Every finding on record at Glenville Health & Rehab

Based on record review and staff interview, the facility failed to ensure residents were transferred according to their assessed plan of care and/or orders. This was true for one (1) of one (1) residents reviewed for accidents during a complaint survey. Resident identifier: #68. Census: 65. This failed practice let to Resident #68 being transferred by only one staff member which resulted in harm. As a result of the inappropriate transfer, Resident #68 experienced an arterial bleed, was sent out to the hospital, and required orthopedic surgical consultation. Resident #68 ranked her pain as a 10 out of 10 at the time of the incident. Findings include:a) Policy A policy titled Safe Lifting of Residents, with no original or revision dates, stated under Number Three (3), Nursing Staff, in conjunction with the rehabilitation staff, shall evaluate individual residents' needs for transfer assistance on an ongoing basis. Number Five (5) read: Staff will document resident transferring and lifting needs in the care plan. A policy titled Accidents and Incidents - Investigating and Reporting, dated 10/01/21, read as follows: Avoidable accident: means that an accident occurred because the facility failed to: Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident. b) Interviews and Record ReviewIn an interview with Unit Manager #25 on 08/26/26 at 8:27 AM, she stated when a new admission comes in the nursing staff uses the transfer status upon discharge for the resident's transfer status and then therapy evaluates and determines the transfer status. In an interview with Director of Rehab #79, at 8:30 AM on 08/26/26, she stated when a new resident is admitted the nursing staff gets the transfer status from the hospital. Once therapy evaluates, therapy sends the resident's transfer status to the nursing staff and the MDS Coordinator to update the care plan. A Nurse-to-Nurse admission Report, with a confirmed date of 05/05/26, listed Resident #68's transfer status as heavy assist x two (2).In an interview with Nurse Aide (NA) #18, on 08/24/26 at 2:32 PM, she stated when she provided care for Resident #68, she always used two (2) people for transfers.A review of the therapy documentation showed a note, dated 05/14/26 with an addendum on 05/20/26, regarding patient and caregiver training that read: continued recommendation for 2 [two] person assist secondary to cognition and knee immobilizer.In an interview with Director of Rehab (DOR) #79, at 2:00 PM on 08/24/26, she stated she had educated the staff regarding using two (2) people for all transfers due to issues with the fitting of the knee immobilizer and resident's cognition. She stated she did not document that education until 05/20/26 because of time constraints. DOR #79 states she does not have record of what staff was in attendance during that education. During a review of the care plan, with a date initiated of 05/07/26, the focus read:-Assistance with ADLS: the resident requires assistance with their Activities of Daily Living related to _____ The goal with date initiated 05/07/26 read:-The resident will improve level of function in activities of daily living to highest practicable level as permitted by health status and underlying conditions through next review period. All of the interventions had a date initiated of 05/19/26.The Kardex, dated 05/18/26, showed partial/moderate assistance with bed mobility and no other transfers listed. The Five (5) Day Minimum Data Set (MDS) ,dated 05/11/26, Section GG showed Resident #68 as dependent with transfers. In an interview with MDS Coordinator #62 at 10:08 AM on 08/26/26, she stated a transfer status for an orthopedic patient should be included on a baseline care plan.In a review of the Incident/Accident Report, dated 05/17/26, a statement by Nurse Aide (NA) #36 read as follows: At approximately 7:30 AM [Resident's Room Number] turned on their call light and asked to go to the bathroom. [Resident's Room Number] prefers to use the restroom and refuses bedpan. I helped her walk to the bathroom with her walker and placed her on the toilet with no issues. She asked if she could have a few minutes of privacy. I left and fed [A Different Resident's Room Number]. [Resident #68's Room Number] turned her bathroom call light on and I came to her, she told me she was done. I helped her off of the toilet with her walker I cleaned her up and put a clean shirt on her. She slowly started walking with me behind her for support to her bed. I asked her if she was doing okay, She stated she was starting to feel dizzy. I placed my left hand on her brief to help steady her but I noticed her starting to loose [lose] balance, I put my arms around her like a hug and slowly placed her to the ground and laid her on her side. Once on the floor she stated that her leg caught underneath her and I noticed blood coming from her brace and told her I needed to go get the nurse.A review of the progress notes dated 05/17/26 at 11:17 AM read as follows: This nurse was called to resident's room by aide who stated that resident had fallen and had busted open surgical sutures. Upon entering room resident was observed by bathroom door directly outside of door on dry tile floor with non slip socks on laying on right side with arms above head and legs toward sink. Resident's walker directly in front of resident. There was a moderate pooling of blood on floor from residents abdomen to feet. Resident was alert and responsive. Resident was dusky in color, lips pale, and skin cool and clammy. Resident stated she was feeling dizzy, this nurse assisted resident onto back and delegated aide to obtain additional nursing staff and crash cart. As Resident was rolled onto back there was a moderate amount of congealed blood under resident. This nurse removed right knee immobilizer and observed active spurting blood with pooling in immobilizer. Noted a gaping wound where steri strips were present starting slightly above right knee and extending approximately 3 [three] inches into femur. Right pedal pulse faint, but present. Resident stated pain 10/10 in RLE [Right Lower Extremity], but no pain elsewhere, also stated decreased sensation. Resident unable to wiggle toes on RLE [right lower extremity]. RLE pale with digits slightly cyanotic (purple in color) with capillary refill >4 [greater than four]. This nurse held pressure to prevent further bleeding. Two nurses came to room. Nurse for hall took over and applied pressure to wound, other nurse called 911. Vitals were assessed. Unit supervisor called doctor. Aide stated that she was with resident during fall and attempted to lower resident safely onto floor when resident stated that she felt light headed. POA [Power of Attorney] notified. EMS [Emergency Medical Service] arrived on scene. Resident is confused and lacks capacity to make medical decisions per facility MD [Medical Doctor]. Encouraged to follow Kardex and care plan for transfers and all ADL [Activities of Daily Living] care. Resident continues to refuse, resident requested to ambulate to bathroom with front wheeled walker with staff assisting. Review of a the facility's Incident/Accident Report, dated 05/18/26, revealed the Director of Nursing (DON) documented, Vital signs were obtained. Resident assessed. EMS called, resident was transported to [Name of Local Hospital] where she was evaluated. Resident was transferred to [Name of a Different Hospital] for orthopedic surgery.In a telephone interview with Nurse Aide #36 at 9:45 AM on 08/26/26, she stated she was by herself during the incident that occurred on 05/17/26. She stated, to be honest, I didn't know she was a two (2) person dependent assist at that time.

Based on policy review, record review, and staff interview, the facility failed to ensure complete and thorough investigations were completed for an injury of unknown origin and resident-to-resident physical abuse incidents. This was true for three (3) of four (4) residents sampled for abuse concerns during the complaint survey process. Resident Identifiers: #67, #65, #60 and #23. Facility Census: 65.a) Policy Review A review of the facility policy titled Abuse, with a revision date of 10/20/22, revealed Part Six (6) Section A read as follows: -The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later that two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility, or his or her designee, and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Furthermore, Part Five (5) Section B stated: -The organization will conduct analysis for trends and patterns related to incidents [i.e., falls, skin tears, bruising or injury of unknown origin, unusual occurrences, reportable incidents, etc.]. b) Resident #67 An orthopedic follow-up note from [Name of Orthopedic Office] signed by [First Name and Last Name of Physician], dated 05/01/26 stated, AP [Anterior Posterior] pelvis and frog lateral radiographs (the frog leg lateral view is a special pelvis radiograph to evaluate the hip) post left hip (surgery) were ordered today in the office and independently reviewed by myself. These images reveal left hip bipolar hemiarthroplasty in good condition and alignment. An eInteract Change in Condition form, dated 05/07/26, stated, Resident is complaining of increased pain in his left hip that has had recent surgical replacement. Resident yells out when being rolled or moved while providing care or being readjusted in bed. Physician notified. In a telephone interview with Medical Director, on 08/25/26 at 2:15 PM, he stated he did not recall this incident but confirmed Resident #67 was not seen by him after 05/07/26 until he returned from the hospital. A progress note, dated 05/09/26 at 10:56 PM, read as follows: Call received from [Name of Local Hospital] with information regarding patient. RN [Registered Nurse] reports upon patient arrival to ER [Emergency Room], left hip was noted to be dislocated with variance of 2 inches. Surgeon recommended a reduction be performed in ER and upon reduction it is reported prosthetic 'broke in half.' Patient is now needing a total hip replacement and will be sent to [Name of Different Hospital] as soon as a bed is available. In an interview with the Administrator and Corporate Registered Nurse #90, on 08/25/26 at approximately 11:00 AM, they confirmed there was no evidence before 05/09/26 ER admission of a dislocated hip. They also confirmed there was no investigation into this injury of unknown origin. c) Review of Facility Reportable Incidents (FRIs) The following FRIs were reviewed during the complaint survey process: On 08/05/26, a resident-to-resident allegation of physical abuse was reported. It was reported Resident #46 smacked Resident #65 after they requested an item from him. On 08/06/26, a resident-to-resident allegation of physical abuse was reported. It was reported Resident #46 extended her leg and made contact with Resident #23. On 02/25/26, a resident-to-resident allegation of physical abuse was reported. It was reported Resident #45 hit Resident #60 and Resident #60 retaliated and hit her back. During review of three (3) Facility Reported Incidents (FRI's) for resident-to-resident physical abuse, dated 08/05/26, 08/06/26 and 02/25/26, nursing assessments for possible affected residents and resident interviews were requested for the incidents. No documentation was given to the state surveyor with the FRI packets/investigations. On 08/24/26 at 4:16 PM, the Administrator acknowledged and confirmed no education or assessments were completed for the incidents on 08/05/26 and 08/06/26 and stated, It does not look like I have education or assessments for the two (2) FRI's. The Administrator reported corporate just put a four (4) point plan into place this date for proper procedures for reporting abuse. On 08/24/26 at 5:00 PM, Social Worker #81 was interviewed concerning abuse investigations. The social worker reported she meets with residents with BIMS (Brief Interview for Mental Status) of eight (8) or higher and asks them a set of questions depending on the incident. The social worker reported nursing completes skin assessments on BIMS seven (7) or less. The social worker then stated the documentation goes in the reportable file. On 08/24/25 at 5:20 PM, the lack of additional resident assessments and resident interviews were reviewed and acknowledged with Administrator, the Corporate Registered Nurse and the Regional Director of Operations. On 08/25/26 at 11:30 AM, the Administrator acknowledged and confirmed the nursing assessments and resident interviews were not found for the FRI dated 02/25/26 for the allegation of resident to resident abuse and stated, I don't have it.

Based on record review and staff interviews, the baseline care plan was not completed to include transfer status for Resident #68 after being discharged from the hospital from a knee surgery. This was true for one (1) of one (1) residents sampled for accidents during the complaint survey process. Resident Identifier: #68. Census: 65.a) Resident #68 A brief record review revealed that Resident #68 was admitted to the facility on [DATE]. During a review Resident #68's baseline care plan, with a date initiated of 05/07/26, the focus read: -Assistance with ADLS (activities of daily living): the resident requires assistance with their Activities of Daily Living related to _____ The goal, with date initiated 05/07/26 read; -The resident will improve level of function in activities of daily living to highest practicable level as permitted by health status and underlying conditions through next review period. There were no interventions with ADL status listed until 05/19/26. In an interview, on 08/26/26 at approximately 10:30 AM, Minimum Data Set (MDS) Coordinator #62 stated she was also responsible for opening care plans. Additionally, MDS Coordinator #62 stated she would expect someone who had an orthopedic surgery on their lower extremity to have transfer status included in the baseline care plan.

Based on record review and staff interview, the facility failed to report a significant injury of unknown origin to the appropriate state agencies. This was true for one (1) of four (4) residents sampled for abuse concerns during the complaint survey. Resident Identifier: #67. Census: 65. a) Policy Review A review of the facility policy titled Abuse, with a revision date of 10/20/22, revealed Part Six (6) Section A read as follows: -The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later that two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility, or his or her designee, and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. b) Resident 67 An orthopedic follow-up note from [Name of Orthopedic Office] signed by [First Name and Last Name of Physician], dated 05/01/26 stated, AP [Anterior Posterior] pelvis and frog lateral radiographs (the frog leg lateral view is a special pelvis radiograph to evaluate the hip) post left hip (surgery) were ordered today in the office and independently reviewed by myself. These images reveal left hip bipolar hemiarthroplasty in good condition and alignment. An eInteract Change in Condition form, dated 05/07/26, stated, Resident is complaining of increased pain in his left hip that has had recent surgical replacement. Resident yells out when being rolled or moved while providing care or being readjusted in bed. Physician notified. A progress note, dated 05/09/26 at 10:56 PM, read as follows: Call received from [Name of Local Hospital] with information regarding patient. RN [Registered Nurse] reports upon patient arrival to ER [Emergency Room], left hip was noted to be dislocated with variance of 2 inches. Surgeon recommended a reduction be performed in ER and upon reduction it is reported prosthetic 'broke in half.' Patient is now needing a total hip replacement and will be sent to [Name of Different Hospital] as soon as a bed is available. In an interview with the Administrator and Corporate Registered Nurse #90, on 08/25/26 at approximately 11:00 AM, they confirmed there was no evidence before 05/09/26 ER admission of a dislocated hip. They also confirmed that after being notified by the hospital on [DATE] the facility failed to to report the injury of unknown origin to the appropriate State Agencies.

Based on record review and staff interviews, the facility failed to implement their abuse policy when a significant injury of unknown origin was identified. This was true for one (1) of four (4) residents sampled for abuse concerns during the complaint survey process. Census: 65.a) Policy Review A review of the facility policy titled Abuse, with a revision date of 10/20/22, revealed Part Six (6) Section A read as follows: -The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later that two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility, or his or her designee, and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. b) Resident 67 An orthopedic follow-up note from [Name of Orthopedic Office] signed by [First Name and Last Name of Physician], dated 05/01/26 stated, AP [Anterior Posterior] pelvis and frog lateral radiographs (the frog leg lateral view is a special pelvis radiograph to evaluate the hip) post left hip (surgery) were ordered today in the office and independently reviewed by myself. These images reveal left hip bipolar hemiarthroplasty in good condition and alignment. An eInteract Change in Condition form, dated 05/07/26, stated, Resident is complaining of increased pain in his left hip that has had recent surgical replacement. Resident yells out when being rolled or moved while providing care or being readjusted in bed. Physician notified. A progress note, dated 05/09/26 at 10:56 PM, read as follows: Call received from [Name of Local Hospital] with information regarding patient. RN [Registered Nurse] reports upon patient arrival to ER [Emergency Room], left hip was noted to be dislocated with variance of 2 inches. Surgeon recommended a reduction be performed in ER and upon reduction it is reported prosthetic 'broke in half.' Patient is now needing a total hip replacement and will be sent to [Name of Different Hospital] as soon as a bed is available. In an interview with the Administrator and Corporate Registered Nurse #90, on 08/25/26 at approximately 11:00 AM, they confirmed there was no evidence before 05/09/26 ER admission of a dislocated hip. They also confirmed that after being notified by the hospital on [DATE] the facility failed to follow their abuse policy and report the injury of unknown origin to the appropriate State Agencies.

Based on record review and staff interview, the facility failed to ensure a care plan was revised and updated following two (2) resident-to-resident Facility Reported Incidents (FRIs) for abuse. This was true for one (1) out of four (4) residents sampled for abuse during the complaint survey process. Resident identifier: #46. Facility Census: 65.Findings included: a) The facility's policy and procedure for Abuse stated, The resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident. The policy and procedure's original date was 10/01/21 and was revised on 10/20/22. b) Resident #46 - The following Facility Reportable Incidents (FRIs) were reviewed during the complaint survey process: On 08/05/26, a resident to resident allegation of physical abuse was reported. It was reported Resident #46 smacked Resident #65 after they requested an item from him. On 08/06/26, a resident to resident allegation of physical abuse was reported. It was reported Resident #46 extended her leg and made contact with Resident #23. Resident #46's care plan was reviewed during a Facility Reported Investigation review of documentation. The resident's care plan had been revised for behaviors on 06/25/26. Two (2) resident to resident abuse incidents occurred on 08/05/26 and 08/06/26. The care plan was not revised or updated following the incidents per stated policy procedure. On 08/25/26 at 11:33 AM, the Minimum Data Set Coordinator - Registered Nurse (MDSC-RN) #62 was interviewed concerning a care plan revision for Resident #46 concerning resident to resident incidents involving Resident #46. The MDSC-RN #62 reported the care plan had not been updated for behaviors following the resident to resident incidents dated 08/05/26 and 08/06/26 and stated that the social worker updates the care plan for behaviors. On 08/25/26 at 11:40 AM, Social Worker #81 reported she updated the care plan for resident to resident behaviors and interventions on 08/24/26 following surveyor intervention.

Based on record review and staff interview, the facility failed to enusre they referred a resident with a newly evident mental disorder to the appropriate state-designated authority for review. This was found to be true for three (3) of eight (8) residents sampled during the long term care survey process. Resident identifiers: #3, #5, #12. Facility census: 63 Findings included: a) Resident #3 Resident #3 was admitted to the facility on [DATE].The resident had the following diagnoses on admission: -PARKINSON'S DISEASE WITHOUT DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS 07/25/25 Principal Diagnosis admission POST-TRAUMATIC STRESS DISORDER, CHRONIC Medical Management 07/25/25 History During the stay at the facility, the resident had a new diagnosis of: -MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, MODERATE 11/5/25 During Stay The MDS dated [DATE], had a primary diagnosis of Parkinson's. Other diagnoses of Post Traumatic Stress Disorder, and depression were indicated on the MDS. The PASARR for the resident is dated 07/23/25, and was completed by an acute care facility. The PASARR has no diagnoses for mental illness or intellectual disabilities. b) Resident #5 This resident was first admitted to the facility on [DATE], with a re-admission date of 07/17/24. Upon admission, the resident had these diagnoses: -ALZHEIMER'S DISEASE, UNSPECIFIED 3/4/2021 Principal Diagnosis admission -UNSPECIFIED CONVULSIONS 03/3/21 admission -MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED 03/03/21 admission During the resident's stay at the facility, additional diagnoses were made, including: -Dementia in other diseases classified elsewhere, unspecified severity, without behavioral, psychotic, mood, or anxiety disturbance 6/21/21 During Stay -ANXIETY DISORDER, UNSPECIFIED 03/10/21 During Stay -DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, MODERATE, WITH MOOD DISTURBANCE 01/30/2026 During Stay -MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED 01/30/2026 During Stay The MDS for the resident was last updated on 03/04/26, and contained all of the above diagnoses. The PASARR was completed on 03/01/21 at an acute care facility. The PASARR did not contain any of those diagnoses. It was marked none for current diagnoses. c) Resident #12 Resident #12 was admitted to the facility on [DATE]. The resident had diagnoses which included: - Bipolar Disorder, Unspecified -Generalized Anxiety Disorder -Depression, Unspecified The most recent MDS was completed on 02/27/26, and had a primary diagnosis of Type II Diabetes. The MDS contained all of the above diagnoses. The current PASARR was completed on 05/07/25 by another long term care facility. The PASARR had diagnoses of bipolar and anxiety disorder, but no diagnosis for depression. The findings of Resident #3, #5, and #12 were reviewed with the Nursing Home Administrator and the Director of Nursing on 04/14/26 at approximately 3:30 PM. The NHA acknowledged the discrepancies.

Based on record review and staff interviews, the facility failed to ensure the menu met the residents' daily nutrition requirements. This had the potential to affect a majority of the residents getting nutrition from the kitchen. Census: 63. Findings included:A policy titled Director of Food and Nutrition Services Responsibilities states that food served will be attractive, palatable and meet the dietary needs of the individuals being served. The lunch menu for 04/13/26 consisted of homemade cream of potato soup, cornbread, jello, choice of milk and beverage of choice. The dietary guidelines provided by the Dietary Manager for 04/13/26 are as follows: Carbohydrates: Required: 16; Total for day: 12 Fruits and Vegetables: Required: 5; Total for day: 2.5 Meats and Proteins: Required: 6;Total for day: 5 In an interview with Dietician #90 on 04/14/26 at approximately 2:30 PM, she confirmed that the menu for 04/13/26 did not match the regional menu that ensures all nutritional requirements are met. An interview with the Regional Dietary Manager and Administrator at approximately 3:00 PM confirmed that the daily nutritional requirements for 04/13/26 were not met.

Based upon record review and staff interviews, the facility failed to revise residents care plan in a timely manner, following significant change in condition. This was found to be true for four (4) of 23 residents reviewed during the long term care survey process. Resident identifiers: #25, #9, #5, #50. Facility census: 63. Findings Include: a) Resident # 25 Resident #25, is [AGE] years old who has capacity to make own medical decisions. The resident was admitted to the facility on [DATE]. A trauma screening was performed on 01/14/26 by the Director of Social Services. To the question, Was care plan updated to reflect the resident's experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization. A response of yes was marked. From the care plan: the resident reported trauma during their trauma screening related to childhood abuse, domestic violence, PTSD, substance abuse and rape. Goal was the residents past traumatic experiences will not cause the distress thru the review period Date Initiated: 01/13/2026 Target Date: 07/14/2026 The interventions were: attempt to determine any triggers that the resident may have related to their pasttrauma and work with staff to avoid those when possibleDate Initiated: 01/13/2026SW refer to psych services as indicatedDate Initiated: 01/13/2026LPNRNSW schedule familiar staff to the resident as possibleDate Initiated: 01/13/2026LPNRNSW trauma screen as indicatedDate Initiated: 01/13/2026 There was nothing in the medical record to suggest the facility attempted to find out triggers for the PTSD. The Director of Social Services offered resident MindCare Services, a psychiatric counseling service, which was accepted by the resident on 01/13/26. The progess notes from the initial Mind Care visit on 01/16/26 stated: Non-Pharmacological Interventions: Dementia: Agitated/ Resistant with Care-- The person may push, grab, or strike out as the caregiver attempts to provide care.-- This may be a way for a patient with difficulty expressing themselves verbally, to tell caregivers they are uncomfortable and/or unwilling to cooperate. Caregivers must listen to the behavior to understand what the problem may be.-- Patient can be anxious because he or she misinterprets the event, or because he or she is cold or hot, or because of modesty concerns, or because the movement of joints causes pain-- Interventions:--- Staff reassurance--- Staff training in how to appropriately approach and calm an anxious patient--- Same-sex attendant--- Slow down, communicate clearly, cue: Slowing down, making eye contact, and explaining step-by-step Instructions on care being provided can be helpful to reduce agitation. Encourage the person to do as much as she/he can by providing cues and limited assistance.--- Adjust routines to fit long-standing habits: Plan care around patterns that are familiar to the person or align with their routine. More flexible bathing methods and schedule (e.g., towel bath)--- Use alternative approaches during bathing: Bathing introduces a number of potential threats that the person with dementia may Resist. Both physical (cold, pain on movement, water in face) and psychological (embarrassed by nudity, frightened by spraying water) discomforts contribute. Adjust the bathroom decor to more inviting, homelike and comfortable. Effective comfort include room and water temperature, soft covers when not being washed, and distractions such pleasant aromas, preferred music, having a snack and singing with the person.Recommendations: Recommendations are provided as a reference for patient-identified behaviors. Please see the EHR/patient chart at thefacility for Patient-specific Care Planning/Documentation. (These are not orders)Non-Pharmacological Interventions: New residentFor the resident who has recently moved-in: welcoming activities and/or orientation activities; Provide support and encouragement during transition to new facility; Encourage socialization and participation in activities;Recommendations: Recommendations are provided as a reference for patient identified behaviors. Please see the EHR/patient chart at the facility for Patient specific Care Planning/Documentation. (These are not orders)Non-Pharmacological Interventions: AnxietyOffer a calm environment, offer own support as well as from family and peers, reassurance during panic attacks, music therapy, pet therapy, massage, art therapy or other relaxing activities, relaxation training, breathing exercises to encourage relaxation, guided imagery, exercise, outdoor walks, and aromatherapy.Non-pharmacological Interventions: DepressionEncourage resident to participate in activities; encourage adequate sleep, nutrition, and exercise; good sleep-hygiene; social interaction; Touch and sensory activities such as massage or aromatherapy; psychotherapy as indicatedNon-Pharmacological Interventions: Dementia: BPSDFor the resident with Behavioral and Psychological Symptoms of Dementia-- Mild to Moderate BPSD: Careful documentation of behaviors and identification of target symptoms, a search for potential triggers or precipitants, recording of the consequences of the behavior,an evaluation to rule out treatable or contributory causes, and consideration of the safety of the patient, their caregiver (including nursing staff), and others in their environment.-- Severe BPSD: The management of BPSD should begin with appropriate assessments, diagnosis, and identification of target symptoms and consideration of safety of the patient, their caregiver/nursing staff and others in their environment. Behavioral management for depression, and education programs for caregivers and staff to teach them how to recognize behavioral problems and to teach them behavior-modification techniques. Music therapy and controlled multi-sensory stimulation. Medications are used when appropriate as a last resort. Examples include but not limited to, those with severe depression, psychosis, or aggression. -- Adjusting caregiver approaches: simplify tasks and communication, use the persons history as a guide, and avoid confronting the person with what they are unable to remember. Breaking tasks and instructions into doable steps, using physical and verbal cues, and accepting misbeliefs as real to the person (using validation vs. reality orientation). Staff training to use multi-component dementia care management approaches.-- Changing the physical and social environment. Reducing the risk of problem behaviors often relies on changing the environment in which persons with dementia live. Simplify the world around the person with dementia.-- Select and individualize non-pharmacological interventions: Selectone or more intervention that fits the problem behavior identified, and then tailor that intervention to the individualized needs of the person. Use the information about the persons cognitive level; physical function; long-standing traits, habits, and interests; preferred routines; and resources to individualize the selected activity.Non-Pharmacological Interventions: Dementia: General Interventions-- Provide opportunities for the resident to engage in structured, meaningful activities throughout theday-- Assure the person exercises which can reduce anxiety, agitation, and restlessness.-- Ensure all basic needs are met including toileting, nutrition, and thirst-- Involve the person in daily activities-- Sensory stimulation or cognitive therapy (e.g., touch/visual/auditory stimulation, reminiscence, or validation therapy) such as special stimulus rooms or equipment; alerting/upbeat music and using alerting aromas or providing fabrics or other materials of varying textures;-- Social engagement (e.g., directed conversation, initiating a resident to resident conversation, pleasure walk or coffee visit);-- Spiritual support, nurturing (e.g., daily devotion, Bible reading, or prayer with or for resident per religious requests/desires);-- Creative, task-oriented activities (e.g., music or pet activities/therapy, letter writing, word puzzles); or Support of self-directed activity (e.g., delivering of library books, craft material to rooms, setting up talking book service).-- Arranging staffing to optimize familiarity with the resident (e.g., consistent caregiver assignment);-- Identifying, to the extent possible, factors that may underlie the residents expressions of distress, as well as applying knowledge of lifelong patterns, preferences, and interests for daily activities to enhance quality of life and individualize routine care.-- Understanding that the resident with dementia may be responding predictably given the situation or surroundings. For example, being awakened at night in his/her bedroom by staff and not recognizing the staff could elicit an aggressive response;-- Matching activities for a resident with dementia to his/her individual cognitive and other abilities and the specific behaviors in that individual based on the assessment. None of these suggestions from Mind Care were included in the resident's care plan. During an interview with the Director of Social Services on 04/16/16 at noon, the surveyor asked about the suggestions provided by MindCare and why were they not implemented in the resident's care plan? The Director of Social Services first statement was it would be up to the Doctor to include that. The Director further stated we did have some of that in the behavior section of the care plan. When surveyor asked what did the facility try to do to identify the resident's triggers for PTSD, the Director of Social Services said let me go get the Administrator. The Surveyor waited ten minutes and Director and Administrator did not come back to provide any answers. Approximately twenty minutes later, the Nursing Home Administrator (NHA) and Social Services Director came to discuss this further. The surveyor asked again, what did the facility do to try to determine triggers and what are things you implemented for trauma informed care? No specific information was provided, but NHA did state she felt the facility could benefit from their corporate office providing some guidance on things they could do to improve trauma informed care. b) Resident #9 Resident #9 was admitted to the facility on [DATE]. This resident does not have capacity to make own medical decisions. The resident is age [AGE]. Upon admission to the facility, the resident weighed 228.6 lbs. On 04/01/2026, the resident weighed 186.4 lbs which is a -18.46% weight loss. His orders pertaining to diet were: -Regular diet, *Regular texture, *Regular/Thin consistencyfortified food at lunch Diet Active 1/27/2026 -Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals)Give 1 tablet by mouth one time a day for wound healingPharmacy Active 01/31/2026 -Vitamin D3 Ultra Potency Oral Tablet 1250 MCG (Cholecalciferol)Give 1 tablet by mouth one time a day every Thu for supplementPharmacy Active 01/29/2026 A Nutritional at Risk Assessment was completed by the facility on 01/30/26. The resident scored 12, which is categorized as normal nutritional status. The Assessment documented resident's BMI as 32.8. The summary stated, Resident receives regular diet, regular textures, thin liquids with excellent meal intakes (majority of meals > 75% consumed). Can eat independently with tray set up, BMI obese for age, gradual loss would be beneficuak if occurs .Will monitor weights, PO intakes, hydration status, labs, and skin integrity. The resident's care plan stated, -Focus: Resident is at risk for malnutrition, related to advanced age, limited mobility, edema, obesity, chronic diseases, sig weight loss. -Goal: Will have gradual weight loss towards BMI WNL (within normal limits) through the review period. Will consume >/= 75% of trays through the review period. The resident will have optimal nutrition and hydration status thru review period. Resident will maintain or improve nutritional status, with no new or worsening signs and symptoms of malnutrition through the review date. -Interventions: Assess for s/s (signs and symptoms) of malnutrition, including PO intake, labs, wts (weights) per facility protocol, skin integrity, and s/s dehydration, Encourage to eat. RD (Registered Dietitician) consult as needed. Record meal % intake. Review dietary preferences with the resident as needed. Therapeutic diet as ordered. Weights as ordered. On 02/24/26, the resident's weight was recorded as 206.8, representing a -9.5% weight loss in one month. A progress note from Dietician #90 on 02/27/26, stated Resident with significant weight loss of -22 lbs (-9.6%) x 1 month since admission. Loss is considered clinically significant and desirable at this time given elevated BMI (29.7, overweight range). Weight change likely multifactorial, including history of wounds with prior Pro-Stat BID use, variable PO intake (50-100%, and overall clinical status Continue to monitor intake, weight trends, wound history, and fluid status closely. MD aware. On 03/10/26, resident's weight was recorded as 191.6, representing a weight loss of -16.18% since admission. A progress note from a different dietician on 03/13/26 stated, Resident with significant weight loss x 1 and 2 months. Loss is considered clinically significant and desirable at this time given elevated BMI. Weight change likely multifactorial, including history of wounds with prior Pro-Stat BID use, variable PO intake (50-100%, and overall clinical status Continue to monitor intake, weight trends, wound history, and fluid status closely. MD aware. A progress note on 04/09/26, stated Resident triggered for unplanned significant weight loss. Rt recently fell and gradual decline in cognition noted last month. Bilateral lower extremity edema noted by RD last month- loss could also be r/t fluid. RD recommended fortified food qd at lunch (4/9/26) .IDT/MD aware. A review of the resident's section of the medical record for significant change in condition assessments, the surveyor found no significant change assessment pertaining to weight loss in the medical record. A discussion was initiated with the Nursing Home Administrator (NHA) on 04/15/2026 at 3:33 PM. Surveyor referred to the care plan, which stated the resident was at risk for malnutrition, yet a goal was set to gradually have weight loss. This seemed contradictory to me, and the NHA agreed. The NHA further stated the resident and his family wanted him to lose weight. They thought it would enable him to be able to walk better. As we walked through the pieces of the resident's medical record, the surveyor said to the NHA, I did not see documented anywhere of the resident wanting to lose weight. If this was true, shouldn't the care plan have stated this? Also asked the NHA, shouldn't the care plan been updated to reflect the significant change in weight? c) Resident #5 This Resident had an unwitnessed fall on 02/18/26. The resident struck head, resulting in a bruise to the forehead. Neurochecks were implemented per the facility's policy. The resident's care plan for falls stated: RISK FOR FALLS: the resident is at riskfor falls related to: cognitive impairment.Has a hx of putting self in floor when upset.Date Initiated: 01/13/2025Revision on: 01/13/2025 Goal: the resident will not have a fallthru the review periodDate Initiated: 08/14/2025Revision on: 12/15/2025Target Date: 06/02/2026 Interventions: Bed locked and in low positionDate Initiated: 01/13/2025Revision on: 06/12/2025 Bedside table/items within reachDate Initiated: 01/13/2025 Encourage resident to go to activities after visiting with daughter to decreaseanxietyDate Initiated: 01/13/2025 non-skid socks while out of bedDate Initiated: 01/13/2025 Place call light within reach while in bed or close proximity to the bed.Date Initiated: 01/13/2025 remind the resident to use their call light to ask for assistance with ADLSDate Initiated: 01/13/2025 Therapy referral for fall on 10/27/2025 and 12/16/25Date Initiated: 10/28/2025 The resident's care plan was not updated with any interventions for falls prevention following fall on 02/18/26. D) Resident #50 An order placed on 02/11/26 reads, Regular diet, puree texture, regular/thin consistency. Resident #50's care plan with a revision date of 02/13/26 reads as follows: - therapeutic diet as ordered: regular; puree/honey thick -Resident is at risk for malnutrition [related to] r/t advanced age, [history] hx of significant weight changes, need for mechanically altered diet texture, need for thickened liquids -[Resident] Res will tolerate mechanically altered diet and thickened liquids without aspiration. An interview with Dietary Manager and Director of Rehab at approximately 12:00PM on 04/15/26 confirm Resident #50 should have thin liquids. An interview with Director of Nursing (DON) at approximately 2:00PM confirms the care plan was not revised when the order was changed to thin liquids.

Based on record review and staff interview, the facility failed to ensure qualified dietary staff carried out the functions of food and nutrition services. This had the potential to affect all of the residents receiving nutrition from the kitchen. Census: 63Findings include: An interview with Dietician #90 on 04/14/26 at 2:30pm confirmed that she works remotely as a consultant and does not come to the facility in person. A review of current credentials revealed the Dietary Manager was not certified as a manager for dietary services. An interview with Regional Dietary Manager and Administrator on 04/14/26 at approximately 3:00PM confirms there is not a Certified Dietary Manager overseeing food and nutrition services at this time and that the Dietician works remotely.

Based on observation, policy and staff interviews, the facility failed to ensure food was prepared and stored under sanitary conditions and that dishes were stored under sanitary conditions. This had the potential to affect a majority of residents receiving nutrition from the kitchen. Census: 63Findings include: a)A policy titled, Food Storage, contains the following: all foods should be covered, labeled and dated and routinely monitored to ensure they will be consumed by their use by dates. A policy titled, Cleaning Instructions: Microwave Oven, reads that the microwave oven interior should be cleaned after each use as needed. In the procedure section states to remove any food particles from the microwave oven interior with a clean, wet cloth and wipe the interior, including the ceiling, with hot sudsy water. A policy titled, General Food Preparation and Handling, states that all food service equipment should be cleaned, sanitized, air-dried and reassembled after each use. During the initial kitchen tour at 11:15 AM on 04/13/26, small ziploc bags of cheese in the walk in refrigerator were not dated or labeled. There was a bag of chopped lettuce with a use by date of 04/10/26 in the walk in refrigerator and two (2) packages of cupcakes in the stand up freezer with a use by date of 03/12/26. These findings were confirmed by the Dietary Manager at 11:20 AM on 04/13/26. During a second kitchen tour on 04/15/26 at 11:00AM, wet nesting (the practice of stacking wet dishes that does not allow for air flow and encourages bacterial growth) was identified in the metal serving dishes. Food particles and a yellow greasy substance were also stuck to the top of the microwave. These findings were confirmed by Regional Dietary Manager confirmed these findings at 11:04 AM.

Based on observation and interviews, the facility failed to ensure the resident environment over which they had control was as free from accident hazards as possible in regards to bed safety and unsecured medication. This was random opportunity for discovery. Resident # 9, #52 and #6 . Facility census: 63. a)Resident #52 During an initial tour of the facility an observation completed on 04/13/26 at 12:16 PM, revealed Resident #6's bed had an approximate 12-inch gap between the mattress and head board. b) Resident #9 During an initial tour of the facility an observation completed on 04/13/26 at 12:30 PM, revealed Resident #9 was lying in bed with an approximate 12-inch gap between the mattress and head board. c) Resident #6 The observation noted Resident #52's bed. The bed had a large gap between the foot board and mattress. During an interview and tour on 04/13/26 at 1:10 PM, the Director of Nursing and Administrator verified the gaps between the mattress and the bed frame. They stated they would fix them immediately. A policy titled, Storage of Medication reads: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration.The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 04/15/2026 at 11:10 AM, the state surveyor observed Aspercreme with lidocaine sitting on top of the treatment cart with no staff nearby. An interview with Healing Partners NP#91 confirmed this was left on the cart without supervision. The Material Safety Data Sheet indicates to keep it out of reach of children. If ingested, induce vomiting and seek immediate medical attention or contact Poison Control Center.

Based on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for four (2) of eight (8) resident reviewed for the category of PASARR, during the long-term care survey. Resident identifiers: #4, and #5, Facility Census: 63. a) Resident #5 This resident was first admitted to the facility on [DATE], with a re-admission date of 07/17/24. Upon admission, the resident had these diagnoses: -ALZHEIMER'S DISEASE, UNSPECIFIED 3/4/2021 Principal Diagnosis admission -UNSPECIFIED CONVULSIONS 03/3/2021 admission -MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED 03/03/2021 admission The PASARR was completed on 03/01/21 in an acute care facility. The PASARR did not contain any of the above diagnoses. It is marked 'none' for current diagnoses. In summary, the PASARR should have been updated when the resident was admitted to the facility. This was reviewed with the Nursing Home Administrator (NHA) and the Director of Nursing on 04/14/26 at approximately 3:30 PM. The NHA acknowledged this discrepancy. b) Resident #4 A review of Resident #4's PASARR revealed that bipolar disorder was not marked as a current diagnosis. Further, 'delusional' is not marked under the clinical and psychological data section. Resident #4 had listed under diagnoses: Bipolar disorder with an onset date of admission and Delusional disorders with an onset of admission. During an interview on 04/14/26 at 11:33 AM it was confirmed with the Administrator that bipolar disorder and delusions were not indicated on the PASARR and should have been.

Based on observation, record review, and staff interview, the facility failed to ensure Resident #6 received Oxygen therapy as ordered by physician. This was true for one (1) of two (2) residents sampled for Oxygen during the Long-Term Care Survey Process. Census: 63 Resident identifier: #6 Findings include: a) Resident #6 On 04/14/2026 at 2:00 PM, state surveyors observed Resident #6 in the therapy gym without oxygen. At 2:41 PM, Resident #6 was still in the therapy gym without oxygen. According to Resident #6's orders and care plan, the resident was to receive five (5) liters/minute at 28% humidification via tracheostomy mask. An interview with the Director of Nursing (DON) and Director of Rehab at 2:41 PM confirmed the resident was without oxygen and had been without oxygen during therapy. An interview with the DON at 4:00 PM confirmed the resident should have oxygen per current documented orders.

Based on Interview, and record review the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regard to monitoring pain levels. This was true for one (1) of five (5) residents reviewed for pain during the long-term survey process. Resident Identifier: #42. Facility census: 63.Findings included: a) Resident #42During an interview on 04/13/26, at 1:18 PM, Resident #42 reported experiencing constant pain. She stated that she was only provided with Tylenol, which she felt was ineffective most of the time. Additionally, she mentioned that she remained awake and wandered throughout the night due to the severity of her discomfort. Medical record review revealed Resident #42's Physician orders for pain management:-Tylenol 8-hour Arthritis Pain Oral Tablet Extended Release 650 MG (Acetaminophen): Give 650 MG by mouth 3 times a day for mild to moderate pain. With supplemental documentation for the pain level. The start date was 07/07/2025. -Monitor for pain every shift. Start date 09/03/2025.A continued review of Medication Administration Record (MAR) revealed:-03/13/26 at 6:00 PM pain level 8 - Acetaminophen 650 Mg tablet given.-03/21/26 at 6:00 PM pain level 7 - Acetaminophen 650 Mg tablet given.-03/22/26 at 6:00 PM pain level 8 - Acetaminophen 650 Mg tablet given.-03/23/26 at 6:00 AM pain level 7 - Acetaminophen 650 Mg tablet given.-03/30/26 at 6:00 PM pain level 7 - Acetaminophen 650 Mg tablet given.-04/02/26 at 12:00 PM pain level 7- Acetaminophen 650 Mg tablet given.-04/03/26 at 6:00 PM pain level 7- Acetaminophen 650 Mg tablet given.-04/04/26 at 6:00 PM pain level 7- Acetaminophen 650 Mg tablet given.-04/05/26 at 6:00 PM pain level 7- Acetaminophen 650 Mg tablet given.-04/06/26 at 6:00 PM pain level 7- Acetaminophen 650 Mg tablet given.-04/08/26 at 6:00 PM pain level 8- Acetaminophen 650 Mg tablet given.-04/09/26 at 6:00 PM pain level 7- Acetaminophen 650 Mg tablet given.-04/10/26 at 6:00 PM pain level 7- Acetaminophen 650 Mg tablet given.-04/11/26 at 6:00 PM pain level 7- Acetaminophen 650 Mg tablet given.-04/12/26 at 6:00 PM pain level 8- Acetaminophen 650 Mg tablet given.-04/13/26 at 6:00 PM pain level 8- Acetaminophen 650 Mg tablet given.-04/14/26 at 6:00 AM pain level 6- Acetaminophen 650 Mg tablet given.-04/03/26 at 6:00 AM pain level 6- Acetaminophen 650 Mg tablet given.Subsequent review found 15 other occurrences of pain levels 5 and below in the last 30 days.A medical record review found no documentation that the physician was notified of increased major pain levels.An interview on 04/16/26 at 11:42 AM with Director of Nursing (DON), confirmed that the physician was not notified of the reported increased pain levels until 04/15/26 after surveyor intervention. She stated that the Physician increased Resident #42's pain medication on 04/15/26.

Based upon record review and staff interview, the facility failed to perform a comprehensive assessment following significant change in a resident with weight loss of over 18% in less than three (3) months. This was found to be true for one (1) of one (1) residents reviewed during the long term care survey process. Resident identifier: #9. Facility census: 63. Findings included: a) Resident #9 Resident #9 was admitted to the facility on [DATE]. This resident does not have capacity to make own medical decisions. The resident is age [AGE]. Upon admission to the facility, the resident weighed 228.6 lbs. On 04/01/2026, the resident weighed 186.4 lbs which is a -18.46% weight loss. Resident #9's orders pertaining to diet were: -Regular diet, *Regular texture, *Regular/Thin consistencyfortified food at lunch Diet Active 1/27/2026 -Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals)Give 1 tablet by mouth one time a day for wound healingPharmacy Active 01/31/2026-Vitamin D3 Ultra Potency Oral Tablet 1250 MCG (Cholecalciferol)Give 1 tablet by mouth one time a day every Thu for supplementPharmacy Active 01/29/2026A Nutritional at Risk Assessment was completed by the facility on 01/30/26. The resident scored 12, which was categorized as normal nutritional status. The Assessment documented resident's BMI as 32.8. The summary stated, Resident receives regular diet, regular textures, thin liquids with excellent meal intakes (majority of meals > 75% consumed). Can eat independently with tray set up, BMI obese for age, gradual loss would be beneficuak if occurs .Will monitor weights, PO intakes, hydration status, labs, and skin integrity. The resident's care plan stated, -Focus: Resident is at risk for malnutrition, related to advanced age, limited mobility, edema, obesity, chronic diseases, sig weight loss. -Goal: Will have gradual weight loss towards BMI WNL (within normal limits) through the review period. Will consume >/= 75% of trays through the review period. The resident will have optimal nutrition and hydration status thru review period. Resident will maintain or improve nutritional status, with no new or worsening signs and symptoms of malnutrition through the review date. -Interventions: Assess for s/s (signs and symptoms) of malnutrition, including PO intake, labs, wts (weights) per facility protocol, skin integrity, and s/s dehydration, Encourage to eat. RD (Registered Dietitician) consult as needed. Record meal % intake. Review dietary preferences with the resident as needed. Therapeutic diet as ordered. Weights as ordered. On 02/24/26, the resident's weight was recorded as 206.8, representing a -9.5% weight loss in one month. A progress note from Dietician #90 on 02/27/26, stated Resident with significant weight loss of -22 lbs (-9.6%) x 1 month since admission. Loss is considered clinically significant and desirable at this time given elevated BMI (29.7, overweight range). Weight change likely multifactorial, including history of wounds with prior Pro-Stat BID use, variable PO intake (50-100%, and overall clinical status Continue to monitor intake, weight trends, wound history, and fluid status closely. MD aware. On 03/10/26, resident's weight was recorded as 191.6, representing a weight loss of -16.18% since admission. A progress note from a different dietician on 03/13/26 stated, Resident with significant weight loss x 1 and 2 months. Loss is considered clinically significant and desirable at this time given elevated BMI. Weight change likely multifactorial, including history of wounds with prior Pro-Stat BID use, variable PO intake (50-100%, and overall clinical status Continue to monitor intake, weight trends, wound history, and fluid status closely. MD aware. A progress note on 04/09/26, stated Resident triggered for unplanned significant weight loss. Rt recently fell and gradual decline in cognition noted last month. Bilateral lower extremity edema noted by RD last month- loss could also be r/t fluid. RD recommended fortified food qd at lunch (4/9/26) .IDT/MD aware. A review of the resident's section of the medical record for significant change in condition assessments, the surveyor found no significant change assessment pertaining to weight loss in the medical record. A discussion was initiated with the Nursing Home Administrator (NHA) on 04/15/2026 at 3:33 PM. Surveyor referred to the care plan, which stated the resident was at risk for malnutrition, yet a goal was set to gradually have weight loss. This seemed contradictory to me, and the NHA agreed. The NHA further stated the resident and his family wanted him to lose weight. They thought it would enable him to be able to walk better. As we walked through the pieces of the resident's medical record, the surveyor said to the NHA, I did not see documented anywhere of the resident wanting to lose weight. If this was true, shouldn't the care plan have stated this? Further, advised NHA a weight loss of this significance should have triggered a change in condition assessment, but none were found.

Based on record review and staff interview, the facility failed to thoroughly investigate a complaint of neglect for Resident #36. Resident identifier: #36. Facility Census: 63.Findings include: a) Resident #36 A policy titled Grievances/Complaints reads, The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law. The grievance policy also states, The Grievance Officer, Administrator and Staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated.The Federal regulation 483.12(c)(1)-(4) require facilities to report allegations of abuse, neglect, exploitation or mistreatment, including injuries ofunknown origin/source and misappropriation of resident property, are reported immediately.The grievance report for Resident #36 stated, Resident reported on 01/11/26 that he had peed in the bed about 9:00 PM and did not get cleaned up until 3:00 AM, and that he had the call light on and reported staff turned off the light and left. The summary of the investigation reads as follows: At this time, there is no conclusive evidence into the investigation to determine an appropriate outcome. The investigation consisted of statements from three (3) nurse aides typed and signed by the Director of Nursing dated 01/12/26 and a skin assessment dated [DATE]. The grievance report states the incident was reported on 01/16/26.In an interview with Administrator and Director of Nursing at approximately 12:00PM on 04/16/26, it was confirmed that this was an allegation of neglect and it was not reported to the appropriate state agencies as per their grievance policy. It was also confirmed that there are no handwritten statements signed by the nurse aides providing care that day.

Based on record review and staff interviews, the facility failed to identify a grievance as neglect and report that to the appropriate state agencies. This failed practice has the potential to affect more than a minimal number of residents. Census: 63Findings include: A policy titled Grievances/Complaints reads, The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law. The grievance report for Resident #36 stated, Resident reported on 01/11/26 he had peed in the bed about 9:00 PM and did not get cleaned up until 3:00 AM and had call light on and reported staff turned off the light and left. In an interview with Administrator and Director of Nursing at approximately 12:00PM on 04/16/26, it was confirmed that this was an allegation of neglect and it was not reported to the appropriate state agencies as per their grievance policy.

Based on record review and staff interview, the facility failed to follow their grievance policy as related to an investigation of neglect for Resident #36. This failed practice has the potential to affect more than a limited number of residents. Resident identifier: #36. Census: 63.Findings include: a) Resident #36 A policy titled Grievances/Complaints reads, The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law. The grievance report for Resident #36 stated, Resident reported on 01/11/26 he had peed in the bed about 9:00bPM and did not get cleaned up until 3:00 AM and had call light on and reported staff turned off the light and left. In an interview with Administrator and Director of Nursing at approximately 12:00PM on 04/16/26, it was confirmed that this was an allegation of neglect and it was not reported to the appropriate state agencies as per their grievance policy.

Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) was accurate regarding toileting schedule for Resident #48. This was true for one (1) of seven (7) residents sampled for accidents during the Long-Term Care Survey Process. Resident identifier: #48. Facility census: 63. Findings include: a) Resident #48 Resident #48's care plan reads, Toileting schedule: toilet resident upon rising, before and after meals and at bedtime. The significant change Minimum Data Set (MDS) dated [DATE] marked 'no' for both the urinary toileting program and the bowel toileting program. An interview with MDS coordinator #61 and the Director of Nursing (DON) at 11:45 AM on 04/15/26 confirmed that the care plan stated Resident #48 had a toileting schedule, but the MDS was marked as having no schedule.

Based on observation, record review and staff interviews, the facility failed to provide treatment or services to prevent and heal pressure ulcers for one (1) of three (3) residents reviewed for pressure ulcers. The resident suffered actual physical harm when further avoidable facility acquired pressure ulcers developed. Resident identifier: #61 Facility Census: 63. Findings included: a) Resident #61 Resident #61 was admitted on [DATE] with the following identified skin issues noted on the Nursing Admission Evaluation dated 07/03/24: Resident #61 had a deep tissue injury measuring 5 centimeters (cm) X 4.5 cm to the left heel. Resident #61 had a pressure ulcer measuring 1 cm X 1.5 cm to the right side of the coccyx. A wound was also noted on the left-hand middle finger. On 08/24/24 a note identified a left heel pressure ulcer/injury or suspected deep tissue injury. This was identified as a new facility acquired unstageable. No size was documented. No description was identified. This area appeared to be the same that was present upon admission but no prior documentation could be found before 08/24/24. On 09/05/24 according to the weekly skin observation sheets a new open area was identified to the right buttock. This was identified as a new skin condition. This wound was not evaluated on any further weekly skin observation sheets or weekly wound evaluation sheets. On 09/11/24 a new facility acquired right heel pressure ulcer/injury or suspected deep tissue injury unstageable with necrotic tissue was identified. No size was documented, the interventions in place were heel protectors. On 09/20/24 the right heel evaluation now was described as necrotic with serosanguinous (thick, watery, pale, red/pink drainage) with no size documented. The interventions in place were to offload heels. 09/28/24 the left heel evaluation showed an unstageable with size documented as 4 cm X 4 cm with slough (yellow, tan, white, stringy) with 60% slough/necrosis and serosanguineous drainage, moderate exudate with moderate dressing saturation. Interventions in place were to off load heels and encourage hydration and mobility. On 10/05/24 the right heel evaluation documented an unstageable 4 cm X 4 cm with slough to the wound bed. 60% slough/necrosis. Wound exudate: serosanguineous with a moderate amount of exudate. Dressing saturation is moderate with 26-75%. interventions in place were off load heels and encourage hydration and nutritional status evaluation. Oon 10/11/24 at 4:15 PM there was a consultation for the wound clinic for bilateral heels for one day. The order was discontinued on 10/12/24. 10/13/24 right heel unstageable 4.5 cm X 6 cm. Wound bed necrotic with 100% slough/necrosis with wound exudate purulent (think, milky, green/yellow/white/brown). Moderate exudate amount of 26-75%. Interventions in place: pressure reducing/relieving mattress, encourage hydration and mobility, nutritional status evaluation, turning and positioning routine On 10/20/24 the right heel Stage III measured 3.5 cm X 2.5 cm X 0.2 cm. The wound bed had granulation with wound exudate serosanguinous with a moderate amount of exudate, dressing saturation moderate 26-75%. Interventions in place were to off-load heels. According to the last wound evaluation dated 10/20/24 the resident had a pressure ulcer/injury or suspected DTI to his right heel which was identified as facility acquired and a Stage III full thickness tissue loss. On 10/21/24 at 12:55 PM observation found Resident #62 in bed. He was observed as tall and thin. His head was to the top of the bed frame and his knees were bent with his heels pressed into the mattress. His knees were bent against the footboard. The bed was too short. When asked, he stated he was 6' 3. On 10/22/24 at 10:10 AM during record review it was noted that Resident #61 had a physician's order dated 07/09/24 for protective heel boots to be worn every day to prevent skin breakdown. On 10/22/24 at 10:10 AM record review shows Resident #61 did not have an order or care plan for an extended length bed. On 10/22/24 at 10:30 AM during an interview with the Administrator she stated she thought he had an extension on his bed. She said she would check and get it placed on the bed or get him a longer bed. On 10/23/24 at 11:00 AM during an interview with Licensed Practical Nurse (LPN) #18 with the resident present the LPN was asked if she felt the resident needed a longer bed, she agreed he probably did. She said she would check why he was not on an extended bed. The resident stated, This is the only bed I have ever had. On 10/22/24 at 1:15 PM the record review shows the following orders: Order Summary: Cleanse right heel with wound cleanser, pat dry, apply Santyl to wound bed, cover with Opti-foam heels then wrap with kling every day shift for wound Order Summary: Clean the left heel with wound cleanser, pat dry, apply Hydrogel, cover with Opti-foam heel protector, wrap with kerlix. every day shift for wound to left heel On 10/23/24 at 11:00 AM during an interview with Licensed Practical Nurse (LPN) #18 with the resident present the LPN was asked if she felt the resident needed a longer bed, she agreed he probably did. She said she would check why he was not on an extended bed. The resident stated, this is the only bed I have ever had. On 10/23/24 at 11:03 AM observation of wound care with Licensed Practical Nurse (LPN) #18 found that wound care on 10/22/24 was not performed as according to the physician's orders. On 10/23/24 at 11:03 AM when LPN #18 removed the previous day's dressing it did not have the Opti-foam feel protector in place on either heel. This was confirmed immediately with LPN #18 who agreed the treatment on 10/22/24 was not performed according to the physicians order. On 10/24/24 at 2:00 PM the resident had an appointment with the Wound Clinic in (name of city). Observation on the following dates and times found the resident to be in bed with his knees bent, heels pressed into the mattress: 10/21/24 at 12:55 PM 10/21/24 at 2:10 PM 10/22/24 at 8:05 AM 10/22/24 at 2:30 PM 10/23/24 at 11:00 AM 10/23/24 at 4:00 PM 10/24/24 at 8:15 AM 10/24/24 at 1:15 PM The following observations found Resident #61 out of bed and not having heel boots on. He had pressure ulcers to bilateral heels. 10/22/24 at 10:10 AM No heel boots on 10/22/24 at 2:05 PM No heel boots on 10/22/24 at 3:20 PM No heel boots on 10/23/24 at 8:30 AM No heel boots on 10/23/24 at 10:22 AM No heel boots on 10/23/24 at 3:15 PM No heel boots on 10/24/24 at 9:05 AM No heel boots on 10/24/24 at 1:15 PM No heel boots on 10/24/24 at 4:35 PM No heel boots on The care plan was reviewed and found an intervention under skin integrity which stated, Heel protectors to be worn when out of bed and as needed (prn). These issues were confirmed with the Administrator on 10/24/24 at 4:45 PM. No futher information was provided.

Based on record review and interview, the facility failed to provide an environment free from accident hazards over which it had control. This failed practice caused actual physical harm to Resident #2. The Resident was left standing without the required assistance (in violation of her Care Plan) and sustained a fall that resulted in a fractured Femur. This failed practice caused actual physical harm to Resident #2 when she was transferred without the required assistance of two (2) staff members (in violation of her Care Plan) and sustained a fall that resulted in a fractured Femur. This practice affected one (1) of six (6) residents reviewed for falls. Resident identifier: #2. Facility census: 63. Findings included: a) Resident #2 A review of the Resident's Care Plan, on 01/07/20 at 8:30 AM, revealed the following: Focus area: -The resident is at high risk for falls due to impaired mobility, history of falls, and history of falls with fracture. Goal: -Resident will have no falls with injury. This focus area and goal had a review date of 10/04/19. In addition, The Resident's Care Plan also included: Focus -Resident requires activities of daily living care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, and toileting related to limited mobility Intervention -Provide the resident with total assist of two (2) for transfers. A review of the Resident's Quarterly Minimum Data Set (MDS) Resident Assessment and Care Screening, on 01/07/20 at 9:15 AM, revealed the MDS Assessment was completed on 09/17/19. The functional status in Section G concerning transfers assessed the Resident as--total dependence--with two plus person assistance when moving from a seated to standing position. The Resident was assessed as not being steady and only able to stabilize with staff assistance. The Resident had a Brief Interview for Mental Status (BIMS) score of 14 which means the Resident had little to no cognitive impairment at the time of the assessment. A review of the Resident's Kardex Report, on 01/07/20 at 9:20 AM, revealed the Resident was marked as needing two (2) plus person assist for all transfers. The Kardex was dated 09/17/19. A Kardex is a medical information system used by nurses and nurse aides as a way to communicate important information on their patients. It is a quick summary of individual patient needs. A review of the Resident's Nurses Notes, on 01/07/20 at 9:25 AM, revealed the Resident had a fall on 10/28/19 and was transferred to the acute care hospital for evaluation and treatment. Further review of the medical record, on 01/7/20 at 9:30 AM, revealed an X-Ray Report that was taken at the acute care hospital. The report stated the Resident had a--distal femoral shaft fracture. The X-Ray Report was dated 10/28/19. A review of the Resident's Fall Investigation Report, on 01/07/20 at 9:45 AM, revealed Nurse Aide (NA) #47 was with the Resident at the time of the fall on 10/28/19. The NA stated she showered the Resident then went outside to find someone to help. The NA did not see anyone to help her. The NA asked the Resident if she could stand. The Resident stated she could. The NA then stood the Resident and the Resident started falling. The NA put her knee on the Resident's behind so she could lower her to the floor. The NA heard a pop as she lowered the Resident to the floor. The Resident was then put on the floor. The NA stated she could tell the Resident was in pain so she went and got a nurse. Further review of the Fall Investigation Report, on 01/07/20 at 9:50 AM, revealed the Resident was interviewed on 11/01/19. The Resident stated she was in the shower room and stood up when her legs got weak and gave out. The Resident stated, it popped. The Resident stated NA #47 lowered her to the floor. The Resident could not recall if the NA asked her if she could stand. A review of the facility's final investigation findings, on 01/07/20 at 10:00 AM, revealed the findings of the fall with fracture with Resident #2 was substantiated. The actions of having the Resident stand without the proper assistance by NA #47 contributed to the fracture that occurred as the result of the fall. The Resident was a two (2) person assist for all transfers at the time of the fall. NA#47 was given a write-up as a result of the incident. An interview with the facility's Administrator, on 01/07/20 at 10:05 AM, revealed NA #47 should have never transferred the Resident without the help of another staff member. The Administrator stated the Resident's transfer requirements were clearly addressed on the Care Plan and Kardex. The Administrator stated the NA was written up and given a final warning over this incident. The Administrator verified the NA was last trained on Accident/Prevention and Safety on 08/09/19. This failed practice caused actual physical harm to Resident #2 when she was transferred without the required assistance of two (2) staff members (in violation of her Care Plan) and sustained a fall that resulted in a fractured Femur.

Based on record review and interview, the facility failed to ensure a resident was free from neglect. This failed practice caused actual physical harm to Resident #2. The Resident was left standing without the required assistance (in violation of her Care Plan) and sustained a fall that resulted in a fractured Femur. This failed practice caused actual physical harm to Resident #2 when she was transferred without the required assistance a two (2) staff members (in violation of her Care Plan) and sustained a fall that resulted in a fractured Femur (thigh bone). This practice affected one (1) of six (6) residents reviewed for falls. Resident identifier: #2. Facility census: 63. Findings included: a) Resident #2 A review of the Resident's Care Plan, on 01/07/20 at 8:30 AM, revealed the following: Focus area: -The resident is at high risk for falls due to impaired mobility, history of falls, and history of falls with fracture. Goal: -Resident will have no falls with injury. This focus area and goal had a review date of 10/04/19. In addition, The Resident's Care Plan also included: Focus -Resident requires activities of daily living care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, and toileting related to limited mobility Intervention -Provide the resident with total assist of two (2) for transfers. A review of the Resident's Quarterly Minimum Data Set (MDS) Resident Assessment and Care Screening, on 01/07/20 at 9:15 AM, revealed the MDS Assessment was completed on 09/17/19. The functional status in Section G concerning transfers assessed the Resident as--total dependence--with two plus person assistance when moving from a seated to standing position. The Resident was assessed as not being steady and only able to stabilize with staff assistance. The Resident had a Brief Interview for Mental Status (BIMS) score of 14 which means the Resident had little to no cognitive impairment at the time of the assessment. A review of the Resident's Kardex Report, on 01/07/20 at 9:20 AM, revealed the Resident was marked as needing two plus person assist for all transfers. The Kardex was dated 09/17/19. A Kardex is a medical information system used by nurses and nurse aides as a way to communicate important information on their patients. It is a quick summary of individual patient needs. A review of the Resident's Nurses Notes, on 01/07/20 at 9:25 AM, revealed the Resident had a fall on 10/28/19 and was transferred to the acute care hospital for evaluation and treatment. Further review of the medical record, on 01/7/20 at 9:30 AM, revealed an X-Ray Report that was taken at the acute care hospital. The report stated the Resident had a distal femoral shaft fracture. The X-Ray Report was dated 10/28/19. A review of the Resident's Fall Investigation Report, on 01/07/20 at 9:45 AM, revealed Nurse Aide (NA) #47 was with the Resident at the time of the fall on 10/28/19. NA #47 stated that she showered the Resident then went outside to find someone to help. NA #47 did not see anyone to help her. Then NA #47 asked the Resident if she could stand. The Resident stated that she could. NA #47 then stood the Resident and the Resident started falling. The NA #47 then put her knee on the Resident's behind so she could lower her to the floor. The NA stated that heard a pop as she lowered the Resident to the floor. The Resident was then put on the floor. NA #47 stated that she could tell the Resident was in pain so she went and got a nurse. Further review of the Fall Investigation Report, on 01/07/20 at 9:50 AM, revealed the Resident was interviewed on 11/01/19. The Resident stated that she was in the shower room and stood up when her legs got weak and gave out. The Resident stated, it popped. The Resident stated NA #47 lowered her to the floor. The Resident could not recall if the NA #47 asked her if she could stand. A review of the facility's final investigation findings, on 01/07/20 at 10:00 AM, revealed the findings of the fall with fracture with Resident #2 was substantiated. The actions of having the Resident stand without the proper assistance by NA #47 contributed to the fracture that occurred as the result of the fall. The Resident was a two (2) person assist for all transfers at the time of the fall. NA #47 was given a write-up as a result of the incident. An interview with the facility's Administrator, on 01/07/20 at 10:05 AM, revealed NA #47 should have never transferred the Resident without the help of another staff member. The Administrator stated that the Resident's transfer requirements were clearly addressed on the Care Plan and Kardex. The Administrator stated the NA #47 was written up and given a final warning over this incident. The Administrator verified the NA #47 was last trained on Accident/Prevention and Safety on 08/09/19. A review of the facility policy titled OPS300 Abuse Prohibition, on 01/07/20 at 10:15 AM, revealed the policy stated Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy had a revision date of 07/01/19. This failed practice caused actual physical harm to Resident #2 when she was transferred without the required assistance a two (2) staff members (in violation of her Care Plan) and sustained a fall that resulted in a fractured Femur (thigh bone). .