Every finding on record at Goldwater Care Toluca

Based on interview and record review, the facility failed to provide supervision for a resident at risk for falls for one of three residents (R3) reviewed for falls in a sample of six. This failure resulted in R3 falling and sustaining a left intertrochanteric proximal femur fracture requiring surgical intervention. This past noncompliance occurred from 4/18/26 through 4/24/26. Findings include: The facility's Fall Prevention Program, revised 11/21/17, documents to assure the safety of all residents in the facility when possible. The program will include measures that determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices, and utilized as necessary Quality Assurance Program will monitor the program to assure ongoing effectiveness. This form documents that Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet. R3's Fall Risk Assessment, dated 2/6/26, documents R3 is at risk of falls with a score of 13. R3's Progress Notes, dated 4/18/26, documents R3 had an unwitnessed fall in her room. This form documents that R3 was left on the commode unattended. R3 showed a change in range of motion from normal baseline, with pain when moving the left leg. R3's Progress Notes document R3 was transferred to the emergency room for an evaluation, then admitted to the hospital. R3's care plan documents R3 has ADL (activities of daily living) self-care performance deficit with varying levels of assistance needed related to Alzheimer's, Dementia, history of femur fracture, right olecranon fracture, right shoulder fracture, and multiple compression fractures. This form documents R3 is dependent on staff for toileting needs and requires a mechanical lift with 2 staff for assistance with transfers. R3's hospital note, dated 4/19/26, documents R3 initially presented to the emergency room with a displaced intertrochanteric trans trochanteric hip fracture after a mechanical fall from standing height. This form documents a closed reduction was performed of the patient's (R3's) operative hip under fluoroscopic imaging. On 8/17/26 at 1:25pm, V6, Certified Nursing Assistant, stated she assisted R3 to the commode in her room. V6 stated the dining room staff came to get her because someone was having behaviors in the dining room. V6 stated she left R3 on the commode unattended. V6 stated she was heading back to R3's room when she heard a thud. V6 stated R3 was on the floor when she entered her room. V6 stated R3 should not have been left alone on the commode because she was a fall risk. On 8/17/26 at 1:35pm, V8, Certified Nursing Assistant, stated she heard a yell and went into R3's room and found her on the floor. V8 stated she went to get the mechanical lift and sling to get R3 off the floor, but V9, Licensed Practical Nurse, and V10, Registered Nurse, stated she is small enough that they can lift R3 up to her wheelchair. V8 stated she did not see the nurses assess R3; they just lifted her to her chair. V8 stated R3 was yelling in pain when they put her into the wheelchair. V8 stated R3 should have been assessed, then lifted with the mechanical lift and put into her bed. V8 stated R3 should not have been left on the commode by herself. V8 stated her and V7, Certified Nursing Assistant, were asked to lay R3 down in her bed, but she did not have a mechanical lift sling under her, so we had to grab her by her arms and pants and bodily lift her to bed. On 8/17/26 at 1:45pm, V4, Registered Nurse, stated residents who are fall risks are not to be left unattended on the toilet or commode. On 8/18/26 at 12:00pm, V1, Administrator, stated two licensed staff were terminated due to this incident. Prior to the survey date of 8/18/26, the facility had taken the following actions to correct the noncompliance. 1.A facility-wide audit of all residents' fall care plans was conducted to ensure interventions are added to the resident care plan and interventions are linked to the residents' Kardex. Completed on 4/23/26. 2. All licensed and non-licensed nursing staff were educated on how to access fall interventions that were put into place by accessing the resident Kardex, by the Director of Nursing and Administrator on 4/23/2026. Staff members who are on FMLA or vacation and all agency staff will be in-service prior to returning to the facility by the Director of Nursing/Designee or Administrator. Completed on 4/23/26. 3. V1, Administrator, and V2, Director of Nursing, were educated on the facility's; Fall Prevention Program policing. policing including but not limited to the Director of Nursing or Designee is responsible for monitoring the Fall Prevention Program, including further staff education programs, purchase of additional equipment, or other appropriate environmental alterations. In addition, the Director of Nursing is responsible for informing the Administrator of program analysis that safety interventions will be implemented for each resident identified at risk; and accident/incident reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. Communication with the direct care staff. Direct care staff will be oriented and trained in the Fall Prevention Program. Periodic quality assurance audit activities of records relating to falls that exhibit adherence to facility policies and implementation of the plan of care by the Regional Nurse Consultant on 4/23/2026. Completed on 4/23/26. 4. All licensed and certified nursing staff were educated on the facility's Fall Prevention Program Policy, Policy including but not limited to methods to identify risk factors, methods to identify residents at risk, notification of physician, family/legal representative, documentation requirements, safety interventions will be implemented for each resident identified at risk, accident/incident reports involving falls will be reviewed by the IDT to ensure appropriate care and services were provided and determine possible safety interventions, communication with the direct care staff. The admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained by the Director of Nursing and Administrator on 4/23/2026. Staff members who are on FMLA or vacation and all agency staff will be in-service prior to returning to the facility by the Director of Nursing/Designee or Administrator. Started on 4/23/26 and ongoing. 5. All licensed and certified staff were educated on the facility's Incident/Accident Policy. Policy including but not limited to all accidents or incidents where there is injury or the potential to result in injury, the Director of Nursing or Assistant Director of Nursing must notify IDPH if an actual injury occurs, documentation in the nurses' notes is to include a description of the occurrence, the extent of injury (if any), the assessment of the resident, vital signs, treatment rendered, and parties notified; a minimum of seventy-two (72) hours of documentation by all three shifts on resident status after the incident. Vitals signs, mental and physical stated, follow-up, test, procedures, and findings are to be determined. All incident/accident reports are reviewed, signed, and investigated by the Director of Nursing, Assistant Director of Nursing or the Administrator by the Director of Nursing and Administrator on 4/23/2026. Staff members who are on FMLA or vacation and all agency staff will be in-service prior to returning to the facility by the Director of Nursing/Designee or Administrator. Started on 4/23/26 and ongoing. 6. All licensed and certified nursing staff were educated on the facility's Pain Management Policy Policy including but not limited to resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in pain. Resident who is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes, and changes in behavior and mood will be used to determine the present of pain. Documentation of pain assessment and monitoring, pain medication shall be appropriate for the population served, when pain assessment protocol will be initiated, nursing and other staff members assignments include information regarding the resident's plan to control pain, documentation of assessments and the resident's response to the pain management plan will be made with each assessment, the resident's physician will be notified of the resident's complaints of pain which are not relieved by comfort measures, including pain medications, pain control will be assessed during routine medication passes by the Director of Nursing and Administrator on 4/23/2026. Staff members who are on FMLA or vacation and all agency staff will be in-service prior to returning to the facility by the Director of Nursing/Designee or Administrator. Started on 4/23/26 and ongoing. 7. All licensed and non-licensed staff were educated on the facility's pain assessment policy including but not limited to the pain assessment tool will be used as indicated as a guide in determining a resident's pain level in addition to their descriptive words, and/or physical signs and behaviors. A pain assessment will be performed as part of the admission assessment and other events during the resident's stay may initiate additional pain assessments. Medications will be administered at the specific request of the patient and when the patient refuses other such interventions for PRN pain medications. Pain control effectiveness will be measured after pain medication is administered and during each medication pass. Documentation of each pain assessment will be recorded on the pain assessment tool, in the nurses' notes or on the MAR. Resident's physician will be notified when assessment reveals inadequate pain control despite implementation of an appropriate plan of care. Resident, family and legal representative will be part of the management program and the programs' effectiveness, medication changes when the resident permits or condition warrants by the Director of Nursing and Administrator on 4/23/2026. Staff members who are on FMLA or vacation and all agency staff will be in-service prior to returning to the facility by the Director of Nursing/Designee or Administrator.Started on 4/23/26 and ongoing. 8. All licensed and non-licensed staff were educated on the facility's physician-family notification - Change in Condition policy including but not limited to accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status; or a decision to transfer or discharge the resident from the facility by the Director of Nursing and Administrator on 4/23/2026. Staff members who are on FMLA or vacation and all agency staff will be in-service prior to returning to the facility by the Director of Nursing/Designee or Administrator. Started on 4/23/26 and ongoing. 9. All licensed and certified nursing staff were educated on the facility's Resident Rounds Guidelines guidelines including but not limited to residents will be observed/interviewed for at least the following: signs and symptoms of clinical problems and/or change in condition or behavior, proper use of medical equipment/supplies, use of pressure relieving devices, turning/repositioning, incontinence management, pain and comfort levels and response to medical plan of care, medications and treatment administrations, and appearance and grooming. Additional rounds are made by the CNA assigned direct care. Residents are also observed during medication and treatment administration, mealtimes, and organized activities by the Director of Nursing and Administrator on 4/23/2026. Staff members who are on FMLA or vacation and all agency staff will be in-service prior to returning to the facility by the Director of Nursing/Designee or Administrator. Started on 4/23/26 and ongoing, 10. All licensed and certified nursing staff were educated on the facility's Basic Care Plan policy including but not limited to upon admission, the admitting nurse will initiate the development of the baseline care plan as part of the admission assessment; baseline care plan should include initial goals based on admission orders, all physician orders which includes medications and administration schedule, dietary orders, therapy services, social services, PASARR recommendations (if completed), and discharge needs of the resident by the Director of Nursing and Administrator on 07/23/2025. Staff members who are on FMLA or vacation and all agency staff will be in-service prior to returning to the facility by the Director of Nursing/Designee or Administrator. Started on 4/23/26 and ongoing. 11. All Interdisciplinary team members were educated on the facility's Comprehensive Care Plan policy including but not limited to a comprehensive care plan must be developed within 7 days after completion of the comprehensive assessment; must describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, resident's goals for admission and desired outcomes, resident's preference and potential for future discharge, including the resident's desire to return to the community and any referrals to local contact agencies. Reviewed and revised by the interdisciplinary team after each assessment and should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving by the Director of Nursing and Administrator on 07/23/2025. Staff members who are on FMLA or vacation and all agency staff will be in-service prior to returning to the facility by the Director of Nursing/Designee or Administrator. Completion date was 4/23/26. 12. An impromptu QAPI meeting was held with the medical director and interdisciplinary team to discuss the deficiency and a facility action plan. Completion date 4/23/26 13. The facility will conduct audits (7 days per week for 6 weeks) to ensure all new unwitnessed and witnessed falls, the interventions have been added to resident's care plan, intervention is physically in place on equipment, room or on person, and the interventions have been linked to the resident's Kardex. A QA tool -will be completed to verify this practice has occurred. The QA tool will be completed by Infection Preventionist/DON or designee, daily for 6 weeks. There will be oversight of the QA tool by RNC. Started on 4/23/26 and ongoing. The in-services were completed on 4/24/26, and the audits continued for 6 weeks. V1, Administrator, stated the audits are completed, but Quality Assurance will continue to address concerns as needed.

Based on interview and record review, the Facility failed to protect Residents' Rights to be free of Mental Abuse and Verbal Abuse from a Facility staff perpetrator that caused mistreatment, emotional distress, and mental anguish for one of three Residents (R1) reviewed for Abuse in a sample of three. Findings include:The Facility Abuse Prevention and Reporting Policy, dated 10/24/22, documents: the Facility affirms the right of our Residents to be free from abuse; the Facility prohibits abuse and mistreatment of Residents; the Facility has established a Resident sensitive and secure environment; the policy assures the Facility is doing all that is within its control to prevent occurrences of abuse; the Facility will establish an environment that promotes Resident sensitivity, security and prevent mistreatment; identify occurrences and patterns of potential mistreatment; implementing systems to promptly and aggressively investigate all reports and allegations of abuse and mistreatment; filing accurate and timely investigative reports; abuse means any mental injury other than by accidental means; abuse is the willful infliction of intimidation, punishment or mental anguish to a Resident; and willful in the definition of abuse means the individual must have acted deliberately; mental abuse is verbal/non-verbal conduct which causes or has the potential to cause the Resident to experience humiliation, intimidation, fear, shame, agitation or degradation; verbal abuse is a type of mental abuse and includes oral or gestured communication to Residents within hearing distance such as harassing a Resident, insulting, yelling or hovering over a Resident with the intent to intimidate and threatening a Resident; and orientation/training of employees includes sensitivity to Resident rights/needs, what constitutes abuse, how to assess/prevent/manage aggressive/violent/catastrophic reactions in a way to protect both Residents and staff and an employees obligation under the law for reporting a suspected crime to the facility, state survey agency and local law enforcement.The Facility Resident Rights Policy, dated 1/4/19, documents: to promote the exercise of rights for each Resident, including any who face barriers (communication problems, hearing problems and cognition limits) in the exercise of these rights; a Resident even though determined to be incompetent, should be able to assert these rights based on his/her degree of capability; to have autonomy to the maximum extent about how they wish to live their everyday lives and receive care, subject to the Facility's rules and regulatory requirements; and the Facility will not hamper, compel, treat differentially or retaliate against a Resident for exercising his/her rights.The Facility Final Abuse Investigation, dated 9/17/25, documents an incident on 9/15/25, between V4 (former Social Service Director) and R1. On 9/15/25, V2 (Director of Nursing/DON) reported to V18 (former Administrator/Abuse Coordinator) an inappropriate conversation/language between V4 and R1. The Final Abuse Investigation documents V4 used profane language during a conversation with R1 and that the profane language was not directed towards R1. The Facility unsubstantiated the allegation. The Facility's Social Service Director Job Description, dated 5/2/17, documents: purpose to assist in planning, organizing, implementing, evaluating and directing the overall operation of our Facility's Social Service Department in accordance with federal, state and local standards, guidelines and regulations, our established policies and procedures, as may be Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis; review Facility policies and procedures as part of the Facility's Interdisciplinary team to assure compliance with state and federal regulations; ensure and provide therapeutic interventions to assist Residents in coping with their transition and adjustment to a long-term care Facility, including social, emotional and psychological needs; and provide clinical interventions to address catastrophic events that occur during the Resident's stay in the FacilityV4's Termination Notice, dated 9/18/25, documents V4's last day worked as 9/15/25. V4's reason for termination is documented that on 9/15/25, a complaint was received from a Resident regarding conduct during an interaction. Specifically, that profane language was used during a conversation and that the behavior was found to be inconsistent with Facility policy which requires staff to treat Residents with courtesy, professionalism and respect at all times. The Employee Conduct Standards which list the use of profane, discourteous or unprofessional language toward Residents is grounds for immediate dismissal. R1's admission Record, dated 12/27/25, documents R1's current age of [AGE] years old and an admission date to the Facility as 9/23/25. R1's current Care Plan documents R1's diagnoses including Anxiety Disorder, Diabetes Type Two, Vertebral Disc Degeneration, Discogenic Back Pain, Heart Failure, Psychoactive Substance Abuse, Liver Disease, Depression, Age Related Nuclear Cataract, Hepatic Encephalopathy, Fall History, Abnormal Gait, Lack of Coordination and Abnormal Posture. R1's Care Plan also documents: Activities of Daily Living performance deficit; risk for falls; at risk for abuse/neglect and will be cared for in a safe manner and verbalize to staff any incidences of abuse or neglect and impaired visual function. The Final Abuse Investigation, dated 9/17/25, documents a written statement from V17 (Certified Nursing Assistant/CNA) wherein V17 was delivering R1 a lunch tray and R1 requested a salad. V17 went to request a salad for R1 from the kitchen and the kitchen was closed. R1 told V17 to Get out of my room. Go. V17 removed R1's lunch tray and exited R1's room. V17 notified V4 (former Social Service Director) that V17 did not want to go back into R1's room by V17's self. V4 went to R1's room to talk to R1 and, V4 told V17 that V4 told R1, He can get up to the dining room and ask for extra things when he wants extra things. V17 stated that prior to that incident, R1 stated R1 was not getting discharge planning help from V4. The Final Abuse Investigation, dated 9/17/25, documents a written statement from V2 (Director of Nursing/DON) that V13 (Certified Occupational Therapy Assistant/COTA) overheard in R1's room. V13 told V2 that V4 (former Social Service Director) told R1 do not be a f****** a****** to my staff. V2 immediately notified V18 (former Administrator).The Final Abuse Investigation, dated 9/17/25, documents a written statement from V13 (Certified Occupational Therapy Assistant/COTA). V13 was in R1's room providing therapy services with shaving at sink level, to R1's roommate. V13 overheard V4 approach R1's bedside and said, You have to quit being an a****** to my staff. V4 proceeded to argue and have a bad attitude with (R1). V4 stated to R1, You can go get your own salad next time and I know you are leaving in a few days, but you cannot yell at the staff, she is the only CNA down here today. V13 stated R1 remained calm during the conversation.The Final Abuse Investigation, dated 9/17/25, documents a typewritten statement, signed by V18 (former Administrator) from V4 (former Social Service Director). V4 was overheard telling R1 do not be an a****** to my staff. The statement documents verbal abuse did not occur, however, V4 displayed unprofessional conduct by cursing during the conversation with R1. The Final Abuse Investigation, dated 9/17/25, documents an unsigned typewritten statement from V4 (former Social Service Director). V17 (CNA) reported to V4, that R1 called V17 a piece of s*** and some other names. R1 called V17 a liar and threw a tray at V17 after V17 returned from the kitchen and said the kitchen did not have a side salad. V4 stated, (V13, COTA) was in R1's bathroom and we could ask (V13) as well.The Final Abuse Investigation, dated 9/17/25, documents an unsigned typewritten statement from R1. R1 stated R1 was frustrated with V17 (CNA) over lunch, when V4 entered R1's room. R1 stated R1 did not like the way V4 approached R1 about R1's discharge from the Facility. R1 stated V4 called R1 a f****** a****** during the conversation. R1 continues to state frustration with V4. On 12/27/25 at 11:02 am, V11 (Therapy Director) stated, (V13/COTA) came to me and told me (V13) overheard (V4) cussing in (R1's) face and (V13) was concerned because (V13's) behavior was inappropriate. Honestly, (V4) was not all the way there and was very weird. (V4) was degrading to even me and I even heard other Residents complain about (V4). On 12/27/25 at 11:30 am, R4 (Resident Council President) stated, I heard people talking about (V4) getting fired for cursing at (R1). I did not surprise me because (V4) had issues. On 12/27/25 at 12:17 pm, V13 (Certified Occupational Therapy Assistant/COTA) stated, I was doing occupational therapy with (R1's) roommate. We were in (R1's) bathroom, because we were practicing shaving. I saw (V4) enter (R1's) room, and (V4) even saw me. (V4) walked in and immediately had an attitude and pretty much got right into (R1's) face and was very aggressive and rude to (R1). (V4) was berating (R1) and called (R1) an a******, and a lot of other bad words. (R1) was so upset. The sad thing is (V4) knew I was in that room and could hear (V4), and (V4) still treated (R1) like that. I immediately reported it, because I thought it was really bad. On 12/27/25 at 9:47 am, R1 stated, (V4) ignored me all the time. I just wanted (V4's) help with my discharge, but (V4) was always too busy for me. I have an explosive attitude, and I cannot help it. I am not going to lie; I was not very nice to (V17). When (V17) came into my room and I asked (V17) for a salad, then (V17) told me that (V17) could not get me one, I got very mad and angry because all I wanted was a salad. Other people heard her talking to me and they all admitted that she did. (V4) ended up getting fired over it. (V4) came into my room right after I got into it with V17 (CNA), (V4) got right in my face, inches from my face, and was cussing and screaming at me. (V4) was telling me to f*** off and called me an a******. (V13/COTA) was in here and heard everything. (V4) belittled me and made me feel terrible. I thought it was totally inappropriate, and it made me even more upset, and (V4) was supposed to be someone that was helping me, but instead (V4) degraded me. I cannot do some things for myself, and I felt so humiliated, helpless, and like an idiot. How do you think I feel if I cannot even go the one person who is supposed to me helping me. It still makes me mad, I cannot even think about it.On 12/27/25 at 9:35 am, V2 (Director of Nursing/DON) stated, (V18/former Administrator) is no longer employed here. I was involved in the incident between (V4) and (R1) and helped with the investigation. (V13/COTA) came to me because (V13) overheard (V4) cursing and yelling at (R1) in R1's room. (V13) reported that (V4) told R1 do not be a f****** a****** to my staff. V2 immediately notified V18 (former Administrator).

Based on observation, interview, and record review, the Facility failed to staff a certified Food Service Manager/Dietary Manager. This failure has the potential to affect all 63 Residents Residing in the Facility.Findings include: The Facility Resident Census Roster, dated 12/24/25, documents 63 Residents residing in the Facility.The Facility Assessment Tool, undated, documents: the purpose of the Assessment is to determine what resources are necessary to care for Residents competently during day-to-day operations; to provide services to the Residents of your Facility; focuses on ensuring each Resident is provided care that allows the Resident to maintain/attain their highest practicable physical, mental and psychosocial well-being; Resident population that must be taken into account when determining staffing and resources needed for daily schedules and food; and identified staff needed to care for the Facility Resident population includes a Food Service Manager/Dietary Manager (Food and Nutrition Services).The Facility Dietary Manager Job Description, dated 3/23/17, documents: is responsible for partnering with the Dietician to plan, organize, develop and direct the overall operation of the Food and Nutrition Services Department in accordance with current federal, state and local standards, guidelines and regulations; participate in survey inspection; assists in planning, developing, organizing, implementing, evaluating and directing the Food Services Department; ensure that the menu's are maintained; knowledgeable on laws, regulations and guidelines; and possess as Food Service Sanitation Manager Certification.Resident Council Minutes, dated 11/17/25, document Dietary looking for a new Dietary Manager, V2 (Director of Nursing/DON) is handling all questions with staff at this time and that no Food Committee Meeting today due to no Manager.Resident Council Minutes, dated 12/15/25, documents still looking for a new Dietary Manager.On 12/27/25, 12/28/25, and 12/29/25, the Facility could not provide/identify a Food Service Manager/Dietary Manager employed in the Facility.The Facility Employee Contact Numbers Report, updated 12/4/25, documents Dietary Manager none.On 12/27/25, 12/28/25, or 12/29/25, a Dietary Manager was not available, and the Facility could not provide a contact person for the Food Service Manager/Dietary Manager.On 12/27/25 at 11:30 am, R4/Resident Council President (alert and oriented) stated, They have not had a kitchen manager for a long time. I used to run kitchens back in my day, and that kitchen is run terrible, we have so many issues with food. The menu is never right compared to what they serve, and the food is cold and undercooked. It would help if they had someone in charge in there. I could do a better job than these people do.On 12/27/25 at 9:20 am, V12 (Minimum Data Set/MDS Registered Nurse/Manager on Duty) stated, (V3/former Dietary Manager) is no longer employed here. We have not had a Dietary Manager for about two months now. The Director of Nursing is overseeing the Dietary department, and everyone just helps out when they need it.On 12/27/25 at 9:40 am, V7 (Dietary Cook) stated, We do not currently have a Dietary Manager. We all just pitch in and do what we can.On 12/27/25 at 9:38 am, V8 (Dietary Aide) stated, We have not had a manager in quite a long time. (V7/Dietary [NAME] and V11/Dietary Cook) handle a lot of the kitchen stuff.On 12/27/25 at 11:02 am, V9 (Dietary Cook) stated, I pretty much do everything I can in the kitchen because we have not had a Dietary Manager since (V3) left a couple months ago.On 12/27/25 at 9:47 am, R1 (alert and oriented) stated, I am on a special diet, and the food absolutely sucks here. I never get what they say I am supposed to get, and they do not want to help when I ask for something. They are always running out of coffee and milk too; heck I cannot even get a turkey sandwich when I want one. I ask to talk to the Dietary Manager, and they tell me that they do not have one.On 12/27/25 at 10:00 am, R2 (alert and oriented) stated, Fifty percent of the time, they never follow the menu, it is messed up quite a bit. For Christmas breakfast I got two dried up pancakes and one piece of toast, no meat, and no fruit. They do not always have milk either. The salad is always brown, and when I say brown, it is not just a little bit brown, it is mushy and slimy brown; it is rotten. I just do not understand how they do not even see that before they serve that.On 12/27/25 at 11:16 am, R3 (alert and oriented) stated, The food is horrible, and they do not even give you a choice. They do not even give you what is on the menu. You just get what you get.On12/27/25 at 10:10 am, R5 (alert and oriented) stated, The food is not edible. It sucks and they do not follow the menu. We cannot get any salads, and if we do, they are not edible. Also, there is never enough food. The food is undercooked or cold. One night we had all carbohydrates like mashed potato and macaroni and cheese together with no fruit or vegetable. Some people are starving after dinner, and the kitchen is all locked up and we cannot get anything. I am diabetic and graham crackers at night for a snack just does not cut it.On 12/27/25 at 10:08 am, R6 (alert and oriented) stated, Sometimes we do even get what is on the menu. They run out of coffee and milk all the time. I like chocolate milk, and I do not even get that half the time.On 12/27/25 at 9:20 am, V12 (Minimum Data Set/MDS Registered Nurse/Manager on Duty) stated, (V3/former Dietary Manager) is no longer employed here. We have not had a Dietary Manager for about two months now. The Director of Nursing is overseeing the Dietary department, and everyone just helps out when they need it. I have heard some of the residents complain that the food is terrible and that they do follow the posted menu.On 12/27/25 at 9:40 am, V7 (Dietary Cook) stated, We do not currently have a Dietary Manager. We all just pitch in and do what we can.On 12/27/25 at 9:38 am, V8 (Dietary Aide) stated, We have not had a manager in quite a long time. (V7/Dietary [NAME] and V11/Dietary Cook) handle a lot of the kitchen stuff.On 12/27/25 at 11:02 am, V9 (Dietary Cook) stated, I pretty much do everything I can in the kitchen because we have not had a Dietary Manager since (V3) left a couple months ago.On 12/29/25 at 10:43 am, V16 (Registered Dietician) stated, When I was at the Facility this last month, they were still looking for a Dietary Manager and had not hired one yet.On 12/29/25 at 10:37 am, V14 (Ombudsman) stated, I attended last month's Resident Council meeting, and everyone told me that the Dietary Manager had been fired. I do not think that they have hired anyone yet, but they are still looking for one.On 12/29/25 at 10:00 am, V10 (Contracted Dietary Supplier) stated, They have not had a Dietary Manager here for a couple of months. (V7/Dietary Cook) and myself usually do the ordering together because there is no Dietary Manager, I think that the staff just do not have any management in that kitchen.On 12/27/25, V2 (Director of Nursing) stated, 'We do not currently have a Dietary Manager. I help out when I can in there.

Based on observation, interview, and record review, the Facility failed to follow the Facility menu. This failure has the potential to affect all 63 Residents residing in the Facility.Findings include:The Facility Resident Census Roster, dated 12/24/25, documents 63 Residents residing in the Facility.The Facility Assessment Tool, undated, documents: the purpose of the Assessment is to determine what resources are necessary to care for Residents competently during day-to-day operations; to provide services to the Residents of your Facility; focuses on ensuring each Resident is provided care that allows the Resident to maintain/attain their highest practicable physical, mental and psychosocial well-being; Resident population that must be taken into account when determining staffing and resources needed for daily schedules and food; and identified staff needed to care for the Facility Resident population includes a Food Service Manager/Dietary Manager (Food and Nutrition Services).The Facility Off Versus Serve Meal Service Policy, dated 2020, documents: keeping with the rights of individual Residents, including person-centered care, planned meals will be offered versus served; and that Residents will be offered items from the planned menu.The Facility Dietary Manager Job Description, dated 3/23/17, documents: is responsible for partnering with the Dietician to plan, organize, develop and direct the overall operation of the Food and Nutrition Services Department in accordance with current federal, state and local standards, guidelines and regulations; participate in survey inspection; assists in planning, developing, organizing, implementing, evaluating and directing the Food Services Department; ensure that the menus are maintained; knowledgeable on laws, regulations and guidelines; and possess as Food Service Sanitation Manager Certification.Resident Council Minutes, dated 9/15/25, document alternative meals available during the week.Resident Council Minutes, dated 10/20/25, documents an apology made to Residents for taking all available off the menu.Resident Council Minutes, dated 11/17/25, document Dietary looking for a new Dietary Manager, V2 (Director of Nursing/DON) is handling all questions with staff at this time and that no Food Committee Meeting today due to no Manager.Resident Council Minutes, dated 12/15/25, documents still looking for a new Dietary Manager and substitutes should not be regular meals.The Facility Dining Manager Western Egg Bake (ground ham) recipe documents seven and a half ounces of diced ham per 15 servings.The Facility Week-at-Glance Menu, dated 12/21/25 through 12/27/25, documents on 12/27/25, western egg bake at breakfast and a baked potato with sour cream and margarine at lunch.On 12/27/25 at 9:05 am, the Western Omelet did not have ham. On 12/27/25 at 12:20 pm, all Residents in the dining room had a sweet potato; no baked potatoes were observed.On 12/27/25 at 11:30 am, R4/Resident Council President (alert and oriented) stated, They have not had a kitchen manager for a long time. I used to run kitchens back in my day, and that kitchen is run terrible, we have so many issues with food. The menu is never right compared to what they serve, and the food is cold and undercooked. It would help if they had someone in charge in there. I could do a better job than these people do.On 12/27/25 at 9:47 am, R1 (alert and oriented) stated, I am on a special diet, and the food absolutely sucks here. I never get what they say I am supposed to get, and they do not want to help when I ask for something. They are always running out of coffee and milk too; heck I cannot even get a turkey sandwich when I want one. I ask to talk to the Dietary Manager, and they tell me that they do not have one.On 12/27/25 at 10:00 am, R2 (alert and oriented) stated, Fifty percent of the time, they never follow the menu, it is messed up quite a bit. For Christmas breakfast I got two dried up pancakes and one piece of toast, no meat and no fruit. They do not always have milk either. The salad is always brown, and when I say brown, it is not just a little bit brown, it is mushy and slimy brown, it is rotten. I just do not understand how they do not even see that before they serve that.On 12/27/25 at 11:16 am, R3 (alert and oriented) stated, The food is horrible, and they do not even give you a choice. They do not even give you what is on the menu. You just get what you get.On12/27/25 at 10:10 am, R5 (alert and oriented) stated, The food is not edible. It sucks and they do not follow the menu. We cannot get any salads and if we do, they are not edible. Also, there is never enough food. The food is undercooked or cold. One night we had all carbohydrates like mashed potato and macaroni and cheese together with no fruit or vegetable. Some people are starving after dinner, and the kitchen is all locked up and we cannot get anything. I am diabetic and graham crackers at night for a snack just does not cut it.On 12/27/25 at 10:08 am, R6 (alert and oriented) stated, Sometimes we do even get what is on the menu. They run out of coffee and milk all the time. I like chocolate milk, and I do not even get that half the time.On 12/27/25 at 9:20 am, V12 (Minimum Data Set/MDS Registered Nurse/Manager on Duty) stated, (V3/former Dietary Manager) is no longer employed here. We have not had a Dietary Manager for about two months now. The Director of Nursing is overseeing the Dietary department, and everyone just helps out when they need it. I have heard some of the Residents complain that the food is terrible and that they do follow the posted menu.On 12/27/25 at 9:40 am, V7 (Dietary Cook) stated, We do not currently have a Dietary Manager. We all just pitch in and do what we can. We have had problems with getting all the ingredients ordered so we can follow the menus that are posted. A lot of times we have to improvise for stuff that we do not have. We always here that 'they' are trying to cut the budget or stay under budget.On 12/27/25 at 9:38 am, V8 (Dietary Aide) stated, We have not had a manager in quite a long time. (V7/Dietary [NAME] and V11/Dietary Cook) handle a lot of the kitchen stuff. I hear the Residents complain that they are not getting the right food, but we do the best we can.On 12/27/25 at 11:02 am, V9 (Dietary Cook) stated, I pretty much do everything I can in the kitchen because we have not had a Dietary Manager since (V3) left a couple months ago. We have had major issues with getting all of our supplies; the corporate people always review our order and make us cut corners, and it makes it hard to make things according to or menu. They will not let us get everything we need because they are trying to cut the budget. This morning, we were supposed to put ham in the Western Omelet according to the recipe and we were not even able to put ham in it, because we did not have any ham, so the residents did not get any meat. At lunch today, we have to substitute sweet potato for baked potato because we do not have any regular potatoes. We are constantly having to re-do the menu because we do not always have what we need to make the food that is supposed to me made. The Residents complain a lot, but there is nothing we can do, and this has been going on for quite a long time. It is very frustrating. Every week we run out of supplies and always run out of milk by the weekend, and our order does not come until Monday, so we go without milk for a day or so.On 12/29/25 at 10:43 am, V16 (Registered Dietician) stated, When I was at the Facility this last month, they were still looking for a Dietary Manager and had not hired one yet.On 12/29/25 at 10:37 am, V14 (Ombudsman) stated, I attended last month's Resident Council meeting, and everyone told me that the Dietary Manager had been fired. I do not think that they have hired anyone yet, but they are still looking for one. The Resident's had complaints about not getting what was on the menu and the alternate food selection.On 12/29/25 at 10:00 am, V10 (Contracted Dietary Supplier) stated, They have not had a Dietary Manager here for a couple of months. (V7/Dietary Cook) and myself usually do the ordering together because there is no Dietary Manager, but I think that the staff just do not have any management in that kitchen, and that is how the menu gets messed up and how they run out of food. We get milk delivered on Mondays and Wednesdays, and our food order comes on Wednesdays. This Facility is always running out of milk; I have never seen a Facility go through so much milk. We ordered 36 pounds of ham on last week's purchase order and received 18 pounds. They did a Christmas potluck on 12/22/25 for the entire staff and residents and served ham, so they ran out of ham for the Denver Omelet on 12/27/25. The kitchen staff do not know how to portion out all the ingredients when they are preparing meals, so a lot of times they run out of product that they need. We could not get bagged lettuce for like 4 weeks, because there were issues with our supplier and if we ordered single heads of lettuce, they would generally just get stuck in the back of the refrigerator and go bad, because no one would cut them up. I do try and stay within or under budget on the food, but the kitchen staff does not follow the correct recipes or serving portions for the food.On 12/27/25, V2 (Director of Nursing) stated, 'We do not currently have a Dietary Manager. I help out when I can in there (kitchen).

Based on interview and record review, the facility failed to identify Abuse for one of three Residents (R1) reviewed for Abuse investigations in a sample of three.Findings include: The Facility Abuse Prevention and Reporting Policy, dated 10/24/22, documents: the Facility affirms the right of our Residents to be free from abuse; assures the Facility is doing all that is within its control to prevent occurrences of abuse; identify occurrences and patterns of potential mistreatment; implementing systems to promptly and aggressively investigate all reports and allegations of abuse and mistreatment; filing accurate and timely investigative reports; abuse means any mental injury other than by accidental means; and willful in the definition of abuse means the individual must have acted deliberately; mental abuse is verbal/non-verbal conduct which causes or has the potential to cause the Resident to experience humiliation, intimidation, fear, shame, agitation or degradation; verbal abuse is a type of mental abuse and includes oral or gestured communication to Residents within hearing distance such as harassing a Resident, insulting, yelling or hovering over a Resident with the intent to intimidate and threatening a Resident; and orientation/training of employees includes sensitivity to Resident rights/needs, what constitutes abuse, how to assess/prevent/manage aggressive/violent/catastrophic reactions in a way to protect both Residents and staff and an employee's obligation under the law for reporting a suspected crime to the facility, state survey agency and local law enforcement. The Facility Final Abuse Investigation, dated 9/17/25, documents an incident on 9/15/25, between V4 (former Social Service Director) and R1. On 9/15/25, V2 (Director of Nursing/DON) reported, to V18 (former Administrator/Abuse Coordinator), an inappropriate conversation/language between V4 and R1. The Final Abuse Investigation documents V4 used profane language during a conversation with R1 and that the profane language was not directed towards R1. The Facility unsubstantiated the allegation. The Final Abuse Investigation, dated 9/17/25, documents a signed and written statement from V17 (Certified Nursing Assistant/CNA) wherein V17 was delivering R1 a lunch tray and R1 requested a salad. V17 went to request a salad for R1 from the kitchen and the kitchen was closed. R1 told V17 to Get out of my room. Go. V17 removed R1's lunch tray and exited R1's room. V17 notified V4 (former Social Service Director) that V17 did not want to go back into R1's room by V17's self. V4 went to R1's room to talk to R1 and, V4 told V17 that V4 told R1 he can get up, to the dining room and ask for extra things when he wants extra things. V17 stated that prior to that incident, R1 state R1 was not getting discharge planning help from V4. The Final Abuse Investigation, dated 9/17/25, documents a signed and written statement from V2 (Director of Nursing/DON) that V13 (Certified Occupational Therapy Assistant/COTA) overheard in R1's room. V13 told V2 that V4 (former Social Service Director) told R1 do not be a f****** a****** to my staff. V2 immediately notified V18 (former Administrator). The Final Abuse Investigation, dated 9/17/25, documents a signed and written statement from V13 (Certified Occupational Therapy Assistant/COTA). V13 was in R1's room providing therapy services with shaving at sink level, to R1's roommate. V13 overheard V4 approach R1's bedside and said, You have to quit being an a****** to my staff. V4 proceeded to argue and have a bad attitude with (R1). V4 stated to R1, You can go get your own salad next time and I know you are leaving in a few days, but you cannot yell at the staff, she is the only CNA down here today. The Final Abuse Investigation, dated 9/17/25, documents a signed typewritten statement from V18 (former Administrator) that was made from V4 (former Social Service Director). V4 was overheard telling R1, Do not be an a****** to my staff. The statement documents verbal abuse did not occur, however, V4 displayed unprofessional conduct by cursing during the conversation with R1. The Final Abuse Investigation, dated 9/17/25, documents an unsigned typewritten statement from V4 (former Social Service Director). V17 (CNA) reported to V4, that R1 called V17 a piece of s*** and some other names. R1 called V17 a liar and threw a tray at V17 after V17 returned from the kitchen and said the kitchen did not have a side salad. V4 stated, V13 (COTA) was in R1's bathroom and we could ask V13 as well. The Final Abuse Investigation, dated 9/17/25, documents an unsigned typewritten statement from R1. R1 stated R1 was frustrated with V17 (CNA) over lunch, when V4 entered R1's room. R1 stated R1 did not like the way V4 approached R1 about R1's discharge from the Facility. R1 stated V4 called R1 a f***** a****** during the conversation. R1 continues to state frustration with V4. V4's Termination Notice, dated 9/18/25, documents V4's last day worked as 9/15/25. V4's reason for termination is documented that on 9/15/25, a complaint was received from a Resident regarding conduct during an interaction. Specifically, that profane language was used during a conversation and that the behavior was found to be inconsistent with Facility policy which requires staff to treat Residents with courtesy, professionalism and respect at all times. The Employee Conduct Standards which list the use of profane, discourteous or unprofessional language toward Residents is grounds for immediate dismissal. On 12/27/25 at 11:02 am, V11 stated, (V13/COTA) came to me and told me that (V13) overheard (V4) cussing in (R1's) face and (V13) was concerned because (V13's) behavior was inappropriate. Honestly, (V4) was not all the way there and was very weird. (V4) was degrading to even me and I even heard other Residents complain about (V4). On 12/27/25 at 11:30 am, R4 (Resident Council President) stated, I heard people talking about (V4) getting fired for cursing at (R1). I did not surprise me because (V4) had issues. On 12/27/25 at 12:17 pm, V13 (Certified Occupational Therapy Assistant/COTA) stated, I was doing occupational therapy with (R1's) roommate. We were in (R1's) bathroom, because we were practicing shaving. I saw (V4) enter (R1's) room, and (V4) even saw me. (V4) walked in and immediately had an attitude and pretty much got right into (R1's) face and was very aggressive and rude to (R1). (V4) was berating (R1) and called (R1) an a******, and a lot of other bad words. (R1) was so upset. The sad thing is that (V4) knew I was in that room and could hear (V4), and (V4) still treated (R1) like that. I immediately reported it, because I thought it was really bad. On 12/27/25 at 9:47 am, R1 stated, (V4) ignored me all the time. I just wanted (V4's) help with my discharge, but (V4) was always too busy for me. I have an explosive attitude, and I cannot help it. I am not going to lie; I was not very nice to (V17). When (V17) came into my room and I asked (V17) for a salad, then (V17) told me that (V17) could not get me one, I got very mad and angry because all I wanted was a salad. Other people heard her talking to me and they all admitted that she did. (V4) ended up getting fired over it. (V4) came into my room right after I got into it with V17 (CNA), (V4) got right in my face, inches from my face, and was cussing and screaming at me. (V4) was telling me to f*** off and called me an a******. (V13/COTA) was in here and heard everything. (V4) belittled me and made me feel terrible. I thought it was totally inappropriate, and it made me even more upset, and (V4) was supposed to be someone that was helping me, but instead (V4) degraded me. I cannot do some things for myself, and I felt so humiliated, helpless and like an idiot. How do you think I feel if I cannot even go the one person who is supposed to me helping me. It still makes me mad, I cannot even think about it. On 12/27/25 at 9:35 am, V2 (Director of Nursing/DON) stated, (V18/former Administrator) is no longer employed here. I was involved in the incident between (V4) and (R1) and helped with the investigation. (V13/COTA) came to me because (V13) overheard (V4) cursing and yelling at (R1) in R1's room. (V13) reported that (V4) told R1, Do not be a f****** a****** to my staff. V2 immediately notified V18 (former Administrator). I am not sure why (V18) did not substantiate the abuse because (V4) did talk to (R1) by cussing and degrading (R1), and there are statements from employees that even witnessed it. I would have considered that to be abuse. (V4) was fired over it. V2 verified the information/statements collected in the investigation proved V4 did mentally and verbally abuse R1 and V18 could have concluded a more thorough determination by substantiating the abuse investigation.

Based on record review and interview, the facility failed to conduct quarterly Quality Assurance/QA Performance Improvement meetings with the required Committee Members present. This failure has the potential to affect all 61 Residents who currently reside in the facility. Findings Include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) form, dated 9/23/25, documents 61 residents reside in the facility. The Facility Quality Assurance Performance Improvement (QA)/QAPI Policy, revised 10/24/22, documents: to ensure the organized quality assessment and improvement process program that includes performance measurement, performance assessment and performance improvement; Committee shall meet at least quarterly to assure activities are performed and identified problems have corrective actions taken or action plan developed; Minutes, related reports and attendance of the Committee members shall be maintained on file in the Administrator's office.The QAPI Meeting Minutes (dated 12/4/24, 2/12/25, 4/9/25, 5/27/25, 6/11/25, 7/9/25 and 9/11/25) do not document V3's (Medical Director's) attendance. The Facility could not provide documentation of QA Meeting Minutes for March 2025. On 9/24/25 at 9:54 am, V1 (Administrator) stated, I hold QA meetings every month. When (V3/Medical Director) is in the building, I try and fill (V3) in on our meeting agenda, because it is hard to coordinate the days that (V3/Medical Director) is here in building and the days that we hold our QA meetings.

Based on interview and record review, the facility failed to test for presence of Legionella throughout the facility's water system. This failure has the potential to affect all 61 residents in the facility.Findings include:On 9/23/25 at approximately 9:20am, V1/Administrator provided the facility's Resident Roster, dated 9/23/25, documenting 61 residents residing in the facility.The facility's Water Management Program for Prevention of Legionella Growth, revised on 6/27/23, documents: The following will be verified and documented at least once weekly: The domestic hot water boiler, storage tanks, verified to be set between 140 - 160 degrees F (Fahrenheit). Thermostat indicating the temperature of water entering the circulating system at the mixing valve is 120 F or above. 9/25/25 at 1:10pm, V11, Maintenance employee, stated the facility does not have a boiler and utilizes a hot water heater to heat the facility's incoming water. V11 stated the Maintenance Department does not keep a weekly log documenting the hot water heater temperatures.

Based on Interview and record review, the facility failed to justify the use of an antipsychotic medication for one of five residents (R10) reviewed for unnecessary medications in the sample of 28.Findings include:R10's medical record documents R10 was admitted to the facility on [DATE], with a diagnosis of Severe Vascular Dementia with Agitation.The facility's Psychotropic Medication policy documents the following, under Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per standards of practice.R10's POS/Physicians Order Sheet includes the following order by V3, Medical Director: Quetiapine Fumarate (antipsychotic primarily used to treat schizophrenia and bipolar disorder) Oral Tablet 150 MG: Give 1 tablet by mouth at bedtime related to Vascular Dementia, Severe, with Agitation.R10's monthly MAR/Medication Administration Records for past 3 months include documentation that Quetiapine has been administered as ordered.R10's medical record includes Progress Notes from the facility's contracted psychiatric provider documenting R10's order for quetiapine for the diagnosis of Severe Vascular Dementia with Agitation.On 9/25/25 at 11:40am, V2, DON/Director of Nursing, verified R10's diagnosis of Severe Dementia with Agitation does not justify the use of Quetiapine, an antipsychotic.

Based on record review and interview, the Facility failed to notify Resident Representatives of transfers/discharges and the reason for discharge and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for two of 15 Residents (R4 and R8) reviewed for transfer and discharge in a sample of 28.Findings include:Facility Bed Hold and Return to Facility Policy, revised 9/26/17, documents: to ensure that Residents and/or Representatives are notified of the Facility Bed Hold Policy and conditions for return to Facility upon admission and at the time of a transfer from the Facility; bed hold policies apply to all Residents; and the Bed Hold Policy will be given to the Resident/Resident Representative at the time of a transfer from the Facility.1.R4's Un-Witness Fall Report, dated 5/24/25, documents R4 was sent to the local Emergency Department for evaluation after a fall.R4's Bed Hold Policy Notice, dated 5/24/25, documents R4 was transferred out of the Facility on 5/24/25. The Notice does not document reason for discharge or notification to Resident Representative.2.R8's admission Record Face Sheet, dated 9/24/25, documents an admission date of 12/8/24 and R8's diagnoses including: Left Femur fracture, Epilepsy, Anxiety, Depression, Chronic Obstruction Pulmonary Disease, Acute Respiratory Failure and Peripheral Vascular Disease.R8's Interdisciplinary Fall Progress Note, dated 5/19/25, documents R8 was sent to the local Emergency Department for a post fall evaluation.R8's Census List, dated 9/24/25, documents R8 discharged to the local hospital on 5/11/25.R8's Bed Hold Policy Notice, dated 5/11/25, documents R8 unable to sign at time of transfer and does not document copy mailed to Representative. The Notice does not document reason for discharge or notification to Resident Representative.The Facility Ombudsman Notification of Discharge/Transfer Log (4/1/25 through 4/30/25), submitted 5/5/25 and Discharge/Transfer Log (5/1/25 through 5/31/25), submitted 6/3/25, do not document R8's 5/11/25 discharge.

Based on interview and record review, the facility failed to revise a care plan for one of 15 residents (R9) reviewed for care planning in a sample of 28.Findings include:The Comprehensive Care Plan policy, revised 11/17/17, documents the Care Plan must describe the services that are being furnished, reviewed and revised by the interdisciplinary team on an ongoing basis to reflect changes in the resident's care.R9 was admitted on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Respiratory Failure, Chronic Pain, Neuropathy, Vascular Dementia, Seizures, Contracture Bilaterial foot and ankles, Dysphagia, Bipolar, and Depression. The Census report documents R9 returned to the facility from a hospitalization on 8/8/25, with Hospice services and was discharged from Hospice services on 8/27/25.R9's current care plan documents on 8/12/25 R9 requires communication and contact assistance with Hospice, staff is to notify the Hospice of any changes in R9's condition and R9 needs a discharge plan and bereavement care.On 9/24/25 at 1:30 PM, V2 (Director of Nursing) confirmed R9 was discharged from Hospice and the care plan should have been updated.

Based on interview and record review, the facility failed to ensure a resident received a nursing assessment and timely provider notifications to ensure medical interventions were received during an acute change of condition for one of three (R28) residents reviewed for change of condition, and failed to ensure wound care was provided as ordered for one of three residents (R6) reviewed for wounds in a sample of 28.Findings include: 1.The Physician-Family Notification-Change in Condition policy, revised on 11/13/18, documents the facility will inform the resident, resident's physician and the resident's representative when there is a significant change in the resident's physical status in either life-threatening conditions or clinical complications and/or transfer or discharge from the facility.R28 was admitted on [DATE], with diagnoses including but not limited to Dyspnea, Hypertension, Anemia, Myocardial Infarction, Ventricular Tachycardia, Major Depressive Disorder Congestive Heart Failure, Atrial Fibrillation, Sleep Apnea, Renal Dialysis and Type II Diabetes Mellitus. R28's Progress Note, dated 9/23/25 at 7:41 PM, documents hosp. (hospital). The notes do not indicate what time R28 was transferred to the hospital, assessment of R28's condition, and interventions that resulted in the transfer or if the physician and/or resident's representative was notified. On 9/24/25 at 11:07 AM, V9 (Registered Nurse/RN) stated, I don't know what happened to him (R28). I think someone said they found him unresponsive. He just got back from the hospital on Sunday. I know he refused to go to dialysis yesterday because he hurt so bad from the broken ribs. Last time he went to the hospital, they had to shock him because he was in full cardiac arrest by the time he got there. That's when he got his ribs broken. On 9/26/25 at 1:00 PM, V2 (Director of Nursing) stated she did not know if the facility had a policy for transfers to the hospital. V2 confirmed the Hospital Transfer Form should be completed by the nurse who provided cares and assessed the resident with all the pertinent details and agreed R28's record did not include an assessment of R28's condition and interventions that resulted in the transfer or if the physician and/or resident's representative was notified. 2.The (State) Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, dated 11/28/18, documents: You (Residents) have the right to safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. The facility's Medication Administration General Guidelines Policy (Undated) documents: Documentation (including electronic): 1. The individual who administers the medication dose records the administration on the resident's MAR/Medication Administration Record directly after the medication is given. 2. Current medications, except topicals used for treatments, are listed on the Medication Administration Record (MAR). 3. Topical medications used in treatments are listed on the Treatment Administration Record (TAR). R6's Minimum Data Set (MDS), dated [DATE], documents R6 has a BIMS (Brief Interview of Mental Status) score of 15. (MDS indicates that on a scale of 0 – 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R6's current Care Plan documents: I have a chronic wound. Site: right groin. (Interventions include: Keep wound site clean/dry. Monitor site for signs/symptoms of infection (i.e.: increased drainage, foul odor, redness, warmth, etc.) Treatment as ordered by MD/medical doctor.) R6's Physician Order dated 9/19/25 and Treatment Administration Record/TAR (September 2025) document: Clindagel External Gel 1%/percent (Clindamycin Phosphate (Topical)); Apply to right groin topically every day and night shift for wound care. (Start Date 9/19/25 6:00pm). R6's Progress Note dated 9/21/25 documents: Clindagel not available. R6's Order Administration Note dated 9/21/25 documents: Waiting for med (Clindagel) to be delivered. R6's Order Administration Note, dated 9/22/25, documents: (Clindagel) on order. R6's Order Administration Note dated 9/22/25 also documents: Unavailable; (Physician/Nurse Practitioner) notified. R6's TAR (Dated 9/2025) documents staff signature on 9/20/25 and 9/22/25 to indicate staff treated R6 with the Clindagel External Gel. On 9/25/24 at 2:00pm, V4 Licensed Practical Nurse/LPN stated that R6's Clindagel External Gel treatment medication did not arrive at the facility until 9/22/24. R6's TAR (Dated 9/2025) also documented signature for V4, Licensed Practical Nurse/LPN, to indicate she had completed R6's treatment on 9/24/25 on the day shift. On 9/24/25 at 12:50pm, V4, LPN, stated she was the nurse for R6. V4 stated she signed R6's TAR for his wound treatment but had not provided the treatment for R6. V4 stated, No, we are not supposed to document and sign off in the TAR before the treatment is done. On 9/24/25 at 12:40pm, R6 stated: They (nursing staff) are supposed to do my treatments (to groin area) twice a day on the day and night shifts; most of the time they (treatments) don't get done. When they have other things to do, my treatments get pushed back. They have run out of my treatment meds; they do not let me know it is out. On 9/25/25 at 10:40am, V2, Director of Nursing/DON, stated regarding staff signature documentation, that it is expected that nurses wait until the treatment is done and then document, just as with the protocol with medications; sign when the medication is given.

Based on interview and record review, the facility failed to ensure daily weights were obtained, notify the physician of weight gains per physician orders, and monitor for discrepancies of weights for one of three residents (R1) with daily weights and failed to clarify diet orders prior to feeding for one of three residents (R9) reviewed for diets in a sample of 28.Findings include: The Weight policy, revised 10/17/19, documents re-weights should be obtained if there is a difference of five pounds or greater (loss or gain) since the previous recorded weight.1. R1 was admitted on [DATE], with diagnoses of Hypertension, Depression, Anxiety, Lymphedema, Obstructive Sleep Apnea, Diabetes Mellitus, and Congestive Heart Failure. R1's Physician Order, dated 11/12/24, documents to weigh R1 daily and to notify the physician if R1's weight gain is greater than three pounds (lbs.) in a day or five pounds in a week.R1's Weight Summary, dated 7/1/25 to 9/24/25, has no documentation of R1's daily weights being obtained for 32 out of the 77 days while R1 was in the facility during the time span of 7/1/25 to-9/24/25. R1's Weight Summary also documents daily weight gain fluctuations varying from 3 lbs. (pounds) to 13 lbs. (7/11-7/13, 13 lbs.; 7/24-7/25, 7 lbs.; 7/25-7/26, 7 lbs.; 8/13-8/14, 10 lbs.; 8/18-8/20, 5 lbs.). R1's current medical record has no documentation of R1's physician being notified of R1's weight gains of more than three pounds in a day and/or five pounds in a week. R1's current medical record has no documentation that R1 was re-weighed with greater than a five-pound loss or gain.On 9/26/25 at 2:40 PM, V2 (Director of Nursing) confirmed R1's daily weights were not obtained as ordered, the physician was not notified of R1's gains of more than three pounds in a day or five pounds in a week per R1's physicians order, nor were R1's weights monitored for discrepancies. V2 reviewed the Weight Summary and confirmed significant weight losses should have also been reported.2. R9 was admitted on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Respiratory Failure, Chronic Pain, Neuropathy, Vascular Dementia, Seizures, Contracture Bilateral foot and ankles, Dysphagia and Bipolar and Depression. R9's Care Plan, initiated 2/12/25, documents R9 has no teeth and does not wear dentures. Diet as Ordered. Consult with dietitian and change if chewing/swallowing problems are noted. R9's revised Care Plan dated 8/22/25 documents R9 is at increased nutritional risk requiring a therapeutic diet, NAS (No Added Salt) diet, mechanical soft texture, thin liquid consistency and that R9 often complains he is unable to chew the mechanical soft vegetables and meats. The Hospital's discharge instructions, dated [DATE], documents R9 was ordered a general diet without restrictions. R9's Hospital Discharge summary, dated [DATE], documents R9 was admitted for Aspiration Pneumonia, failed his swallow evaluation, refused a feeding tube and to return to the facility with Hospice and continue to eat. R9's census report indicated R9 returned to the facility on 8/8/25 with Hospice services and revoked Hospice services on 8/27/25. The Hospice Plan of Care, dated 8/8/25, documented R9 was ordered a Regular Diet as tolerated. R9's Physician's order, dated 10/23/24, documents R9 was ordered a no added salt mechanical soft textured and thin liquids diet. The orders had not been clarified and/or updated post swallow function test and discharge from Hospital and/or Hospice. On 9/23/25 at 10:00 AM, R9 stated he wants to talk with the Speech Therapist and said, Something is wrong. They make me eat Dog Food. They make me eat a mechanical soft diet because I don't have teeth, but I want to eat egg salad, tuna salad, ham salad, ravioli and meatloaf. I made them a list but (V14/Dietary Manager) refuses to provide food other than what's on the menu for that day. On 9/25/25 at 1:00 PM, V14 (Dietary Manager) stated she has spoken with R9 multiple times. R9 wants egg salad, ham salad and tuna salad. R9 should be on a pureed diet because he does not have teeth and can't chew. Plus, the facility does not have the requested food all the time. V14 stated I will try to get him stuff he likes but I just can't make him what he likes, every meal just for him. Yes, he can eat bread and technically he could eat egg salad and ham salad. On 9/26/25 at 1:15 PM, V1 (Administrator) confirmed R9's diet order should have been clarified so that food preferences could be honored and provided as requested.

Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was maintained per physician's order for one of three residents (R1) reviewed with oxygen in a sample of 28. Findings include:The Oxygen and Respiratory Equipment Changing and Cleaning policy, dated 9/8/16, documents the handheld nebulizer should be changed weekly and on as needed basis. R1 was admitted on [DATE], with diagnoses of Hypertension, Depression, Anxiety, Lymphedema, Obstructive Sleep Apnea, Diabetes Mellitus, and Congestive Heart Failure. R1's Physician Order, dated 10/26/23, documents to change out, date, and label nebulizer mask and tubing weekly and on an as needed basis when in use. R1's Medication Administration Record (MAR), dated 7/21/25, documents R1 receives nebulizer treatments daily between 9/1/25 to 9/25/25.On 9/23/25 at 10:45 AM, R1's Nebulizer mask and tubing were not labeled with a date as to when they were changed.On 9/25/25 at 2:00 PM, V13 (Licensed Practical Nurse) confirmed oxygen equipment should be dated.

Based on interview and record review, the facility failed to log, track and justify the prophylactic use of an antibiotic with no stop date for one of five residents (R39) reviewed for antibiotic use in the sample of 28.Findings include:R39's medical record documents R39 was admitted to the facility on [DATE], with the following diagnoses: Cerebral Palsy; Type 2 Diabetes; Morbid Obesity; Schizophrenia; Follicular Disorder, and Idiopathic Progressive Neuropathy.The facility's Infection Prevention and Control Program policy, last revised on 11/28/17, documents the following: Purpose: To comply with the core elements of Antibiotic Stewardship to reduce the unnecessary use of antibiotics. This policy also documents: Antibiotic use will be logged and tracked to ensure prescribing practices and outcomes are monitored for trends. Prophylactic long-term use of antibiotics will be discouraged unless clinical rationale is provided for ongoing use. R39's current POS/Physicians Order Sheet includes the following antibiotic order by V3, Medical Director, dated 01/25/25: Doxycycline Monohydrate Tablet 100 MG: Give 1 tablet by mouth one time a day for infection related to follicular disorder, unspecified. Prophylactic No stop date.There is no documentation of R39's ongoing prophylactic antibiotic use noted in the facility's monthly Infection Logs for July/2025; August/20265 and September/2025.On 9/25/25 at 11:40am, V2 DON/Director of Nursing stated she was aware of the prophylactic antibiotic order for R39. V2 verified there was no documentation in the monthly Infection Logs tracking the daily prophylactic antibiotic ordered, nor was there Physicians justification provided for the open-ended use of the prophylactic antibiotic.

Based on observation, interview, and record review, the facility failed to transfer a resident with a gait belt for one (R1) of three residents reviewed for accident/incidents in a sample of three. This failure resulted in R1 falling and injuring her left wrist where she was transported to the hospital, X-Rays obtained, R1 was ordered a wrist splint to be worn, and follow up appointment with an Orthopedic doctor. Findings include: Facility Transfer-Manual Gait Belt and Mechanical Lifts, revised on 1/19/18, documents Use of gait belt for all physical assist transfers is mandatory. One person transfer requires a gait belt. Facility Handbook, dated 1/2023, documents Resident Injuries and Incidents- A common cause of resident injury is falling. Falls are often caused by leaving a resident unattended; leaving a resident in the bathroom without supervision; and failing to use gait belt when transferring or ambulating a resident. Facility Safety Belt Policy, dated 8/10/24 and signed by V5 CNA/Certified Nurse Aid documents All staff that assists residents with ambulation and/or transfers will use a safety belt as indicated to promote safety for the resident and staff. I have received a safety belt from the facility, and I have my own safety belt. V5 CNA/Certified Nurse Aid Employee File documents V5 was hired on 8/2/24. R1's Incident Report, dated 12/19/24, documents the following: (R1) was being toilet by the CNA (V5). (R1) described the CNA (V5) as hurrying to transfer which resident believes to have resulted in her fall. Complaints of pain to left arm. Change of plane from the toilet to the floor in her bathroom. The CNA (V5) tried to assist her off the toilet by her bra resulting in a change of plane from the toilet to the bathroom floor. (R1) pointed to her left arm when asked if any pain. (V8) Nurse and (V5) CNA assisted (R1) off the floor and into bed (no gait belt used). (V8) Nurse standing behind (R1) and (V5) CNA standing in front of (R1) helped (R1) off the floor and (R1) got into bed. Terminated (V5) CNA and DNR/do not return (V8) agency nurse due to improper transfer per facility policy while getting resident up off floor. Facility Daily Shift Assignment, dated 12/18/24, documents V5 CNA worked from 11PM on 12/18/24 until 7AM on 12/19/24. R1's current Care Plan with a date initiated on 4/18/24, documents I have an ADL/Activities of Daily Living self-care/mobility performance deficit that may fluctuate with activity throughout the day. This same Care Plan with a date initiated on 7/11/24, documents I am at risk for fall/injury related to wandering and poor safety awareness. CNAs/Certified Nurse Aids were re-educated on using appropriate transfer techniques transfer/manual gait belt and mechanical lift policy when assisting or transferring residents. R1's Minimum Data Set/MDS, dated [DATE], documents R1 is partial/moderate assistance for toilet transfer, and frequently incontinent of urine. R1's Nurses Note, dated 12/19/2024 at 4:45AM by V8 RN/Registered Nurse, documents Nurse standing at med cart at the nurses station preparing meds for morning med pass, heard loud crying from C wing (R1); Fax sent to MD/Medical Doctor to inform as well as ask if x-ray for right wrist was ok. R1's Pain Assessment, dated 12/19/24, documents Pain the left forearm, complained of pain in the left wrist, previous fracture, and received pain medication. R1's Progress Note, dated 12/16/2024 documents (R1) is a [AGE] year-old female presented to the OT/Occupation Therapy department due to (R1) recently had a cast from LUE (left upper extremity) wrist/forearm removed and returned from MD/Medical Doctor with orders to address left wrist ROM/Range of Motion and strengthening - no restrictions per MD note. R1's X-Ray, dated 12/19/2024, documents Acute comminuted, slightly dorsally impacted fracture of the distal radial epiphysis with resultant slight positive ulnar variance. R1's X-Ray, dated 12/21/24, documents History of left wrist fracture status post fall 12/19/24. Intra-articular distal radial fracture with re-demonstrated dorsal impaction. Acute chronic non-displaced fracture is difficult to exclude by imaging and clinical correlation is advised. R1's After Visit Summary, dated 12/21/24, documents R1 had a fall with an arm injury and diagnosed with left wrist pain; follow up appointment on January 13, 2025, at 8:30AM with an Orthopedic office; and instructions to Wear Velcro splint as tolerated. Continue with over-the-counter pain medication if needed. Follow up with Orthopedics for a recheck as needed. R1's medication record, dated 12/22/24, documents R1 was prescribed Tylenol 650 mg/milligrams by mouth every six hours as needed for pain. R1's Progress Note, dated 12/23/2024 by V6 APRN/Advanced Practice Registered Nurse, documents (R1) was seen on this day for a follow-up visit. (R1) has had a recent fall on 12/20/24, that resulted in Left wrist/forearm discomfort. (R1) had had a previous injury to her left wrist/forearm are that resulted in two fractures - previous x-ray results from 8/30/24 revealed a non-displaced fracture of the ulnar styloid and a comminuted intra-articular fracture of the distal radius. (R1) had a follow-up x-ray on 12/19/24 that had similar results to the x-ray completed in 8/2024 - this result includes a dorsally impacted, intra-articular fracture of the distal radius, and stated to have no comparison exam. The fracture was not stated to be new or healing. (R1) was sent to local ER/emergency roiagnom on [DATE] where an additional x-ray was completed. This x-ray revealed the intra-articular distal radial fracture that was stated to have re-demonstrated dorsal impaction. On 12/26/24 at 11:50AM, R4 (R1's roommate) was alert and oriented and stated (V5 CNA) toileted (R1) on 12/19/24. (R1) needs help wiping herself, she goes to the bathroom a lot about 2-3 times an hour, and the staff gets impatient. (V5) took her in the bathroom to toilet, she fell somehow with (V5), but I couldn't see everything because the bathroom door was partially closed but I could hear a commotion of voices in the bathroom, and now (R1's) arm is in a brace. (R1) said (V5) made her fall. On 12/26/24 at 12PM, V7 LPN/Licensed Practical Nurse stated I worked midnights until December 2024. (R1) she needs assistance with toileting because she wears a pull up and needs assistance wiping her behind because her arms are too short. 12/26/24 at 12:10PM, V3 RN/MDS/Interpreter stated (R1) had a fracture of her left arm a few months back. On 12/19/24 (R1) stated (V5 CNA) toileted her, (V5) grabbed her bra in the front of her that she was wearing to help her off the toilet and she fell on her hands and knees and hurt her left wrist. (V5) left the room after (R1) screamed and went to get the nurse. On 12/26/24 at 12:15PM, R1 was interviewed through V3 RN (Registered Nurse)/MDS (Minimum Data Set)/Translator due to R1 Spanish speaking only. At that time, R1 confirmed the following: she fell when in the bathroom with V5 CNA when V5 CNA assisted R1 off the toilet by her bra and R1 lost her balance and went down on the bathroom floor on her hands and knees; R1 needs assistance with toileting and wiping herself; V5 CNA did not use a gait belt to get her on/off the toilet; and V5 CNA and V8 RN/Registered Nurse did not use a gait belt to get her off the floor. At that same time, R1 was observed wearing a brace to her left wrist and stated her left wrist hurts. On 12/26/24 at 12:45PM, V1 Administrator stated (V5 CNA) was terminated and the agency nurse was DNR due to not following our transfer policy (on 12/19/24). When asked if due to no gait belt used V1 nodded and stated Yes they did not use a gait belt to get (R1) off the floor and that is our policy for transfers. (V5) was trying to get (R1) dressed for the day and (V5) transferred her off the toilet. (V8) had already heard (R1) scream and start crying and saw (V5) come out the adjoining bathroom door. (R1) had fallen and broke her left wrist prior. Her wrist was healing, and she was not wearing the brace anymore. (R1) came to the nursing home in September 2024.

Based on interview and record review the facility failed to employ a certified Infection Prevention Nurse. This failure has the potential to affect all 62 residents residing in the facility. Findings include: On 12/10/24 at 9:00am V1 (Administrator) stated the facility just hired an Infection Prevention Nurse (V3), but she is not certified yet. V1 (Administrator) also stated V3 is signed up for the courses, but has not started them. On 12/11/24 at 9:45am V1 (Administrator) stated that V3 (Registered Nurse/Infection Preventionist) was hired in October 2024 and started work October 29, 2024. On 12/11/24 at 10:00am V3's (Registered Nurse/Infection Preventionist) employee file was reviewed and documents a hire date of October 29, 2024. No certification or Infection Preventionist Training was noted. The Resident Census dated 12/6/24 documents 62 residents currently reside in the facility.

Based on observation, interview, and record review the facility failed to place a soiled incontinence brief in a trash receptacle and failed to remove soiled gloves before touching clean items in a resident room for one of three residents (R2) reviewed for infection control in the sample of six. Findings include: The facility's Infection Prevention and Control Program policy, revised 11/28/17, documents, Purpose: To comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for All residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. Guidelines: 1. The facility has established an Infection Control Program which addresses all phases of the organization's operation to reduce or prevent the risk of nosocomial infections in residents and health care workers. On 12/10/24 at 11:00am V3 (RN/Registered Nurse) was preparing to do wound care on R2. Upon unfastening R2's incontinence brief, it was noted that R2 had a bowel movement. While wearing clean gloves, V3 removed R2's stool covered wound dressing, placed it in the soiled incontinence brief, rolled the brief, removing it from R2, and placed it on the floor by V3's feet. While wearing the same soiled gloves, V3 grabbed the door handle to R2's room and looked out into the hallway for V10 (Certified Nursing Assistant/CNA). V10 entered R2's room with clean towels and wash rags. V3 (RN) took the clean linens from V10 with V3's soiled gloved hands. V3 (RN) went to the side of R2's bed, moved the soiled incontinence brief, that was on the floor, with V3's shoe and proceeded to provide incontinence care to R2 while wearing the same soiled gloves. On 12/10/24 at 11:30am V3 (RN) stated she usually places dirty incontinence briefs in a trash can if available but if not places on the floor, then picks them up when she is done with cares. V3 (RN) also stated she was not aware she should not touch clean items with soiled gloves on.

Based on interview and record review, the facility failed to conduct the required quarterly Quality Assurance meetings and failed to ensure the required Quality Assurance committee members were in attendance. These failures have the potential to affect all 63 residents currently residing in the facility. FINDINGS INCLUDE: The facility policy, Quality Assurance and Performance Improvement Plan, dated (effective) January 02, 2024 documents, The QAPI program at (the facility) will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice and quality of daily life for residents and family by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis and corrective action. The Quality Assessment and Assurance Committee reports to the executive leadership and Governing Body and is responsible for meeting for: Meeting, at a minimum, on a quarterly basis; more frequently, if necessary. The Quality Assessment and Assurance Committee will consist of the Medical Director/Designee, Director of Nursing Services, Administrator/Owner/Board Member/Other Leader, Infection Prevention and Control Officer, Maintenance, Business Officer Manager, Minimum Data Set Nurse, Wound Nurse, Social Services Director, Activity Director, Dietary Manager and Housekeeping Supervisor. The facility Quality Assurance Performance Improvement Meeting Minutes attendance sign-in sheets, provided by V1/Administrator include April 12, 2023 (missing Medical Director signature); February 8, 2024 and April 3, 2024 (missing Medical Director and Director of Nurses signature). No Quality Assurance Performance Improvement Meeting Minutes are available for July and October 2023 or January 2024. On 05/02/24 at 9:09 A.M., V1/Administrator verified the missing signatures for the 4/12/23 and 4/3/24 sheets. At that time, V1 also confirmed the missing sign in sheets for July 2023, October 2023 and January 2024. The facility Resident Census and Conditions Report for Medicare and Medicaid Services (CMS), dated 4/30/2024 and signed by V1/Administrator documents 63 residents currently reside in the facility.

Based on observation, interview, and record review the facility failed to utilize PPE (Personal Protective Equipment), failed to audit for appropriateness/compliance of PPE and failed to screen staff during a COVID-19 outbreak. This has the potential to affect 63 residents residing in the facility. Findings include: The Infection Control-Interim COVID-19 policy, dated 7/24/23, PPE Use in Red & Yellow Zone Residents with Suspected or Confirmed COVID-19 Infection HCP (Health Care Providers) who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH (National Institute of Occupational Health) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Respirators should be used in context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection standard. PPE including N95 should be discarded and new applied between each resident encounter, Testing of Staff and Residents: Newly identified COVID-19 positive staff or resident in a facility that can identify close contact. Test all staff regardless of vaccination status that had a higher-risk exposure with a COVID-19 positive individual. Test all residents, regardless of vaccination status that had close contact with a COVID-19 positive individual. The Infection Surveillance, Tracking and QA (Quality Assurance) Reporting policy, dated 2/14/18, Purpose: To identify, monitor, track and report infections and monitor adherence to infection control practices. Infection surveillance for compliance may include but is not limited to: Direct observation of care and procedures performed by staff. Direct observations of adherence to hand hygiene and proper use of PPE. Monitoring the availability of PPE. The Center for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 3/18/24, Personal Protective Equipment HCP (Health Care Providers) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH. Approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The CDC's NIOSH-Approved Particulate Filtering Facepiece Respirators this list is reviewed and updated weekly, A respirator labeled as a KN95 respirator is expected to conform to China's GB2626 standard. NIOSH does not approve KN95 products or any other respiratory protective devices certified to international standards. R317's Physician's Orders, dated 4/29/24, Follow Facility Protocol for COVID19 Screening/Precautions Droplet Precautions. On 4/29/24 at 10:06 AM, outside of R317's room posted on wall next to the door was a Droplet and Contact/Red Zone precautions signage. On 4/29/24 at 10:07 AM, V6 (Agency Certified Nursing Assistant) donned PPE and entered R317's room without tying the gown closed. V6 stated I'm Agency. This is my first rodeo here. They asked me to come in 15 minutes early to get the door codes and had a basic quick introduction and then I got started. On 4/29/24 at 10:10 AM, R317 was observed to leave the room with a mask on and no other PPE. R317 walked down to nurse's station and was then redirected back to R317's room by V4 (Registered Nurse). On 4/29/24 at 10:11 AM, V4 (Registered Nurse) was observed to enter R317's room without donning PPE (N-95, goggles, gloves and/or gown). V4, sat R317 down in a chair, took disposable stethoscope and blood pressure cuff out of R317's hands and put it on the overhead table. V4 exited the R317's room and performed hand hygiene. On 4/29/24 at 10:13 AM, V4 stated, R317 wanders out in the hall all day and has to be redirect back to R317's room. On 4/30/24 at 11:55 AM, R317 was walking down B-hall with a mask donned and V10 (Registered Nurse) redirected and escorted R317 back to R317's room. R317 was observed to immediately walk out of room, past V10 and walked to the nurse's station approximately 45 ft. V9 (Registered Nurse) was observed at the Nurses Station and redirected and escorted R317 back to R317's room. At 11:58 AM, R317 walked back out into the B-hall, again walked past V10 to nurse's station where the V9 stated I Know you are hungry. Lunch is coming soon and escorted R317 back to her room. The Infection Prevention COVID positive tracking list, dated 3/1/24 through 5/1/24, documents R317 tested positive for COVID-19 on 4/23/24, R60 tested positive for COVID-19 on 4/23/24 and R63 tested positive for COVID-19 on 4/29/24. On 4/30/24 at 10:00 AM, a Droplet and Contact/Red Zone precautions sign was post outside of R63's and R60's room (directly across from one another) in B-hall. On 5/1/24 at 1:00 PM, two PPE supply cabinets in the B-hall outside of R63's room and outside of R317's room each contained 1 (one) box each with 20 (twenty) KN95 Disposable Non-Medical Face Masks Product Model: JDK-01, Jinhue Jiadaifu Medical Supplies Company. The CDC guidelines do not list KN95 Disposable Non-Medical Face Masks Product Model: JDK-01, Jinhue Jiadaifu Medical Supplies Company as NIOSH approved mask. On 5/1/24 at 2:08 PM, V13 (Agency CNA) stated If I have to go into one of those rooms (R63 and/or R60's COVID isolation rooms), I use the PPE out of that cabinet (V15 pointed at the cabinet outside of R63's room which contained the non-approved NIOSH KN95 masks.) V15 (CNA) was present and stated V15 would as well use the PPE in the cabinet. On 5/1/24 at 2:10 PM, V16 (Occupational Therapy Assistant) was observed in R63's room with the non-approved NIOSH mask donned. On 5/1/24 at 12:49 PM, V3 (Infection Control Preventionist) stated I'm going to start doing PPE audits since we have had this big outbreak. I only monitor hand hygiene compliance now. The Daily Shift Assignment form dated 4/20/24 through 4/30/24 documents the following: 10 Agency staff worked on 4/23/24; 5 agency staff on 4/26/24; 4/29/24 7 agency staff. On 5/1/24, the Staff Source Testing binder included facility staff rapid COVID-19 testing results conducted on 4/23/24, 4/26/24 and 4/29/24. The binder lacked documentation that Agency staff were tested . On 5/1/24 at 12:35 PM, V17 (Agency Certified Nurse Aide/CNA) stated Our Agency doesn't have us test (COVID-19). No, they didn't test me here. On 5/1/24 at 12:45 PM, V13 (Agency CNA) stated Our Agency does not require testing (COVID-19). I just got done doing the on-boarding paperwork with the DON (Director of Nursing) and nothing was said about testing. They (facility) haven't tested me. On 5/2/24 at 1:00 PM, V3 stated Agency staff are not included in source testing for COVID-19. V3 agreed without including the Agency staff in the source testing, the sampling would be skewed and not all-inclusive. 34048 2. 4/29/24 at 12:30pm, V4, Registered Nurse, entered R60's room to pass medications. R60's has a RED ZONE sign on the door, indicating that R60 is on droplet precautions and full personal protective equipment is required. V4 had on a surgical mask, then donned a plastic face shield. V4 entered R60's and gave her the medication. V4 exited R60's room and used hand sanitizer and removed the plastic face shield. V4 continued to pass the medication on the unit. V4 verified that she did not don full PPE prior to entering R60's droplet isolation room. V4 also stated that she did not change her change her mask after leaving R60's room. The facility's Long-Term Care Facility Application for Medicare and Medicaid form, dated 4/30/24, documents that 63 residents reside in the facility.

Based upon observation, interview and record review, the facility failed to provide clean, stain-free linens for bathing for 9 residents (R7, R15, R22, R25, R30, R32, R44, R48 and R57) of 9 residents reviewed for dignity, in a sample of 30. The facility policy, Dignity, dated (reviewed) 4/23/18 directs staff, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. 1. On 4/29/24 at 10:38 A.M., R44 held up two (2) discolored wash clothes which had brown/tan stains. R44 stated Would you want to wash yourself with these? This is gross. This is supposed to be my house and I sure wouldn't use this to wash my car. It's not dignified. I even posted pictures on (Social Media). Ever since this new company took this place over, they can't get wipes, so they (staff) have to wipe our a***s with them. Then they just put them right back in the laundry. I bet those washing machines are full of feces and that's not right. Go culture them and see what grows out of them. I feel so contaminated 2. On 4/29/24 at 9:46 A.M., R25 was seated in her wheelchair, in her room. At that time, R25 stated, I'm so upset about this. Look at this filthy washcloth. Staff brought this into my room this past weekend and wanted me to use it to wash my face. It's a dignity problem. It is so undignified to even think of using something that someone else used to wipe their butt with. They took away our disposable wipes and told us we have to use these stained up washcloths. Last week when I went to take my shower, they wanted me to sit on a community shower chair that was covered with a blood stained white towel. R25 held up a greyish-looking washcloth covered with brown stains. On 4/29/24 at 10:55 AM, V7 (Housekeeping Manager) stated If the laundry is stained after we wash it, we pull it out and give it to housekeeping or the kitchen to use as rags. Over there (pointed at multiple boxes on clean side of laundry room) are full of brand new towels and wash clothes. If it is really bad (dirty washcloth), the CNA's are suppose to wash it in the hopper and put it in a bag before they put it in the laundry. It gets cleaned with all other whites. Soiled (wash clothes saturated with brown substances.) laundry was observed in the laundry bin in front of the washing machine. V7/Housekeeping Manager verified the laundry in the bin with the soiled material was ready for wash. 3. On 4/29/24 at 2:47 P.M., V48 stated, I am the (facility) Resident Council President. Many residents have voiced concerns to me about dingy, brown stained washcloths that we are given for bathing. We feel demeaned by being forced to use (feces) stained washcloths to wash ourselves. On 4/30/24 at 1:00 P.M., during the facility Group Meeting, R48 stated, Please do something about these dirty, stained wash cloths they make us wash with. It is demeaning to be treated this way. At that time, the other residents in attendance (R7, R15, R22, R30, R32 and R57) were in agreement. On 4/30/24 at 2:40 P.M., V1/Administrator stated, Our company policy is that we no longer buy (disposable) wipes for incontinence care. Staff have to use washcloths for peri care. They're not supposed to use the stained ones. I will talk to laundry and remind them to throw the stained ones away.

Based on observation, interview and record review the facility failed to prevent resident to resident physical abuse of one resident (R8) of three residents reviewed for abuse. This failure resulted in pain to R8 and losing a tooth after being punched in the mouth by R7. Findings include: Facility Policy/Abuse Prevention and Reporting dated 11/28/16 indicates residents have the right to be free from abuse. MDS/BIMS (Minimum Data Set/Brief Interview for Mental Status) dated 10/11/18 indicates R7 scores 15/15, is cognitively intact, understands and can be understood. MDS/BIMS dated 10/18/18 indicates R8 scores 8/15 and has mild cognitive impairments. Final Abuse Investigation report indicates that on 10/21/18 at 8:15amV11, LPN (Licensed Practical Nurse) was notified by R12 that R7 may have struck R8 in the mouth around 6am. Report indicates that R8 was noted to have a missing top front tooth. Report indicates that V1, Administrator reviewed the video from 10/21/18 and found that at 5:47am, R8 was talking to R7 at the nursing station. R7 waited until R12 passed by then reached out with his left hand, made contact to R8's mouth then immediately backed his wheelchair away from R8 and moved into the dining room. Video shows after altercation other residents passing by, however no staff were seen near the nursing station at the time of the incident. On 11/29/18 at 1:30pm V11, LPN stated that at approximately 8:30am (after breakfast), a CNA (Certified Nurse Assistant) brought a tooth that he said came from R8. V11 stated that they initially didn't know what happened so started asking residents and staff if they knew anything. V11 stated that R12 told her that R7 may have hit R8 in the mouth earlier in the morning. V11 stated that the altercation was not reported by anyone until then and that R8 had no bleeding or other signs of injury. V11 stated she immediately reported the incident to V1, Administrator. V11 stated that when she questioned R8 he said he hit me. V11 stated that R8 often says racial things to antagonize other residents. On 11/29/18 at 3:15pm R8 was observed with front tooth missing. R8 stated that the tooth was knocked out when R7 hit him in the mouth and that it hurt. R8 denied being hit accidentally and that R7 hit him intentionally after they were talking. R8 stated that he now stays away from R7. On 11/29/18 at 3:30pm V1, Administrator stated that she believes R7 hit R8 in response to R8 calling R7 a racial slur. V1 acknowledged that R7 striking R8 was not accidental.

Based on observation, interview and record review the facility failed to recognize four incidents of verbal aggression as potential abuse, resulting in a failure to report and investigate the incidents as required. E7/CNA (Certified Nursing Assistant) was verbally abusive to R19 and E2/DON (Director of Nursing) failed to remove E7 from patient contact during the ongoing investigation. R11 was verbally aggressive toward other residents on three separate occasions, and the behaviors were not reported or investigated. These failures have the potential to affect all 74 residents. Findings include: On 3/10/14 at 9:45 AM R19 stated, "(E7) was very, very abusive", "(E7) was right in my face" and "(E7) called me a b****, 'h* and f******* c***." R19 demonstrated, with first and second fingers an inch apart, how occurrence made R19 feel and stated, "made me feel small." R19 reported the incident occurred on 3-7-14. R19 stated E7 is working in the facility, 3 days after allegation was made and no one has discussed this occurrence with R19. On 3/10/14 at 7:30 AM, E7/CNA was going in and out of resident rooms on B Wing hallway and walking in and out of the Nurses Station. Facility Investigation for Allegation of Verbal Abuse, dated 3/10/14, completed by E2 DON/Director of Nursing, documents that on 3/7/14, in the afternoon, E6 CNA/Certified Nursing Assistant reported an allegation of verbal abuse to E5 LPN/Licensed Practical Nurse, E8 Activity Director and to E4 MDS/Minimum Data Set Coordinator witnessing E7 CNA arguing, yelling, cursing and calling R19 names. The investigation documents E4 MDS notified E2 DON on 3/7/14. Investigation also documents, "(E7 CNA) was assigned down a hallway apart from the above resident while an investigation was conducted this morning." The investigation, dated 3/10/14, documents R19's allegation of E7 arguing with and calling R19 an inappropriate name and states, "After further investigation, a witness was able to corroborate (R19's) allegation that (E7) had been raising her voice towards (R19) and indeed had called (R19) an inappropriate name." The investigation also documents E7 CNA continued to work scheduled shift on 3/7/14 and 3/10/14 after verbal abuse allegation was made known to E5 LPN, E8 Activity Director, E4 MDS and E2 DON. E7 CNA's Timecard Report, dated 3/7/14, verifies E7 clocked in at 6:20 AM and clocked out at 2:22 PM. E7's Timecard Report, dated 3/10/14, verifies E7 punched in at 6:08 AM. 2. MDS Assessment (Minimum Data Set) dated 2/20/14 for R 11 lists a BIMS (Brief Interview for Mental Status) score of 15, indicating R11 has full cognitive capacity. Nurse's Note for R11, dated 12/19/13 at 9:30 PM, states, "Res(ident) heard yelling at other res(sident) down the hall. Resident cussing at resident and telling him to get out of her 'f****** chair.' Res(ident) continues to be very agitated." Nurse's Note dated 1/9/14 at 7:30 PM for R11 states, "Resident racing down to roommate door. Resident yelling and cussing. Resident in smoking shed and got into disagreement with another resident in the shed. When resident coming back cussing and threatening. Res stated, 'Would punch other resident in eyes.' " Nurse's Note dated 3/2/14 at 6:55 PM for R11 states, "Resident heard yelling at male resident from another hall to get off of 'A' hall, that is 'my hall' and 'If I catch you in my room I will break your f****** fingers. Resident told writer nurse to 'shut the f*** up and stay out of it.' Resident continued to yell and holler at male resident." On 3/12/14 at 10:30 AM, E2/DON (Director of Nursing)/Abuse Coordinator stated that she was not aware of the incidents on 12/19/13, 1/9/14 and 3/2/14 or she would have investigated these incidents as abuse. Resident Census and Conditions of Residents, dated 3/10/14, documents facility census at 74 residents.

Based on interview and record review the facility failed to assist one of one resident (R15) in the sample of fifteen residents and one resident (R18) on the supplemental sample with obtaining transportation to medical appointments. This failure resulted in one resident (R18) waiting for four months for a dental clearance prior to knee replacement surgery, resulting in severe pain that affects the resident's psychological status and ability to walk. Findings include: 1. The face sheet for R18 includes the following Diagnoses: [REDACTED]. Physician Note dated 11/11/11 for R18 from the orthopedic physician states, "She (R18) has a history of [MEDICAL CONDITION] arthritis. She has been having a lot of pain lately. She has had Cortisone injections in the past with some relief but they have not helped lately...Her pain requires concessions in activity and can be severe at times. She has pain at night and when arising from a seated position. Her present condition is causing her to be depressed. She walks with a moderate limp. Requires a cane or walker for support. Plan: Schedule a right knee total arthroplasty as soon as possible. The patient will get dental clearance first then contact us to set up the procedure." Doctor's orders and progress notes dated 1/6/12 for R18 from the pain clinic states, "Please refer patient to a rheumatologist for evaluation and treatment of [REDACTED]." Doctor's orders and progress notes dated 1/14/12 for R18 from the dentist indicate that teeth #3, 4, 5 were extracted and R18 would require more extractions. Physician Notes dated 1/30/12 for R18 from the rheumatologist states, "She needs right knee replacement surgery and is waiting to be cleared from a dental standpoint." Physician order [REDACTED]. Doctor's Orders and Progress notes dated 1/6/12 for R18 from the pain clinic states, "[MEDICATION NAME] ([MEDICATION NAME]) 15 mg two PO TID (three times a day) for breakthrough pain." Controlled Substance Proof of Use Sheets indicate R18 received thirteen doses of [MEDICATION NAME] 30 mg in January 2012, sixty-seven doses of [MEDICATION NAME] 30 mg in February 2012, and ten doses of [MEDICATION NAME] 30 mg currently in March 2012 for breakthrough pain. On 3/16/12 at 8:45 AM, R18 stated "I need my last appointment with the dentist so I can get my dental work finished so I can get my right knee surgery done. My surgeon was all set in December to do my knee surgery but my dental work wasn't completed. I can barely walk because of the pain. They canceled my dental appointment about a month ago and it hasn't been rescheduled because the van broke down. I'm over anxious because of the pain. I just want to get this all done." On 3/16/12 at 9:45 AM, E2/DON (Director of Nursing) stated that the facility was unable to transport R18 to her dental appointments because the van was broke. 2. The facesheet for R15 includes the following Diagnoses: [REDACTED]. Nurses Notes dated 1/18/12 for R15 states, "Has (appointment) with (physician) for annual mammogram on 2/1/12." Nurses Notes dated 2/6/12 at 10:00 AM for R15 states, "Telephone order from (physician)-schedule diagnostic mammogram due to calcifications." Nurses Notes dated 2/16/12 at 3:15 PM for R15 states, "Returned from mammogram." Doctor's Orders and Progress Notes dated 2/27/12 for R15 states, "General Surgery. Left Breast Calcifications. Plan/Stereotactic biopsy." After Visit Summary from physician office visit dated 2/27/12 for R15 states, "Future Appointments 3/1/12 at 2:00 PM at Breast Center." There is no evidence in R15's clinical record that she was present for the March 1 appointment. Prep directions for Breast stereotactic biopsy in clinical record for R15 list a date of March 1. The original date of March 1 is crossed out and March 14 has been written in above original date. There is no evidence in R15's clinical record that she was present for the March 14 appointment. On 3/15/12 at 3:45 PM, R15 stated, "They found three lumps in my breast. One of the vans broke down so I wasn't able to get the biopsy done. The facility then canceled again because they weren't able to find someone to drive the van. They told me they weren't going to reschedule the biopsy and I should have my family take me. My husband can't take me because he lives in Wisconsin." On 3/16/12 at 9:45 AM, E2/DON (Director of Nursing) stated that the facility was unable to transport R15 to her breast appointments because the van was broke. .

Based on observation, interview and record review, the facility failed to develop a plan for evacuation and failed to train all employees in emergency procedures to ensure that staff were knowledgeable of how to handle fire and disaster emergencies for Bariatric residents. This deficient practice resulted in an Immediate Jeopardy affecting four of four bariatric residents (R1, R4, R6, R7) in the sample of 16 and eleven bariatric residents (R18, R21, R24, R25, R28, R30, R39, R40, R41, R42, R43) in the supplemental sample. While the Immediate Jeopardy was removed on 4/13/2011, the facility remains out of compliance at a Severity Level two as additional time is needed to assess the effectiveness of the inservices and the implementation of the daily updates to the bariatric resident's evacuation status. Findings include: On 4/4/11 at 10:30 AM, R7 stated that she has lived in this facility since 9/06. R7 stated that she gained so much weight that she could no longer take care of herself and that this facility was the closest to her home that would accept bariatric residents. R7 stated that she has no use of her legs, therefore she is totally dependent on staff to transfer her using an electronic lift. R7 stated that up until about two months ago when the wheel broke off the shower bed, staff transferred her from her large bariatric bed to a shower gurney so she could attend activities. R7 stated that she has been "stuck in her room ever since." R7 stated that her bed is too large to fit through the door. According to the current physician's orders [REDACTED]. The Occupational Therapist Seating/Evaluation dated 4/26/10 documents that R7 is bed bound due to [MEDICAL CONDITION] and long term nonuse of legs. The Activities of Daily Living assessment section documents that R7 is dependent on staff for all activities except for eating. E15 (Social Service) stated on 4/5/11 at 10:30 AM that she knows that the shower bed is broken and they have not done anything about it. E15 stated that the shower bed was the only way R7 could come out of her room to activities. "It is the only way she has to be mobile. The wheelchair that (R7) brought from home does not fit. It needs to be modified." E15 verified that R7 has been in her room for at least 2 months with no way out. E15 stated that she don't know how they would evacuate R7 from the building in an emergency unless they used the mechanical lift, like they did the day the shower bed wheel broke off. The staff pushed the mechanical lift with R7 dangling in the sling from the kitchen to her room, approximately 50 feet. On 4/5/11 at 1:15 PM, E7, Licensed Practical Nurse(LPN) stated the R7 really wants to get out of her room for activities, but there in no way to get her out of her room. The wheelchair does not fit her right now and the wheels won't work. The shower bed which was used to take her out of the room broke and doesn't work. We have the bariatric lift, but it is used for other residents too. In case of emergency, I am not sure how we would evacuate R7. If the bariatric lift was not available, I suppose we could use a draw sheet with several staff on it to drag her out or put resident on plastic blue mat and drag her out. On 4/6/11 at 10:00 AM, E2 (Director of Nurses) stated that the bariatric residents have a vinyl stretcher hanging on the bathroom door to use for emergencies. E2 stated that it takes eight people to use this stretcher( three on each side and one on each end to carry any of 10 bariatric residents in this facility weighing between 300 and 500 pounds.) E2 stated that the staff have not had any hands on training, but they all know where they are located. E2 stated that usually five Certified Nursing assistants are scheduled to work on second shift with two nurses and on 3rd shift 2 CNAs are scheduled with one to two nurses. E2 stated that they don't have specific instructions in the Evacuation Plan for the bariatric residents or in the Fire Safety Plan. On 4/6/11 at 1:00pm, E17 Certified Nurse Assistant (CNA) stated that she has had fire safety training at least once a year. E17 stated that she is aware of how to use fire extinguisher because about a year ago she put out a small grease fire in the kitchen. Kitchen staff were not aware of how to use extinguisher. E17 stated that she has not had any training on use of the vinyl stretcher or any training specific to the bariatric residents. On 4/6/11, E20, E22 and E23 (Certified Nurse Assistants) from 1:45pm - 2:30 pm all stated that they have the fire training at least once a year. All stated that they had not been trained on how to evacuate the bariatric residents They could not give specific information on R7. They all stated that there is a slide board hanging on the bathroom door that they could put her on it and drag her out. They stated that they have not practiced an evacuation using the vinyl stretcher with weight applied up to 500 pounds to see if it was possible. They all stated that they would have to wait for firemen to arrive to help. E22 stated that she would cover R7 up with fire blanket and wait for firemen. On 4/7/11 at 2:00pm, E2 took this surveyor to R6's room and removed the black vinyl stretcher from the bathroom door. E2 measured the width of the vinyl stretcher. It measured 3 feet wide E2 stated that she could not find the specifications for this stretcher. E2 stated that she is not sure how much weight it is designed to carry. There was no blue slide board hanging on the bathroom door. R7 had a black vinyl stretcher hanging on the bathroom door, also. There was no blue slide board in R7's room either. On 4/13/11 at 1:30pm, E2 stated that the blue slide is not intended to be dragged on the floor for evacuation usage. On 4/7/11 at 3:30 pm, E2 presented a list of bariatric residents. Five weigh over 400 pounds.(R39, R30, R18, R28, R7) Two use the bariatric lift to transfer from bed.(R6, R7) One (R7) is bed fast and has no wheelchair that fits in order to get out of bed. R6 transfers to a wheelchair (cannot bear weight) with the bariatric lift. Three bariatric residents weighing over 200 pounds need the other mechanical lift to transfer from bed to the wheelchair.(R21, R1, R4).Seven are ambulatory with assist, (R30, R18, R28, R42, R25, R41, R40). Four bariatric residents are ambulatory independently.(R24, R43, R4, R39). E2 provided a list of slings for the mechanical lifts, 13 in total, one 400-600 lbs, five 325-400 lbs, one 400 -700 lbs and three less than 325. According to this list there are 15 residents requiring transfer with the mechanical lift. On 4/5/11 at 10:30am, E30 (Maintenance Supervisor) stated that the shower bed has been fixed for about two weeks. E30 stated that it was reported broken on 2/25/11. E30 stated that he had to order parts. E30 stated that the bariatric shower bed is very old, so, parts are hard to get. The Evacuation Policy Procedure dated 1/01/98 documents to evacuate residents in an orderly fashion. Evacuate in the following manner: Move residents in great danger first, Evacuate horizontally first, Evacuate the fastest moving ambulatory residents first, then slower ambulatory residents and lastly wheelchair residents using the two man chair carry. Bedfast residents will be moved last. CNA's will assist residents at the end of each exit wing and will tell a designated person who will write the resident's name down. This evacuation policy does not address the bariatric residents who are non ambulatory and bedfast who require mechanical lifts. and the one bariatric resident who has no use of her lower extremities and does not have a wheelchair that fits. The Immediate Jeopardy was identified on 4/7/11. The Immediate Jeopardy began on 2/25/11 when the bariatric shower cart broke and the facility failed to explore alternative methods to evacuate bariatric residents in case of an emergency. E2, Director of Nursing was notified of the Immediate Jeopardy on 4/7/11 at 11:45 a.m. The surveyor confirmed through interview and observation that the following actions were taken to remove the Immediate Jeopardy: 1. 4/12/11 Evacuation plan procedures were revised to include bariatric resident procedures. 2. 4/12/11 All employees on every shift were inserviced on the the revised evacuation procedures. A practice drill was completed on each shift. 3. 4/12/11 Staff will not be allowed to work until inservice has been completed. This will be done prior to the oncoming shift. 4. 4/13/11 All residents were assessed to determine the level of assist the will need in the event of an emergency or disaster. 5. 4/13/11 Floor plans have been marked to indicate the resident's room placement in the facility as well as what level of assist is needed. Floor plans will indicate where special equipment is located as well. 6. 4/13/11 Floor plans will be checked daily by the Director of Nursing or designee to ensure that they are correct and up to date. 7. 4/13/11 Floor plans will be located at each nurse's station as well as in each Department Head's office. 8. 4/13/11 All staff were re-inserviced on the floor plan information and location of needed equipment.

Based on observation, interview and record review, the facility failed to ensure that two residents (R6, R18) on the sample of 16 and four residents (R21, R23, R24, R25) on the supplemental sample were provided care without encountering mental or verbal abuse from Nurse Aide E12. Facility administrative staff failed to recognize and take necessary actions to prevent re-occurrence of this type of abuse to the residents. Findings include: 1. On 04/03/11 at 1:30 p.m., E20, E21, and E12 (Certified Nurse Aides) transferred R6 from wheelchair to bed using a mechanical lift. During this transfer, E12, E20 and E21 were joking and laughing with each other. E20 bumped R6 into the 1/2 rail on R6's bed. Surveyor had warned E20 that E20 was about to run R6 into the side rail but E20 continued to talk while R6's left buttock and back hit the side rail. R6 was able to grab the rail and swing himself around the side rail while still in the mechanical lift. R6 stated that the side rail did not bump him hard and he was not hurt. E20 was asked why she did not stop the mechanical lift when the surveyor warned her that she was going to run R6 into the side rail. E20 stated, "Oh, I knew he would grab the rail, he always does to help out." Staff continued to joke with each other as if nothing had happened. E2 (Director of Nursing) was informed of staff joking around and not paying attention to R6 during the mechanical lift transfer. E2 stated at 1:45 PM on 4/3/11 that sometimes the joking on the part of the nurse aides can "go too far." E2 said that one aide in particular, E12, can "go too far" and that he can be "rude." E2 said that despite that fact, E12 is a "good aide." 2. During the group interview on 4/4/11 at 1 PM with R6, R21, R24, R25, R26, R27 in response to a question asking whether they had problems with any staff members, a number of the residents present mentioned the name of nurse aide E12. The consensus of the residents was that E12 is "rude" and disrespectful to them. R6, Resident Council Secretary, described E12 as being verbally "abusive." The residents said that E12 has been a problem in the past, but that since E12 had a [MEDICAL CONDITION] last year, the situation with E12 is "getting worse." 3. R21, Resident Council President, stated in the group interview on 4/4/11 at 1 PM that just that morning, R21 had an incontinent episode and R21's dress was wet. R21 stated that she was in her wheelchair in the hall at about 10:30 to 11 AM near the Director of Nursing's (DON's) office, when E12 came up to her, pulled up R21's dress, and said in a "snotty" manner, "You need to change that dress." R21 said that another female resident R24 was also in that area, and that R21 was "exposed" to R24. R24 stated that she did witness the event, and felt bad for the embarrassment to R21 at the time. R24 then started crying about the matter. 4. R25 stated during this same meeting that one time about six months ago, when E12 was preparing to help R25 with her shower, E12 brought two wash cloths to use. R25 stated that when she asked E12 why E12 had two wash clothes, E12 told her that "there is a lot of woman there." 5. A number of residents in the meeting stated that E12 does not like male resident R23. R25 stated that last fall, she overheard E12 tell R23, while in the shower room, to "shut-up." R25 also stated that about three weeks ago, she overheard E12 tell R23 in the shower room, "wash your d---." R21 stated that she has told the Administrator (E1), DON (E2), and Assistant DON (E28) about E12's conduct, but that nothing has been done about the situation. On 4/4/11 at 2:30 PM, the survey team informed E2, Director of Nursing, about the allegations made by residents in the group meeting that afternoon pertaining to E12. E2 said that she would begin an investigation. E1 (Administrator) stated on 4/6/11 at 2:15 PM by telephone that she has never received any complaints regarding E12's conduct toward residents. E1 said that E2 (Director of Nursing) is the facility's abuse coordinator. E2 stated on 4/5/11 at 9:30 AM that she has not personally received complaints from residents about E12 (Certified Nurse Aide) being abusive, but that E2 has talked to E12 in the past about speaking quieter when addressing residents. E2 said that so far in her investigation related to group interview allegations, she had interviewed E12, and E12 had denied the allegations. E2 stated that she has noticed that E12 is "more loud, edgy, and easily offended if people aren't taking him serious" since E12 had a [MEDICAL CONDITION] last fall. E2 stated at 2:30 PM on 4/5/11 that the abuse investigation so far indicated that those residents from the group meeting reported negative things about E12; and other residents on the wing that E12 works (A wing) reported positive things about E12, when interviewed by Social Service Designee E15. E2 stated that she was not finished with the investigation yet, but she did not see how she could fire E12 with these opposing resident view points. E15 stated on 4/5/11 at 9:40 AM that she had interviewed many residents last evening, including R21, R24 and R25. E12 said those three residents re-iterated the allegations against E12 made earlier in the day during the group meeting. E15 said that other residents R23, R28 and R29 on A wing stated that they like E12 and E12 takes good care of them. E15 (Social Service Designee) also stated that R18 told her that aide E12 is all right toward R18 now, but that four to five months ago, E12 called R18 a "piece of s---," and that everyone knew about it. E15 said R18 told her that E12 was frustrated at R18 at that time because E12 could not understand what R18 was trying to say. E15 said that R18 reported the incident to Activity Director E11 after it occurred. E15 said that E15 has noticed that E12 is "more needy" and "more easily offended" since E12's [MEDICAL CONDITION] last fall. E15 said that E12 talks loudly to every one, including residents, and that E15 "could see how residents could see him (E12) as abusive." Activity Director E11 stated on 4/5/11 at 10:30 AM that she talks with R18 on a daily basis and has a good rapport with R18. E11 said that E11 has not received any complaints from R18 regarding aide E12's conduct towards R18. E11 said that the only issue reported to E11 by residents concerning E12 involved the time that E12 changed the channel on the central area TV while residents were watching it. E2's signed final investigation report dated 4/6/11 for E12's alleged misconduct toward residents indicated that residents, staff, and the guardian for R21 were interviewed as part of the investigation. The report's conclusion was that the allegations were "unfounded."

A. Falls/Transfer Based on observation, interview, and record review the facility failed to investigate falls for trends and patterns to identify the root cause of the falls and failed to develop and implement new interventions to prevent further falls for four of five residents (R1, R9, R10, R13) reviewed for falls in the sample of 16. R10 fell multiple times sustaining fractures of the ribs,and a large bruise to the right side of the face from the forehead to mid cheek. R9 sustained a left hip fracture. The facility failed to practice safe transfer technique for one of one residents (R23) randomly observed for transfers in the supplemental sample. Findings include: 1. Incident reports ranging from 5/23/10 through 3/31/11 and the care plan dated 1/27/09 documented that R10 had ten falls. The fall that occurred on 5/31/10 was witnessed and did not have a completed investigation. The fall on 5/31/10 resulted in rib fractures. The falls that occurred on 5/24/10, 8/5/10 and 3/31/11 resulted in skin tears. The fall that occurred on 3/20/11 was unwitnessed. The incident report for this fall documented that R10 was found on the floor lying on her right side while ambulating from the bed. The fall on 3/20/11 resulted in skin tears and bruising. The care plan dated 1/27/09 shows that the basic interventions are documented on the care plan dated 2009 for falls. There are no new individualized interventions after each fall since 1/09 except for the fall that occurred on 5/31/10 resulting in rib fractures. The new intervention added was to encourage to use walker. R10 was observed at various times throughout the day from 4/4/11 through 4/7/11 walking behind her wheelchair and pushing it. E2 (Director of Nursing) stated on 4/5/11 at 1 pm that the facility gave R10 the wheelchair so R10 would sit and wheel herself around and not fall but now she just wants to push it. The care plan does not contain individualized interventions and does not provide any directions to prevent further falls. The facility's Non Medication Incident Report Form consists of a check off list with a small area provided to give a brief description of the Incident, action taken and supervisor signature. The front of the form provides 2 lines for the Administrator and Medical director to sign indicating they reviewed it. There is not a indicated space to identify staff present during falls. On 4/5/11 at 1:00 pm E 2 (Director of Nursing) stated that she does not investigate after each fall. E2 stated that she reviews the fall incident reports and if she thinks something needs to go on the care plan she tells E3 (Minimum Date Set/Care Plan Coordinator) or care plan persons to add new interventions. E2 stated they do not have a fall committee that reviews falls to identify trends, patterns and root cause analysis to prevent further falls. E2 stated that she has the information and programs to do it but has not had the time to implement the programs. E2 stated that the fall the occurred on 3/20/11 involving R10 occurred as R10 was sitting in her wheelchair in her room late at night. R10 fell forward and hit a snow globe that was located in R10's room on top of stacked plastic drawers. E2 stated that the facility cannot put R10 in restraints and "what else are they supposed to do" because R10 falls all of the time. The facility's undated Incident/Accident Procedure documents that the Nursing Administration will review all incident report forms with the facility Administrator who maintains files of completed reports. The Nursing Administration will review needed changes in resident Care Plans with the Multidisciplinary team. The team will update the interventions as necessary and as discussed. The Medical Director will review all Incident Reports at the Quarterly Quality Assurance Meeting. On 4/5/11 at 1:00 pm E2 verified that the facility is not following the facilities incident/accident procedure. 2. The current physician's orders [REDACTED]. R9's most recent Minimum Data Set (MDS) documents that R9 is alert and oriented times three. R9 is assessed at high risk for falls according to the fall Risk assessment dated [DATE], 12/7/10 and 3/8/11. The Incident report dated 11/5/10 and received by the facility on 12/23/10 signed by the Medical Director documents that on 11/4/10 at 5:15 PM, R9 fell in bathroom when she went to close the door and lost her balance. The Incident Report of 12/8/10 with no time recorded and received on 12/23/10 signed by the Medical Director documents that R9 fell in her room while ambulating with her walker. The roommate bumped into her and R9 fell on to her butt. The Incident Report dated 12/9/10 documents that R9 fell at 3:50 AM on 12/9/10. "Resident found on the bathroom floor facing outward in doorway complained of butt hurt, reddened. No deformities of pelvis or leg. Went for assistance to get resident up. Resident unable to pull self up to walker. Complained that (R9) can't bear weight to Right foot, ankle or leg." The Incident Report of 3/23/11 documents that R9 fell in front hallway of the nursing facility on this date at 9:45 am. "(R9) was walking with a roller walker, was walking fast and her feet appeared to have crossed and she fell to the floor towards her left side. (R9) complained of pain in the left upper leg. (R9) was sent by ambulance to hospital. Xray determined Left hip fracture." R9's care plan dated 11/4/10 and updated 1/6/11 for the Problem of Resident at risk for falls per facility assessment tool documents the normal approaches on 11/4/10: keep room free of clutter, keep call light in reach, be certain shoes have non skid soles, etc. There are no new individual approaches added after the falls of 11/4/10, 12/8/10, 12/9/10 listed in the above paragraph. It documents to use "same approaches" except for 3/23/11 when "Remind resident when using walker to walk slow and keep control of walker." On 4/5/11 at 2:30 PM, E2, Director of Nurses(DON) stated that on 3/23/11, R9 was waiting for someone from the community to pick her up to go to a community living facility. E2 stated that the physical therapist had just evaluated R9 for a rolling wheeled walker a few days before. E2 stated that she observed R9 going too fast with the walker and not having good control of it which made her concerned that R9 might fall. E2 stated that she walked beside R9 and told her she needed to slow down, but did not inform the physical therapist of her observation of R9. E2 stated that R9 did not go to the community living facility as planned because of the fall with fracture on 3/23/11. On 4/5/11 at 1:00 PM, E2, Director of Nurses, stated that she does not do an investigation after each fall, interview staff on duty in order to find any precipitating factors which might have contributed to the falls. E2 stated that they don't have a fall committee to review the falls for possible trends and patterns and do a root cause analysis to prevent further falls. E2 stated that she reviews the Incident Reports and if she thinks of any approaches that needs added, she tells E3, Minimum Data Set(MDS)/Care Plan Coordinator otherwise E3 adds new interventions. E2 stated that they don't meet as a multidisciplinary team to review the falls and update interventions as necessary. The Facility Incident/Accident Procedure documents that an Incident Report Form will be completed for any Resident at the time an unexpected or unintended event occurs that does or can cause bodily injury. The resident will be monitored for 72 hours, for possible injury not noted at the time of the injury. The nursing Administration will review all Incident Report forms with the facility Administrator who maintains files of completed reports. The nursing Administration will review needed changes in resident Care plans with the Multidisciplinary Team. The team will update interventions as necessary and as discussed. 3. R13's Admission record notes R13 was admitted on [DATE] with [DIAGNOSES REDACTED]. R13's physician orders [REDACTED]. R13's Fall Risk assessment dated [DATE], documents R13 is at high risk for falls related to R13's history of falls, decrease mobility, confusion, and because R13 is receiving antipsychotic medications. On 04/03/11 at 11:20 a.m., R13 was scooting her wheel chair from her table in the dining room to the exit door (approximately 20 feet) with both wheels locked on the wheel chair. E20 (Certified Nursing Aide) stated on 04/03/11 at 11:25 a.m., that R13 was placed at the dining room table for lunch and the wheelchair was locked because R13 will not stay in place. No alarm was placed or monitoring was provided. On 04/04/11 at 10:15 a.m., R13 was sitting at a dining room table for an activity with both wheels locked with staff present in the dining room. At 11:20 a.m. on 04/04/11, R13 was brought to the dining room and R13's wheelchair was locked. Staff left the dining room to bring in more residents for lunch. R13 did not have an alarm placed on her wheel chair. E22 and E23 (Certified Nurse Aides) stated on 4/4/11 at 11:30 am that R13 wears an alarm while in bed but they were not aware that R13's care plan documents for R13 to wear an alarm while up in a chair, also. R13's current Care Plan dated 02/17/11 documents to ensure that R13's body alarm is on while in bed or up in chair, redirect R13 from the front lobby, ensure bed alarm is working properly and is applied to R13's bed every shift, remind R13 not to get up without assist, and to monitor R13 when wandering down halls and in rooms. R13's care plan dated 02/07/11 documents that R13 fell on [DATE], 12/12/10, 12/29/10 and "same approaches" and R13 fell on and 02/01/11 and the care plan notes "no new approaches". R13's care plan indicates R13 has fallen 20 times since admission on 05/07/09. On 04/22/10 and 04/27/10, the same approach is provided to ensure that staff are using the bed alarm and that the bed alarm is working. Incident Report dated 02/02/11 documents R13 was "using a wheel chair as a walker and went to back up out of a room and fell " and on 12/30/11, R13 was found on the floor in room in front of the bathroom door with R13's pants down and received a small skin tear on the right elbow. No new approaches were provided. 4. R1's Physician Record dated 03/28/11 documents R1's [DIAGNOSES REDACTED]. R1's Care Plan dated 03/03/11 documents R1 is at risk for falls and is unable to ambulate on own and requires a mechanical lift for transfers, assist with repositioning, assist with bathing and dressing, is unable to ambulate. An incident investigation dated 11/08/10 documents R1 has made attempts to climb out of bed with bilateral side rails in place. R1's care plan on 03/03/11 documents to not leave R1 alone while in a chair or while R1 is in a room related to past falls documented on the care plan. On 03/30/11, the care plan documents R1 slid out of her chair without injury and to use the "same approaches". No new approaches were developed after the fall. On 04/07/11 at 9:07 a.m., R1 was in her room alone, sitting in her wheel chair. E7 (Licensed Practical Nurse) had just left R1's room after starting R1's respiratory treatment. E7 did not stay to monitor R1, but left R1 alone in the room without a body alarm in place and without a call light available for R1 to use. 5. On 4/3/11 12:40 pm after the noon meal, E12, Certified Nurse Assistant, approached R23 in the dining room. R23 was in a wheelchair. E12, CNA, told R23 to "get up" without any explanation to the resident's questions/comments. E12, CNA, placed the gait belt on R23, but did not fasten the belt securely around the resident's waist. E12, CNA, allowed an approximate 5 inch slack in the gait belt and twisted it behind the resident's back, before ambulating the resident out of the dining room. B. Unlocked Chemicals During the general tour on 4/11/11 from 10 AM to 11:30 AM with E29 (Housekeeping Supervisor) and E30 (Maintenance Supervisor), chemicals posting "Keep out of Reach of Children" warnings were present in the following areas: One bottle of Hibiclens skin cleanser was present in an unlocked cabinet, and at least twenty bottles of Purell hand sanitizer gel were present on a counter in the unlocked A wing medication room. Two - 40 tablet boxes of Freshmint denture cleanser were present in a plastic tub in the unlocked A wing linen closet. One can of Viatricide HBV disinfectant spray was present in an unlocked wooden cabinet in the unlocked B wing clinical sink closet. One partially full box of Freshmint denture cleanser tablets was present in a plastic tub in the unlocked B wing linen closet.