Every finding on record at Harborview Sarasota

Based on observation, review of facility policy, resident and staff interview, and record review, the facility failed to provide the necessary assistance as outlined in the resident's care plan and according to residents' preferences for 4 (Residents #1, # 2, #55 and #90) of 7 residents reviewed for activities of daily living (ADL's).The findings included:The facility policy Activities of Daily Living implemented 3/1/22 (revised 3/1/25) specified, The facility will, based on a residence comprehensive assessment and consistent with the resident's needs and choices, ensure a residence abilities in ADL's do not deteriorate unless deterioration is unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility will maintain individual objectives of the care plan and periodic review and evaluation. 1. On 3/30/26 at 1:27 p.m., Resident #1 was observed in his room in bed. In an interview, Resident #1 said he needed to have his nails trimmed and his facial hair shaved. He said he did not usually have a beard or mustache. Resident #1's nails were observed to extend approximately 1/2 inch with an accumulation of a brown substance under the nails. The resident was unshaven with approximately one week of facial hair growth. Review of the clinical record revealed Resident #1 had an admission date of 6/13/25 with diagnoses including chronic osteomyelitis (an infection in the bones), complete traumatic left ankle and foot amputation of two or more toes and chronic ulcer of part of the left foot. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/2/26 documented a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #1 had no cognitive impairment. The MDS indicated the resident required substantial to maximum assistance with personal hygiene, dressing, bathing and partial to moderate assistance with oral hygiene. Review of the care plan initiated 3/27/26 identified the resident needed assistance with grooming, bathing, and personal hygiene related to (r/t) mobility impairment non weight bearing on the right foot due to hospitalization and amputation of the right mid foot. The care plan interventions instructed staff to assist up and out of bed for all meals, as tolerated via resident. Bathing assist of (1). Bed mobility assistance of (1). Call bell within reach and reminders to use it as needed. Dressing assistance of (1). Eating assist of 1. Encourage choices with care. Monitor and report changes in physical functioning ability. Nail care as needed. Personal Hygiene assistance of (1). On 3/31/26 at 12:34 p.m., Resident #1 was observed in bed sleeping. He was unshaven with over a week of facial hair growth; His nails remained long with a black/brown substance under the nails. On 4/1/26 at 8:26 a.m., Resident #1 was observed sitting up in bed. A Certified Nursing Assistant (CNA) came in with the morning meal, set up the resident's tray up and left the room. On 4/1/26 at 8:29 a.m., a different CNA went into the resident's room and removed the untouched breakfast tray. Resident #1's roommate said they gave him a tray and then picked it back up. On 4/1/2026 at 8:32 a.m., in an interview, CNA Staff E, the resident's assigned said Resident #1 was able to feed himself and he ate very good today. CNA Staff E said residents are shaved once a week when they get a shower, the nails are cut and cleaned every week. On 4/1/26 at 9:45 a.m., in an interview, the Director of Nursing (DON) said some men want to be shaved every day, male residents should be shaved daily if needed and twice a week during showers. 2. On 3/30/26 at 12:00 p.m., Resident #55 was observed in his room in bed. The resident had approximately 3 days of facial hair growth. His fingernails extended approximately 1/4 inch with a black substance under the nails. In an interview, Resident #55 said he was not able to cut his own nails and the staff did not always come to help him; He lays in bed waiting. Review of the clinical record revealed Resident #55 was [AGE] years old with diagnoses including dementia, stage 3 chronic kidney disease, anxiety, edema, hypertensive heart disease, and major depressive disorder. Review of the Quarterly MDS with an ARD (Assessment Reference Date) of 12/29/25 revealed Resident #55 scored 05 on the BIMS, indicating severe cognitive impairment. The MDS noted the resident required substantial to maximum assistance with personal hygiene, bathing, and toileting. Review of Resident #55's care plan initiated on 11/2/21 identified he had an ADL self-care performance deficit related to fall with subacute hematoma, Dementia, unsteadiness on feet, history of visual hallucinations, immobility, history of repeated falls and incontinence. The care plan interventions included: Showers require substantial assistance.Dressing: Allow sufficient time for dressing and undressing. Dressing: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self. Personal hygiene/oral care: setup assist for oral care and substantial assist with personal hygiene. Review of the CNA documentation for March 2026 revealed Resident #55 received assistance with personal hygiene daily, including shaving. On 3/31/26 at 12:36 p.m., and on 4/1/26 at 9:01 a.m., observation of Resident #55 revealed he remained unshaven with 4 or more days of facial hair; his nails remained untrimmed, with a black substance under the nails. Resident #55's feet were observed to be dry, scaly and flaky. On 4/1/26 at 10:53 a.m., in an interview the Administrator said she was aware of the care concerns for Resident #1 but did not know about Resident #55. She said, We did nails yesterday but they could use cleaning. 3. On 3/30/26 at 1:53 p.m., Resident #90 was observed in bed. The resident's fingernails extended approximately 1/2 inch with a black/ brown substance under the nails. The resident's right-hand fingers were curled in a partially closed fist. No splinting device was observed in the resident's right hand. Review of the clinical record revealed Resident #90 was [AGE] years old with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (stroke) affecting the right dominant side, dementia and aphasia (impaired ability with language). Review of the Quarterly MDS with an ARD of 1/23/26 revealed Resident #90 was dependent for all ADLs and resident's decision making ability regarding tasks of daily life was severely impaired. Review of the care plan initiated 10/20/25 identified Resident #90 needed assistance with grooming, bathing, and personal hygiene related to self-care impairment. The care plan interventions included: Bathing assist of (2). Bed mobility assistance of (2). Dressing assistance of (2). Palm guard to right hand (prevents fingers from digging into the palm). Personal Hygiene assistance of (1). On 3/31/26 at 8:44 a.m., Resident #90 was observed in bed. The resident did not answer to interview questions. Her fingernails remained untrimmed with a black substance under the nails. Resident #90's right hand fingers were curled into a fist. The palm guard was not in place to the right hand. A foul odor was noted coming from the right hand. On 4/1/26 at 8:54 a.m., observation of Resident #90 revealed her fingernails remained untrimmed with the black substance under the nails. A foul odor was noted coming from the resident's right hand from three feet away. On 4/1/26 at 9:56 a.m., in an interview, the DON said nail care should be completed weekly and as needed. On 4/2/26 at 10:06 a.m., in an interview, CNA Staff D said she was assigned to Resident #90. She said the resident required total care. On 4/2/26 at 10:18 a.m., CNA Staff D and the DON were observed in Resident #90's room. The resident's bottom lip was sticking out and was coated with a thick, dry, brown substance. The DON verified the observation of the resident's lips and said, Her lips are dry. The DON instructed CNA Staff D to provide oral care to the resident. Record review for Resident #2 revealed an admission date of 4/23/25. Diagnoses included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side. Review of Quarterly MDS dated [DATE], revealed Resident #2 scored 13 on the BIMS, indicating of intact cognition. The MDS noted that Resident #2 It also needed set-up for eating and oral hygiene. Resident #2 was dependent for grooming. On 3/30/26 at 10:38 a.m., in an interview, Resident #2 she that her left arm was paralyzed from a stroke. She said that she was unable to clip her fingernails. She has asked staff to have them clipped, but it has not been done. Resident #2 said that staff did not help her to brush her teeth. She said she could not remember the last time her teeth were brushed. Observation of the resident during the interview revealed her fingernails extended beyond her fingertips. A white substance was observed at the gumline of her lower front teeth. On 3/30/26 at 1:38 p.m., Resident #2 was observed in bed. Her fingernails remained untrimmed. The white substance remained at the gumline of her lower front teeth. A meal tray was observed on the Resident #2's bedside table. An open hot dog roll topped with shredded brown meat and melted cheese was observed untouched on the tray. In an interview, Resident #2 stated that she was not able to pick up and eat the sandwich with one hand without spilling it all over herself. A review of Resident #2's care plan revealed the resident needed assistance with grooming, bathing, and personal hygiene related to mobility impairment and self-care impairment. The care plan specified the resident required the assistance of 1 for eating, and personal hygiene. On 3/31/26 at 9:27 a.m., and 3/31/26 at 12:35 p.m., observation of Resident #2 revealed the resident's bottom front teeth remained with the white substance at the gum line. On 3/31/26 at 2:55 p.m., in an interview CNA Staff B stated that Resident #2 was able to brush her own teeth and eat independently. CNA Staff B stated that she didn't know if there was a Kardex (contains resident care instructions) for Resident #2. On 3/31/26 at approximately 3:00 p.m., in an interview the Assistant Director of Nursing (ADON) verified that Resident #2's Kardex specified she required the assistance of one for meals and oral care. The ADON said he spoke with Resident #2 and agreed that the resident's teeth needed to be brushed and her nails trimmed. The ADON stated that the resident was able to use her right hand to eat but he understood how some food items were difficult for her to manage. On 3/31/26 at 3:44 p.m., an interview was held with the Director of Rehab and the Regional Director of Rehab. The Director of Rehab said that Resident #2 was discharged from Occupational Therapy on 6/16/25 with recommendation to set up for eating. The Regional Director of Rehab said that set up included cutting sandwiches into small pieces. On 4/1/26 at 10:03 a.m., in an interview, the DON said Resident #2's teeth should be brushed at least twice a day, ideally in the morning, after every meal, and at bedtime. He said the staff should be doing nail care with showers/baths or have the hairdresser do them.

Based on interview, record review and facility policy the facility failed to ensure that 5 (Licensed Practical Nurses Staff H, Staff N, Staff O, Staff P, and Staff Q) of 5 Licensed Practical Nurses reviewed had appropriate skill sets, and certifications to administer intravenous antibiotic therapy (IV) for 2 (Residents #73 and #66) of 3 residents reviewed for IV Therapy.The findings included:Review of facility policy Intravenous Therapy date implemented 3/1/22, date reviewed/revised 3/1/25 documented: The facility will adhere to accepted standards of practice regarding infusion practices in accordance with state regulations. Definitions: Intravenous (IV) Therapy is the administration of parenteral fluids or medications through an IV catheter to treat a condition. Compliance Guidelines: (14) The Registered Nurse or certified Licensed Practical Nurse (LPN) will evaluate the associated risks due to IV fluid administration (15) IV documentation is recorded in the nurses' notes and/or Medication Administration Record. Continuous Infusion, IV push and intermittent medication infusion procedures to be completed by RN or certified LPN.Review of the clinical record for Resident #73 revealed an admission date of 2/27/26. Diagnoses included chronic osteomyelitis right foot and ankle (infection of the bone tissue), peripheral vascular disease, Type 2 diabetes mellitus, history of osteomyelitis left foot and ankle with below the knee amputation.Review of the admission Minimum Data Set (MDS) with an assessment reference date of 3/5/26 documented Resident #73 was receiving IV medications.Review of the Physician's Order dated 3/2/26 included to administer Meropenem (Antibiotic) Intravenous Solution Reconstituted, 1 gram intravenously every 8 hours for wound infection until 4/2/26.The care plan date initiated revised on 3/2/26 documented that Resident #73 required IV therapy and was at risk for complications. The interventions included to administer IV medication as ordered, monitor for side effects and report to physician.Review of Medication Administration Record (MAR) for March 2026 revealed:LPN Staff H administered the Meropenem IV to Resident #73 on 3/20/26 at 2:00 p.m., and 10:00 p.m.; On 3/21/26 at 10:00 p.m.LPN Staff N administered the Meropenem IV to Resident #73 on 3/9/26 at 10:00 p.m., 3/16/26 at 10:00 p.m.; 3/23/26 at 10:00 p.m.; 3/24/26 at 10:00 p.m.; 3/28/26 at 10:00 p.m.LPN Staff O administered the Meropenem IV to Resident #73 on 3/3/26 at 10:00 p.m.LPN Staff P administered the Meropenem IV to Resident #73 on 3/6/26 at 2:00 p.m.; 3/14/26 at 2:00 p.m.;3/15/26 at 2:00p.m.LPN Staff Q administered the Meropenem IV to Resident #73 on 3/3/26 at10:00 p.m.; 3/12/26 at 10:00 p.m.; 3/13/26 at 10:00 p.m.; 3/15/26 at 6:00 a.m.; 3/17/26 at 10:00 p.m.; 3/21/26 at 6:00 a.m.; 3/27/26 at 6:00 a.m.; 3/29/26 at 10:00 p.m.The facility was unable to provide documentation of IV therapy Certification for the intravenous antibiotic doses administered by the LPNs.Review of the clinical record for Resident #66 revealed an admission date of 2/10/26. Diagnoses included periprosthetic fracture around internal prosthetic (fractures around the joint replacement), presence of left artificial knee joint, infection and inflammatory reaction due to internal left knee prosthesis, age-related osteoporosis (thinner and weaker bones), and chronic pain.Review of the 5-Day Minimum Data Set (MDS) with an assessment date of 2/22/26 documented that Resident #66 was receiving IV medications.The Physician's order for 2/16/26 included to administer Meropenem Intravenous Solution Reconstituted 1 gram intravenously every 8 hours for infection related to infection and inflammatory reaction due to internal left knee prosthesis until 3/19/26.Review of the MAR for 3/2026 revealed:LPN Staff N administered the Meropenem IV on 3/2/26 at 10:00 p.m.; 3/9/26 at 10:00 p.m.; 3/16/26 at 10:00 p.m.LPN Staff O administered the Meropenem IV to Resident # 66 on 3/3/26 at 10:00 p.m.LPN Staff P administered the Meropenem IV to Resident # 66 on 3/6/26 at 2:00 p.m.; 3/14/26 at 2:00 p.m.; 3/15/26 at 2:00 p.m.LPN Staff Q administered the Meropenem IV to Resident # 66 on 3/12/26 at 10:00 p.m.; 3/13/26 at 10;00 p.m.; 3/14/26 at 6:00 a.m.; 3/15/26 at 6:00 a.m.; 3/17/26 at 10:00 p.m.; 3/18/26 at 10:00 p.m.On 4/2/26 at 11:20 a.m., in an interview, the Assistant Director of Nursing (ADON) said that LPNs should be IV Certified to administer IV medications.On 4/2/26 at 11:31 a.m., in an interview the Director of Nursing (DON) said LPNs have to be IV certified to administer IV medications. He said if the LPN is not IV certified, one of the Registered Nurses supervisors should administer the IV medication. The DON stated that administering IV medications fell outside of practice for LPNs who were not IV certified and that it was an issue.

Based on record review, review of facility's policy and procedure and staff interviews, the facility failed to have documentation that 2 (Residents #73 and #66) of 3 residents reviewed, received intravenous antibiotics as ordered. Missed dosages of antibiotics could jeopardize the residents' health and safety. The findings included:A review of the Facility's Policy Medication Administration with a date implemented of 3/1/22, documented, Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . 12b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Sign MAR (Medication Administration Record) after administered. 22. Report and document any adverse side effects or refusals. 23. Correct any discrepancies and report to nurse manager.Review of the clinical record for Resident #73 revealed an admission date of 2/27/26. Diagnoses included chronic osteomyelitis right foot and ankle (infection of the bone tissue).Review of the physician's orders dated 3/2/26 revealed to administer Meropenem (antibiotic) Intravenous Solution, 1 gram intravenously every 8 hours for wound infection until 4/2/26.Review of the Medication Administration Record (MAR) for March 2023 revealed the Meropenem was scheduled to be administered at 6:00 a.m., 2:00 p.m., and 10:00 p.m. The MAR failed to show documentation that the Meropenem was administered as ordered to Resident #73 on 3/3/26 at 6:00 a.m., 3/3/26 at 2:00 p.m., 3/4/26 at 2:00 p.m., 3/6/26 at 6:00 a.m., 3/12/26 at 6:00 a.m., 3/13/26 at 6:00 a.m., 3/14/26 at 6:00 a.m., 3/22/26 at 2:00p.m., 3/24/26 at 2:00 p.m., 3/25/26 at 2:00p.m., 3/25/26 at 10:00 p.m., and 3/26/26 at 6:00 a.m.The progress notes for March 2023 failed to reveal an explanation for the doses of Meropenem not documented as administered or physician notification of missed doses.Review of the clinical record documented Resident #66 revealed an admission date of 2/10/26. Diagnoses included infection and inflammatory reaction due to internal left knee prosthesis, and chronic pain.Review of the physician's orders dated 2/16/26 revealed to administer Meropenem intravenous solution reconstituted, 1 gram intravenously every 8 hours for infection and inflammatory reaction due to internal left knee prosthesis until 3/19/26.Review of the MAR for March 2026 failed to show documentation that the intravenous Meropenem was administered as orders on 3/3/26 at 6:00 a.m., 3/3/26 at 2:00 p.m., 3/12/26 at 6:00 a.m., and 3/13/26 at 6:00 p.m.The progress notes for March 2023 failed to reveal an explanation for the doses of Meropenem not documented as administered or physician notification of missed doses.On 4/2/26 at 11:00 a.m., in an interview, Licensed Practical Nurse (LPN) Staff F said that the physician should be notified of missed or refused doses of medications and documented in the clinical record. LPN Staff E said that missed doses of antibiotics could cause the infection to worsen. On 4/2/26 at 11:10 a.m., in an interview, LPN Staff G said medications are documented as given on the MAR after the medication has been administered. LPN Staff G said that the physician should be notified of missed or refused doses of medications and documented on the MAR. LPN Staff G said that missed doses of antibiotics could cause the infection to worsen.On 4/2/26 at 11:21 a.m., in an interview, the Assistant Director of Nursing (ADON) said that if there are no initials on the MAR for the scheduled administration time, it is then assumed that the medication was not administered, but there is no way to know. He said that missed doses of medications should be addressed at the morning meeting and the physician should be notified of the missed doses of medications. The ADON said that the nurse who hangs the IV antibiotic should be signing on the MAR that the medication was given.On 4/2/26 at 11:32 a.m., during an interview, the Director of Nursing (DON) verified that the MAR for Residents #73 and #66 lacked documentation that multiple doses of intravenous antibiotics were administered. The DON said that not administering the antibiotics as ordered could cause the infection to worsen and the physician should be notified of missed/refused doses of antibiotics.

Based on record review and interview, the facility failed to offer and/or administer the flu and/or pneumonia vaccine for 5 (Residents #8, #2, #92, #49, and #66 ) of 5 residents reviewed for vaccinations. The findings included:Review of the facility's policy and procedure titled Infection Prevention and Control Program, with a revision date of 2/1/25 indicated: 7. Influenza and Pneumococcal Immunization a. Residents will be offered the influenza vaccine each year between October 1 and March 31, unless contraindicated or received the vaccine elsewhere. B. Residents will be offered the pneumococcal vaccines recommended by the Center for Disease Control (CDC), upon admission, unless contraindicated or received the vaccines elsewhere.On 3/31/26 review of Resident #8's clinical record revealed that the legal representative consented to the pneumococcal vaccine on 10/3/25. The clinical record lacked documentation that the vaccine was administered. There was no documentation of contraindication for the vaccine.On 3/31/26 review of Resident #2's clinical record revealed a consent form for the pneumococcal vaccine dated 10/3/25. The area to indicate whether the resident wanted to receive the vaccine or declined the vaccine was left blank. The clinical record lacked documentation that Resident #2 accepted or refused the vaccine or that the vaccine was contraindicated.On 3/31/26 review of the clinical record for Resident #92 revealed a consent form for the pneumococcal vaccine dated 10/3/25. The form was left blank and did not indicate whether the resident wanted to receive or declined the pneumococcal vaccine. There was no documentation of contraindication to the vaccine. On 3/31/26 review of the clinical record for Resident #49 revealed that on 10/26/25, the resident consented to receive the pneumococcal vaccine. The clinical record lacked documentation that the pneumococcal vaccine was administered. There was no documentation that the vaccine was contraindicated.On 3/31/26 review of the clinical record review for Resident #66 revealed a consent form for the pneumococcal vaccination dated 10/3/25. There was no documentation on the consent form that the resident accepted or refused the pneumococcal vaccination or that the vaccine was contraindicated.On 3/31/26 at 11:28 a.m., in an interview, the Infection Control Preventionist (ICP) said that on admission, all residents are offered the influenza, pneumococcal and COVID vaccine. The ICP said that the consent form was included in the admission packet. He said they explain the benefits of getting vaccinated to the resident. If the resident is alert and oriented, they sign the form indicating whether they wanted the vaccine or not. If not alert and oriented, it would be discussed with the resident's legal representative who would sign the consent. He said if a vaccine is received or refused it is documented on the immunizations tab. The ICP reviewed the clinical record of Residents #8, #2, #92, #49, and #66. He verified that Residents #8 and #49 consented to the pneumococcal vaccination but the clinical records lacked documentation the residents received the vaccine. He verified that the consent forms for pneumococcal vaccination for Residents #2, #92 and #66 were incomplete and did not indicate whether the residents accepted or refused the pneumococcal vaccination or that the vaccine was contraindicated. He said he had no explanation for the missed vaccines or the incomplete forms.

Based on record review and interview, the facility failed to ensure that 5 (Residents #8, #2, #92, #49, and #66 ) of 5 residents reviewed for vaccinations were offered and administered the COVID-19 vaccine unless the immunization was medically contraindicated.The findings included:On 3/31/26 clinical record review for Resident #8 revealed the resident's legal representative consented to the COVID-19 vaccine on 10/3/25. The clinical record lacked documentation that the vaccine was administered or that the vaccine was contraindicated.On 3/31/26, review of the clinical record review for Resident #2 revealed a COVID-19 consent form dated 10/3/25. The area to document whether the resident wanted to receive or declined the COVID-19 vaccine was left blank. The clinical record lacked documentation that the resident accepted or declined the vaccine or that the vaccine was contraindicated.On 3/31/26, clinical record review for Resident #92 revealed a COVID-19 consent form dated 10/3/25. The area to document whether the resident wanted to receive or declined the COVID-19 vaccine was left blank. The clinical record lacked documentation that the resident accepted or declined the vaccine or that the vaccine was contraindicated. On 3/31/26 clinical record review for Resident #49 revealed that on 10/26/25, the resident consented to the COVID-19 vaccination. The clinical record lacked documentation that the resident received the COVID-19 vaccine as requested or that the vaccine was contraindicated.On 3/31/26 clinical record review for Resident #66 revealed a COVID-19 consent form dated 10/3/25. The area to document whether the resident wanted to receive or declined the COVID-19 vaccine was left blank. The clinical record lacked documentation that the resident accepted or declined the vaccine or that the vaccine was contraindicated. On 3/31/26 at 11:28 a.m., in an interview, the Infection Control Preventionist (ICP) said that the consent form for the COVID-19 vaccine was included in the admission packet. He said that on admission, and annually, all residents are offered the COVID-19 vaccine. The benefits of the vaccine are explained to the residents. Residents who are alert and oriented sign the consent form, indicating whether they wanted or declined the vaccine. For the residents who are not alert and oriented, the vaccination is discussed with the legal representative who would then sign the consent form and indicate whether or not to administer the COVID-19 vaccine.The ICP reviewed the clinical records of Residents #8, #2, #92, #49, and #66. He verified that Residents #8 and #49 consented to the COVID-19 vaccine and the lack of documentation that the residents received the vaccine.The ICP verified that the consent form for the COVID-19 vaccine was incomplete for Residents #2, #92, and #66 and did not indicate whether the residents accepted or declined the vaccine or that the vaccine was contraindicated.

Based on observations, review of facility policy and staff interviews, the facility failed to ensure a safe, clean, sanitary and homelike environment that emphasizes and enhances resident comfort for the residents in the 100, 200, and 400 halls.The findings included: Review of the facility policy Resident Personal Belongings implemented 3/1/22 (revised 1/1/26) documented It is the policy of this facility to protect the residents right to possess personal belongings, such as clothing and furnishings, for their use while in the facility. All resident possessions, regardless of their apparent value to others will be treated with respect. The facility will support the residents' right to retain and use personal possessions to promote a home-like environment and maintain their independence. The facility will ensure resident belongings are kept in a neat and orderly fashion and maintained in each residents room. On 3/30/26 at 10:00 a.m., during an initial tour of the 100 hall the following observations were noted: 1. In the shared bathroom of room [ROOM NUMBER], a box of disinfecting wipes was observed on the bathroom counter. Photographic evidence obtained 2. In the shared bathroom of room [ROOM NUMBER], two unlabeled wash basins were observed stacked on the counter. Wheelchair footrests were observed stored on the floor, under the counter. Trash was observed on the bathroom floor. Photographic evidence obtained. 3. In the shared bathroom of room104, an unlabeled bedpan and a wash basin were stored on the counter. A wheelchair cushion was stored on the floor under the counter. Photographic evidence obtained. A corroded tube feeding pole was observed in room [ROOM NUMBER]. Multiple yellow, dried stains were observed on the bottom of the pole. Photographic evidence obtained. 4. In room [ROOM NUMBER]'s shared bathroom, two unlabeled, uncovered wash basins, and two unlabeled bottles of soap and lotion were observed stored on the counter. 5. In the shared bathroom of room107, an unlabeled, uncovered washbasin, an unlabeled bottle of cleansing foam and an unlabeled, uncovered toothbrush were observed stored on the counter. An unlabeled, uncovered was basin was observed stored on the floor under the counter. An unlabeled bedpan was stacked in the wash basin. Photographic evidence obtained. 5. In room [ROOM NUMBER]'s shared bathroom, the following was observed: Two stacked unlabeled and uncovered wash basins, an uncapped razor and an unlabeled wash basin with personal care items. Photographic evidence obtained. The call light in the room for bed A was clipped to the privacy curtain and out of the residents reach as he laid in the bed. Photographic evidence obtained. 6. In the shared bathroom of room [ROOM NUMBER], an unlabeled and uncovered bedpan was observed stored on a wash basin on the floor under the counter. Photographic evidence obtained. On 3/30/26 at 11:39 a.m., the Director of Nursing verified the observation that the call light for Resident #59 and Resident #55 were attached to the privacy curtain and were not within the residents reach. On 3/31/26 at 9:30 a.m., Resident #1's catheter drainage bag was attached to the bedframe and was touching the floor. On 4/1/26 at 9:15 a.m., in an interview, Licensed Practical Nurse Staff A said the facility was aware of concerns of personal items in shared bathrooms not labeled or stored properly. On 4/1/2026 at 9:50 a.m., in an interview the Administrator said that the facility did not have a policy on storage of personal items in shared bathrooms and said, We can do better than that. 7. On 3/30/26 at 10:00 a.m., during a tour, the walls near the air conditioning units in rooms [ROOM NUMBER] were observed to be stained, the paint was peeling and cracking. The baseboards were discolored and pulling from the wall. Black bio growth was observed on the wall where the paint had peeled. On 4/2/26 at 11:00 a.m., in an interview the Maintenance Director said he had been employed at the facility for 5 months and had been working through the repairs. 8. On 3/31/26 at 2:15 p.m., in an interview, Resident #66 said that approximately a month ago, the chairs were taken out of the room and never brought back. She said when her family visits, her sister has to sit on the bed, and her brother-in-law must stand. She said her visitors don't stay long since they must stand. On 3/31/26 at 3:00 p.m. revealed 6 of 11 rooms in the 400-hallway did not have a chair, rooms 402, 403, 406, 407, 410, and 411. room [ROOM NUMBER] was shared by two residents and had one chair.

Based on observation, record review, review of facility's policies and procedures and staff interviews, the facility failed to have documentation of fall investigations and failed to implement care planned interventions to reduce the risk of avoidable accidents for 1 (Resident #999) of 3 residents reviewed with multiple falls at the facility.The findings included: Review of the facility policy Fall Prevention Program implemented 3/1/22 (revised 1/1/25) revealed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.High Risk Protocols:a. The resident may be placed on the facility's Fall Prevention Program.i. Indicate fall risk on care plan.Implement appropriate interventions.c. Provide interventions that address unique risk factors measured by the risk assessment tool.d. Provide additional interventions as directed by the resident's assessment, may include but not limited to:i. Assistive devices.ii. Increased frequency of rounds.iv. Low bed.8. Interventions will be monitored for effectiveness.Review of the clinical record for Resident #999 revealed an admission date of 1/25/23. Diagnoses included Dementia, generalized anxiety disorder, difficulty in walking, abnormalities of gait and mobility, and fracture of the right femur.Review of the fall risk evaluations dated 5/25/25 and 8/17/25 noted Resident #999 was at high risk for falls. Review of the care plan initiated on 1/27/2023 revealed Resident #999 was very impulsive and will not use call light to ask for assistance with transfers and will attempt to self-transfer. Resident #999 would tell his family that he was feeding squirrels through the window in his bedroom and has also shown physical aggression towards staff. The goal was to monitor the resident daily for his behaviors.The care plan initiated on 5/13/25 noted Resident #999 displayed behaviors which include hitting during care, playing in feces, shouting, spitting, tearing things up, yelling out during care, refusing medications and care, and placing self on the floor.The goal was for the resident not to harm self or others daily. The care plan initiated on 1/31/23 and revised on 8/26/25 revealed Resident #999 was at high risk for falls related to gait/balance problems and medications that put him at risk.The care plan noted the resident would not use the call light to ask for assistance with ambulation around his room, to or from the bathroom with or without the use of an assistive device, due to impaired cognition.The goal for Resident #999 was to Minimize the risk of falls through next review date.The care plan noted Resident #999 sustained a fall on 5/12/25, 5/25/25, 7/19/25 and 8/17/25.The interventions included:Bed in lowest locked position. Date initiated: 1/31/23. Revision on 9/30/25.Dycem (non-slip mat) to wheelchair. Date initiated 5/22/23. Revision on 6/25/24.Offer toileting assistance prior to meals. Date initiated 5/25/25. Revision on 8/18/25.Perimeter mattress (mattress with raised borders to help guide the patient back toward the center of the mattress and away from dangerous position near the edge of the bed). Date initiated 4/24/23. Revision on 8/18/25.Review of the progress notes revealed on 5/26/25 at 12:19 a.m., Unwitnessed fall at 1600 [4:00 p.m.], without severe injury. Abrasions on bilateral legs. Patient was found in room on [sic] sitting in front of door.On 5/28/25, an interdisciplinary progress note documented the resident was reviewed related to fall. Resident is identified as a fall risk related to behavior of placing self on floor, aggression, and unstable gait. Resident is noncompliant with requesting assistance and requires frequent cueing. Resident will be offered toileting assistance prior to meals in an attempt to reduce risk of falls.The progress note did not include the root cause of the fall to determine toileting assistance before meals was an appropriate intervention to prevent further falls.On 7/19/25 at 10:08 p.m., a nursing progress note documented the Certified Nursing Assistant found Resident #999, with head and upper body on floor and feet still on bed. Resident alert with confusion cannot explain what happened. No visible hematoma (collection of blood outside of blood vessels), skin tear noted to R (right) leg behind the knee. EMS [Emergency Medical Services] called . The resident was taken to a local hospital via stretcher.On 7/21/25 a progress note documented the resident was reviewed by the Interdisciplinary Team related to safety. Resident had a fall from the bed on 7/19/25. Resident with diagnosis of confusion and unable to verbalize cause of fall. Interventions in place at time of fall include bed maintained in lowest position while occupied with fall recovery matt at bedside in an attempt to prevent injury in the event of a fall, resident is offered toileting assistance prior to meals, and nonskid footwear is provided. Intervention for this event is that when staff place resident to bed for HS (bedtime), and HS snack is offered and comfort needs ensured prior to leaving room .The progress note did not document that the perimeter mattress initiated on 4/24/23 was in place at the time of the fall.On 8/17/25 at 9:46 p.m., a nursing progress noted, Unwitnessed fall, the patient was found behind his room door seated. Vitals WNL (within normal limits), no injuries noted. Alert to self.On 8/18/25 a progress note documented the resident was reviewed by the interdisciplinary team for safety. Resident had an unwitnessed fall on 8/17/25. Current interventions include: resident's bed maintained in lowest position while occupied, Dycem is in w/c (wheelchair) to prevent slipping, bilateral assist rails to bed frame to promote independence with bed mobility. Resident provided toileting assistance prior to meals, and nonskid footwear. Current interventions are providing toileting assistance prior to returning to bed . Will continue to monitor per facility's guidelines for effectiveness of interventions and need for additional interventions.The progress notes did not include a root cause of the incident or specify if the resident was in a wheelchair or the bed with the perimeter mattress in use before the fall.On 8/18/25 a post fall progress note documented Resident #999 was complaining of pain to the right leg.On 8/19/25 an X-ray of the right femur documented findings of an acute intertrochanteric right femoral fracture.On 8/19/25, Resident #999 was transferred to an acute care hospital for evaluation. Resident #999 underwent a surgical repair of the right femur fracture.On 8/22/25 a nursing progress note documented Resident #999 returned to the facility. Bilateral rails were in place to promote independence with bed mobility. Perimeter mattress in place to increase awareness of parameters of bed surface. Ensured a pair of nonskid footwear were in the room. The call light was placed within reach of the resident and demonstrated usage. Bed was placed in the lowest position. Staff was reminded that toileting assistance will be offered at bedtime and meals.Review of the End of Part A Stay Minimum Data Set (MDS) assessment with a reference date of 10/24/25 revealed Resident #999 scored 12 on the Brief Interview for Mental Status, indicating moderate cognitive impairment.The MDS noted the resident required partial to moderate assistance to come to a standing position from sitting in a chair, wheelchair, on the side of the bed, or to get on and off the toilet.On 11/14/25 at 10:30 a.m., a nursing progress note documented the resident was in the television room in his wheelchair and was trying to reach his shoes, lost his balance and fell on his side, no injuries were noted. Resident #999 sustained superficial skin tears to his left knee.The fall report documentation dated 11/14/25 at 12:33 p.m. noted Resident #999 was Not oriented to person, place, time or situation.The active physician's orders included:Bed maintained in lowest position while occupied. Nurse to validate each shift. Start date 9/5/25.Bilateral enabler bar to standard bed to promote independence with bed mobility. Start date of 8/25/25. On 12/8/25 review of the Medication Administration Record (MAR) for December 2025 revealed the nurse signed, validating the bed was maintained in the lowest locked position when occupied on 12/8/25 for the 7:00 a.m., to 3:00 p.m. shift.The nurse also signed, validating that on 12/8/25, the bilateral enabler bar [sic] was in place to the standard bed to promote independence with bed mobility for the morning shift.On 12/8/25 at 11:00 a.m., Resident #999 was observed in bed. The fall prevention interventions specified in the care plan and signed by the nurse in the MAR for 12/8/25 for the morning shift were not in place. The bed was not in the lowest position. The perimeter mattress was not in place. The bed had no enablers bilaterally. In an interview, Resident #999 said he remembered falling and breaking his leg but did not remember how it happened.On 12/8/25 at 12:15 p.m., the Director of Nursing (DON) verified through observation that Resident #999's bed was not in the lowest position and the enablers were not in place. The DON said he was not aware that the resident's fall interventions in the care plan included a perimeter mattress. The DON verified the nurse documented on the MAR that the fall prevention interventions were in place when they were not.On 12/8/25 at 12:37 p.m., in an interview the Administrator said she did not have documentation of Resident #999's fall investigation for 8/17/25 and the right femur fracture identified on 8/19/25.The Administrator said she initiated an abuse/neglect investigation on 9/23/25 when the resident's responsible party alleged that Resident #999 was being abused or neglected. The responsible party said his concern was with the fall and he wanted full side rails on the bed. She said her investigation did not address the fall since the incident occurred with the former administration. She said she did not know if they investigated the fall and fracture. The Administrator said she spoke with Resident #999 who had no concerns regarding care.Review of the facility provided incident investigation for an incident date of 9/23/25 revealed an allegation of physical abuse and neglect. The allegation details noted the resident's responsible party alleged that Resident #999 was being abused or neglected. No other information had been provided at that time. The investigation noted the representative voiced allegation of neglect regarding the use of full side rails. Resident #999 stated that he had no concerns with care and felt safe at the facility. The investigation noted Resident #999 has had previous falls, care plan reflects noncompliance with fall interventions and Activities of Daily Living care. The conclusion noted after investigation the facility was not able to verify abuse and neglect due to care plan interventions followed per individualized plan of care. The investigation noted the resident was not deemed incapacitated and had a Brief Interview for Mental Status score of 13 (which is indicative of intact cognition). The resident was able to make his own decisions regarding use of full length side rails.On 12/9/25 at 8:37 a.m., in an interview the Administrator said as part of the fall prevention program, the facility implemented daily fall and change of shift huddles, walking rounds, and would provide the documentation.On 12/9/25 at 4:00 p.m., at the time of exit, the Administrator failed to provide documentation of an investigation for Resident #999's fall on 8/17/25 resulting in fracture of the right femur and emergency transfer to an acute care hospital.

Based on observations, record review and interviews, the facility failed to maintain an effective pest control program to contain and eradicate common household pests.The findings included:Review of the facilities Pest Control Program policy (last revised on 3/1/2022) stated, it is the policy of this facility to maintain an effective pest control program that eradicated and contains common household pests and rodents. The policy further states effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats).Review of the facilities Resident Environmental Quality policy (last revised on 3/1/2025) states the facility shall maintain an effective pest control program so the facility is free from pests and rodents.On 12/8/25 at 9:04 a.m., in an interview Resident #2 said she has a problem with bugs. She said there were little cockroaches in the bathroom. She has let everyone know but they were still there. She said there are times she won't take a shower because of the cockroaches. She said they come up from the shower drain. She said when it rains they come in as well. She said, I get a couple of brown paper bags and take care of them by squishing them.On 12/8/25 at 9:14 a.m., in an interview Resident #3 said she has issues with cockroaches. She said she saw one a couple of days ago.On 12/8/25 at 9:18 a.m., in an interview Resident #4 said, I see the little roaches crawling around. She said when her family comes in to visit, they have to squish them in the bathroom.On 12/8/25 at 9:25 a.m., in an interview Resident #5 said there are cockroaches in the bathroom and they crawl on the walls. She said the cockroaches also come out of the air conditioning vent. She said she did not know when the last time someone sprayed for cockroaches. During the interview a small brown bug was observed crawling on the bathroom floor. Photographic evidence obtained.On 12/8/25 at 9:30 a.m., in an interview Resident #6 said she sees cockroaches around her room. She could not recall when she last saw one but said it was not long ago, they are around. On 12/8/25 at 9:34 a.m., in an interview Resident #7 said there are cockroaches in his room. He said, I feel them crawling on me at night. Observation of the resident's room and bathroom revealed 3 black bugs crawling in the bathroom above and below the resident's toilet. On 12/8/25 at 9:38 a.m., in an interview Resident #15 said he has a problem with ants. He said the ants come from the detached baseboard. He said the staff tape the baseboard, but it never stays.Observation of the resident's floor revealed the baseboard was detached from the wall and laying on the resident's floor. Photographic evidence obtained.On 12/8/25 at 9:49 a.m., in an interview Resident #8 said she saw a cockroach the day before in her room and another one a few days ago. She said, they are baby roaches. They are everywhere. She said she used to tell the staff but it didn't help so now she squishes them herself.On 12/8/25 at 9:43 a.m., in an interview Resident #9 said, I had a roach in my bed a month ago crawling on me. She said the nurse aide found the cockroach on her while changing her brief. She said when the nurse aid took the brief off, the roach came crawling out from inside her brief.On 12/9/25 at 11:12 a.m., a small brown bug was observed crawling in Resident #10's room. Photographic evidence obtained.On 12/8/25 at 1:04 p.m., in an interview Resident #13 said they have a problem with cockroaches. Resident #13 said when her family comes to visit, they have to open the drawers and kill all of the roaches. She said, It is embarrassing. During the interview a small brown bug was observed on the floor. Photographic evidence obtained.On 12/8/25 at 9:22 a.m., in an interview Licensed Practical Nurse (LPN) Staff C said, We have a problem with roaches. Staff C said if there is a pest sighting, it goes in the pest logbook. Staff C said, They are never going to fully fix the problem. On 12/8/25 at 9:22 a.m., in an interview LPN Staff D said, I see roaches around here but not today. Staff D said she lets maintenance know when she sees one.On 12/8/25 at 9:47 a.m., in an interview LPN Staff E said, I've seen big roaches around here. Staff E said when she sees one, she kills it, throws it away and then let maintenance know.On 12/8/25 at 12:08 p.m., review of the facility provided Pest Sighting Log showed on 12/1/25 Resident #16 reported roaches in dresser drawer. This sighting was not listed as treated. On 11/19/25, Resident #11 reported roaches around bed, bathroom and soap dispenser. The sighting was marked as treated by the pest control company. On 11/6/25, the activities department reported roaches, activity room cabinets. The sighting was marked as treated by the contracted pest control company.Review of the Resident Council Minutes reviewed for 11/12/25 revealed, Resident #11 talked about having roaches in her room and needing someone to come and take care of them.On 12/8/25 at 12:10 p.m., in an interview Resident #11 said she reported the roaches a month ago and there has been no change. Resident #11 said the roaches are in the bathroom, by her bed, they climb up and down the wall, behind the television and are behind the soap dispenser. Resident #11 said she just saw a cockroach last night go behind her television. Resident #11 said she also saw a cockroach in the bathroom this morning on the ceiling while showering. She said she let the Nursing Assistants know. A small brown bug was observed crawling on the floor next to the resident's bed. A small brown bug was observed on the bathroom wall. Photographic evidence obtained.On 12/8/25 at approximately 12:15 p.m., Staff F was observed removing the cover of the soap dispenser affixed to the bathroom wall. Multiple brown bugs were observed scurrying from behind the soap dispenser. Staff F dropped the soap dispenser, brushed off and washed her hands. Black bio growth was also observed inside of the soap dispenser. Photographic evidence obtained.On 12/8/25 at 12:22 p.m., in an interview the Housekeeping Supervisor said the soap dispensers are changed monthly and, That soap has not been changed for a while.On 12/8/25 at 12:30 p.m., in an interview Resident #12 said there were cockroaches in her dresser drawers. Resident #12 said she let the staff know but the roaches were still there. With Resident #12's permission, the dresser drawers were observed. Upon opening the top drawer, a large brown bug was observed scurrying deeper into the dresser. Resident #12 said, There is roach poop in the drawer. Black bio growth observed in the Resident #12's drawer which contained medical equipment, soap, ear plugs and deodorant. Resident #12 said she was extremely embarrassed that anyone had to see the condition of her drawer. Multiple brown bugs observed stuck to a sticky mat trap on the ground next to the resident's toilet. Photographic evidence obtained.On 12/8/25 at 1:17 p.m., a kitchen tour was conducted with the [NAME] Supervisor. In an interview the [NAME] Supervisor said the pest company bombed the kitchen and food storage area last week due to roaches. The [NAME] Supervisor was unable to give a timeline for how long the pest problem had been going on. Dead brown bug observed outside of the kitchen door. Multiple dead brown bugs observed in the food storage area.On 12/8/25 at 2:20 p.m., the activities room was observed with the cabinets open and emptied. The items in the cabinet were observed on the table in the center of the room. In an interview the Activities Director said her assistant reported a roach on her desk and sent a picture of it. The Activities Director said they are in the process of removing things out of the cabinet and a family member volunteered to take things home to wash them.Review of the contracted pest control company log revealed:On 7/16/25 the pest control technician noted under Cockroach program that Only had one room ready for me when arrived. Rooms were to be ready by 10 am.On 8/20/25 the pest control technician noted under Cockroach problem that No rooms were fogged today. They did not have any rooms ready.On 8/27/25 the pest control technician noted under Cockroach problem that Arrived at location it's 1020. No rooms were ready. An email was sent on Monday and there was notes at the nurses station but no rooms were ready.On 9/17/25 the pest control technician noted under Cockroach problem that I am stopping my weekly visits. Any structural or sanitation issues that have been marked down have not been addressed yet. It has been a few months. Will resume after structural issues have been resolved and sanitation.On 12/4/25 the pest control technician noted, Some of the rooms still had personal belongings in the drawers, so it's not able to fog nightstand.On 12/8/25 at 2:48 p.m., in a telephone interview the pest control technician said he serviced the building but, I won't get into too much detail. He said he was going to the facility weekly at one point. He said that he stopped coming weekly because the rooms were not ready when he arrived.On 12/8/25 at 3:30 p.m., in an interview the Maintenance Director said there is a pest sighting logbook at every nurse's station. The Maintenance Director said the pest control company sprays weekly. Upon reviewing the pesto control documentation showing the weekly visits had stopped on 9/17/25, the Maintenance Director said weekly visits started again last week. When asked about the pest control technician documentation that rooms were not ready to be treated multiple times when he arrived, causing him to stop the weekly visits, the Maintenance Director said they were working on it. The Maintenance Director said his expectation is if rooms need to be ready, they should be ready for the pest control technician. When asked about the live crawling insects observed behind the soap dispenser in Resident #11's room, the Maintenance Director said, I did not know to look behind the soap dispenser. The Maintenance Director said the photographic evidence of Resident #11's drawer looked like pest droppings. The observation of the live crawling insect in Residents' drawers was shared with the Maintenance Director. He said the expectation was to document on the log to be treated during the weekly pest control visits on Thursdays. On 12/9/25 at 12:40 p.m., an interview was held with the Nursing Home Administrator related to the lack of an effective pest control program. The Administrator said if there is a pest sighting, it is to be put in the log immediately. The Nursing Home Administrator confirmed the pest control company came out to service the facility on 9/17/25, 10/16/25, 11/21/25 and 12/4/25. The pest control recommendations were not completed when the technician arrived. The Administrator said the facility resumed the weekly visits last week.Review of the facility's provided documentation revealed the pest control company has been providing services to the facility since 10/4/24. Review of the contracted pest control company's website revealed, Cockroaches can carry diseases such as Salmonellosis (Salmonella food poisoning), Staphylococcus infections (gastrointestinal illness), Escherichia coli (bacterial infection), Typhoid fever (life-threatening illness that can multiply and spread into the bloodstream) and Gastroenteritis (inflammation of the stomach, small and large intestines).

Based on observation, review of the clinical record, review of facility policy and procedure, and resident, family and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 1(Resident #999) of 3 residents reviewed for activities of daily living.The findings included:Review of the facility policy Activities of Daily Living (ADLs) implemented 3/1/22 (revised 6/1/25) documented, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain grooming, and personal and oral hygiene.Review of the clinical record revealed Resident #999 had an admission date of 1/25/23 with a re-admission date of 8/22/25. Diagnoses included displaced intertrochanteric fracture of right femur on 8/22/25, type 2 diabetes mellitus, dementia, anxiety, and fracture of right femur 2/8/23.Review of the End of Part A stay Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 10/24/25 documented Resident #999 required partial to moderate assistance with oral hygiene, and substantial to maximum assistance with showers/bathing.The MDS noted the resident scored 12 on the Brief Interview for Mental Status, indicating the resident's cognitive skills for daily decision making were moderately impaired.Review of the plan of care revealed Resident #999 had an ADL self-care performance deficit and required assistance of one staff. The interventions included for staff to provide set up, one assist with extensive assistance for personal hygiene and oral care.On 12/8/25 at 9:00 a.m., Resident #999 was observed in bed in his room. The room had a very strong, foul odor of urine. The resident was noted to be unkempt, unshaven with a long scraggly beard and mustache. The bed sheets were soiled with a brown substance. His hair was matted, greasy and uncombed and extended past his ears.On 12/8/25 at 11:00 a.m., in an interview Resident #999 said he has not been shaved or had a hair cut in a very long time. He said he would like to be shaved. Resident #999's teeth had black spots and a thick, white coating. His mouth was dry with foul breath.Review of the clinical record revealed Resident #999's admission photo of a clean-shaven male with no beard or mustache and neatly trimmed hair.Review of the Certified Nursing Assistants (CNA) documentation for October 2025, and November 2025 revealed the resident's scheduled shower days were Mondays and Thursdays on the 7:00 a.m., to 3:00 p.m., shift. There was no documentation Resident #999 received his scheduled showers on 10/2/25, 10/9/25,10/23/25, 11/3/25, 11/6/25, and 11/10/25.On 12/9/25 at 1:45 p.m., in an interview the [NAME] President of Operations said Resident #999 was shaved last evening and just received a haircut. The [NAME] President of Operations said the facility's policy was for staff to shave men two to three times a week or at their preference.On 12/9/25 at 2:40 p.m., in an interview CNA Staff G said men are shaved when they have their shower or if they ask. The CNA said they brush the residents' teeth. If the residents can brush their own teeth, they get things ready and are there to help.

Based on review of the clinical record, review of policy and procedures and resident and staff interviews, the facility failed to protect vulnerable residents' rights to be free from abuse by failing to ensure residents were protected from mental and verbal abuse for 4 (Residents #699, # 700, #800 and #850) of 4 residents reviewed for allegations of abuse. The findings included: The facility policy Abuse, Neglect and Exploitation implemented 3/1/22 (revised 3/1/23) documented, It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse and mental abuse. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation. Review of the facility investigation documented an allegation was made by Resident #699 and Resident #700 involving concerns about inappropriate verbal interactions and improper care practices by a certified nursing assistant (CNA) Staff A during evening care period the allegation includes potential and verbal threats and failure to follow proper hygiene procedures. The allegation occurred on 4/17/25 at 3:29 p.m. Review of the clinical record revealed Resident #699 a [AGE] year-old female (YOF) readmitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia, heart failure and anxiety. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date (ARD) of 2/27/25 documented Resident #699's cognitive skills for daily decision making were intact. On 5/7/25 at 9:00 a.m., in an interview Resident #699 said, Certified Nursing Assistant (CNA) Staff A, was nasty and she was big, and I was afraid of her. She would not listen to me when I tried to tell her about the steps for my shower. She said to me, Shut up or I will leave you in this chair and not come back. She did not use the lift like she should have to get me up. She just picked me up out of bed and was rough and put me in the wheelchair (w/c). I told her I needed to use the bathroom, that is how they always do it, but she was nasty. She did not hit me, but she was rough. I couldn't stand and she grabbed me and put me in the w/c. I was afraid she would leave me in the w/c. I had a bowel movement (BM) in my brief during the shower; and she did not take it off. The CNA washed me in the w/c with the dirty brief on. I tried to tell her how to do it to make it easier for her and she told me, I know what I'm doing, she did not listen to me. I was shaking and afraid she would do something to me. She did not want to put me in the shower chair, and she washed me with the BM diaper on and in my w/c. She ruined my w/c cushion and the w/c. There was BM all over it and it was wet. The CNA brought me back to the room full of BM and picked me up and put me in bed. She was mean and rough. She told me again if I said anything she would leave me in the w/c and not come back. She made me shut up. She was a big lady. I was afraid of her, and I did not want to see her again. Resident #699 said, About a week later the police came in and asked me about it and took my statement. He told me the CNA had been fired. I think the facility should have told me, because every time the door opened, I was afraid she was back, or she would retaliate against me or have someone else do it. That was my biggest fear that she would come back. It would have made me feel more comfortable if I knew the CNA was not here anymore. I was afraid she was going to come back, and they should have told me she was not here anymore. They left me feeling afraid for a week. I was very upset. Review of the clinical record revealed Resident #700 a 65 YOF admitted on [DATE] with diagnoses including chronic pain and major depressive disorder. The Quarterly MDS dated [DATE] documented the resident was independent with her care needs. The MDS noted Resident #700's cognitive skills for daily decision making were intact. On 5/7/25 at 8:30 a.m., in an interview Resident #700 said, I was very respectful and nice to CNA Staff A. I don't remember her name but for a week prior to the incident she would come in the room to bring ice and what not and did not really bother us but she was not friendly or nice. You could tell she was not happy with the job, but she never said anything. Resident #700 said, On 4/17/25 on 3 p.m., to 11 p.m., shift, I don't know the exact time, the CNA came into the room and my roommate Resident #699 had asked for a shower. The CNA got mad and said it was not her time. We explained to her that they changed our showers to 3-11 p.m. The CNA was thick, strong and built like a linebacker. She looked mean like she would hurt you. I tried to explain to her, and she looked right at me in the eyes like she wanted to hurt me and said, Shut up. I was a social worker and I'm mostly independent so I help my roommate out when I can. My roommate was telling her how she usually gets her shower, they bring the shower chair in, and they take her to the bathroom for a BM and then wheel her to the shower room. The CNA said, Don't tell me how to do my job, I know what I'm doing. I watched her pick my roommate up out of bed without the lift and she was rough and slammed her into the w/c. My roommate was shaking, and I could see she was afraid and getting anxious. She left the room without toileting her and returned a while later. My roommate had a BM in the brief because she did not toilet her. The CNA gave her a shower in the w/c in the soiled brief. It took her 45 minutes to get her back in bed and clean her up. I was watching her with my roommate, and she was rough and mean. She was moving her around in bed like a bag of wet cement. My roommate was saying stop but she kept up. There was BM everywhere on the cushion in the w/c and it stunk. I told my roommate we need to report it, but she was afraid of retaliation, so I called her daughter and told her. The next morning, I told the nurse. Then the Management Team came in and spoke to us about it. They had the police in about a week after that to get our statements and I told him everything. The facility did not tell us the CNA was no longer working here. My poor roommate was afraid, and they should have told us she was no longer employed here. I saw how she was handling my roommate, and I tried to tell her how to do it, but she was not listening to me and she turned and glared at me with a look that said she would hurt me. We have been roommates for years and we look out for each other, so I was watching how she got her in and out of the bed. She was very rough with her, and she was shaking, she was afraid. I think the facility did what they were supposed to do because that first week we had so many people here asking us about it and we told them just like we are telling you. The story did not change, and it will not change because it is the truth. On 5/7/25 at 9:45 a.m., in an interview with Licensed Practical Nurse (LPN) Staff C said, I was not here the night it happened with CNA Staff A. I work the 7 a.m., to 3 p.m., shift and this occurred on the 3-11 shift. Resident #700 told me what had happened, and I had her fill out a grievance form and I assisted Resident #699 to fill hers out. I went right to the Administrator and gave her the grievance forms and told her what they said had happened. That is all I know, really. Like I said, I was not here when it happened. Further review of the facility investigation documented The allegation was determined to be unsubstantiated based on the investigation findings; the CNA's behavior was found inconsistent with facility standards. The CNA was found to have violated the facilities Code of Conduct and Resident Rights policies through the use of inappropriate and unprofessional communication. The facility reported a second allegation of abuse to the State Agency involving Resident #800 and #850. The report documented on 4/25/25 at 5:00 a.m., two residents have raised concerns alleging a staff member, CNA Staff B, displayed aggressive behavior toward them in their shared room. In addition, Staff D reported witnessing concerning interactions involving CNA Staff B and the residents. The residents have voiced concerns regarding their comfort and feelings of safety within their room. Supportive measures have been initiated, including increased monitoring and emotional support. Review of the clinical record revealed Resident #850 was an 84 YOF with an admitted [DATE]. Diagnoses included a fracture of the right fibula, dementia and chronic pain syndrome. The Admission MDS dated [DATE] indicated the resident required substantial to maximum assistance with toileting, showers, bed mobility and personal hygiene. The MDS noted Resident #850's cognitive skills for daily decision making were intact. On 5/8/25 at 8:30 a.m., in an interview Resident #850 said on 4/25/25 the CNA that night came in to change her and her roommate Resident #800. CNA Staff B pulled my covers back and moved my gown up, then said she would be right back. The CNA did not come back for 45 minutes. I was at that point covered in urine and cold. I had taken my wet gown off and thrown it in the corner. I was in a fetal position and so cold. The CNA began mumbling things in a different language and was rough when pulling the wet pad out from under me. She was mumbling something in a different language the whole time. She then sprayed me with cold water to clean me, and I said, please don't do that but she continued to do it. I felt abused, hurt and I don't think I was being taken care of. I was so scared to say something. If I had said something, who knows what she would have done the next night. Resident #850 said being left uncovered for 45 minutes felt demeaning and hurtful. She said she was never physically hit; the CNA was just rough when changing me and mumbling things. Resident #850 was observed tearful and emotional during the interview. Resident #850 said the same thing happened similarly the week before with this CNA, but she did not report it. Prior to that incident, the resident said the CNA came in and yelled, it's 12:00 a.m., turn the television off. Resident #850 said, She then pulled my curtain shut and put my remote out of reach so I couldn't turn it back on. Resident #800, an 83 YOF with an admitted [DATE] and diagnoses including chronic kidney disease Stage 3, Hypertensive heart disease, Type 2 diabetes Mellitus, and major depressive disorder. The Medicare 5-day MDS dated [DATE] documented the resident's cognitive skills for daily decision making were moderately impaired. On 5/8/25 at 11:27 a.m., in interview with Resident #800, said she did not know about the incident on 4/25/25 with CNA Staff B. She said she was probably sleeping at the time and did not remember the incident. The resident said, I just felt uncomfortable when she was around me, she was not nice. On 5/8/25 at 9:30 a.m., in an interview, Central Supply Staff D, said, on 4/25/25 at around 5 a.m., I was doing rounds, and I was in Resident #800 and #850's room. I felt the CNA Staff B was verbally abusive, she was just very short with Resident #850. These folks are here in our care and if we don't care we shouldn't be here. CNA Staff B was very short the way she was talking with her and I saw her be rough with her. I saw her. She jerked Resident #850's arm when she was trying to get her arm in her sweater. She was rough and I had been told by Resident #850 that the CNA was mean to her all the time. About a week ago I was taking with Resident #850 on the way to a doctor's appointment because I also drive the facility van. The resident said I'm afraid of my night aid, she is very mean, and she said it was Staff B. CNA Staff B was very big and intimidating, she gave me a look when I said something to her about what I saw, but she did not say anything to me. Resident #850 said she was intimidated, she never said Staff B hit her. I reported it to the nurse on duty at the time because the Director of Nursing (DON) was not here. The DON did speak with me about what I saw. That is what I observed, I felt like the CNA treated Resident #850 worse when I was not in the room because I could call her on it and the resident could not. I visit the room most every day. Further review of the facility investigation documented, Due to a lack of definitive evidence to confirm or disprove the allegation, the findings are classified as inconclusive. However, based on administration concerns related to customer service, CNA Staff B's employment has been terminated. On 5/7/25 at 10:50 a.m., in an interview the Administrator said she had reposted her phone number and spoke with everyone about abuse, not really abuse but customer service. We reach out to family and residents to make sure they are ok. This company is all about customer service and right now it is not acceptable. We have a new leadership team, and we are not tolerating it. The Administrator confirmed there was no documentation of the increased monitoring after the allegations. The Administrator said, I spoke with the residents; skin sweeps were done and there were no injuries. I re-educated the staff on customer service. I think that is the problem, customer service is not where it needs to be. On 5/8/25 at 8:45 a.m., in an interview the Administrator said regarding the abuse/neglect allegations, I have done education, and the Regional Nurse Consultant is reviewing that now because it is on-going and we want to make sure everyone is on the list. I did education and we have online learning and there is a lot of things about customer service. I have told the staff to take care of themselves and not work a lot of overtime because that can lead to issues.

Based on review of policies and procedures, clinical record review, and staff interview, the facility failed to provide the necessary interventions to prevent the development of avoidable pressure ulcers for 1(Resident #799) of 3 residents identified as at risk for developing pressure ulcers. The findings included: The facility policy Pressure Injury Prevention and Management initiated 3/1/22 (revised 3/1/23) documented, this facility is committed to the prevention of avoidable pressure injuries unless clinically unavoidable and to provide treatment and services to heal the pressure injury, prevent infection and the development of additional pressure injuries. Pressure ulcer injury refers to localized damage to the skin and or underlying soft tissue usually over a Bony prominence or related to a medical or other device. The facility shall establish and utilize a systematic approach for pressure injury prevention and management including prompt assessment and treatment intervening to stabilize reduce or remove underlying risk factors monitoring the impact of the interventions and modifying the interventions as appropriate. Review of the clinical record revealed Resident #799 was [AGE] years old and admitted to the facility on [DATE]. Diagnoses included: dementia, chronic kidney disease, muscle weakness and fracture of the left femur. The Admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 12/27/24 documented Resident #799 was dependent for bed mobility, transfers, toileting and bathing. The MDS documented that the resident was not at risk for pressure injury and had no pressure injuries at admission. The MDS noted Resident #799's cognitive skills for daily decision making were moderately impaired. The care plan initiated 12/25/24 did not address the resident's skin condition including the potential/risk for pressure injury. Review of the Admission Assessment completed on 12/25/24 documented a surgical wound to the left hip and no pressure injuries. The assessment documented that the resident was not at risk for pressure injury/ulcer. The clinical record showed no documentation of preventive measures to decrease the risk of skin breakdown for Resident #799. The weekly skin assessment dated [DATE] documented admission, no open areas. A Braden scale (used to determine a resident's risk for skin breakdown) was completed on 12/28/24 and documented a score of 14 indicating moderate risk for skin breakdown. On 1/4/25 at 6:10 p.m., a nursing progress note documented the resident was transferred to the local emergency department at the request of the family. The resident did not return to the facility. On 1/6/25 at 9:39 a.m., a Progress note written after transfer to the hospital documented, Darkened area to back of resident's left heel identified as deep tissue injury. POA (power of attorney) aware of identification and treatment plan consisting of the addition of podus boots while in bed and skin prep to heel q (every) shift. Review of the Treatment Administration Record did not show documentation the skin prep was ordered or applied to the left heel. A late entry progress note dated 1/7/25 at 2:43 p.m., documented: Late entry. Interdisciplinary Team (IDT) reviewed skin issue. Resident was sent to the hospital shortly after identification and is still at the hospital. New order for skin prep and a boot to the heel. When returns from the hospital we will assess the wound at that time and involve wound care physician and dietician if appropriate. On 5/7/25 at 9:38 a.m., in an interview the Administrator said, We have a new wound company and a new Director of Nursing (DON), we are all new and working together. We have weekly and daily meetings for wounds and the new wound company will start next week. On 5/7/25 at 10:50 a.m., in an interview the DON said she was hired 2 weeks ago as the Wound Care Nurse and on May 1, 2025, she took the position of the DON. The DON said, We are just starting this new process of weekly skin sweeps, and ensuring a skin assessment is completed at admission. With all new admissions the plan is for myself, the Assistant Director of Nursing (ADON) and the Unit Manager will follow up in 24 hours to assess the skin and complete another skin assessment. Review of the facility investigation dated 1/4/25 documented, Resident was noted to have developed a pressure injury during her stay, which was documented and treated. The pressure injury that developed during the residents stay was assessed and treated according to facility protocol.

Based on record review, review of the facility's policies and procedures, staff and resident interview the facility failed to implement their policies and procedures and demonstrate ongoing coordination to promote residents' rights and ensure 1 (Resident #45) of 25 residents reviewed for Advanced Directives accurately reflected their expressed wishes. The findings included: The facility policy Advanced Directives Policy (revised [DATE]) documented Each resident has the right to be informed and provided written information to all concerning the right to accept, refuse or discontinue medical treatment, to participate in or refuse to participate in experimental research and the right to formulate and advanced directive. The facility will provide a written description of the facilities policy to implement advanced and applicable state law, evaluate and document each residents advance care planning decision. The facility will evaluate the residents desired code status decision and ensure they are honored. The facility will document those decisions, and obtain the state required documentation as needed. Review of Resident #45's clinical record revealed an admitted [DATE] with diagnoses including malignant neoplasm of the parotid gland, dementia, dysphagia, vertigo and dry mouth. Review of the electronic record revealed a physician order dated [DATE] for Do Not Resuscitate (DNR). Review of the paper chart showed Resident #45 had a yellow DNR order in the front of the chart. Under the Advanced Directive tab of the chart there was an Advanced Directives Discussion Document that had a checked box indicating the resident wanted Cardiopulmonary Resuscitation (CPR). Photographic evidence obtained. On [DATE] at 3:17 p.m., in an interview Resident #45 said she had wanted to be a full code but since her caner diagnosis she knows that if there can't be anything done for me then let me go. The resident said she knew the meaning of DNR and it was what she wanted. On [DATE] at 3:30 p.m., in an interview Unit Manager Staff A confirmed the residents chart contained both an advanced directive form signed [DATE] that documented the resident wanted to be a full code and the DNR form dated [DATE]. On [DATE] at 3:40 p.m., in an interview the Director of Nursing (DON) confirmed to avoid confusion the facility should have had Resident #45 complete a new Advanced Directives Discussion Document. The DON said, oh that was when she first came in she wanted to be a full code. The DNR was signed after, we would go by the DNR and not the other form. The nurses go by the yellow DNR. It isn't confusing, the nurses know to follow the yellow DNR. Review of the care plan initiated [DATE] (revised [DATE]), documented the resident has advanced directives. Full Code. Will have advanced directive followed. On [DATE] at 11:27 a.m., in an interview the DON reviewed Resident #45's care plan and confirmed the care plan documented the resident was a full code. The DON said once the conflicting documents were identified I had the Social Service Director do a full house audit to make sure everyone's advanced directives were correct. The DON said it would not have made a difference if anything had happened to the resident because the staff have been instructed to open the chart and look for the yellow DNR. They have to have the yellow DNR, that is what they would go by. On [DATE] at 8:49 a.m., in an interview the DON said the process for Advanced Directives was at a new admission the Social Service Director gets involved and speaks with the resident about their wishes. We have the sheet they sign that want CPR or they don't want CPR. Then we get an order for the yellow sheet DNR and it goes on the front of the Chart. We make sure everything is signed and put it in the care plan. Nurses go by the yellow sheet in the front of the chart and 2 nurses check that. They go by the yellow sheet of paper in the front of the chart. I understand there was the care plan and the advanced directive form stating a full code but the nurse is only to look for a yellow DNR. On [DATE] at 9:30 a.m., in an interview Licensed Practical Nurse Staff G said, if a resident coded you get the chart and you check the Advanced Directive tab to see if they want to be full code or not. Some charts have a yellow DNR in the front and you check the advanced directive section of the chart. You still check the Advanced directive form, if they don't have the yellow form, that is how you know what their wishes are.

Based on observation, record review, staff, and resident interviews the facility failed to identify and promptly notify the physician of a rapid significant weight gain for 1 (Resident #67) of 1 with a diagnosis of congestive heart failure and observed with swelling of the abdomen, legs, and feet. The findings included: Review of a facility policy titled, Weight Management dated 5/22/23 noted, It is the policy of the facility to provide care and services related to weight management in accordance to state and federal regulations . Dietary will evaluate all weights by the seventh of each month. A re-weight will be obtained for any weight change of +/- (plus or minus) (3) lbs. from the previous weight unless other parameters have been ordered by the physician .The physician and the resident or resident representative will be notified by the resident's nurse of any significant unexpected and or unplanned weight changes. The nurse will document the notification in the resident electronic medical record by completing the Event Report. Review of the clinical record revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses included Atrial Fibrillation (type of abnormal heart rhythm), Chronic Kidney Disease, and Chronic Congestive Heart Failure (chronic condition in which the heart doesn't pump blood as well as it should). The Quarterly Minimum Data Set (MDS) with a target date of 1/5/24 noted Resident #67 had a Brief Interview for Mental Status score of 14, indicating intact cognition. Resident #67 was dependent on staff for toileting, bathing, dressing and personal hygiene. The MDS noted the resident's weight was 220 pounds (lbs.) at the time of the assessment. The care plan initiated on 10/13/23 noted the resident had altered cardiovascular status related to Congestive Heart Failure (CHF), and Atrial Fibrillation. The goal was for the resident to be free from complications of cardiac problems. The interventions included to monitor, document and report as needed any signs and symptoms of coronary artery disease, including shortness of breath, dependent edema (swelling due to excess fluid collection into body tissues). Review of the Physicians Encounter note dated 1/30/24 revealed the resident was positive for chronic leg swelling, positive for cough and shortness of breath. The resident had 2+ edema (three to four millimeters of depression when pressure is applied) to the lower extremity. The resident had a wet cough, moderate rales (rattling sound) in the lung bases bilaterally but no wheezing or respiratory distress. Resident #67's medications as of 1/20/24 included Bumex 2 milligrams (diuretic used to remove excess water from the body), 1.5 tablet daily related to Chronic Congestive Heart Failure. On 2/12/24 at 12:04 p.m., Resident #67 was observed laying in his bed with the head of bed elevated approximately 30 degrees. Resident #67 was wearing a hospital gown and was covered from the waist down. Resident #67's abdomen appeared distended. The resident's face and hands looked puffy. was dressed in a hospital gown and was covered to his waist with sheet and blanket. Resident was observed to be a large man with a large, distended abdomen. Resident face and hands appeared to be puffy. On 2/12/24 at 12:59 p.m., in an interview Resident #67 said his legs and feet were very swollen and felt it was an issue. Resident #67 also said he'd like to get up but staff did not get him out of bed very often. He said he was not able to keep his strength. On 2/14/24 at 10:40 a.m., two staff members were observed providing extensive assistance to turn Resident #67 from side to side in bed. Resident #67's legs and feet looked extremely swollen. Resident #67 was apologizing to the staff for not being able to help more. A review of Resident #67's weight from 12/25/23 through 2/14/24 showed: 12/25/23: 217 lbs. via mechanical lift. 1/4/24: 220 lbs. via mechanical lift. (Gain of 3 lbs. in 10 days) 2/2/24: 230 lbs. via mechanical lift (Gain of 10 lbs. in 29 days) 2/14/24: 244.4 lbs. via mechanical lift (Gain of 14.4 lbs. in 12 days). Resident #67 had a 27.4 lbs. weight gain from 12/25/23 to 2/14/24. On 2/14/24 at 2:52 p.m., in an interview Licensed Practical Nurse (LPN) Staff I said Resident #67 had significant edema in his legs, feet, and abdomen. On 2/14/24 at 3:20 p.m., in an interview LPN Staff B stated Resident #67's weight has been fluctuating. She verified Resident #67 experienced a three lbs. weight gain between December and January and an additional 10 lbs. weight gain between 1/4/24 and 2/2/24. LPN Staff B said she was aware of the weight gain and stated, I am going to be totally honest with you I did not get a reweigh on him after the 10 pounds weight gain. I did not notify the dietitian and I did not call the doctor. LPN staff B verified she did not follow the facility's weight management policy. On 2/15/24 at 10:37 a.m., in an interview LPN Staff G said the Restorative Certified Nursing Assistant (CNA) Staff H obtains the weight and reports it to the Restorative Nurse and the Registered Dietitian. On 2/15/24 at 10:53 a.m., in an interview CNA Staff H said she does the weekly and monthly weights and documents them on paper. She said she can see the previous weight. CNA Staff H said, I knew Resident #67 weight was up so I re-did the weight again right there and it was correct. CNA Staff H said she gives the weights to LPN Staff B, the restorative nurse who puts them into the electronic clinical record. CNA Staff H said she was not responsible to report the weights to the Dietitian or the nurse on the cart. She was just supposed to report the weights to the Restorative Nurse. On 2/15/24 at 11:14 a.m., in an interview Resident #67's physician said Resident #67 had cardiorenal syndrome (acute or chronic problem in the heart and kidneys that could result in acute or chronic problem of the other) and was delicate. He said he encourages staff to get him out of bed. He should be getting up at least twice a day. The physician said the facility did not inform him of the weight gain. He said the facility should have notified him of the 10 lbs. weight gain on February 2nd. He would have addressed it right away. The physician said he expected the facility to follow their weight management policy, and report and weight changes of three lbs. On 2/15/24 at 12:08 p.m., in a telephone interview, the Registered Dietitian said, I do not have anything to do with the weight gain if I know the person is a person with water weight gain. I do not address weight gain or make a note if the weight gain is due to water weight gain. I cannot make notes on every resident that gains weight due to water weight and not from over amount of food intake.

Based on observation, review of facility's policies and procedures, resident and staff interviews, the facility failed to maintain respiratory care equipment in accordance with manufacturer's specification for 1 (Resident #59) of 16 residents reviewed with oxygen therapy. The findings included: Review of the facility's policy titled, Physical Environment-Safe Environment dated 10/1/2023 showed documentation, The facility will maintain all essential mechanical electrical and patient care equipment in safe operating condition. Review of the clinical record revealed Resident #59 was admitted to the facility on [DATE]. On 2/12/24 at 10:00 a.m., Resident #59 was observed receiving oxygen through a nasal cannula attached to an oxygen concentrator (medical device that gives extra oxygen). In an interview, Resident #59 said she has not seen anyone changing the concentrator's filter. On 2/13/24 at 4:09 p.m., in an interview the Director of Nursing (DON) said the maintenance department was responsible for the maintenance of the oxygen concentrators' filters. Review of the Oxygen Concentrator User Manual provided by the facility noted, Between-Patient Maintenance: The concentrator must be serviced and reconditioned between patients as follows: . Replace the cabinet filter and Air In-Take Filter . Weekly caregiver/Patient Maintenance: . Clean the cabinet filter . Wash the filter with water and mild detergent . Set the filter aside to air dry . Be sure the filter is completely dry before re-installing . On 2/13/24 at 4:19 p.m., in an interview the Maintenance Director said the housekeeping department was responsible to clean the filters. On 2/13/24 at 4:21 p.m., in an interview the Director of Nursing (DON) said the facility owned the concentrators. The DON then told the Maintenance Director his department was responsible to clean the oxygen concentrators' filters. The DON turned to the Administrator and said they needed to write up something for that. On 2/15/24 at 11:22 a.m., in an interview the Housekeeping Supervisor said the housekeeping department only did the terminal cleaning of the oxygen concentrators between residents but they do not replace the filters. She said they use a multipurpose peroxide cleaner on the outside, remove the filters and wash them with soap and water. She said once the filter is dry, they put it back on the concentrator and bag the machine for the next resident's use. The Housekeeping Supervisor said they did not have replacement filters for the concentrators and did not know who would order them. On 2/15/24 at 11:26 a.m., in an interview the administrator said she did not know the concentrators needed a new filter between residents and will be ordering the filters.

Based on record review, staff and resident interview, the facility interview and record review the facility failed to implement policies and procedure and assist 1 (Resident #130) of three sampled residents with transportation arrangement to scheduled medical practitioner's appointments. The findings included: Review of the clinical record revealed Resident #130 was admitted to the facility on [DATE]. Diagnoses included pubic (one of the three bones that make up the pelvis) fracture. On 2/13/24 at 4:11 p.m., in a telephone interview Resident #130 said during his stay at the facility, his scheduled follow up Orthopedic Surgeon appointment had to be rescheduled twice since the facility had problems with their transportation bus. The resident said he offered to get his own transportation but staff told him he could not arrange his own transportation. On 2/14/24 at 12:51 p.m., in an interview the Social Service Director said he contacted the Orthopedic surgeon and verified Resident #130 missed the scheduled 8/9/23 appointment. The Social Service Director verified staff did not document in the clinical record the reason for the missed appointment. On 2/14/24 at 2:59 p.m., in an interview the Director of Nursing (DON) said the facility had no current policy or procedure to ensure staff documented information in the resident's medical record regarding assistance with transportation to outside medical appointments. The DON said whoever makes the appointment for transportation fills out a form and the appointment is usually scheduled by the medical supply person for transport.

Based on observation, review of facility's policy and procedure, and staff interview the facility failed to safely store medications to prevent unauthorized access. The findings included: A Review of a facility policy titled, Storage of Medications (no dated) specified, Policy - Drugs and biologicals should be stored in a safe, secure, and orderly manner. Policy Interpretation and Implementation 6. drugs and biologicals are locked when not in use and items are not left unattended. 7. Drugs are stored in an orderly manner in cabinets, drawers, or carts. On 2/13/23 at 8:15 a.m., a large package was observed on a credenza in the front lobby of the facility approximately five feet from the door. The package was labeled, Pharmacy Returns. The package was next to the outgoing mailbox located approximately 10-15 feet from the front desk where the receptionist sat. On 2/13/24 at 8:17 a.m., Receptionist Staff J did not answer when asked about the content, and who was watching the bag labeled, Pharmacy returns. On 2/13/24 at 8:18 a.m., in an interview the Administrator stated the medications should be secured and removed the bag. On 2/13/24 at 8:20 a.m., the Director of Nursing (DON) verified the unsecured bag labeled Pharmacy returns contained medications to be returned to the pharmacy. Observation of the content of the bag with the DON revealed the following medications: Pravastatin 40 milligrams, 25 tablets (Medication for high cholesterol). Sertraline 50 milligrams, 11 pills (Medication for depression). Farxiga 5 milligrams, 14 pills (Medication for chronic kidney disease, heart failure and type 2 diabetes). Carvedilol 25 milligrams, 30 pills (Medication for high blood pressure). Carvedilol 25 milligrams, 6 pills (Medication for high blood pressure). Potassium Chloride 10 milligrams, 27 pills (medication to treat hypokalemia). Diltiazem 120 milligrams, 21 pills (Medication to treat high blood pressure). Albuterol inhaler (Medication to treat breathing problems). Omeprazole 20 milligrams, 27 pills (Medication to treat heartburn, stomach ulcers and reflux disease). Dicyclomine 20 milligrams, 24 pills (medication to treat gut spasms for irritable bowel syndrome). The DON verified the medications on the front lobby credenza were left unsecured and unattended and will change the process for returning medications to the pharmacy.

Based on review of the clinical record and staff interviews, the facility failed to have processes in place to ensure an accurate evaluation of cognitively impaired residents upon admission to accurately reflect smoking status and implement adequate interventions to prevent avoidable accidents related to smoking for 1(Resident #999) of 4 newly admitted residents. The findings included: A review of Resident #999's clinical record documented an initial admission to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, alcohol abuse and schizoaffective disorder. The smoking evaluation completed on 3/4/23 noted the resident was not able to light the cigarette safely, smoke safely, or utilize ashtray safely and properly. The resident was not able to extinguish the cigarette safely and completely. The evaluation documented in comments, Resident chooses not to smoke at this time due to respiratory condition and use of oxygen. Declines patch at this time. The rest of the evaluation was not completed since the resident chose not to smoke at this time. Resident #999 was discharged from the facility on 3/27/23, return not anticipated. The hospital history and physical dated 4/5/23 noted Resident #999 was admitted to the hospital on 4/5/23, and noted the resident had a 50-year smoking history and almost daily alcohol however unknown amount. Reports he is still smoking. The facility record showed the resident was admitted to the facility on [DATE] from the acute care hospital. The clinical record revealed an Admission Data Collection signed on 4/14/23 at 9:56 p.m. The nurse completing the admission data collection noted the resident's level of consciousness as lethargic. The resident was oriented to person and place. The data collection form also noted the Resident was on continuous use of 4 Liters(L) of oxygen via nasal cannula. In the hot liquid risk indicators section, the nurse checked Yes noting the resident had severe cognitive impairment or no safety awareness or Brief Interview for Mental Status score of less than 8. In the elopement risk evaluation section of the form, the nurse checked Yes to the following questions: 1. Is the resident cognitively impaired? 2. Does the resident have poor decision-making skills? In the safety section of the form, the nurse entered No to the question: 1. Does the resident smoke (including electronic cigarettes)? The clinical record contained a copy of the facility policy/procedure, Resident Smoking dated and signed by Resident #999 on 4/14/23. The progress note dated 4/15/23 at 8:41 p.m., documented Education not provided. Resident is sleeping and does not interact . Oxygen is used via nasal cannula 4L (liters). The progress note dated 4/15/23 at 11:36 p.m., noted the resident was lethargic but pleasant and cooperative early in the shift, but became increasingly angry when they administered his intravenous antibiotic at 10:00 p.m. On 4/16/23 at 4:42 p.m., the nurse documented, Resident #999 was observed in his room by his Certified Nursing Assistant standing by the bathroom door with a lit cigarette in his mouth. The resident was using oxygen via nasal cannula. The cigarette and lighter were taken from the resident and he was advised that smoking was not allowed in the room. A review of the incident note dated 4/17/23 at 7:45 a.m., documented the nurse and the Administrator in Training spoke to Resident #999 regarding the incident on 4/16/23 and his noncompliance following the facility's smoking policy. Verbal consent was obtained from the resident to search his room/person and belongings for any smoking material, and none was found. They specifically discussed safety issues related to smoking in the facility and the immediate danger it poses to himself other residents and staff especially with the use of oxygen. The smoking policy was resigned by the resident and a new smoking evaluation completed. On 5/15/23 at 9:50 a.m., the Director of Nursing (DON) said Resident #999 was a smoker who used oxygen but was forgetful and did not understand the smoking rules. The DON said we had the resident sign the smoking policy at admission and he signed another one on 4/17/23. On 5/15/23 at 11:05 a.m., the DON said, when Resident #999 was admitted the nurse asked if he was a smoker and he said no. He came from the hospital, and they did not search the resident or his belongings. They did not know he had cigarettes on him. The DON was not able to locate an inventory of the resident's possessions at the time of admission which could have identified the smoking materials. On 5/15/23 at 2:00 p.m., the DON said the facility's process for identifying smokers was to ask the resident or family upon admission. She said the nurse was responsible for reviewing all the information from the hospital if available when the resident is admitted . The DON confirmed the facility had no policy for completion and accuracy of the admission assessment when a resident is cognitively impaired and said the admitting nurse should have read the hospital's record and use the information in the admission evaluation. The DON said Resident #999 denied smoking at admission on 4/14/23 but the admitting nurse failed to read the hospital history and physical identifying the Resident was still smoking.

Based on observations, staff and resident interviews and record review the facility failed to ensure they stored smoking materials and obtained a signed agreement, from each resident, attesting they will abide by the facility smoking policies and procedures for 4 Residents (#18, #53, #39 and #47) of 4 residents reviewed who smoke at the facility. The findings included: On 6/06/22 at 10:30 a.m., during an interview with Resident #18, in her room, a cigarette pack was observed in her purse. Resident #18 said she smokes several times a day and the facility let her always keep her cigarettes and lighter with her. On 6/06/22 at 2:23 p.m., the Activity Director was observed monitoring Resident #18 and 3 other residents smoking in the designated smoking area. The Activity Director said, the residents who smoke would get their cigarettes and lighter from the nursing station and when the resident(s) were done smoking, they are required to return their cigarettes and lighter back to the nursing station. On 6/06/22 at 3:13 p.m., during an interview with Resident #18, she was observed to have had her cigarettes and lighter. Resident #18 said the facility staff did not ask her to return her cigarettes and lighter after she was done smoking and she didn't remember ever signing a smoking agreement stating she would abide by the facility smoking policies. On 6/07/22 at 3:30 p.m., Resident #47 said she was a smoker, and the facility staff allowed her to keep her cigarettes and lighter sometimes. She further said she didn't always have to return them to the nursing station after she was done smoking. Resident #47 said she didn't remember signing a smoking agreement stating she would abide by the facility's smoking policies when she was admitted to the facility. On 6/08/22 review of the facility's Smoking policy and procedure, revised on 2/07/20 stated the facility would retain and store matches, lighters, etc. for all residents and all residents who wished to smoke would sign an agreement they would abide by the facility's smoking policy and procedures. On 6/08/22 at 1:10 p.m., the Administrator confirmed the facility's Smoking policy and procedure revised on 2/07/20, which stated the facility would retain and store matches, lighters, etc. for all residents and all residents who wish to smoke would sign an agreement they would abide by the facility's smoking policy and procedures. He said when a resident was done smoking, they were required to return all smoking items as noted in their smoking policy to the nursing station for safe keeping. He further said it was the facility's policy to inform all residents who wish to smoke about their smoking policy and have them sign an agreement they would follow the facility's smoking policy and procedures. On 6/09/22 at 11:02 a.m., the Director of Nursing (DON) said when a resident was admitted to the facility and they wished to smoke, the admission office would have the resident sign the smoking agreement policy and the nurse would assess the resident to ensure they were a safe smoker. On 6/09/22 at 2:45 p.m., the DON said she was able to find documentation nursing had completed the smoking evaluation as required for the residents who smoke at the facility, but they were unable to find documentation the residents who smoke had signed the facility's smoking agreement as required and noted in their Smoking policy and procedures acknowledging all smoking materials would be returned after each smoking session. On 6/8/22 at 12:00 p.m., in an interview Resident #53 said she keeps her cigarettes and lighter with her. Resident #53 cigarettes were observed in the basket of her walker. On 6/8/22 at 12:05 p.m., during an interview Resident #39 said she gives the nurses the cigarette carton her family brings in. Resident #39 confirmed she keeps her cigarettes and lighter with her in her room.

Based on staff interviews and staff record reviews, the facility failed to ensure 4 (Staff E, H, I, and J) of 4 Certified Nursing Assistant (CNA)'s employee records reviewed had a performance review completed at least once every 12 months. The facility failed to ensure staff had in-service education based on the outcome of their performance reviews by not having annual competency evaluations. The findings included: On 6/08/22, a review of Employee Guidebook revealed on page 25, section Performance Evaluation, it stated employee performance is reviewed on a continuous and ongoing basis, periodically and employees will receive a formal written appraisal from their supervisor. The performance evaluation provides an opportunity to discuss the employee's past performance as well as future goals. All performance evaluations become a permanent part of their employee record. The performance evaluation should be completed 90 days after hire and annually on the employee anniversary date of hire per facility policy. On 6/08/22, a review of Certified Nursing Assistant (CNA) Staff E's employee file revealed a hire date of 8/06/2008. There was no documentation an employee performance evaluation review was completed for Staff E in 2021. On 6/08/22, a review of CNA Staff H's employee file revealed a hire date of 11/08/2016. There was no documentation an employee performance evaluation review was completed for Staff H in 2021. On 6/08/22, a review of CNA Staff I's employee file revealed a hire date of 3/13/2019. There was no documentation an employee performance evaluation review was completed for Staff I in 2021. On 6/08/22, a review of CNA Staff J's employee file revealed a hire date of 10/02/2020. There was no documentation an employee performance evaluation review was completed for Staff J in 2021. On 6/08/22 at 10:25 a.m., the Human Resources Director (HRD) said the corporate office told her last year not to do the employee performance evaluations because they were not giving their employees a pay raise. The HRD reviewed the Employee Guidebook and confirmed the facility is required to conduct a written Performance Evaluation on all their employees 90 days after hire and yearly on each employee's hire date. The HRD reviewed Staff E, Staff H, Staff I, and Staff J employee records and confirmed there was no documentation they had completed their required yearly performance evaluation. The HRD said they did not do any employee performance evaluation last year as per the corporate office directive. On 6/09/22 at 11:00 a.m., the Director of Nursing (DON) said throughout the year the HRD would generate an employee performance evaluation annually prior to the employee's hire date to be completed by the director of each department. She said she gives the employee performance evaluation to the unit managers. The unit managers will give her the completed employee performance evaluation which she reviews to determine and ensure each employee is performing as required and conduct staff education as determined by their employee performance evaluation. The DON said HRD did not generate any employee performance evaluation in 2021 and she does not remember herself and/or the unit managers conducting any nursing staff performance evaluation in 2021 as written in the Employee Guidebook. On 6/09/22 at 2:03 p.m., the DON said she talked with the unit managers, and they were unable to find documentation they had completed the required annual employee performance evaluation for Staff E, Staff H, Staff I, and Staff J as required.

Based on review of the facility records and staff interviews the facility failed to provide documentation of an updated, written agreement for the provision of hospice services to reflect current ownership for 3 (Resident #16, #46, and #60) of 3 residents reviewed for hospice services. The findings included: On 6/6/22, upon request of the facility agreement with the hospice provider, the Administrator provided a hospice agreement signed 4/1/14 between the hospice and the previous owner of the facility. On 6/8/22 at 12:02 p.m., in an interview the Director of Nursing (DON) confirmed the facility had changed ownership. The DON confirmed the current hospice agreement provided by the facility was not valid with the new corporation and the facility needed to obtain a new contract. On 6/8/22 at 3:30 p.m., the DON confirmed the facility currently had 3 residents receiving hospice services.

Based on record review, observation, and staff interviews, the facility failed to accurately assess 2 (Residents #5 and #68) of 2 residents reviewed for facility acquired pressure ulcers. The facility failed to alter the plan of care to include more frequent repositioning or offloading the area when pressure ulcers developed and then worsened. The facility failed to provide interventions to prevent the development and worsening of pressure ulcers. The lack of interventions for a resident at risk, resulted in the resident developing full thickness stage III pressure ulcers. The findings included: Current standard of practice for pressure ulcer assessments were outlined in the National Pressure Ulcer Advisory Panel (NPUAP web site at http://www.npuap.org). The NPUAP defines pressure ulcer as localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of pressure. A stage II pressure ulcer is partial loss of dermis, presents as shallow open ulcer with red/pink wound bed. Granulation tissue, slough, and eschar (dead tissue) are not present. A stage III is a full thickness skin loss and granulation tissue is often present. Slough and/or eschar may be present in the wound. Under prevention and treatment; avoid positioning the individual on body areas with pressure injury; consider more frequent repositioning and replacing the mattress for more effective pressure redistribution for an individual who fails to heal or demonstrates ulcer deterioration and/or is at high risk for additional pressure ulcers; off-loading and pressure redistribution may allow re-perfusion (restore blood flow) to injured tissue. 1. Resident #5's clinical record revealed a quarterly Minimum Data Set 3.0 (MDS) assessment completed on 5/7/17. The MDS indicated the resident had developed a stage II pressure ulcer on 4/4/17 and was dependent on the assistance of 1 staff member for bed mobility. A quarterly MDS completed on 10/19/17 indicated the resident had 2 stage II pressure ulcers. An annual MDS completed on 1/9/18 indicated the resident had severe cognitive impairment, required the extensive assistance of 2 staff members for bed mobility, and has a stage II pressure ulcer present since 4/4/17. Braden Scale assessments were completed on 2/13/17 and 9/30/17, and indicated the resident was at moderate risk for developing a pressure ulcer. Review of pressure ulcer records indicated on 4/4/17, Resident #5 developed a stage II pressure ulcer 0.5 centimeter (cm) by 0.5 cm in size with 0.1 cm depth on her right outer ankle. Granulation tissue was noted in the wound bed. On 8/22/17 the pressure ulcer was noted 2.0 cm by 2.0 cm in size, and continued to be coded a stage II pressure ulcer with granulation tissue present. On 12/6/17, the wound was 0.5 cm by 0.5 cm in size and unable to determine depth due to the presence of black eschar tissue in the wound bed. On 3/27/18 the wound was noted 0.6 cm by 0.5 cm in size, and stage II with granulation tissue present. On 4/2/18 at 10:55 a.m., Resident #5 was observed in bed lying on her right side in the fetal position with her right outer ankle in contact with the mattress. On 4/2/18 at 1:12 p.m., Licensed Practical Nurse (LPN) Staff J and LPN Staff L were observed doing wound care to Resident #5's pressure ulcer. The resident had a partially healed stage III pressure ulcer on her right outer ankle 2.0 cm by 1.0 cm in size with a 0.75 cm by 0.5 cm open area in the lower part of the wound bed. A 0.25 cm area of brown tissue was noted on the lower border. On 4/4/18 at 9:26 a.m., Resident #5 was observed lying in bed on her right side with her right outer ankle in contact with the mattress. On 4/4/18 at 1:17 p.m., Certified Nursing Assistant (CNA) Staff N said Resident #5 had to be moved and positioned by staff. CNA Staff N was not aware of any special skin care other than lotion to the resident's buttocks. On 4/4/18 at 4:15 p.m., CNA Staff G said she did not do anything special for Resident #5's skin but reposition her a few times during her shift. Resident #5's care plan for impaired skin integrity indicated the resident had a pressure ulcer on her right ankle and right hip related to fragile skin, incontinence and end stage dementia. The pressure ulcer on the right hip was noted to be resolved on 10/31/17. The goal was for interventions to remain in place to prevent further impaired skin. Interventions dated 10/31/17, included to remind and assist resident with turning and repositioning as needed, and avoid positioning the resident on her right side. There had been no revisions to the interventions on the plan of care for skin integrity since 10/31/17. On 4/5/18 at 11:10 a.m., the facility's wound care consultant (WCC) said the most effective intervention for healing the pressure ulcer on Resident #5's lateral ankle was 100% off loading. The WCC confirmed the resident's pressure ulcer was currently not a stage II. There was no evidence of any interventions other than treatment orders to Resident #5's pressure ulcer after being identified on 4/4/17. The resident's wound continued to worsen, increasing in size and stage to become a full thickness wound over a bony prominence. The facility did not consider other support surfaces to reduce pressure, offloading the wound, or a more frequent turning schedule to promote healing. No policies or procedures were evident to guide staff when a resident's Braden Scale showed at moderate risk or when a pressure ulcer developed, worsened or had delayed healing. On 4/5/18 at 11:28 a.m., the Director of Nursing (DON) confirmed the pressure ulcer assessments were inaccurate and there was no evidence of nursing interventions other than routine positioning and a standard mattress for Resident #5. The DON acknowledged even with the worsening and delayed healing of the wound, the resident essentially had the same interventions in place as when she initially developed the pressure ulcer. 2. Resident #68's clinical record revealed a 14 day comprehensive MDS 3.0 assessment dated [DATE]. The MDS indicated the resident required extensive assistance of 2 staff members for bed mobility and transfer. The MDS indicated the resident had developed a stage II pressure ulcer on 3/15/18. Review of the pressure ulcer records indicated on 3/15/18 Resident #68 developed a stage II pressure ulcer to the left heel measuring 1.6 cm by 2.7 cm with 0.01 cm in depth. The DON noted granulation was present in the wound bed. On 3/30/18, the DON documented the pressure ulcer remained a stage II with the presence of granulation tissue in the wound bed. Review of the Resident Assessment instrument manual instruction for coding pressure ulcers revealed granulation tissue, slough and eschar are not present in stage II pressure ulcers. Pressure ulcers as having granulation, slough or eschar tissue should not be coded as stage II. On 4/4/18 at 9:50 a.m., interview with the Registered Nurse (RN) MDS coordinator revealed she relied on the documentation in the clinical record to code the pressure ulcers. She said sometimes she looked at pressure ulcers but had not looked at this particular resident's wound nor had she discussed the wound with the DON. The MDS coordinator said she did not remember anything in the documentation that made her question the stage of Resident #68's pressure ulcer. On 4/4/18 at 12:13 p.m., RN Staff Q was observed cleaning and bandaging Resident #68's pressure ulcer. The wound bed was partially covered with yellow slough with areas of red granulation tissue. At the completion of the wound care, RN Staff Q said she thought the wound was unstageable. The DON who was present during the wound care said she saw granulation in the wound bed and stated It's a stage II. Review of the interdisciplinary progress notes on 4/3/18 revealed the last dietary progress note was dated 3/27/18 and documented to continue with plan of care. On 4/4/18 at 1:08 p.m., interview with the Registered Dietician (RD) revealed she came in twice a week to the facility but no one told her Resident #68 had developed a pressure ulcer or she would have recalculated the dietary needs of the resident to aid in the healing process. The RD said the interventions were partially based on the stage of the pressure ulcer. On 4/5/18 at 9:00 a.m., interview during the survey with the DON revealed there was no specific process to alert the dietician of a new wound. She said she just left the wound reports in the dietician's box but had no way of verifying if the RD received the notice. She said the WCC assessed the resident's wound the evening of 4/4/18 and determined the resident's pressure ulcer to be a stage III and the treatment was changed. The DON acknowledged the pressure ulcer assessment was inaccurate and confirmed the lack of coordination with the RD to ensure timely assessment and dietary intervention to aid in the healing process of the wound.