Every finding on record at Ghent Health and Rehabilitation

Based on observations, resident and staff interviews, facility document review, and clinical record review, it was determined that the facility staff failed to maintain a clean and homelike environment for residents across four of the facility's four units, which constituted substandard quality of care (SQC). The findings include: 1. The facility staff failed to maintain a clean and homelike environment for Resident #35 (R35). Observation of the bathroom for room [ROOM NUMBER] on 2/3/26 evidenced no hot water. Water was left running for 4 minutes without it getting warm. R35 was admitted to the facility on [DATE] with diagnosis that included but were not limited to traumatic subdural hemorrhage, syncope, falls and COPD (chronic obstructive pulmonary disease) R35's most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 1/23/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as maximal assist for bed mobility, transfer, hygiene. A review of R35's comprehensive care plan dated 1/29/26 revealed, FOCUS: The resident has ADL (activities of daily living) self-care performance deficit related to impaired mobility. INTERVENTIONS: praise all self-care efforts. During interview with R35 on 2/3/26 at approximately 1:00 PM, R35 stated that we do not have hot water, R35's daughter was present and verified she was unable to obtain hot water from bathroom sink. On 2/3/26 at 1:05 PM, an interview was conducted with CNA (certified nursing assistant) #1. Asked if the water was hot in the bathroom for room [ROOM NUMBER], CNA #1 stated, no, it is not getting warm. On 2/6/26 at 11:50, the administrator and Director of Nursing (DON) were made aware of the findings. A review of the facility's Safe and Homelike Environment policy which reveals, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/ hyperthermia and is comfortable for the residents. No further information was provided prior to exit. 2. The facility staff failed to maintain a clean and home-like environment for R47. Observation of the bathroom for room [ROOM NUMBER] on 2/3/26 evidenced no hot water and the toilet was on half to three fourths full of urine and did not flush. Water was left running for 4 minutes without it getting warm. Observation of bathroom form room [ROOM NUMBER] on 2/4/26 revealed, no hot water and toilet was approximately three fourths full and did not flush R47 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: OSA (obstructive sleep apnea), acute cystitis and malignant neoplasm of prostate. R47's most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 1/28/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as moderate assist for bed mobility, transfer, hygiene. A review of R47's comprehensive care plan dated 1/22/26 revealed, FOCUS: The resident has a Urinary Tract Infection related to acute cystitis with hematuria. INTERVENTIONS: Encourage fluid intake and monitor/document/report to physician as needed signs/symptoms of UTI (urinary tract infection). During interview with Resident #47 on 2/3/26 at approximately 12:40 PM, R47 stated, we do not have hot water, the toilet does not flush and the heat went off last night 2/2/26. On 2/3/26 at 12:42 PM, an interview was conducted with CNA (certified nursing assistant) #1. Asked if the water was hot in the bathroom for room [ROOM NUMBER], CNA #1 stated, no, it is not getting warm. Asked if she was able to flush the toilet, CNA #1 stated, no, it does not flush. On 2/6/26 at 11:50 AM, the administrator and DON were made aware of the findings. No further information was provided prior to exit. 3. The facility staff failed to maintain a clean and homelike environment for Resident #137 (R137). Observation of the bathroom for room [ROOM NUMBER] on 2/3/26 evidenced no hot water and the toilet was on half to three fourths full of urine and did not flush. Water was left running for 4 minutes without it getting warm. Observation of bathroom form room [ROOM NUMBER] on 2/4/26 revealed, no hot water and toilet was approximately three fourths full and did not flush and the heat went off last night 2/2/26. On 2/9/26 R137 stated, the heat went off Saturday night into Sunday morning, it was cold and they had to reset it R137 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ICH (intracranial hemorrhage) DM (diabetes mellitus) and TIA (transient ischemic attack). R137's most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/2/26, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as maximal assist for bed mobility, transfer, hygiene. A review of R137's comprehensive care plan dated 1/29/26 revealed, FOCUS: The resident has an ADL (activity of daily living) self-care performance deficit related to impaired mobility. INTERVENTIONS: Praise all efforts at self-care. During interview with R137 on 2/3/26 at approximately 12:40 PM, R137 stated, we do not have hot water, the toilet does not flush and the heat went off last night 2/2/26. On 2/3/26 at 12:42 PM, an interview was conducted with CNA (certified nursing assistant) #1. Asked if the water was hot in the bathroom for room [ROOM NUMBER], CNA #1 stated, no, it is not getting warm. Asked if she was able to flush the toilet, CNA #1 stated, no, it does not flush. On 2/4/26 at 7:20 AM R137 stated the heat went off again last night, they restarted it about 10 minutes ago. On 2/4/26 at 9:15 AM an interview was conducted with LPN (licensed practical nurse) #1, when asked about the lack of hot water in 135 and 139 and toilet not flushing in room [ROOM NUMBER], LPN #1 stated, let me check, was unable to flush toilet or have hot water. On 2/4/26 at approximately 12:00 PM, the maintenance director stated, we have fixed the toilet in room [ROOM NUMBER] and when I came in this morning at 7:00 AM, I saw the heat in TELS (electronic work order system) and reset it about 7:10 AM. 2/6/26 at 10:00 AM an interview was conducted with the administrator. Asked about the heating in room [ROOM NUMBER] on Unit 1-B, ASM #1 stated, that unit was the first area we renovated. When we replaced the old heating units, there was a duct to the outside with a vent for air intake. After we put the new heating units in each resident room, we found that with the cold weather, the cold air was coming in through the outside vents and trips the heating unit causing it to turn off. We have been working with STR-our contractor to fix this issue. They are fabricating metal plates that will place on the outside of the vent so cold air will not trip the system requiring a manual reset. As we are renovating the rest of the building, we are insulating the vent from the inside to keep it from tripping the heating system. The issue with the no hot water on 2/3 and 2/4 was due to STR shutting it off on the area they were working in on the first floor.the other end of the hall from 1B. On 2/6/26 at 11:50 AM, the administrator and DON were made aware of the findings. No further information was provided prior to exit. - 4.Observations during the survey period of 2/3/26-2/6/26 and 2/9/26-2/11/26 revealed, observations of roaches and mice. On 2/4/2026 at 10:33 AM, an observation was made of Resident #129 in their room. A large brown roach was observed climbing up to the top of the nightstand and then proceeding to the back side of the nightstand. The roach was observed by two surveyors. On 2/5/2026 at 6:45 AM, this surveyor observed a mouse running across hallway from the biohazard room on first floor to underneath the door of a locked room. A review of the pest control invoices revealed this number of invoices per month: 7/25-1, 9/25-6, 10/25-5, 11/25-6, 12/25-14 and 1/26-10. A review of the pest control logs for the units reveal the following: 1/25-3/25 (mice-2, roaches/ants-7), 4/25-6/25 (mice-9, roaches/ants-7), 7/25-10/25 (mice-16, roaches/ants-17), 11/25 (mice-6, roaches/ants-3), 12/25 (mice-2, roaches/ants-2), 1/26 (mice-4, roaches/ants-3), 2/26 (mice-1, roaches/ants-1). On 2/3/2026 at 12:50 PM, an interview was conducted with Resident #84, a cognitively intact resident, who stated that there was a mouse living in their room and that he had discussed it with the assistant administrator because it had come through the ventilation system. On 2/3/2026 at 2:00 PM, an interview was conducted with Resident #28 (R28), a cognitively intact resident, who stated that he has had a mouse in his room that runs from under the door and goes behind the grey baseboard (baseboard is pulled up at one end). On 2/3/2026 at 3:33 PM, an interview was conducted with Resident #125 (R125), a cognitively intact resident, who stated that there had been roaches in the facility for quite a while and they had gotten better recently in their room. R125 stated that in December he had a roach fall out of the food dome when he opened his meal, so he had stopped eating for a while. R125 stated that there were mice at the facility and within the past week there had been a mouse coming in the room under the door with something in its mouth and was squeaking really loud. On 2/5/2026 at 10:28 AM, R125 stated that when maintenance came in to fix the motor in his heater yesterday, they found a dead mouse inside. R125 stated that he also saw a roach crawling up the wall in his room yesterday. On 2/4/2026, at 7:05 AM an interview was conducted with CNA (certified nursing assistant) #2 a night CNA. CNA #2 described there are pests and rodents, it is documented in the pest control log and pest control comes three times a week. You can hear something running in the ceiling at night. On 2/5/2026 at 6:50 AM an interview was conducted with the maintenance director. He was informed of the mouse running across the hall into the locked room. The maintenance director went to the locked room, entered and looked for the mouse and said he must have gone behind the wall; it has gotten better, we have a pest control company come three times a week. They review the pest logs on the units and treat those areas and any areas we are having difficulty with. I had heard about rodents in the ceiling and have put traps up there. We tell them not to keep food out and not to have clothes on floors and stacked in chairs as rodents love to nest in them. On 2/5/2026 at 12:05 PM, an interview was conducted with Resident #7 (R7), a moderately impaired resident, who stated that some baby mice were seen running around in his room yesterday. R7 stated that they did not get in his belongings but ran around the room. On 2/5/2026 at 1:00 PM, during resident council, Resident #34 (R34) a cognitively intact resident described that there was a mouse on a glue pad in his room. During observation at 4:00 PM, there was no observation of mouse on glue pad and no glue pad in room. Unable to locate any staff who may have removed mice. On 2/6/26 at 10:25 AM, an interview was conducted with the pest control representative who described his treatment schedule of three times a week; for rodent control we do traps in non-public areas and glue boards. Baiting in patient rooms and resident areas. We review the pest sighting logs and identify any other areas to treat. On 2/6/26 at 11:50 AM, the administrator and the DONwere made aware of the findings. A review of the facility's Pest Control Program policy revealed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. No further information was provided prior to exit. 5. The facility staff failed to provide a safe, clean, comfortable, and homelike environment for Resident #58. Resident #58 was admitted to the facility on [DATE]. The resident's diagnoses included a stroke, atrial fibrillation, and dementia. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/24/25, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 14 out of 15. This indicated that Resident #58's cognitive abilities for daily decision-making were intact. On 2/3/26 at approximately 3:59 PM, Resident #58 stated that every night he saw roaches and many mice in his bedroom, including pregnant mice. The resident stated that there are far more mice than roaches. Several glue traps and pest-control boxes were observed throughout the room, and no pests were observed. On 2/4/26 at 10:12 AM, the resident stated that his bathroom was dirty. An observation of the bathroom revealed that all the water in the commode was dark brown and odorous. On 2/5/26 at 2:10 PM, an observation of the resident's commode revealed that it still contained the dark brown, odorous liquid. An interview was conducted with the Maintenance Director. The Maintenance Director stated that a resident on the hall places eating utensils in the toilet, which backs up the system and prevents the toilets from flushing. The Maintenance Director further stated that the company comes out every two weeks to get the system running again. The Maintenance Director showed the intervention in place to prevent the resident from flushing items that should not be flushed. The Maintenance Director stated that it had not prevented the problem. On 2/6/26 at approximately 11:55 AM, an inspection of Resident #58's bathroom was completed with the Assistant Director of Nursing (ADON). On 2/11/26 at approximately 5:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and voiced no concerns. 6. The facility staff failed to provide a safe, clean, comfortable, and homelike environment for Resident #107. Resident #107 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included a stroke, diabetes, and a seizure disorder. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 1/2/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 13 out of 15. This indicated that Resident #107's cognitive abilities for daily decision-making were intact. On 2/4/26 at approximately 10:27 AM, the resident was observed walking quickly in the corridor. He was observed entering the shower room. After toileting in the shower room, the resident returned to his room. He stated that the commode in his room had been out of order for weeks. He also said that the maintenance man removed the old commode and installed a new one, but it doesn't work. An observation of the resident's toilet in his room revealed a commode half-filled with a dark brown liquid and wads of toilet paper. It would not flush when the handle was activated. On 2/6/26 at 12:20 PM, the resident was seen in the corridor, very upset. He stated that while he was eating his lunch, the maintenance man entered and began working on the commode, and that they should have waited until after lunch. On 2/6/26 at approximately 11:55 AM, an inspection of Resident #107's bathroom was completed with the Assistant Director of Nursing (ADON). On 2/11/26 at approximately 5:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and voiced no concerns. 7. The facility staff failed to provide a safe, clean, comfortable, and homelike environment for Resident #64. Resident #64 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included diabetes and dementia. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/2/25, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 10 out of 15. This indicated that Resident #64's cognitive abilities for daily decision-making were moderately impaired. On 2/4/26 at approximately 10:12 AM, an interview was conducted with Resident #64. The resident stated he had moved to another room for two days and regretted agreeing to return to room [ROOM NUMBER]. Resident #64 stated that the commode in the other room flushed, but the toilet in the current room did not. It hadn't flushed for over 30 days when he left two days ago, and it still does not. The resident further stated that the only difference is that when he left, it was full, and now it is only a quarter full. The resident stated that having a dirty bathroom for so long was unhealthy, and it made him sick. The resident stated he had to walk to the end of the hall to use the toilet in the shower room because the toilet was flushed. On 2/4/26 at 10:16 AM, an observation was made of the commode in room [ROOM NUMBER]. It was partially filled with dark brown liquid and had a strong urine odor. Feces and toilet paper were in the commode, and the odor was extremely foul. On 2/6/26 at approximately 11:55 AM, an inspection of Resident #107's bathroom was completed with the Assistant Director of Nursing (ADON). On 2/11/26 at approximately 5:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and voiced no concerns. 8. For Resident #125 (R125), the facility staff failed to secure a portable air conditioner to the window to maintain a homelike environment. On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date of 1/29/2026, the resident scored 15 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. On 2/3/2026 at 3:33 PM, an observation was made of R125's room. Observation revealed a portable air conditioning unit on the floor beside R125's bed. The unit was connected to a hose, and a window panel was attached to the window in the room, partially secured with tan masking tape. Observation of the window revealed that the tape had peeled off the plastic panel on the underside and the left side, exposing a gap between the window and the panel to the facility exterior, approximately 4 inches wide. The gap exposed the brick on the outside of the building. At that time, an interview was conducted with R125, who stated that the unit had been in place since the end of summer, when the air conditioner had broken, and that he had requested it be left in place because the room became hot even in winter. R125 stated that the tape had been coming off for a while and he had issues in the past with flies and gnats getting in, but it was too cold for them right now. On 2/3/2026 at 4:50 PM, an interview was conducted with the director of plant operations. He stated that R125 was the only resident left who had wanted to keep the portable air conditioning unit in their room for the winter, and they checked it monthly. The director of plant operations stated that the windows open 4 inches for the hose to stick out, and they use window insulation and tape around the window to keep it sealed. He observed R125's window and stated that he could see the outside and that it looked like it had been blown loose by the wind, and it needed to be retaped. The facility policy Safe and Homelike Environment revised 10/14/2025, documented in part, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk . Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment . On 2/4/2026 at approximately 5:00 PM, the administrator and the director of nursing were made aware of the concern. No further information was provided prior to exit. 9. The facility staff failed to maintain a clean and homelike environment for Resident #127. Resident #127 was originally admitted to the facility on [DATE] after an acute care hospital stay. The admission diagnoses included: major depressive disorder, schizoaffective disorder, malignant neoplasm of the lower lobe, and essential hypertension. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/22/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated that Resident #127's cognitive abilities for daily decision-making were intact. On 2/11/26 at 10:10 AM, during an observation tour of the bathroom in room [ROOM NUMBER], it was observed that the toilet had been removed from the floor and was inoperable. On 2/11/26 at 10:15 AM, an interview was conducted with Resident #127. Resident #127 stated that the toilet was removed from the floor the day prior, in the afternoon. Resident #127 also stated that she has been using the toilet in the shower room since yesterday afternoon. On 2/11/26 at 10:30 AM, an interview was conducted with the Administrator, Director of Maintenance, and the Regional Director of Maintenance. The Director of Maintenance stated that the toilet was removed from the floor this morning due to a clogged pipe. The Director of Maintenance also stated that the contractor is currently on-site working on fixing this issue. The Director of Maintenance further stated that this same issue occurred on 1/22/26, and the contractor fixed the issue at that time; the pipe is clogged again. A review of facility documentation dated 1/22/26 read: pulled toilet, snaked drainage line and dislodged clog. Cut 2 inch line that connected to drum trap coming from tub. Removed drum trap and plugged off line. Remounted toilet and tested. No further information was provided prior to exit. 10. The facility staff failed to maintain a clean and homelike environment for Resident #106. Resident #106 was originally admitted to the facility on [DATE] after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included: urinary tract infection. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/17/2025, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #106's cognitive abilities for daily decision making were intact. The personal-centered care plan dated 11/19/25 noted that the resident has an indwelling catheter (20 Fr, 10 cc) r/t Urinary Retention. The Goal for the resident is he will be/remain free from catheter-related trauma through review date. The Intervention: Check tubing for kinks each shift and the resident has (20 FR.) (Foley Catheter). Position catheter bag and tubing below the level of the bladder and away from entrance room door. In section GG(Functional Abilities Goals) the resident was coded as dependent with toileting hygiene, shower/bathe self and putting on taking off footwear. Requiring supervision or touching assistance with personal hygiene, requiring partial to moderate assistance with upper and lower body dressing and Independent with eating. requiring supervision or touch assistance with eating, oral hygiene and personal hygiene. In section H (Bladder and Bowel) the resident was coded as having an indwelling catheter. On 2/5/26 at approximately 1:05 pm., while touring unit 1A, Resident #106, in room [ROOM NUMBER] bed B, asked if he could get water to shave himself. The resident's room had a strong urine odor. The Certified Nursing Assistant #15 said his room had that odor for a while and believed it was coming from his mattress. The UM, Licensed Practical Nurse (LPN) #6, was asked to come to room [ROOM NUMBER]B concerning an odor. LPN #6 said, I may be nose-blind to the smell. Indicating that she didn't smell an odor. On 2/06/2026 at 10:00 am, room [ROOM NUMBER]B still had a strong urine odor. On 2/11/26 at approximately 5:30 pm., a pre-exit interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and voiced no concerns.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide COVID-19 vaccinations to residents 2025 and failed to maintain COVID-19 staff vaccination status. The findings include:During the facility task of Infection Prevention and review of facility documents, on 2/10/26 and 2/11/26, there was no evidence of resident COVID-19 vaccination for 2025 and no evidence of maintenance of staff COVID-19 vaccination status.On 2/11/26 at 9:00 AM an interview was conducted with LPN (licensed practical nurse) #4, the Infection Preventionist. LPN #4 stated, this role is new for me as of June of 2025. In regard to the COVID vaccinations for 2025, our pharmacy OMNICARE initially told us they did not have the vaccine; not sure who would have contacted them or another pharmacy to get the COVID vaccine. In regard to the staff COVID-19 vaccination status logs, they are not here, have checked my file cabinets and other file cabinets and they are not here. On 2/11/26 at 2:30 PM, the administrator and the director of nursing were made aware of the findings. A review of the facility's COVID-19 Vaccination policy revealed, It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. The facility will maintain documentation related to staff COVID-19 vaccination and include at a minimum: the COVID-19 vaccine status of staff and related information as indicated by NHSN.No further information was provided prior to exit.

Based on resident and staff interviews, the facility staff failed to respect residents' personal clothing and to ensure items were returned after laundering for 3 of 80 residents (Residents #20, #107, and #58) in the survey sample. The findings included: 1. The facility staff failed to protect and maintain Resident #20's personal clothing that was sent to the laundry. Resident #20 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included a stroke, hemiparesis, and aphasia. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 1/6/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 11 out of 15. This indicated that Resident #20's cognitive abilities for daily decision-making were moderately impaired. On 2/4/26 at approximately 9:24 AM, Resident #20 stated that he had sent clothing to the laundry over a week ago and had not been returned. The resident patted his chest and repeatedly stated that it was nasty that he had to wear the same clothing over and over, because his clothing was not returned. The resident was observed on 2/4/26 at approximately 2:18 PM asking staff for assistance in retrieving his clothing from the laundry. On 2/5/26 at approximately 11:00 AM, Resident #20 was observed asking staff to assist him in retrieving his clothing from the laundry. On 2/6/26 at approximately 11:55 AM, an interview was conducted with Resident #20 in his room with the Assistant Director of Nursing (ADON) present. The ADON assured the resident that someone would go to the laundry to retrieve her clothing. On 2/11/26 at approximately 5:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team. The Administrator stated that the facility staff was unable to locate Resident #20's clothing; therefore, new clothing was purchased for him, and his name was added to the items to facilitate their return after laundering. 2. The facility staff failed to ensure Resident #107's personal clothing was returned to him after laundering. Resident #107 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included a stroke, diabetes, and a seizure disorder. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 1/2/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 13 out of 15. This indicated that Resident #107's cognitive abilities for daily decision-making were intact. On 2/4/26 at approximately 10:27 AM, the resident stated that all of his clothing was missing because his clothing was not returned from the laundry after the items were sent out for cleaning. Resident #107 stated that staff continues to bring other residents' clothing in his size, but he wants his clothing returned. Resident #107 pointed to a pair of jeans and a sweater on his bed and stated that the staff donated them to him this morning. The resident further stated that he watches other residents to see who will show up wearing his clothing. On 2/6/26 at approximately 11:55 AM, an interview was conducted with Resident #107 regarding his missing clothing, with the Assistant Director of Nursing (ADON) present. The ADON assured the resident that a staff member would make every effort to locate his missing clothing and return the items to him. On 2/11/26 at approximately 5:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and expressed no concerns. 3. The facility staff failed to assist Resident #58 in keeping his personal clothing in his possession after laundering. Resident #58 was admitted to the facility on [DATE]. The resident's diagnoses included a stroke, atrial fibrillation, and dementia. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/24/25, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 14 out of 15. This indicated that Resident #58's cognitive abilities for daily decision-making were intact. On 2/3/26 at approximately 3:59 PM, Resident #58 was observed seated on his bed wearing a navy blue puffer jacket. The resident stated that he and his brother were sharp dressers while growing up in [NAME], and that not having his personal clothing was extremely difficult. The resident stated that all his coats were missing, and he was afraid to remove the one he was wearing because it might be lost. On 2/6/26 at 10:15 AM, an observation was made of him having his face shaved and his hair cut in his room. At approximately 11:05 AM, the resident was observed coming out of the shower room. He stated that he had enjoyed a warm shower and was returning to his room for lunch. On 2/6/26 at approximately 11:55 AM, an interview was conducted with Resident #58 regarding his missing clothing, with the Assistant Director of Nursing (ADON) present. The ADON assured the resident that a staff member would make every effort to locate his missing coats and return the items to him. On 2/11/26 at approximately 5:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and expressed no concerns.

Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to monitor fluid intake for one of 80 residents, Resident #137 (R137). The findings include:The facility failed to evidence monitoring of fluid restriction for R137. R137 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ICH (intracranial hemorrhage) DM (diabetes mellitus) and TIA (transient ischemic attack).R137's most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/2/26, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as maximal assist for bed mobility, transfer, hygiene.A review of R137's comprehensive care plan dated 1/29/26 revealed, FOCUS: The resident has an ADL (activity of daily living) self-care performance deficit related to impaired mobility. INTERVENTIONS: Praise all efforts at self-care.A review of the physician's order dated 1/26/26 revealed, Fluid Restriction - 1420cc / day.A review of the January and February 2026 MAR-TAR (medication administration record-treatment administration record) did not evidence any fluid restriction monitoringA review of R137's meal slips did not reveal any evidence of fluid restriction monitoring.An interview was conducted on 2/5/26 at 9:30 AM with R137 who had no knowledge of fluid restrictions.An interview was conducted on 2/5/26 at 1:30 PM with LPN (licensed practical nurse) #3. In describing the fluid restriction process, LPN #3 described that fluid intake is monitored. On 2/10/26, the director of nursing, asked what evidence we were looking for. Described that evidence of monitoring fluid intake totals by shift including nursing and dietary, the director of nursing stated, fluid restrictions are not tracked that way.On 2/9/26 at 5:00 PM, the administrator and the director of nursing, were made aware of the concerns.A review of the facility's Fluid Restriction policy reveals It is the policy of this facility to ensure that fluid restrictions will be followed in accordance with physician's orders. The nurse will obtain and verify the physician's order for the fluid restriction and an order written to include the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department and will be recorded on the medication record or other format as per facility protocol.No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to provide ADL care for six dependent residents (Resident #9, Resident #106, Resident #109, Resident #12, Resident #35, and Resident #169) in a survey sample of 80 residents. The finings include:1.The facility staff failed to ensure Activity of Daily Living (ADL) care and incontinent care was carried out appropriately. Resident #106 was originally admitted to the facility 5/12/25 after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included; Urinary Tract Infection. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/17/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #106 cognitive abilities for daily decision making were intact. The personal-centered care plan dated 11/19/25 reads the resident has an indwelling catheter (20Fr 10cc) r/t Urinary Retention. The Goal for the resident is that he will be/remain free from catheter-related trauma through the review date. The Intervention: Check tubing for kinks each shift, and the resident has (20 FR.) (Foley Catheter). Position the catheter bag and tubing below the level of the bladder and away from the entrance room door. In section GG(Functional Abilities Goals) the resident was coded as dependent with toileting hygiene, shower/bathe self and putting on taking off footwear. Requiring supervision or touching assistance with personal hygiene, requiring partial to moderate assistance with upper and lower body dressing and Independent with eating. requiring supervision or touch assistance with eating, oral hygiene and personal hygiene. In section H (Bladder and Bowel) the resident was coded as having an indwelling catheter. On 2/06/26 at approximately 10:00 am, permission was received from Resident #106 to observe an Activity of Daily Living (ADL), a bed bath. On 2/06/26 at approximately 10:02 am, an observation of a bed bath and incontinence care was conducted with Certified Nursing Assistant (CNA) #8. CNA #8 was observed giving the resident a bath and providing incontinent care in the following order: CNA donned gloves, removed dirty linens from the bed, and placed them in a clear bag on the floor. The resident was not provided with a bed/bath blanket or was covered with a towel during the entire bed bath (the resident remained exposed). CNA had one basin filled with water. CNA retrieved hygiene bottles from the top drawer of the dresser next to the resident's bed. CNA lathered a washcloth and began washing the resident's right upper body, back, and legs/feet. CNA used a dry towel to wipe off the resident. CNA did not rinse soap off the resident's body; used lotion on the resident's back. CNA began removing dirty linens on the right side of the bed. CNA then removed the brief to perform incontinence care- no bed/bath blanket or towel was utilized. CNA placed the same washcloth used to bathe the resident in soapy water to clean up the resident after a bowel movement. CNA then placed a washcloth in the dirty linen bag. On 2/06/26 at approximately 12:06 pm., a brief interview was conducted with CNA #8 concerning not rinsing the soap off of the resident and using the same washcloth to provide incontinent care. CNA #8 said that she was taught to give bed baths like she performed them today. On 2/10/26 at approximately 4:30 pm., during the end-of-day meeting, the above concern was discussed with the Director of Nursing (DON), the Administrator, and the Regional Director. 2. The facility staff failed to ensure the residents' chin hair was removed. Resident #9 was originally admitted to the facility on [DATE] after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included a need for assistance with personal care and an overactive bladder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/27/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated that Resident #106's cognitive abilities for daily decision making were intact. The person-centered care plan read that Resident #9 has ADL self-care performance deficit r/t impaired gait, and generalized weakness. The Goal for Resident #9 is that the resident will maintain current level of function. Interventions for the resident is to praise resident for self-care and encourage the resident to use the call bell for assistance. In section GG(Functional Abilities Goals), the resident was coded as set up or clean up assistance with shower/bathe self, oral hygiene, and personal hygiene. Independent with eating and toileting hygiene. On 2/05/26 at approximately 8:48 am, the resident was observed ambulating in her room, and a few medium-length strands of chin hair were noted. On 2/06/26 at approximately 9:40 am, an interview was conducted with Resident #9, who indicated that she would like to get her hair cut. The resident was asked whether she wanted her chin or facial hair trimmed. She replied, Yes, both. On 2/09/26 at 3:05 pm, a brief interview was conducted with Certified Nursing Assistant (CNA) #11. CNA #11 said that when residents receive showers twice a week, other ADL care should be provided, such as removing facial hair. On 2/10/26 at approximately 1:27 pm, an interview was conducted with Licensed Practical Nurse (LPN) #4, concerning Resident #9's chin/facial hair. LPN #4 said that removing chin hair is a part of ADL care. On 2/10/26 at approximately 4:30 pm., during the end-of-day meeting, the above concern was discussed with the Director of Nursing (DON), the Administrator, and the Regional Director. 3. The facility staff failed to ensure Resident #109 received at least two (2) showers a week, including washing her hair. Resident #109 was originally admitted to the facility 05/23/25 after an acute care hospital stay. The resident had never been discharged from the facility. The current diagnoses included: need for assistance with personal care and unspecified urinary incontinence. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/25/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. This indicated Resident #109 cognitive abilities for daily decision making were severely impaired. Blvd In sectionGG(Functional Abilities) the resident was coded as being dependent with eating, oral hygiene, toileting, shower/bathe self and personal hygiene. The person-centered care plan dated 5/03/25 read that the resident requires assistance with toileting hygiene r/t incontinence of bowel and bladder. The Goal was that the resident would remain free from skin breakdown due to incontinence and brief use through the review date. The interventions are: clean the peri-area with each incontinence episode; monitor/document for s/sx of UTI; and monitor/document/report as needed (PRN) any possible causes of incontinence. On 02/04/2026 at approximately 12:30 pm., during the initial tour, an interview was conducted with the resident and her daughter concerning Activity of Daily Living (ADL) care. Resident #109's daughter would interpret because the resident spoke mostly Spanish. The daughter inferred from her mother that she would like more showers and to have her hair washed. The resident's daughter got up and went to the closet tacking out a bath basin that had foam taped around it. The resident's daughter said that because the facility won't wash her hair, she uses the bath basin and washes her mother's hair at bedside. A review of the ADL document for February 2026 showed that the Resident received baths/showers on Wednesday and Saturday during the 7:00 am-3:00 pm. shift. The ADL sheet did not show a breakdown of showers or bed baths; they were combined. A review of the ADL document for January 2026 showed that the Resident received missed baths/showers on Saturday January 24th 2026. A review of the ADL document for December 2025 revealed that no baths/showers were documented as given on the following days: Wednesday December 3rd and Saturday December 13th. On 2/11/26 at approximately 4:40 pm., a brief interview was conducted with CNA #12 concerning Resident #109 receiving showers. CNA #12 said that the resident is scheduled to get showers on Wednesdays and Saturdays. CNA #12 also reviewed the shower book, which showed that the resident received only 1 shower per week from December 2025 through January 2026. CNA #12 was asked if she could get the unit manager to give make a copy of the shower sheets. The Unit manager and Director of Nursing were approached on numerous occasions on 2/11/26 for a copy of the resident's bath/shower sheet, but neither provided one. On 2/11/26 at approximately 5:30 pm., during the pre-exit, the above concern was discussed with the Director of Nursing (DON), the Administrator and with the Regional Director. No comments were made. 4.The facility staff failed to provide ADL (activities of daily living) specifically incontinence care for a dependent resident, Resident #12 (R12). R12 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular attack), DM (diabetes mellitus) and epilepsy. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/1/26, coded the resident as scoring an 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing; dependent for toileting and supervision for eating. A review of the comprehensive care plan dated 5/13/24 revealed, FOCUS: Resident has an ADL self-care performance deficit related to Hemiplegia, Impaired balance, Limited Mobility, and Stroke. INTERVENTIONS: Toileting/ PERSONAL HYGIENE/ORAL CARE: The resident requires limited to extensive assistance by staff to maximize independence. A review of the ADL (activities of daily living) record revealed missing documentation for 'hygiene, bowel and bladder continence' on the following dates and shifts: December 2025-evening shift: 12/2, 12/3, night shift: 12/3, 12/28, and 12/31; January 2026-day shift: 1/23, night shift: the 4th and 1/31. An interview was conducted on 2/5/26 at 2:05 PM with CNA (certified nursing assistant) #4. Asked the incontinence care process, CNA #4 stated, we round on the residents and provide incontinence care. Asked if there are time frames for incontinence care to be provided, CNA #4 stated, about every two hours. When asked where the care is documented, CNA #4 stated, on the ADL form in PCC (point click care), we use our tablets. Asked if that is where evidence of care is documented, what does missing documentation designate, CNA #4 stated, if it was not documented, it was not done. On 2/10/26 at 5:00 PM the administrator and the director of nursing, RN (registered nurse) were made aware of the concerns. No further information was provided prior to exit. 5.The facility staff failed to provide ADL (activities of daily living) specifically incontinence care for a dependent resident, Resident #35 (R35). R35 was admitted to the facility on [DATE] with diagnosis that included but were not limited to traumatic subdural hemorrhage, syncope, falls and COPD (chronic obstructive pulmonary disease) R35's most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 1/23/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as maximal assist for bed mobility, transfer, hygiene. A review of R35's comprehensive care plan dated 1/29/26 revealed, FOCUS: The resident has ADL (activities of daily living) self-care performance deficit related to impaired mobility. INTERVENTIONS: praise all self-care efforts. A review of the ADL (activities of daily living) record revealed missing documentation for 'hygiene, bowel and bladder continence' on the following dates and shifts: January 2026-day shift: 1/21, night shift: 1/25 and 1/31. An interview was conducted on 2/5/26 at 2:05 PM with CNA (certified nursing assistant) #4. Asked the incontinence care process, CNA #4 stated, we round on the residents and provide incontinence care. Asked if there are time frames for incontinence care to be provided, CNA #4 stated, about every two hours. When asked where the care is documented, CNA #4 stated, on the ADL form in PCC (point click care), we use our tablets. Asked if that is where evidence of care is documented, what does missing documentation designate, CNA #4 stated, if it was not documented, it was not done. On 2/10/26 at 5:00 PM the administrator and the director of nursing, RN (registered nurse) were made aware of the concerns. No further information was provided prior to exit. 6. For Resident #169 (R169) the facility staff failed to provide hygiene care. For Resident #169 (R169) was admitted to the facility with a diagnosis that included but not limited to schizoaffective disorder (1), and depression. On the most recent comprehensive MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 07/08/2022, R169 scored 6 (six) of 15 on the BIMS (brief interview for mental status), indicating R169 was severely impaired of cognition making daily decisions. Section G0110 Activities of daily Living (ADL) Assistance coded R169 as requiring one person assistance for personal hygiene (including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands). Review of the ADL (activities of daily living) tracking sheet for R169's personal hygiene (combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands) dated November 2023 documented blanks on 11/05/2022 for the day shift (7:00 a.m. to 3:00 p.m.), evening shift (3:00 p.m. to 11:00 p.m.) and on the night shift (11:00 p.m. to 7:00 a.m.), 11/06/2022 for the day shift (7:00 a.m. to 3:00 p.m.), evening shift (3:00 p.m. to 11:00 p.m.) and Not Applicable on the night shift (11:00 p.m. to 7:00 a.m.). Review of the ADL (activities of daily living) tracking sheet for R169's personal hygiene dated December 2023 documented blanks on 12/09/2022, 12/10/2022, 12/11/2022, 12/12/2022, 12/13/2022, 12/14/2022, 12/15/2022, 12/16/2022, 12/17/2022, 12/18/2022 and on 12/19/2022 for the day shift (7:00 a.m. to 3:00 p.m.), evening shift (3:00 p.m. to 11:00 p.m.) and on the night shift (11:00 p.m. to 7:00 a.m.) each day. On 02/10/2026 at approximately 8:57 a.m. an interview was conducted with CNA (certified nursing assistant) #3 regarding hygiene care for R169. She stated that she did not recall R169. She also stated hygiene care included assisting the resident with washing, brushing teeth, combing their hair, dressing, providing incontinent care or toileting if needed. When asked how it is evidenced that a resident has received hygiene and ADL (activities of daily living) care she stated that it is documented in PCC (point click care) on the ADL tracking sheet. After reviewing the ADL tracking sheet for R169's personal hygiene listed above she stated that she did not know what the blanks indicated. On 02/10/2026 at approximately 9:25 a.m. an interview was conducted with RN (registered nurse) #1 regarding hygiene care for R169. When asked about providing hygiene care to a resident she stated the resident has their hair and face washed, hair combed, fingernails cleaned and trimmed if needed, showers or bed baths and incontinent care if needed. When asked how it is evidenced that a resident has received hygiene and ADL care she stated that it is documented in PCC. On 02/11/2026 at approximately 4:40 p.m., the administrator, DON and the Regional Director, were made aware of the above findings. No further information was provided prior to exit. Reference: (1) A mental condition that causes both a loss of contact with reality [psychosis] and mood problems [depression or mania]. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/000930.htm.

Based on resident/staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to maintain an effective pest control program so that the facility is free of pests and rodents.The findings include: 1.Observations during the survey period of 2/3/26-2/6/26 and 2/9/26-2/11/26 revealed, observations of roaches and mice. On 2/4/2026 at 10:33 AM, an observation was made of Resident #129 in their room. A large brown roach was observed climbing up to the top of the nightstand and then proceeding to the back side of the nightstand. The roach was observed by two surveyors. On 2/4/26 no observations of pests and rodents in the kitchen. On 2/5/2026 at 6:45 AM, this surveyor observed a mouse running across hallway from the biohazard room on first floor to underneath the door of a locked room. A review of the pest control invoices revealed this number of invoices per month: 7/25-1, 9/25-6, 10/25-5, 11/25-6, 12/25-14 and 1/26-10. A review of the pest control logs for the units reveal the following: 1/25-3/25 (mice-2, roaches/ants-7), 4/25-6/25 (mice-9, roaches/ants-7), 7/25-10/25 (mice-16, roaches/ants-17), 11/25 (mice-6, roaches/ants-3), 12/25 (mice-2, roaches/ants-2), 1/26 (mice-4, roaches/ants-3), 2/26 (mice-1, roaches/ants-1). On 2/3/2026 at 12:50 PM, an interview was conducted with Resident #84, a cognitively intact resident, who stated that there was a mouse who lived in their room and he had discussed it with the assistant administrator because it came through the ventilation system. On 2/3/2026 at 2:00 PM an interview was conducted with Resident #28 (R28), a cognitively intact resident, who stated that he has had a mouse in his room that runs from under the door and goes behind the grey baseboard (baseboard is pulled up at one end). No observations of mouse in the room at the time. On 2/3/2026 at 3:33 PM, an interview was conducted with Resident #125 (R125), a cognitively intact resident, who stated that there had been roaches in the facility for quite a while and they had gotten better recently in their room. R125 stated that in December he had a roach fall out of the food dome when he opened his meal, so he had stopped eating for a while. R125 stated that there were mice at the facility and within the past week there had been a mouse coming in the room under the door with something in its mouth and was squeaking really loud. On 2/5/2026 at 10:28 AM, R125 stated that when maintenance came in to fix the motor in his heater yesterday, they found a dead mouse inside. R125 stated that he also saw a roach crawling up the wall in his room yesterday. On 2/4/2026, at 7:05 AM an interview was conducted with CNA (certified nursing assistant) #2 a night CNA. Asked about pests and rodents, CNA #2 stated, yes, we have them. Pest control comes three times a week and we keep a pest control log. You can hear something running in the ceiling at night. On 2/5/2026 at 6:50 AM an interview was conducted with OSM (other staff member) #2, the maintenance director. He was informed of the mouse running across the hall into the locked room. OSM #2 went to the locked room, entered and looked for the mouse. OSM #2 stated, he must have gone behind the wall. When asked about the pest and rodents in the facility, OSM #2 stated, it has gotten better, we have a pest control company come three times a week. They review the pest logs on the units and treat those areas and any areas we are having difficulty with. I had heard about rodents in the ceiling and have put traps up there. Asked what education has been done for the residents, OSM #2 states, we tell them not to keep food out and to not have clothes on floors and stacked in chairs as rodents love to nest in them. On 2/5/2026 at 12:05 PM, an interview was conducted with Resident #7 (R7), a moderately impaired resident, who stated that he had seen some baby mice running around in his room yesterday. R7 stated that they did not get in his belongings but ran around the room. On 2/5/2026 at 1:00 PM, during resident council, Resident #34 (R34) a cognitively intact resident stated, that there was a mouse on a glue pad in his room. During observation at 4:00 PM, there was no observation of mouse on glue pad and no glue pad in room. Unable to locate any staff who may have removed mice. On 2/6/26 at 10:25 AM, an interview was conducted with OSM #3, the pest control representative. Asked about pest control for the facility, OSM #3 stated, they are on three times a week schedule. For rodent control we do traps in non-public areas and glue boards. Baiting in patient rooms and resident areas. We review the pest sighting logs and identify any other areas to treat. On 2/6/26 at 11:50 AM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. A review of the facility's Pest Control Program policy revealed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. No further information was provided prior to exit. 2. The facility staff failed to eradicate roaches from the environment. During the survey, observations were conducted in Unit 1B from 2/3/26 through 2/6/26 and from 2/9/26 through 2/11/26 because most interviewable residents reported roaches and mice in their rooms. On 2/4/26, a large brown roach was observed in the corridor lying on its back with its legs wiggling. On 2/6/26 at approximately 11:40 AM, while making observations of the unit with the Assistant Director of Nursing (ADON), a small dark colored roach was observed crawling quickly on the toilet seat in the bathroom of room [ROOM NUMBER]. The ADON closed the bathroom door and stated she would document the sighting on the pest control log. On 2/11/26 at approximately 5:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and voiced no concerns.

Based on staff interviews, facility document review, and clinical record review, it was determined that the facility staff failed to maintain a safe, functional, and comfortable environment in the facility's shower rooms.The findings include: 1.The facility staff failed to provide a safe, functional, sanitary, and comfortable environment for the residents to shower On 2/05/2026 an observation of the shower room on unit 1A was conducted at 3:26 pm, with the unit manager, Licensed Practical Nurse (LPN) #6. The observation revealed a small to moderate brown substance on the commode seat. LPN #6 said that she will make sure the area is cleaned. LPN #6 was asked who's responsible for cleaning the commode. LPN #6 said that once the nursing staff clean off the toilet seat, they will contact housekeeping to get the commode sanitized. On 2/09/26 at 4:40 pm., End of day meeting with the administrator, the Director of Nursing and Regional Director. 2. The facility staff failed to provide a safe, functional, sanitary, and comfortable environment for the residents to shower. On 2/6/26 at 11:40 AM, an inspection of the Unit 1B shower room was completed with the Assistant Director of Nursing. Upon entering the shower room, it smelled of stale water. A green bottle of [NAME] Spring shower gel and a disposable razor were on the shower chair seat. Beneath the chair was a worn and soiled area in which the resident's naked foot would touch. In the shower room, approximately 21 shower chairs were cluttered throughout, and in the area where the resident showered, the individual had to face them. There was no privacy when others entered the shower room, and the door was left unlocked because this room was frequently used by others whose in-room toilets were out of order. Around the base of the toilet was brown dirt and debris, along with dingy floor stains. An interview was conducted with the ADON on 2/6/26 at approximately 12:04 PM. The ADON stated she was unaware of the clutter and appearance of the shower room. On 2/11/26 at approximately 5:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and voiced no concerns.

Based on observations and staff interviews, the facility staff failed to follow infection control practices, increasing the chances of infection, illnesses, and diseases, and the facility staff failed to follow enhanced barrier precautions (EBP) during an observation of wound care on 2/4/26 having the potential to infect others in the facility and specific to 1 of 80 residents (Resident #129) in the survey sample.The findings include: 1. The facility staff failed to ensure the commode seat in the community shower room was clean. On 2/5/26 at 3:26 pm, a small to moderate amount of brown substance was observed on the commode seat. On 2/5/26, an observation of the shower room on unit 1A was conducted at 3:26 pm with the unit manager and Licensed Practical Nurse (LPN) #6. The observation revealed a small to moderate brown substance on the commode seat. LPN #6 said that she will make sure the area is cleaned. LPN #6 was asked who was responsible for cleaning the commode. LPN #6 said that once the nursing staff cleans off the toilet seat, they should contact housekeeping to get the commode sanitized. On 2/09/26 at 4:40 pm, the end-of-day meeting was conducted with the administrator, the Director of Nursing, and the Regional Director. 2. For Resident #129 (R129), the facility staff failed to follow enhanced barrier precautions (EBP) during an observation of wound care on 2/4/26. On the most recent minimum data set (MDS), an admission assessment with an assessment reference date (ARD) of 1/14/2026, the resident was assessed as being moderately impaired for making daily decisions, under hospice care and not having a pressure injury. The physician orders for R129 documented in part, Clean area to R (right) hip with DWC (Dakin's wound cleanser), pat dry, apply calcium alginate. Cover with dry dressing. one time a day for wound tx (treatment). Order Date: 02/03/2026. The comprehensive care plan for R129 documented in part, [R129] has a wound to Right trochanter. Date Initiated: 02/03/2026. On 2/3/2026 at 4:07 PM, an observation was made of R129 in their room. Observation of the outside of R129's room revealed a sign with a red stop sign which documented, Enhanced Barrier Precautions- Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and gowns for the following High-Contact Resident Activities: .Wound care: any skin opening requiring a dressing . On 2/4/2026 at 10:33 AM, an observation was made of licensed practical nurse (LPN) #1 providing wound care to R129's pressure injury. Registered nurse (RN) #1 was observed assisting LPN #1 with positioning R129 and holding the resident in place during wound care. Neither staff member was observed to wear a gown during the wound care procedure. On 2/4/2026 at 11:05 AM, an interview was conducted with LPN #1 who stated that residents were placed on EBP when they had an open skin area, wound, intravenous line, dialysis site, feeding tube or catheter. She stated that the staff wore gowns and gloves when providing care to protect the resident and themselves from spreading any infection. LPN #1 stated that she should have had a gown on during the wound care for R129 and it had been overlooked. On 2/9/2026 at 3:50 PM, an interview was conducted with LPN #4, the infection preventionist. LPN #4 stated that when a resident had a wound, they were placed on EBP, and a sign was placed outside the door which instructed the staff to wear a gown and gloves during high-contact activities, including wound care. The facility policy Enhanced Barrier Precautions effective 9/1/2022 documented in part, Enhanced Barrier Precautions (EBP) is used to reduce the spread of Multidrug-resistant organisms (MDROs) among residents by utilizing gloves and gowns for high contact resident care activities . Identify residents who are appropriate for EBP including: .Residents who have a wound and/or indwelling medical devices . On 2/6/2026 at 11:54 AM, the administrator and director of nursing were made aware of the concern. No further information was provided prior to exit.

Based on staff interviews and review of facility documents, the facility staff failed to adequately identify, keep systems functioning properly, and implement necessary action plans to assure the quality of life for the residents using the Quality Assurance and Performance Improvement (QAPI) committee to identify deficiencies if the area of Safe/Clean/Comfortable/Homelike Environment.The findings included:During the recertification survey completed on 2/11/26 the facility failed to: provide hot water in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on Unit 2A; address current observations of mice and roaches on all units: 1A, 1B, 2A, 2B; have operable toilets that are able to flush on unit 2A and unit 1B; provide a safe, functional, sanitary, and comfortable environment for the residents to shower on units 1A and 1B; and provide heat in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on Unit 2A.On 2/26/26 at 12:08 PM an interview was conducted with the Administrator regarding the issues identified during the recertification survey in the area of Safe/Clean/Comfortable/Homelike Environment. The Administrator stated that the QAPI committee did not discuss the issues regarding pest control management, heat issues, hot water issues, inoperable toilets, and the unsanitary shower rooms. The Administrator also stated, I don't have the time regarding developing and implementing data collection systems, feedback, monitoring, analysis, and action plans in the areas identified. The facility's Quality Assurance and Performance Improvement (QAPI) policy with a date reviewed/revised of 10/22/2025 reads, Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. 4. The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include, but is not limited to: b. Systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events. On 2/26/26 at approximately 2:55 PM, a final interview was conducted with the Administrator, Assistant Director of Nursing, Regional Minimum Data Set Consultant, and Regional Nursing Consultant. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on staff interviews and review of facility documents, the facility's Governing Body failed to ensure facility policies were implemented regarding management and operation of the facility to ensure effective systems were in place to assure the quality of life for the residents in the area of Safe/Clean/Comfortable/ Homelike Environment.The findings included:During the recertification survey completed on 2/11/26 the facility failed to: provide hot water in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on Unit 2A; address current observations of mice and roaches on all units: 1A, 1B, 2A, 2B; have operable toilets that are able to flush on unit 2A and unit 1B; provide a safe, functional, sanitary, and comfortable environment for the residents to shower on units 1A and 1B; and provide heat in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on Unit 2A.On 2/26/26 at 12:08 PM an interview was conducted with the Administrator regarding the issues identified during the recertification survey in the area of Safe/Clean/Comfortable/Homelike Environment. The Administrator stated that the Quality Assurance and Performance Improvement (QAPI) committee did not discuss the issues regarding pest control management, heat issues, hot water issues, inoperable toilets, and the unsanitary shower rooms. The Administrator also stated, I don't have the time regarding developing and implementing data collection systems, feedback, monitoring, analysis, and action plans in the areas identified. The Administrator further stated that the Administrator is responsible and accountable for the QAPI program. The facility's Governing Body policy with a date reviewed/revised of 10/15/2025 reads, Policy: The facility will have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. 2. The governing body is responsible and accountable for the QAPI program. On 2/26/26 at approximately 2:55 PM, a final interview was conducted with the Administrator, Assistant Director of Nursing, Regional Minimum Data Set Consultant, and Regional Nursing Consultant. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on staff interviews and review of facility documents, the facility staff failed to provide leadership and oversight to ensure effective systems were in place to assure the quality of life for the residents in the area of Safe/Clean/Comfortable/ Homelike Environment.The findings included:During the recertification survey completed on 2/11/26 the facility failed to: provide hot water in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on Unit 2A; address current observations of mice and roaches on all units: 1A, 1B, 2A, 2B; have operable toilets that are able to flush on unit 2A and unit 1B; provide a safe, functional, sanitary, and comfortable environment for the residents to shower on units 1A and 1B; and provide heat in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on Unit 2A.On 2/26/26 at 12:08 PM an interview was conducted with the Administrator regarding the issues identified during the recertification survey in the area of Safe/Clean/Comfortable/Homelike Environment. The Administrator stated that the Quality Assurance and Performance Improvement (QAPI) committee did not discuss the issues regarding pest control management, heat issues, hot water issues, inoperable toilets, and the unsanitary shower rooms. The Administrator also stated, I don't have the time regarding developing and implementing data collection systems, feedback, monitoring, analysis, and action plans in the areas identified. The Administrator further stated that the Administrator is responsible and accountable for the QAPI program. The facility's Administration of Facility policy with a date reviewed/revised of 10/14/2025 reads, Policy: This facility will provide policies and systems to ensure that it is administered in a manner that will focus on attaining and maintaining the highest practicable physical, mental, and psychosocial well-being of each resident. 7. The facility must have a governing body that is legally responsible for establishing and implementing policies regarding management and operation of the facility as well as QAPI. On 2/26/26 at approximately 2:55 PM, a final interview was conducted with the Administrator, Assistant Director of Nursing, Regional Minimum Data Set Consultant, and Regional Nursing Consultant. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on resident and staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 80 residents in the survey sample, Resident #53 (R53).The findings include:The facility failed to provide evidence of monitoring fistula for bruit/thrill/bleeding and communication with dialysis facility for R53.R53 was admitted to the facility on [DATE] with diagnosis that included but were not limited to chronic kidney disease, diabetes mellitus and neuromuscular dysfunction of bladderThe most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/31/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being independent for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 5/24/23 revealed, FOCUS: Resident needs dialysis related to renal failure, has AV shunt Left arm. INTERVENTIONS: Check and change dressing daily at access site. Document as indicated. Hemodialysis: Pickup 0530. Monday-Wednesday-Friday.A review of the physician's order dated 5/9/25 revealed, Hemodialysis- Assess Left Forearm Fistula for bleeding /symptoms of infection every shift for dialysis. Dialysis Midtown- [NAME]- [PHONE NUMBER], Monday, Wednesday, Friday.On 2/05/2026 at 8:30 AM review of dialysis communication book from 12/1/25 to 2/4/26. Missing communication sheet documentation on 12/15, 12/19, 12/22, 12/24, 12/31, 1/12, 1/14, 1/16, 1/19, 1/21, 1/28, 1/30. A review of the December 2025 TAR (treatment administration record) revealed, Hemodialysis- Assess Left Forearm Fistula for bleeding /symptoms of infection every shift for dialysis documented day/evening/night 12/1-12/9/25. Was discontinued on 12/9/25.An interview was conducted with R53 on 2/5/26 at 8:40 AM, who described his dialysis care as, the facility staff do not check his fistula for bleeding, bruit and thrill (showed fistula in left arm) but they do at the dialysis center and he takes his communication book with him to appointments.An interview was conducted on 2/5/26 at 8:50 AM with LPN (licensed practical nurse) #2. LPN #2 described the purpose of the dialysis communication book as providing information of the resident's vital signs, weight and any other pertinent information. Checking the fistula for bruit/thrill and check for bleeding is documented on the MAR-TAR (medication administration record-treatment administration record).On 2/9/26 at 5:00 PM, the administrator and the director of nursing, were made aware of the concerns.Facility did not provide a policy regarding dialysis care. A review of the dialysis contract reveals The nursing facility shall ensure that there is documented evidence of collaboration of care and communication between the nursing facility and the ESRD (end stage renal disease) facility.No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide a call bell accessible from the floor in the bathroom for one of 80 residents in the survey sample, Resident #6. The findings include:For Resident #6 (R6), the facility staff failed to ensure the bathroom call bell was accessible to the resident from the floor. On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 1/6/2026, the resident scored 14 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. The assessment further documented R6 not having any upper or lower extremity functional limitations in range of motion, using a wheelchair and requiring setup or clean-up assistance for toilet transfers and toileting hygiene. R6 was assessed as being occasionally incontinent of urine and frequently incontinent of bowel. On 2/5/2026 at 9:08 AM, R6 was not in their room, an observation of the shared bathroom for R6 revealed a bathroom approximately 10 feet wide by six feet depth with a toilet located on the right wall with approximately eight-inches space between the wall and the toilet. On the wall beside the toilet was a small grab bar, toilet paper holder and a call bell cord located just below the seat level of the toilet. The call bell cord was observed coming from the wall approximately 12-inches hanging towards the floor. The space on the left side of the toilet was approximately six feet to the opposite wall with no call bell access from that side of the room if the resident were to fall onto the floor. On 2/5/2026 at 2:05 PM, an interview was conducted with R6 in their room. R6 was observed lying in bed on top of the sheets fully dressed with a fall mat down to the left side of the bed. When asked about the fall mat, R6 stated that it had been a while since they fell but the staff kept the mat down just in case. R6 stated that they ambulated around in the room and bathroom by themselves. R6 further stated that they used the bathroom independently and they were not sure if they were able to reach the call bell in the bathroom or not because they had never needed to use it. Fall risk evaluations for R6 documented a high fall risk on 11/2/2025. Review of the clinical record for R6 documented a fall without injury in the residents room on 11/14/2025 and another fall without injury on 12/6/2025. The activities of daily living (ADL) documentation for R6 dated 1/1/26-1/31/26 and 2/1/26-2/28/26 documented R6 independently toileting during 58 shifts in January and 14 shifts in February. On 2/9/2026 at 2:21 PM, an interview was conducted with certified nursing assistant (CNA) #6 who stated that in the bathrooms the residents had call bells that they used to alert the staff when they needed assistance. She stated that the resident pulled on the string which cut the light on outside of the room to let them know to go check on them. On 2/9/2026 at 2:28 PM, an interview was conducted with licensed practical nurse (LPN) #5 who stated that there were emergency call bells in the bathrooms and they sounded when the resident pulled the cord. She stated that the staff were able to see the light outside of the room and on the board at the nurses station. LPN #5 stated that R6 used the bathroom by themselves and she was not sure what type of call bell was in the bathroom. On 2/9/2026 at approximately 2:35 PM, an observation was conducted with LPN #5 of R6's bathroom. LPN #5 observed the call bell located to the right of the toilet on the wall with the approximately 12-inch cord hanging towards the floor. When asked if the resident would be able to reach the cord if they were in the floor on the space to the left of the toilet, LPN #5 stated, No, she could not get to it. On 2/9/2026 at 2:37 PM, an interview was conducted with CNA #5 who stated that R6 was independent when toileting. She stated that there were call bells in the bathroom and if any assistance was needed the residents would pull the cords on the call lights to alert them to come to assist. The facility policy Call Lights: Accessibility and Timely Response revised 11/7/2025 documented in part, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response . The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor . On 2/9/2026 at approximately 4:37 PM, the administrator and the director of nursing were made aware of the concern. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide reasonable access to private use of the telephone to one of 80 residents in the survey sample, Resident #84.The findings include:For Resident #84 (R84), the facility staff failed to provide private access to a telephone for resident use.On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date of 1/15/2026, the resident scored 13 out of 15 on the brief interview for mental status (BIMS), indicating they were cognitively intact for making daily decisions. On 2/3/2026 at 12:50 PM, an interview was conducted with R84 who stated that they did not have access to a telephone to speak to anyone privately. R84 stated that they had to go to the nurses station and beg to use the phone. On 2/5/2026 at 12:13 PM, an observation was made of R84 using the telephone at the nurses station. Two staff members were seated behind the nurses station, and one staff member was at the medication cart which was parked beside the nurses station at the time R84 was using the telephone. R84 was observed in a wheelchair at the outside of the nurses station with the telephone sitting on top of the ledge of the nurses station approximately two feet above their head. Further observation revealed R84 attempting to hang up the receiver from the wheelchair and dropping it down onto the nurses station due to the height of the ledge from the wheelchair.On 2/5/2026 at 1:22 PM, an interview was conducted with licensed practical nurse (LPN) #3 who stated that residents who did not have cell phones of their own could use the nurses station phone when they needed to call someone. She stated that the phone was available to them any time day or night and they sat it up on the ledge of the nurses station for the resident to sit outside of the station because they were not allowed inside. When asked about privacy, LPN #3 stated that the phones could not reach that far, but they pushed them out as much as they could and that was all they had to offer them at the nurses station. On 2/9/2026 at 9:42 AM, an interview was conducted with registered nurse (RN) #2 who stated that residents were allowed to use the telephone at the nurses station. She stated that the staff placed the phone up on the edge of the counter and the resident sat outside of the nurses station to talk and could use it anytime of day or night. On 2/9/2026 at 2:21 PM, an interview was conducted with certified nursing assistant (CNA) #6 who stated that residents normally went to the nurses station to use the telephone. She stated that residents could not go inside the nurses station but could sit outside and use the telephone.On 2/9/2026 at 3:02 PM, an interview was conducted with the director of nursing (DON) who stated that there were telephone lines throughout the building that were available for the residents to use but she did not think that there was a designated spot for the residents if they were looking to have a private phone call, but anyone would allow them to come into their office to use the telephone.The facility policy Resident Rights revised 11/14/2025 documented in part, The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility . The resident has the right to have reasonable access to the use of a telephone, including TTY (Teletypewriter) and TDD (Telecommunications Device for the Deaf) services, and a place in the facility where calls can be made without being overhead. This includes the right to retain and use a cellular phone at the resident's own expense On 2/9/2026 at approximately 4:37 PM, the administrator and the director of nursing were made aware of the concern.No further information was provided prior to exit.

Based on staff interview, clinical record review, facility document review, the facility staff failed to resolve grievances for one of 80 residents in the survey sample, Resident #125 (R125). The findings include:For Resident #125 (R125), facility staff failed to provide resolutions to grievances filed on 06/09/2025, 07/17/2025, 07/30/2025, and 07/31/2025. On 2/5/2026 at 10:28 AM, an interview was conducted with R125, who stated that they had filed multiple grievances with the facility, and they never received any follow-up regarding the outcomes. On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date of 1/29/2026, Resident #125 (R125) scored 15 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. The facility's grievances filed by R125 dated 06/09/2025, 07/17/2025, 07/30/2025, and 07/31/2025 failed to document resolutions. On 02/10/2026 at approximately 10:30 a.m. an interview was conducted with the Social Worker regarding the process of completing the facility's grievance forms. She stated that anyone could file (fill out) a grievance form and it came to social services for review. She stated that depending on the area of concerns the grievance addresses, she gave it to the corresponding department for them to address and complete the grievance form. She further stated that all portions of the grievance form should be completed and the resolution for the grievance should be documented on the form. After reviewing the facility's grievance forms from R125 as dated above the Social Worker stated that there were no resolutions completed. When asked why it was important to have a resolution for a grievance, she stated that the resident could lose trust in the facility staff and feel as though the facility did not take their concerns seriously. The facility's policy Resident and Family Grievances documented in part, Policy Explanation and Compliance Guidelines: 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. 10. Procedure: g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: i. The date the grievance was received. Ii. The steps taken to investigate the grievance. iii. A summary of the pertinent findings or conclusions regarding the resident's concern(s). iv. A statement as to whether the grievance was confirmed or not confirmed. v. Any corrective action taken or to be taken by the facility as a result of the grievance. vi. The date the written decision was issued. On 02/10/2026 at approximately 4:36 p.m., the Administrator, Director of Nursing, and the Regional Director were made aware of the above findings. No further information was provided prior to exit.

Based on resident and staff interviews, a review of the clinical record, and facility documents, the facility staff failed to protect the residents' right to be free from verbal and physical abuse for 1 of 80 residents (Resident #3) in the survey sample. The findings included: Resident #3 was initially admitted to the facility on [DATE] from a community home. The residents' diagnoses included dementia, a psychotic disorder, and an anxiety disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/9/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 12 out of 15. This indicated Resident #3's cognitive abilities for daily decision making were intact. In section GG0130. (Self-Care), The resident was coded as requiring setup or clean-up assistance with eating, partial/moderate assistance with upper and lower body dressing, and putting on footwear, dependent on toileting, oral hygiene, and showers/baths.A review of facility documents revealed that Certified Nursing Assistant (CNA) #10 was verbally and physically abusive to Resident #3 on 4/16/25 during and after a shower. A report was filed alleging that CNA #10 called the resident a witch multiple times and, while traveling in the corridor after her shower, rolled the resident in front of a fan, causing her to yell due to discomfort from the cold air.An interview was conducted with the Resident #3 on 2/10/26 at 9:24 AM. The resident stated that no staff member mistreated her. The resident also stated she has a bad temper and is very vocal, which irritates people. On 2/10/26 at 9:53 AM, an interview was conducted with CNA #9. CNA #9 stated that Resident #3 takes showers without conflict. She stated that the resident will say I'm cold during care. CNA #9 further stated that the resident is not aggressive but becomes impatient during care.On 2/10/26 at 9:58 AM, an interview was conducted with Licensed Practical Nurse (LPN) #8. LPN #8 stated that whenever there is an allegation of abuse anywhere in the facility, all staff are educated on abuse, and at least once per year, they have to complete the abuse in-service. LPN #8 stated that the resident is often difficult to care for and that, at times, two staff members are required to provide her care. LPN #8 stated that she instructs the CNA staff that, whenever behaviors are exhibited, they should ensure the resident is safe, step away, report the behaviors to the nurse, and return later.The facility conducted the following actions after the allegation was voiced. The resident was interviewed and assessed for further abuse. The resident was referred for psychological services for her psychosocial well-being. All other residents the employee had cared for were interviewed and/or assessed for indications of abuse. Staff training on abuse was validated by signatures. The employee was suspended during the investigation and later terminated. The allegation and finding were reported to the state agency. A further review revealed the staff member had no criminal past and she had completed two abuse in-services over the year. No current findings of abuse were identified during the survey.On 2/11/26 at approximately 5:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Regional [NAME] President, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and voiced no concerns.

Based on staff interview, clinical record review, facility document review, the facility staff failed to investigate an allegation of abuse for one of 80 residents in the survey sample, Resident #170 (R170). The findings include:For Resident #170 (R170), facility staff failed to investigate an allegation of abuse. R170 was admitted to the facility with a diagnosis that included but not limited to paraplegia (1), and depression. On the most recent MDS (minimum data set), a discharge assessment with an ARD (assessment reference date) of 10/27/2023. Section C0700 Cognitive Skills for Daily Decision Making coded R170 as Independent - decisions consistent/reasonable. The facility's nursing progress note for R170 dated 10/27/2023 documented, 05:47 (5:47 a.m.) Note Text : can reported to this nurse that another resident stated that this resident (R170) pulled out a knife on him and that he was afraid for his life. DON (Director of Nursing) was called and made aware. Resident is to be 1:1 (one-to-one) and to stay in his room per DON. This nurse called 911. police arrived and spoke with both residents. officer stated that they did not have protocol to search his things. This nurse and cna (certified nursing assistant) went in resident [sic] to search his things. resident refused to let us search his bags but did allow us to search everything else. resident refused to stay in his room and went off unit. Review of facility documents failed to evidence that an incident report and investigation was conducted by the facility regarding the incident on 10/27/2023. On 02/11/2026 at approximately 8:12 a.m. an interview was conducted with the facility's Administrator (ADM) regarding the procedure for completing a facility related incident (FRI). She stated that a FRI is initiated by her when there is an incident outside of daily operations such as a resident-to-resident altercation, staff-to-resident altercation, allegations of abuse, neglect or mistreatment, injury of unknown origin, etc The ADM stated that she notifies the Ombudsman, APS (adult protective services), the state agency (office of licensure and certification) and the police if necessary of the alleged allegation and then initiates an investigation that includes interviews with the parties involved and obtains witness statements and review of the resident's clinical record if necessary. The ADM stated that she has five days to complete the investigation and send her findings to the parties listed above. She also stated that if there is an allegation of abuse the investigation needs to be initiated within two hours of being informed of the allegation. Regarding the allegation of R170 threatening a resident with a knife she stated that she could not locate a facility investigation and further stated that an investigation should have been initiated. The facility's policy Compliance with Reporting Allegations of Abuse/Neglect/Exploitation documented in part, It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. On 02/11/2026 at approximately 4:40 p.m., ASM, the DON and the Regional Director, were made aware of the above findings. No further information was provided prior to exit. References:(1) The symptom of paralysis that mainly affects your legs. This information was obtained from the website: https://my.clevelandclinic.org/health/symptoms/23984-paraplegia.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for two of 80 residents, Resident #173 and Resident #137. The findings include: 1. For Resident #173 (R173), the facility staff failed to implement the comprehensive care plan to provide pain medications per order. On the most recent minimum data set (MDS), an admission assessment with an assessment reference date (ARD) of 4/5/2024, the resident was assessed as having a surgical wound, receiving scheduled pain medication and having occasional pain. The comprehensive care plan for R173 documented in part, [R173] actual impaired skin to Lower back r/t (related to) Laminectomy. Date Initiated: 04/01/2024. Under Interventions it documented in part, Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Date Initiated: 04/01/2024 . It further documented, [R173] has pain r/t Wound (surgical). Date Initiated: 04/11/2024. The emergency room discharge notes dated 3/28/2024-3/29/2024 documented in part, .Your current discharge medications are: . Hydrocodone-Acetaminophen (Norco 5) (1) 5-325mg po (by mouth) tabs take 1 tab by mouth every 4 hours for 5 days . The physician orders for R173 documented in part, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (milligram) (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours for pain until 04/03/2024 23:59 (11:59PM). Order Date: 3/29/2024. Review of the electronic medication administration record (eMAR) for R173 dated 3/1-3/31/2024 documented the Hydrocodone-Acetaminophen scheduled to begin on 3/29/2024 at 4:00 PM. The eMAR further documented R173 not receiving the scheduled doses on 3/29/2024 at 8:00 PM, 4/30/2024 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM and 4:00 PM. Review of the progress notes for R173 documented in part, - 3/29/2024 20:25 (8:25 PM) Note Text: New admit. Pharmacy stated did not receive fax. Called [Name of nurse practitioner] to e-scribe new order. - 3/30/2024 00:58 (12:58 AM) Note Text: Called pharmacy to check status. Stated they never received a prescription through the fax or escribe done earlier. Called on-call regarding a new e-scribe for medication. - 3/30/2024 04:05 (4:05 AM) Note Text: Spoke with on call. Informed provider would not have access to send rx (prescription) to pharmacy until 8am. Instructions to hold medicine until then. - 3/30/2024 16:31 (4:31 PM) Note Text: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG. Give 1 tablet by mouth every 4 hours for pain until 04/03/2024 23:59. Waiting pharmacy delivery. MD aware. On 2/4/2026 at approximately 2:00 PM, the director of nursing (DON) provided a list of in-house medication stock and stated that as far as she knew it was the same as what was available in March of 2024. Review of the in-house medication stock list documented a house par level of 10 Hydrocodone-Acetaminophen 5-325mg tablets available in the facility. On 2/9/2026 at 9:42 AM, an interview was conducted with registered nurse (RN) #2 who stated that medications were reconciled on admission with the discharge summary from the hospital and confirmed with the physician prior to being sent to the pharmacy. She stated that the normal turn around time to receive the medications was within 24 hours and anything needed urgently was pulled from the in-house medication stock or delivered to them from the pharmacy stat. RN #2 stated that the purpose of the care plan was to show the residents goals, treatment plan and what they needed to do for the resident. She stated that the care plan should be implemented so that everyone knew what was happening with the resident and everyone could access it. On 2/9/2026 at 2:14 PM, an interview was conducted with licensed practical nurse (LPN) #1, unit manager. LPN #1 stated that residents medications were taken from the discharge summary and verified with the physician on admission. She stated that the orders were sent to the pharmacy and any narcotic orders were escribed or a written prescription was sent by fax. LPN #1 stated that prior to the pharmacy delivering the medications they were able to pull medications from the in-house medication stock by calling the pharmacy and getting a code. On 2/9/2026 at 2:28 PM, an interview was conducted with LPN #5 who stated that when medications had not been delivered by the pharmacy they could call the pharmacy to have them send over stat or they could provide them a code to pull the medication from the in-house medication stock. She stated that she had worked at the facility for the past three years and they had the same in-house medication system for the three years. On 2/9/2026 at 3:02 PM, an interview was conducted with the DON who stated that medications were verified with the physician on admission and then were pushed through to the pharmacy. She stated that they kept the in-house medication stock due to insurance issues or issues getting medications. The DON stated that all nurses had access to the in-house medication and the nurses received a code from the pharmacy to pull out medications with a witness required to remove narcotics. The facility policy Comprehensive Care Plans revised 11/14/2025 documented in part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . On 2/10/2026 at 4:37 PM, the administrator and director of nursing were made aware of the concern. No further information was provided prior to exit. Reference: (1) Hydrocodone is available in combination with other ingredients, and different combination products are prescribed for different uses. Some hydrocodone combination products are used to relieve severe pain . This information was obtained from the website: Hydrocodone Combination Products: MedlinePlus Drug Information 2. The facility staff failed to develop the comprehensive care plan for fluid restriction monitoring for Resident #137 (R137). R137 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ICH (intracranial hemorrhage) DM (diabetes mellitus) and TIA (transient ischemic attack). R137's most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/2/26, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as maximal assist for bed mobility, transfer, hygiene. A review of R137's comprehensive care plan dated 1/29/26 revealed, FOCUS: The resident has an ADL (activity of daily living) self-care performance deficit related to impaired mobility. INTERVENTIONS: Praise all efforts at self-care. A review of the physician's order dated 1/26/26 revealed, Fluid Restriction - 1420cc / day. A review of the January and February 2026 MAR-TAR (medication administration record-treatment administration record) did not evidence any fluid restriction monitoring. A review of R137's meal slips did not reveal any evidence of fluid restriction monitoring. An interview was conducted on 2/5/26 at 9:30 AM with R137, when asked if he is on a fluid restriction, R137 stated, not that I know of. An interview was conducted on 2/5/26 at 1:30 PM with LPN (licensed practical nurse) #3, when asked what steps are taken to monitor a fluid restriction, LPN #3 stated, we would watch what his intake was. Asked the purpose of the care plan, LPN #3 stated to identify the interventions needed to care for each resident. Asked if the fluid restriction should be on the care plan, LPN #3 stated, yes, it should. On 2/9/26 at 5:00 PM the administrator and the director of nursing, RN (registered nurse) was made aware of the concerns. No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of a surgical wound for 1 of 80 residents, Resident #173. The findings include:For Resident #173 (R173), the facility staff failed to assess and treat a surgical wound until 4/1/2024 after admission to the facility on 3/29/2024. On the most recent minimum data set (MDS), an admission assessment with an assessment reference date (ARD) of 4/5/2024, the resident was assessed as having a surgical wound and receiving surgical wound care. The emergency room discharge notes dated 3/28/2024-3/29/2024 documented in part, . here for getting placed into a rehab facility . She is also status post lumbar laminectomy done at [Name of hospital] on March 20. She was discharged home on March 22 to go home to her daughter's house with home health. Patient states that the home health nurse came out yesterday for the first time and that her daughter really cannot care for her at home and she wants to be placed in a rehab center until she can get back to normal functioning . Dressing over her laminectomy appears to be normal and was not taken down as is placed on March 23 . The nursing admission assessment for R173 dated 3/29/2024 documented no skin impairment. A skin assessment dated [DATE] documented in part, .Surgical incision to lower back. measurements 10x0.1x0.1 with one intact suture. Surgical wound 80% granulation tissue present and 20% scab. Moderate serous drainage . The assessment documented the surgical wound present on admission. The physician orders for R173 documented in part, Cleanse surgical wound of the lower back with wound cleanser and pat dry. Apply calcium alginate and a silicone foam dressing QD (every day) and prn (as needed) soilage until healed. every day shift for surgical wound care. Order Date: 04/01/2024. The physician orders failed to evidence a treatment to the surgical wound prior to 4/1/2024 or an order to not remove the dressing. Review of the electronic treatment administration record (eTAR) for R173 dated 3/1-3/31/2024 failed to evidence any treatments completed. The comprehensive care plan for R173 documented in part, [R173] actual impaired skin to Lower back r/t (related to) Laminectomy. Date Initiated: 04/01/2024. On 2/9/2026 at 9:42 AM, an interview was conducted with registered nurse (RN) #2 who stated that when a resident was admitted a full body skin assessment was completed to identify any wounds. She stated that she did not remember R173 but if they came in with a surgical wound they would remove the dressing to assess the site unless they came with an order from the physician to not remove the dressing. RN #2 stated that the wound assessment was documented in the clinical record and treatment orders were entered as sent from the surgeon or obtained from the facility physician. On 2/9/2026 at 2:14 PM, an interview was conducted with licensed practical nurse (LPN) #1, the unit manager, who stated that the admission nurse completed a head-to-toe skin assessment on each resident when they arrived. LPN #1 stated that any wounds should be identified on admission and treatment orders were obtained either from the hospital discharge summary or from the facility physician or nurse practitioner. She stated that any resident admitted with a surgical wound should have either a treatment in place or an order to not remove the dressing. On 2/9/2026 at 3:02 PM, an interview was conducted with the director of nursing (DON) who stated that normally they knew if resident had a surgical wound and treatment before they were admitted to the facility. She stated that the hospital normally advised them to leave a dressing in place or gave treatment orders and there would be orders placed in the medical record either way to alert staff. The DON stated that she would expect staff to contact the surgeons office or the case worker at the hospital to see what the treatment to the surgical wound should be and ideally have this in place prior to the resident arriving. The facility policy Skin Assessment revised 11/7/2025 documented in part, .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter . On 2/10/2026 at approximately 4:37 PM, the administrator and DON were made aware of the concern. No further information was provided prior to exit.

Based on observation, resident interview, and staff interview, the facility's staff failed to ensure the resident was allowed privacy while talking on the facility telephone located at the nurses' station for one (1) of 80 residents (Resident #82), in the survey sample.The finding include: Resident #82 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The current diagnoses included: aphasia following cerebral infarction and contracture of the muscles of the right hand.The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/15/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 8 out of a possible 15. This indicated that Resident #82's cognitive abilities for daily decision making were moderately impaired.The care plan dated 12/30/25 read resident is independent in meeting emotional, intellectual, physical, and social needs r/t ambulation. The Goal is that the resident will maintain involvement in cognitive stimulation and social activities as desired. The interventions are: Encourage ongoing family involvement. Invite residents' family to attend special events, activities, meals, and preferred activities are: visiting with mother and family, socializing with peers in the smoke area, and watching television. On 02/09/2026 at approximately 1:22 pm, Resident #82 was overheard on the phone at the nurse's station talking to his mother. At one point, the Licensed Practical Nurse (LPN) #4 was heard saying to the resident, You're not falling asleep, are you? The resident shook his head, indicating no, and continued talking on the phone. A brief interview was conducted with LPN #4 concerning Resident #82. LPN #4 said that the resident used to have his own cell phone, but now uses the phone at the nurse's station to call his mother. LPN #4 was asked if they ever had a cordless phone at the nurses' station for privacy. She said, Yes, but I don't know what happened to it. On 02/09/2026 at approximately 4:40 p.m., the above findings were shared with the Administrator, Director of Nursing, and Regional Director.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to prohibit unsafe smoking practices for two (2) of 11 residents in the survey sample, Residents #1 and #6. Resident #1 was inaccurately assessed to be safe to have a cigarette lighter at the bedside. On 2/26/23, he lit a cigarette in his room, while receiving continuous oxygen therapy, resulting in harmful burns on his lip, ear, chest, and back. When the resident returned to the facility, the facility did not implement the newly revised care plan for 1:1 supervision to keep the resident safe. Resident #6, who was assessed to be an unsafe smoker, was observed by the surveyor lighting his own cigarette on 2/28/23 and 3/1/23. On 3/2/23 at 4:00 p.m., the ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, the vice president of operations, and ASM #4, the regional clinical director were informed that these findings resulted in a determination of harm at the level of immediate jeopardy. On 3/6/23 the survey team verified the removal plan had been fully implemented by the facility. On 3/6/23 at 2:40 p.m., ASM #1, ASM #2, ASM #3, and ASM #4 were informed the removal plan had been verified and the IJ had been abated. The scope and severity of the deficiency was lowered to a level 3, isolated. The findings include: 1. For Resident #1, the resident was inaccurately assessed to be safe to have a cigarette lighter at the bedside. On 2/26/23, he lit a cigarette in his room, while receiving continuous oxygen therapy, resulting in burns on his face, chest, and left flank. When the resident returned to the facility, the facility did not implement the newly revised plan for 1:1 supervision to keep the resident safe. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/8/23, Resident #1 was coded as being moderately cognitively impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring the extensive assistance of staff for bed mobility. He was originally admitted to the facility with diagnoses including COPD (chronic obstructive pulmonary disease) (1) and schizoaffective disorder (2). On 3/1/23 at 1:35 p.m. and 3:50 p.m., Resident #1 was observed by the surveyor lying in bed, with no staff in the room or within line of sight of the resident. A review of Resident #1's progress notes revealed: 2/26/23 Resident rec'd (received) order to be transferred to ER (emergency room ) after receiving blisters to face, nose and back during his unauthorized smoking in bed. Resident is his own responsible party. 2/26/23 Resident admitted [to local hospital.]' A review of the facility synopsis of events dated 2/26/23 revealed, in part: [Resident #1] resides in [room number]. [Resident #1], who is oxygen dependent was smoking in his room and caught his (sic) self on fire. Fire put out and oxygen turned off and removed. [Resident #1] obtained a burn to the tip of his nose, right lower lip, burn to the right and left chest and left back. [Resident #1's] smoking material confiscated, and resident sent to emergency room for evaluation of burns. Investigation initiated. A review of Resident #1's hospital discharge summary dated 2/28/23 revealed, in part: admitted : 2/26/2023. discharge date [DATE]. Chief Complaint: Trauma Major. Discharge Diagnosis: 5% TBSA (total body surface area) superficial partial thickness burn to face, chest, left flank .74 y.o. (year old) male with COPD on home O2 (oxygen) who was [NAME] to [local hospital] as an alpha trauma for management of flash burns to the face sustained while lighting a cigarette while on home O2 .[Resident #1] was admitted to the ICU (intensive care unit) for airway watch. There was no inhalation injury. He underwent burn scrub on the day of admission .He was transferred out of the ICU on 2/27. He was deemed medically ready for transfer back to his facility on 2/28. A review of Resident #1 most recent smoking evaluation prior to 2/26/23 revealed, in part: 1/31/23. Observations. 1. Resident is able to communicate why oxygen must always be shut off prior to lighting cigarette. No. 2. Resident is able to communicate the risks associated with smoking. No .4. Resident smokes safely. Yes. Summary of Evaluation: Resident is determined to be [a] safe smoker. Supervision needed while smoking: None. A review of Resident #1's care plan initiated 11/13/19, and in effect on 2/26/23 revealed, in part: 11/13/19 [Resident #1] is a smoker. Noncompliant with smoking policy .[Resident #1] is able to: light own cigarette, keep lighter at bedside. Date Initiated 2/12/19 .[Resident #1] requires supervision while smoking .[Resident #1's] smoking supplies are stored at the nurses station. A review of Resident #1's care plan initiated 2/28/23 revealed, in part: Resident is an unsafe smoker .will be educated on the risk of smoking with oxygen .[Resident #1] will be place (sic) on 1:1 supervision. A review of Resident #1's physician orders revealed the following order dated 1/28/23: Oxygen as Needed .2L/min (liters per minute) as needed. A review of the facility policy in place on 2/26/23 regarding resident smoking revealed, in part: Smoking - Supervised .The Center will provide a safe, designated smoking area for residents. For the safety of all residents, the designated smoking area will be monitored by a staff member during authorized smoking times. Smoking is only allowed in designated areas and during designated times. Oxygen is not permitted in the designated smoking area .Residents that wish to smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking. If a resident is identified during the smoking evaluation to require assistance or supervision with smoking, the Center will include the appropriate information in the care plan. The Center will establish and post designated smoking areas and times. During designated smoking times staff will be assigned to assist or supervise residents whose care plans indicate assistance or supervision is required while smoking. The Center will retain and store matches, lighters, etc. for all residents. On 3/1/23 at 9:24 a.m., LPN (licensed practical nurse) #1, Resident #1's unit manager, was interviewed. She stated the facility staff completes smoking safety assessments at least quarterly. She stated if she completes the assessment, she takes the resident outside to the designated smoking area to observe them smoking. She looks for changes since the previous assessment, for how the resident holds the lighter and lights the cigarette, how firm the residents grip is on the cigarette, and if the resident appropriately discards the cigarette but in a non-flammable receptacle. She stated she completed Resident #1's safe smoking evaluation on 1/31/23. She stated the resident wears oxygen all the time. She asked him what would happen if he smoked in his room while wearing oxygen, and he could not answer the question. She stated he also could not answer the question about the risks of smoking. She stated Resident #1 had always (prior to 2/26/23) removed his oxygen and gone downstairs to the designated smoking area to smoke. She stated that despite the fact that the resident could not identify the risks associated with smoking while [NAME] oxygen, she determined he was safe to smoke. She stated she based this on the premise that the resident would always smoke without wearing oxygen outside in the designated smoking area. When asked if Resident #1 should have been allowed to keep a lighter at his bedside on 2/26/23, she stated: Based on my assessment, he was safe to smoke. LPN #1 reviewed Resident #1's care plan in effect on 2/26/23, but made no comment specifically on Resident #1's safety of having a lighter at the bedside. She stated: At that time [2/26/23], the ones that can safely smoke, the residents were allowed to have smoking materials at the bedside. During the above interview, when LPN#1 was asked again if Resident #1 was safe to have a lighter at the bedside on 2/26/23, she stated: No. He was wearing oxygen in the bed all the time. He should not have been allowed to have a lighter at the bedside. She stated she was working on 2/26/23 when Resident #1's nurse asked her to go in and assess Resident #1. She stated the resident had pink areas on his chest and flank, and that areas on his face were extremely discolored. She stated the tip of the resident's nose was red and already blistered. She stated she called emergency services immediately. When asked what it means if a resident's care plan calls for 1:1 supervision. She stated it means that a CNA (certified nursing assistant) or other staff member must be sitting with the resident at all times. She stated the 1:1 supervision is a nursing intervention for a resident's safety, and does not require a physician's order. She stated when Resident #1 returned from the hospital on 2/28/23, the clinical team decided that 1:1 supervision was best for him due to safety concerns. On 3/1/23 at 10:43 a.m., LPN #8, who was caring for Resident #1 on 2/26/23 when he was burned, was interviewed. She stated she heard someone yelling from the vicinity of Resident #1's room. She stated when she saw Resident #1, there was no fire, but the resident obviously had been burned. She stated she could smell burned flesh. She stated she removed Resident #1's oxygen cannula, and put the cannula and oxygen concentrator out in the hallway. She stated the tip of the oxygen tubing was black from being burned. She stated Resident #1 had a blister on his right lip when his cigarette must have been positioned. She stated he had a blister on top of his chest. She stated Resident #1's roommate tried to communicate to her what had happened, but she could not understand him. She stated LPN #1 arrived to help her assess Resident #1. They turned him over, and saw a large blister on the resident's back. She stated she saw a lighter and two cigarette butts on the floor. She stated Resident #1 told her he had been smoking in bed. She stated LPN #1 called the physician emergency medical services. She stated Resident #1 was quickly transferred to the hospital by the paramedics. She stated she was not aware that Resident #1's care plan allowed him to have a lighter at the bedside. She stated she normally does not work Resident #1's unit. On 3/2/23 at 10:57 a.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, and ASM #3, the vice president of operations, were interviewed. ASM #2 stated the facility staff complete a safe smoking assessment on admission, readmission, and quarterly. If residents are deemed to be safe smokers, they can smoke in the outside designated smoking area unsupervised. ASM #1 stated the facility employs a smoking attendant 24 hours a day, seven days a week in the designated smoking area as an extra precaution toward resident smoking safety. When asked how information regarding a resident's smoking safety is transferred from the smoking assessment to the care plan, and finally to the staff responsible for taking care of the resident), ASM #2 stated: MDS is supposed to update the care plan. Sometimes I update it, or the unit managers update it, too. When asked where residents who are assessed to be safe smokers are allowed to smoke, ASM #3 stated, everyone is supposed to only smoke in the designed smoking area in the outside courtyard. He stated that is the only smoking area. 2. The facility staff failed to assist Resident #6, who was assessed to be an unsafe smoker, with lighting a cigarette. On 2/28/23 and 3/1/23, Resident #6 was observed lighting the resident's own cigarette. Resident #6's diagnoses included but were not limited to Huntington's disease (1). A smoking evaluation dated 2/27/23 documented Resident #6 was an unsafe smoker who needed constant supervision while smoking and was not able to safely light a cigarette with a lighter. Resident #6's comprehensive care plan dated 11/16/21 documented, (Resident #6) is a smoker. Instruct (Resident #6) about the facility policy on smoking: locations, times, safety concerns . The care plan failed to document information regarding lighting a cigarette. On 2/28/23 at 4:07 p.m. and on 3/1/23 at 12:00 p.m., in the designated smoking area and in line of sight of the smoking attendant, Resident #6 lit the resident's own cigarette. During both observations, Resident #6 was observed with involuntary jerking movements of both arms, which required multiple attempts before successfully lighting the cigarette. On 3/2/23 at 9:24 a.m., an interview was conducted with LPN (licensed practical nurse) #1 (the nurse who completed Resident #6's smoking evaluation). LPN #1 stated that while completing a smoking evaluation, she observes how a resident holds a lighter, puts the lighter up to the cigarette, how the resident holds the cigarette and if the resident is able to put the cigarette into the receptacle. LPN #1 stated it was not safe for Resident #6 to light a cigarette because of all of the resident's movements. On 3/2/23 at 11:58 a.m., an interview was conducted with OSM (other staff member) #2 (the smoking attendant on 3/1/23). OSM #2 stated she was supposed to light all residents' cigarettes. OSM #2 was made aware Resident #6 was observed lighting the resident's own cigarette in her line of sight on 3/1/23. OSM #2 stated, It might have been a point where I was doing a couple of things: opening doors, making sure they (other residents) were coming in without tripping or falling and I did not see (Resident #6) lighting a cigarette. On 3/2/23 at 1:40 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of clinical services). ASM #2 stated staff should light a resident's cigarette if the resident is assessed as not being safe to light his own cigarette. On 3/2/23 at 4:00 p.m., ASM #1 (the executive director), ASM #2 and ASM #3 (the vice president of operations) were made aware of the above concern. Reference: 1. Huntington disease is a progressive brain disorder that causes uncontrolled movements, emotional problems, and loss of thinking ability (cognition) .Early signs and symptoms can include irritability, depression, small involuntary movements, poor coordination, and trouble learning new information or making decisions Many people with Huntington disease develop involuntary jerking or twitching movements known as chorea. This information was obtained from the website: https://medlineplus.gov/genetics/condition/huntington-disease/. On 3/2/23 at 4:00 p.m., after conversations with the long term care supervisors, the survey team met with ASM #1, ASM #2, and ASM #3 and informed them that the facility was in immediate jeopardy (IJ). The facility presented the following IJ removal plan which the team, after consultation with supervisory staff, accepted on 3/2/23 at 7:10 p.m. 1. Residents Affected by Deficient Practice Resident #1 - Resident #1's roommate extinguished the fire. Resident #1's oxygen was removed. Resident #1 was sent to hospital. Resident readmitted to facility on 2/28/23. Smoking assessment revealed resident is an unsafe smoker. Care plan has been updated to reflect unsafe smoking status. Resident will be placed on 1:1 supervision for safety. Resident will be reassessed as needed for safe smoking. If resident desires to smoke, he will be 1:1 supervision Resident #6 - Resident #6's smoking assessment and care plan have been reviewed and updated. Resident #6 is an unsafe smoker and requires supervision during smoking, to include assistance with lighting cigarette and smoking apron. Resident #6's smoking material includes cigarette and lighter; all smoking materials are being maintained in a locked cart by staff. 2. Other Residents Identified to be At Risk Current residents were interviewed to validate their wishes to smoke. Residents identified as smokers were assessed using safe smoking assessments to determine the need for supervision when smoking by DCS/designee. DCS/designee completed education with smokers in facility and/or RP on the policy and procedure related to smoking. Each resident/RP will sign contract. Adhoc resident council meeting was held to ensure they are aware of the facility's smoking policy and procedure. DCS/designee to educate all facility staff on the smoking policy and procedure to ensure all tobacco materials (lighters, tobacco products, vape or electronic cigarettes) are secured in medication cart or resident issued lock box. No staff member will return to duty without receiving education prior to the start of his/her next scheduled shift. DCS to provide designated smoke aid education on the role of smoke aid. No staff member will return to duty without receiving education prior to the start of his/her next scheduled shift. Residents identified as smokers will have his/her care plan reviewed and updated if appropriate to ensure safety and decreased potential for injury. Full sweep of residents identified as unsafe smokers. Assessed for any smoking material (lighters, tobacco products, and electronic cigarettes) with potential to cause or contribute to a burn type injury. Items found were removed from resident care areas by DON/designee and secured at nursing station or issued lock box. Facility maintenance director completed audit of all resident rooms identified with oxygen in use to ensure oxygen signage was posted outside the resident door. Fire drill was completed on all shifts to ensure that staff responded appropriately. Safety observation was completed by maintenance director to ensure designated smoking areas were equipped with approved ashtray, container, fire blankets, and appropriate receptacles. Adhoc QA meeting to review all information and documentation related to incident including policy review, audits, and internal POC. Adhoc QA meeting to review IJ template and updates to the original plan 3. Systemic Changes All staff in service initiated immediately regarding facility smoking policy with particular emphasis of ensuring smoking materials must be stored at the nursing station or personal lock box when resident is not in designated smoking area outside the facility. No staff member will return to duty without receiving education prior to the start of his/her next scheduled shift. Education was initiated regarding residents classified as unsafe smokers will have NO smoking material on them (lighters, tobacco products, E-cigarettes) or in their rooms. They must be kept with the smoking attendant. If the resident refuses to give smoking materials to the resident attendant, the resident will be placed on monitoring, and director of nursing/administrator will be contacted for further assistance. Smoking attendants are to light the cigarettes of all unsafe smokers and monitor them while they smoke. No staff member will return to duty without receiving education prior to the start of his/her next scheduled shift. Residents identified as unsafe smokers were provided education regarding tobacco material must be stored with smoking attendant. The education also included the resident attendant providing supervision and necessary assistance per the care plan, and action that will be taken if the resident does not comply with the process. The regional director of clinical services provided education to the clinical administration team (unit managers, assistant director of nursing and staff development) in regard to completing a smoking assessment. The assessment includes observing the resident while smoking. The resident care plan will be reviewed after completing the smoking assessment, and revised as indicated. The smoking assistant will be informed of any changes to resident plan of care in relation to smoking immediately. Residents identified as needing supervision with smoking will be given one cigarette once outside in the designated smoking area, and smoking aid will provide/or supervise the lighting of the tobacco product/or provide appropriate equipment. Smoking Aid will be available 24 hours, 7 days a week 4. How will the deficient practice be monitored to ensure compliance? The DCS/designee will conduct a weekly quality review of 10 residents on each unit weekly times four weeks, and then every two weeks times two months. The findings of these reviews will be reported in the monthly Quality Assurance Improvement Committee meeting for four months. The committee will review the findings to determine if further action is needed. 5. Date of Substantial Compliance 3/4/23 On 3/6/23 the survey team verified the removal plan had been fully implemented by the facility. On 3/6/23 at 2:40 p.m., ASM #1, ASM #2, ASM #3, and ASM #4, the regional clinical director, were informed the removal plan had been verified and the IJ had been abated. The scope and severity of the deficiency was lowered to a level 3, isolated. No further information was provided prior to exit. 31753

Based on interview, record review, and review of facility policy, the facility failed to protect residents from abuse resulting in harm for two residents of five residents (Resident (R) 191, and R89) reviewed for abuse in a total sample of 65 residents. Specifically, physical altercations resulted in R89 requiring an evaluation at the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility's policy, Abuse, Neglect, Exploitation, and Misappropriation, dated 11/28/17 documented It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse. physical abuse includes. hitting. biting. The center is committed to the prevention of abuse, neglect. Monitoring of resident who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk or vulnerable for abuse, for indications of changes in behavior, changes in condition or other non-verbal indications of abuse. 1. The facility-provided Facility Reported Incident (FRI) document dated 01/23/21 revealed, Allegation of Resident to Resident Contact. Residents immediately separated, a head to toe observation was conducted of both residents by a licensed nurse for injuries. Increased supervision implemented for safety. Law enforcement notified. Investigation initiated [sic]. Review of Certified Nursing Assistant (CNA) 8's Witness Statement dated 01/27/21, indicated that while charting behind the desk she heard R191 and R159 fussing, and R159 was directly up on [R191] like he was ready to hit him [sic]. At this time, she heard License Practical Nurse (LPN)17 tell R159 not to hit R191, and then R159 rolled down the hall to eat his dinner. CNA8 was unsure as to when R159 returned but heard a commotion and when she looked back R191's face bleeding. Review of LPN17's undated Witness Statement, revealed while LPN17 was passing medications she saw R159 approached R191 in his wheelchair and stated, I heard you down the hallway calling out at the staff to suck your dick. At this time LPN17 asked R159 to back away from R191. R159 said O.K. and left down the hallway. LPN17 continued with her medication pass and was in another resident's room when she heard someone say OOH. LPN17 came out of the room and saw [R191] bleeding and [R159] leaving the unit with a cane. Review of R159's undated Witness Statement, revealed R191 was talking smack to the nurses and yelling out inappropriately, suck my dick. R159 told R191 to stop, then went to his room, and got the cane and hit [R191]. He shouldn't be talking that mess. Review of R191's undated Witness Statement indicated that R159 came up to him and hit him with a cane. R191 denied having an exchange of words. Review of the facility-provided Incident Report/five day follow up dated 01/29/21, revealed that R191 acquired multiple lacerations from the altercation with R159, was evaluated by nursing staff, and was then transferred to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The Police Report provided by the facility, dated 01/23/21, documented Victim and suspect who reside in the same nursing home got into a verbal disagreement. Suspect struck the victim with a cane, causing laceration to his right forehead requiring stitches. Both individuals are mentally incapacitated. Review of R159's face sheet located in the Electronic Medical Record (EMR) in the Profile tab revealed that R159 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/15/21 revealed R159 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The assessment indicated that the resident was not ambulatory and only had use of his right arm but is able to self-propel in a wheelchair. The assessment also showed R159 displayed no behaviors during the look back period. Review of R159's care plan under the Care Plan tab revealed the resident had the potential for impaired and inappropriate behaviors due to major depressive disorder and mood disorder. R159 refused medications often. During an interview on 11/10/21 at 6:33 PM, R159 indicated that he did hit R191 with his cane because he told me to suck his dick and kiss his ass. R159 further stated that staff had told him to leave R191 alone and to stay away from him but he had to save face and protect himself. During an interview on 11/10/21 at 6:25 PM, LPN40 reported R159 spent quite a bit of time in the smoking area, but he also signed himself out and often returned to the facility with obvious signs of drinking alcohol. Review of R191's face sheet found in the EMR under the Profile tab revealed that R191 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R191's quarterly MDS with an ARD of 10/23/21 revealed that R191 had a BIMS of eight out of 15, indicating moderate cognitive impairment. R191 has limited range of motion on one side of this body and rejected care assistance one to three days of the look back period. The care plan located in R191's EMR under the Care Plan tab directed staff to: intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; and remove the resident from the situation and take to an alternate location as needed. The progress note dated 01/23/21 located in the EMR in the Progress Notes tab documented R191 returned to the facility with sutures above his right eyebrow. During an interview on 11/09/21 at 5:46 PM, R191 stated that he can't quite remember if he was hit or not .I believe so, but I can't recall it, but if he did, he did. R191 indicated that he felt safe and did not suffer any harm. During an interview on 11/10/21 at 1:29 PM, CNA8 indicated she remembered R159 and R191 having words, but a lot of the residents [NAME] every now and again. CNA8 stated she heard the nurse ask them to stop and remembered R159 self-propelling down the hall, and then suddenly she heard a yell out and R191's face was bloody. CNA8 indicated that R191 returned with stitches in his forehead. During an interview on 11/12/21 at approximately 11:50 AM, LPN17 indicated she remembered R191 was being crude and R159 started to approach him, but she intervened, then R159 wheeled himself to his room. LPN17, stated she continued with her medication pass. LPN17 stated while she was in another resident's room, she heard someone yell. When she came out into the hallway, R191 was bleeding from his face and R159 was wheeling back to his room with a cane. LPN17 stated she immediately assessed R191 and sent him to the emergency room for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN17 indicated that staff tried to intervene when they saw any resident escalating for any reason and tried to redirect them. 2. Review of the facility's investigation for an incident on 07/02/21 between R1 and R89 revealed, in the five-day report summary, that R1 engaged in a physical altercation with R89 resulting in R89 going to the hospital for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R89's Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R89's Quarterly MDS with an ARD of 06/14/21 revealed a BIMS score of four out of 15, indicating severe cognitive impairment. The assessment documented R89 did not display behaviors during the look back period. Review of R89's Progress Notes tab in the EMR revealed in a nursing note dated 07/02/21 at 3:34 PM, Resident escorted to the floor as he was in an altercation with another resident. [Nurse Practitioner] notified as well as next of kin. Resident transported to the [emergency room ] for scratches to the face, red right eye, several human bites to the right arm and elbow area open area to the mid chest, scrapped right knee. Sent for evaluation and treatment. [sic] Review of R1's Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS with an ARD of 07/23/21, located in the EMR under the MDS tab, revealed a BIMS score of seven out of 15, indicating severe cognitive impairment. The assessment documented R1 displayed behaviors of rejection of care one to three days of the look back period. Review of R1's Progress Notes tab in the EMR revealed the following. a. On 07/02/21 at 3:14 PM, .Mood status is angry. Behavioral problems are verbal behaviors (screaming, cursing, etc.) [sic]. Patient was reported having an altercation with another resident. Education provided on medication management. Patient refused all his scheduled medications on this shift. [Nurse Practitioner, family] and unit manager aware. b. On 07/02/21 at 3:23 PM, Social Service Progress Note. [R1] was observed in a physical altercation with another resident in the smoking area. Police were called. [Community mental health services] conducted a [video] interview and decided to TDO [temporary detention order (psychiatric hold/evaluation)] resident. SW [Social Worker] faxed face sheet, orders, and progress notes to [Community mental health services]. Police were called to pick up resident to be taken to the hospital for evaluation and treatment. c. On 07/02/21 at 8:51 PM, Resident at this time was escorted out the building with 911 to be transported to [hospital] will notify emergency contact. During an interview on 11/08/21 at 3:44 PM, R89 stated he had an altercation with a resident that resulted in him (R89) going to the hospital for stitches. R89 stated the other resident (R1) no longer lived in the facility and went to prison. R89 stated that he felt safe in the facility. During an interview on 11/09/21 at 5:24 PM, SW4 stated on 07/02/21 she saw the Registered Nurse (RN) 20 and another staff member running past her door. SW4 stated she followed them to the smoking area where she saw R89 on top of R1 in his wheelchair. SW4 stated after staff separated the residents, R89 stated he had asked R1 to move, and R1 reacted physically. SW4 stated R89 reported he jumped on R1 to stop him, because R1 was biting him (R89). SW4 stated the facility called the police, the police came out but did not do anything since they had not witnessed it. SW4 stated R89 was sent to the emergency room for an evaluation of bite marks and injuries. SW4 stated the staff secured the smoking area and kept R1 supervised there as he continued to have behaviors. SW4 stated the facility called the local mental health service via video so they could witness R1's behaviors, who agreed with sending R1 to the emergency room for a psychiatric evaluation as he was a danger to himself and others. SW4 stated R1 was often confused; in his own world; heard voices; was often agitated; was argumentative with staff and residents; and he would yell at staff, residents, or internal stimuli. SW4 stated that prior to this incident, R1's behaviors were verbal, and he would deescalate on his own after his outbursts. SW4 stated that R1 had been refusing his psychiatric medications as well as refusing cares and services from staff. SW4 stated R89 was calm, childlike, got along with others, made friends, and was not believed to have done anything to provoke R1. R89 had not had other resident to resident altercations. SW4 stated that there was always a staff member present in the smoking area, but she did not recall who was on duty the day of the altercation between R89 and R1. During interview on 11/10/21 at 10:15 AM, the Director of Nursing (DON) stated that on 07/02/21 she and several other staff (RN20 and a former social worker) ran to the smoking area when they heard what sounded like an altercation occurring. The DON could not recall exactly what was happening when staff arrived but stated R1 was talking to himself and other residents in the area stated R1 attacked R89. The DON stated R89 had asked R1 to move so others could get by when he was attacked by R1. The DON recalled taking R89 to evaluate his injuries, he had several lacerations and cuts, so he was sent out to the emergency room . The DON stated staff cleared the smoking area and stayed with R1 in the smoking area until he was able to be evaluated and sent out for a psychiatric hold. The DON recalled that R1 would talk to himself and curse; but did not recall other altercations with residents. The DON stated the facility assigned a staff member to the smoking area for all shifts; however, there was no one scheduled during the shift of the incident. She reported that many of the staff's office windows overlooked the smoking area and pointed across the hall where the windows looked out into the smoking area. The DON stated that if no one was assigned to the smoking area, staff were informed so they could do regular rounds of the smoking area. The DON could not recall what staff were in the smoking area when the incident occurred.

Based on observation, resident interview, staff interview, clinical record review, and review of the facility's policy, the facility staff failed to ensure that pain management was provided for 1 of 62 residents (Resident #80) in the survey sample. The facility staff failed to administer the scheduled opioid pain medication ([MEDICATION NAME]-[MEDICATION NAME] tablet 5/325 milligrams) to Resident #80, for over 16 consecutive hours; resulting in unnecessary and debilitating pain, constituting harm. The findings included: Resident #80 was originally admitted to the facility 2/1/18 and had never been discharged . The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/12/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #80's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring supervision after set-up with bed mobility, transfers, walking, locomotion, personal hygiene, dressing and eating, extensive assistance of 1 with bathing and toilet use. In section J Resident #80 completed the pain interview which was coded as he was not experiencing pain and he was not receiving scheduled or as needed pain medication, but at section N0410H; the resident was coded as receiving opiods 7 out of 7 days. An initial interview was attempted with Resident #80 on 2/12/19, at approximately 12:40 p.m., but he asked for the interview to be completed later. The resident was observed lying in bed in a fetal position, with his arms folded. An interview was conducted with Resident #80, 02/13/19, at approximately 1:33 p.m. The resident stated when you came by yesterday I was hurting too bad I wanted to talk but I couldn't even get out of bed to empty my urinal. He further stated he had last received his scheduled pain medicine 2/11/19, at approximately 1:00 p.m. and didn't receive any more until after 2:00 p.m., 2/12/19. The resident also stated the nurses allowed his medication to run out before they ordered more and it wasn't the first time it happened. The resident stated, he felt they only got the medication for me to take on 2/12/19, because the state was in the building and stated by that time the nurse gave it me, (he) hurt so bad I had tears in my eyes. The resident stated when my pain gets bad like it did on 2/12/19, it takes at least two days to get pain back to a level tolerable. Resident #80 also stated that, the nurses tell me when there is no [MEDICATION NAME]-[MEDICATION NAME] tablet 5/325 milligrams available, I can have Tylenol, which does not help, so I don't take it. The physician order [REDACTED].#80 had a physician's orders [REDACTED]. Give one tablet by mouth every eight hours related to other chronic pain. The active care plan dated 8/22/18, had a problem which read; (name of resident) has alteration in pain/comfort related to left stump [MEDICAL CONDITION]. The first goal read; (name of resident) will voice/demonstrate no side effects related to the use of [MEDICATION NAME] through the review date 4/30/19. The second goal read, (name of resident) will not have an interruption in normal activities due to pain through the next review date 4/30/18. The third goal read, (name of resident) will not demonstrate decline in overall function related to pain through the next review 4/30/18. The interventions included; treatment per current physician order [REDACTED]. Evaluate the effectiveness of pain interventions. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor and report for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls. Report occurrences to the physician and/or nurse practitioner. Social service consult as needed. [MEDICATION NAME]-[MEDICATION NAME] is a schedule III opioid pain medication. Review of the Controlled Medication Utilization Record revealed on 2/11/19 at 2:00 p.m. Resident #80 was administered one [MEDICATION NAME]-[MEDICATION NAME] tablet 5/325 milligrams and the next dose was administered 2/12/19 at 2:00 p.m. Also a bold printed note dated 1/31/19, was written on the top of the Controlled Medication Utilization Record from the pharmacy which read; please contact your physician for a new prescription to maintain therapy. This is the last partial fill from this prescription. On 2/1/19, the facility's nurse who received the medication wrote on the form, [MEDICATION NAME]-[MEDICATION NAME] tablet 5/325 milligrams; thirty tablets received. A nurse's note dated 2/11/19 at 9:35 p.m. read an order was received for [MEDICATION NAME]-[MEDICATION NAME] tablet 5/325 milligrams. Give 1 tablet by mouth every eight hours related to other chronic pain, awaiting pharmacy. The hard script dated 2/11/19, for [MEDICATION NAME]-[MEDICATION NAME] tablet 5/325 milligrams was signed by the nurse practitioner for thirty tablets was observed. A concern note dated 2/12/19, (no time documented) was written on behalf of Resident #80. It read; Concern: Did not receive pain medication, medication ran out. Investigation: No medication on the cart, called pharmacy, spoke with (name of the individual). Resident has two orders (for what medication was not documented) one with refills. One with refills, will send out on noon run. Action taken: Medication pulled from back up box. Assistant Director of Nursing was aware Resident #80's personal [MEDICATION NAME]-[MEDICATION NAME] was exhausted she obtained the medication from the contingency supply box. The process requires the nurse to call the pharmacy, who will review the prescription and give the nurse a code, the nurse will document the authorization code and obtain the medication from the contingency box to administer to the resident. This procedure ensures a resident is never in pain because the pain medication isn't available in their personal supply when it is available in the contingency box. A Removal of Controlled Substance Medication From Contingency Supply form dated 2/12/19, at 2:00 p.m., revealed one [MEDICATION NAME]-[MEDICATION NAME] tablet 5/325 milligrams was obtained for Resident #80. On 2/19/18, at approximately 2:00 p.m. the above findings were shared with the Administrator, Assistant Administrator, the Director of Nursing and the Regional Director of Clinical Services. The Director of Nursing stated the resident had two prescriptions one had refills and the controlled medication box contained the medication [MEDICATION NAME]-[MEDICATION NAME] tablet 5/325 milligrams for which the resident had a prescription. The Director of Nursing also stated medications should be reordered at when a three day supply is left to ensure it arrives to the facility timely. The facility's undated policy titled Ordering Schedule III, IV and V controlled Medications. Under Procedure 4.6 1 read; schedule III, IV and V medications may be dispensed and delivered to the Community only upon valid prescription written by a Physician/Prescriber and received by the Pharmacy, or facsimile of a prescription from the Physician/Prescriber's office or pursuant to an oral prescription from the Physician/Prescriber made directly to the pharmacist. 3. New and refill orders for Schedule III, IV and V controlled medications must be ordered as specified in the regular ordering medication procedure.

Based on observations, clinical record review, staff and family interviews, and facility documentation review, the facility staff failed to ensure 2 out of 39 residents (Resident #13 and #25) in the survey sample who did not enter the facility with pressure ulcers did not develop them unless they were unavoidable. 1. The facility staff failed to prevent the development of a pressure ulcer to Resident #13's left inner heel from a splint device, first discovered at an advanced stage (Stage III full thickness skin loss with necrotic tissue and drainage) on 6/26/15. The facility staff failed to perform skin assessments and monitoring of the left foot from 5/14/15 to 6/26/15, as well as obtain and replace the splint device with the physician ordered air CAM (Controlled Ankle Motion) boot on 5/20/15. 2. The facility staff failed to prevent the development of a Stage II pressure Ulcer on Resident #25's left (L) inner knee. The area advanced to a Stage III. The findings include: 1. Resident #13 was admitted to the nursing facility on 10/4/12 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a significant change status assessment dated [DATE] and coded the resident with short and long term memory and severely impaired in the skills needed for daily decision making. Resident #13 was completely dependent on two staff for bed mobility and transfer. She was dependent on one staff for dressing, eating, toilet use, personal hygiene and bathing. She had limitations in range of motion on one side of lower extremity. She was coded always incontinent of bowel and bladder. Resident #13 was assessed at risk for the development of pressure ulcers and coded as not currently having any or were admitted with them. The revised care plan dated 6/3/15 identified Resident #13 was dependent on staff for all of her Activities of Daily Living (ADL) with the potential for impaired skin integrity due to immobility, incontinence and a brace. The goal set for the resident by the staff was that the resident would have intact skin, free of blisters or discolorization through next review date of 9/3/15. Some of the approaches the staff set for the resident to implement the goal included notify nurse of any new areas of skin breakdown: redness, blisters, bruises, discolorization noted during bath or daily care. Weekly skin checks by the licensed nurse and placement of adaptive device (cushion). The care plan was not revised to include the air CAM boot that was ordered on [DATE]. The care plan was revised on 6/26/15 after the heel pressure ulcer was discovered due to a brace. Interventions included monitor for pain and float heels. The care plan was not revised to include the PRAFO boots ordered on [DATE]. A PRAFO (Pressure Relief Ankle Foot Orthosis) is an AFO (ankle foot orthodic) that can help manage many of the ankle/foot anomalies your patients present to you with positive heel suspension (http://www.aoptinc.com/PDF/PRAFO.pdf). The Certified Nursing Assistant's (CNA) Information Kardex indicated the resident was able to receive showers on day shift scheduled for Wednesdays and Saturdays. The Kardex identified the resident had an ankle splint. The Kardex did not reflect the use of the air CAM boot or the PRAFO boots. The nurse's notes entry by the Wound Care Nurse (WCN) dated 6/26/15 indicated an open area was observed on the left inner heel during the resident's shower. It was recorded in the nurse's notes that the area had slough and bloody drainage. The nurse's note had indicated on 5/13/15, Resident #13's left ankle was observed swollen and warm and she was complaining of pain. The physician ordered a mobile (in house) x-ray of the ankle which revealed mildly displaced fracture along the distal tibial (the largest bone of the lower leg) metaphysis (the wider part of the shaft of a long bone). In the case of the Resident #13, the fracture was near the ankle. The resident was transferred to the local emergency department on 5/13/15 at 10:35 p.m. and returned on 5/14/15 at 2:25 a.m. with a [DIAGNOSES REDACTED]. An ankle splint was placed on the left ankle and orders to follow-up with the resident's attending physician for further treatment as soon as possible. Additional orders included observe, assess and monitor resident for increase or severe pain, coolness of foot to touch, paleness, change in color, tightness, reddened areas and swelling. This order was placed on the Treatment Administration Record (TAR), but not signed off that the monitoring and assessments took place. The physician's nurse practitioner (NP) followed up and evaluated Resident #13 on 5/20/15 and ordered a CAM boot placement on the left foot for 4 weeks. This boot was signed off by the licensed nurses in place on all three shifts. The Licensed Practical Nurse (LPN #11) who signed the orders for the CAM boot were taken off and transcribed, was interviewed on 7/2/15 at 5:15 p.m. She stated she did not know what a CAM boot was and thought it may have been the black splint she had on from the ER, but was wearing yellow boots now because of the pressure ulcer. The nursing staff at the nursing station said the order could have been flagged if it was something they needed to follow-up on in the morning, but did not think it was because there was no evidence that a CAM had been ordered. The weekly skin checks reviewed for the dates of 5/18/15, 5/25/15, 6/1/15, 6/8/15, 6/15/15 and 6/22/15 indicated skin checks were performed by Licensed Practical Nurse (LPN) #5 and the resident's skin was intact. On 6/30/15 at 12:30 p.m., an interview was conducted with LPN #5. She went to the resident's bedside and showed this writer a black splint that was taken off the resident the day the pressure ulcer was discovered on 6/26/15. It was observed to be an athletic type splint with fleece covered hard plastic side pieces to include the sides of the heel. Inspection of this device revealed the back of the heel portion of this ankle splint was open and clearly visible upon inspection, as well as the top of the ankle, top of the foot and soles of the foot, but the sides of the heel would not be visible unless the Velcro straps were opened and the splint spread apart or the splint completely taken off. Closer examination of the splint revealed an obnoxious odor and old dried blood on the inner aspects of left heel side of the device. The resident was observed to currently have large yellow foam boots in place. During the interview, LPN #5 was asked how she performed skin checks, as well as assessment of the foot as ordered on [DATE], she picked up the splint and stated, I would open the Velcro straps and peek around to make my skin assessments. I never saw anything until (Certified Nursing Assistant's name-{CNA #4}) told me there was a black area on the inside of her heel 6/26/15. Once she got the sore we took off the hard brace and placed both her feet in the soft foam heel lifts with Velcro straps. We will not be putting the black brace on as far as I know. She added the resident's full time CNA (#1) was afraid of it so he never removed it, but when he was off and the CNA #4 found it when she showered the resident. The WCN joined the above interview on 6/30/15 at 12:45 p.m. The WCN stated she was made aware of the area on the inner heel by LPN #5 who had been told by the CNA #4. She stated the resident wore the hard black splint until they identified the pressure ulcer, after which the heel lift foam boots were implemented. The WCN was shown the physician's orders [REDACTED]. Is this not a CAM boot? I guess we thought it was. When shown the order on the TAR for explicit monitoring/assessments of the foot, she stated, This should have been signed off as assessed on every shift or at least in the nurse's notes and maybe we would have caught this earlier. The area did not develop overnight, it developed over time. The WCN stated on 6/26/15, she initially assessed the wound as a Stage III with necrotic tissue and slough, but could not make a definitive assessment because the wound bed was covered in the necrotic tissue. She stated the treatment orders dated 6/26/15 included cleaning with normal saline, applying Santyl (topical debrider) and wrap with Kling. LPN #5 stated the experience was a learning one for her and said, I dropped the ball. LPN #5 also said when she reviewed the orders, she thought the black splint was the right device in place and she did not know about the monitoring/assessment order. LPN #5 stated the previous NP (no longer working for the facility) ordered to continue to continue the splint on 5/18/15, but the LPN did not indicate she knew about the subsequent order written by the current NP on 5/20/15 for the CAM boot. The LPN was shown the order for the CAM boot and she stated, I believe the black splint she came with from the ER is the CAM boot. She also stated the resident had an orthopedic (ortho) appointment for 7/1/15, which was the first one after the ED evaluation. She said they followed all orders for the care of the foot from the resident's attending physician/nurse practitioner until seen by the orthopedic doctor. On 6/30/15 at 2:20 p.m., an interview was conducted with the Administrator, the Director of Nursing (DON) and the ADON. The Administrator stated Friday afternoon on 6/26/15, she received an email that Resident #13 had a wound and followed-up with an email to the DON who was at a training seminar. The Administrator stated when she came in on Sunday 6/28/15, she learned more details from the Wound Care Nurse (WCN) that the prn CNA #4 discovered the area during a shower. She said the WCN informed her the pressure area was the result of pressure from an ortho splint. She stated on Monday, she initiated a 4 point plan to assess all residents wearing ortho boots for breakdown, all facility skin sweep, check shower books and educate staff on assessments, proper ADL care and documentation. She stated if residents were not receiving showers, it would cue them to ask why and possibly discover any areas early on to cover all bases and close any loops. They did not include in the four point plan about taking off and implementing physician orders. They were currently not aware physician orders [REDACTED]. In addition, they were not currently aware the orders to monitor skin, foot was not signed off on the TAR or documented in the nurse's notes as done. Until this interview, they were not aware the wrong device, the one that created the sore, was on the resident all along. During the above interview, they stated during their investigation of the pressure ulcer for Resident #13, LPN #5 told them explicitly that she did not do any skin assessments of the resident left foot, which told them she did not in any way peek around the splint or remove it to inspect skin. The DON stated, How do you inspect the skin if you never remove the splint? She wrote it and reported to us she did not take the splint off. They also stated they were not aware, until 6/26/15, that CNA #1 never removed the splint to provide ADL care during bed baths and that he did not verify with anyone whether to shower or not shower the resident. The DON stated the resident was able to have showers and thought she was having them, otherwise there would have been an order to give bed baths only. CNA #4, who discovered the wound during the shower on 6/26/15, was interviewed via telephone on 7/2/15 at 4:00 p.m. She stated when she removed the left foot black splint, she saw a black area on her ankle and immediately informed the nurse and later spoke to the Unit Manager. She said the WCN followed up with a treatment after she finished the resident's shower. She said no one told her the resident could not have a shower and showers were listed on her Kardex. Resident #13's regularly scheduled CNA (#1) was interviewed on 7/1/15 at 3:00 p.m. The CNA stated he did not shower the resident because of the black splint she had in place. He said the resident did not wear a sock with the splint. He stated he washed above the splint which was a little above the ankle, the top of the foot, the part seen on the bottom of the foot and toes. He said he did not ask anyone to clarify whether he could remove it for showers or bathing in general and no one told him anything about the splint. He stated he wasn't sure if the licensed nurses removed it to check the skin. He said, Now since she has the yellow foam boots, I wash everything. On 7/1/15 at 10:30 a.m., the DON presented an addendum to the original four point plan and stated, I will adding more to our four point plan to include educating the nurses on following through on the TAR, signing off and not just leaving it there. If it was important enough to put it on the TAR, it was important enough to monitor. The nurse's notes should have reflected monitoring too. She also stated the 11/7 nurses check the charts and did not pick up any orders that needed to be clarified, taken off or signed off. On 7/1/15 at 1:30 p.m.,wound care to the left inner heel was observed performed by the WCN. The resident had just returned from the orthopedic doctor. A type of PRAFO (Pressure Relief Ankle Foot Orthosis) heel lift boots were observed on both feet as was observed during previous observations. They were thick foam yellow boots that encompassed the calf and the foot secured in place by Velcro straps. The heels were suspended within the boot. The WCN called the yellow boots heel lifts. When the WCN removed the boot on the left foot, the hard black splint was observed on the foot as well. It appeared to be tight fitting, especially with the dressings that were in place. The WCN removed the black splint and continued with the wound care procedure. The entire wound bed presented as Eschar (hard black necrotic tissue) with minimal drainage around the edges and measured 2.3 centimeters (cm) x (by) 2.5 cm. Parts of the perimeter of the wound exhibited bruising. The WCN stated the wound was considered to be unstageable and could not assess for any depth or stage the wound until the black eschar came off. Unstageable is a full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. She stated the wound looked pretty much the same when it was first identified on 6/26/15. The documentation on the pressure ulcer record dated 6/26/15 indicated the pressure ulcer was a Stage III, firm, slough (necrotic tissue) with pink red drainage that measured 2.3 cm x 2.1 cm and 0.1 depth. The WCN cleansed the wound with normal saline, applied Santyl with a cotton tipped applicator, covered with a gauze pad and wrapped the heel and ankle with Kling wrap. The resident jerked her leg and cried out during the cleaning of the wound bed and around the wound. She then re-applied the black hard splint and placed the foot back into the PRAFO boot (yellow foam boot). She called the black splint the PRAFO boot and said, I guess he wants this back on her. This writer asked the WCN why would the ortho doctor place a device on the foot that generated the pressure ulcer; to which she responded, I better call him and ask him. On 7/1/15 at 5:30 p.m., the WCN stated she called the ortho doctor and he did not want the black splint on the resident, only the yellow heel lifts which was considered a type of PRAFO. She said she officially discontinued the black splint and officially entered on the TAR, the heel lifts to be worn at all times, remove for showers, wound care and hygiene every shift and as needed, and inspect skin for redness, swelling and changes. She stated she did not know who re-applied the black splint when she came back from the ortho appointment, but knew LPN #3 accepted her back from the ortho doctor on 7/1/15. On 7/1/15 at 5:40 p.m., the NP was seeing the resident and stated she worked orthopedics and was very familiar with orthotics (orthopedic devices). She said she ordered the CAM boot on 5/20/15 and thought the resident had it until the ortho doctor saw the resident and made his treatment recommendation and orders. This writer took her to the room to identify if the black splint was a CAM boot. When the NP saw the black splint at the bedside, she said, I don't know what this is. It's like something an athlete would wear in a shoe. This is not a CAM boot. The CAM boot was ordered when the fracture first occurred to keep the ankle straight, as well as protect the skin from breakdown. So, she never got it. When told the conflicting information from LPN #5 that she said she checked the skin, the NP said, Well she did not check the skin because we have this bad spot on the side of her heel. We are now going with what the ortho doctor has ordered as of 7/1/15. On 7/1/15 at 6:00 p.m., the Rehabilitation Director presented a picture of a CAM boot and an ankle brace/splint. The CAM boot was described in the professional literature as a boot that conformed to the leg ensuring a better fit with medial/lateral adjustable air cell padding systems that inflated equally on both sides. It had a shock absorbing insoles and a wide foot bed with Velcro strapping. The ankle brace was designed to be worn for chronic instability during activity and ankle sprains. LPN #3 was interviewed via telephone on 7/2/15 at 5:20 p.m. She stated the resident went to the ortho doctor on 7/1/15 around 9:00 a.m. and she had soft foam yellow boots in place. She further said she accepted the resident back from the ortho doctor around 11:00 a.m., read the physician's orders [REDACTED]. She said she put the black splint on the left foot and the yellow soft boot over top of it. Resident #13 had returned from the ortho doctor with the following orders dated 7/1/15 at 9:56 a.m.: Non-displaced, stable left tibia and fibula fracture. Non-operative treatment using current PRAFO. I recommend a formal wound care consult for heel ulcer and strict pressure relief. Follow-up prn (as needed) with ortho. On 7/2/15 at 3:10 p.m., a telephone interview was conducted with Resident #13's Responsible Party (RP). She stated, I was fine with the care my mother was receiving up to the point of her getting that sore. Obviously no one ever checked that brace. It was completely avoidable and I was very unhappy about it. The Unit Manager spoke to me and said the nursing staff should have been looking at it and she was profusely apologetic. On 7/2/15 at 4:28 p.m., a telephone interview was conducted with the ortho doctor. He stated when he saw the resident on 7/1/15, she did not have a black splint in place and he did not know what the WCN or this writer was referring to because the resident arrived at his office in a type of PRAFO boots and left with the same boots. He stated the resident was not ambulatory, the fractures were stable and thought the yellow foam PRAFO boots she had in place were acceptable. He added, She just needs to not get any more sores. On 7/2/15 at 5:45 p.m., the aforementioned concerns were reviewed again with the Administrator, DON, Assistant Director of Nursing (ADON), as well as the Corporate nurse. No additional information was provided to the survey team prior to survey exit. The facility's policy and procedure entitled Skin Evaluation dated 11/30/14 indicated the licensed nurse would complete a total body evaluation on each resident weekly and document the observation on the weekly Skin Integrity Review form. The evaluating nurse must date and sign each review. 2. Facility staff failed to prevent the development of a Stage II pressure ulcer on Resident #25's left (L) inner knee. The area advanced to a Stage III, but at the time of the survey was noted to have a pencil eraser size area of slough with the rest of the quarter size wound observed with granulating tissue. The Minimum Data Set (3.0) Section M, SKIN CONDITIONS offers the following definitions: Stage 2 : Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage 3: Full thickness loss of dermis. Subcutaneous fat may be visible but, bone, tendon or muscle is not exposed. Slough maybe present but does not obscure the depth of tissue loss. May include undermining. Granulation tissue is pink or red tissue with shiny moist, granular appearance. Slough is yellow or white that adheres to the ulcer bed in strings or thick clumps, or is mucinious. Resident #25's significant change 5/4/2015 Minimum Data Set evidenced she was cognitively intact with a BIMS (brief interview for mental status) score of 14 of possible 15. The resident understood others and was able to make herself understood. The resident required total assistance of two persons for all activities of daily living except eating which required only one assistance. Resident #25 was admitted to the facility on [DATE]. At the time of the survey the resident was [AGE] years old. [DIAGNOSES REDACTED]. The symptoms and progression of the disease vary from person to person depending on which nerves are destroyed. Resident #25 was a paraplegic. [DIAGNOSES REDACTED]. Review of Resident #25's returned from the hospital on [DATE]. The readmission skin assessment, which was not dated but presented to the survey team at approximately 4 p.m. on 7/2/15, by the Director of Nurses, as the one completed following the above hospitalization . The skin assessment did not identify a blister or open area on the resident's Left inner knee. A long standing sacral pressure ulcer was identified. The Braden Scale assessment (undated) for the potential development of pressure ulcers described the resident as at moderate risk. However, another Braden Scale (undated) presented to the team earlier in the day had the resident as a high risk. The resident is unable to move her legs. The Braden Scale that was completed for moderate risk evidenced the resident had no restriction in mobility. The high risk assessment noted limitations in mobility. The MDS evidenced the resident was total assistance of two staff for bed mobility. Review of Resident #25's clinical record evidenced that she developed an intact blister on the Left inner knee on 4/30/15. The certified nursing assistant discovered the area and informed the nurse. An order was received for skin prep. On 5/5/15 the blister was documented on the weekly skin sheets as open. The treatment was changed to clean with NS (normal saline) and use Arglas powder and Zinc oxide. A 5/4/15 nurses note described the wound as open but tissue granulating. In the wound care meeting on 5/7/15 the interventions were turning and positioning and a pressure alternating mattress, which was observed in use during the survey. The 5/14/15, 5/21/15, 5/28/15 and 6/11/15 wound care meetings evidenced the inclusion of two different supplements, the same treatment and turning and positioning. Neither the wound care meeting documentation or the weekly skin assessment sheets described the stage or a description of the Left inner knee. On 6/18/15 Santyl, a chemical debridement cream, was ordered. Santyl is used for the removal of slough (and indicator of a Stage 3) . The description of the wound on the 6/16/15 weekly skin sheet was open blister. On 6/25/15 the wound care meeting documentation noted the change in treatment to Santyl. The 6/28/15 weekly skin sheet noted, open blister. On 6/29/15 a nursing note evidenced the wound bed , was cleaner. The resident's care plan was reviewed. Although the Left knee blister was noted on 4/30/15 the care plan was not up dated until 5/19/15. The interventions included serving the diet as ordered, administering medications as ordered, assisting resident with turning and positioning (MDS noted she was totally dependent with bed mobility), and reporting any new areas to the physician. While in the resident's room at 4:30 pm on 7/1/15 a positioning device to separate knees was noted in the chair in the room. LPN #10 was requested to accompany the surveyor back to the resident's room. LPN was requested to uncover the residents legs so the legs could be observed. A dressing with the current date on it was observed on the Left inner knee. The resident was on her back and her legs were straight and not touching one another, A bed pillow was observed folded in half and between the resident's knees. LPN #10 noted it was the correct positioning device for Resident #25. When asked how the resident had pressure to the inner L knee she replied that when the resident was placed on her side facing the window, her right knee rested on her left knee and that was how the blister developed. LPN # 10 continued, that position caused the blister but placing the pillow between her knees is what caused the blister to open. The following morning (7/2/15), two CNAs were observed leaving Resident #25's room, just having finished ADL care. They responded no when asked if the blue positioning device had been used. They continued that Resident #25 had refused and that it was the restorative aide who placed the positioning device. They lifted the sheet to show the bed pillow between the the resident's knees. The Restorative aide was then interviewed, (approximately 11 am), and stated the resident did refuse the positioning device. When asked how frequently she refused (not in use 7/1 or 7/2) she stated sometimes. When asked if it was more or less that half the time she stated more. The restorative aide was unsure if anyone else knew of the refusals. At 2:20 pm on 7/2/15 the Director of Nurses was interviewed she was shown the care plan for the wound. and asked why there were no specific interventions. She responded that specifics were not placed on the care plan but rather on the Kardex that the certified nursing assistants used. The documentation that had been provided to the surveyor did not contain information about when the positioning device was ordered or started; the DON was requested to find that information. A Kardex is a care plan for the CNAs to follow in caring for the resident. About 2:30 pm the wound nurse was asked if she had completed the wound dressing. She stated she had but could easily pull back the tape so the surveyor could see the wound. As we approached the room the wound nurse stated, it (wound) is getting so much better. The wound nurse pulled back the tape exposing an area about the size of a quarter. The wound was observed to have pink to red granulating tissue, on the dressing was a small spot of drainage, less than the size of a pencil eraser. The wound nurse commented that there was just that one small area of slough remaining On 7/2/15 the Unit supervisor was requested to review the Kardex with the surveyor. The Kardex showed only turning and positioning for this resident. The supervisor was unable to explain how a certified nursing assistant would know how to position the resident to keep pressure from between the resident's knees (and to also relieve pressure from the sacral area). Neither the care plan or the Kardex indicated the location of the wounds (the resident had a long standing sacral wound as well) and how to best relieve pressure to the affected areas. The use of the knee positioner or the use of the bed pillow with refusal had not been included.

Based on closed record review and staff interview, facility staff failed to: a) accurately identify recognized symptoms of gastrointestinal (GI- digestive tract) bleeding, b) provide ongoing assessment and monitoring of decline in condition, and: c) obtain lab test as ordered to assess the condition; all of which delayed treatment for 1 of 30 residents in the survey sample, Resident #28. The resident was subsequently hospitalized and determined to have active GI bleeding requiring blood [MEDICAL CONDITIONS] and dehydration. Facility staff held the resident's antihypertensive medication without notifying the physician of the low blood pressures or obtaining an order, and failed to obtain blood pressures before administering the medication. The findings include: 1. Clinical record review revealed, Resident #28 was an [AGE] year old male admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] means occurs occasionally), tachy-brady syndrome (both rapid and slow irregular heartbeats), status [REDACTED]. The 30 day Minimum Data Set (MDS) assessment, dated 10/13/10 stated he had short and long term memory problems and rarely made decisions. He needed limited staff assistance with eating. He needed extensive assistance with bed mobility, transfers, dressing and toilet use. He was totally dependent on staff assistance for personal hygiene and bathing. He was 71" tall and weighed 128 pounds. He had a significant weight loss (defined as 5% in 30 days or 10% in 180 days) and was not on a physician prescribed weight-loss regimen. He received a daily insulin injection in the 7 days prior to the assessment. The hospital discharge summary, dated 9/15/10, stated "... chief complaint patient presents with dizziness...cardiology consulted...suspect recent event could be consistent with AF with RVR (A-Fib with rapid ventricular return) 150-200 bpm (beats per minute) range. Low dose betablocker (medication used to treat multiple [DIAGNOSES REDACTED]. Medications adjusted due to labile (easily changed) blood pressures with episodes of hyper and [MEDICAL CONDITION] (high and low blood pressure), No anticoagulation (medication used for multiple purposes including A-Fib) due to high fall risk and past GI bleed..." Test results obtained on 9/20/10 at 7:25 AM were as follows: white blood cells 5.4 (normal 4.0-11.0), red blood cells 4.73 (normal 3.8-5.8), hemoglobin 14.7 (normal 12.6-17.1), hematocrit 43.1 (normal 37.8-52.2), BUN 19 (normal 6-22), creatinine 1.1 (normal 0.8 -1.6), sodium 133 (136-145), carbon [MEDICATION NAME] 25 (normal 20-32). Urine culture and sensitivity test results, dated 10/6/10 at 11:12 AM stated there was greater than 100,00 organisms/milliliter of proteus mirabilis (bacteria) in the urine sample. The physician wrote an order to administer the antibiotic bactrim DS twice a day for 7 days. A nurse's note, dated 10/6/10 at 1:15 PM stated the resident's vital signs were: blood pressure 160/118, temperature 97.5 degrees, respiration 18, pulse 66. The note said the resident was started on an antibiotic for a urinary tract infection. The note said there was blood in the resident's urine and stool. The note said the resident was acting lethargic but was responding. The note said the resident was up in his wheelchair but kept sliding and the certified nursing assistant (CNA) laid him down. A nurse's note dated 10/6/10 at 4:00 PM stated the resident had coffee colored emesis (vomit which may have blood in it) and tarry stools (blood in the stool). The note said the on-call physician ordered the following: obtain a CBC (complete blood count test used to measure various parts of the blood including hemoglobin and hematocrit) in the morning, hold the resident's [MEDICATION NAME] due to a low systolic blood pressure of 106, obtain a GI consult, and give 20 mg of [MEDICATION NAME] (used to treat ulcers) a day. There was no evidence in the clinical record, such as test results or a nurse's note that the CBC was obtained. On 2/18/11 at 12:05 PM the director of nursing (DON) stated she reviewed the clinical record and could not find the CBC results the physician ordered on [DATE]. On 2/18/11 at 2:50 PM, the DON stated the lab service provider was contacted. She said the provider did not have CBC test results for 10/7/10. A nurse's note dated 10/6/10 at 10:00 PM stated the resident's vital signs were: blood pressure 106/78, temperature 98.4 degrees, respiration 20, pulse 82. The note stated the resident was alert and responsive with periods of confusion. The note said here were no observations of blood in the resident's urine or stool. The note said the resident was able to participate with verbal cues. A nurse's note, dated 10/9/10 at 0001 (sic) stated the resident was observed on the floor at 11:45 PM. The note stated the resident's vital signs were: blood pressure 130/76, temperature 97.6 degrees, respiration 18, pulse 80. The note said the resident was in no apparent distress and had no injuries. A nurse's note dated 10/9/10 at 1:30 AM stated the resident was mildly agitated, resistant to redirection and impulsively trying to get out of bed. The note stated the resident was medicated with [MEDICATION NAME] for agitation. A nurse's note dated 10/9/10 at 8:20 AM stated the resident's nurse practitioner was notified of the "above". There were no new orders. A nurse's note dated 10/9/10 at 2:00 PM stated the resident's vital signs were: blood pressure 90/66, temperature 97.9 degrees, respiration 20, pulse 72. The note said the resident was alert and verbally responsive. There was no evidence in the clinical record, such s a nurse's note or a physician's orders [REDACTED]. A physician's telephone order from the NP, dated 10/15/10 (no time recorded) stated obtain a BMP (basic metabolic panel is a blood test used to measure sugar, fluids and electrolytes in the blood), a CBC with differential, a urinalysis, and a culture and sensitivity. There were no nurse's notes pertaining to the reason for the telephone order. There was no evidence in the clinical record, such as test results or a nurse's note that these lab tests were obtained. On 2/18/11 at 7:05 PM the director of nursing (DON) stated the lab service provider was contacted. She said the provider did not have BPM, CBC or urinalysis test results for 10/16/10. A nurse's note dated 10/16/10 at 4:00 AM stated the resident's vital signs were blood pressure 158/78, temperature 98.5 degrees, respiration 20, pulse 88. A nurse's note, dated 10/16/10 at 2:45 PM stated the resident's vital signs were blood pressure 133/52, temperature 97.5 degrees, respiration 62 (sic), pulse 88. The note stated the resident was observed throwing up blood. The note stated there was a new order for 12.5 mg of [MEDICATION NAME] as needed for nausea and vomiting. The note said to monitor the resident and notify the physician if the signs and symptoms got worse. A physician's orders [REDACTED]. A nurse's note, dated 10/16/10 at 7:00 PM and written by Licensed Practical Nurse (LPN) #5, stated the resident was noted with 1 episode of coffee colored emesis. The note stated the resident complained of nausea and 12.5 mg of [MEDICATION NAME] was administered at 6:00 PM with positive results. The resident's vital signs were not recorded in the nurse's note. A nurse's note, dated 10/16/10 at 7:15 PM and written by Licensed Practical Nurse (LPN) #5, stated the resident had a large amount of tarry stool. The note stated the resident said he felt better after incontinence care was provided. The note said the resident ate less than 25% of his dinner tray, and drank liquids without difficulty. The note said "Will continue to monitor for pain and distress". The resident's vital signs were not recorded in the nurse's note. A nurse's note dated 10/16/10 at 8:30 PM and written by Licensed Practical Nurse (LPN) #5, stated the resident was "...noted to be faint/weak but responding verbally/alert. No c/o N/V (no complaint of nausea or vomiting) noted. No S/S (signs/symptoms) distress @ present time. Resident denies pain. VS 97.9-60-18-110/78. Will continue to monitor." A nurse's note, dated 10/16/10 at 9:00 PM and written by Licensed Practical Nurse (LPN) #5, stated the resident was "...resting in bed (with) eyes closed. Alert/responsive to stimuli (with) confusion noted. No c/o pain or discomfort. No S/S of distress noted. (no) episodes of emesis. Resident is total assist. (no) behavior noted. Will continue to monitor." The resident's vital signs were not recorded in the nurse's note. There was no evidence in the clinical record, such as a nurse's note or a physician's orders [REDACTED]. The National Institute of Diabetes and Digestive and Kidney Diseases states the following at the web site http://digestive.niddk.nih.gov/ddiseases/pubs/bleeding/: "...Bleeding in the digestive tract is a symptom of a disease rather than a disease itself. A number of different conditions can cause bleeding. Most causes of bleeding are related to conditions that can be cured or controlled, such as ulcers or hemorrhoids. Some causes of bleeding may be life threatening...The signs of bleeding in the digestive tract depend on the site and severity of bleeding. Signs of bleeding in the upper digestive tract include -bright red blood in vomit -vomit that looks like coffee grounds -black or tarry stool -dark blood mixed with stool -stool mixed or coated with bright red blood Signs of bleeding in the lower digestive tract include -black or tarry stool -dark blood mixed with stool -stool mixed or coated with bright red blood Sudden, severe bleeding is called acute bleeding. If acute bleeding occurs, symptoms may include -weakness -dizziness or faintness -shortness of breath -crampy abdominal pain -diarrhea -paleness A person with acute bleeding may go into shock, experiencing a rapid pulse, a drop in blood pressure, and difficulty producing urine. Light bleeding that continues for a long time or starts and stops is called chronic bleeding. If bleeding is chronic, a person may notice that fatigue, lethargy, and shortness of breath develop over time. Chronic blood loss can also lead to [MEDICAL CONDITION], a condition in which the blood ' s iron-rich substance, hemoglobin, is diminished...A variety of conditions can cause bleeding in the digestive tract. Causes of bleeding in the upper digestive tract include the following: [MEDICAL CONDITION] ulcers. Helicobacter pylori (H. pylori) infections and long-term use of nonsteroidal anti-[MEDICAL CONDITION] drugs (NSAIDs), such as aspirin and [MEDICATION NAME], are common causes of [MEDICAL CONDITION] ulcers...Benign tumors [MEDICAL CONDITION]. A benign tumor is an abnormal tissue growth that is [MEDICAL CONDITION]. Benign tumors [MEDICAL CONDITION] in the esophagus, stomach, or duodenum may cause bleeding...The first step in diagnosing bleeding in the digestive tract is locating the site of the bleeding. The doctor will take the patient ' s complete medical history and perform a physical examination. Symptoms such as changes in bowel habits, black or red stools, and pain or tenderness in the abdomen may tell the doctor which area of the digestive tract is bleeding. The doctor may need to test the stool for blood. Iron supplements, [MEDICATION NAME] (Pepto-Bismol), or certain foods such as beets can give the stool the same appearance as bleeding from the digestive tract. Stool tests can also show bleeding that is not visible to the patient. A blood test can help determine the extent of the bleeding and whether the patient is anemic." A nurse's note, dated 10/16/10 at 9:55 PM and written by the evening supervisor LPN #4 was reviewed. LPN #4 did not write her nurse's note below LPN #5. The note was written on a separate sheet of nurse's notes. The note said "CNA (certified nursing assistant) alerted nursing supervisor that something was wrong (with) the resident. Upon my assessment resident was noted to be semi-conscious. trying to verbally respond to me, but nothing was coming out. Eyes were rolling back, after about 20 seconds resident was fully arousable (with) some weakness, immediately regained his strength was able to squeeze both of my hands very tight when asked if he was in any pain, headache/dizziness he stated 'No, just a little weak'. 1/2 hr (hour) later resident was observed doing the same thing again Resident has hx (history) of [MEDICAL CONDITION] & A Fib (with) a pacemaker. MD phoned new order given from N/P (nurse practitioner)... to send pt to ER...ER phoned & made aware of resident's current episodes of possible [MEDICAL CONDITION]/A-Fib." An undated, untimed nurse's note written by LPN #4 stated the resident's vital signs were: blood pressure 75/40, temperature 97.1 degrees, respirations 18, pulse 58. The blood oxygen saturation was 95% on room air. The note stated the resident's blood sugar was 350 and 5 units of [MEDICATION NAME]were administered. The note said the resident was not short of breath. The note said the resident did not have a productive cough. A physician's orders [REDACTED]. The medical transport document stated the resident was picked up at 10:40 PM (45 minutes after the physician's orders [REDACTED]. The report said the residents blood sugar was 350 at 10:40 PM. The report said at 11:00 PM the resident was awake and disoriented, his skin was warm and dry and his blood pressure was 128/100, his respirations were 16 and his pulse was 111 and irregular. The resident's temperature was not recorded on the report. The report stated "While assessing pt, pt eyes rolled into back of head and he was non responsive to verbal and (illegible word) stimuli...This episode witnessed by us lasted for approx(imately) 1 min(ute) 30 seconds. After episode pt was alert and responding normally for patient and had no complaints...IV attempted x 3..." The ER nurse's note, dated 10/16/10 at 11:20 PM stated "Pt arrived by medical transport, pt unresponsive...Dr...at bedside, accu ck (blood sugar test) 410, pt responding to painful stimuli, bp systolic in 60's, pt placed on the monitor, rectal temperature 92.1. lg (large)clots of blood noted , (sic) IV X 2 established. Blood drawn and sent to lab." The ER physician's note, dated 10/16/10 at 11:39 PM stated "1. GI bleed 2.[MEDICAL CONDITION] (severe infection) 3. Lactic acidosis (very high blood levels of lactic acid, which are indicative of inadequate oxygen supplies, and decreased blood flow to the tissue) 4. [MEDICAL CONDITION] 5. [MEDICAL CONDITION] 6. diabetes mellitus 7. [MEDICAL CONDITION] (high blood sugar). Assessment/Differential Diagnoses: [REDACTED]. Pt critically ill appearing on arrival. Pale, minimally responsive, agonal respirations (also known as gasping), hypothermic (abnormally low body temperature). ABG (arterial blood gas-directly measures the amount of oxygen in the blood) obtained as extremities too cool to obtain accurate pulse ox (a machine that indirectly measures the oxygen saturation of the blood through the fingernail). On exam, dehydrated, pale, cool, large amount of maroon colored clots in depends. abdomen...nontender. On review of records, hx (history of) PUD (stomach ulcer), so given [MEDICATION NAME] severe [MEDICAL CONDITION], type and cross for 2 units of PRBCs (packed red blood cells) transfusion begun due to acute GI bleed/[MEDICAL CONDITION] (low blood pressure). Severe lactic acidosis, hypothermia, given [MEDICATION NAME]/vanc/cipro (antibiotics) for [MEDICAL CONDITION]. Pt mental status improving after resuscitation with 2 liters normal saline, blood...Discussed with ICU resident, will admit...Systems at risk for life threatening failure: Respiratory, Cardiac and Circulatory Associated problems: [MEDICAL CONDITION], Shock, Bleeding, Dehydration, Metabolic changes, Acidosis, Arrythmia (irregular heartbeat) and Infection..." The ER physician's note stated the resident's vital signs were as follows: -10/17/10 at 1:45 AM temp(erature) 94.2 F, heart rate 93, resp(iriations) 20, B/P 75/52. -10/17/10 at 1:00 AM temp 92.9 F, heart rate 93, resp 20, B/P 73/49, SpO2 (blood oxygen saturation) 97% -10/17/10 at 12:045 AM temp 93.1 F, heart rate 101, resp 16, B/P 62/49, SpO2 100% -10/16/10 at 11:14 PM temp 92.1 F, heart rate 58, resp 16, B/P 128/100 The ER lab test results, dated 10/16/10 at 11:40 PM were as follows: white blood cells 18.5 (normal 4.0-11.0), red blood cells 2.2 (normal 3.8-5.8), hemoglobin 6.7 (normal 12.6-17.1), hematocrit 20.8 (normal 37.8-52.2), BUN 84 (normal 6-22), creatinine 2.3 (normal 0.8 -1.6), sodium 133 (136-145), carbon [MEDICATION NAME] 9 (normal 20-32), lactic acid 15.3 (normal 0.5-2.2). Facility staff sent the Resident #28 to the ER via medical transport rather than calling 911 and failed recognize the resident was experiencing symptoms of GI bleeding or the emergency nature of his condition. 2. Facility staff held the resident ' s antihypertensive medication without notifying the physician of the low blood pressures or obtaining an order, and failed to obtain blood pressures before administering the medication. Resident #28 had physician's orders [REDACTED]. Review of the Vital Signs Flow Record revealed the resident's vital signs were obtained 24 times from 9/16/10 (on the 11-7 shift) through 10/5/10 (on the 7-3 shift). The systolic blood pressures (top number of a blood pressure) ranged from 120 to 140, and the diastolic blood pressure (bottom number of a blood pressure) ranged from 70-86. Blood pressures (BP) outside this range included the following: 170/72 on 9/21/10 on the 11-7 shift, 170/62 on 9/22/10 on the 11-7 shift and 104/68 on 9/29/10 on the 11-7 shift. A nurse's note, dated 10/5/10 at 8:00 PM stated the resident was found on the floor. The note stated the resident said he hit his head on the floor. The resident's vital signs were: blood pressure 158/62, temperature 98.9 degrees, respiration 16, pulse 80. The note stated there were no signs or symptoms of discomfort. Urine culture and sensitivity test results, dated 10/6/10 at 11:12 AM stated there was greater than 100,00 organisms/milliliter of proteus mirabilis (bacteria) in the urine sample. The physician wrote an order to administer the antibiotic bactrim DS twice a day for 7 days. A nurse's note, dated 10/6/10 at 1:00 AM stated the resident's vital signs were: blood pressure 118/70, temperature 98.7 degrees, respiration 20, pulse 76. A nurse's note dated 10/6/10 at 4:00 PM stated the resident had coffee colored emesis (vomit which may have blood in it) and tarry stools (blood in the stool). The note stated, in addition to labs tests, a consult and a medication for ulcers, the on-call physician ordered to hold the resident's [MEDICATION NAME] due to a low systolic blood pressure of 106. The Medication Administration Record (MAR) stated the resident's 4:00 PM [MEDICATION NAME] dose was held on 10/6/10 as the physician ordered. Nurse's notes dated 10/7/10 stated the resident was verbally responsive and his vital signs were as follows: -at 4:00 AM blood pressure 112/58, temperature 97.8 degrees, respiration 20, pulse 76. -at 1:50 PM blood pressure 100/60, temperature 97.7 degrees, respiration 20, pulse 64. -at 11:15 PM blood pressure 102/64, temperature 97.7 degrees, respiration 20, pulse 64. The MAR stated the resident's 8:00 AM dose of [MEDICATION NAME] was administered on 10/7/10. The BP prior to the administration of the [MEDICATION NAME] was not recorded on the MAR. The MAR showed the 4:00 PM [MEDICATION NAME] dose was held on 10/7/10 because of a low systolic BP (the top number of the blood pressure). The BP taken at 4:00 PM was not recorded on the MAR. There was no evidence in the clinical record, such s a nurse's note or a physician's orders [REDACTED]. The MAR stated the resident's 8:00 AM dose of [MEDICATION NAME] was administered on 10/8/10. The BP prior to the administration of the [MEDICATION NAME] was not recorded on the MAR. The MAR stated the resident's 4:00 PM dose of [MEDICATION NAME] was not administered on 10/8/10. A nurse's note, dated 10/9/10 at 0001 (sic) stated the resident was observed on the floor at 11:45 PM. The note stated the resident's vital signs were: blood pressure 130/76, temperature 97.6 degrees, respiration 18, pulse 80. The note said the resident was in no apparent distress and had no injuries. A nurse's note dated 10/9/10 at 1:30 AM stated the resident was mildly agitated, resistant to redirection and impulsively trying to get out of bed. The note stated the resident was medicated with [MEDICATION NAME] for agitation. A nurse's note dated 10/9/10 at 8:20 AM stated the resident's nurse practitioner was notified of the "above". There were no new orders. A nurse's note dated 10/9/10 at 2:00 PM stated the resident's vital signs were: blood pressure 90/66, temperature 97.9 degrees, respiration 20, pulse 72. The note said the resident was alert and verbally responsive. There was no evidence in the clinical record, such s a nurse's note or a physician's orders [REDACTED]. A nurse's note dated 10/9/10 at 10:50 PM stated the resident's vital signs were: blood pressure 114/62, temperature 98.1 degrees, respiration 18, pulse 70. The note said the resident was trying to walk. The note said he was putting clothes in a pillowcase and stated "he was going to (illegible word)". The MAR stated the resident's 8:00 AM and 4:00 PM doses of [MEDICATION NAME] were administered on 10/9/10. The BP's obtained prior to administration of the [MEDICATION NAME] were not recorded on the MAR. The following vital signs were recorded in the nurse's notes: 10/10/10 at 8:00 AM: BP 100/62 10/11/10 at 1:00 AM: BP 118/56 10/12/10 at 3:45 AM: BP 128/98 10/12/10 at 1:45 PM: BP 132/72 temperature 97.4 degrees, respiration 18, pulse 84. 10/12/10 at 9:00 PM: BP 112/94 10/13/10 at 1:00 AM: BP 134/62 10/13/10 at 10:00 PM: BP 140/70, temperature 97.9 degrees, respiration 20, pulse 55. 10/14/10 at 4:00 AM: BP 122/68, temperature 97.2 degrees, respiration 20, pulse 78. 10/14/10 at 1:55 PM: BP 98/56, temperature 98.9 degrees, respiration 20, pulse 72. 10/15/10 at 3:00 AM: BP 124/68. 10/15/10 at 10:30 PM: BP 90/58, temperature 98.8 degrees, respiration 20, pulse 70. The MAR stated the resident's 8:00 AM and 4:00 PM doses of [MEDICATION NAME] were administered on 10/10/10, 10/14/10, 10/15/10. The MAR stated the 10/11/10 8:00 AM dose of [MEDICATION NAME] was refused. The MAR said the resident's 4:00 PM dose of [MEDICATION NAME] was administered on 10/11/10. The BP's obtained prior to administration of the [MEDICATION NAME] were not recorded on the MAR. There was no evidence in the clinical record, such s a nurse's note or a physician's orders [REDACTED]. On 2/17/11 at 3:50 PM, the evening supervisor, LPN #4 and CNA #7 were interviewed. LPN #4 said she thought CNA #7 was assigned to the resident on 10/16/10. CNA #7 stated she remembered the resident, but could not remember details about 10/16/10. CNA #7 left the room. LPN #4 said she may have been sitting at the nurse's station when the CNA came to tell her about Resident #28. LPN #4 stated the resident did not "look right". She noted she was shaking him and asking him if he was all right. LPN #4 stated she could not remember where LPN #5 was on 10/16/10. She noted she was not sure when the vital signs recorded in her 10/16/10 were taken. LPN #4 said a BP of 75/40 was "very low". She noted they were probably taken after the 2nd syncopal episode. LPN #4 stated she should have taken the resident's vital signs after the 1st syncopal episode because the BP goes down with [MEDICAL CONDITION]. She said she did not know why she waited for 30 minutes after the 1st syncopal episode to call the physician. She noted the resident was easily arousable after a few seconds so she decided to monitor the resident. LPN #4 stated the physician should have been notified after the coffee colored emesis and the tarry stool were observed. LPN #4 stated coffee colored emesis and tarry stool were symptoms of GI bleeding. LPN #4 could not remember if LPN#5 told her about the coffee colored emesis and the tarry stool. LPN #4 said she would have spoken to and reviewed LPN #5's nurse's notes. LPN #4 stated she did not document a conversation with LPN #5 about the coffee colored emesis and the tarry stool. LPN #4 said she told LPN #5 what she found on assessment and she could not remember what was said. LPN #4 said LPN #5 never told her about the tarry stool. LPN #4 said the 7-3 shift nurse reported the resident threw up 1 time and the resident received [MEDICATION NAME]. LPN #4 said she should have been told the resident had tarry stools. On 2/17/11 at 5:00 PM, LPN #5 was contacted by phone. LPN #5 said she remembered Resident #28 but could not remember the details of 10/16/10. She said she had to review her nurse's notes. She noted she would be in on the 3-11 shift on 2/18/11. She stated tarry or bloody stools were symptoms of GI bleeding. She stated she did not know how GI bleeding would effect a BP. She noted an assessment included checking vital signs, pupil reactions and lungs and the last time the resident voided and had a BM She noted assessments should be documented. On 2/18/11 at 3:25 PM, LPN #5 was interviewed. LPN #5 said during shift change report LPN #6 stated the resident had an episode of emesis and [MEDICATION NAME] was administered. LPN #5 said she was monitoring for N&V, tarry stools, bleeding, food intake and level of cognition. She noted the physician should be notified if the symptoms got worse. She noted she did not know what happened with the BP during GI bleeding. LPN #5 stated she did not take the resident's BP after the episode of coffee colored emesis. LPN #5 said the CNA cleaned the tarry stool at 7:15 PM. LPN #5 stated she did not take the resident's BP after the tarry stool. LPN #5 said if the resident was not all right she would have called the physician. LPN #5 said she takes the residents' BP before administering BP medications. She noted she sometimes documented the BP, but she always documented the BP if it was not within normal limits. On 2/18/11 at 4:30 PM the DON reviewed the vital signs flow sheet and the resident's BP on 10/7/10. She there was a difference in the BP's on the flow sheet and the BP's on 10/7/10. She said she would have called the physician. The DON noted the BP on 10/8/10 at 10:30 AM followed the resident's usual trend. She noted the BP on 10/8/10 at 1:00 AM and 8:15 PM did not correlate with the BP's on the vital signs flow sheet.