Every finding on record at Five Points Nursing & Rehabilitation of College St

Based on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 7 residents (Resident #1 and Resident #2) reviewed for personal hygiene. 1. The facility failed to provide Resident #1 with 6 scheduled showers between 06/30/2026 and 07/30/2026. 2. The facility failed to provide Resident #2 with 2 scheduled showers on 07/21/2026 and 7/23/2026.These failures could place residents at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections.Findings include:1. Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to facility on 08/26/2025. Resident #1 had diagnoses which included unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), muscle weakness ( a feeling or objective observation that reduced effort, such as attempting to lift or move, fails to produce normal muscle contraction), and major depressive disorder, recurrent, moderate (A mental health condition featuring persistent low mood, loss of pleasure in activities ,and changes in energy, experienced 2 or more episodes). Record review of Resident #1's admission MDS, dated [DATE], reflected Resident #1 had a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #1's Comprehensive Care Plan, dated 7/30/2026, reflected a focus area titled The resident has an ADL Self Care Performance Deficit with interventions: bathing: requires staff x 1 for assistance, bed mobility: requires staff x 1 for assistance.Record review of Resident #1's shower log in PointClickCare (cloud based electronic health record platform for long-term care providers) reflected Resident #1's showers were Tuesdays, Thursdays, and Saturdays, the resident did not receive a shower on 6/30/2026, 7/02/2026, 7/04/2026, 7/09/2026,7/21/2026, and 7/23/2026.2. A record review of Resident #2's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility originally 01/03/2025 and readmitted on [DATE]. Resident #2 had diagnoses which included chronic obstructive pulmonary disease (incurable lung disease), Type II diabetes mellitus (body resists the effects of insulin and sugar builds up in blood), anxiety (excessive worry and irritability) and morbid obesity due to excess calories. A record review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #2's, undated, Comprehensive Person-Centered Care Plan, reflected, [Resident #2] has an ADL self-care performance deficit with interventions, [Resident #2] requires (assistance by [1]) staff with bathing. Record review of Resident #2's shower log in PointClickCare reflected Resident #2 did not receive her scheduled baths on 7/21/2026 and 07/23/2026. Interview conducted on 07/30/2026 at 9:37 AM, Resident # 1 stated her showers were scheduled for three days a week on Tuesday, Thursday, and Saturday. She stated she had not received her showers as scheduled. She stated when she was home, she showered daily and she understood when she came to the facility it was limited showers. Resident #1 stated it bothered her when she did not get showers on the few days that were scheduled. Resident #1 stated she was told there had been a shortage of towels which caused missed showers. Resident #1 stated she had not received showers on 6/30/2026, 7/02/2026, 7/04/2026, 7/09/2026, 7/21/2026 and 7/23/2026, she showed the information documented in her journal she kept daily. She stated on Tuesday of the prior week (7/21/2026) she did not get a shower. She stated CNA A told her she could not give her a shower due to her having the hallway by herself. Resident #1 stated CNA A told her if she got any help, she would shower her, but the shower did not happen. Resident #1 stated she was positive that others were not receiving showers also. Resident #1 stated she and her family member had previously spoken to the ADM about her not getting showers and the ADM advised her to come to her if she did not receive a shower and she would see that she received one.Interview conducted on 07/30/2026 at 11:29 AM, Resident # 2 stated she received her baths this week but last week she missed a few baths.Interview conducted on 07/30/2026 at 1:48 PM, MA E stated she had been with the facility for 2 years. MA E stated when she had some down time she helped on the floor with showers. She stated Resident #2 one day on a Thursday mentioned to her she did not have a bath that day and she offered to help her but Resident #2 said she needed to wait because her family member was coming to visit and she would wait until she laid down. MA E stated she could not get to Resident #2 later that day but told her she would help her on her return to work on that Saturday. MA E further stated Resident #1 mentioned to her a few weeks ago she had not had a shower and she sat in with the resident while she showered. MA E stated residents not getting showers lead to bad hygiene and skin issues.Interview conducted on 07/30/2026 at 3:34 PM, CNA B stated she did work 100-hall on 7/21/2026, however, she did not remember which beds she was assigned for showers/baths on that day without checking. She stated towels were an issue at the facility, which interfered with them not being able to do their jobs as needed.Interview conducted on 07/30/2026 at 4:58 PM, the DON stated some residents complained they did not receive their scheduled baths. She stated providing baths was a struggle during the previous week. The DON stated Resident #1 and Resident #2 had not reported to her that they missed showers or baths. She stated her expectation was that staff provided all residents with showers and baths according to their scheduled bathing days. She stated if a resident refused a bath, staff was expected to notify the nurse. Interview conducted on 07/30/2026 at 5:08 PM, Resident #1's family member stated they had recently met with the facility's IDT. The family member stated Resident #1's scheduled bath days were Tuesdays, Thursdays, and Saturdays; however, she was not consistently receiving her showers. The family member stated this had been frustrating for some time. The family member stated Resident #1 received three showers per week for approximately two weeks, but the issue started again, with the hitting and missing of showers. The family member stated staff turnover appeared to be contributing to the problem. Interview conducted on 07/30/2026 at 5:21 PM, CNA A stated she received training on resident rights and worked at the facility for one year. CNA A stated she had always provided Resident #1 with her scheduled showers. She stated a shower may have been missed if she was working on the hallway by herself. CNA A stated if a shower was missed, she notified the charge nurse. She stated potential harm to a resident who does not receive scheduled showers could include the development of infections. Interview conducted on 07/30/2026 at 5:36 PM, the ADM stated a grievance had previously been filed regarding residents not receiving scheduled showers. The Administrator stated she conducted an in-service with staff following the grievance; however, she stated this occurred some time ago and not recently. The ADM stated the facility had implemented morning champion rounds (department heads speak to residents in the mornings). She stated if a resident reported not receiving a scheduled shower, the concern was discussed during the morning meeting, and they would make sure the resident got a shower. The ADM further stated she just created a shower sign-in sheet for CNAs and residents to document and acknowledge a shower was provided. Record review of the facility's policy on Activities of Daily Living (ADLs), dated 2001, reflected Residents will be provided with care, treatment, and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal, and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible and failed to ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for 1 of 7 residents (Resident #1) reviewed for resident rights.1.The facility failed to ensure Resident #1's bed linens were changed several days between 6/30/2026-7/30/2026.2.The facility failed to maintain an adequate supply of clean linen that included bed linens and towels, to ensure resident's bedding could be changed when needed and that clean towels were available for residents' showers and personal care.These failures could place residents at risk for an unclean, unsafe, and uncomfortable environment.Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to facility on 08/26/2025. Resident #1 had diagnoses which included unspecified dementia, unspecified severity, with mood disturbance, ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and there is mood changes), muscle weakness ( a feeling or objective observation that reduced effort, such as attempting to lift or move, fails to produce normal muscle contraction), and major depressive disorder, recurrent, moderate (A mental health condition featuring persistent low mood, loss of pleasure in activities ,and changes in energy, experienced 2 or more episodes). Record review of Resident #1's admission MDS, dated [DATE], reflected Resident #1 had a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #1's Comprehensive Care Plan, dated 7/30/2026, reflected a focus area titled The resident has an ADL Self Care Performance Deficit with interventions: bathing: requires staff x 1 for assistance, bed mobility: requires staff x 1 for assistance.Observation and interview conducted on 07/30/2026 at 11:20 AM, the laundry room was observed to have a very little amount of clean laundry, no towels or bed sheets were present in the area. Laundry staff D, who was in the laundry room at the time, stated he believed the facility was low on towels and sheets as he did not see many available.Observation conducted on 07/30/2026 at 11:36 AM, Hall 100 linen closet was observed to have no towels, 1 sheet, and 4 pillowcases.Observation conducted on 07/30/2026 at 11:38 AM, Hall 400 linen closet was observed to have no towels or bed linens.Observation conducted on 07/30/2026 at 11:42 AM, Hall 200 linen closet was observed to have 5 bed sheets, 2 face towels, and 13 bath towels.Observation and interview conducted on 07/30/2026 at 12:06 PM, Hall 300 linen cart was observed with the DON. The cart was observed to have 3 bath towels, 3 wash cloths, and no sheets. The DON stated she had been working for the facility since the beginning of July 2026. She reported the linen shortage had been a consistent problem since she began working at the facility. Also, CNA B on hall 300 stated the facility needed to buy an order of linen because she believed some people were throwing away the linen. She stated it had been a problem for about a month.Interview conducted on 07/30/2026 at 9:35 AM, Resident # 3 stated her roommate, Resident #1 was not getting her linen changed regularly and her family member assisted Resident #1 with getting clean linen on several occasions.Interview conducted on 07/30/2026 at 9:37 AM, Resident # 1 stated her bed linen was supposed to be changed on shower days, three times a week but since she was not getting showered on somedays, the bed linen was not changed. Resident #1 stated she was told there was a shortage of towels which caused missed showers. Resident #1 stated her roommate's family member went and searched for clean linen throughout the facility and could not find any to change her bed linens. Resident #1 stated her bed did not get changed on 6/30/2026, 7/02/2026, 7/04/2026,7/09/2026, 7/21/2026, and 7/23/2026, she showed the information documented in her journal that she kept daily. Resident #1 stated the situation bothered her.Interview conducted on 07/30/2026 at 10:51 AM, family member to Resident #1's roommate stated there was no clean linen located in the facility on 7/24/2026. The family member stated they had to take linen to their home to wash and return so Resident #1 could have her bed linen changed. The family member stated residents should have clean bed linen and the facility needed to do better job.Interview conducted on 07/30/2026 at 11:25 AM, the HSK Supervisor stated she began working at the facility in June 2026. She reported the facility had been experiencing shortages of linens and towels. She stated she recently received training on ordering linens. The HSK Supervisor stated her supervisor was responsible for placing linen orders until she assumed those duties. She stated she just recently submitted an order for additional linens and offered to provide a copy of the order for review.Interview conducted on 07/30/2026 at 1:26 PM, CNA C stated she was trained in resident rights, she stated residents had the right to live in a clean environment. CNA C stated bed linens were changed when they were dirty and on shower days. She stated they were out of linen lately on hall 100. She stated she would have to grab some from the 300/400 hallways or check with the laundry department. CNA C stated they usually had some linen and towels in the mornings. She stated not having clean linen could cause residents to not feel good, smell bad, or change mood.Interview conducted on 07/30/2026 at 5:36 PM, the ADM stated the linen supply was based on the different shifts and different turnaround times. The ADM stated the turnaround time was two hours for linen to come back from laundry. The ADM stated last month there was a complaint that the linen had run out but not last week to her knowledge, she stated she was not present at the facility last week. The ADM stated some residents' families complained about linen not being changed and when she went to observe and speak with the residents, the residents would say they were changed. The ADM stated her expectations were for residents to have clean bed linens.Record review of Resident #1s PointClickCare (cloud based electronic health record platform for long-term care providers) reflected Resident #1 did not get a shower on 6/30/2026, 7/02/2026, 7/04/2026, 7/09/2026,7/21/2026, and 7/23/2026, indicative of resident's linen not changed.Record review of facility's linen order on 7/27/2026, reflected a delay shipping date of 08/01/2026.Record review of the facility's, undated, Resident Rights, reflected: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.The facility will provide the Resident Rights to each newly admitted resident and upon any revision to the Resident Rights to each resident and/or resident representatives.

Based on interviews and record reviews, the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one facility reviewed for social work services in that:The facility, which was licensed for 130 beds, failed to employ a qualified social worker on a full-time basis since 2/21/2026.This failure could place residents at risk for unmet social services and psychosocial needs. Findings included:Review of the Facility Summary Report from the Texas Unified Licensure Information Portal (TULIP) dated 06/24/2024 reflected the facility had a total licensed capacity of 130 beds. Review of facility's Resident Council meeting minutes dated 03/04/2026, Social Services section noted in minutes read We need one, we don't have one. Review of facility's Resident Council meeting minutes dated 06/01/2026, Social Services section noted in minutes read We don't have one. Review of facility's Resident Council meeting minutes dated 07/01/2026, Social Services section noted in minutes read Residents say, we don't have one. Review of the undated job description for the facility's 'Social Worker' revealed: Knowledge Base: Develops social histories of residents and develops a social assessment and care plan for each resident which identifies medically related social and emotional problems and needs. Participates in interdisciplinary care plan conferences and contributes to the development of care plans for residents. Establishes specific social action plans and realistic goals for each resident consistent with medically related social and emotional needs. Provides individual and group help for residents and families at times of adjustment, crisis or particular need. Orients residents and families to the facility environment and assists the adjustment of both through individual and group programs. Coordinates discharge planning with staff, residents, and families. Coordinates social services in-service and educational programs for staff.This was signed by the unlicensed SW on 04/17/2026. In an interview conducted on 06/18/2026 at 11:45 AM with SW, she stated that she had been working at the facility since 04/17/2026. SW stated she was a PRN Social Worker for the facility, and she worked after hours and on Saturdays. She stated she does not work full-time. SW stated she completed assessments and set up careplan meetings. SW stated she was told the facility hired another Social Worker, but she did not have any information on a start date. In an interview conducted on 06/18/2026 at 11:51 AM with the HRC , she stated she has been employed with the facility since 03/02/2026. The HRC stated the facility's last fulltime SW's last day of employment was on 02/20/2026. She further stated the current SW is not a full-time employee, and she worked on evenings and weekends. The HRC stated the residents report concerns to the Administrator if needed. In an interview conducted on 06/18/2026 at 2:49 PM, the Administrator stated the facility has a licensed capacity of 130 residents. She stated that the current social worker was hired April 16, 2026 and worked on a part-time basis rather than full-time. The Administrator was asked how the facility ensures resident's social service needs are met in the social worker's absence , she stated the residents brought their concerns to her or the DON, and they addressed the residents' issues as needed.The facility's Social Worker Policy was requested 06/17/2026 at 9:18 AM and again on 6/18/2026 at 12:05 PM from the Administrator. The Interim DON stated the facility did not have a Social Work policy and that the facility followed the National Association of Social Workers Long-term Standards .Review of National Association of Social Workers Long-term Standards assessed on 6/18/2026 reflected: Standard 5. StaffingA sufficient number of appropriately trained licensed or credentialed and experienced social work and supportive personnel shall be available to plan, provide, evaluate, and modify all social work services. InterpretationThe number and qualifications of the social work staff and the level of consultation needed shall be based on criteria related to the type, scope, and complexity of the social work program, the size of the facility, and the biopsychosocial needs and characteristics of the population served. All social work services shall be provided by social workers with experience in long-term care and a master's degree in social work or a baccalaureate degree in social work from an accredited school of social work. All social work staff and consultants shall be licensed, certified, or registered as mandated by specific state licensing agency requirements in the state in which the social worker practices. The social work program shall have a sufficient number of appropriately trained or experienced support personnel to enable the provision of social work services that ensure each resident maintains or attains the highest practicable levelof well-being.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure that SNA J sanitized hands between food tray distribution on hallway 200.2. The facility failed to ensure DC M used proper hand hygiene prior to putting on gloves. 3. The facility failed to ensure the [NAME] used proper sanitation when touching kitchen chicken broth jar lid. These deficient practices could place residents at risk for food borne illness.Findings Included: During an observation on initial tour of the kitchen on 06/16/2026 at 11:00 a.m., SNA J failed to sanitize hands between distributing lunch trays to room [ROOM NUMBER] and room # 213. During an interview on 06/16/2026 at 12:55 a.m., SNA J stated, I did use sanitizer when I delivered meals on the 200 hallways. She stated she did not remember that she did not use hand sanitizer when entering rooms [ROOM NUMBERS]. SNA J stated, she was trained on hand sanitation and hand sanitation is important to prevent germs. During an observation and interview on 06/17/2026 at 8:19 a.m., DC M picked up a can of pudding from the pantry, and she moved across the kitchen to a preparation counter where she served individual portions of pudding in small cups. Observation revealed DC M failed to wash her hands before serving the pudding into the small cups. DC M stated she was trained in proper hand hygiene; she is supposed to use gloves when working with food and she is to wash her hands between tasks. DC M said if proper hand hygiene is not practiced there could be cross contamination and someone could get sick. During a phone interview on 06/17/2026 at 9:34 a.m., RD stated it is her expectation that all staff will use proper hand sanitation to prevent food borne illness. RD said that staff are expected to always use gloves when working with food. During an observation and on 06/17/2026 at 11:08 a.m., during the puree process, DC L dropped the chicken broth jar lid onto the kitchen floor. Observation revealed DC L picked the lid up from the floor and she rinsed the lid in the kitchen sink before she replaced the soiled lid on top of the chicken broth jar. During an interview on 06/17/2026 at 11:08 a.m., DC L stated she had cleaned the lid to the chicken broth jar, and it was ok for her to put the lid back on the jar. During an observation on 06/17/2026 at 11:27 a.m., DC M walked in the kitchen, from the dry goods pantry where she had been moving the inventory boxes around and she proceeded to walk to the dishwasher where she obtained the clip board and pen used for logging the dishwasher temperatures. DC M failed to wash hands before putting on gloves and approaching salad prep station where she performed preparation of individual portions of salad Findings Included: During an observation on initial tour of the kitchen on 06/16/2026 at 11:00 a.m., SNA J failed to sanitize hands between distributing lunch trays to room [ROOM NUMBER] and room # 213. During an interview on 06/16/2026 at 12:55 a.m., SNA J stated, I did use sanitizer when I delivered meals on the 200 hallways. She stated she did not remember that she did not use hand sanitizer when entering rooms [ROOM NUMBERS]. SNA J stated that she was trained on hand sanitation, and hand sanitation is important to prevent germs. During an observation and interview on 06/17/2026 at 8:19 a.m., DC M picked up a can of pudding from the pantry, and she moved across the kitchen to a preparation counter where she served individual portions of pudding in small cups. Observation revealed DC M failed to wash her hands before serving the pudding into the small cups. DC M stated she was trained in proper hand hygiene; she is supposed to use gloves when working with food and she is to wash her hands between tasks. DC M said if proper hand hygiene is not practiced there could be cross contamination and someone could get sick. During a phone interview on 06/17/2026 at 9:34 a.m., RD stated it is her expectation that all staff will use proper hand sanitation to prevent food borne illness. RD said that staff are expected to always use gloves when working with food. During an observation on 06/17/2026 at 11:08 a.m., during the puree process, DC L dropped the chicken broth jar lid onto the kitchen floor. Observation revealed DC L picked the lid up from the floor and she rinsed the lid in the kitchen sink before she replaced the soiled lid on top of the chicken broth jar. During an observation on 06/17/2026 at 11:27 a.m., DC M walked in the kitchen, from the dry goods pantry to the dishwasher where she logged the dishwasher temperature. DC M failed to wash hands before putting on gloves and approaching salad prep station where she performed preparation of individual portions of salad. Record review of Food Handler Certificates reflected all kitchen staff had valid food handler's cards. Record Review of Dietary Services Policy & Procedures Manual 2012, revised 4/9/25 reflected: Infection Control We will ensure that all employees practice infection control in the Food and Nutrition Services Department and maintain sanitary food Preparation. Procedure: Personal cleanliness is required in sanitary food preparation. Employees should follow general sanitation guidelines from the Center of Disease Control and the state food code when working in the Food and Nutrition Department. Careful hand-washing by personnel with be done in the following situations: b. Between handling dirty dishes, boxes, or equipment and handling clean food or utensils. 5. All kitchenware and food contact used in the preparation and/or serving of food are cleaned and sanitized before use and cleaned after each meal preparation. 6. Plastic disposable gloves are used when handling raw foods or in salad and sandwich preparation. There shall be no bare hand to foods or in salad and sandwich preparation. There shall be no bare hand to food contact. However, gloves are not a substitute for through and frequents handwashing. When using gloves, always wash hands before touching or putting on new gloves, and use single use gloves for on task. 10. Ware washing a. In order to ensure that all dishware is appropriately cleaned and sanitized the dish machine and three compartment sink must be operated at the appropriate chemical and temperature level. Fundamentals of Infection Control Precautions Hand hygiene is a general term that applies to washing hands with water and either plain soap or soap/detergent containing an antiseptic agent; or thoroughly applying an alcohol-based hand rub (ABHR). Hand washing refers to washing hands with plain (i.e., nonantimicrobial) soap and water. Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene Gloving Gloves are worn for three important reasons 1 To provide protective barriers and prevent. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves.

Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one of five residents (Resident # 9) reviewed for activities.The facility failed to provide Resident #9 in room activities three times per week from April 2026 through June 18, 2026.This failure could place residents at risk for boredom, depression, and a diminished quality of life. Findings include:Record review of Resident #9's face sheet, dated 06/17/2026, reflected an [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, mild, with mood disturbance ( early-stage of minor memory decline that affects daily functioning, but the exact cause has not been specifically identified), cognitive communication deficit ( an impaired ability to communicate caused by disruptions in brain function such as: attention, memory, or problem-solving rather than physical speech or primary language issues), and anxiety disorder (a group of mental health conditions that cause intense, persistent, and excessive fear or worry in non-threatening situations).Record review of Resident #9's Significant Change MDS Assessment, dated 03/31/2026 reflected Resident #9 had a BIMS score of 9 indicating her cognition was moderately impaired. She was assessed by the staff in Section F Preferences for Customary Routine and Activities of not wanting the following:Choosing clothes to wearCaring for personal belongingsReceiving a showerReceiving bed bathReceiving sponge bathSnacks between mealsStaying up past 8:00 p.m.Family or significant other involvement in care discussions.Use of phone in privatePlace to lock personal belongingsReading books, newspapers, or magazinesListening to music.Keeping up with the news.Doing things with groups of peopleParticipating in favorite activitiesSpending time away from the nursing home.Participating in religious activities or practices.Record review of Resident #9's Activity Assessment, dated 04/07/2026 reflected Resident #9 preferred not to participate in group activities. Resident #9 received one on one ( in room activities) three times per week. She enjoyed reading, watching television, the news, and coloring. Signed by the Activity Director.Record review of Resident #9's Care Plan, revised on 05/06/2026, reflected Resident was dependent on staff for activities, cognitive stimulation, and social interaction related to physical limitations. Interventions: Introduce Resident #9 to other residents with similar interests and encourage interaction. Invite Resident #9 to scheduled activities.Observation and Interview on 06/16/2026 at 9:15 a.m. Resident #9 was lying in bed. She did not respond to a lot of conversation about her activities. She stated no when asked if she attended group activities or if anyone came to her room and visited with her or did activities with her in the room. Resident #9 stated, Yes I would when asked if she would enjoy for someone to come to her room and do an activity in her room. She did not respond to any further questions. There was not any sensory stimulation in Resident #9's room.In an interview on 06/18/2026 at 7:50 a.m., CNA D stated if a resident was not receiving any type of activities there was a possibility a resident may become bored or lonely. She stated she knew who Resident #9 was and she did not recall observing anyone in Resident #9's room assisting with activities. She stated she had been working at the facility a few weeks. Interview on 06/18/2026 at 8:05 a.m., the Activity Director stated Resident #9 was on the in-room activity program. She stated Resident #9 did not receive in-room activities during the months of April 2026, May 2026, or from June 1st through June 18th, 2026. She stated , I forgot to add Resident #9's name to the in-room activity list. The Activity Director stated if a resident was not receiving in-room activities there was a possibility a resident may become bored, feel isolated, and may have a decline in their mental status. She stated she was responsible to ensure all residents received the activities they needed. The Activity Director stated she had been an employee as Activity Director since December 11, 2025. In an interview on 06/18/2026 at 10:40 a.m., LVN A stated she was not aware of Resident #9 socializing outside of her room. She stated she had a change of condition over the past few months and stayed in her room. LVN A stated she had not observed anyone in Resident #9's room doing any type of activity. She stated she was assigned to Resident #9 frequently, however, she did not recall how many days a week or month.Interview on 06/18/2026 at 9:52 a.m., the Administrator stated it was very important for the residents unable to come out of their room or unable to participate in group activities to receive activities in their room. She stated the Activity Director was over the activity department and she was her supervisor. She stated there was a possibility that a resident may become lonely if they were not receiving activities in their room. The Administrator stated she expected all activities to be documented on every resident on a daily basis to capture who was attending group activities and what the residents were doing during in-room activities. The Administrator stated anytime a resident was assessed by the Activity Director to receive in-room activities her expectations were the Activity Director to begin the in-room activities immediately and follow the resident's activity preferences. Record review of the Facility's Policy on Activity Programming , dated 2011, reflected The Activity Director and staff will provide for ongoing Activity programs. PRACTICE GUIDELINES: Recreation programs are based on the interests and needs of the residents expressed through the Activity assessment.Resident's or family's expressed needs and interests are included in the development of programs. Input from residents may be done individually or discussed at Resident Advisory Council meeting.Activity programs are based on resident's leisure interests and implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent, and sensory) of the residents.Programs will be geared to maintain functional ADL's, provide social interaction and, at the same time, protect residents from environmental over stimulation.Those who cannot participate in group settings are provided individual programming. Inability to participate could include those who refuse to participate in activities, those who are in isolation, or physician ordered bed rest.

Based on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for residents # 12, # 18 and Confidential Resident # 1 who consumed foods orally from the only kitchen in the facility in that: The facility failed to provide palatable food that was appetizing to residents who complained the food did not taste good, it was too salty and that it was frequently cold. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life.The findings included: Observation on 06/17/2026 at 1:50 p.m., revealed the 3 lunch test trays for a regular diet, a pureed diet, and a mechanically soft altered diet were tasted. The meal consisted of Chicken Fajitas, Charro Beans, Guacamole & Lettuce Salad, Warm Tortilla, Tapioca Pudding w/ Topping and Iced Tea. Observation revealed the chicken and charro beans were very salty. During an observation/interview conducted on 06/16/2026 at 11:16 AM, Resident #12 was sitting in her bed. Resident #12 reported a concern regarding meal service. She stated the food had changed a lot. She stated the food is too spicy, and it is cold when served in the room. A record review of Resident #12's, undated, face sheet revealed a [AGE] year-old female who was admitted to the facility originally 01/03/2025 and readmitted on [DATE]. Resident #12 had diagnoses which included chronic obstructive pulmonary disease (incurable lung disease), Type II diabetes mellitus (body resists the effects of insulin and sugar builds up in blood), anxiety (excessive worry and irritability) and morbid obesity due to excess calories. A record review of Resident #12's quarterly MDS, dated [DATE], revealed a BIMS of 15, which indicated the resident was cognitively intact. Additional interview conducted 06/18/2026 at 2:06 PM, Resident #12 stated her mash potatoes were salty at lunch meal. She stated the food is too spicy for more days than salty. She stated, the chicken and dumplings are always too salty. During an interview on 06/16/2026 at 1:05 p.m., it was revealed that Resident #18's only complaint was that her soup was too salty. During a confidential interview on an undisclosed date and time, Confidential Resident # 1 stated the food was not all that great'. Confidential Resident # 1 stated he ate in his room and lunch and dinner were served cool. He stated it was so salty I can't eat it most of the time. Confidential Resident # 1 denied complaining to anyone about the food. During an interview on 06/16/2026 at 10:15 a.m., DC K said the Dietary Manager was out for the day and DC K oversaw the kitchen for the day. DC K stated she has worked at this facility for 1 year and she stated the menus are planned by the DM and the RD, and she simply follows the recipes she is given for the daily menus. During an interview on 06/17 /2026 at 9:34 a.m., RD said she is responsible for meal plans and for establishing the dietary requirements for all residents. RD was not aware of the complaint that the food was too salty. Record Review of Policy Preparation for Food Production and Meal Service Table of Contents Preparation of Foods dated 6/2020, reflected: We will establish safe and nutritional preparation of food. Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value. Procedure: 2. All food will be prepared by methods that preserve nutritive value, flavor, and appearance with a variety of color, and will be attractively served at the proper temperature and in a form to meet the individual needs of the resident . 6. The Dietary Service Manager and cooks will taste and test meals daily. The administrator and DON may taste test meals if requested.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident # 60 and Resident # 78) reviewed for ADL care. The facility failed to ensure Resident #60's nails were cleaned on 06/16/2026.The facility failed to ensure Resident # 78's facial hair on chin, under chin, and above upper lip was removed on 06/16/2026. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings include:1. Record review of Resident #60's face sheet, dated 06/16/2026, reflected a [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #60 had diagnoses which included muscle weakness (the affected muscle cannot move normally or contract with the required power, even when you try as hard as you can), type 2 diabetes mellitus with diabetic chronic kidney disease ( prolonged high blood sugar has caused a person's body to struggle to process insulin, resulting to damage to a person's kidneys), and unspecified lack of coordination ( impaired ability to perform smooth, controlled, and voluntary muscle movement). Record review of Resident #60's Quarterly MDS Assessment, dated 05/18/2026, reflected Resident #60 had a BIMS score of 14, which indicated her cognition was intact. Resident #60 was dependent on staff for showers and toileting hygiene.Record review of Resident #60's Comprehensive Care Plan, revised on 06/12/2026 reflected Resident #60 had an ADL self-care performance deficit. Intervention: Bathing: check nail length, trim, and clean on bath day and as needed. Report any changes to the nurse. If diabetic, the nurse will provide toenail care.Observation and interview on 06/16/2026 at 9:44 a.m. revealed Resident #60 was sitting near her bed in her wheelchair. She was talking to her roommate. Resident #60's fingernails on her right hand underneath her forefinger, middle and ring fingernails had a blackish/ brownish substance. She stated I don't know when asked about if staff cleaned her fingernails. Resident #60 did not respond to any further questions about her ADL care of fingernails. 2. Record review of Resident #78's face sheet, dated 06/16/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #78 had diagnoses which included muscle weakness (the affected muscle cannot move normally or contract with the required power, even when you try as hard as you can), lack of coordination ( impaired ability to perform smooth, controlled, and voluntary muscle movement), and cognitive communication deficit (an impaired ability to communicate caused by disruptions in brain function such as attention, memory, or problem-solving rather than physical speech, or primary language issues). Record review of Resident #78's Quarterly MDS Assessment, completed on 05/06/2026, reflected Resident #78 had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #78 required partial/moderate assistance (helper does less than half the effort) with personal hygiene. She was dependent on staff for showers, lower body dressing and toileting hygiene. Resident #78 required substantial / maximal assistance (helper does more than half the effort) with upper body dressing.Record review of Resident #78's Comprehensive Care Plan, dated 06/12/2026, reflected Resident #78 had impaired visual function. Intervention: Arrange consultation with eye care practitioner as required. Encourage Resident to wear her glasses. Resident #78 had an ADL self-care performance deficit. Intervention: Bathing required one person with assistance. Encourage Resident #78 to discuss feelings about self-care deficit.Observation and interview on 06/16/2026 at 9:50 a.m. Resident #78 was sitting in her wheelchair near her bed in her room. She was talking to her roommate. Resident #78 had approximately 6 long hairs ( approximately 1/2 inch in length) under her chin. She had approximately 5 long hairs ( approximately 1/2 inch in length) on her chin and above her lip. Resident #78 stated she did not know she had hair on her face. She stated she never let hair grow on her face and she could not get it off of her face. She did not respond to any further questions about her facial hair grooming.In an interview on 06/18/2026 at 7:35 a.m., CNA C stated if a CNA observed any problems with a resident's nails the CNAs was to report it to the nurse supervisor with any resident. CNA C stated the CNAs completed all nail care for residents without a diabetes diagnosis. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as nausea and diarrhea. CNA C stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated if a female resident had facial hair there was a possibility the female resident may become embarrassed and not want to be around other residents. She stated the nursing staff was expected to check for facial hair on female residents during showers and when giving ADL care. CNA C stated anytime a resident refused any type of care she reported it to the charge nurse and the charge nurse would document it in the resident's medical record. CNA C stated she had given some care to Resident #78 and Resident #60, however, she did not recall if they refused nail care. She stated she was not aware of Resident #78 or Resident #60 shower schedules. CNA C stated she was not assigned to Resident #78 or Resident #60 on 06/16/2026.In an interview on 06/18/2026 at 9:20 a.m., the Nurse Consultant (interim DON) stated the CNAs were responsible to clean and trim all residents' nails except for the residents with diabetes. She stated the residents' nails were usually cleaned during shower days and as needed. She stated if a resident ingested blackish/brownish substance there was a potential the resident may experience vomiting or diarrhea. The Nurse Consultant stated it depended on the type of bacteria. She stated she expected nail care to be completed as needed and on shower days. The Nurse Consultant stated anytime there was an issue with nails the staff was to report it to the nurse supervisor. She stated any refusal of care would be documented on the resident's care plan. The Nurse Consultant stated if a female resident had facial hair and it was the resident's preference for it to be removed she expected the nursing staff to remove the facial hair during showers or as needed. She stated a female resident may become humiliated if she was seen by other people with facial hair on her chin, above her lip or under her chin. Record review of the facility's policy on Activities of Daily Living (ADLs), dated 2001, reflected Residents will be provided with care, treatment, and services appropriate to maintain or improve their ability to carry out activities of daily living ( ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal, and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care). Record review of the facility's Policy on Nail Care, not dated, reflected Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle and is usually done during the bath. Record review of the facility's Policy on Dressing and Personal Grooming, not dated, reflected The purposes of this procedure are to assist the resident as necessary with dressing and undressing and to promote cleanliness.Should be performed according to the resident centered plan of care. Report abnormalities to charge nurse.

Based on observation, interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for one of seven residents (Resident #9) reviewed for care plans. The facility failed to update the comprehensive care plan to reflect Resident #9 received in room activity programs and resident preferences of not wanting showers, baths, snacks, and not having family involved with care discussions. These failures could place residents at risk of not receiving appropriate interventions to meet their psychosocial needs. Findings include: Record review of Resident #9's face sheet, dated 06/17/2026, reflected an [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, mild, with mood disturbance ( early-stage of minor memory decline that affects daily functioning, but the exact cause has not been specifically identified), cognitive communication deficit ( an impaired ability to communicate caused by disruptions in brain function such as: attention, memory, or problem-solving rather than physical speech or primary language issues), and anxiety disorder (a group of mental health conditions that cause intense, persistent, and excessive fear or worry in non-threatening situations).Record review of Resident #9's Significant Change MDS Assessment, dated 03/31/2026 reflected Resident #9 had a BIMS score of 9 indicating her cognition was moderately impaired. She was assessed by the staff in Section F Preferences for Customary Routine and Activities of not wanting the following:Caring for personal belongingsReceiving a showerReceiving bed bathReceiving sponge bathSnacks between mealsStaying up past 8:00 p.m.Family or significant other involvement in care discussions.Use of phone in privatePlace to lock personal belongingsReading books, newspapers, or magazinesListening to music.Keeping up with the news.Doing things with groups of peopleParticipating in favorite activitiesSpending time away from the nursing home.Participating in religious activities or practices.Record review of Resident #9's Care Plan, revised on 05/06/2026, reflected there was not a focus area on the care plan for in-room visits, resident's preferences of not having baths or showers, not receiving snacks and not having family involved with care discussions.Record review of Resident #9's Activity Assessment, dated 04/07/2026 reflected Resident #9 received one on one ( in room activities) three times per week. Signed by the Activity Director.Observation and Interview on 06/16/2026 at 9:15 a.m. Resident #9 was lying in bed. She did not respond to a lot of conversation about her activities. She stated no when asked if she attended group activities or if anyone came to her room and visited with her or did activities with her in the room. Resident #9 stated, Yes I would when asked if she would enjoy for someone to come to her room and do an activity in her room. She did not respond to any further questions. Interview on 06/18/2026 at 8:05 a.m., the Activity Director stated Resident #9 was on the in-room activity program. She stated all residents were expected to have their care plan revised to meet their activity preferences. The Activity Director stated she did not revise Resident # 9's care plan to meet their current activity preferences of receiving in-room activities. She stated she did not realize she did not revise Resident #9's care plan. She stated, if a resident was feeling lonely or had behavior issues the staff would not have the information of the activities to use to help the resident.In an interview on 06/18/2026 at 8:25 a.m., the MDS Coordinator RN stated the information the CNAs followed on the Kardex (electronic system for CNAs use to know what type of care to give the residents) came from the care plan. She stated if a resident needed a certain type of care or had behaviors and it was not care planned, the CNAs or nurses would not have that information to know what type of care to give the residents. The MDS Coordinator stated it was the Activity Director's responsibility to ensure the activity care plans of the residents' activity preferences were documented on the care plan. She stated the residents' preferences of care, food, activities, etc. were expected to be care planned and she was not responsible to ensure the residents' preferences were on the care plan. The MDS Coordinator did not respond when asked if a resident had a preference of bathing/ showers or any type of ADL care who was responsible to document these preferences on the care plan. She stated it was the facility's protocol and policy the DON is responsible for the Comprehensive Care Plan and revising the care plans. The MDS Coordinator RN stated it was not her responsibility to ensure the care plans were completed and accurate. She stated the IDT met once a week and discussed residents' care plans due that week. She stated the Activity Director attended weekly care plan meetings. The MDS Coordinator RN stated the interdisciplinary care plan team consists of the following:Social WorkerActivity DirectorMDS Coordinator RNNursing administration either ADON or DONSometimes Director of TherapyDietary ManagerIn an interview on 06/18/2026 at 9:20 a.m., the Nurse Consultant ( interim DON) stated there was not a facility policy reflecting the DON is responsible for the Comprehensive Care Plan and revising the care plans. She stated it was the MDS Coordinator's responsibility to ensure the Comprehensive Care Plan was completed. She stated the IDT met weekly to discuss care plans. She stated anytime there was an acute concern with a resident the DON or ADON would revise the care plan. The Nurse Consultant stated all disciplines were responsible for their own care plans and each resident's plans were expected to be discussed as a group during the weekly care plan meetings. She stated all residents were expected to have their activity preferences documented on the comprehensive care plan. The Nurse Consultant stated if a resident was sad or had behaviors, the staff would refer to the care plan to know what their activity preferences were to re-direct the resident.In an interview on 06/18/2026 at 9:52 a.m., the Administrator stated her expectations of care plans were the IDT discussed care of each resident and if there was a change with anything which included resident preferences the care plan was expected to be revised. She stated the IDT was expected to ensure the resident's information to give appropriate care to each resident was documented on the care plan whether it was physical, emotional, resident preference, activities, etc. She stated there was not a facility policy or protocol reflecting the DON was responsible for the comprehensive care plan. The Administrator stated the MDS Coordinator RN was responsible for the comprehensive care plan and ensuring the care plans were completed on time. She stated the Interdisciplinary Team consists of the following:MDS Coordinator RNSocial WorkerDietary ManagerActivity DirectorSomeone from nurse administration ( DON, ADON), if neededDirector of Therapy - if applicableRecord review of the facility's Comprehensive Care Planning, not dated, reflected Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan. Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility. Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. The care plan will be prepared by an interdisciplinary team. Interdisciplinary means that the professional disciplines, as appropriate , will work together to provide the greatest benefit to the resident.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 10 residents (Resident #20 and Resident #34) reviewed for resident rights. The facility failed to ensure SNA J knocked on Resident #20 and Resident #34's door when going into the residents' rooms to deliver lunch meal. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home.Findings included: Review of Resident #20's Face Sheet dated 06/18/2026 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20's diagnoses included Chronic Obstructive Pulmonary Disease (Is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.), Chronic Respiratory Failure ( is a long-term condition where the lungs cannot maintain adequate oxygen levels or remove carbon dioxide from the blood), and unspecified Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.) Record review of Resident #20's Quarterly MDS assessment dated [DATE] revealed that Resident #20's BIMS score was 12 which means the resident had moderate problems with thinking and memory. Review of Resident #34's Face Sheet dated 05/18/2026 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #34's diagnoses included Inclusion Body Myositis (IBM, a progressive muscle disease that causes gradual weakness, particularly in the wrists, fingers, and front thigh muscles), Unspecified Dementia (loss of cognitive functioning that interferes with daily life and activities), and Essential Hypertension (High Blood Pressure). Record review of Resident #34's Quarterly MDS assessment dated [DATE] revealed that Resident #34's BIMS score was 09 which means the resident had moderate problems with thinking and memory. Observation done on 200 hallway on 06/16/2026 at 12:55 a.m., revealed SNA J did not knock on Resident # 20 or Resident # 34's door before entering the residents' rooms. During an interview with Resident # 34 on 06/18/2026 at 8:40 a.m. he said they never knock on his door. Resident #34 said he does not like it when staff come into his room without knocking. He said that he likes to know who is coming in his room. During an interview with Resident # 20 on 06/18/2026 at 8:35 a.m. she said that staff do not knock all the time. She said, I like to be able to relax and sometimes it bothers me when they do that because I'm not expecting anyone. During an interview on 06/16/2026 at 12:55 a.m., SNA J said she was a student nurse. SNA J said she has been trained in Residents Rights and residents have a right to dignity. She stated she was taught that staff should knock before entering a resident's room. During an interview on 06/16/2026 at 12:25 p.m., CNA H said residents have rights and they have choices. CNA H said a resident has a right to privacy and staff should knock before entering a resident's room. Record review of SNA J's Employee file reflected SNA J's training included resident rights. SNA J was employable, background check was acceptable Record Review of the undated facility Policy of Resident Rights reflected: Resident Rights The resident has a right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents.

Based on interviews, observation, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two of eight (Resident #1 and Resident #2) residents reviewed for quality of care. 1. The facility failed to provide urostomy (a surgical procedure that creates an alternate pathway for urine to leave the body though an artificial opening on the abdomen) bags for Resident #1.2. The facility failed to provide tracheostomy (a surgical hole created through the neck to the trachea to assist with breathing) inner cannulas (a removable tube within a tracheostomy that helps keep the airway clear of mucus and debris) and Enemeez (a docusate sodium mini enema used to treat constipation) for Resident #2.These failures placed residents at risk of injury, infection, not receiving adequate care and services, and decreased quality of life.Findings include:Review of Resident #1's admission record, dated 05/06/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included: quadriplegia (a condition that causes paralysis in all four limbs) and other artificial openings of urinary tract status. Review of Resident #1's quarterly MDS assessment, dated 04/24/2026, reflected a BIMS score of 15 indicating no cognitive impairment. Review of Resident #1's physician order summary, dated 05/06/2026, reflected Urostomy bag - change PRN with a start date of 01/08/2025. Review of Resident #1's care plan, dated 08/06/2025, reflected The resident has an urostomy with interventions that included .Perform ostomy (a surgical hole to create an artificial opening) care as ordered.change urostomy bag & ring prn.During an interview and observation on 05/06/2026 at 2:06 PM, Resident #1 stated he had his family purchase urostomy bags because the bags provided by the facility were not the correct bags. Resident #1 stated he spoke with the CSC and the bags she was able to obtain were colostomy (an artificial opening on the abdomen to divert waste from the digestive system) bags and not urostomy bags. He stated the colostomy bags did not provide a drain with extension to reach his foley catheter (a collection device for urine) bag. He stated he had provided his FM with $60 every month for 2 months to purchase the urostomy bags. Observation of the bags provided by the facility revealed a box of colostomy bags. Review of Resident #2's admission record, dated 05/06/2026, reflected a [AGE] year-old female, admitted to the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses that included: quadriplegia (a condition that causes paralysis in all four limbs), neurogenic bowel (a condition in which nerve damage disrupts normal bowel function leading to constipation, fecal incontinence, or difficulty controlling bowel movements), neuromuscular dysfunction of bladder (a condition in which the normal communication between the bladder and the nervous system is disrupted causing bladder control issues), dysphagia (difficulty swallowing), and tracheostomy status (a surgically created opening in the trachea used to assist with breathing). Review of Resident #2's comprehensive MDS assessment, dated 04/05/2026, reflected a BIMS score of 15 indicating no cognitive impairment. Review of Resident #2's physician order summary dated 05/06/2026 reflected the following orders: Change inner Cannula size 4 Shiley (type of inner cannula) every shift related to TRACHEOSTOMY STATUS with a start date of 04/13/2026, Enemeez Mini Rectal Enema 283 MG/5ML Insert 1 insert rectally one time a day related to NEUROGENIC BOWEL with a start date of 04/04/2026, DSS Oral Capsule 100 MG Give 1 capsule by mouth three times a day related to NEUROGENIC BOWEL with a start date of 04/04/2026, and Senna Oral Tablet Give 8.6 mg by mouth three times a day for Constipation take before meals. Take before lunch specifically with a start date 04/04/2026. Resident #2 had an order as follows: 1. Position on left side 2. Inert [sp?] lubricated loved [sp?] finger into the rectum, if you feel hard stool, gently remove it 3. Insert suppository, high into rectum beyond external internal sphincter 4. Push the suppository against the side of the rectal wall. 5. After 15 minutes perform digital stimulation. Insert finger into rectum, slightly stretch the anus. Move the finger in a circular motion around the rectal wall. Continue for 1 minute. 6. After 15 minutes if there is no results repeat x2 at bedtime related to NEUROGENIC BOWEL for 2 days with a start date of 04/05/2026 and end date of 04/07/2026. Review of Resident #2's care plan, dated 04/12/2026, reflected The resident has Tracheostomy r/t with interventions that included TUBE OUT PROCEDURES: Keep extra trach tube at bedside. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Notify EMS IMMEDIATELY.Review of Resident #2's care plan, dated 04/12/2026, reflected The resident has hemiplegia/Hemiparesis (paralysis or weakness on one side of the body) r/t with interventions that included Give medications as ordered. Monitor/document for side effects and effectiveness.During an interview on 05/06/2026 at 11:23 AM, FM A stated they had to purchase the inner cannulas and Enemeez for Resident #2 because the facility did not have the needed supplies. She stated Enemeez, quantity of 35, was purchased on 04/16/2026 and inner cannulas, quantity of 10, were purchased on 04/17/2026. FM A stated there was a care plan meeting with the ADM and the DON on 04/13/2026 related to the care needed for Resident #2 and the necessary supplies. She stated the supplies were not provided after that meeting which prompted the family to purchase and provide the facility with the supplies.Record review of a facility provided invoice, dated 04/07/2026, reflected an order for Mini-Enemas quantity of 5 purchased. Record review of a facility provided invoice, dated 04/17/2026, reflected an order for CANNULA, INNER, SHILEY, SIZE 4. quantity of 1 pk purchased.During an interview on 05/07/2026 at 01:12 PM, the NP stated Resident #2 had a re-usable inner cannula that just needed to be cleaned and not changed until 04/13/2026. She stated she believed the facility was providing care by cleaning the inner cannula from 04/03/2026 until 04/13/2026 when the order was added to change the inner cannula. She stated the facility was using oral docusate sodium, senna, and the digital stimulation program in place of using the Enemeez, and the combination of the 3 was equivalent. The NP stated a colostomy bag is not the same as a urostomy bag. She stated the bag needed a connector for the urine to drain from the bag and into the foley catheter bag. The NP stated if a colostomy bag was used in place of a urostomy bag then the bag would probably leak urine. During a phone interview on 05/07/2026 at 04:16 PM, LVN A stated she worked with Resident #2 on 04/18/2026 and 04/19/2026. She stated on 04/18/2026, FM A provided inner cannulas for Resident #2, and the inner cannula was changed that day. She stated she was not scheduled to administer the Enemeez and was unsure if it was available. During an interview on 05/08/2026 at 09:42 AM, the CSC stated she had been trained in ordering needed supplies for the facility when she accepted the position. She stated, if supplies were not available to be ordered through their supplier, then she could go to the store or order it on-line. She stated Resident #1 had his family purchase his own urostomy bags because he was particular about the type that was ordered and he preferred a different bag than the facility provided. She stated she notified the ADM and DON about Resident #1's family purchasing his urostomy bags. She stated she did not know the difference between urostomy and colostomy bags. The CSC stated was not informed about the need for the inner cannula until 04/14/2026 and she ordered them that day. She stated she did not have any inner cannulas in the facility prior to that order. The CSC stated she ordered the Enemeez on 04/07/2026 from a local store. After reviewing the invoice, the CSC stated she purchased a quantity of 5 that would have lasted 5 days. She stated she was not told to order any more after that. During an interview on 05/08/2026 at 1:43 PM, the DON stated she was notified that Resident #1's family was purchasing his urostomy bags recently by Resident #1. She stated she had changed Resident #1's urostomy bag recently and he indicated he wanted to use the urostomy bags that his family had purchased. During the interview a picture of the bag purchased by the facility was provided to the DON. She stated that the picture reflected a colostomy bag and not a urostomy bag. She stated a colostomy bag could not be used in place of a urostomy bag because the bag needs a drain for the tube to connect to the foley drainage bag. The DON stated the facility was responsible for purchasing the correct urostomy bags for Resident #1. The DON stated that when the facility received report for Resident #2, they were told that Resident #2 was in the process of trying to discontinue her tracheostomy and they were told that no care was needed for the tracheostomy, including changing the inner cannula. She stated the facility did not have tracheostomy inner cannulas in the facility when Resident #2 was admitted . She stated that it is a standard of care to keep an extra inner cannula at the bedside in case of dislodgement, but thought that if it did become dislodged, they had the supplies to clean the inner cannula to be able to reinsert it. She stated not having extra inner cannulas in the facility could cause breathing difficulties if the tracheostomy were to become dislodged. The DON stated she was not aware if Resident #2's family had purchased inner cannulas and brought them into the facility. She stated the facility ordered inner cannulas after a discussion with the family of Resident #2. The DON stated it was the responsibility of the facility to provide inner cannulas for Resident #2. The DON stated she assumed the Enemeez were not started upon admission to the facility because they were difficult to locate in store and had to be ordered online. After reviewing the invoice for the Enemeez purchased by the facility she stated the facility received a quantity of 5 on 4/7/2026 that should have lasted Resident #2 for 5 days. She stated she was unsure if any additional Enemeez were purchased for Resident #2 after the initial purchase. The DON stated the facility was responsible for providing Enemeez for Resident #2. She stated she expected the CSC to notify her if there are any difficulties in obtaining the needed supplies for residents. The DON stated if the residents had to purchase their own needed medical supplies, then it could affect the residents financially. During an interview on 05/08/2026 at 04:08 PM, the ADM stated she was not notified that the facility had ordered colostomy bags for Resident #1 instead of the urostomy bags. She stated it was not her expectation to use colostomy bags in place of urostomy bags. The ADM stated she would expect to be notified by the CSC about difficulty in locating supplies. She stated she did not think that the CSC knew the difference between colostomy and urostomy bags. The ADM stated she was not aware that Resident #1's family was purchasing his urostomy bags. She stated the facility was responsible for providing the urostomy bags for Resident #1 and she had intentions on reimbursing Resident #1's family for the urostomy bags they had purchased. The ADM stated that when Resident #2 was admitted to the facility, the facility received in report that Resident #2 had a tracheostomy but Resident #2 was being weaned off the tracheostomy and did not require any care for it. The ADM stated there was not an order from the previous facility related to order to change the inner cannula. She stated it was not until the family raised a concern about changing the inner cannula, that the facility realized it needed to be changed and the facility ordered the supplies. She was unsure of the date she spoke with the family related to their concerns. The ADM stated the Enemeez was not in stock in the facility when Resident #2 was admitted , but they ordered it. After reviewing the invoice for Enemeez, the ADM stated they ordered a quantity of 5 Enemeez, and that quantity would have lasted Resident #2 for 5 days. She stated it was the facility's responsibility to provide the inner cannulas and Enemeez for Resident #2. She stated Resident #2's family brought in a box of Enemeez for Resident #2 because they did not want them to go to waste. The ADM stated she was unsure how the missing supplies could affect the residents, but to her knowledge there were no adverse effects to the residents due to the lack of supplies. Review of the, undated, facility admission agreement reflected .MEDICAL SUPPLIES AND EQUIPMENT1. Medical accessories and equipment ordered by Resident's physician and required to provide treatment ordered such as: cannulas, tubes, masks, catheters, ostomy bags and supplies, IV fluids and equipment, wheelchairs, crutches, canes, walkers, trapeze bars, mattresses and hospital type beds, enteral pumps and oxygen equipment are paid by Medicaid for Medicaid residents.MEDICARE PART A SKILLED STAY COVERED SERVICES & CHARGES.These charges are included, you will not be billed for the following services:Room and BoardRoutine Nursing CareRoutine Supplies and EquipmentThese charges are included, you will not be billed for the following services, with appropriate physician orders:PharmacyRadiologySpeech PathologyChargeable Medical SuppliesIV TherapyLaboratoryOccupational TherapyPhysical Therapy.

Based on interview and record review the facility failed to provide care, consistent with professional standards of practice, to heal pressure injuries for one resident (Resident #2) out of four residents reviewed for pressure injuries.The facility failed to assess the wound to Resident #2's sacrum (the triangular area at the base of the spine fused between the hips) and acquire orders upon admission on [DATE] until 04/08/2026. This failure could place residents at risk of worsening wounds, infections and pain. Findings included:Review of Resident #2's admission record, dated 05/06/2026, reflected a [AGE] year-old female, admitted to the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses that included: quadriplegia (a condition that causes paralysis in all four limbs), paralytic syndrome (a medical condition characterized by partial or complete loss of muscle function due to nerve or neurological impairment), and other reduce mobility. Review of Resident #2's comprehensive admission MDS, dated [DATE], reflected a BIMS score of 15 indicating no cognitive impairment. Section M - Skin Conditions reflected Resident #2 had a pressure ulcer/injury that was classified as Unstageable - Deep tissue injury. Review of Resident #2's order summary, dated 05/06/2026, reflected clean unstageable wound to sacrum with normal saline, pack with moistened gauzed [sp?], apply skin prep to periwound (area directly around the wound), cover with bordered foam. Two times a day for unstageable wound to sacrum with start date of 04/08/2026 and was discontinued without an end date; Stage 4 (a wound that extends through all layers of the skin and fat tissue reaching deeper structures such as muscle, tendon, ligament, cartilage, or bone) sacrum: Clean with NS, pack with moistened (NS) gauzed [sp?], apply skin prep to peri wound, cover with dry dressing. Two times a day for unstageable wound to sacrum with start date of 04/12/2026 and Doxycycline Hyclate Oral Tablet 100 MG Give 1 tablet by mouth two times a day for wound infection for 10 days with a start date of 04/12/2026. Review of Resident #2's care plan, dated 04/12/2026, reflected The resident has a pressure ulcer or potential for pressure ulcer development: Stage 4 Sacrum with interventions that included Follow facility policies/protocols for the prevention/treatment of skin breakdown.Review of Resident #2's initial progress note, dated 04/04/2026 reflected, Unstageable (a pressure ulcer whose depth and severity cannot be determined because the wound bed is completely covered by dead tissue) to sacrum.Review of Resident #2's the wound care provider note, dated 04/08/2026, reflected a stage 4 pressure wound to the sacrum that was 5 x 6 x 1.1 cm with treatment plan of Primary dressing Gauze sponge sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days: NS mosit [sp?] to dry daily changes. Secondary Dressing Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. During an interview on 05/06/2026 at 11:23 AM with Resident #2 and FM A, they stated they were concerned about worsening condition of Resident #2's wound due to staff not providing care to the wound. During an interview on 05/07/2026 at 10:53 AM, the wound care doctor stated he had evaluated and treated Resident #2's wound 2 times while at the facility. He stated even though there were no orders for wound care from 04/04/2026 until 04/08/2026, Resident #2's wound had no change in condition since she left the hospital. The wound care doctor stated Resident #2's wound had necrosis (premature cell death) to the wound bed, and the wound was getting better by getting rid of the necrosis. He stated he was disappointed at the hospital in which Resident #2 resided prior to admission to the facility because Resident #2 should not have been discharged from the hospital with the wound in the condition it was in with all of the necrosis.During an interview on 05/07/2026 at 1:12 PM, the NP stated the smell to Resident #2's wound had changed on 04/12/2026 and she started doxycycline until the wound care doctor could assess the wound. She stated Resident #2's hospitalization was not related to no wound care provided from 04/03/2026-04/08/2026 because too much time had passed prior to her hospitalization on 04/19/2026 for it to be related. She stated Resident #2's hospitalization was inevitable due to her comorbidities and history of previous hospitalizations. During an interview on 05/07/2026 at 3:24 PM, the treatment LVN stated his first day as the treatment nurse was on 05/06/2026, but he was one of the charge nurses that provided care to Resident #2 prior to her hospitalization on 04/19/2026. He stated he worked with Resident #2 on 04/06/2026 and he did a dressing change by cleaning the wound and applying a foam bordered dressing, even though there was not an order, because the dressing was soiled. He stated prior to her hospitalization on 04/19/2026, Resident #2's wound was starting to improve but it did develop an odor. During an interview on 05/08/2026 at 01:43 PM, the DON stated the admitting nurse was responsible for obtaining wound care orders, but she was unsure who the admitting nurse was. She stated she was responsible for ensuring orders were obtained on the next business day after any admission. She stated she was unsure why no orders were obtained upon Resident #2's admission to the facility. The DON stated if a resident were admitted with a wound and no orders were obtained to treat the wound, then the resident would be at risk of infection. During an interview on 05/08/2026 at 3:25 PM, LVN B stated she worked with Resident #2 on 04/04/2026, 04/05/2026, 04/08/2026, 04/09/2026, 04/13/2026, 04/14/2026, and 04/17/2026. She stated on 04/04/2026 and 04/05/2026 she performed a wet-to-dry dressing because the dressing in place was soiled. LVN B stated she documented Resident #2 had an unstageable wound to her sacrum, but it was an oversight to not document the wound care provided. She stated she did not contact the on-call provider for orders related to wound care during that time. LVN B stated Resident #2's wound had some changes in color to the tissue and a consultation with the wound care provider occurred for an evaluation of the wound. She stated, to her knowledge, Resident #2 had no adverse effects due to the lack of orders for wound care from 04/03/2026 until 04/08/2026. During an interview on 05/08/2026 at 03:49 PM, LVN C stated she worked with Resident #2 on 04/04/2026, 04/05/2026, 04/07/2026, 04/08/2026, 04/14/2026, 04/16/2026, 04/17/2026, and 04/18/2026. She stated on 04/04/2026, 04/05/2026, and 04/07/2026 she observed the dressing to Resident #2's wound but did not touch the dressing because there was not an order to change the dressing. She stated it was the responsibility of the day shift nurse to obtain orders for wound care and she worked night shifts. LVN B stated the standard of care for nursing would be to have an order to monitor and care for each wound and not having an order put the resident at risk of infection. During an interview on 05/08/2026 at 04:08 PM, the ADM stated she was informed Resident #2 had a wound upon admission on [DATE]. She expected the admitting nurse to initiate standing orders for wound care that included monitoring of the wound, dressing changes and a wound care provider consultation. The ADM stated the wound care provider did an initial evaluation on Resident #2's wound on 04/08/2026 and the order for wound care was initiated at that time per direction of the wound care doctor. She stated she wanted to believe the nursing staff provided wound care from 04/03/2026 until 04/08/2026, but she was unsure if the nursing staff documented the wound care. The ADM stated if a resident went 5 days without wound care it could affect a resident because the wound could become uncomfortable or the resident would not feel good about the care provided to the wound. Review of facility policy titled Pressure Ulcer: Prevention, Assessment and Treatment Protocol, dated 05/05/2025, reflected Procedure:1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection.3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will:1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician. 2. Notify family and dietary department. Document Notification.6. Nursing Action/Rationale: . 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site. Sign off on treatment sheet any treatment completed.

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents hazards and supervision. The facility failed to ensure Resident #1's fall mat was in place, and the bed was in low position on 02/12/2026 at approximately 7:00 a.m., when he was found lying on the floor. The noncompliance was identified as PNC. The noncompliance began on 02/12/2026 and ended on 02/12/2026. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for falls with the possibility of injury, including fractures.Findings included: Record review of Resident #1's face sheet, dated 03/02/2026, reflected a [AGE] year-old male admitted to the facility on [DATE], diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (cognitive - decline where the specific cause has not been determined, and the person shows no significant behavioral or mood disturbances), reduced mobility ( having a significantly limited ability to move around , walk safely and without pain), repeated falls (experiencing two or more falls within a 12-month period), abnormalities of gait and mobility (irregularities in walking, running, or movement patterns), history of transient ischemic attack, and cerebral infarction without residual deficits ( a temporary blockage of blood flow to the brain, causing stroke- like symptoms (e.g. , weakness, numbness, and/or speech issues) the lack of blood flow was brief enough that no permanent brain tissue damage or lasting), and lack of coordination ( a condition causing shaking, unsteady, or clumsy movements due to impaired muscle control). Record review of Resident #1's Quarterly MDS Assessment, dated 01/13/2026, reflected Resident #1 had a BIMS score of 3 which indicated his cognition was severely impaired. Resident #1 had limited range of motion (the specific, often limited range of joint movement necessary to independently perform daily activities, such as reaching overhead, walking, or sitting) on one side of upper extremity and both sides of lower extremity. Resident #1 was dependent on staff for the following: personal hygiene, putting on/taking off footwear, upper and lower dressing, and toileting hygiene. He required substantial/ maximal assistance (helper does more than half the effort) for the following: oral hygiene and showers. Resident #1 required partial/moderate assistance (helper does less than half the effort) with all transfers. Review of Resident #1's Comprehensive Care plan was revised on 1/22/2026, indicated Resident #1 was at risk for injury for falls. Interventions included (initiated on 06/29/2025) Resident #1 required fall mat beside bed when lying in bed. Resident #1 needed a safe environment with a working and reachable call light, the bed in low position at night. The care plan indicated Resident #1 had an ADL self-care performance deficit such as: Interventions included: Required assistance with two staff for transfers, bed mobility, and bathing. Required one staff assistance with bed mobility. Required a mechanical lift (Hoyer) for all transfers.Used a wheelchair. The care plan indicated Resident # 1 had limited physical mobility related to weakness (a reduction in muscle strength, where you feel as though you need to exert extra effort to move your arms, legs, or other muscles). Intervention: Resident #1 is totally dependent on staff for locomotion. Record review of Resident #1's Activity Note, dated 02/12/2026 at 8:45 AM, reflected Called to resident's (Resident #1) room, resident (Resident #1) had fallen from bed onto the floor. Resident (Resident #1) had hit his head and mouth. Resident (Resident #1) stated he was trying to get up. Performed initial assessment, received from LVN A. LVN A stayed with resident (Resident #1) while RN B contacted 911 with report and request for transport. LVN A called Resident #1's daughter and reported the incident with her father (Resident #1) and transport him to hospital. RN B called the Administrator, attempted to call director of nurses, Nurse Practitioner and left message. Record review of Resident #1's Transfer Form to hospital, dated 02/1/2026 at 8:45 a.m. reflected Resident #1 was transferred to hospital related to a fall with a possible head injury. Record Review of Resident #1's Nursing notes dated 02/12/2026 at 12:37 p.m., reflected Resident (Resident #1) returned from hospital ER status post fall from bed this morning (02/12/2026). Residents (Resident #1) treatment included laceration wound care, naproxen 250 mg and amoxicillin-clavulanate 875-125 mg tablet for 14 days. Residents (Resident #1) TDAP () was updated. Record Review of Resident #1's Weekly Skin Assessment notes, dated 02/12/206 at 1:15 pm, reflected Resident #1 had an abrasion to right side of lip and inside of mouth no measurements were documented. The assessment indicated Resident #1 had laceration on top of right side of head, 3 staples there were no measurements documented. Record Review of Resident #1's Neuro Assessment, dated 02/12/2026 at 2:20 p.m. reflected the following;Blood Pressure- 126/78Pulse 81Respirations 17Eyes opening- spontaneouslyVerbal Response - Confused- not oriented, but communication is coherent (this is his baseline)Obey commands; example stick out your tongue, squeeze my handPupils equal and reactive to lightHand grips equal- No (this is his baseline)The physician or Nurse Practitioner should not be notified regarding a sign of neurological change. Record review of Resident #1's hospital records dated 02/12/2026 reflected Resident #1 had the following: 1. Procedure of Lower lip Laceration on lower lip - 1 cm No full thickness lip lacerationNo Foreign bodiesNo tendon involvementNo nerve involvementNo vascular damageSkin closure with glueRepair type was simple 2. Procedure of Laceration Repair Local AnesthesiaBody area was the head/neckLocation details was the scalpLaceration length: 2 cmNo foreign bodiesNo tendons involved No vascular damageUsed syringe to irrigateIrrigation solution was salineAmount of cleaning: extensiveNo debridementNo degree of underminingSkin closer- staplesNumber of sutures- 3Repair type was simple 3. Fractures - no acute fractures (Spine, Neck, head)Brain Parenchyma; No acute hemorrhage. No mass effect or herniation(protrusion of an anatomic structure from its normal anatomic psotion). Record review of (Resident #1, Resident #2,Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) care plans interventions reflected:fall mats beside the bed when resident was lying in bed was on each of these residents care plan. Record review on 03/02/2026 of CNAs C personnel record reflected CNA C was suspended on 02/12/2026 until the facility investigation was completed. Record review on 03/02/2026 of the facility investigation report dated 02/19/2026 reflected the following:CNA C was suspended pending investigationAssessed Resident #1Revised Resident #1 care plan.Re-in serviced all staff on how to use Kardex, abuse/ neglect, pain management, trauma informed care, fall prevention, fall risk, and shift change rounding.Interviewed 10 staff members per week to ensure they have the knowledge to locate information in Kardex related to fall intervention. This will be ongoing for the next 3 months.During stand-up morning meetings ADON, DON, Administrator, Activity Director, Dietary Manager, MDS Coordinator, Social Worker, - all department heads and Nurse supervisor) in am reviewed residents at risk for falls and residents had a recent fall to ensure all interventions are in place. This is ongoing for next 3 months.AD Hoc QAPI meeting was held with the medical director, Administrator, Social Worker, and Director of Nurses about the plan the facility has in place after Resident #1's fall incident on 02/12/2026.Director of Nurses and ADON will meet 3 times per week and follow up with fall interventions. The Director of Nurses and ADON will enter each residents rooms (fall risk residents) and ensure fall interventions are in place. This will be ongoing for next three months.Director of Nurses will at least five times per week monitor residents with unwitness falls or resident hit their head during a fall to ensure neuro checks and assessments are completed and physician was notified.This will be ongoing for the next three months.Director of Nurses or Designee will interview residents with a fall to determine if the resident had pain and what level was the pain. Interview on 03/02/2026 at 12:00 p.m., CNA C stated she worked from 6:00 p.m. to 6:00 a.m. on 02/11/2026 to 02/12/2026. She stated she assisted Resident #1 to bed approximately 6:00 p.m. on 02/11/026. She stated he was asleep her entire shift. CNA C stated she did not see any fall mats in Resident #1's room. She stated he was lying on his back in middle of the bed whenever she entered Resident #1's room. CNA C stated she had been a CNA approximately 20 years. She stated she knew her residents and the care the residents required from nursing. CNA C stated it was nurses responsibility to inform CNAs when there were any changes with the residents. She stated she was aware of the Kardex for CNAs to review for the care of each resident. CNA C stated Resident #1 did not have fall mats beside his bed and she was not aware he required fall mats. CNA C stated the last time she saw Resident #1 he was in bed asleep, and his bed was in low position. CNA C did not respond to any other questions about fall mats with Resident #1, his condition. She became agitated when questions was asked about Kardex, Resident #1's bed/fall mats, if he should have had fall mats, etc. The interview was stopped due to her agitation and refusing to answer questions. Interview on 03/02/2026 at 1:13 p.m., via phone call CNA D stated she was working on 02/12/2026 from 6 a.m. to 6 p.m. She stated she was making her morning rounds and when she entered Resident #1 room approximately 6:50 a.m., she observed Resident #1 on the floor beside his bed with blood coming from his head. She stated she asked CNA E to come to Resident #1's room and help her. She stated she requested CNA E to stay with Resident #1 while she found the nurse. She stated she saw RN B and explained she was needed immediately in Resident #1 room he had fallen and was bleeding. She stated RN B immediately went to Resident #1's room and RN B asked her and CNA E to find LVN A. LVN A entered Resident #1's room and RN B and CNA E was talking. She stated RN B exited the room and called 911. CNA D stated when she entered the room Resident #1was on the floor next to the bed. She stated his head was toward the top of the bed and his legs was toward the end of the bed. CNA D stated he was not lying on the floor mats and the bed was in high position. She stated the floor mats was rolled up and leaning against the wall near the window. CNA D stated he was required to have his bed in low position and fall mats were always required to be beside his bed whenever he was lying in bed. She stated Resident #1 was a fall risk. CNA D stated when she asked Resident #1 what happened, he stated he rolled out of bed. She stated if the fall mats had been on the floor beside the bed and the bed was in low position she did not believe he would have had an injury or a head injury. CNA D stated she had been in-serviced on fall protocol and abuse/neglect. She stated if you found a resident on the floor the CNAs were not to touch the resident and immediately call for a nurse. She stated the CNA was to follow the nurse guidance. CNA D stated examples of abuse was the following: physical such as hitting, yelling at a resident, and can be sexual. She stated examples of neglect was not assisting a resident to the bathroom, not giving resident their meals, and/ or not giving resident their medications. In an interview on 03/02/2026 at 1:27 p.m., RN B stated she was on 200 hall and CNA D explained to her she was needed in Resident #1's room immediately he had fallen and there was blood coming from his head. She stated she entered Resident #1 room and he was lying on the floor. She stated his head was facing the head of the bed and feet was toward end of the bed. She stated there was blood on the floor and appeared to be coming from his head. RN B stated resident was approximately 2 or 3 feet from the side of his bed. She stated she asked CNA D and CNA E to find LVN A while she stayed with Resident #1. She stated LVN A entered the room within 5 minutes. RN B stated LVN A asked her to immediately go to the nurses station and call 911. She stated she called 911 and EMS arrived at the facility and transported Resident #1 to the hospital. RN B stated Resident #1 was not lying on fall mats and she did not see any fall mats under him or by the bed. She said she did not notice if there were any fall mats in the room or if the bed was in low position. RN B stated she called the physician on call and left a message, she notified the responsible party, DON, and the Administrator. She stated Resident #1 was a fall risk prior to his fall on 02/12/2026. RN B stated she did not recall if Resident #1 required fall mats or needed his bed in low position prior to his fall on 02/12/2026 and would need to review his chart to find the information. In an interview on 03/02/2026 at 2:41 p.m., LVN A stated CNA D and CNA E came and got her and said she was needed immediately in Resident #1's room that he fell and blood was on the floor. She stated she immediately went to Resident #1's room and Resident #1 was lying on the floor and there was blood on the floor. LVN A stated Resident #1's head was toward the front of the bed and legs were toward the end of the bed. She stated he was lying on the floor and was not lying on any fall mats. LVN A stated she instructed RN B to call 911 immediately and she would stay with Resident #1. She stated RN B called 911. LVN A stated she did not see any floor mats beside Resident #1's bed and did not look in the room to notice if there were fall mats in the room. LVN A stated the bed was not in the lowest position. She stated she thought the bed was mid-position not high and not low. She stated she had been in-serviced on fall protocol, neglect and abuse. She stated if a CNA or any staff except for a nurse found a resident on the floor the staff was not to touch the resident until the nurse observed the resident and did an assessment. She stated she did not have time to do an assessment on Resident #1 he needed to immediately be transferred to the hospital. LVN A stated the nurse was expected to complete head to toe assessment, pain assessment, and obtain vital signs. She stated the physician, Responsible Party, DON, and Administrator were to be contacted. LVN A stated nurses were to follow the guidance of the physician. She stated abuse was when a resident was cussed, hit, or stole money from a resident. She stated neglect was not giving resident their medications, not changing the resident if they were soiled, refusing to assist resident to the bathroom. In an interview on 03/02/26 at 2:46 p.m., CNA E stated CNA D yelled for him to come to Resident #1's room. He stated when he entered Resident #1's room he saw Resident #1 lying on the floor and blood coming from his head. CNA E stated Resident #1 was lying on the floor and there was no floor mats beside his bed. CNA E stated he saw floor mats rolled up against the wall. He stated Resident #1's bed was in high position. CNA E stated he stayed with Resident #1 when CNA D exited the room immediately when he entered to find a nurse. He stated RN B entered the room within less than 5 minutes but did not recall the exact time she entered the room. He stated it was beginning of the shift and he worked 6 a.m. to 6 p.m. on 02/12/2026. CNA E stated when RN B entered the room, she requested for him and CNA D to find LVN A and ask her to come and assist with Resident #1. CNA E stated within 5 minutes or less they (CNA E and CNA D) found LVN A and CNA D told LVN A she was immediately needed in Resident #1's room he had fallen and was bleeding. He stated LVN A immediately walked to Resident #1's room and instructed RN B to go and call 911. CNA E stated RN B called 911 immediately. He stated he exited Resident #1's room CNA D and LVN A was in the room. He stated he had been in-service on fall protocol, abuse, and neglect. He stated if he found a resident on the floor, he would not touch the resident, he would call for help and wait for the nurse and follow the nurses orders. CNA E stated neglect was when staff would not give resident some water, refused to feed a resident or take a resident to the bathroom. He stated abuse could be cussing a resident, hitting a resident, or stealing money or anything from a resident. He stated he had been in-service on falls, abuse and neglect many times and the last time was in February 2026. He stated he did not recall the exact date. Observation on 03/02/2026 at 3:10 p.m. of residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) rooms revealed all residents had fall mats beside their beds. Residents were lying in their beds. There were no concerns noted. In an interview on 03/02/2026 at 4:15 p.m., LVN A stated if fall mats had been beside Resident #1's bed and he had fallen on the fall mats there was a possibility he may not have been injured, or his injury may not have been where he acquired a laceration to his head. In an interview on 03/02/2026 at 4:25 p.m., RN B stated there was a possibility if Resident #1's bed had been in low position and he had fall mats beside his bed he would not have sustained an injury and the laceration to his head might have been prevented. In an interview on 03/02/2026 at 5:11 p.m. CNA F stated she had given Resident #1 care numerous times (she did not recall how many times per week or month). She stated she had given care to Resident #1 on the day shift (6 a.m. to 6 p.m.) and on night shift (6 p.m. to 6 a.m.). CNA F stated Resident #1 was a fall risk prior to his recent fall in February 2026. She stated he required fall mats beside his bed whenever he was in bed. She stated his bed was to be in low position. CNA F stated she worked the night shift and she did not see any fall mats in room she would not assist Resident #1 to be until she found fall mats and placed them beside his bed after she assisted him to bed. CNA F stated she would ensure his bed was in low position. She stated it was on the Kardex prior to his fall in February 2026 (when he had cut on his head) stating Resident #1 was a fall risk, he was to have fall mats and bed in low position. She stated she had been in-service on fall protocol, abuse and neglect. She stated if witnessed a fall or saw a resident on the floor she was not to touch the resident until the nurse entered the room and assessed the resident. She stated she was to follow the nurses advice. CNA F stated abuse was when someone slapped a resident, yelled at a resident or could be sexual abuse. She stated neglect was refusing to give resident their meals, refusing to change their briefs, and refusing to give them water during the day. She stated she had been in-service on fall protocol, abuse and neglect many times and most recently was few weeks ago in February 2026. She stated she did not recall the date. In an interview on 03/02/2026 at 5:30 pm, The Administrator stated all staff was expected to follow care plan interventions. She stated the care plan was in place for the staff to know each resident's physical and emotional needs to prevent falls, injuries, becoming more depressed or have emotional needs. She stated if a staff did not understand the care plan or Kardex the staff was to ask Director of Nurses, Nurse Supervisor or Administrator. She stated if the fall mats were beside Resident #1's bed there was a possibility Resident #1 might not have sustained a laceration. She stated nurses were responsible to ensure CNAs followed the care plan of the Residents. Record review of the facility's Fall Policy, not dated, reflected Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Environmental: utilize low bed if indicated.

Based on observation, interviews, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #2) of 3 residents. The facility failed, on 12/08/25, to ensure two staff members assisted Resident #2 off the toilet and onto her wheelchair. Resident #2 fell and hit her knee on the toilet paper dispenser when CNA E transferred her off the toilet alone. Resident complained of pain. On 12/10/25 an x-ray revealed Resident #2 had a broken femur, was sent to the hospital and had surgery. An Immediate Jeopardy (IJ) was identified on 12/21/2025. The IJ template was provided to the facility on [DATE] at 2:07 pm. While the IJ was removed on 12/22/25 at 7:54 pm, the facility remained out of compliance at a scope of isolated and severity level of no actual harm. Findings included: Record review of Resident #2's face sheet, dated 12/21/25, revealed a ninety-three-year-old woman who was admitted to the facility on [DATE] and readmitted on [DATE]. Her admitting diagnoses included fracture of left femur (a severe break in the thigh bone, causing intense pain, swelling, deformity, and inability to bear weight), peripheral vascular disease (a circulatory problem where narrowed blood vessels outside the heart and brain reduce blood flow to limbs and organs, most commonly the legs, often due to plaque buildup (atherosclerosis), and congestive heart failure (a chronic condition where the heart muscle weakens or stiffens, preventing it from pumping enough blood to meet the body's needs, causing blood and fluid to back up, often into the lungs, legs, and feet).Record review of Resident #2's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns dated 11/23/25 revealed a score of 15 indicating no cognitive issues and Section GG - Functional Abilities - toileting hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement managing an ostomy, include wiping the opening but not managing equipment dependent - helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity.Record review of Resident #2's care plan revealed a focus dated 11/09/25 that indicated Resident #2 had ADL self-care performance deficit with interventions:Toilet use: required staff x2 for assistance dated 11/09/25 and the resident required mechanical aid ([mechanical lift] x2 assist) for transfers dated 07/30/25 and Resident #2 required mechanical aid ([mechanical lift] x2 assist) for transfers dated 07/30/25.Review of the facility's self-report to HHS dated 12/16/25 reflected an incident occurred on 12/08/25 in Resident #2's bathroom and the facility first learned of the incident on 12/10/25. Resident #2's RP reported that [Resident #2's] injury was caused by 1 person assisting her to the bathroom instead of two. Record review of a statement dated 12/08/25 by the ADON reflected, I was notified that [Resident #2] was on the floor by [CNA D] when I entered the restroom I observed the [CNA E] assisting [Resident #2] to the floor. The CNA stated that the [Resident #2] believed she could stand up to get in the chair on her own so she stood up and her [left] knee gave out so she lowered her to the floor before the other CNA could answer the emergency light. I notified the nurse taking care of the resident of the fall. [Resident #2] was assessed and placed back into wheelchair. No apparent injuries were noted at that time.Record review of a statement dated 12/08/25 by CNA E reflected, on Dec. 8th [ 2025] I assisted the resident onto the toilet with another CNA and waited for the emergency light to come on. The other CNA went to go help another resident in the meantime and when the bathroom light came on, I went inside and the resident was ready to get in the wheelchair, so she stood up before the other CNA came back and then her leg gave out and I was forced to lower the resident to the floor. I them immediately went to get help did notify hall 4 nurse. Record review of an interview taken by the Administrator from Resident #2 reflected, On 12/16, I spoke with the resident [Resident #2], about the incident that occurred on 12/8 [2025], the resident raised her two fingers and stated there should have been two people. Record review of an interview taken by the Administrator from Resident #2's RP reflected, On 12/16 [2025], I spoke with the [RP] who mentioned that [Resident #2] was assisted out from the toilet by one staff member instead of two. I stated that I was informed that she was attempting to get out of the commode and her knee gave out, so the CNA assisted her to the floor. [RP] mentioned that [Resident #2] would not attempt to get up without assistance. The [RP] stated that the nurse mentioned exactly what I stated, but there is no way [Resident #2] will attempt to get up without assistance. I told the family that I will investigate. Review of Resident #2's progress note dated 12/15/25 by the DON reflected Resident #2 had a witnessed fall resulting in a fracture to her left femur. After assessment by the nurse and NP in the facility, no immediate injuries were observed. The NP recommended no x-ray at that time. The resident was offered as needed pain medication and accepted at the time of the incident. The facility MD was making rounds the next day and ordered an x-ray of the left hip with results that showed a fracture of the left femur. Resident #2's care escalated to the emergency room per the RP request. Resident #2's statement, I fell in the bathroom. Review of Resident #2's hospital records dated 12/10/25 revealed chief complaint: fall/left femur fracture, mechanism fall, [AGE] year-old female presented to emergency room with a complaint of left hip pain, ground-level fall when the resident was being moved into the bathroom at the nursing facility when she lost her balance and fell. Review of Resident #2's hospital records dated 12/12/25 revealed Resident #2 was postop day 1 from trochanteric femoral nail on the left (an orthopedic implant used to fix hip fractures, particularly those extending down the femur (thigh bone), by stabilizing the broken bone from within, using a metal rod (nail) inserted down the marrow canal and secured with screws). Review of video received from Resident #2's RP reflected Resident #2 transferred on 11/04/25 by CNA M by mechanical lift from her wheelchair to her bed by 1 staff member. Review of video received from Resident #2's RP reflected Resident #2 transferred on 11/05/25 by mechanical lift from her wheelchair to her bed by 1 staff member (name of staff member unknown). Review of video received from Resident #2's RP reflected Resident #2 transferred on 11/07/25 by CNA M by mechanical lift from her wheelchair to her bed by one staff member. Review of video received from Resident #2's RP reflected Resident #2 transferred on 11/07/25 by CNA N by mechanical lift from her wheelchair to her bed by one staff member. Review of video received from Resident #2's RP reflected Resident #2 transferred on 12/07/25 by CNA M alone, no mechanical lift, from her wheelchair to her bed by one staff member. Review of video received from Resident 2's RP reflected Resident #2 transferred on 12/09/25 by mechanical lift from her wheelchair to her bed by one staff member (name of staff member unknown). Review of video received from Resident #1's RP reflected Resident #2 transferred on 12/16/25 by mechanical lift from her wheelchair to her bed by one staff member (name of staff member unknown). Interview on 12/21/25 at 7:42 am with the ADON revealed CNA D came to get the ADON when Resident #2 was on the floor in the bathroom. When the ADON arrived at Resident #2's restroom, CNA E was with Resident #2. The ADON assessed Resident #2 who complained of pain. The ADON said that CNA E was in the restroom with Resident #2 alone when Resident #2 fell. The ADON said Resident #2 was care planned for 2 people to be in the restroom with her. The ADON said that CNA D and CNA E were both present and assisted Resident #2 to the toilet. The ADON said CNA D left Resident #2's room after Resident #2 got on the toilet. The ADON said Resident #2's knees buckled and Resident #2, on the way down to the floor, bumped her knee on the toilet paper dispenser. The ADON said the videos that reflected CNAs operating a mechanical lift to transfer a resident were because of staffing issues. The ADON said they had staffing issues, especially in the evenings, for several months. She said the facility needed a minimum of 7 CNAs in the building and half the time only 4 - 5 CNAs showed up. The ADON said residents fell all the time. She said the lack of staff had gone on for months and a lack of staff had made 1 person transfers a reality. The ADON said the possible negative effect of not having 2 people when transferring a resident who was a 2 person assist and 2 people when transferring a resident by mechanical lift was possible injury to the resident. Interview on 12/21/25 8:47 am with LVN L revealed that she was the facility scheduler. She said they had trouble scheduling nurses and MAs but they did pretty good with CNAs except that CNAs called in a lot. She said she did not feel 2 nurses and 5 CNAs were a sufficient number to staff a shift and address the residents' needs. She said the reason why residents were being transferred by 1 person instead of 2 people was because of lack of staffing. She said the possible negative effect of having 1 person doing a 2 person transfer was the resident could get hurt. She said it was the responsibility of all staff to make sure the residents were being transferred appropriately. Interview via phone on 12/21/25 9:13 am with CNA M revealed that when they were transferring a resident using a mechanical lift, there should always be two staff members transferring the resident. He said residents could get hurt if they only use 1 person when transferring a person with a mechanical lift. He said he sometimes transferred residents by himself using a mechanical lift because of staffing issues. He said they could wait for a second person to come and help with a mechanical lift transfer, but residents had specific requests, and they ere not able to meet them if you had to wait for a 2nd staff member. He said it was the responsibility of everyone to make sure that residents were transferred safely but specifically it was the responsibility of the staff who worked directly with the residents. Interview via phone on 12/21/25 at 9:24 am with the facility MD revealed Resident #2 was wheelchair bound and non-ambulatory. Resident #2 had osteopenia (bones that are weaker than average and residents have an increased risk of developing osteoporosis (a bone disease causing bones to become weak, porous, and brittle, making them prone to fractures) and fracturing bones, especially with age or minor injury). Resident #2's bones were significantly weaker and more prone to fractures and the trauma to her knee when she fell could have caused the fracture because the knee is located at the bottom of the femur. Interview via phone on 12/21/25 at 9:35 am with CNA N revealed that if they ere transferring a resident by mechanical lift or if the resident required 2 people for a transfer, they needed to have 2 people in case anything happened to the resident. CNA N said he had transferred residents who were 2 person transfers by himself multiple times because of the shortage of staff. He said one night (date unknown) he was the only staff member in his hallway. He said there was definitely a shortage of staff at the facility. Interview via telephone on 12/21/25 at 11:02 am with RN C reflected that generally 1 person could transfer a resident operating a mechanical lift, it depended on the resident. RN C said the policy might state that 2 people were needed to operate a mechanical lift but policy was one thing, reality was another thing. She said it was too much for Resident #2's family to expect 2 people to take Resident #2 to the restroom, but that was what the family wanted. She said it was her directive for her staff to follow policy. RN C said she had no control over staffing. Interview via telephone on 12/2125 at 11:19 am with CNA E revealed she and CNA D transferred Resident #2 to the toilet and CNA D left Resident #2 in the care of CNA E. CNA D said she was not in the bathroom at the time Resident #2 fell. CNA D said she had access to the Kardex (an electronic a quick-reference patient care system that included the resident's transfer status) and Resident #2 was a 2 person transfer both on and off the toilet. CNA D said she told CNA E to call her if she needed assistance transferring Resident #2 off the toilet. CNA D said they had multiple call lights on and after Resident #2 was transferred to the toilet, CNA D left to respond to other resident call lights. CNA D said CNA E found her and told her Resident #2 had fallen. CNA D said she had transferred residents who were 2 person assist by herself multiple times because of staffing issues. She thought 100% the incident with Resident #2 could had have been prevented if the facility had more staff. Interview via telephone on 12/21/25 at 1:05 pm with CNA E revealed she did not know that Resident #2 was a 2 person transfer in the bathroom. She said she did not know how to look at the Kardex. CNA E said she helped Resident #2 in the bathroom the week before by herself and it was fine. She said she was in the bathroom with CNA D and together they transferred Resident #2 to the toilet. She said CNA D left, and CNA D said to call her when Resident #2 was ready to be transferred off the toilet. CNA E said she pulled the light for CNA D to come, but CNA D did not come. She said Resident #2 had been waiting a while and because CNA E transferred Resident #2 the week before with no problem she tried it again. CNA E said when Resident #2 was standing up Resident #2 was a little shaky and Resident #2 was too heavy for her. CNA E said she was behind Resident #2 and when Resident #2 was lowered to the floor, Resident #2's knee hit the bottom of the toilet paper dispenser. CNA E said that CNA D had transferred Resident #2 by herself. She said it would have been better if CNA D had been in the bathroom with her when she transferred Resident #2. CNA E said she and CNA D were the only CNAs who worked that hallway that day and CNA D left after they got Resident #2 on the toilet to answer other resident call lights. She said the facility was sometimes short staffed. She said every CNA and MA transferred residents who were a 2 person transfer with 1 person all the time except when a state surveyor was in the building. Interview on 12/21/25 at 1:18 pm with the DON revealed there was 1 CNA in the bathroom with Resident #2 when she fell. She said that was absolutely a problem because Resident #2 was care planned for a 2 person assist in the bathroom and it posed a risk to Resident #2 for only one person to be in the bathroom with her. She said that there was not a staffing issue every day, but a lot of times they had to send a nurse manager home for the day to come back and work the floor in the evening because they did not have enough staff. She said that staffing was not where it should have been and facility policy was to always follow the residents' care plans. Interview on 12/22/25 at 4:10 pm with the ADON revealed she told the Administrator about the lack of staff availability when mechanical lifts needed to be used for residents. The ADON said multiple staff members were doing 1 person mechanical lift transfers. Interview on 12/22/25 at 5:51 pm with the RNC revealed she did not think the facility had a lack of staff problem that caused Resident #2 to have 1 staff person in the bathroom when Resident #2 needed to transfer from the toilet to her wheelchair. The RNC said it was a lack of staff education about 2 person assist transfers. She said that if there was not someone available to help with a resident transfer that required 2 staff members, staff needed to wait until a 2nd staff member was available before the transfer was made. Interview on 12/22/5 at 6:50 pm with the DON revealed she believed a communication issue caused the problem with Resident #2 not being transferred by 2 people when she was in the bathroom. The DON said the CNAs should have communicated with each other better. She said CNAs should know how to read the resident Kardex. She said it was the responsibility of the ADON, DON, and Administrator to make sure residents were transferred property. She said the possible negative effect of not transferring a resident properly, using the correct number of staff, was the resident could be injured. She said, it would not be ideal, but if there was only one other person in the facility to assist with a 2 person transfer, staff should wait until there were 2 people available to perform the transfer. Interview on 12/22/25 at 7:02 pm with the Administrator revealed Resident #2 stood up in the bathroom and she was assisted to the floor by CNA E. The Administrator said at the time of the incident, there was just a skin tear to Resident #2's knee from where her knee hit the toilet paper dispenser. The Administrator said Resident #2 was care planned for a 2X assist, and there was one person in the bathroom and there should have been two people in the bathroom. Review of the facility policy, undated, Lifting Machine, Using a Mechanical -F689 - Lifting Machine, Using a Mechanical Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines:at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift, or assistance required per manufacturer recommendationsReview of facility policy, undated, Moving A Resident, Bed To Chair/Chair To BedPurpose: The purposes of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the Procedure: Note: This procedure may require two (2) persons The Administrator was notified on 12/21/2025 at 2:07 pm that an IJ had been identified. An IJ template was provided and a POR was requested. The following POR was approved on 12/22/2025 at 9:50 am and indicated: Date: 12/21/25Plan of Removal F689 Free of Accident Hazards/Supervision/DevicesResident #1 fell during a 1 person assist (CNA E) in the bathroom. Which resulted in Resident #1 landing on her knee and fracturing her femur. Resident #1 was seen on video being transferred with a mechanical lift with 1 person assist instead of 2 person assist. All residents requiring 2 person assist with transfers could have been affected by the deficient practice. Interventions:Action: All residents requiring 2 person assist during transfer were assessed by the ADONs and Charge Nurses for any injuries. No additional injuries from an improper transfer were assessed on any residents. Completion date 12/21/25. Inservice Action: The CNA was provided with 1:1 in-service for the following:Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. Mechanical Lifts Transfer: includes 2 certified or licensed staff members who are mandatory to perform a mechanical lift transfer. The staff members will NOT perform the task under any circumstance until the proper number of staff is available. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff is available.CNA Retention Checks: CNA was provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained. Return demonstration was received from CNA with all transfers with rehab director.Provided by: Director of NursingStart Date: 12/21/2025Completion Date: 12/21/2025 The administrator, DON, and ADONs were 1:1 in-serviced by the Regional Compliance Nurse and ADO on the following topics below. Competency was determined by correctly answering a post test. Completed 12/21/25.Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. Mechanical Lift Transfers: includes 2 certified or licensed staff members are mandatory to perform a mechanical lift transfer. The staff members will NOT perform the task under any circumstance until the proper number of staff is available. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff is available. New Process: The administrator and DON will assess and determine staffing levels daily in accordance with the census and facility assessment. If needed, the facility will offer full-time and PRN staff extra shift bonuses to meet any staffing needs. Sign on bonuses will be provided if needed to attract new employees. Company sister facilities will be contacted for assistance with staffing needs if needed. The Administrator/DON will be responsible for building out the schedule at a minimum of 1 week in advance. Open shifts will then be able to be reviewed timely to determine the need for extra shift bonuses or assistance from sister facilities. Training on this new process was provided by the Area Director of Operation. Completion date: 12/21/25.Employee Retention Checks: Administrator and DON were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained.Start Date: 12/21/2025Completion Date: 12/21/2025The Regional Compliance Nurse, Administrator, DON, and ADON will in-service all certified and licensed staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. Staff will sign the in-service sheet to verify that they acknowledge and understand the facility directive. All agency staff will be in-serviced prior to assuming scheduled shift. A posttest will be provided by the Regional Compliance Nurse, DON, and ADON to confirm understanding. Completed 12/21/25.Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. Mechanical Lift Transfers: includes 2 certified or licensed staff members are mandatory to perform a mechanical lift transfer. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff are available. Return demonstration by each staff member will be required for the mechanical transfer check-off. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL, including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff member will NOT perform the task under any circumstance until the proper number of staff is available. Employee Retention Checks: All staff were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained. Post test were conducted and returned to Administrator and DON. Start Date: 12/21/2025Completion Date: 12/21/2025 Involvement of the Medical Director: The Medical Director was notified of the immediate jeopardy citation on 12/21/25 by the Administrator. Completed 12/21/25. ADHOC QAPI: This meeting was conducted on 12/21/25 to include the IDT Team and the Medical Director to review the immediate jeopardy citation and plan of removal. Completed 12/21/25.Please accept this letter as our plan of removal for the determination of immediate jeopardy issued on 12/21/2025. Monitoring: Record review on 12/22/25 of documentation by the ADON and charge nurses that all residents requiring 2 person assist during transfer were assessed for any injuries and no additional injuries from an improper transfer were determined. Record review on 12/22/25 of in-services and interviews on 12/22/25 at 4:24 pm with CNA E reflected she received 1:1 in-service for: Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. Mechanical Lifts Transfer: includes 2 certified or licensed staff members who are mandatory to perform a mechanical lift transfer. The staff members will NOT perform the task under any circumstance until the proper number of staff is available. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff is available.Review on 12/22/25 of the written in-service cheat sheet CNA E was to place in her name badge for quick reference. Interview on 12/22/25 at 4:24 pm with CNA E confirmed she received training from the therapy department on transfers for both mechanical lift and gait belt and demonstration she was competent in safe resident transfers. Interview with the Regional Compliance Nurse on 12/22/25 at 4:30 pm and review of an in-service reflected she in-serviced the Administrator, DON, and ADONs on Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. Mechanical Lift Transfers: includes 2 certified or licensed staff members are mandatory to perform a mechanical lift transfer. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff are available. Return demonstration by each staff member will be required for the mechanical transfer check-off. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL, including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff member will NOT perform the task under any circumstance until the proper number of staff is available.Interview with the ADO 12/22/25 at 5:35 pm and review of an in-service reflected she in-serviced the Administrator, DON, and ADONs on Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. Mechanical Lift Transfers: includes 2 certified or licensed staff members are mandatory to perform a mechanical lift transfer. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff are available. Return demonstration by each staff member will be required for the mechanical transfer check-off. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL, including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff member will NOT perform the task under any circumstance until the proper number of staff is available. Interview with the Administrator on 12/22/25 at 7:13 pm, the DON 6:56 pm, the ADON 3:39 pm and ADON F at 4:11 pm who confirmed they received a 1:1 in-serviced by the Regional Compliance Nurse and ADO on the following topics below. Competency was determined by correctly answering a post test. a. Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. b. Mechanical Lift Transfers: includes 2 certified or licensed staff members are mandatory to perform a mechanical lift transfer. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff are available. Return demonstration by each staff member will be required for the mechanical transfer check-off. c. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL, including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff member will NOT perform the task under any circumstance until the proper number of staff is available. During interviews on 12/22/25 from 3:10 pm - 7:13 pm one RN, seven LVNs, three MAs, and six CNAs from different shifts all stated they were in-serviced before working their shift onAbuse and Neglect Policy: to include failure to provide the proper number of staff needed

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of two residents reviewed for medication administration, in that: The facility failed to ensure they administered Resident #1 a one-time order, dated 12/10/25, of 500 ml of Sodium Chloride 0.9%. Resident #1 instead received approximately 900 ml of Sodium Chloride 0.9%. Resident #1 was sent to the hospital for SOB, and returned the same day with a diagnosis of pneumonia, no fluid overload. The failure placed residents at risk for fluid overload, shortness of breath, blood pressure issues, physical injury to organ failure. Findings included: Record review of Resident #1's face sheet, dated 12/18/25, revealed a seventy-six-year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her admitting diagnoses included acute combined systolic (congestive) and diastolic (congestive) heart failure (the heart struggles to both contract forcefully and relax properly, leading to fluid backup (congestion) in the lungs and body, causing severe symptoms like shortness of breath and swelling), chronic obstructive pulmonary disease (a progressive lung condition making it hard to breathe, characterized by inflamed airways and damaged air sacs (emphysema/bronchitis) leading to persistent cough, wheezing, and shortness of breath), and morbid (severe) obesity due to excess calories (a serious chronic condition defined by a BMI (a measure of body fat based on height and weight) of 40+ or 35+ with severe health issues, often stemming from consistently consuming more calories than the body burns, leading to excess fat storage). Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns dated 12/02/25 revealed a score of 14 indicating no cognitive issues. Record review of Resident #1's care plan revealed a focus dated 12/11/25 that Resident #1 had congestive heart failure and was at risk for fluid volume overload with an intervention dated 01/03/25 to report to the charge nurse any new or increased swelling, breathing problems, change in skin color, or increased difficulty performing tasks. Record review of Resident #1's order dated 12/10/25 reflected Sodium Chloride Solution 0.9% use 500 ml intravenously one time only for dehydration for 1 day; run at 75ml/hour, reassess at 250ml and 500ml. Record review of Resident #1's nurses progress note by the DON dated 12/11/25 reflected, The resident received the wrong dose of IV fluid. Record review of Resident #1's nurses progress note by RN B dated 12/11/25 reflected, [Resident #1] was transferred to a hospital on [DATE] 12:00 AM related to SOB, O2 sat 85% while pt is on 4L o2 [sic]. Record review of Resident #1's hospital records dated 12/11/25 reflected Resident #1's chief complaint was SOB. The hospital visit diagnoses was a cough and pneumonia. Review of the Provider Investigation Report dated 11/11/25 reflected, The nurse administered 900 ml of sodium chloride 0.9% instead of 500 ml. Resident [#1] was assessed and transferred to the ER. The nurse received an order to administered [sic] 500 ml sodium chloride 0.9% to the resident [#1] for dehydration. The nurse hung a 1000 ML bag. According to the nurse, he reported to the incoming nurse who was assigned to another Hall about the order and treatment plan, since his relieve [sic] was running late. The nurse assigned to the resident stated she was not informed, and did not read the order. During her last round, she noted 450-550 ml and was instructed by the incoming nurse to continue the infusion. Incoming nurse denied being given such direction. He went to the room and discontinued the IV. Around 8:01 am on 12/11 [2025] the resident complained of shortness of breath. The provider was notified and order [sic] oxygen therapy. Resident symptoms didn't improve and was transferred to the ER. The resident had a diagnosis of pneumonia. Record review of a statement by LVN A undated reflected, During my shift on 12/10/25, I arrived to the facility for my NOC shift at 1830. There was on the NOC nurse for 300/400. During my round, upon assessment, it was observed at 0650 that resident had approximately 800 - 700 ml of Normal Saline in the bag. During my mid early morning rounds, I went to get the U/A that was ordered and also to administer the resident's Synthroid, there still was alot of fluid left in the bag. I had to take care of a resident on 200 for quite some time. When I made my last rounds, the resident had approx. 450-550 ml remained [sic] at around 0551. The dayshift RN advised meto [sic] allow the infusion to continue until he was able to consult with the Nurse Practitioner (NP) citing concern regarding the resident Systolic BP [the top number in a blood pressure reading, measuring the pressure in your arteries when your heart beats and pushes blood out], which was noted to be I the [sic] high 90s. Resident was stable @ 0600. Report given to [RN B]. This nurse left the facility @ or around 0647. Record review of a statement by RN B dated 12/11/25 reflected, report to night nursing staff to end NS drip for patient [Resident #1] at 500 ml and reassess. In am when I returned to work and rounded I saw that the whole 1000 ml bag was nearly gone. I immediately stopped IV and reported to the ADON. Interview on 12/18/25 at 9:57 am with the DON revealed the PPHP NP wrote the order for Resident #1 to receive Sodium Chloride Solution 0.9% 500 ML intravenously. The DON said that the PPHP NP spoke with the MDS nurse about the order who relayed the information to the charge nurse, RN B. The DON said they did not have a Sodium Chloride Solution 0.9% bag of 500 ML, only a 1,000 ML fluid bag. The MDS nurse relayed the order to the charge nurse, RN B, who pulled the 1,000 ML fluid bag from the emergency kit and hung the fluid. RN B gave report to LVN C, the oncoming charge nurse. The DON said he told LVN C to stop the fluids 500 ML. The DON said that when RN B returned the following morning and checked Resident #1, it was evident that Resident #1 had received more than 500 MLs of Sodium Chloride Solution 0.9%. She said RN B said the bag was almost empty and it was estimated she received 900 MLs of Sodium Chloride Solution 0.9%. The DON said RN B told her he stopped the IV and assessed Resident #1. The DON said RN B said that Resident #1's O2 saturation was a little low and she had SOB. The DON said RN B told her he notified the facility practitioner who recommended Resident #1 be sent to the hospital for evaluation. The DON said the hospital diagnosed Resident #1 with pneumonia and Resident #1 returned to the facility the same day. The DON said the resident receiving approximately 900 MLs of Sodium Chloride Solution 0.9% instead of the prescribed 500 MLs was a medication error. The DON said it was the responsibility of nursing management, that consisted of the DON, ADON, and charge nurse to have made sure there were no medication errors. The DON said the possible negative effects of a medication error were that residents could have an unneeded hospital transfer. The DON said the nurse on duty should have rounded on Resident #1 every two hours and calculated the IV flow rate for the time that the IV would have been lowered to 500 MLs. The DON said she did not feel that Resident #1 suffered harm, and the facility took the right action when the error was discovered. The DON said Resident #1 returned stable from the hospital that same day with no significant changes to her orders except for antibiotics for Resident #1's diagnoses of pneumonia. Interview on 12/18/25 at 10:32 am with Resident #1 revealed that the facility did not tell her that she was given too much IV fluid and she did not remember why she went to the hospital. She thought it was because of her cough and she was spitting up green stuff. Interview on 12/18/25 at 10:46 am with the facility NP revealed there was an order for Resident #1 to receive 500 MLs of Sodium Chloride Solution 0.9% that was given by the PPHP NP. The facility NP said that when Resident #1 received approximately 900 MLs of Sodium Chloride Solution 0.9% that was communicated to the PPHP NP. The NP for the facility said Resident #1 received too much fluid and had SOB that could present as fluid overload. The NP for the facility said SOB was a classic symptom of fluid overload. The facility NP said the chest x-ray from the hospital reflected Resident #1 had pneumonia. She said Resident #1 receiving approximately 500 MLs more Sodium Chloride Solution 0.9% than prescribed was a medication error and a huge snafu. The facility NP said that RN B marked with a pen on the outside of Resident #1's fluid bag at the 500 ML mark to indicate where to stop the fluid. She said the nurse on duty should have calculated the flow rate and the time to stop the bag when it reached 500 MLs. Interview via phone on 12/28/25 at 4:58 with LVN A revealed that she arrived late for her shift on 12/10/25. Her shift began at 6:00 pm and she arrived closer to 7:00 pm. She said it was very busy when she arrived. She said she did not receive report from the nurse who worked prior to her shift and did not know Resident #1 was on an IV bag. She said when she sat down at the computer, she did see the order for Resident #1's IV bag but got distracted and did not check Resident #1's IV. She said when the day shift started RN B asked her if anyone gave her report and she said no. RN A told her the IV should have been stopped at 500 MLs. She said she was informed by the DON that Resident #1 received too much fluid and the facility suspended her. She said she did not receive either a written report or a verbal report from a nurse during her shift beginning on 12/10/25 and ending 12/11/25. She said she should have asked the nurse on shift if there was anything additional she should have know or called RN A and asked him to give her report from his shift. She said she made a mistake and learned her lesson. She said it was her responsibility to review any new resident orders. She said if a resident got too much fluid, it could result in fluid overload. Interview on 12/18/25 at 5:24 pm via phone with the facility MD revealed he knew that Resident #1 received approximately 400 MLs too much fluid. The facility MD said Resident #1 did not have fluid overload and Resident #1's hospital BNP (a hormone that helps regulate blood pressure and fluid balance) of 227 did not indicate that Resident #1 had fluid overload and BNP was chronically elevated in a person with CHF. He said Resident #1 probably had SOB because she had pneumonia which was what was revealed in the hospital chest x-ray. Interview on 12/19/25 at 12:42 pm with RN A revealed an order was written on 12/10/25 for Resident #1 for Sodium Chloride Solution 0.9% IV not to exceed 500 MLs. RN A said his shift ended and LVN A was late for her shift, and he gave report to LVN C to give to LVN A and he told LVN C to not let LVN A forget to stop Resident #1's IV fluids. RN A said he did not know if LVN C gave LVN A the report. RN A said he came in on 12/11/25 and checked on Resident #1 and her IV had not been stopped. He said he immediately stopped the bag and assessed Resident #1. He said Resident #1 complained of wheezing and he spoke with the NP who said to send Resident #1 to the hospital. RN A said it was the responsibility of the residents' primary nurse had made sure orders were followed. He said that was a medication error. He said there was a breakdown in the communication between LVN A and LVN C. He said the possible negative effect of this medication error would be fluid overload. Interview via phone on 12/21/25 at 2:43 pm with LVN C reflected RN B told her about Resident #1's IV order. LVN C said she told RN B to write it down and leave the information on the cart so it would not be missed. LVN C said she was busy, and on 12/10/25 she did not speak with LVN A about Resident #1's IV fluids. The next day, on 12/11/25, LVN A said no one told her about the IV fluids for Resident #1 and LVN C said she told RN A to write the information down for LVN A to see. LVN C said Resident #1 receiving fluid exceeded the amount that was ordered was a medication error. She said the charge nurse for that resident was responsible for making sure the resident received medication according to the provider's order. Interview on 12/22/25 at 4:13 pm with the ADON revealed the order for Resident #1's IV fluids was not communicated to the nurse who came on duty. The ADON said anything that was not done in accordance with a provider's order was a medication error. The ADON said it was charge nurses responsibility to have made sure the resident received medications according to what the provider wrote in the order. The ADON said the possible negative effect of giving someone too much fluid was death. She said that all errors can possibility lead to death. Interview on 12/22/15 at 5:15 pm with the RCN revealed Resident #1 receiving too much IV fluid was a communication error that ended up being a medication administration error. The RCN said it was the responsibility of both charge nurses to have made sure that the IV fluids order was communicated. The RCN said RN B should have put the information in writing and LVN C should have tended to the order when she saw it. She said the possible negative effect of giving too much fluid to a resident was fluid overload, which can cause death. Interview on 12/22/25 at 7:02 pm with the Administrator revealed Resident #1 did not get the proper amount of fluids because of a communication problem. The Administrator said there was an IV on the resident and it needed to be checked. The Administrator said if you have any questions about an order or resident care, then you needed to call the prior nurse. She said it was the responsibility of the charge nurse for that resident to have checked report, records, and the computer for new orders. She said providers order was not followed and Resident #1 was given too much fluid. The possible negative effect of giving a resident too much fluid was that the resident could have SOB and be sent to the hospital for evaluation. Review of facility policy Medication Administration and General Guidelines undated reflected, Medications are administered in accordance with written orders of the attending physician.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keysfor 1 of 3 medication carts (Medication Cart #1) reviewed for medication storage. The facility failed to prevent Medication Cart #1 was locked and medications were secure and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the counter medications. Findings included: Observation on 10/28/2025 at 2:37 AM revealed an unlocked medication cart #1 in front of one of one nurses' station. RN C was sitting behind the nurse's station. Interview on 10/28/2025 at 2:40 AM RN C stated she did not realize the medication cart was unlocked. She stated all medication carts were to be locked except when a nurse was obtaining medications from the cart. RN C stated if a resident did ingest medications the resident was allergic to there was a possibility the resident may have a reaction and possibly die. She stated a resident also had a potential of overdosing on medications or give the medications to another resident. RN C stated she had been in-serviced on locking medication carts; however, she did not recall the date of this in-service. Observation on 10/28/2025 at 3:58 AM revealed an unlocked medication cart #1 in front one of one nurses' station. There was not a nurse around the medication cart or around the nurse's station. RN C walked from 300 hall toward the nurses' station approximately 10 minutes after the medication cart was found unlocked by the surveyor. Interview on 10/28/2025 at 4:15AM RN C stated she walked away from the cart to assist a resident down the hall. She stated she thought she locked the medication cart. RN C stated this is second time today I forgot to lock the medication cart. She stated she did not have an explanation of why she did not lock the medication cart. She stated a resident, staff or visitor had access to the medications and anyone could have taken the medications, and no one would have known a resident, staff or visitor had taken the medication. She stated if a resident was allergic to the medication they may need to be hospitalized and possibly could die from an overdose. She stated she did not recall the date she was in-service on locking medication cart. RN C stated the ADON informed her earlier she would be in-serviced today (10/28/2025) on locking medication cart. Interview on 10/28/2025 at 4:35 AM the ADON stated her expectation was for all medication carts to be locked when the nurse was not administering medications. She stated the staff had been in-serviced on securing the medication carts when not in use. ADON stated she was starting an in-service today and she did not recall the last time the facility had in-service on locking medication carts with the nurses and medication aides. She stated it was the nurse's responsibility to ensure the medication cart was locked when not dispensing a resident's medication. Record review of the Facilities Policy on Medication Storage in the Facility, not dated, reflected Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, or staff members lawfully authorized to administer medications.

Based on interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or promote wound healing for one (Resident #1) of three residents reviewed for pressure ulcers. The facility failed to provide treatments on from 10/03/2025 thru 10/09/2025 to a skin tear on Resident #1's shin on the right lower leg. This failure could place residents at risk for worsening skin concerns leading to discomfort, pain, and potential infections. Findings included: Review of Resident #1's face sheet, dated 09/16/2025, reflected a [AGE] year-old male who was admitted on [DATE] with diagnoses which included type 2 diabetes (a chronic condition where the body either does not use insulin properly or does not produce enough insulin, leading to high blood sugar levels), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (memory loss, difficulty with communication, confusion and problems with making decisions the specific underlying cause cannot be identified. The person does not have behaviors with dementia), heart failure- unspecified (a general decline in the heart's ability to pump blood effectively without specifying the underlying cause), unspecified protein -calorie malnutrition (a condition where a person does not consume enough protein and calories to meet their nutritional needs). Review of Resident #1's admission MDS Assessment, dated 09/19/2025, reflected Resident #1 had a BIMS score of 13 which indicated his cognition was intact. Resident #1 was dependent on staff for putting on/taking off footwear, transfers, and toileting hygiene. He required substantial/maximal assistance- (helper does more than half the effort) with showers and lower body dressing. Resident #1 required partial/moderate assistance (helper does less than half the effort) with upper body dressing. Resident #1 had was at risk for developing pressure ulcers/injuries. He had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Resident #1 had a diabetic foot ulcer. Review of Resident #1's Comprehensive Care Plan, revised on 10/16/2025, reflected Resident #1 had diabetes mellitus. Intervention: Check all body for breaks in skin and treat promptly as ordered by doctor. Resident #1 had a skin tear, laceration or abrasion to right leg. Intervention: Perform any wound care as ordered. Monitor and treat pain as indicated. Resident #1 was at risk for falls related to chronic ulcer to right foot. Resident #1 was admitted to facility with deep tissue injury (a type of pressure ulcer where damage occurs to the underlying skin and soft tissue) to right first toe and right heel and diabetes mellitus to right second and third toe (all have been healed). Record review of Resident #1's physician order, dated 09/30/2025, reflected skin tear right shin: cleanse with NS, pat dry with gauze. Apply xeroform and cover with dry dressing. Resident #1's wound treatment was one time a day for wound healing on Monday, Wednesday and Friday every night between 6 PM to 6 AM. Record review of Resident#1's Physician Order, dated 10/09/2025, reflected skin tear right shin: cleanse with NS, pat dry with gauze. Apply calcium alginate and cover with dry dressing, one time a day every Monday, Wednesday, and Friday for wound healing. Record review of Resident #1's Weekly Non-Ulcer Wound Assessment, dated 09/30/2025, reflected Resident #1 had a wound on right shin (lower leg). The type of wound was skin tear. The measurement of the skin tear was length- 2.5 cm, width 1.0 cm, depth 0.1 cm. The skin tear exudate (a fluid, rich in cells and proteins, that leaks from blood vessels into nearby tissues due to inflammation) amount was moderate, color was yellow, and exudate character was clear. There was no odor. Record review of Resident #1's Weekly Non-Ulcer Wound Assessment, dated 10/09/2025, reflected Resident #1 had a wound on right shin (lower leg). The type of wound was skin tear. The measurement of the skin tear was length- 3.0 cm, width 1.0 cm, depth 0.1 cm. The skin tear exudate amount was moderate, exudate color was yellow, and exudate character was clear. Resident #1's skin tear did not have any odor. Record review of Resident #1's treatment record reflected Resident #1 received treatment to his right leg on 10/02/2025, 10/03/2025, 10/06/2025,10/08/2025 and 10/10/2025. Interview on 10/28/2025 at 8:35 AM Treatment Nurse LVN A stated the treatment records was not correct. She stated LVN B documented she completed treatment to Resident #1's right shin on the following dates: 10/06/2025, 10/08/2025, and 10/10/2025 on the treatment administration record by mistake and LVN B did not provide any type of treatment on these dates to Resident #1 right shin. Treatment Nurse LVN A stated Resident #1 did not receive treatment to his right shin from 10/02/2025 until 10/10/2025. She stated she entered the order for Resident #1 on 09/30/2025 and it was the wrong order. Treatment Nurse LVN A stated she made a mistake and entered for Resident #1 to receive treatment to his shin Monday, Wednesday and Friday at night. She stated the order was for him to receive treatment Monday, Wednesday, and Friday once a day, but not at night. She stated Resident #1's family called the facility on 10/09/2025 and reported Resident #1 had a bandage on his right shin with the date 10/02/2025. She stated she immediately reviewed Resident #1's medical record and realized she made a mistake when she entered the order in Resident #1's physician orders in the medical record. Treatment Nurse LVN A stated she immediately called the doctor and the family. She entered the correct order on 10/09/2025. She stated on 09/30/2025 Resident #1 measurement for skin tear to his right shin was 2.5 length, 1.0 width, and 0.1 depth. Treatment Nurse LVN A stated on 10/09/2025 his measurement for skin tear to his right shin was 3.0 length, 1.0 width, and 0.1 depth. She stated if a resident did not receive the appropriate treatment to any skin concerns there was a risk for an infection to the resident's skin. She stated there was also a potential the area of the skin tear, or wound may become larger. The treatment nurse LVN A stated she was responsible to ensure all treatments are completed to all residents with any type of skin concerns. She stated it was the DON and ADON responsibility to monitor treatments. She stated she had been in-serviced on treatments including documenting the correct orders and monitoring treatments. Interview on 10/28/2025 at 8:54 AM Resident #1's Primary Care Physician stated there was no adverse effect of Resident #1 not receiving treatment to skin tear from 10/02/2025 until 10/09/2025. He stated if the measurement increased length .25, he would not have any concerns about Resident #1's skin tear. The Physician stated there was no harm to Resident #1. Interview on 10/28/2025 at 11:45 AM, LVN B stated she accidentally clicked on the treatment form in the electronic medical records that she did treatment on Resident #1's right shin. She stated that was a mistake. She thought she was documenting something else, and she did not give Resident #1 treatment on 10/06/2025, 10/08/2025 or 10/10/2025. She stated she did receive one on one in-service on documentation and completing treatments to skin concerns on residents. LVN B stated she did not recall the exact date; however, she stated it was either 10/11/2025 or 10/12/2025. She stated she worked the night shift, and the night shift nurses did not do routine treatments on skin concerns unless it was a new skin concern. Interview on 10/28/2025 at 2:15 PM ADON stated if a resident did not receive treatment to skin concerns there was a possibility a resident may develop an infection or sepsis ( a life-threatening medical emergency where an infection triggers a dangerous and extreme inflammatory response from the body). She stated the Treatment Nurse was responsible for all treatment orders and to enter the orders into the electronic medical record in the physician orders. The ADON stated it was the DON's and her responsibility to monitor all treatments. She stated she had been in-serviced on monitoring treatments and documenting in the physician orders of the correct treatment including time of the treatment to be completed by nursing staff. She stated Resident #1 did not receive treatment to his right shin between 10/02/2025 and 10/09/2025. She stated LVN B did not treat Resident #1's right shin between the dates 10/02/2025 and 10/09/2025. ADON stated the Treatment Nurse A entered the wrong time for the treatment to be given and this was the reason the treatment for Resident #1 was missed. She stated all nurses were in-serviced on documentation and to double-check new orders entered into the electronic medical records. Record review of the facility's policy on Pressure Injury: Prevention, Assessment and Treatment, dated 05/05/2025, reflected Nursing Personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will notify the physician or pressure sore and obtain and follow any new orders as directed by the physician.

Based on observation, interviews and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 out of 8 residents (Resident #1) reviewed for abuse/neglect. The facility failed to ensure Resident #1 was not neglected by not checking on Resident #1 from 2:40pm - 4:40pm on 08/26/2025. Resident #1 was found outside with a temperature of 104 degrees [F] and sent to the hospital due to being unresponsive and tachycardic (your heart is beating too fast, over 100 times a minute at rest). The temperature on 08/26/25 was a high of 97 degrees [F]. An IJ was identified on 08/28/2025 at 4:15 PM. While the IJ was removed on 08/29/2025 at 10:27 AM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems This deficient practice could place residents at risk of injury, psychosocial harm, hospitalization and death. Findings included: Record review of Resident #1's admission record, dated 08/28/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: multiple sclerosis (a disease where your immune system mistakenly attacks the protective fatty covering around your nerve in the brain and spinal cord), sickle cell (a condition where red blood cells become abnormally sickle), scoliosis (an abnormal sideways curving of the spine that often looks like a C or S shape when viewed from the back), adult failure to thrive (a syndrome not a specific disease, characterized by a general decline in health, marked by weight loss, decreased appetite, poor nutrition, and increased inactivity), and unspecified lack of coordination (trouble controlling you movements, making them jerky, unsteady, and clumsy instead of smooth and precise). Record review of Resident #1's Quarterly MDS assessment, dated 06/06/2025, reflected the resident had a BIMS score of 15, which indicated cognition intact. Resident #1 was dependent in the areas of eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #1's care plan, dated 08/28/2025, reflected Resident #1 wanted to go outside and sit and move himself around by himself. This focus was not added to Resident #1's care plan until 08/28/2025. Review of Resident #1's hospital records, dated 08/26/25, reflected He was apparently left outside in his w/c. He was found to be slumped in the WC with temp of 104 [F]. Initial temp here is 100.4 degrees [F] and he has sinus tachycardia (a normal, but faster than usual, heart rhythm) in the 110s. Record review of the local weather app with outside temperatures for the local area on 08/26/2025 was a high of 97 degrees [F}. Review of Resident #1's readmission Nurses' Note, dated 08/27/25, reflected the reason for his recent hospitalization was systemic inflammatory response syndrome (An exaggerated defense response from your body to a harmful stressor. It causes severe inflammation throughout your body. This can lead to reversible or irreversible organ failure and even death). During an interview with Resident #1 on 08/28/2025 at 12:40 PM, Resident #1 stated that went outside after lunch around 1:30pm. Resident #1 stated the NA A took him outside and left him there. Resident #1 stated that he rolled himself in the sun but did not remember anything after that. Resident #1 stated it was very hot outside and he wanted to go back inside but nobody was around to take him back inside. During an interview with LVN A on 08/28/2025 at 10:25 AM, LVN A stated the NP possibly brought Resident #1 in from outside around 4:40pm, but she was not certain. LVN A stated the NP wheeled the resident to the nurse's station and asked if she could take his vitals because he wasn't responding to touch or verbal commands. LVN A stated she took Resident #1's blood pressure and pulse but did not take Resident #1's temperature. LVN A stated the facility put damp towels on Resident #1's arms, forehead, and the back of his neck to cool him down. LVN A stated she did not know how long Resident #1 was outside and stated she did not see him at 1:15pm when she went to lunch. LVN A stated she was not sure who was responsible for checking on the residents when they sat outside. LVN A stated that a negative outcome could be the resident could have heat exhaustion from sitting in the sun. During an interview with the DON on 08/28/2025 at 10:55 AM, the DON stated she was not aware of how Resident #1 got outside. The DON stated the resident was outside for about 30-45minutes per the GRC. The DON stated when she walked up Resident #1 was at the nurse station with LVN A receiving oxygen. The DON stated that Resident #1's vital were good but he was sent out per the NP. The DON stated that she was not aware that Resident #1's temperature was not taken prior to him going to the hospital. The DON stated while at the nurse station Resident #1 was slumped over with a little bit of drool coming from his mouth. The DON stated Resident #1 was not verbally saying anything at that time. The DON stated she was told that Resident #1 went outside daily to sit in the sun. The DON stated Resident #1 stated that someone would have had to open the door for him due to the resident not being able to open the front door. The DON stated a negative outcome from being in the sun for a long period of time could be heat exhaustion. The DON stated she did not remember the outside temperature on 08/26/2025 but in her opinion the resident did not suffer from heat exhaustion.During an interview with the GRC on 08/28/2025 at 11:05 AM, the GRC stated she did not let Resident #1 outside on 08/26/2025 nor was she aware who did. The GRC stated she went to lunch at 2:40pm and at that time Resident #1 was sitting by the door in the shade. The GRC stated when she returned to the facility around 3:50pm Resident #1 was sitting in the sun (sunning) but stated she did not think nothing of it because he was talking to her as she entered the facility. The GRC stated she did not see anyone bring Resident #1 back in the facility. The GRC stated prior to the incident residents who sat in front of the building were not required to sign out. The GRC stated that she was not sure who was supposed to check on the residents that sat outside. During an interview with the NP on 08/28/2025 at 11:45 AM, the NP stated someone came inside and told her there was a resident on the sidewalk that needed help. The NP stated she did not know the lady that alerted her about Resident #1 but thought it could have been a family member visiting the facility. The NP stated she did not know how long Resident #1 was outside. The NP stated she took Resident #1 immediately to the nurse station around 4:40pm. The NP stated that Resident #1 received oxygen, and damp cool rags prior to being taken by EMS. The NP stated Resident #1 was unresponsive but breathing. The NP stated when EMS put Resident #1 on the stretcher, he began to become alert. The NP stated it was 5-7 minute from the time she brought Resident #1 inside before EMS arrived. The NP stated a negative outcome would have to depend on the temperature outside and how long the resident was in the sun. The NP stated if Resident #1 suffered a heat stroke/heat exhaustion there would be signs of organ damage in which Resident #1 did not have. During an interview with NA A on 08/28/2025 at 1:10 PM, NA A stated he assisted Resident #1 outside around 2:40 PM. NA A stated that Resident #1 was outside of the front door in the shaded area. NA A stated that Resident #1 was able to self-propel his wheelchair. NA A stated he did not check on Resident #1 while he was outside. NA A stated it was not until Resident #1 was brought in the facility unresponsive before he had seen him again. NA A stated when Resident #1 was brought in the facility, Resident #1 had his head down unresponsive and drooling. NA A stated he was the NA responsible for checking on the residents on Resident #1 hall. NA A stated that NAs were supposed to make rounds at least every two hours. NA A stated during rounds they should check to see if a resident needs water, go to the restroom and check to see if the resident was comfortable. NA A stated he was no aware who was responsible for checking on the residents when they were outside. NA A stated a negative outcome form a resident being left outside on a hot day would be the resident could pass out and no one would know. During a interview with the ADM on 08/29/2025 at 2:45 PM, the ADM stated no one was assigned to check on Resident #1 while he was outside. The ADM stated Resident #1 was outside for 30-45 minutes per the GRC. The ADM stated prior to Resident #1 going to the hospital his vitals were within normal limits. The ADM stated that she was not aware the Resident #1's temperature was not taken prior to him going to the hospital. The ADM stated a negative outcome from sitting in the sun could be heat exhaustion. A record review of the facility's Abuse/Neglect policy, undated, reflected The resident has the right to be free of abuse neglect, and misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment or residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Definitions 7 Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. This was determined to be an Immediate Jeopardy on 08/28/2025 at 4:15 PM. The ADM was notified. The ADM was provided with the IJ template on 08/28/2025 at 4:15 PM. The Plan of Removal was accepted on 08/29/2025 at 10:27 AM and included the following: All listed items will be completed by 08/29/2025 with continued follow-up: Resident #1 was assessed by the DON for any signs of heat exhaustion on 8/28/25. No further signs and symptoms of heat exhaustion were noted. All residents who have been observed to be sitting outside in the last 24hrs were assessed for any signs of heat exhaustion by the DON, ADON and Charge Nurses. No further residents were noted with any signs of a change in condition. 3. The Administrator and DON were in-serviced 1:1 on the following policies:a. Abuse and Neglect: failure to check on residents every 1 hour while outside during hot weather could result in harm and be considered neglect. b. Notification of a change in condition policy: including sign and symptoms of heat exhaustion such as lethargy, unresponsive, and elevated temperature, excessive sweating, thirst cramping or elevated temperature. c. Residents who are sitting out on porch will be rounded on every 1hr. They will be checked on by the charge nurses, CNAs or designee for any signs of heat exhaustion and offered hydration. Staff rounds will continue during the hot weather until further directed by the Administrator. A sign out sheet/binder has been implemented by the administrator for residents that go outside of the facility. Staff have been in-serviced on this process. d. New Process: a hydration cooler will be placed outside of residents who sit on the porch. The charge nurse, CNA or designated staff member will round every hour on all residents outside for any signs of heat exhaustion. The staff members will offer residents hydration and the opportunity to return inside the facility. If any resident shows signs of heat exhaustion, the charge will be notified immediately. This process will start 8/28/25 and continue indefinitely. 4. Administrator and DON were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained. 5. All staff were in-serviced on the following topics: Abuse and Neglect, notification of a change in condition policy, check on resident sitting outside every hour, signs and symptoms of heat exhaustion, and the hydration cooler placed outside for resident who sit outside. Any staff member not present or in-serviced as of 8/28/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completion date 8/29/25. 6. A hydration cooler was placed outside for residents who sit on the porch. The charge nurse, CNA or designated staff member will round every hour on all residents outside for any signs of heat exhaustion. The staff members will offer residents hydration and the opportunity to return inside the facility. If any resident shows signs of heat exhaustion, the charge will be notified immediately. 7. Involvement of the Medical Director: The medical director was notified of the immediate jeopardy on 8/28/25 by the DON. 8. ADHOC QAPI: This meeting was completed by the interdisciplinary team to include the Medical Director on 08/28/2025 Monitoring: During an observation on 08/29/2025 at 9:45 AM, reflected there was 3 resident outside near the hydration cooler. The hydration cooler was observed to have cold water in it. Record review of the facility's Resident Sign Out/In sheet on 08/29/2025 at 9:50 AM, reflected the current residents sitting outside had been signed out properly. Record review of the facility's Nursing Progress notes on 08/29/2025 at 10:00 AM, reflected there was 5 residents observed setting outside in the last 24 hours. All were assessed and there were no signs of heat exhaustion noted. Record review of the facility's Abuse and Neglect, Notification of a change in condition policy, check on resident sitting outside every hour, Signs and symptoms of heat exhaustion, and the hydration cooler placed outside for resident who sit outside inservices, on 08/29/2025 at 10:00 AM, reflected the ADM and DON had been inserviced on those topics. Record review of the facility's Monitoring Chart sheet on 08/29/2025 at 10:30 AM, reflected the resident sitting outside were being monitored hourly. Record review of the facility's Off Cycle (ADHOC) QA meeting document on 08/29/2025 at 10:45 AM, reflected the QA meeting was conducted on 08/28/2025 and there were 6 member that attended the meeting. During an observation on 08/29/2025 at 11:00 AM, reflected a CNA was monitoring the resident outside of the facility. During interviews and observations on 08/29/2025 from 12:00 pm - 1:30 pm with 14 staff members (3 6am - 6pm LVNs, 3 6am-6pm CNAs, 2 6pm - 6 am LVNs, 2 6pm - 6am CNAs, 2 7:00 am - 3pm housekeepers, 2 dietary staff), reflected they were able to articulate information from the following in-services: abuse and neglect, notification of a change in condition policy, check on resident sitting outside every hour, signs and symptoms of heat exhaustion, and the hydration cooler placed outside for resident who sit outside. All staff interviewed were observed with their in-service cheat sheet in their name badge. During an interview with the DON on 08/29/2025 at 2:30 PM, the DON was able to articulate information from the following in-services: abuse and neglect, notification of a change in condition policy, check on resident sitting outside every hour, signs and symptoms of heat exhaustion, and the hydration cooler placed outside for resident who sit outside. The DON was observed with her in-service cheat sheet in their name badge. During an interview with the ADM on 08/29/2025 at 2:45 PM, the ADM was able to articulate information from the following in-services: abuse and neglect, notification of a change in condition policy, check on resident sitting outside every hour, signs and symptoms of heat exhaustion, and the hydration cooler placed outside for resident who sit outside. The ADM was observed with her in-service cheat sheet in their name badge.While the IJ was removed on 08/29/2025 at 10:27 AM, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interviews and record review the facility failed to ensure each resident received adequate supervision for 1 of 8 resident (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 had adequate supervision or was checked on for over two hours as he was found outside on 08/26/25 with a temperature of 104 degrees [F] and sent to the hospital due to being unresponsive and tachycardic (your heart is beating too fast, over 100 times a minute at rest). The temperature on 08/26/25 was a high of 97 degrees [F]. An IJ was identified on 08/28/2025 at 4:15 PM. While the IJ was removed on 08/29/2025 at 10:27 AM, the facility remained out of compliance at a level of no actual harm at a scope of isolated with a potential for more than minimal harm, that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems This deficient practice placed residents at risk for falls, injuries, dehydration, hospitalization, and death. Findings included: Record review of Resident #1's admission record, dated 08/28/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: multiple sclerosis (a disease where your immune system mistakenly attacks the protective fatty covering around your nerve in the brain and spinal cord), sickle cell (a condition where red blood cells become abnormally sickle), scoliosis (an abnormal sideways curving of the spine that often looks like a C or S shape when viewed from the back), adult failure to thrive (a syndrome not a specific disease, characterized by a general decline in health, marked by weight loss, decreased appetite, poor nutrition, and increased inactivity), and unspecified lack of coordination (trouble controlling you movements, making them jerky, unsteady, and clumsy instead of smooth and precise). Record review of Resident #1's Quarterly MDS assessment, dated 06/06/2025, reflected the resident had a BIMS score of 15, which indicated cognitive intact. Resident #1 was dependent in the areas of eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #1's care plan, dated 08/28/2025, reflected Resident #1 want to go outside and sit and move himself around by himself. This focus was not added to Resident #1's care plan until 08/28/2025. Review of Resident #1's hospital records, dated 08/26/25, reflected He was apparently left outside in his w/c. He was found to be slumped in the WC with temp of 104 [F]. Initial temp here is 100.4 degrees [F] and he has sinus tachycardia (a normal, but faster than usual, heart rhythm) in the 110s. Record review of the local weather app with outside temperatures for the local area on 08/26/2025 was a high of 97 degrees [F}. Review of Resident #1's readmission Nurses' Note, dated 08/27/25, reflected the reason for his recent hospitalization was systemic inflammatory response syndrome (An exaggerated defense response from your body to a harmful stressor. It causes severe inflammation throughout your body. This can lead to reversible or irreversible organ failure and even death). During an interview with the Resident #1 on 08/28/2025 at 12:40 PM, Resident #1 stated that went outside after lunch around 1:30pm. Resident #1 stated that NA A took him outside and left him there. Resident #1 stated that he rolled himself in the but doesn't remember anything after that. Resident #1 stated it was very hot outside and he wanted to go back inside but nobody was around to take him back inside. During an interview with the LVN A on 08/28/2025 at 10:25 AM, the LVN A stated the NP possibly brought Resident #1 in from outside around 4:40pm, but she was not certain. LVN A stated that the NP wheeled the resident to the nurse's station and asked if she could take his vitals because he wasn't responding to touch or verbal commands. LVN A stated she took Resident #1 blood pressure, pulse, but did not take Resident #1 temperature. LVN A stated the facility put damp towels on Resident #1's arms, forehead, and the back of the neck to cool him down. LVN stated she did not know how long Resident #1 was outside but stated she did not see him at 1:15pm when she went to lunch. LVN stated she was no sure who was responsible for checking on the residents when they sat outside. LVN A stated that a negative outcome could be resident could have heat exhaustion from setting in the sun. During an interview with the DON on 08/28/2025 at 10:55 AM, the DON stated she was not aware of how Resident #1 got outside. The DON stated that resident was outside for about 30-45minutes per the GRC. The DON stated when she walked up the Resident #1 was at the nurse station with LVN A receiving oxygen. The DON stated that Resident #1 vital were good but was sent out per the NP. The DON stated that she was not aware that Resident #1 temperature was not taken prior to him going to the hospital. The DON stated while at the nurse station Resident #1 was slumped over with a little bit of drool coming from his mouth. The DON stated Resident #1 was not verbally saying anything at that time. The DON stated she was told that Resident #1 goes outside daily to sit in the sun. The DON stated Resident #1 stated that someone would have had to open the door for Resident due to the resident not being able to open the front door. The DON stated there was nothing in place to monitor resident while they were outside. The DON stated a negative outcome from being in the sun for a long period of time could be heat exhaustion. The DON stated she does not remember the outside temperature on 08/26/2025 but in her opinion the resident was not suffering from heat exhaustion. During an interview with the GRC on 08/28/2025 at 11:05 AM, the GRC stated she did not let Resident #1 outside on 08/26/2025 nor was she aware who did. The GRC stated she went to lunch at 2:40pm and at that time Resident #1 was sitting by the door in the shade. The GRC stated when she returned to the facility around 3:50pm Resident #1 was sitting in the sun (sunning) but stated she did not think nothing of it because he was talking to her as she entered the facility. The GRC stated she did not see anyone bring Resident #1 back in the facility. The GRC stated prior to the incident resident who sat in front of the building were not required to sign out. The GRC stated that she was no sure who was supposed to check on the resident that sit outside. During an interview with the NP on 08/28/2025 at 11:45 AM, the NP stated someone came inside and told her they there the resident on the sidewalk that needed help. The stated she did not know the lady that alerted her about Resident #1 but thinks it could have been a family member visiting the facility. The NP stated she did not know how long Resident #1 was outside. NP stated she took Resident #1 immediately to the nurse station 4:40pm. The NP stated that Resident #1 received oxygen, and damp cool rags prior to being taken by EMS. The NP stated Resident #1 was unresponsive but breathing. The NP stated when EMS put Resident #1 on the stretcher, he began to be alert. The NP stated it was 5-7 minute from the time she brought Resident #1 inside before EMS arrived. The NP stated a negative outcome would have to depend on the temperature outside and how long the resident was in the sun. The NP stated if Resident #1 suffered a heat stroke/heat exhaustion there would be signs of organ damaged in which Resident #1 did not have. During an interview with the NA A on 08/28/2025 at 1:10 PM, NA A stated he assisted Resident #1 outside around 2:40 PM. NA A stated that Resident #1 was placed outside of the front door in the shaded area. NA stated he did not check on Resident #1 while he was outside. NA A stated it was not until Resident #1 was brought in the facility unresponsive before he had seen him again. NA A stated when Resident #1 was brought in the facility, Resident #1 had his head down unresponsive and drooling. NA A stated he was the NA responsible for checking on the resident on Resident #1 hall. NA A stated that NAs are supposed to make rounds at least every two hours. NA A stated during round you should check to see if a resident needs water, go to the restroom and check to see if the resident was comfortable. NA A stated he was no aware on who was responsible for checking on the residents when they were outside. NA A stated a negative outcome form a resident being left outside on a hot day would be the resident could pass out and no one would know. During an interview with the ADM on 08/29/2025 at 2:45 PM, the ADM stated no one assigned to check on Resident #1 while he was outside. The ADM stated there was nothing in place to monitor resident while they were outside. The ADM stated Resident #1 was outside for 30-45 minutes per the GRC. The ADM stated prior to Resident #1 going to the hospital his vital were within normal limits. The ADM stated that she was not aware the Resident #1 temperature was not taken prior to him going to the hospital. The ADM stated a negative outcome from sitting in the sun could be heat exhaustion. Review of the facility's Resident Rights policy, revised dated 11/28/2016, reflected The residents has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognized each resident's individuality. The facility must protect and promote the rights of the resident. Respect and dignity - The resident has a right to be treated with respect and dignity, including:3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of other residents. This was determined to be an Immediate Jeopardy on 08/28/2025 at 4:15 PM. The ADM was notified. The ADM was provided with the IJ template on 08/28/2025 at 4:15 PM. The Plan of Removal was accepted on 08/29/2025 at 10:27 AM and included the following: All listed items will be completed by 08/29/2025 with continued follow-up: Resident #1 was assessed by the DON for any signs of heat exhaustion on 8/28/25. No further signs and symptoms of heat exhaustion were noted. All residents who have been observed to be sitting outside in the last 24hrs were assessed for any signs of heat exhaustion by the DON, ADON and Charge Nurses. No further residents were noted with any signs of a change in condition. 3. The Administrator and DON were in-serviced 1:1 on the following policies:a. Abuse and Neglect: failure to check on residents every 1 hour while outside during hot weather could result in harm and be considered neglect. b. Notification of a change in condition policy: including sign and symptoms of heat exhaustion such as lethargy, unresponsive, and elevated temperature, excessive sweating, thirst cramping or elevated temperature. c. Residents who are sitting out on porch will be rounded on every 1hr. They will be checked on by the charge nurses, CNAs or designee for any signs of heat exhaustion and offered hydration. Staff rounds will continue during the hot weather until further directed by the Administrator. A sign out sheet/binder has been implemented by the administrator for residents that go outside of the facility. Staff have been in-serviced on this process. d. New Process: a hydration cooler will be placed outside of residents who sit on the porch. The charge nurse, CNA or designated staff member will round every hour on all residents outside for any signs of heat exhaustion. The staff members will offer residents hydration and the opportunity to return inside the facility. If any resident shows signs of heat exhaustion, the charge will be notified immediately. This process will start 8/28/25 and continue indefinitely. 4. Administrator and DON were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained. 5. All staff were in-serviced on the following topics: Abuse and Neglect, notification of a change in condition policy, check on resident sitting outside every hour, signs and symptoms of heat exhaustion, and the hydration cooler placed outside for resident who sit outside. Any staff member not present or in-serviced as of 8/28/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completion date 8/29/25. 6. A hydration cooler was placed outside for residents who sit on the porch. The charge nurse, CNA or designated staff member will round every hour on all residents outside for any signs of heat exhaustion. The staff members will offer residents hydration and the opportunity to return inside the facility. If any resident shows signs of heat exhaustion, the charge will be notified immediately. 7. Involvement of the Medical Director: The medical director was notified of the immediate jeopardy on 8/28/25 by the DON. 8. ADHOC QAPI: This meeting was completed by the interdisciplinary team to include the Medical Director on 08/28/2025 Monitoring: During an observation on 08/29/2025 at 9:45 AM, reflected there was 3 resident outside near the hydration cooler. The hydration cooler was observed to have cold water in it. Record review of the facility's Resident Sign Out/In sheet on 08/29/2025 at 9:50 AM, reflected the current residents sitting outside had been signed out properly. Record review of the facility's Nursing Progress notes on 08/29/2025 at 10:00 AM, reflected there was 5 residents observed setting outside in the last 24 hours. All were assessed and there were no signs of heat exhaustion noted. Record review of the facility's Abuse and Neglect, Notification of a change in condition policy, Check on resident sitting outside every hour, Signs and symptoms of heat exhaustion, and The hydration cooler placed outside for resident who sit outside inservices, on 08/29/2025 at 10:00 AM, reflected the ADM and DON had been inserviced on those topics. Record review of the facility's Monitoring Chart sheet on 08/29/2025 at 10:30 AM, reflected the resident sitting outside were being monitored hourly. Record review of the facility's Off Cycle (ADHOC) QA meeting document on 08/29/2025 at 10:45 AM, reflected the QA meeting was conducted on 08/28/2025 and there were 6 member that attended the meeting. During an observation on 08/29/2025 at 11:00 AM, reflected a CNA was monitoring the resident outside of the facility. During interviews and observations on 08/29/2025 from 12:00 pm - 1:30 pm with 14 staff members (3 6am - 6pm LVNs, 3 6am-6pm CNAs, 2 6pm - 6 am LVNs, 2 6pm - 6am CNAs, 2 7:00 am - 3pm housekeepers, 2 dietary staff), reflected they were able to articulate information from the following in-services: abuse and neglect, notification of a change in condition policy, check on resident sitting outside every hour, signs and symptoms of heat exhaustion, and the hydration cooler placed outside for resident who sit outside. All staff interviewed were observed with their in-service cheat sheet in their name badge. During an interview with the DON on 08/29/2025 at 2:30 PM, the DON was able to articulate information from the following in-services: abuse and neglect, notification of a change in condition policy, check on resident sitting outside every hour, signs and symptoms of heat exhaustion, and the hydration cooler placed outside for resident who sit outside. The DON was observed with her in-service cheat sheet in their name badge. During an interview with the ADM on 08/29/2025 at 2:45 PM, the ADM was able to articulate information from the following in-services: abuse and neglect, notification of a change in condition policy, check on resident sitting outside every hour, signs and symptoms of heat exhaustion, and the hydration cooler placed outside for resident who sit outside. The ADM was observed with her in-service cheat sheet in their name badge. While the IJ was removed on 08/29/2025 at 10:27 AM, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation and interview, and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 3 (08/26/2025, 08/27/2025, 08/28/2025) of 4 days reviewed for nurse staffing posting.The facility failed to post the daily staffing information in a prominent place on 08/26/2025, 08/27/2025, and 08/28/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings:During an observation on 08/28/2025 at 9:06 am, revealed the nursing staffing information posted outside out the DON's office was dated 08/25/2025.During an interview with the DON on 08/29/2025 at 2:30 PM, the DON stated she was responsible for posting the nursing staffing information. The DON stated she had not posted the nursing staff information since 08/25/2025. The DON stated the residents would not be affected by the nursing information not being posted. The DON stated the nursing staffing show transparency of the number of staff present for each shift. During an interview with the ADM on 08/29/2025 at 2:45 PM, the ADM stated the nursing staffing information should be posted daily. The ADM it was the DON's or the ADON's responsibility to ensure it was posted daily. The ADM stated the purpose of posting the nursing staffing information was to show that the facility had adequate staffing. The ADM stated the residents would not suffer any adverse effects if the nursing staff information was not posted. The ADM stated the facility did not have a policy regarding the posting of the nursing staff information.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3 call light was within reach on 06/03/2025. This failure could place residents at risk of their needs not being met. Findings include: Record review of Resident #3's admission record, dated 06/03/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: unspecified dementia severity without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety (memory loss and thinking difficulties), major depressive disorder (mental health condition characterized by persistent feelings of sadness, loss of interest, and reduce functioning in various areas of life), and essential primary hypertension (high blood pressure). Record review of Resident #3's admission MDS assessment, dated 05/08/2025, reflected the resident had a BIMS score of 06, which indicated severe cognitive impairment. Resident #3 was dependent in the areas of toileting hygiene and putting on/taking off footwear. Resident #3 required substantial/maximal assistance in the areas of shower/bathe self, lower body dressing, and personal hygiene. Record review of Resident #3's care plan, dated 06/03/2025, reflected Resident #3 was care planned for falls r/t impaired mobility function, cognition and communication and had an intervention of be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an interview and observation on 06/03/2025 at 9:20 AM., Resident #3 was observed sitting in his recliner while his call light on the ground approximately 2 feet away from him. Resident #3 was not able to be interviewed due to his cognitive impairment. During an interview and observation on 06/03/2025 at 11:05 AM., Resident #3 was observed sitting in his recliner while his call light on the ground approximately 2 feet away from him. Resident #3's call light was observed in the same location from the previous observation on 9:20 AM on 06/03/25. During an interview on 06/03/2025 at 3:10 PM, CNA A stated she was the CNA for Resident #3. CNA A stated that she was not aware that the resident's call light was not within reach from 9:20am - 11:05am. CNA A stated she was not working with Resident #3 during those times. CNA A stated there was a CNA working with Resident #3 at those times. CNA A stated that the other CNA left to go to an appointment. CNA A stated that once she put Resident #3 in his bed after lunch, she places his call light within reach. CNA A stated that was everyone responsible to ensure call lights were within reach. CNA A stated if a resident's call light was not within reach, then the resident would not be able to call for assistance. During an interview with the DON on 06/03/2025 at 4:30PM, the DON stated all residents call lights should be always within reach. The DON stated it was everyone's responsibility to ensure residents call lights were always within reach. The DON stated if a resident's call light was not within reach, the resident would not be able to call for assistance. During an interview with the ADM on 06/03/2025 at 5:25 PM, the ADM stated call lights should always be within reach. The ADM stated it was everyone's responsibility to ensure the call lights were within reach. The ADM stated if a resident's call light was not within reach, then the resident would not be able to express their needs nor have their needs met. The ADM stated her expectation was for staff members to ensure call lights were within reach prior to exiting the resident's rooms. The facility does not have a policy regarding call lights.

Based on interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with a current accurate facility assessment for 9 of 11 residents ( Residents #1, #2, #3, #4 #5, #6, #7,#8 and #11). 1. The facility failed to ensure sufficient staff to provide Resident #6 needed care to prevent feelings of helplessness and pain from prolonged exposure to diarrhea for 3 hours while unable to obtain assistance. Residents #4 and #7 needed care including incontinent care and repositioning on 1/23/2025 for an unknown amount of time. 2. The facility failed to provide adequate staff to provide showers to Residents #1, #2, #3, #4 #5, #6, #7,#8 and #11 in compliance with their shower schedules. These failures placed residents at risk of inadequate supervision, an unsafe environment, skin breakdowns, falls and serious harm. Findings included: 1.) Review of Resident #6's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included complex tear of lateral meniscus of left knee (cartilage between the femur and shin), difficulty walking and hypertension (high blood pressure). Review of Resident #6's admission MDS assessment, dated 1/15/25, reflected a BIMS score of 15, which indicated cognition was intact. Section H (Bladder and Bowel) reflected she was occasionally incontinent of bladder and bowel. Review of Resident #6's care plan, initiated on 1/17/25, reflected she had a potential for pressure ulcer development, interventions include Incontinent care after each episode and apply a moisture barrier and needs assistance with repositioning at least every 2 hours. During an interview on 1/26/2025 at 2:40pm with Resident #6 revealed she had been having issues with constipation and had taken laxatives on 1/23/2025. Resident #6 stated the laxative began working after she had finished dinner. She stated she used her call light to get help with cleaning up after her bowels had released. Resident #6 stated it had happened before that staff took up to an hour to answer call lights because they were short staffed. She waited over an hour then began calling the front desk to ask for help. Resident #6 stated the diarrhea was burning her skin, was uncomfortable and she felt helpless because she cannot get up out of bed by herself. She stated when she could not get anyone to answer the phone she was feeling even worse. After calling for over another hour, the call was answered and she told the person she had diarrhea all over herself and needed to be changed, the person answering the call said they would be there to help as soon as possible. Resident #6 stated she waited about 45 minutes then she called the non-emergency 911 and told the person answering that she could not get help. Resident #6 stated she was so upset, feeling helpless and having burning skin sensations and she did not know what else to do to get help. She stated in a few minutes the firefighters showed up but the staff were just leaving her room having come to change her right after she called the fire department. Resident #6 stated she did not know if they heard her make the call or if that was just when they finally showed up but it was 3 hours after she had started calling using the call light . Review of Resident #7's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included cerebral infarction (blood flow to the brain blocked by a blood clot causing brain tissue damage), dysphagia (difficulty swallowing), hypertension (high blood pressure). Review of Resident #7's quarterly MDS assessment, dated 1/8/25, reflected a BIMS score of 12, which indicated cognition was moderately impaired. Section H (Bladder and Bowel) reflected she was always incontinent of bladder and frequently incontinent of bowel. Review of Resident #7's care plan, initiated on 11/9/24, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs including incontinence. Interventions include incontinent care after each episode apply a moisture barrier. During an interview on 1/25/25 at 11:34am with Resident #7's FM revealed the resident had called and spoken to the FM about not being able to get anyone to take her to the bathroom; that there were no CNAs only 2 nurses. The FM stated she called the facility and after the phone rang for a long time a nurse answered and admitted that there were no CNAs; that the nurses were trying to do everything. The FM stated there have been concerns over staffing before, but it usually was that there was not enough CNAs, but there had not been none before, that they knew about. The FM stated when they arrived the police were in the parking lot and they told the police they were there to take Resident #7 to the bathroom because she could not get anyone to help her. The FM stated when she got on the hall that Resident #7 was on, almost all the call lights were on outside the rooms on that hall. The FM stated they began assisting Resident #7 to the bathroom but a CNA that had just arrived to work came in to help her. The FM stated Resident #7 was so relieved and told them it was so uncomfortable having to hold it for that long once you realized you needed to go. The CNA assisted Resident #7 to bed and then helped her roommate who was also up in her wheelchair and who was incontinent. The FM stated it was well after 9:30 pm when Resident #7 and Resident #4(roommate) were put to bed and that usually they are in bed by 8pm. The FM stated when they got home they looked at the video from a camera in Resident #7's room and realized no staff had been to her room to assist her to the bathroom after she was taken at 3:30 pm. During an interview on 1/25/25 at 11:34am with Resident #7 revealed she recalled being uncomfortable on the evening of 1/23/2024. Resident #7 stated her call light was on the whole evening but she heard someone in the hall saying there was only 2 nurses no CNA's. Resident #7 stated she finally called her FM who she hated to disturb, and asked for help going to the bathroom, she could not hold it any longer. Review of Resident #4's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included dementia (group of thinking and social symptoms that interferes with daily functioning), Williams syndrome (genetic condition with cognitive delays), and severe intellectual disabilities. Review of Resident #4's admission MDS assessment, dated 11/05/24, reflected a BIMS score of 7, which indicated severe cognitive impairment. Section H (Bladder and Bowel) reflected she was always incontinent of bladder and bowel. Review of Resident #4's care plan, revised on 1/25/25, reflected she had a potential for pressure ulcer development, bladder incontinence, and bowel incontinence. Each of the three focus areas included an intervention of incontinent care after each episode and apply a moisture barrier. During an interview on 1/25/25 at 12:53pm with Resident #4's Guardian revealed she was notified of the staffing issue on 1/23/2025. She stated she looked at the video footage and saw that Resident #4 was sitting in her wheelchair beside her bed from 5:30pm to 9:30pm with no one coming in the room. The Guardian stated Resident #4 has an intellectual disability and she relies on staff to check on her and make sure Resident #4 was safe. The Guardian stated Resident #4 is usually in bed at 8pm so she knew Resident #4 was uncomfortable as she was not used to being in one position that long. Review of the facility staffing sheet for 1/23/2025 revealed there were 2 nurses listed for 6pm to 6am, 1 CNA listed for 6pm to 10pm, and three listed for 10pm-6am. During an interview on 1/25/25 at 7:30pm with RN B revealed she had made the schedule for 1/23/2025. She stated she was told she would be making the staffing schedules but she was not given any training or direction. RN B stated she was told, Use this and given a list of staff. She stated she had made the staff schedule on the 20th and realized there was only one staff available to put on the 6pm to 10pm timeframe for the 23rd. RN B stated she had notified the Corporate Traveling DON who was acting as the DON of the facility and assumed she would plan for others to be scheduled. RN B stated she was not aware that no other CNAs were added or that the one she scheduled called out as she was not the on-call person for that night. During an interview on 1/26/25 at 1:50pm with Corporate Traveling Nurse RN-C revealed she was the acting DON for the facility prior to the new DON starting. RN C stated she had not been notified that only one CNA was scheduled to work from 6p to 10p. RN C stated they had never worked with just one CNA on that shift while she was there. She stated the staffing depends on census and they typically have 2 nurses and 4 CNAs. During an interview on 1/25/2025 at 3:00pm with the facility DON revealed that 1/23/2025 was her second day working at the facility. She stated she stayed over to work as one of the nurses scheduled for 6pm to 6am had a family emergency and would not be working. The DON stated she reached out to different nurses to see if they would pick up the shift but no one was available. The CNA that had been scheduled to work did not show up. There should have been more scheduled. The DON stated they had one CNA from the day shift stay over till 7:30pm, when she had to leave. After 7:30pm she and another nurse were the only ones there until 9:30pm when a CNA came. They had scheduled 2 other CNAs a total of 3 working on the 10pm to 6am shift, one for that shift called out also. The DON stated the police and firefighters came around 9pm saying they had received a call from Resident #6 that she needed help. The DON stated they been in the process of cleaning Resident #6 up when the police and fire department showed up. They did not find any residents in need of care so the police considered the visit a welfare concern and the firefighters left. She stated the facility was currently having staffing issues that she planned to address. Part of the problem she felt was the split shifts she planned to make all positions 12-hour shifts so everyone would be working a 6 to 6 shift. They also are in the process of hiring five CNAs that are starting next week. The DON stated it was not planned and she did not think 2 nurses was enough staff to care for 76 residents. She did not know if they could have evacuated all the residents if there had been an emergency when there was just the two of them but she felt like they would have been able to do so. During an interview on 1/25/25 at 2:39pm with the facility Administrator revealed she had not been aware there had been only one staff scheduled for the 6pm to 10pm time, on 1/23/25. She stated on 1/23/25 she received a call at 9:07pm from the DON saying the Fire Department was at the building and then at 9:34pm the police were here. She stated she had arrived soon after. The Administrator stated the police had reported that Resident #6 had called saying that she could not get any help. The Administrator stated she had known there were call ins but did not know how many staff there were. She stated she later found out there were only 2 staff in the building, which is not acceptable, but was working to get positions filled. The Administrator stated Resident #6 stated she did not feel neglected just that it took too long for someone to help her. The Administrator stated that it had not happened before that there were only two staff working the building, that they have been short staffed but have been pulling people from other positions such as the office to meet the resident's needs. The Administrator stated she did not know if two people would have been able to evacuate the building. She said they started having people be a manager on duty so they can monitor. She said she did not know if they would be able to evacuate the residents with only 2 staff. The Administrator stated the facility assessment was what they based staffing on. In an additional interview on 1/26/2025 at 11:58am the Administrator revealed when asked how many staff were needed to meet the residents' personal care needs, the Administrator stated they did not have a number. They know what they would like to have but that is not a regulation. The Administrator explained that the acuity levels change, they were a new facility and it was more of a moving number. She stated they have hired more CNAs and nurses. Review of the facility Daily Census on 1/25/25 revealed the census was 76 residents . Review of the Facility Assessment Tool provided by the facility, dated 7/25/2024, indicated an average daily census in the last year was 8. The staffing plan indicated: Licensed Nurses: RN, LPN, LVN providing direct care 1 during the day shift 6am to 6pm, 1 during the evening shift 1 6pm to 6am. Nurse Aides: 2 during the day shift, 1 during the 6pm to 6am shift. Review of the facility document titled Facility Assessment, updated, provided after a request of staffing policy, revealed the following: This facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. The facility will review and update that assessment, as necessary, and at least annually. The facility will also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment addresses the following: 1. The facility's resident population, including, but not limited to: o Both the number of residents and the facility's resident capacity; o The care required by the resident population, using evidence-based, data-driven methods that considering the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments as required under S 483.20; o The staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population; o The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and o Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. 2. The facility's resources, including but not limited to the following: All buildings and/or other physical structures and vehicles; Equipment (medical and non- medical); Services provided, such as physical therapy, pharmacy, behavioral health, and specific rehabilitation therapies; All personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. 3. A facility-based and community-based risk assessment, utilizing an all- hazards approach. In conducting the facility assessment, the facility will ensure: Active involvement of the following participants in the process: Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; and Direct care staff, including but not limited to, RNs, LPNs/LVNs, NAs, and representatives of the direct care staff, if applicable. The facility will also solicit and consider input received from residents, resident representatives, and family members vis suggestion boxes throughout the facility. The facility will use this facility assessment to: Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required in S 483.35(a)(3). Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population. Consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population. Develop and maintain a plan to maximize recruitment and retention of direct care staff. Inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care. 2.) A. Review of Resident #1's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE], with a readmission on 01/04/25. Resident #1 had diagnoses which included chronic (persisting) kidney disease, major depressive disorder (depressed mood), low back pain and muscle weakness. Review of Resident #1's quarterly MDS assessment, dated 12/08/24, reflected a BIMS score of 12, which indicated moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required partial/moderate assistance with showering. Review of Resident #1's care plan, revised on 12/06/24, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of assistance of one staff with showering. Review of Resident #1's showering schedule, provided by the facility, revealed she was scheduled to receive showers every Monday, Wednesday, and Friday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #1's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected there were no showers documented during these dates. During an interview on 01/25/25 at 10:36 am, with Resident #1 revealed she stated she usually bathes herself in her bathroom. Resident #1 stated there was not enough staff to answer a call then there was not enough to stay in the shower with her. Resident #1 stated if the facility ever got enough staff she would be taking showers because she feels cleaner. B. Review of Resident #2's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE], with a readmission on 01/08/25. Resident #2 had diagnoses which included chronic total occlusion of coronary artery (a blockage in coronary artery that has been present longer than three months), mild dementia (group of thinking and social symptoms that interferes with daily functioning) with anxiety, and repeated falls. Review of Resident #2's quarterly MDS assessment, dated 1/11/25, reflected a BIMS score of 11, which indicated moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected he was dependent on staff assistance with showering. Review of Resident #2's care plan, revised on 1/17/24, reflected he had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of requiring assistance of two staff with showering. Review of Resident #2's showering schedule, provided by the facility, revealed he was scheduled to receive showers every Tuesday, Thursday, and Saturday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #2's showering tasks in his EMR, from 12/26/24 - 01/26/25, reflected there were 5 showers documented during these dates. C. Review of Resident #3's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE], with a readmission on 01/08/25. Resident #3 had diagnoses which included dementia (group of thinking and social symptoms that interferes with daily functioning) and combined systolic and diastolic congestive heart failure (the hearts ventricles do not pump or fill with enough blood). Review of Resident #3's admission MDS assessment, dated 11/09/24, reflected a BIMS score of 9, which indicated moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent on staff assistance with showering. Review of Resident #3's care plan, initiated on 11/06/24, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of one staff assistance with showering. Review of Resident #3's showering schedule, provided by the facility, revealed she was scheduled to receive showers every Monday, Wednesday, and Friday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #3's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected there were 4 showers documented during these dates and 4 refusals from Resident #3. C. Review of Resident #4's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included dementia (group of thinking and social symptoms that interferes with daily functioning), Williams syndrome (genetic condition with cognitive delays), and severe intellectual disabilities. Review of Resident #4's admission MDS assessment, dated 11/05/24, reflected a BIMS score of 7, which indicated severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent on substantial maximum assistance with showering. Review of Resident #4's care plan, revised on 1/25/25, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of one staff assistance with bathing. Review of Resident #4's showering schedule, provided by the facility, revealed she was scheduled to receive showers every Monday, Wednesday, and Friday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #4's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected there were 6 showers documented during these dates, and one refusal. During an interview on 1/25/25 at 12:53pm with Resident #4's Guardian revealed the biggest concern was the lack of adequate staff. The CNAs are hard working but they are being assigned to many residents to provide appropriate care. Resident #4's Guardian stated Resident #4 had gotten some of her showers but she was not getting three showers a week, she can tell when she visits her. The Guardian stated she worries about what effects of bad hygiene practices will affect Resident #4 long term. D. Review of Resident #5's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included dementia (group of thinking and social symptoms that interferes with daily functioning) and displaced subtrochanteric fracture of the left femur (a break in the upper part of thigh bone below the hip joint. Review of Resident #5's admission MDS assessment, dated 12/23/24, reflected a BIMS score of 4, which indicated severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent on staff assistance with showering. Review of Resident #5's care plan, initiated on 12/26/24, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of assistance of two staff with showering. Review of Resident #5's showering schedule, provided by the facility, revealed she was scheduled to receive showers every Monday, Wednesday, and Friday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #5's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected there were 4 showers documented during these dates. E. Review of Resident #6's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included complex tear of lateral meniscus of left knee (cartilage between the femur and shin), difficulty walking and hypertension (high blood pressure). Review of Resident #6's admission MDS assessment, dated 1/15/25, reflected a BIMS score of 15, which indicated cognition was intact. Section GG (Functional Abilities and Goals) reflected she was dependent on substantial/maximal assistance with showering. Review of Resident #6's showering schedule, provided by the facility, revealed she was scheduled to receive showers every Monday, Wednesday, and Friday. Indicating five showers were scheduled during the dates 1/15/24 - 01/26/25. Review of Resident #6's showering tasks in her EMR, from 1/15/24 - 01/26/25, reflected 1 shower was documented during these dates. During an interview on 1/26/2025 at 2:40pm with Resident #6 revealed she had not had a shower since she had been at the facility, although she had known she needed one. Resident #6 stated all the sudden today the staff acted insistent that she take a shower. She stated she felt like they were insinuating she had been refusing to shower but she had not previously been offered a shower. F. Review of Resident #7's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included cerebral infarction (blood flow to the brain blocked by a blood clot causing brain tissue damage), dysphagia (difficulty swallowing), hypertension (high blood pressure). Review of Resident #7's quarterly MDS assessment, dated 1/8/25, reflected a BIMS score of 12, which indicated cognition was intact. Section GG (Functional Abilities and Goals) reflected she required substantial/maximal staff assistance with showering. Review of Resident #7's care plan, initiated on 11/9/24, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of assistance of one staff with showering. Review of Resident #7's showering schedule, provided by the facility, revealed she was scheduled to receive showers every Tuesday, Thursday, and Saturday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #7's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected there were 6 showers documented during these dates. During an interview on 1/25/25 at 11:34am with Resident #7's FM revealed the resident want a lot more showers than she was given. The FM stated during the admission process they were told Resident #7 would be showered three times a week if she wanted. There was no indication that at times there would not be enough staff to provide her with assistance or that showers occurring depended on staff availability. The FM stated it makes Resident #7 uncomfortable when she was not clean. During an interview on 1/25/25 at 11:34am with Resident #7 revealed she does not get her showers like she was supposed to, like they had told her she would. Resident #7 stated she had asked before to be given a shower but the CNA will say they do not have enough time. G. Review of Resident #8's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included dementia (group of thinking and social symptoms that interferes with daily functioning) and repeated falls. Review of Resident #8's quarterly MDS assessment, dated 12/10/25, reflected a BIMS score of 6, which indicated cognition was intact. Section GG (Functional Abilities and Goals) reflected he required substantial/maximal staff assistance with showering. Review of Resident #8's care plan, revised on 12/17/24, reflected he had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of assistance of one staff with showering. Review of Resident #8's showering schedule, provided by the facility, revealed he was scheduled to receive showers every Monday, Wednesday, and Friday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #8's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected there were no showers documented during these dates. H. Review of Resident 11's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included dementia (group of thinking and social symptoms that interferes with daily functioning), Diabetes Mellitus Type II (uncontrollable blood sugar levels), and muscle weakness. Review of Resident #11's admission MDS assessment, dated 8/1/24, reflected a BIMS score of 0, which indicated severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required partial/moderate staff assistance with showering. Review of Resident #11's care plan, initiated on 1/25/25, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of assistance of two staff with showering. Review of Resident #11's showering schedule, provided by the facility, revealed he was scheduled to receive showers every Tuesday, Thursday, and Saturday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #11's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected one shower was documented during these dates. During an interview on 1/25/2025 at 2:11 pm with CNA A revealed she works the 6am to 6pm shift, she stated she was able to complete her assigned showers. She documents the showers she has given in the EHR, under the task section. CNA C stated she does have residents complaining to her that they are not getting their showers that are scheduled during other shifts. During a confidential interview with a facility CNA revealed they stated there has not been enough staff to give showers. The CNA stated frequently they must tell the residents that request a shower that they cannot shower them. They are trying to make sure people are cleaned well with adult briefs/incontinence changes because they all know about skin breakdown. During a confidential interview with a facility Nurse revealed they stated when there are only two nurses and one CNA in the evening, which has happened several times lately, the staff make sure the residents are fed, changed as needed and assisted to bed. The Nurse stated showers are placed at the bottom of the list so frequently no showers are given as there was not time. During an interview on 1/25/2025 at 2:39 pm with the facility Administrator revealed she had recognized a concern of residents not receiving showers as scheduled. There have been some staffing shortages that may have affected showers recently. The problem was something they are working on; she does expect that showers be given as scheduled. During an interview on 1/25/2025 at 3:00 pm with the facility DON she revealed she has been at the facility for 3 days. She stated she had not looked at the shower issues completely but recognizes it needs to be addressed although she has not had any residents complain to her about not recei [TRUNCATED]

Based on interviews, and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for for 9 of 11 residents ( Residents #1, #2, #3, #4 #5, #6, #7,#8 and #11). 1. The facility Administration failed to ensure an effective system to monitor for adequate staffing to provide Resident #6 needed care to prevent feelings of helplessness and pain from prolonged exposure to diarrhea for 3 hours while unable to obtain assistance. Residents #4 and #7 needed care including incontinent care and repositioning on 1/23/2025 for an unknown amount of time. 2. The facility Administration failed to ensure an effective monitoring system for adequate staffing to provide showers to Residents #1, #2, #3, #4 #5, #6, #7,#8 and #11 in compliance with their shower schedules. These failures placed residents at risk of inadequate supervision, an unsafe environment, skin breakdowns, falls and serious harm. Findings included: 1. Review of Resident #6's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included complex tear of lateral meniscus of left knee (cartilage between the femur and shin), difficulty walking and hypertension (high blood pressure). Review of Resident #6's admission MDS assessment, dated 1/15/25, reflected a BIMS score of 15, which indicated cognition was intact. Section H (Bladder and Bowel) reflected she was occasionally incontinent of bladder and bowel. Review of Resident #6's care plan, initiated on 1/17/25, reflected she had a potential for pressure ulcer development, interventions include Incontinent care after each episode and apply a moisture barrier and needs assistance with repositioning at least every 2 hours. During an interview on 1/26/2025 at 2:40pm with Resident #6 revealed she had been having issues with constipation and had taken laxatives on 1/23/2025. Resident #6 stated the laxative began working after she had finished dinner. She stated she used her call light to get help with cleaning up after her bowels had released. Resident #6 stated it had happened before that staff take up to an hour to answer call lights because they were short staffed. She waited over an hour than began calling the front desk to ask for help. Resident #6 stated the diarrhea was burning her skin, was uncomfortable and she felt helpless because she cannot get up out of bed by herself. She stated when she could not get anyone to answer the phone she was feeling even worse after calling for over another hour the call was answered and she told the person she had diarrhea all over herself and needed to be changed, the person answering the call said they would be there to help as soon as possible. Resident #6 stated she waited about 45 minutes than she called the non-emergency 911 and told the person answering that she could not get help. Resident #6 stated she was so upset, feeling helpless and having burning skin sensations and she did not know what else to do to get help. She stated in a few minutes the firefighters showed up but the staff were just leaving her room having came to change her right after she called the fire department. Resident #6 stated she did not know if they heard her make the call or if that was just when they finally showed up but it was 3 hours after she had started calling using the call light. Review of Resident #7's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included cerebral infarction (blood flow to the brain blocked by a blood clot causing brain tissue damage), dysphagia (difficulty swallowing), hypertension (high blood pressure). Review of Resident #7's quarterly MDS assessment, dated 1/8/25, reflected a BIMS score of 12, which indicated moderate cognitive impairment. Section H (Bladder and Bowel) reflected she was always incontinent of bladder and frequently incontinent of bowel. Review of Resident #7's care plan, initiated on 11/9/24, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs including incontinence. Interventions include incontinent care after each episode apply a moisture barrier. During an interview on 1/25/25 at 11:34am with Resident #7's FM revealed the resident had called and spoken to the FM about not being able to get anyone to take her to the bathroom that there were no CNAs only 2 nurses. The FM stated she called the facility and after the phone rang for a long time a nurse answered and admitted that there were no CNAs that the nurses were trying to do everything. The FM stated there have been concerns over staffing before but it usually was that there was not enough CNAs but had not been none before that they knew about. The FM stated when they arrived the police were in the parking lot and they told the police they were there to take Resident #7 to the bathroom because she could not get anyone to help her. The FM stated when she got on the hall that Resident #7 was on that almost all the call lights were on outside the room. The FM stated they began assisting Resident #7 to the bathroom but a CNA that had just arrived to work came in to help her. The FM stated Resident #7 was so relieved and told them it was so uncomfortable having to hold it for that long once you realized you needed to go. The CNA assisted Resident #7 to bed and then help her roommate who was also up in her wheelchair and who was incontinent. The FM stated it was well after 9:30 pm when Resident #7 and Resident #4 (Roommate) were put to bed and that usually they are in bed by 8pm. The FM stated when they got home they looked at the video from a camera in Resident #7's room and realized no staff had been to her room to assist her to the bathroom after she was taken at 3:30 pm. During an interview on 1/25/25 at 11:34am with Resident #7 revealed she recalled being uncomfortable on the evening of 1/23/2024. Resident #7 stated her call light was on the whole evening but she heard someone in the hall saying there was only 2 nurses no CNA's. Resident #7 stated she finally called her FM who she hated to disturb, and asked for help going to the bathroom, she could not hold it any longer. Review of Resident #4's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included dementia (group of thinking and social symptoms that interferes with daily functioning), Williams syndrome (genetic condition with cognitive delays), and severe intellectual disabilities. Review of Resident #4's admission MDS assessment, dated 11/05/24, reflected a BIMS score of 7, which indicated severe cognitive impairment. Section H (Bladder and Bowel) reflected she was always incontinent of bladder and bowel. Review of Resident #4's care plan, revised on 1/25/25, reflected she had a potential for pressure ulcer development, bladder incontinence, and bowel incontinence. Each of the tree focus areas include an intervention of incontinent care after each episode and apply a moisture barrier. During an interview on 1/25/25 at 12:53pm with Resident #4's Guardian revealed she was notified of the staffing issue on 1/23/2025. She stated she looked at the video footage and saw that Resident #4 was sitting in her wheelchair beside her bed from 5:30pm to 9:30pm with no one coming in the room. The Guardian stated Resident #4 has an intellectual disability and she relies on staff to check on her and make sure Resident #4 was safe. The Guardian stated Resident #4 is usually in bed at 8pm so she knew Resident #4 was uncomfortable as she was not used to being in one position that long. Review of the facility staffing sheet for 1/23/2025 revealed there were 2 nurses listed for 6pm to 6am, 1 CNA listed for 6pm to 10pm, and three listed for 10pm-6am. During an interview on 1/25/25 at 7:30pm with RN B revealed she had made the schedule for 1/23/2025. She stated she was told she would be making the staffing schedules but she was not given any training or direction. RN B stated she was told use this and given a list of staff. She stated she had made the staff schedule on the 20th and realized when she it there was only one staff available to put on the 6pm to 10pm timeframe for the 23rd. RN B stated she had notified the Corporate Traveling DON who was acting as the DON of the facility and assumed she would plan for others to be scheduled. RN B stated she was not aware that no other CNAs were added or that the one she scheduled called out as she was not the on-call person for that night. During an interview on 1/26/25 at 1:50pm with Corporate Traveling Nurse RN-C revealed she was the acting DON for the facility prior to the new DON starting. RN C stated she had not been notified that only one CNA was scheduled to work from 6p to 10p. RN C stated they had never worked with just one CNA on that shift while she was there. She stated the staffing depends on census and they typically have 2 nurses and 4 CNAs. During an interview on 1/25/2025 at 3:00pm with the facility DON revealed that 1/23/2025 was her second day working at the facility. She stated she stayed over to work as one of the nurses scheduled for 6pm to 6am had a family emergency and would not be working. The DON stated she reached out to different nurses to see if they would pick up the shift but no one was available. The CNA that had been scheduled to work did not show up. There should have been more scheduled. The DON stated they had one CNA from the day shift stay over till 7:30pm, when she had to leave. After 7:30pm she and another nurse were the only ones there until 9:30pm when a CNA came. They had scheduled 2 other CNAs a total of 3 working on the 10pm to 6am shift, one for that shift called out also. The DON stated the police and firefighters came around 9pm saying they had received a call from Resident #6 that she needed help. The DON stated they been in the process of cleaning Resident #6 up when the police and fire department showed up. They did not find any residents in need of care so the police considered the visit a welfare concern and the firefighters left. She stated the facility was currently having staffing issues that she planned to address. Part of the problem she felt was the split shifts she planned to make all positions 12-hour shifts so everyone would be working a 6 to 6 shift. They also are in the process of hiring five CNAs that are starting next week. The DON stated it was not planned and she did not think 2 nurses was enough staff to care for 76 residents. She did not know if they could have evacuated all the residents if there had been an emergency when there was just the two of them but she felt like they would have been able to do so. During an interview on 1/25/25 at 2:39pm with the facility Administrator revealed she had not been aware there had been only one staff scheduled for the 6pm to 10pm time, on 1/23/25. She stated on 1/23/25 she received a call at 9:07pm from the DON saying the Fire Department was at the building and then at 9:34pm the police were here. She stated she had arrived soon after. The Administrator stated the police had reported that Resident #6 had called saying that she could not get any help. The Administrator stated she had known there were call ins but did not know how many staff there were. She stated she later found out there were only 2 staff in the building, which is not acceptable, but we are working to get positions filled. The Administrator stated Resident #6 stated she did not feel neglected just that it took too long for someone to help her. The Administrator stated that it had not happened before that there were only two staff working the building, that they have been short staffed but have been pulling people from other positions such as the office to meet the resident's needs. The Administrator stated she did not know if two people would have been able to evacuate the building. We have started having people be a manager on duty so they can monitor. Do not know if they would be able to evacuate. The Administrator stated the facility assessment is what they base staffing on. In an additional interview on 1/26/2025 at 11:58am revealed when asked how many staff are needed to meet the residents personal care, the Administrator stated they do not have a number they know what they would like to have but that is not a regulation. The Administrator explained that the acuity levels change, they are a new facility it was more of a moving number. She stated they have hired more CNAs and nurses. Review of the facility Daily Census on 1/25/25 revealed the census was 76 residents. Review of the Facility Assessment Tool provided by the facility, dated 7/25/2024, indicated an average daily census in the last year was 8. The staffing plan indicated: Licensed Nurses: RN, LPN, LVN providing direct care 1 during the day shift 6am to 6pm, 1 during the evening shift 1 6pm to 6am. Nurse Aides: 2 during the day shift, 1 during the 6pm to 6am shift. Review of the facility document titled Facility Assessment, updated, provided after a request of staffing policy, revealed the following: This facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. The facility will review and update that assessment, as necessary, and at least annually. The facility will also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment addresses the following: 4. The facility's resident population, including, but not limited to: o Both the number of residents and the facility's resident capacity; o The care required by the resident population, using evidence-based, data-driven methods that considering the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments as required under S 483.20; o The staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population; o The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and o Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. 5. The facility's resources, including but not limited to the following: All buildings and/or other physical structures and vehicles; Equipment (medical and non- medical); Services provided, such as physical therapy, pharmacy, behavioral health, and specific rehabilitation therapies; All personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. 6. A facility-based and community-based risk assessment, utilizing an all- hazards approach. In conducting the facility assessment, the facility will ensure: Active involvement of the following participants in the process: Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; and Direct care staff, including but not limited to, RNs, LPNs/LVNs, NAs, and representatives of the direct care staff, if applicable. The facility will also solicit and consider input received from residents, resident representatives, and family members vis suggestion boxes throughout the facility. The facility will use this facility assessment to: Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required in S 483.35(a)(3). Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population. Consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population. Develop and maintain a plan to maximize recruitment and retention of direct care staff. Inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care. 2. 1. Review of Resident #1's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE], with a readmission on 01/04/25. Resident #1 had diagnoses which included chronic (persisting) kidney disease, major depressive disorder (depressed mood), low back pain and muscle weakness. Review of Resident #1's quarterly MDS assessment, dated 12/08/24, reflected a BIMS score of 12, which indicated moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required partial/moderate assistance with showering. Review of Resident #1's care plan, revised on 12/06/24, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of assistance of one staff with showering. Review of Resident #1's showering schedule, provided by the facility, revealed she was scheduled to receive showers every Monday, Wednesday, and Friday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #1's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected there were no showers documented during these dates. During an interview on 01/25/25 at 10:36 am, with Resident #1 revealed she stated she usually bathes herself in her bathroom. Resident #1 stated there was not enough staff to answer a call then there was not enough to stay in the shower with her. Resident #1 stated if the facility ever got enough staff she would be taking showers because she feels cleaner. 2. A. Review of Resident #2's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE], with a readmission on 01/08/25. Resident #2 had diagnoses which included chronic total occlusion of coronary artery (a blockage in coronary artery that has been present longer than three months), mild dementia (group of thinking and social symptoms that interferes with daily functioning) with anxiety, and repeated falls. Review of Resident #2's quarterly MDS assessment, dated 1/11/25, reflected a BIMS score of 11, which indicated moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected he was dependent on staff assistance with showering. Review of Resident #2's care plan, revised on 1/17/24, reflected he had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of requiring assistance of two staff with showering. Review of Resident #2's showering schedule, provided by the facility, revealed he was scheduled to receive showers every Tuesday, Thursday, and Saturday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #2's showering tasks in his EMR, from 12/26/24 - 01/26/25, reflected there were 5 showers documented during these dates. B. Review of Resident #3's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE], with a readmission on 01/08/25. Resident #3 had diagnoses which included dementia (group of thinking and social symptoms that interferes with daily functioning) and combined systolic and diastolic congestive heart failure (the hearts ventricles do not pump or fill with enough blood). Review of Resident #3's admission MDS assessment, dated 11/09/24, reflected a BIMS score of 9, which indicated moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent on staff assistance with showering. Review of Resident #3's care plan, initiated on 11/06/24, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of one staff assistance with showering. Review of Resident #3's showering schedule, provided by the facility, revealed she was scheduled to receive showers every Monday, Wednesday, and Friday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #3's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected there were 4 showers documented during these dates and 4 refusals from Resident #3. C. Review of Resident #4's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included dementia (group of thinking and social symptoms that interferes with daily functioning), Williams syndrome (genetic condition with cognitive delays), and severe intellectual disabilities. Review of Resident #4's admission MDS assessment, dated 11/05/24, reflected a BIMS score of 7, which indicated severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent on substantial maximum assistance with showering. Review of Resident #4's care plan, revised on 1/25/25, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of one staff assistance with bathing. Review of Resident #4's showering schedule, provided by the facility, revealed she was scheduled to receive showers every Monday, Wednesday, and Friday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #4's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected there were 6 showers documented during these dates, and one refusal. During an interview on 1/25/25 at 12:53pm with Resident #4's Guardian revealed the biggest concern was the lack of adequate staff. The CNAs are hard working but they are being assigned to many residents to provide appropriate care. Resident #4's Guardian stated Resident #4 had gotten some of her showers but she was not getting three showers a week, she can tell when she visits her. The Guardian stated she worries about what effects of bad hygiene practices will affect Resident #4 long term. D. Review of Resident #5's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included dementia (group of thinking and social symptoms that interferes with daily functioning) and displaced subtrochanteric fracture of the left femur (a break in the upper part of thigh bone below the hip joint. Review of Resident #5's admission MDS assessment, dated 12/23/24, reflected a BIMS score of 4, which indicated severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent on staff assistance with showering. Review of Resident #5's care plan, initiated on 12/26/24, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of assistance of two staff with showering. Review of Resident #5's showering schedule, provided by the facility, revealed she was scheduled to receive showers every Monday, Wednesday, and Friday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #5's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected there were 4 showers documented during these dates. E. Review of Resident #6's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included complex tear of lateral meniscus of left knee (cartilage between the femur and shin), difficulty walking and hypertension (high blood pressure). Review of Resident #6's admission MDS assessment, dated 1/15/25, reflected a BIMS score of 15, which indicated cognition was intact. Section GG (Functional Abilities and Goals) reflected she was dependent on substantial/maximal assistance with showering. Review of Resident #6's showering schedule, provided by the facility, revealed she was scheduled to receive showers every Monday, Wednesday, and Friday. Indicating five showers were scheduled during the dates 1/15/24 - 01/26/25. Review of Resident #6's showering tasks in her EMR, from 1/15/24 - 01/26/25, reflected 1 shower was documented during these dates. During an interview on 1/26/2025 at 2:40pm with Resident #6 revealed she had not had a shower since she had been at the facility, although she had known she needed one. Resident #6 stated all the sudden today the staff acted insistent that she take a shower. She stated she felt like they were insinuating she had been refusing to shower but she had not previously been offered a shower. F. Review of Resident #7's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included cerebral infarction (blood flow to the brain blocked by a blood clot causing brain tissue damage), dysphagia (difficulty swallowing), hypertension (high blood pressure). Review of Resident #7's quarterly MDS assessment, dated 1/8/25, reflected a BIMS score of 12, which indicated cognition was intact. Section GG (Functional Abilities and Goals) reflected she required substantial/maximal staff assistance with showering. Review of Resident #7's care plan, initiated on 11/9/24, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of assistance of one staff with showering. Review of Resident #7's showering schedule, provided by the facility, revealed she was scheduled to receive showers every Tuesday, Thursday, and Saturday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #7's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected there were 6 showers documented during these dates. During an interview on 1/25/25 at 11:34am with Resident #7's FM revealed the resident want a lot more showers than she was given. The FM stated during the admission process they were told Resident #7 would be showered three times a week if she wanted. There was no indication that at times there would not be enough staff to provide her with assistance or that showers occurring depended on staff availability. The FM stated it makes Resident #7 uncomfortable when she was not clean. During an interview on 1/25/25 at 11:34am with Resident #7 revealed she does not get her showers like she was supposed to, like they had told her she would. Resident #7 stated she had asked before to be given a shower but the CNA will say they do not have enough time. G. Review of Resident #8's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included dementia (group of thinking and social symptoms that interferes with daily functioning) and repeated falls. Review of Resident #8's quarterly MDS assessment, dated 12/10/25, reflected a BIMS score of 6, which indicated cognition was intact. Section GG (Functional Abilities and Goals) reflected he required substantial/maximal staff assistance with showering. Review of Resident #8's care plan, revised on 12/17/24, reflected he had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of assistance of one staff with showering. Review of Resident #8's showering schedule, provided by the facility, revealed he was scheduled to receive showers every Monday, Wednesday, and Friday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #8's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected there were no showers documented during these dates. H. Review of Resident 11's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included dementia (group of thinking and social symptoms that interferes with daily functioning), Diabetes Mellitus Type II (uncontrollable blood sugar levels), and muscle weakness. Review of Resident #11's admission MDS assessment, dated 8/1/24, reflected a BIMS score of 0, which indicated severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required partial/moderate staff assistance with showering. Review of Resident #11's care plan, initiated on 1/25/25, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of assistance of two staff with showering. Review of Resident #11's showering schedule, provided by the facility, revealed he was scheduled to receive showers every Tuesday, Thursday, and Saturday. Indicating thirteen showers were scheduled during the dates 12/26/24 - 01/26/25. Review of Resident #11's showering tasks in her EMR, from 12/26/24 - 01/26/25, reflected one shower was documented during these dates. During an interview on 1/25/2025 at 2:11 pm with CNA A revealed she works the 6am to 6pm shift, she stated she was able to complete her assigned showers. She documents the showers she has given in the EHR, under the task section. CNA C stated she does have residents complaining to her that they are not getting their showers that are scheduled during other shifts. During a confidential interview with a facility CNA revealed they stated there has not been enough staff to give showers. The CNA stated frequently they must tell the residents that request a shower that they cannot shower them. They are trying to make sure people are cleaned well with adult briefs/incontinence changes because they all know about skin breakdown. During a confidential interview with a facility Nurse revealed they stated when there are only two nurses and one CNA in the evening, which has happened several times lately, the staff make sure the residents are fed, changed as needed and assisted to bed. The Nurse stated showers are placed at the bottom of the list so frequently no showers are given as there was not time. During an interview on 1/25/2025 at 2:39 pm with the facility Administrator revealed she had recognized a concern of residents not receiving showers as scheduled. There have been some staffing shortages that may have affected showers recently. The problem was something they are working on; she does expect that showers be given as scheduled. During an interview on 1/25/2025 at 3:00 pm with the facility DON she revealed she has been at the facility for 3 days. She stated she had not looked at the shower issues completely but recognizes it needs to be addressed although she has not had any residents complain to her about not receiving a shower. The DON stated her expectation was that showers are provided as scheduled. Review of the facility's Nursing Policy and Procedure Manual, dated 2003, reflected the following: Bath, Tub/Shower Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganis [TRUNCATED]