On 07/13/11 at 9:50 a.m., the DON was interviewed. She was asked how she assessed the residents' skin. She reported she would ask the staff about the skin conditions and would also look at the skin at times. She reported she did not do head to toe assessments. She was asked about an admission weight for the resident. She reported the scale had been broke and the resident had not been weighed. She was asked if a skin assessment had been completed for the resident when admitted . She reported if it wasn't in the chart it had not been done. 2. Resident #4 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's admission order documented, "Wound care to evaluate & treat pressure ulcer R buttock." There was no further documentation of the pressure sore until 03/06/11. The nurse's note on 03/06/11, documented, N.O. [MEDICATION NAME] to open area to R BTX (buttock) q shift until resolved. Apply Calmo to gluteal cleft q shift until resolved..." A care plan, dated 03/06/11, documented, "Problem Resident noted with open area on buttocks and to gluteal fold, Dr (Name deleted) notified with new orders received. Goal No further skin breakdown to be noted Approach Apply [MEDICATION NAME] to open area on right buttocks Q shift till resolved Apply [MEDICATION NAME] to gluteal cleft q shift till resolved Monitor for further skin breakdown Monitor for resolving of current breakdown Notify physician with any changes" A Weekly Skin Condition Report, dated 03/10/11, documented, "3/10/11 Skin WDI (warm, dry, intact), no problems noted." A nurse's note on 03/13/11, documented, "...noted sm .25 cm open area to R upper buttock. [MEDICATION NAME] applied to buttock per order..." The March 2011, treatment sheet documented the [MEDICATION NAME] was applied TID from March 7th until March 14th when the resident went to the hospital. The areas were resolved when the resident returned on March 21st. The above pressure sores were not assessed as to the stage, type of wound, length, width, depth, any tunneling, drainage, or description of the wound bed. The admission assessment, dated 04/20/11, identified the resident was alert and oriented with no cognitive deficits, required extensive assistance with bed mobility, total assistance with transfers, was non ambulatory, was continent of bowels, used an indwelling urinary catheter and was at high risk for pressure ulcers. A nurse's note, dated 07/02/11, documented, "Noted to have open area to crease of buttocks N.O. Received for treatment." A physician's telephone order dated 07/02/11, documented, "[MEDICATION NAME] to buttock crease open area q shift & PRN till Resolved." The above pressure area was not assessed as to the stage, type of wound, length, width, depth, any tunneling, drainage or description of the wound bed. A care plan, dated 07/02/11, documented, "Problem During care nursing notes open area to buttocks crease. Resident states it hurts when they clean her. Dr (Name deleted) notified with new orders noted Goal Open area will be resolved by 7/20 No further skin breakdown will be noted throughout this quarter Approach [MEDICATION NAME] to open area in buttocks crease q shift and PRN till resolved Monitor for further skin breakdown Instruct aides to clean her good with each bathing or incont episode Notify physician with any changes" A quarterly assessment, dated 07/05/11, documented the resident was alert and oriented with no cognitive deficits, was at risk of developing pressure ulcers and currently had one stage II pressure ulcer with the date of the oldest stage II pressure ulcer of 07/03/2011. A Weekly Skin Condition Report, dated 07/07/11, documented, "7/7/11 Skin WDI (warm, dry, intact), no problems noted." On 07/11/11 at 1:30 p.m., LPN #1 was asked to have the surveyor observe the treatment to the resident's coccyx. She reported the resident did not want the surveyor to observe the treatment related to privacy concerns. The LPN was notified the resident had the right to refuse the observation. The pressure sore was not able to be visualized related to the resident's wish for privacy. On 07/12/11, the measurements provided by the DON, for the pressure sore were 0.4 x 0.8 cm. On 07/12/11 at 9:30 a.m., the DON was interviewed regarding the pressure sores. She was asked about the physician's orders [REDACTED]. She reported she did not remember the resident having a pressure sore upon admission. She reported no measurements of the pressure sores had been done. She was asked if residents should be assessed weekly, if the resident was at high risk for pressure sores. She stated, "Yes." She reported she did not do head to toe assessments but would sometimes ask staff about the residents' skin conditions.