Every finding on record at Greenbrier Nursing & Rehabilitation Center of Tyle

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 7 residents (Resident #1 and Resident #2) reviewed for accidents and supervision. The facility failed to ensure staff were present on the secured unit, resulting in a resident-to-resident altercation between Resident #1, the aggressor, and Resident #2 on 06/29/2026 and 07/09/2026. This failure could place residents at an increased risk of avoidable accidents, abuse, and resident-to-resident altercations. The findings included: 1. A record review of a face sheet dated 08/17/2026 indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included dementia (loss of memory and other thinking abilities severe enough to interfere with daily life), Parkinson's disease (a progressive brain disorder that damages dopamine producing neurons which can result in symptoms including stiffness, slow movement, and tremors), Alzheimer's disease (a progressive neurodegenerative disorder that primarily effects memory, thinking, and behavior). A record review of Resident #1's most recent Quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS of 1, which indicated severely impaired cognition. Resident #1 had physical and verbal behavioral symptoms directed toward others 4 to 6 days, but less than daily and other behavioral symptoms not directed toward others daily. Resident #1 rejected care 4 to 6 days, but less than daily. Resident #1 wandered daily. A record review of a progress note dated 06/27/2026 at 4:45 PM by LVN A indicated she entered the secured unit and a chair was noted laying on the floor. Another resident began pointing at Resident #1 and stated that Resident #1 hit her in the face and she responded by pushing a chair. Resident #1 stated well, I might have. She had unfolded my clothes and she treats the dogs bad. A record review of Resident #1's comprehensive care plan most recently revised on 07/07/2026 indicated Resident #1 had the potential to demonstrate physical behaviors initiated 11/25/2025. The care plan indicated interventions included Analyze/document key times, places circumstances, triggers, and what de-escalates behavior. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level; provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Evaluate for side effects of medications. Give resident as many choices as possible about care and activities. If resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Notify the charge nurse of any physically abusive behaviors. Psychiatric/Psychogeriatric consult as indicated. When resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if the response is aggressive, staff to walk calmy away and approach later. A record review of a Social Services progress note dated 07/09/2026 at 4:16 PM indicated Resident #1 was witnessed hitting a female resident on the secured unit. The progress note indicated Resident #1 was seen walking up to another resident who was in a wheelchair and kicked at their legs and hit them on the head with her hand twice. The progress note indicated the residents were separated and when Resident #1 was asked about the incident she stated, I think they made it up. Resident #1 was transported to the hospital. A record review of Resident #1's psychiatric progress note dated 07/28/2026 indicated Resident #1 was seen for confusion, dementia, long-term memory problems, restlessness, short-term memory problems, and wandering. Resident #1's current medications were Lexapro Oral Tablet 10 milligram (an antidepressant used to treat depression and anxiety) 1 tablet by mouth one time a day for depression and Carbidopa-Levodopa Extended Release Oral Tablet 25-100 milligram (a prescription medication used to treat symptoms of Parkinson's disease) 1 tablet by mouth 2 times a day for Parkinsonism and spasmodic torticollis (a condition in which the neck muscles contract involuntarily, causing the head to twist or turn to one side). During an interview and observation on 08/18/2026 at 1:31 PM, Resident #1 did not answer questions in an appropriate manner, instead discussing mixing milk. Resident #1 appeared clean and comfortable and did not have bruising or other indicators of abuse. Resident #1 resided on the secured unit and interacted appropriately with other residents. 2. A record review of Resident #2's face sheet dated 08/17/2026 indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included Parkinson's disease, anxiety disorder, chronic kidney disease stage 2 (mildly decreased kidney function), and depression. A record of Resident #2's most recent Quarterly MDS assessment dated [DATE] indicated Resident #2 had a BIMS of 0, which indicated severely impaired cognition. Resident #2 had no physical or verbal behavioral symptoms directed toward others and had other behavioral symptoms not directed at others 1 to 3 days. Resident #2 utilized a manual wheelchair. Resident #2's preferred language was Spanish. A record review of Resident #2's comprehensive care plan indicated a focus initiated 06/29/2026 and revised 07/09/2026 which stated Resident #2 had been a victim of two altercations with another resident. The care plan indicated interventions dated 06/29/2026 included educate resident to disengage/call for a staff member if another resident engages with her inappropriately. Ensure a staff member is present on the secure unit at all times. Monitor for any signs/symptoms of emotional distress. Refer resident to a psych provider if consent is provided. A record review of the facility's provider investigation report dated 07/03/2026 indicated in the investigation summary the ADM reviewed camera footage and observed Resident #1 and Resident #2 in the dining area of the secured unit at around 3:00 PM exchanging words. The report indicated Resident #1 stood behind a chair near where Resident #2 was sitting and moved the chair closer to Resident #2. Resident #2 then pushed the chair away and it fell onto the floor. LVN A is then seen walking into the dining area and Resident #2 mad a gesture at her face and pointed toward Resident #1. LVN A was seen looking at Resident #2's face and legs, picking up the chair, speaking to Resident #2 and exiting the area. Resident #2 was seen getting out of her wheelchair and walking around the area. Resident #1 was seen coming back into the area and the residents are again seen exchanging words, Resident #1 pushes the chair toward Resident #2, and Resident #2 knocks it over again. LVN A entered the dining area again, Resident #2 gestured a hand to the face, and LVN A was seen assessing Resident #2's face and legs. A record review of the facility's provider investigation reported 07/10/2026 indicated Resident #2 on 07/10/2026 reported no fear during a determination of psychosocial well-being assessment on 07/10/2026. A record review of a progress note dated 06/27/2026 at 8:52 PM indicated Resident #2 stated another resident hit her in the face and she responded by pushing a chair onto the other residents legs. Resident #2 stated she was not in pain and no signs of bruising were noted. A record review of a progress note dated 07/09/2026 at 4:14 PM indicated another resident hit Resident #2 on the head and body and was separated from the aggressor. The note indicated neurological and behavior monitoring was initiated, Resident #2's responsible party was notified, and the Nurse Practitioner was notified. A record review of a skin assessment for Resident #2 on 06/27/2026 at 8:46 PM indicated no bruising, skin tears, abrasions, or lacerations and a normal skin color. A record review of a skin assessment for Resident #2 on 07/09/2026 at 3:59 PM indicated no bruising, skin tears, abrasions, or lacerations and a normal skin color. A record review of a social services progress note dated 07/09/2026 at 3:44 PM indicated a Trauma Informed Assessment was completed for Resident #2. The note indicated at 3:00 PM a nurse witnessed a female resident on the secured unit whom Resident #2 had previously experienced conflict with on 06/27/2026 struck Resident #2 on the head. The note indicated the nurse stated they did not hear either resident exchange words nor did staff report witnessing either resident interacting negatively earlier in the day. The note indicated Spanish speaking staff interviewed Resident #2 who stated the other resident approached her while she was in her wheelchair near the secure unit doors and hit her twice on the head and once on the bottom. The note indicated per witness report from a CNA, the other resident reportedly kicked at Resident #2's legs once and hit her in the head with her hand twice. Resident #2 reported feeling scared of the other resident and expressed fear that another incident would occur. The note indicated administrative staff would discuss additional measures to put into place to ensure a similar event did not occur again and Resident #2 would remain on psychiatric services and be monitored for distress. During an interview on 08/17/2026 at 9:57 AM, LVN A indicated on 07/09/2026 she was at the nurses station outside the secured unit and saw Resident #1 hitting Resident #2 on the other side of the glass doors to the secured unit. LVN A stated the CNA assigned to the unit was not on the secured unit at the time and was returning as she was about to go onto the unit. LVN A stated there were no staff on the secured unit at that time for an estimated 5 minutes. LVN A stated there was supposed to be a staff member at all times on the secured unit. During an interview and observation on 08/17/2026 at 10:08 AM, Resident #2 appeared clean and comfortable with no bruising or other signs of abuse. Resident #2 was no longer on the secured unit and was observed interacting appropriately with other residents. An attempt to interview using telephone translation services was made, but Resident #2 appeared to become frustrated with the interpreter and the call was ended. Resident #2 nodded when asked if she spoke a little English. When asked if she had been hit by another resident, Resident #2 nodded her head up and down to indicate yes, made a punching motion with her hand, pointed at the back of her neck, held up three fingers, and began kicking her feet. When asked if she was doing better now, Resident #2 smiled and nodded her head up and down to indicate yes. During an interview on 08/17/2026 at 1:37 PM, LVN A stated on 06/27/2026 the CNA assigned to the secured unit was assisting with another resident on another hall and was not on the secured unit. LVN A stated she was walking back to the secured unit and found the chair on the floor in the dining room. During an interview on 08/17/2026 at 2:45 PM, CNA B stated she was assigned to the secured unit on 06/27/2026, but she did not recall the incident that occurred between Resident #1 and Resident #2. CNA B stated on 07/09/2026 she was not on the secured unit and saw through the glass doors to the secured unit Resident #1 hit Resident #2 with an open hand on the top of her head. CNA B stated she was not assigned to the secured unit, but had requested the CNA who was assigned to the secured unit to assist her with a resident on another hall. CNA B stated there was supposed to be staff on the secured unit at all times. During an interview on 08/17/2026 at 2:58 PM, CNA C stated she was assigned to the secured unit on 07/09/2026. CNA C stated CNA B asked for her to assist with another resident on a different hall and as they were about to provide that resident care, CNA B stated she forgot something and walked back toward the area outside the secured unit and began running saying no, don't do that. CNA C stated she did not witness Resident #1 hitting Resident #2. CNA C stated when staff left the secured unit they were to let another staff member know so they could relieve them. CNA C stated she notified LVN A she was leaving the secured unit to assist CNA B and received verbal permission, but did not witness LVN A enter the secured unit before leaving. During an interview on 08/17/2026 at 4:03 PM, the SW stated there were no staff members on the secured unit when the resident-to-resident altercation occurred on 07/09/2026. The SW stated the nurse was at the nurses station outside of the secured unit. The SW stated there was always supposed to be staff on the unit. During an interview on 08/18/2026 at 8:59 AM, the ADON stated she was not at the facility when the resident-to-residents altercations occurred so she cannot say exactly what happened. The ADON stated there was supposed to be staff on the secured unit at all times. The ADON stated staff were supposed to wait until they visually saw somebody enter the secured unit to relieve them before they left. The ADON stated it had been an issue where staff left prior to ensuring another staff member entered the secured unit. During an interview on 08/18/2026 at 9:14 AM, the SW stated she updated Resident #2's care plan after the incident on 06/27/2026. The SW stated it was her understanding there was no staff on the secured unit during the incident on 06/27/2026 and that was why she included that as an intervention on the care plan. The SW stated there was supposed to be a CNA or a nurse on the secured unit at all times and it was unsafe for only nonclinical staff members to be on the unit. During an interview on 08/18/2026 at 9:43 AM, the DON stated she was still in orientation during the incident that occurred on 06/27/2026. When provided with information from the facility's provider investigation report and interviews, the DON stated it sounded like nobody was on the secured unit for either incident. The DON stated staff knew there was supposed to be a staff member on the secured unit at all times. The DON stated resident safety could be placed at risk if there was not a staff member on the secured unit. During an interview on 08/18/2026 at 10:06 AM, the ADM stated she would know who the staff members were that were scheduled to be on the secured unit by reviewing staffing sheets, but she could not place who was where at what time. The ADM stated it was a given that the secured unit should always be staffed. The ADM stated it was her expectation staff wait until somebody was on the unit to take their place before leaving. The ADM stated the risk to residents for the secured unit not having staff included falls or resident-to-resident incidents. A record review of the facility's policy, last revised January 2026, titled SecureCare Program Staffing Requirements indicated the following: The SecureCare Program will provide staffing to meet the distinct needs of residents living with dementia. Staffing guidelines will provide residents with consistent staff members that promote an activity intensive environment specifically designed to meet the individual needs of residents. Employees will encourage maximum levels of independence while providing safety and security. Licensed staff will be maintained and assigned to the SecureCare Program.

Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to ensure that Resident #1's care plan included interventions for aggressive behaviors after a resident-to-resident altercation on 07/09/2026. This failure could place residents at an increased risk of not having individualized, person-centered care plans developed and maintained to address their identified needs, goals, and interventions necessary to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The findings included: A record review of a face sheet dated 08/17/2026 indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included dementia (loss of memory and other thinking abilities severe enough to interfere with daily life), Parkinson's disease (a progressive brain disorder that damages dopamine producing neurons which can result in symptoms including stiffness, slow movement, and tremors), Alzheimer's disease (a progressive neurodegenerative disorder that primarily effects memory, thinking, and behavior). A record review of Resident #1's most recent Quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS of 1, which indicated severely impaired cognition. Resident #1 had physical and verbal behavioral symptoms directed toward others 4 to 6 days, but less than daily and other behavioral symptoms not directed toward others daily. Resident #1 rejected care 4 to 6 days, but less than daily. Resident #1 wandered daily. Resident #1 was independent of functional abilities which included walking and the ability to come to a standing position from sitting. A record review of Resident #1's comprehensive care plan most recently revised on 07/07/2026 indicated Resident #1 had the potential to demonstrate physical behaviors initiated 11/25/2025. The care plan indicated interventions included Analyze/document key times, places circumstances, triggers, and what de-escalates behavior. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level; provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Evaluate for side effects of medications. Give resident as many choices as possible about care and activities. If resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Notify the charge nurse of any physically abusive behaviors. Psychiatric/Psychogeriatric consult as indicated. When resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if the response is aggressive, staff to walk calmy away and approach later. The care plan did not indicate the instance of actual aggression and what interventions were put in place. A record review of a Social Services progress note dated 07/09/2026 at 4:16 PM indicated Resident #1 was witnessed hitting a female resident on the secured unit. The progress note indicated Resident #1 was seen walking up to another resident who was in a wheelchair and kicked at their legs and hit them on the head with her hand twice. The progress note indicated the residents were separated and when Resident #1 was asked about the incident she stated, I think they made it up. Resident #1 was transported to the medical hospital. A record review of a psychiatric progress note dated 07/28/2026 indicated Resident #1 was seen for confusion, dementia, long-term memory problems, restlessness, short-term memory problems, and wandering. Resident #1's current medications were Lexapro Oral Tablet 10 milligram (an antidepressant used to treat depression and anxiety) 1 tablet by mouth one time a day for depression and Carbidopa-Levodopa Extended Release Oral Tablet 25-100 milligram (a prescription medication used to treat symptoms of Parkinson's disease) 1 tablet by mouth 2 times a day for Parkinsonism and spasmodic torticollis (a condition in which the neck muscles contract involuntarily, causing the head to twist or turn to one side). During an interview on 08/18/2026 at 8:59 AM, the ADON stated she did some care plans and was still being trained on them. The ADON stated the SW and the MDS Coordinator usually did the care plan meetings. The ADON stated if there was a confirmed resident-to-resident altercation the care plan should have been updated to indicate actual aggression. The ADON stated Resident #1's care plan should have been updated. The ADON stated the risk to residents for the care plan not accurately reflecting Resident #1's status including staff could be providing care and not know that she had aggressive behaviors and they would not be monitored correctly. During an interview on 08/18/2026 at 9:08 AM, the MDS coordinator stated the SW typically updated care plans for behavioral concerns. The MDS coordinator stated Resident #1's care plan should have been updated to reflect an actual instance of resident-to-resident aggression. The MDS coordinator stated more incidents of aggression could occur if Resident #1's care plan did not accurately reflect her status as staff might not have known what to look out for. During an interview on 08/18/2026 at 9:15 AM, the SW stated Resident #1's care plan should have been updated. The SW stated she was still learning about care plans and when they should be updated. The SW stated the risk to residents for Resident #1's care plan not accurately reflecting her status including staff not knowing what interventions to put into place. During an interview on 08/18/2026 at 9:56 AM, the DON stated an actual occurrence of resident-to-resident aggression would typically be something that should be care planned. The DON stated she was not sure why this had not been care planned for Resident #1. The DON stated they have been falling behind with care plans in general and that is probably why it was not updated, but it should have taken priority. The DON stated the risk to residents could be the safety of the resident that is aggressive and other residents and staff being unaware of the behavior. During an interview on 08/18/2026 at 10:17 AM, the ADM stated care plans should be updated with each event. The ADM stated Resident #1's care plan not indicating an instance of aggressive behavior toward another resident was probably due to oversight. The ADM stated the care plan is an instruction manual for each staff member and without an accurate care plan staff had a lack of knowledge for appropriate care. During an interview and observation on 08/18/2026 at 1:31 PM, Resident #1 did not answer questions in an appropriate manner, instead discussing mixing milk. Resident #1 appeared clean and comfortable and did not have bruising or other indicators of abuse. Resident #1 resided on the secured unit and interacted appropriately with other residents. A record review of the facility's undated policy titled Comprehensive Care Planning indicated the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans may include but are not limited to resident Kardex records, baseline care plans, and task listings. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and The right to refuse treatment.residents' preferences and goals may change throughout their stay so facilities should have ongoing discussion with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures accurate acquiring, receiving, dispensing, and administering of medications for 1 of 2 medication storage rooms (East Wing) reviewed for pharmacy services.The facility failed to remove (2) expired vials of pneumococcal vaccine and bisacodyl suppositories (used to treat constipation) from the refrigerator in the medication room on the East Wing on 3/24/2026.This failure could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and infection. Findings included:During an observation on 3/24/2026 at 11:39 am, the medication on the East Wing refrigerator revealed:-(2) vials of pneumococcal vaccine expired [DATE].- a box of bisacodyl 10 mg suppositories dispensed date 9/27/2024 and prescription said do not use after 9/27/2025.-(1) box of bisacodyl 10 mg expired 4/2025.During an interview on 3/24/2026 at 11:39 am, LVN B said the Transport CNA was responsible for checking the medication carts and medication rooms for expired medications monthly. She said medications would not be as effective if given past their expiration dates. During an interview on 3/24/2026 at 1:34 pm, the Transport CNA said he was responsible for checking the medication carts and medication rooms but not the refrigerators. He said it had been more than a month or longer since he last checked them because he had been on transport taking residents to appointments. He said the staff assigned to the carts should also check them along with the Pharmacy Consultant when they came to the facility. He said medication errors could occur or a reaction to the medications if they were given and expired.During an interview on 3/25/2026 at 10:31 am, the Pharmacy Consultant said she visited the facility every other month and her last visit was 2/11/26. She said when she was at the facility she destroyed drugs, checked medication carts and rooms, observed a medication pass, and provided the facility with recommendations. She said when her visit was complete, she would send the facility a copy of her audit. She said if she found anything that was expired, she would remove them. She said if medications were given past the expiration dates, they could lose efficacy.During an interview on 3/25/2026 at 2:43 pm, the Administrator said the Pharmacy Consultant did audits of the carts and rooms in the facility. She said she sent a report to the facility after every visit. She said the Transport Aide used to be responsible for central supply and he would restock things and was not aware that he was checking the medication rooms or carts. She said if medications were given past their expiration dates, they might lose potency and the residents would not be given the appropriate strength.Record review of a policy titled Medication Storage in the Facility undated indicated, .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. 13. Outdated medications are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists .

Based on observations, interviews, and record reviews, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 3 of 12 residents (Residents #11, #15, and #43) reviewed for quality of care.1. The facility failed to ensure neurological checks were performed on Resident #11 when she had an unwitnessed fall on 2/08/2026.2. The facility failed to ensure the full gamut of neurological checks were performed on Resident #15 after a fall on 3/12/2026.3. The facility failed to ensure neurological checks were performed on Resident #43 after an unwitnessed fall on 3/23/2026.This failure could place residents at risk of not receiving appropriate care and treatment and/or decline in their health.Findings include:1. Record review of Resident 11's facility face sheet, dated 3/25/2026, indicated Resident #11 was an [AGE] year-old female, readmitted [DATE], with diagnosis of Alzheimer's. Record review of Resident #11's quarterly MDS assessment, dated 02/11/2026, revealed a BIMS score of 00 that indicated Resident #11 had severely impaired cognition. She required minimal assistance with ADLs. Record review of Resident #11's comprehensive care plan, revision date 03/10/2026, indicated Resident #11 was at risk for falls related to confusion.Record review of Resident #11's fall event note dated 2/08/2026 indicated Resident #11 had an unwitnessed fall and the nurse did not initiate nor complete any neurological check following the fall. During an observation and attempted interview on 3/23/2026 at 10:13 am, Resident #11 was asleep in bed. She aroused and had no complaints. She was unable to answer questions.During an interview on 3/24/2026 at 4:10 pm, the ADON said she was the charge nurse for Resident #11 on 2/08/2026. She said the aide alerted her that Resident #11 was on the floor. She said when she arrived Resident #11 was on the floor with her feet elevated in a chair. She said she assessed her but forgot to start neurological checks. She said that with an unwitnessed fall a neurological assessment should be completed every 15 minutes following the fall for the first hour, then every hour, for 4 hours and then every 4 hours for a total of 72 hours of monitoring. She said the exact times were automatic in the electronic record. She said if they were not completed, a negative resident outcome could occur. 2. Record review of a facility face sheet dated 3/24/26 for Resident #15 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of sepsis (a life-threatening reaction to an infection that causes your immune system to harm healthy tissues and organs).Record review of a Medicare 5-day MDS dated [DATE] for Resident #15 indicated a BIMS score of 14, indicating intact cognitive status. He required partial/moderate assistance with most ADLs. He had not sustained any falls prior to admission or while a resident.Record review of a comprehensive care plan dated 2/22/26 for Resident #15 indicated he was at risk for falls.Record review of an incident report dated 3/12/26 at 4:00 pm for Resident #15 indicated he sustained a fall in his room, resulting in injuries to his head. There was no documentation of a neurological check on the incident report.Record review of Resident #15's electronic medical record indicated the following neurological checks: 3/12/26 at 6:20 pm; and 3/13/26 at 7:25 pm; and 3/14/26 at 02:27 am.There were no other neurological checks documented.During an observation and interview on 3/23/26 at 10:32 am Resident #15 was observed in his room lying down on his bed. He had multiple scabbed areas to his forehead and above his right eye. He also had a dark purple bruise observed to his right eye. He said he had fallen recently in his bathroom, hitting his head. He had no complaints regarding the care he received after the fall.3. Record review of Resident 43's facility face sheet, dated 3/24/2026, indicated Resident #43 was a [AGE] year-old female, readmitted [DATE], with diagnosis of dementia. Record review of Resident #43's quarterly MDS assessment, dated 02/06/2026, revealed a BIMS score of 01 that indicated Resident #43 had severely impaired cognition. She required minimal assistance with ADL's. Record review of Resident #43's comprehensive care plan, revision date 02/17/2026, indicated Resident #43 was a fall risk. Record review of Resident #43's fall event note dated 3/23/2026 indicated Resident #43 had an unwitnessed fall on 3/23/2026 at 7:50 am. The nurse initiated a neurological assessment at the time of the fall but did not conduct another neurological check until 2:45 pm on 3/23/2026.During an observation and attempted interview on 03/23/2026 at 10:17 am, Resident #43 was sitting in a chair in her room. She was awake and alert, but unable to answer questions.During an interview on 3/23/2026 at 2:16 pm, LVN D said that she was assigned to the west side of the facility as the charge nurse. She said Resident #43 fell that morning at 7:50 am and she assessed her. She said she was not hurt, and she initiated neurological checks, but had gotten behind with other tasks and had not completed any other checks or entered her documentation. She said she was aware of the neurological check schedule and by not doing them, a negative outcome could occur. During an interview on 3/23/2026 at 4:33 pm, the DON said that she was new to the position for one week. She said when an unwitnessed fall occurred, or a fall resulting in head injury, neurological checks were always to be initiated and the resident should be assessed following the neurological check time frames to ensure no significant injury had occurred. She said that by not following through with neurological checks, resident safety could be compromised. She said that falls should be reviewed in the morning meeting to ensure the fall protocol was followed. During an interview on 3/23/2026 at 4:45pm, the Administrator said, regarding falls, she was not a clinician, but if a fall were to occur, the nurse should be following their fall management plan and contacting the family and doctor. She said missed neurological checks could result in unassessed neurological changes. She said she expected the nurses to always follow the facility's policy and procedures for falls.Record review of the Nurse Proficiency Audit for LVN D dated 2/20/2026 indicated LVN D was proficient in neurological assessments. Record review of the Nurse Proficiency Audit for the ADON dated 2/11/2026 indicated that the ADON was proficient in neurological assessments. Record review of the undated facility's policy titled Neurological Checks indicated, .Neurologic checks are a combination of objective observations and measurements done to evaluate neurologic status. The results of the checks assist to determine nervous system damage and/or deterioration.

Based on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 7 of 31 (2026 in March 8, 12, 13, 14, 17, 20, and 23) days reviewed for care and services. The facility failed to provide sufficient CNAs according to the facility assessment on March 8, 12, 13, 14, 17, 20, and 23 in 2026. This failure placed residents at risk of inadequate supervision, an unsafe environment, falls, serious harm and injury, exacerbations of disease processes, abuse, and death.Findings Include: Record review of a grievance note dated 3/09/2026 indicated a family member filed a grievance due to being unable to find clinical staff over the weekend. The facility summary of findings indicated a CNA position was unfilled and the CNA from the other side of the facility had to float to provide care. Record review of a Raw Time Entry Report dated March 1, 2026 to March 25, 2026 day shift 6:00 am to 2:00 pm indicated:March 08, 2026 - 2 CNAs and 1 MA with census of 60 residents.March 12, 2026 - 3 CNAs and 1 MA with census of 60 residents.March 13, 2026 - 2 CNAs and 1 MA with census of 59 residents.March 14, 2026 - 3 CNAs and 0 MA with census of 59 residents.March 17, 2026 - 3 CNAs and 1 MA with census of 57 residents.March 20, 2026 - 3 CNAs and 1 MA with census of 58 residents.March 23, 2026 - 3 CNAs and 1 MA with census of 58 residents. Record review of the Direct Care posting for 3/12/2026, 3/17/2026, 3/20/2026, and 3/23/2026 indicated there were 4 scheduled certified nurse aides and medication aide for the day shift and 3/14/2026, 3 scheduled certified nurse aides and medication aide. The resident census for those days were 57-60 residents. Record review of the direct care sign in sheets dated 3/08/2026, 3/12/2026, 3/13/2026, 3/14/2026, 3/17/2026, 3/20/2026, and 3/23/2026 indicated the facility had staffed 3 certified nurse aides and 1 medication aide on the schedule. Record review of the PBJ Staffing Data ReportFY Quarter 1 2026 (October 1 - December 31) indicated the facility had a 1-star staffing rating. Record review of a Resident List Report dated March 23, 2026 indicated the facility had 58 residents inhouse.During an observation on 03/23/2026 at 10:25 am, CNA A was off the secured unit at the computer charting outside the glass doors. She had eyesight of the secured unit hallway but not the residents in the dining room. She returned to the secured unit at 10:42 am. During an observation on 3/23/2026 at 12:00 pm, CNA A was off the secured unit to assist on the other side of the hall. There were no staff present on the secured unit until she returned at 12:08 pm. During an interview on 3/23/2026 at 12:20 pm, CNA A said she had been at the facility for about 3 weeks. She said she was assigned to the secured unit that day as well as 3 other residents on the other side of the unit. She said she had to leave to help the other aide because there were only 3 aides in total working that day. She said she would tell the nurse or aide that she was off the unit for them to supervise, but they were short and often could not stop to supervise the unit. She said on the day shift, there were many days, where only 3 aides showed up for the day shift. She said that having a shortage of nurse aides affected the resident's supervision and care and could result in injuries. During an interview on 3/23/2026 at 2:16 pm, LVN D said that she was assigned to the west side of the facility as the charge nurse with 34 residents and the other nurse on the east side had 24 residents. She said it was difficult for her to do everything in a timely manner. She said the aide on the unit also helped on the other side because of being shorthanded, and she had 2 CNAs for the west side and there was 1 aide on the east side today. She said that not having enough staff in the facility affects resident care and could result in injuries. During an interview on 03/23/2026 at 3:31 pm, a family member stated, at times when he visited, he must look for the aide and there were times that no aide was on the secured unit. He was told they were short staffed. During an interview on 3/23/2026 at 4:23 pm, the ADON said she was responsible for the nursing staff schedule. She said that the breakdown was to have 2 nurses on each shift, 5 nurse aides on the day shift, 4 nurse aides on the evening shift and 3 nurse aides on the night shift. She said that she and the treatment nurse were the ones that covered the shifts, and there were days that only 3 nurse aides were assigned. She said that she and the treatment nurse helped, but they had their own job responsibilities as well. She said the CNA assigned to the unit should not be assigned residents off the unit and should never leave the unit unsupervised. She said having insufficient staffing could result in delays in care and injuries. During an interview on 3/23/2026 at 4:33 pm, the DON said that she was new to the position for one week. She said she was not completely aware of the systems and staffing patterns. She said she knew there was a need for more nurse aides, but she was not aware there were only 3 nurse aides assigned for the day shift and that the CNA on the secured unit was leaving to help off the unit. She said she would speak with her corporate nurse to discuss the schedule. She said that being shorthanded could result in negative outcomes for the residents. During an interview on 3/23/2026 at 4:45 pm, the Administrator said there was no policy for staffing, and they used the facility assessment. She said that the facility assessment was current but that they did not follow the nurse staffing numbers in the assessment. She said they calculated the number based on census and that currently with 58 residents, there should be 4 1/2 nurse aides on day shift, 4 nurse aides on evening shift and 3 nurse aides on night shift. She said she was not aware there were only 3 nurse aides assigned for that day nor any other day. She said management staff were responsible for filling in and helping. She said the nurse aide on the unit should not be leaving the unit unless someone else came to supervise and she was not aware the nurse aide on the unit was being assigned residents off the unit. She said that decreased staffing could result in care issues. During an interview on 3/24/2026 at 7:54 am, CNA E was present on the secured unit. She said that she was assigned to the secured unit most of the time and that she would also have residents outside the unit to care for when they were short nurse aides for the shift. She said that the nurse and medication aide was to supervise the unit when she was off but that did not always happen. She said that on the days there were only 3 nurse aides on the schedule, they worked together and did their best. She said that when working short staff, some tasks such as showers and toileting were missed. She said that management staff would help, but they had their own duties and could not stay on the hall the entire time. She said having insufficient staff could result in resident injuries, poor hygiene and overall health issues. During an interview on 3/24/2026 at 2:45 pm, the Treatment Nurse said she was assigned to the hall yesterday around 11 am when the assigned nurse aide had to leave. She said she was the treatment nurse but frequently had to help work on the floor. Record review of the Facility assessment dated [DATE] indicated, .staff assignments were based on resident centered collaborative care and nurse staffing for certified nurse aide on the day shift would be 5 and medication aide 1 .

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 6 residents reviewed for ADL care. (Resident #2)The facility failed to ensure Resident #2 received timely incontinent care on 3/23/2026.This failure could place residents at risk of embarrassment, discomfort, and skin breakdown. Findings included:Record review of an admission Record for Resident #2 dated 3/25/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (a decline in mental ability that can interfere with daily life), GERD (acid reflux disease), and anxiety disorder (a persistent, excessive and uncontrollable fear, worry or dread that interferes with daily life).Record review of a Significant Change MDS Assessment for Resident #2 dated 2/26/2026 indicated she had severe impairment in cognition with a BIMS score of 0. She required substantial/maximal assistance with toileting hygiene. Her urinary continence was not rated but she was always incontinent of bowel.Record review of a care plan for Resident #2 dated 10/18/2023 indicated she had bladder and bowel incontinence with interventions to check resident every two hours and assist with toileting as needed.During an observation on 3/23/2026 at 12:20 pm, Resident #2 was in the dining room eating lunch.During an observation on 3/23/2026 at 2:00 pm, Resident #2 was sitting in a wheelchair in the lobby with other residents holding a baby doll.During an observation on 3/23/2026 at 2:27 pm, Resident #2 was in the lobby standing up by her wheelchair with staff present. The back of her pants was soaked with urine. Staff took the resident to her room to change her.During an interview on 3/24/2026 at 2:45 pm, the Treatment Nurse said she was assigned to the hall where Resident #2 resided 3/23/2026, and around 11 am the assigned nurse aide had to leave for the day. She said she was the Treatment Nurse for the facility, but frequently had to help work on the floor. She said she was going back and forth yesterday between halls and the secure unit. She said she tried to check the residents at least every two hours, and she checked some of the residents who were in bed and took the residents who were up to their rooms to get changed. She said she checked Resident #2 before lunch on 3/23/2026 and after lunch did not make it back to check on her because it was almost 2 pm and the unit staff needed relief. She said after lunch on 3/23/2026, they placed Resident #2 in the lobby, and she was not aware she had an accident where she urinated on herself. She said it would make her feel bad if she was left wet and there were not enough staff to care for the residents.During an interview on 3/25/2026 at 11:10 am, the DON said she had been in the facility for two weeks. She said incontinent care should be provided every 2 hours. She said she was aware of Resident #2 on 3/23/2026 being left wet for an undetermined amount of time. She said she would not feel good if she was dependent on staff to provide care for her. She said it would be a dignity issue. During an interview on 3/25/2026 at 2:43 pm, the Administrator said care should be provided as needed and the staff should conduct frequent checks and usually it was every 2 hours. She said she was not aware that Resident #2 was wet and not checked every 2 hours on 3/23/2026. She said it would make her feel like it was a dignity issue and could be a comfort issue. She said she expected the staff to make sure the residents were clean and dry. Surveyor requested a copy of the facility policy on ADL Care on 3/25/2026, but none was provided. The facility did not have specific policy related to ADL Care.

Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services for 1 of 1 kitchen reviewed for competent dietary support personnel. (Dietary Aide G) Dietary Aide G was preparing food and did not have a valid Food Handler's License. This failure could place residents in the facility who eat in the dining room at risk for food-borne illnesses. Findings Include: During an interview on 3/24/2026 at 11:20 am, Dietary Aide G said she had been employed at the facility since August of 2025. Dietary Aide G said she was responsible for preparing drinks and desserts as well as refilling the coffee/drink bar in the lobby and preparing trays. Dietary Aide G said she did not have a valid food handler's license. Dietary Aide G said she could not recall when her license expired and she did not have time to renew it. Dietary Aide G said she always practiced sanitary food handling practices and said not having a license did not pose any risk to residents. During an interview on 3/24/26 at 11:40 AM, the DM said she hired Dietary Aide G to work in the kitchen and knew at that time she did not have a valid food handler's license. The DM said she got busy with other things and did not get the dietary aide's food handler's license renewed. The DM said she did not feel there was any risk to residents or staff working in the kitchen without a valid food handler's license. The DM said the staff in question, Dietary Aide G, always observed sanitary practices and she had no concerns with having her working in the kitchen without a valid food handler's license. The DM said she would ensure Dietary Aide G completed her license renewal that day and going forward would ensure all staff members maintained current competencies for their employment. During an interview on 3/25/26 at 12:37 p.m., the Administrator said the DM was responsible for ensuring all kitchen staff had a valid food handler's license. The Administrator said she was not aware the facility had employed a dietary aide with an expired license. The Administrator said she felt there was no risk posed to residents due to Dietary Aide G performing their job duties under the supervision of a registered dietary manager. The Administrator said she was not sure if there was a policy that covered kitchen staff qualifications. A kitchen staffing policy was requested from the facility and was not provided. Review of food handler's licenses revealed Dietary Aide G completed a Food Handler Certificate Program on 3/25/26.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication storage rooms (East Wing) and 1 of 4 medication carts (East Wing) reviewed for labeling and storage.The facility failed to store an unopened insulin pen in the refrigerator on 3/24/2026 it was in the East Wing nurse medication cart.These deficient practices could place residents at risk for not receiving the intended therapeutic effects of their medications causing a health decline. Findings included:During an observation on 3/24/2026 at 11:04 am, the nurse medication cart for the East Wing was checked. LVN B was present. There was an insulin pen for Resident #18 that was unopened in a box. The insulin was degludec pen, and the order was to inject 20 units daily. The prescription was filled at a local pharmacy on 12/16/2025. The box said to keep in a cold place until first use. Store at 36 to 46 degrees.During an interview on 3/24/2026 at 11:39 am, LVN B said the Transport CNA was responsible for checking the medication carts and medication rooms for expired medications monthly. She said insulin should be stored in the refrigerator if it was not opened, and if not stored at the proper temperature would not be as effective. She said she would call the pharmacy and NP to get a new prescription for the insulin for Resident #18. She said she did not check the medication cart but only about once a week. She said Resident #18 brought the insulin in from home when he admitted on [DATE] and it was found in his room. She said someone placed it in the medication cart and said the resident told the staff the insulin did not need to be refrigerated. She said medications would not be as effective if given past their expiration dates. During an interview on 3/24/2026 at 1:34 pm, the Transport CNA said he was responsible for checking the medication carts and medication rooms but not the refrigerators. He said it had been more than a month or longer since he last checked them because he had been on transports taking residents to appointments. He said the staff assigned to the carts should also check them along with the Pharmacy Consultant when they came to the facility. He said medication errors could occur or a reaction to the medications if they were given and expired. During an interview on 3/25/2026 at 10:31 am, the Pharmacy Consultant said she visited the facility every other month and her last visit was 2/11/26. She said when she was at the facility she destroyed drugs, checked medication carts and rooms, observed a medication pass, and provided the facility with recommendations. She said when her visit was complete, she would send the facility a copy of her audit. She said if she found anything that was expired, she would remove them. She said unopened insulin should be stored in the refrigerator, if not it could go bad and not retain its use. She said if medications were given past the expiration dates, they could lose efficacy.During an interview on 3/25/2026 at 2:43 pm, the Administrator said the Pharmacy Consultant did audits of the carts and rooms in the facility. She said she sent a report to the facility after every visit. She said the Transport Aide used to be responsible for central supply and he would restock things and was not aware that he was checking the medication rooms or carts. She said if medications were given past their expiration dates, they might lose potency and the residents would not be given the appropriate strength. She said the unopened insulin should be stored in the refrigerator. Record review of a policy titled Medication Storage in the Facility undated indicated, .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier.11. Medications requiring refrigeration or temperatures between 36 degrees and 46 degrees are kept in a refrigerator. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. 13. Outdated medications are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists .

Based on observation, interviews, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 4 residents (Resident #32) reviewed for significant medication errors.The facility failed to ensure LVN B administered the correct dose of Novolog and Novolin R insulin (used to treat diabetes) to Resident #32 on 3/24/2026 during a medication pass.This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health.Findings included:Record review of an admission Record for Resident #32 dated 3/25/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (a decline in mental ability that can interfere with daily life), Parkinson's Disease (a movement disorder that worsens over time), diabetes mellitus, and bipolar disorder (mental health condition that causes extreme mood swings).Record review of active physician orders for Resident #32 dated 3/25/2026 indicated an order for Novolin R flex pan 100 unit/ml inject 25 units subcutaneously one time a day and an order for Novolog flex pen 100 units/ml per sliding scale: if 250-299=4 units; 300-349=6 units; 350-399=8 and to call the hospice agency.Record review of a Quarterly MDS Assessment for Resident #32 dated 1/17/2026 indicated he did not have any impairment in thinking with a BIMS score of 15. During the seven look back period he received insulin injections.Record review of a care plan for Resident #32 revised on 8/12/2025 indicated he had diabetes mellitus with interventions to give diabetic medications as ordered by doctor. Record review of Resident #32's blood sugars revealed:-3/24/2026 at 4:16 pm, blood sugar was 147,3/24/2026 at 7:50 pm, blood sugar was 192,and on-3/25/2026 at 6:58 am, blood sugar was 207.During an observation on 3/24/2026 at 11:01 am, LVN B checked Resident #32's blood sugar and it was 255. LVN B said the resident would receive 25 units of Novolin R and would get 4 units of NovoLog per sliding scale for a total of 29 units. LVN B took the NovoLog flex pen out of the medication cart and dialed it to 29 units. This Surveyor questioned LVN B about the dosage of insulin and she said the pen was for both insulins Novolog and Novolin R and administered 29 units of Novolog insulin to the resident.During an interview on 3/24/2026 at 1:30 pm, LVN B said she used one pen when she administered the insulin to Resident #32. She said the 4 units of Novolog should have been from his NovoLog pen instead of all being from the Novolin pen. She said the resident could have a reaction to the insulin if he were given the wrong dosage that could cause his blood sugar to drop. She said she should have looked at the MAR first and compared the orders before administering medications and she did not check the orders. She said she was not sure what happened that day and why she gave the resident 29 units of Novolog. She said the resident had a separate insulin pen for Novolin R in the medication cart.Record review of an Audit for LVN B dated 6/30/2025 indicated she was satisfactory with medication administration.During an observation on 3/24/2026 at 1:35 pm, the medication cart that LVN B was assigned to for that day revealed 1 insulin pen for Novolog, 1 pen for Novolin R, and 1 pen for Lantus that was prescribed to Resident #32.During an interview on 3/25/2026 at 11:10 am, the DON said she had been employed at the facility for 2 weeks. She said staff should follow the rights of medications that included the right medication and dosage. She said she was aware of the incident with Resident #32 when he received the wrong dose of insulin. She said they contacted the NP, made changes to his orders, and received new orders to check his blood sugar TID and prn. She said he has not had any issues since the incident with his blood sugar dropping or getting too high. She said she planned to in-service the staff and would provide a 1:1 education with LVN B. She said there was a risk for a resident's blood sugar to drop, or they might not receive enough insulin if not given the correct medication or dose.During an interview on 3/245/2026 at 10:31 am, the Pharmacy Consultant said she visited the facility every other month and her last visit was 2/11/26. She said when she was at the facility she helped to destroy drugs, checked medication carts and rooms, observed a medication pass, and provided the facility with recommendations. She said when her visit was complete, she would send the facility a copy of her audit. She said Resident #32's order for insulin that included Novolin R and Novolog were both short acting insulins that both had similar onsets of actions including peak actions. She said Novolin R would act longer but should not make a huge difference. She said she tried to make recommendations for the simplification of insulin regimens as if could make it difficult and room for errors if not. She said there was a risk for hypoglycemia but since both were short acting it would be less of a risk.During an interview on 3/25/2026 at 2:43 pm, the Administrator said staff should verify the correct medicine, dosage, the right resident, and should check to make sure the order was correct before administering any medicine. She said if residents were given too much insulin their blood sugar could drop. She said they started an in-service with the staff and planned to provide LVN B with 1:1 education and put a monitoring tool in place. She said the nurse called and notified everyone including the physician and an error report and was told to monitor Resident #32.Record review of a facility policy titled Medication Discrepancies and Adverse medication reactions dated 3/2025 indicated, .Medication discrepancies and adverse medication reactions are documented and reported to the residents' attending physician and designated personnel/committee of the facility .Record review of a facility policy titled Medication Administration Procedures undated indicated, .20. The 10 rights of medication should always be adhered to: 2. right medication; 3. right dose .

Based on interview and record review, the facility failed to make sure a comprehensive care plan was prepared by an interdisciplinary team, that included but not limited to the participation of the resident and the resident representative for 1 of 17 residents (Resident #7) reviewed for care plans.1. The facility failed to ensure Resident #7's representative was invited to attend the resident's care plan conferences.2. The facility failed to ensure care plan conferences were held quarterly for Resident #7.This failure could place residents at risk of not receiving the care and services to meet their needs.Findings include:Record review of a facility face sheet dated 3/23/26 for Resident #7 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Face sheet indicated his daughter was his RP.Record review of a comprehensive MDS assessment dated [DATE] for Resident #7 indicated a BIMS score of 00, indicating a severe cognitive impairment. He was dependent on staff for assistance with all ADLs. He was always incontinent of bowel and bladder. Resident #7 and his representative were active in participating in the assessment and goal setting.Record review of a care plan conference dated 1/14/25 for Resident #7 indicated Resident #7 nor his representative attended. The Care Plan Conference form indicated Resident #7, and his representative were unable to attend. Record review of Resident #7's electronic medical record indicated there was no documentation of a quarterly care plan conference in April of 2025 or until 09/09/25.Record review of a care plan conference dated 9/9/25 for Resident #7 indicated Resident #7 did not attend due to not understanding the purpose of the meeting and indicated that his representative did not attend due to prior commitments.Record review of an electronic medical record for Resident #7 indicated there was no documentation of a quarterly care plan conference in December 2025.Record review of a care plan conference dated 1/6/26 for Resident #7 indicated Resident #7 did not attend due to not understanding the purpose of the meeting and indicated that his representative was unable to attend.During an interview on 03/24/2026 at 8:55 am, the Social Worker said she was responsible for coordinating the care plan meetings and notifying family members in advance. She said she did not send out letters because families were not receiving them. She said she would notify them either by phone, or in person, but said she had not been documenting the notifications. She said there was had been a gap in Resident #7's quarterly meetings around the time last year when she took responsibility for coordinating the meetings from the MDS nurse. She was unsure exactly what happened or how it got missed. During an interview on 3/24/26 at 3:45 pm, Resident #7's representative said she had not been invited either by phone, letter, or in person to attend a care plan meeting within the last year. During an interview on 03/25/2026 at 10:50 am, the Social Worker said if families were not involved in care plan meetings, the facility may not be informed of resident's baseline, their routine at home prior to admission, and families may not be aware of resident's condition. She said, going forward, she would ensure families/responsible parties were invited to meetings and ensure that meetings were held appropriately. She said if meetings were not held as required, care plans may not be updated as needed, and staff may not be aware of the residents' needs.During an interview on 03/25/2026 at 11:00 am, the DON said she had only been there 2 weeks, and could not speak on anything that happened before she started. She said the Social Worker was responsible for coordination of the meetings and notifying family members in advance. She said that care plan meetings should be held at least quarterly and families should be invited when appropriate. She said if families were not invited to meetings, they may not know what is going on with the residents or may not be able to contribute to resident's care. She said if meetings were not held timely and as required, care plans may not be updated as needed and staff may not know how to care for residents. During an interview on 03/25/2026 at 11:16 am, the Administrator said the social worker coordinated the care plan meetings and invited the family members. She said they were going to go back to sending letters ahead of time for the care plan meetings. She said if meetings were not held timely or involved family members then families may not be included in resident care. She said she would ensure meetings were held timely going forward and that family members were invited.Record review of the facility's undated policy titled Comprehensive Care Planning, reflected, .The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preference and needs of the resident and in response to current interventions .The facility will provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation in care planning can be accomplished in many forms such as holding care planning conferences at a time the resident representative is available to participate, holding conference calls or video conferencing .Facility are expected to facilitate the residents' and if applicable, the resident representatives' participation in the care planning process .

Based on interview and record review, the facility failed to assess each resident quarterly, once every three months, using the quarterly review instrument specified by the state and approved by CMS for 1 of 17 residents (Resident # 14) reviewed for resident assessments. The facility failed to ensure Resident # 14 had a quarterly MDS assessment completed within three months from the previous assessment on 2/21/26.This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions.Findings included:Record review of a facility face sheet dated 3/25/26 for Resident #14 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs). Record review of a quarterly MDS assessment dated [DATE] for Resident #14 indicated a BIMS score of 8, which indicated moderately impaired cognition and an Assessment Reference Date of 11/21/25. The quarterly assessment was due 2/21/26, but was not put in the system 3/20/26, and showed in progress; which was 27 days overdue.During an interview on 3/25/26 at 9:17 am, the MDS nurse said she was unsure how she missed doing the assessment, but she said assessments should be done every 3 months and he should have had one in February. She said if assessments were not completed appropriately, they could be inaccurate, and since care plans were triggered from the assessments, the care plans may not be updated accordingly. She said she would keep better track when assessments were due going forward. During an interview on 03/25/2026 at 11:00 am, the DON said she had only been employed at the facility 2 weeks and could not speak on anything that happened before she started. She said if MDS assessments were not completed appropriately, then care plans may not be updated as needed and staff may not know how to care for residents. She said she would ensure the MDS nurse completed assessments appropriately going forward. During an interview on 03/25/2026 at 11:16 am, the Administrator said that it was very unusual for the MDS nurse to miss an assessment, and she was unsure how that happened. She said that the MDS triggered their payments, quality measures, and care plans. She said if assessments were not completed appropriately, then care plans could miss getting updated when needed. She said she would ensure MDS completed assessments timely going forward.Record review of the facility's policy titled Resident assessment dated 2003 reflected, .The facility will examine each resident and review the minimum data set expanded core elements specified in RAI no less than once every three (3) months and as appropriate .

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 30 opportunities, resulting in a 6.67% percent medication error involving 1 of 4 residents (Resident #32) reviewed for pharmacy services. LVN B administered an incorrect dose of Novolog insulin (used to treat diabetes) to Resident #32 on 3/24/2026 during a medication pass.LVN B failed to administer a dose of Novolin R (used to treat diabetes) to Resident #32 on 3/24/2026 during a medication pass.These failures could place residents at risk for inaccurate drug administration resulting in decline in health and decreased quality of life.Findings included:Record review of an admission Record for Resident #32 dated 3/25/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (a decline in mental ability that can interfere with daily life), and diabetes mellitus.Record review of a Quarterly MDS Assessment for Resident #32 dated 1/17/2026 indicated he did not have any impairment in thinking with a BIMS score of 15. During the seven look back period he received insulin injections.Record review of a care plan for Resident #32 revised on 8/12/2025 indicated he had diabetes mellitus with interventions to give diabetic medications as ordered by doctor. Record review of active physician orders for Resident #32 dated 3/25/2026 indicated an order for Novolin R flex pan 100 unit/ml inject 25 units subcutaneously one time a day and an order for Novolog flex pen 100 units/ml per sliding scale: if 250-299=4 units; 300-349=6 units; 350-399=8 and to call the hospice agency. Record review of Resident #32's blood sugars (normal blood sugar ranges before meals range from 70-130):3/24/2026 4:16 pm blood sugar was 147.3/24/2026 7:50 pm blood sugar was 192.3/25/2026 6:58 am blood sugar was 207.During an observation on 3/24/2026 at 11:01 am, LVN B checked Resident #32's blood sugar and it was 255. LVN B said the resident would receive 25 units of Novolin R and would get 4 units of NovoLog per sliding scale for a total of 29 units. LVN B took the NovoLog flex pen out of the medication care and dialed it to 29 units. This Surveyor questioned LVN B about the dosage of insulin and she said the pen was for both insulins Novolog and Novolin R and administered 29 units of Novolog insulin to the resident.During an interview on 3/24/2026 at 1:30 pm, LVN B said she used one pen when she administered the insulin to Resident #32. She said the 4 units of Novolog (rapid acting insulin) should have been from his NovoLog pen instead of all being from the Novolin (short acting insulin) pen. She said the resident could have a reaction to the insulin if he was given the wrong dosage that could cause his blood sugar to drop. She said she should have looked at the MAR first and compared the orders before administering medications and she did not check the orders. She said she was not sure what happened that day and why she gave the resident 29 units of Novolog. She said the resident had a separate insulin pen for Novolin R in the medication cart. She said the resident's blood sugar could drop or get too high if the correct dose was not given.During an observation on 3/24/2026 at 1:35 pm, the medication cart that LVN B was assigned to for that day revealed 1 insulin pen for Novolog, 1 pen for Novolin R, and 1 pen for Lantus that were prescribed to Resident #32.During an interview on 3/25/2026 at 11:10 am, the DON said she had been employed at the facility for 2 weeks. She said staff should follow the rights of medications that included the right medication and dosage. She said she was made aware of the incident with Resident #32 when he received the wrong dose of insulin. She said they contacted the NP, made changes to his orders, and received new orders to check his blood sugar TID and prn. She said he had not had any issues since the incident with his blood sugar dropping or getting too high. She said she planned to in-service the staff and would provide a 1:1 education with LVN B. She said there was a risk for a resident's blood sugar to drop, or they might not receive enough insulin if not given the correct medication or dose.During an interview on 3/245/2026 at 10:31 am, the Pharmacy Consultant said she visited the facility every other month and her last visit was February 11, 2026. She said when she was at the facility she helped to destroy drugs, checked medication carts and rooms, observed a medication pass, and provided the facility with recommendations. She said when her visit was complete, she would send the facility a copy of her audit. She said Resident #32's order for insulin that included Novolin R and Novolog were both short acting insulins that both had similar onsets of actions including peak actions. She said Novolin R would act longer, but should not make a huge difference. She said she tried to make recommendations for the simplification of insulin regimens as it could make it difficult with room for errors if not. She said there was a risk for hypoglycemia but since both were short acting it would be less of a risk.During an interview on 3/25/2026 at 2:43 PM, the Administrator said staff should verify the correct medicine, dosage, the right resident, and should check to make sure the order was correct before administering any medicine. She said if residents were given too much insulin, their blood sugar could drop. She said they started an in-service with the staff and planned to provide LVN B with 1:1 education, and put a monitoring tool in place. She said the nurse called and notified everyone including the physician and an error report and they were told to monitor Resident #32.Record review of an Audit for LVN B dated 6/30/2025 indicated she was satisfactory with medication administration.Record review of the facility's policy titled Medication Discrepancies and Adverse medication reactions dated March 2025 indicated, .Medication discrepancies and adverse medication reactions are documented and reported to the residents' attending physician and designated personnel/committee of the facility .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food under sanitary conditions in 1 of 1 facility kitchens. There was expired coleslaw in a facility refrigerator. This failure could place residents who ate meals prepared in the kitchen at risk for food borne illness.Findings included: During an observation on 3/23/26 at 9:50 a.m. of facility refrigerator revealed a bag of coleslaw dated with the use by date of 3/20/26. During an interview on 03/24/26 at 11:30 a.m., [NAME] H said all kitchen staff were responsible for spot-checking and removing expired food from the refrigerators. [NAME] H said there was not any set schedule or assignment of who should be checking for expired food items and when they should be doing it. [NAME] H said there was no risk to residents if the coleslaw dated use by 3/20/26 had been served to residents. During an interview on 3/24/26 at 11:40 a.m., the DM said all kitchen staff were responsible for ensuring food in the refrigerator was properly labeled/dated and expired food to be removed. The DM said she didn't believe the food (coleslaw) in question was expired, only misdated. DM said the food was improperly dated when stored and presented no risk to residents if it had been served. During an interview on 3/25/26 at 12:37 p.m., the Administrator said the DM was responsible for supervision of the kitchen staff. The ADM said she was not sure what frequency the refrigerators were scheduled to be cleaned out, but she believed they were checked every day in the morning for expired items. The Administrator said the risk to residents would depend on the item and there was no risk from the coleslaw dated use by 3/20/26 if it had been served. Review of an undated facility policy titled Food Storage and Supplies indicated .Perishable items that are refrigerated are dated once opened and used within 7 days if they do not have an expiration date.

Based on observations, interviews, and records review, the facility failed to ensure handrails were firmly affixed to the wall in 1 of 2 shower rooms (East Unit shower room) reviewed for handrails. The facility failed to ensure a handrail in the shower room of the East Unit was securely affixed to the wall, it was observed to be loose and pulled away from the wall. This failure could place residents who use the shower room at risk for falls, injuries, and hospitalizations. Findings include: During an anonymous interview it was said she was concerned about a loose handrail in the shower of the East Wing shower room. They said a resident attempted to hold the rail, and it pulled away from the wall. During an observation on 3/24/26 at 2:10 p.m., of the shower room on the East Unit 1 of 2 shower stalls being used for resident showers had a shower handrail which was pulled away from and not firmly affixed to the wall. During an interview on 3/24/26 at 2:15 p.m., CNA C said she was unaware there was a loose shower handrail. CNA C said staff normally would submit a repair request by scanning a QR code which creates a maintenance request, but the facility had no maintenance man on staff. CNA C said there had been no maintenance man for approximately 1 week. CNA C said a loose handrail could cause a resident to fall. During an interview on 3/24/26 at 2:20 p.m., CNA F said she knew the shower rail was broken and had reported it using the maintenance repair request electronic form. CNA F said there was no maintenance man currently at the facility, so no repairs were made. CNA F said the shower rail had been broken for about a week. CNA F said she did not use that shower stall for residents due to the loose shower rail. CNA F said a loose handrail could cause a resident to fall. During an interview on 3/25/26 at 12:37 p.m., the ADM said she was unaware of the loose shower rail until that previous day. The ADM said she repaired the handrail herself because the facility had no maintenance director currently. The ADM said if staff were submitting tickets through the electronic reporting system she would not know about it because she had no access to the system. The ADM said a loose shower rail could be a fall risk but added residents were always showered under supervision of staff and most utilized a shower chair and did not stand to use the rail. The ADM said going forward she had interviews scheduled to hire a new maintenance director and she would continue to work with corporate maintenance to repair big issues in the facility. The ADM said she was working on minor issues herself and would ensure staff reported issues to her directly and not use the reporting system. Review of an undated facility policy titled Resident Rights indicated .The resident has a right to be treated with respect and dignity, including: .3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences .

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 staff (CNA C) reviewed for infection control.The facility failed to ensure CNA C washed or sanitized her hands when incontinent care was provided to Resident #2 on 3/24/2026.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #2 dated 3/25/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (a decline in mental ability that can interfere with daily life), GERD (acid reflux disease), and anxiety disorder (a persistent, excessive and uncontrollable fear, worry or dread that interferes with daily life).Record review of a Significant Change MDS Assessment for Resident #2 dated 2/26/2026 indicated she had severe impairment in cognition with a BIMS score of 0. She required substantial/maximal assistance with toileting hygiene. Her urinary continence was not rated but was always incontinent of bowel.Record review of a care plan for Resident #2 dated 10/18/2023 indicated she had bladder and bowel incontinence with interventions to check resident every two hours and assist with toileting as needed.During an observation on 3/24/2026 at 1:44 pm, CNA C took Resident #2 to the bathroom to provide incontinent care. CNA C placed gloves on her hands without washing or sanitizing them. She helped the resident to stand and positioned her on the toilet. Resident #2 urinated in the toilet. CNA C had the resident stand and used a wipe to clean the resident's perineal area from front to back and placed the wipe in the trash along with her gloves. CNA C applied gloves without washing or sanitizing her hands and wiped the perineal area again with another wipe and placed the wipe in the trash. CNA C removed the glove from her left hand and placed it in the trash and applied a glove only to her left hand and wiped the resident again from front to back and placed the wipe in the trash. CNA C removed her gloves and put them in the trash and placed a brief on the resident without wearing any gloves and positioned the resident back in her wheelchair. CNA C washed her hands and wheeled the resident back into the hallway.During an interview on 3/24/2026 at 1:55 pm, CNA C said she should have washed her hands before care was started, and she forgot that she should have washed or sanitized her hands between glove changes. She said her hands were clean after she removed her gloves when she placed the brief on Resident #2, She said she had been employed at the facility for 26 years and her last skills check-off was about a month ago. She said there was a risk of infections if they did not wash or sanitize their hands when care was provided or wore gloves when care was provided. Record review of a CNA Proficiency Audit for CNA C dated 7/23/2025 indicated she was satisfactory with perineal care for a female resident.During an interview on 3/25/2026 at 11:10 am, the DON said hand hygiene included washing or sanitizing should be performed before care, during, and after care and between glove changes. She said if staff did not follow protocol there was a risk of infections if they did not. She said staff should wear gloves when incontinent care was provided to the residents.During an interview on 3/25/2026 at 2:43 pm, the Administrator said staff should perform hand hygiene before and after. She said she expected her staff to follow policy and procedures as there was a risk of infections with not performing hand hygiene appropriately.Record review of a facility policy titled Fundamentals of Infection Control Precautions undated indicated, .Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: when coming on duty; after removing gloves .

Based on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 1 smoking areas.The facility failed to keep cigarette butts out of a trash can designated for trash.This failure could place residents at risk for injury, burns, and an unsafe smoking environment. Findings include:During an observation and interview on 3/24/2026 at 9:01 am, the smoking area had a trash can with a plastic liner with cigarette butts and trash. There was a red smoking can with a lock and it was indicated for the cigarette butts. Five residents were present with CNA K who were outside smoking. CNA K said when the residents were finished smoking, she would empty the ash trays into the red smoking can. She said staff were supposed to empty the ash trays after each break. CNA K observed the trash can and she said it had cigarette butts with trash and the butts should not be in the trash. She said there was a risk of residents going into the trash and getting them or there could be a risk of fire. She said Maintenance was responsible for emptying the red smoking cans, but they did not have a Maintenance Supervisor at the present time. During an interview on 3/25/2026 at 10:20 am, the HSK Supervisor said Maintenance was normally responsible for emptying the ashtrays into the red smoking cans, but he was terminated as of last week. She said she started checking the red cans this week and had a key to it. She said the cigarette butts go in the ash trays and at the end of smoke break they were emptied into the red cans. She said cigarette butts should never be placed in the trash as there could be a risk for fires.During an interview on 3/25/2026 at 2:43 pm, the Administrator said they had a resident that liked to empty the ashtrays into the trash. She said the person who supervised the smokers during the break should empty them into the red smoking can and going forward they would empty the ashtrays into the butt can (red smoking can). She said the previous Maintenance Supervisor was responsible for checking emptying the ash trays. She said the red can had a lock. She said after each smoke break the ashtrays were emptied into the red can. She said cigarette butts should not be placed in the trash as it was a risk of fires.Record review of a facility policy titled Smoking Policy undated indicated, .4. Ashtrays of noncombustible materials and safe design will be provided in all areas where smoking is permitted. Ashtrays will be a metal container with a self-closing cover device into which ashtrays may be emptied .

Based on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative where there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 6 residents (Resident #43) reviewed for resident rights.The facility failed to inform Resident #43's responsible party when she fell on 3/23/2026. This failure could place residents at risk of not having family members or representatives notified of changes in condition and allowing them to participate in care decisions.Findings Include: Record review of Resident 43's face sheet, dated 3/24/2026, indicated Resident #43 was a [AGE] year-old female, admitted [DATE], with diagnosis of dementia. Record review of Resident #43's quarterly MDS assessment, dated 02/06/2026, revealed a BIMS score of 01 that indicated Resident #43 had severely impaired cognition. She required minimal assistance with ADLs. Record review of Resident #43's comprehensive care plan, revision date 02/17/2026, indicated Resident #43 was a fall risk. Record review of a grievance note dated 3/19/2026 indicated Resident #43's family filed a grievance with concerns around interventions to address recent falls and results of recent tests performed. Record review of Resident #43's fall event note dated 3/23/2026 indicated Resident #43's family was not notified of her fall. During an interview on 03/23/2026 at 3:40 pm, Resident #43's family member said the nurse had not called about the fall that morning, and that happened in the past when she would have falls or changes in her condition. During an interview on 3/23/2026 at 2:16 pm, LVN D said that she was assigned to the west side of the facility as the charge nurse. She said CNA A told her about Resident #43's fall at 7:50 am, and she assessed her. She said she notified the doctor but had not called the family. She said there was only her and another nurse on the other side, and it was difficult for her to do everything in a timely manner. She said the family had the right to be kept aware of the resident changes. During an interview on 3/23/2026 at 4:33 pm, the DON said that she was new to the position for one week. She said that with each incident the doctor and the family should be notified as soon as the resident was safe. She said the family had the right to know what had happened, and what the plan would be going forward to prevent further incidents. During an interview on 3/23/2026 at 4:45 pm, the Administrator said anytime an incident occurred with a resident, the nurse should be notifying the family. She said that falls should be reviewed in the morning meeting and nurse management should review that all things were put in place and proper notification occurred. She said that families should always be kept informed of any changes and expected the staff to follow the facility's policy for resident rights. Record review of the Nurse Proficiency Audit for LVN D dated 2/20/2026 indicated LVN D was proficient in resident rights and documentation. Record review of an undated facility policy titled Notifying the Physician of Change in Status indicated, .5. The resident' s family member or legal guardian should be notified of significant change in resident' s status unless the resident has specified otherwise.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 staff (CNA C) and 1 of 5 residents (Resident #2) reviewed for infection control. The facility failed to ensure CNA C changed gloves and performed hand hygiene during Resident #2's incontinent care. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include:Record review of the face sheet dated 8/8/25 indicated Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, dementia, anxiety, and hypertension (elevated blood pressure). Record review of the MDS dated [DATE] indicated Resident #2 usually understood others and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 05 and was severely cognitively impaired. The MDS indicated Resident #2 was dependent for toileting. Record review of the care plan last revised 4/3/25 indicated Resident #2 had an ADL self-care performance deficit with intervention including requiring extensive assistance of 2 staff members for toileting. During an observation on 8/8/25 at 1:32 p.m. CNA C performed a mechanical lift (a device designed to safely move individuals with limited mobility from one position to another, reducing risk of injury to both the patient and caregiver) transfer and incontinent care with assistance from CNA D on Resident #2. CNA C had gloves on when surveyor entered Resident #2's room. After CNA C transferred Resident #2 to her bed, she did not change her gloves or perform hand hygiene. CNA C pulled down Resident #2's pants and opened her brief. CNA C did not change gloves or perform hand hygiene. CNA C used disposable wipes to wipe Resident #2's pelvic and vaginal area. CNA C and CNA D rolled Resident #2 on her side and CNA C rolled the wet brief and mechanical lift pad up. CNA C did not change her gloves or perform hand hygiene. CNA C used disposable wipes to wipe Resident #2's bottom. CNA C did not change gloves or perform hand hygiene. CNA C put clean brief under Resident #2. CNA C and CNA D rolled Resident #2 on to her other side. CNA D removed the rolled up wet brief and mechanical lift pad and bagged the items in separate trash bags. CNA C rolled Resident #2 back on to her back and fastened the clean brief. CNA C changed Resident #2 into clean clothing. During an interview on 8/8/25 at 1:50 p.m. CNA C said gloves should be changed when providing care and going from dirty to clean or from one area to another. CNA C said she probably should have changed her gloves after transferring Resident #2 and before starting incontinent care. CNA C said she should have changed her gloves after wiping Resident #2 and before putting on a clean brief. CNA C said she did not change her gloves or perform hand hygiene while providing care because she was nervous with the surveyor watching her. CNA C said the importance of changing gloves and proper hand hygiene was to prevent the spread of bacteria and for infection control. During an interview on 8/13/25 at 11:15 am the DON said during incontinent care she expected staff to change their gloves and perform hand hygiene after removing the dirty brief and cleaning the resident prior to putting on a clean brief and changing the resident into clean clothes. The DON said she expected staff to change gloves and perform hand hygiene after performing a mechanical lift transfer and prior to providing incontinent care. The DON said the importance of changing gloves and performing hand hygiene was to prevent cross contamination and for infection control. Record review of the facility's undated Fundamentals of Infection Control Precautions policy indicated, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility.Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene.Before and after assisting a resident with toileting.After handling soiled or used linens, dressings, bedpans, catheters, and urinals.After removing gloves or aprons.Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections. Record review of the facility's Perineal (the area of skin and tissue between the vulva (the external female genital organs) (in females) or scrotum (in males) and the anus) Care policy dated 4/25/22 indicated, An incontinent resident of urine and/or bowl should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible.Procedure Content.Start: 10. Perform Hand Hygiene 11. [NAME] (put on) gloves and all other PPE per standard precautions.Back.21. Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area.24. Doff (take off) gloves and PPE 25. Perform Hand Hygiene. Conclude: 26. Provide resident comfort and safety by re-clothing (if applicable-incontinence pad(s) and briefs), straightening bedding, adjusting bed and/or side rails, and placing call light within resident's reach.

Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 1 residents (Residents#1) reviewed for grievances. The facility did not ensure the grievance dated 4/26/25 regarding Resident #1's showers was resolved. This failure could place resident at risk for grievances not being addressed or resolved promptly.Findings included: Record review of the face sheet dated 8/8/25 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hemiplegia (muscle weakness or partial paralysis on one side of the body), diabetes, contracture (a structural change in the body's soft tissues, like muscles, tendons, ligaments, or skin, that causes them to stiffen and shorten) of the left hand, and hypertension (elevated blood pressure). Record review of the MDS dated [DATE] indicated Resident #1 was usually understood by others and sometimes understood others. The MDS indicated Resident #1 had a BIMS of 99 indicating he was unable to complete the interview. The MDS indicated Resident #1 required substantial/maximum assistance with personal hygiene and bathing. Record review of the care plan last revised 5/5/25 indicated Resident #1 had an ADL self-care performance deficit with interventions including charge nurse is to monitor to ensure shower is given on scheduled shower days and PRN. Record review of the Resident Grievance Report dated 4/26/25 indicated Resident #1's family had filed a grievance regarding Resident #1 appearing not to have received a shower in several days as evidenced by noticeable body odor and foul odor to his contracted hand. The Resident Grievance Report indicated the corrective action taken was the CNA (no name specified) was instructed to shower the resident and the nurses were instructed to provide hand hygiene at this time. The Resident Grievance Report indicated the charge nurse would monitor every Tuesday, Thursday, and Friday to ensure adequate showers were given. The Resident Grievance Report indicated the grievance was resolved. Record review of Resident #1's Documentation Survey Reports dated May 2025, June 2025, and July 2025 indicated Resident #1 was scheduled for showers on Tuesdays, Thursdays, and Saturdays. The Documentation Survey Report indicated: May 2025-Resident #1 was scheduled for 14 showers and did not receive 7 of the 14 scheduled showers. Resident #1 did not receive his showers on 5/1/25, 5/3/25, 5/6/25, 5/8/25, 5/20/25, 5/24/25, and 5/27/25. June 2025-Resident #1 was scheduled for 12 showers and did not receive 6 of the 12 scheduled showers. Resident #1 did not receive a shower on 6/3/25, 6/5/25, 6/7/25, 6/10/25, 6/17/25, or 6/19/25 July 2025-Resident #1 was scheduled for 14 showers and did not receive 10 of the 14 scheduled showers. Resident #1 did not receive a shower on 7/1/25, 7/3/25, 7/5/25, 7/8/25, 7/10/25, 7/12/25,7/19/25, 7/22/25, 7/26/25, or 7/29/25. During an interview on 8/8/25 at 3:16 p.m. Resident #1's Family said Resident #1 was still not receiving his scheduled showers even after they filed a grievance regarding him not receiving showers on 4/23/25. Resident #1's Family said she was ensured by facility staff (name unknown) this issue would be resolved when she filed the grievance but has not seen any change. Resident #1's Family still had noticeable body odor when she visits. During an interview on 8/13/25 at 9:40 a.m. LVN A said he was familiar with Resident #1. LVN A said he had been given instruction regarding monitoring to ensure residents received their showers. LVN A said monitoring of showers was done by CNAs completing shower sheets and the nurses signing the shower sheets. During an interview on 8/13/25 at 9:55 a.m. the DON said showers were documented in the electronic medical records. The DON said Resident #1's family would occasionally give him his showers. The DON said the CNAs did not document when the family gave Resident #1 his showers. The DON said the only place showers were documented was in the electronic medical records. The DON said some CNAs used to fill out paper showers sheets, but she had not seen any paper shower sheets in a long time. The DON said if a date of a scheduled shower was left blank then it meant the shower was not provided or not documented. The DON said there was not a way to prove a shower was given if it was not documented. The DON said if 8, 8 was documented on a scheduled shower day it indicated activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity. The DON said there was no way to differentiate whether or not the activity occurred or the care was provided by non-facility staff. The DON said nurses monitored to ensure showers were given with paper showers sheets, visually, verbally, and in the electronic medical records. During an interview on 8/13/25 at 10:38 a.m. the DON said they had looked and could not find any paper shower sheets for Resident #1. During an interview on 8/13/25 at 10:57 a.m. the SW said when a grievance came to her she wrote up the complaint in the electronic medical records and distributed it to the appropriate department. The SW said she usually followed-up in 1-2 days to see if the grievance had been resolved. The SW said she ensured a grievance has been resolved by speaking with the staff responsible for the grievance, ensuring there had been a response entered into the electronic medical records, and speaking with the resident/resident family. The SW said if the grievance was not resolved she would then elevate the issue to the Administrator. The SW said regarding the grievance on 4/26/25 about Resident #1 not receiving his showers that he had been receiving bed baths since the grievance had been filed. The surveyor pointed out that neither showers or bed baths were being documented as having been provided. The SW said if showers or bed baths were not documented it could not be proven they were being provided to Resident #1. The SW said the importance of ensuring grievances were addressed was to ensure issues were resolved and because residents' rights need to be respected. Record review of the facility's Grievances policy last revised 11/2/16 indicated, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal.The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have.The grievance official of this facility if the Administrator or their designee. The grievance official will: Oversee the grievance process, Receive and track grievances to their conclusion, Lead any necessary investigations by the facility.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 1 of 5 (Resident #1) residents reviewed for ADLs. The facility failed to ensure Resident #1 received his scheduled showers in May 2025, June 2025, and July 2025 These failures could place residents at risk of not receiving services/care and decreased quality of life.Findings Include: Record review of the face sheet dated 8/8/25 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hemiplegia (muscle weakness or partial paralysis on one side of the body), diabetes, contracture (a structural change in the body's soft tissues, like muscles, tendons, ligaments, or skin, that causes them to stiffen and shorten) of the left hand, and hypertension (elevated blood pressure). Record review of the MDS dated [DATE] indicated Resident #1 was usually understood by others and sometimes understood others. The MDS indicated Resident #1 had a BIMS of 99 indicating he was unable to complete the interview. The MDS indicated Resident #1 required substantial/maximum assistance with personal hygiene and bathing. Record review of the care plan last revised 5/5/25 indicated Resident #1 had an ADL self-care performance deficit with interventions including charge nurse is to monitor to ensure shower is given on scheduled shower days and PRN. Record review of Resident #1's Documentation Survey Reports dated May 2025, June 2025, and July 2025 indicated Resident #1 was scheduled for showers on Tuesdays, Thursdays, and Saturdays. The Documentation Survey Report indicated: May 2025-Resident #1 was scheduled for 14 showers and did not receive 7 of the 14 scheduled showers. Resident #1 did not receive his showers on 5/1/25, 5/3/25, 5/6/25, 5/8/25, 5/20/25, 5/24/25, and 5/27/25. June 2025-Resident #1 was scheduled for 12 showers and did not receive 6 of the 12 scheduled showers. Resident #1 did not receive a shower on 6/3/25, 6/5/25, 6/7/25, 6/10/25, 6/17/25, or 6/19/25. July 2025-Resident #1 was scheduled for 14 showers and did not receive 10 of the 14 scheduled showers. Resident #1 did not receive a shower on 7/1/25, 7/3/25, 7/5/25, 7/8/25, 7/10/25, 7/12/25,7/19/25, 7/22/25, 7/26/25, or 7/29/25. During an interview on 8/13/25 at 9:40 a.m. LVN A said he was familiar with Resident #1. LVN A said he had been given instruction regarding monitoring to ensure residents received their showers. LVN A said monitoring of showers was done by CNAs completing shower sheets and the nurses signing the shower sheets. LVN A said he was not aware of Resident #1 refusing any showers. LVN A said the importance of residents receiving their scheduled showers was to maintain hygiene and for skin inspections. During an observation on 8/8/25 at 12:35 p.m. Resident #1 was lying in bed with the head of the bed elevated and sleeping. Resident #1 was observed to covered from feet to shoulders with a sheet and blanket. During an interview on 8/13/25 at 9:47 a.m. CNA B said he worked the 2:00 p.m. to 10:00 p.m. shift at the facility. CNA B said he was familiar with Resident #1. CNA B said he was not sure of what days were Resident #1's shower days but his showers were usually given early in the shift. CNA B said Resident #1 did not refuse showers. CNA B said showers were documented in the electronic medical records. CNA B said the facility had a paper shower schedule but there was not a place to check off on the paper shower schedule. CNA B said paper shower sheets were not filled out when showers were given. CNA B said all charting was done electronically. CNA B said facility CNAs provided showers to Resident #1 most of the time. CNA B said Resident #1's family provided his showers some of the time. CNA B the importance of resident receiving their scheduled showers was to maintain humanity, keep them comfortable, and for hygiene. During an interview on 8/13/25 at 9:55 a.m. the DON said showers were documented in the electronic medical records. The DON said Resident #1's family would occasionally give him his showers. The DON said the CNAs did not document when the facility gave Resident #1 his showers. The DON said the only place showers were documented was in the electronic medical records. The DON said some CNAs used to fill out paper showers sheets, but she had not seen any paper shower sheets in a long time. The DON said if a date of a scheduled shower was left blank then it meant the shower was not provided or not documented. The DON said there was not a way to prove a shower was given if it was not documented. The DON said if 8, 8 was documented on a scheduled shower day it indicated activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity. The DON said there was no way to differentiate whether or not the activity occurred, or the care was provided by non-facility staff. The DON said nurses monitored to ensure showers were given with paper showers sheets, visually, verbally, and in the electronic medical records. The DON said the importance of ensuring residents received their scheduled showers was for skin inspections, to reduce skin breakdown, cleanliness, and for the residents to just feel better overall. During an interview on 8/13/25 at 10:38 a.m. the DON said they had looked and could not find any paper shower sheets for Resident #1. During an interview on 8/13/25 at 11:15 a.m. the DON said Resident #1's family did not provide him showers 100% of the time and the dates documented 8,8 for bathing would indicate activity did not occur due to family not providing bathing 100% of the time as the documentation survey report indicates those are the 2 reason to document 8,8. Record review of the facility's undated Bath, Tub/Shower policy indicated, Bathing by tub bath or shower is done to remove soil, dead epithelial cells (a type of cell that forms the protective covering for the body's surfaces, cavities, and organs), microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation.The aging skin becomes dry, wrinkled, thinners, and blemished with various aging spots over time and is easily affected by environmental temperature and humidity, sun exposure, soaps, and clothing fabrics.Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed.The resident will receive assistance with bathing according to their resident centered plan of care.

Based on interview and record review, the facility failed to ensure the right to be free from any significant medication error was provided for 1 of 3 residents reviewed for significant medication errors. (Resident #1) The facility did not administer [MEDICATION NAME] ([MEDICATION NAME] (antipsychotic) 10mg (milligram) twice daily as prescribed by the physician from [DATE] through 01/7/20 for Resident #1. He received an extra 20mg of medication for 20 days. Resident #1 began to become difficult to arouse and was sent to the hospital on [DATE] and was diagnosed with [REDACTED]. Findings included: A face sheet dated January 14, 2020 indicated Resident #1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A medication reconciliation note dated 10/29/19, indicated Resident #1 was to receive [MEDICATION NAME] 20mg tablet one-half tablet by mouth twice a day for [MEDICAL CONDITION]. A physician after-visit summary report dated 11/05/19 indicated Resident #1 was to receive [MEDICATION NAME] 10 mg by mouth twice a day for [MEDICAL CONDITION]. The report indicated **Must be blister packed for nursing home** A Follow-up appointment was indicated to be on [DATE] at 2:30 p.m. A care plan dated 10/09/19 indicated Resident #1 was PASRR (Preadmission Screening and Resident Review) positive for mental impairment and required [MEDICAL CONDITION] medication [MEDICATION NAME] ([MEDICATION NAME]) for [DIAGNOSES REDACTED]. The goal indicated Resident #1 would be/remain free of drug related complications, including cognitive/behavioral impairment. Interventions included educate family and caregivers about risks, benefits, and the side effects. An MDS dated [DATE] indicated Resident #1 had clear speech, sometimes understood others and was usually understood. The MDS indicated Resident #1 required supervision and 1- person assistance with walking in his room and the corridor, supervision and set-up help only with locomotion, and limited 1-person assistance with eating. The December 2019 MAR indicated [REDACTED] The January 2020 MAR indicated [REDACTED] A weekly nursing summary report dated 12/26/19 indicated Resident #1 walks without assistance and was able to express ideas and wants. An SBAR (Situation, Background, Assessment, Recommendation) form dated 01/07/20 indicated Resident #1 had a functional status change of decreased mobility. Symptoms or signs indicated: not waking up, tried sternal rub and resident will not awaken. Resident #1 was sent out to the hospital per family request at 1:00 p.m. A medication error form dated 01/13/20 at 1:30 a.m., indicated: transcription error starting [DATE] by the DON. The description on the incident report stated: I put in the order for [MEDICATION NAME] 20 mg into the computer. I read the order wrong. A hospital physician discharge summary dated 1/14/20 indicated Resident #1's was hospitalized from [DATE] to 1/14/20, his [DIAGNOSES REDACTED]. Resident #1 discharged on [MEDICATION NAME] ([MEDICATION NAME] (antidepressant), the [MEDICATION NAME] was discontinued. A psychiatry progress note dated [DATE] indicated Resident #1 presented with AMS (altered mental status), UTI (urinary tract infection), somnolence, and rigidity after receiving [MEDICATION NAME] 20mg BID (twice a day) in nursing home and was admitted for serotoni[DIAGNOSES REDACTED] and potential NMS ([DIAGNOSES REDACTED]). Psychiatry was consulted for AMS. The note indicated evidence of rigidity (decreased) and mild tremor on exam. Within the last 24hrs temperature ranged between 99.2-101.1 F (Fahrenheit) (temperature max 101.7 on admission), BP (blood pressure) between [AGE]-166/55-129 (normal range systolic 90-120 and diastolic [AGE]-90), HR (heart rate) 71-103 (normal [AGE] to 100), and WBC 5.5 which was down trending from 11.1 on admission. The CK ([MEDICATION NAME] kinase) muscle cells in your body need CK to function) was 4711 down from [AGE]59 on admission (normal range 22-233). The note indicated Resident #1's preliminary [DIAGNOSES REDACTED]. The note indicated a recommendation to continuing [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) regimen until tremor/rigidity resolve. The noted A neurology consult note dated 1/8//20 indicated Resident #1 was admitted to the hospital after his wife found him slumped over and unresponsive. The note indicated the wife also noted tremulous (shaking or quivering slightly) movements of his hands that could represent [MEDICAL CONDITION] activity. On admission the UA (urinary analysis) showed Resident #1 was positive for Leukocyte esterase (test to detect white blood cells in the urine), WBC (white blood cells) in the urine was 54 (range 0-10), and moderate bacteria was noted, antibiotics were started. Resident #1's WBC (white blood count) on admission was 11.1 (normal range 4.5-11.0). During an interview on 1/14/20 at 10:50 a.m., the DON said, on this particular order she messed up. She said the medication aide administered the wrong medication, but she is the one that put the orders in the computer. The DON said Resident #1 received more medication then what he was supposed to receive. She said the medication was the [MEDICATION NAME] ([MEDICATION NAME]). She said Resident #1 was supposed to get 10 mg twice a day but was administered 20 mg twice a day. The DON said she discovered the error 01/13/20 when Resident #1's wife called and said that he had been getting the wrong dosage since [DATE] when there was a change in the order. The DON said Resident #1 was almost unresponsive, not answering questions, slow to respond, and would not follow commands when he was sent out on 01/07/20. During an interview on 1/14/20 at 11:19 a.m., LVN A said on 01/07/20 Resident #1 was leaning over on the table in the unit and she thought he was sleeping. She said she checked the order and she went to the DON and ask her about the medication. LVN A said she did not know anything was wrong because Resident #1 just looked tired. LVN A said she tried to talk to Resident #1 and he was slow to answer and looked tired. During an interview on 1/14/20 at 1:46 p.m., CNA B said on 01/07/20, Resident #1 was sleepy, like he did not want to move. She said he usually fed himself, but it was hard to. CNA B said Resident #1 would usually walk without assistance but needed assistance, he was talking, but not like normal, and he could not stand in the bathroom. CNA B said she thought Resident #1 was just sleepy. During an interview on 1/14/20 at 2:29 p.m., the DON said she did not know why she changed the order on [DATE], and she cannot find the VA summary report for [DATE] with an order change. The DON said she changed the order in the computer. During an interview on 1/14/20 at 3:27 p.m., the DON said she checks behind the nurses regarding medication administration. She said the nurse consultant comes once a month and randomly pulls files to review. The DON said nobody checks behind her, and it is her job to check behind the nurses. A Medication Administration Procedures policy revised 10/25/17 indicated 20. The five rights of medication should always be adhered to: 1. Right drug 2. Right dose 3. Right resident 4. Right time 5. Right route

Based on interview and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents reviewed for accidents. (Resident #1) The facility did not provide the required one person assistance for Resident #1's transfer. Resident #1 fell while attempting to transfer alone, receiving a [MEDICAL CONDITION]. Finding included: A Face sheet dated 09/18/18 indicated Resident #1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan initiated 11/21/16 and revised 10/26/17 indicated Resident #1 required one staff member to assist with transfers and walking. An MDS dated [DATE] indicated Resident #1 was ambulatory who required a one-person and used a walker as a mobility device. Resident #1 was a limited assistance who required a one-person physical assist with transfers. Resident #1 had severely impaired cognition. During an interview on 09/18/18 at 2:14 p.m., the dietary manager said Resident #1 was sitting in the dining room after lunch and requested to go to bed. The dietary manager said she walked with Resident #1 back to her room and left Resident #1 standing by her bed with her walker. The dietary manager said she asked a MA if Resident #1 required assistance and the MA said no. The dietary manager said she left Resident #1 unattended in her room and walked out. She said as she walked down the hallway, she heard a noise from Resident #1's room. She said she went back to Resident #1's room and found the resident lying on the floor with her walker out of reach. The DM said there were no staff in the room to assist Resident #1 to bed before the fall or at the time of the fall. Nursing notes dated 09/05/18 at 1:42 p.m. indicated Resident #1 was in her room on the floor with her walker on the floor. The notes indicated Resident #1 said she lost her balance when she walked away from her walker and fell on the floor. During an interview on 09/18/18 at 9:07 a.m., LVN A said Resident #1 had a fall during her shift. LVN A said she assessed Resident #1 immediately after the incident and Resident #1 moved all extremities and denied pain. LVN A said her and another staff assisted Resident #1 to a shower chair. During an interview on 09/18/18 at 3:30 p.m., RN B said on 09/05/18 Resident #1 had a fall on the previous shift. RN B said Resident #1 complained of pain to her right hip between 4:30 p.m. and 5:00 p.m. and was administered Tylenol. RN B said Resident #1 got sick and was cleaned up by the DON. RN B said she was called to Resident #1's room and the DON instructed her to call the physician and she received an order for [REDACTED]. Nursing notes dated 09/05/18 at 4:35 p.m. indicated Resident #1 complained of pain to her lower extremity at her thigh and hip area. Resident #1 was assessed with [REDACTED]. Nursing notes dated 09/05/18 at 7:13 p.m. indicated Resident #1 had an order for [REDACTED]. An x-ray dated 09/05/18 indicated Resident #1 had an acute minimally displaced right femoral neck fracture. Nursing notes dated 09/05/18 at 9:49 p.m. indicated the facility was notified of Resident #1's x-ray result and Resident #1 was transferred to the hospital. During an interview on 09/18/18 at 3:48 p.m., the DON said Resident #1 had an unwitnessed fall and had a right femoral neck fracture. The DON said Resident #1's MDS and care plan indicated the resident required one staff member to assist during transfers; however, the facility did not follow the MDS or care plan. The DON said all nursing staff had access to residents' care plans when they logged into the facility's electronic charting.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to main the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive plan of care for 1 of 5 residents reviewed for quality of care. (Resident #1) The facility did not prevent Resident #1 from becoming infected with bed bugs and pubic lice. Resident #1 complained for approximately a month of itching and discomfort; however, the facility did not assess him or notify the physician. The resident was sent to the hospital for shortness of breath and was found infested with lice and bed bugs and bites with pustules. Resident #1's roommate, Resident #2, had casings of bed bugs found in his mattress. This failure could place the 28 residents who resided on the West Hall at risk for skin issues, pain, discomfort, and emotional distress. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 understood others and made his needs know. Resident #1 did not have behavioral symptoms. He required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and he was dependent on staff for baths. He was incontinent of bowel and bladder. Resident #1 had no issues related to skin. A care plan dated 04/03/17 indicated Resident #1 was at risk for altered skin integrity and interventions included to monitor, document, and report to the physician any changes in skin status. Resident #1 had a self-care deficit and required assistance with ADLs (activities of daily living). A skin assessment dated [DATE] indicated Resident #1 had redness to his perineal area. Nursing notes dated 04/29/17 at 10:31 a.m. indicated Resident #1 was sent to the emergency room (ER) for shortness of breath. Hospital records dated 04/29/17 indicated Resident #1 had a pustule on his penis and a pustule on his scrotum when he arrived to the ER. Hospital records dated 04/30/17 indicated Resident #1 was found to have pubic lice and bed bugs all over his body when he came in to the ER from the nursing facility on 04/29/17. His pubic area had to be shaved to facilitate the clearing of the parasitic infestation. During an observation and interview on 05/04/17 at 1:14 p.m., Resident #1 was at the local hospital. He said when he went to theER on [DATE] and hospital staff saw that he was infested with bed bugs and pubic lice. He said hospital staff had to shave his pubic hair. He said he was embarrassed. He said he told several facility staff for about a month that he was itching and they did not do anything for him. He said he had bites on his back, legs, arms, and underarms when he came to theER on [DATE]. He said the bites on his skin have healed since being in the hospital. Resident #1 said he was upset with the facility because of the condition he was in when he came to the hospital on [DATE]. He said the facility ignored him when he told them he was itching and did not assist him with showers. He said he was pushed into the shower room and left alone to bathe. He said he was unable to bend over and see his perineal area and had no idea he had bugs on him. He said he did not want to go back to the facility even after being there for 9 years. During an interview on 05/04/17 at 1:29 p.m., the ER RN said Resident #1 came to theER on [DATE] for shortness of breath and when she listened to his lungs with her stethoscope; a bug ran across the back of her hand. She said she noticed several bugs on Resident #1. She said her and another nurse suited up in a silver-gray jump suit similar to a hazmat suit that covered them from head to toe to treat the resident for bugs. She said she cut Resident #1's clothes off and bugs were crawling all over the resident. She said Resident #1 was infested with pubic lice and she had to shave the resident's pubic area because Resident #1 had so many nits in his hair. She said Resident #1 had bugs in his hair on his head too. She said Resident #1 had bites on his back, groin, underarms, and legs. She said Resident #1 had pustules on his pubic area and the ER physician said that it was from the bugs burrowing in the resident's skin. During an interview on 05/04/17 at 10:22 a.m., the treatment nurse said she assessed Resident #1's skin on 04/28/17 and he had redness to his perineal area. She said when she assessed Resident #1's skin, she was looking for pressure areas and not bugs. She said she did not look through the resident's hair for bugs or nits. She said residents on Resident #1's hall received a skin assessment for bugs after they were notified by the hospital of Resident #1's bug infestation. During an interview on 05/05/17 at 11:09 a.m., LVN H said Resident #1 complained about itching all over his body for at least a month. She said Resident #1 had several medication changes and she thought his medications caused his itching. During an interview on 05/04/17 at 9:59 a.m., Resident #2 said he was Resident #1's roommate. He said Resident #1 complained to staff that he was itching. He said he heard Resident #1 complain of itching to the staff for about a month. During an observation and interview on 05/05/17 at 12:10 p.m., a flesh colored specimen with brown center was removed from the Resident #2's pubic hair by the treatment nurse. The treatment nurse said it looked suspicious as a bug. During an interview on 05/04/17 at 9:31 a.m., CNA A said Resident #1 complained of itching and he had redness to his perineal area. She said she did not see any bites on his skin. She said she applied barrier cream to his peri-area. She said did not remember if she reported it to the nurse. During an interview on 05/04/17 at 4:07 p.m., CNA F said Resident #1 complained of itching and would scratch his buttocks. She said she did not tell the nurse and applied barrier cream to his bottom. During an interview on 05/04/17 at 9:38 a.m., CNA B said Resident #1 complained of itching, but she did not see that he had bites on his skin. She said she applied barrier cream to his perineal area. She said did not remember if she reported it to the nurse. During an interview on 05/04/17 at 9:53 a.m., CNA C said Resident #1 complained of itching all over his body. She said she thought the itching was caused by his medications. She said did not remember if she reported it to the nurse. During an interview on 05/04/17 at 11:32 a.m., CNA D said Resident #1 complained of itching to her. She said she told the nurse. She said did not remember if she reported it to the nurse. During an interview o 05/05/17 at 10:57 a.m., MA G said Resident #1 complained to her that he thought something was crawling all over his body. She said she thought it was caused by his medications. She said did not remember if she reported it to the nurse. During an interview on 05/04/17 at 10:53 a.m., the DON said the hospital contacted the facility when Resident #1 went to theER on [DATE] and told them that Resident #1 had bed bugs. The DON said they called pest control to treat the room. He said the pest control technician said there were no signs of bed bugs in Resident #1's room. He said they threw away Resident #1 and #2's mattresses even though there were no signs of bed bugs. He said they searched the rooms on Resident #1's hall, but did not search all the rooms in the facility. A pest control treatment sheet dated 04/29/17 indicated that signs of bed bugs were found in Resident #1 and #2's room. During an interview on 05/05/17 at 2:49 p.m., the pest control technician said he came to the facility on [DATE] and treated Resident #1's room for bed bugs. He said Resident #1 and #2's mattresses had cracks in them. He said he found signs of bed bugs in Resident #2's mattress. He said he did not treat the room for lice. During an interview on 05/05/17 at 11:00 a.m., Housekeeper K said she used no specialized precautions or services to clean Resident #1 and #2's room and had never been told any were needed. She said she was not trained on infection control, pest control, or cross contamination practices. During an interview on 05/05/17 at 3:11 p.m., the administrator said when Resident #1 went to the hospital on [DATE]; hospital staff called her and notified her that Resident #1 came to the hospital with bed bugs and lice. The facility roster dated 05/05/17 indicated 28 residents resided on the West Hall.

Based on observation, interview, and record review, the facility failed to provide a sanitary and comfortable environment for 2 of 5 residents reviewed for environmental conditions. (Resident #1) The facility did not prevent Resident #1 from becoming infected with bed bugs and pubic lice. Resident #1 complained for approximately a month of itching and discomfort. The resident was sent to the hospital for shortness of breath and was found infested with lice and bed bugs and bites with pustules. Resident #1's roommate, Resident #2, had casings of bed bugs found in his mattress. This failure could place the 28 residents who resided on the West Hall at risk for skin issues, unsanitary environment, and discomfort. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 understood others and made his needs know. Resident #1 did not have behavioral symptoms. He required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and he was dependent on staff for baths. He was incontinent of bowel and bladder. Resident #1 had no issues related to skin. A care plan dated 04/03/17 indicated Resident #1 was at risk for altered skin integrity and interventions included to monitor, document, and report to the physician any changes in skin status. Resident #1 had a self-care deficit and required assistance with ADLs (activities of daily living). A skin assessment dated [DATE] indicated Resident #1 had redness to his perineal area. Nursing notes dated 04/29/17 at 10:31 a.m. indicated Resident #1 was sent to the emergency room (ER) for shortness of breath. Hospital records dated 04/29/17 indicated Resident #1 had a pustule on his penis and a pustule on his scrotum when he arrived to the ER. Hospital records dated 04/30/17 indicated Resident #1 was found to have pubic lice and bed bugs all over his body when he came in to the ER from the nursing facility on 04/29/17. His pubic area had to be shaved to facilitate the clearing of the parasitic infestation. During an observation and interview on 05/04/17 at 1:14 p.m., Resident #1 was at the local hospital. He said when he went to theER on [DATE] and hospital staff saw that he was infested with bed bugs and pubic lice. He said hospital staff had to shave his pubic hair. He said he was embarrassed. He said he told several facility staff for about a month that he was itching and they did not do anything for him. He said he had bites on his back, legs, arms, and underarms when he came to theER on [DATE]. He said the bites on his skin have healed since being in the hospital. Resident #1 said he was upset with the facility because of the condition he was in when he came to the hospital on [DATE]. He said the facility ignored him when he told them he was itching and did not assist him with showers. He said he was pushed into the shower room and left alone to bathe. He said he was unable to bend over and see his perineal area and had no idea he had bugs on him. He said he did not want to go back to the facility even after being there for 9 years. During an interview on 05/04/17 at 1:29 p.m., the ER RN said Resident #1 came to theER on [DATE] for shortness of breath and when she listened to his lungs with her stethoscope; a bug ran across the back of her hand. She said she noticed several bugs on Resident #1. She said her and another nurse suited up in a silver-gray jump suit similar to a hazmat suit that covered them from head to toe to treat the resident for bugs. She said she cut Resident #1's clothes off and bugs were crawling all over the resident. She said Resident #1 was infested with pubic lice and she had to shave the resident's pubic area because Resident #1 had so many nits in his hair. She said Resident #1 had bugs in his hair on his head too. She said Resident #1 had bites on his back, groin, underarms, and legs. She said Resident #1 had pustules on his pubic area and the ER physician said that it was from the bugs burrowing in the resident's skin. During an interview on 05/04/17 at 10:22 a.m., the treatment nurse said she assessed Resident #1's skin on 04/28/17 and he had redness to his perineal area. She said when she assessed Resident #1's skin, she was looking for pressure areas and not bugs. She said she did not look through the resident's hair for bugs or nits. She said residents on Resident #1's hall received a skin assessment for bugs after they were notified by the hospital of Resident #1's bug infestation. During an interview on 05/05/17 at 11:09 a.m., LVN H said Resident #1 complained about itching all over his body for at least a month. She said Resident #1 had several medication changes and she thought his medications caused his itching. During an interview on 05/04/17 at 9:59 a.m., Resident #2 said he was Resident #1's roommate. He said Resident #1 complained to staff that he was itching. He said he heard Resident #1 complain of itching to the staff for about a month. During an observation and interview on 05/05/17 at 12:10 p.m., a flesh colored specimen with brown center was removed from the Resident #2's pubic hair by the treatment nurse. The treatment nurse said it looked suspicious as a bug. During an interview on 05/04/17 at 9:31 a.m., CNA A said Resident #1 complained of itching and he had redness to his perineal area. She said she did not see any bites on his skin. She said she applied barrier cream to his peri-area. She said did not remember if she reported it to the nurse. During an interview on 05/04/17 at 4:07 p.m., CNA F said Resident #1 complained of itching and would scratch his buttocks. She said she did not tell the nurse and applied barrier cream to his bottom. During an interview on 05/04/17 at 9:38 a.m., CNA B said Resident #1 complained of itching, but she did not see that he had bites on his skin. She said she applied barrier cream to his perineal area. She said did not remember if she reported it to the nurse. During an interview on 05/04/17 at 9:53 a.m., CNA C said Resident #1 complained of itching all over his body. She said she thought the itching was caused by his medications. She said did not remember if she reported it to the nurse. During an interview on 05/04/17 at 11:32 a.m., CNA D said Resident #1 complained of itching to her. She said she told the nurse. She said did not remember if she reported it to the nurse. During an interview o 05/05/17 at 10:57 a.m., MA G said Resident #1 complained to her that he thought something was crawling all over his body. She said she thought it was caused by his medications. She said did not remember if she reported it to the nurse. During an interview on 05/04/17 at 10:53 a.m., the DON said the hospital contacted the facility when Resident #1 went to theER on [DATE] and told them that Resident #1 had bed bugs. The DON said they called pest control to treat the room. He said the pest control technician said there were no signs of bed bugs in Resident #1's room. He said they threw away Resident #1 and #2's mattresses even though there were no signs of bed bugs. He said they searched the rooms on Resident #1's hall, but did not search all the rooms in the facility. A pest control treatment sheet dated 04/29/17 indicated that signs of bed bugs were found in Resident #1 and #2's room. During an interview on 05/05/17 at 2:49 p.m., the pest control technician said he came to the facility on [DATE] and treated Resident #1's room for bed bugs. He said Resident #1 and #2's mattresses had cracks in them. He said he found signs of bed bugs in Resident #2's mattress. He said he did not treat the room for lice. During an interview on 05/05/17 at 11:00 a.m., Housekeeper K said she used no specialized precautions or services to clean Resident #1 and #2's room and had never been told any were needed. She said she was not trained on infection control, pest control, or cross contamination practices. During an interview on 05/05/17 at 3:11 p.m., the administrator said when Resident #1 went to the hospital on [DATE]; hospital staff called her and notified her that Resident #1 came to the hospital with bed bugs and lice. The facility roster dated 05/05/17 indicated 28 residents resided on the West Hall.