Every finding on record at Gardens of North Olmsted

Based on observation, medical record review, resident interview, staff interview, law enforcement interview, sexual assault nurse examiner (SANE) interview, certified nurse practitioner (CNP) interview, therapeutic provider interview, review of witness statements, review of a local police department report, review of hospital and emergency department (ED) records, review of a self-reported incident (SRI), review of an electronic mail (email) correspondence document, and review of a facility policy, the facility failed to protect Resident #1's right to be free from sexual abuse by Resident #76. This resulted in Immediate Jeopardy and Actual Harm (serious injury) beginning on 07/27/26 at 2:23 P.M., when Resident #76, who had a history of hyper-sexual stimulation, engaged in non-consensual sexual contact with Resident #1. Resident #76 placed his finger inside Resident #1's vagina while Resident #1 was lying in her bed. Resident #1 repeatedly asked Resident #76 to stop and that he was hurting her. Resident #76 did not stop and continued to assault her with his finger for approximately 10 minutes until Resident #1 loudly told Resident #76 to stop, causing Resident #76 to stop and leave the room. Resident #1 was transported to the local hospital ED, received an examination, and was found to have vaginal bleeding, a severe vaginal laceration, and vaginal soreness. This affected one (Resident #1) of three residents for abuse. The census was 75. On 08/04/26 at 11:16 A.M., the Administrator and Regional Director of Clinical Services (RDCS) #200, were notified Immediate Jeopardy began on 07/27/26 at 2:23 P.M. when the facility failed to protect Resident #1's right to be free from sexual abuse by Resident #76. The Immediate Jeopardy was removed on 07/29/26 when the facility implemented the following corrective actions:- On 07/27/26 at 5:47 P.M., the Administrator was notified of an allegation regarding a resident being inappropriately touched. - On 07/27/26 between 6:15 P.M. and 6:27 P.M., the Administrator began interviewing all female residents with Brief Interview for Mental Status (BIMS) scores higher than 13 (indicating intact cognition) and nurses began skin checks on female residents with BIMS scores of 12 and under (indicting impaired cognition). All assessments and interviews revealed no concerns.- On 07/27/26 between 6:15 P.M. and 6:27 P.M., the facility placed Resident #76 on a one-on-one observation.- On 07/27/26 at 6:36 P.M., Regional Director of Clinical Services (RDCS) #200 completed a head-to-toe assessment on Resident #1. - On 07/27/26, between 6:47 P.M. and 10:36 P.M. a head-to-toe assessment was completed, and Resident #1 had a Braden assessment, a pain assessment, a dental assessment, a weekly skin check completed, and her vital signs were checked. At 10:36 P.M. the facility sent Resident #1 to the hospital for an evaluation.- On 07/27/26 at 6:53 P.M., RDCS #200 called the police. - On 07/27/26 at 6:56 P.M., RDCS #200 completed a head-to-toe assessment on Resident #76. - On 7/27/26 at 7:03 P.M., Medical Director #219 was notified by the Administrator and Resident #76's Guardian was made aware of the incident by RDCS #200.- On 07/27/26 at 8:07 P.M., a self-reported incident (SRI) was initiated by the Administrator, and interviews were completed by the Administrator on all residents with BIMS scores above 13. The Director of Nursing (DON) completed skin assessments on all residents with BIMS scores of 12 and below.- On 07/27/26, a root cause analysis was completed by the Administrator and the facility concluded Resident #1 was in a consensual relationship with Resident #76 in the past which, according to Resident #1, had ended about a month prior. However, the facility failed to complete a comprehensive assessment and develop individualized care plans addressing the relationship, resident preferences, and staff guidance. The facility lacked a process to assess, document, and care plan consensual intimate relationships between residents, resulting in inconsistent staff understanding and management of the relationship.- On 07/27/26, education began by RDCS #200 and was targeted at all facility staff. The facility educated all staff on the abuse policy, including identifying abuse, reporting abuse, and interventions. Staff are to report to management any concerns of increased sexual behaviors or verbalization of desire. All staff were educated by 07/28/26. - On 07/28/26, Unit Manager/Licensed Practical Nurse (LPN) #220 completed a review of each resident's diagnoses with no residents noted with diagnoses related to hypersexual behaviors.- On 07/28/26, Minimum Data Set (MDS) #221 completed a review of all resident care plans for hypersexual behaviors.- On 07/28/26, Psychiatric Certified Nurse Practitioner (CNP) #204 was notified of the allegation.- On 07/28/26, the DON completed a psychosocial follow up for Resident #1. - On 07/28/26, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the system change as a result of the root cause analysis and education provided to staff. Staff members in attendance included Medical Director #219, the Administrator, the DON, Unit Manager/LPN #220, Activities Director #222, Dietary Manager #224, Maintenance Director #223, LPN #207, and Housekeeping Supervisor #212.- On 07/28/26 at 10:15 A.M. Resident #76 was moved to a different room and remained on one-on-one observation.- Beginning on 07/28/26 the facility implemented a plan for any resident with hypersexual behaviors would be seen by psychiatric services immediately and hyper-sexual behaviors would be care-planned with interventions. - Beginning on 07/28/26, all investigations of alleged abuse would be reviewed by RDCS #200 for a thorough investigation and proper interventions for four weeks.- Beginning on 07/28/26, nursing management would review any new admission, readmission, referrals, and review of the 24-hour report for all in-house residents, and will be audited by the DON or designee, for increased sexual behaviors or verbalized desire to ensure proper interventions and monitoring are in place and care planned. This will occur five times per week for four weeks. - Beginning on 07/28/26, an audit of five random residents with a BIMS score of 13 and above will be interviewed and five random residents with a BIMS score of 12 and below will be assessed for abuse by the DON or designee five times per week for four weeks.- On 07/29/26, Resident #76 was transferred from the facility, and his guardian was updated by the Administrator. - Interviews on 08/05/26 between 10:55 A.M. and 1:05 P.M. with LPNs #207 and #209 and Certified Nurse Aides (CNAs) #213, #214, #215, #216, and #217 revealed they received abuse training within the past week and were able to state the appropriate procedure to follow if they witnessed or were aware of an abuse situation involving a resident. Although the Immediate Jeopardy was removed on 07/29/26, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.Findings include:Review of Resident #1's medical record revealed an admission date of 07/30/25 with diagnoses including type two diabetes mellitus with diabetic polyneuropathy, bipolar disorder, generalized anxiety disorder, and suicidal behavior.Review of Resident #1's care plan revised 05/14/26 revealed Resident #1 had alterations in mood and behaviors related to diagnoses of bipolar disorder, anxiety, history of polysubstance abuse, and history of suicidal ideation. The goal for Resident #1 was to maintain her baseline mood without decompensation through the review date. Interventions included educating the resident on interventions for triggers and reassurance; notifying the physician of changes/decline with mood triggers; psychiatric consultation and treatment as ordered; and administering medications as ordered. Further record review revealed no documented evidence of what the resident's triggers were or what individualized and comprehensive interventions were to be implemented to address triggers. Review of Resident #1's care plans dated 07/30/25 through 08/04/26 revealed no evidence of a care plan for past physical and sexual abuse or a plan of care related to sexual activity. Review of Resident #1's care plans dated 07/30/25 through 07/27/26 revealed care plans were initiated related to the resident's behaviors, but none related specifically to manipulative behavior or false accusations.A psychiatric note dated 09/11/25 revealed no mention of sexual activity or sexual relations with other facility residents. Review of Resident #1's medical record including progress notes, psychiatric notes, and care plan dated 05/07/26 through 07/27/26 revealed no evidence Resident #1 had a consensual sexual relationship with any other facility resident(s), including Resident #76. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. Resident #1 was independent with activity of daily living (ADLs) and was always continent of bowel and bladder. Resident #1 felt down, depressed, hopeless, had trouble falling or staying asleep, felt tired, and was feeling bad about herself for seven to eleven days over the last two weeks. Resident #1 did not reject care during the seven-day assessment look-back period.Review of Resident #1's Therapeutic Behavioral Specialist/Community Psychiatric Supportive Treatment (TBS/CPST) note dated 07/27/26 at 10:32 A.M. included TBS #205 wrote that Resident #1 opened up about an incident at the facility that made her uncomfortable. After problem solving with TBS #205, Resident #1 decided to open-up to the facility about the situation.Review of Resident #1's progress note dated 07/27/26 at 6:47 P.M. revealed Resident #1 notified the facility of an incident. A head-to-toe assessment was completed. Resident #1 denied pain or discomfort. The police were notified of the incident, Resident #1's physician was notified, and a new order was given to send Resident #1 to the ED for evaluation.Review of Resident #76's medical record revealed an admission date of 01/12/26 with diagnoses including Parkinsonism, schizoaffective disorder, bipolar type, anxiety disorder, and major depressive disorder. Resident #76 had impairment of speech, orientation, motor behavior, thought process, affect, memory, concentration and comprehension, and judgement. Review of Resident #76's progress note dated 05/23/26 at 3:00 P.M. revealed the resident complained of feeling super anxious and was hyper-sexually stimulated. Resident #76 stated, I need help. Resident #76's physician was notified and orders were given to send the resident to the local hospital ED for evaluation and treatment. Review of Resident #76's hospital documentation revealed the resident was admitted to the hospital on [DATE] and remained hospitalized through 06/02/26. Hospital documentation included that Resident #76 was increasingly sexually preoccupied, and he felt like the thoughts were overwhelming he needed to constantly have sex. The hospital documentation included Resident #76 had sex at the facility with various other people and indicated these encounters were usually consensual, and he was not sure if he was being too aggressive in some cases. Resident #76 reported escalating sexual urges, and he had difficulty controlling these impulses. Resident #76 identified he felt like he was pushing himself too hard regarding wanting a relationship and wanting things to happen quickly. On 06/01/26 at 2:43 P.M. a progress note revealed Resident #76 had no frank sexual preoccupation. On 06/02/26 the resident was re-admitted to the facility.Review of a facility self-reported incident (SRI), tracking number 277356, dated 07/27/26 at 7:56 P.M. revealed the facility reported an allegation of sexual abuse. The SRI included the facility had received communication from outside source regarding an alleged sexual assault by resident (first name noted). No victim alleged. The initial source of the allegation was noted to be visitor/family. As a result of an investigation, the facility unsubstantiated an incident of sexual abuse. Review of Resident #1's facility witness statement dated 07/27/26, with no time documented, revealed the statement was written by RDCS #200 based on an interview with Resident #1. At approximately 4:00 P.M. on 07/27/26, Resident #76 knocked on Resident #1's door and Resident #1 told him to come in and that the birds were out. Resident #1 was lying in bed and Resident #76 was standing and talking to Resident #1. Resident #76 became wobbly on his feet and Resident #1 told him to have a seat on a chair at the end of the bed. Resident #1 sat down and the two of them started talking about their day. Resident #76 gave Resident #1 a two-liter bottle of soda and placed it on the bedside table. Resident #1's foot was out of the blanket and Resident #76 started tickling her foot. Resident #1 told Resident #76 to stop tickling her foot then he began to move his hand up her leg as he was pretending to tickle her. Resident #1 told Resident #76 to stop when he penetrated her vagina with two of his fingers. Resident #1 told Resident #76 he was hurting her and he removed his two fingers. Resident #1 told him she was going to sleep and he just left. Review of Resident #76's facility witness statement dated 07/27/26, with no time documented and written by RDCS #200, revealed Resident #76 left the facility around 1:00 P.M. on 07/27/26, to go to the store and he asked Resident #1 if she would like to go. Resident #1 was with Therapeutic Behavioral Specialist (TBS) #205 and did not go to the store with him. When Resident #76 returned from the store, he knocked on Resident #1's door, she answered, and told him her birds were out, then she laid in bed and covered herself and talked about her day. Resident #76 gave Resident #1 a two-liter bottle of soda that he bought her from the store. Resident #1 and Resident #76 talked until Resident #1 said she was going to go to sleep. Resident #1 put the birds away and Resident #76 took it as his cue to leave her room. Resident #76 revealed at no time did he make sexual contact with Resident #1. Review of a local police department incident/offense report revealed a call was received on 07/27/26 at 8:54 P.M. and police officers arrived at the facility on 07/27/26 at 9:18 P.M. for reports of a sex crime. Upon arrival at the facility, RDCS #200 told the police officers Resident #1 reported to staff she was sexually assaulted by Resident #76 in the afternoon of 07/27/26. Patrolman #201 was told by staff that Resident #1 requested to be transported to the hospital to have a sexual assault kit done. Resident #1 explained to Patrolman #201 that Resident #76 knocked on her door on 07/27/26 at approximately 4:00 P.M. Resident #1 indicated she told Resident #76 her birds were out of their cage and Resident #76 entered her room and closed the door. Resident #76 gave Resident #1 a two-liter bottle of soda. Resident #1 was lying in bed and was completely covered from head to toe with a blanket and Resident #76 stood by the bed talking to her. Resident #76 seemed unsteady on his feet and Resident #1 offered him a chair to sit on that was near her bed. Resident #1 and Resident #76 talked. and Resident #76 randomly got up from the chair and started to tickle her foot that was sticking out of the blanket. Resident #76 continued to touch Resident #1 and began to move his hand up her leg and eventually touched her vagina. Resident #1 asked him to stop because it hurt, but Resident #76 continued to touch her vagina for approximately ten minutes. Eventually, Resident #1 was able to get Resident #76 to stop after she again stated to him that he was hurting her. Resident #1 told Resident #76 she was going to go to sleep, and Resident #76 left the room. Resident #1 indicated she had been abused before and was sexually assaulted in the past. Resident #1 was transported to the local hospital after a written statement was obtained because she requested to have a sexual assault kit completed. The police report included Resident #1 and Resident #76 were in a relationship in the past, but the relationship ended a month ago. (The report did not include the specifics of the type of relationship). Information contained in the police report included none of the sexual touches were consensual. Review of Resident #1's hospital ED notes for an admission [DATE] through 07/28/26 revealed Resident #1 reported being in her room at the facility when a known male (Resident #76) entered her room and sexually assaulted her. Resident #1 presented to the ED from the facility for evaluation of a sexual assault. Resident #1 indicated just prior to arrival that she was in her room, another resident came into her room, sat down in a bedside chair, and then began touching her feet, legs, and her vaginal area. Resident #1 revealed Resident #76 placed a finger inside her and assaulted her with his finger for approximately 10 minutes. There was minimal amount of bleeding immediately after, Resident #1 did not have persistent bleeding, and reported a mild burning pain at that time. Further review revealed Resident #1 was positive for vaginal bleeding and vaginal pain. Resident #1's differential diagnoses were sexual assault and severe vaginal laceration. Interview on 07/30/26 at 11:06 A.M. with TBS #205 revealed she worked with psychiatric services and was not a counselor but offered support for Resident #1. During the interview, TBS #205 shared Resident #1, Resident #76, and Resident #77 were friends and used to hang out together. Resident #77 passed away a few months ago, and Resident #1 was very upset about the loss of her friend. Resident #1 told TBS #205 that Resident #76 wanted to rub her feet at times and would give money to her. Resident #76 would do the same thing to Resident #77. Resident #1 did not really like it and found it annoying, but it did not make her uncomfortable, so TBS #205 revealed she never reported the behavior. TBS #205 indicated on 07/27/26 she visited Resident #1 around 10:30 A.M. TBS #205 stated she was leaving Resident #1's room after talking to her a second time around 2:30 P.M., the birds were out in the room, and Resident #1 told her she was going to sleep. When TBS #205 left the room, she saw Resident #76 heading for Resident #1's room and told him Resident #1 wanted to sleep and her birds were out. TBS #205 indicated she left the facility after she talked to Resident #76. When TBS #205 returned to the building on 07/28/26, she was told by a staff member that Resident #76 assaulted Resident #1. TBS #205 revealed she was told Resident #76 walked into Resident #1's room when she was asleep, he touched her and his hand was in Resident #1's vagina, and she told him it hurt and to get off her. TBS #205 revealed Resident #1 never told her she had any previous sexual interactions with Resident #76. On 07/30/26 at 11:43 A.M. Resident #1 was observed lying in bed in her room and was completely covered by a blanket from head to foot. Upon the surveyor entering the room, Resident #1 uncovered her head, was pleasant, and was able to answer questions appropriately. Interview with Resident #1 at the time of the observation revealed on 07/27/26 she was sleeping in her room and was sexually assaulted. Resident #1 indicated TBS #205 was visiting her and when she left the room Resident #76 came in and sat in a chair. Resident #1 stated Resident #76 talked to her, then he tickled her foot and she said, No, but he would not stop. Resident #76 went higher and stuck his finger into her vagina. Resident #1 told Resident #76 he was hurting her and to please stop. Resident #76 did not stop for approximately 10 minutes, and Resident #1 told him approximately three times to stop and he was hurting her, but he did not stop. Resident #1 stated Resident #76 was getting more forceful each time she told him to stop. Resident #1 stated she told Resident #76 he was hurting her and the last time she told him to stop she said it much louder, and Resident #76 finally stopped and left her room. Resident #1 stated she thought Resident #76 stopped because he thought someone might hear her. Resident #1 revealed she did not want to tell anyone what happened because anything that happened at the facility, Goes around the gossip mill. Resident #1 stated she was also afraid everyone would think it was her fault and blame her. Resident #1 stated after the incident on 07/27/26, she texted her friend (who did not live at the facility) about what happened and he contacted the facility and told them what happened. The Administrator then came to Resident #1's room after her friend called the facility, the police were called, and Resident #1 went to the ED to have a rape kit done. During the interview, Resident #1 indicated she had a camera in her room and Detective #206 took the video camera footage to review but had not brought it back.Interview on 07/30/26 at 3:14 P.M. with the DON revealed all she knew about the incident (that occurred on 07/27/26) between Resident #1 and Resident #76 was that he touched her inappropriately and she did not like it. The DON indicated she was at home when it happened and the Administrator and RDCS #200 handled most of it. The DON stated Resident #1 was transported to the hospital for a work-up, and Resident #76 was put on one-to-one supervision. The DON revealed she had no knowledge of Resident #76 touching residents or staff inappropriately. The DON stated following the incident, Resident #76 was transferred to a sister facility because he could not be in the same building as Resident #1. Interview on 07/30/26 at 3:18 P.M. with the Administrator revealed (on 07/27/26) Resident #1 said she was touched inappropriately. The Administrator indicated Resident #1 told her Resident #76 was dropping off groceries, he took a seat, and he was being playful and tickled her feet. Resident #76 went higher and Resident #1 said she was uncomfortable. The police came to the facility. The Administrator stated Resident #76 did not do anything like this before and he did not talk about sexual thoughts regarding other people. The Administrator revealed she was aware Resident #76 liked to pleasure himself but stated she was not aware if he had consensual sex with other residents. The Administrator indicated Resident #76 came to her in May 2026 and said he felt like he could not please himself enough and asked for different medications. Resident #76 was transferred to the hospital. Upon re-admission, the Administrator indicated Resident #76's hospital paperwork should have been reviewed by the facility staff including nursing, admissions and the Administrator, but she did not specify which staff members reviewed the hospital paperwork. The Administrator stated when she talked to Resident #76, she did not know if he understood sexual differences and she stated he did not get erect enough to penetrate for sexual intercourse. The Administrator then indicated Resident #76 had consensual intimacy with Resident #77 who passed away in April 2026, but she did not know if they had sexual intercourse. The Administrator revealed she was not sure if any precautions were put in place when Resident #76 returned to the facility on [DATE]. During a follow-up interview on 07/30/26 at 4:24 P.M. with Resident #1, the resident stated the incident involving Resident #76 (on 07/27/26) made her feel ashamed and she did not say anything right away because she thought everyone would think it was her fault and would blame her. Resident #1 indicated she had abusive relationships in the past and Resident #76 doing what he did made her remember getting beat up, hit, and punched. Resident #1 again stated she was afraid everyone would think it was her fault. She stated she knew it was not her fault, but that was how she felt.During an interview on 07/30/26 at 4:31 P.M. with the Administrator, RDCS #200, and the DON the stated Resident #76 had no relationship with any residents in the facility (this interview was contradictory to the interview with the Administrator on 07/30/26 at 3:18 P.M.). However, RDCS #200 confirmed Resident #76 had been hospitalized and re-admitted on [DATE] after being evaluated/treated for hypersexuality. There were no interventions or safety measures implemented at that time to address the resident's hypersexuality or prevent incidents of sexual abuse. Then the DON indicated when Resident #76 came back from the hospital on [DATE], the facility saw the hypersexual notes and all residents in the facility were interviewed and skin checks were completed. In addition, on 06/03/26 Resident #76 was visited by Certified Nurse Practitioner (CNP) #203 after the hyper-sexual notes were found in his hospital records. The Administrator then indicated she was of the opinion Resident #76 was in a consensual relationship with Resident #1 based on information the residents had provided during an interview on 06/03/26. The Administrator stated she was of the opinion Resident #1 and Resident #76 never had sex, only kissed, and nothing physical happened between them. The Administrator indicated there was no care plan initiated because she was of the opinion this relationship was consensual and there was no need for a care plan. The Administrator stated that while Resident #76 was admitted to the hospital, he had a medication adjustment, and he was seen by CNP #203 on 06/03/26. An additional interview on 08/03/26 at 9:20 A.M. with Resident #1 revealed after the incident on 07/27/26, Resident #1 felt like she had the weight of the world on her shoulders and did not want to leave her room. Resident #1 indicated her anxiety was very high, and she would open her door to make sure there was a nurse aide nearby. Resident #1 stated she had high anxiety and a low dose of fear because Resident #76 was a big guy and could beat the living (expletive) out of her. Resident #1 indicated she did not go to therapy because of the situation. During the interview, Resident #1 stated she was only ever friends with Resident #76 and had never been in a relationship with him. Resident #1 stated she did not know why people kept saying she was in a consensual sexual relationship with Resident #76 because she was never in a relationship with him. Resident #1 stated she saw the police report, and that it was documented in the police report that she had a past consensual sexual relationship with Resident #76 that ended about a month ago. Resident #1, again, stated it was not true.Interview on 08/03/26 at 10:01 A.M. with LPN #207 revealed she was often assigned to work on the nursing unit Resident #1 resided on, and she would see Resident #1 and Resident #76 talk to each other, but she never saw Resident #76 go in Resident #1's room. LPN #207 revealed she had no knowledge of any consensual sexual relations between Resident #76 and Resident #1. Interview on 08/03/26 at 11:30 A.M. with Resident #1 revealed RDCS #200 and the Administrator had asked her if she was in a consensual sexual relationship with Resident #76, and she told them, No, that she was never in a relationship with him. Resident #1 indicated she did not know why things escalated to where Resident #76 thought it was okay to touch her like he did on 07/27/26.Interview on 08/03/26 at 2:27 P.M. with CNA #208 revealed the CNA denied knowledge of any type of (consensual) sexual relationship between Resident #1 and Resident #76. Interview on 08/03/26 at 2:34 P.M. with LPN #209 revealed on 07/27/26 she was assigned to the nursing unit Resident #1 resided on, but she was at lunch and not on the nursing unit when the incident happened. LPN #209 revealed she never saw consensual sexual contact between Resident #1 and Resident #76 prior to 07/27/26 and denied any knowledge the residents being in any type of relationship. Interview on 08/03/26 at 2:41 P.M. with CNA #210 revealed he was aware Resident #1 and Resident #76 were friends, and they were often together and would eat their meals together. CNA #210 was not aware of any relationship other than a friendship between Resident #1 and Resident #76.Interview on 08/03/26 at 2:58 P.M. with Sexual Assault Nurse Examiner (SANE) #211 revealed she examined Resident #1 when she was admitted to the ED on 07/27/26. Resident #1 told SANE #211 she was lying in bed in her room when Resident #76 came stumbling in her room. Resident #1 knew Resident #76 and they were acquaintances. SANE #211 indicated Resident #1 told Resident #76 to have a seat because he was unsteady and the next thing he was on the bed, touching her feet. SANE #211 stated Resident #1 told her the resident told Resident #76, No, as he worked his hand up the resident's leg and the next thing Resident #1 knew his finger was in her vagina. Resident #1 asked Resident #76 to stop, but he would not stop and it lasted approximately ten minutes. SANE #211 stated Resident #1 told her this was the second time this had happened but Resident #1 did not tell anyone the first time because she was ashamed and fearful of being beat up for saying, No. SANE #211 stated when she completed the examination on Resident #1, there was bleeding on the vaginal swabs and Resident #1 complained of vaginal soreness. SANE #211 stated a speculum examination was not done and Resident #1 told her it felt like the area between her vagina and anus had a tear.Interview on 08/04/26 at 8:28 A.M. with Housekeeping Supervisor (HS) #212 revealed Resident #1 and Resident #76 were just friends, and everyone knew that. HS #212 indicated TBS #205 came to the office on 07/28/26 looking for the Administrator and said she felt bad for Resident #1 and wished she had reported what she knew about Resident #76 rubbing Resident #1's feet and offering money. Interview on 08/04/26 at 10:29 A.M. with Detective #206 revealed Resident #1's video footage was being sent to the prosecutor, but it was hard to establish what had happened on 07/27/26 because the video was not constantly running. Detective #206 stated he asked Resident #1 if they (she and Resident #76) had a sexual relationship and she said she had no relationship with Resident #76. Detective #206 indicated Resident #76 told him he had a kind of relationship with Resident #1, but Resident #76 was not specific. Interview on 08/04/26 at 10:30 A.M. with CNP #204 revealed Resident #1 never mentioned Resident #76 during her visits. CNP #204 indicated she visited both Resident #1 and Resident #76, and Resident #76 told her he was in love with someone, but he did not specify who he was in love with and only said she did not treat him right. The CNP revealed Resident #1 never mentioned anything about a relationship or any problems, and CNP #204 felt the resident would have mentioned if there was a relationship because Resident #1 was very open in their conversations.Review of an electronic mail (email) sent from the Administrator dated 08/05/26 at 9:46 A.M. revealed on 07/27/26 Resident #76 entered Resident #1's room at 2:23 P.M. and he left the room at 3:06 P.M.Interview on 08/10/26 at 8:27 A.M. with the Administrator revealed TBS #205 came to the office on 07/28/26 in the morning, RDCS #200 was also present, and TBS #205 indicated she wanted to report an incident that happened between Resident #1 and Resident #76. The Administrator stated TBS #205 was not asked what incident she wanted to report, only if it concerned Resident #1 and Resident #76 and when TBS #205 stated yes she was thanked for reporting the incident and was told the facility was handling it. The Administrator stated TBS #205 was not asked what happened during the incident she came to the office to report.Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, revised 11/01/19, included the facility would not tolerate abuse, neglect, exploitation of its residents or the misappropriation of resident property. Abuse[KA2.1][TM2.2] was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or phys[TRUNCATED]

Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure medications were stored in a safe manner. This affected one resident (Resident #1) of four residents reviewed for medication storage. The facility census was 75. Findings include: Review of Resident #1's medical record revealed an admission date of 07/30/25 with diagnoses including type two diabetes mellitus with diabetic polyneuropathy, bipolar disorder, generalized anxiety disorder, and suicidal behavior.Review of Resident #1's care plan revised 05/14/26 revealed Resident #1 had alterations in mood and behaviors related to diagnoses of bipolar disorder, anxiety, history of polysubstance abuse, and history of suicidal ideation. The goal was for Resident #1 to maintain her baseline mood without decompensation through the review date. Interventions included educating the resident on interventions for triggers and reassurance; notify the physician of changes/decline with mood triggers; psychiatric consultation and treatment as ordered; and administer medications as ordered.Review of Resident #1's Nursing Admit/Readmit No Care Plan dated 06/12/26 revealed Resident #1 did not wish to self-administer her medications.Review of Resident #1's orders dated 06/12/26 revealed the resident was ordered Zofran (ondansetron) oral tablet four (4) milligrams (mg) with instructions to give 4 mg by mouth every eight hours as needed for nausea.Review of Resident #1's medication administration record (MAR) dated 06/12/26 through 08/03/26 did not reveal evidence Resident #1 was administered Zofran 4 mg for nausea. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. Resident #1 was independent with activities of daily living (ADLs) and was always continent of bowel and bladder. Resident #1 felt down, depressed, hopeless, had trouble falling or staying asleep, felt tired, and was feeling bad about herself for seven to 11 days over the last two weeks. Resident #1 did not reject care during the seven-day assessment look-back period.Observation and interview on 08/03/26 at 9:20 A.M. revealed Licensed Practical Nurse (LPN) #207 entered Resident #1's room to administer her medications. Resident #1 pointed to a small white pill on her bedside table and stated, I want to know what the (expletive) the pill was that was given to me over the weekend for the past three days. The small, oval white pill had an F written on one side and a nine (9) and a one (1) on the other side. Resident #1 indicated she took the pill two times and the third time it fell out of her mouth when she tried to take it. LPN #207 identified the medication as Zofran (ondansetron hydrochloride) 4 mg and stated it was ordered as needed and was a medication for nausea. LPN #207 confirmed Resident #1 had the pill in her room at the time of the observation. Interview on 08/10/26 at 5:11 P.M. with the Director of Nursing (DON) revealed nurses should not leave the resident until all their medications were administered. The DON indicated the nurse should have stayed with Resident #1 to ensure her medications was administered.Review of the facility policy titled, Storage of Medications, revised 04/2007, revealed the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug and bioloigcals shall be stored in the packaging, containers or other dispensing systes in which they are received.This deficiency represents an incidental finding discovered during the complaint investigation.

Based on observation, medical record review, resident and staff interview, and facility policy review, the facility failed to ensure an anti-nausea medication ordered to be administered as needed was given to a resident with adequate indications for use. This affected one resident (Resident #1) of four reviewed for medication administration. The facility census was 75. Findings include:Review of Resident #1's medical record revealed an admission date of 07/30/25 with diagnoses including type two diabetes mellitus with diabetic polyneuropathy, bipolar disorder, generalized anxiety disorder, and suicidal behavior.Review of Resident #1's care plan revised 05/14/26 revealed Resident #1 had alterations in mood and behaviors related to diagnoses of bipolar disorder, anxiety, history of polysubstance abuse, and history of suicidal ideation. The goal was for Resident #1 to maintain her baseline mood without decompensation through the review date. Interventions included educating the resident on interventions for triggers and reassurance; notify the physician of changes/decline with mood triggers; psychiatric consultation and treatment as ordered; and administer medications as ordered.Review of Resident #1's orders dated 06/12/26 revealed the resident was ordered Zofran (ondansetron) oral tablet four (4) milligrams (mg) with instructions to give 4 mg by mouth every eight hours as needed for nausea.Review of Resident #1's medication administration record (MAR) dated 06/12/26 through 08/03/26 did not reveal evidence Resident #1 was administered Zofran 4 mg for nausea. Review of Resident #1's progress notes dated 07/06/26 through 08/05/26 did not reveal evidence Resident #1 was nauseated and/or requested Zofran.Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. Resident #1 was independent with activities of daily living (ADLs) and was always continent of bowel and bladder. Resident #1 felt down, depressed, hopeless, had trouble falling or staying asleep, felt tired, and was feeling bad about herself for seven to 11 days over the last two weeks. Resident #1 did not reject care during the seven-day assessment look-back period.Observation on 08/03/26 at 9:20 A.M. revealed Licensed Practical Nurse (LPN) #207 was standing at the medication cart outside Resident #1's room preparing to administer the resident her medications. LPN #207 placed an amlodipine 10 mg tablet, three gabapentin 100 mg capsules to equal 300 mg, hydrochlorothiazide 25 mg tablet, lisinopril five (5) mg, Ativan one (1) mg tablet, magnesium oxide 400 mg, and simvastatin 40 mg in a small plastic cup. LPN #207 handed the medications to Resident #1 and Resident #1 looked at the medications and stated, I want to know what the (expletive) the pill was that was given to me over the weekend for the past three days. Resident #1 indicated the unknown pill was not included in the plastic cup with the medications just handed to her. Resident #1 took the medications, swallowed them, and pointed to her bedside table and a small oval white pill was seen on the bedside table. Resident #1 revealed the small white pill was given to her by a different nurse and it fell out of her mouth when she took the previous pills. Resident #1 indicated she wanted the pill identified. The small, oval white pill had an F written on one side and a nine (9) and a 1 on the other side. Resident #1 indicated she took the pill two times and the third time it fell out of her mouth when she tried to take it. Resident #1 revealed she had no idea if the pill was hers or another residents. LPN #207 identified the medication as Zofran (ondansetron hydrochloride) 4 mg and stated it was ordered as needed and was a medication for nausea. Resident #1 stated she did not have nausea and she did not ask for the medication.Interview on 08/03/26 at 10:01 A.M. with LPN #207 revealed she checked Resident #1's progress notes, including the electronic MAR notes for the past three days and there was no evidence Resident #1 was nauseated and asked for medication for nausea. LPN #207 revealed Resident #1 was not always compliant with her medications.Interview on 08/03/26 at 10:16 A.M. with the Director of Nursing (DON) revealed, from time-to-time, Resident #1 got her own pills from the pharmacy. The DON indicated a pharmacy was located very close to the facility and Resident #1 could go on a leave of absence and go to the pharmacy. The DON did not provide evidence Resident #1 obtained Zofran 4 mg from the local pharmacy.Observation on 08/03/26 at 3:49 P.M. of Resident #1's medication card labeled Zofran 4 mg tablet, with LPN #207, revealed seven (7) tablets were missing from the card. LPN #207 indicated she could not explain how 7 tablets were missing, and verified she never administered Zofran to Resident #1 and none were signed out on Resident #1's MARs.Interview on 08/03/26 at 5:02 P.M. with the DON revealed she could not explain how 7 pills were missing from Resident #1's Zofran medication card. The DON indicated the lights might have gone out at the facility and a paper MAR had to be used. The DON did not provide evidence a paper MAR was used to sign out Resident #1's Zofran tablets. Review of the facility policy titled, Administering Medications, revised 12/2012, revealed only persons licensed or permitted by the state to prepare, administer and document the administration of medications may do so. Medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must check the label three times to verify the right resident, the right medication, the right dosage, right time and right method (route) of administration before giving the medication. As required or indicated for a medication, the individual administering the medication would record in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed and the signature and titles of the person administering the drug.This deficiency represents non-compliance investigated under Complaint Number 3123823.

Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure the accurate documentation of medication administered to a resident per facility policy. This affected one resident (Resident #1) of four reviewed for medication administration. The facility census was 75.Findings include: Review of Resident #1's medical record revealed an admission date of 07/30/25 with diagnoses including type two diabetes mellitus with diabetic polyneuropathy, bipolar disorder, generalized anxiety disorder, and suicidal behavior.Review of Resident #1's care plan revised 05/14/26 revealed Resident #1 had alterations in mood and behaviors related to diagnoses of bipolar disorder, anxiety, history of polysubstance abuse, and history of suicidal ideation. The goal was for Resident #1 to maintain her baseline mood without decompensation through the review date. Interventions included educating the resident on interventions for triggers and reassurance; notify the physician of changes/decline with mood triggers; psychiatric consultation and treatment as ordered; and administer medications as ordered.Review of Resident #1's orders dated 06/12/26 revealed the resident was ordered Zofran (ondansetron) oral tablet four (4) milligrams (mg) with instructions to give 4 mg by mouth every eight hours as needed for nausea.Review of Resident #1's medication administration record (MAR) dated 06/12/26 through 08/03/26 did not reveal evidence Resident #1 was administered Zofran 4 mg for nausea. Review of Resident #1's progress notes dated 07/06/26 through 08/05/26 did not reveal evidence Resident #1 was nauseated and/or requested Zofran.Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. Resident #1 was independent with activities of daily living (ADLs) and was always continent of bowel and bladder. Resident #1 felt down, depressed, hopeless, had trouble falling or staying asleep, felt tired, and was feeling bad about herself for seven to 11 days over the last two weeks. Resident #1 did not reject care during the seven-day assessment look-back period.Observation on 08/03/26 at 9:20 A.M. revealed Licensed Practical Nurse (LPN) #207 was standing at the medication cart outside Resident #1's room preparing to administer the resident her medications. LPN #207 handed the medications to Resident #1 and Resident #1 looked at the medications and stated, I want to know what the (expletive) the pill was that was given to me over the weekend for the past three days. Resident #1 indicated the unknown pill was not included in the plastic cup with the medications just handed to her. Resident #1 took the medications, swallowed them, and pointed to her bedside table and a small oval white pill was seen on the bedside table. Resident #1 revealed the small white pill was given to her by a different nurse and it fell out of her mouth when she took the previous pills. Resident #1 indicated she wanted the pill identified. The small, oval white pill had an F written on one side and a nine (9) and a 1 on the other side. Resident #1 indicated she took the pill two times and the third time it fell out of her mouth when she tried to take it. Resident #1 revealed she had no idea if the pill was hers or another residents. LPN #207 identified the medication as Zofran (ondansetron hydrochloride) 4 mg and stated it was ordered as needed and was a medication for nausea. Resident #1 stated she did not have nausea and she did not ask for the medication.Interview on 08/03/26 at 10:01 A.M. with LPN #207 revealed she checked Resident #1's progress notes, including the electronic MAR notes for the past three days and there was no evidence Resident #1 was nauseated and asked for medication for nausea. LPN #207 revealed Resident #1 was not always compliant with her medications.Observation on 08/03/26 at 3:49 P.M. of Resident #1's medication card labeled Zofran 4 mg tablet, with LPN #207, revealed seven (7) tablets were missing from the card. LPN #207 indicated she could not explain how 7 tablets were missing, and verified she never administered Zofran to Resident #1 and none were signed out on Resident #1's MARs.Interview on 08/03/26 at 5:02 P.M. with the Director of Nursing (DON) revealed she could not explain how 7 pills were missing from Resident #1's Zofran medication card. The DON indicated the lights might have gone out at the facility and a paper MAR had to be used. The DON did not provide evidence a paper MAR was used to sign out Resident #1's Zofran tablets. Review of the facility policy titled, Administering Medications, revised 12/2012, revealed only persons licensed or permitted by the state to prepare, administer and document the administration of medications may do so. As required or indicated for a medication, the individual administering the medication would record in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed and the signature and titles of the person administering the drug.This deficiency represents an incidental finding discovered during the complaint investigation.

Based on medical record review, hospital documentation review, review of a self-reported incident (SRI), staff interview, and review of a facility policy, the facility failed to develop and implement a comprehensive and individualized plan of care to address the behavioral health care needs of Resident #76 following a hospitalization. This affected one resident (#76) of three sampled residents. The census was 75.Findings Include:Review of Resident #76's medical record revealed an admission date of 01/12/26 with diagnoses including Parkinsonism, schizoaffective disorder, bipolar type, anxiety disorder, and major depressive disorder. A statement of expert evaluation document dated 04/01/25 through 04/29/25 revealed Resident #76 had neuroleptic malignant syndrome, schizoaffective disorder, bipolar type and malignant catatonia, and an alcohol use disorder. Resident #76 had impairment of speech, orientation, motor behavior, thought process, affect, memory, concentration and comprehension, and judgement. The document included the condition was not stabilized but was reversible. Further review revealed guardianship should be established for Resident #76. Review of Resident #76's care plan dated 05/04/26 included Resident #76 had alterations in mood and behaviors related to diagnoses of bipolar schizoaffective disorder, depression, anxiety, and insomnia. The goal was for Resident #76 to maintain his baseline mood without decompensation through the review date. Interventions included educating the resident on interventions for triggers and reassurance; administering medications as ordered; notifying the physician of changes/decline with mood triggers; and psychiatric consultation and treatment as ordered. Review of Resident #76's plan of care dated 01/12/26 through 05/23/26 revealed no plan of care related to sexual activity/sexual encounters with other residents or hypersexuality. Review of Resident #76's progress note dated 05/23/26 at 3:00 P.M. revealed the resident complained of feeling super anxious and was hyper-sexually stimulated. Resident #76 stated, I need help. Resident #76's physician was notified and orders were given to send the resident to the local hospital ED for evaluation and treatment.Review of Resident #76's hospital documentation revealed the resident was admitted to the hospital on [DATE] and remained hospitalized through 06/02/26. On 06/02/26 the resident was re-admitted to the facility. Hospital documentation included the resident had a history of schizoaffective disorder, substance use, depression, and other diagnoses presented with suicidal ideation. Resident #76 was having increasing thoughts of wanting to harm himself using a knife. Resident #76 was also increasingly sexually preoccupied, and he felt like the thoughts were overwhelming he needed to constantly have sex. Resident #76 had sexual preoccupation and significant guilt, was tearful, and was concerned he would lose housing due to his sexual preoccupation. The hospital documentation included Resident #76 had sex at the facility with various other people and indicated these encounters were usually consensual, and he was not sure if he was being too aggressive in some cases. Resident #76 reported escalating sexual urges, and he had difficulty controlling these impulses. Resident #76 identified he felt like he was pushing himself too hard regarding wanting a relationship and wanting things to happen quickly. Resident #76 felt these thoughts were overwhelming. Resident #76 denied wanting to harm anyone else. Resident #76 had monthly maintenance electroconvulsive therapy (ECT) treatments since December 2025 for a suspected suicide attempt and catatonia complicated by neuroleptic malignant syndrome (NMS). Resident #76 endorsed ongoing [NAME]-dystonic sexual intrusive thoughts; however, reported a decreased urge to act on them. Resident #76 expressed interest in pursuing outpatient sex therapy. Resident #76 recalled history of his mother with schizophrenia and inappropriate sexual behavior during his childhood. On 06/01/26 at 2:43 P.M. a progress note revealed Resident #76 had resolution of guilt, had no current suicidal ideation intent or plan, was focused on the future, and had no frank sexual preoccupation.Review of Resident #76's psychiatric note dated 06/03/26 at 12:30 P.M., written by Certified Nurse Practitioner (CNP) #203, revealed Resident #76 was seen on 06/03/26 for a psychiatric assessment. Resident #76 had a pertinent psychiatric history including schizoaffective bipolar type, anxiety, and catatonia. The note included Resident #76 was seen on 06/03/26 per the Director of Nursing's (DON) request for sex education following a recent psychiatric hospitalization related to psychiatric symptoms. Resident #76 indicated he experienced sexual desires at times and expressed interest in engaging in a mutually consensual relationship with a peer. Resident #76 denied urges, thoughts, or intentions related to non-consensual activity. Education was provided regarding appropriate boundaries, consent, respect for others, and facility expectations. The note included Resident #76 was receptive to the discussion and verbalized understanding. Resident #76 described his anxiety as, up and down. Collaboration of care was completed with the facility nurse. The nurse reported no recent inappropriate sexual behaviors, increased agitation, or behavioral disturbances.Review of Resident #76's care plans dated 06/02/26 through 07/30/26 revealed no evidence a plan of care was developed related to Resident #76 feeling extremely anxious and hyper-sexually stimulated. There were no goals or interventions initiated to address the resident's hyper-sexual stimulation. In addition, following the visit from CNP #203 there was no evidence a plan of care was developed related to sexual activity and/or how staff were to monitor and/or ensure the resident only engaged in consensual sexual relations (as appropriate) with other residents and/or to ensue the safety of residents. Review of Resident #76's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was cognitively intact. Resident #76 required supervision, touching assistance for bathing, partial to moderate assistance for toileting hygiene, and was independent for other activities of daily living (ADLs). Review of a facility self-reported incident (SRI), tracking number 277356, dated 07/27/26 at 7:56 P.M. revealed the facility reported an allegation of sexual abuse. The SRI included the facility had received communication from outside source regarding an alleged sexual assault by resident (first name noted). No victim alleged. The initial source of the allegation was noted to be visitor/family. As a result of an investigation, the facility unsubstantiated an incident of sexual abuse. Review of the SRI revealed Resident #76 was named as the individual responsible for the sexual assault. (See findings under F600).Interview on 07/30/26 at 3:14 P.M. with the DON revealed all she knew about the incident (that occurred on 07/27/26) between Resident #1 and Resident #76 was that he touched her inappropriately and she did not like it. The DON indicated she was at home when it happened and the Administrator and Regional Director of Clinical Services (RDCS) #200 handled most of it. The DON stated Resident #1 was transported to the hospital for a work-up, and Resident #76 was put on one-to-one supervision. The DON revealed she had no knowledge of Resident #76 touching residents or staff inappropriately. The DON stated following the incident, Resident #76 was transferred to a sister facility because he could not be in the same building as Resident #1. Interview on 07/30/26 at 3:18 P.M. with the Administrator revealed she was aware Resident #76 liked to pleasure himself but stated she was not aware if he had consensual sex with other residents. The Administrator indicated Resident #76 came to her in May 2026 and said he felt like he could not please himself enough and asked for different medications. Resident #76 was transferred to the hospital. Upon re-admission, the Administrator indicated Resident #76's hospital paperwork should have been reviewed by the facility staff including nursing, admissions and the Administrator, but she did not specify which staff members reviewed the hospital paperwork. The Administrator stated when she talked to Resident #76, she did not know if he understood sexual differences and she stated he did not get erect enough to penetrate for sexual intercourse. The Administrator then indicated Resident #76 had consensual intimacy with Resident #77 who passed away in April 2026, but she did not know if they had sexual intercourse. The Administrator revealed she was not sure if any precautions were put in place when Resident #76 returned to the facility on [DATE]. During an interview on 07/30/26 at 4:31 P.M. with the Administrator, RDCS #200, and the DON the stated Resident #76 had no relationship with any residents in the facility (this interview was contradictory to the interview with the Administrator on 07/30/26 at 3:18 P.M.). However, RDCS #200 confirmed Resident #76 had been hospitalized and re-admitted on [DATE] after being evaluated/treated for hypersexuality. There were no interventions or safety measures implemented at that time to address the resident's hypersexuality or prevent incidents of sexual abuse. Then the DON indicated when Resident #76 came back from the hospital on [DATE], the facility saw the hypersexual notes and all residents in the facility were interviewed and skin checks were completed. In addition, on 06/03/26 Resident #76 was visited by Certified Nurse Practitioner (CNP) #203 after the hyper-sexual notes were found in his hospital records. The Administrator then indicated she was of the opinion Resident #76 was in a consensual relationship with Resident #1 based on information the residents had provided during an interview on 06/03/26. The Administrator stated she was of the opinion Resident #1 and Resident #76 never had sex, only kissed, and nothing physical happened between them. The Administrator indicated there was no care plan initiated because she was of the opinion this relationship was consensual and there was no need for a care plan. The Administrator stated that while Resident #76 was admitted to the hospital, he had a medication adjustment, and he was seen by CNP #203 on 06/03/26. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Identifying problem areas and their causes, and developing interventions that were targeted and meaningful to the resident, were the endpoint of an interdisciplinary process. No single discipline can manage an approach in isolation. This deficiency represents an incidental finding discovered during the complaint investigation.

Based on observation, resident and staff interviews, and review of daily staff schedules, staff time punch detail, daily posted nurse staffing, the Facility Assessment (FA), and the Payroll Based Journal (PBJ) report, the facility failed to have sufficient staffing. This affected one resident (Resident #10) reviewed for incontinence care, five residents (Residents #2, #29, #52, #67 and #78) who voiced staffing concerns, and had the potential to affect all 78 residents residing in the facility. Findings include:1. Review of the PBJ report for the third quarter of 2025 revealed the facility had a one-star staffing rating and was identified with low weekend staffing.2. Review of the FA, not dated, revealed the following:The average daily census was 73. The facility was to staff licensed nurses providing non-direct care as follows: one full-time day shift Registered Nurse (RN) as a Director of Nursing (DON); one full-time day shift RN as an Assistant Director of Nursing (ADON); one full-time day shift Unit Manager (UM) either an RN or Licensed Practical Nurse (LPN); and one full-time day shift RN as a Minimum Data Set (MDS) Coordinator. The facility was to staff licensed nurses and Certified Nursing Assistants (CNAs) providing direct care as follows: one LPN or RN charge nurse for every 20 residents for each shift, first shift 7:00 A.M. to 3:30 P.M. (eight hours), second shift 3:00 P.M. to 11:00 P.M. (eight hours), and third shift 11:00 P.M. to 7:30 A.M. (eight hours); one CNA for every ten to 13 residents on first shift; one CNA for every 13 to 18 residents on second shift; one CNA for every 17 to 20 residents on third shift; and one CNA as a shower aide from 7:00 A.M. to 3:00 P.M. every Monday through Saturday.The total number of direct care hours per resident day was to be 3.0, excluding in-service, orientation and meeting time.Review of staff schedules revealed it was divided into three eight-hour shifts. Schedules selected for review were based upon dates received from interviews and/or complaint allegations. The following dates were reviewed for sufficient staffing: 01/15/26, 04/14/26, 04/24/26, 04/27/26, 04/28/26 and 05/10/26. These schedules were reconciled with staff punch detail and daily posted staffing. The results were reviewed with Administrator and/or DON which revealed the following findings:a. The time punch detail dated 01/15/26 revealed there was no shower aide for day shift. There were three nurses on day shift, and two nurses on night shift. Only two of the seven CNAs on day shift worked eight hours. DON was the RN for the eight-hour requirement, and the facility census was 79. Review of the daily posted nurse staffing for 01/15/26 revealed the number of hours for day shift CNAs was 92; however, the actual hours were 58. The total number of direct care hours per resident day (PPD) was 2.66.b. The time punch detail dated 04/14/26 revealed there were three nurses on day shift and three on the night shift. DON was the RN for the eight-hour requirement.Review of the daily posted nurse staffing for 04/14/26 revealed the number of hours for RNs was eight for day shift and eight for night shift; however, the actual hours were eight total which were covered by the DON.c. The time punch detail dated 04/24/26 revealed there were three and one-half nurses on day shift and two nurses on night shift. DON was the RN for the eight-hour requirement. The census was 78.Review of the daily posted nurse staffing for 04/24/26 revealed the number of hours for RNs was eight for day shift and eight for night shift; however, the actual hours were eight total which were covered by the DON. The PPD was 2.88.d. The time punch detail dated 04/27/26 revealed there were three nurses on day shift and two nurses on night shift. The DON worked three hours in the evening to pass medications. The census was 79.Review of the daily posted nurse staffing for 04/27/26 revealed the number of hours for CNAs day shift was 80; however, the actual hours were 69.5. The number of hours for CNAs night shift was 70; however, the actual hours were 49.75. The number of hours for LPNs day shift was 32; however, the actual hours were 31. The number of hours for LPNs night shift hours was 32; however, the actual hours were 19.50. The PPD was 2.55.e. The time punch detail dated 04/28/26 revealed there were three nurses on day shift and two nurses after 11:30 P.M. until Wound Nurse (WN)/LPN #539 came in from 2:43 A.M. until 4:20 A.M. The census was 78.Review of the daily posted nurse staffing for 04/28/26 revealed the number of hours for CNAs day shift was 92; however, the actual hours were 72.75. The number of hours for LPNs day shift was 36; however, the actual hours were 34. The number of hours for RNs night shift was 16; however, the actual hours were four.f. The time punch detail dated 05/10/26 revealed there were three nurses on day shift including the DON and WN/LPN #539 who both worked as staff nurses, and three nurses at night. The census was 80.Review of the daily posted nurse staffing for 05/10/26 revealed the number of hours for CNAs day shift was 82; however, the actual hours were 76.25. The number of hours for LPNs day shift was 40; however, the actual hours were 31. The number of hours for RNs day shift was eight hours completed by DON. The number of hours for RNs night shift was 12 hours; however, the actual hours were zero.Interview on 05/18/26 at 2:11 P.M. with Administrator revealed she was aware there was a staffing issue. She verified she reported the necessary information for the PBJ and did the schedules as there was no one in that position at the time. Review of the daily posted nurse staffing with her revealed some were done per person while others were done by hours. Administrator verified the FA stated a one to 20 ratio for nurses to residents which equaled 3.9 nurses for a census of 78. She also verified the facility set the PPD at 3.0 in the FA. Administrator stated not being aware of what the FA said about staffing ratios prior to this.3. Review of additional staff schedules and time punch detail for DON revealed she worked as a staff nurse on 04/08/26 from 9:11 A.M. to 7:00 P.M.; 04/11/26 from 7:08 A.M. to 7:24 P.M.; 04/20/26 from 08:41 A.M. to 7:38 P.M., 04/21/26 from 8:48 A.M. to 8:35 P.M., 04/22/26 from 8:00 A.M. to 6:37 P.M., 04/25/26 from 3:44 P.M. to 6:00 P.M., 04/27/26 from 8:36 P.M. to 11:30 P.M., 04/29/26 from 7:44 A.M. to 11:31 P.M, and 05/01/26 from 10:14 A.M. to 11:12 P.M. Interview on 05/11/26 at 4:30 P.M. with DON verified she worked the above hours as a floor nurse.Review of the facility daily census revealed it was 83 on 04/08/26, 83 on 04/11/26, 80 on 04/20/26, 80 on 04/21/26, 78 on 04/22/26, 78 on 04/25/26, 79 on 04/27/26, 79 on 04/29/26 and 90 on 05/01/26.Interview on 05/18/26 at 4:13 P.M. with DON verified she did not know what the expectation was for the DON covering the floor. She stated, I just come in. When asked about what risks there were for having only two nurses at night she stated none. She stated she had worked with only two nurses at night and said they were working within their standard. It was not normal but not unheard of to have only two nurses on night shift. DON stated she was not familiar with the FA. When asked about how on-call worked, she stated it listed at the bottom of the schedule who was on-call. The calls then escalated from the first on-call nurse to the second, to the Administrator and then the Regional Nurse. DON verified the ADON/RN's last day was 04/22/26. The only RNs the facility had were the DON and two RNs from other buildings. The MDS nurse was an RN but did not work on the floor.4. Review of additional staff schedules and time punch details for WN/LPN #539 revealed she worked as the floor nurse on 04/05/26 from 2:52 P.M. to 8:20 P.M., 04/11/26 from 10 A.M. to 7:41 P.M., 04/12/26 from 1:51 P.M. to 7:31 P.M., 04/16/26 from 10:09 A.M. to 11:41 P.M., 04/16/26 from 9:42 A.M. to 11:13 P.M., 04/18/26 from 3:30 P.M. to 11:38 P.M., 04/19/26 from 9:15 A.M. to 7:00 P.M., 04/25/26 from 3:00 P.M. to 11:31 P.M., 04/26/26 from 8:46 P.M. to 5:11 P.M. and 04/29/26 from 2:43 A.M. to 04:20 A.M. then 11:00 A.M. to 11:07 P.M.Interview on 05/12/26 at 4:10 P.M. with WN/LPN #539 verified she worked the above hours as a floor nurse and not as the wound nurse.5. Interview on 05/12/26 at 3:32 P.M. with Regional Clinical Nurse (RCN) #590 verified she worked on 05/02/26 from 7:00 P.M. to 12:30 A.M. and 05/09/26 from 7:00 P.M. to 11:30 P.M. due to staffing issues.6. Observation on 05/11/26 at 2:04 P.M. revealed a strong odor of stool upon entering Resident #10's room. The resident was lying in bed with food on his chest. Interview at the time of the observation with Resident #10 stated the last time he had been checked or changed was at 8:00 A.M. Observation on 05/11/26 at 2:06 P.M. with CNA #521 of Resident #10 revealed deep skin creases on the resident's back from the positioning pad, dried stool on the skin, and redness of the buttocks. CNA #521 confirmed Resident #10 had finished eating approximately 35 minutes earlier but had not been changed prior to or after the meal.Interview on 05/11/26 at 2:24 P.M. with CNA #521, who was identified as Resident #10's primary CNA, stated the unit was short staffed. She reported Resident #10 was last changed at 8:00 AM. She further stated that staff were not allowed to check and change during meals, and if residents became incontinent during meals or during tray pass, they have to wait. The CNA reported she went on break immediately after lunch, so Resident #10 was not checked or changed. She also reported a lack of teamwork and stated she had three people to feed and no assistance from other staff so residents who needed to be changed just had to wait.Observation on 05/14/26 at 1:58 P.M. revealed a strong foul odor of stool upon entering Resident #10's room. Interview at the time of the observation with Resident #10 stated the last time he had been changed was at 10:30 A.M. Interview on 05/14/26 at 1:59 P.M. with CNA #701, who was in the hall stated she had last checked the resident at 11:00 AM and stated, He always smells like that. He is tube fed. When asked to check the resident again due to the strong odor, CNA #701 replied she was going on break and would check the resident when she returned, asking, You really want me to do it right now? I am doing my rounds. When I get back from break, okay? You okay with that? CNA #701 then turned and walked down the main hall exiting the unit. There was no nurse available on the unit at that time. One CNA (#701) was on break and the other was giving a shower. Interview on 05/14/26 at 2:03 P.M. with Resident #10 revealed he could not feel when he had a bowel movement.During an interview on 05/14/26 at 2:12 P.M. with RCN #590, Resident #10's need for assistance was reported. RCN #590 entered Resident #10's room and confirmed the presence of stool. Additional interview on 05/14/26 at 2:38 P.M. with RCN #590 confirmed she smelled stool when she went into the room and stated staff were to assist residents with incontinence care whenever they needed it.7. Phone interview on 05/12/26 at 1:49 P.M. with Former RN #606 confirmed she worked on 04/28/26, and stated she worked the first floor, secured unit at 3:00 P.M. She was told to cover the second floor at shift change (around 7:00 P.M) after the scheduled nurse left after 15 minutes. She stated by 11:30 P.M. there was no replacement for her, so she notified the two other nurses (LPN #531 and LPN #543) on the first floor. She stated both refused to take the keys from her. In the meantime, she tried to get ahold of the on-call nurse which was WN/LPN #539 and the DON without success. She stated she did get ahold of the Administrator at one point. Former RN #606 stated the Administrator told her the other two nurses would need to split her assignment, but she stated both nurses refused a second time. So, she took it upon herself to take the medication cart keys to the local police station stating others had done it before. She told the police someone would be by to pick them up. She stated she had not heard from DON or WN/LPN #539 when she left around midnight, but the facility called her the next day and terminated her.Phone interview on 05/12/26 at 2:21 P.M. with LPN #531 revealed she came into work on 04/28/26 at 7:00 P.M. She was going to work on the secured unit when Former LPN #537, who was supposed to be on the second floor at 7:00 P.M., came to the first floor and told her she was going home. LPN #531 called the Administrator. LPN #531 then told Former RN #606 she would have to go upstairs while the other two nurses split the first floor. She stated that Former RN #606 was scheduled to leave at 11:00 P.M. Administrator texted LPN #531 stating someone was coming in but then they cancelled shortly after that. Former RN #606 came down at 11:27 P.M. and tried to give the keys but LPN #531 said she refused. She stated LPN #543 also refused. LPN #531 said she went upstairs at 12:00 A.M. which was when she found out from CNA #523 that Former RN #606 had left and took keys to the police station. LPN #531 asked LPN #543 who he called and he stated everyone, but no one answered. LPN #531 said she spoke to WN/LPN #539 at 1:40 A.M. and acknowledged situation. She stated WN/LPN #539 called back at 2:27 A.M. asking LPN #531, If I go get the keys, are you going to take them? Or corporate will have to be your third nurse. LPN #531 stated she was frustrated but said she would help. WN/LPN #539 said the DON would come in at 5:00 A.M. or 6:00 A.M. to pass medications. WN/LPN #539 showed up between 3:30 to 3:40 A.M. and took care of any medications needed. LPN #531 passed medications on the secured unit at 5:30 A.M. The Administrator arrived at 6:27 A.M. to update her. They called the DON who said she was on the way by 6:32 A.M. The day shift nurse called off. LPN #531's replacement came in however DON did not come in until 7:30 A.M. and she needed to cover two units.Phone interview on 05/12/26 at 4:00 P.M. with LPN #543 revealed on 04/28/26 at approximately 11:30 P.M., Former RN #606 came to him to tell him she had to leave. He stated he would get ahold of the DON or on-call nurse (WN/LPN #539). There was no answer by DON, so he sent a text message. He texted Administrator who did not answer right away. He called WN/LPN #539. He then went upstairs to tell Former RN #606, but they stated she was already gone around 12:00 A.M. He stated WN/LPN #539 came early in the morning, and he left at 7:30 A.M.Interview on 05/12/26 at 4:10 P.M. with WN/LPN #539 revealed she was the nurse who picked up the keys at the police department. She stated LPN #531 had called her around 1:30 A.M. She called DON first who said to call the RCN #591. She also got ahold of Administrator. WN/LPN #539 said it took her 30 to 40 minutes to get to the facility. She stopped at the facility first as there was an extra set of keys before picking up the other keys from the police station. She stated LPN #531 took the keys but WN/LPN #539 medicated three residents first around 3:00 A.M. WN/LPN #539 was under the impression LPN #543 was going to take the keys from Former RN #606, but she had already left.Interview on 05/12/26 at 4:24 P.M. with CNA #507 confirmed she worked on 04/28/26 when Former RN #606 took the keys to the police department. She stated the on-coming nurse never accepted the keys at 7:00 P.M. and quit that day stating, I'm not putting my license on the line. CNA #507 stated Former RN #606 went to the second floor to call the on-call nurse and DON, however no one answered. Other staff were also calling them. She stated Former RN #606 was terminated.Interview on 05/13/26 at 1:04 P.M. with LPN #537 revealed she went into the building at 7:00 P.M. to get report but the nurse (LPN #528) would not give her report. LPN #537 stated they had an issue with each other two weeks prior. She told the supervisor (LPN #543). She stated they do not have nursing management who will answer their phones, and the building was understaffed which caused delays in care.Interview on 05/18/26 at 2:13 P.M. with Administrator verified Former RN #606 was reported to the Ohio Board of Nursing for taking the keys to the police station and provided evidence of the online report.Interview on 05/18/26 at 4:00 P.M. with DON revealed she received a phone call from LPN #531 on 04/29/26 at 1:00 A.M. She stated the expectation was for nurses to count medications with each other. LPN #543 said Former RN #606 was gone by 11:22 P.M, and he denied he refused the keys. 8. Interview on 05/11/26 at 9:56 A.M. with Resident #67 revealed it frequently took over half an hour for staff to answer call lights, and they do not bring water back. Interview on 05/11/26 at 10:14 A.M. with Resident #78 revealed there was a lot of staff turnover, and call lights were not being answered.Interview on 05/11/26 at 10:20 A.M. with Resident #2 revealed staff were slow to answer call lights or change incontinence briefs.Interview on 05/11/26 at 11:17 A.M. with Resident #29 revealed there was low staffing at night and slow response to call lights.Interview on 05/11/26 at 11:46 A.M. with Resident #52 revealed there was slow response to call lights.Interview on 05/11/26 at 5:03 P.M. with CNA #504 revealed there was not enough staff, and they were short a lot. There were supposed to be three CNAs on one unit (Grand) but said it was overwhelming stating call lights took longer to answer, and passing trays and feeding residents took longer.Interview on 05/11/26 at 5:21 P.M. with LPN #542 revealed there was not enough staff. The facility did not use agency so if no one picked up, then no one covered the call-offs. Nurses helped pass trays but that put them behind on medication pass. Staff were not answering call lights in a timely manner or getting showers done.Observation on 05/11/26 at 5:29 P.M. revealed dinner trays arrived. Department heads (RCN #590, WN/LPN #539, Housekeeping Supervisor #567 and Social Service Designee #584) came to assist. Interview at the time of the observation with all of the department heads revealed they did not normally pass trays on this shift.Interview on 05/12/26 at 6:08 A.M. with LPN #540 revealed the on-call nurse (WN/LPN #539) would not come in to cover one night. She stated the on-call nurses did not answer the phone or return calls, and at times there were no nurses who remained on the secured unit and second floor.This deficiency represents non-compliance investigated under Master Complaint Number 3000374 and Complaint Number 2983197.

Based on review of staff schedules, staff time punch detail and interview, the facility failed to ensure the Director of Nursing (DON) worked full-time as the DON and did not work as a staff nurse when the census was over 60. This had the potential to affect all 78 residents residing in the facility.Findings include:Review of staff schedules and time punch detail for DON revealed she worked as a staff nurse on 04/08/26 from 9:11 A.M. to 7:00 P.M.; 04/11/26 from 7:08 A.M. to 7:24 P.M.; 04/20/26 from 08:41 A.M. to 7:38 P.M., 04/21/26 from 8:48 A.M. to 8:35 P.M., 04/22/26 from 8:00 A.M. to 6:37 P.M., 04/25/26 from 3:44 P.M. to 6:00 P.M., 04/27/26 from 8:36 P.M. to 11:30 P.M., 04/29/26 from 7:44 A.M. to 11:31 P.M, and 05/01/26 from 10:14 A.M. to 11:12 P.M. Interview on 05/11/26 at 4:30 P.M. with DON verified she worked the above hours as a floor nurse.Review of the facility daily census revealed it was 83 on 04/08/26, 83 on 04/11/26, 80 on 04/20/26, 80 on 04/21/26, 78 on 04/22/26, 78 on 04/25/26, 79 on 04/27/26, 79 on 04/29/26 and 90 on 05/01/26.This deficiency represents non-compliance investigated under Master Complaint Number 3000374 and Complaint Number 2983197.

Based on observation, interview, and review of facility dietary menus, the facility failed to ensure meals were served at a palatable temperature. This affected three residents (Residents #11, #29 and #67) and had the potential to affect all other residents who received meals from the kitchen. The facility indicated one resident (Resident #2) who received nothing by mouth. The facility census was 78.Findings include:Interview on 05/12/26 at 9:52 A.M. with Resident #67, who was noted to receive a mechanical soft diet, stated the food was not good and the portions were not always big enough.Interview on 05/11/26 at 11:18 A.M. with Resident #29, who was noted to receive a regular no added salt diet, stated the meals were frequently cold.Interview on 05/11/26 at 12:46 P.M. with Resident #11, who was noted to receive a regular double portion diet, stated the food did not taste good and was usually cold so he ordered out a lot.Observation on 05/13/26 at 11:03 A.M. with Regional Dietary Manager (RDM) #601 of lunch tray line temperatures revealed Swedish meatballs at 171 degrees Fahrenheit (F); rice at 197 degrees F; spinach at 189 degrees F; mechanical soft meatballs at 176 degrees F; plain meatballs at 177 degrees F; mashed potatoes at 190 degrees F; pureed meatballs at 176 degrees F; pureed rice at 186 degrees F; hamburgers at 181 degrees F; pureed spinach at 182 degrees F; gravy at 171 degrees F; cinnamon apples at 194 degrees F; and pureed cinnamon apples at 183 degrees F.Observation on 05/13/26 at 11:14 A.M. revealed the lunch tray line service started. Plates were noted to not have heat pellet underneath them, but a dome cover was placed over the plates. Throughout the lunch service, four staff worked the line and RDM #601 assisted to make additional ground meat for the mechanical soft diets, made additional Swedish meatballs, and remade the pureed rice due to the previously prepared rice was dry, hard and not servable. Observation on 05/13/26 at 12:20 P.M. revealed the fourth (last) cart left the kitchen. After arrival at the unit, tray pass was initiated at 12:22 P.M. and the last resident room tray was delivered at 12:28 P.M.Observation on 05/13/26 at 12:30 P.M. of the test tray with RDM #601 revealed the following temperatures: chocolate milk at 42 degrees F; yogurt at 49.6 degrees F; spinach at 122.5 degrees F; Swedish meatballs at 127 degrees F; rice at 120 degrees F; and pureed meatballs at 99 degrees F. Interview at the time of the observation with RDM #601 confirmed the meatballs and spinach were not warm enough and the yogurt should have been colder. RDM #601 also confirmed he did not work in the kitchen every day and the tray line service length would have been longer if he had not assisted with preparing additional foods during tray service.

Based on observation, interview, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen and failed to ensure resident room refrigerators were monitored and maintained as required. This had the potential to affect all residents receiving meals from the kitchen, and affected three residents (Residents #18, #29 and #35) of three residents reviewed for room refrigerators. The facility indicated one resident (Resident #2) who received nothing by mouth. The facility census was 78.Findings include:1. Observation on 05/11/26 at 8:31 A.M. with Dietary Manager (DM) #550 during the initial kitchen tour revealed the outside of the convection ovens had multiple dried stains and the handles were sticky. The following were identified in the walk-in refrigerator: an opened five-pound (lb.) container of sour cream with a use by date of 04/13/26; an opened ten lb. box of turkey bacon that was completely thawed with no opened date on the box; a ten lb. unopened thawed tube of ground beef on a tray with a large amount of blood surrounding the tube of meat with no date on the tray or the tube of meat; an opened, undated package of sliced cheese; and two opened cream pies with no open or use by date. DM #550 confirmed the findings at the time of the observation and confirmed the items should have an open date and a use by date.Observation on 05/11/26 at 8:40 A.M. of the reach-in refrigerator with four compartments revealed a dried red substance on the bottom of the refrigerator. The doors were also noted to have dried food spills/debris on it, and the handles were sticky and had dried food on it. The front of the double convection oven was heavily soiled, and it was sticky on the outside. There was a large amount of dried splatter observed inside of the oven doors. The top compartment of the double steamer was soiled on the bottom, and the front of both steamer doors were soiled with dried food spillage and debris. DM #550 confirmed the findings at the time of the observation.Observation on 05/13/26 at 11:06 A.M. revealed Dietary Aide (DA) #607 had a beard net on in the kitchen, but it was below his chin and not covering his mustache or beard as required. Interview at the time of the observation with DA #607 confirmed his beard guard was not covering his beard and mustache as required.Observation on 05/13/26 at 11:16 A.M. revealed DA #608 had a beard net on in the kitchen, but it was below his chin and was not covering his mustache or beard. Interview at the time of the observation with DA #608 confirmed his beard guard was not covering his beard and mustache as required.Observation on 05/14/26 at 2:25 P.M. revealed DM #550, who had facial hair, was walking within the kitchen without a hairnet or beard net on. Interview at the time of the observation with DM #550 confirmed he was supposed to have a hair and beard net on when in the kitchen.2. Observation on 05/12/26 at 1:40 P.M. of resident room refrigerators with Licensed Practical Nurse (LPN) #529 revealed the following:a. Resident #29's room refrigerator had three four-ounce containers of cranberry juice with a use by date of 05/24/25, one four-ounce cranberry juice with a use by date of 07/02/25, and one four-ounce container of apple juice with a use by date of 05/23/25.b. Resident #18's room refrigerator was empty, but it had various dried stains in it. The temperature logs were current for May 2026, but the April 2026 temperature logs were not completed from 04/01/26 to 04/09/26, 04/19/26 to 04/22/26, 04/24/26 to 04/25/26 and 04/29/26 to 04/31/26.c. Resident #35's room refrigerator was empty, but it had multiple dried stains in it and had ice buildup. The temperature logs for April 2026 had only 04/01/26 and 04/02/26 completed, and there was no evidence of a temperature log for May 2026.Interview on 05/12/26 at 2:52 P.M. with LPN #529 confirmed the temperature logs were not completed as required and confirmed the expired food should have been thrown out and the refrigerators monitored for cleanliness.Review of the February 2014 revised facility policy titled, Foods Brought by Family/Visitors, revealed perishable foods must be stored in re-sealable containers with tightly fitted lids or in zip lock bags in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. The nursing and/or food service staff must discard any food prepared for the residents that shows obvious signs of potential foodborne danger.Review of the undated facility policy titled, Personal Hygiene, revealed if hair was long and not covered properly with a cap, a hair net must be worn. [NAME] nets must be worn whenever there was risk of facial hair coming into contact with exposed food, food contact surfaces or clean equipment. Review of the undated facility policy titled, Cleaning and Sanitizing Dietary Areas and Equipment, revealed all kitchen areas and equipment should be maintained in a sanitary manner and be free of buildup of food, grease or other soil. The facility will provide sanitary food service that meets state and federal regulations. Review of the undated facility policy titled, Sanitation, revealed leftover foods were placed in shallow containers, dated, labeled and chilled rapidly. These were used within 48 hours. All food contact surfaces, including plates and kitchenware and surfaces of all equipment were washed, rinsed and sanitized after each use to prevent cross-contamination.

Based on observation, interview, record review, and review of facility policy, the facility failed to maintain a safe environment by permitting smoking materials (lighters, tobacco paraphernalia and vapes) in resident rooms which violated facility policy and safe smoking protocols. This affected five residents (Residents #6, #31, #60, #73 and #74) of six residents reviewed for smoking. The facility census was 78. Findings include:1. Record review for Resident #31 revealed an admission date of 10/24/25. Diagnoses included post-traumatic stress disorder, schizophrenia, and cannabis use. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was severely cognitively impaired, required set up or clean up assistance with eating, bed mobility and partial to moderate assistance with toileting hygiene. Resident #31 had physical behavioral symptoms directed towards others one to three out of seven days and had verbal symptoms directed towards others four to six out of seven days. Review of the care plan dated 10/27/25 revealed Resident #31 had a history of smoking in the community, was a current vape user in the facility, and was non-compliant with vape materials. Interventions included completing a smoking evaluation per facility guidelines, not leaving unattended while vaping, and following the facility smoking policy. Review of the Smoking Policy Resident Acknowledgement signed by Resident #31's Guardian dated 10/28/25 revealed the facility established and maintained safe resident smoking practices. Any resident with restricted smoking privileges who required monitoring would always have the direct supervision of staff while smoking. Residents were not permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. Electronic cigarettes and chargers were considered smoking articles and not to be kept in the resident's possession. E-cigarette use in the resident's room was prohibited.Observation on 05/11/26 at 10:32 A.M. revealed a vape was setting on top of the stand in Resident #31's room. The room had a strong odor of a recently used vape. Interview at the time of the observation with Resident #31 confirmed she used the vape in her room whenever she wanted. Observation on 05/11/26 at 10:50 A.M. with Certified Nursing Assistant (CNA) #513 confirmed Resident #31 had a vape stored in her room. Interview at the time of the observation with CNA #513 stated the resident had several vapes in her room, and Resident #31 had used the vape in her room unattended since she was admitted to the facility, having always been allowed to vape.Interview on 05/12/26 at 9:35 A.M. with Licensed Practical Nurse (LPN) #536 confirmed she was Resident #31's primary care nurse and stated Resident #31's family member sent her vapes in the mail as Resident #31 was allowed to vape in her room unattended.Interview on 05/12/26 at 9:50 A.M. with Social Worker Designee (SWD) #584 revealed if a resident smoked cigarettes or used a vape, they must go outside. SWD #584 stated Resident #31 had behavioral issues and did not fully understand the rules. After reviewing the smoking policy provided by SWD #584, it revealed the resident was not allowed to keep the vapes in her room. SWD #584 confirmed it was the current policy she gave to all new residents and no smoking materials were allowed to be kept with any residents on their person or in their room while residing in the facility.2. Record review for Resident #6 revealed an admission date of 09/02/25. Diagnoses included spinal stenosis, muscle weakness, schizoaffective disorder bipolar type, and nicotine dependence. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #6 was mildly cognitively impaired. Resident #6 used a wheelchair and/or walker for mobility.Review of the care plan dated 09/03/25 revealed Resident #6 had a history of smoking in the community, was a current smoker in the facility, and was non-compliant with smoking materials. Interventions included to not leave unattended while smoking, and to follow the facility smoking policy. Review of the Smoking Safety Screen dated 03/23/26 at 1:53 P.M. revealed Resident #6 was able to smoke following the facility policy. Resident #6 agreed to the facility policy for smoking.Review of the Smoking Policy Resident Acknowledgement completed by SWD #584 and signed by Resident #6 dated 10/01/25 revealed residents were not permitted to keep in their possession any cigarettes, pipes, tobacco, and other smoking articles. Observation on 05/13/26 at 9:15 A.M. revealed Resident #6 was in the facility courtyard smoking cigarettes with three other residents (Residents #60, #73 and #74). Housekeeping Supervisor (HS) #567 monitored. Resident #6 took a clear sandwich bag which contained multiple cigarettes out of his shirt pocket, and then took a lighter out of his pants pocket, lit his cigarette, before putting the items back into his pockets.Observation on 05/13/26 at 9:37 A.M. revealed Resident #6 was sitting in a chair in his room. Interview at the time of the observation with Resident #6 confirmed he kept his cigarettes and lighter in his room. Resident #6 then pulled his baggie of cigarettes and lighter out of his coat pocket to reveal it.Interview on 05/13/26 at 9:44 A.M. with HS #567 revealed each resident who smoked had a locked box in which their smoking materials were kept, and it was stored in a large cabinet. The staff kept the keys to the cabinet so smoking materials were secure. No residents were permitted to keep smoking materials including cigarettes and lighters in their room.Interview on 05/13/26 at 9:47 A.M. with HS #567 confirmed she found Resident #6's cigarettes and lighter in his room. Observation at the time of the interview with HS #567 of the cabinet used to store smoking supplies revealed the cabinet was kept in the lounge area near the exit where residents went outside to smoke. HS #567 verified the cabinet was not locked, no staff were monitoring the unlocked cabinet with the smoking supplies, and residents had access to the unlocked cabinet.3. Record review for Resident #60 revealed an admission date of 10/09/25. Diagnoses included polyosteoarthritis, unspecified dementia, and nicotine dependance.Review of the Quarterly MDS assessment dated [DATE] revealed Resident #60 was cognitively intact, used a wheelchair for mobility, and required supervision or touch assistance with personal hygiene.Review of the care plan dated 10/09/25 revealed Resident #60 had a history of smoking in the community and was a current smoker in the facility. Interventions included following the facility smoking policy. Review of the Smoking Safety Screen dated 04/06/26 at 9:03 A.M. completed by SWD #584 revealed Resident #60 was safe to smoke with supervision, and per facility policy smoking for all residents was supervised during smoke times.Review of Resident #60's medical record for the Smoking Policy Resident Acknowledgement revealed there was none in the medical record.Observation on 05/13/26 at 9:34 A.M. revealed Resident #60 was sitting in a chair in his room. Resident #60 removed a partially smoked cigarette and lighter from his coat pocket. Interview on 05/13/26 at 11:25 A.M. with Regional Director of Operations (RDO) #589 verified residents should not have cigarettes or lighters in their room. Interview on 05/13/26 at 10:04 A.M. with HS #567 confirmed Resident #60 kept his cigarettes and lighter in his room.4. Record review for Resident #73 revealed an admission date of 12/04/25. Diagnoses included malignant neoplasms of the upper lobe left bronchus or lung, chronic obstructive pulmonary disease, and nicotine dependence. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #73 was cognitively intact. Resident #73 required setup or clean up assistance with eating, and supervision or touching assistance with chair/bed to chair transfers. Review of the care plan dated 12/04/25 revealed Resident #73 had a history of smoking in the community and was a current smoker in the facility. Interventions included to complete a smoking evaluation per the facility guidelines, do not leave unattended while smoking, and to follow the facility smoking policy. Review of the facility Smoking Safety Screen dated 03/05/26 revealed Resident #73 agreed to the facility policy for smoking.Review of the Smoking Policy Resident Acknowledgement completed by SWD #584 and signed by Resident #73 dated 12/05/25 revealed residents were not permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. Observation and interview on 05/13/26 at 9:57 A.M. confirmed Resident #73 kept his lighter in his pants pocket while unattended in his room.Observation and interview on 05/13/26 at 4:01 P.M. with HS #567 confirmed Resident #73 kept his cigarettes and lighter in his room. 5. Record review for Resident #74 revealed an admission date of 02/13/25. Diagnoses included syncope and collapse and nicotine dependence. Review of the Annual MDS assessment dated [DATE] revealed Resident #74 was cognitively intact and used a wheelchair and/or walker for mobility.Review of the care plan dated 02/13/25 revealed Resident #74 had a history of smoking in the community, was a current smoker in the facility, and non-compliant with smoking materials. Interventions included not leaving unattended while smoking. Review of the Smoking Safety Screen for Resident #74 dated 04/03/26 at 8:41 A.M. completed by SWD #584 revealed Resident #74 was safe to smoke with supervision.Review of the Smoking Policy Resident Acknowledgement completed by SWD #584 and signed by Resident #74 dated 10/01/25 revealed residents were not permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. Observation and interview on 05/13/26 at 10:01 A.M. revealed Resident #74 kept his cigarettes in his top dresser drawer and his lighter in his pants pocket. Interview on 05/13/26 at 10:13 A.M. with HS #567 confirmed Resident #74 had his cigarettes and lighter stored in his room. This deficiency represents non-compliance investigated under Complaint Number 2983197.

Based on record review, interviews, and review of facility policy, the facility failed to initiate an abuse investigation for an allegation of verbal abuse and take action to prevent further mistreatment by the alleged perpetrator (CNA #588) pending the outcome of the investigation. This affected one resident (Resident #39) of three residents reviewed for abuse. The facility census was 78.Findings include:Record review for Resident #39 revealed an admission date of 07/25/23. Diagnosis included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Interview on 05/12/26 at 3:35 P.M. with Resident #39 revealed a while back, CNA #588 cursed at her and stated, It made me feel bad. They didn't listen to me. I don't understand why she is in here when I asked her not to be. She cussed me out. I cried so hard. She came back and apologized, but I just don't want her in here. Resident #39 appeared stressed during the interview and became teary eyed.During an interview on 05/12/26 at 4:41 P.M. with the Director of Nursing (DON) notification was made by informing the DON of Resident #39's allegation of CNA #588 cursing at her and making her cry. The allegation was discussed and DON twice repeated Resident #39's concern, stating an investigation was needed.During a follow-up interview on 05/13/26 at 8:59 A.M., the DON stated, I did talk to (CNA #588) this morning. I have not talked to the resident (Resident #39) yet. (CNA #588) said that was never a thing. I guess there was something a week ago where the resident called her out of her name. (CNA #511) said (Resident #39) preferred her. The last piece of the puzzle is I will talk to the resident. My understanding is (Resident #39) just wants (CNA #511) instead of (CNA #588).Interview on 05/13/26 at 12:48 P.M. with CNA #588 who was observed working on the second floor where Resident #39 resided revealed she started her shift as usual at 7:00 A.M. CNA #588 verified the DON talked to her after the start of the shift and told her if a resident asked her to leave then she needed to leave.Interview on 05/14/26 at 8:42 A.M. with DON and Administrator revealed the Administrator confirmed if a resident made an allegation that a CNA cursed at her making the resident cry, an SRI (Self-Reported Incident) should have been opened, the CNA should have been suspended, and an investigation initiated. DON confirmed she was notified on 05/12/26 of the allegation regarding CNA #588 cursing at Resident #39 and making her cry. Administrator confirmed that an SRI was not opened, CNA #588 was not suspended, and an investigation was not initiated per the facility policy on abuse.Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, undated, revealed an investigation of abuse must be completed within five (5) working days, unless special circumstances require more time. The person conducting the investigation should generally complete the following actions: interview the resident, the accused, and all witnesses, and if no direct witnesses exist, interviews may be expanded to all employees on the unit or shift; obtain written statements from the residents (if possible), the accused, and each witness; review the residents' records; and if the accused is an employee, the facility should immediately remove the staff member from the facility and the schedule pending the outcome of the investigation. All evidence gathered during the investigation must be documented.This deficiency represents non-compliance investigated under Master Complaint Number 3000374.

Based on observation, record review, interview and facility policy review, the facility failed to provide timely incontinence care for Resident #10 who was dependent on staff for toileting hygiene and incontinence of bowel resulting in being left in a soiled incontinence brief, having dried stool on the skin for extended periods, and prolonged exposure to stool odors. This affected one resident (Resident #10) of three residents reviewed for incontinence care. The facility census was 78.Findings include:Record review for Resident #10 revealed an admission date of 03/03/26, with diagnoses including gastrostomy malfunction, hemiplegia and hemiparesis, muscle weakness, and a need for assistance with personal care. Review of the five day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had an indwelling catheter, was always incontinent of stool, had one sided upper and lower extremity impairment, and was dependent on toileting hygiene.Review of the care plan revised 03/16/26 revealed the resident was at risk for skin breakdown due to decreased mobility, desensitized skin, and bowel incontinence, with interventions including keeping the skin clean, dry, and odor free, and checking for incontinence with cleansing and drying of the skin when wet or soiled.Observation on 05/11/26 at 2:04 P.M. revealed a strong odor of stool upon entering Resident #10's room. The resident was lying in bed with food on his chest. Interview at the time of the observation with Resident #10 stated the last time he had been checked or changed was at 8:00 A.M. Observation on 05/11/26 at 2:06 P.M. with Certified Nursing Assistant (CNA) #521 of Resident #10 revealed deep skin creases on the resident's back from the positioning pad, dried stool on the skin, and redness of the buttocks. CNA #521 confirmed Resident #10 had finished eating approximately 35 minutes earlier but had not been changed prior to or after the meal.Interview on 05/11/26 at 2:24 P.M. with CNA #521, who was identified as Resident #10's primary CNA, stated the unit was short staffed. She reported Resident #10 was last changed at 8:00 AM. She further stated that staff were not allowed to check and change during meals, and if residents became incontinent during meals or during tray pass, they have to wait. The CNA reported she went on break immediately after lunch, so Resident #10 was not checked or changed. She also reported a lack of teamwork and stated she had three people to feed and no assistance from other staff so residents who needed to be changed just had to wait.Observation on 05/14/26 at 1:58 P.M. revealed a strong foul odor of stool upon entering Resident #10's room. Interview at the time of the observation with Resident #10 stated the last time he had been changed was at 10:30 A.M. Interview on 05/14/26 at 1:59 P.M. with CNA #701, who was in the hall stated she had last checked the resident at 11:00 AM and stated, He always smells like that. He is tube fed. When asked to check the resident again due to the strong odor, CNA #701 replied she was going on break and would check the resident when she returned, asking, You really want me to do it right now? I am doing my rounds. When I get back from break, okay? You okay with that? CNA #701 then turned and walked down the main hall exiting the unit. There was no nurse available on the unit at that time. One CNA (#701) was on break and the other was giving a shower. During an interview on 05/14/26 at 2:12 P.M. with Regional Clinical Nurse (RCN) #590, Resident #10's need for assistance was reported. RCN #590 entered Resident #10's room and confirmed the presence of stool. Additional interview on 05/14/26 at 2:38 P.M. with RCN #590 confirmed she smelled stool when she went into the room and stated staff were to assist residents with incontinence care whenever they needed it.Review of the facility policy titled, Urinary Continence and Incontinence - Assessment and Management, revised September 2010, revealed when a resident was always incontinent, staff would utilize a check and change strategy which involved checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals were to maintain dignity and comfort and to protect the skin.The deficiency represents non-compliance investigated under Master Complaint Number 3000374 and Complaint Number 2800362.

Based on observation, interview, and review of the medical record and facility policy, the facility failed to ensure dental concerns were addressed timely. The affected one resident (Resident #7) of one resident reviewed for dental care. The facility census was 78.Findings include:Review of the medical record for Resident #7 revealed an admission date of 12/22/23. Diagnoses included but were not limited to Parkinson's disease with dyskinesia, type II diabetes mellitus, dementia and osteoporosis.Review of the 07/15/24 physician order for Resident #7 revealed a diet order of no added salt, reduced concentrated sweets regular texture diet. Review of the 03/14/26 Minimum Data Set (MDS) 3.0 assessment for Resident #7 revealed a Brief Interview of Mental Status of 11 which indicated moderate cognitive impairment. Resident #7 was noted to require supervision with eating and moderate assistance with oral hygiene. Resident #7 was not noted to have concerns with obvious or likely cavities or broken natural teeth and no noted dental concerns.Review of the 03/14/26 nutrition assessment for Resident #7 revealed the current diet order was appropriate and no noted swallowing difficulties.Review of the care plan last reviewed on 03/24/26 for Resident #7 revealed the resident was at risk for oral/dental health problems due to missing most teeth with an upper and lower partial. Interventions included a consult with dietitian and change (diet) if chewing/swallowing problems were noted; monitor/document/report signs and symptoms of oral/dental problems needing attention including pain (gums, toothache, palate), abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, or decayed; and provide mouth care as per activities of daily living for personal hygiene.Review of the 03/24/26 multidisciplinary therapy screen for Resident #7 revealed Patient remains at baseline with swallowing and cognition. No complaints of weight loss or difficulty swallowing. No changes in communication. Physical therapy and occupational therapy were indicated with a check mark at the bottom and Speech-Language Pathologist was indicated with an X.Observation on 05/11/26 at 2:58 P.M. of Resident #7 revealed the resident had one tooth left on the bottom which was brown/black in color and was noted to have a hole in it. Interview at the time of the observation with Resident #7 revealed sometimes it was hard to eat. Upper dentures were not noted in her mouth.Interview on 05/12/26 at 1:08 P.M. with Resident #7 revealed she could not wear her upper dentures due to it not fitting correctly.Interview on 05/13/26 at 9:10 A.M. with Certified Nurse Aide (CNA) #573 revealed Resident #7 usually ate 100% of breakfast but usually ate less for lunch and dinner. CNA #573 stated Resident #7 seemed to have a harder time chewing meat and stated she had complained about having pain in her mouth but had reported it. CNA #573 was unsure if Resident #7 had dentures.Interview on 05/13/26 at 12:47 P.M. with Resident #7 revealed the staff had assisted her to put in her upper dentures today but they did not fit right so she took them out. She was able to eat her meatballs at lunch since they were soft. Sometimes she had issues chewing meat due to it being tough and only having one tooth. If she was unable to chew the meat, she would suck out the juice and then spit the meat out. Resident #7 confirmed she wanted to get her dentures fixed so they fit right and get the bottom denture, which broke a long time ago, replaced. Interview on 05/14/26 at 9:14 A.M. with Speech Therapist (ST) #571 revealed evaluations were completed on admission, readmission and if there was a change or referral. ST #571 stated the last time Resident #7 was evaluated for swallowing was 08/25 and had not been made aware of any pain or chewing concerns since then to complete an evaluation.Interview on 05/14/26 at 9:32 A.M. with Resident #7 revealed she did not like to smile because everyone could see she did not have teeth. Resident #7 asked how to put the denture cream on and proceeded to get the denture cream out of her drawer but then put it away stating she would do it later and left her room.Interview on 05/14/26 at 10:37 A.M. with Respiratory Manager (RM) #562 confirmed a five-minute therapy screen was completed on 03/24/26 for transfer and activities of daily living participation. RM #562 stated that since chewing concerns or mouth pain were not reported, no evaluation was completed for chewing or swallowing.Interview on 05/14/26 at 10:46 A.M. with CNA #573 revealed Resident #7's chewing concerns were reported several times but after reporting it several times, CNA #573 stopped reporting it since nothing seemed to change.Interview on 05/14/26 at 10:50 A.M. with Licensed Practical Nurse (LPN) #536 revealed Resident #7 used to be independent with her dentures but now needed assistance with putting in her dentures and applying the cream.Interview on 05/14/26 at 10:57 A.M. with CNA #573 revealed Resident #7 was able to put in her own dentures and apply the cream and CNA #573 only assisted with it when the resident put on her call light. CNA #573 did not observe Resident #7 put in her dentures and had not asked if she needed assistance.Phone interview on 05/14/26 at 11:43 A.M. with Ancillary Dental Coordinator #605 revealed at Resident #7's appointment on 01/28/26 it was noted extractions were needed for three lower teeth. One was exposed and the other two were broken teeth with roots covered by gum tissue. The teeth needed to come out when pain was indicated. The dental appointment on 03/31/26 indicated Resident #7 reported her upper denture was not fitting properly and the resident was not appropriate for a lower denture replacement until the lower teeth were extracted.Phone interview on 05/18/26 at 10:59 A.M. with Registered Dietitian #591 revealed she was not made aware of any chewing or swallowing concerns related to Resident #7 and if she had been made aware of a concern, she would have made a referral for a swallow evaluation to be completed.Observation on 05/18/26 at 12:05 P.M. in memory care area revealed Resident #7 was observed putting some pork in her mouth and then removing it onto her plate. Resident #7 was able to tolerate mashed potatoes, noodles and her soup. Resident #7 was able to eat her meal independently with set up assistance by staff and was observed to eat approximately 25% of her meal.Interview on 05/18/26 at 3:52 P.M. with the Administrator confirmed there was not a scheduled follow-up appointment following the dental visit on 03/31/26.Review of the December 2013 revised facility policy titled, Dental Examination/Assessment, revealed the resident shall be offered dental services as needed. Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist.

Based on observation, interview and record review, the facility failed to respect and honor a resident's choice to not have care provided by Certified Nursing Assistant (CNA) #588. This affected one resident (Resident #39) of three residents reviewed for respect and dignity. The facility census was 78. Findings include:Record review for Resident #39 revealed an admission date of 07/25/23. Diagnosis included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was moderately cognitively impaired, used a wheelchair for mobility, was always incontinent of urine and occasionally incontinent of bowel. Resident #39 was dependent for toileting hygiene and bed mobility.Observation on 05/12/26 at 2:18 P.M. revealed Resident #39 was lying in bed. Interview with Resident #39 at the time of the observation revealed she was incontinent and waiting for staff to assist with care.Interview on 05/12/26 at 2:39 P.M. with CNA #511 revealed she did not normally have Resident #39 on her routine assignment. Resident #39 was on another CNA's assignment, but when CNA #588 worked, like today, she (CNA #511) had to add Resident #39 to her assignment because Resident #39 did not want CNA #588 caring for her. Observation at the time of the interview revealed CNA #511 gathered supplies for incontinence care and entered Resident #39's room. Wound Nurse #539 then entered Resident #39's room and reminded CNA #511 to wear her Personal Protective Equipment (PPE). After donning the PPE, CNA #511 began to care for Resident #39. CNA #588 entered the room. Resident #39 looked up at CNA #511 and stated loudly, I don't want her in here. CNA #511 stated, Shhh, while shaking her head no and whispered, It will be alright. Resident #39 looked up at CNA #511 with her mouth opened and her eyebrows crunched but did not respond. CNA #588 assisted with incontinence care for Resident #39 including turning and repositioning. Interview on 05/12/26 at 3:35 P.M. with Resident #39 who complained in a loud and angry tone, I didn't want her (CNA #588) in here. I said that and she stayed anyway. I did not want her here. She cussed at me before that's why. I didn't want her here. Resident #39 stated a while back, CNA #588 had cursed at her, then stated, It made me feel bad. They didn't listen to me. I don't understand why she is in here when I asked her not to be. She cussed me out. I cried so hard. She came back and apologized, but I just don't want her in here. Resident #39 appeared stressed during the interview and became teary eyed.Interview on 05/12/26 at 3:39 P.M. with CNA #511 who stated, We were told we had to have two staff because the resident makes up stories, so someone else had to be there. When asked about the response she gave to Resident #39 during care, CNA #511 stated, I didn't know what to say. There had to be two. CNA #511 revealed she never told anyone about Resident #39 not wanting CNA #588 to work with her because she thought everyone else already knew.Interview on 05/12/26 at 4:41 P.M. with Director of Nursing (DON) revealed residents were allowed to request not to have a certain staff member provide care, and that it was their right. DON stated she was not aware Resident #39 did not want care provided by CNA #588. This deficiency represents non-compliance investigated under Complaint Number 2803899.

Based on observation, interview, and review of facility menu and policy, the facility failed to ensure a physician ordered therapeutic diet was followed. This affected one resident (Resident #13) of one resident reviewed for therapeutic diets. This had the potential to affect 48 residents (Residents #3, #4, #6, #7, #10, #11, #12, #13, #14, #17, #18, #19, #24, #26, #27, #28, #29, #33, #34, #36, #37, #39, #42, #44, #45, #47, #48, #49, #50, #52, #54, #56, #59, #62, #64, #65, #66, #67, #68, #69, #70, #71, #72, #74, #75, #76, #78 and #79) who received a therapeutic diet. The facility census was 78.Findings include:Review of the medical record for Resident #13 revealed an admission date of 11/07/25. Diagnoses included but were not limited to end stage renal disease with dependence on dialysis, cognitive social or emotional deficit following stroke, vascular dementia and type II diabetes mellitus. Review of the 05/13/26 hospital discharge Minimum Data Set (MDS) 3.0 assessment for Resident #13 revealed moderate memory impairment. Resident #13 was noted to be independent for eating. Review of the 03/06/26 physician order for Resident #13 revealed a diet order of a liberalized renal diet with regular texture and thin liquids.Review of the care plan last reviewed on 03/21/26 for Resident #13 revealed the resident had a nutritional problem or potential nutritional problem related to past medical history of end stage renal disease on hemodialysis, type II diabetes mellitus and need for therapeutic diet. One of the interventions listed was to provide and serve diet as ordered.Review of the facility menu titled, Garden 2026 Spring/Summer Menus Week Four, revealed the Wednesday diet for liberalized renal diets were to receive three ounces of plain meatballs, four ounces of no salt added fluffy steamed rice, four ounces of buttered cabbage, one dinner roll, four ounces of cinnamon baked apples, four ounces of cranberry juice cocktail and margarine. Observation on 05/13/26 at 11:46 A.M. with Regional Dietary Manager (RDM) #601 confirmed the plate prepared for Resident #13 who was on a renal diet had plain meatballs, rice, spinach, a roll and cinnamon apples. RDM #601 confirmed the facility menu stated renal diets were to receive buttered cabbage instead of spinach and it had not been prepared prior to the start of tray line.Review of the November 2015 revised facility policy titled, Therapeutic Diets, revealed mechanically altered diets as well as diets modified for medical or nutritional needs were considered a therapeutic diet. Diets were determined in accordance with the residents' informed choices, preferences, treatment goals and wishes. The clinical dietitian, nursing staff and attending physician reviewed, along with other orders, the need for and resident acceptance of prescribed therapeutic diets. Routine menus were planned by the food services manager and approved by a registered dietitian for nutritional adequacy. The food services manager established and used a tray identification system to ensure that each resident received his or her diet as ordered. This deficiency represents non-compliance investigated under Complaint Number 2800362.

Based on observation, interview, and review of the medical record and facility policy, the facility failed to adequately prepare food to address a resident's pain and chewing difficulties. This affected one resident (Resident #7) of one resident reviewed for chewing difficulties. The facility census was 78.Findings include:Review of the medical record for Resident #7 revealed an admission date of 12/22/23. Diagnoses included but were not limited to Parkinson's disease with dyskinesia, type II diabetes mellitus, dementia and osteoporosis.Review of the 07/15/24 physician order for Resident #7 revealed a diet order of no added salt, reduced concentrated sweets regular texture diet. Review of the 03/14/26 Minimum Data Set (MDS) 3.0 assessment for Resident #7 revealed a Brief Interview of Mental Status of 11 which indicated moderate cognitive impairment. Resident #7 was noted to require supervision with eating and moderate assistance with oral hygiene. Resident #7 was not noted to have concerns with obvious or likely cavities or broken natural teeth and no noted dental concerns.Review of the 03/14/26 nutrition assessment for Resident #7 revealed the current diet order was appropriate and no noted swallowing difficulties.Review of the care plan last reviewed on 03/24/26 for Resident #7 revealed the resident was at risk for oral/dental health problems due to missing most teeth with an upper and lower partial. Interventions included a consult with dietitian and change (diet) if chewing/swallowing problems were noted; monitor/document/report signs and symptoms of oral/dental problems needing attention including pain (gums, toothache, palate), abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, or decayed; and provide mouth care as per activities of daily living for personal hygiene.Review of the 03/24/26 multidisciplinary therapy screen for Resident #7 revealed Patient remains at baseline with swallowing and cognition. No complaints of weight loss or difficulty swallowing. No changes in communication. Physical therapy and occupational therapy were indicated with a check mark at the bottom and Speech-Language Pathologist was indicated with an X.Observation on 05/11/26 at 2:58 P.M. of Resident #7 revealed the resident had one tooth left on the bottom which was brown/black in color and was noted to have a hole in it. Interview at the time of the observation with Resident #7 revealed sometimes it was hard to eat. Upper dentures were not noted in her mouth.Interview on 05/12/26 at 1:08 P.M. with Resident #7 revealed she could not wear her upper dentures due to it not fitting correctly.Interview on 05/13/26 at 8:51 A.M. with Resident #7 revealed sometimes she had pain in her mouth and right now she had really chapped lips which were bothering her.Interview on 05/13/26 at 9:10 A.M. with Certified Nurse Aide (CNA) #573 revealed Resident #7 usually ate 100% of breakfast but usually ate less for lunch and dinner. CNA #573 stated Resident #7 seemed to have a harder time chewing meat and stated she had complained about having pain in her mouth but had reported it. CNA #573 was unsure if Resident #7 had dentures.Interview on 05/13/26 at 12:47 P.M. with Resident #7 revealed the staff had assisted her to put in her upper dentures today but they did not fit right so she took them out. She was able to eat her meatballs at lunch since they were soft. Sometimes she had issues chewing meat due to it being tough and only having one tooth. If she was unable to chew the meat, she would suck out the juice and then spit the meat out. Interview on 05/14/26 at 9:14 A.M. with Speech Therapist (ST) #571 revealed evaluations were completed on admission, readmission and if there was a change or referral. ST #571 stated the last time Resident #7 was evaluated for swallowing was 08/25 and had not been made aware of any pain or chewing concerns since then to complete an evaluation.Interview on 05/14/26 at 10:37 A.M. with Respiratory Manager (RM) #562 confirmed a five-minute therapy screen was completed on 03/24/26 for transfer and activities of daily living participation. RM #562 stated that since chewing concerns or mouth pain were not reported, no evaluation was completed for chewing or swallowing.Interview on 05/14/26 at 10:46 A.M. with CNA #573 revealed Resident #7's chewing concerns were reported several times but after reporting it several times, CNA #573 stopped reporting it since nothing seemed to change.Phone interview on 05/14/26 at 11:43 A.M. with Ancillary Dental Coordinator #605 revealed at Resident #7's appointment on 01/28/26 it was noted extractions were needed for three lower teeth. One was exposed and the other two were broken teeth with roots covered by gum tissue. The teeth needed to come out when pain was indicated. The dental appointment on 03/31/26 indicated Resident #7 reported her upper denture was not fitting properly and the resident was not appropriate for a lower denture replacement until the lower teeth were extracted.Phone interview on 05/18/26 at 10:59 A.M. with Registered Dietitian #591 revealed she was not made aware of any chewing or swallowing concerns related to Resident #7 and if she had been made aware of a concern, she would have made a referral for a swallow evaluation to be completed.Observation on 05/18/26 at 12:05 P.M. in memory care area revealed Resident #7 was observed putting some pork in her mouth and then removing it onto her plate. Resident #7 was able to tolerate mashed potatoes, noodles and her soup. Resident #7 was able to eat her meal independently with set up assistance by staff and was observed to eat approximately 25% of her meal.Interview on 05/18/26 at 3:52 P.M. with the Administrator confirmed there was not a scheduled follow-up appointment following the dental visit on 03/31/26 and was unable to provide evidence Resident #7 had declined a trial of mechanical meats.Review of the November 2015 revised facility policy titled, Therapeutic Diets, revealed mechanically altered diets as well as diets modified for medical or nutritional needs were considered therapeutic diets. Diets were determined in accordance with the residents' informed choices, preferences, treatment goals and wishes. The clinical dietitian, nursing staff and attending physician would review, along with other orders, the need for and resident acceptance of prescribed therapeutic diets.

Based on record review, interviews, and review of the facility policy, the facility failed to complete a Self-Reported Incident (SRI) when an allegation of verbal abuse was reported involving Certified Nursing Assistant (CNA) #588 cursing at Resident #39. This affected one resident (Resident #39) of three residents reviewed for abuse. The facility census was 78.Findings include:Record review for Resident #39 revealed an admission date of 07/25/23. Diagnosis included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Interview on 05/12/26 at 3:35 P.M. with Resident #39 revealed a while back, CNA #588 cursed at her and stated, It made me feel bad. They didn't listen to me. I don't understand why she is in here when I asked her not to be. She cussed me out. I cried so hard. She came back and apologized, but I just don't want her in here. Resident #39 appeared stressed during the interview and became teary eyed.During an interview on 05/12/26 at 4:41 P.M. with the Director of Nursing (DON) notification was made by informing the DON of Resident #39's allegation of CNA #588 cursing at her and making her cry. The allegation was discussed and DON twice repeated Resident #39's concern, stating an investigation was needed.Review of the facility Self-Reported Incidents (SRI) made to the State Agency from 05/12/26 to 05/14/26 revealed an SRI was not initiated for the abuse allegation made by Resident #39 on 05/12/26. Interview on 05/14/26 at 8:42 A.M. with DON and Administrator revealed the Administrator confirmed if a resident made an allegation that a CNA cursed at her making the resident cry, an SRI should have been opened. DON confirmed she was notified on 05/12/26 of the allegation regarding CNA #588 cursing at Resident #39 and making her cry. Administrator confirmed that an SRI was not opened.Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, undated revealed all incidents and allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, and injuries of unknown source must be reported to the State Agency no later than two hours after the allegation is made. All other allegations (without injury) must be reported as soon as possible, but no later than 24 hours after the staff member becomes aware of the incident or allegation. This deficiency represents non-compliance investigated under Master Complaint Number 3000374.

Based on record review, interview, and facility policy review, the facility failed to ensure staff obtained proper Cardiopulmonary Recusation (CPR) certification for healthcare providers. This had the potential affect 59 Residents (#1, #2, #3, #4, #9, #11, #13, #14, #15, #16, #17,#19, #20, #21, #22, #23, #28, #30, #31, #33 ,#34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #48, #50,#52, #53, #56, #57, #59, #61, #62, #63, #64, #65, #69, #70, #73, #74, #75, #76, #77, #81, #83, #84, #86, #88, #89, and #91) who had elected for an advance directive of full code status . The facility census was 91. Findings include: Review of the staff certifications for CPR certification revealed the following:Review of Licensed Practical Nurse (LPN) #101's personnel record revealed a date of hire of [DATE]. There was no CPR certification contained in LPN #101's personnel record.Review of LPN #107's personnel record revealed a date of hire of [DATE]. The CPR certification included adult, child, infant and automatic electronic defibrillator (AED). The completion date was [DATE] with a renewal date of [DATE]. The card did not include an indication that the training course covered basic life support (BLS) and did not indicate it was a certification for healthcare providers.Review of LPN #111's personnel record revealed a date of hire of [DATE]. There was no CPR certification contained in LPN #111's personnel record.Review of Registered Nurse (RN) #114's personnel record revealed a date of hire of [DATE]. There was no CPR certification contained in RN #114's personnel record.Review of LPN #115's personnel record revealed a date of hire of [DATE]. The CPR certification included adult, child, infant and AED. The completion date was [DATE] and renewal date of [DATE]. The course did not include Basic Life Support (BLS) and did not indicate it was a certification for healthcare providers.Review of LPN #116's personnel record revealed a date of hire of [DATE]. The CPR certification included adult, child, infant and AED. The completion date was [DATE] and renewal date of [DATE]. The course did not include Basic Life Support (BLS) and did not indicate it was a certification for healthcare providers.Review of LPN #118's personnel record revealed a date of hire of [DATE]. There was no CPR certification contained in LPN #118's personnel record.Review of LPN #120's personnel record revealed a date of hire of [DATE]. The CPR certification included adult, child, infant and AED. The completion date was [DATE] and renewal date of [DATE]. The course did not include Basic Life Support (BLS) and did not indicate it was a certification for healthcare providers.Interview on [DATE] at 9:38 A.M. with the Director of Nursing (DON) verified RN #114, and LPNs #101, #111, and #118 had no current CPR certification on file. Additionally, the DON confirmed LPNs #107, #115, #116, and #120's CPR certification did not include BLS or have a designation that it was a certification for healthcare providers.Review of the policy titled Licensure, Certification, and Registration of Personnel revise [DATE] stated Personnel who require a license, certification, or registration to perform their duties must present verification of such license/certification registration to the Human Resources Director prior to or upon employment.Review of the policy titled Emergency Procedure Cardiopulmonary Resuscitation revised [DATE] stated Resuscitation (CPR) for key clinical staff member who will direct resuscitative efforts, including non-licensed personnel will obtain and or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS) Cardiopulmonary Resuscitation (CPR).This deficiency represents non-compliance investigated under Master Complaint Number 2733342 and Complaint Number 2717021.

Based on record review, interview, and facility policy review, the facility failed to ensure pain medications were available for administration. This affected one resident (#58) of three residents reviewed for medications. The facility census was 91. Findings include: Review of the medical record for Resident #58 revealed an admission date of 09/01/24 with diagnosis of rheumatoid arthritis, failure to thrive, depression, post cholecystectomy syndrome.Review of the quarterly Minimum Data Set 3.0 dated 01/07/26 revealed the resident had intact cognition and was dependent on staff for toileting and transfers. The assessment indicated the resident had pain and received scheduled and as-needed pain medications.Review of the physicians ordered for January 2026 revealed two order for pain medication. Oxycodone (a opioid analgesic) 15 milligrams (mg) to be administered every four hours and Acetaminophen (an over-the-counter mild pain reliever) 500 mg, a pain reliever, to be administered every six hours as needed. Review of the Medication Administration Record (MAR) for January 2026 revealed on 01/20/26 Oxycodone 15 mg was sign off as not administered and to see progress note at 6:00 A.M., 10:00 A.M, 2:00 P.M. and 6:00 P.M. Review of progress notes dated 01/20/26 timed 10:07 A.M., 1:13 P.M., and 5:42 P.M. revealed the doses were not administered on 01/20/26 as the facility was waiting on the pharmacy to deliver Resident #58's Oxycodone. Continued review of Resident #58's MAR for January 2026 revealed Oxycodone 15 mg was left blank on 01/25/26 at 10:00 P.M. and 01/26/26 at 2:00 A.M., 6:00 A.M. and 2:00 P.M.Interview on 01/29/26 at 5:00 P.M. with the Director of Nursing (DON) verified Resident #58 was not administered Oxycodone on 01/20/26, 01/25/26, and 01/26/26 due to a delay with pharmacy delivery. There were no notes related to why Resident #58's Oxycodone was not administered on 01/25/26 and 01/26/25.Review of the policy Administering Medications revised December 2012 revealed medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. This deficiency represents non-compliance investigated under Complaint Number 2711748.

Based on closed record review, interview, review of emergency medical services (EMS) run report, review of the facility's timeline and investigation, and facility policy review, the facility failed to ensure a resident's change in condition was timely addressed. This affected one resident (#34) of three residents reviewed for changes in condition. The facility census was 91. Findings include:Review of the closed medical record for Resident #34 revealed an admission date of [DATE] with medical diagnoses including presence of a tracheostomy (a surgically-created opening in the neck through which an airway is established; it involves inserting a tube to bypass the upper airway), chronic respiratory failure with hypoxia, malignant neoplasm (cancer) of the larynx, malnutrition, gastrostomy status, and gastroesophageal reflux disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and was dependent on staff for toileting, showers, and transfers. The resident received enteral nutrition via a feeding tube, oxygen therapy, tracheostomy care, and suctioning. Review of the Care Plan dated [DATE] revealed Resident #34 had altered respiratory status and difficulty breathing related to tracheal squamous cell cancer and chronic hypoxia. Interventions including administering humidified oxygen via tracheostomy mask to maintain oxygen saturation level of 92 percent (%) and providing oral suction to clear secretion and elevate the head of the bed for easier breathing. Review of Resident #34's physician orders revealed an order date [DATE] for full code status, indicating resuscitation efforts were to be provided (up to and including cardiopulmonary resuscitation (CPR)) in the event or cardiac or respiratory arrest. Review of Resident #34's medical record revealed he elected for hospice services on [DATE]. Review of Resident #34's physician orders revealed an order dated [DATE], initiated after electing for hospice services, to discontinue all laboratory testing and do not hospitalize. Review of the facility's investigation and timeline revealed on [DATE] at 5:50 A.M., Resident #34's tracheostomy inner cannula had come dislodged. At 5:55 A.M., the (unnamed) Certified Nursing Assistant (CNA) alerted the nurse that the resident had difficulty breathing. At 6:06 A.M., staff went to get another nurse in the building. At 6:10 A.M., CPR was initiated and EMS was called. At 6:15 A.M., EMS arrived at the facility. Review of the EMS run report dated [DATE] revealed a call was received by EMS at 6:26 A.M. The report indicated the EMS crew arrived at the facility at 6:36 A.M. and arrived at the patient at 6:38 A.M. Upon arrival, CPR was in progress by facility staff. The report indicated facility staff had witnessed the arrest after Resident #34 had taken out his tracheostomy tube and then went quickly into full arrest. The EMS report indicated EMS staff continued care and Resident #34 was transported to a local hospital. Review of Resident #34's progress notes dated [DATE] at 8:28 A.M. revealed the nurse was alerted the resident was in respiratory distress and CPR was initiated. EMS was called and the physician was notified. The note concluded by referencing the resident regained consciousness and a slight pulse before leaving the facility. The note did not specify what time the change in condition occurred or any additional details about the arrest. Further review of Resident #34's progress notes revealed he returned to the facility on [DATE]. Interview with the Corporate Quality Assurance Registered Nurse (QARN) #220 on [DATE] at 10:29 A.M. revealed she received a call on [DATE] at 7:00 A.M. that Resident #34 had coded. An investigation was conducted. The investigation identified that there was a delay in giving care to Resident #34. CNA #138 had alerted the nurse. However, the nurse went to another unit to get help and left Resident #34 alone. Interview with CNA #138 on [DATE] at 12:08 P.M. revealed on [DATE] around 5:50 A.M., she was passing water and Resident #34 waved her down and was pointing at his tracheostomy tube and noted that it was disconnected. CNA #138 notified Licensed Practical Nurse (LPN) #116 that Resident #34 needed him and Resident #34's tracheostomy hose was disconnected. LPN #116 was passing morning medications to other residents and replied to give him a few minutes. CNA #138 waited with Resident #34 for eight minutes and then left the room to notify CNA #140 that LPN #116 has not come to assess Resident #34. CNA#138 went on to provide care to her assigned residents. Two minutes later, LPN #116 entered Resident #34's room. Fifteen minutes later, she went back to Resident #34's room and LPN #116, LPN #119, and LPN #113 were present in the room. Resident #34's trach was pulled completely out and sitting on his chest. Resident #34 was not breathing, and CPR was initiated and EMS was called. Interview with LPN #119 on [DATE] at 12:58 P.M. revealed she was assigned to the secured unit on the first floor when LPN #116 and LPN #113 came in and notified her that Resident #34 was in respiratory distress. LPN #119 stated they were on the first floor and took the elevator up to the second floor to get to Resident #34's room. Upon entering, Resident #34 had a grey tone and was not breathing. LPN #113 grabbed the crash cart and called 911. LPN #116 started CPR. LPN #119 estimated the time to be in the 6:00 A.M. hour. Interview with LPN #113 on [DATE] at 1:15 P.M. revealed on [DATE] at approximately 6:15 A.M., LPN #116 came to her unit and stated Resident #34 had been in respiratory distress for some time. Upon entering the room, the resident was grey and had difficulty breathing. Resident #34 he took a few breaths and then stopped. There were no staff with the resident. LPN #113 estimated at 6:20 A.M., EMS was called and CPR was initiated. Interview with the Medical Director (MD) on [DATE] at 3:02 P.M. stated he was notified of Resident #34 coding. However, he was unaware of the delayed response time in addressing the resident's respiratory distress. Interview with LPN #116 on [DATE] at 11:34 A.M. revealed during shift report [on the evening of [DATE]], he had been informed Resident #34 had signed on to hospice services. At 5:30 A.M. [on [DATE]] he began his morning medication pass. LPN #116 was preparing another resident's medication across the hall when he was notified by CNA #138 that Resident #34 was having a hard time breathing. LPN #116 told CNA #138 to give him a minute to finish the resident's medication administration. Upon entering room, he observed Resident #34 in respiratory distress. LPN #116 went to suction Resident #34 when the resident was observed to pull out his whole tracheostomy tube. LPN #116 tried to re-insert the tracheostomy tube but could not. He looked out the hall for help and saw no one, so he continued to walk to a unit on the first floor to get a nurse and then to the secured unit to get another nurse. They all took the elevator back up to second floor. At that time Resident #34 was noted to not be breathing and CPR was started and EMS was called. LPN #116 reported EMS arrived within approximately ten to fifteen minutes after they were called. Interview with the Director of Nursing (DON) on [DATE] at 12:12 P.M. verified there was a delay in addressing Resident #34's change of condition on the morning of [DATE]. LPN #116 should have immediately assessed Resident #34 trach tube when alerted he was in distress instead of administering medication to another resident and confirmed a staff member should have stayed with Resident #34. The DON reported a code should have been called through the overhead paging system. The DON stated it had been difficult to come up with accurate timeline as staff statements and interviews as staff had not recorded or provided times of the incident on [DATE]. Review of the facility policy titled Change in a Resident's Condition revised [DATE] revealed a significant change of condition is a major decline or improvement in the resident status that will not normally resolve itself without intervention by staff. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the undated document Change in Condition revealed if any changes are observed, report to the nurse. The nurse will communicate pertinent changes to the doctor or nurse practitioner (NP) when observed. Staff must monitor changes and document resident's progress and responses to treatment. This deficiency represents non-compliance identified under Master Complaint Number 2733342 and is a recite to the survey completed on [DATE].