Every finding on record at Folkston Park Care and Rehabilitation Center

Based on observations, interviews, and the policy titled, Kitchen Sanitation, the facility failed to ensure clean food contact equipment was maintained in a sanitary manner when 24 plate warmers were observed visibly wet and stacked together in the clean storage area in preparation for resident meal service. This deficient practice had the potential to contaminate clean food contact surfaces used for resident meals. Findings include:1. Observation on 08/05/2026, at 12:55 PM the facility's outside dumpster was observed with a broken lid that was unable to completely close. The condition prevented the dumpster from being maintained in a fully covered condition when not being loaded.During an interview on 08/05/2026, at 1:30 PM with the Maintenance Director (MD), the MD stated, I was not aware that the dumpster lid was broken and it should not have been left open.During an interview on 08/05/2026, at 2:00 PM with the Administrator, the Administrator stated, I was not aware the dumpster lid was broken, and it should not have been. I will contact the waste management company to have the condition corrected.Review of the facility's policy titled, Disposal of Garbage and Refuse, implemented January 2018 and reviewed/revised January 2026, revealed, The facility shall properly dispose of kitchen garbage refuse. 2. Garbage and refuse containers shall be durable, cleanable, and free from cracks or leaks and covered when not in use. 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attraction are minimized. 10. Storage areas, enclosures, and receptables for refuse shall be maintained in good repair and cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents.2. Observation on 08/05/2026 at 12:30 PM in the kitchen revealed 24 clean plate warmers visibly wet and stacked together in the clean storage area in preparation for resident meal service. The plate warmers had not been allowed to adequately air dry prior to being stacked.During an interview on 08/05/2026 at 12:32 PM, Dietary Manager (DM) stated, I don't know why those plate warmers are wet, but they shouldn't be wet.During an interview on 08/06/2026 at 5:51 PM, the Administrator stated she expected the dietary areas and food contact surfaces to be always maintained in sanitary conditions. The Administrator stated dietary staff had been educated regarding cleanliness and sanitation expectations and that she conducted rounds every morning.Review of the facility's policy titled, Kitchen Sanitation, issued January 2016, revealed, It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents, roaches, flies and other insects.4. b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations.6. The dietary manager should develop and provide food service personnel with standard operating procedures for sanitation and daily inspections.

Based on observations, interviews, and the policy titled, Disposal of Garbage and Refuse, the facility failed to ensure outside refuse containers were maintained in good repair and kept covered when not being loaded when a dumpster lid was observed broken and unable to completely close. This deficient practice had the potential to expose refuse and increase the risk of insect and rodent access. Findings include:Observation on 08/05/2026, at 12:55 PM the facility's outside dumpster was observed with a broken lid that was unable to completely close. The condition prevented the dumpster from being maintained in a fully covered condition when not being loaded.During an interview on 08/05/2026, at 1:30 PM with the Maintenance Director (MD), the MD stated, I was not aware that the dumpster lid was broken and it should not have been left open.During an interview on 08/05/2026 at 2:00 PM, the Administrator stated, I was not aware the dumpster lid was broken, and it should not have been. I will contact the waste management company to have the condition corrected.Review of the facility's policy titled, Disposal of Garbage and Refuse, implemented January 2018 and reviewed/revised January 2026, revealed, The facility shall properly dispose of kitchen garbage refuse. 2. Garbage and refuse containers shall be durable, cleanable, and free from cracks or leaks and covered when not in use. 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attraction are minimized. 10. Storage areas, enclosures, and receptables for refuse shall be maintained in good repair and cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents.

Based on observations, interviews, record review, and review of the facility policy, titled, Freedom of Abuse, Abuse Prevention, the facility failed to keep the resident's(R)(R60) right to be free from sexual abuse from resident to resident. The facility failed to keep R60 free from sexual abuse by R24 for one of 24 sampled Rs reviewed for abuse. Failing to protect a resident from sexual abuse can result in serious physical, emotional, and psychological harm.Findings include:1. Review of R60's electronic medical record (EMR) under the profile tab, revealed medical diagnoses that included but not limited to, dementia, major depressive disorder, anxiety, and cognitive communication deficit. Review of Progress Notes, dated 06/02/2026 and located in the EMR Progress Note tab, revealed, R60 was observed in the media room of the memory care unit seated next to R24. R24 was observed with his penis exposed and R60's hand in contact with it.Review of R60's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/2026, revealed the facility assessed R60 to have a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R60 was severely cognitively impaired.Review of R60's Care Plan located under the Care Plan tab in the EMR revealed that R60 is at risk for sexual behaviors with other residents. Per MD (Medical Doctor) R60 cannot consent to sexual activity related to BIMS. Interventions include staff observe and report behaviors. Date initiated 09/27/2022 with separate individuals involved in sexual activity initiated 06/02/2026.2. Review of R24's undated admission Record, included dementia, major depressive disorder, cognitive communication deficit, and other sexual dysfunction not due to a substance or known physiological condition. Review of R24's progress notes revealed a behavior note dated 07/13/2026, Resident was out in the hallway in the Geri chair and was enjoying looking out the window, when staff noticed R24 taking his penis out of his pants trying to show it to the other residents. Staff intervened and reminded R24 that is not allowed and that he will have to go back to his room if he continues this behavior. R24 then tried to show the nurse his penis and could not be redirected to any other activity so R24 was assisted back to his room where R24 continued to expose himself and make sexual comments to nurse.Review of Progress Notes, dated 06/02/2026 and located in the EMR Progress Note tab, revealed, R60 was observed in the media room of the memory care unit seated next to R24. R24 was observed with his penis exposed and R60's hand in contact with it.Review of R24's Care Plan located in the EMR revealed R24 has a behavior problem related to hypersexual behavior. Interventions included frequent staff observation date initiated 09/16/2020, notify Administrator and Director of Nursing (DON) immediately if hypersexual behaviors occurred, date initiated 09/16/2020. Separate residents involved in sexual activity, date initiated 06/22/2026; R24 does not have the decisional capacity to seek out and engage in consensual intimacy and/or sexual expression. Interventions included assist R24 in dressing of adult onesie to secure safety for himself and others as needed initiated 06/25/2026. Intervene if at any time the resident is observed by staff seeking out or engaging in sexual expression or intimacy. Redirect the resident through use of food, drink, conversation or activity having meaning to him/her. Date initiated 06/25/2026.During an observation on 08/03/2026 at 11:45 AM, R24 was seated in the media room with his back to the wall next to the window. R24 was dressed in a shirt and sweatpants.During an interview on 08/03/2026 at 11:50 AM with Registered Nurse (RN), RN1 stated, I witnessed the incident on 06/02/2026 and separated them and then reported it to the Administrator. R24 pulled out the front of his sweatpants and had R60 place her hand on his groin. I said excuse me and they both jumped and I separated them; I had staff stay with them and reported it to the administrator. I then went back and assessed both residents. R24 has history of being inappropriate to staff members and had been taking medication for a long time related to his thoughts. When he started saying things to staff, staff redirected him to other things.The facility investigation found the allegation to be not conclusive due to the cognitive status for both residents, the lack of knowledge of what happened and who initiated the incident.During an interview on 08/06/2026 at 8:10 AM with the Director of Rehabilitation (DOR), the DOR revealed, on 07/30/2026 a second incident occurred while R24 and R60 were in therapy. R24 was observed taking R60's hand and attempted to place onto his groin. The residents were separated and R24 was returned to his unit. At the time R24 was not wearing onesie. During an interview on 08/06/2026, at 11:20 AM with the Certified Occupational Therapy Assistant (COTA) COTA1 stated, Last week I was working with R11 and observed R24 take R60's hand and started to place her hand onto his groin area, I don't think it got there. I called for the DOR, and she separated them and took R24 back to the unit. The incident was reported to the floor nurse but was not reported to anyone else.Review of the facility policy, Freedom of Abuse, Abuse Prevention: Fast Alerts, dated 01/2025, revealed, Policy: The purpose of this written Freedom of Abuse, Neglect, Exploitation; Abuse Prevention Standards is to outline the preventive and action steps token to reduce the potential for abuse, mistreatment and neglect of residents and the misappropriation of resident property and to review practices and omissions which if allowed to go unchecked. could lead to abuse. This policy demonstrates a Zero Tolerance of Abuse of any type or manner and will address accordingly. Resident-to-Resident Abuse Policy: It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from any type of abuse listed from other residents. Procedures: 1. If A resident-to-resident altercation occurs, staff should intervene immediately. Separate the residents and take them to aeras away from each other until the situation has diffused. 1:1 supervision may be needed if resident behaviors are harmful or considered inappropriate. It is imperative to keep residents safe by separation or other interventions needed while investigation is in progress. 5. Notify the Director of Nursing and the Administrator immediately. Notify the physician and family/guardian. Notify the Regional Nurse Consultant for guidance. If the resident-to-resident altercation involves inappropriate sexual behaviors, then the Allegation of Abuse for Inappropriate Sexual Behaviors should be implemented immediately.

Based on interviews, record review, and the policy titled, Freedom of Abuse, Abuse Prevention, the facility failed to ensure allegations of abuse were reported for two of three residents (R) (R24, and R60) reviewed for abuse. The facility failed to report to the State Agency (SA) an incident of resident-to-resident abuse between R24 and R60. Refer to F600.Findings include:1. Review of R60's undated electronic medical record (EMR) under the profile tab, revealed an admission with medical diagnoses that included but not limited to dementia, major depressive disorder, anxiety, and cognitive communication deficit.2. Review of R24's undated EMR under the profile tab, revealed medical diagnoses that included but not limited to dementia, major depressive disorder, cognitive communication deficit, and other sexual dysfunction not due to a substance or known physiological condition.During an interview on 08/03/2026 at 11:50 AM with Registered Nurse (RN), RN1 stated, I witnessed the incident on 06/02/2026 and separated them and then reported it to the Administrator. R24 pulled out the front of his sweatpants and had R60 place her hand on his groin. I said excuse me and they both jumped. I separated them and had staff remain with them and I went to report it to the Administrator. I went back and assessed both residents. R24 has history of being inappropriate with staff members and had been taking medication for a long time related to his thoughts. When he starts saying things to staff, staff redirect him to other things.During an interview on 08/06/2026 at 8:10 AM, the Director of Rehabilitation (DOR), revealed on 07/30/2026 a second incident occurred while R24 and R60 were in therapy. R24 was observed taking R60's hand and attempting to place onto his groin. The residents were separated and R24 was returned to his unit.During an interview on 08/06/2026 at 8:45 AM, the Administrator stated, I was just informed of a new incident between R24 and R60 that happened on 07/30/26. The DOR just told me about it; this is the first I've heard of it. I will report it and start my investigation.During a phone interview on 08/06/2026 at 9:00 AM with Licensed Practical Nurse (LPN), LPN 2 stated, I was told by the DOR that R24 had placed R60's hand onto his groin area while in therapy. I did not witness the incident, and I documented the behavior on the medication administration report (MAR). Since it occurred in the therapy area I assumed they had reported it to the Administrator.During an interview on 08/06/2026 at 11:20 AM, Certified Occupational Therapy Assistant (COTA), COTA1 stated, Last week I was working with R11 and observed R24 take R60's hand and started to place her hand onto his groin area, I don't think it got there. I called for the DOR, and she separated them and then took R24 back to the unit. The incident was reported to the floor nurse but was not reported to anyone else.Review of the facility policy, Freedom of Abuse, Abuse Prevention: Fast Alerts, dated 01/2025, revealed, Policy: If the resident-to-resident altercation involves inappropriate sexual behaviors, then the Allegation of Abuse for Inappropriate Sexual Behaviors should be implemented immediately. Reporting/Investigation/Response Policy: Any complaint, allegation, observation or suspicion of resident abuse, mistreatment, or neglect, whether physical, verbal, mental or sexual, involuntary, or voluntary. is to be communicated to the Abuse Coordinator, thoroughly reported, investigated, and documented in a uniform manner as detailed below. Reporting: All employees are required to immediately notify the Administrator or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment, or neglect so thot the resident's needs can be addressed immediately, and investigation con be undertaken promptly. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident properly ore reported immediately, but not later than 2 hours after the allegation is mode, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on record review interviews, and the facility policy titled, Freedom of Abuse, Abuse Prevention, the facility failed to complete thorough investigations for two of three sampled residents (R24 and R60) reviewed for a facility reported incident of resident to resident abuse. This deficient practice had the potential risks for unaddressed abuse, and inadequate monitoring, placing residents at continued risk for physical harm, emotional distress, and an unsafe environment. Findings include:1. Review of R60's electronic medical record (EMR) under the profile tab, revealed admission with medical diagnoses that included but not limited to dementia, major depressive disorder, anxiety, and cognitive communication deficit.Review of R60's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/2026, revealed the facility assessed R60 to have a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R60 was severely cognitively impaired.Review of Progress Notes, dated 06/02/2026 and located in the EMR Progress Note tab, revealed, R60 was observed in the media room of the memory care unit seated next to R24. R24 was observed with his penis exposed and R60's hand in contact with it.2. Review of R24's EMR under the profile tab, revealed an admission with medical diagnoses that included but not limited to dementia, major depressive disorder, cognitive communication deficit, and other sexual dysfunction not due to a substance or known physiological condition.Review of R24's quarterly MDS with an ARD of 06/19/2026, revealed the facility assessed R24 to have a BIMS score of three out of 15 which indicated R24 was severely cognitively impaired.Review of Progress Notes, dated 06/02/2026 and located in the EMR Progress Note tab, revealed, R60 was observed in the media room of the memory care unit seated next to R24. R24 was observed with his penis exposed and R60's hand in contact with it.During an interview on 08/03/2026 at 11:50 AM, with Registered Nurse (RN), RN1 stated, I witnessed the incident on 06/02/2026 and separated them and then reported it to the Administrator. R24 pulled out the front of his sweatpants and had R60 place her hand on his groin. I said excuse me and they both jumped and I separated them; I had staff stay with them and reported it to the administrator. I then went back and assessed both residents. R24 has history of being inappropriate to staff members and had been taking medication for a long time related to his thoughts. When he started saying things to staff, staff redirected him to other things.A review of the facility's 5- day incident investigation following the incident on 06/02/2026, revealed all statements were written by the Administrator and not the actual person completing the statement.Review of the facility policy, Freedom of Abuse, Abuse Prevention: Fast Alerts, dated 01/25, revealed, Policy: . 7. The investigation protocol must be implemented, and a report given to the appropriate agencies as specified by law and regulations. Reporting/Investigation/Response Policy: Any complaint, allegation, observation or suspicion of resident abuse, mistreatment, or neglect, whether physical, verbal, mental or sexual, involuntary, or voluntary. is to be communicated to the Abuse Coordinator, thoroughly reported, investigated, and documented in a uniform manner as detailed below.

Based on record review and staff interviews, the facility failed to develop and implement a person-centered comprehensive care plan for one of five residents (R) (R1) receiving a pureed diet. Specifically, the facility failed to address the resident's diet, behaviors of wandering into other residents' rooms, and seeking non mechanically altered food items. This failure resulted in R1 choking and expiring on 10/25/2025. The facility's failure to develop and implement a person-centered comprehensive care plan caused or was likely to cause serious injury, harm, impairment, or death to a resident. An Immediate Jeopardy (IJ) was identified on 11/13/2025 and was determined to have existed on 10/25/2025. The Administrator and Regional Operations Manager were informed of the IJ on 11/13/2025. An acceptable Removal Plan was received on 11/17/2025. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice were removed on 11/15/2025. Findings include:A review of the electronic medical record (EMR) revealed that on 10/25/2025 at approximately 9:03 am, Certified Nursing Assistant (CNA) BB was feeding a resident in Room A5 when she heard a thud and left Room A5 to find out the cause of the noise. When CNA BB entered Room A7, she found R1 on the floor, face down with a biscuit hanging out of his mouth. The CNA reported the incident to Licensed Practical Nurse (LPN) AA; LPN AA initiated emergency care at 9:06 am; Emergency Medical Services (EMS) was called at 9:09 am; the EMS team arrived at 9:13 am; and provided emergency services until 9:40 am before pronouncing R1 as expired at 9:40 am.A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Pattern) revealed a Brief Interview for Mental Status (BIMS) was not conducted due to resident was rarely/never understood. Section GG (Functional Abilities) revealed that R1 was dependent with eating and personal hygiene. Section I (Active Diagnosis) revealed diagnoses that included but not limited to, Alzheimer's disease, cognitive communication deficit, need for personal care, and anxiety disorder. Section K (Swallowing disorder) revealed the resident was on a mechanically altered diet.A review of R1's diet order dated 8/17/2025 revealed, a large portion diet, pureed texture, nectar consistency, no rolls or bread with meals.Record review of R1's psychiatry note dated 9/23/2025 at 11:08 am revealed, the resident was on secure unit of facility due to wandering and exit-seeking behaviors. Staff reports increased agitation and impulsivity.Record review of R1's behavior note dated 10/17/2025 at 8:03 pm revealed, This resident is completely uncontrollable. He's become impossible to redirect. He is charging in other resident's rooms while they're completely unaware he's coming. He's just walking into other rooms getting into their beds, using they're restroom and completely leaving it covered in feces or urinating on the floor, and taking their food or drinks from them while in the dining room eating meals. He is completely out of sorts when he's up and alert. His new behavior is eating anything that's not edible. I had to take his pillows away from him because for the past 2 days, he has started eating the stuffing out of them. When I took them away, he started eating his blanket. A review of the care plan dated 10/1/2025 revealed that R1 had a potential for nutritional problems with interventions that included but not limited to, ensure 3 (three) compartment trays are used at all meals, provide and serve diet as order, and provide and serve supplements as ordered however, the care plan failed to address the resident's diet, behaviors of wandering into other residents' rooms, and seeking non mechanically altered food items. Further review of the care plan revealed, R1 had impaired cognitive function/dementia or impaired thought processes with interventions that included, administer medications as ordered with monitoring of side effects of medication and to cue, reorient, and supervise as needed.An interview with LPN AA on 11/17/2025 at 4:57 pm revealed that care plans can be seen in electronic records. She revealed that she receives a list with all the information about the patient such as diet and type of care to provide.An interview with the Weekend LPN Supervisor on 11/19/2025 at 10:58 am revealed that care plans were usually updated by management or the MDS coordinator. She stated that care plans can be seen in the EMR, but that they usually obtain the information from the 24-hour report, order reports, or word of mouth.An interview with Director of Nursing (DON) revealed that she was currently completing care plans until the new MDS coordinator started. She revealed that Cooperate was helping with care plans. She confirmed that R1 care plan was not updated to reflect his diet, behaviors of wandering into other residents' rooms and seeking non mechanically altered food items. The DON revealed that she had a board that she used to monitor when to update care plans. She confirmed that the care plan should be updated immediately.

Based on record review and staff interviews, the facility failed to provide adequate supervision to prevent an avoidable accident for one of five residents (R) (R1) on A Hall (the secured memory unit) with a pureed diet. Specifically, R1 was ordered a pureed texture, nectar consistency, with no rolls or bread. R1 was left unsupervised, resulting in him obtaining a non-mechanically altered food and subsequently choking. This failure resulted in R1 expiring on 10/25/2025.The facility's failure to provide adequate supervision to prevent an avoidable accident caused or was likely to cause serious injury, harm, impairment, or death to a resident. An Immediate Jeopardy (IJ) was identified on 11/13/2025 and was determined to have existed on 10/25/2025. The Administrator and Regional Operations Manager were informed of the IJ on 11/13/2025. An acceptable Removal Plan was received on 11/17/2025. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice were removed on 11/15/2025.Findings include:A review of the electronic medical record (EMR) revealed that on 10/25/2025 at approximately 9:03 am, Certified Nursing Assistant (CNA) BB was feeding a resident in Room A5 when she heard a thud and left Room A5 to find out the cause of the noise. When CNA BB entered Room A7, she found R1 on the floor, face down with a biscuit hanging out of his mouth. The CNA reported the incident to Licensed Practical Nurse (LPN) AA; LPN AA initiated emergency care at 9:06 am; Emergency Medical Services (EMS) was called at 9:09 am; the EMS team arrived at 9:13 am; and provided emergency services until 9:40 am before pronouncing R1 as expired at 9:40 am.A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Pattern) revealed a Brief Interview for Mental Status (BIMS) was not conducted due to resident was rarely/never understood. Section GG (Functional Abilities) revealed that R1 was dependent with eating and personal hygiene. Section I (Active Diagnosis) revealed diagnoses that included but not limited to, Alzheimer's disease, cognitive communication deficit, need for personal care, and anxiety disorder. Section K (swallowing disorder) revealed the resident was on a mechanically altered diet.Record review of R1's behavior note dated 9/22/2025 at 7:45 pm revealed, He continues to stuff his mouth with food causing him to choke. When I am present, I will feed him and instruct him to chew and swallow the food that's already in his mouth before putting more in but he continues to pack his mouth.Record review of R1's behavior note dated 10/17/2025 at 8:03 pm revealed, This resident is completely uncontrollable. He's become impossible to redirect. He is charging in other resident's rooms while they're completely unaware he's coming. He's just walking into other rooms getting into their beds, using they're restroom and completely leaving it covered in feces or urinating on the floor, and taking their food or drinks from them while in the dining room eating meals. He is completely out of sorts when he's up and alert. His new behavior is eating anything that's not edible. I had to take his pillows away from him because for the past 2 days, he has started eating the stuffing out of them. When I took them away, he started eating his blanket.Record review revealed a staffing assignment sheet for A Hall dated 10/25/2025 which indicated one LPN and one CNA were assigned to care for 23 residents with the following acuity: 17 residents at risk for elopement, 13 incontinent residents, one resident who requires two person total assistance with Activities of daily living (ADL) hygiene care, transferring, and bed mobility, and four residents who require total assistance with feeding. Interview on 10/27/2025 at 3:31 pm with LPN AA revealed the staffing pattern on A Hall was problematic. She revealed that the unit cares for residents with dementia and other cognitive impairments. She revealed that prior to the incident on 10/25/2025 with R1, she and one CNA were scheduled to care for the entire secured unit. She revealed that it was impossible to monitor and provide adequate care to all 23 residents. She revealed she and the CNA did the best they could but admitted that residents were not monitored. LPN AA revealed that R1 was constantly in and out of other residents rooms, attempting to eat their food. LPNA AA revealed R1 could not be redirected and staff had to follow him constantly. LPN AA revealed that there were multiple residents that required assistance with feeding, when she and the CNA were assisting with feeding that left no one to monitor the other residents, including those who wander. She revealed that she voiced her concerns to management, including the Administrator, but they ignored her. She stated the incident with R1 was avoidable but due to lack of staff the accident occurred. Interview on 10/27/2025 at 5:24 pm with CNA BB revealed the incident on 10/25/2025 with R1 was avoidable but that management refused to staff A Hall with more than one CNA and one nurse. She stated the unit required a lot of care. She stated if nurse was passing medication and she was assisting a resident it left no one to monitor the other residents, residents who have behaviors such as wandering in and out of the residents' rooms. She revealed R1 required constant monitoring because he was known to shove food that was not pureed into his mouth and other objects such as the stuffing of a pillow. She revealed that she asked for more staff on the unit to assist with ADL care and with assistance with feeding residents during meals because she knew the residents were being neglected.Interview on 10/28/2025 at 2:30 pm with the Director of Nursing (DON) revealed R1 was eating anything he could get his hands on. He had issues with shoveling food into his mouth and not chewing, he required assistance with feeding to ensure he ate appropriately and safely. She stated she was aware he was a wanderer and that he was discussed in risk management and they made him a feeder. The DON revealed there are numerous residents on the secured unit that wander in and out of other resident rooms and the hall. She admitted that one CNA and one nurse is not adequate to supervise A Hall and confirmed that the residents were not being monitored on 10/25/2025 when R1 choked to death. She revealed she asked corporate for help with staffing but instead they cut staff based on the census being low. She stated the facility does not staff the facility according to acuity but rather on census.Interview on 10/28/2025 at 2:50 pm with the scheduler revealed the facility was staffed according to census and not acuity. She revealed she was told by the DON on how to staff A Hall and confirmed it was staffed with one CNA and one nurse. She revealed five residents on that unit required assistance with feeding at the time R1 choked on 10/25/2025. She revealed those two staff cannot be observing, monitoring, or caring for the rest of the 22-23 residents. She revealed the residents were more at risk for accidents such as falls. She revealed she was familiar with R1 and his behaviors such as wandering and attempting to eat whatever he could. She revealed staff did the best they could and that the Administrator and corporate knew A Hall could use more staff to better monitor residents, but they cut staff to the facility instead of adding. Interview on 10/28/2025 at 3:03 pm with the Administrator revealed that A Hall unit was staffed with one CNA and one nurse. She revealed that after the incident with R1 on 10/25/2025, corporate approved an additional CNA to be scheduled for both day and night shifts. She admitted she was aware staffing was a concern but that the facility had not implemented any staffing changes. She confirmed she knew R1 had behaviors such as wandering but did not know his behaviors were increasing and was unaware R1 ate stuffing out of a pillow. She confirmed that there was no staff monitoring or supervising the other 21 residents including R1 on 10/25/2025 when the two staff scheduled were occupied with feeding two other residents.An interview with Medical Director on 10/30/2025 at 12:03 pm revealed that when he entered the facility to make rounds, he was told that R1 was having an emergency and found EMS providing emergency interventions. He called the time of death at 9:40 am on 10/25/2025 after 30 minutes of cardiopulmonary resuscitation. The Medical Director confirmed that the unit needed more staff especially since there was five residents needing assistant with feeding. He confirmed that R1 needed one-on-one care. He revealed that he was just made aware that there was one nurse and one aide on the hallway.

Based on record review and staff interviews, the facility failed to provide sufficient nursing staff to monitor one of 23 residents (R) (R1) on A Hall (the secured memory unit), resulting in R1 choking and expiring on 10/25/2025. Specifically, the facility failed to have sufficient nursing staff to provide nursing and related services, considering the number, acuity, and diagnoses of the facility's resident population. The facility's failure to provide sufficient nursing staff and related services caused or was likely to cause serious injury, harm, impairment, or death to a resident. An Immediate Jeopardy (IJ) was identified on 11/13/2025 and was determined to have existed on 10/25/2025. The Administrator and Regional Operations Manager were informed of the IJ on 11/13/2025. An acceptable Removal Plan was received on 11/17/2025. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice were removed on 11/15/2025.Findings include:Review of R1's EMR revealed he was admitted to the facility with diagnoses that included but not limited to Alzheimer's Disease, unspecified, dementia in other diseases classified elsewhere unspecified severity, with agitation, and need for assistance with personal care.A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Pattern) revealed a Brief Interview for Mental Status (BIMS) was not conducted due to resident is rarely/never understood. Section GG (Functional Abilities) revealed that R1 was dependent with eating and personal hygiene. Section K (swallowing disorder) revealed the resident was on a mechanically altered diet.Record review of R1's behavior note dated 9/22/2025 at 7:45 pm revealed, He continues to stuff his mouth with food causing him to choke. When I am present, I will feed him and instruct him to chew and swallow the food that's already in his mouth before putting more in but he continues to pack his mouth.Record review of R1's psychiatry note dated 9/23/2025 at 11:08 am revealed, the resident was on secure unit of facility due to wandering and exit-seeking behaviors. Staff reports increased agitation and impulsivity.Record review of R1's neurologic progress note dated 10/7/2025 at 10:20 am revealed that residents mood and behavior was anxious and he was disruptive because he was charging into other residents' rooms and close the door and get into residents bed or bathroom.Record review of R1's behavior note dated 10/17/2025 at 8:03 pm revealed, This resident is completely uncontrollable. He's become impossible to redirect. He is charging in other resident's rooms while they're completely unaware he's coming. He's just walking into other rooms getting into their beds, using they're restroom and completely leaving it covered in feces or urinating on the floor, and taking their food or drinks from them while in the dining room eating meals. He is completely out of sorts when he's up and alert. His new behavior is eating anything that's not edible. I had to take his pillows away from him because for the past 2 days, he has started eating the stuffing out of them. When I took them away, he started eating his blanket. Record review revealed a staffing assignment sheet for A Hall dated 10/25/2025 which indicated one LPN and one CNA were assigned to care for 23 residents with the following acuity: 17 residents at risk for elopement, 13 incontinent residents, one resident who requires two person total assistance with Activities of daily living (ADL) hygiene care, transferring, and bed mobility, and four residents who require total assistance with feeding. Interview on 10/27/2025 at 3:31 pm with LPN AA revealed the staffing pattern on A Hall was problematic. She revealed that the unit cares for residents with dementia and other cognitive impairments. She revealed that prior to the incident on 10/25/2025 with R1, she and one CNA were scheduled to care for the entire secured unit. She revealed that it was impossible to monitor and provide adequate care to all 23 residents. She revealed she and the CNA did the best they could but admitted that residents were not monitored. LPN AA revealed that R1 was constantly in and out of other residents rooms, attempting to eat their food. LPNA AA revealed R1 could not be re directed and staff had to follow him constantly. LPN AA revealed that there were multiple residents that required assistance with feeding, when she and the CNA were assisting with feeding that left no one to monitor the other residents, including those who wander. She revealed that she voiced her concerns to management, including the Administrator, but they ignored her. She stated the incident with R1 was avoidable but due to lack of staff the accident occurred. Interview on 10/27/2025 at 5:24 pm with CNA BB revealed the incident on 10/25/2025 with R1 was avoidable but that management refused to staff A Hall with more than one CNA and one nurse. She stated the unit required a lot of care. She stated if nurse was passing medication and she was assisting a resident it left no one to monitor the other residents, residents who have behaviors such as wandering in and out of the residents' rooms. She revealed R1 required constant monitoring because he was known to shove food that was not pureed into his mouth and other objects such as the stuffing of a pillow. She revealed that she asked for more staff on the unit to assist with ADL care and with assistance with feeding residents during meals because she knew the residents were being neglected.Interview on 10/28/2025 at 12:55 pm with CNA EE revealed the secured unit was staffed with one CNA and one nurse. She stated that sometimes during the weekdays front office staff will come to the unit to assist with feeding the residents, but the weekends were difficult because there were only two staff assisting with feeding and providing all care, which was not manageable. Interview on 10/28/2025 at 2:30 pm with the Director of Nursing (DON) revealed R1 was eating anything he could get his hands on. He had issues with shoveling food into his mouth and not chewing, he required assistance with feeding to ensure he ate appropriately and safely. She stated she was aware he was a wanderer and that he was discussed in risk management and they made him a feeder. The DON revealed there are numerous residents on the secured unit that wander in and out of other resident rooms and the hall. She admitted that one CNA and one nurse is not adequate to supervise A Hall and confirmed that the residents were not being monitored on 10/25/2025 when R1 choked to death. She revealed she asked corporate for help with staffing but instead they cut staff based on the census being low. She stated the facility does not staff the facility according to acuity but rather on census.Interview on 10/28/2025 at 2:50 pm with the scheduler revealed the facility was staffed according to census and not acuity. She revealed she was told by the DON on how to staff A Hall and confirmed it was staffed with one CNA and one nurse. She revealed five residents on that unit required assistance with feeding at the time R1 choked on 10/25/2025. She revealed those two staff cannot be observing, monitoring, or caring for the rest of the 22-23 residents. She revealed the residents were more at risk for accidents such as falls. She revealed she was familiar with R1 and his behaviors such as wandering and attempting to eat whatever he could. She revealed staff did the best they could and that the Administrator and corporate knew A Hall could use more staff to better monitor residents, but they cut staff to the facility instead of adding. Interview on 10/28/2025 at 3:03 pm with the Administrator revealed that A Hall unit was staffed with one CNA and one nurse. She revealed that after the incident with R1 on 10/25/2025, corporate approved an additional CNA to be scheduled for both day and night shifts. She admitted she was aware staffing was a concern but that the facility had not implemented any staffing changes. She confirmed she knew R1 had behaviors such as wandering but did not know his behaviors were increasing and was unaware R1 ate stuffing out of a pillow. She confirmed that there was no staff monitoring or supervising the other 21 residents including R1 on 10/25/2025 when the two staff scheduled were occupied with feeding two other residents.

Based on staff interviews, record reviews, and review of the facility's documents titled, Licensed Nursing Home Administrator and Director of Nursing (DON), the administration failed to provide sufficient nursing staff to monitor one of 23 residents (R1) on A Hall (the secured memory unit ). This resulted in an avoidable choking accident and the death of R1 on 10/25/2025. Specifically, Administration knew there was insufficient staffing on A Hall (secured memory unit) and failed to staff A Hall in manner that efficiently maintained the highest practicable physical, mental, and psychosocial well-being of each resident. The failure to take action caused R1 to be left unsupervised, resulting in his death. The facility's failure to provide sufficient nursing staff caused or was likely to cause serious injury, harm, impairment, or death to a resident. An Immediate Jeopardy (IJ) was identified on 11/13/2025 and was determined to have existed on 10/25/2025. The Administrator and Regional Operations Manager were informed of the IJ on 11/13/2025. An acceptable Removal Plan was received on 11/17/2025. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice were removed on 11/15/2025.Findings include:Review of the facility's document titled, Licensed Nursing Home Administrator under the Job Duties and Responsibilities section revealed, Oversee that residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other residents. Under the Human Resources section revealed, Maintain responsibility for an adequate number of appropriately trained professional and auxiliary personnel being on duty at all times to meet the needs of the residents.Review of the facility's document titled, Director of Nursing under the Job Summary: revealed, The primary purpose of the Director of Nursing position is to plan, organize, develop and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times.Review of the staffing sheets from September 1, 2025, through October 27, 2025, for A Hall (the secured memory unit) revealed that the unit was staffed with one CNA and one nurse. The census on the unit ranged from 21 to 23 residents during those two months.Record review revealed a staffing assignment sheet for A Hall dated 10/25/2025 which indicated one Licensed Practical Nurse (LPN) and one Certified Nurse Assistant (CNA) were assigned to care for 23 residents with the following acuity: 17 residents at risk for elopement, 13 incontinent residents, one resident who requires two person total assistance with Activities of daily living (ADL) hygiene care, transferring, and bed mobility, and four residents who require total assistance with feeding. Interview on 10/28/2025 at 2:30 pm with the Director of Nursing (DON) revealed there were numerous residents with behaviors on the secured unit. She confirmed that one CNA and one nurse was not adequate to supervise A Hall and confirmed that the residents were not being monitored on 10/25/2025 when R1 choked to death. She revealed she asked corporate for help with staffing but instead they cut staff based on the census being low. She revealed that the facility did not staff the facility according to acuity but rather on the census.Interview on 10/28/2025 at 3:03 pm with the Administrator revealed that the A Hall unit was staffed with one CNA and one nurse. She confirmed she was aware that lack of staffing was a concern for the unit but that the facility had not implemented any staffing changes.

Based on staff interviews, record review, and review of the facility's policy titled, Medication Administration Guidelines, the facility failed to notify the provider and obtain an order to administer medication for one of three sampled residents (R) (R7). This failure placed the resident at risk not to receive the treatment and care in accordance with professional standards of practice.Findings include:Review of the facility's policy titled, Medication Administration Guidelines dated June 2022 under Guidelines revealed, To enforce and adhere to the Nurse Practice Act and DEA (Drug Enforcement Administration) requirement of safe practice of administering medications. Under the section titled Medication Administration revealed, Prior to administering medications, there must be a physician order prescribing the medication.Review of the most recent Quarterly Minimal Data Set (MDS) dated [DATE] for Section C (Cognitive Pattern) revealed that R7 had a Brief Interview for Mental Status (BIMS) score of one indicating severe cognitive impairment. Section I (Active Diagnosis) revealed diagnoses that included but not limited to, congestive heart failure, hypertension, Alzheimer's disease, and metabolic encephalopathy.Review of R7's electronic medical record (EMR) revealed that R7 did not have an order for Benadryl (an allergy medication) as of 10/30/2025. Review of a nurse practitioner note dated 8/12/2025 revealed that R7 received Benadryl (allergy medication) however, review of R7's medication administration record (MAR) dated August 2025 revealed there was no documentation of Benadryl.During an interview on 11/18/2025 at 10:04 am with Licensed Practical Nurse (LPN) KK, Unit Manager confirmed that there was not an order for Benadryl (an allergy medication) nor was there documentation of Benadryl on the MAR for R7.An interview on 11/18/2025 at 11:29 am with the Director of Nursing (DON) confirmed that the R7 did not have an order for Benadryl and that it was not documented on the MAR. She confirmed that the nurse provided the Benadryl medication without an order. She revealed that the nurse found an old standing order in the narcotic box. She further revealed that standing orders were discontinued in 2024.An interview on 11/18/2025 at 2:27 pm with the Medical Director revealed that he did not recall receiving a call from the nurse on that day. He stated that if he had received a call that he would have ordered Benadryl (an allergy medication) and prednisone at the same time to address an allergic reaction. He stated that the resident was sent out the next morning when the Nurse Practitioner evaluated R7.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Medication Administration Guidelines and Tube Feeding Management, the facility failed to ensure a medication error rate of less than five percent. There were three errors from 36 opportunities observed for a medication error rate of 8.33%. This deficient practice has the potential to place Residents (R) R2, R3, and R9 at risk of medical complications.Findings include:Review of the facility's policy titled, Medication Administration Guidelines dated June 2022 under Guidelines revealed, To enforce and adhere to the Nurse Practice Act and DEA (Drug Enforcement Administration) requirement of safe practice of administering medications. Under the section titled Medication Administration revealed, Prior to administering medications, there must be a physician order prescribing the medication.Some medications are NOT to be crushed. Facility to check with pharmacy before crushing medications.Review of the facility's policy titled Tube Feeding Management, dated January 2025 under the section titled Procedure revealed, that the placement of tube is verified and to check gastric contents for residual feeding.A review of the facility's list titled, Common Oral Dosage Forms that Should Not be Crushed revealed that asprin enteric coated was not to be crushed.1. A review of R2's Medication Administration Record (MAR) revealed the following order dated 6/16/2023 for Asprin EC tablet Delayed Release 81 mg (milligram) one tablet once a day by mouth.A review of physician orders for R2 dated 6/15/2023 revealed that may crush all medications per physician order.An observation on 11/13/2025 at 8:09 am of R2 medication administration on A Hall revealed that Licensed Practical Nurse (LPN) FF crushed an aspirin enteric coated (EC) tablet then mixed it with pudding2. A review of the Medication Administration Record (MAR) revealed the following order for R3 Asprin tablet Chewable 81mg one tablet once a day by mouth.A review of physician orders for R3 dated 4/23/2022 revealed an order, may crush all medications per physician orders.An observation on 11/13/2025 at 8:28 am of R3 medication administration on A hall revealed that Licensed Practical Nurse (LPN) FF crushed an aspirin enteric coated (EC) tablet then mixed it with pudding.An observation and interview with LPN FF on 11/13/2025 at 9:40 am revealed that she received a list of residents that need crushed medications. She confirmed that she crushed asprin 81mg enteric coated (EC) for R2 and R3. She revealed that she crushed them because the residents cannot swallow the pills whole. She stated that she learned in school that you were not to crush enteric coated medication. She revealed was not sure about a do not crush list. She confirmed that R3 had an order for asprin 81mg chewable but crushed and administered asprin EC 81mg to R3. She revealed that she had a bottle of asprin chewable on the A Hall cart available.3. A review of R9's Medication Administration Record (MAR) revealed the following order dated 6/18/2025 for hydrocodone 10-325 mg- one tablet, give via (by way of) gastrostomy tube (g-tube) every four hours as needed for pain.A review of physician orders for R9 dated 10/3/2024 revealed may crush all medications per physician orders. A physician order dated 4/14/2025 revealed that every shift flush peg tube with 30 ml (milliliters) of water before and after medications.An observation on 11/13/2025 at 11:54 am of medication administration on B hall revealed that LPN CC administered hydrocodone via g-tube. LPN CC crushed the pill and mixed it with 30 milliliters (ml) of water. She then proceeded to flush the tube with 30 ml of water before and after medication administration however, she did not check placement of the g-tube and residual prior to flushing the tube with 30 ml of water.An interview on 11/13/2025 11:59 am with LPN CC confirmed that she did not check placement of the g-tube and residual prior to flushing the tube with 30 ml of water. She revealed that she forgot to check placement. She confirmed that she needed to check placement before giving the hydrocodone.An interview with the Pharmacy Consultant on 11/18/2025 at 12:24 pm revealed that asprin enteric coated was on the do not crush list. She stated that the medication should not be crushed unless there was a specific order from the physician instructing to crush the asprin. She admits that asprin enteric coated 81mg and asprin chewable 81 mg cannot be used interchangeable.An interview with Director of Nursing (DON) on 11/18/2025 at 12:49 pm revealed that asprin enteric coated (EC) should not be crushed. She confirmed that asprin enteric coated was found on the facilities Common Oral Dosage Forms that Should Not be Crushed list. She confirmed that the order for R2 aspirin EC was not changed when he required medications to be crushed. She confirmed that R3 has an order for asprin 81mg chewable and that was what the nurse should have given. The DON revealed that she expect staff to follow the policies. She revealed that the expectation was that the nurse check placement before administering medication or anything in the tube. She revealed that the policy states that placement should be verified before administering medication through a g- tube.An interview on 11/18/2025 at 4:50 pm with LPN OO revealed that when administering medication through a g-tube, the placement should be checked prior to administering medication. Each medication should be crushed individually and flushed prior to and after administering medication with the ordered amount of water.

Based on observations, staff interviews, and record review, the facility failed to ensure pureed therapeutic diets were properly prepared for one out of eight residents (R) (R4) receiving a therapeutic pureed diet. This deficient practice had the potential to cause medical complications and place the resident at risk for unmet nutritional needs.Findings include:Record review of R4's electronic health record (EHR) revealed R4 had diagnoses that included but not limited to Alzheimer, dementia, amnesia, transient ischemic attack (TIA), and dysphasia.Record review of R4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the following assessment for Section C (Cognitive Patterns) revealed, a Brief Interview of Mental Status (BIMS) score of 99 which indicated severe cognition impairment. Section K (Swallowing/Nutritional status) revealed that the resident received a mechanically altered diet (which required change in texture of food or liquid, puree food).Review of R4's Physician Order Form (POF) revealed a dietary order dated 8/18/2025 for regular pureed texture, thin consistency.Observation 11/15/2025 at 1:26 pm on revealed R4 in the dining room sitting at a table with two other residents, eating her meal, a non-pureed diet independently without staff assistance. Continued observation of the resident meal revealed beef (appearance was lumpy with mixture of ground beef, corn was thick, lumpy with kernels, and bread was thick and lumpy). Review of the R4's meal tray revealed a diet for pureed, thin consistency.During an observation at the time of interview on 11/15/2025 at 1:30 pm of R4's meal with the Administrator and Corporate Nurse, both administrative staff confirmed that R4's meal was of non-pureed consistency. The Administrator reported that the facility did not have a dietary manager and this error was a result lack of guidance. The Administrator reported that her plan was to educate the dietary staff on pureed preparation. She described the risk for any resident on a puree diet receiving food of non-puree consistency could potentially cause choking/aspiration.Interview on 11/24/2025 at 1:00 pm, the Registered Dietician (RD) revealed, that she was able to review the photo of R4's meal. The RD described the meal as non-pureed due to dietary staff failure to achieve the ultimate consistency of ensuring that each food item was completely pureed. She described the beef as containing ground particles of beef, corn as containing mixture of the husk, and the roll as lumpy. She reported that the rice food item was the only true consistent puree item on the plate.

Based on staff interviews and record review the facility failed to accurately maintain medical records for one of three sampled residents (R) (R7). Specifically, the facility failed to ensure R7's allergies was updated. This failure has the potential to place resident at risk for an allergic reaction or clinical decline.Findings include:Review of the most recent Quarterly Minimal Data Set (MDS) dated [DATE] for Section C (Cognitive Pattern) revealed that R7 had a Brief Interview for Mental Status (BIMS) score of one indicating severe cognitive impairment. Section I (Active Diagnosis) revealed diagnoses that included but not limited to, congestive heart failure, hypertension, Alzheimer's disease, and metabolic encephalopathy.Review of the electronic medical record (EMR) on 10/30/2025 revealed that R7 had no known allergies however, review of the hospital discharge record dated 8/13/2025 revealed that R7 had allergies to codeine, dilaudid, morphine and lisinopril.During an interview on 11/13/2025 at 9:40 am with Licensed Practical Nurse (LPN) FF, she confirmed that R7 electronic medical record (EMR) had no known allergies listed upon review. She revealed that allergies would have been listed in red.During an interview on 11/18/2025 at 10:04 am with LPN KK, she confirmed that the EMR for R7 reflected that the resident had no known allergies listed on his profile upon review. Following his readmission on [DATE], the discharge hospital records demonstrated resident had allergies to dilaudid, codeine, morphine, and lisinopril. She confirmed that she should have updated the EMR when R7 was readmitted on [DATE] with the listed allergies. She revealed that the process was that when a resident returns from the hospital she would enter all the medications and allergies that were approved by the Medical Director. She revealed that she then place a check mark next to the medication or allergy that the Medical Director would like to continue and a X mark next to the medication or allergy that the Medical Director did not want to continue.An interview on 11/18/2025 at 10:54 am with Consultant Pharmacy revealed that she reviewed medical records monthly. The review consists of all the electronic records which includes allergies. She revealed that when a resident was readmitted , allergies were to be reviewed. She confirmed the EMR for R7 listed no known allergies. She revealed that admissions and readmissions reviews were completed between 24 and 72 hours, which included reviewing the hospital paperwork. She revealed that she reviewed the admission paperwork for 8/13/2025 that demonstrated resident had allergy to Dilaudid, Codeine, Morphine, and Lisinopril on 8/18/2025 then again in September and October but the allergies were not updated.An interview on 11/18/2025 at 11:29 am with the Director of Nursing (DON) confirmed that the EMR for R7 list the resident as having no known allergies. She revealed that the Unit Manager enters the order and the floor nurse enters the orders after hours and on the weekend. She revealed that the weekend supervisor will also help put in the admission orders. She revealed that the allergies would be reviewed and included with this process. The unit manager or nurse would then put a check by the medication or allergies that the Medical Director would like to continue and then enter the information into the EMR.

Based on observation, interviews, and record review, and review of the facility's policy titled, Infection Control Preventionist, the facility failed to use gloves to handle pills to crush medication for two of seven sampled residents (R) (R2 and R3). This deficient practice had the potential to place residents at high risk for infection.Findings include:A review of the of the facility's policy titled, Infection Control Preventionist dated January 2025 under the Policy section revealed that the ICP [Infection Control Preventionist] is responsible for the center's activities aimed at preventing healthcare associated infections by ensuring that the sources of infections are isolated to limit the spread of infectious organisms. Under the Duties section revealed, The ICP conducts rounds, discusses and monitors infection prevention practices with staff members, collects infection data from departments, maintains records for each case of HAI, conducts outbreak investigations, trains staff members on incidents of infection and reports such incidents to the appropriate person/department, and ensures availability of supplies required for infection prevention activities. 1. A review of order dated 6/15/2023 for R 2 revealed may crush all medications per physician orders.An observation on 11/13/2025 at 8:09 am of R2 medication administration on A Hall revealed that Licensed Practical Nurse (LPN) FF used her bare hands to pick up pills to place in a pouch to crush medication.2. A review of order dated 4/23/2022 for R3 revealed may crush all medications per physician order.An observation on 11/13/2025 at 8:28 am of R3 medication administration on A hall revealed that Licensed Practical Nurse (LPN) FF used her bare hands to pick up pills to place in a pouch to crush medication.Interview on 11/13/2025 at 9:40 am with Licensed Practical Nurse (LPN) FF confirmed she used her bare hands to pick up pills to place in a pouch to crush medication. She confirmed that she was not using gloves to pick up the pills to place in pouch for R2 and R3. She acknowledged that she should always wear gloves to handle residents' pills.An interview on 11/18/2025 at 10:45 am with Registered Nurse Unit Manager/Infection Preventionist confirmed that nursing staff were to wear gloves when handling residents' pills.An interview on 11/18/2025 at 12:49 pm with the Director of Nursing (DON) revealed that she expect nursing staff to wear gloves when handling residents' pills.

Based on observations and staff interviews, the facility failed to provide information so that residents and/or visitors were aware of how to report complaints, abuse or neglect, to the state survey office. The facility census was 71 residents. Findings include: Tour and observation on 5/4/2025 during initial tour and screening of residents, and tour of the facility on 5/7/2025 at 2:00 pm on Hall 100, Hall 200, Hall 300, the front entrance area, common area, nurses station, and dining area of the facility revealed there were no signs posted with information on how residents could report complaints, abuse or neglect to the state agency (SA). Observation and interview on 5/7/2025 at 2:40 pm with the Administrator and the Team Coordinator for the state survey team during a walk-through, the Administrator confirmed there was no signage or Elder Abuse Act poster with information on how residents and/or visitors could report complaints. The Administrator revealed they did have signs up and they were next to the Ombudsman poster. The Administrator further revealed that the Ombudsman came about six weeks prior and changed out her contact information on the Ombudsman poster and she must have taken down the facility's signs for reporting complaints. The Administrator confirmed the information should be posted on how to contact the state office and report complaints, and she would put one up immediately. A phone call on 5/7/2025 at 2:57 pm was placed to the Ombudsman to inquire if she removed the facility's signs/poster/notice for reporting complaints. There was no answer. A message was left with a request to return the call. Observation on 5/7/2025 at 3:18 pm revealed a small notice had been posted. The notice appeared to be a 8 x 10 size piece of copy paper folded in half with typed information that read, For Concerns/Complaints . The information included a toll free (800) phone number, two (404 area code) Complaint Intake Unit phone numbers, and two email addresses, one for general inquiries and one to request records. The notice with printed information was small, hard to read, and placed beneath the Ombudsman poster at the far end of 200 hall.

Based on observations, staff interviews, and review of the facility policy titled, Food Handling Procedures, the facility failed to maintain the cleanliness of the facility minimizing the risk of food-borne illness and to promote safe food handling practices. The deficient practice had the potential to place residents who received an oral diet from the kitchen at risk of foodborne illnesses. Findings include: Review of the facility policy titled Food Handling Procedures with a review date of 4/14/2025 revealed under Subject: HAZARD ANALYSIS AND CRITICALCONTROL POINT (HACCP) FOR FOOD PREPERATION: Is a process control system that identifies critical points in the production and service of food items to prevent food safety and sanitation hazards. Under Procedures: . identify critical control points at which procedures may result in a food safety hazard An observation on 5/4/2025 at 9:56 am of the two-door stand-up refrigerator inside the kitchen revealed a clear plastic container labeled breakfast meat with a used by date of 4/5/2025 and a box of bell peppers with a use by date of 4/27/2025. There was a sealable plastic bag with meat opened with no use by date. An interview on 5/4/2025 at 9:59 am with the Dietary Manager (DM) confirmed that the meat did not have a use by date. The clear plastic container labeled breakfast meat had a use by date of 4/5/2025 and the bell peppers had a use by date of 4/27/2025. The DM stated that the date on the breakfast meat was wrong, the breakfast meat has the wrong use by date but she discarded the item. The DM also discarded the bell peppers and the meat in the sealable plastic bag. The DM revealed that staff discard leftovers after 3 days. An observation on 5/4/2025 at 10:50 am of the ice machine on the 300 hall revealed a black flakey substance and the machine had a rusty substance. The DM confirmed the ice machine on the 300 hall had a black flakey substance and rust on the machine. The facility turned the machine off on the 300 hall and the Administrator ordered a new ice machine for the hall. The DM stated the facility was getting additional ice until the new ice machine was delivered.

Based on resident and staff interviews and record review, the facility failed to protect and maintain the rights and dignity of three of 34 sampled residents (R) (RA, RB, and RC). Specifically, the facility failed to ensure that facility staff nurse, Licensed Practical Nurse (LPN) (LPN CC) treated RA, RB, and RC with dignity and respect in a manner and environment that promoted, maintained, or enhanced their quality of life. The deficient practice had the potential for negative psychosocial outcomes related to fear of retaliation if staff found out that residents reported the nurse. Findings included: Review of the LTCO (Long Term Care Ombudsman) report dated 4/17/2025 reported findings: Staff interaction with residents: Some staff work hard and are good with the residents, but the feedback I get more often is that they are sorely understaffed, and that residents' needs are not being met. On weekends and nights, there have been reports both inside and outside of the facility that staff are either nonexistent, not attentive, or disrespectful to residents. Residents at this facility, for years, have been very apprehensive about filing complaints and grievances as many times I have heard and believe that there is a real fear of retaliation. Other: Lots of management staff turnover, Staff in key roles are not adept and uncooperative. Continued review of the LTCO report revealed: Significant changes in this facility during the past year: 1. Resident Care: Many residents often do not appear well groomed: i.e., oily hair, need haircuts, long beards, and clean clothes, but do not report for fear of retaliation. 2. Residents are afraid of retaliation. 3. In a place that is relatively isolated, many residents have no family. 4. New DON (Director of Nursing). 5. It is difficult to reach the facility on the phone and get return calls from administrative staff. 6. Number of complaints received in past year: 28. Number of times each complaint code has been used over the past year: Abuse: Psychological-1 Rights: Dignity and respect-3 Response to complaints-1 Other rights and preferences-1 Care: Response to requests for assistance-1 Policies, Procedures, Practices: Administrative oversight-1 Staffing-1 1. Review of the electronic medical record (EMR) revealed RA had diagnoses of but not limited to Type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebrovascular disease, acquired absence of left and right leg below knee, depression, anxiety disorder, adult failure to thrive, phantom limbs syndrome with pain, and need for assistance for personal care. Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating little to no cognitive impairment. Section GG-Lower extremity impairment, required partial/moderate to set-up assistance (assist) for care. Section N-received antianxiety, antidepressant, anticoagulant, opioid, and antiplatelet medications. Did not receive antipsychotic medications in the look-back period. Review of the care plan dated included but not limited to, has an amputation, bilateral bka (below knee amputation), requires assistance with ADL's (Activities of Daily Living) related to (r/t) bka, failure to thrive, no plans to discharge, is a smoker, requests to smoke, has little activity involvement due to preferring to spend most time in room or bed, risk for falls r/t bilateral bka, has phantom pain, on pain medication r/t chronic pain, is at risk for insomnia r/t taking sedative/hypnotic therapy medication, uses anti-anxiety medications r/t anxiety disorder, uses antidepressant medication r/t insomnia. Review of RA's MAR (Medication Administration Record) revealed night time medications (meds) and orders included but not limited to atorvastatin for cholesterol, eszopiclone for insomnia, melatonin for insomnia, trazodone for insomnia, carvedilol for hypertension, Eliquis for embolism and thrombosis, protein liquid for supplement, artificial tears for dry eyes, dicyclomine for irritable bowel syndrome, Zanaflex for muscle spasms, insulin for diabetes, Tramadol for pain prn (as needed), Norco for pain-(scheduled), pain assessment, monitoring for med side effects r/t antianxiety, anticoagulant, antidepressant, and sedative/hypnotic meds, behavior monitoring for insomnia and changes in sleep, monitor BM (bowel movement), fsbs (finger stick blood sugar) with insulin per sliding scale coverage. Observation and interview on 5/4/2025 at 12:56 pm during screening of residents, RA revealed that a facility nurse, LPN CC had a bad attitude toward RA, did not converse when providing care, did not ask if RA was alright, or needed anything, or had a bowel movement in five days, she says nothing. RA reported LPN CC withheld meds at times and gave them late. LPN CC worked on the night shift, and residents wanted their meds timely so they could go to sleep. If RA used the call light, LPN CC would come into RA's room and ask, what you want? RA would tell the nurse what was needed. At times the nurse would turn and walk out without saying anything and not come back with the requested item. Other times the nurse would say, tell the CNA (Certified Nursing Assistant), or at times LPN CC would tell the CNA (who was busy) and they would assist, sometimes much later. RA revealed being told that LPN CC was talking about RA to other residents, telling others not to talk to RA. When RA knew LPN CC was working the night shift, RA got a sick feeling and said it made the resident feel anxious. When asked if RA had reported LPN CC or filed a Grievance, RA revealed no and indicated it was because of fear of retaliation if he talked or reported her. When asked what kind of retaliation, RAsaid the way they treat you, basically ignore you, will not talk to you, and will not get them things asked for or care needed. RA reported LPN CC did not talk to him now. She just walked in and did what she had to do and left, and if LPN CC found out they reported her, it would be much worse. 2. Review of the EMR revealed RB had diagnoses of but not limited to multiple sclerosis (MS), lack of coordination, generalized weakness, major depressive disorder, anxiety disorder, and need for personal assistance. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating little to no cognitive impairment. Section GG, Functional Abilities and Goals-upper and lower body impairment on both sides, required total to moderate assist for all care needs, Section N, Medications-received antianxiety, antidepressant, hypnotic, diuretic, and opioid medications. Did not receive antipsychotic medications. Review of the care plan dated included but not limited to, has multiple sclerosis, incontinent of bladder and bowel r/t MS, neurogenic bladder, and restricted mobility, no plans to discharge, requires assistance with ADL's r/t restless leg syndrome, MS, weakness, history of falls, poor safety awareness, evaluated by therapy and is a Hoyer lift ONLY for transfers, is a smoker, requests to smoke, has a mood problem r/t anxiety, depressive disorder, history of suicidal ideation, and insomnia, risk for falls r/t MS, lower extremity weakness, alteration in musculoskeletal status r/t MS, has pain r/t restless leg syndrome, MS, neurogenic bladder, medication r/t chronic pain, is at risk for insomnia r/t taking sedative/hypnotic therapy medication, uses anti-anxiety medications r/t anxiety disorder, uses antidepressant medication r/t depression. Review of RB's MAR revealed night time meds and orders included but not limited to astorvastin for hyperlipidemia, Melatonin 2 tablets for sleep r/t insomnia, trazodone for major depressive disorder, Zetia for hyperlipidemia, metoprolol for hypertension, oxybutynin for neuromuscular dysfunction of bladder, artificial tears for dry eyes, buspirone for anxiety, gabapentin for MS, Requip for MS, baclofen for pain, Acetaminophen every 6 hours prn pain, Norco every 6 hours prn pain, monitoring for antidepressant and antianxiety med side effects, pain scale assess, behavior monitoring. Observation and interview on 5/5/2025 at 8:45 pm with RB revealed there was only one staff member that was bad, all of the others were pleasant. Staff nurse [LPN CC] does not care about the residents she sees. She treats them disrespectfully. RB revealed the whole mood of the residents changed when they realized LPN CC was working. LPN CC worked the night shift. 3. Record review revealed RC had diagnoses of but not limited to essential primary hypertension, atherosclerotic heart disease, repeated falls, muscle weakness, difficulty in walking, unsteadiness on feet, reduced mobility, anxiety disorder, depression, and need for assistance with personal care. Review of the Quarterly MDS assessment for RC dated 3/28/2025 revealed a BIMS score of 11, indicating mild to moderate cognitive impairment. Section GG, Functional Abilities-required set-up or supervision for most care needs. Section N, Medication-received antidepressant and opioid medications. Did not receive antipsychotic medications. Review of the care plan for RC dated included but not limited to, potential for adjustment difficulty r/t facility placement, entered for short-term rehab, history of adult maltreatment prior to admission, risk for psychosocial well-being concern r/t male resident attempting a financial manipulative situation, uses antianxiety medications, uses antidepressant medication r/t depression, risk for generalized pain, on pain med therapy r/t generalized pain, occasionally incontinent of bladder and bowel, requires assistance with ADLs r/t activity intolerance and weakness, behavior problems r/t anxiety, risk for falls r/t gait problem, unaware of safety needs, history of falls. Review of RC's MAR revealed night time meds and orders included but not limited to Aricept for dementia, sertraline for depression, Systane Ophthalmic drops for dry eye syndrome, hydrocodone-acetaminophen every 4 hours prn pain, pain scale assess, monitoring for antidepressant med side effects, behavior monitoring. Observation and interview on 5/5/2025 at 8:50 pm with RC revealed that one staff member was very difficult, and all of the others were good, the nurse was [LPN C] she did not care about the residents and treated them disrespectfully. The whole mood of the residents changed when they realized LPN CC was working. LPN CC worked at night. Review of the Resident Council minutes from June 2024 to April 2025 included but not limited to the following concerns related to resident rights: Night nurse has attitude: 4/16/2025 Call lights not being answered at night: 1/15/2025, 12/18/2024, 10/16/2024 Short staffed night shift: 11/20/2024, 10/16/2024, 9/18/2024, 8/21/2024 Not enough staff: 2/19/2025, 6/19/2024 Short staffed every weekend: 2/19/2025, 7/24/2024 Meds not passed on time: 4/16/2025, 3/19/2025, 8/21/2024, 7/24/2024, 6/19/2024 Not getting changed in a timely manner: 12/18/2024 Residents are not gotten up (weekends): 3/19/2025 Staff need to stay off phones: 1/15/2025, 12/18/2024, 11/20/2024 Interviews during the Resident Council (RC) review meeting on 5/6/2025 starting at 1:50 pm with five residents revealed issues with night shift LPN CC. Residents revealed they knew how to file a Grievance but did not because they were fearful of retaliation by LPN CC. Asked what they meant by retaliation, and to give specific examples, residents reported LPN CC's bad attitude, she would hold your meds (medications) and/or would not give on time, would intentionally take a long time to give meds, when they asked LPN CC for something she wouldn't do it. She would say, What do you want? We would tell her and she would walk out and never come back or would say tell the CNA, or she would tell the CNA and the CNA would bring what was needed a long time later. One resident reported LPN CC would come in and ask what they wanted, the resident would tell her, LPN CC would repeat the request and say, so you want . (such and such, whatever the request was), turn and walk out and not come back. Residents remarks included, Her bedside manner is brutal. She will make your life miserable. One resident revealed when he knew LPN CC was scheduled to work the night shift he felt sick and anxious. Three residents reported, She is prejudiced against white people, and prejudiced against smokers. She would come in the room and stand over the resident, make negative remarks like, Uh, you smell like smoke. Then she will go and get some kind of spray and start spraying heavily in the rooms of smokers. The spray was strong, it stank, and you could hardly breathe after she sprayed the room. Residents revealed it was normal practice to get meds on time, except for when LPN CC worked. She worked the night shift, and residents revealed they wanted and needed their meds so they could go to sleep. Residents felt LPN CC at times would intentionally withhold meds until late causing residents not to be able to go to sleep, or they would go to sleep and awakened. Interview on 5/7/2025 at 10:12 am with the Administrator and the Regional Operations Manager revealed what they have done to address the complaints about the nurse by multiple residents. The Administrator revealed they started an investigation and suspended the nurse pending investigation. The Administrator revealed, depending on resident interviews, that would determine if LPN CC would be terminated, and if she would file a FRI (Facility Reported Incident) to the State Survey Agency (SA). She revealed they had begun collecting interviews with staff, doing education on abuse and customer service, and have done questionnaires for the residents. Interview on 5/7/2025 at 10:15 am the Regional Operations Manager revealed they completed interviews with all residents the prior day, and the interviews were being reviewed. She provided a copy of the interview questions which included: Do you believe you are receiving good care from staff? Are there any specific problems that you are having with your care? Are staff polite when they interact with you? Are any members of the staff mean towards you? Have you ever been in seclusion or witnessed any seclusion of any other residents? Have you ever been physically, verbally, mentally, sexually abused or have you ever witnessed such acts? Do you know of any acts throughout the facility where residents are punished for misbehavior? Do you feel safe living at [named facility]? Interview on 5/7/2025 at 11:30 am the Regional Operations Manager revealed to the survey team that they had finished reviewing all the resident interviews and based on answers to the Quality of Care Questionnaire they would be submitting a report (FRI) to the SA. Review of a FRI (202504675) dated 5/7/2025 for staff-to-resident abuse revealed that the Administrator was notified of residents stating LPN CC was giving them attitude, didn't address them, will not speak to them, they were afraid of retaliation by the nurse if they reported, and they may have to wait on care or medication. An investigation was started and included but not limited to interviewing residents and the education of the staff. Observation and interview on 5/7/2025 at 2:40 pm during a walk-through of the facility, the Administrator confirmed there were no state agency or Elder Abuse Act posters or signage with information on reporting complaints. She revealed the signs should be by the Ombudsman poster. The Administrator stated, The Ombudsman came about six weeks ago and changed out her contact information on the Ombudsman poster and must have taken down the facility's signs for reporting complaints.

Based on staff interviews, record review, and review of the facility's policy titled, Resident Funds: Residents have access to their funds 24 hours a day, 7 days a week, 365 days a year, the facility failed to assure that residents with trust funds were able to get access to requested funds. The deficient practice affected three of 74 residents (R) (R276, R29 and R11) with trust funds. Findings include: Review of the facility's policy titled Resident Funds: Residents have access to their funds 24 hours a day, 7 days a week, 365 days a year revealed under Policy: Resident funds are maintained in accordance with the guidelines of the state, the management of the funds of the resident is the responsibility of the Administrator, Controller, Central Business Office, and the Resident Trust Account Custodian (bank teller). This policy has been established to ensure compliance with maintaining a complete and accurate accounting of resident funds. Under Procedure: Residents have access to their funds 24 hours a day, 7 days a week, 365 days a year. Interview on 5/4/2025 at 11:17 am with R29 stated that he always received his money late. He stated that money was distributed on a first come first serve basis. He stated that it happened all the time, he was used to it. Interview on 5/4/2025 at 1:10 pm with R11 stated that her money came when it came. She stated that she hasn't gotten it this month. She stated that for last month's distribution, she just got her money a week ago. She stated that the facility doesn't send enough money to everyone in the whole facility to get their money. She stated that 1/3 of the residents got their money last week for the month of April 2025. Review of Grievances on 5/6/2025 at 9:45 am revealed that there was only one grievance reported regarding money, which was reported by R231. The grievance was filed on 6/19/2024 to the Social Services Director (SSD). The SSD revealed that R231 stated that the SSD had not done what she was asked by sending a referral for money following the resident. SSD stated that she made a phone call and sent an email while R231 was present. Review of Petty Cash Withdrawal Records revealed that for the months of June 2024 through April 2025, residents were receiving their money that they requested two to three days after the requested date. Interview on 5/6/2025 at 10:10 am with the Business Office Manager (BOM) revealed that if residents were mobile they could come to her office and request money. If they were not mobile, someone (CNA or Nurse) would let me know and I would go to their room and talk to them regarding requesting money. They could get their money as long as we had it in the building. Otherwise, the BOM must send a request to corporate. She stated that she sent up a request, and corporate would issue a check. She stated that she would give the Administrator the check and the administrator would get the check cashed. She stated that the process usually takes two to three days. Interview on 5/6/2025 at 2:08 pm with the Administrator stated that she felt that $600.00 was enough on hand for the residents here; however, they probably do get close to running out of money for the residents. She stated that when the petty cash gets low as $30.00 to $50.00, they started the process of requesting petty cash. She stated that she felt that the residents wanted the full $70.00 and a lot of the time it was already at the end of the month or a week before the beginning of the month. She stated that when the residents requested the money during that period, the facility didn't have the money to reimburse. She stated that residents received their money as soon as the BOM informed her. The Administrator verified that they didn't have $70.00 per resident, they only had the $600.00 total in the replenishing box (Petty Cash). She stated that the money was expended first come-first served. She stated that it took 24 hours for the residents to receive their money. Interview on 5/6/2025 at 3:14 pm with the Administrator and Regional Consultant along with a team of five surveyors. The surveyors reported one of two main issues that was brought to our attention: What is your process for residents being able to get their money? She stated that the BOM kept up with the resident's accounts, she maintained around $600.00 dollars in petty cash, and she would replenish the petty cash and when the money started getting low, she would go ahead and request money/a check from corporate. She stated that the check would be received in a couple days. She stated that if it was not enough petty cash, they would have to request money from corporate, even for ten dollars. She stated that the BOM should report that the petty cash was running low to the Administrator, then the BOM would send all the receipts up to corporate, and they (corporate) would reconcile. On average do you monitor how much is requested? It was not acceptable for residents to have to wait a few days, or around the 20th of the month, if they requested money on the 1st, 2nd, or 3rd of the month. She stated that on nights and weekends, Petty Cash ranging around $30.00 to $35.00 dollars was left on the nurses' cart if residents requested money. Interview on 5/7/2025 at 9:45 am with Regional Accounts Receivable verified that they (the facility) do not have enough petty cash on hand to fulfil all of the residents requests.

Based on staff interviews, record review, and review of the facility's policy titled, Advance Directive, the facility failed to provide residents and/or their representative with written information regarding the right to accept or refuse medical or surgical treatment for four of 34 sampled residents (R) (R38, R49, R34, and R32). Findings include: Review of policy titled Advanced Directives dated January 2025 revealed under Policy: The facility must inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advanced directive. Under Process: Upon admission/readmission, the facility Social Services Director will inform and educate the resident, or POA (Power of Attorney) in writing about the right to refuse medical and surgical treatment and their right to an advance directive. Review of the sample residents revealed four residents' Advanced Directive did not have evidence that options or written information about the right to accept or refuse medical or surgical treatment was provided. The Regional Operations Manager confirmed these four residents' (R38, R49, R34, and R32) Advanced Directive did not include language about being informed of medical and surgical treatment options. 1. Review of medical records revealed R38 was admitted to the facility with primary admitting diagnoses of but not limited to hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease, atrial fibrillation, essential primary hypertension, cardiomyopathy, and history of malignant neoplasm of prostrate. Review of Physician orders revealed R38 had an order for Full code-attempt resuscitation with a revision date of 12/3/2024. Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed R38 was assessed with a BIMS (Brief Interview for Mental Status) score of 13, indicating little to no cognitive impairment. Review of R38's Admission packet dated 2/21/2022 revealed the Admission Packet Control Sheet had a checklist of required paperwork, and under the section Advance Directive Record, an X indicated it had been scanned. Also, the POLST (Physician's Orders for Life Sustaining Treatment) was scanned and on chart. Review of R38's POLST revealed his wishes for cardiopulmonary resuscitation, medical interventions, antibiotics, and artificially administered nutrition/fluids. The POLST was signed by R38 on 2/22/2022. Review of medical record for R38 revealed no signed acknowledgement or evidence in the record that R38, or a resident's representative, was provided with options and/or written information about the right to accept or refuse medical or surgical treatment. Interview on 5/5/2025 at 12:10 pm with the Corporate Nurse Consultant revealed the Social Services Coordinator/Social Worker (SW) was in charge of getting the advanced directive checklist completed at admission. She confirmed the SW did not complete the advance directive checklist for R38. 49681 2. Review of the electronic medical record (EMR) revealed that R49 did not have an Advance Directive on file. Resident R49 diagnoses included but not limited to dementia with other behavioral disturbances. R49's MDS revealed a BIMS score of 00, which indicates resident is not cognitively intact. Review of EMR for R49 revealed no signed acknowledgement or evidence in the record that R49, or a resident's representative, was provided with options and/or written information about the right to accept or refuse medical or surgical treatment. Review of Physician orders revealed R49 had an order for Full code-attempt resuscitation. Interview on 5/5/2025 at 12:10 pm with the Corporate Nurse Consultant revealed the Social Services Coordinator/Social Worker (SW) was in charge of getting the advanced directive checklist completed at admission. She confirmed the SW did not complete the advance directive checklist for R38. 50879 3. Review of the EMR revealed R34 was admitted to the facility with diagnoses that include but are not limited to end stage renal disease, elopement, hypertensive heart and kidney disease with heart failure and stage 5 chronic kidney disease, difficulty walking, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R34's BIMS score of 13, indicating intact cognitition. Interview on 5/5/2025 with the Corporate Nurse Consultant revealed the Social Worker Coordinator was in charge of getting the advanced directive check list completed at admission. She revealed the SW did not complete the advance directive checklist for R34. 50941 4. Review of the EMR revealed that R32 did not have an Advance Directive on file. Interview on 5/5/2025 at am with the Corporate Nurse Consultant, (CNC), revealed and verified that R32 did not have an Advance Directive. CNC stated that the Social Worker Coordinator, oversaw getting the advanced directive check list completed at admission. She revealed that the SW did not complete the advance directive checklist for R32.

Based on record review, staff interview, and the facility policy titled, Advance Beneficiary Notices (ABN) 2025, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to the resident or responsible party upon discharge from Medicare Part A services to indicate that they understood the contents of the form for three of 34 sampled residents (R) (R32, R42, and R56). Findings include: Review of the undated facility policy titled Advance Beneficiary Notices 2025 revealed under Policy: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. 5a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CM-10055. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R32 was discharged from Medicare Part A skilled services on 1/6/2025 and remained in the facility. R42 was discharged from Medicare Part A skilled services on 3/21/2025 and remained in the facility. R56 was discharged from Medicare Part A skilled services on 2/13/2025 and remained in the facility. There was no evidence provided that the SNFABN was provided to R32, R42, or R56 and or their responsible party. Interview on 5/7/2025 at 10:35 am with the Minimum Data Set (MDS) Coordinator revealed prior to surveyors coming into the facility, she was not aware she was to use the SNFABN form when residents discharged from Medicare Part A services. The MDS Coordinator confirmed that she did not provide SNFABN forms to R32, R42, and R56 and or their representatives. She revealed when she found out about the ABNs on 5/6/2025, she called all three resident representatives and notified them.

Based on record review, staff interviews, and the review of the policy titled, Fall Management Standard, the facility failed to ensure that Activities of Daily Living (ADL) care was provided by using appropriate techniques, to prevent accidents, for two residents (R#9 and R#35) of three residents reviewed for falls. Actual harm occurred on 11/24/2022, when a Certified Nursing Assistant (CNA), rolled R#9 away from her while providing ADL care. Subsequently, R#9 fell from the bed resulting in a right femur fracture. Findings include: 1. A review of the facility policy, Fall Management Standard dated of July 2021, under What Exactly is a Fall, bullet three states, When a resident is found on the floor, the facility is responsible for investigating the reason for this. They are also responsible for putting in place an intervention to keep this from happening again. Record review revealed R#9 admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, major depressive disorder, psychotic disturbances, mood disturbances, anxiety, history of falling, repeated falls, cerebrovascular disease, and atrial fibrillation. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed R#9's functional status as required extensive assistance with two-person physical assist for bed mobility and toileting. Review of the Progress Notes dated 11/24/2022 at 3:50 p.m. revealed CNA was providing resident with incontinent care. CNA moved R#9 over to the other side of the bed, so she could roll her over and get the wet linen out from under her. When the resident was rolled the opposite way, she rolled off the bed and landed on her right side between the bed and the window, with her head by the bedside table and her feet toward the foot of the bed. Nurse performed Range of Motion (ROM) without difficulty. R#9 did not express any signs or symptoms (S/Sx) of pain or discomfort. Resident was assisted back to bed by staff and incontinent care completed. Physician, family and Director of Nursing (DON) aware. Call light within reach, bed in lowest position. Review of Fall Risk assessment dated [DATE] revealed R#9 was disoriented x 3 at all times and chairbound. This assessment also indicated that R#9 had had 1-2 falls in the last 3 months and the gait/balance resident was unable to perform this function. Review of Progress Notes dated 11/25/2022 it was noted that resident had a bruise noted to her right knee and resident was complaining of pain to right knee. The Physician was notified of resident current condition. An order was received for a mobile x-ray. The Progress Notes dated 11/26/2022 revealed an impression of Acute supracondylar fracture the physician was notified, and orders received to transport resident to the Emergency Department. Review of hospital emergency room report dated 11/27/2022 revealed fall, right knee pain as the reason for the visit. Review of diagnostic imaging x-ray report received report results: 1. marked deformity of the distal right femur with cortical lucency and discontinuity of the medial and lateral femoral metaphysis extending to the intercondylar notch most consistent with acute fracture on background of advanced, severe osteoarthritic changes. 2. Extensive soft tissue swelling about the right knee joint. 3. Severe tricompartmental osteoarthritic changes of the right knee joint. R# 9 was admitted to the hospital. Observation on 1/7/2023 at 10:28 a.m. revealed Certified Nursing Assistant (CNA) AA in the room with R#9 performing ADL care alone. There was another CNA in the hallway assisting another resident. Observation 1/7/2023 at 2:16 p.m. revealed CNA AA in the room with resident performing ADL care alone. During an interview on 1/8/2023 at 9:12 a.m. with CNA AA revealed she is aware that R#9 fell from the bed and got a fracture to her right leg. CNA AA confirmed that she assists R#9 with ADL care. She further revealed that she usually performed all care for R#9 alone because there are only two CNAs assigned to the hall and most residents on the unit require staff assistance. CNA AA stated the other assigned CNA to the unit is usually busy assisting other residents. CNA AA revealed the hall is usually staffed with two CNAs on the day shift and one CNA on the night shift, so there is not a lot of help to assist the residents. During an interview on 1/8/2023 at 9:47 a.m. CNA CC revealed that she was caring for R#9 on 11/24/22 when resident rolled out of the bed. CNA CC stated Generally, I would give her assistance with turning over then guide her hands to the bedrail for her to hold on. I am not sure if she wasn't holding on tight and she continued to roll off the other side of the bed. I tried to grab her, but lost grip because I didn't want to injure her fragile skin. CNA CC stated that R#9 was a one person assist for bed mobility at that time and she always assisted her alone. CNA CC stated that now there are usually two people in the room to assist R#9 with ADLs. During an interview on 1/8/2023 at 9:59 a.m. with the DON it was revealed that she conducted an investigation regarding the fall. She stated that R#9 was typically a one person assist with the bed mobility at the time before the injury but now she is a two person assist because of her wound and her leg. DON stated that she was not aware the care was currently being provided by one CNA. DON further stated that a resident coded as extensive assistance with two-person physical assist should always have two-person assistance with ADLs with no exceptions. 41914 2. Record review for R#35 revealed resident had diagnoses not all inclusive of paranoid schizophrenia, anemia, hypertension, peripheral vascular disease, neurogenic bladder, diabetes mellitus, hyponatremia, paraplegia, seizure disorder, anxiety disorder, depression, polyneuropathy, generalized muscle weakness, severe morbid obesity, hypothyroidism, gastroesophageal reflux disease, and hypocalcemia. Review of Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating resident is cognitively intact; required extensive assistance from two persons for bed mobility and toilet use; and was totally dependent on two-person assistance for transfer. Review of the Post Fall Evaluation dated 11/13/2022 indicated R#35 experienced a fall while staff were providing peri care. It further revealed that R#35 was too close to the edge as the CNA was turning her over and she rolled over the edge of the bed. The document further indicated that the resident vocalized complaints of pain to her shoulder. Review of R#35 x-ray results dated 11/13/2022 that were received from the acute hospital findings revealed: The osseous structures are intact with no evidence for fracture. The articular structures are well aligned. Unremarkable soft tissues. Osteoarthritis of the acromioclavicular and glenohumeral joints. Review of x-ray results that were completed at the facility on 11/13/2022 revealed under findings: There was no fracture or dislocation, no abnormal soft tissue swelling is evident. Joint spaces are preserved. There are no abnormal calcifications. Interview with R#35 on 1/7/2023 at 8:27 a.m. revealed that there had been a fall that occurred when a CNA was trying to change her by herself, and she rolled off the bed. R#35 denied any further incidents of falls. R#35 denied any injury to her shoulder. Interview with DON on 1/7/2023 at 10:41 a.m. revealed R#35 was being changed by one CNA when she should have been changed by two. It was reported that R#35's leg slipped off the bed resulting in the fall. The nurse assessed resident and R#35 complained of shoulder pain so an x-ray was ordered. DON further reported that the x-ray technician indicated that the resident had a dislocated shoulder, and resident was sent to the hospital for further evaluation and treatment. DON then reported that the CNA providing the care was suspended for providing care of the resident without assistance putting the resident at risk for injury. It was later determined at the hospital that R#35 had not dislocated her shoulder as a result of the fall.

Based on interview, record review, and review of facility policy, the facility failed to ensure one of three residents (Resident (R) 6) reviewed for abuse was free from abuse. This deficient practice resulted in physical harm to R6 when R9 grabbed the right arm of R6 and caused an avulsion (skin was pulled from the resident's arm). This action caused R6 to sustain actual harm from the incident. Findings include: Review of a document provided by the facility titled Freedom from Abuse, Neglect and Exploitation; Abuse Prevention Standard, dated 12/18 indicated . The purpose of this written Freedom of Abuse, Neglect, Exploitation; Abuse Prevention Standard is to outline the preventive and action steps taken to reduce the potential for abuse, mistreatment and neglect of residents and the misappropriation of resident property and to review practices and omissions which if allowed to go unchecked, could lead to abuse.The scope of this program shall apply to the prevention of an abuse committed by anyone including but not limited to.Residents. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. 1. Review of R6's electronic medical record (EMR) titled Admission Record undated indicated the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/04/22 indicated the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which revealed the resident was cognitively intact. This assessment indicated the resident was able to get in and out of bed and ambulate with the assistance of a walker. Review of R6's EMR titled nursing incident Progress Note, located under the Prog Note tab dated 08/12/22 revealed R6 was met while she was coming down the hallway by Licensed Practical Nurse (LPN). LPN2 wrote the resident was found with a flat sheet wrapped around her right arm, and when the sheet was removed, the nurse wrote that R6 sustained a skin tear which went down to the dermas and exposed blood vessels. The note revealed R6 reported R9 would come to her side of the room and open her curtain and say Ahhh and then pull the curtains shut. The note indicated R6 told R9 that she was going to get out of bed. R6 got out of bed and went over to R9's side of the room. R6 had her backscratcher in her hand and R9 said R6 had her back scratcher and R6 said the back scratcher was hers. R6 reported R9 went over and attempted to grab the back scratcher and R9 grabbed R6's arm. Review of documents provided by the facility titled emergency room Documentation, dated 08/12/22 indicated R6 . Was ln an altercation at the nursing home. EMS [Emergency Medical Service] reports the other person caused an avulsion of her right forearm by tearing the skin with their fingernails. The avulsion was from the resident's wrist to her elbow. 2. Review of R9's EMR titled Admission Record, undated indicated the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R9's admission MDS with an ARD of 04/25/22 indicated the resident had a BIMS score of 13 out of 15 which revealed the resident was cognitively intact. This assessment indicated the resident had no physical or verbal behaviors during this assessment period. This assessment indicated the resident was able to get in and out of bed on her own and was able to ambulate. Review of R9's Progress Notes, under Prog Note tab indicated the resident had no history of physical altercations with residents or staff. Review of the facility's investigation, provided by the facility, in response to R6 and R9's altercation revealed a thorough investigation and timely reporting to the State Survey Agency (SSA). The investigation revealed the police were notified and interviewed R6. A police report was filed, and the physician was notified. The physician ordered immediate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R9 was placed on one-on-one with staff. R9 was eventually transferred out to a local hospital and was given a 30-day discharge notice due to R9 being a danger to others. There was evidence to support the facility took steps to protect R6 from R9 after the altercation was initiated by R9. During an interview on 10/03/22 at 5:30 PM, R6 confirmed that she got herself out of bed and went over to R9's side of the room. R6 stated she reached over to grab her backscratcher, and this was when R9 grabbed her right arm and the skin just pulled off. R6 stated the area began to bleed immediately and she walked out to the hallway and called for help. R6 stated the staff removed R9 immediately and took care of my arm and sent me to the hospital. R6 was observed with a covering to her right arm during this interview. R6 stated she had skin graphs to repair her arm. During an interview 10/04/22 at 11:11 AM, the Administrator stated he completed an investigation of the incident. The Administrator stated R9 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator stated R9 was seeing the facility's mental health unit they were contracted with prior to this event. The Administrator confirmed the resident to resident was abuse. During an interview on 10/04/22 at 1:22 PM, LPN2 confirmed she was the nurse on duty when R9 physically attacked R6. LPN2 stated she heard R6 yelling for help and found her in the hallway and immediately took care of the arm. LPN2 stated she notified the physician and R9 was brought next to the nursing station and told not to return to her prior room. LPN2 stated R9 had a staff member sitting next to her. The staff member stated there were no other physically aggressive behaviors from R9 and stated there were none prior to this incident.