Every finding on record at Gallatin Rest Home

Based on observation, interview, and record review, the facility failed to ensure opened food products were labeled with the date opened, and failed to properly store opened food products after opening. The failure placed all residents receiving food from the kitchen at increased risk of receiving expired, contaminated, or deteriorated food products. Findings include:During an observation of the kitchen dry storage and cold storage areas on 6/15/26 at 2:00 p.m., the following were observed: - An open, unsealed 25-pound bag of flour with approximately one quarter of the contents remaining; no open date. - Several open bulk spice containers, partially used (onion powder, nutmeg, paprika, garlic powder, thyme, and cloves); no open dates. - One bag of dry oat cereal rolled closed and stored on a preparation shelf; no open date. - Three opened and partially used gallons of milk stored in the refrigerator; no open dates. - One open box containing frozen hamburger patties in an unsealed manufacturer's plastic bag, exposing the patties to air; no open date.During an observation of the kitchen dry storage and cold storage areas on 6/16/26 at 3:40 p.m., the following were observed: - One open box of Cream of Wheat, unsealed and stored on a preparation shelf, with approximately one fourth of the contents remaining; no open date. - One open container of quick oats; no open date. - One refrigerated container labeled Garlic, with approximately one fourth of the contents remaining; no open date. - One refrigerated container labeled Caesar Dressing, with approximately three quarters of the contents remaining; no open date.During an interview on 6/15/26 at 2:00 p.m., staff member L stated opened food products should be labeled with the date opened to ensure proper stock rotation and prevent the use of outdated food products. When asked how long spices could be stored after opening, staff member L stated, I think about a year.During an interview on 6/16/26 at 3:40 p.m., staff member M was asked how long opened dry cereals would be kept after opening. Staff member M stated, Maybe a year, or 30 days?Review of a facility policy titled, Receiving, revised 2/23, showed, Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items . 5. All food items will be appropriately labeled and dated . 6. All food items will be stored in a manner that ensures appropriate and timely utilization based on the principles of 'first in-first out' (FIFO) inventory management .Review of an online reference titled, USDA Food Code 2022, last updated 5/1/26 and accessed on 6/22/26, showed, . all foods should be stored in a manner to preserve safety, integrity, and quality . prevent contamination .A request was made on 6/17/26 for policies pertaining to the storage of refrigerated, potentially hazardous foods, and frozen foods as clarification of a 6/16/26 request for food storage policies. No additional documentation was received by the end of the survey.

Based on interview and record review, the facility failed to ensure a resident was free from physical abuse by agency staff for 1 (#27); failed to ensure a resident was free from verbal abuse by agency staff for 2 (#s 39 and 60); failed to ensure a resident was free from physical and verbal abuse by another resident for 2 (#s 46 and 59); and failed to ensure a resident was free from neglect of care for 1 (#13) of 8 residents sampled for abuse. The failure placed the residents at risk for physical injury, emotional distress, diminished quality of life, and loss of dignity. Findings include:1. Review of a Facility-Reported Incident, submitted to the State Survey Agency on [DATE], showed NF2 was observed grabbing resident #27 by the arm and directing the resident into a seated position. The facility investigated the incident and substantiated the allegation of abuse. During an interview on [DATE] at 12:05 p.m., staff member B stated NF2 was a travel staff member completing a 13-week contract; however, following the abuse investigation, his contract was terminated. Staff member B stated there had been previous concerns addressed with NF2's travel agency regarding lack of motivation, attitude, and insubordination. Staff member B stated NF2 had been counseled by his agency for the prior concerns. During an interview on [DATE] at 3:00 p.m., staff member N stated she observed and reported the incident involving NF2 and resident #27. Staff member N stated NF2 was attempting to prevent resident #27 from standing. Staff member N stated that when resident #27 attempted to stand, NF2 yelled at the resident to sit down, grabbed the resident by the arm, forced the resident into a seated position, and did not let go. Staff member N stated NF2 then made a hand gesture as if reaching for an imaginary handgun. Staff member N stated, I intervened by taking the wheelchair from [NF2] and wheeling resident #27 to the end of the hall for a snack. Staff member N stated there had been previous concerns regarding NF2's behavior toward residents and lack of concern for resident well-being. Staff member N stated she had previously reported concerns to staff member B, including NF2 being sarcastic and uncaring toward residents in his care. Staff member N stated she believed NF2 did not think she would report the incident because they were friends outside of work; however, . my residents come first. Review of facility emails between NF2's travel agency and staff member B showed NF2 had previously been reported for concerns related to resident care and professionalism. On one occasion, NF2 was reported to have his head on a table while using his phone when he was assigned to monitor safety for a resident during a meal. On another occasion, NF2 was assisting a resident when the resident became upset and combative. Other staff intervened and removed the resident from NF2's proximity, and as the resident was being escorted away, NF2 made sarcastic comments toward the resident. Facility email communication between NF2's agency and the facility showed the agency would provide re-education on the previous concerns regarding NF2's behavior, although the email communication did not include documentation of the facility's monitoring of NF2's behavior. NF2 received a final warning on [DATE] for lack of professionalism, and on [DATE], the abuse incident involving resident #27 occurred. Review of NF2's travel staff personnel record and email communication between the facility and NF2's agency failed to show evidence that the facility monitored NF2 for behavior and resident care improvement. Review of a facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated [DATE], showed, Prevention: . The facility will identify, correct, and intervene in situations in which abuse . of residents is likely to occur . 2. Review of a Facility-Reported Incident, submitted to the State Survey Agency on [DATE], showed that a contract CNA had been verbally abusive to resident #39 and refused to provide care to resident #13. The reason for the refusal was that resident #13's speech was difficult to understand. The report showed the facility investigated the situation and determined verbal abuse had occurred, and the CNA's contract was terminated. The facility failed to ensure the staff member had the necessary training/oversight, and skills to address the resident's care needs and prevent abuse. During an interview on [DATE] at 8:37 a.m., resident #39 stated she remembered an incident with a CNA being verbally abusive to her. During an interview on [DATE] at 3:19 p.m., resident #13 did not remember the issue with a travel CNA from September of 2025. 3. Review of a Facility-Reported Incident, submitted to the State Survey Agency on [DATE], showed resident #46 entered resident #59's room and was overheard saying, I am going to smack and punch you. A CNA corrected resident #46 and removed him from resident 59's room. At the time, it was believed to have been only verbal abuse. Later, resident #59 was found to have a resolving bruise near his right eye. When staff interviewed resident #59, he was able to answer only yes or no questions. The resident said he had been hit by resident #46. It was determined that resident #46 struck resident #59 at some point in time. Resident #46 was moved to another hall and counseled that physical violence and verbal threats are not acceptable. During an interview on [DATE]at 9:05 a.m., resident #46 stated he did not want to talk about the incident, and he was seeing a counselor and making progress. Resident #46 stated he knew resident #59 had died. 4. Review of a Facility-Reported Incident, submitted to the State Survey Agency on [DATE], showed two staff members reported an agency employee (NF3) had verbally abusive interactions with resident #60 the evening of [DATE]. NF3 went into resident #60's room to tell her to shut up multiple times. The two staff members reported NF3 told resident #60 she had a severe migraine, and resident #60 needed to Grow up, and act like an adult and stop yelling. The facility reported incident findings showed the alleged violation was verified, and NF3 was removed from duty with her remaining contract time cancelled. The findings showed resident #60 had no memory of the incident, and ongoing behaviors had not increased following the incident. The facility failed to ensure the staff member had the necessary training, skills, and oversight to ensure a resident was not treated in a manner that was abusive. Review of resident #60's electronic medical record showed an admission date of [DATE] with a primary diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance. Review of resident #60's care plan, dated [DATE], showed resident #60 had behavioral concerns displayed by refusal of care, agitation, and restlessness related to her diagnoses of dementia with behavioral disturbance, anxiety, and depression. The care plan provided interventions to interact with resident #60 by approaching and speaking calmly, and to explain a procedure before starting, giving her time to adjust. NF3 did not follow the individualized care plan interventions for resident #60's conditions by interacting with her in a verbally abusive manner. During an interview on [DATE] at 10:38 a.m., staff member A stated that the incident with resident #60 and NF3 had occurred. Staff member A stated the facility relied primarily on contract nursing staff to fill resident care needs. Staff member A stated there had been abuse training before the incident and after the incident with nursing staff, and education on the need to immediately report any alleged abuse incidents. Review of a facility policy titled Abuse, Neglect and Exploitation, revised [DATE], showed: . It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by . implementing written policies and procedures that prohibit and prevent abuse. Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.

Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse for 7 (#s 13, 27, 37, 39, 46, 55 and 59) of 8 residents sampled for abuse. The failure resulted in incomplete investigations, which did not show the evaluation of ongoing actions taken for the residents' well-being, did not identify resident-specific interventions, revise care planning, or document other measures implemented to protect residents and prevent recurrence of similar incidents. Findings include: 1. Review of a Facility-Reported Incident, submitted to the State Survey Agency on [DATE], showed resident #37 and resident #55 were involved in a physical altercation without injuries. Staff intervened, separated the residents, and completed initial assessments. Resident #55 was transferred to another facility approximately six weeks after the incident. During an interview on [DATE] at 7:50 a.m., resident #37 stated, No one followed up with me, and no one told me to stay away from her (#55). Review of a Facility-Reported Incident, submitted to the State Survey Agency on [DATE], showed NF2 was observed grabbing resident #27 by the arm and directing the resident into a seated position. The facility investigated the incident, substantiated the allegation of abuse, and terminated the agency staff member; however, it did not provide evidence of any psychosocial monitoring, care planning, or revision of care post-event. During an interview on [DATE] at 1:42 p.m., staff member A stated the facility's post-incident process included educating staff as needed and, when applicable, verbally instructing staff to keep residents separated or monitor residents following an incident; however, the instructions were not documented in the electronic health record, kardex, or task list. Staff member A stated psychosocial follow-up visits or assessments were not completed for residents #27, #37, or #55 following the respective incidents and stated she did not know they were required. During an interview on [DATE] at 4:02 p.m., staff member N stated if there were instructions to monitor for behavioral changes or keep residents separated following an incident, the instructions would typically be communicated verbally during the report. Staff member N stated she was unaware whether those instructions were documented anywhere in the electronic health record and did not recall whether there were any post-event instructions for the incidents identified above. Review of the electronic health records for residents #27, #37, and #55 failed to show documentation of increased supervision, emotional support, counseling, psychosocial follow-up, monitoring of resident interactions, monitoring for behavioral changes related to the incidents, care plan revisions, or other protective measures implemented following the incidents to prevent recurrence. Review of a facility policy titled Abuse, Neglect and Exploitation, revised on [DATE], showed: . Protection of Resident . The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: . C. Increased supervision of the alleged victim and residents; D. Providing emotional support and counseling to the resident during and after the investigation, as needed; . G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of abuse. A request was made on [DATE] for documentation of post-incident psychosocial monitoring and evidence of measures implemented to prevent recurrence of the abuse events. No documentation was provided by the end of the survey. 2. Review of a Facility-Reported Incident, submitted to the State Survey Agency on [DATE], showed that a contract CNA was verbally abusive to resident #39 and was neglectful with resident #13. The report showed the facility determined verbal abuse had occurred, and the CNA's contract was terminated. The report failed to show that the facility had attempted to determine if any other residents were affected by the contract CNA. During an interview on [DATE] at 8:37 a.m., resident #39 stated she remembered an incident with a CNA being verbally abusive to her. Resident #39 stated she felt the facility handled the situation. 3. Review of a Facility-Reported Incident, submitted to the State Survey Agency on [DATE], showed resident #46 entered resident #59's room and was overheard saying, I am going to smack and punch you. A CNA corrected resident #46 and removed him from resident 59's room. At the time, it was believed to have been only verbal abuse. Later, resident #59 was found to have a resolving bruise near his right eye. When staff interviewed resident #59, he was able to answer only yes-or-no questions. The resident said he had been hit by resident #46 but felt safe in the facility. It was determined that resident #46 struck resident #59 at some point in time. Resident #46 was moved to another hall and counseled that physical violence and verbal threats are not acceptable. During an interview on [DATE] at 9:05 a.m., resident #46 stated he did not want to talk about the incident and that he was seeing a counselor and making progress. Resident #46 stated he knew resident #59 had died. During an interview on [DATE] at 10:25 a.m., when staff member A was asked what she did to ensure no other residents were affected by the CNA's behavior, she stated, Could not tell you. I don't know that I talked to anyone. I may have asked staff to check with other residents.

Based on observation, interview, and record review, the facility failed to assess the risks and benefits associated with the use of a wander guard alarm and obtain informed consent for 1 (#1) of 5 residents sampled for wandering. The failure placed the resident at risk for restriction of movement and psychosocial distress; and failed to ensure a door to the outside of the facility was checked for eloping residents when alarmed, which had the potential to affect 5 residents who wander (#s 1, 3, 11, 18, and 34) of 23 sampled and supplemental residents. Findings include:1. During an interview on 6/15/26 at 4:45 p.m., staff member D stated resident #1 could become agitated and wander during the early evening hours. Staff member D stated resident #1 used a walker for ambulation and had exhibited exit-seeking behaviors in the recent past; therefore, a wander guard alarm was placed on the resident's walker. During an interview on 6/16/26 at 8:40 a.m., NF4 stated she was not familiar with a wander guard alarm or how it was used. NF4 stated she did not recall being notified of the use of a wander guard alarm. During an interview on 6/18/26 at 8:30 a.m., staff member B stated she had never heard of obtaining a risk-benefit assessment or informed consent for the use of a wander guard alarm in her 20 years of experience. Staff member B stated wander guard alarm safety assessments and consents were not currently used in the facility. Review of resident #1's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/12/26, showed the resident had a Brief Interview for Mental Status (BIMS) score of 8; reflecting moderate cognitive impairment. Section E, Wandering, was coded Yes for wandering that placed the resident at significant risk of entering a potentially dangerous place. The assessment further showed the resident's wandering significantly intruded on the privacy or activities of others. Review of resident #1's electronic health record showed a physician order dated 5/17/26 for a wander guard alarm related to exit-seeking behavior. Review of resident #1's electronic health record showed an initial elopement assessment had been completed which identified the resident was at risk for elopement. Review of resident #1's electronic health record failed to show documentation evaluating the risks and benefits associated with the use of a wander guard alarm or informed consent from the resident's representative. Review of a facility policy titled, Resident Alarms, dated 4/18/22, showed: . Identification of risk . c. When alarms are in use or are under consideration, risks of adverse consequences related to the alarms should be identified. Implementation of interventions . b. Alarms shall be initiated only . when the benefit of the alarm outweighs the risk associated with its use. . 5. Monitoring and modification . b. iii. Monitoring for adverse consequences associated with the use of the alarms, including psychosocial concerns. A request was made on 6/16/26 for documentation supporting the implementation and use of a wander guard alarm for resident #1, including a risk-benefit assessment and informed consent. No additional documentation was provided by the end of the survey. 2. During an observation on 6/17/26 at 7:36 a.m., the surveyor opened door 8, down a long hallway from the conference room, and an alarm went off. At 6/17/26 at 7:39 a.m., staff member C walked by the entrance to the hallway and looked down at door 8. Staff member C kept walking to the nurse's station and spoke with staff member D. Staff member C left the nursing station, walked past door 8's hallway, and looked down the hallway again. Staff member C did not check the door or the outside of it to see if a resident had left through the door. During an interview on 6/17/26 at 7:40 a.m., staff member D stated staff member C had asked if all the residents were accounted for, and staff member D said, Yes, and staff member C left. During an interview on 6/17/26 at 7:43 a.m., staff member E stated when a door alarm went off, staff were to check to see if a resident was outside and safe. During an interview on 6/17/26 at 8:05 a.m., staff member C stated when the alarm went off for door 8, she used her walkie-talkie to ask if anyone had eyes on the door. Staff member C then stated she walked to the hallway for door 8, looked down the hallway, and saw surveyors there, then walked to the nursing station. Staff member C stated, The smart thing to do would be to check outside the door for residents. Staff member C stated she did not check outside door 8 because staff usually went through that door. Staff member C stated there were a number of wanderers at the facility, including residents #s 1, 3, 11, 18, and 34. During an interview on 6/17/26 at 12:52 p.m., staff member B stated that when a door alarm went off, staff were to go and visually inspect the door, including for door 8. Staff member B stated there were a lot of deliveries outside door 8, but staff should still use the paging system and check the door to make sure residents had not gone through it. Staff member B stated the facility has had residents go through that door before. Review of the facility's policy, Staff Response to Door Alarm Activations, dated 2/20/26, showed, . 3. Visual Assessment: If the alarm was not set off by another staff member, then scan the immediate surroundings, hallways, and parking lots through windows or open doors to check for any exiting resident.

Based on observation, interview, and record review, the facility failed to ensure staff adhered to infection control processes during an ostomy bag change and peri-care for 1 (#29); failed to perform proper hand hygiene and glucometer sanitizing during medication administration for 1 (#14); and failed to ensure enhanced barrier precautions were implemented for 1 (#40) of 23 sampled and supplemental residents. These deficient practices increased the risk of the spread of infections for residents in the facility. Findings include: 1. During an observation on 6/17/26 at 9:33 a.m., staff member C entered resident #29's room and donned gloves. Staff member C checked resident #29's ostomy bag. Staff member C did not perform hand hygiene prior to donning the gloves. During an observation on 6/17/26 at 9:34 a.m., staff member C disposed of the previous gloves, and donned a gown and a new pair of gloves. Staff member C did not perform hand hygiene before donning the new gloves. Staff member C opened the door to resident #29's bathroom, grabbed a trash bag, and doffed her gloves. Staff member C donned a new pair of gloves without performing hand hygiene prior. Staff member C then emptied resident #29's ostomy bag into the trash bag. Staff member C cleaned the ostomy bag. During an observation on 6/17/26 at 9:42 a.m., staff member C washed her hands with soap and water in resident #29's sink and donned new gloves. Staff member C cleaned resident #29's body with a warm, soapy washcloth. When staff member C went to clean resident #29's groove between her buttocks, she wiped the resident from the top of the groove of her buttocks towards her vaginal area. Staff member C then doffed her gloves and placed them on the resident's bed. During an observation on 6/17/26 at 9:52 a.m., staff member C doffed the single glove and gown and placed them in the trash. During an interview on 6/17/26 at 9:53 a.m., staff member C stated that the facility policy shows staff are to perform hand hygiene before and after gloving. Staff member C stated she did not do that when performing care on resident #29. During an interview on 6/18/26 at 8:38 a.m., staff member B stated that staff were expected to sanitize or wash their hands upon entering a resident's room. Staff member B stated that staff were to wash their hands or perform hand hygiene before donning gloves and after taking them off. Staff member B stated dirty gloves were to be disposed of immediately into the trash. Review of the facility's policy titled Hand Hygiene, revised 5/21/24, showed: . 6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. The Hand Hygiene Table on the back of the policy showed either soap and water or alcohol based hand rub (ABHR is preferred), was to be used for: - After handling contaminated objects, - Before performing resident care procedures, and - After handling items potentially contaminated with blood, bodily fluids, secretions, or excretions. 2. During an observation and interview on 6/18/26 at 7:43 a.m., staff member I did not disinfect resident #14's glucometer before using it to obtain a blood sugar. Staff member I did not use EPA (Environmental Protection Agency) wipes to disinfect the resident's glucometer after use. Individual resident glucometers were all stored in the same white basket in the medication cart, touching. Staff member I did not perform proper hand hygiene after removing gloves and before prepping resident #14's medication after cleaning the glucometer. During an interview on 6/18/26 at 9:21 a.m., staff member I stated, .alcohol does the same thing ., regarding not using the EPA wipes to clean resident #14's glucometer after use. During an interview on 6/18/26 at 9:52 a.m., staff member B stated the staff were supposed to use the orange top EPA wipes to clean off the residents' glucometers, not the green top wipes, as they did not break down the blood. Staff member B stated she did not think the alcohol wipes would work and would have to look at the policy. Review of the facility's policy titled, Glucometer Disinfection, revised on 5/20/26, showed, .Policy Explanation of Compliance Guidelines . 3. The glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus . 5. Procedure . k: After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe ., i: Discard disinfectant wipes in waste receptacle, . m: Perform hand hygiene. 3. During an observation on 6/16/26 at 8:46 a.m., resident #40 had a wound in his right groin and a suprapubic catheter. A gown sticker on the resident's name plate indicated he was on enhanced barrier precautions. Resident #40's wound was changed by NF1 and assisted by staff member F. Neither staff member was wearing an isolation gown or a mask at any time during the dressing change. After completion of the dressing change, staff member H and staff member J assisted resident #40 to get dressed and ready for the day. Staff members H and J were not wearing isolation gowns or masks during resident #40's care. During an interview on 6/16/26 at 8:51 a.m., staff member J was asked what PPE was to be used when a resident had enhanced barrier precautions. Staff member J stated she was supposed to perform hand hygiene with soap or hand sanitizer. Staff member J stated the PPE used depended on what was going on with the resident. Staff member J stated she did not remember any education related to enhanced barrier precautions. During an interview on 6/16/26 at 8:59 a.m., when staff member H was asked what she knew about enhanced barrier precautions, staff member H stated she was not sure what enhanced barrier precautions were. Staff member H stated she did not remember receiving any education related to enhanced barrier precautions. During an interview on 6/16/26 at 9:18 a.m., staff member F stated she had been at the facility for two years. When asked what she knew about enhanced barrier precautions, staff member F stated it involved hand hygiene, changing gloves between residents and more PPE if the resident had something like clostridium difficile. When asked if there was any specific PPE to be used when a resident had a urinary catheter, a colostomy, or a wound, she stated there was nothing specific with regard to PPE. During an interview on 6/17/26 at 3:47 p.m., staff member G stated he had provided training on enhanced barrier precautions at least once during the past year. Staff member G denied performing monitoring and assessment of adherence to enhanced barrier precautions to determine the need for additional training and education. Review of the facility document titled, Infection Control Survey/New Policies Reportable Incidents, dated 6/25/25, showed a list of signatures of staff who had attended the training. The form did not provide an agenda or the presence of any handouts. No other training records were provided by the facility. Review of the facility policy titled, Enhanced Barrier Precautions, dated 6/16/24, showed, . EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.

Based on interview and record review, the facility failed to implement, and maintain an effective behavioral health training program for all staff. This deficient practice had the potential to affect resident #14 and all other residents with behavioral health needs. Findings include:During an interview on 6/16/26 at 2:02 p.m., staff member H stated they had not received training on behavioral health services during their employment at the facility. During an interview on 6/17/26 at 8:11 a.m., staff member K stated they were not aware of any education regarding suicide attempts or ideations, staff member B provided that education so she would not know what was done. During an interview on 6/17/26 at 12:52 p.m., staff member B stated verbal education was given after resident #14's discharge from the emergency room. Staff member B stated she provided, . verbal coaching ., to staff regarding the resident's safety plan. During an interview on 6/18/26 at 9:31 a.m., staff member C stated they did not know the protocol if a resident attempted suicide or voiced suicidal ideations. Staff member C stated they had not received behavioral health training at the facility. Staff member C stated, To be honest, I have not had any education or training on anything here . A request was made on 6/16/26 for behavioral health training and in-service documentation. The facility could not provide the requested documentation by the end of the survey.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice when they did not use a resident's respiratory therapy (CPAP) equipment, failed to notify the resident's provider, and failed to document the reason for the non-use of CPAP therapy for 1 (#5) of 15 sampled residents. Findings include:During an interview on 6/16/26 at 11:24 a.m., resident #5 stated she did not use her CPAP/BiPAP machine because there was an electrical part missing. Resident #5 was not able to say how long she had been unable to use her machine.During an interview on 6/18/26 at 8:42 a.m., staff member I stated when she worked evening shifts, it was her responsibility to put on resident #5's CPAP mask at bedtime. Staff member I stated if there were parts missing, she would pull the equipment from use and notify the resident's provider. Staff member I stated she would document the circumstances in the resident's chart.Review of resident #5's diagnosis list showed she was admitted to the facility with a diagnosis of obstructive sleep apnea.Review of resident #5's physician order, dated 2/2/26, showed, BiPAP on each evening.Review of resident #5's MAR, dated 5/1/26 to 5/31/26, showed of the 31 opportunities to use the CPAP/BiPAP machine, 11 days were documented with the Chart Code 9 (Other/See Progress Notes).Review of resident #5's nursing progress notes, dated 5/1/26 to 5/31/26, failed to show any notes related to the use of resident #5's CPAP/BiPAP machine.Review of resident #5's MAR, dated 6/1/26 to 6/15/26, showed of the 15 opportunities to use the CPAP/BiPAP machine, 15 had a Chart Code 9 documented.Review of resident #5's nursing progress notes, dated 6/1/26 to 6/15/26, failed to show any notes related to the use of resident #5's CPAP/BiPAP machine.A request was made on 6/18/26 for documentation related to the missing power cord for resident #5's CPAP machine. There was no documentation received by the end of the survey.

Based on observation, interview, and record review, the facility failed to assess the safety and appropriateness of bed rail use and obtain informed consent for the use of two upper side rails for 1 (#49) of 23 sampled and supplemental residents. The failure placed the resident at risk for injury related to bed rail use, including entrapment, falls, and restriction of movement. Findings include:During an observation on 6/16/26 at 8:12 a.m., resident #49 was observed in bed with two upper side rails in the raised position.During an interview on 6/16/26 at 4:23 p.m., staff member A stated the facility did not complete a bed rail safety assessment or obtain informed consent for resident #49 because the resident was receiving hospice services.During an interview on 6/17/26 at 11:44 a.m., staff member B stated the facility should have documentation supporting the use of bed rails, including a safety assessment and informed consent from the resident or resident's representative.During an interview on 6/17/26 at 2:45 p.m., staff member A stated the facility did not have any policies pertaining to bed rails, . because we do not use them.Review of resident #49's electronic health record showed a physician order dated 7/22/25 stating, Bed Rail - 2 upper rails for safety and repositioning.Review of resident #49's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/16/26, showed the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3.Review of resident #49's electronic health record failed to show documentation evaluating the risks and benefits associated with bed rail use or informed consent from the resident's representative for the use of the bed rails.A request was made on 6/16/26 for documentation supporting the use of bed rails for resident #49, including a bed rail safety assessment, informed consent, and facility policies regarding bed rail use. No documentation was provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to obtain necessary services for the behavioral health care needs of 1 (#14) of 15 sampled residents. This deficient practice increased the risk of declining mental health for the resident. Findings include:During an observation and interview on 6/15/26 at 3:56 p.m., resident #14 was sitting in her reclining chair. Resident #14 stated she previously attempted suicide; she tried hanging herself with her call light, and now she did not have a call light. A cord, approximately two inches long, was sticking out of the wall where the call light used to be. Resident #14 stated that when she needed help, she used the chair alarm on her bedside table. Resident #14 stated she saw a psychiatrist, a counselor who came to the building, and a nurse practitioner who, . does her meds.During an interview on 6/16/26 at 1:44 p.m., resident #14 stated her husband of 44 years passed away ten years ago. Resident #14 stated she had two children but lost her son when he was in his twenties, resulting in increased loneliness and depression.During an interview on 6/16/26 at 2:02 p.m., staff member H stated she had been working at the facility for approximately ten months. Staff member H stated she was not working on the day of resident #14's suicide attempt but did work the next day while resident #14 was still in the hospital. Staff member H stated she did not know resident #14 well enough to know her (mood/behavior) triggers and de-escalation routine. Staff member H stated that the triggers and de-escalation routine were in the Kardex if she needed to look them up. Staff member H stated that after resident #14's suicide attempt, there was no training on suicide prevention. Staff member H stated she would not know what to do if she walked into a room where a resident was attempting suicide or voicing suicidal ideations. Staff member H stated that before resident #14's suicide attempt, the resident was depressed and had spats with her roommate regarding the television volume and overall adjusting to her first time being at the facility.During an interview on 6/17/26 at 8:11 a.m., staff member K stated resident #14 did not attempt suicide, but voiced suicidal ideations on 5/13/26, and was sent to the emergency room. Staff member K stated that after resident #14 was discharged from the emergency room, her call lights were removed, and the staff was checking on her for a certain amount of time. Staff member K stated that resident #14 did not see a counselor or psychiatrist until after the emergency room visit for her suicidal ideations. Staff member K stated that resident #14 was at the facility before and did so well that she went to an assisted living facility (ALF). While at the ALF, resident #14 attempted suicide by an overdose of pills. From there, she was transferred to another skilled nursing facility (SNF). Staff member K stated resident #14's daughter was not happy with the care given at that SNF and had her moved back to this facility in March of 2026. Staff member K stated she was not aware of any education given regarding resident suicide attempts or ideations. Staff member K stated that the Director of Nursing (DON) provided that education, so she did not know what was done. Staff member K stated she was responsible for coordinating mental health referrals at the facility. Staff member K stated, I will be honest, I don't have a process for referral follow-up, and there was not a facility policy or procedure for following up on referrals placed for mental health services. Staff member K stated resident #14's first referral to counselling was placed at the Hospital by the LSW (Licensed Social Worker) through palliative care to the facility's in-house counselor, who was too busy to see resident #14. Staff member K stated she then requested a second referral to an additional counselor. Resident #14's first appointment with the other counselor was on 5/27/26. Staff member K stated that resident #14 went to the behavioral health clinic on 6/9/26, to see a psychiatrist. Staff member K stated her current referral process included receiving the referral order and filling out the paper referral form. Once the paperwork was completed, she stacked it on her desk. Then, when she saw the in-house counselor in the facility, she handed the stack of referrals to the in-house counselor. Staff member K stated she received resident #14's March referral for counselling, but kept missing the in-house counselor. Staff member K stated that anyone could have given the stack of referrals to the in-house counselor, but it did not happen. Staff member K stated on 5/5/26 that she sent a text message to the in-house counselor that a stack of paperwork was waiting for her. Then on 5/18/26, she sent a second text message to resident #14's provider for the new referral to a second counselor as the in-house counselor was too busy. During an interview on 6/17/26 at 12:52 p.m., staff member B stated resident #14 was previously in a different facility. At that facility, resident #14 was taken off her mental health medications, and did not do well. Staff member B stated resident #14 returned to this facility on 3/18/26. Staff member B stated she could not remember how she found out resident #14 was having suicidal ideations, but approached her on 5/13/26 to talk. Staff member B stated resident #14 expressed suicidal ideations due to not being on her mental health medications. Staff member B stated resident #14 said, Why do I need to live? Then the resident shared three specific plans to kill herself. She was sent to the emergency room at that time. Staff member B stated that resident #14 was discharged the same day with a safety plan in place. Staff member B stated she was not aware of an order for resident #14, dated 3/20/26, from the resident's provider for in-house counseling services. Staff member B stated that after resident #14 went to the emergency room on 5/13/26, a referral was placed to the in-house counseling services at that time. Staff member B stated she was not aware of a policy or procedure for mental health referrals, as staff member K was responsible for the mental health referral process. During an interview on 6/17/26 at 4:10 p.m., resident #14 stated, When I feel depressed, it makes it hard to function. You sit here and think of ways to die. Before counseling, it made it hard to eat and do activities. It makes me just want to be alone.Review of resident #14's provider orders, dated 3/20/26, showed, Referral to [Therapy Name] for treatment of depression/anxiety.Review of resident #14's provider visit note, dated 5/5/26, showed, . had something sad happen with one of her grandchildren, so has been struggling with that circumstance. Referral placed to counselor on admission. Facility has reached out to counselor who comes to the building, but referral has not yet gone through. Facility admin to reach out again today . She also has some stress/anxiety/conflict with her roommate. Facility admin to discuss moving rooms . Does not currently feel suicidal. Does have those ideas from time to time but reports no plan.Review of resident #14's social work progress note, dated 5/27/26, showed resident #14's first counselling appointment. This initial appointment occurred over ten weeks after the provider ordered counselling services on 3/20/26.

Based on interview and record review, the facility failed to ensure all the irregularities noted by the pharmacist on the monthly medication regimen review were addressed and documented in the resident's medical record for 2 (#s 5 and 13) of 15 sampled residents. Findings include:1. Review of the [Pharmacy Name] Monthly Consulting document, dated February of 2026, showed the following nursing recommendation for resident #5, [Resident #5] needs an AIMS assessment due to Seroquel use.Review of resident #5's Assessments section of the EHR, dated between 1/1/26 and 6/15/26, showed one AIMS assessment was completed on 5/18/26. No other AIMS assessments were completed during that time.2. Review of the [Pharmacy Name] Monthly Consulting document, dated February of 2026, showed the following nursing recommendation for resident #13, Please clarify diagnosis for mirtazapine. It's being used for insomnia which is an off label indication and duplication of therapy due to zolpidem use. [Resident #13] has a diagnosis of anxiety which may be more appropriate. Review of resident #13's physician order, dated 2/4/26, showed an order for mirtazapine 15 mg at bedtime related to unspecified insomnia. The order was still active as of 6/15/26.Review of resident #13's nursing progress notes, dated 2/4/26 through 2/28/26, failed to show the rationale for not changing the mirtazapine indication to something other than insomnia.Review of resident #13's physician progress note, dated 2/6/26, failed to show a rationale for continuing the mirtazapine for insomnia.During an interview on 6/18/26 at 8:25 a.m., staff member B stated she was responsible for managing the medication regimen review process. Staff member B stated there were two different reports received monthly. One report was directed to nursing to address, and the other was for the attending provider to complete. When asked about how she maintained documentation showing the nursing recommendations were completed or the documentation of why the recommendation was not completed, staff member B stated she did not have any documentation but would start making copies of the nursing recommendations so the necessary documentation was maintained.Review of the facility's policy titled, Medication Regimen Review, dated 3/13/26, showed, The pharmacist shall document either that no irregularity was identified or the nature of any identified irregularities.

Based on interview and record review, the facility failed to maintain documentation of staff education of the risks and benefits associated with the COVID-19 vaccine and documentation of the COVID-19 vaccination status for all staff members. Findings include:During an interview on 6/16/26 at 4:00 p.m., staff member A stated, I do not ask staff about their COVID status because it (the vaccine) is no longer mandatory. We don't provide any education to staff regarding COVID vaccines.During an interview on 6/17/26 at 3:47 p.m., staff member G stated the facility was not tracking COVID-19 status documentation unless it was self-reported by staff.A request was made on 6/16/26 for the COVID-19 vaccination status, consent or declination, education, and administration for staff member K. No documentation was provided prior to the end of the survey.

2. During an observation on 6/5/25 at 7:57 a.m., resident #13 received morning cares from staff members F and K. Resident #13 was lying on her back in the bed. Resident #13 had a wound dressing on her right heel which was left in place. When resident #13 was turned to her right side for incontinence care, an open area was noted on her coccyx. There was no wound dressing in place. Staff member F applied moisture barrier cream, and a new incontinence brief. Resident #13 called out in pain and cried when she was moved in her bed. The crying stopped as soon as the resident was left alone. During an interview on 6/4/25 at 12:47 p.m., staff member G stated the wound nurse had been seeing the resident weekly, otherwise staff did the dressing changes. Review of resident #13's nursing progress notes showed the following: - 3/17/25, bruising to buttocks, present on admission, no measurements documented, - 4/14/25, bruising to buttocks resolved, - 4/21/25, new pressure ulcer on coccyx, scheduled to see the wound nurse on 4/22/25, - 4/22/25, Unstageable pressure ulcer on medial gluteus and coccyx, moisture barrier cream and a dressing, change every three to four days; and, - 5/27/25, Stage III pressure ulcer to medial gluteus, wound border macerated and raised, apply moisture barrier cream after each brief change. Based on observations, interviews, and record review, the facility failed to ensure residents received necessary treatment and services to prevent pressure ulcers and promote healing for 2 (#s 1 and #13) of 7 residents sampled with pressure ulcers. This practice contributed to chronic (>three months) Stage II and Stage III pressure ulcers for resident #1 and a Stage III for resident #13. Findings include: 1. During an observation on 6/2/25 at 2:35 p.m., resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. A neck pillow/collar was in his wheelchair. During an observation on 6/2/25 at 2:46 p.m., resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward and to the left side. Neck pillow/collar was in his wheelchair. During an observation on 6/2/25 at 3:35 p.m., resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. A neck pillow/collar was in his wheelchair. During an observation on 6/2/25 at 4:43 p.m., resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. A neck pillow/collar was on his wound supply shelf. During observations on 6/3/25, from 7:45 a.m. to 4:32 p.m., resident #1 was observed every 30 minutes and found to be in the same position in bed. Resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. The neck pillow/collar was in his wheelchair. During an interview on 6/4/25 at 10:13 a.m., staff member B stated she was aware wound documentation was not being completed and was working on a wound program, including camera use and staging (determining severity) education. Staff member B stated resident #1 was supposed to be up in his wheelchair for 2-3 hours each day for activities. Staff member B stated resident #1 did not get up in the evenings. Staff member B stated resident #1 should be turned and repositioned every two hours and should be checked and changed every two hours. Staff member B stated resident #1 did have a collar pillow to prevent pressure on his neck and ear. Staff member B stated resident #1 had a history of pressure injuries and maceration on his ear and neck area related to his positioning and moisture. During an observation on 6/4/25 at 10:01 a.m., resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. The neck pillow/collar was in his wheelchair. During an observation on 6/5/25 at 7:10 a.m., resident #1 was in bed sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. NF1 assessed resident #1's pressure wounds on his buttocks. NF1 stated he had three wound openings with a large area which was a Stage I pressure sore covering 13.5 cm by 8.5 cm on the right buttock and 13.5 cm by 7.0 cm on the left buttock. The openings included: - 1.5 cm by 9.0 cm by 0 cm: Stage I - 1.1 cm by 1.0 cm by 0.1 cm: Stage II - 0.8 cm by 0.5 cm by 0.15 cm: Stage II NF1 stated frequent turning and positioning were critical, along with frequent brief changes related to incontinence. Staff member L entered to assist NF1 during the dressing change. Staff member L stated the neck pillow was only used during times resident #1 was in his wheelchair. NF1 stated the pressure sores on resident #1's buttocks have waxed and waned, but the wounds were worse than the last time she evaluated them. NF1 stated it was hard to achieve compliance with turning and positioning with all the travel staff used by the building. During an observation on 6/5/25 at 9:20 a.m., resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. Review of resident #1's Nursing Care Plan, with a revision date of 4/22/25, reflected: - . Use soft cervical collar-type pillow to prevent left ear from resting on shoulder. Pillow should be on left side only with no pressure to ear. Ask for assist to properly position as needed. Check collar frequently to monitor for positioning, pressure areas, and to insure breathing and circulation are not compromised. [sic] - . [Resident #1] needs total assistance to REPOSITION ROUTINELY THROUGHOUT THE DAY/NIGHT; use turn sheet when he is in bed to prevent shearing. 2-3 hours maximum time in w/c and reposition every 2 hours in bed. Review of resident #1's EHR nursing progress note, dated 1/6/25 reflected resident #1 developed a new pressure wound on his buttocks. No measurements were available. Review of the facility provided tracker, Treatment/Svcs to prevent/heal pressure sores, dated 1/7/25 through 6/3/25, reflected: - On 1/7/25 the report showed: . 6.8 x 5 x 0.01 increased significantly in size from previous measurement 12/13 of 4.8 x 3.6 *requested air mattress overlay for bed - On 1/14/25 the report showed: . Air mattress overlay placed 1/7/25 measurements have increased to 7.9 x 6.4 x 0.01 - On 3/11/25 the report showed: .Wound 1.5 x 2.5 x 0.1 - On 4/8/25 the report showed: . 3 x 3.5 x 0.01, scattered wounds - On 5/13/25 the report showed: . scattered wounds - On 6/3/25 the report showed: . scattered wounds-improving Refer to observation on 6/5/25 at 7:10 a.m. for the most current measurements. Review of resident #1's Braden Scale, dated 10/15/24, reflected resident #1 was at high risk for pressure ulcers with a score of 10. A score of 12 or less reflects a High Risk.

Based on observation, interview, and record review, the facility failed to review and revise resident care plans for 3 (#s 13, 32, and 43) of 21 sampled residents. Findings include: 1. During an observation on 6/2/25 at 4:07 p.m., resident #13 was sitting in her wheelchair with both feet elevated on the foot pedals. There was no evidence of a urinary catheter. During an observation on 6/5/25 at 7:57 a.m., staff member F and K were providing morning care for resident #13. Resident #13 had an incontinence brief on, and there was no evidence of a urinary catheter. Review of resident #13's physician orders, dated 5/6/25, showed an order to remove the indwelling urinary catheter. Review of resident #13's care plan, dated 3/11/25, accessed on 6/4/25, showed the resident had an indwelling Foley catheter due to urinary retention. The goals and interventions, dated 3/11/25, continued to show cares related to the urinary catheter. During an interview on 6/5/25 at 7:50 a.m., staff member B stated all nurses should be updating resident care plans. Staff member B could not explain why resident #13's care plan showed she had a urinary catheter. The care plan was not revised. 2. During an observation on 6/3/25 at 8:46 a.m., resident #32 was seen sitting in the dining room, her walker placed behind her, and against the wall. During an observation on 6/4/25 at 1:00 p.m., resident #32 was seen ambulating in the hallway using a walker. An unidentified facility staff member was walking with resident #32 and gave the resident directions to her room. Review of resident #32's nursing progress note, dated 12/11/24, showed resident #32 sustained an unwitnessed fall while ambulating in her room. The section labeled Actioned Clinical Suggestions, was blank. The note failed to show what changes were implemented after this fall to prevent future falls. Review of resident #32's nursing progress note, dated 3/26/25 at 7:11 a.m., showed the resident sustained an unwitnessed fall in her room. The note failed to show any contributing factors. The resident did complain of bilateral knee pain. The section labeled Actioned Clinical Suggestions was blank. The note failed to show what changes were implemented after this fall to prevent future falls. Review of resident #32's nursing progress note, dated 3/26/25 at 11:17 a.m., showed the resident was found on the floor. The resident sustained a second unwitnessed fall on 3/26/25. Review of resident #32's nursing progress note, dated 5/31/25, showed the resident sustained an unwitnessed fall while ambulating in her room. The section labeled Actioned Clinical Suggestions, was blank. The note failed to show what changes were implemented after this fall to prevent future falls. Review of resident #32's care plan, dated 5/4/24, showed a focus of At Risk for Falls. An intervention, dated 5/3/24, included educating resident and family about safety reminders and to ensure the resident was wearing non-skid footwear. There was also an intervention, dated 2/7/25, which showed therapy was to evaluate and treat as needed. Review of resident #32's care plan, dated 1/28/25, showed a focus of Risk for Falls. The intervention, dated 1/28/25, was to utilize therapy recommendations for ambulation and transfers. The care plan also showed interventions, dated 2/7/25, to ensure call light was available, to alert the provider if a fall occurred, and to initiate frequent neuro (neurological) and bleeding evaluation per facility protocol. Review of resident #32's care plan, dated 3/27/25, showed a focus of an actual fall. The care plan failed to show the resident had falls on 12/11/24 and 5/31/25. The care plan also failed to show any new interventions implemented after the fall on 12/11/24, or the fall which occurred on 5/31/25. During an interview on 6/5/25 at 7:50 a.m., staff member B stated it was the responsibility of all nurses to update and revise care plans as needed. Staff member B could not explain why resident #32's care plan failed to show ongoing interventions implemented after each of the resident's falls. 3. During an observation and interview on 6/3/25 at 8:09 a.m., resident #43 was sitting in his wheelchair, waiting for transportation to take him to a dental appointment. The resident stated he had a urinary catheter hooked up to a leg bag. Review of resident #43's physician orders, dated 3/5/25, showed the resident was admitted from the hospital with a Foley catheter, with output being monitored every shift, and the resident was on an antibiotic for seven days because of a urinary tract infection. Review of resident #43's MAR, dated March of 2025, showed the resident was given sulfamethazole-trimethoprim 800-160 mg tablet, twice daily, for seven days. Review of resident #43's care plan, dated 3/5/25, showed the resident had a urinary tract infection related to obstruction and urinary retention. The care plan failed to show the urinary tract infection had resolved. The care plan was not revised.

Based on observation, interview, and record review, the facility failed to maintain proper hand hygiene for 4 (#s 14, 16, 21, and 208) of 7 observed medication passes; failed to maintain cleanable surfaces on floor mats for 2 (#s 1 and 36) of 2 sampled residents with floor mats; failed to maintain clean respiratory equipment for 1 (#36) of 6 sampled residents with respiratory equipment; and failed to properly store tube feeding supply sanitarily for 1 (#1) of 1 sampled resident with tube feeding supplies. These deficient practices had the potential to increase the risk of infections and spread of infections for all residents receiving care. Findings include: 1. During an observation on 6/3/25 at 4:10 p.m., staff member E prepared the medications for resident #208. Staff member E entered resident #208's room without completing hand hygiene, began to assist the resident with medications by feeding her the pills with a spoon and giving her drinks of water between. Resident #208 stopped staff member E and stated she wanted the pills in applesauce. Staff member E obtained the applesauce and mixed the pills in the applesauce. Resident #208 then stated she meant to say apple juice. Staff member E then stated water was all she had available, and spoon fed the pills to resident #208. Resident #208 stopped her and said she could not take the larger pills unless they were cut in half. Staff member E exited the room, took the pill cutter out from the top drawer of the cart and put the wet pill in the pill cutter and cut it in half. Staff member E then returned to the room and administered the remaining medication. The pill cutter was not cleaned prior to use and was left on the cart after using. The pill cutter had dust/dirt in the cup holder portion of the pill cutter prior to use by staff member E. Staff member E did not perform hand hygiene when entering or exiting the room to collect the applesauce or cut the pill, and did not perform hand hygiene prior to entering the room at the beginning. 2. During an observation on 6/4/25 at 7:33 a.m., staff member D was preparing medications for resident #21, including miconazole cream 2%. Staff member D put on gloves without completing hand hygiene, cleansed under resident #21's breasts with wound cleanser, dried the areas with gauze, and applied miconazole cream 2% to both areas under the breasts. No hand hygiene or glove changes were completed between dirty and clean tasks. Resident #21 then asked staff member D to clean and apply cream to her pannus. Staff member D used her same gloves to clean her pannus and applied cream and degloved. Staff member D then returned to her medication cart and started prepping the next resident's medications without completing hand hygiene. 3. During an observation on 6/4/25 at 8:19 a.m., staff member D prepared medications for resident #16, including antifungal powder. During the administration of the powder, staff member D cleansed under resident #16's breasts with wet wash cloth, dried with a towel, and applied the powder. Staff member D then gave the resident a drink of the MiraLAX and stated she should keep working on drinking the MiraLAX. Staff member D degloved, gave a remaining pill in a cup to the resident by spoon and another drink. Staff member D took the dirty washcloth and towel and placed them on the food tray, left the room, placed the dirty linens in the dirty linen bin and took the tray to the food cart for return to the kitchen. Staff member D then walked to the other end of the hall to the nutrition room of the unit and washed her hands. Staff member D stated she washed her hands in the nutrition room because it was the only place to wash her hands on the unit. No hand hygiene was completed between dirty and clean tasks. 4. During an observation on 6/4/25 at 8:43 a.m., staff member D prepared medication for resident #14, including teriparatide Pen 620 mcg-20 mcg and muscle rub cream 10-15% for the neck/shoulder. Staff member D put on gloves without completing hand hygiene, gave the injection and applied muscle rub, and degloved. Staff member D then left the room and carried the injection pen down to the medication room, then placed the pen in the refrigerator. Staff member D then returned to her medication cart and started to prep the next resident's medication. No hand hygiene was completed before or after gloving/degloving or when exiting the room. A review of staff member D's education file showed no hand hygiene education was located in the file. 5. During an observation on 6/2/25 at 2:44 p.m., a bottle of tube feeding was found in the open cupboard of resident #1's room, and it had a thick chunky layer over a black liquid layer, separated from the rest of the liquid in the bottle. The bottle appeared unopened but it was unable to tell if the bottle had a rupture or leaked. The other bottles in the cupboard, the cupboard walls, and door, had dried thick areas of tube feeding liquid (dark creamy color) and was sticky. 6. During an observation on 6/2/25 at 2:27 p.m., a suction machine was observed in the room of resident #36. The suction machine canister was 2/3 full of a white milky liquid, with a thick hardened crust around the top. 7. During an observation on 6/2/25 at 2:47 p.m., the floor mat was next to the bed while resident #1 was sleeping. Staff member C stated resident #1 often would slide out of bed. The floor mat was cracked, dirty, had chunks missing at the corners and was not cleanable. There was a furry layer over the top from the mat top coming apart. During an interview on 6/3/25 at 2:52 p.m., staff member C stated the floor mats were not cleanable, and the cabinet was not cleaned. Staff member C stated he did not understand why the floor staff were not cleaning the cupboard when they saw the mess or when they used the suction machine. Staff member C stated the facility was aware the floor mats were not cleanable but had not addressed them as a priority. Staff member C stated resident #1 had a seizure the previous week and suction was used at that time, and the staff should have cleaned the canister afterwards. Review of the facility's policy, Hand Hygiene, dated 5/21/24, reflected: - . Hand Hygiene Table: - . Between resident contacts. - . Before applying and after removing personal protective equipment, including gloves. - . Before preparing or handling medications; and - . When, during resident care, moving from a contaminated body site to a clean body site. A request was made for a policy specific to intermittent suctioning and equipment maintenance of the suction equipment, but the facility did not have one.

Based on observation, interview, and record review, the facility failed to ensure the resident, and the resident's representative, were made aware of the risks and benefits associated with the use of psychotropic medications prior to the start of treatment for 1 (#32) of 21 sampled residents. Findings include: During an observation on 6/4/25 at 1:05 p.m., resident #32 was ambulating from the dining room towards her room. The resident's gait was slow, and she was using a walker for support. Facility staff had to direct resident #32 towards her room. Review of resident #32's physician orders showed the following psychotropic medications being given to the resident: - 2/11/25 to 3/17/25, Seroquel 25 mg once daily, as needed, for sleeplessness or agitation - 4/29/25 to 5/29/25, olanzapine 2.5 mg twice daily, as needed, for agitation; and, - 5/2/25 to current, sertraline 50 mg daily for mild dementia with psychotic disturbance. Review of resident #32's EHR, accessed between 6/2/25 and 6/5/25, failed to show documentation of the risks and benefits of using the above listed psychotropic medications. During an interview on 6/5/25 at 7:20 a.m., staff member C stated they (the facility) were trying to, hash out a good process for completing the consent with risks and benefits before the psychotropic medication was started. Staff member C stated he was responsible for obtaining this documentation. Staff member C stated if he was out of the office, the forms did not consistently get done. A request was made on 6/3/25, for the consent documents for the resident's Seroquel, olanzapine, and sertraline used for resident #32. None were received prior to the end of the survey.

Based on observation, interview, and record review, the facility failed to fully investigate an allegation of theft to ensure no other residents were affected for 1 (#34) of 21 sampled residents. Findings include: During an observation and interview, on 6/2/25 at 2:35 p.m., resident #34 was in her power wheelchair having a difficult time grabbing the handle and speaking. Resident #34 stated she had several hundred dollars go missing from her purse in her drawer. She stated she told facility management, and they reimbursed her $100.00 of the money missing, but did not tell if they found out who took the money. During an interview on 6/3/25 at 2:48 p.m., NF4 stated resident #34 had $300.00 go missing from her purse in her room. NF4 stated he did not realize she had cashed a check when he transferred resident #34 from the hospital to the facility as she normally would not have that amount of cash on her person. NF4 stated she kept a purse unzipped due to it being too hard to zip shut. NF4 stated the facility informed him they would be conducting an investigation. NF4 stated other than reimbursing resident #34 for $100.00, he did not know of the investigation conclusion. NF4 stated he did not know where the money was located currently, the facility made him bring in a lockbox. During an interview on 6/4/25 at 8:15 a.m., staff member J stated resident #34 initially reported the theft to her. She looked in resident #34's drawer and only found an envelope that did not match the description from the resident. Staff member J stated she told the facility administrator, and they took over investigation. During an interview on 6/4/25 at 8:58 a.m., staff member A stated all the information for the theft allegation by resident #34 was provided. Staff member A stated it was reported three days after it could have happened and at least 50 people could have been in and out of her room in that time. Staff member A stated they did not interview anyone that could have been in the room. Staff member A stated they did not interview or review any other residents for potentially being affected. Staff member A stated the initial allegation reported to her was $200.00, then on interview with resident #34, it was said to be $300.00. Staff member A stated they told resident #34's son to bring a lockbox ,but she was not sure if he brought one in. Staff member A stated they had some money in a slush fund so they gave resident #34 $100.00. Staff member A stated she reported the allegation to the local police, and they said they doubted they would find who stole the money. During an interview on 6/4/25 at 12:35 p.m., staff member I stated she was in training to do allegations of abuse reporting, and worked collectively with the administrator and nurse manager ,to determine what to report and investigate. Staff member I stated resident #34's son was visiting when they were notified of the theft allegation, and she was in on the discussion notifying him. Review of the facility reported incident initially reported on 4/8/25, showed resident #34 reported the allegation of theft from her purse of $200.00 to staff member J and another nurse. The nurses checked her room without finding the money so they reported the theft allegation to administration. Resident #34's purse was zipped shut and missing an envelope of money. Resident #34 never zipped her purse shut. Local law enforcement was notified, and both the facility and law enforcement told the resident it was unlikely to be found. No further investigation was provided as the facility did not interview any other potential victims or witnesses to determine who stole the money, who else could have missing money, or for the determination of any trending of missing items.

Based on observation, interview, and record review, the facility failed to utilize a system for identifying root causes for falls, and failed to develop and implement individualized fall prevention strategies for 1 (#32) of 21 sampled residents. Finding include: During an observation on 6/4/25 at 1:00 p.m., resident #32 was seen ambulating with a walker and accompanied by an unknown staff member. The resident required verbal cues to locate her room. Review of resident #32's nursing progress note, dated 12/11/25, showed the resident sustained an unwitnessed fall in her room. The note failed to show any contributing factors or possible causes for the fall. Review of resident 32's nursing progress note, dated 3/26/25, showed the resident had an unwitnessed fall and was complaining of knee pain. The note failed to show any contributing factors or possible causes for the fall. Review of resident #32's nursing progress note, dated 5/31/25, showed the resident sustained an unwitnessed fall in her room. The note failed to show any contributing factors or possible causes for the fall. Review of resident #32's EHR, accessed on 6/4/25, failed to show any documentation in the available and provided records for the identification of the root causes for the resident's falls. During an interview on 6/4/25 at 10:13 a.m., staff member B stated she felt she needed further training in root cause analysis and had struggled to understand the root cause process. Review of resident #32's At Risk for Fall care plan, dated 2/7/25, showed the resident was at risk for falls and had interventions which included, assist resident with ambulation and transfers, call light available, notify provider if fall occurs, and initiate neurological and bleeding evaluations if a fall occurs. The careplan failed to show interventions reflective of the root cause of the fall on 12/11/25. Review of resident #32's Fall care plan, dated 3/27/25, showed the resident had an actual fall and interventions to monitor for changes for 72 hours and provide activities which promote exercise and strengthening. The careplan failed to show interventions reflective of the root cause of the fall on 3/26/25. Review of resident #32's care plan, dated 5/4/25, showed the resident was at risk for falls and had family and resident education regarding safety, ensure proper footwear, and refer to therapy, as needed, for interventions. Review of the facility's policy titled, Fall Prevention Program, with a revision date 5/14/24, showed the facility had two risk protocols. The low to moderate fall risk protocol identified basic intervention such as limiting clutter, make sure the bed is at it's lowest level and locked, adequate lighting, assistive devices in good repair, and monitoring residents for changes in gait, mobility, and balance. The high risk protocol contained all of the low to moderate risk interventions, increased frequency of rounds, scheduled ambulation or toileting assistance, therapy referrals, and interventions which addressed any unique risk factors.

Based on observation, interview, and record review, the facility failed to have policies for dialysis care and management, policies for dialysis transportation, a contract and communication with the dialysis center providing dialysis treatment, and failed to have proper dialysis monitoring of the resident before and after dialysis appointments, for 1 (#207) of 1 sampled resident for dialysis. Findings include: During an observation and interview on 6/4/25 at 8:04 a.m., staff member J stated resident #207 was on dialysis and stated the resident's electronic chart would show orders for the dialysis, and resident #207 went twice a week, leaving at 10:30 a.m. Staff member J pulled up the chart of resident #207, and the orders did not show resident #207 was on dialysis, when he was to go to dialysis, or any monitoring for his dialysis. Staff member J stated she would get the order input into the chart, but knew she added the dialysis information to resident #207's care plan. Staff member J stated the facility did not transport resident #207, there was a non-emergent ambulance service setup prior to his admission. Staff member J stated she was unaware of any communication with the dialysis center or facility monitoring of resident #207 as she was under the impression dialysis managed monitoring for resident #207. Staff member J provided the hard copy chart for resident #207, in which only a form titled, Physician Certification for Ambulance Services, with the dialysis center name and reason for the ambulance transport as hip fracture and dialysis with inability to tolerate sitting up during transport, and it was signed on 5/29/25. During an interview on 6/4/25 at 7:39 a.m., resident #207 was observed in a reclined chair, with a bed sheet over him. Resident #207 stated he was going to dialysis that day. He stated he had been receiving dialysis treatment through a dialysis port. He stated there was transport setup for him before he left the hospital. He did not have food brought with him for lunch from the facility, but he preferred to eat after returning, rather than trying to bring food with him. During an interview on 6/4/25 at 8:42 a.m., NF5 stated resident #207 was going to the dialysis center for a while and had transport figured out prior to his hospital discharge as to not miss a treatment. NF5 stated resident #207 had dialysis three times a week, and dialysis did clinical assessments per their policy, and did pre and post dialysis weights as part of the process. All of the information was documented in their electronic medical records, but he was not aware of anything they sent to the facility. During an interview on 6/5/25 at 10:29 a.m., NF2 stated she was not aware of any policies for the facility on dialysis residents. During an interview on 6/5/25 at 11:04 a.m., staff member B stated the facility had no contract or policies for dialysis and had not been monitoring resident #207 for his pre and post dialysis care. Staff member B stated they admitted resident #207 without realizing they had a lot of missing parts of the process. Review of the entrance conference information provided by the facility, on 6/3/25, showed the facility had no policy for dialysis monitoring and management, no policy on transportation to and from dialysis, and no contract with the dialysis provider. Review of resident #207's electronic medical record and hard copy chart, reviewed on 6/5/25, showed he was admitted on [DATE]. The only weight entered was on his admission day. There were no physician orders for dialysis appointments or monitoring the resident's pre and post dialysis status. There was only a care plan area showing he was on dialysis and a non-emergent transport ambulance service for dialysis. A request was made for the nursing monitoring, completed by the facility, for #207's pre and post dialysis status, since admission, a dialysis and transportation policy, and the dialysis contract was requested on 6/4/25. The items were not provided by the end of the survey.

Based on observations and interviews, the facility failed to provide residents with meals with no more than 14 hours between the evening meal and breakfast; failed to provide a nourishing snack at bedtime; and failed to document a resident group approval of the mealtime hours for 7 (#s 2, 9, 17, 18, 19, 21, and 28) of 13 sampled residents. This practice had the potential to affect all residents who receive meals from the dining service. Findings include: During an observation on 7/2/24 at 8:20 a.m., breakfast began to be served in the dining room. The sign posted on the entry to the dining room showed breakfast was to start at 8:00 a.m., lunch at 12:00 p.m., and dinner at 5:00 p.m. The times scheduled included a 15-hour gap between dinner and breakfast. Residents #21 and #28 were sitting together in the dining room waiting for their meal to arrive. Resident #21 stated she was very hungry. When asked, residents #21 and #28 stated they did not receive snacks at night, before bed. Resident #21 stated they had never been offered snacks at bedtime as far as she could recall. Resident #28 stated she had not been offered snacks at bedtime either, but was aware of the snacks in the refrigerator at the nursing station. Residents #17 and #18 were sitting at a different table. Resident #18 called the surveyor to her table and stated, I don't know about any snacks. Resident #17 stated, They don't come offer snacks to me or my roommate either. I know about snacks in the nurses' station, but I'm blind so I cannot go get them, and those poor girls are so busy at night getting everyone ready for bed, so I don't go there (requesting a snack). During an interview on 7/2/24 at 8:28 a.m., staff member F stated, We don't go around specifically asking about snacks, but we have health shakes for the weight loss people. It's a pretty late breakfast compared to other facilities I have been in. Offering snacks at night would be hard since we are rushing to get meds (medications) in, since residents all want to go to bed right after dinner. Very few stay up long enough to be offered a snack. During an interview on 7/2/24 at 10:13 a.m., staff member C stated, There should only be 14 hours between dinner and breakfast. I thought we did something to change that to ensure the 14 hours was met. I will have to follow-up with the kitchen. During an interview on 7/2/24 at 11:26 a.m., staff member G stated the mealtimes had always been 8:00 a.m., 12:00 p.m., and 5:00 p.m. Staff member G stated the kitchen stocked the nurses' stations with snacks, but it was up to nursing to offer the snacks. During an interview on 7/2/24 at 11:35 a.m., staff member A stated residents did not want the mealtimes changed when they were asked in the past. Staff member A stated she was not able to locate documentation of resident council approving the mealtimes. Staff member A stated, The nurses' stations are stocked with snacks and residents can ask for a snack. Staff aren't going around in the evening asking them if they (residents) want a snack. During an interview on 7/2/24 at 1:25 p.m., resident #s 2, 9, 17 and 19 stated they did not get offered snacks in the evening before bedtime. The residents stated if they ask for a snack they will get one, but it is usually pop and crackers.

Based on observation, interviews, and record review, the facility failed to ensure implementation and monitoring of measures to prevent the growth of Legionella or other opportunistic waterborne pathogens in the building's water systems; and maintain cleanable surfaces on ice/water dispenser machine. This practice had the potential to affect all residents. Findings include: 1. During an observation on 7/1/24 at 3:30 p.m., the ice/water dispenser, on the rehabilitation unit, was dirty with a black film, white mineral deposits and rust on the tray where you place the cups and along the bottom wall of the dispensing area. The dispenser tray was no longer cleanable. 2. During an interview on 7/2/24 at 7:10 a.m., staff member H stated, I haven't been documenting anywhere that we do flushes or clean the ice machines. Maybe [staff member B] does that, he may be going around and flushing the lines and documenting. I've been here [AGE] years, and have never been asked about documentation, so I don't have any. During an interview on 7/2/24 at 8:30 a.m., staff member B stated, I have a water management plan binder, but it looks like you got me, we haven't been documenting and doing all the tasks (for Legionnaires prevention). We have the binder, but it's not fully implemented obviously. A review of the facility's, Risk Management Plan for Legionella Control, dated 1/25/23, reflected: . Section 3 Risk Management 3.1 9). Less Frequently Used Areas: . .All documentation is housed in the maintenance department and is available upon request. . 3.2.1 Operational Monitoring: Internal facility logs will be used to monitor implementation of control measures. Effectiveness of the control plan will be monitored through infection control surveillance

Based on interview and record review, the facility failed to maintain scale equipment, resulting in a fall with an injury, for 1 (#28) of 2 sampled residents. Findings include: Review of an incident for resident #28, dated 2/21/23, showed, Upon entry into room resident was on all fours on the floor with a pool of blood near left leg .Was in the chair scale and fell out when a wheel fell off, Resident thinks she hit her head . [sic]. During an interview on 6/7/23 at 10:16 a.m., staff member F stated resident #28 required assistance with transfers and had a history of falls. During an interview on 6/7/23 at 10:58 a.m., staff member A stated the facility did not have maintenance records for the chair scale, and staff member A did not know why staff did not notify maintenance of any previous issues with the chair, before resident #28's fall on 2/21/23. Staff member A stated maintenance fixed items as needed in the facility. During an interview on 6/7/23 at 12:38 p.m., staff member G stated she recalled the incident with resident #28's fall from the scale chair. Staff member G stated the wheel came off the leg of the chair, and she fell out. Staff member G stated if something was wrong with a piece of equipment in the facility, work orders were given to staff member E. During an interview on 6/7/23 at 12:40 p.m., staff member E stated the chair scale was not checked or maintained annually, and there was not a schedule to check the chair's function. Staff member E stated he was called to fix the chair scale after the incident with resident #28 on 2/21/23, and the wheel had come loose. There was no schedule for maintenance created for the chair after the incident. During an interview on 6/8/23 at 8:02 a.m., staff member A stated she did not know if resident #28's fall on 2/21/23 was a QAPI discussion, as it was viewed as a fluke. Staff member A stated she thought an informal education was done for staff to check equipment moving forward, but nothing was documented. Review of resident #28's Emergency Department Provider Notes, dated 2/21/23, showed the resident had the following injury from the fall from the chair scale: Complex 12 cm laceration overlying the left lower leg. This penetrates into the subcutaneous tissue .Repair method: Sutures .Number of sutures: 20. A review of the facility's policy, Preventative Maintenance Program, dated 8/19/22, showed, 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on record review, staff and resident interviews, and observations, the facility failed to prevent injury to the resident as a result of intermittent catheterization and the facility continued catheterization in the presence of an injury without interventions to reduce discomfort and pain for 1 (#6) of 15 sampled residents. Findings include: Resident #6 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the medical record showed evidence that resident #6 was admitted to the facility with an indwelling catheter that was removed on 4/10/14. A communication via fax between the facility and the physician on 4/8/14 showed evidence that the physician ordered the removal of the indwelling catheter and that staff were to monitor bladder levels. The facility did not have a bladder scanner to test bladder levels, so nursing staff requested an order for [REDACTED]. The Daily Skin Integrity Record, dated 4/11/14 through 4/21/14, showed evidence of an injury to the tip of the penis near the meatus. The Skin Integrity Nurses Note dated 4/12/14, showed evidence that the injury was "possibly from foley catheter." The facility did not provide evidence that the physician had addressed the injury or interventions to treat the injury. The Skin Integrity Nurses Note showed evidence that the resident reported pain with intermittent catheterization and application of iodine. The Skin Integrity Nurses Note showed monitoring for s/s of infection/progression as the treatment. The medical record did not address the resident's level of pain and/or discomfort during the healing process. The Daily Skin Integrity Record addressed the appearance of the injury but did not show evidence of any interventions for pain management. Review of the medication record showed evidence that on 4/11/14, the resident was to be intermittently catheterized two times daily and as needed. The record showed that resident #6 was catheterized 23 times in a 9 day period with output ranging from 600 to 1400 cc of urine during each catheterization. Beginning on 4/19/14, the record showed that the resident was to be catheterized four times daily. Documentation showed he had been catheterized 10 times in 3 days with output ranging from 245 to 1350 cc or urine. There was no documentation in the medical record regarding pain related to the repeated catheterization. Communication via fax with the resident's physician dated 4/17/14 showed evidence that the resident was complaining of increasing pain with intermittent catheterization. The fax showed evidence that the facility had requested an increase in the number of times per day for catheterization, but did not request anything for pain relief. Staff member B, the DNS, stated during an interview on 4/24/14 that the injury to the resident's genital area was a, "result of intermittent catheterization." She reported that, "to my knowledge" the nursing staff had not tried any interventions for pain management prior to each catheterization. Staff member B stated that the resident's pain control during catheterization, "wasn't the best." Review of the medication record showed evidence that resident #6 was treated for [REDACTED]. Resident #6 stated during an interview on 4/24/14 that it, "hurt a lot" while he was catheterized and also reported that he didn't look forward to it, "especially the stuff they used to clean it." Daily nurses notes from 4/11/14 through 4/22/14, did not show evidence that the facility addressed the pain experienced by resident #6 related to intermittent catheterization or made any attempts to minimize his discomfort during process.