Every finding on record at Fondulac Rehabilitation and Health Care Center

Based on observation, interview, and record review, the facility failed to assess and treat skin alterations timely and provide necessary interventions for two residents (R1 and R2) in the sample list of three. This failure resulted in R1 not receiving ordered daily treatment for approximately six days, and R2's skin alteration remaining without a complete assessment for six days before being identified as a 15 (centimeter) cm x 15 cm partial-thickness MASD (Moisture Associated Skin Damage) wound with exposed dermis. Findings include:1.R1' Census Line documents R1 admitted to the facility on [DATE]. R1's admission assessment dated [DATE] did not contain documentation of a DTI (Deep Tissue Injury) to R1's heel or an assessment of the area. R1's Braden assessment dated [DATE] documented R1 was at risk for skin alteration. R1's medical record did not contain documentation of an assessment of the left heel until 8/12/26, seven days following admission. R1's Initial Wound Evaluation and Management Summary dated 08/12/26 documented a focused wound examination of the left heel identifying an Unstageable DTI of the left heel, undetermined thickness. The wound was identified as pressure-related, with purple/maroon discoloration and intact skin, measuring 6 cm (centimeters) x 6 cm, with a surface area of 36 cm^2. The wound assessment documented the objective as healing/maintain healing, with fair healing potential and an estimated healing time of one to two months. The treatment approach included off-loading, close monitoring, optimizing moist wound healing, education and counseling, and debridement as needed. The dressing treatment plan ordered Skin Prep once daily and as needed for 30 days. The recommendations included off-loading the wound. R1's Wound assessment dated [DATE] documents the unstageable DTI of the left heel remained 6 cm x 6 cm, with a surface area of 36 cm^2. The clinician documented the measurements exactly the same as the previous visit. The skin remained intact with purple/maroon discoloration, and wound progress was documented as not at goal due to need more time. The treatment plan documents to continue Skin Prep once daily and as needed for 23 days. Recommendations included off-loading the wound and use of a pressure off-loading boot. The individualized treatment plan documented the DTI remained not at goal and was undergoing autolytic debridement. Follow-up evaluation by the wound care provider was planned weekly or sooner as needed. R1's orders dated 08/19/26 documented Skin Prep daily on second shift. R1's TAR (Treatment Assessment Record) does not contain documentation that R1's Treatment was completed from 8/19/26 through 8/24/26. On 8/24/26 at 12:15 PM, R1 was observed lying in bed with his feet on the mattress. R1's pressure off-loading boots were observed lying in a chair at the foot of the bed. R1's left heel was resting directly on the mattress without off-loading. During the same observation, R1's sock was removed and an old, wrinkled adhesive bandage dated 8/19/26 and initialed was observed on R1's left heel. R1's left heel had a large brown area covering the heel. R1 stated the area was often painful.On 8/24/26 at 12:15 PM, V9 (Licensed Practical Nurse/LPN) stated she was aware R1 had a pressure ulcer on his heel but believed the pressure ulcer had been healed the previous week. During the interview and observation, V9 entered R1's room and R1's sock was removed. An old, wrinkled adhesive bandage dated 08/19/26 and initialed was observed. R1's pressure off-loading boots were in a chair at the foot of the bed, and R1's heel was resting directly on the mattress without off-loading. V9 reviewed R1's orders and identified the 8/19/26 order for Skin Prep daily on second shift. V9 stated the treatment had obviously not been completed since 8/19/26 because there was never an order for an adhesive bandage to cover the left heel, and staff could not apply Skin Prep to the heel while it remained covered by the old bandage dated 8/19/26.On 8/24/26 at 11:35 AM, V2 (Director of Nursing/DON) stated she was not aware there was no documentation of R1's DTI to the left heel upon admission and was not aware that the first wound documentation was not completed until 08/12/26. V2 further stated she was not aware that R1's treatments to the left heel were not being completed as ordered.On 8/25/26 at 10:06 AM, V11 (Wound Physician) stated he last assessed R1 on 08/19/26 and ordered Skin Prep to the DTI daily. V11 stated that if the dressing observed on R1 on 08/24/26 was the same dressing dated 08/19/26, then the facility had not been providing the correct treatment for six days. V11 stated this was an issue and could cause the wound to worsen. V11 further stated he ordered R1's left heel to remain off-loaded while in bed and that R1's heel should not have been directly on the mattress.2. R2's Census line documents R2 admitted to the facility on [DATE].R2's admission Skin assessment dated [DATE] documented redness to the coccyx. The assessment did not contain measurements or further description of the area.R2's Braden assessment dated [DATE] documented R2 was at risk for skin alteration.R2's medical record did not contain documentation of a further skin assessment with measurements or description of the area until 8/12/26, seven days following admission.R2's Initial Wound Assessment Note dated 8/12/26 documents a focused wound examination identifying a partial-thickness non-pressure wound of the bilateral buttocks with an etiology of Moisture Associated Skin Damage (MASD). The wound was documented as greater than 10 days in duration and present on admission per staff. The wound measured 15 cm x 15 cm x 0.1 cm with a surface area of 225 cm^2. The wound had light serous exudate and open areas with exposed dermis. R2 reported mild pain. The assessment documented no signs of infection and fair healing potential, with an estimated healing time of one to two months. The treatment approach included off-loading, close monitoring, optimizing moist wound healing, education and counseling, and debridement as needed. The treatment plan included Hydrocolloid paste (e.g., Triad) twice daily and as needed if saturated, soiled, or dislodged for 30 days. Recommendations included off-loading the wound.On 8/25/26 at 11:00 AM, V10 (Certified Nursing Assistant/ CNA) stated R2 was dependent on staff for all care and required a mechanical lift for transfers. V10 stated R2 had no control of his bowels and would activate the call light after having a bowel movement. V10 stated R2 has a large sore on his coccyx.On 8/25/26 at 11:45 AM, V3 (Wound Nurse/LPN) stated that when a resident is admitted and a nurse makes V3 aware of a wound, V3 assesses the resident within 24 hours. V3 stated she could not remember when she was first informed of R2's wounds and skin issues but assessed the areas once she was informed. During the same interview, V3 and V2 (DON) confirmed there was no skin assessment containing measurements or a description of R2's wounds until 8/12/26. V2 stated a skin assessment with measurements should have been completed and documented within 24 hours of admission.On 8/25/26 at 1:00 PM, V2 (DON) stated the facility did not timely assess and follow up on R2's skin alteration. V2 confirmed the facility should have followed up on the redness to R2's bottom identified on admission and should not have waited six days to complete an assessment.The facility's Skin Identification, Evaluation, and Monitoring Policy documented that a licensed nurse will evaluate skin integrity through a physical skin evaluation upon admission, weekly, and when a significant change is identified. If a skin condition is present on admission, the licensed nurse is to initiate protective dressing and preventative and/or treatment interventions as indicated; notify the health care provider for further treatment orders; notify the community wound care nurse and Director of Nursing of pressure injury identification; document the evaluation, findings, and notifications in the medical record; and update the baseline care plan with initial interventions. The policy further documented that licensed nurses are to complete weekly skin checks to evaluate changes in skin integrity and complete weekly re-evaluations of previously identified skin alterations/wounds. Treatment is to be applied or initiated according to the health care provider's order, the evaluation documented in the medical record, and the plan of care updated with each intervention. The facility's Interventions and Prevention: SKIN policy documented that residents at risk of developing pressure injuries are to be placed on a pressure-reducing surface and regular and frequent repositioning is to be scheduled for bed- and chair-bound residents. The facility's Skin Integrity Treatment Program documented that the source of pressure is to be eliminated or reduced using positioning techniques, preventative measures are to be implemented to reduce the risk of further tissue loss, and interventions are to be provided to increase the potential for healing.

Based on observation, interview and record review the facility failed to ensure necessary PICC (peripherally inserted central catheter) line care was timely implemented, provided, and documented in accordance with physician orders and established PICC line maintenance guidance for two (R1 and R2) of five residents reviewed for PICC line care. Findings include:1.R1's hospital discharge orders dated 08/04/26 documented an order for Ceftriaxone 2 grams every 24 hours for six (6) weeks, beginning 08/06/26, for Endocarditis. The discharge instructions documented that R1 had a PICC line placed on 08/03/26 and that the PICC line dressing was to be changed every seven (7) days. Instructions for care of the PICC line site were attached to the discharge orders. R1 Census line documents admitted to the facility on [DATE]. R1's August 2026 MAR/TAR (Medication administration Record/ Treatment Administration Record) documents, beginning 08/12/26, an order to Change IV dressing on day shift every Wed for Dressing change. R1's MAR/TAR for the PICC line dressing change was blank on 08/12/26 and 08/19/26, with no documentation that the scheduled PICC line dressing changes were completed on those dates or that a physician was notified the dressings were not changed. R1's medical record did not contain documentation of PICC line upper arm circumference or external catheter length measurements. On 8/24/26 at 9:00 AM, R1 was sitting up in R1s room in a manual wheelchair. R1's PICC line dressing on right chest was dated 8/23/26 and appeared to have dried blood underneath clear adhesive dressing. On 8/24/26 at 10:10 AM, V7 (Ombudsman) stated V7 had received several complaints from R1 and his family regarding R1's PICC line dressing not being changed as ordered. V7 stated she had made V2 (Director of Nursing) aware of the concerns. On 8/24/26 at 10:30 AM, V6 (R1's Family Member) stated V6 was at the facility on 08/23/26 and observed that R1's PICC line dressing was dirty and did not have a date or initials. V6 stated she notified the unknown nurse, who stated the dressing would be changed. V6 stated the facility did not know how to care for the PICC line and was not changing the dressing as ordered. On 8/24/26 at 11:25 AM, V4 (Registered Nurse) stated V4 changed R1's PICC line dressing on 08/23/26 at the family's request because the dressing was dirty. V4 stated she did not recall documenting the dressing change because 8/23/26 was not a scheduled PICC dressing change day and stated the dressing change should have been documented in R1's Nurse Progress Notes. V4 further stated she had completed other PICC line dressing changes for R1 but could not recall when they occurred and was not aware that the dressing changes had not been documented in R1's chart. V4 stated nurses should document scheduled PICC line dressing changes on the TAR. On 8/24/26 at 11:35 AM, V2 (Director of Nursing/DON) stated she was not aware why the PICC line orders were not entered into R1's chart until 08/12/26 and stated the admission nurse should have entered the order. V2 acknowledged she was aware staff were not documenting R1's PICC line dressing changes on the TAR or in progress notes. V2 further stated staff needed training regarding PICC line care and that an RN is often pulled from another hall to complete the care and may forget to document it. 2.R2's physician orders dated 8/06/26 documents an order for Ceftriaxone Sodium 2 grams daily for six (6) weeks for necrotizing fasciitis. R2's Physician Orders documents an order for a PICC line dressing change once weekly every Thursday. The order was placed on 08/20/26. R2's medical record contained only one documented PICC line dressing change dated 8/20/26. R2's medical record did not contain documentation of PICC line upper arm circumference or external catheter length measurements. On 8/25/26 at 11:45 AM, V2 (DON) stated the orders for R2's PICC line dressing changes should have been obtained and implemented within 24 hours of admission. The facility's United RX Pharmacy Infusion Maintenance Table, revised 01/2016, documented that for a PICC line, transparent dressing changes are to occur 24 hours after insertion and then every week and as needed. The guidance also documented that the upper arm circumference and external catheter length are to be measured upon admission, every week, as needed, after blood transfusions and blood draws, and every 24 hours with TPN.

Based on interview and record review the facility failed to develop a comprehensive care plan with interventions to address the resident's care needs while on therapeutic leave for one resident (R1) of three residents reviewed for care plans. Findings include:R1's Care Plan dated 6/27/2026 does not address R1's frequent therapeutic leave and therefore does not have interventions in place to address missed services, missed physician visits, medication and treatment reconciliation, and communication with R1 while on therapeutic leave.On 7/14/2026 at 12:50 PM, R1 and V8 (R1's family member) stated they have concerns about R1 missing medications, labs, and lack of communication with the facility, such as calling to check on R1 while R1 is on frequent Therapeutic Leaves with family.R1's Electronic Health Record (EHR) shows a Health Status Note dated 7/2/2026 which states Resident not seen by provider today d/t (do to) being out of the facility.R1's Resident Sign Out Sheet documents on 7/1/2026 R1 signed out and did not return to the facility until 7/3/2026.R1's Electronic Health Record (EHR) shows a Social Service Note dated 7/9/2026 which documents the company contracted to provide long term care assessments and screenings had been to the facility a to do a SLP (Supportive Living Program) screen on R1 approximately three different times but each time R1 missed the screenings because R1 was on therapeutic leave. Notice of Supportive Living Program Screen Outcome letter dated 7/1/2026 documents that R1 needs to complete a Specialized Mental Health SLP (Supportive Living Program) Assessment. The clinician will seek to determine any persistent needs and risks and the likely appropriateness of the Support Living Program for your individual needs.On 7/16/2026 at 10:50 AM, V2 (Director of Nursing) provided the last six months of R1's psychiatry visits notes stating psychiatry comes to the facility about twice a month and she believes R1 has missed psychiatry visits while being on therapeutic leave.R1's psychiatry visit notes for the past six months were dated 3/12/2026, 6/11/2026, and 7/9/2026. There were no documented visits with R1 for April 2026 and May 2026.R1's Resident Sign Out Sheets document 24 sign outs from 3/21/2026 to 7/14/2026 with most being overnight leaves or multiple consecutive day and overnight leaves.

Based on interview and record review, the facility failed to ensure physician orders for blood glucose monitoring were followed for one resident (R1) out of three residents reviewed for quality of care. Findings include: On 7/14/2026 at 12:50 PM, R1 voiced concerns that the facility had not checked his A1C (hemoglobin A1C blood test) in a long time and that he was supposed to have it checked every six weeks.On 7/15/2026 at 12:50 PM, V2 (DON) provided printed copies of R1's labs dated 1/10/2025 to 8/8/2025 and stated these were all the labs she had for R1. V2 stated the last A1C lab she could find was drawn 4/16/2025. V2 stated she thought the order for an A1C every six weeks was not correct but acknowledged it is an active order and could not provide documentation explaining why the labs were not done in over a year. R1's lab results dated 4/16/2025 document an abnormal, high glycohemoglobin-HGBA1C result.R1's Treatment Administration Record (TAR) for the month of December 2025 documents a physician order dated 12/10/2024 for Lab: A1C Every 6 Weeks every day shift every 42 days for elevated glucose lab. This same TAR lacks documentation on 12/23/2025 which is when the A1C lab was due to be drawn. The facility was unable to provide a record showing the A1C lab was drawn, results or documentation as to why the lab was not drawn.R1's TAR for the month of February 2026 documents a physician order dated 12/10/2024 for Lab: A1C Every 6 Weeks every day shift every 42 days for elevated glucose lab. This same TAR lacks documentation on 2/3/2026 which is when the A1C lab was due to be drawn. The facility was unable to provide a record showing the A1C lab was drawn, results or documentation as to why the lab was not drawn.R1's TAR for the month of April 2026 documents a physician order dated 12/10/2024 for Lab: A1C Every 6 Weeks every day shift every 42 days for elevated glucose lab. This same TAR documents the lab was administered as scheduled on 4/28/2026. However, no record of the lab being performed or results could be produced by the facility.R1's TAR for the month of June 2026 documents a physician order dated 12/10/2024 for Lab: A1C Every 6 Weeks every day shift every 42 days for elevated glucose lab. This same TAR documents the lab was administered as scheduled on 6/9/2026. However, no record of the lab being performed or results could be produced by the facility.On 7/14/2026 at 12:50 PM, R1 voiced concerns that the facility was not checking his blood sugar every day and that when he is out of the facility visiting friends or family, many times over night and for several days at a time, he does not have a way to check his blood sugar.On 7/15/2026 at 9:30 AM, V2 (Director or Nursing/DON) stated R1 frequently leaves the facility on Therapeutic Leave and when R1 is on Therapeutic Leave for multiple days in a row, the facility cannot check his blood sugar daily as ordered. V2 stated she does not know if R1 has a way of checking his blood sugar when he is out of the facility.The facility's Therapeutic Leave Policy dated 4/2025 documents the facility will provide any necessary medications, treatments, or instructions required during the (resident's) absence.R1's Medication Administration Report/Treatment Administration Report (MAR/TAR) dated April 2026 documents a physician order for Blood Glucose Monitoring one time a day. This MAR/TAR documents R1 did not have blood glucose monitoring 10 days out of 30 days.R1's MAR/TAR dated May 2026 documents a physician order for Blood Glucose Monitoring one time a day. This MAR/TAR documents R1 did not have blood glucose monitoring 19 days out of 31 days.R1's MAR/TAR dated June 2026 documents a physician order for Blood Glucose Monitoring one time a day. This MAR/TAR documents R1 did not have blood glucose monitoring 5 days out of 30 days.R1's MAR/TAR dated July 2026 documents a physician order for Blood Glucose Monitoring one time a day. This MAR/TAR documents R1 did not have blood glucose monitoring 10 days out of 16 days (at the time of this survey).

Based on observation, interview, and record review, the facility failed to ensure residents received necessary care and services to maintain their highest practicable physical, mental, and psychosocial well-being for one resident (R1) in a sample of 14 reviewed for abuse and neglect. These failures resulted in R1 experiencing avoidable pain, fear, distress, discomfort, and humiliation when left waiting in a wheelchair while in pain, left in stool despite being able to make needs known, and left suspended in a mechanical lift sling instead of being promptly transferred and repositioned for comfort and safety. Findings include:R1's admission record documented R1 was a [AGE] year-old admitted to the facility on [DATE] from a local hospital with diagnoses including fusion of cervical spine, occipital condyle fracture, chronic pain syndrome, stiffness of the right shoulder and elbow, muscle wasting and atrophy, dysphagia, and lack of coordination.R1's hospital discharge records, dated 5/15/26, documented R1 was discharged from a local hospital to the facility on 5/15/26 after hospitalization from 4/10/26 to 5/15/26 related to a motorcycle accident. The records documented multiple traumatic injuries and post-surgical needs, including cervical spinal fusion, multiple fractures, mobility restrictions, braces/splints to extremities, anticoagulation therapy, and pain management medications.R1's nursing progress note, backdated to 5/15/26 at 10:35 AM, documented R1 arrived via ambulance with a family member, was alert and able to make needs known, and had multiple fractures including acetabulum, wrist, and skull fractures. The note documented R1 was non-weight bearing to the right upper extremity, left upper extremity, and right lower extremity, and weight bearing as tolerated to the left lower extremity for transfers only.R1's Social Service note, dated 5/15/26 at 2:42 PM, documented R1 was admitted from a local hospital after a motorcycle accident, was currently unable to use his arms, and was independent with decision making.R1's nursing progress note, dated 5/18/26 at 11:39 AM, showed V2/DON documented R1's mother reported R1 had his call light on for 40 minutes and was in pain wanting to be put back in bed. The note documented the CNA was waiting for someone from another hall to assist with transferring R1 back to bed. The record did not show an assessment of R1's pain level at that time, did not show documentation of an intervention to relieve R1's pain, and did not show documentation that R1 was timely assisted back to bed.On 6/17/26 at 11:40 AM, R1 was observed in his room awake, alert, and able to make his needs known. R1 stated he arrived at the facility on 5/15/26 around 10:00 AM. R1 stated no one came to his room until a few hours later. R1 stated when he later switched rooms, the beds in the new room had to be switched because they were not functioning. R1 stated staff transferred him from his wheelchair with a mechanical lift and sling before realizing the beds needed to be switched. R1 stated he was left suspended in the mechanical lift sling for approximately 15 minutes while staff switched the beds. R1 stated no staff members were present while he was suspended in the mechanical lift sling.On 6/17/26 at 11:40 AM, R1 stated that approximately three days after admission, on 5/18/26, he was in his wheelchair in pain and wanted to go back to bed. R1 stated he pressed the call light with no response, attempted to call the facility's phone number with no answer, and then called V14/R1's Family Member for assistance.On 6/17/26 at 11:40 AM, R1 stated that a few weeks prior at night, he had his call light on due to having a bowel movement and had to lay in the bowel movement with the call light on for over two hours before receiving assistance. R1 stated, I'm 26-years-old and shouldn't have to lay in my own feces like a child. That's humiliating and disgusting.On 6/18/26 at 12:24 PM, V15/R1's Family Friend stated she followed R1 in the ambulance to the facility on 5/15/26 and stayed with him from approximately 10:00 AM until 6:00 PM because she did not want to leave R1 at the facility after the day unfolded. V15 stated R1 sat in the initial room until approximately 2:00 PM without seeing anyone. V15 stated R1 did not want to stay after the first four hours, and they called the non-emergency line to transfer R1 to a different facility. V15 stated, I was crying it was so bad. V15 stated two staff came in and offered to move R1 to a new room, and R1 was left suspended in the mechanical lift sling for about 15 minutes while staff switched out beds in the new room. V15 stated one bed was a crank bed, and the other bed did not work. V15 stated R1 complained his neck hurt and he was in obvious pain while in the lift. V15 stated R1 did not receive medications, including pain medication, no vitals were completed, and no nursing assessment was performed while she was present from approximately 10:00 AM until 6:00 PM.On 6/18/26 at 11:28 AM, V14/R1's Family Member stated R1 and V15 told her R1 was left in the air in a sling for approximately 15 minutes during transfer from the wheelchair to the bed while staff switched the beds. V14 stated R1's legs were going numb, R1 was in pain, and R1 was yelling out for help with no one around.On 6/18/26 at 11:28 AM, V14 stated she received a phone call from R1 on 5/18/26. V14 stated R1 told her his call light had been on while he was left in his wheelchair in pain and no one answered the call light for over an hour. V14 stated R1 then attempted to call the facility and could not get through, so he called her. V14 stated this was one of R1's first times up in the chair after the wreck, injuries, and hospitalization, so she was concerned for his safety because she was three hours away. V14 stated she called the facility and spoke with V2/DON. V14 stated V2 told her R1 would have to wait because he required two people to transfer and one CNA on the hall was on break.On 6/18/26 at 12:35 PM, V2/Director of Nursing stated CNAs should not leave a resident suspended in a mechanical lift sling unattended or for prolonged periods of time. V2 stated she would expect staff to transfer the resident back to the chair and not leave the resident in the mechanical lift.On 6/18/26 at 12:35 PM, V2/DON stated she did tell V14 that R1 was going to have to wait. V2 stated she did not offer to go down and told the nurse and CNA taking care of R1 that shift. V2 stated, I assumed they would take care of it.R1's Nursing Admission/re-admission Data Collection showed an opened date of 5/15/26 at 6:01 PM, approximately eight hours after admission, and a locked date of 5/16/26 at 11:02 AM. The assessment documented R1 was not assessed by a nurse until 6:01 PM on 5/15/26 and the assessment was not completed until 5/16/26 at 11:02 AM.On 6/18/26 at 12:35 PM, V2/Director of Nursing stated an admission nursing assessment should be done in a timely manner, and she would expect it to be done within four hours to obtain a baseline picture of the resident. V2 confirmed the admission nursing assessment was not locked until 5/16/26 when V2 locked the assessment.On 6/18/26 at 2:20 PM, V3/Licensed Practical Nurse stated she worked second shift on 5/15/26 and completed R1's admission assessment after 6:00 PM to help her coworker. V3 stated there was a lot of passing on between nurses related to the admission and that was another reason the assessment was completed late. V3 stated, The assessment should have been completed sooner, but we were busy.On 6/18/26 at 2:30 PM, V9/Registered Nurse stated she was the nurse assigned to R1's original room assignment hall on 5/15/26 and received report from the hospital. V9 stated she did not assess R1 because she was busy entering medication orders. V9 stated, I did not do any vital signs or assessments on R1 when he got here. I only put a note in stating that he arrived at the building.R1's vital sign records showed R1 had only one documented set of vital signs after admission. Blood pressure was documented on 5/15/26 at 6:07 PM as 140/79 mmHg; temperature on 5/15/26 at 6:08 PM as 97.4 degrees Fahrenheit; respirations on 5/15/26 at 6:08 PM as 16 breaths per minute; pulse on 5/15/26 at 6:18 PM as 78 beats per minute; and oxygen saturation on 5/15/26 at 6:19 PM as 98% on room air. R1's electronic health record did not include any additional documented blood pressure, temperature, pulse, respirations, or oxygen saturation monitoring after 5/15/26 through 6/17/26, despite R1's recent hospitalization, multiple fractures, cervical spinal fusion, pain medication use, anticoagulant use, immobility, and need for skilled nursing observation and assessment.R1's current physician order summary, dated 6/17/26, did not include orders to monitor vital signs or pain level.On 6/23/26 at 10:35 AM, V9/Registered Nurse, V22/Licensed Practical Nurse, and V23/Licensed Practical Nurse stated all residents should have a pain assessment completed every shift and residents receiving skilled nursing care should have vital signs completed every shift. V9, V22, and V23 confirmed R1 did not have orders for vital signs or pain assessments and confirmed R1 had no vital signs entered since 5/15/26 and had multiple occasions with several days between pain assessments.On 6/23/26 at 11:15 AM, V2/Director of Nursing stated there was nothing in R1's care plan or orders about pain or vital signs. V2 confirmed R1 did not have vital signs documented since admission and had holes of multiple days in pain assessments. V2 stated nurses should complete vitals and pain assessments with skilled nursing assessment at minimum daily, but mostly every shift, and they were not completing them.The facility failed to follow its Vital Sign Policy when it failed to obtain and document vital signs according to R1's condition and needs after admission.R1's physician order summary showed orders for hydrocodone-acetaminophen, oxycodone, acetaminophen, methocarbamol, non-weight-bearing status, brace/splint use, passive range of motion, therapy, and CPM (Continuous Passive Motion) machine use.R1's pain level summary showed R1 had ongoing moderate to severe pain, including pain scores of 9/10 on 5/18/26, 7/10 on 5/21/26, 7/10 on 5/22/26, 10/10 on 6/4/26, 9/10 on 6/8/26, and 10/10 on 6/17/26. The pain record showed multi-day gaps without documented pain assessments, including gaps from 5/18/26 to 5/21/26, 5/22/26 to 5/29/26, 5/29/26 to 6/4/26, and 6/12/26 to 6/17/26.The facility failed to follow its Pain Management policy, which required pain assessments at least every shift, when R1 had multi-day gaps without documented pain assessments despite repeated moderate to severe pain, multiple traumatic injuries, cervical spinal fusion, chronic pain syndrome, immobility, and prescribed pain medications.R1's daily skilled nursing notes dated 5/17/26, 5/18/26, 5/19/26, 5/20/26, 5/21/26, 5/31/26, 6/2/26, 6/5/26, and 6/10/26 documented R1 required skilled services including nursing observation and assessment, management of the care plan, therapy, medication management, and/or teaching and training. The notes identified the reason for skilled services as motor vehicle accident, multiple fractures, immobility, pain, therapy, and/or wound care.R1's electronic health record showed R1 was continent of bowel in daily skilled nursing notes and was able to make needs known. R1 required extensive staff assistance due to multiple fractures, non-weight-bearing restrictions, braces, immobility, and pain.The facility failed to ensure timely toileting/incontinence care for R1, which resulted in R1 being left in stool despite being continent of bowel and able to communicate needs. This caused humiliation, distress, and discomfort for R1.The facility failed to ensure R1 received necessary care and services after admission from the hospital with multiple fractures, cervical spinal fusion, chronic pain syndrome, immobility, pain medication use, and weight-bearing restrictions. The facility's failures resulted in actual harm to R1, including prolonged pain, fear, distress, discomfort, and humiliation.The facility policy titled, The Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documented residents have the right to make their own choices, be treated with dignity and respect, receive care that promotes quality of life, receive equal access to quality care, receive services to keep physical and mental health at their highest practicable levels, and receive services/items included in the plan of care.The facility policy titled, Facility Resident Rights Policy, dated 12/2024, documented residents have the right to a dignified existence and access to persons and services inside and outside of the community.The facility policy titled, Pain Management, dated 2/2025, documented each resident has the right to optimal pain assessment and management. The policy documented unrelieved pain can have adverse psychological and physiological effects, and pain management enhances healing and promotes physical and psychological wellness. The policy documented pain assessments were to be completed at least every shift.The facility policy titled, Vital Sign Policy, approved 4/2026, documented vital signs should be obtained according to the resident's service plan, as determined by the resident's healthcare provider, and frequency may vary based on the resident's condition and needs. The policy documented vital signs should be recorded in the medical/electronic health record with the date, time, and staff member's name.The facility policy titled, SNF (Skilled Nursing Facility) Call Light Policy & Procedure, approved 7/2025, documented resident call lights will be answered in a timely and efficient manner once engaged. The policy documented call lights are answered based on first engaged and urgency of resident need, call lights shall be within reach, and if a resident requires an alternative call light device, the facility will provide and care plan for the needed device.The facility policy titled, SNF Mechanical Lift Procedure, approved 5/2025, documented the mechanical lift program was intended to promote resident and staff safety during transfers. The procedure required at least two trained staff for all mechanical lift transfers, proper sling placement, secure sling attachments, slow raising/lowering, transfer to the designated surface, removal of the sling if appropriate, and repositioning for comfort and safety.The facility policy titled, Safe Lifting and Movement of Residents, approved 12/2024, documented resident safety, dignity, comfort, and medical condition will be incorporated into decisions regarding safe lifting and moving. The policy documented staff will be trained in mechanical lifting devices, observed for competency, and expected to follow safe lifting procedures.The facility document titled, Certified Nursing Assistant/CNA Job Description, undated, documented CNAs are responsible for assisting residents with daily needs, ADLs (Activities of Daily Living), personal hygiene, answering call lights promptly, keeping residents dry, following care plan approaches, implementing positioning and transfer techniques, and promoting resident rights.

Based on observation, interview, and record review, the facility failed to ensure necessary grooming, hair care, personal hygiene, and personal appearance services were provided to maintain the highest practicable physical, mental, and psychosocial well-being for one (R12) resident reviewed for quality of care in a total sample of 14 residents.This deficient practice was evidenced by the facility's failure to provide and/or arrange timely hair care and grooming services for R12, whose hair was observed to be matted. The facility failed to follow its Resident Rights policy and Beautician/Barber policy to ensure R12's grooming and personal appearance needs were met in a manner consistent with R12's preferences, dignity, and quality of life. As a result, R12 experienced embarrassment, distress, and humiliation related to the condition of R12's hair.Findings include:R12's admission record documented R12 is a [AGE] year-old African American female admitted to the facility on [DATE] from a long-term acute care hospital. R12's medical diagnoses included primary progressive multiple sclerosis, incomplete paraplegia, disorder of muscle, ataxia, cognitive communication deficit, chronic pain, heart failure, and protein-calorie malnutrition.R12's current care plan documented a focus area for R12- Care/ADL Preferences, initiated 5/18/26. The goal documented staff would honor R12's preferences while caring for her.R12's care plan further documented a focus area for ADL Self Care Performance Deficit, initiated 5/18/26. The goal documented R12 would maintain her current level of function through the next review date. The care plan documented R12 needed staff assistance with bathing, including set up, supervision, and hands-on assistance with washing and drying. The care plan documented R12 required total assistance with personal hygiene care, was bedfast all or most of the time, was totally dependent on staff for toilet use, and required mechanical aid for transfers.R12's care plan did not document a focus, goal, or intervention for hair care, grooming assistance related to hair, personal appearance preferences, beautician/barber services, or monitoring/prevention of matted or tangled hair, despite R12's diagnoses of primary progressive multiple sclerosis, incomplete paraplegia, disorder of muscle, and ataxia, and despite R12's documented need for total assistance with personal hygiene care, staff assistance with bathing, bedfast status, and dependence on staff for ADLs.On 6/23/26 at 10:45 AM, R12 was observed wearing a head covering in her room in bed while V17/Certified Nursing Assistant was providing incontinence care and bathing. R12's hair was observed to be matted and tangled under the head covering. R12 appeared upset and tearful when discussing her hair. R12 stated, This shouldn't be happening. We shouldn't have to go through this. R12 stated no one comes to fix her hair and it gets matted, so she has to wear a covering to hide it. R12 stated, I don't like my hair like this. I'm embarrassed and don't want to be seen by anyone looking like this. I can't braid my own hair. I only have one hand that works, or I would do it myself.On 6/23/26 at 10:47 AM, V17/Certified Nursing Assistant stated she used to braid R12's hair but was told not to because she was not licensed. V17 stated there is no beautician who comes to the facility to do residents' hair anymore. V17 stated another CNA, V18, is licensed and does residents' hair sometimes, but due to staffing V18 cannot do the residents' hair like it should be done because V18 has to work the floor.On 6/23/26 at 11:17 AM, V2/Director of Nursing stated the facility has not been able to find a beautician for years. V2 stated CNAs are allowed to provide hair care to residents without a license if they are not using chemicals or cutting hair.On 6/23/26 at 11:47 AM, V1/Administrator stated the facility does not have a contract with a beautician at this time. V12/Certified Nursing Assistant helps when she can.The facility failed to ensure R12 received grooming, hair care, personal hygiene, and personal appearance services consistent with R12's assessed needs, preferences, dignity, and quality of life. R12's diagnoses included primary progressive multiple sclerosis, incomplete paraplegia, disorder of muscle, and ataxia. R12's care plan documented R12 required total assistance with personal hygiene, staff assistance with bathing, was bedfast all or most of the time, and required a mechanical aid for transfers. Despite this dependence, the facility failed to ensure staff assisted R12 with routine grooming/hair care or ensured R12 had timely access to beautician/barber services. As a result, R12's hair became matted and tangled, and R12 experienced embarrassment, distress, and humiliation.The facility failed to follow its Resident Rights policies and Beautician/Barber Policy when it failed to provide grooming and personal appearance services consistent with R12's preferences, dignity, and quality of life. The facility also failed to ensure ADL and personal hygiene care was provided to meet R12's needs and maintain R12's highest practicable physical and psychosocial well-being.The facility policy titled, The Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documented residents have the right to make their own choices, be treated with dignity and respect, receive care that promotes quality of life, receive equal access to quality care, receive services to keep physical and mental health at their highest practicable levels, and receive services/items included in the plan of care.The facility policy titled, Facility Resident Rights Policy, dated 12/2024, documented residents have the right to a dignified existence and access to persons and services inside and outside of the community.The facility document titled, Certified Nursing Assistant/CNA Job Description, undated, documented CNAs are responsible for assisting residents with daily needs, ADLs (Activities of Daily Living), personal hygiene, following care plan approaches and promoting resident rights.The facility policy titled, Beautician/Barber Policy, dated 8/2025, documented the facility will ensure residents have access to grooming and personal appearance services consistent with resident preferences, dignity, and quality of life requirements.

Based on interview and record review, the facility failed to provide necessary pain assessment, monitoring, and intervention to maintain the highest practicable physical and psychosocial well-being for one (R1) resident reviewed for pain management, in a total sample of 14 residents. This failure to assess and intervene when R1 was reported to be in pain during care and transfers, including when R1 was left suspended in a mechanical lift sling while beds were switched and when R1 waited an extended period in a wheelchair after activating the call light and requesting to return to bed due to pain. This failure resulted in R1 experiencing prolonged, unassessed, and/or unmanaged moderate-to-severe pain.Findings include:R1's admission record documented R1 was a [AGE] year-old admitted to the facility on [DATE] from a local hospital with diagnoses including fusion of cervical spine, occipital condyle fracture, chronic pain syndrome, stiffness of the right shoulder and elbow, muscle wasting and atrophy, dysphagia, and lack of coordination.R1's hospital discharge records, dated 5/15/26, documented R1 was discharged from a local hospital to the facility on 5/15/26 after hospitalization from 4/10/26 to 5/15/26 related to a motorcycle accident. The records documented multiple traumatic injuries and post-surgical needs, including cervical spinal fusion, multiple fractures, mobility restrictions, braces/splints to extremities, anticoagulation therapy, and pain management medications.R1's nursing progress note, back-dated to 5/15/26 at 10:35 AM, documented R1 arrived via ambulance with a family member, was alert and able to make needs known, and had multiple fractures including acetabulum, wrist, and skull fractures. The note documented R1 was non-weight bearing to the right upper extremity, left upper extremity, and right lower extremity, and weight bearing as tolerated to the left lower extremity for transfers only.R1's Social Service note, dated 5/15/26 at 2:42 PM, documented R1 was admitted from a local hospital after a motorcycle accident, was currently unable to use his arms, and was independent with decision making.R1's nursing progress note, dated 5/18/26 at 11:39 AM, showed V2/DON documented R1's mother reported R1 had his call light on for 40 minutes and was in pain wanting to be put back in bed. The note documented the CNA was waiting for someone from another hall to assist with transferring R1 back to bed. The record did not show an assessment of R1's pain level at that time, did not show documentation of an intervention to relieve R1's pain, and did not show documentation that R1 was timely assisted back to bed.On 6/17/26 at 11:40 AM, R1 stated that approximately three days after admission, on 5/18/26, he was in his wheelchair in pain and wanted to go back to bed. R1 stated he pressed the call light with no response, attempted to call the facility's phone number with no answer, and then called V14/R1's Family Member for assistance.On 6/18/26 at 11:28 AM, V14 stated she received a phone call from R1 on 5/18/26. V14 stated R1 told her his call light had been on while he was left in his wheelchair in pain and no one answered the call light for over an hour. V14 stated R1 then attempted to call the facility and could not get through, so he called her. V14 stated this was one of R1's first times up in the chair after the wreck, injuries, and hospitalization, so she was concerned for his safety because she was three hours away. V14 stated she called the facility and spoke with V2/DON. V14 stated V2 told her R1 would have to wait because he required two people to transfer and one CNA on the hall was on break.On 6/18/26 at 11:28 AM, V14/R1's Family Member stated R1 and V15 told her R1 was left in the air in a sling for approximately 15 minutes during transfer from the wheelchair to the bed while staff switched the beds. V14 stated R1's legs were going numb, R1 was in pain, and R1 was yelling out for help with no one around.On 6/18/26 at 12:24 PM, V15/R1's Family Friend stated V15 stated two staff came in and offered to move R1 to a new room, and R1 was left suspended in the mechanical lift sling for about 15 minutes while staff switched out beds in the new room. V15 stated one bed was a crank bed and the other bed did not work. V15 stated R1 complained his neck hurt and he was in obvious pain while in the lift. V15 stated R1 did not receive medications, including pain medication, no vitals were completed, and no nursing assessment was performed while she was present from approximately 10:00 AM until 6:00 PM.On 6/18/26 at 12:35 PM, V2/DON stated she did tell V14 that R1 was going to have to wait. V2 stated she did not offer to go down and told the nurse and CNA taking care of R1 that shift. V2 stated, I assumed they would take care of it.On 6/18/26 at 2:20 PM, V3/Licensed Practical Nurse stated she worked second shift on 5/15/26 and completed R1's admission assessment after 6:00 PM to help her coworker. V3 stated there was a lot of passing on between nurses related to the admission and that was another reason the assessment was completed late. V3 stated, The assessment should have been completed sooner, but we were busy.On 6/18/26 at 2:30 PM, V9/Registered Nurse stated she was the nurse assigned to R1's original room assignment hall on 5/15/26 and received report from the hospital. V9 stated she did not assess R1 because she was busy entering medication orders. V9 stated, I did not do any vital signs or assessments on R1 when he got here. I only put a note in stating that he arrived at the building.R1's current physician order summary, dated 6/17/26, did not include orders to monitor vital signs or pain level.On 6/23/26 at 10:35 AM, V9/Registered Nurse, V22/Licensed Practical Nurse, and V23/Licensed Practical Nurse stated all residents should have a pain assessment completed every shift and residents receiving skilled nursing care should have vital signs completed every shift. V9, V22, and V23 confirmed R1 did not have orders for vital signs or pain assessments and confirmed R1 had no vital signs entered since 5/15/26 and had multiple occasions with several days between pain assessments.On 6/23/26 at 11:15 AM, V2/Director of Nursing stated there was nothing in R1's care plan or orders about pain or vital signs. V2 confirmed R1 did not have vital signs documented since admission and had holes of multiple days in pain assessments. V2 stated nurses should complete vitals and pain assessments with skilled nursing assessment at minimum daily, but mostly every shift, and they were not completing them.R1's physician order summary showed orders for hydrocodone-acetaminophen, oxycodone, acetaminophen, methocarbamol, non-weight-bearing status, brace/splint use, passive range of motion, therapy, and CPM (Continuous Passive Motion) machine use.R1's pain level summary showed R1 had ongoing moderate to severe pain, including pain scores of 9/10 on 5/18/26, 7/10 on 5/21/26, 7/10 on 5/22/26, 10/10 on 6/4/26, 9/10 on 6/8/26, and 10/10 on 6/17/26. The pain record showed multi-day gaps without documented pain assessments, including gaps from 5/18/26 to 5/21/26, 5/22/26 to 5/29/26, 5/29/26 to 6/4/26, and 6/12/26 to 6/17/26.The facility failed to follow its Pain Management policy, which required pain assessments at least every shift, when R1 had multi-day gaps without documented pain assessments despite repeated moderate to severe pain, multiple traumatic injuries, cervical spinal fusion, chronic pain syndrome, immobility, and prescribed pain medications.R1's daily skilled nursing notes dated 5/17/26, 5/18/26, 5/19/26, 5/20/26, 5/21/26, 5/31/26, 6/2/26, 6/5/26, and 6/10/26 documented R1 required skilled services including nursing observation and assessment, management of the care plan, therapy, medication management, and/or teaching and training. The notes identified the reason for skilled services as motor vehicle accident, multiple fractures, immobility, pain, therapy, and/or wound care.The facility policy titled, Pain Management, dated 2/2025, documented each resident has the right to optimal pain assessment and management. The policy documented unrelieved pain can have adverse psychological and physiological effects, and pain management enhances healing and promotes physical and psychological wellness. The policy documented pain assessments were to be completed at least every shift.

Based on interview and record review the Facility failed to guarantee Residents reasonable telephone access by not providing phone service access for family members to contact residents for four residents (R1, R3, R6, and R14) reviewed for telephone communication in a sample of 14.Findings include: 1. On 6/17/26 at 8:51 am, V24 (R3's Sister/Power of Attorney) stated, I have called and left numerous messages, and no one returns my phone call or the phone just rings and rings, and no one answers it. This has happened on multiple occasions. My sister (R3) discharged from the facility and I called looking for personal items and no one ever calls me back. 2. On 6/17/26 at 9:06 am, V25 (R14's Granddaughter) stated, I have called my grandmother so many times, and the phone just rings and rings. When they answer, sometimes I am on hold for over twenty minutes. They have no cordless or portable phones, so that does not help either, if they are busy, they have to run up the hallway to the nurse's desk to answer the phone. At night, the nurses and aides must answer the phones, and they are just too busy sometimes to answer the phones. 3. On 6/17/26 at 11:40 AM, R1 stated he tried to call the facility before to get help and could not get anyone to answer the phone. It's usually in the evenings when friend or family have tried calling and cannot get through. 4. On 6/18/26 at 8:55 AM, R6 stated everybody has issues with getting phone calls here. It is not usually during the day, but after 4:00 PM is iffy to get a phone call because nobody is in the office and staff are busy in the evenings. Nobody really answers the phone after 4:00 PM. On 6/18/26 at 11:28 AM, V14/R1's family member stated, (R1) attempted to call the facility with his call light on needing assistance one day and could not get through to anyone, so he had to call me and I had to call the building myself to get ahold of someone. On 6/18/26 at 9:55 AM, V1/Administrator stated he was made aware of an issue about a month ago with a resident's family member not being able to get through to the facility after hours. Medical Records is responsible for answering the phone during the day between the hours of 7:30 AM and 4:00 PM Monday through Friday. Clinical staff, including nurses and Certified Nursing Assistants are responsible for answering the phone after hours. There are no mobile or cordless phones for staff, only the phones at the nurse's stations on the halls and in the offices. There is no full-time receptionist. Medical Records is not here today so managers and nurses will answer the phones today. On 6/23/26 at 12:20 PM, V/21 Medical Records/Receptionist stated she answers the phone when present Monday through Friday between the hours of 7:30 AM and 4:00 PM and after hours the calls go to the clinical staff. Family call sometimes in the morning when I get here and state that they could not get anyone to answer after I left. There are times I come in and there are 50 or more missed calls on the phone. We don't have a voicemail box set up to leave a message, so they would have to call back during the day to follow up. The Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documents: right to make own choices; must treat you with dignity and respect and care for you in a manner that promotes quality of life; must provide equal access to quality care regardless of diagnoses or condition; must provide services to keep physical and mental health at their highest practical levels; should be provided services and/or items included in plan of care; and you have the right to make and receive phone calls in private and to have access to use of a telephone where calls can be made without being overheard. The Facility Wide Assessment, dated 1/1/26, documents: the facility assessment must include an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs; and facility documents administration needs. The Facility Resident Rights Policy, dated 12/2024, documents: has the right to a dignified existence; and access to persons and services inside and outside of the community. The Facility Receptionist/Clerk/Administrative Assistant Job Description, undated, documents: responsible for interpreting company policies; answer telephone and directs caller to correct station, takes messages, answers questions of callers; cooperates with facility personnel to ensure services can be adequately maintained to meet needs of the residents; and understands, upholds and promotes the rights of the residents.

Based on interview and record review, the facility failed to ensure call lights were answered in a timely manner and failed to follow its Call Light Policy for one (R1) resident reviewed for call lights in the sample of 14 when R1's call light was not answered in a timely and efficient manner after R1 requested assistance due to pain and wanting to return to bed. Findings include:R1's nursing progress note, dated 5/18/26 at 11:39 AM, showed V2/DON/Director of Nursing documented R1's mother reported R1 had his call light on for 40 minutes and was in pain wanting to be put back in bed. The note documented the CNA/Certified Nursing Assistant was waiting for someone from another hall to assist with transferring R1 back to bed. The record did not show an assessment of R1's pain level at that time, did not show documentation of an intervention to relieve R1's pain, and did not show documentation that R1 was timely assisted back to bed.On 6/17/26 at 11:40 AM, R1 stated that approximately three days after admission, on 5/18/26, he was in his wheelchair in pain and wanted to go back to bed. R1 stated he pressed the call light with no response, attempted to call the facility's phone number with no answer, and then called V14/R1's Family Member for assistance.On 6/18/26 at 11:28 AM, V14 stated she received a phone call from R1 on 5/18/26. V14 stated R1 told her his call light had been on while he was left in his wheelchair in pain and no one answered the call light for over an hour. V14 stated R1 then attempted to call the facility and could not get through, so he called her. V14 stated this was one of R1's first times up in the chair after the wreck, injuries, and hospitalization, so she was concerned for his safety because she was three hours away. V14 stated she called the facility and spoke with V2/DON. V14 stated V2 told her R1 would have to wait because he required two people to transfer and one CNA on the hall was on break.On 6/18/26 at 12:35 PM, V2/DON stated she did tell V14 that R1 was going to have to wait. V2 stated she did not offer to go down and told the nurse and CNA taking care of R1 that shift. V2 stated, I assumed they would take care of it.The facility policy titled, SNF (Skilled Nursing Facility) Call Light Policy & Procedure, approved 7/2025, documented resident call lights will be answered in a timely and efficient manner once engaged. The policy documented call lights are answered based on first engaged and urgency of resident need, call lights shall be within reach, and if a resident requires an alternative call light device, the facility will provide and care plan for the needed device.The facility document titled, Certified Nursing Assistant/CNA Job Description, undated, documented CNAs are responsible for assisting residents with daily needs, ADLs (Activities of Daily Living), personal hygiene, answering call lights promptly, keeping residents dry, following care plan approaches, implementing positioning and transfer techniques, and promoting resident rights.

Based on interview and record the Facility failed to verify and document personal inventory items for one resident (R3) reviewed for discharge in a sample of 14.Findings include:R3's Physician Order Sheet/POS, dated 6/18/26, documents R3 admitted to the facility on [DATE] with diagnoses including Compression Fracture of the T11-T12 Vertebrae and Low Back Pain. The POS documents an order dated 7/20/25, for a Shoulder-Thoracic-Sacral/STS back brace.R3's Nursing Progress Notes (dated 4/5/26 at 8:06 am and 4/6/26 at 6:35 am), document R3 is in the hospital.R3's Nursing Progress Note, dated 5/15/26 at 10:51 am, documents a late entry follow up with family and sister has decided to have (R3) admitted to another facility closer to her.R3's Nursing Notes, dated 4/5/26 through 5/15/26, do not document R3's personal inventory items/belongings were sent upon R3's discharge and do not document follow up telephone calls with V24 (R3's Sister/Power of Attorney).On 6/17/26 at 8:51 am, V24 (R3's Sister/Power of Attorney) stated, My sister (R3) discharged and went to the hospital, then never went back to the facility, because we put her in a different facility. The new facility called and spoke to someone at the old facility about (R3's) wheelchair and back brace, and they told her that they did not have it. When my sister (R3) went to the hospital, I went to the facility to get her belongings and no one was around to help, so I packed up the clothing items that were in her drawers and could not find the wheelchair or brace. (R3's) insurance had paid for that wheelchair and on a former hospital visit, the hospital had given (R3) the back brace before being admitted to the facility. I called the facility, and no one could locate either of them.On 6/23/26 at 2:21 pm, V19 (Certified Nursing Assistant) stated, We fill out the inventory sheets and give them to the nurse. I am not sure where they go after that. If families bring in new clothing or items, we are supposed to write them on the inventory sheets.On 6/18/26 at 11:10 am, V2 (Director of Nursing) stated, I cannot find an inventory sheet for (R3), and I do not see that anything is documented in the progress notes for (R3's) personal items. It is the nursing staff responsibility to record personal belongings on the inventory sheet.On 6/18/26 at 8:50 am, V1 (Administrator) stated, After (R3) discharged , (V24) called us and asked if we had (R3's) belongings, we talked with (V24) and told (V24) that the wheelchair that (R3) was using was the facility wheelchair. When (R3) originally admitted , R3 had a wheelchair with (R3's) name on the back and we thought that (V24) took that wheelchair home because we could never find it. (R3) also admitted with a back brace and we also assumed that (V24) had taken that also, because we never found any of those items.The Facility Discharge Summary and Plan Policy, dated 8/2025, documents: the discharge plan will include resident and family collaboration to support the resident's transition to community living; nurse will document a discharge note in the progress notes section of the resident record and include what belongings were sent with them; and Social Services/Designee will make a post discharge follow up call with the discharged Resident 48 hours after discharge and if there are identified concerns during this call, Social Services/Designee should continue post discharge follow up calls until the concerns are resolved and document the outcome of each call.

Based on interview and record review, the facility failed to develop and revise comprehensive, person-centered care plans to include resident-specific problems, goals, and interventions for three (R1, R6, and R12) residents reviewed for comprehensive care plans in the sample of 14. Findings include:1. R1's admission record documented R1 was a [AGE] year-old admitted to the facility on [DATE] from a local hospital with diagnoses including fusion of cervical spine, occipital condyle fracture, chronic pain syndrome, stiffness of the right shoulder and elbow, muscle wasting and atrophy, dysphagia, and lack of coordination.R1's hospital discharge records, dated 5/15/26, documented R1 was discharged from the hospital to the facility after hospitalization related to a motorcycle accident. The records documented multiple traumatic injuries and post-surgical needs, including cervical spinal fusion, multiple fractures, mobility restrictions, braces/splints, anticoagulation therapy, and pain management medications.R1's pain level summary showed ongoing moderate to severe pain, including pain scores of 9 out of 10 on 5/18/26, 7 out of 10 on 5/21/26, 7 out of 10 on 5/22/26, 10 out of 10 on 6/4/26, 9 out of 10 on 6/8/26, and 10 out of 10 on 6/17/26. The pain record showed multi-day gaps without documented pain assessments.R1's vital sign records showed only one documented set of vital signs after admission, completed on 5/15/26. R1's electronic health record did not include additional documented blood pressure, temperature, pulse, respirations, or oxygen saturation monitoring after 5/15/26 through 6/17/26.R1's electronic health record documented R1 was continent of bowel and able to make needs known. R1 required extensive staff assistance due to multiple fractures, non-weight-bearing restrictions, braces, immobility, and pain.R1's current care plan documented orthopedic restrictions, including weight-bearing restrictions and brace/splint instructions; however, R1's care plan did not comprehensively address R1's pain assessment and management needs, vital sign monitoring needs based on condition/skilled status, timely call light response and assistance needs, toileting/continence assistance needs, or safe mechanical lift transfer needs.On 6/23/26 at 11:15 AM, V2/Director of Nursing stated there was nothing in R1's care plan or orders about pain or vital signs. V2 confirmed R1 did not have vital signs documented since admission and had holes of multiple days in pain assessments. V2 stated nurses should complete vital signs and pain assessments with skilled nursing assessment at minimum daily, but mostly every shift, and staff were not completing them.2. R6's admission record documented R6 had medical diagnoses including: chronic obstructive pulmonary disease, hemiplegia affecting the left dominant side, hypertension, muscle wasting and atrophy, chronic pain syndrome, major depressive disorder, alcoholic hepatitis with ascites, atrial fibrillation, heart failure, orthopnea, nicotine dependence, weakness, and other abnormalities of breathing.R6's current care plan documented a focus area for elopement/unit placement, initiated 8/30/24 and revised 5/23/25, which documented R6 will at times sign himself out and go with family or go independently to various places in the community. The goal documented R6 would be safe and secure during his stay. Interventions included R6 was not at risk of leaving home unattended, Social Services would intervene if needed, and wandering/elopement assessments would be completed on admission, quarterly, significant change in condition, and/or as needed.R6's care plan documented a cognition focus area, initiated 9/3/24 and revised 9/24/24, which documented R6 did not always make good decisions as evidenced by leaving the facility and returning with alcohol. The goal documented R6 would make good decisions as able regarding healthy and safe choices when absent from the facility. Interventions included reminding R6 it was not safe to drink while out of the facility, reminding R6 alcohol was prohibited without a physician order, Social Services to intervene as needed, and that R6 had been counseled and reminded he was not to bring alcohol onto the property.R6's care plan also documented R6 was able to participate in therapeutic leave with or without accompaniment. The goal documented R6 would alert staff when he left the building. Interventions included notifying the physician if nursing felt R6 was under the influence and having R6 sign in and out at the nurses' station.3. R12's admission record documented R12 was a [AGE] year-old African American female admitted to the facility on [DATE] from a long-term acute care hospital. R12's medical diagnoses included primary progressive multiple sclerosis, incomplete paraplegia, disorder of muscle, ataxia, cognitive communication deficit, chronic pain, heart failure, and protein-calorie malnutrition.R12's current care plan documented a focus area for YOUNITE Story - Care/ADL (Activities of Daily Living) Preferences, initiated 5/18/26. The goal documented staff would honor R12's preferences while caring for her.R12's care plan further documented a focus area for ADL Self Care Performance Deficit, initiated 5/18/26. The goal documented R12 would maintain her current level of function through the next review date. The care plan documented R12 needed staff assistance with bathing, including set up, supervision, and hands-on assistance with washing and drying. The care plan documented R12 required total assistance with personal hygiene care, was bedfast all or most of the time, was totally dependent on staff for toilet use, and required a mechanical aid for transfers.R12's care plan did not document a focus, goal, or intervention for hair care, grooming assistance related to hair, personal appearance preferences, beautician/barber services, or monitoring/prevention of matted or tangled hair, despite R12's diagnoses and documented need for total assistance with personal hygiene care, staff assistance with bathing, bedfast status, and dependence on staff for ADL care.On 6/23/26 at 10:45 AM, R12 was observed wearing a head covering in her room in bed while V17/Certified Nursing Assistant (CNA) provided incontinence care and bathing. R12's hair was observed to be matted and tangled under the head covering. R12 appeared upset and tearful when discussing her hair. R12 stated no one comes to fix her hair and it gets matted, so she has to wear a covering to hide it. R12 stated she could not braid her own hair because only one hand works.On 6/23/26 at 10:47 AM, V17/Certified Nursing Assistant stated she used to braid R12's hair but was told not to because she was not licensed. V17 stated there was no beautician who comes to the facility to do residents' hair anymore.On 6/23/26 at 11:17 AM, V2/Director of Nursing stated the facility had not been able to find a beautician for years. CNAs are allowed to provide hair care to residents without a license as long as they are not using chemicals or cutting hair.On 6/23/26 at 11:47 AM, V1/Administrator stated the facility did not have a contract with a beautician at that time.R6's care plan did not include current, resident-specific interventions addressing how staff were to monitor, supervise, assess, or intervene when R6 left the facility, returned from the community, or was suspected of returning with alcohol. The care plan did not include clear direction for assessment of intoxication, alcohol possession, notification criteria, staff responsibility, monitoring frequency, safety checks upon return, or interventions related to R6's alcohol-related risk in the context of alcoholic hepatitis with ascites, chronic obstructive pulmonary disease, heart failure, atrial fibrillation, major depressive disorder, chronic pain syndrome, weakness, and hemiplegia.The facility failed to ensure R6's comprehensive care plan was resident-specific and revised to address R6's alcohol-related safety risks, therapeutic leave needs, and monitoring/supervision needs when leaving and returning to the facility.On 6/23/26 at 11:18 AM, V2/Director of Nursing stated each resident should have an individualized care plan that address resident-specific problems and should include a goal and interventions to address each problem identified to ensure residents receive proper care. V2 confirmed care plans were missing important care areas that were resident-specific.The Facility Care Planning Policy, dated 12/2024, documents: purpose to assess each resident's strengths, weaknesses and care needs; use assessment data to develop a comprehensive Plan of Care for each Resident in achieving and maintaining the highest practical level of mental functioning, physical functioning and wellbeing as possible.

Based on interview and record review the Facility failed to finalize a completed fall investigation, document and monitor a head injury and prevent a staff assisted fall and the facility failed to follow its SNF (Skilled Nursing Facility) Mechanical Lift Procedure and Safe Lifting and Movement of Residents policy when staff failed to promptly transfer R1 to the designated surface and reposition R1 for comfort and safety. R1 had multiple fractures, cervical spinal fusion, weight-bearing restrictions, limited upper-extremity use, immobility, and pain. Leaving R1 suspended in the mechanical lift sling while staff switched the beds failed to promote R1's safety, dignity, comfort, and medical condition, and resulted in avoidable pain, fear, discomfort, and distress for two (R1 and R3) residents reviewed for accidents/hazards in a sample of 14.Findings include: 1. R1's admission record documented R1 was a [AGE] year-old admitted to the facility on [DATE] from a local hospital with diagnoses including fusion of cervical spine, occipital condyle fracture, chronic pain syndrome, stiffness of the right shoulder and elbow, muscle wasting and atrophy, dysphagia, and lack of coordination. R1's hospital discharge records, dated 5/15/26, documented R1 was discharged from a local hospital to the facility on 5/15/26 after hospitalization from 4/10/26 to 5/15/26 related to a motorcycle accident. The records documented multiple traumatic injuries and post-surgical needs, including cervical spinal fusion, multiple fractures, mobility restrictions, braces/splints to extremities, anticoagulation therapy, and pain management medications. R1's nursing progress note, backdated to 5/15/26 at 10:35 AM, documented R1 arrived via ambulance with a family member, was alert and able to make needs known, and had multiple fractures including acetabulum, wrist, and skull fractures. The note documented R1 was non-weight bearing to the right upper extremity, left upper extremity, and right lower extremity, and weight bearing as tolerated to the left lower extremity for transfers only. R1's Social Service note, dated 5/15/26 at 2:42 PM, documented R1 was admitted from a local hospital after a motorcycle accident, was currently unable to use his arms, and was independent with decision making. On 6/17/26 at 11:40 AM, R1 was observed in his room awake, alert, and able to make his needs known. R1 stated he arrived at the facility on 5/15/26 around 10:00 AM. R1 stated no one came to his room until a few hours later. R1 stated when he later switched rooms, the beds in the new room had to be switched because they were not functioning. R1 stated staff transferred him from his wheelchair with a mechanical lift and sling before realizing the beds needed to be switched. R1 stated he was left suspended in the mechanical lift sling for approximately 15 minutes while staff switched the beds. R1 stated no staff members were present while he was suspended in the mechanical lift sling. On 6/18/26 at 12:24 PM, V15/R1's Family Friend stated she followed R1 in the ambulance to the facility on 5/15/26 and stayed with him from approximately 10:00 AM until 6:00 PM because she did not want to leave R1 at the facility after the day unfolded. V15 stated R1 sat in the initial room until approximately 2:00 PM without seeing anyone. V15 stated R1 did not want to stay after the first four hours, and they called the non-emergency line to transfer R1 to a different facility. V15 stated, I was crying it was so bad. V15 stated two staff came in and offered to move R1 to a new room, and R1 was left suspended in the mechanical lift sling for about 15 minutes while staff switched out beds in the new room. V15 stated one bed was a crank bed, and the other bed did not work. V15 stated R1 complained his neck hurt and he was in obvious pain while in the lift. V15 stated R1 did not receive medications, including pain medication, no vitals were completed, and no nursing assessment was performed while she was present from approximately 10:00 AM until 6:00 PM. On 6/18/26 at 11:28 AM, V14/R1's Family Member stated R1 and V15 told her R1 was left in the air in a sling for approximately 15 minutes during transfer from the wheelchair to the bed while staff switched the beds. V14 stated R1's legs were going numb, R1 was in pain, and R1 was yelling out for help with no one around. On 6/18/26 at 12:35 PM, V2/Director of Nursing stated CNAs should not leave a resident suspended in a mechanical lift sling unattended or for prolonged periods of time. V2 stated she would expect staff to transfer the resident back to the chair and not leave the resident in the mechanical lift. The Facility Skilled Fall Policy, dated 5/2025, documents: the purpose is to develop, implement, observe and evaluate an interdisciplinary approach and manage strategies and interventions that foster resident independence and quality of life; promotes safety, prevention and education of both staff and residents; each resident will be provided services and care that ensures the resident's environment remains as free from accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents; each resident who experiences a fall will be treated and assessed to adequately treat any current injuries and comprehensively assessed to determine casual effects; and after each fall, the occurrence report will be completed, root cause will be determined and interventions implemented. The Facility Post Fall Workflow Policy, dated 5/2025, documents: steps to be taken will include the residents provider and representative must be notified of the resident's fall; an occurrence report must be completed and reviewed by nursing administration for completeness in the next daily meeting; nursing administration will investigate and conclude each, document root cause, record witness statements and finalize the occurrence report; a progress note must be documented in the resident's record, including root cause analysis, resident representative notification, details of injury, pertinent statements and other details surrounding the resident's fall; and post fall documentation must be done every shift for 72 hours following the fall. The Facility Fall Analysis Log, dated 3/2026, documents a fall for R3 on 3/26/26 at 8:00 am, in R3's room. The Log documents R3 tipped over backwards in wheelchair, had no injury and was hospitalized . The new intervention was anti-tip backs on R3's wheelchair. 2.R3's Physician Order Sheet, dated 6/18/26, documents R3 admitted to the facility on [DATE], with diagnoses including Epilepsy, Seizures, Depressive Disorder, Left Foot Drop, Right Foot Drop, Panic Disorder, Lumbar Region Radiculopathy and Wedge Compression Fracture of T11-T12 Vertebra. V9 (Registered Nurse/RN) completed R3's Fall Investigation Report, dated 3/26/26 at 8:00 am, documents resident wheelchair laying on its back with resident (R3) in it. Resident did hit head on floor. The Fall Report documents R3 has bump on back of head and also documents no injury observed. The Fall Report is not entirely completed and does not document mental status, injury description (size and location), pain level, predisposing environmental factors or predisposing situation factors. The Fall Report documents V24 (R3's Sister/Power of Attorney) was notified on 3/26/26 at 8:30 am. The Fall Report does not document witnesses/staff present interviews, monitoring of a description of size, color or location of R3's head injury/bump. R3's Fall Investigation Reports document previous falls on 1/21/26, 1/31/26, 2/2/26 and 2/20/26. R3's Nursing Progress Note, dated 3/26/26 at 9:59 am, documents R3 had a change in condition and is currently experiencing is fall struck head. R3's Nursing Progress Note, dated 3/26/26 at 10:17 am, documents (R3's) wheelchair tipped over while staff was trying to get clothing unwrapped from wheelchair wheel. (R3) hit head on the floor and that (R3) complained of increased pain to the head after (pain medication) was given. R3's Nursing Progress Note, dated 3/26/26 at 12:38 pm, documents at Emergency Room/ER. R3's late entry Nursing Progress Note, dated 3/26/26 at 4:30 pm, documents resident returned from the ER. R3's Nursing Progress Notes, dated 3/26/26 through 3/30/26, do not document monitoring of a description of size, color or location of R3's head injury, or witnesses/staff present interviews R3's current Care Plan documents R3 is at risk for falls and documents interventions for falls. On 6/18/26 at 10:45 am, V9 (Registered Nurse/RN) stated, I was the nurse on duty when (R3) fell on 3/26/26, but I do not remember which CNA's (Certified Nursing Assistants) were here, and I did not document their names on anything in the medical record. (R3) was in the middle of the hallway and (R3's) clothing got caught in (R3's) wheelchair wheels. When the CNAs were helping (R3), the wheelchair tipped backwards and (R3) hit her head on the floor. I did not document any description of the bump on (R3's) head but I do think, if I remember correctly, (R3) had a bump on the back left side of head. (R3) was complaining of pain and we sent (R3) to the hospital emergency department. I do not remember if I called and notified (V24/R3's Sister) or not. On 6/17/26 at 8:51 am, V24 (R3's Sister/Power of Attorney) stated, I found out from my sister (R3), that they tipped her out of her wheelchair and hit her head. No one ever notified me, my sister (R3) told me later. On 6/18/26 at 11:05 am, V2 (Director of Nursing) stated, The nurses are responsible for entirely completing the fall investigations when a fall occurs. They should include a description of injuries and any witnesses present. I do not see that the staff that were helping (R3) with the clothing that was stuck in the wheelchair wheel were identified. I also do not see that any description or monitoring of measurements, size or exact place of (R3's) head injury was documented. The facility policy titled, SNF Mechanical Lift Procedure, approved 5/2025, documented the mechanical lift program was intended to promote resident and staff safety during transfers. The procedure required at least two trained staff for all mechanical lift transfers, proper sling placement, secure sling attachments, slow raising/lowering, transfer to the designated surface, removal of the sling if appropriate, and repositioning for comfort and safety. The facility policy titled, Safe Lifting and Movement of Residents, approved 12/2024, documented resident safety, dignity, comfort, and medical condition will be incorporated into decisions regarding safe lifting and moving. The policy documented staff will be trained in mechanical lifting devices, observed for competency, and expected to follow safe lifting procedures.

Based on observation, interview and record review the Facility failed to maintain environmental equipment safety, comfortability and appearance for a torn/ripped bed mattress that created unsafe gaps for one resident (R10) reviewed for environment in a sample of 14.Findings include:On 6/18/26 at 8:11 am, R10 was sitting in a wheelchair in R10's room and R10's bed was unmade (no sheets/blankets/bedspread). An exposed blue mattress had a moderate amount of brown/tan punctures on the outer layer that exposed the internal mattress materials and exposed dips/lumps were noted on the sleeping surface. R10 stated, Oh, they know about it, I have been telling them about this mattress for over a year. It looks terrible and is very uncomfortable. I do not know why they do not notice it when they change my bedding.On 6/18/26 at 8:06 am, V7 (Housekeeping Supervisor) stated, Staff are real good about letting me know about mattresses that need to be changed out. They tell me if they see a dirty or worn mattress, so we can swap it out.On 6/18/26 at 8:35 am, V7 (Housekeeping Supervisor) entered R10's room, and exchanged R10's mattress. V7 stated, I overheard you talking to (R10), so I just took it upon myself to change the mattress.On 6/25/26 at 10:00 am, V1 (Administrator) stated, I have been ordering new mattresses, I am not sure how they missed that one. The nursing staff, housekeeping staff and maintenance all usually work together when they see a mattress that needs changed.The Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documents: right to make own choices; must treat you with dignity and respect and care for you in a manner that promotes quality of life; must provide equal access to quality care regardless of diagnoses or condition; must provide services to keep physical and mental health at their highest practical levels; and should be provided services and/or items included in plan of care.The Facility Resident Rights Policy, dated 12/2024, documents residents have the right to a dignified existence.The Certified Nursing Assistant/CNA Job Description, undated documents: responsible for delivering and assisting residents with daily needs; to provide activities of daily living; responsible for knowledge of proper procedures to provide personal care services; prepares equipment; serves and protects by adhering to professional standards, company policies and procedures, federal, state and local requirements; and understands, upholds and promotes the rights of the residents.

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment by failing to ensure resident bathrooms were free of fecal matter, resident rooms were cleaned daily with trash removed daily, floors throughout the facility were swept and mopped, and soiled linens and adult briefs were properly disposed of. These failures have the potential to affect all 74 residents residing in the facility reviewed for physical environment. Findings Include:On 5/30/2026 at 9:30 AM, during the initial tour of the facility, the floors in the front entrance, dining room, and main nurses' station were observed to have dirt, debris, and a sticky substance that adhered to shoes while walking. On Hall A, dirt, debris, and a sticky substance were present on the hallway floors and in all resident rooms. Most rooms were missing trash can liners, and several rooms contained dried stains accompanied by a urine odor. Rooms A2, A3, A6, A10, A13, and A15 had no bed sheets on the beds. Room A4 contained urine-soaked bed sheets and an adult brief saturated with urine on the floor. Room A5 had an overflowing trash can. On Hall B, dirt, debris, and a sticky substance were observed on the hallway floors and throughout all resident rooms. Several rooms had a noticeable urine odor. Rooms B2, B3, B8, and B11 had no bed sheets on the beds. On Hall C, dirt, debris, and a sticky substance were observed on the hallway floors and throughout all resident rooms. Several rooms had a noticeable urine odor. Rooms C5, C7, and C13 had no bed sheets on the beds.The facility's A, B, and C Assignment Sheet not dated documents, Clean ALL rooms on your hall (Even unoccupied rooms) *Attached is a checklist of what you are EXPECTED to do daily in each room. A: Clean sunroom, front lobby, employee rest room on A Hall, clean all closets on your hall, dirty linen, housekeeping, hopper. B Hall: clean doctor's office, clean shower rooms, clean beauty shop. C Hall: clean break room and bathroom, clean nourishment room, clean nurses station. 1 deep clean as scheduled (check deep clean calendar), you are expected to pull out all the furniture in the room and clean under and behind it. Pay special attention to the bed frames, windows, windowsills, and edges; straighten the closet (if needed). Clean dining room after breakfast and lunch, dust hallway and wipe down rails, dust and mop your hall at the end of shift, focus on the project of the day.On 5/30/2026 at 10:15 AM, R1 was in his room, in his bed, dressed, with his bedside table over his lap. R1's floor had dark black scuffs on the floor, and the floor was sticky. R1 had all his braces on his bilateral legs and left arm. R1 stated the facility never sweeps. R1 stated, They mop sometimes, but right over crumbs and whatever is on the floor, it always smells like urine. R1 stated his room is hardly cleaned, and the trash is taken out when he asks.On 5/30/2026 at 10:10 AM, V7 (R1's Family Member) stated that it always smells like urine in the facility, and staff are hard to find as well. V7 stated he will not attempt to use the bathroom at the facility because he never sees anyone cleaning it and knows how gross it is.On 5/30/2026 at 10:00 AM, R2 was observed sitting at the end of his bed in his room, fully dressed. The room was noted to be cluttered, with multiple empty Styrofoam bowls, food wrappers, and miscellaneous items on the bedside table and dresser. A urine container approximately three-quarters full was located next to the bed. The trash can was full, and R2 stated that it had not been emptied during the previous day. The floor throughout the room contained dirt, debris, and other scattered items and was noted to be sticky in several areas. The shared bathroom contained brown smears on the floor and around the toilet area. A strong foul odor consistent with feces was present. R2 stated that these conditions were not new and reported that the resident who shares the bathroom frequently leaves feces on the floor and toilet. R2 further stated that the bathroom is not cleaned daily and that the room is typically cleaned usually every three to four days per week.On 5/30/2026 at 9:40 AM, R3 was in her bed, and V8 (Certified Nurse Assistant) was in R3's room performing incontinence care. R3's floor contained urine-soaked bed sheets and an adult brief saturated with urine on the floor. After the cares were finished, R3 stated that the staff did not mop the floor after cleaning up the sheets and her adult brief.On 5/30/2026 at 12:30 PM, R4 stated she usually makes her bed, and staff does not make her bed. R4 stated she sees staff come in sometimes and clean the floors and mops. R4 stated that staff do not always sweep and mop but usually take her trash out.On 5/30/2026 at 9:45 AM, V8 (Certified Nurse Assistant) confirmed she placed R3's urine-soaked bed sheets and urine-soaked adult brief on the floor instead of in an enclosed protective bag.On 5/30/2026 at 10:45 AM, V2 (Director of Nursing) stated that nursing staff are to always put dirty adult briefs and dirty linen in a concealed bag. V2 also stated that when a resident gets bodily fluids on or around the toilet area, nursing staff are expected to clean it promptly and tell housekeeping staff once they disinfect and use bleach wipes.On 5/30/2026 at 12:00 PM, V6 (Certified Nurse Assistant) stated she did not clean R1's room right away after the resident next door got feces on the floor. V6 stated her job is to make sure she wipes up any bodily fluids and then lets housekeeping know to come in after she disinfects to clean again. V6 stated she strips the beds when she has a resident who urinates or has fecal matter in the beds, or when they are up for showers, and she will wipe the bed down, and sometimes it takes a while to make the bed again. V6 stated she does her job but feels that sometimes 3rd shift isn't the best sometimes.On 5/30/2026 at 10:30 AM, V4 (Housekeeper) stated she usually does her job, and stated sometimes she does not clean a resident's room because they do not want her to. V4 stated she cannot say the same for other staff because the facility is not as clean as it should be.On 5/30/2026 at 10:40 AM, V5 (Housekeeper) cannot speak English; V4 (Housekeeper) translated. V5 confirmed R1's room had a lot of clutter, old Styrofoam bowels, dirty bedside table, and a bedside dresser had trash and clutter. V4 verified that there was brown fecal matter on the floor with strong-smelling feces in the bathroom. V5 stated that when bodily fluids are found, CNAs (certified nurse assistants) are supposed to come clean the bodily fluids, then she can come in and clean after them.On 5/30/2026 at 10:00 AM, V3 (Housekeeping Director) stated she has three housekeepers on 1st shift, and two housekeepers on 2nd shift daily. V3 stated housekeeping assignments are set up for one person to take A Hall, one person assigned to B Hall, and another person assigned to C Hall. V3 stated that additional assignments that are assigned daily are the front hall, shower rooms, beauty shop, nurses' station, the break room, and the hall by the break room. V3 stated that an additional deep clean is also assigned, where staff are expected to pull out all the furniture in the room and clean under and behind it. Staff in each hall must clean bed frames, windows, window ledges, toilets, edges, and straighten the closet if needed. V3 confirmed the facility floors and rooms were not being kept clean as they should be and stated, This has been a problem for some time now. The facility's Infection Prevention and Control Manual Resident Care policy dated 2019 documents, All nursing activities will be performed in a manner to minimize the potential for infection to residents, staff, and visitors. Some of the specific guidelines include: 5. Resident rooms will be clean and orderly.The facility's Infection Prevention and Control Program Manual Surveillance dated 2019 documents, Blood and Body Fluid Exposure, if an unexpected cut, abrasion, or other injury occurs during a service and results in exposure to blood or other body fluids, or when other body fluids appear as a result of a service. 4. Clean and disinfect any contaminated surfaces. 5. Contaminated tools, implements, and equipment must be cleaned and disinfected.The facility's Housekeeping Aide Job Description, not dated, documents, Position Description, performs day-to-day activities of the housekeeping and maintenance department in accordance with current Federal, State, and Local standards, guidelines, and regulations governing our facility and as may be directed by the Administrator and/or supervisor. Responsible for facility maintenance to ensure a clean, safe, and comfortable environment. Performs a variety of general housekeeping/cleaning duties in various areas to maintain the center in a sanitary, safe, attractive, and orderly condition. Follows work assignments from the supervisor and performs assignments from the supervisor. Cleans, dusts, washes, and disinfects all fixtures, floors, walls, doors, and ceilings, as required; Scours and polishes sinks, mirrors, glass panels in doors and partitions, brass and movable and stationary furnishings and fixtures. Cleans floors, to include sweeping, dusting, damp/wet mopping, disinfecting, etc.; Ensures that appropriate caution/safety signs are properly set up prior to performing such duties.The facility's Certified Nursing Assistant Job Description, not dated, documents, Certified nursing assistant (CNA) responsible for delivering and assisting residents with daily needs, including personal care needs, preparation for activity and social programs, and routine activities in accordance with accepted standards of practice, state and federal regulations and licensing requirements. Provides basic nursing care to residents within the scope of the nursing assistant responsibilities and performs basic nursing procedures under the direction of the licensed nurse supervisor. Principal Responsibilities: Makes beds (occupied and unoccupied); changes bed linens and keeps linens tight to avoid wrinkles from forming under residents; Handles linens according to infection control guidelines. Keeps residents dry (changes gown, clothing, linen, etc., when they become wet or soiled). Assists residents with bowel and bladder functions. Maintains cleanliness of resident units, central bathing area, treatment supply rooms, workrooms, and linen closets, cleans bedpans, urinals, and commodes; washes basins and emesis basins; sanitizes bathtub after each resident use; cleans floors if resident is incontinent; wipes spilled foods and liquids.

Based on interview and record review the facility failed to follow their own discharge policy for discharging a resident for one resident (R5). This failure led to R5 being discharged to a home with no running water, with all of R5's medical supplies being left in the weather elements and being ruined, no food in the home and no home health assistance as ordered by the doctor. The failure of leaving R5's medical supplies on the porch has the potential for R5 to get infections in wounds that could lead to hospitalizations, serious illness or even death. The failure to have no home health set up for home could lead to multiple health concerns worsening and causing illness, hospitalizations and death. The Immediate Jeopardy began on 3/31/26 at unknown time when R5 was transported home with all of his belongings left on the front porch with no home health set up for assistance with anything. V1 (Administrator) was notified of Immediate Jeopardy on 5/15/26 at 11:54 AM. The immediacy was removed on 5/15/2026 the facility remains out of compliance at a severity Level 2 while the facility evaluates the effectiveness of their removal plan. R5's Medical Record documents he was admitted on [DATE] with diagnosis to include but not limited to Chronic Respiratory Failure with Hypoxia, Chronic Peripheral Venous Insufficiency, and Type II Diabetes Mellitus. R5's Medical Record documents that he was cognitively intact and made all of his own decisions. On 5/15/2026 V6 (Social Service Director at Local Police Department) stated that R5 called the police department on 4/1/2026 (1 day after discharge) because all of his belongings were on the front porch and it was raining, V6 stated upon arrival to R5's homes she discovered all of his bandages were ruined because they were on the front porch. V6 stated R5 had no running water or food at his house and did not have any home health, friends or family to assist him.On 5/15/2026 R5 stated I was promised home health help and I did not get that. They (staff) dumped my stuff on the porch and said see ya later. They did not like me, no one there (at the facility) did. On 5/13/2026 V8 (Social Services Director) confirmed that she did not set up any home health assistance for R5, V8 stated she was on vacation when R5 left. (R5) never knew what he wanted. He just didn't want to pay the bill for sure. On 5/13/2026 V2 (Director of Nursing) confirmed that she did not set up any home health or do any safety screening or questions with R5. (V8/Social Services Director) should do all of that. On 5/15/2026 V7 (Certified Nurse Aide) confirmed that she was the staff member who drove R5 home on 3/31/2026. V7 (CNA) confirmed she put all of his stuff including some medical stuff on his front porch. V7 (CNA) confirmed she had worked with R5 during his stay at the facility and V7 stated that she did not believe that R5 had the ability to move his belongings inside by himself. On 5/15/2026 V9 (R5's Doctor/Medical Director) stated he wrote for R5 to discharge home with home health, I would not have wrote it if I didn't think he really needed it. V9 stated All conditions for safety must be met before a resident is left alone after discharge. R5's last care plan dated 3/9/26 documents Long term stay in facility is anticipated. R5's medical record does not contain any discharge planning, discharge assessment, recapitulation of stay for R5, disposition of his belongings and/or medicine.On 5/15/2026 V1 (Administrator) confirmed there was no documentation of any discharge planning or any indication that R5 discharged home and on what date. The Facility's Discharge Summary and Plan policy dated 8/2025 documents The discharge plan will include resident and family/caregiver educations needs and will initiate or maintain collaboration between the nursing facility and other post-acute providers to support the resident's transition to community living. The Discharge Plan, Instructions and Summary provides a recapitulation or summary of the resident's stay. Documentation of discharge plan will be completed utilizing the Interdisciplinary Care Conference Note 48 Hour Meeting assessment by Social Service director or Social Service Designee. Social Service Director or Social Service Designee will initiate and upgrade the discharge plan in the Care Plan section of the resident's record. The Facility's Discharge Summary and Plan policy dated 8/2025 documents Discharge Education a. Nurse will review discharge instructions and medications with resident/resident representative. Copy of Disposition of Medication form will be given to resident/resident representative and a copy scanned into the record. b. Social Services Director or designee will include the Discharge Plan, Instructions, and summary in the Discharge Packet. 6. Nurse will document discharge note in the progress notes section of the resident record Discharge note will include-skin assessment, who they discharged with, where they are discharging to, what belongings were sent with them and other pertinent information. The Facility's Discharge Summary and Plan policy dated 8/2025 documents Social Services or designee will make post discharge follow up call with the discharged resident 48 hours after discharge. If there are identified concerns during this call, Social Services or designee should continue post discharge follow up calls daily until the concerns are resolved. The Post Discharge Call Follow up UDA must be completed by Social Services, or designee to document the outcome of each call.The Facility submitted an Abatement plan on 5/15/2026 at 1:57 PM. The Facility's Abatement plan was accepted on 5/15/2026 at 2:22 PM. On 5/15/26 the surveyor confirmed through record review and interview that the following steps were taken to remove the immediacy: On 5.15.26, Administrator and SSD called R5 to discuss discharge and if any services are still needed. On 5.15.26, Social Service Director and BOM completed a home visit on R5 to ensure their safety. On 5.15.26, Social Services Director called all discharges since 3/30/26 to ensure discharge was successful On 5.15.26, SSD, DON, MDS, and Admin conducted audit of all discharges in the last 30 days to ensure needs are met. On 5.15.26, Ad Hoc QAPI completed and Medical Director notified of deficiencies. On 5.15.26, Discharge review checklist was created to be utilized for all future discharges. On 5.15.26 IDT team was educated on Discharge policy and procedure. On 5.15.26, Administrator in serviced Social Services Director on ensuring discharge requirements are made prior not resident discharging from facility.Immediate action(s) taken to ensure discharge planning process is followed: On 5.15.26, Discharge Policy and procedure was reviewed to ensure compliance. On 5.15.26, IDT Team was educated on discharge policy and procedure. On 5.15.26, IDT was educated on discharge checklist completion prior to discharge. On 5.15.26, IDT Team completed a review of all discharges in the last 30 days and current planned discharges to ensure compliance.Immediate action(s) taken to ensure the discharge process has been properly communicated with residents and providers for a safe discharge: On 5/15.26, Social Services Director called all discharged since 3.30.26 to ensure discharge was successful. On 5.15.26, Administrator in-service IDT on ensure education was completed for discharging residents. On 5.15.26, DON inservced RN's/LPN's on completing discharge education.Immediate action(s) taken to ensure a QAA process is in place for safe discharges: On 5.15.26, Ad Hoc QAPI was completed with IDT to review process and deficiencies. On 5.15.26, Administrator in-serviced IDT on discussing all discharges during morning stand-up meeting. On 5.15.26, Administrator in-serviced IDT on discharge checklist.Abatement completion date: 5/15/26

Based on interview and record review the facility failed to ensure fall assessments were done and accurate for 4 residents (R1, R4, R11, R12, failed to document any follow up assessments after a fall for one resident (R11), provide adequate supervision while showering for one resident (R4), and failed to assess the safety of residents who request to shower independently for five residents (R8, R9, R10, R11, R12). These failures led to R1 falling and breaking her hip, requiring surgery and an increase in need for assistance with Activities of Daily Living. These failures led to R4 being left alone in the shower with no assistance then falling and breaking her arm. On 5/20/2026 V11 (Licensed Practical Nurse), V12 (Certified Nurse Aide) and V18 (Certified Nurse Aide) described an independent shower resident as a resident that staff will turn the shower on to warm it up, set out towels and wash cloths and let the resident know to go take a shower. V11 (LPN), V12 (CNA) and V18 (CNA) all agreed that when a resident is an Independent shower that staff would answer other call lights and do other duties and check on the resident every once in a while. 1.R1's Medical Record documents that she was admitted to the facility on [DATE] after she had a pacemaker put in. R1's admission Nursing assessment dated [DATE] documents that R1 planned on doing therapy for strengthening and then return home. R1's Medical Record documents that she was alert and could make her own health care decisions but did defer to her family often.R1's Nurse's Note dated 3/9/2026 document that on 3/8/2026 at 11:40 PM R1 walked into the hallway from her room and appeared to lose her balance and fell onto her right side. R1's notes document she was sent to the hospital and admitted for surgery to repair a right broken hip. R1's Medical Record did not contain a care plan or fall risk assessment until 3/9/2026 (morning after fall with fracture). On 5/19/2026 V10 (Licensed Practical Nurse/Care Plan Coordinator) confirmed there was no care plan or fall risk assessment for R1 until 3/9/26. V10 (LPN) stated she didn't know why there was no documentation of fall risk assessment or care plan for fall prevention. On 5/20/26 V2 (Registered Nurse/Director of Nursing) confirmed there was no assessment of R1's fall risk and no care plan of any fall prevention interventions prior to R1 falling and fracturing her hip on 3/9/26. V2 confirmed there should be both in R1's record upon admission.On 5/20/2026 V20 (Registered Nurse who was on duty during R4's fall on 3/8/26) stated (R1) was a new admission. I can't recall any specific fall interventions in place. V20 (RN) stated (R1) would sometimes toilet herself (without assistance) even though she shouldn't. V20 (RN) stated R1 should not be toileting herself without assistance due to a lot of fall risks that (all elderly) have. V20 (RN) stated that R1 used her call light when she wanted to. On 5/19/2026 V23 (R1's family member) stated that it didn't seem like the facility was ready for R1 when she actually arrived on 3/5/2026. No one seemed to know what was going on. The hospital always told us that (R1) was a high fall risk. V23 stated she did not see any signs of any fall precautions in place for R1, and then I get a call she fell and broke her hip, I don't feel like they (facility) know how to take care of people. 2. R4's Medical Record documents R4 was admitted on [DATE] after a fall at home. R4's Medical Record includes diagnoses Type II Diabetes Mellitus, Crohn's Disease and Chronic Atrial Fibrillation. R4's Medical Record documents that R4 is alert and able to make all of her own decisions. The Facility's undated Final Report documents that on 4/9/2025 (R4) states she lost her balance while taking a shower. X-Ray orders obtained from (V9/Doctor) show left humerus fracture, send resident to ED (Emergency Department) for evaluation and treatment. On 5/19/2026 V1 (Administrator) stated that the results of the investigation into R4's fall showed that R4 was left alone in the shower because she preferred showering alone. V16 (Certified Nurse Aide)'s written/signed statement dated 4/9/26 documents that V16 left R4 in the shower unsupervised because R4 stated she doesn't have anyone in there with her when she showers. R4's Medical Record does not contain any documented request to shower alone, safety risk assessment or education of R4 about the risk of falling if left unsupervised.On 5/15/2026 R4 confirmed she was alone in the shower on 4/9/2026 when she fell and broke her arm. R4 stated she didn't know why no one was in the shower room with her. I expect they had other things to do. R4's Discharge Summary from hospital dated 2/4/26 documents Previously independent: reports multiple falls over the past year. Recent fall which brought her to (hospital) patient hit head, states she was turning around and fell. R4's admission Fall Risk Data Collection dated 2/10/2026 signed by V10 (Licensed Practical Nurse/Care Plan Coordinator) documents Fall History: 0. No History and vision Pattern 0. Adequate-able to see in adequate light. The Fall Risk Data Collection documented R4 was Low Risk for falls.On 5/19/2026 V10 (LPN/CPC) confirmed that R4's admission Fall Risk Data Collection dated 2/10/2026 was marked wrong. Should have been yes to falls and No to adequate vision per other documentation in R4's medical record. V10 (LPN/CPC) confirmed that those changes would have made R4 High Risk for falls instead of Low Risk.On 5/19/26 V10 (LPN/CPC) confirmed that R4's Care Plan did not include any fall risk assessment or interventions until 4/10/2026 (1 day after fall with fractured arm). 3. R11's Medical Record documents that he was admitted on [DATE] with diagnoses to include but not limited to Chronic Obstructive Pulmonary Disease, Hypertension and Depression. R11's Medical Record documents that he is alert and oriented and makes all of his own decisions. R11 refused to be interviewed throughout the survey. R11's Fall Risk Data Collection dated 3/18/26 documents Medication use and lists categories of medications: Antihistamines, Diuretics, Hypoglycemic agents, Antiseizure/Antiepileptics, Antihypertensive, NSAIDS (Non-Steroidal Anti-Inflammatory Drugs), Benzodiazepines, Narcotics, Psychotropics, Anti-Parkinson's, Cathartics, Sedatives/Hypnotics. None of these boxes were checked. R11's Medication Administration Record dated March 2026 document that he received the following medications Metformin (Hypoglycemic Agent) 500 mg (milligram) every day, Hydrocodone (Narcotic) 5-325 mg twice daily and Trazadone (Sedative/Hypnotics) 150 mg every night.On 5/20/26 V10 (LPN/CPC) confirmed that none of the medications were marked on the fall risk assessment. I guess I didn't see those (medications) on the MAR (Medication Administration Record) in March. V10 (LPN/CPC) confirmed that those medications would have increased R11's fall risk score. On 5/20/2026 V11 (Licensed Practical Nurse) and V18 (Certified Nurse Aide) confirmed that R11 is considered an independent shower. On 5/20/2026 V2 (Registered Nurse/Director of Nursing) confirmed that there was no documentation in R11's medical record that R11 requests to shower alone. V2 (RN/DON) confirmed there was no care plan or interventions in place for R11 to shower without supervision. 4. R12's Medical Record documents that he was admitted on [DATE] with diagnoses to include but not limited to Hypertension, Schizoaffective Disorder and Mixed Hyperlipidemia. R12's Medical Record documents that he is alert and oriented and makes his own decisions. R12's Fall Risk Data Collection dated 3/12/26 documents Medication use and lists categories of medications: Antihistamines, Diuretics, Hypoglycemic agents, Antiseizure/Antiepileptics, Antihypertensive, NSAIDS (Non-Steroidal Anti-Inflammatory Drugs), Benzodiazepines, Narcotics, Psychotropics, Anti-Parkinson's, Cathartics, Sedatives/Hypnotics. None of these boxes were checked. R12's Medication Administration Record dated March 2026 documents that R12 received Lasix (Diuretics) 60 mg twice daily, Olanzapine (Psychotropic) 10 mg every night and Metoprolol (Antihypertensives) 25 mg twice daily.On 5/20/2026 V2 (Registered Nurse/Director of Nursing) confirmed that R12's Fall Risk Data Collection was marked incorrectly and that the addition of the medications would have changed his fall risk assessment score. R12's Nurse's Notes dated 2/26/26 at 4:30 AM documents resident was found on the floor on face down and had a raised area on forehead.On 5/20/2026 V2 (RN/DON) confirmed that there was no further assessment such as condition of the injury to forehead or physical assessment documentation for R12 at all in R12's Medical Record. R12's Nurse's Notes dated 2/27/26 documents that R12 was upset and entered his room and began screaming that he was on the floor and staff entered room to find resident on the floor. Immediate Action Taken: DON notified. MD/medical doctor faxed. (R12) in (wheelchair) for time being. On 5/20/2026 V2 (RN/DON) confirmed that there was no actual physical assessment of R12 documented and that there was no follow up monitoring of R12 for 72 hours as per facility policy. V2 (RN/DON) stated she wasn't sure if R12 always used the wheelchair now or if he continued to attempt to walk. Throughout the survey R12 propelled himself in a wheelchair and transferred himself independently. R12 declined to be interviewed during survey process. On 5/20/2025 V11 (LPN) V12 (CNA) and V18 (CNA) stated R12 is considered to be independent to shower. 5. On 5/20/2026 V11 (LPN), V12 (CNA) and V18 (CNA) reported that R8, R9 and R10 were all considered to be independent showers. On 5/20/2026 V2 (RN/DON) confirmed that R8, R9 and R10 had documented request to shower alone, safety risk assessment to do so or care plan interventions to enable R8, R9 and R10 to shower independently. The Facility's Skilled Fall Policy dated 5/2025 documents The community shall ensure that the Fall Program is maintained to reduce the occurrence of falls, reduce risk of injury, and promote independence and safety. Each resident residing at this facility will be provided services and care that ensures that the resident's environment remains as free from accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. The Facility's Skilled Fall Policy dated 5/2025 documents Staff must complete root cause analysis to determine why the resident fell. A progress note must be documented in the resident's record, including root cause analysis, resident provider notification, resident representative notification, details if injury is present, new intervention, pertinent statements, and any other details surrounding the resident's fall. Post-fall documentation must be done every shift for 72 hours following the fall.

Based on record review and interview the facility failed to ensure accuracy of the plan of care for one resident (R5) of three resident's reviewed for care plan accuracy. R5's Medical Record documents that he was admitted on [DATE] with diagnoses to include but not limited to Chronic Respiratory Failure with Hypoxia, Type II Diabetes Mellitus and Chronic Peripheral Insufficiency. R5's Medical Record documents he was cognitively intact and made all of his own decisions. R5's care plan dated 3/9/26 documents focus areas as (R5) has a behavior problem relating to false accusations. (R5) refuses showers and will tell other staff no shower was offered. The resident has mood problem, he has delusional thoughts, he will state everyone is against him, if you don't agree with him, he thinks you are calling him a liar. These care plans were entered by V2 (Registered Nurse/Director of Nursing). On 5/15/2026 V2 (RN/DON) denied knowledge of the care plan focus areas on 3/9/26. I have to sign a lot of care plans. On 5/15/2026 V10 (Licensed Practical Nurse/Care Plan Coordinator) stated she was the person who initiated the 3/9/26 care plan entries. V10 (LPN) could not provide an investigation or any supporting documentation of R5 making false accusations. On 5/15/26 both V2 (RN/DON) and V10 (LPN) confirmed neither one of them had ever investigated any accusations made by R5. V10 stated she was told by staff that R5 lies. The Facility's undated Care Planning policy documents Every resident will have a comprehensive Plan of Care for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible.

Based on observation, interview, and record review the facility failed to protect a resident (R2) from resident-to-resident sexual abuse for one of four residents (R2) reviewed for abuse in the sample of ten. This failure resulted in R1 a cognitively intact resident sexually assaulting R2 a cognitively impaired resident on more than one occasion. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/3/25 when the facility failed to protect a resident (R2) from resident-to-resident sexual abuse. V2 (Director of Nursing) was notified of the Immediate Jeopardy on 5/24/25 at 9:00 AM. On 5/24/25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: While the immediacy was removed on 5/24/25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include: On 5/21/25 at 9:25 AM, V6 (Certified Nursing Assistant/CNA), stated on Saturday 5/3/25 during breakfast V6 saw R1 sitting in the dining room at a table with R2. R1 had R2's toy in R1's right hand and R1's left hand was between R2's legs touching R2's vagina. V6 told R1 don't touch her like that and V6 moved R2 to the middle of the dining room away from R1.V6 stated she left the dining room and came back 20 minutes later and R1 was sitting next to R2 again, with R1's hand further up between R2's legs. V7 couldn't see R1's hand because it was all the way up R2's shorts. V7 stated she told R1 this is the second time I have told you not to do that. V7 stated V15 (Licensed Practical Nurse)/LPN called V1 (Administrator in Training) to report the abuse allegation. V6 stated V1 did not come to the facility and did not give the staff guidance on safety interventions to put in place to keep R2 from further sexual abuse from R1. On 5/21/25 at 10:16 am, (V7 CNA) stated Saturday morning on 5/3/25, V7 walked in the dining room and saw R1 and R2 sitting at the table, and R1 was sitting next to R2. R1 had R2's baby doll in R1's right hand and R1's left hand was in between R2's legs up R2's shorts and touching R2's private area. V7 stated V7 stopped R1 and told R1 it's not right to touch R2. V7 stated V7 immediately told V15 (LPN) of what V7 witnessed in the dining room. V7 stated we immediately removed R2, and R1 starting crying and said, I'm sorry. V7 further stated R2 has been having increased behaviors where R2 is crying out and pointing to her vagina since this incident happened. On 5/22/25 at 12:36 PM, V15 (LPN) stated V7 and V6 came up to V15 and stated they had witnessed R1 touching R2 between R2's legs and on R2's vagina. V15 stated V15 first contacted V5 (Assistant Director of Nursing) who told V15 to call V1 (Administrator in Training). V15 called V1 to report the sexual abuse between R1 and R2 to V1. V1 told V15 to leave it alone and not do anything until V1 came in to do the investigation. V15 stated V1 did not come to the facility that weekend to do the investigation. V15 stated V1 did not give any further interventions or instructions to keep R1 away from R2. On 5/20/25 at 4:00 PM, V4 CNA, stated one day after the occurrence between R1 and R2, R1 told V4 that R1 shouldn't have, but R1 touched R2. V4 stated R2 has the mindset of a four-year-old and is nonverbal. V4 stated R1 can self-propel in manual wheelchair around the facility. On 5/21/25 at 11:53 AM, V9 (Guardian), stated V9 was not made aware of an allegation of sexual abuse towards R2. V9 stated R2 would be so upset and scared that this happened to R2. R2 has been mentally and physically handicapped R2's entire life. On 5/20/25 at 4:01 PM, R2 was lying in bed in low position with a fall mat on the floor. R2 was alert but nonverbal. On 5/20/25 at 3:30 PM, R1 was laying in R1's bed watching television. R1 was alert and answered questions appropriately. R1 stated R1 didn't want to talk about what happened with R2. On 5/21/25 at 12:19 PM, R1 was observed in the dining room sitting two tables away from R2. R2's Minimum Data set (MDS) dated [DATE] documents R2 is severely cognitively impaired. R2's current Medical Diagnosis list documents R2 has diagnoses of cerebral palsy, intellectual disabilities, anxiety, and depression. R2's current care plan does not contain documentation of interventions to keep R2 free from sexual abuse. R2's current medical record does not include any documentation or assessment of R2 after being sexually abused by R1. R2's medical record does not include a completed trauma care assessment after the alleged sexual abuse on 5/3/25. R1's current care plan does not include interventions to address R1's sexual behaviors. R1's current medical record does not include documentation of R1's sexual abuse allegation that occurred on 5/3/25. The facility's Abuse, Prevention, &Prohibition Policy dated 12/2024 documents each resident has the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, agency staff, family members or legal guardians, friends, or other individual. While the facility investigation is under way, steps will be taken to prevent further abuse. The person identified in the allegation of abuse will have no contact with residents or other employees during the investigation process. A licensed Nurse will assess the resident for injuries and notify the residents physician and responsible party. Social Services will complete a Trauma Informed care assessment and provide follow up care regardless of if allegation is substituted. This policy documents sexual abuse is defined as non-consensual sexual contact of any type with a resident. The Immediate Jeopardy began on 5/3/25 when the facility failed to protect a resident (R2) from resident-to-resident sexual abuse. V2 (Director of Nursing) was notified of the Immediate Jeopardy on 5-24-25 at 9:00 AM. On 5-24-25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R2 was assessed by V2 (Director of Nursing) with no changes noted 5/24/2025. 2. R2's trauma assessment was completed by V14 (Social Service Director) on 5/24/25. 3. R2's plan of care was reviewed by interdisciplinary team (IDT) and updated on 5/24/25, by minimum data set (MDS) to include to have R2 in staff visual when not in room. 4. R1's plan of care updated on 5/24/25 to include counseling 1:1 (one to one) with social services, educated to not be within proximity of R2, 15-minute visual checks plan to care updated on 5/23/2025 and reviewed with IDT again on plan of care updated by minimum data set on 5/24/2025. 5. V16 (Medical Director) in conjunction with interdisciplinary team (IDT) reviewed abuse policy and procedure and assured policy and procedure included steps to report to appropriate parties and agencies including state agency, police department, resident representative, and abuse coordinator as well as proper investigation on 5/24/2025. 6. All staff in-service initiated on Abuse by V2 (DON) to be done prior to next scheduled shift for all staff. Inservice to include emphasis on preventing abuse including sexual abuse and reporting requirements on 5/24/2025. 7. All residents reviewed by IDT for risk to be victim of sexual abuse and if identified to have been a high risk, plan of care reviewed, and new interventions added, if necessary, on 5/24/2025. 8. V1 (Administrator in Training) willfully resigned employment effective 5/24/2025. 9. Abuse Coordinator role assigned to V23 (Corporate Administrator), and staff educated on clear signs posted for Abuse Coordinator Contact Information on 5/24/2025.

Based on observation, interview, and record review the facility failed to initiate a resident head count once an exit door was alarming without known cause, failed to ensure a gait to the outside smoking patio was kept secure, failed to develop a care plan and implement interventions for residents at risk for elopement, and failed to provide adequate supervision for two of three residents (R6 and R7) reviewed for elopement risk in the sample of 10. These failures resulted in cognitively impaired resident (R6) who required assistance with ADL's (Activities of Daily Living) exiting the facility without staff knowledge or supervision on 4-22-25, and being found 2.2 miles away from the facility, on a concrete median, by a stop light, in the dark, with complaints of being cold. The road R6 traveled along was a busy main road that had numerous steep hills and curves. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 4-22-24 at 2:00 AM when R6, a cognitively impaired resident, exited the facility without staff knowledge or supervision and was found 2.2 miles away from the facility, on a concrete median, by a stop light, in the dark, with complaints of being cold. V1 (Administrator-In-Training) and V18 (Assistant [NAME] President of Operations) were notified of the Immediate Jeopardy on 5-23-25 at 10:48 AM. While the immediacy was removed on 5-23-25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include: 1. R6's MDS (Minimum Data Set) dated 4-4-25 documents R6 is cognitively impaired. R6's admission Record documents R6 was admitted to the facility on [DATE] with the diagnoses of Chronic Obstructive Pulmonary Disease, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Type II Diabetes Mellitus, Obstructive Sleep Apnea, Chronic Pain, and Depression. R6's Elopement Risk assessment dated [DATE] documents R6 was a moderate risk for elopement and exit-seeks at times. R6's admission Care Plan dated 6-24-25 through discharge date d 4-24-25 documents R6 has impaired cognitive function or thought processes and requires staff assistance with transfers and toilet use. R6's Care Plan does not include any interventions to address R6's exit-seeking or risk for elopement as identified on R6's Elopement Risk assessment dated [DATE], until after R6 eloped on 4-22-25. R6's Fall Risk assessment dated [DATE] documents R6 was at high risk for falling and has intermittent confusion. R6's Final Report dated 4-22-25 and signed by V1 (Administrator-in-Training) documents, Summary: (R6) noted off facility grounds by oncoming staff. Noted (R6) to have left facility without notification or staff knowledge. Staff Interviews: (V11/Licensed Practical Nurse/LPN) reported noting smoking patio alarm sounding. Did not note anyone around, assumed wind to have blown open. Stated did not enact facility procedure as this was not an exit and residents typically would not be able to exit facility grounds through this door or patio. R6's Social Service Progress Note dated 4-4-25 at 10:12 AM and signed by V14 (Social Service Director) documents, (V14) has reviewed (R6's) assess (assessment). (R6) initially kept saying he needed to get to the bank, transportation took (R6) to the bank, (and) it was not the correct bank. As I had noted before (R6) has poor cognition but doesn't feel he does. This has all recently started with (R6) wanting to go to the bank. R6's Social Services Progress Note dated 4-22-25 at 2:58 PM and signed by V14 documents, (R6) left the facility without alerting staff. (R6) was located and brought back to the facility. On 5-22-25 at 10:20 AM this surveyor observed the smoking patio where R6 exited the facility. The exit to this patio leads to a rocky embankment and then to a sidewalk that leads to the front parking lot. This surveyor drove from the front parking lot to the college campus where R6 was found. During the drive there was a steep hill that leads to the main road. From this main road to the local college where R6 was found per odometer reading was 2.2 miles from the facility and the road had many curves and hills. On 5-22-25 at 9:00 AM V12 (LPN) stated, I came into work early on 4-22-25 and came by the (community college) at 5:00 AM. I was at a stop light, and I saw (R6) standing with a wheeled walker in the middle of a concrete divider that separates two streets. I asked (R6) what he was doing, and he said he was going home. (R6) said he wasn't going back there (the facility). I tried several times to get (R6) to get in the car with me. I called the nursing home and (V1/Administrator-in-Training) and I had to turn around because I was at stop light. By the time I turned around (R6) was gone. It was dark and (R6) had dark colored clothes on. (V13/CNA/Certified Nursing Assistant) came and met with me to look for (R6). (R6) had gotten inside a college building and (V13) brought (R6) to my car and we were able to get (R6) in and bring him back to the facility. The weather was chilly and (R6) had a black jacket and stocking cap on. It was 47 degrees out. (R6) stated he was cold. (R6) stated he had left the facility around midnight. I called (V11/LPN) and (V11) was not aware that (R6) had left the facility unattended. I brought (R6) back to the facility. The road (R6) was found on is very busy with stop lights and lots of traffic from college students and other traffic. On 5-22-25 at 9:10 AM V13 (CNA) stated, (R6) was very quiet and had confusion. (R6) went out to the front parking lot around two months ago and threatened to leave and I was able to get (R6) back inside. (R6) was walking with a walker within the facility. On 4-22-25 I was told (R6) went out the door where the residents smoke. The alarm went off and the nurse (V11) thought the alarm was going off due to a resident going outside to smoke. (V11) shut the alarm off. V12 (LPN) called me and had me come and help find (R6). (R6) was over two miles away. (V12) lost sight of (R6). I found (R6) inside the college. It was 5:50 AM, dark, and cold. (R6) wanted to go home. (R6) was wanting to get on a bus to go home. (R6) would not be safe to by outside by himself. On 5-22-25 at 10:25 AM V14 (Social Service Director) stated, (R4) had poor cognition at times. (R4) was not safe to walk outside on the road by himself. (R4) needed a walker. On 5-22-25 at 11:15 AM V2 (Director of Nursing) stated, (R4) had confusion and needed a walker. (R4) was not safe to leave the facility unattended and away from the facility 2.2 miles. A lot of the road (R4) used did not have sidewalks. On 5-22-25 at 1:00 PM V11 (LPN) stated, I was working the night of 4-22-25 and heard the smoking patio door alarming around 2:00 AM. I went to the alarm and thought the wind blew the door open and sounded the alarm. I did not see any residents outside, so I shut the alarm off. I should have done a resident head count and did not. Sometime after 5:00 AM that morning, (V12/LPN) called the facility and said she had found (R6) wandering around by the college. I had no idea (R6) was even missing from the facility. On 5-22-26 at 1:30 PM V10 (LPN) stated, (R6) has a lot of confusion and would try to exit-seek. Prior to (R6's) elopement, (R6) would set off alarms and try to leave the facility. (R6) would not be safe leaving the building unattended by staff, especially after dark. 2. R7's current Care Plan documents Potential risk for elopement related to cognitive deficits, history of wandering, walks, or wheels about aimlessly without a purpose. (R7) is at high risk. Interventions: Place electronic sensor device to alert staff of exit attempt (or if unavailable, place on 1:1 (one on one) observations). Routinely check device placement, check battery function, check door device functioning, and evaluate effectiveness. R7's Elopement Risk assessment dated [DATE] documents R7 is a high risk for elopement. On 5-22-25 from 12:45 PM to 1:05 PM R7 was wandering aimlessly up and down the hallways and the dining room. R7 did not have one on one staff supervision or and electronic sensor device in place during this time. On 5-23-25 at 9:45 AM R7 was lying in bed and V12 (LPN) and V13 were providing incontinence cares. R7 did not have an electronic sensor device in place. On 5-23-25 at 9:50 AM V12 (LPN) stated, (R7) has never had an electronic monitoring device on or one-on-one staff supervision that I am aware of. The facility's Elopement Policy dated 04/2025 documents, Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. Responsibility: All staff is responsible. Definitions: For the purpose of this policy, missing resident or eloped if he/she is seen leaving the buildings or is seen walking away as a result of responding to a door alarm. 4. When a door alarm sounds, staff shall immediately respond to and determine the cause of the alarm. The staff person responding to the alarm will check the outside of the building to determine if a resident has exited the building. If, upon investigation, no reason can be found for the sounding off that alarm the charge nurse will initiate an accounting of all residents at risk for elopement. If, after all at-risk residents are accounted for, the cause of the alarm is still undetermined, a complete head count of all residents will be conducted. The Immediate Jeopardy started on 4-22-24 at 2:00 AM when R6, a cognitively impaired resident, exited the facility without staff knowledge or supervision and was found 2.2 miles away from the facility, on a concrete median, by a stop light, in the dark, with complaints of being cold. V1 (Administrator-In-Training) and V18 (Assistant [NAME] President of Operations) were notified of the Immediate Jeopardy on 5-23-25 at 10:48 AM. On 5-24-25 this surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R6 was assessed on 4-22-25, after the elopement, and no injuries were found. 2. On 4-22-25 V16 (R6's Physician) was made aware of R6's elopement and plan of care for a safe discharge back to home. 3. On 4-22-25 and 5-23-25 V16 and the Inter-Disciplinary Team reviewed facility policies and procedures to assure that processes are in place to supervise and prevent further residents from eloping. 4. On 5-23-25 all staff were in-serviced by V1 (Administrator-In-Training) on the facility's Elopement Policy and contacting all necessary parties, including law enforcement, when an elopement occurs. 5. On 5-23-25 V14 (Social Service Director) assessed all residents for elopement risk accuracy and completeness. 6. On 5-23-25 all residents deemed moderate or high risk on the Elopement Assessments were included in an elopement book located at the nurses' station. 7. On 5-23-25 V14 updated all residents at moderate to high risk for elopement care plans with interventions to increase safety. 8. On 5-23-25 V22 (Maintenance Director) checked all door alarms to ensure all door alarms were in proper working order. 9. On 4-22-25 V22 secured the smoking patio door with a padlock. 10. On 4-22-25 V11 (LPN) was provided one-on-one education and disciplinary action from V1 on the company's policy for responding to door alarms.

Based on observation, interview and record review the facility failed to implement their abuse policy and procedures to identify and report resident to resident suspected crime and sexual abuse immediately to local law enforcement, resident representatives, and the state agency for two (R1, R2) of three residents reviewed for reporting abuse in the sample of ten. These failures resulted in R1 having unsupervised access to all 79 residents within the facility after R1 sexually assaulted R2. Findings include: The facility's Resident Listing dated 5-20-25 documents 79 residents currently reside within the facility. On 5/21/25 at 10:30 AM, V6 (Certified Nursing Assistant) stated on 5/3/25 V6 witnessed R1 putting R1's hand up R2's shorts, placing R1's hand on R2's vagina on two occasions. V6 stated she made V15 (Licensed Practical Nurse) aware after R1 touched R2 on the vagina for the second time. V6 stated V15 called V1 (Administrator in Training) while V6 was standing at the nurse's station. On 5/21/25 at 10:35 AM V7 (Certified Nursing Assistant) stated on 5/3/25 V7 witnessed R1 putting R1's hand up R2's shorts, placing R1's hand on R2's vagina on two occasions. V7 confirmed the first interaction between R1 and R2 was not reported to V1. V7 stated she and V6 made V15 aware of R1 touching R2's vagina after the second interaction and V15 called V1 to report the allegation. On 5/20/25 at 3:15 PM, V1 (Administrator in Training) stated a report was not sent to the state agency regarding V6 and V7 witnessing R1 putting his hand up R2's shorts and touching R2's vagina. V1 also verified that V1 did not report V6 and V7's allegations of R1 and R2 to the local police department, resident representative, or state agency. R1's was observed from 5/20/25-5/24/25 between 9:00 AM and 3:30 PM, self-propelling in R1's manual wheelchair throughout the facility. The facility's Abuse, Prevention, &Prohibition Policy dated 12/2024 documents each resident has the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, agency staff, family members or legal guardians, friends, or other individuals. Resident abuse must be reported immediately to the administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. The facility will complete summarized investigation within five business days and submit to required agencies. Resident to Resident abuse means the individual's action was deliberate, regardless of whether the individual intended to inflict injury or harm. This policy further documents Administrator will report all allegations of abuse to the mandated state agency and Law enforcement. The allegation will be reported no later than two hours, or per state regulations, after the allegation is made.

Based on interview and record review, the facility failed to ensure resident safety prior to repositioning for one of three residents (R1) reviewed for incidents and accidents in the sample of three. This failure resulted in R1 sustaining a deep leg laceration requiring a hospital visit, receiving 13 stitches, and antibiotic treatment. Findings include: The facility's Skin condition Monitoring policy and procedure, dated 1/18, documents It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. 1. Upon notification of a skin lesion, wound, or other skin abnormality, the Nurse will assess and document the findings in the nurses' notes and complete the QA (Quality Assurance) form for Newly Acquired Skin condition . 3. Any skin abnormality will have a specific treatment order until area is resolved . 4. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: c. Prevention techniques that are in use for the resident. The Residents' Rights for People in Long-Term Care Facilities, dated 1/18, documents Your rights to safety includes the following: The facility must provide services to keep your physical and mental health at their highest practical levels and Your facility must be safe, clean, comfortable and homelike. The undated Certified Nurses Aide/CNA Job Summary documents CNAs provide personal care and assistance to residents to assure their safety and comfort and demonstrates support of the philosophy of (the facility) by adhering to policies, procedures, and established Standards of Nursing Practices. The Clinical Medical Record for R1 documents R1 with the following diagnoses: Chronic Obstructive Pulmonary Disease, Emphysema, Dysphagia, Scoliosis, Osteoporosis, Abnormal Posture, and Muscle Wasting. The Nurse Progress Note for R1, dated 2/4/25 at 6:44 am, documents nurse was notified of R1 with leg injury and noted R1 with deep tissue skin tear. CNA reported R1 was injured during transfer from bed to the chair and was sent to the local hospital. The Skin Tear report for R1, dated 2/4/25, documents Nurse was notified by V6 CNA that R1's leg was injured with deep tissue skin tear to her right lower leg, No injuries observed at the time of incident, and was sent to the local hospital for evaluation. The local hospital record for R1, dated 2/4/25, documents the reason for R1's visit as Laceration of right lower extremity, initial encounter. Primary Dx (diagnosis): Leg pain, anterior right with laceration repair. The Medication Administration Record documents R1 received the pain medication Norco 7.5-325 mg (milligrams) one time at 8:44 am and lidocaine-Epinephrine 1% 10 ml (milliliters) was injected one time on 2/4/25 at 10:03 am. An x-ray of R1's right tibia and fibula was obtained on 2/4/25 at 9:02 am and findings as: Laceration related soft tissue changes are seen overlying the mid anterior tibia. R1 was treated for a laceration of right lower extremity. The current Order Summary Report for R1, documents a 2/5/25 physician order for Cephalexin (antibiotic) 500 mg (milligrams) one capsule four times daily for leg wound. The Infection Progress Note for R1, dated 2/4/25, documents R1 to receive Keflex 500 mg (milligrams) one capsule four times daily for 7 days for leg wound. The Nursing Progress Note for R1, dated 2/4/25 at 1:47 pm, documents R1 returned from the local hospital with 10.5 cm (centimeter) deep tissue laceration with 13 stitches to R1's right leg mid-calf. The Nursing Progress Note for R1, dated 2/4/25 at 8:09 pm, documents New order for Abt (antibiotic) d/t (due to) laceration on LLE (left lower extremity). The current Care Plan for R1, documents 2/4/25 Laceration to right lower extremity with intervention to monitor for s/s of infection and on 2/10/25 exchange bed frame. The Incident Progress Note for R1, dated 2/10/25, documents After investigation it was determined that the skin tear/laceration occurred while CNA was titling (reclining wheelchair) back due to restlessness. (R1) put her leg over side of chair and received a 10.5 cm (centimeter) laceration to right lower extremity from bottom edge of bed requiring 13 stitches. Intervention: replace bed frame, terminate CNA (V6), and monitor s/s (signs and symptoms) of infection. The facility Investigation for R1's incident, dated 2/4/25, documents V5 CNA assisted V6 Former CNA to mechanically transfer R1 from her bed to a reclining back wheelchair and left R1 in her room. V5 reported there were no injuries at the time of the transfer. Shortly after V6 saw R1, in her room, attempting to get out of the wheelchair. V6 reported R1's leg got stuck under edge of bed as V6 was tipping R1's reclining wheelchair backward. V4 RN (Registered Nurse) was notified and assessed R1 with a large bleeding wound on lower anterior and lateral aspect of right lower leg. V3 ADON (Assistant Director of Nursing) reported assessed R1's leg and noted a large skin tear to anterior/lateral aspect of distal right leg. V6 Former CNA reported to V3 ADON that R1 was attempting to get out of the reclining wheelchair, so V6 Former CNA attempted to recline R1 back and R1's leg hit the lower edge of the bed causing the skin tear. The facility Final Notification Form for R1, dated 2/10/25, documents R1 received a laceration to right lower leg, was sent to the local hospital. After investigation it was determined that skin tear/laceration occurred while CNA (V6) was tilting (reclining) chair back due to restlessness. (R1) put her leg over side of chair and received a 10.5 cm (centimeter) laceration to right lower extremity from bottom edge of bed requiring 13 stitches. Intervention: Replaced bed frame, terminated CNA and monitor for s/s (signs and symptoms) of infection. The Incident Log dated 3/20/25 documents R1 with skin tear on 2/4/25. On 3/20/25 at 11:00 am. V1 AIT (Administrator in Training) stated R1 required help for everything, was not cognitively intact, and did not move around on her own. V6 Former CNA was moving R1's wheelchair and caught R1's leg on a bolt on the bend of the bed causing a skin tear to R1's leg. R1 was sent out to the hospital and came back with stitches. On 3/21/25 at 12:12 pm, V3 ADON (Assistant Director of Nursing) stated she was called down to R1's room to assess R1's right leg due to the nurses doing shift change report and noted a deep open wound bleeding wound to R1's right leg and a small amount of blood on R1's bed frame. V6 reported (V6) reclined R1's wheelchair and R1's right leg hit the lower edge of the bed frame causing the skin tear. V3 ADON confirmed V6 should have looked to see where R1's legs were prior to moving R1's wheelchair and that V6 was terminated for sleeping on third shift and causing the skin care. On 3/21/25 at 12:20 pm, V5 CNA stated she helped V6 mechanically lift R1 from her bed into her wheelchair, there were no injuries during that time, and then V5 left R1's room. V5 stated she didn't see R1's wound until R1 returned from the hospital. It was a pretty large skin tear that was stitched back up. On 3/21/25 at 3:30 pm, V1 AIT stated V6 should have looked to see where R1's legs were prior to moving R1 and V6 was terminated after working that shift for poor work performance and sleeping on the job. V1 stated the facility does not have a QA form for Newly Acquired Skin condition for R1 due to no longer using the form.

Based on interview and record review the facility failed to administer physician ordered insulin to a resident (R12) with a diagnosis of Type Two Diabetes Mellitus with Diabetic Chronic Kidney disease for one of one resident reviewed for insulin use in a sample of 47. This failure resulted in R12's emotional distress feeling like the facility was going to kill him because he wasn't getting his insulin as ordered and resulted in multiple abnormal laboratory values that reflected hyperglycemia. Findings include: The facilities Adverse Drug Reactions and Medication Discrepancy policy dated 11/6/18 documents, Procedure: 1. A medication discrepancy/error has been made when one of the following occurs: wrong medication administered, wrong dose administered, medication administered by wrong route, medication administered to wrong resident, medication administered at wrong time, and medication not administered. The facilities Medication Administration policy, undated documents, The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. Procedure: Medications must be prepared and administered within one hour of the designated time or as ordered; after a drug is given, record the date, time, name of drug, dose and route on the resident's individual medication administration record; document any medications not administered for any reason by circling initials and documenting on the back of the MAR (medication administration record) the date, the time, the medication and dosage, reason for omission and initials; notify the physician as soon as practical when a scheduled dose of a medication has not been administered for any reason. According to the CDC's (Centers for Disease Control) Testing for Diabetes and Prediabetes: A1C, dated 5/15/24, The A1C test measures your average blood sugar levels over the past 3 months. When sugar enters your bloodstream, it attaches to hemoglobin, a protein in your red blood cells. Everybody has some sugar attached to their hemoglobin, but people with higher blood sugar levels have more. The A1C test measures the percentage of your red blood cells that have sugar-coated hemoglobin. Your red blood cells regenerate roughly every 3 months. That's why the A1C test measures your blood sugar levels from that time period. A1C results: The following ranges are used to diagnose prediabetes and diabetes: Normal: below 5.7% (percent); Prediabetes: 5.7% to 6.4%; Diabetes: 6.5% or above. When living with diabetes, your A1C also shows how well managed your condition is. Your A1C can estimate your average blood sugar: A1C% 9=Estimated average glucose of 212. A1C goals: For most people with diabetes, the A1C goal is 7% or less. Your doctor will determine your specific goal based on your full medical history. Higher A1C levels are linked to health complications, so reaching and maintaining your goal is key to living well with diabetes. On 08/18/24 at 9:59 AM, R12 was smiling and pleasant at first but became angry and belligerent when asked about his use of insulin. R12 was distressed explaining about staff not doing his insulin correctly. R12 does not feel that he is getting his insulin and that they (nurses) are going to kill him. R12's current care plan documents R12 has a diagnosis of Type Two Diabetes Mellitus with Diabetic Chronic Kidney Disease. Care Plan also documents the intervention to administered diabetes medication as ordered by the doctor, and to monitor/document for side effects and effectiveness. R12's physician orders dated 08/2024, documents that R12 has orders for Tresiba Flextouch 100u/ml (units/milliliter) 50 units subcutaneous in the am and 20 units subcutaneous at bedtime, Trulicity 3mg (milligrams)/0.5ml give 0.5ml subcutaneous every week on Saturday, Insulin Lispro Kwikpen 100u/ml per sliding scale starting at blood glucose level of 200 four times a day and blood glucose level checks four times a day. R12's Medication Administration Record, dated May 5/1/24 to 5/31/24, has no documentation of blood glucose level checks done for 40 of 124 opportunities, 9 of 62 opportunities of no Tresiba insulin being administered, and 65 of 124 opportunities of no Lispro sliding scale insulin being administered. R12's Medication Administration Record, dated June 6/1/24 to 6/30/24, has no documentation of blood glucose level checks done for 48 of 120 opportunities, 7 of 60 opportunities of no Tresiba insulin being administered, 3 of 5 opportunities of Trulicity insulin not being administered, and 59 of 124 opportunities of no Lispro sliding scale insulin being administered. R12's Medication Administration Record, dated July 7/1/24 to 7/31/24, has no documentation of blood glucose level checks done for 65 of 124 opportunities, 2 of 62 opportunities of no Tresiba insulin being administered, 3 of 4 opportunities of Trulicity insulin not being administered, and 59 of 124 opportunities of no Lispro sliding scale insulin being administered. R12's Medication Administration Record, dated August 8/1/24 to 8/19/24 2024, has no documentation of Lispro sliding scale insulin being administered for 11 of 76 opportunities. R12's Fasting Glucose laboratory results, dated 4/23/24, documents R12's blood glucose level is high at 132 (range 65-99). The laboratory results also document the physician's response to the high glucose level to obtain a hemoglobin A1C. R12's Fasting Glucose laboratory results, dated 7/30/24, documents R12's blood glucose level is high at 169 (range 65-99). R12's Hemoglobin A1C laboratory results, dated 8/5/24, documents R12's Glycohemoglobin-HGBA1C level is high at 9.3 (range 4.1-6.1%). R12's medical records has no documentation of a hemoglobin A1C being done prior to these results. On 08/20/24 at 12:44 AM, V3 (Assistant Director of Nursing) stated that the expectation for the nurses when it comes to documenting blood glucose levels and units of insulin given is they (nurses) will initial the box for blood glucose level and write the level and then in a separate box the nurses will initial and document the amount of insulin units given. V3 stated that if the glucose level and insulin units are left blank it can be interpreted as not completed. V2 (Director of Nursing) was present and agreed with V3's statement. On 08/21/24 at 08:18 AM, V21 (R12's physician) stated he had ordered a Hemoglobin A1C based on R12's glucose level on a Basic Metabolic Panel in April, and his expectation was to have it done next lab day. V21 is aware that R12's Hemoglobin A1C was not done until 8/5/24 and the level of 9.3 which he states is higher than expected and he wants it 8 or below. V21 stated that not receiving insulin or having routine monitoring of blood sugars could have an effect on R12's hemoglobin A1C levels.

Based on interview and record review, the facility failed to supervise a cognitively impaired resident during an evening dinner meal and follow a Physician's Diet Order for a Mechanically Altered Diet for one resident (R2). These failures results in R2 choking, requiring Cardiopulmonary Resuscitation and subsequently died . These failures have the potential to affect all twelve residents (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) residing in the facility that receive a Mechanically Altered Diet for residents reviewed for diets received in a sample of 14. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. Findings include: The Facility COVID Policy, revised [DATE], documents the Residents on Transmission Based Precautions/TBP cannot participate in communal dining. The Facility Dietary Policy/Cycle Menu, revised ,d+[DATE], documents: A Mechanical Soft diet is designated for individuals who have difficulty chewing but are able to tolerate a wide variety of foods; this diet is designed to permit easy chewing, ground meat and soft bread and cereal products; modifications in the diet need to be individualized according to the Resident's needs; and diet ordered which are not found on the modified spreadsheets shall be referenced using the Diet Manual and have posted instructions in the serving area. The Facility Room Trays Policy, dated ,d+[DATE], documents: It is the policy of the Facility that residents who choose not to or are unable to attend the dining room for meals will be served appropriate meals in his/her room. Facility Diet Listing, dated [DATE], and provided on [DATE], documents that twelve residents receive a Mechanically Altered Diet (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14). The Facility Diet Listing documents R2's diet order as Regular, Thin Liquids with Finger Foods. Facility Resident Council Minutes, dated [DATE], document that the Facility is under COVID precautions and Residents have been eating in their rooms. Facility Licensed Practical/LPN Nurse Job Description, undated, documents: The LPN responsibility is to assist in completing the nurse admission assessment on admission or assigned residents; participates in identification of problems on assigned residents; reviews Physician Orders on assigned Residents prior to care; demonstrates support of the philosophy of the nursing department by adhering to policies, procedures and established standards of nursing; and maintains current knowledge in present nursing practice area. Facility Registered Nurse/RN Job Description, undated, documents: Must possess a general knowledge and understanding of the State and Federal laws as they pertain to long term care; completes the nursing admission assessment on admission or assigned residents per procedure utilizing proper techniques, tools and history and for caring for each resident; consults other departments as required or needed; reviews Physician Orders on assigned Residents prior to care and integrates therapeutic plans of care in collaboration with the Interdisciplinary Team. Facility Daily Assignment Sheet, dated [DATE], documents that V5 (Licensed Practical Nurse/LPN), V7 (Certified Nursing Assistant/CNA) and V8 (CNA) were scheduled on the A Hall (R2's Hall). V4 (Certified Nursing Assistant/CNA) was scheduled on B Hall. Facility Week at a Glance Menu, dated Sunday [DATE], documents that Salisbury Steak with Gravy, Asparagus, Bread/Margarine, Fruit of Choice, Gelatin and Milk were served for the evening dinner meal. Facility Admission History Report, documents that R2 admitted to the facility on [DATE] and readmitted to the facility on [DATE]. R2's Physician Order Sheet, dated [DATE], documents a Physician Diet Order for Mechanical Soft, Nectar Thick Liquids. R2's current Baseline Care Plan documents that R2 requires the assistance of one staff member for eating, has poor safety awareness, cognitive deficits, forgetful and poor mobility requiring staff assistance. The Care Plan does not document R2's Mechanical Soft Diet, Swallow Precautions or Nectar Thick Liquids. R2's Nutritional Assessment, dated [DATE], does not document R2's Physician Diet order of Mechanical Soft, Nectar Thick Liquids. The Nutritional Assessment documents Regular, Thin Liquids and Finger Foods. The current Diet Order Form, dated [DATE], documents a Physician Diet Order of Regular, Thin Liquids. The Facility could not provide an updated Diet Order for the [DATE] admission. R2's current Minimum Data Set, dated dated [DATE], documents that R2 requires one person physical assistance with eating. R2's AIM for Wellness Assessment, dated [DATE] (no time), documents that R2 was found unresponsive. The AIM for Wellness documents Approximately four minutes earlier (V4/Certified Nursing Assistant) readied (R2) for evening (PM) meal and set up tray. Called (V5/Licensed Practical Nurse) to Resident room per (V4) observed resident slumped over to the left of the bed, pupils fixed, no pulse or respirations. (R2) was lowered to the floor and Cardiopulmonary Resuscitation (CPR) initiated. Emergency Services (AMT) called, when arrived took over 'code.' Pronounced time of death at 6:42 pm. R2's Nursing Note, dated [DATE] at 4:00 pm, documents that R2 admitted back to the Facility with a Physician Diet Order of Thickened, Honey Liquids. The Nursing Note does not document the Mechanical Soft Diet Order. The Nursing Note documents that R2 is not able to use the call light and does require assistance of staff for Activity of Daily Living. R2's Nursing Note, dated [DATE] at 6:07 pm, documents, Approximately four minutes earlier (V4/Certified Nursing Assistant) readied (R2) for evening (PM) meal and set up tray. Called (V5/Licensed Practical Nurse) to Resident room observed resident slumped over to the left of the bed Pupils fixed, no spontaneous respirations, no radial pulse palpated, no apical heart tones. (R2) lowered to the floor and CPR initiated, Emergency Services (911) called. R2's Nursing Note, dated [DATE] at 6:20 pm, documents, Emergency Services (AMT) here and took over 'code.' Called time of death at 6:42 pm. R2's Hospital After Visit Summary Record, dated [DATE], documents that R2's diet upon discharge is Mechanical Soft Restrictions and Nectar Thick Liquids. The After Visit Summary Record documents diagnoses including Right Ankle Fracture, Diabetes, Acute Encephalopathy, Hypoglycemia, Chronic Obstructive Pulmonary Disease, Acute Kidney Injury and Right Side Lucanar Stroke. The Emergency Services Report/EMS Report, dated [DATE], documents that on [DATE], EMS responded to a call that R2 was unresponsive and had a dinner tray delivered approximately 20 minutes prior and the staff found R2 unresponsive approximately ten minutes after the dinner tray was delivered. The staff denied R2 being sick recently or change in medications. The EMS Report documents there was noted emesis in R2's mouth and R2 required suctioning. The EMS Report documents that EMS relieved staff of CPR upon arrival to the Facility. R2's Preliminary Autopsy Report, dated, [DATE], documents the cause of death as Aspiration of food, with bits of food within the bilateral bronchi of the lungs and residual bits in the trachea. On [DATE] at 3:35 pm, V4 (CNA) stated, I was not assigned to that hallway, but they called a 'code' on the A Hall, so I started compressions. (R2) was already blue. (V7/CNA) and myself alternated CPR (Cardiopulmonary Resuscitation) for about fifteen to twenty minutes until the Paramedics arrived. V7 (CNA) delivered R2's room tray and said she cut up (R2's) food and started her eating, then went down the hallway to deliver more room trays, because the whole facility was on quarantine status and eating in their rooms, because of the positive COVID in the building. On [DATE] at 3:14 pm, V5 (Licensed Practical Nurse/LPN) stated, I was (R2's) nurse on [DATE] at about 6:00 pm, for the evening meal. We were under quarantine, so all residents were eating in their rooms. (V7/CNA) told me that (V7) delivered (R2's) room tray and cut up the meat (Salisbury Steak) and gave her a bite, left (R2's) room, then delivered the other room trays down the hall. When (V7) came back up the hallway, after delivering the trays, (V7) noticed that (R2) was blue, so (V7) came and got me. I went down to (R2's) room and there were no respirations or pulse and R2 was already mottling at (R2's) neck. I looked in (R2's) mouth and did not see anything. We got her to the floor and (V4 and V7) started CPR (Cardiopulmonary Resuscitation), while I went and called Emergency Services (911). They arrived and took over and she was pronounced dead around 6:42 pm. On [DATE] at 3:14 pm, V13 (Certified Nursing Assistant/CNA) stated, Everyone was talking about how (R2) got the wrong diet on [DATE]. They served her the wrong food consistency; she got a Regular, Thin Liquid tray. She readmitted back on [DATE], and had been getting Regular, Thin Liquids since [DATE]. They never corrected her diet tray. I took care of her and when she came back on [DATE], she was confused on and off. When someone has a diet order of Mechanical Soft and Honey Thick Liquids, they should not be left in their room alone. We do not have enough staff to accommodate all those people being quarantined in their rooms that need assistance with eating. We normally only have about one or two people available to watch over the residents that need supervised with eating. None of the nurses or management staff help us, and it would be nice if they did. On [DATE] at 4:51 pm, V11 (Dietary Manager) stated, (R2) was served a Regular, Thin Liquid meal tray on [DATE]. The meal was Salisbury Steak, broccoli, bread/butter and fruit cocktail. We substituted the broccoli for asparagus because no one like asparagus and we did not serve jell-o, because someone forgot to make it. My documentation shows that she (R2) is on a General, Regular Diet with thin liquids and finger foods. On [DATE] at 2:20 pm, V1 (Administrator) stated, The whole facility was eating in their rooms because we were in quarantine status because we had a positive COVID test. That is our protocol. (R2) was passed a room tray on [DATE] of Salisbury Steak, mashed potatoes and finger foods. She came to us around [DATE] and was sent out to the hospital and came back on [DATE]. I know that four to five minutes went by from the time she received the wrong tray until V7 (CNA) went back and found her unconscious in bed. They performed CPR (Cardiopulmonary Resuscitation) and (R2) was pronounced dead at 6:42 pm. I did not notify the Local Health Department, because I did not think (R2's) death needed to be. I thought it was a natural death. On [DATE] at 9:28 am, V1 stated, After we looked at the COVID Policy, (R2) should have come out of her room for dining, only COVID positive should have stayed in their room for dining. On [DATE] at 9:28 am, V1 stated, We did all of the audits and found that the Dietary Department was delivered the new diet order for (R2), but no one could find it, so (R2's) diet never got changed to the Mechanical Soft, Honey Thick Liquids. It is hard to cover all of the assuasive feeders with the amount of staff we have, especially when they are all room trays. On [DATE] at 3:07 pm, V12 (Coroner) stated, The Death Certificate is not available yet. It will take about three weeks, but (R2's) death is ruled accidental and the cause of death is Aspiration of food. We performed an autopsy so that is what is delaying the Death Certificate. The autopsy showed Aspiration of food, with bits of food within the bilateral bronchi of the lungs and residual bits in the trachea. A lot of times if CPR is being performed in a forceful way, the debris gets 'stuffed deeper' into the airway, so that is why I performed an autopsy. The Emergency Services Report stated that (R2) aspirated and there was debris in the airway. (V9/R2's Physician) stated initially upon death, before the autopsy, that (V9) was leaning towards Aspiration as the cause of death. The Immediate Jeopardy started on [DATE], when R2 was served a General, Regular Diet with Thin Liquids for the Evening meal tray. V1 (Administrator) and V2 (Director of Nursing/DON) were notified of the Immediate Jeopardy on [DATE] at 11:58 am. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On [DATE] Dietary Manager and Administrator in Training reconciled all diets to ensure resident's diet orders were current and correct. 2. On [DATE] Quality Assurance members completed an audit to ensure care plans included correct diet and interventions. 3. On [DATE] MDSC (Minimum Data Set/Care Plan Nurse) and SSD (Social Service Director) initiated an audit of Cognitive Assessments and Cognitive Care Plans to assure accuracy. 4. All residents identified at risk will have a food and swallowing precautions card on the meal tray in addition to the diet card. 5. On [DATE] all staff was in-serviced on Abdominal Thrust Maneuver, Emergency Care CPR, Diet Cards, Cognitive Assessments, New Admission Notices and Comprehensive and Baseline Care Plans by the Director of Nursing. 6. On [DATE] Quality Assurance Member and Licensed staff was in-serviced on Conformance with Physicians' orders by the Director of Nursing. 7. Any staff not in attendance at the Mandatory 3:00 PM in-service will not be allowed to punch in for their next tour of duty until the training is completed with a Nurse Manager or the Administrator in Training. 8. The facility has updated the daily staffing assignment sheet to include hall assignments during mealtimes for any hall trays/sick trays being served. The staffs have been in-serviced [DATE] to the updated form. 9. The Regional Director of Clinical Operations has formulated and posted a Manager Team Meal Schedule Calendar that requires a manager to attend meal pass three times a day.

Based on observation, interview and record review, the facility failed to assess, monitor, and supervise a cognitively impaired, oxygen dependent resident (R5) during a designated smoking time for three residents reviewed for smoking in a sample of five. This failure resulted in R5 suffering [CONDITION(S)] to the face and requiring hospitalization causing R5 to become intubated and admitted to the burn unit. These failures have the potential to affect all eleven smoking residents residing in the Facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 11/2/22, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols, education, and monitoring. Findings include: Facility Resident Smoking Policy, undated, documents: the patio area to the side of the dining room has been designated as the only resident smoking area for the facility; each resident whom chooses to smoke will have a smoking assessment completed prior; and all residents choosing to smoke will have a responsible staff member outside on the patio at the designated smoke times (9:00 am to 9:15 am, 10:30 am to 10:45 am, 1:30 pm to 1:45 pm, 4:00 pm to 4:15 pm and 7:00 pm to 7:15 pm). Facility List of Smoker's, undated, documents R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14 as smokers. The list also documents R5 and R6 as the only two Resident's on oxygen therapy. Facility Smoking Policy, undated, documents that residents must always be accompanied by a staff member to smoke and may not keep his/her own smoking materials. Facility Local Health Department Five Day Final Report, dated 10/31/22, documents that R5's Brief Interview for Mental Status/BIMS score shows that (R5) has moderate cognitive deficit (score of 9/15). (R5) was on the Facility smoking patio and a staff member witnessed R5 with an oxygen tank turned on flames coming from the side of his (R5's) face and that the employee hollered for help and went outside to ensure the safety of the resident and other resident that was smoking. The Report concludes that R5 was admitted to a local Hospital for [CONDITION(S)] to the face. R5's Physician Order Sheet, dated 10/1/22 through 10/31/22, documents diagnoses including [CONDITION(S)], Cognitive Deficit, [CONDITION(S)], Neurocognitive Disorder with Behaviors, [CONDITION(S)], Asthma and [CONDITION(S)]. R5's Facility Smoking Assessment, undated, documents that the Resident must be evaluated with the following physical abilities to be permitted to smoke per Facility Policies and Procedures and that a Physician's Order is in place to permit the Resident to smoke. R5's Smoking assessment dated [DATE] documents a handwritten note, no changes on 12/31/21 and 4/6/22. The Smoking Assessment documents that R5 was able to flick the lighter on and off, demonstrate safety measures for handling cigarette, exhibit clear understanding of the smoking policy and require moderate assistance with smoking. The Facility could not produce a Smoking Disclosure Form or any additional Smoking Assessments for R5. R5's Hospital History and Physical/H&P, dated 10/27/22, documents: that R5 presented to the Hospital, and admitted to the Burn Unit, after suffering [CONDITION(S)] to the face while smoking a cigarette on oxygen, there was soot noted to the patient's nares (nose) and visualized in the nasopharynx/oropharynx, hair burnt off on right eyebrow and singed left eyebrow, [CONDITION(S)] to lips and eye; R5 was intubated and started on a medication for post intubation hypotension; facial [CONDITION(S)] required Intravenous medication ([MEDICATION(S)] (antibiotic), [MEDICATION(S)] (elevates blood pressure) and [MEDICATION(S)] (sedation) and topical (apply to skin) medication treatment ([MEDICATION(S)], mineral oil-hydrophilic and [NAME]-[NAME] (topical that creates a protective layer) and a wound consultation; R5 was diagnosed with Acute Hypoxic and Hypercapnia (rapid breathing) Respiratory Failure and was Intubated and on minimal Ventilator settings. The H&P documents that R5 had a high probability of imminent or life-threatening deterioration, high probability of imminent threat to life, acute impairment of one or more vital organ systems and/or required high complexity medical decision making due to Respiratory Failure and Shock. The H&P also documents that R5 had superficial partial and deep partial thickness [CONDITION(S)] to significant areas of the face and neck. On 11/2/22, at 10:32 am, R7 was on the smoking patio and stated, There is never anyone out here with us. On 11/1/22, at 10:24 am, R4 stated, I was on the smoking patio with (R5) when (R5's) oxygen tubing caught his face on fire. (R5) was not able to use his lighter, he was not able to use the lighter, you know, so I helped him light his cigarette. All of the sudden, I saw (R5's) face shoot up in flames, so I immediately went over to him and pulled his oxygen hose off and unwrapped it and threw it on the ground, because it was still burning, and it burned for a little while, while it was still on the ground. (V15/Activity Director) then came running out. (R5) had his face covered in soot and his beard was singed off. See that large black burn spot right there on the ground, right outside of the exit door, that is where I threw (R5's) oxygen tubing. There was no staff out there, just me and him (R5). We never usually have any staff out here with us, we even know the code to get out of the door. On 11/1/22, at 10:28 am, an approximate one foot by one foot black circular area was within five feet of the Facility's smoking patio exit door. R7, entered the exit code and the smokers proceeded out the exit door to the patio. (V17/Certified Nursing Assistant) was present in the smoking area, handing out smoking supplies. On 11/1/22, at 11:09 am, (V15/Activity Director) stated, Around 4:00 pm, I was walking through the small dining area, with my arms full of board games, and I saw (R5) through the window to the smoking patio, and I started screaming, because (R5) had flames coming from his face. I dropped the games and ran outside, and (R4) was pulling his oxygen tubing off of his face. R1's Nurse (V16) came running out and told me to shut off (R5's) oxygen tank, and (V16) started to pat the flames out on (R5's) face and neck. No staff was present and there was only one other person out on the smoking patio and that was (R4). On 10/31/22, at 1:10 pm, V2 (Director of Nursing) stated, On 10/27/22, at 4:00 pm, during the designated smoking time, R5 stopped at the nursing station with an empty tank of oxygen. (R5) got two cigarettes and (V10/Licensed Practical Nurse) identified that (R5's) oxygen tank was empty, so (V10) put on a new full oxygen tank and (R5) proceeded to the Facility smoking patio. No staff were on the smoking patio when this happened, but (V15/Activity Director) saw flames coming from R5's face, through a window, and screamed for help and ran outside onto the smoking patio. (V15) saw (R4) pulling (R5's) oxygen tubing away from (R5's) face and (R5's) nurse (V16) started emergent care. (R5's) face was covered in soot and (R5's) beard was singed. (R5) was sent out to the emergency room , admitted to the Hospital and eventually became intubated. (R5) is still in the Hospital. On 11/2/22, at 11:47 pm, V1 (Administrator) stated, The Smoking Assessments should be completed every quarter. We should have had a Smoking Disclosure Form for (R5) but we did not get one from him, but we will when he gets back to the Facility. V1 verified that the handwritten entry on to the Smoking Assessment Form should have been re-evaluated due to (R5's) cognition and the Facility should have completed a new form. The Immediate Jeopardy started on 10/27/22 when R5, receiving oxygen therapy, was unsupervised on the Facility smoking patio. V1 (Administrator) and V2 (Director of Nursing/DON) were notified of the Immediate Jeopardy on 11/02/22 at 11:34 am. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Inservice of all staff on smoking policy and Resident's receiving Oxygen Therapy that smoke. 2. Locked all smoking supplies up at the nurses station. 3. Assigned a staff member to the outside smoking patio for the Facility smoking times. 4. Inservice to smoking resident's on the Smoking Policy. 5. Reviewed all Resident Smoking Assessments. As part of the facility's ongoing quality improvement program, the following measures will be taken to ensure the practice does not recur: QAT to conduct random rounds to ensure residents and staff are following the assigned smoking times. QAT to conduct random rounds to ensure the residents and staff are practicing safe smoking practices and not smoking with oxygen in place. Administrator or designee will educate new staff members and new residents on the assigned smoking schedule. Administrator or designee will in-service on Smoking Assessment, Smoking Disclosures, Smoking Policy including designated smoking times and locations, Emergency care of [CONDITION(S)], Oxygen Safety, Oxygen Therapy and Nasal Canula weekly x 4 weeks then monthly times 3 months starting 11/3/2022 Administrator and/or Director of Nursing will conduct random chart audits to ensure the smoking assessments, and Care Plans are completed upon admission, quarterly and as needed for the residents who smoke.

Based on record review and interview the facility failed to obtain and administer physician ordered medications for a new admission for one (R1) resident of four reviewed for medication administration in a sample of four. This failure resulted in R1 being hospitalized for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Facility Medication Administration Policy, revised 11/18/2017, documents: the complete act of administration entails verifying the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Nursing Note, dated 10/11/22, at 5:20 pm, documents that R1 arrived and admitted to the Facility. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Medication Administration Record/MAR, dated 10/11/22 through 10/18/22, does not document administration of medication ([MEDICATION(S)]): for [CONDITION(S)] secondary to [CONDITION(S)] ([CONDITION(S)] disease of the liver) on 10/12/22 at 8:00 am and 12:00 pm; [CONDITION(S)] medication ([MEDICATION(S)], treats diarrhea) on 10/12/22, 10/14/22 and 10/18/22, at 8:00 am. R1's MAR, dated 10/11/22 through 10//18/22, also does not document administration of Facility stock and other medication: Vitamins (Vitamin C, Multivitamin, Vitamin D, Iron and [MEDICATION(S)]) on 10/12/22 and 10/14/22, at 8:00 am; diuretic ([MEDICATION(S)]) on 10/12/22 and 10/18/22, at 8:00 am; liver medication for fluid build-up ([MEDICATION(S)]) on 10/12/22 at 8:00 am; Steroid Nasal Spray for ([MEDICATION(S)]) and on 10/12/22 and 10/18/22 at 8:00 am; and a Proton Pump Inhibitor for Esophagus Disorders ([MEDICATION(S)]) on 10/12/22 at 8:00 am. R1's Nursing Notes, dated 10/11/22 through 10/18/22, does not document that R1's Physician was notified of the missed doses of medication. R1's Nursing Note, dated 10/18/22, at 10:00 pm, documents that R1 was sent to the local hospital for evaluation of Altered Mental Status. R1's Hospital Admission History and Physical Record, dated 10/19/22, documents that R1 admitted to the hospital with the clinical impression diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospital Record also documents factors that made the patient critically ill were the subdural hematoma and Patient's sister is in the room with her and provides history. States that she is been altered since going to rehab facility last week. Last known normal was earlier last week, over a week ago. The Record also documents, on 10/19/22, Labs remarkable for elevated ammonia. Neurosurgery evaluated the patient and advised based on Commuted Tomography (CT) and their exam they believe subdural hemorrhage is not the cause of her presentation. With ammonia being elevated most likely [CONDITION(S)] and sister says this is consistent with previous episodes of [CONDITION(S)]. Discussed with general medicine team who agreed to admit the patient and noted on CT, regarding the subdural Hemorrhage, while in the Emergency Department unlikely to be cause of her AMS (Altered Mental Status) as level of consciousness out of proportion size of hemorrhage. The Hospital Records also document Patient was discharged on [DATE], with strict instructions take her [MEDICATION(S)] and [MEDICATION(S)]/[MEDICATION(S)]. Patient unfortunately had worsening [CONDITION(S)] from ammonia retention and was readmitted in the hospital 10/19/2022. Patient subsequently got better with [MEDICATION(S)] [CONDITION(S)], oral [MEDICATION(S)] and was back to her baseline. On 10/28/22, at 8:05 am, V13 (R1's Sister) stated, I had to talk (V2/Director of Nursing) on 10/12/22, because my Sister (R1) had not gotten any of her (R1) medication since she admitted the night before. (V2) told me that when a new admission comes to the Facility after 4:00 pm, it is too late for the Facility to get the medications in, and that the Facility will not get them in until the next night. My Sister (R1) went without important medication for her [CONDITION(S)] and if she does not get that [MEDICATION(S)] or [MEDICATION(S)] it can cause her ammonia level to rise and makes her have extremely confused. On 10/28/22, at 12:12 pm, V10 (Licensed Practical Nurse) stated, I was the nurse that admitted (R1) and she was alert and oriented. I sent her medications off to the pharmacy to be filled. Some of her medications could have been given through the stock supply, but the [MEDICATION(S)] and [MEDICATION(S)] needed to be delivered. From what I know, the medications did not come in until around noon the next day. On 10/28/22, V2 (DON) stated, (R1) admitted to the Facility late on the night of October 11, 2022. If our Pharmacy does not have the new orders by 4:00 pm the day prior, the Resident's medication does get delivered until the next night. We have a backup pharmacy that can be called, and also have stock box of medications that we can use, even [MEDICATION(S)] is not a stock medication. The nurses should document all of this, especially if the back up pharmacy was called and they should also document that the Physician was called if the medication is not available. I actually saw (R1's) medications get delivered at lunch time on October 12, 2022, the next day, I think it came from the backup pharmacy. (V12/R1's sister) called me and was upset about (R1) not getting (R1's) [MEDICATION(S)] and [MEDICATION(S)] medication for (R1's) [CONDITION(S)]. (V12) had concerns about (R1) getting confused and having problems, if any doses were missed. I told her (V12) that I could not give (R1) any medications that were already missed, even though we had just received them, because it was against the law. On 11/1/22, at 10:25 am, V2 (Director of Nursing) stated, We have a back up stock box and I am not sure why the nurses did not even pull out the stock medications like the Vitamins and give them for her morning dose on 10/12/22, until her medications were delivered. (R1) has been in the hospital since 10/19/22 and has still not been discharged back to us. On 10/31/22, at 1:24 pm, V13 (R1's Physician) stated, I was not notified that (R1) had not received her prescribed medication. Ammonia buildup is due to her (R1) hospitalization problems and can definitely cause confusion. The only way to get the ammonia out of (R1's) body is by 'pooping' and that is the purpose of the [MEDICATION(S)] and [MEDICATION(S)]. There really is no alternative and they also kill bacteria. Missed doses of these medications could definitely cause (R1's) Ammonia levels to rise, which caused her altered mental status.

Based on record review and interview the facility failed to revise fall interventions after increased weakness and respiratory issues from a recent hospitalization for one (R1) of three residents reviewed for falls in a sample of three. This failure resulted in R1falling on [DATE], and sustaining a Left [CONDITION(S)], requiring hospitalization and subsequently expired on [DATE]. Findings include: Facility Fall Prevention Policy, revised [DATE], documents: to provide safety and to minimize injuries related to falls, decrease falls and still honor each resident's wishes/desires for maximum independence and mobility; all staff must observe residents for safety. If residents with a high risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident; appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours; assignment of the fall risk category will be determined by the Interdisciplinary Team at their conferences based on fall risk score, history of falls and medical condition which directly impacts on equilibrium and/or ambulation. Facility Comprehensive Care Planning, revised [DATE], documents that the Facility will comprehensively assess and periodically reassess each Resident admitted to the facility; the results of the Resident assessment shall serve as the basis for determining each Resident's strengths, needs and goals to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain and maintain the Resident's highest practicable physical, mental and psychosocial well-being; and will be reviewed after each Minimum Data Set and revised as necessary to reflect the Resident's current medical, nursing, mental and psychosocial needs as identified by the Interdisciplinary Team. The Care Plan did not identify problems, initiate new goals or interventions upon R1's return from the Emergency Department on [DATE], to reflect R1's cognitive and activity of daily living status. Facility Local State Agency Notification Form, dated [DATE], documents that R1 sustained a fall and was transported to the local Emergency Department. R1's Quality Assurance Fall Analysis Record, revised ,d+[DATE], documents a fall on [DATE] and [DATE] with interventions of education to lock wheelchair and provide wheelchair support pad (non-slip pad). The Record also documents an unwitnessed fall on [DATE] at 8:00 am, in R1's room, with an intervention of educate Resident to request assistance from staff when needed. R1's Physician Order Sheet, dated [DATE] through [DATE], documents that R1 admitted to the the facility on [DATE], with diagnoses including Chronic Hypoxemic Respiratory Failure, Acute [CONDITION(S)], Stroke like episode, Moderate Oropharyngeal (middle of the throat) Dysphagia (difficulty swallowing), Chronic Obstructive Pulmonary Disease Stage Four and Seizures. R1's Nursing Notes, dated [DATE] at 11:30 am, document that R1 was transported to the local Emergency Department and was drooling, lethargic and not acting appropriately. On [DATE] at 7:30 pm, R1 returned to the facility with no new orders. R1's Nursing Notes, dated [DATE] at 5:00 am, document that R1 was having shortness of breath and R1's oxygen saturation levels (SPO2) was at 87 percent/%. R1's Nursing Notes, dated [DATE] at 8:00 am, document that (V4/Licensed Practical Nurse) was walking down the hallway and heard a noise that said 'help.' V4 walked back up the hallway to R1's room and R1 was on the floor between wheelchair and door. R1 stated that R1 hit head on door and complained of right hip pain (right hip pain is documented in the Nursing Notes, XRay results showed Left Comminuted Intertrochanteric Femoral Neck Fracture). R1's Nursing Notes, dated [DATE] at 8:05 am, document that R1 was transported to the local Emergency Department. R1's Nursing Notes, dated [DATE] at 9:00 am, document that R1 was admitted to the local hospital for diagnosis of femur fracture. R1's current Care Plan documents R1 has risk factors that require monitoring and intervention to reduce potential for self injury. The Care Plan documents to review quarterly and as needed during daily care and services of Resident's plan for safety; assist as needed when resident is not feeling well, feeling weak or dizzy; and as needed with change of condition. The Care Plan also documents that R1 is severely impaired with decision making and is unable to answer questions appropriately, has self-care deficits and requires supervision and/or assist to complete quality of care, has a history of falls ([DATE] and [DATE]) and requires use of [CONDITION(S)] medication. The Care Plan also documents previous fall interventions of education to lock wheelchair and educate to ask for staff assistance. R1's Minimum Data Set/MDS, dates [DATE], documents that R1 has moderate cognitive deficits (Brief Interview for Mental Status score of ,d+[DATE]) and requires staff assistance for bed mobility transfer, locomotion, dressing, hygiene and bathing. R1's Fall Risk Assessments, dated [DATE], [DATE] and [DATE], document that R1 has a high fall risk score (,d+[DATE]). R1's Quality Care Reporting Form, dated [DATE], documents R1 sustained a fall on [DATE] at 8:00 am and was transported to the local Emergency Department for Right Hip pain. The Reporting Form documents that R1 got out of bed unassisted to adjust pants and fell over and the intervention was to educate to request staff assistance. R1's Emergency Department History and Physical, dated [DATE], documents that R1 admitted to the Emergency Department for a ground level fall at the Nursing Home and an X-Ray result showed a Left Comminuted Intertrochanteric Femoral Neck Fracture. On [DATE] at 8:40 am, V3 (Agency Licensed Practical Nurse/LPN) stated, I was (R1's) nurse on the day (R1) fell . It was in the morning and I was passing medications and I heard a loud thump. (R1's) call light was not sounding, but I immediately went to (R1's) room. (R1) was lying on (R1's) left side, on the floor, by the door to the entrance of R1's room. I noticed (R1) had hit his head on the door and since it was an unwitnessed fall, I immediately called Emergency 911 and had (R1) transported to the Emergency Department for evaluation. (R1) was also complaining of right hip pain and kept saying 'ohhh.' (R1) would ambulate in (R1's) room all the time and would transfer himself. (R1) was alert but was confused at times. (R1) had just gotten back from the hospital and I guess we should have been monitoring him better because he was so weak. Two days after the fall, I actually had to call the hospital back because I had not heard anything from them and when I called they told me that (R1) had tested positive for COVID and also fractured (R1's) right hip. I do not think educating a confused resident to ask for staff assistance is a good intervention for a fall. On [DATE] at 10:40 am, V1 (Administrator) stated, R1 was sent to the hospital on [DATE] for a fall in (R1's) room. When we talked to the Coroner, I was told that (R1) died on [DATE] and that (R1's) fall was one of the causes of death on (R1's) Death Certificate. Although (R1) required the help of staff for ambulating, (R1) would often ambulate on own when (R1) should not have. V1 verified that the facility should have re-assessed and updated R1's cognitive status and activities of daily living assistance upon return from the hospitalization of [DATE]. R1's Death Certificate documents the cause of death as, Acute on Chronic Hypoxic Respiratory Failure and Left Femur Fracture due to a fall.

Based on observation, interview, and record review, the facility failed to initiate a physician ordered treatment to prevent MASD (Moisture Associated Skin Damage), perform daily skin checks, and notify of an open area for one of one resident (R54) reviewed for skin breakdown in the sample of 25. This failure resulted in R54's skin breaking down with no physician ordered treatment and causing R54 excessive pain during incontinent care. Findings include: According to Woundsource.com MASD: What Are The Types of Moisture Associated Skin Damage, dated 2/1/18, Moisture-associated skin damage or MASD is defined as inflammation and erosion of the skin caused by prolonged exposure to moisture and its contents, including urine, stool, perspiration, wound exudates (drainage), mucus, or saliva. The facility's Preventative Skin Care policy, no date available, documents, After thorough cleansing of the skin, lotion is to be applied and observation of any reddened areas will be reported to the Charge nurse. R54's Face sheet documents R54 was admitted to the facility on [DATE]. R54's admission orders [REDACTED]. R54's Admission Assessment, dated 3/20/19, documents that R54's buttocks were reddened upon admission. R54's Nurse's note, dated 3/20/19, documents upon admission R54's has reddened buttocks. R54's Infection Care plan, dated 3/20/19, documents that R54 is on contact precautions for [MEDICATION NAME] related to [MEDICAL CONDITIONS]. R54's Incontinent Care plan, dated 3/28/19, documents R54 has a potential for alteration in bowel elimination related to incontinence. R54's Skin Care plan, dated 3/28/19, documents, R54 is a moderate risk for pressure ulcer. The care plan has no documentation addressing R54's skin breakdown. On 06/03/19 at 10:26 AM, R54 was incontinent of runny liquid stool. V7 (Certified Nursing Assistant-CNA) and V8 (CNA) transferred R54 to the commode where R54 was continent of the runny liquid stool. V7 stood R54 up while V8 provided incontinent care. V8 wiped R54's soiled buttocks with a soapy wash cloth. Moderate amount of bright red blood was on the wash cloth. R54's bilateral buttocks excoriated with multiple open areas and actively bleeding. V8 stated, The blood is from his open areas from being incontinent at all times of liquid stool from the [MEDICAL CONDITION]. V8 wiped R54's buttocks an additional three times with blood being present on each wash cloth. With each wiping of R54's buttocks R54 kept wincing and repeating, Ouch! What are you doing? R54's TAR (Treatment Administration Record), dated 3/2019-6/2019, have no documentation of a treatment for [REDACTED]. R54's MDS (Minimum Data Set), dated 3/27/19, documents in Section C-Cognitive patterns that R54's BIMS score was a 12 (Cognitively Intact). On 06/06/19 at 09:05 AM, R54 stated, I've had a sore bottom since I got here. When they clean my bottom it hurts really bad each and every time. On 06/05/19 at 11:08 AM V6 (Licensed Practical Nurse) states I am aware that R54 has had redness but I was not aware that he had open areas. V7 and V8 did not notify me of the open areas on 6/3/19 and they should have. He had a treatment order for zinc paste twice a day but it has not been carried over to this month for some reason. I need to notify the doctor to see if we can continue this or even do something different with the areas being open now. He is a daily skin check on day shift but sometimes I'm not able to get to it. I did not do skin checks 6/3/19 and 6/4/19. On 06/06/19 at 08:39 AM, V2 (Director of Nursing) stated, If an open area was identified the CNA should have notified the nurse so that the nurse could notify the doctor for a treatment. In order to treat the MASD we would need a treatment order. On 06/06/19 at 11:00 AM, V11 (Physician's Assistant) stated, The [MEDICAL CONDITION] stool is irritating and with R54's constant leakage of the stool it will break down the skin. MASD can be a painful and irritating problem. If the zinc oxide had been initiated at admission these areas could have been prevented.

Based on record review and interview facility failed to follow their policy on medication administration and administered the wrong medication to one of 16 residents (R9) reviewed for medications and one resident (R11) on the supplemental sample. This failure resulted in R9 developing a swollen tongue, lethargy, and hallucinatory behavior requiring R9 being sent to the emergency room for treatment. Findings include: 1. Incident Report for R9 dated 03/14/12 documents that R9 received [MEDICATION NAME] 200mg and [MEDICATION NAME] 150mg that was not ordered by the physician. Nurses notes for R9 dated 03/14/12 document that R9 developed a swollen/red tongue, difficulty swallowing, disorganized speech, hallucinations, and inability to grasp objects. The same nurses notes for R9 document that on 03/15/12 at 5:10AM the resident was sent to the emergency room for treatment. Hospital History dated 03/16/12 documents that R9 was sent to the emergency room after receiving [MEDICATION NAME] 200mg by mistake and was treated with [MEDICATION NAME] (steroidal anti-[MEDICAL CONDITION]) and [MEDICATION NAME] (anti-[MEDICATION NAME]). In a written statement dated 03/16/12 and signed by E18 (LPN/Licensed Practical Nurse) documents that E18 set up medications for another resident (R20) who was to receive [MEDICATION NAME] and [MEDICATION NAME]. When E18 noticed that R20 was not in the dining room, E18 put the medications in the top drawer of the medication cart. E18 then went to R9's room and took the medications intended for R20 out of the medication cart and administered them to R9. Facility Medication Administration Policy dated 10/2007 documents the following: "Medication must be identified by using the five rights of administration: 1) Right resident; 2) Right dose; 3) Right drug; 4) Right time; and 5) Right route." The same policy also documents the following: "Destroy medications prepared for a resident if not used immediately." On 06/27/12 at 2:00PM E2 stated, "We terminated that nurse (E18) because of the error made. She should never have set up medications ahead of time and should have made sure the resident was in the dining room before setting up those meds." 2. R11's POS for August, 2011 contains the order dated 8-12-12 states to decrease [MEDICATION NAME] to 60 mg daily alternating with 60 mg twice a day. The POS also contains a subsequent order dated 8-18-11 to discontinue [MEDICATION NAME] . R11's MAR for August 2011 shows R11 was given the alternating [MEDICATION NAME] dose for thru 8-31-11 (for 13 days after the medication was discontinued). The Medication Discrepancy Report dated 9-2-11 shows the medication error was found on 9-1-11. R11's physician was notified 9-1-11 with orders to decrease R11's [MEDICATION NAME] to 60 mg per day. R11's POS for December, 2011 contains an order dated 12-6-11 for Bactrim DS 800/60 one tablet two times a day for seven days for a urinary tract infection. R11's MAR for December 2011 shows R11 was given Bactrim DS 800/60 one tablet three times a day (instead of twice daily as ordered) starting 12-6-12 at 4pm thru 12-12-11 at 8am. The Medication Discrepancy Report dated 12-11-11 states the physician order [REDACTED].[REDACTED] R11's physician orders [REDACTED]. On 6-28-12 at 2:10 pm, E2 stated she was not there at the time of the medication errors and does not know what follow up if any was implemented after the above errors.