Every finding on record at Harrisonburg HLTH & Rehab CNTR

An unannounced Medicare/Medicaid third revisit to the 2/13/2026 standard certification survey was conducted on 7/2/26. The first revisit survey was conducted 4/13/26 through 4/15/26. The second revisit was conducted 6/8/2026 through 6/10/2026. Corrections are required for compliance with the following 42 CFR Part 483 Federal Long Term Care requirements. Two complaints were investigated during the survey (3076062 -Compliant; 3072965 - Non-Compliant with deficiency). Corrected deficiencies are identified on the CMS-2567B. The census in this 180 certified bed facility was 141 at the time of the survey. The survey sample consisted eight current resident reviews and one closed record review.On 7/15/26 at 8:55 a.m., an observation of the facility was conducted. Layers of sticky dirt and dust were observed in the vents of the heating/air conditioning units in rooms #86, #26, #19, #12, #6, #5, #3, #41, and #34, in the ceiling air vents in the resident room bathrooms #84, #27, #8, #5, and #35, and #34, and in the ceiling air vents at the South unit nurse's station, and on the East unit short hall and the East unit long hall.On 7/15/26 at approximately 3:35 p.m., an interview was conducted with the Director of Maintenance. The Director of Maintenance stated the maintenance staff typically clean the vents of the heating/air conditioning units in the resident rooms and the ceiling air vents in the resident bathrooms once a month and clean the ceiling air vents on the halls every three months. The Director of Maintenance stated the staff had got behind on cleaning the vents due to other environmental projects. The Director of Maintenance stated that due to those other environmental projects, there has been a lot of sanding in the facility lately and this clogs up the vents so the maintenance staff would probably have to increase their cleaning schedules.On 7/15/26 at 4:58 p.m., the Administrator and Director of Nursing were made aware of the above concern.The facility did not provide a policy regarding a clean and sanitary environment.No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain a clean and homelike environment for three of 37 residents, Residents #227, #228 and #237; in one of six shower rooms; and in four of 89 resident rooms, room [ROOM NUMBER], #42, #45, and #5. The findings include: 1. The facility staff failed to maintain a homelike environment for Resident #227 (R227). R227's wall in their room contained a large black scuff mark and multiple areas with discolored yellowish colored painted areas on the wall. On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 5/11/2026, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating moderate cognitive impairment. On 6/8/2026 at 2:35 PM, an observation of R227's room was conducted and interview with R227 was conducted. Observation of R227's room revealed a black scuff mark on the wall along the doorway to the room approximately 24 inches long and six inches wide. R227 stated that he had reported the scuff to staff many times and they kept saying they were going to paint but had not gotten to it. R227 pointed to an area above the black scuff which contained a yellowish colored area on the beige wall and stated that it had been there for a long time and needed painting. R227 pointed to another area on the wall in front of his bed which contained a large yellowish colored area on the beige wall and stated that it had been there for a long time as well. R227 stated that he did not like the patchy colors on his walls and the scuff on the wall and had complained multiple times but had not had any follow up from anyone about when it was going to get painted. Additional observations of R227's room as described above were made on 6/8/2026 at 4:48 PM, 6/9/2026 8:43 AM, and 3:10 PM. On 6/9/2026 at 3:19 PM, an interview was conducted with the Director of maintenance who stated that he was made aware of repairs needed in the facility by the staff entering work orders in the computer system. He stated that he prioritized any safety needs first and then cosmetic repairs were last. He stated that he had just hired an additional staff member and anticipated being able to take on more of the cosmetic repairs needed in the building soon and had a plan to paint all the walls and repair the drywall. The director reviewed the active work orders and stated that there were none for R227's room. At 3:35 PM, the director observed R227's room and stated that he was not sure what the yellowish color was on the walls but there was a plan to paint all the rooms and that would cover up the black scuff on the wall as well. He stated that he was without any help for a long time and for a time nothing was done in the rooms and they had suffered but recently they had completed a lot of improvements in the rooms. On 6/10/2026 at approximately 1:25 PM, the Administrator observed R227's room and stated that the building was old and they were working to repaint and replace floors, but it took a while to get it all done. He stated that the yellowish colors on R227's walls were from a previous paint that was ordered that was not the correct color. The Administrator stated that they were working to order the correct color for the walls and get the rooms painted and the scuff on the wall will be covered when it is painted. On 6/10/2026 at 2:21 PM, the Administrator and the Director of Nursing were made aware of the concern. On 6/10/2026 at 3:28 PM, the Regional Director of Clinical Services stated that they did not have a policy regarding homelike environment to provide. No further information was provided prior to exit. 2. For Resident #228 (R228), the facility staff failed to maintain a homelike environment. R228's bathroom door would not fully close, the baseboard in the bathroom was coming apart from the wall and held in by push pins on one end and there were small round holes from previous grab bars in the wall behind the toilet. On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 3/12/2026, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is oriented to person, place and time and has unimpaired immediate recall. On 6/8/2026 at 2:45 PM, an observation was made of R228's room and interview conducted with R228. Observation of R228's bathroom revealed the baseboard on the doorway wall of the bathroom coming apart from the wall with glue fibers visible between the baseboard and the wall surface. Four pushpins were observed holding the baseboard to the wall on the end near the doorway. Observation of the area behind the toilet revealed four small round holes in the wall surface and the door to the bathroom would not close completely. R228 stated that the baseboard was coming off the wall and had push pins holding it on and she had been told that it would never stay because there was no wall there. R228 stated that there were holes behind the toilet from hand bars that were taken off and the bathroom door was warped and would not close completely. Additional observations of the areas listed above were made on 6/8/2026 at 3:26 PM, 6/9/2026 at 8:45 AM and 3:08 PM. On 6/9/2026 at 3:19 PM, an interview was conducted with the Director of maintenance who stated that he was made aware of repairs needed in the facility by the staff entering work orders in the computer system. He stated that he prioritized any safety needs first and then cosmetic repairs were last. He stated that he had just hired an additional staff member and anticipated being able to take on more of the cosmetic repairs needed in the building soon. The director reviewed the active work orders and stated that there were none for R228's room and the baseboard was last repaired in 2016. At 3:26 PM, the director observed R228's room and stated that he was aware that the bathroom door would not close and he was waiting to get a blade that would trim the door down so it would fully close. He stated that the holes behind the toilet needed to be filled in and painted and he had not noticed that the baseboard had come off the wall or the push pins. He stated that he could smell fresh glue and thought that maybe someone had tried to fix it and it had just popped off. On 6/10/2026 at approximately 1:25 PM, the Administrator observed R228's room and stated that maintenance was aware of the bathroom door needing to be filed down and they were working on it. He stated that there was glue on the baseboard and it looked like they had put the pushpins there to hold the baseboard in place while it dried. When asked if it was homelike, the Administrator stated that it looked like it was a repair you would do at home. On 6/10/2026 at 2:21 PM, the Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit. 3. For Resident #237 (R237), the facility staff failed to maintain a clean and homelike environment. R237's bathroom wall was observed to have significant moisture damage to the wall beside the toilet and discoloration and debris build-up on the bathroom floor. On the most recent minimum data set (MDS), an annual assessment with an assessment reference date (ARD) of 5/31/2026, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is oriented to person, place and time and has unimpaired immediate recall. On 6/8/2026 at 2:45 PM, an observation was made of R237's room and interview conducted with R237. Observation of R237's bathroom revealed the bathroom floor having brownish/tan colored square tiles which showed evidence of heavy wear and discoloration. The areas between the seams of the tiles were blackened with debris build-up. Observation of the wall beside the toilet revealed the area from the baseboard up the wall approximately two feet with visible moisture damage. The wall surface was visibly bubbled and uneven. R237 stated that the bathroom was nasty, and he had been told they would fix it, but no one had ever been in to do it. Additional observations of the areas listed above were made on 6/8/2026 at 3:28 PM, 6/9/2026 at 8:43 AM and 3:10 PM. On 6/9/2026 at 3:02 PM, an interview was conducted with the Director of housekeeping and laundry who stated that resident rooms were cleaned daily including the bathrooms which were cleaned from top to bottom. At approximately 3:10 PM, the director observed R237's bathroom and stated that the floor needed to be cleaned but even if they cleaned it they would not be able to get it completely clean because it needed to be replaced. On 6/9/2026 at 3:19 PM, an interview was conducted with the Director of maintenance who stated that he was made aware of repairs needed in the facility by the staff entering work orders in the computer system. He stated that he prioritized any safety needs first and then cosmetic repairs were last. He stated that he had just hired an additional staff member and anticipated being able to take on more of the cosmetic repairs needed in the building soon. The director reviewed the active work orders and stated that there was an active work order for R237's room regarding the wall by the sink area but none for the bathroom. At 3:32 PM, the director observed R237's room and stated that the tiles on the floor should have been replaced because they recently did a sweep of all the bathrooms and replaced the tiles in all of them and must have missed this one. He stated that they had patched the wall in the bathroom, but it needed to be repaired and thought that maybe the residents urinated on the wall and caused the wall damage. On 6/10/2026 at approximately 1:25 PM, the Administrator observed R237's room and stated that the building was old and they were working on replacing floors, but it took a while to get it all done. He observed R237's bathroom floor and stated that it had not been replaced yet. The facility policy Patient Rooms & Restrooms- Disinfect/Sanitize Daily effective 6/1/2026, documented in part, All patient rooms and restrooms will be cleaned and sanitized with fresh disposable sanitizing wipes and mopped with sanitizing solution using microfiber system daily, and more often as needed . On 6/10/2026 at 2:21 PM, the Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit. 4. In one of six shower rooms, the South hallway shower room, the facility staff failed to maintain a clean and homelike environment. On 6/8/2026 at 11:59 AM an observation was made of the shower room on the South hallway in the facility. Observation of the shower room revealed a shower that was approximately four feet wide by 12 feet long. A black slime-like build-up was observed between the white tiles on the inside wall of the shower surface on the lower portion of the shower approximately 12 inches to the floor on the three walls surrounding the shower. Additional observations of the shower room were made on 6/8/2026 at 3:03 PM and 6/9/2026 at 8:34 AM. The observations were as described above. On 6/9/2026 at 3:02 PM, an interview was conducted with the Director of housekeeping and laundry who stated that the shower rooms were cleaned daily with a cream tile cleaner to clean the bathroom tiles. At approximately 3:08 PM, the director observed the South hallway shower room and stated that the tiles needed to be cleaned and there was an ongoing problem with the black slime-like build-up due to the moisture in the room. The facility policy Disinfecting/Sanitizing Daily effective 6/1/2026 documented in part, The central bathing area of each unit will be cleaned with fresh disposable sanitizing wipes and mopped with sanitizing solution using the microfiber system daily or more often as needed . Clean bathing tub inside and outside and fixtures with cloth and sanitizing or disinfecting solution . On 6/10/2026 at 2:21 PM, the Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit. 5. In room [ROOM NUMBER], the facility staff failed to maintain a clean and homelike environment. room [ROOM NUMBER] was observed with brown splatter debris on the toilet riser and toilet bowl, brown material on the wall above the trash can and brown material on the floor. Observation of the bathroom in room [ROOM NUMBER] on 6/8/2026 at 12:07 PM revealed two areas on the floor in front of the toilet approximately two inches and four inches with dried brown material, a trash can against the wall in front of the toilet with brown material on the wall approximately 1/2 inch wide and a toilet riser sitting on top of the toilet with visible brown splatter on the inside of the toilet bowl and inside of the toilet riser. Additional observations of the bathroom in room [ROOM NUMBER] were made on 6/8/2026 4:38 PM and 6/9/2026 at 8:55 AM. The observations were the same as described above. On 6/9/2026 at 3:02 PM, an interview was conducted with the Director of housekeeping and laundry who stated that resident rooms were cleaned daily including the bathrooms which were cleaned from top to bottom. She stated that she had three housekeepers on each unit each day from 7:00 AM to 3:00 PM and 12:00 PM to 8:00 PM. At approximately 3:06 PM, the director observed room [ROOM NUMBER]'s bathroom, the toilet riser had been cleaned however the brown material remained on the floor. On 6/10/2026 at 2:21 PM, the Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit. 6. In room [ROOM NUMBER], the facility staff failed to maintain a clean and home-like environment. room [ROOM NUMBER]'s bathroom was observed with brown material in the toilet, smeared on the toilet rim and above the trash can. Observation of the bathroom in room [ROOM NUMBER] on 6/8/2026 at 3:08 PM revealed brown material in the toilet, smeared on the toilet rim and above the trash can against the wall in front of the toilet. Additional observations of the bathroom in room [ROOM NUMBER] were made on 6/8/2026 at 4:44 PM and 6/9/2026 at 9:19 AM. The observations were the same as described above. On 6/9/2026 at 3:02 PM, an interview was conducted with the Director of housekeeping and laundry who stated that resident rooms were cleaned daily including the bathrooms which were cleaned from top to bottom. She stated that she had three housekeepers on each unit each day from 7:00 AM to 3:00 PM and 12:00 PM to 8:00 PM. At approximately 3:06 PM, the director observed room [ROOM NUMBER]'s bathroom and stated that it needed to be cleaned. On 6/10/2026 at 2:21 PM, the Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit. 7. The facility staff failed to maintain a comfortable home-like environment by failing to maintain an accurate clock for two of 89 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). a. Observation during initial tour on 06/08/2026 at 12:16 p.m. revealed that the time on the clock in room [ROOM NUMBER] was 11:14. Additional observation on 06/10/2026 at 12:45 p.m. revealed that the time on the clock in room [ROOM NUMBER] was 11:43. During an interview with the administrator, we observed the clock in room [ROOM NUMBER] on 06/10/2026 at 1:30pm, he stated the clock was an hour behind and they must have missed it. The administrator declined to answer a question regarding the homelike nature of a clock not on the accurate time. b. Observation during initial tour on 06/08/2026 at 12:33 p.m. revealed that the time on the clock in room [ROOM NUMBER] was 11:38. Additional observation on 06/10/2026 at 12:46 p.m. revealed that the time on the clock in room [ROOM NUMBER] was 6:20. During an interview with the administrator, we observed the clock in room [ROOM NUMBER] on 06/10/2026 at 1:35 p.m., he stated the time on the clock was not accurate to the current time. The administrator did not respond when asked regarding the homelike nature of a clock not on the accurate time. No further information was provided prior to exit.

Based on observations, staff interview, and facility document review, the facility staff failed to maintain a clean, comfortable, homelike environment for 3 of 3 nursing units, public congregate spaces, and the building as a whole.The findings included:From the time of initial tour on 4-13-26, through the course of survey concluding on 4-15-26, the physical plant was observed and inspected. Those observations continue below. Initial tour of the facility revealed Residents #101, #103, #107, and #114's rooms on 3 different units to be crowded (hoarded) with boxes, food items, personal items, and plastic storage containers in front of, and on top of the air conditioning/heating units restricting air flow. Also observed were articles of clothing balled up in beds with soiled linens, soiled clothing articles scattered around the rooms. Large opened (16 to 18 ounce) containers of food sauces (Texas [NAME] sauce and others), and food spices spilled on and over the overbed tables, and bedside cabinet surfaces. Privacy curtains between beds in the semi private rooms had stains and brown colored smears on them which caused them to stick to them selves in places. Found were partially eaten corn bread squares which were spoiled with obvious blue mold on them. Different food items and drink items in cups and plastic glasses appearing to be mixed and were unidentifiable. No food or drink items were refrigerated, and the rooms had a sour spoiled food smell comingled with a strong odor of urine. Resident #101 was laying on a soiled bed encrusted with spilled food. The Resident's black sweatshirt was encrusted in a 6-inch by 6-inch stain on the front with dried, spilled foods and liquids, and the resident stated when asked I don't know what it is. Resident #101 was naked from the waist down covered partially by a soiled sheet. The Resident's roommate was not in the room, however, his side of the semi-private room looked very similar to Resident #101's side of the room. There were several rooms with hoarding habitation noted during tour, and an interview with the Administrator revealed that he knew of the hoarding, however, did not want to upset the Residents and so had not cleaned certain areas of those rooms. It was noted by all 5 surveyors that during the rest of the survey that shower rooms revealed a black substance along corners and caulking areas. Broken tiles were noted in the shower rooms, used soap and hair were found in the drain covers. The hallway floors had holes in them which were trip hazards. Base boards were found to be knocked down in places, and the main hallways and resident room floors were covered in black track marks and a sticky substance. Rooms had food crumbs, paper and plastic wrappers scattered about, and in the corners of rooms a built-up crust of dirt and black grime [which could be scratched off easily] was found in most areas. On 4-14-26 at 12:00 P.M., an interview was conducted with a housekeeping staff member cleaning the hallway on one of the units. She was asked what her workload was like daily, and she replied, I am the only one here today, and I can't do it all. The facility consisted of 180 beds on 3 units, shower rooms on each unit, activity rooms, courtyards, dining rooms, and various other offices and gathering spaces. The statement made by the lone housekeeper was confirmed by the Environmental Services Director who was the only laundry attendant for the day also, by her own admission. The laundry room was found with soiled clothing and linens stacked in a large mound over 5 feet tall. When she left the facility for the day, all of the dryers were full, and the washing machines were full of wet clothes and linens to wait overnight to mildew before someone would return the following morning to pick up where she left off.Clean linen carts in the hallways of each unit were observed and surveyors found approximately the following on each cart; 3-4 sheets, 5 pillowcases, 4-5 bath towels, 6 wash cloths, and 3 hospital gowns per unit for a 180 bed facility. This was clearly insufficient for evening hygiene and bathing needs as residents prepared for bed.The Administrator was again interviewed at approximately 5:00 P.M. and he said we have had a lot of call outs, and we have terminated some staff.The tables and floor in the main dining room were spattered with paint, chipped in places, encrusted and smeared with a slippery/greasy black substance on the floors. The dining tables were smeared and dirty, and stained chairs were piled and stacked against the wall in the front corner of the room. Dirty linen rooms held large bins of soiled clothing, and linens, which were draped over the bins flowing onto the floor. Sharps/needle containers with blood in them, and biohazardous materials in red 55-gallon bins were found in one unlocked [taped open] room, and chemicals were found in another unlocked room. Both rooms were open to anyone who wished to enter. The 2 rooms were next to each other on a side hallway not visible from the nursing station, where several residents were sitting in wheelchairs and found to be cognitively impaired. There were other ambulatory residents walking in the hallway with rolling walkers as well. On 4-14-26, and 4-15-26 at the end of day debriefing, the Administrator, DON and Regional [NAME] President of Operations were notified of the concerns of hoarding, unsafe, and unclean areas. They stated on 4-15-26 prior to exit that cleaning had been completed in those areas mentioned, and surveyors did see improvements. They stated at that time they had no further information to provide. 2. The facility staff failed to provide a safe, clean, comfortable, and homelike environment by failing to ensure adequate linen supply and routine housekeeping services, including daily cleaning of resident rooms, across all three units.Observations conducted from 4/13/26 - 4/15/26 on all three units revealed linen carts contained minimal supplies, including only a few pillowcases and approximately two towels, with no wash clothes or blankets available. Resident rooms were observed without facility-provided bedspreads, with some residents using personal blankets from home in place of appropriate bedding.On 4/13/26 at 2:00 pm, an interview was conducted with Resident #119(R119). He reported ongoing concerns regarding insufficient linen availability, stating there was not enough linen for his bed and that he did not have a bedspread. The resident reported his room had not been cleaned for approximately two weeks.On 4/13/26 at 5:32 pm, an observation of the laundry room was conducted. During the observation, there was excessive accumulation of personal clothing and facility linen. Clothing and linens were observed piled on top of trash cans, and the pile was to the vent on the top part of the wall, personal clothing was piled on top of a tote, and linen was piled on chemical buckets and the pile was halfway up the wall. There was another pile of personal clothes that was on a trash can and was piled high and covering the electrical boxes. The piles were excessive high piles of clothing. Multiple bin containers were overflowing, and excessive amount of bags of wet laundry were noted piled on the floor in front of the laundry room doors as high as half way up the door. The three dyers and three washers were full of linen and personal clothing and were just sitting in the machines.On 4/14/26 at 10:36 am, an interview was conducted with a licensed practical nurse, LPN#2 (LPN2). LPN2 said, it is very true that linen is short on the units. We struggle, do what we can and seems like a third world country here trying to survive. Families bring in linen, not enough staff in laundry to do the laundry and when is sits down there becomes molded and it's thrown away. Observation of R119's room revealed trash under both beds, black scuff marks on the floor, and cobwebs present in the corners of the room.A review of grievances and Resident Council meeting minutes revealed repeated concerns regarding rooms not being cleaned and personal items missing and not returned.A review of the facility policy titled, Daily Resident/Patient Room Cleaning, read in part, housekeepers are responsible for ensuring they are adequately supplied for tasks of the day with appropriate supplies, equipment, tools, and personal protective equipment (PPE). On 4/14/26 at 5:00 pm, an end of day meeting was held with the administrator, director of nursing, regional director of clinical services, and vice president of operations and the above concerns were discussed. They stated that they were working on getting more staff for the laundry and housekeeping services. On 4/15/26 at 10:00 am, an exit conference was conducted with the administrator, director of nursing, regional director of clinical services, and vice president of operations. During the exit conference they stated that staff had been in the building late the previous evening cleaning the facility and addressing laundry backlog. There was noticeable difference in the cleanliness of the hallways and dining area. No more new information was provided prior to exit.

Based on observations, staff and resident interviews and facility document review, the facility staff failed to maintain a safe environment for two of forty-three residents in the survey sample (Resident #108 and Resident #142). One oxygen cylinder was observed free-standing, unsecured constituting the identification of immediate jeopardy (IJ) at Level Four, Isolated scope and severity resulting in substandard quality of care. Upon verification of the removal of the IJ, the scope and severity were lowered to Level Two, Isolated. The facility also failed to ensure an electric space heater was not used as a primary source of heat for one of forty-three residents (Resident #80). The findings include: On 2/10/26 at 1:13 PM, during initial rounds, one oxygen e-tank was observed sitting on the floor, freestanding in an upright position, not contained in a stand or holder in Resident#108 and Resident#142's room. It was observed that the gauge on the green tank read as being full. (An E tank or E cylinder is a common medical oxygen cylinder, typically holding around 680 liters of highly flammable gas.) On 2/10/26 at approximately 1:35 PM, a second observation was made of the free-standing oxygen e-tank with two surveyors. Resident #108 was observed lying in his bed with oxygen being administered by nasal cannula via a concentrator at 3 liters per minute. The cylinder tank was freestanding approximately 2 inches from the wall and approximately 3 feet across from the foot of Resident #108's bed. Resident #108's wheelchair was positioned against the oxygen tank. Resident #142 was observed sitting in his wheelchair between the two beds. On 2/10/26 at 1:40 PM, an interview was conducted with a licensed practical nurse (LPN#9) on how oxygen is to be stored in a resident's room and she replied, we place them on the back of the resident's wheelchair or in the storage area is all I know. On 2/10/26 at 1:45 PM, an interview was conducted with Resident #108 (R108) to ask if he was aware of how long the oxygen tank was stored on the floor, unsecured. According to R108, the tank was not on his wheelchair 2/09/26 as he recalled being in his wheelchair, in his room and the oxygen tubing was attached to his concentrator. He said the tank was on back of his wheelchair the day prior [2/8/26]. On 2/10/26 at 2:05 PM, an interview was conducted with LPN#8 on proper storage of oxygen in resident rooms. According to LPN#8 oxygen tanks can only be in a resident room if in a tank holder or attached to the back of the resident's wheelchair with the sling holder so they don't fall over and explode or propel like a rocket. An interview was conducted with the UM (Unit Manager) for the [NAME] Unit regarding her expectations of how oxygen is to be stored in the residents' rooms. According to the UM, oxygen is to be stored in a caddy, never free-standing due risk of possible fire or explosion if the tank is accidentally knocked over. Resident #108 was admitted to the facility 12/09/2020 with diagnoses including but not limited to chronic obstructive pulmonary disease, chronic kidney disease, stage 3A, heart failure, hypertension, chronic respiratory failure, major depressive disorder, diabetes mellitus, type 2, and anxiety. Resident #108 had a physician order for oxygen 3 liters per minute via nasal cannula. Resident #108's most recent MDS (Minimum Data Set) Quarterly Assessment with ARD (Assessment Reference Date) 1/16/26 was coded in Section C. Cognitive Pattern with a score of 14 out of 15 indicating resident is cognitively aware. Section GG. Functional Ability for sit to stand, roll side to side and chair to bed to chair transfer is coded as 03 indicating resident requires supervision or touching assistance and once seated in his wheelchair has the ability to wheel himself at least 50 feet and make two turns. This same MDS coded Resident #108 as having used oxygen. Resident #142 was admitted to the facility 10/3/25 with diagnoses to include but limited to non-Alzheimer's dementia, hypertension, diabetes mellitus, type 2, and mood disorder. Resident#142's most recent MDS (Minimum Data Set) Quarterly Assessment with ARD (Assessment Reference Date) 1/7/26 was coded in Section C. Cognitive Pattern with a score of 4 out of 15 indicating resident was cognitively impaired with impaired safety awareness. Section GG. Functional Ability was coded for chair to bed to chair, sit to stand, roll side to side as requiring substantial to maximum assistance. On 2/10/26 at 2:30PM, the survey team conducted a sweep of the entire facility and there was no other unsecured oxygen tanks found in the facility. An inspection of the facility's oxygen storage area was conducted where all oxygen tanks were observed securely stored in stands and/or racks. On 2/10/26 at 4:55 PM, a meeting was conducted with the Administrator, Director of Nursing and Regional Director of Clinical Services to inform them of Immediate Jeopardy due to the observation of the oxygen cylinder tank stored unsecured in Resident #108 and #142's room on the [NAME] Unit. The risk of these unsecured tanks posed an imminent risk of safety for all residents, all visitors and all staff, which required immediate action by the facility. The potential exists that the oxygen e-tank could fall or be knocked over rupturing the valve which could cause a projectile hazard, fire and/or explosion risk. Unsecured oxygen tank(s) pose high risk for projectile hazards, fire and explosions to not only Resident #108 and Resident #142 but to all nearby residents. The e-tank was observed sitting on the floor, free standing in an upright position, not contained in a stand or holder which makes serious adverse outcome likely. The immediate jeopardy was determined to have started on 2/9/26. A review of the facility's policy #1901 Respiratory Care & Oxygen Equipment dated, 1/29/2024, read in part: paragraph entitled, Safety Guidelines: 3. When not in use, store oxygen cylinders securely, upright, in appropriate carts/holders. On 2/10/26, the Administrator submitted the facility's IJ (Immediate Jeopardy) Removal Plan. The IJ Removal Plan was reviewed by the survey team, sent to the State Agency for review and the IJ Removal Plan was accepted at 6:17 PM. The facility's IJ Removal Plan read, Plan Corrective Action for those residents found to be affected by the deficient practice: Resident #108 and Resident #142 had no negative outcomes related to the deficient practice. The oxygen tank was properly secured onto the back of the wheelchair per policy after it was found free-standing. Corrective Actions taken for residents with potential to be affected by deficient practice: A sweep of all residents' rooms to ensure no free-standing oxygen tanks. All areas but not limited to activities room, therapy and dining rooms where residents may have oxygen. Systemic Changes put into place to ensure the deficient practice does not recur: The Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Director of Social Work, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, Human Resources, and Unit Managers) will be educated by the Regional Director of Clinical Services on the facility's policy for proper storage of oxygen tanks being secured, upright and in appropriate carts/holder. All facility staff will be educated by the Director of Nursing or designee on the proper storage of oxygen tanks, to be upright and in appropriate holders. This training will be given to new facility staff prior to starting with the facility. Any member of staff who hasn't completed the education will be educated prior to the start of their next shift. The Administrator to conduct an ADHOC Quality Assurance Performance Improvement Meeting on 2/10/26 including Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Director of Social Work, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry Services and Unit Managers to review the policy of oxygen tanks. Completion of the removal plan 2/10/26 at 11:30AM. The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone on 2/10/26 at 5:21PM. On 2/11/26, from 8:30AM to 9:35AM, the survey team validated the facility's removal plan to include interviews were conducted with multiple staff across varying departments related to the storage of oxygen. All staff interviewed confirmed they had received education on storage of oxygen tanks and were able to verbalize the proper storage of oxygen tanks to store oxygen tanks, upright and in appropriate carts/holders or racks. In addition to interviewing staff on receiving education on proper oxygen storage, education attendance records were reviewed and verified to confirm all staff working had received education. Rounds were conducted to verify no other oxygen tanks were observed unsecured. The immediate jeopardy (IJ) was determined to be removed effective 2/11/26 at 9:40 AM. The Administrator, Director of Nursing, [NAME] President of Operations and Regional Director of Clinical Services were made aware that the IJ Removal Plan was verified and IJ removed effective 9:40 AM. Following the removal of IJ, the scope and severity was lowered to a level two, isolated. 2. The facility was using a portable space heater as a primary source of heat in Resident #80 (R80) room (room [ROOM NUMBER]). R80's diagnoses included neuropathy, respiratory failure, and chronic kidney disease. The most recent MDS (minimum data set) was an annual dated 2/2/26 and indicated R80 was cognitively intact, was able to self-propel in wheelchair and self-transfer. On 2/10/2026 at 2:41 p.m. an interview was conducted with R80. During the interview it was noted that R80 was using a portable electric heater to heat the room. R80 verbalized the permanent heating system had not been working for months. The heater was located near the middle of the room away from combustible materials and directly plugged into an outlet (no extension cords). On 2/11/2026 at 4:37 p.m. the maintenance director was interviewed regarding the heating system in room [ROOM NUMBER] where R80 resided. The maintenance director explained that the facilities heating comes from a boiler system and a coil had busted in R80's room which resulted in water escaping. The heating unit had to be taken off-line and R80 refused to move out of the room, so a portable heater was put in place. The maintenance director verbalized to fix the problem, the heating system throughout the building would have to be shut down and due to the cold weather, it would not be a good time to work in one room that could have an impact on many rooms. The maintenance director verbalized uncertainty as to how long the heater had been down, saying that it probably has been down since October 2025 before the weather had gotten cold. The maintenance director was unable to provide any documentation regarding a work order or a quote for the repair of the heating system. Specification information for the heater was presented and indicated that the heater had an anti-tip over shut off mechanism. On 2/12/2026 at 5:10 p.m. the administrator and director of nursing (DON) was informed of the above finding. On 2/13/2026 at 9:22 a.m. the administrator was interviewed. The administrator verbalized that R80 had been relocated to another room and verbalized unawareness regarding the use of electric space heaters. The administrator went on to say that an HVAC (heating ventilation and air conditioning) company has been contacted for an estimate of repairs. No other information was presented prior to exiting on 2/13/2026.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure proper fitting of a mattress and bed frame for one of forty-three residents in the survey sample (Resident #130) and failed to conduct regular inspections of all bed frames, mattresses and bed rails for identification of possible entrapment risks as part of the facility's maintenance program.The findings include:1. Resident #130, with a recently installed mattress, had no prior inspection to identify possible entrapment risks and to ensure proper fit. The mattress was observed in use without appropriate adjustment of the bed frame to maintain proper mattress position.Resident #130 (R130) was admitted to the facility with diagnoses that included polyarthritis, chronic respiratory failure, diabetes, Crohn's disease, anemia, glaucoma, Asperger's syndrome, irritable bowel syndrome, obstructive sleep apnea, bipolar disorder and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R130 as cognitively intact.On 2/10/26 at 4:14 p.m., R130 was observed in bed. The mattress was not centered on the bed frame and there was an approximately 5-inch gap between the bed frame edge and mattress on the left side (facing foot of bed). There were raised grab rails on both sides of the bed near the headboard. R130 stated he used to have a concave mattress but switched to a standard bariatric mattress about a month ago. R130 stated the current mattress had slipped over a little, was not centered on the bed and that he used the bed rails to move about in bed.On 2/11/16 at 3:30 p.m., the licensed practical nurse (LPN #11) unit manager caring for R130 was interviewed about the mattress/bed frame. The unit manager stated R130's current mattress was installed on 1/21/26. The unit manager stated R130 had a bariatric bed frame with a bariatric mattress. The unit manager stated she was not sure if maintenance had inspected the frame with the current mattress.On 2/11/26 at 4:24 p.m., accompanied by the maintenance director (other staff #7), R130's bed/mattress were observed. The bed frame had been adjusted with the previously observed gap eliminated. The maintenance director stated the bed frame width was adjustable with the frame edge held in place with spring-loaded pins. The maintenance director stated the frame looked as if someone had adjusted the frame width to match the mattress, but he was not sure who adjusted it. The maintenance director stated he had no record of installing or checking R130's current bed frame and mattress. The maintenance director stated if he was notified of the mattress change, he would have conducted an inspection to ensure proper fit and eliminate potential entrapment risks.On 2/12/26 at 2:13 p.m., the maintenance director (other staff #7) was interviewed again about any inspections for R130's newly installed mattress. The maintenance director stated nursing installed R130's mattress, did not inform maintenance prior to the installation and that the bed frame should have been adjusted to match the new mattress to eliminate gaps prior to use. 2. Facility staff failed to conduct regular inspections of all bed frames, mattresses and bed rails for identification of possible entrapment risks as part of the facility's maintenance program.On 2/12/26 at 2:13 p.m., the maintenance director (other staff #7) and administrator were interviewed about a maintenance program in the facility regarding bed frames, mattresses and bed rails to identify/minimize entrapments risks. The maintenance director stated the facility had an audit policy regarding beds, mattresses and rails but he had no evidence the program had been implemented. The administrator stated an outside vendor conducted an inspection of all facility beds on 8/11/25, but this was focused on electrical functioning and bed controls. The administrator stated the vendor inspection did not include inspection of bed frames, mattresses or rails. The administrator stated he had no evidence that the bed frame, mattress and bed rail checks for entrapment risks had been completed, and he did not know when these required inspections were last done. The administrator stated there had been no reported incidents of resident injury or entrapment related to the bed frames, mattresses or rails.The facility's policy titled Bed System Audits (dated 12/2018) documented, .Maintenance will conduct annually a full bed audit on each bed to identify and mitigate areas of risk for possible entrapment and bed safety. This audit will occur as scheduled in the electronic preventative maintenance electronic record (TELS) .The inspection will include the frame, the deck, the headboard, the footboard, the mattress, and any installed bed rails and/or assistive devices in order to .Assess for correct installation .identify and mitigate areas of risk for possible entrapment and/or bed safety .Identify gaps .Ensure a tight fit of mattress to the bed system .If appropriate, inspect for mattress compressiblity [sic] .Annual bed audits will reference the FDA's Seven Zones of Entrapment, the dimensional criteria as established by the HBSW (Hospital Bed Safety Workgroup) guidelines and other areas of potential safety risk within the bed system .Maintenance will conduct an intermittent audit immediately upon notification by nursing of any individual change of a bed frame, assistive device, mattress, or bed rail .Bed will be assessed collaboratively with nursing . The facility's bed audit policies listed that all inspections were to be documented on logs that identified bed frame identification numbers, brand/make of bed/mattress, model numbers, date inspections were completed, pass/fail status of inspection and initials of person completing the inspection. These findings were reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 2/12/26 at 5:10 p.m. with no further information presented prior to the end of the survey.

Based on observations, staff interviews, and facility document review, it was determined that the facility staff failed to maintain the main kitchen and one of the three unit pantries (West Unit) in a sanitary manner. The findings include:On 2/10/26 at 11:35AM, during the initial tour of the kitchen, a package of sliced ham was observed on top shelf, open and exposed to air/elements without an open date. The Assistant Dietary Manager who accompanied the surveyor on kitchen tour stated, They know better than that. The Dietary Manager arrived at 11:40AM and accompanied the surveyor on the rest of the kitchen tour. During inspection of the dishwasher area, two trays were observed with missing pieces of the corked surface and two trays noted with chipped edges. According to the Dietary Manager, I had not seen these before, I was not aware that this could be an issue. On 2/10/26, the Director of Nursing, [NAME] President of Operations and Regional Director of Clinical Service were informed of the above concerns. A review of the facility's Food Storage-Cold policy revealed, The Dining Services Director or designee ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination.On 2/11/26 an inspection was completed of the facility's three-unit pantries. In the pantry refrigerator on the [NAME] Unit, a bag of frozen meatballs was observed in the freezer section open and exposed to air/elements without an open date or name. According to the Unit Manager (West Unit) she stated they would need to be discarded due to no open date or name. On 2/11/26, the Director of Nursing, [NAME] President of Operations and Regional Director of Clinical Service were informed of the findings in the unit pantries. A review of the facility's policy entitled Outside Food which revealed, Procedure: 2. The items must be labeled and dated with the patient's name, room number, and the use-by-date. 3. Food that is sealed in original manufacturer's packaging may be kept until manufacturer's expiration date.On 2/12/26, during the end of the day meeting with the Administrator, Director of Nursing Services, Regional Director of Clinical Services and Regional [NAME] President of Operations, an opportunity was offered to the facility staff to present additional information. They had no further comments regarding the above findings.

Based on observation, staff interviews and facility document review, the facility staff failed to ensure medications used in the facility were labeled in accordance with currently accepted professional principles to include prescription labels and used within expiration dates for 2 of 3 medication storage rooms (West and South Units) and 4 of 9 medication carts (West, East and South Units).Findings included:On 2/12/26, medication storage rooms and medication carts were inspected, which revealed the following: Medication Storage Room [NAME] Unit Over the counter medications: 3 bottles of vitamin D3 - expiration dates 12/2025. 1/2025, 8/2025; 3 bottles Vitamin C - expiration date 12/2025; 1 bottle Calcium with Vitamin D3 - expiration date 11/2024; 2 bottles multivitamin - expiration date 8/2025[ 2 bottles Magnesium - expired 11/2025; 2 bottles Zinc - expired dates 8/25, one expired for 1/26Lab collection tubes - seven purple top expiration date 12/31/25, ten blue top tubes expiration date 4/30/25 and six red top tubes expiration date 9/30/25Under sink - caution tape, 1 bottle of neutral floor cleaner, a battery for mechanical lift, one gray bath basin and two glass flower vasesMedication Storage Room South Unit Over-the-counter medications on shelf: one bottle of Tylenol expiration date 12/2025Lab collection tubes - three purple top tubes with expiration date of 12/2025A vial of injectable Haldol was observed on the shelf with over-the-counter medications - no name, no prescription (a high-potency medication used in the treatment of schizophrenia, Tourette's disorder and acute agitation which requires a prescription)Medication Refrigerator: one bottle of Aplisol opened 11/24/25 (a sterile diagnostic solution administered under the skin and used in detecting tuberculosis); two bags of intravenous Vancomycin (an antibiotic) with a used by date of 9/25/25Medication Cart [NAME] Unit Middle Cart:Over-the-counter medications: one bottle of Vitamin C expired 12/25One insulin (Lantus pen) opened 1/10/26, open date reveals insulin has been opened and unrefrigerated for thirty-three days after opening (Lantus has a special expiration date of 28 days after opening) Medication Cart [NAME] Unit Long Cart:One insulin pen (Lantus) dated 12/23/25, 51 days past special expiration date of 28 days after opening Medication Cart [NAME] Unit Cart for Room of 60's:Over-the-counter medications: CoQ10 expired 12/23 (an over-the-counter nutrient that acts like a vitamin to improve heart health, combat fatigue, reduce migraine frequency and help to reduce muscle aches caused by medications used to treat high cholesterol).Medication Cart East Unit Middle Cart:Over-the-counter medications: one bottle Geri-dryl expiration date 12/25 (an over-the-counter antihistamine used to temporarily relieve allergy symptoms), one package Mucus relief tablets (over-the-counter medication used to thin and loosen mucus in the airways) expiration date 12/25; one bottle magnesium oxide expiration date 7/25.Insulins: one pen Humulin open date 12/1/2025, one Lantus open date 11/1/2025, one Humulin R pen open date 10/1/2025.Observed a syringe with needle exposed on top of medication cart, interview with LPN#8 conducted and when asked what the exposed syringe was on top of cart she replied, Oh, yes, that is not acceptable, I left that there while I was putting other medications away, I need to discard this one and start over.Small drawer top right of medication cart revealed a variety of routes of medications stored without separation of route, without resident identifier or prescription label, expired medications and completed courses of antibiotics: eye drops dispensed 11/6/2025 and 10/20/2025 with directions to be administered in both eyes at bedtime; one vial of Erythromycin eye drops for seven days (per Unit Manager the resident had completed the antibiotic course), two vials of powdered prednisone expired 10/14//2025 and 5/2025 - no resident name; two vials of liquid Lidocaine - no name no date - one vial open and one not; Midodrine 10mg tablets (prescription medication used to treat symptomatic low blood pressure) in blistered packs (according to the Unit Manager, the nurse cuts medication blisters from the bingo card dispensed from pharmacy and sends with the resident to dialysis, tablets were without resident name or prescription label; 2 tablets in blistered packs no name, no prescription label.On 2/12/2025 at 2:40PM, an interview was conducted with the DON (Director of Nursing) on her expectations on medication storage. According to the DON, she expects nurses to adhere to basic principles of medication storage to ensure medication rooms and carts are kept clean and multiple dose vials or bottles of medications are dated upon opening and administered within expiration dates and to discard any medications once the resident has completed course, or when the medication is either discontinued or expired.A review of the facility policy, Storage of Medications Policy #4. Read in part: Procedures: General Guidelines: I. 3. All medications dispensed by the pharmacy are stored in the pharmacy container with the pharmacy label.4. Orally administered medications are stored separately from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc. Eye medications are stored separately according to the facility policy.8. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medications disposal, and reordered from the pharmacy if a current order exists.General Guidelines: III.3. Certain medications or package types, such as IV (fluids through the veins), multiple dose injectable vials, ophthalmic, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency.6. The nurse will check the expiration date of each medication before administering it7. No expired medication will be administered to a resident. 8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. On 2/12/2026, during the end of the day meeting with the Administrator, Director of Nursing Services, Regional Director of Clinical Services and Regional [NAME] President of Operations, an opportunity was offered to the facility staff to present additional information. No further information was provided regarding the above findings.

Based on staff interview and clinical record review, the facility staff failed to ensure dialysis communication logs were completed for one of 43 residents in a survey sample. The Findings Include: Resident #198 (R198) did not have dialysis communication logs completed over a ten-week period. R198 diagnoses include osteomyelitis, renal dialysis related to end stage renal failure, polyneuropathy, and dementia. The most recent MDS (minimum data set) was a discharge date d 11/17/25 and indicated R198 was cognitively intact. Review of R198's clinical record indicated dialysis was being provided three times a week (Tuesday, Thursday, and Saturday). Review of R198's dialysis communication logs indicated the log was last completed on 11/25/25 consecutively. After 11/25/25 there were two other communication entries dated 12/1/25/and 12/27/25. On 2/12/2026 at 840 a.m. the medical records director (MR director) was interviewed. The MR director verbalized that a dialysis packet is sent with the resident which includes a communication form which is to be filled out and returned to the facility and then scanned into the electronic record. On 2/12/2026 at 9:09 p.m. the MR director returned and verbalized medical records for R198 had been reviewed and found two other communication forms that had not been scanned into the medical record. The MR director indicated the missing communication logs were not found. On 2/12/2026 at 5:10 p.m. the above information was presented to the administrator and director of nursing (DON). On 2/13/2026 at 8:12 a.m. the DON was interviewed. The DON verbalized that the communication logs were reviewed and had not been completed and should have been. No other information was presented prior to exit conference on 2/13/2026.

Based on resident interviews, staff interviews, facility document review and clinical record review, the facility staff failed to make prompt efforts to resolve grievances for two of forty-three residents in the survey sample (Residents #6 and #69) and make information of how to file a grievance available to seven out of seven residents in the resident council group meeting. The findings include: On 02/11/26, at approximately 2:00 p.m., a Resident Group meeting was held with the President, and six Residents who attends the group meeting regularly. It was the consensus of seven out of seven residents, including the President, that they did not know how to file a grievance or the process. On 02/11/26, at approximately 3:30 p.m. brief interview was conducted with the Administrator concerning the above. The Administrator stated the facility's grievance policy is available to the residents and that the process is explained on admission and often at meetings with the residents. The Administrator went on to say that the staff was trained in conflict resolution and how to assist residents with grievances. On 2/12/26, at approximately 5:10 p.m., during the end of day meeting, the above concerns were addressed with the Administrator, Director of Nursing, and the Regional Nurse Consultant. No additional information was provided prior to exit. 2. A grievance for Resident #6 (R6) missing mirror was not promptly resolved. Diagnoses for R6 included Cerebral infarction, congestive heart failure, peripheral vascular disease, and chronic sacral ulcer. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 12/17/2025. R6 was assessed with a cognitive score of 15 indicating cognitively intact. On 2/10/2026 at 1:03 p.m. an interview was conducted with R6. R6 verbalized that he had been missing a mirror that is used to shave with for about six months and it had been reported but nothing had been done. A grievance summary dated 9/2/2025 was obtained and indicated a missing Brown leather mirror fold up [sic]. The summary did not evidence any documentation under the headings of Resolved Date, Summary of Investigation, Summary of Findings, or Summary of Actions Taken. On 2/12/2026 at 3:20 p.m. the director of nursing (DON) was interviewed regarding missing mirror. The DON verbalized after a report of a missing item, the report is turned into a grievance and is filed. The grievance officer (the administrator) reviews grievance and emails the department that is responsible for investigating and concluding the grievance. The DON reviewed R6's grievance and verbalized it appears the grievance for the mirror was not assigned. On 2/12/2026 at 3:25 p.m. the administrator was interviewed. The administrator reviewed the grievance and verbalized that it wasn't processed. The facilities policy titled Service Concerns/Grievances read in part Center Nursing Staff, Social Work and Discharge Planners or any other team member receiving questions or issues of concern regarding care and/or services are to immediately respond at the point of service in an effort to satisfactorily resolve issues of concerns. No other information was presented prior to exiting the facility on 2/13/26. 1. Facility staff failed to promptly respond to grievances entered by Resident #69 regarding missing personal items following room changes. Resident #69 (R69) was admitted to the facility with diagnoses that included cerebral infarction, atherosclerotic heart disease, liver cirrhosis, peripheral vascular disease, dementia, anxiety, insomnia, seizures, urine retention and COPD (chronic obstructive pulmonary disease). The minimum data set (MDS) dated [DATE] assessed R65 with moderately impaired cognitive skills. On 2/10/26 at 3:50 p.m., R69 stated he had recently moved rooms, and his pictures and other personal items were lost during the room move. R69 stated he was most concerned about 14 laminated pictures of his kids/pets. R69 stated grievances were entered about the items but he had never received a response and was not aware if anyone had searched and/or located his items. R69's clinical record documented room changes on 10/10/25 and 11/16/25. Two grievances were documented in the facility's tracking system for R69. R69 had a grievance entered on 12/16/25 regarding missing items following a room change on 11/16/25. This grievance form documented, Patient was moved from [room numbers] .When the patient was moved some of his belongings came up missing through the transfer. The patient is missing glasses, fingernail clippers and several pictures of his family This form documented no investigation, no findings and no actions taken in response to the report as these sections on the form were blank. Another grievance was entered on 1/8/26 regarding R69's missing items. This grievance documented, resident reports he is missing 2 hats and a small white fan from his last room move, missing multiple laminated pictures from last room move . This form documented no investigation, no findings and no actions taken regarding the grievance. On 2/11/26 at 8:25 a.m., the licensed practical nurse unit manager (LPN #11) caring for R69 was interviewed about the grievances entered. The unit manager stated she was aware that a grievance had been entered about the lost pictures, but she was not sure of the status. On 2/12/26 at 9:51 a.m., the administrator was interviewed about R69's missing items. The administrator stated the grievances were entered into the facility's tracking system and were supposed to be assigned to the appropriate department for investigation and follow up. The administrator stated that no response or actions had been taken regarding R69's grievances entered on 12/16/25 and 1/8/26. On 2/12/26 at 11:04 a.m., the administrator stated the housekeeping supervisor should have been assigned to investigate and that no action had been taken. The administrator stated, We messed up. The administrator stated no department or staff person had been assigned to investigate the two grievances filed by R69. On 2/12/26 at 11:44 a.m., the housekeeping supervisor (other staff #1) was interviewed about R69's reported missing items. The housekeeping supervisor stated she did not know what happened to R69's personal items and that she was never assigned to investigate any grievances for this resident. On 2/12/26 at 4:17 p.m., the social services director (other staff #5) was interviewed about R69's grievances about missing items. The social services director stated she was not aware R69 was missing any items or that grievances were filed for this resident. The facility's policy titled Service Concerns/Grievances (effective 3/1/25) documented, .The Administrator is responsible for ensuring that the management staff are trained in appropriately resolving in-house patient/family service concerns and grievances at the point of service as promptly as possible. The management staff .is charged with listening and responding to questions, needs, problems, or concerns brought to their attention by patients and/or families .The patient has the right to voice/file grievances/complaints (orally, in writing or anonymously) without fear of discrimination or reprisal. The Administrator serves as the grievance official of the Center and is responsible for overseeing the grievance process and for receiving and tracking to their conclusion .Center Nursing Staff, Social Work and Discharge Planners or any other team member receiving questions or issues of concern regarding care and/or services are to immediately respond at the point of service in an effort to satisfactorily resolve issues of concern .If an issue of concern cannot be immediately and satisfactorily resolved at the point of service, the management staff member will notify the patient/family member that the concern is being submitted to the appropriate department manager and that follow up for resolution will be provided as quickly as possible. The company Grievance form is to be promptly submitted by the staff member through the electronic system .The Administrator will follow up as needed with the patient/family regarding satisfactory resolution and will verify the final outcome in the electronic system under the resolution section of the grievance form . This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 2/12/26 at 5:10 p.m. with no further information provided prior to the end of the survey.

Based on observation, resident interview, family interview, staff interview, facility document review and clinical record review, the facility staff failed to provide a clean, homelike room environment for two of forty-three residents in the survey sample (Residents #130 and #165), failed to provide protections to prevent loss/theft of personal property for two of forty-three residents in the survey sample (Residents #6 and #69) and failed to process laundry timely for multiple residents on three of three units. The findings include:1. Facility staff failed to consistently provide a properly sized fitted sheet for Resident #130's bed as required in the resident's plan of care. Resident #130 (R130) was admitted to the facility with diagnoses that included polyarthritis, chronic respiratory failure, diabetes, Crohn's disease, anemia, glaucoma, Asperger's syndrome, irritable bowel syndrome, obstructive sleep apnea, bipolar disorder and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R130 as cognitively intact. On 2/10/26 at 3:30 p.m., R130 was observed in bed. The fitted sheet on the bed did not cover the entire mattress with the left corner of the mattress exposed due to the ill-fitted sheet. R130 was interviewed at this time about the sheet. R130 stated he switched from a concave mattress to a standard bariatric mattress a few weeks ago and that the facility did not always have a properly sized sheet for the current mattress. R130 stated the current sheet was too small for the mattress and if the sheet was stretched to fit, the corner of the mattress would raise up. R130 stated he showered in the evenings and sheets were usually changed when he took a shower. R130 stated the orange trimmed sheets fit the mattress best and that many times these sheets were not available in the linen room. The resident demonstrated there was no orange trim on the current fitted sheet. On 2/11/26 at 3:50 p.m., accompanied by the licensed practical nurse unit manager (LPN #11) caring for R130, the linen supply on R130's unit was inspected. There was a supply of sheets, towels and washcloths in the room. There were two teal trimmed sheets, but no orange trimmed sheets available in the linen supply room. The unit manager stated R130 had expressed concerns to her a couple of times about sheets not available for his new mattress. On 2/11/26 at 4:30 p.m., R130 was in bed with a teal trimmed fitted sheet on the bed. The sheet covered the mattress but was tight and pulled at the corners. R130 stated the teal trimmed sheet did not fit. R130 stated that the orange trimmed sheet fit best and that staff reported that there were not many orange trimmed sheets available. On 2/12/26 at 8:18 a.m., the unit manager (LPN #11) was interviewed again about R130's sheet that did not cover the mattress. The unit manager stated she thought the sheet with the teal trim fitted the mattress and she did not know why a proper fitting sheet was not used on the bed. On 2/12/26 at 8:20 a.m., the certified nurse's aide (CNA #7) that routinely cared for R130 was interviewed. CNA #7 stated R130 was adamant that the fitted sheet got replaced at shower time. CNA #7 stated the teal or orange trimmed sheets fit R130's current mattress and that at times those sheets were not in the supply room. CNA #7 stated staff had access to the laundry area on all the shifts and that additional linen was available in clean laundry if not available in the linen room. CNA #7 stated she thought at times the aides waited until the actual shower time to find a sheet and if the sheets were not in the linen room, that whatever sheet was available was used without attempts to get the correct sheet from laundry. CNA #7 stated she did not know why the correct size sheet was not on R130's bed. On 2/12/26 at 10:45 a.m., accompanied by the laundry supervisor (other staff #1), the clean laundry supply was observed. The laundry supervisor stated that the orange trimmed sheet best fit R130's mattress. The laundry supervisor stated there were approximately ten residents with that type of mattress in the facility and she had a supply of 24 orange trimmed sheets. The laundry supervisor stated that amount of inventory was adequate to ensure sheet availability for R130's bed. The laundry supervisor stated if proper sheets were not in the unit linen rooms, that staff had access around the clock to the clean linen area in laundry. R130's plan of care (revised 1/15/26) documented the resident has behaviors secondary to Asperger's and bipolar disorder that included refusal of care, hoarding items, cluttered room, refusal to have dirty linens changed and will only use bariatric sheets with orange thread . Interventions to minimize stress included assigning staff members that are familiar or preferred by the resident, if possible, assure the resident is safe if distressed and provide emotional support stuffies. This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 2/12/26 at 5:10 p.m. with no further information presented prior to the end of the survey. 2. Housekeeping was not provided/maintained in Resident #165's room. Resident #165 (R165) was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), mood disorder, chronic pain syndrome, major depressive disorder, anxiety, hypothyroidism and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R165 with severely impaired cognitive skills. On 2/10/26 at 1:23 p.m., R165's room was observed with the resident in bed. Paint was scraped from the wall to the right of the window. Brown/tan colored drips and spatters were observed on the wall right of the room's window. Multiple paper trash items and candy wrappers were on the floor beside and under R165's bed. The wall behind the bed had multiple deep scrapes in the drywall. There was a missing section of drywall along the left side of the window. The floor in the room was dirty with black/gray color film visible across floor. Drips and footprints were visible on the floor around the bed, near the sink and in the bathroom. Black/brown specks were observed scattered on the wall to the right of the toilet. On 2/11/26 at 8:14 a.m., the floor in R165's room remained dirty with same spatters, footprints and black/gray film observed on the floor. The same splatters on the floor and wall were observed along with the same candy wrappers and paper trash seen on 2/10/26. A used Styrofoam cup was on the floor to the left side of the bed along with the top and a straw. On 2/11/25 at 9:56 a.m., R165's family member (other #8) was interviewed about housekeeping. The family member stated she visited R165 several days ago and picked up trash from the floor. The family member stated, Housekeeping could be better. On 2/11/26 at 4:30 p.m., the maintenance director (other staff #7) was interviewed about the missing drywall and wall damage in R165's room. The maintenance director stated he was not aware of the damaged walls, and no work order had been entered for the repairs. On 2/12/26 at 8:26 a.m., R165's room was observed again with the empty cup on the floor to the left of the bed. The floor remained dirty to the left of the resident's bed, near the sink and door with footprints visible. On 2/12/26 at 10:39 a.m., the housekeeping supervisor (other staff #1) was interviewed. The housekeeping supervisor stated that resident rooms and bathrooms were supposed to be cleaned each day and that cleaning included sweeping, mopping, cleaning toilets and emptying trash. The housekeeping supervisor stated she currently had adequate staffing to provide needed housekeeping. On 2/12/26 at 10:52 a.m., accompanied by the housekeeping supervisor, R165's room was observed. Regarding the dirty floor, the housekeeping supervisor stated the floor definitely needed cleaning and possible stripping/wax. The housekeeping supervisor observed the spatters around the toilet and in the floor around the resident's bed and stated, Yes. This needs cleaning. On 2/12/26 at 11:08 a.m., the housekeeper (other staff #4) on R165's unit was interviewed. The housekeeper stated resident rooms were supposed to be clean each day and that included sweeping, mopping and emptying trash. The housekeeper stated there recently had been a lot of room changes. The housekeeper stated room changes required a deep clean that was more thorough and time-consuming. The housekeeper stated if she had a lot of room changes, that she did not have time to get to all the rooms each day. The housekeeper stated she got to every room at least every other day. The housekeeper stated staff or residents notified her if extra cleaning was needed for a spill or accident. This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 2/12/26 at 5:10 p.m. with no further information provided prior to the end of the survey. 3. Facility staff failed to implement interventions to protect Resident #69's personal property from loss during room changes. Resident #69 (R69) was admitted to the facility with diagnoses that included cerebral infarction, atherosclerotic heart disease, liver cirrhosis, peripheral vascular disease, dementia, anxiety, insomnia, seizures, urine retention and COPD (chronic obstructive pulmonary disease). The minimum data set (MDS) dated [DATE] assessed R65 with moderately impaired cognitive skills. On 2/10/26 at 3:50 p.m., R69 stated he had recently moved rooms, and his pictures and other personal items were lost during the room move. R69 stated he was most concerned about 14 laminated pictures of his kids/pets. R69 stated a grievance was entered about the items but he had never received a response and was not aware if anyone had searched and/or located his personal items. R69's clinical record documented room changes on 10/10/25 and 11/16/25. R69's clinical record documented no personal belongings inventory list upon or since admission. Two grievances were documented in the facility's tracking system for R69. R69 had a grievance concern entered on 12/16/25 regarding missing items following a room change on 11/16/25. This grievance form documented, Patient was moved from [room numbers] .When the patient was moved some of his belongings came up missing through the transfer. The patient is missing glasses, fingernail clippers and several pictures of his family This form documented no investigation, no findings and no actions taken in response to the report as the sections for these were blank. Another grievance was entered on 1/8/26 regarding R69's missing items. This grievance documented, resident reports he is missing 2 hats and a small white fan from his last room move, missing multiple laminated pictures from last room move . This form documented no investigation, no finding and no actions taken regarding the missing items. On 2/11/26 at 8:25 a.m., the licensed practical nurse unit manager (LPN #11) caring for R69 was interviewed about the lost items. The unit manager stated she was aware that a grievance had been entered about the lost pictures, but she was not sure of the status. On 2/12/26 at 9:51 a.m., the administrator was interviewed about R69's missing items. The administrator stated the grievances were entered into the facility's tracking system and were supposed to be assigned to the appropriate department for follow up and/or search for missing items. The administrator stated that no response or actions had been taken regarding R69's missing items. On 2/12/26 at 11:04 a.m., the administrator stated the housekeeping supervisor should have been assigned to investigate and that no action had been taken. The administrator stated, We messed up. The administrator stated no department or staff person was assigned to investigate the two grievances filed by R69. On 2/12/26 at 11:44 a.m., the housekeeping supervisor (other staff #1) was interviewed about R69's reported missing items. The housekeeping supervisor stated when resident items came to the storage area, that items were entered on a log for tracking. The housekeeping supervisor stated there were no personal items entered on the log storage book for R69. The housekeeping supervisor stated R69 had at least one room move due to a pest issue and that personal items remained in the room for cleaning/treating. The housekeeping supervisor stated she did not know what happened to R69's personal items and that she was never assigned to investigate any grievances for this resident. On 2/12/26 at 4:17 p.m., the social services director (other staff #5) was interviewed about R69's missing personal items. The social services director stated R69's most recent room change (11/16/25) was due to a pest issue and personal items remained in the room for cleaning/treating. The social services director stated R69's personal items should have been returned to the resident after cleaning/treatment were completed. The social services director stated for standard room changes when cleaning/treatments are not required, personal items were moved with the resident at the time of the room change. The social services director stated she was not aware R69 was missing any items. The social services director stated, to account for personal items, the facility required completion of an inventory list upon admission and this list was updated if new items were acquired. On 2/12/26 at 4:24 p.m., the unit manager (LPN #11) caring for R69 was interviewed again about the reported missing items. The unit manager reviewed R69's clinical record and stated she found no personal item inventory list completed upon or since admission. The unit manager stated for the standard room move on 1010/25, R69's personal items should have been moved with the resident. The unit manager stated the room move on 11/16/25 was due to a pest issue and R69's personal items remained in the room for a time for cleaning/treatment. The unit manager stated whoever deep cleaned R69's old room should have accounted for the personal items. The facility's policy titled Admitting a Patient (effective 1/29/24) documented, .Complete Resident Property List after advising the patient to send his/her valuables and money home. Contact the Business Office manager if the patient chooses to keep her/his valuables in the Business Office. Patient or responsible party sign the Resident Property List .Mark clothing and personal belongings with the patient's name . The facility's policy titled Service Concerns/Grievances (effective 3/1/25) documented, .The Administrator is responsible for ensuring that the management staff are trained in appropriately resolving in-house patient/family service concerns and grievances at the point of service as promptly as possible. The management staff .is charged with listening and responding to questions, needs, problems, or concerns brought to their attention by patients and/or families .The Administrator serves as the grievance official of the Center and is responsible for overseeing the grievance process and for receiving and tracking to their conclusion . This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 2/12/26 at 5:10 p.m. with no further information provided prior to the end of the survey. 4. Resident #6 (R6) did not have an accurate or complete personal property invoice. Diagnoses for R6 included Cerebral infarction, congestive heart failure, peripheral vascular disease, and chronic sacral ulcer. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 12/17/2025. R6 was assessed with a cognitive score of 15 indicating cognitively intact. On 2/10/2026 at 1:03 p.m. an interview was conducted with R6. R6 verbalized that he had been missing a mirror that is used to shave with for about six months and it had been reported but nothing had been done. R6's property list was reviewed and did not specifically list a mirror but did list toiletries. The property list did not evidence R6's signature or a responsible party's signature (signature space was not filled in). The property list had no dates or signatures filled out when an item was added or taken off the list. On 2/13/2026 at 8:17 a.m. the director of nursing (DON) was interviewed regarding the above finding. The DON reviewed the list and verbalized that the personal property list should have been completed accurately. A policy titled Admitting a Patient read in part 4. Complete Resident Property List [.] Patient or responsible party sign the Resident Property List [SIC]. No other information was presented prior to exiting the facility on 2/13/26. 5. On 02/11/26, at approximately 2:00 p.m., a Resident Group meeting was held with the President, and six Residents who attends the group meeting regularly. It was the consensus of seven out of seven residents, including the President, that there has been problem with receiving personal clothing back timely from laundry. Residents went on to say that the laundry takes more than two weeks to be returned and is not returned in the order in which it was sent to laundry, stating that they have received clothing/personal items that are not theirs, or items that were just recently sent to laundry but have not received items that were sent two weeks prior. On 02/11/26 at approximately 4:00 p.m., during an evening tour of the laundry department, large amounts (approximately 25 bags) of mixed soiled facility and resident personal laundry were observed located in bags on the floor at the bottom of the laundry chute. There were approximately five rolling bins of soiled laundry waiting to be washed and folded. There were 2 tables piled high of clean facility linen to be folded, and a long hanging rack, running the length of the back wall, of clean resident personal clothing items ready to be returned to the units. There were two of four dryers and two of four washers being used at the time of the tour. On 02/11/26, an interview was conducted with the Environmental Services (EVS) Director during the tour of the laundry department. When asked about the process regarding resident laundry and turnaround times, she stated three of four washers and three of four dyers are operable. She also stated that she has two full time laundry employees, and that as of 02/11/26, she would add one part-time laundry staff to work six hours in the evening, explaining that she has one part time position available. When discussing the residents' concerns regarding the time it takes to get their laundry back and the missing items, she stated that there are times when laundry gets backed up and that it has taken longer to get laundry processed. Also, if items are not labeled, they are added to the lost and found which also delays processing. She stated she takes the lost and found items up to the units once a month for residents to identify any possible missing items. When asked when the last time was, she had done this, she stated about two months ago. The EVS Director stated the goal is to have resident laundry/clothing laundered and returned within three days. On 2/12/26, at approximately 5:10 p.m., during the end of day meeting, the above concerns were addressed with the Administrator, Director of Nursing, and the Regional Nurse Consultant. No additional information was provided prior to exit.

Based on observation, resident interviews, and staff interviews, the facility failed to ensure a heater was functioning for one of forty-three residents and failed to maintain essential equipment for one of four washers and one of four dryers in the laundry area. The findings included: 1. Resident #80 (R80) did not have a proper standard functioning heating system and relied on a portable heater. On 2/10/2026 at 2:41 p.m. an interview was conducted with R80. During the interview it was noted that R80 was using a portable electric heater to heat the room. R80 verbalized the permanent heating system had not been working for months. On 2/11/2026 at 4:37 p.m. the maintenance director was interviewed regarding the heating system in room [ROOM NUMBER] where R80 resided. The maintenance director explained that the facilities heating comes from a boiler system and a coil had busted in R80's room which resulted in water escaping. The heating unit had to be taken off-line and R80 refused to move out of the room, so a portable heater was put in place. The maintenance director verbalized to fix the problem, the heating system throughout the building would have to be shut down and due to the cold weather, it would not be a good time to work on one room that could have an impact on many rooms. The maintenance director verbalized uncertainty as to how long the heater had been down, saying that it probably has been down since October 2025 before the weather had gotten cold. The maintenance director was unable to provide any documentation regarding a work order or a quote for the repair of the heating system. On 2/12/2026 at 5:10 p.m. the administrator and director of nursing (DON) was informed of the above finding. On 2/13/2026 at 9:22 a.m. the administrator was interviewed. The administrator verbalized that R80 had been relocated to another room, and an HVAC company has been contacted for an estimate of repairs. No other information was presented prior to exiting on 2/13/2026. On 02/11/26 at approximately 4:00 p.m., during an evening tour of the laundry department, large amounts (approximately 25 bags) of mixed soiled facility and resident personal laundry were observed located in bags on the floor at the bottom of the laundry chute. There were approximately five rolling bins of soiled laundry waiting to be washed and folded. There were 2 tables piled high of clean facility linen to be folded, and a long hanging rack, running the length of the back wall, of clean resident personal clothing items ready to be returned to the units. There were two of four dryers going and two of four washers. On 02/11/26, an interview was conducted with the Environmental Services (EVS) Director during the tour of the laundry department. When asked about the process regarding resident laundry and turn around times, she stated three of four washing machines and three of four dyers are operable stating that the washer was recently repaired but recently broke again. 2. On 2/12/26, at approximately 5:10 p.m., during the end of day meeting, the above concerns were addressed with the Administrator, Director of Nursing, and the Regional Nurse Consultant. No additional information was provided prior to exit. On 2/12/26, at approximately 11:30 a.m. The maintenance director verbalized that the one broken washer in the laundry area had been repaired but it needs a part that they have not been able to obtain and that they are in the process of looking for a replacement part. When asked about the malfunctioning dryer. The maintenance director states that the dryer works, it just takes longer than the other three to heat taking longer to dry items, so it is utilized last. The maintenance director was unable to provide any documentation regarding a work order regarding the washer. On 2/12/2026 at 5:10 p.m. the administrator and director of nursing (DON) was informed of the above finding. No other information was presented prior to exit.

Based on observations, interviews, record review and facility policy review, the facility failed to provide detailed and accurate notification regarding the ending of Medicare covered services for 3 out of 3 residents (Residents 93,155 and 200) reviewed. Findings included:A review of Resident #155's Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (ABN) dated 9/16/2025 and signed by Resident #155 on 9/12/2025, had the box for Daily Skilled Nursing Care check-marked indicating that service would end. An interview with Resident #155 was conducted on 2/11/2026 at 4:00pm. Resident #155 confirmed the signature on the ABN but could not remember the details. Resident #155 acknowledged that a staff member discussed ABN. However, neither document was fully understood by Resident #155.An interview was completed with the Discharge Planner (other #5) on 2/11/2026 at 4:14pm. The Discharge Planner confirmed Resident #155 was receiving Physical Therapy and Occupational Therapy that was to end however, the ABN was incorrectly check-marked indicating Daily Skilled Nursing Care would be ending. A review of Resident #93's Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (ABN) dated 12/25/2025 and signed by Resident #93 on 12/23/25, had boxes for Physical Therapy, Occupational Therapy and Daily Skilled Nursing Care all check-marked indicating those services would end. An interview with Resident #93 was conducted on 2/11/2026 at 3:37pm. Resident #93 confirmed the signature on the ABN but did not remember signing it. Resident #93 also acknowledged that a staff member reviewed the ABN. However, neither document was fully understood by Resident #93. An interview with the Discharge Planner (other #5) on 2/11/2026 at 4:14pm revealed that Resident #93 was receiving Speech Therapy prior to receiving the ABN. The Discharge Planner confirmed that the ABN had been marked incorrectly by including check marks in the 3 boxes marked Physical Therapy, Occupational Therapy and Daily Skilled Nursing Care. A review of discharged Resident #200's Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (ABN) dated 10/6/2025 and issued to resident #200's wife/POA, on 10/3/2025 at 2:30pm, had the box for Daily Skilled Nursing Care check-marked indicating that service would end. On 2/11/2026 at 5:02pm the Discharge Planner (other #5) discussed Resident #200's ABN information and confirmed that this resident had been receiving Physical Therapy prior to receiving the ABN form. The ABN had the Daily Skilled Nursing Care box check-marked, indicating that service would end. The Discharge Planner (other #5) acknowledged the Daily Skilled Nursing Care box was check-marked by mistake. The Discharge Planner (other #5) was interviewed on 2/11/2026 at 4:14pm. The Discharge Planner (other #5) stated that the ABN is reviewed with the residents or resident's responsible party, as well as the appeals process. The ABN lists the services that the resident has been receiving that will end, and a daily cost to continue services is included. The Discharge Planner (other #5) stated that the intent of the ABN is to make the resident aware of what specific services would be stopping so the resident can make an informed decision about their care. The Discharge Planner (other #5) also stated that the ABN had 4 boxes that could be marked, indicating which service would end. The boxes include Physical Therapy, Occupational Therapy, Daily Skilled Nursing Care and Other. The Discharge Planner (other #5) advised that the ABN is discussed in great detail with the resident however, there was no documentation listed on the ABN that included any details or examples of services that would be ending. The Discharge Planner (other #5) agreed that it was difficult to determine which specific services would stop based on what was marked on the ABN. An interview was conducted with the Director of Nursing (DON) at 5:31pm on 2/11/2026. The discussion reviewed the ABN process. The DON advised that she was not familiar with the process and did not know how it was done. On 2/12/2026 at 8:32am an interview with the facility Administrator was performed. The Administrator advised that the facility has a designated staff member that handles them. The Administrator explained the purpose is to notify the residents of Medicare services to end and why and that the resident can appeal. The resident can choose to stay in the facility and continue to receive services and bill Medicare, the resident can receive services and pay out of pocket, or the resident can choose not to receive services.

Based on observation, and staff interview, the facility staff failed to maintain a clean and sanitary environment for nine of 89 resident rooms (rooms #86, #26, #19, #12, #6, #5, #3, #41, and #34), six of 89 resident room bathrooms (resident room bathrooms #84, #27, #8, #5, and #35, and #34), and two of three units (the South unit and East unit). The findings include:On 7/15/26 at 8:55 a.m., an observation of the facility was conducted. Layers of sticky dirt and dust were observed in the vents of the heating/air conditioning units in rooms #86, #26, #19, #12, #6, #5, #3, #41, and #34, in the ceiling air vents in the resident room bathrooms #84, #27, #8, #5, and #35, and #34, and in the ceiling air vents at the South unit nurse's station, and on the East unit short hall and the East unit long hall.On 7/15/26 at approximately 3:35 p.m., an interview was conducted with the Director of Maintenance. The Director of Maintenance stated the maintenance staff typically clean the vents of the heating/air conditioning units in the resident rooms and the ceiling air vents in the resident bathrooms once a month and clean the ceiling air vents on the halls every three months. The Director of MaintBased on observation, and staff interview, the facility staff failed to maintain a clean and sanitary environment for nine of 89 resident rooms (rooms #86, #26, #19, #12, #6, #5, #3, #41, and #34), six of 89 resident room bathrooms (resident room bathrooms #84, #27, #8, #5, and #35, and #34), and two of three units (the South unit and East unit).The findings include:On 7/15/26 at 8:55 a.m., an observation of the facility was conducted. Layers of sticky dirt and dust were observed in the vents of the heating/air conditioning units in rooms #86, #26, #19, #12, #6, #5, #3, #41, and #34, in the ceiling air vents in the resident room bathrooms #84, #27, #8, #5, and #35, and #34, and in the ceiling air vents at the South unit nurse's station, and on the East unit short hall and the East unit long hall.On 7/15/26 at approximately 3:35 p.m., an interview was conducted with the Director of Maintenance. The Director of Maintenance stated the maintenance staff typically clean the vents of the heating/air conditioning units in the resident rooms and the ceiling air vents in the resident bathrooms once a month and clean the ceiling air vents on the halls every three months. The Director of Maintenance stated the staff had got behind on cleaning the vents due to other environmental projects. The Director of Maintenance stated that due to those other environmental projects, there has been a lot of sanding in the facility lately and this clogs up the vents so the maintenance staff would probably have to increase their cleaning schedules.On 7/15/26 at 4:58 p.m., the Administrator and Director of Nursing were made aware of the above concern.The facility did not provide a policy regarding a clean and sanitary environment.No further information was provided prior to exit.enance stated the staff had got behind on cleaning the vents due to other environmental projects. The Director of Maintenance stated that due to those other environmental projects, there has been a lot of sanding in the facility lately and this clogs up the vents so the maintenance staff would probably have to increase their cleaning schedules.On 7/15/26 at 4:58 p.m., the Administrator and Director of Nursing were made aware of the above concern.The facility did not provide a policy regarding a clean and sanitary environment.No further information was provided prior to exit.

Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to maintain a performance improvement program that corrected previously identified concern regarding a clean, comfortable, homelike environment and ensure the availability of linen sufficient to provide daily care of residents. The facility's quality assurance and performance improvement program failed to ensure thd implementation of actions to improve and sustain regulatory compliance, which affected residents on three of three units. The findings included:On 4/13/26, upon surveyor entry to the facility, observations were conducted on each of the three resident units. The facility was found to be unclean, floors severely soiled, rooms overcrowded, and there was a lack of adequate linen. On 4/13/26, observations of Residents #101, #103, #107, and #114's rooms on 3 different units were noted to be hoarded with boxes, food items, personal items, and plastic storage containers in front of, and on top of the air conditioning/heating units restricting air flow. Observations conducted from 4/13/26 - 4/15/26 on all three units revealed linen carts contained minimal supplies, including only a few pillowcases and approximately two towels, with no wash clothes or blankets available. Resident rooms were observed without facility-provided bedspreads, with some residents using personal blankets from home.Also observed were articles of clothing balled up in beds with soiled linens, soiled clothing articles scattered around the rooms. Large opened (16 to 18 ounce) containers of food sauces (Texas [NAME] sauce and others), and food spices spilled on and over the overbed tables, and bedside cabinet surfaces. Privacy curtains between beds in the semi-private rooms had stains and brown colored smears on them which caused them to stick to themselves in places. Found were partially eaten corn bread squares which were spoiled with obvious blue mold on them. Different food items and drink items in cups and plastic glasses appeared to be mixed and were unidentifiable.No food or drink items were refrigerated, and the rooms had a sour spoiled food smell comingled with a strong odor of urine. Resident #101 was laying on a soiled bed encrusted with spilled food. The Resident's black sweatshirt was encrusted in a 6-inch by 6-inch stain on the front with dried, spilled foods and liquids, and the resident stated when asked I don't know what it is. Resident #101 was naked from the waist down covered partially by a soiled sheet. The Resident's roommate was not in the room, however, his side of the semi-private room looked very similar to Resident #101's side of the room.On 4/13/26 at 2:00 pm, an interview was conducted with Resident #119(R119). He reported ongoing concerns regarding insufficient linen availability, stating there was not enough linen for his bed and that he did not have a bedspread. The resident reported his room had not been cleaned for approximately two weeks. Observation of R119's room revealed trash under both beds, black scuff marks on the floor, and cobwebs present in the corners of the room.On 4/13/26 at 1:15 PM, an interview was conducted with a housekeeper. The housekeeper reported she was the only housekeeper for the entire facility working that day, as two others had not reported for their assigned shift. The housekeeper went on to report that her manager was having to work in the laundry department. When asked about the cleaning of resident rooms, the housekeeper reported every resident room was to be cleaned daily. When asked if that happens, the housekeeper said, No. Since I've been put over here, I've been trying to get these rooms cleaned, sometimes I don't even get to the rooms on the long hall. The housekeeper went on to report that the rooms are actually cleaned every three to four days or once a week. On 4/13/26, in the afternoon, a resident's family member was observed sweeping the room. The resident in the hallway reported that was his roommate's family member and reported he had been a resident of the facility for seven weeks and had not seen any housekeeping staff clean his room since his arrival.On 4/13/26 at 5:32 pm, an observation of the laundry room was conducted. During the observation, there was excessive accumulation of personal clothing and facility linen. Bags of soiled clothing were noted in a corner where the laundry chute was and the bags were piled to the bottom of the chute which was halfway up the wall. Resident's personal clothing was observed piled on top of several 55-gallon trash cans and large capacity bins that were piled within inches of the ceiling. Soiled linens were piled on top of chemical buckets, and the pile was halfway up the wall. There was another pile of personal clothes that was on a trash can and was piled high and covering the electrical boxes. The piles were excessive. Multiple bin containers were overflowing, and excessive numbers of bags of wet laundry were noted piled on the floor in front of the laundry room doors as high as halfway up the door. The three dyers and three washers were full of linen and personal clothing and were just sitting in the machines.On 4/14/26 at 10:36 am, an interview was conducted with a licensed practical nurse, LPN#2 (LPN2). LPN2 said, it is very true that linen is short on the units. We struggle, do what we can and seems like a third world country here trying to survive. Families bring in linen, not enough staff in laundry to do the laundry and when it sits down there becomes molded and it's thrown away. On 4/14/26 in the early afternoon, an interview was conducted with Resident #119, who reported he had clothes he had sent to laundry over a month ago that hasn't been returned. He further reported that he had just received notification that they [the facility] was going to reimburse him for some missing clothing items and pointed to a form lying on his over bed table. Resident #119 went to say, I just want my clothes.A review of grievances and Resident Council meeting minutes revealed repeated concerns regarding rooms not being cleaned and personal items missing and not returned.A review of the facility policy titled, Daily Resident/Patient Room Cleaning, read in part, housekeepers are responsible for ensuring they are adequately supplied for tasks of the day with appropriate supplies, equipment, tools, and personal protective equipment (PPE). On 4/14/26, it was noted by all 5 surveyors that during the rest of the survey that shower rooms revealed a black substance along corners and caulking areas. Broken tiles were noted in the shower rooms, used soap and hair were found in the drain covers. The hallway floors had holes in them which were trip hazards. Base boards were found to be knocked down in places, and the main hallways and resident room floors were covered in black track marks and a sticky substance. Rooms had food crumbs, paper and plastic wrappers scattered about, and in the corners of rooms a built-up crust of dirt and black grime [which could be scratched off easily] was found in most areas.On 4-14-26 at 12:00 P.M., an interview was conducted with a housekeeping staff member cleaning the hallway on one of the units. She was asked what her workload was like daily, and she replied, I am the only one here today, and I can't do it all. The facility consisted of 180 beds on 3 units, shower rooms on each unit, activity rooms, courtyards, dining rooms, and various other offices and gathering spaces. The tables and floor in the main dining room were spattered with paint, chipped in places, encrusted and smeared with a slippery/greasy black substance on the floors. The dining tables were smeared and dirty, and stained chairs were piled and stacked against the wall in the front corner of the room. The surveyor's shoe stuck to the floor in places to the point that as she stepped her foot came out of the shoe and the shoe remained stuck to the floor. During a prior survey conducted by the state survey agency from 2/10/26-2/13/26, similar concerns were identified. The facility alleged in their plan of correction for the citation that . DON [director of nursing] or designee will educate staff to ensure residents' rooms are clean, free of trash on the floors, and liners in trash cans. DON or designee will audit new admissions 5x a week for 8 weeks to ensure the resident property list has been completed in its entirety. DON or designee will audit residents with bariatric fitted sheets 2x a week for 8 weeks to ensure correct fitting sheets in place. DON or designee will audit 10 rooms a week for 8 weeks to ensure room cleanliness. The facility alleged they had corrected the issues and would be in compliance with the regulatory requirement as of 3/19/26. The facility's Quality Assurance and Performance Improvement Plan dated January 1, 2026, was received and reviewed. The document read in part, . iii. QAPI efforts. Effective performance improvement efforts will focus on the development, maintenance and periodic improvement of systems that influence organizational outcomes. Systems will be designed and modified to achieve reliable and efficient outcomes. Feedback systems may include but are not limited to the following: . resident council meetings,. regulatory surveys, grievance/service concern logs. e. PIP [performance improvement program] Team Reporting Process. 1. The PIP team will meet daily, weekly, and quarterly as needed. IV. Systematic Analysis and Systemic Action: The facility leadership will be responsible for assessing the outcome and impact of changes implemented. Leadership should ask questions such as 'Have the revisions or changes had a positive impact on resident outcomes?' or 'Have the revisions or changes improved the residents' quality of life?'.On 4/14/26 at 4:23 PM, an interview was conducted with the facility's administrator. The administrator was asked to explain the purpose and role of the quality assurance program and performance improvement (QAPI). The administrator said, quality assurance and performance improvement, we look at metrics in each department and how to improve things. With QAPI, we also go over survey tags [instances of cited deficient practice], what plan of correction we are going to be going over and metrics for that. The administrator was asked specifically about things such as cleanliness, laundry, linens, personal laundry, and the general living environment within the facility which are all quality of life items for residents. The administrator went on to state, Those are things we have been working on and tackling. We are making sure we are staffing appropriately, we have been actively hiring and posting, it [housekeeping and laundry] are an outsourced entity, they are trying it hire but because this is a rural area we are working on retaining people. When asked, the administrator confirmed they have used agency staffing to support their laundry and housekeeping departments but are currently not utilizing those services. The administrator was asked when the last time he visited the laundry department was. The administrator reported he has been to the laundry department last Friday [4/10/26]. When asked if he had concerns, the administrator said, no, not any big concerns. We had an evening laundry person because we identified that our laundry was not to capacity. He went on to say, we have been down there, and our team stays down there and hits it and gets it knocked out. When asked if he had laundry staff working over the weekend of 4/11/26-4/12/26, the administrator said, I don't know, I will have to look at the schedule. During the above interview with the facility administrator, the observations of the laundry department on the afternoon/evening of 4/13/26 were discussed. The mounds of laundry that was stacked within inches of the ceiling was discussed along with resident complaints. The observations within the facility regarding the lack of cleaning, the rooms being filthy, hallways with black marks throughout and the dining room were all reviewed. The administrator stated that in the past when they had linen issues, they ordered more linen. When the discussion about only have one housekeeper on 4/13/26 and the housekeeping/laundry supervisor being the only employee working in laundry on 4/13/26 was shared, the administrator stated that there is more money in the budget and if needed, we will use overtime or use agency to come in and get the work done. We aren't pulling housekeepers to get the laundry done, we get someone in. It was explained that those things are not happening because there is a lack of cleanliness observed throughout the entire facility, residents are complaining about the lack of linen and personal clothes not being returned and the survey team has confirmed those allegations. The administrator said, I am doing my best to get involved with the residents and talk to them daily. On 4/15/26, at 4:44 PM an end of day debriefing was conducted with the administrator, director of nursing, regional director of clinical services and regional vice president of operations were notified of the concerns of hoarding, unsafe, and unclean areas, as well as the mounds of resident personal laundry and linen in the laundry department waiting to be laundered. The RVPO confirmed that the contracted agency for housekeeping and laundry, was having their contract terminated. The survey team shared the concern about the lack of an effective QAPI program with sustainable outcomes.No further information was provided.

Based on information obtained during the Resident Group interview, observations, staff interviews, and Resident Group meeting minutes, the facility staff failed to demonstrate their response, action and/or rationale regarding Resident Group concerns and requests. The findings included:On 02/11/26, at approximately 2:00 p.m., a Resident Group meeting was held with the President, and six Residents who attends the group meeting regularly. It was the consensus of seven out of seven residents, including the President, that they have been provided no feedback, updates, or outcomes regarding concerns or requests that were voiced during past group meetings. The President stated that the Activities Director, the facility designated staff person approved by the resident group, is responsible for aiding and responding to written requests that result from group meetings. The president went on to say that she was told, by the activity's director, that she could not take notes during the meeting and that she, the Activities Director, would take notes and forward the requests and concerns to the Administrator. On 02/11/26, at approximately 3:30 p.m. brief interview was conducted with the Administrator concerning the above. The Administrator stated he did receive meeting minutes, request and concerns from the Resident Council Group meetings from the Activities Director prior to her termination of employment approximately two weeks ago. The Administrator went on to say that he had not communicated or provided written outcomes, results or actions regarding the requests and concerns resulting from the Resident Group meetings to the Resident Council President or group. On 02/11/26, six months of Resident Council meeting minutes form were reviewed and revealed there were no entries/answers under the Administrative Resolutions, or Resolved from last meeting tabs on the form. On 2/12/26, at approximately 5:10 p.m., during the end of day meeting, the above concerns were addressed with the Administrator, Director of Nursing, and the Regional Nurse Consultant. No additional information was provided prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to assess one of forty-three residents for safe self-administration of medication (Resident #44).The findings include:Resident #44, with a self-managed insulin pump, had no assessment for self-administration of medication.Resident #44 (R44) was admitted to the facility with diagnoses that included hip fracture, diabetes, anemia, osteoporosis, hypothyroidism, cerebral infarction, major depressive disorder and asthma. The minimum data set (MDS) dated [DATE] assessed R44 as cognitively intact.On 2/10/26 at 1:49 p.m., R44 was interviewed about medication administration, including insulin. R44 stated she had an insulin pump for management of diabetes that provided insulin and monitoring of blood sugar levels. R44 stated she had the insulin pump prior to admission to the facility, had managed the pump/insulin without difficulty for years and that her family member provided supplies as needed. R44's clinical record documented a physician order dated 12/30/25 for a Lispro insulin pump with instructions stating, Resident manages pump. The record included a physician's order dated 12/30/25 for Dexcom to be changed every 10 days with instructions stating, Family will provide.R44's plan of care (revised 1/14/26) included no problems, goals and/or interventions regarding self-administration of medications. R44's medication administration record for January 2026 documented the Dexcom was changed every 10 days and blood sugar readings before meals and at bedtime but made no mention of administration of Lispro insulin via the insulin pump.On 2/11/26 at 3:26 p.m., the licensed practical nurse unit manager (LPN #11) caring for R44 was interviewed. The unit manager stated R44 had orders for the insulin pump, but she was not sure that an assessment for self-administration had been done.On 2/12/26 at 8:16 a.m., the unit manager stated she reviewed R44's clinical record and found no record of an assessment for self-administration of the insulin and/or insulin pump.The facility's policy titled Self-Administration of Medication at Bedside (effective 1/29/24) documented, .A licensed nurse will assess patient's ability to self-administer medication .Complete Medication Self-Administration Safety Screen assessment .The Interdisciplinary Team will review the assessment and together, use clinical judgement to determine if the patient is eligible .If eligible, medications that are ordered by a provider to be self-administered will be identified in the medical record .A licensed nurse will monitor and chart self-administered medications and will monitor for proper storage on each medication pass .The Medication Self-Administration Safety Screen assessment will be reviewed quarterly by the Interdisciplinary Team .This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 2/12/26 at 5:10 p.m. with no further information provided prior to the end of the survey.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to protect the resident's right to be free from verbal abuse by a staff member for one of forty-three residents in the survey sample (Resident #44).The findings include:In response to a request for assistance with the bedpan, a certified nurse's aide (CNA #8) yelled at Resident #44, told R44 to change her own brief and provided rushed assistance with bedpan placement. Resident #44 (R44) was admitted to the facility with diagnoses that included hip fracture, diabetes, anemia, osteoporosis, hypothyroidism, cerebral infarction, major depressive disorder and asthma. The minimum data set (MDS) dated [DATE] assessed R44 as cognitively intact.On 2/10/26 at 1:36 p.m., R44 was interviewed about quality of life/care in the facility. When asked about any concerns with abuse, R44 stated she recently reported an issue with a CNA and that the facility had addressed the incident. R44 stated late one evening after asking for assistance, an aide pointed her finger and said, We're not doing this tonight. R44 stated voices raised high and the conversation got heated. R44 stated she did not remember what all was said but that she talked with the head nurse about the incident. R44 stated when she asked for help with the bedpan, this CNA threw a clean brief toward her that landed on her legs and the CNA told her to do it yourself. R44 stated when this aide assisted with the bedpan, she felt rushed when getting off the pan. R44 stated she had pain in her hip when she moved a certain way, and this CNA did not allow her to get off the bedpan at her own pace. R44 stated she thought the aide was agency, that nursing backed her about the incident and she had not seen the CNA since the incident. R44 stated she was upset by the way the CNA treated her, felt the facility responded and she was ok following the incident. R44 stated she had never reported anyone before but was glad that she reported the incident. R44 stated she had experienced no problems with any other staff members and had no prior incidents with this CNA. R44 stated she did not remember the date but that she talked with the head nurse about the incident the next morning after it happened.A report was sent to the state agency on 1/27/26 documented that R44 reported verbal abuse during incontinence care that occurred on 1/26/26 by a staff member identified as CNA #8. This report documented that CNA #8 was suspended pending investigation and that notifications of the incident were made to the physician, responsible party, adult protective services, department of health professions and law enforcement. The facility's investigation documented an interview with R44 by the director of nursing (DON) on 1/27/26. This interview documented R44's report of the incident as, I am having issues with my leg. I had to go to the bathroom, she put me on the bedpan, and did not let me help. She put her finger in my face and said, 'we are not having this tonight.' She [CNA #8] rolled me back over, threw the brief, and stated, 'you can do it yourself.' She [CNA #8] yelled at me because I was upset that she would not let me assist in turning myself. The facility's investigation included an interview with R44's roommate (Resident #28) dated 1/27/26. This interview documented that the roommate (R28) saw CNA #8 throw the incontinence brief toward R44 and heard CNA #8 yell at the resident to change the brief herself. The roommate's interview documented that R28 described CNA #8 as not professional and acting with an attitude. A written statement by CNA #8 about the incident documented that the resident was lying and documented refusal to provide any other statements about the incident. Statements obtained from other residents cared for by CNA #8 documented no issues or concerns with improper treatment by any staff members. The facility assessed the roommate (R28) on 1/8/26 as cognitively intact.A skin assessment for R44 was documented on 1/27/26 listing the resident's skin was warm and dry with no impairments noted other than a left hip surgical incision. This assessment documented the resident had no pain, no signs of infection with no identified concerns with the condition of the incision or skin in general.The nurse practitioner (NP) assessed R44 on 1/27/26, 1/29/26, 1/30/26, 2/4/26 and 2/9/26 with no concerns documented resulting from the reported mistreatment by CNA #8. R44 was assessed by psychiatry on 2/4/26 with the resident reporting no concerns about abuse/neglect. Psychiatry documented the resident was oriented with appropriate/cooperative attitude and no signs of psychological distress. The psychiatrist ordered the resident's dose of the antidepressant medication Wellbutrin decreased from 300 mg (milligrams) per day to 150 mg per day.A social services note dated 2/9/26 documented follow up with R44 about the reported incident with CNA #8. This note documented the resident stated she was doing okay, that she had talked with her sister about the incident and that she had shared her experience with some staff members. The social services director documented the resident requested no additional support services and that further support was available if needed.On 2/11/26 at 3:22 p.m., the licensed practical nurse unit manager (LPN #11) caring for R44 was interviewed about the reported verbal abuse by CNA #8. The unit manager stated the incident was reported on 1/27/26, that CNA #8 was suspended and had since been terminated. The unit manager stated R44 reported that she asked for assistance with the bedpan, that CNA #8 got upset and words were exchanged. The unit manager stated she had talked with R44 following the incident, explained the investigation/protocol and that R44 stated she was pleased with the outcome/response. The unit manager stated there had been no prior reports of concerns with CNA #8.On 2/11/26 at 4:47 p.m., the administrator was interviewed about the abuse incident with R44 and CNA #8. The administrator stated, We substantiated verbal abuse. The administrator stated CNA #8 was suspended at the time the incident was reported. The administrator stated the abuse was substantiated based on the investigation that included R44's statement and statements from R44's roommate (R28). The administrator stated R28 (R44's roommate) witnessed CNA #8 throw the incontinence brief at the resident and tell the resident to change the brief herself. The administrator stated R44 was assessed following the incident, had follow up by social services and had voiced no further concerns. The administrator stated a plan of correction was initiated in response to the incident and monitoring was ongoing.On 2/11/26 at 5:13 p.m., R44 was interviewed again about the abuse incident with CNA #8. R44 stated she was fine following the incident. R44 stated she did not like getting treated like that but was glad the facility took care of it. R44 stated she had experienced no issues with staff prior to or since this incident and that she knew she could report any concerns to nursing. R44 stated she had seen psychiatry since the incident and said, They have cut my antidepressant in half and that so far, she was doing well with that adjustment.On 2/11/26 at 5:13 p.m., the DON was interviewed about R44's incident of reported verbal abuse. The DON stated R44 reported on 1/27/26 that the CNA on the evening of 1/26/26 told her to change her own incontinence brief, that the CNA would not let her do the bedpan as she liked. The DON stated that R44 usually assisted with getting on/off the bedpan and reported that the CNA wanted to do it. The DON stated R44 stated that she got frustrated with the CNA and that the CNA hollered back, shook her finger at her, threw a brief on the bed and told the resident to change the brief herself. The DON stated CNA #8 was identified as the aide involved in the incident. The DON stated that CNA #8 was immediately suspended, the incident was reported to the state agency and other required agencies and an investigation was started. The DON stated the resident's roommate (R28) witnessed CNA #8 get loud with the resident and saw CNA #8 shake her finger and tell R44 to change her own brief. The DON stated CNA #8 was terminated and reported to the department of health professions. The DON stated a plan of correction was initiated regarding the identified verbal abuse. The DON stated CNA #8 was an agency staff member and there had been no prior complaints from residents or staff about CNA #8. The DON stated CNA #8 had received the required education about abuse prevention and a criminal background check prior to working in the facility. Required abuse education and criminal background checks for CNA #8 were requested and reviewed. In-serviced education was documented for CNA #8 on 10/26/25 that included abuse prevention/policies, neglect, timely call bell response, timely incontinence care, psychosocial well-being and resident rights. The objectives of this training were documented as, The facility staff will ensure that all residents are free from abuse/neglect. Call bells will be answered timely and incontinence care provided timely. Resident's psychosocial wellbeing and resident rights will be upheld. The facility's abuse prevention policies were included in this training with CNA #8 listed as passing a post-test regarding abuse prevention/policies. Criminal background checks for CNA #8 were completed on 10/27/25 and documented no findings from checks conducted through the state police website and a national sex offender registry. The facility's policy titled Abuse/Neglect/Misappropriation/Crime (effective 10/17/23) documented, .There is a zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center .Patients of the Center have the legal right to be free from verbal, sexual, mental, and physical abuse, corporal punishment, involuntary seclusion including abuse facilitated or enabled through the use of technology . This policy defined verbal abuse as, .Threats of harm, saying things to intentionally frighten a patient. Statements made to a patient which result in ridicule or humiliation of the patient .Any use of oral, written, or gestured language that includes cursing, disparaging and derogatory terms to other patients or visitors within hearing range, to describe patients, regardless of their age, ability to comprehend or disability .The facility presented the following plan of correction for abuse initiated on 2/3/26 in response to this incident.1. The facility reported an allegation of abuse on 1/27/26 between a resident (R44) and a CNA (CNA #8). The CNA's license was reported to DHP (department of health professions), and the employee was suspended pending investigation. On 2/3/26, the facility substantiated the allegation of abuse and the CNA was terminated. 2. All residents with BIMS (brief interview for mental status) of 13 or higher were interviewed to ensure no forms of abuse had taken place. All residents with a BIMS of 12 or below had skin assessments completed to ensure no injuries of unknown origin.3.The DON or designee will educate staff on the abuse policy, to include verbal abuse, and professionalism in the workplace.4.The DON or designee will audit 5 residents daily five times per week for 4 weeks, then 3 residents three times a week for 4 weeks to ensure residents are free from abuse and professionalism in the workplace is being maintained. The DON or designee will audit 5 resident skin assessments five times a week for 4 weeks, then 3 resident skin assessments three times a week for 4 weeks to ensure no injuries of unknown origin.5. Date of compliance: 2/12/26.The surveyor verified that the abuse incident involving CNA #8 was reported to the state agency, department of health professions, adult protective services in addition to the physician and responsible party. Interviews with residents with BIMS of 13 or higher were documented and included responses to questions: Has a staff member mistreated you since you have been a resident here .Have you seen or heard any resident here being abuses or mistreated .If yes, did you tell anyone what happened; what was their response .Do you feel the staff acted professionally when providing care? Interviews were documented as completed on 2/5/26 and 2/9/25 and indicated no abuse and positive results for professionalism. Education for all staff was documented on 2/3/26 regarding the facility's abuse prevention policies. Multiple staff members on each unit were interviewed on 2/13/26 regarding the education. All staff members interviewed verified education had been completed and were able to voice abuse prevention/reporting protocols. Skin audits were documented as completed by 2/11/26 on a checklist for residents with BIMS scores of 12 or below with no injuries of unknown origin identified. The DON conducted five resident interviews on 2/13/26 regarding abuse/professionalism as part of the monitoring plan with no indications of abuse or lack of professionalism noted. The survey team deemed the plan of correction implemented as listed with monitoring ongoing.Resident interviews, family interviews, a resident council interview, staff interviews and record reviews conducted during the current standard survey revealed no further allegations/incidents of abuse since R44's incident or prior to the survey exit on 2/13/26. This deficiency was cited as past non-compliance with correction date of 2/12/26.

Based on observations, resident/staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for one of 37 residents in the survey sample, Resident #233.The findings include: The facility staff failed to complete an accurate MDS (minimum data set), an annual assessment for Resident #233. Resident #233 (R233) was admitted to the facility on [DATE] with diagnosis that included but were not limited to idiopathic neuropathy, left toe amputation and depression. The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 3/11/26, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is oriented to person, place and time and has unimpaired immediate recall. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for locomotion/transfer/dressing/toileting, hygiene and eating. Section J-health conditions: J1300. Current Tobacco Use-coded as no.A review of the comprehensive care plan dated 4/14/25 revealed, FOCUS: Resident prefers to smoke cigarettes. INTERVENTIONS: Educate on facility smoking policy. OT (occupational therapy) referral as needed. Smoking assessment as needed.A review of the smoking safety screen for R233 dated 1/29/26 revealed, Does the resident smoke? Coded R233 'yes'.Observations on 6/8/26 at approximately 11:40 AM and 6/9/26 at 10:00 AM revealed, R233 smoking outside off facility property.An interview was conducted on 6/9/26 at 10:05 AM with R233. Asked how frequently he smokes, R233 stated, probably eight to ten times a day. Asked has he smoked since admission, R233 stated, oh yes, have been smoking for over thirty years.On 6/10/26 at 10:25 AM with the MDS coordinator. Asked to review R233's 3/11/26 annual assessment, Section J1300, the MDS coordinator stated, this is coded incorrectly by an agency person that was working here. The MDS will be revised today.On 6/10/26 at 1:55 PM, the Administrator, Director of Nursing, Regional Director of Clinical Services and the Regional Director of Operations were made aware of the findings. According to the RAI (resident assessment instrument) MDS Section J1300: Current Tobacco Use. Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff to develop a comprehensive care plan for two of forty-three residents in the survey sample (Residents #44 and #198). The findings include:1. Resident #44 had no plan of care developed regarding self-administration of insulin and self-management of an insulin pump. Resident #44 (R44) was admitted to the facility with diagnoses that included hip fracture, diabetes, anemia, osteoporosis, hypothyroidism, cerebral infarction, major depressive disorder and asthma. The minimum data set (MDS) dated [DATE] assessed R44 as cognitively intact. On 2/10/26 at 1:49 p.m., R44 was interviewed about medication administration, including insulin. R44 stated she had an insulin pump for management of diabetes that provided insulin and monitoring of blood sugar levels. R44 stated she had the insulin pump prior to admission to the facility, had managed the pump/insulin without difficulty for years and that a family member provided supplies as needed. R44's clinical record documented a physician order dated 12/30/25 for a Lispro insulin pump with instructions stating, Resident manages pump. The record included a physician's order dated 12/30/25 for Dexcom to be changed every 10 days with instructions stating, Family will provide. R44's plan of care (revised 1/14/26) included no problems, goals and/or interventions regarding self-administration of insulin or management of an insulin pump. The care plan documented that the resident was at risk of complications and blood sugar fluctuations related to diabetes. Interventions to prevent complications included insulin as ordered by the physician. The care plan made included no interventions referencing use of the insulin pump or management of the Dexcom monitoring device. On 2/11/26 at 3:26 p.m., the licensed practical nurse unit manager (LPN #11) caring for R44 was interviewed. The unit manager stated R44's pump was self-adjusting and that the blood sugar readings were monitored on the resident's cell phone. The unit manager stated she thought the insulin pump and management of the pump should be included in the resident's care plan. On 2/12/26 at 8:49 a.m., the licensed practical nurse (LPN #12) responsible for MDS assessments and care planning was interviewed. The MDS coordinator reviewed R44's plan of care and stated all that was listed was to administer insulin as ordered. The MDS coordinator stated R44's last care plan meeting was held on 1/13/26 and that the unit managers attended the care plan meeting with no requests to add the insulin pump. The facility's policy titled Care Planning (effective 11/1/19) documented, .A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient . This finding was reviewed with the administrator and director of nursing during a meeting on 2/12/26 at 5:10 p.m. with no further information provided prior to the end of the survey. 2. Resident #198 (R198) did not have a complete care plan related to dialysis interventions. R198 diagnoses include osteomyelitis, renal dialysis related to end stage renal failure, polyneuropathy, and dementia. The most recent MDS (minimum data set) was a discharge date d 11/17/25 and indicated R198 was cognitively intact. Review of R198's clinical record indicated care plan interventions for dialysis were not specific to dialysis days, the dialysis center, what type of vascular access R198 had and location of the vascular device. On 2/12/2026 at 5:10 p.m. the above information was presented to the administrator and director of nursing. On 2/13/2026 at 8:12 a.m. the DON was interviewed. The DON verbalized reviewing the care plan and indicated R198 had been readmitted to the facility from the hospital. Upon admission a dialysis care plan was generated which includes a template for interventions; however, the template was not properly filled out. No other information was presented prior to exit conference on 2/13/2026.

Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to revise the comprehensive care plan for one of 37 residents in the survey sample, Resident #215. The findings include:For Resident #215 (R215), the facility staff failed to revise the comprehensive care plan regarding smoking status. On the most recent annual minimum data set (MDS) with an assessment reference date (ARD) of 2/2/2026, the resident was assessed as being a current tobacco user. The comprehensive care plan for R215 documented in part, The resident prefers to smoke cigarettes. Created on: 07/12/2024. Revision on: 12/28/2025. Under Interventions it documented in part, .May smoke independently. Created on: 08/14/2024 . Supervise with smoking. Created on: 03/12/2026. On the most recent smoking safety screen dated 3/13/2026, R215 was assessed as scoring a five indicating they required supervison with smoking. The section of the assessment titled Care Plan documented in part, Intervention: May smoke independently .Intervention: supervise with smoking. On 6/10/2026 at 10:24 AM, an interview was conducted with the MDS coordinator who stated that the care plan was developed to corespond with the MDS assessment and was revised as needed with anything that needed to be updated daily. She stated that they reviewed the orders daily and updated the care plan as needed. The MDS coordinator stated that the purpose of the care plan was to show an overall picture of the resident and to show what was going on with them. She reviewed R215's care plan and the smoking assessment and stated that both independent and supervised were checked, and it should have been revised because it was not clear which status was current. The facility policy Care Planning effective 11/1/2019 documented in part, . Care plans will be updated on an ongoing basis as changes in the patient occur, and reviewed quarterly with the quarterly assessment . On 6/10/2026 at 2:21 PM, the Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide adequate supervision and an environment free of accident hazards to prevent injury to residents, that resulted in two instances of injury/harm to Resident #12 (R12) and one occurrence of harm for Resident #18 (R18). Having the potential to affect multiple residents residing on three of three nursing units, the noncompliance resulted in the identification of immediate jeopardy (IJ) and substandard quality of care. The findings included: 1. The facility staff failed to ensure the environment was free of accident hazards, which resulted in R12 ingesting body wash, requiring hospitalization for respiratory failure and intubation, and the subsequent placement of a trach and a feeding tube. On 4/4/25, a closed record review was conducted of R12's chart. This review revealed a progress note written by a licensed practical nurse (LPN #5) dated 3/17/25 at 5:45 a.m., that was titled, eInteract SBAR Summary for Providers. This note read in part, Blood pressure: 173/98- 3/17/2025 at 5:50 a.m., Position: Sitting r/arm [right arm]. Pulse: 110, R 22 [respirations] Temp 97.5- 3/14/25 23:00 route: Forehead non-contact . Pulse Oximetry: O2 90%- 3/17/2025 at 5:49 a.m Outcomes of Physical Assessment: . Respiratory Status Evaluation: Shortness of breath, abnormal lung sounds (rales, rhonchi, wheezing), Cardiovascular Status Evaluation: Resting pulse greater than 100 or less than 50 . Nursing observations, evaluation, and recommendations are patient grabbed and ingested unknown specific amount of soap. patient bubbling from mouth with wheezing heard from lung sounds. tachycardia noted as well as hypertension. patient decreased response to stimuli. on call contacted, MD and NP [medical doctor and nurse practitioner] no answer. emergency contact was reached, and patient was sent to ER [emergency room] via 911. report [sic]. On 3/17/25 at 6:15 a.m., another nursing progress note entry by LPN #5 was entered into R12's chart that read, . patient grabbed and ingested unknown specific amount of soap. patient bubbling from mouth with wheezing heard from lung sounds. tachycardia noted as well as hypertension. patient decreased response to stimuli. on call contacted, MD and NP no answer. emergency contact was reached, and patient was sent to ER via 911 at 0615. report called to [name redacted] ER nurse at [hospital name redacted]. According to hospital records dated 3/17/25, and titled, Pulmonary & Critical Care Specialist- ICU intake note read in part, . In summary this [AGE] years old female with severe dementia who is functionally limited . found to be hypoxic with change in mental status but also the staff noticed that she has ingested liquid body wash of 20 cc which has not been witnessed but patient was smelling fruity like the body wash in the room. When EMS arrived, she was hypoxic and confused unresponsive. She came to ER on nonrebreather. She is found to have a new airspace disease involving the right lung, metabolic acidosis with anion gap, lactic acidosis, venous blood gas shows metabolic as well as respiratory acidosis . Assessment: 1. Acute hypoxic and hypercapnic respiratory failure- currently on high flow 2. Accidental ingestion poisoning of liquid body wash/unknown amount and duration at the nursing home . According to hospital records dated 4/1/25, titled, Physician Discharge Summary which read in part, . brought to the emergency room where she was hypoxic hypercapnic could not tolerate BiPAP and she was eventually intubated, patient was extubated in March 22 and she did not tolerate and has to be reintubated in March 22 after discussion with the family decision was made for tracheostomy and PEG tube placement . According to the facility provided documents regarding the incident of R12, the facility only talked with and interviewed licensed practical nurse (LPN #12) and a certified nursing assistant (CNA #3). According to the nursing schedule for the overnight shift from 3/16/25-3/17/25, two nursing assistants (CNA #3 and CNA #2) worked the unit where R12 was a resident, and two licensed practical nurses (LPN #12 and LPN #11) worked the unit. LPN #5, who made the entries into R12's chart had been assigned to another unit. On 4/4/25 at 9:40 a.m., an interview was conducted with resident #2 (R2), who was R12's roommate. R2 was asked about the day R12 was sent to the hospital, R2 stated, I remember hearing coughing, it sounded like she was choking. I kept ringing the buzzer. I heard her drinking something . I didn't know that kind of stuff was over there, she must have been thirsty. When asked what she drank, R2 said, Body wash. When asked how she knew this, R2 stated, I heard them [facility staff] saying she drank body wash. They said they could tell by her poop. She had a major blow out . It sounded like she was choking. R2 stated she couldn't see R12 because the privacy curtain was pulled. On 4/7/25 at 4:30 p.m., an interview was conducted with licensed practical nurse #11 (LPN #11), who also worked the unit where R12 was a resident the night of the incident. LPN #11 stated, I was fairly new. I was only working there two weeks, but she would grab you when you walk by. I was working night shift and the nurse assigned came and told me she swallowed soap. She had aspirated; she had soap coming from her nose and mouth, it was tan colored. The nurse from the other side came to help. She [R12] was having massive diarrhea. When asked if she thought R12 had drank shower gel, LPN #11 said, Definitely! I was a CNA for 20 years and I know for sure it was bath and body works, maroon colored. I saw the bottle when the EMTs [emergency medical technicians] came and most likely the CNA left it on the bedside table. She would grab things . It was a bunch of CNAs trying to help. [LPN #5's name redacted] was helping, [LPN #12's name redacted] was on the phone with the doctor and we got vitals. I saw her aspirating from her nasal, she sounded like she was under water. She was struggling to breathe. She was not at her baseline. She had a lot of fluid sounds. LPN #11 went on to report that when the EMT's came they had four trainees, and they were getting instructions on how to lift R12. They applied oxygen, she was in the wheelchair. I was doing something and remember [LPN #11's name redacted] saying this isn't good. I dropped what I was doing to go help. Yes, I was present. When asked if any of the facility administration had attempted to reach her to get information about what had happened, she stated, They never called or reached out. The next day they had a whole protocol on keeping stuff out of reach. On 4/7/25 at 4:53 p.m., the vice president of operations (VPO) provided the survey team with a plan of correction the facility had implemented in response to R12's incident. The VPO said, We can't tell for certain it happened, but we put a plan in place. The documents included a paper with a grid that noted, . Problem: Toiletry Items: Date of Implementation: 3/17/25. Problem: 1. Toiletry items not stored correctly in pt [patient] bedrooms. Immediate response- what was done at the time: 1. 100% audit of all rooms to ensure toiletry items stored correctly. How to identify other residents: 1. All residents have the potential to be affected. What measures were put in place to prevent reoccurrence: 1. Education to nursing staff, provided by DON [director of nursing], or designee: On ensuring toiletry items are stored in closet, nightstand drawer or with staff. Ensuring all cleaning supplies are locked up. How to monitor to ensure the problem does not reoccurrence [sic] 1. The DON or designee will audit 10 rooms weekly for 4 weeks then 3 rooms weekly for 4 weeks to ensure toiletry item and cleaning supplies are stored correctly. QA: [quality assurance] The results will be reported to the monthly quality committee for review and discussion. To ensure substantial compliance. Once the QA committee determines the problem no longer exists, then review will be completed on a random basis. ADHOC QAPI: 3/24/25. QAPI Meeting: 4/13/25. Date of compliance: 3/27/25. Also included in the documents provided by the VPO was a typed paragraph that read, On 3/17/25 resident #1 [identified as R12 in this survey report] noted with hypertension, tachycardia, wheezing, and secretions from mouth. The medical provider was notified and ordered resident to be sent to ED for further evaluation after it was discovered that the patient may have ingested shower gel that was used for her bed bath previously. The RP [responsible party] was notified. The resident was admitted to the hospital for further evaluation. No staff member witnessed patient grabbing or ingesting the shower gel. A midnight census report dated 3/17/25, which listed all residents in the facility was provided that had a handwritten note across the top that read, 3/17/25 100% audit all rooms. All toiletry items stored correctly. There were no other notes or marks on the forms. Also provided was In-service education records that noted subject: Storage of toiletries, cleaning supplies . Summary of content: All toiletry items for patients will be stored away in their close, nightstand, or with staff. The in-service education records were signed by 145 staff members. There was also evidence of audits that were conducted for three weeks. On 4/7/25 at 8:10 p.m., an interview was conducted with CNA #3. CNA #3 was asked about the night R12 was sent to the hospital. CNA #3 stated, I was working with one other CNA, we had 40-60 residents. The CNA working with me would not finish a full round. The only resident she got cleaned up was [R12's name redacted]. They let her sit from 3-11 p.m. in the chair. The CNA on the prior shift said she was acting crazy because she had been refusing medications for several days. The CNA [CNA #2] washed her up and changed her into her gown. I helped hold her up while she was washing her and got her in bed. I was walking by and on the bedside table I noticed soap was missing from the bottle. I went and told the nurse that on the table was a bottle of soap and it was missing soap out of it. I told the nurse. I think she went to check on her. I went back about 20 minutes later to check on her and she was still sitting there, she had diarrhea and was breathing heavy. The other CNA was sitting at the station. We were both working the floor together because she was new. [R12's name redacted] was sitting up with soap missing and the top off. It was something the family provided; it said black cherry [on the label]. She had taken her gown off . it was the reason I went in the room, and I noticed she was breathing weird. I told [LPN #12], and she wanted to know how much she had drank. I told her a good amount and she said she will probably just puke it out. When asked if she had worked with R12 previously and what she was like. CNA #3 said, I had worked with her. She was always reaching out, that night she was aggressive and hitting. We kept her at the nursing station until she was ready to go to bed. The other CNA was a new agency person. CNA #3 went on to report that . the rescue squad staff took the soap with them. She had red stuff in her mouth, I noticed foaming, we were wiping that off, it was pink tinted. When asked how R12 got the soap, CNA #3 said that the other CNA working that night, . heard the same things I did. She had dementia and is grabbing at things; she is off her meds. I think it is kind of negligent; why would you leave soap right there on the overbed table? On 4/8/25 at 8:47 a.m., an interview was conducted with LPN #5. LPN #5 reported he had walked to the unit where R12 was a resident to get a vital sign machine. LPN #5 reported, The nurses and CNAs looked like something was wrong. They said, 'She grabbed soap and ingested it.' I contacted 911, started her file to send with her. That was between 5-6 a.m. When asked how R12 got the soap, LPN #5 said, I'm not sure, I thought I heard them say she grabbed it off the bedside table. I'm not sure if while getting her cleaned up and stepped away to get a towel or something. One nurse said they thought she drank soap and had suds and bubbles coming out of her mouth and nose. So I started the ball rolling to get EMS there. That soap lines the esophagus and can be aspirated. When asked if she saw or assessed R12, LPN #5 stated, No. Usually my role in emergency situations is to get 911 there and do the paperwork. On 4/8/25 at 9:13 a.m., an interview was conducted with LPN #12. LPN #12 reported, I was on my med cart and had been on the hall and walked by the room and saw her [R12] laying sideways. She had a bowel movement, and it was all over her; it was bubbly and pink tinged, it even smelled like it [the soap]. The CNA said 'I think she may have drank it [the soap]' I could hear her in her respiratory, she was very congested. The CNA said she had washed her up. [R12's name redacted] was new to our hall and the CNA is a traveler. When asked if R12 was restless, confused or grabbing at things, LPN #12 said, All the time! When asked if R12 had any clinical symptoms, LPN #12 stated, Her lips were discolored, vitals surprisingly weren't too off baseline for her, which I've learned means nothing. She just looked at you with a stare. Respiratory was bad, I knew she had to go. That facility has a protocol you have to call three people to send someone out and no body answered, so I called on-call back. LPN #12 was asked if she suctioned R12. LPN #12 said, I didn't suction her because I wiped out of her mouth what was coming from her was deep you could wipe the bubbles and it kept coming; it smelled perfume, it was foamy bubbles with a pink tinge. When asked if anything else could have happened, LPN #12 said, No. I don't think it was intentional but there is no other explanation. On 4/8/25 at 9:32 a.m., an interview was conducted with CNA #2. CNA #2 reported, It was the first time I had worked with her, we gave her a bath. Prior to that she was sitting at the nursing station, when I came in at 11 p.m. I think we put her to bed maybe around 4 a.m. When we brought her to the bed, we washed her off and changed her brief. The other aide was doing rounds and called me to come. We saw bubbles coming out of her mouth, she was foaming. We called for the nurse at the desk, I think she said she was aspirated. We sat in the room until the ambulance came. We think she drank the soap on her nightstand. She literally had bubbles coming out. We didn't give her anything to drink, it was bubbles, it was on her nightstand when we brought her in the room. CNA #2 went on to state that she had seen the soap on the bedside table and said, So I didn't think anything about it. It was my first time with her, so I didn't really know her. When asked if she had gotten any kind of report on the residents she was to be assigned, CNA #2 said, I could have, I don't recall. CNA #2 continued the interview and said, She [R12] was demented. It was a nightmare. I feel horrible for her; she had bubbles coming out of her mouth, so I assume she drank the soap. You could hear her gurgling, at that point I'm thinking she aspirated, it was like she was choking. When asked if R12 was having any difficulty breathing, CNA #2 said, Yes, you could hear the sound like gurgling. During the survey on 4/3/25, 4/7/25 and 4/8/25, the shower rooms on the east and west units were noted to have the doors open and gallon jugs of shampoo & body wash were noted to be accessible to anyone entering the shower rooms. On 4/7/25, Resident #20 (R20) was noted to be sitting in the hallway near the nursing station. R20 was not able to answer questions and replied unintelligibly. A review of the clinical record revealed that R20 had a BIMS of 3. On 4/7/25 at 1p.m., during an interview with R20's roommate, who was Resident #9 (R9), observations of the room revealed that R9 had aerosol air freshener and two cans of Raid ant and roach spray in the room that was not secured. When questioned, R9 reported that she had the bug spray for ants. On 4/8/25 at 10:35 a.m., observations of R20 's room revealed that the over bed table was located by the sink, with the breakfast tray and a bottle of dove silver shampoo sitting on the table. On 4/8/25 at 11:17 a.m., an interview was conducted with licensed practical nurse #13 (LPN #13), who was the unit manager where R20 resided. When asked about R20, LPN #13 said, Some days are better than others, she does have dementia. Her decision making is impaired, she has very minimal safety awareness and is very impulsive. We try to keep her in high traffic areas, try to keep her busy and she goes to activities. When asked how toiletry items are to be stored, LPN #13 said, In the nightstand or closet. When asked why they are to be stored there, LPN #13 stated, Due to the potential of someone with impaired memory thinking it is something else. LPN #13 accompanied the surveyor to R20's room and confirmed the observation of the bottle of shampoo on the overbed table beside R20's cup of water and breakfast tray. LPN #13 said, This should not be out, and the breakfast tray should have been taken out. On 4/8/25 at 11:35 a.m., an interview was conducted with licensed practical nurse #3 (LPN #3), who was a unit manager. When asked about R12, LPN #3 stated, She was a sweet, demented lady. We tried to keep her up here with us to keep an eye on her, she was grabby, she would grab at you as you walk by and would touch other residents' arms if they stay by her. She was not oriented, she was total care for everything, was fed by staff, incontinent of bowel and bladder. When asked about her knowledge and involvement the day R12 was sent to the hospital, LPN #3 said, I was on call that morning when [LPN #12's name redacted] called me and said [R12's name redacted] had gotten a hold to some soap and drank it. She called for transport to send her out, she said she was still alert and at her baseline, was coughing up soap bubbles. Following that we put a plan of correction in place to be observant of toiletries being out of reach and stored in closets or bedside drawers. When asked if any consideration had been given to toiletry items in the shower rooms, LPN #3 stated, Nothing is to be left out in the shower rooms. When LPN #3 was notified that the survey team had observed gallon jugs of shampoo and body wash was unsecured on multiple occasions and even sitting on the floor while the shower room doors were open and accessible to anyone coming into the rooms, LPN #3 stated, There is a holder on the wall it should have been placed in. When I walk by, I try to shut the doors. On 4/8/25 at 1:02 p.m., following confirmation of IJ existence by the SA, the facility's administrator, director of nursing, and corporate staff were made aware that the survey team had identified the facility was in Immediate Jeopardy (IJ), which also constituted substandard quality of care. The IJ template was read and a copy emailed to the facility administrator and vice president of operations (VPO). Immediate Jeopardy was identified to have begun on 1/8/25, when R12 was not appropriately assessed for the risk of injury from hot liquids. On 4/8/25 at 4:45 p.m., the facility administration provided the following IJ removal plan: F689 Accidents and Hazards Removal Plan. Plan Corrective Action for those residents found to be affected by the deficient practice: A. R#12 is no longer residing in the facility. B. R#12 is no longer residing in the facility. All items for R#20 and R#9 have been stored appropriately. Corrective Actions taken for residents with potential to be affected by deficient practice: A. All residents who drink hot liquids have the potential to be affected by this deficient practice. Nursing team will conduct hot liquid assessments on all patients to determine an appropriate level of intervention for each patient. Care plans will be updated based on findings. B. All residents who reside in the facility have the potential to be affected by this deficient practice. The interdisciplinary team will audit all resident rooms to ensure items are stored appropriately in resident rooms and shower rooms. The Facility Administrator will conduct a town hall meeting on 4/8/25 at 6:00pm with the resident counsel to review appropriate items that can be in the room and how it can be stored. Those residents not in attendance will be given a handout with this information, and resident families will be called to be educated for patients who are not able to be educated. Systemic Changes put into place to ensure the deficient practice does not recur: A. The Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Maintenance, Director of Housekeeping and Laundry, Human Resources, and Unit Managers) will be educated by the [NAME] President of Operations on the policy which states the acceptable hot liquid temperatures. Starting 4/8/25 all facility staff will be educated on the hot liquids policy to include the appropriate temperatures to serve to residents before it leaves the kitchen. The kitchen will keep a temperate log of coffee temperatures prior to it leaving the kitchen. A list of residents with hot liquid interventions will be provided to the dietary staff and floor staff to ensure all interventions are in place. This education will be provided to all new employees as part of new hire orientation to include agency staff. No employee will be allowed to work until they have been educated. The [NAME] President of Operations to conduct an ADHOC Quality Assurance Performance Improvement Meeting on 4/8/25 including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, and Unit Managers to review the hot liquids policy and procedure. B. The Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Maintenance, Director of Housekeeping and Laundry, Human Resources, and Unit Managers) will be educated by the [NAME] President of Operations on what is appropriate to store in resident rooms and how they need to be stored. Starting 4/8/25 all facility staff will be educated on what is appropriate to store in resident rooms and how they need to be stored. This education will be provided to all new employees as part of new hire orientation to include agency staff. No employee will be allowed to work until they are educated. The [NAME] President of Operations to conduct an ADHOC Quality Assurance Performance Improvement Meeting on 4/8/25 including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, and Unit Managers to review the procedure for storing hazardous items in resident rooms and in shower rooms. Monitoring of corrective action to ensure the deficient practice does not recur. A. Facility will monitor the temperature of coffee that is poured for residents to ensure it is following the policy for proper temperature before leaving the kitchen. B. Facility will monitor resident rooms, common areas, and shower rooms to ensure items are stored appropriately. Completion of removal plan 4/8/25 at 10:00pm. The Regional Director of Clinical Services made the Medical Director aware of the Immediate Jeopardy via telephone on 4/8/25 at 3:08pm. Following consultation with the SA, the facility was notified of the acceptance of their IJ removal plan. On 4/9/25, the survey team verified the implementation of the facility's removal plan through clinical record reviews to ensure that all resident's had been assessed for risk of injury from hot liquids by facility staff's completion of a hot liquid safety evaluation. The resident's identified at risk had their care plan reviewed to ensure that the care plan included the risk for injury and interventions to prevent accidents from hot liquids. During the review, one resident was listed on a list titled, List of residents needing intervention for hot liquids that did not match the interventions identified on the hot liquid safety evaluation. There was an additional resident that according to the hot liquid safety evaluation required interventions and that resident was not listed on the list of residents needing interventions for hot liquids. These concerns were brought to the attention of the facility's administrator and corporate staff and were immediately corrected with a revised listing provided to the survey team at 10:03 a.m. On 4/9/25, observations were conducted throughout the facility, in the shower rooms, and in resident rooms to ensure that no potentially hazardous items were readily accessible to cognitively impaired residents. Interviews were conducted with a sample of residents to ensure they had been made aware of how to store toiletry items. Handouts were observed in resident rooms that included the safe storage of potentially hazardous items and the temperature of hot liquids being monitored. On 4/9/25, the survey team was provided with a revised policy titled, Hot Beverage Policy that read, 1. The dining services director will ensure that coffee temperatures of hot beverages will arrive for service at a temperature range of 150 F or less. 2. When beverages have been reheated in a microwave the following must occur: a. Time of microwaving should not exceed 2 minutes. b. Using a sanitized (alcohol wipe) probe thermometer, the temperature must not exceed 140 degrees before deliver of the hot beverage. c. The staff will be provided with a probe thermometer and alcohol wipes to sanitize the thermometer. Staff who take the temperature will have adequate training on the proper sanitizing and use of a probe thermometer. d. If the temperature exceeds 150 degrees the beverage shall remain under the direction of the person reheating until the beverage is less than 150-degree temperature range. 3. The hot beverage should be covered with a lid during transport back to the resident. On 4/9/25, the staff education sign-in sheets were compared to the working schedule to ensure that all present staff, in all departments, had received training regarding the appropriate serving temperature of hot liquids and the storage of potentially hazardous items. No concerns noted. On 4/9/25, the survey team conducted staff interviews with staff across all departments to verify education was provided and to confirm their understanding of the serving temperature for hot liquids and appropriate storage of hazardous items. No concerns noted. On 4/9/25, observations were conducted in the kitchen and noted that a new Hot Beverage Service Temperature Log had been implemented. The dietary staff were observed to be monitoring the temperature of the coffee being put into the thermal dispensers to ensure it was less than 150 degrees, and prior to the beverage carts being delivered to the unit. Dietary staff were interviewed to confirm their knowledge of the appropriate serving temperatures. No concerns noted. On 4/9/25 at 11:15 a.m., after having verified that the removal plan had been fully implemented and that facility actions had eliminated the likelihood of serious injury, serious harm, serious impairment, or death, the facility was notified that the immediacy had been removed. The scope and severity of the remaining noncompliance was then lowered to a level three, isolated. 2. The facility staff did not have a system or protocol to monitor the temperature of hot liquids served to residents, to ensure safety, which resulted in R12 sustaining an injury from spilled coffee that required medical treatment to prevent further severity On 4/4/25, a closed record review was conducted of R12's chart. According to the hot liquid safety evaluation completed on 1/8/25, the questions in section 2B that indicated easily agitated, mood varies, and impulsive acts was not checked as having applied to R12. Section 2A was checked as yes and 2B1g was checked. Section 3 noted, If two or more indicators are checked in safety factors section 2, than the resident is at risk for injury from hot liquids and requires an intervention selected from below. Section 3 was blank and did not indicate R12 was at risk, despite having two areas checked in section 2. According to progress notes dated 1/1/25-1/8/25, the week prior to completion of the hot liquid safety evaluation, there were multiple entries indicating that R12 was agitated, restless, disrobing, and was administered lorazepam on several occasions due to behaviors. The hot liquid safety evaluation did not have the section checked that easily agitated, mood varies, and impulsive acts as being applicable R12, which was inaccurate based on nursing documentation. A progress note dated 3/5/25, was noted to read, During dinner time patient spilled coffee on herself. Slight redness on her thigh noted. NP [nurse practitioner] made aware. patient doesn't seem to be in distressed. No new order. Zinc oxide was applied. Staff will continue to monitor. On 4/7/25 at 11:40 a.m., an interview was conducted with the dietary manager (Other Employee #1- OE#1). OE #1 stated that they do not monitor or measure the temperature of coffee served to residents. OE #1 stated, After it comes out of the machine, it is supposed to go down [the temperature], so we don't scald anyone. When asked if they check the temperature of coffee, OE #1 said, No. Are we supposed to? Because we don't. At another facility I worked, we did check the temperature to make sure it wasn't too hot because someone got burned. We made sure it was 140 degrees Fahrenheit (F) or below before we sent it out of the kitchen. It is not part of the routine here. The kitchen temperature logs were reviewed for the past month and revealed no evidence of the kitchen staff monitoring coffee or other hot liquids temperatures prior to serving to residents. On 4/7/25 at 4:45 p.m., OE #1 accompanied the surveyor to each beverage cart and checked the temperature of the coffee using a digital thermometer. The coffee being served on the East wing was 159 F. After the coffee on the west wing measured 153 F, OE #1 drank the coffee to see how hot it was and said, It's hot. The coffee on the south wing measured 150.8 F. On 4/8/25, the facility administrator provided a policy titled, Hot Beverage Delivery. According to the policy, which read in part, 1. The dining services director will ensure that coffee temperatures from the coffee machine do not exceed 165 degrees. 2. The dining services director will ensure that coffee temperatures of hot beverages will arrive for service at a temperature range of 150 F or less. On 4/8/25 at 10 a.m., OE #1 was observed in the kitchen to measure the temperature of the coffee after it was brewed, and it was noted to be at 176 F. OE #1 said, When it first brews, it is around 180 degrees F, and we have to let it sit to cool. When asked if he was monitoring the temperatures prior to today, OE #1 said, No, we didn't have a policy that I knew about until today, if I'm being honest with you. 3. T[TRUNCATED]

2. For Resident #10 (R10), the facility staff neglected to respond to the residents call for assistance to have incontinence care provided, which resulted in R10 being left to sit in feces for fifty minutes, which resulted in psychosocial harm. On 4/3/25 at 9:38 a.m., upon the surveyor's arrival to the south unit, it was noted that several call bells were engaged. A light could be seen outside of the rooms and an auditory sound could be heard beeping in the hallways. On 4/3/25 at 9:41 a.m., the surveyor entered the room of R10, whose call light was on. R10 acknowledged that he had his call light on and reported that he needed to be changed. When asked how long his call light had been on, R10 said, Go look for yourself. R10 then explained that the surveyor could go to the nursing station and observe how long his call light had been on. When asked how often he experiences an extended wait for care, R10 didn't respond. On 4/3/25 at 9:49 a.m., the surveyor went to the nursing station and observed a computer screen that listed three call bells that were engaged. The duration listed for R10's call light was noted to be 50 minutes and 17 seconds. On 4/3/25 at 9:52 a.m., licensed practical nurse (LPN #19) was observed to enter the room, the call light went out, and LPN #19 exited the room. As LPN #19 was coming down the hall, she reported to certified nursing assistant (CNA #4) who passed her in the hall, that R10 needed to be changed. On 4/3/25 at 9:54 a.m., an interview was conducted with LPN #19 and inquired as to what R10 needed. LPN #19 stated, He needs to be changed. When notified that the call light had been engaged for over 50 minutes, LPN #19 was asked if this was common. LPN #19 said, Sometimes it is and sometimes it isn't. I didn't know that was the case this morning. Normally he tells me about it, but he didn't today. On 4/3/25, facility staff were notified of the above concerns related to R10. On 4/9/25, a clinical record review was conducted of R10's chart. This review revealed that R10's diagnosis included, but were not limited to unspecified cord compression, central cord syndrome at C2 level of cervical spinal cord, person injured in unspecified motor-vehicle accident, and quadriplegia. According to R10's most recent minimum data set (MDS - an assessment tool) with an assessment reference date of 3/30/25, R10 was coded as having a BIMS (brief interview for mental status score) of 15 out of 15, which indicated he was cognitively intact. The assessment also noted that R10 was dependent upon the assistance of two staff persons for bed mobility, transfers, and toileting. R10 was also coded on that same assessment as having had no skin impairments. According to the care plan, R10 was noted to be at risk for pressure ulcers due to immobility, inability to turn and reposition independently, incontinence, and quadriplegia. Care plan interventions included, Keep skin clean and dry as possible. The care plan also stated, The resident requires assistance with ADLs [activities of daily living] related to chronic health conditions, inability to perform ADLs, weakness, quadriplegia and spinal cord compression. The interventions included, Hoyer lift for all transfers x 2 staff, 2 person assist for bed mobility as needed . Also in the care plan, it was noted that R10 was incontinent of bladder and bowel. The interventions included . provide toileting hygiene with brief changes . According to a skin observation conducted on 3/29/25, R10 was documented with no skin impairments. On 4/1/25, R10 was noted with an incontinence associated dermatitis (iad) to his right buttock that measured 3.5 x 3.5 x 0.1 cm and another area of iad on his left buttock that measured 0.8 x 1 x 0.1 cm. According to the 4/1/25 progress note, the wound care nurse practitioner noted that . wound assessment: location: left buttock, primary etiology: incontinence associated dermatitis (IAD), stage/severity: partial thickness, wound status: new, size: 0.8 cm x 1 cm x 0.1 cm, exposed tissue: dermis, peri wound: fragile, wound base: 100% epithelial; exudate: scant amount of serosanguineous . A second wound was noted on the .right buttock, primary etiology: incontinence associated dermatitis (IAD), stage/severity: partial thickness, wound status: new, size: 3.5 cm x 3.5 cm x 0.1 cm, wound base: 100% epithelial; peri wound: fragile, exudate: scant amount of serosanguineous, exposed tissue: dermis . The progress note went on to give the treatment plan for both areas, which read as: Treatment Recommendations: 1. Cleanse wound with wound cleanser and pat dry. 2. apply Hydrocolloid to base of the wound. 3. change 3 times per week . PREVENTATIVE MEASURES: The patient is incontinent of urine and stool and is at an increased risk of skin breakdown. Recommend continuing ongoing interventions and protocol for swift incontinence management . NEW RECOMMENDATIONS: Staff report new incontinence associated skin breakdown to bilateral buttocks. See new treatment orders. Patient is at high risk for skin breakdown related to decreased mobility, inability to reposition self, comorbidities, incontinence of urine and stool. On 4/9/25 in the morning, a follow up interview was conducted with R10. R10 explained that he is totally dependent on staff for all care, including being fed, and must wait extended periods of time on a routine basis. R10 explained that he doesn't say anything because .what can I do? I have no choice. R10 confirmed that having to sit in his feces for extended periods of times makes him .angry, feel humiliated, and unimportant. I feel all of that but what can I do? R10 then was observed to have tears in his eyes that rolled down his check while talking to the surveyor. On 4/10/25 at 9:15 a.m-9:45 a.m., interviews were conducted with multiple staff, which included licensed practical nurses (LPN #6 & LPN #7) and certified nursing assistants (CNA #1, CNA #4, and CNA #5). All of whom reported that call bells should be answered within five minutes. On 4/10/25, the facility administration reported that they had no policy regarding incontinence care or call bell response times. The facility administration was made aware of the serious concerns related to the above findings. 3. The facility staff neglected to provide incontinent care in a timely manner for Resident #17(R17), which resulted in harm. R17 was admitted to the facility on [DATE]. Diagnoses for R17 included but are not limited to urinary tract infection, muscle weakness and underweight. R17's Reentry Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/3/25 coded R17 with severe cognitive impairment. R17 was dependent on the activity of daily living care. R17 was no longer a resident at the facility, so a closed record review was conducted. On 4/3/25 at 11:00 a.m., an interview was conducted with R17's daughter who was his responsible party. The daughter stated when she visited that she had found her dad in a saturated brief and the bedding was wet. The daughter stated she cleaned him up and took him to therapy. The daughter stated that she had marked R17's brief with a number 12 at 12 o'clock and when she returned to the facility around 8:00 p.m., he was in the same brief she had marked at noon. On 4/3/25 at 4:00 p.m., an interview was conducted with the administrator. The administrator stated that R17 was up and out of bed after doing therapy around 1:00 p.m., sitting at the nurse's station until the daughter came back in around 7:00 p.m., or 8:00 p.m. The administrator stated he spoke with two staff members that came in to work that evening and stated R17's brief did not appear to have been saturated. 4/3/25 at 5:08 p.m., an interview was conducted with certified nursing assistant CNA#18. CNA#18 stated that incontinent rounds should be made every two hours, adding, Sometimes those lines are not accurate. Sometimes those [moisture indicator] lines on the brief are clear and [the resident] will be sitting in a pool of urine. I open the brief to check. 4/3/25 at 5:08 p.m., an interview was conducted with CNA#19. CNA#19 said, I check the residents every two hours unless they use the call bell. Check the strips on the brief and roll them to make sure their bottom isn't wet. I will leave the same brief on for one round but the next round I will change the brief even if dry. I will let the nurse know if the resident goes eight hours without going to the bathroom. On 4/3/25 at 5:30 p.m., an interview with CNA#9 was conducted about the incident that happened on 3/15/25 with R17. CNA#9 said, [R17's] daughter came in at 7:55 p.m. She reported that her father was wearing the same brief she tagged at 12 o' clock. So I went back and looked at the brief and it was marked, like she said. Looking at the brief lines, I would not have changed him, but he was wet. He was wet enough to be changed. CNA#9 showed pictures of the wet brief and the time that was written on the brief. CNA#9 stated that the pictures the daughter had provided were time stamped. On 4/3/25 at 7:20 p.m., an interview was conducted with LPN#5 about the incident that happened on 3/15/25 with R17. LPN#5 stated that R17 had the same brief on that was numbered with a 12 by his daughter. R17's brief was wet, and that cream was applied to his scrotum that LPN#5 said, .was like a flush cheek red. LPN#5 stated that it was understandable why R17's daughter was upset by R17 being in the same brief for eight hours. On 4/7/25 at 12:10 p.m., an interview was conducted with the assistant director of nursing (ADON). The ADON stated that incontinent care was prn, and the typical standard is every two hours. The ADON said, I would pull back the brief to see if they had a bowel movement. Common sense tells me I would change them, and not leave the brief on for eight hours. The ADON stated that she would expect staff to change a patient's brief every other round, even if the brief lines are clear due to the brief holding moisture, and the patient can sweat, which can cause moisture associated dermatitis. The ADON stated patient's briefs can hold heat causing the patient to sweat, and the brief would need to be changed due to the moisture. On 4/8/25 at 11:00 a.m., an interview was conducted with LPN#13 the unit manager of the south wing. LPN#13 stated that R17's daughter sent her pictures of a saturated brief and a dirty bed pad with dried urine stains on the bed pad. LPN#13 stated that R17's daughter was in the facility around 8:00 p.m., and sent another picture to her with a brief marked with a 12, and of R17 sitting in his wheelchair in his room, and of the wall clock that had 8:00 p.m. On 4/8/25 at 2:00 p.m., a review of R17's clinical record was conducted. On 3/16/25 skin assessment was completed, which documented redness to R17's coccyx area. R17 was getting treatment for MASD (moisture associated skin damage) to sacrum, and groin areas but on 3/16/25 treatment was started to coccyx area. According to the National Institute on Health (NIH) moisture associated skin damage (MASD) is discussed and read in part, . Moisture-associated skin damage (MASD) occurs with exposure to various sources of moisture (bodily secretions or effluents) such as urine or fecal matter, perspiration, wound exudate, mucus, digestive secretions, respiratory secretions, or saliva . Accessed online at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9093722/#fn-group1 According to Wounds International, Moisture-associated skin damage (MASD) represents a significant problem and can have a negative effect on patient wellbeing and quality of life MASD is a complex and increasingly commonly recognized condition. Overexposure of the skin to bodily fluids can compromise its integrity and barrier function, making it more permeable and susceptible to damage (Gray et al, 2001; [NAME] et al, 2017). Individuals with MASD experience persistent symptoms that affect quality of life, including pain, burning and pruritis (Gray et al, 2011; [NAME] et al, 2017). MASD is classified as an irritant-contact dermatitis; see Table 1 (WHO, 2020). Common irritants can include urine, stool, perspiration, saliva, intestinal liquids from stomas and exudate from wounds. As such, MASD is an umbrella term and forms of MASD may be subdivided into four types (see Figure 1): IAD Peristomal dermatitis (relating to colostomy, ileostomy/ ileal conduit, urostomy, suprapu-bic catheter, or tracheostomy) ? Intertriginous dermatitis (intertrigo: where two skin areas may touch or rub together) Peri wound maceration . The article went on to read, .Managing continence As a priority, wherever possible, the cause of incontinence should be identified and eliminated, and treatment options exam-ined if possible - although this may be due to a range of factors including health conditions and mobility issues (Wishin et al, 2008; Beeckman et al, 2020). This should include evaluation of bladder and kidney function regarding urinary incontinence, and that of the intestine and colon in the case of fecal incontinence (Beele et al, 2017). If continence enhancement is not possible, suitable incontinence products should be used and non-invasive behavioral interventions implemented (Beeckman et al, 2018). Behavioral interventions may include nutritional and fluid management, mobility enhancement, and use of different toileting techniques (Wishin et al, 2008; Beeckman et al, 2020). While IAD does not only affect elderly people, evidence from studies involving elderly nursing home residents suggests that structured toileting and exercise interventions can improve incontinence (Bates-[NAME] et al, 2003; Beeckman et al, 2020). The type and frequency of incontinence should be re-assessed on regular basis, in order to tailor incontinence management strategies to the individual and assess the risk of skin-related damage (Beeckman et al, 2018). Wherever possible, indirect risk factors should be mitigated . Accessed online at: https://woundsinternational.com/wp-content/uploads/2023/02/77ece7a46c5c084762956b97f9096e53.pdf On 4/10/25 at 2:40 p.m., following consultation with the SA that verified the existence of IJ, the survey team met with the facility's director of nursing, two regional director of clinical services nurses, and the vice president of operations (VPO) were made aware that the facility was in Immediate Jeopardy (IJ) in the care area of Free from Abuse, Neglect, and Exploitation. On 4/10/25 at 5:43 p.m., the facility administration submitted the following plan of removal for the IJ: F600 Abuse Removal Plan. Plan Corrective Action for those residents found to be affected by the deficient practice: R#10 and R#23 will have a psychosocial assessment completed by the Regional Director of Social Work to determine current state of wellbeing. Corrective Actions taken for residents with potential to be affected by deficient practice: Staff will interview residents with a BIMS of 13 or higher about abuse, neglect, timely call bell response, timely incontinence care, psychosocial well-being, and resident rights are upheld. Residents with a BIMS of 12 or less will have their responsible party contacted about concerns related to abuse, neglect, timely call bell response, timely incontinence care, psychosocial well-being, and resident rights are upheld. Skin assessments will also be conducted on the residents with a BIMS of 12 or less. Care plans will be updated based on findings and provider and RP notified as well. The call bell system will be audited for each room to ensure functionality of the call bells. Systemic Changes put into place to ensure the deficient practice does not recur: All facility staff will be educated on the abuse, neglect, timely call bell response, timely incontinence care, psychosocial well-being, and resident rights are upheld. This education will be provided for all new employees as part of new hire orientation to include agency staff. No employee will be allowed to work until they are educated. Audits will be randomly conducted weekly to assess call bell response times, timely incontinence care, and abuse and neglect by a member of the Interdisciplinary Team. The [NAME] President of Operations to conduct an ADHOC Quality Assurance Performance Improvement Meeting on 4/10/25 including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Regional Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, and Unit Managers to review the abuse policy to include neglect, reporting of abuse and neglect, call bell response time, and the importance of timely incontinence care Monitoring of corrective action to ensure the deficient practice does not recur. The Administrator or designee will monitor call bell response times to ensure they are answered within 15 minutes. Residents with BIMS of 13 or higher will be interviewed at random weekly to validate the timeliness of their incontinence care, call bell response time, abuse and neglect, and psychosocial well-being. Residents with a BIMS of 12 or less will have their responsible party contacted about concerns related to abuse, neglect, timely call bell response, timely incontinence care, psychosocial well-being, and resident rights are upheld. All residents will have a skin assessment completed weekly. Completion of removal plan 4/10/25 at 11:00pm. The [NAME] President of Operations made the Medical Director aware of the Immediate Jeopardy via telephone on 4/10/25 at 3:26 pm. Following review with the SA, the removal plan was accepted. On 4/11/25, the survey team returned to verify that the facility had fully implemented their removal plan. The survey team verified that R10 and R23 had a psychosocial assessment completed by the regional director of social work. The facility's documentation of resident interviews for all residents with a brief interview for mental status (BIMS) score of 13 or higher was reviewed. The survey team conducted a sample of resident interviews to ensure they had been interviewed, and any concerns were shared. The survey team verified that the facility staff had documentation of family interviews being conducted for residents with a BIMS score of less than 13. The survey team reviewed the staff education regarding abuse/neglect, including psychosocial well-being, timely call bell response, and timely incontinence care. The sign-in sheet for the education was compared to the schedule of staff working to ensure all staff had received education. A sample of staff across all departments was interviewed to verify they had received education and had knowledge of abuse/neglect, how to report such allegations, timely call bell response, timely incontinence care, and psychosocial well-being. No concerns noted. The survey team conducted observations on each of the three resident care units and monitored staff's response to call bells. Calls for assistance were responded to within 15 minutes of the call bells being initiated. The facility provided evidence of a call bell audit that was conducted. According to the facility documentation, they identified several residents whose call-bells were noted to not be operational. The survey team then went to those selected rooms and verified that the call bell was working. The surveyor identified two resident rooms, four residents affected, that the call bell was not working when checked. The facility's VPO was made aware of the above findings regarding the in operatable call bells and that they would not be able to abate the IJ. On 4/11/25 at 9:25 a.m., the survey team was made aware that the call bells in two rooms were replaced and functioning, while the residents in one other room had been distributed hand bells to use to notify staff if assistance was needed. The survey team verified this with no further concerns noted. On 4/11/25 at 10:15 a.m., the facility's administration and regional team were made aware that the survey team needed evidence that the facility was responding to concerns and/or allegations of abuse/neglect shared by residents and families during the interview process. The facility provided the survey team with evidence that three allegations of abuse/neglect were being investigated, and all other concerns were being addressed through the facility's grievance procedure. On 4/11/25 at 12 noon, after having verified that the removal plan had been fully implemented and that facility actions had eliminated the likelihood of serious injury, harm, impairment, or death, the facility was notified that the immediacy had been removed. The scope and severity of the remaining noncompliance was lowered to a level three, isolated. Based on observation, resident and staff interviews, clinical record review and facility documentation review, the facility failed to protect the residents' right to be free from neglect for three residents (Resident #17-R17, Resident #23-R23, and Resident #10- R10) in a survey sample of 26 residents, which resulted in harm for two residents (Resident #10- R10 and Resident #23-R23) and the identification of Immediate Jeopardy (IJ) and substandard Quality of Care. The findings included: 1. The facility staff neglected to provide timely incontinence care for Resident #23 (R23), which resulted in skin injury and psychosocial harm. According to clinical record review, R23 was admitted to the facility on [DATE]. Diagnoses for R23 included but were not limited to chronic diastolic heart failure, muscle weakness and chronic respiratory failure with hypoxia. R23's Quarterly Minimum Data Set (an assessment protocol), with an Assessment Reference Date of 3/25/25, coded R23 with no cognitive impairment. This assessment also documented that R23 was dependent on staff for toileting and required moderate to maximal assistance with bed mobility, transferring, and bathing. On 4/9/25 at 6:35 p.m., upon entering R23's room, it was noted that the privacy curtain had been pulled. When addressing the resident through the curtain, R23 replied, She's changing me. I'll talk to you in just a minute, she almost done. From behind the curtain, R23 was then heard saying, Ouch, Ouch! Be gentle, it burns. The CNA was heard to say, Ok, I'm being gentle. I'm almost done. On 4/9/25 at 6:45 p.m., an interview was conducted with R23. When questioned about care, R23 said, There have been several times that I have had to sit in my urine or feces for long periods of time. R23 said, Last Thursday [4/3/24], I was wearing the wrong size brief, and I sat in my own feces for two hours. When I rang for help, the aide came in at 8:30 a.m., and I told her I needed to be changed, that I had a bowel movement, and that it leaked out of my brief. The aide turned the call bell off, said that state was here, so she had to take care of other residents first, and then she would come back to change me. R23 stated that approximately 10:10 a.m., .another certified nursing assistant [CNA# 7] came to the door, asked how I was doing, and if I needed anything. R23 stated that she told CNA#7 that she needed to be changed, had been sitting in a bowel movement for almost two hours, and that (CNA#6's name redacted) was supposed to come back to do it but had not been back. R23 stated that CNA#7 indicated that she would provide the needed care but had to go get all the supplies she needed. R23 stated that CNA#7 came back at 10:30 a.m. and provided the care. R23 said, My bottom was burning me as she was cleaning me up, and [CNA#7 name redacted] pointed out to me that it was some bad spots down there. R23 said, This made me feel others were more important to me. Made me feel like crap. I have never been treated like this before. R23 stated that CNA#6 had been her aide several times but had never left her waiting that long before. R23 stated that she had reported the incident to someone from Adult Protective Services who came to see her yesterday. When questioned if she had told anyone else, R23 stated that she reported this incident to CNA#7 on Thursday (4/3/25), she told the ADON on Friday (4/4/25), and told the administrator on Saturday (4/5/25). R23 then showed pictures that she stated had been taken that day. One photo showed that fecal material was outside of the incontinent brief, on both sides of her thighs, on the incontinent bed pad, and with a large brown stain on the lower bed sheet. R23 then displayed another picture on her cell phone that she had taken after care was provided, which showed bright red appearance of her groin area and thighs. When questioned if the areas were better, R23 stated that she was suffering with burning to her peritoneal area and thighs. Displaying her inner thighs and groin area, it was observed that R23's mid to inner thighs appeared deep beefy red in color, while the groin area was bright red. On 4/9/25 at 7:30 p.m., an interview was conducted with the assistant director of nursing (ADON). When questioned about R23's complaint, the ADON said, I talked to her sometime on Friday. She hollered at me from her bed. She told me it took [CNA#6's name redacted] a long time to get in here to take care of me. The ADON stated that she told R23 that she would look into it and check the assignment sheet. On 4/9/25 at 7:45 p.m., the ADON, the director of nursing (DON) and the regional director of clinical services (RDCS) were made aware of the above findings related to R23, during a meeting. The response was that they had not been aware that R23 was sitting in feces for two hours until this meeting. When the RDCS stated that the change in skin condition could be related to yeast, a joint observation was suggested and agreed upon. 4/9/25 at 8:00 p.m., an observation was conducted with the RDCS. R23 retold how she had been left in feces on 4/3/25 to the RDCS. When the RDCS asked to see the affected area, R23 consented and showed her. When the RDCS attempted to move R23's legs apart, R23 began grimacing, wincing, and moving away from the contact. The RDCS asked if she needed something for pain, R23 stated, No, I handle pain well. The RDCS asked R23 if the area itches, and R23 said, No, it burns! The RDCS asked R23 if she had ever had cream applied in that area before, and R23 said, Under my abdomen but never down there. I have never had anything down there until Thursday. On 4/9/25 about 8:10 p.m., an end-of-day meeting was conducted with the administrator, director of nursing and corporate staff, during which they were made aware of the above concerns and the potential for neglect. On 4/10/25 at 9:50 a.m. an interview with CNA#7 was conducted via phone call. CNA#7 stated that when she went to do her rounds, she asked R23 is she needed help or anything. That was when she told me she was needing to be changed and she had been sitting in it for a while. CNA#7 said, She was upset. [R23's name redacted] was sitting in a mess. The feces were up the front of the brief, down the sides of legs, on the chuck pad, on the sheets, and I had to change all bed linen. CNA#7 said, After cleaning her up, the creases of her thighs were red. CNA#7 stated that R23 was upset and mad because CNA#6 was supposed to come back to change her and never came back. CNA#7 stated that she did not report to anyone how she found R23, nor that R23 had reported that she had been laying there for 2 hours in feces waiting on CNA#6 to come back and change her. On 4/10/25 at 10:15 a.m., an interview with CNA#6 was conducted via phone call. CNA#6 stated that when she entered R23's room, she was needing to be changed. CNA#6 stated that she had been asking for help, but no one would come help her with answering the call bell lights. CNA#6 stated that she had another resident that she had to get ready for an appointment, who needed to bathed, dressed, transferred with a lift, and to the lobby for her pick up time or she would miss the appointment. CNA#6 stated that when CNA#7 showed up, she was taking care of R23. CNA#6 stated that she had taken care of R23 several times, and that R23 had no skin issues or red areas. CNA#6 stated that she did not mention state being her in the facility, but she did turn off the call light. CNA#6 stated that the administrator, and APS had talked with her about the incident. On 4/11/25, a review of Resident #23 clinical record was conducted. Resident #23 was seen by the nurse practition-er (NP) on 4/10/25. The progress note read in part, .patient was seen per nursing request for redness to groin/inner thighs. The NP note read in part, .MASD [moisture-associated skin damage], inner thighs/groin. The NP ordered .zinc bid [twice daily] until Greers goo arrives. Greers goo bid until healed. No additional information was provided prior to exit.

3. For Resident #10 (R10), who suffered from quadriplegia and was totally dependent upon facility staff, the facility staff failed to respond to the call bell to provide incontinence care in a timely manner, resulting in psychosocial harm. On 4/3/25 at 9:38 a.m., upon the surveyor's arrival to the south unit, observations revealed multiple call bells/lights engaged. On 4/3/25 at 9:41 a.m., the surveyor entered the room where one of the call lights was engaged as evidenced by a light being illuminated outside the door in the hallway and a beeping auditory sound being heard. R10 acknowledged that he had his call light on and reported he needed to be changed. When asked how long his call light had been on, R10 said, Go look for yourself. When asked, R10 explained that the surveyor could go to the nursing station and observe how long his call light had been on. When asked if this happens often, R10 didn't respond. On 4/3/25 at 9:49 a.m., the surveyor was at the nursing station and observed a computer screen that listed three call bells that were engaged. The duration listed for R10's call light was noted to be 50 minutes and 17 seconds. On 4/3/25 at 9:52 a.m., licensed practical nurse (LPN #19) was observed to enter the room, reset/disengage the call light and exit the room. As LPN #19 was coming down the hall, she reported to certified nursing assistant (CNA #4) that R10 needed to be changed. The surveyor stopped LPN #19 and inquired as to what R10 needed and again LPN #19 stated, He needs to be changed. When notified that the call light was noted to have been engaged for over 50 minutes, and asked if this is common, LPN #19 stated, Sometimes it is and sometimes it isn't. I didn't know that was the case this morning. Normally he tells me about it, but he didn't today. When the surveyor explained that he had reported to it to the surveyor, LPN #19 said, Oh, maybe that's why he didn't tell me. On 4/3/2025, the facility administration was made aware of the concerns regarding findings that incontinence care was not being provided timely. On 4/9/25, a clinical record review was conducted of R10's chart. This review revealed that R10's diagnosis included, but were not limited to unspecified cord compression, central cord syndrome at C2 level of cervical spinal cord, person injured in unspecified motor-vehicle accident, and quadriplegia. According to R10's most recent minimum data set [MDS, an assessment tool] with an assessment reference date of 3/30/25, coded R10 as having required the assistance of two staff persons for bed mobility, transfers, and toileting. R10 was also coded on that same assessment as having had no skin impairments. According to R10's care plan, he was noted to be at risk for pressure ulcers due to immobility, inability to turn and reposition independently, incontinence and quadriplegia. One intervention was noted to read, Keep skin clean and dry as possible. The care plan also noted, The resident requires assistance with ADLs [activities of daily living] related to chronic health conditions, inability to perform ADLs, weakness, quadriplegia and spinal cord compression. The interventions included, Hoyer lift for all transfers x 2 staff, 2 person assist for bed mobility as needed . Also in the care plan, it was noted that R10 was incontinent of bladder and bowels. The interventions included, . provide toileting hygiene with brief changes . According to a skin observation conducted on 3/29/25, R10 was noted with no skin impairments. On 4/1/25, R10 was noted with iad [incontinence associated dermatitis] to his right buttock that measured 3.5 x 3.5 x 0.1 cm and another area of iad on his left buttock that had measurements of 0.8 x 1 x 0.1 cm. According to a progress note written by the wound care nurse practitioner on 4/1/25, it noted, . wound assessment: location: left buttock, primary etiology: incontinence associated dermatitis (IAD), stage/severity: partial thickness, wound status: new, size: 0.8 cm x 1 cm x 0.1 cm, exposed tissue: dermis, peri wound: fragile, wound base: 100% epithelial; exudate: scant amount of serosanguineous . A second wound was noted on the right buttock, primary etiology: incontinence associated dermatitis (IAD), stage/severity: partial thickness, wound status: new, size: 3.5 cm x 3.5 cm x 0.1 cm, wound base: 100% epithelial; peri wound: fragile, exudate: scant amount of serosanguineous, exposed tissue: dermis . The progress note went on to give the treatment plan for both areas, which read as: Treatment Recommendations: 1. Cleanse wound with wound cleanser and pat dry. 2. apply Hydrocolloid to base of the wound. 3. change 3 times per week . PREVENTATIVE MEASURES: The patient is incontinent of urine and stool and is at an increased risk of skin breakdown. Recommend continuing ongoing interventions and protocol for swift incontinence management . NEW RECOMMENDATIONS: Staff report new incontinence associated skin breakdown to bilateral buttocks. See new treatment orders. Patient is at high risk for skin breakdown related to decreased mobility, inability to reposition self, comorbidities, incontinence of urine and stool. On 4/9/25 in the morning, a follow up interview was conducted with R10. R10 explained that he is totally dependent on staff for all care, including being fed and must wait extended periods of time on a routine basis. R10 explained that he doesn't say anything because What can I do? I have no choice. R10 confirmed that having to sit in his feces for extended periods of times makes him . angry, feel humiliated and unimportant. I feel all of that but what can I do? R10 then was observed to have tears in his eyes that rolled down his check while talking to the surveyor. On 4/10/25 at 9:15 a.m-9:45 a.m., interviews were conducted with multiple staff, which included, licensed practical nurses LPN #6 & LPN #7, certified nursing assistants, CNA #1, CNA #4, and CNA #5. All of whom reported that call bells should be answered within five minutes. On 4/10/25, the facility administration reported that they had no policy regarding incontinence care or call bell response times. The facility administration was made aware of the above findings, potentially constituting harm. No additional information was provided. Based on observation, resident interviews, staff interviews, facility documentation, clinical record review the facility staff failed to provide timely incontinence care to three residents (Resident #17, Resident #23 and Resident #10) out of a survey sample of 26 residents, resulting in harm. The findings included: 1. The facility failed to provide incontinent care timely for Resident #23 (R23). R23 was admitted to the facility on [DATE]. Diagnoses for R23 included but are not limited to chronic diastolic heart failure, muscle weakness and chronic respiratory failure with hypoxia. R23's Quarterly Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/25/25 coded R23 with no cognitive impairment. R23 was dependent for toileting and required moderate to maximal assistants with bed mobility, transferring, and bathing. On 4/9/25 at 6:35 p.m., an observation was made of R23 having incontinence care being provided. The surveyor was standing on the roommate's side of the room, and the curtain was pulled, and the surveyor heard R23 stated to be gentle, it hurts when you are cleaning me to the aide. R23 was saying ouch and making whimpering noises during her incontinence care. On 4/9/25 at 6:45 p.m., an interview was conducted with R23. R23 stated that there had been several times that I have had to sit in my urine or feces for long periods of time. R23 stated that last Thursday (4/3/25) I was wearing the wrong size brief, and I sat in my own feces for two hours. R23 said, the aide came in at 8:30 a.m., and I told her I needed to be changed, that I had a bowel movement, and it leaked out of my brief. R23 stated that the certified nursing assistant CNA #6 turned the call off and stated that state was here so she had to take care of the other residents first, and then she would come back to change me. R23 stated that approximately 10:10 a.m., that CNA# 7 came to the door, and asked how I was doing, and if I needed anything. R23 stated she told CNA#7 that she needed to be changed and had been sitting in my bowel movement for almost two hours, and CNA#6 was supposed to come back to change me but has not been back. R23 stated that CNA#7 was going to change her but had to go get all the supplies she needed. R23 stated that CNA#7 came back at 10:30 a.m. to change me. R23 said, my bottom was burning me as she was cleaning me up, and [CNA#7 name redacted] pointed out to me that it was some bad spots down there. R23 stated that she told the assistant director of nursing (ADON) after CNA#7 had cleaned her up. R23 stated that the ADON was going to have the physician to order some new cream today because the zinc ointment they were using was not helping. R23 said, this made me feel others were more important to me. Made me feel like crap I have never been treated like this was. R23 stated CNA#6 was her aide several times but never left me waiting that long before. R23 stated that someone from Adult Protective Services came to see her yesterday. R23 stated that she reported this incident to CNA#7 on Thursday (4/3/25), she told the ADON on Friday (4/4/25), and the administrator on Saturday (4/5/25). R23 showed the surveyor a picture she had taken that day. Feces were out of her brief, on both sides of her thighs, on the incontinent bed pad, and down to the sheet on the bed. R23 showed the surveyor a picture she had taken of her groin area, and thighs after being cleaned up. On 4/9/25 at 7:00 p.m., an observation was made of R23 inner thighs, and groin area. Observed both inner thighs were dark red in color, and the groin area was red. R23 had some areas on her thighs had white cream that was applied. On 4/9/25 at 7:30 p.m., an interview was conducted with ADON. ADON said, I talked to her sometime on Friday. She hollered me from her bed. She told me it took [CNA#6's name redacted] a long time to get in here to take care of me. ADON stated she told R23 that she would look into it and check the assignment sheet. On 4/9/25 at 7:45 p.m., there is a meeting with ADON, the director of nursing (DON) and the regional director of clinical services (RDCS). The ADON, DON, and RDCS were made aware of the concerns with R23. They were not aware that R23 was sitting in feces for two hours until the surveyor informed them at this meeting. 4/9/25 at 8:00 p.m., an observation was conducted with the RDCS. The surveyor and the RDCS went into R23's room, and R23 stated what had happened on 4/3/25 to the RDCS. The RDCS asked R23 if it was alright for her to look at her inner thighs, and R23 showed her. The RDCS put on gloves, and moved her legs apart, and when she did this R23 began sliding up in the bed, grimacing, and whelping. The RDCS asked her if she needed something for pain, R23 stated no that she handled pain well. The RDCS asked R23 if the area itches, and R23 said, no it burns. The RDCS asked R23 if she had ever had cream in that area before, and R23 said, under my abdomen but never down there. I have never had anything down there until Thursday. On 4/3/25 at 8:10 p.m., an end-of-day meeting was conducted with the administrator, director of nursing and corporate staff, and they were made aware of the above concerns. On 4/10/25 at 9:50 a.m. an interview with CNA#7 was conducted via phone call. CNA#7 stated when she went to do her rounds, she asked R23 is she needed help or anything, and that is when R23 told me she was needing to be changed because she had been sitting in it for a while. CNA#7 said, She was upset. [R23's name redacted] was sitting in a mess. The feces were up the front of the brief, down the sides of legs, on the chuck pad, on the sheets, and I had to change all bed linen. CNA#7 said, after cleaning her up the creases of her thighs were red. CNA#7 stated that R23 was upset and mad because CNA#6 was supposed to come back to change her and, never came back. CNA#7 stated that she did not report to anyone how she found R23, and that she had been laying there for 2 hours in feces waiting on CNA#6 to come back and change her. On 4/10/25 at 10:15 a.m. an interview with CNA#6 was conducted via phone call. CNA#6 stated when she entered R23's room that she was needing to be changed. CNA#6 stated she was asking for help, and no one would come help her with the call bell lights. CNA#6 stated she had a resident that had an appointment, and she had to put in the lobby for her pick up time or she would miss the appointment. CNA#6 stated that when CNA#7 showed up she was taking care of R23. CNA#6 stated she had taken care of R23 several times, and that R23 had no skin issues or red areas. CNA#6 stated that she did not mention state being her in the facility, and she did turn off the call light. CNA#6 stated that the administrator, and APS had talked with her about the incident. According to the National Institute on Health (NIH) moisture associated skin damage (MASD) is discussed and read in part, . Moisture-associated skin damage (MASD) occurs with exposure to various sources of moisture (bodily secretions or effluents) such as urine or fecal matter, perspiration, wound exudate, mucus, digestive secretions, respiratory secretions, or saliva . Accessed online at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9093722/#fn-group1 According to Wounds International, Moisture-associated skin damage (MASD) represents a significant problem and can have a negative effect on patient wellbeing and quality of life MASD is a complex and increasingly commonly recognized condition. Overexposure of the skin to bodily fluids can compromise its integrity and barrier function, making it more permeable and susceptible to damage (Gray et al, 2001; [NAME] et al, 2017). Individuals with MASD experience persistent symptoms that affect quality of life, including pain, burn-ing and pruritis (Gray et al, 2011; [NAME] et al, 2017). MASD is classified as an irritant-contact dermatitis; see Table 1 (WHO, 2020). Common irritants can include urine, stool, perspira-tion, saliva, intestinal liquids from stomas and exudate from wounds. As such, MASD is an umbrella term and forms of MASD may be subdivided into four types (see Figure 1): ? IAD ? Peristomal dermatitis (relating to colostomy, ileostomy/ ileal conduit, urostomy, suprapu-bic catheter, or tracheostomy) ? Intertriginous dermatitis (intertrigo: where two skin areas may touch or rub together) ? Peri wound maceration . The article went on to read, .Managing continence As a priority, wherever possible, the cause of incontinence should be identified and eliminated, and treatment options exam-ined if possible - although this may be due to a range of factors including health conditions and mobility issues (Wishin et al, 2008; Beeckman et al, 2020). This should include evalua-tion of bladder and kidney function regarding urinary incontinence, and that of the intestine and colon in the case of fecal incontinence (Beele et al, 2017). If continence enhancement is not possible, suitable incontinence products should be used and non-invasive behavior-al interventions implemented (Beeckman et al, 2018). Behavioral interventions may in-clude nutritional and fluid management, mobility enhancement, and use of different toilet-ing techniques (Wishin et al, 2008; Beeckman et al, 2020). While IAD does not only affect elderly people, evidence from studies involving elderly nursing home residents suggests that structured toileting and exercise interventions can improve incontinence (Bates-[NAME] et al, 2003; Beeckman et al, 2020). The type and frequency of incontinence should be re-assessed on regular basis, in order to tailor incontinence management strategies to the individual and assess the risk of skin-related damage (Beeckman et al, 2018). Wherev-er possible, indirect risk factors should be mitigated . Accessed online at: https://woundsinternational.com/wp-content/uploads/2023/02/77ece7a46c5c084762956b97f9096e53.pdf. No additional information was provided prior to exit. 2. The facility staff failed to provide incontinence care timely to Resident#17 (R17). R17 was admitted to the facility on [DATE]. Diagnoses for R17 included but are not limited to urinary tract infection, muscle weakness and underweight. R17's Reentry Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/3/25 coded R17 with severe cognitive impairment. R17 was dependent on the activity of daily living care. On 4/3/25 at 4:00 p.m., an interview was conducted with the administrator. The administrator stated that R17 was up, and out of bed after doing therapy around 1:00 p.m., sitting at the nurse's station until the daughter came back in around 7:00 p.m., or 8:00 p.m. The administrator stated he spoke with two staff members that came in to work that evening and stated R17's brief did not appear to have been saturated. 4/3/25 at 5:08 p.m., an interview was conducted with certified nursing assistant CNA#18. CNA#18 stated that incontinent rounds should be made every two hours, CNA#18 said, sometimes those lines are not accurate, sometimes those lines on the brief are clear and will be sitting in a pool of urine. I open the brief to check. 4/3/25 at 5:08 p.m., an interview was conducted with CNA#19. CNA#19 said, I check the residents every two hours unless they use the call bell. Check the strips on the brief and roll them to make sure their bottom isn't wet. I will leave the same brief on for one round but the next round I will change the brief even if dry. I will let the nurse know if the resident goes eight hours without going to the bathroom. On 4/3/25 at 5:30 p.m., an interview with CNA#9 was conducted about the incident that happened on 3/15/25 with R17. CNA#9 said, daughter came in at 7:55 p.m., brief was tagged at 12 o' clock I went back and looked at the brief and it was marked. Looking at the brief lines I would not have changed him, but he was wet. He was wet enough to be changed. CNA#9 showed pictures of the wet brief and the time that was wrote on the brief. CNA#9 stated that the pictures were time stamped. On 4/3/25 at 7:20 p.m., an interview was conducted with LPN#5 about the incident that happened on 3/15/25 with R17. LPN#5 stated that R17 had the same brief on that was numbered with a 12 by his daughter. R17's brief was wet, and cream was applied to his scrotum that LPN#5 said, .was like a flush cheek red. LPN#5 stated that it was understandable why R17's daughter was upset due to being in the same brief for eight hours. 4/7/25 at 12:10 p.m., an interview was conducted with the assistant director of nursing (ADON). The ADON stated that incontinent care was prn, and the typical standard is every two hours. The ADON said, I would pull back the brief to see if they had a bowel movement. Common sense tells me I would change them and not leave the brief on for eight hours. The ADON stated she would expect staff to change a patient's brief every other round even if the brief lines are clear due to the brief holding moisture, and the patient can sweat, and cause moisture associated with dermatitis. The ADON stated patient's briefs can hold heat causing the patient to sweat, and the brief would need to be changed due to the moisture. On 4/8/25 at 11:00 a.m., an interview was conducted with LPN#13 the unit manager of the south wing. LPN#13 stated that R17's daughter sent her pictures of a saturated brief and a dirty bed pad with dried urine stains on the bed pad. LPN#13 stated that R17's daughter was in the facility around 8:00 p.m., and sent another picture to her with a brief marked with a 12, and of R17 sitting in his wheelchair in his room, and of the wall clock that had 8:00 p.m. On 4/8/25 at 2:00 p.m., a review of R17's clinical record was conducted. On 3/16/25 skin assessment was completed and had redness to coccyx noted. R17 was getting treatment for MASD (moisture associated skin damage) to sacrum, and groin areas but on 3/16/25 was being applied to coccyx area.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents maintain acceptable parameters of nutritional status for one resident (Resident #5) in a survey sample of 26 residents. The findings included: For Resident #5 (R5), who was admitted with a known significant weight loss, then lost 18 pounds in the first nine days at the facility, and lost 24 pounds in 5 weeks, the facility staff failed to implement interventions timely to prevent further significant weight loss. On 4/4/25 at 7:50 a.m., an interview was conducted with R5. R5 had his breakfast tray and observations revealed he had all items in bowls. There was a bowl of broth, two bowls of oatmeal, two bowls of Jello, a bowl of pudding and a yogurt cup. According to R5's meal/tray ticket it noted R5 was to receive clear liquid, large portions. On 4/7/25 at 11:56 a.m., observations were conducted of R5's lunch meal. According to the meal ticket, R5 was to have received ice cream, which was not present on his tray. When asked, R5 stated that he liked ice cream. R5 was asked about the food and his meals and reported, It's always the same. On 4/7/25 a clinical record review was conducted of R5's chart. According to the hospital Discharge summary dated [DATE], it documented that R5 . presents to ER with 1 day history of generalized weakness and inability to walk, patient has been trying to lose weight and did not eat over the last couple of weeks. He has been drinking water since then. Pt [patient] says that he lost 40 lbs . Diagnosis included: history of bipolar disorder, lactic acidosis, starvation ketosis, generalized weakness and achalasia. According to the hospital discharge summary, it noted, Discharge recommendations and follow-up: . 3. Follow up with [hospital name redacted] gastroenterology . Diet: full liquid . According to the census tab, R5 was admitted to the facility on [DATE], from the hospital. According to the weights and vitals tab of the chart, R5's weight on admission was recorded as 205.5 lbs. Additional weights revealed that on 2/23/25 and 2/24/25, R5 had a recorded weight of 205.5 lbs. On 3/4/25, R5's weight was 187.1 lbs., on 3/18/25, his weight was 185.5 lbs, and on 4/2/25, R5 weighed 181.3 lbs. According to the physician orders, R5's diet was noted as Full liquid diet, full liquid texture, thin liquids consistency. A supplement order was initiated on 3/28/25, which read, 2.0 House Supplement, three times a day for To Prevent Malnutrition/Additional Nutritional Intake Give 90 ml via PO TID [by mouth, three times a day] [sic]. There was also an order entered 3/31/25, that read, Appointment with Digestive Health Dr [physician's name redacted] [hospital name, address and phone number redacted]. According to a Malnutrition Universal Screening Tool completed 2/28/25, by a registered dietician, the resident was at low risk (routine clinical care). According to the progress notes, the registered dietician didn't have any further documentation regarding R5. According to a progress note from a surgical consultant physician dated 3/5/25, R5 was seen for follow-up of asymptomatic cholelithiasis. The note read in part, . Patient likely has achalasia based on GI work up. He and his nurse state they have not heard from [hospital name redacted] about an appointment. I have reached out to Dr. [name redacted] to make sure everything was placed correctly since the patient has currently been restricted to a full liquid diet for this reason . On 4/2/25, a registered dietician made an entry into R5's chart and added fortified pudding three times daily and ice cream twice daily noted R5 had a 11.8% weight loss. According to a progress note by the facility's nurse practitioner dated 4/4/25, R5 was seen Patient seen per nursing request for weight loss. The note read in part, . Assessment and Plan: Weight Loss: start large portions of full liquid diet, c/w [continue with] 2.0 house supplement TID [three times daily], Start CBC, CMP, TSH [complete blood count, complete metabolic panel, and thyroid stimulating hormone] [labs], start referral to Dr [name redacted of gastrointestinal doctor] at [hospital name redacted] for achalasia to see if can get sooner appointment than the one at [hospital name redacted] . On 4/7/25 at 1:56 p.m., an interview was conducted with other employee #8 (OE#8), who handled appointments. OE #8 stated, I make all the appointments. OE #8 was asked about an appointment with the doctor the nurse practitioner noted in her note on 4/4/25, for R5. OE #8 said, I have not received any information regarding a need for an appointment with Dr. [name redacted]. OE #8 asked the surveyor if she could write down the doctor's name and location. OE#8 accessed the records for R5 and noted he had an appointment on 7/29/25 with a digestive health doctor. On 4/7/25 at 2:45 p.m., an interview was conducted with the nurse practitioner (NP) (Other employee #3- OE #3), who was the primary care provider for R5 in the facility. The NP was asked about R5's weight loss and what was being done. The NP said, Apparently there are only two GI [gastrointestinal] doctors in the state that manage achalasia. He [R5] was sent to us without already having an appointment. The unit secretary called, and they wanted his records to review . On my end its not popping up on the alerts that he is eating less but I am doing weekly labs to ensure he is not going into malnutrition. If the labs start showing malnutrition we may have to send him to the hospital for a feeding tube. On 4/7/25 at 3:00 p.m., an interview was conducted with other employee #4 (OE#4), who was the unit secretary. When asked about appointments for R5, OE #4 said, We have a pending appointment, but it is so far out, I have sent his discharge summary to this digestive doctor in [alternate hospital location noted in the NP's note dated 4/4/25], I need to touch base with them in the morning. OE #4 went on to state that she was back and forth with the other location where the appointment is scheduled for July, trying to get an appointment sooner. OE #4 showed the surveyor a document titled, appointment and transportation form for R5 that was dated 3/31/25 and noted the scheduled appointment for 7/29/25. When asked if she had any evidence of working to get the appointment prior to 3/31/25, OE #4 stated that was all they had. On 4/7/25 at 3:41 p.m., an interview was conducted with the registered dietician (RD), other employee #2- (OE #2). The RD reported that they are currently looking for an RD for the facility who can provide 24 hours per week coverage. She went on to report that the previous RD was moving cross country and was going to continue to work remotely, but she [OE #2] noticed the prior RD went off the grid, so I stepped in the 3rd week of March and had to terminate her [the prior RD]. When asked about R5 and the accuracy of the malnutrition screening completed for R5 by the prior RD, OE #2 explained that I don't know why she didn't include weight loss, and it is my expectation that they attach an assessment in a progress note. When the surveyor stated she had not seen a note with an assessment by the RD, OE #2 confirmed there was no evidence or progress note to indicate it had been completed. OE#2 went on to say, I talked to his home health dietician on Friday [4/4/25]. When the surveyor explained that R5 was admitted to the facility with a known history of significant weight loss as documented in the hospital records, was on a liquid diet only, there was a lack of any intervention documented until 3/28/25 and no evidence that the facility had attempted to make the follow-up GI appointment until 3/31/25. OE #2 said, I'm right there with you, when I caught this, I about fell out of my chair, and I immediately notified the nurse practitioner. He has wounds . there was a period of about three weeks that he fell through the cracks . OE #2 stated that she had reached out to the home health dietician trying to get R5 into the GI doctor sooner because, he is too high risk. I wanted to get him on pureed food, but the hospital says he can't be upgraded whatsoever until seen by GI. I spoke to the nurse practitioner on Wednesday [4/2/25] and his nutritionist on Friday [4/4/25], he is very much on our radar, we added ice cream to come on his meal trays at lunch and dinner. The surveyor explained that she had conducted observations of two of R5's meals, one breakfast and one lunch, neither of them had ice cream. OE #2 went on to say, I hate it, it went three weeks for us to figure this out. I was taking drinks from a fire hydrant; I've never had someone just leave a job and that's when I terminated her. I hate it, I'm so mad. I don't know what I could have done differently, she kept saying she was going to work on the laptop while traveling, so I don't understand. I'm so disappointed to say the least. On 4/7/25 at 4:08 p.m., a follow-up interview was conducted with R5. When asked about ice cream, he stated he liked ice cream but has only received it 1-2 times since he has been at the facility. R5 said he was not aware of what was going on with why he had to be on a liquid diet. On 4/7/25 at 5:15 p.m., observations of R5's meal revealed he did not have ice cream on his meal tray. On 4/7/25 at 5:20 p.m., an end of day meeting was held with the facility administrator, director of nursing and corporate staff. The above findings were discussed, and the facility was asked to provide any evidence they had regarding attempts to get R5 an appointment with the GI doctor prior to 3/31/25 and/or any other interventions that were put in place. On 4/8/25, the survey team was notified that R5 was going to the gastroenterologist that day. The facility reported that the office where R5 had an appointment for 7/29/25 had called and had a cancellation. On the afternoon of 4/8/25, the surveyor was able to obtain the documents that returned with R5 from the appointment. The notes indicated, plan for manometry, increase to omeprazole 40 mg BID [twice daily], daily weight, calorie count if possible, and f/u [follow-up] in 3 months. According to the facility policy titled, Transportation and Appointments, which read in part, 1. The center will schedule a provider appointment when a consult recommendation is received . The facility was asked to provide any policy they had with regards to weight management. The facility provided a policy titled, Weight Monitoring and Tracking. According to this policy, it read, 1. The director of nursing is responsible for ensuring patients are weighed in an acceptable timeframe, using proper technique. Nursing staff are responsible for recording weight in the medical record. 2. Patients will be weighed on admission/readmission and weekly x 4 weeks thereafter, or until the interdisciplinary team determines weight is stable, then monthly thereafter. 3. Weights will be verified when a weight variance of 5 pounds from the last weight and/or when a significant weight change is identified. 4. Significant weight changes will be identified and discussed by the interdisciplinary team using the table below: 5%=1 month, 7.5%=3 months, 10%=6 months. 5. Members of the team may include, but are not limited to, director of nursing or designee, other members of nursing administration and/or nursing team, and the registered dietician as available. 6. Weekly weights should continue greater than 4 weeks if one or more of the following criteria are met: significant unplanned weight change, identified trends in weight change, new or unstable enterally or parenterally fed patients, patients with pressure ulcers or wounds for 4 weeks or greater, patients <100 pounds if < UBW/IBW [usual body weight/ideal body weight], provider ordered. 7. The team can determine the frequently of weight measurement needed or may discontinue weekly weight monitoring and change to monthly monitoring on any patient that is deemed stable. 8. The team will notify the provider and responsible party of significant weight changes, investigate possible causes of the weight change, discuss interventions, and document a progress note. No additional information was provided prior to the survey conclusion on 4/11/25.

Based on resident interview, staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to protect the residents' right to be free from sexual and/or mental abuse by a staff member (identified by the facility as CNA #4) for four of sixteen residents (Residents #2, #8, #13, and #15) in the survey sample, which resulted in Resident #8 sustaining trauma to the perineal/vaginal area. This constitutes harm. The findings include: 1. Resident #8 sustained unwanted sexual touching/penetration to her perineal/vaginal area by a staff member the facility identified as CNA #4 and was found subsequently to have vaginal abrasion with bleeding upon assessment. The 11/1/22 facility reported incident, that was forwarded to the state agency, documented that Resident #8 had reported to the occupational therapist (OT) that she had been raped a few nights ago by a short African-American CNA, identified by the facility as CNA #4. The report documented that Resident #8 reported that the CNA had put his fingers in Resident #8's vagina when changing her brief and then left the room. According to the 11/1/22 FRI, the resident was assessed with findings that included blood in her brief and on her labia/vaginal area and was sent to the emergency room for evaluation. The facility's investigation included a statement from the occupational therapist (other staff #1) stating during a therapy session on 11/1/22, Resident #8 stated, .I think that foreign man that works here raped me. I'm traumatized. When questioned .patient stated event occurred, 'the night before last' and it was the 'short African man who works here' and it occurred, 'while he was changing my brief.' . The investigation also included the 11/1/22 resident interview by the administrator and DON, which documented that the Resident #8 reported she was raped, and that the CNA put his fingers in her vagina. The interview documented the resident reported the incident the next morning. The facility's investigation also documented a statement from CNA #4 stating he took care of Resident #8 on Monday night (10/31/22) until Tuesday morning (11/1/22). CNA #4 wrote, .at six o'clock .I was giving that resident a small bed bath and dressed her for her physical therapy .When I was undressing her brief I smelled bad other coming from that bottom and I was thinking that she did a BM [bowel movement] but unfortunately it wasn't a BM. then I used the wipes to wipe here there five times because until the wipes were moving dirty from that delicate part of her body I showed her all the wipes which were really black and yellow of dirty to make her be sure that not only she was really dirty, but I cleaned her very good. After that I dressed her properly .Saying that i abused her sexually is not true. because all gestures I did was only to clean her very good without any sexual intention or violence. And during all the time I performed that task, she didn't stopped me for any reason . (Sic) A review of the clinical record included an 11/1/22 skin assessment, which was performed by the assistant director of nursing (RN #2) and RN #3, after the reported allegation. This assessment documented, .Blood was noted in resident's brief and on her genitalia, bleeding was near her clitoris, bleeding did not appear to be vaginal. No bruising or swelling was noted to breasts, thighs, buttocks, or genitalia. There was no blood noted under her fingernails . Resident #8 was evaluated at the emergency department on 11/1/22 in response to the rape allegations. The emergency department report dated 11/1/22 documented, .presents with alleged sexual assault. On 10/30/2022 a caregiver was helping to change her briefs .She states that the male staff member put his fingers in her vagina. Patient did not consent to this. There was no intercourse. No rectal penetration . The physician assistant's examination documented, Positive for vaginal bleeding. Negative for dysuria, urgency, frequency, hematuria and flank pain .does not bruise/bleed easily . The report listed the resident's mental status as alert and that the resident appeared anxious. A family nurse practitioner (other staff #10) assessed Resident #8 on 11/2/22 and documented, .Today, vaginal abrasion visualized and unchanged .continue to monitor daily . According to the clinical record, the psychiatric nurse practioner (other staff #5) assessed Resident #8 on 11/3/22. The psychiatric NP documented that when asked if she was getting along with the staff and other residents, resident #8 replied .I was raped by a foreigner . This entry also documented that the psychiatric NP assessed the resident as .not overly agitated or emotional. The 11/8/22 facility investigation report that was sent to the state survey agency documented that the facility was unable to substantiate Resident #8's allegations because the rape evaluation requested by police was pending and that CNA #4 was no longer employed with the facility. On 11/9/22 at 2:43 p.m., Resident #8 was interviewed about her allegations made on 11/1/22. Resident #8 stated the short man with dark complexion and foreign accent stuck his fingers in her vagina. Resident #8 stated she did not know the staff member's name but she had seen him before in the hallway. Resident #8 stated this staff person came in her room during the night shift and asked if she needed changing. Resident #8 stated that she said yes and the staff person put his fingers into her vagina while he was changing her. Resident #8 stated that she told him to stop and he did then put a clean brief on her and left the room. Resident #8 stated that she reported the incident the next morning to a therapist. Resident #8 stated she had some vaginal bleeding after the incident and was initially sore. Resident #8 stated that the staff person talked with a foreign accent but made no sexual comments to her. Resident #8 stated that she routinely required help from staff for brief changes. On 11/9/22 at 3:18 p.m., the occupational therapist (OT - other staff #1) was interviewed about Resident #8. The OT stated on the morning of 11/1/22 that Resident #8 told him a foreign man had raped her night before last during a brief change. The OT stated he immediately reported it to his supervisor and then the administrator. On 11/10/22 at 7:30 a.m., the ADON (RN #2) was interviewed about the allegations made by Resident #8. RN #2 stated she and RN #3 got Resident #8 from the therapy room on 11/1/22 after the resident reported the incident and performed a head-to-toe skin assessment. RN #2 stated when Resident #8's brief was pulled back there was blood noted on the brief and on the resident's labia. RN #2 stated the resident's fingernails were clean and the brief was dry. RN #2 stated she saw nothing and found no other explanation for the bleeding and the resident had no history of self-injurious behaviors. RN #2 stated the staff person Resident #8 described was identified as CNA #4 as he was the only male aide with a foreign accent and dark complexion that worked nights. RN #2 stated in response to Resident #8's allegations, all cognitively intact residents were interviewed about any concerns with CNA #4. RN #2 stated during these interviews, Resident #13 stated a short, dark complexion male aide had been rough with her during a brief change. On 11/10/22 at 10:35 a.m., the administrator, DON and ADON (RN #2) were interviewed about the allegations of sexual abuse made by Resident #8. The administrator stated when Resident #8 was interviewed she described a short, African man that stuck his fingers in her vagina. The administrator stated they reviewed the schedule and nobody else fit the resident's description. The administrator stated CNA #4 was the only male CNA with a foreign accent. When questioned, the administrator and DON had no other explanation for the resident #8's genital trauma. The DON stated interviews done with other staff members caring for Resident #8 revealed no previous reports of blood in the resident's brief or perineal area. The administrator stated based on allegations from multiple residents, as APS made him aware that similar concerns about CNA #4 had been reported from other facilities in the area, the administrator stated CNA #4's agency was contacted about the allegations and that CNA #4 was no longer allowed to work in the facility. A review of the comprehensive care plan (dated 11/7/22) documented that Resident #8 had episodes of bladder/bowel incontinence and required staff assistance for toileting and hygiene. 2. Resident #2 was subjected to unwanted touching of her perineal/vaginal area and unwelcomed sexual remarks by certified nurses' aide the facility identified as CNA #4. During the complaint investigation, a review of the facility reported incident form (FRI) dated 10/24/22 revealed that Resident #2 had reported to the facility staff that a certified nurses' aide (CNA #4) had wiped her for an inappropriate length of time in her perineal area and made her uncomfortable. The facility's investigation of that incident documented an interview with Resident #2 by the director of nursing (DON) dated 10/24/22. This interview documented, . [Resident #2] told me that months ago that a short, black CNA asked to check her brief during the night shift. She said he wiped her for 10 minutes and she got a bad vibe from him .continued to say that when she was .being isolated for Covid he was her aide again. She said he was performing incontinent care and she asked him to stop. She said he replied with, 'I don't know why you don't like this because my girlfriend does' . (Sic) The facility's investigation also included an interview by the administrator, dated 10/24/22, which documented that Resident #2 stated CNA #4 wiped her for a .very long time, approximately 10 minutes and that she was concerned about how rough she was wiped. This interview documented that the resident was not sure of the date this occurrence but that it was while she was isolated on the COVID unit. A review of the facility's investigation documented a written statement from Resident #2's routine CNA (#3) dated 10/24/22 stating, On Wednesday night/Thursday morning [10/19/22 - 10/20/22] .Resident #2 made a complaint to me about an aide [CNA #4] wiping her inappropriately and saying 'that's how my girlfriend likes it'. I reported it to the nurse on duty and gave her my statement. [Resident #2] also stated that she had reported this incident to the APS [adult protective service] person that had been in to see her during the day .informed my nurse [licensed practical nurse #2] Agency. (Sic) The facility investigation included an interview by the director of nursing (DON) with CNA #1, dated 10/26/22, which documented, . [CNA #1] stated that when [Resident #2] was isolating for Covid .she told her that she did not like [CNA #4] because of the way he wiped her during incontinent care. The facility investigation included an interview by the DON with registered nurse (RN) #1, which documented, . [RN #1] stated that [Resident #2] told her months ago that she did not like the way [CNA #4] wiped her during incontinent care and that he used too many wipes. [RN #1] stated that [Resident #2] did not act like the incident was a big deal at the time and did not give her any reason to believe it was anything but her not liking the way he did ADL care. The facility investigation included the undated written statement by CNA #4 denying the allegations and stating he had never worked in [Resident #2's] room. On 11/9/22 at 11:30 a.m., Resident #2 was interviewed about her care in the facility and the allegations regarding CNA #4. Resident #2 stated that approximately 3 to 4 months ago, CNA #4 came in her room around 2:00 a.m. and said he wanted to check her brief to see if she was wet. Resident #2 stated she told CNA #4 that she was ok, but CNA #4 then stated he needed to check her anyway because that was his job. Resident #2 stated CNA #4 wiped me for 10 minutes using cleansing wipes. Resident #2 stated she watched the clock and he cleaned her for 10 minutes continually wiping her perineal area. Resident #2 stated CNA #4 was down there a long time and she was very uncomfortable with the continued wiping. Resident #2 stated she told her usual nurse (registered nurse #1) about the incident when she next worked and requested that CNA #4 not provide care for her anymore. Resident #2 stated registered nurse (RN) #1 agreed to not assign CNA #4 to her and she did not see CNA #4 again until she was moved to another unit after getting COVID-19. When questioned, Resident #2 stated she did not recall the exact date but she had been moved to the COVID unit in September (2022) for isolation and while on that unit, CNA #4 came in her room and stated he wanted to check/change her brief. Resident #2 stated that she told CNA #4 that he was not supposed to be in her room or to provide care for her. Resident #2 stated that CNA #4 said he needed to check her and began wiping her buttock area. Resident #2 stated she told CNA #4 that he had done enough wiping, but he then started wiping her vaginal area. Resident #2 stated she told CNA #4 to stop and that's when CNA #4 told her that he did not understand why she did not like it because his girlfriend liked it. Resident #2 stated, I was scared of him. Resident #2 stated that CNA #1 had come into her room and she told her that CNA #4 was not supposed to be providing care for her and that he kept wiping her pretty hard. Resident #2 stated that CNA #1 later said that she had reported the incident to the nurse, but Resident #2 was not aware of the nurse's name. Resident #2 stated, I was fighting him off. Told him he'd done enough wiping . I was only wet. When questioned, Resident #2 stated that CNA #4 had not provided her routine care and she only encountered him on those two occasions. When questioned further, Resident #2 stated that she was upset about the incident. I was shocked that it happened again because I had reported him [CNA #4] to [redacted name - RN #1] several months ago and thought the issue was taken care of. When questioned if she had reported the incident to anyone else, Resident #2 stated that when she returned to her previous unit/room after COVID, she told her regular CNA (CNA #3) about the incident on the COVID unit. When asked what specifically she had reported, Resident #2 replied that she had reported that CNA #4 had touched her inappropriately and made her uncomfortable twice, once several months ago, which she had reported to RN #1, and then about the incident on the COVID unit, which she had reported to CNA #1 and CNA #3. When questioned further, Resident #2 stated, I had trouble sleeping for a few days after the last incident . was tearful when I had to talk with the police . but I feel better now that he [CNA #4] no longer works here. On 11/9/22 at 4:10 p.m., CNA #1 was interviewed about the allegations made by Resident #2. Stating that she did not remember the exact date of the incident, CNA #1 stated, that day, me and CNA #4 worked on the COVID unit. CNA #1 stated that shortly after shift change at 11:00 p.m., Resident #2's call light was on. CNA #1 stated that when she responded to the light and entered the room, CNA #4 was putting on gloves and pulling the curtain around Resident #2. CNA #1 stated Resident #2 told her that CNA #4 was not supposed to be in her room or care for her. CNA #1 stated she left the room and told the nurse working the unit that Resident #2 did not want CNA #4 caring for her. CNA #1 stated that he nurse she reported this to was an agency employee and she did not know her name, but added that CNA #4 was moved to the West unit after her report. On 11/10/22 at 6:00 a.m., RN #1 was interviewed about Resident #2. RN #1 stated she routinely cared for Resident #2 on the night shift (11:00 p.m. until 7:00 a.m.). RN #1 stated Resident #2 told her .several months ago that she did not like the way CNA #4 wiped her during incontinence care and had requested that he not care for her anymore. RN #1 stated that since that report she had not assigned CNA #4 to care for Resident #2. When asked if she had asked Resident #2 to elaborate on why she did not want care by CNA #4, RN #1 stated, No. When asked if she had reported the concern, RN #1 stated that she interpreted the issue to be about mechanics and had not reported the issue to supervision or administration. On 11/10/22 at 6:15 a.m. CNA #3, who routinely cared for Resident #2, was interviewed. CNA #3 stated during the night shift, starting at 11:00 p.m. on 10/19/22 until 7:00 a.m. on 10/20/22, Resident #2 had reported to her that CNA #4 had cleaned her perineal area for a long time while she was on the COVID unit. CNA #3 stated that Resident #2 had told her that she was scared of CNA #4 because CNA #4 kept wiping her peri-area, even after she told him to stop and had made a comment to her that she should like it because his girlfriend liked it. CNA #3 stated the resident had .acted a little scared of him. When asked if the comments had been reported, CNA #3 stated that she immediately went to the nursing station and reported Resident #2's concern to licensed practical nurse (LPN) #2. CNA #3 stated that she also wrote a statement about what the resident said and gave it to LPN #2. CNA #3 stated that when she came back to work on Saturday (10/22/22), CNA #4 was working on the unit. CNA #3 stated that she told the agency nurse working that she was uncomfortable with him (CNA #4) on the unit because she had reported an issue with Resident #2 earlier in the week that regarded [CNA #4]. CNA #3 stated CNA #4 worked on Resident #2's unit that shift but was not assigned to Resident #2. CNA #3 stated the next shift she worked was on Monday (10/24/22), but CNA #4 was still scheduled to work. CNA #3 stated that she did not understand why he had not been suspended, when she had reported what Resident #2 had said. When questioned further, CNA #3 stated that she had cared for Resident #2 routinely for almost two years and that the resident had never reported any concerns with staff members or problems with ADL care until the issue with CNA #4. On 11/10/22 at 8:50 a.m., LPN #2 was interviewed by telephone about CNA #3's report of Resident #2's allegations. LPN #2 stated she was not made aware of Resident #2's inappropriate care. LPN #2 stated she heard over-talking by CNA #3 and some other CNAs mentioning CNA #4's name, but she did not know what the discussion was about. LPN #2 denied that CNA #3 told her about Resident #2's allegations of inappropriate touching and stated she never received a written statement from CNA #3 about the incident. LPN #2 stated she was not aware of the allegations until the DON asked her about them on 10/24/22. LPN #2 stated again that CNA #2 did not directly report to her Resident #2's allegation regarding CNA #4. On 11/10/22 at 9:00 a.m., CNA #3 was interviewed again about reporting Resident #2's allegations regarding CNA #4 on 10/20/22. CNA #3 stated, I was standing in front of her [LPN #2] when I told her. CNA #3 stated she wrote a statement on her own and gave it to LPN #2. CNA #3 stated that she was later told that her original statement was lost and so she wrote it again. A review of the clinical record documented that resident #2 was moved from her usual room to the COVID isolation unit on 9/22/22 and returned to her previous room/unit on 10/2/22. Resident #2's clinical record documented a skin assessment on 10/24/22 with no impairments noted. Nursing notes from 9/21/22 through 11/8/22 made no mention of the resident #2's allegations or any changes in condition. The comprehensive care plan, revised on 10/31/22, documented that resident #2 had frequent bladder incontinence due to diuretics and required assistance from staff for hygiene after incontinence. On 11/10/22 at 10:35 a.m., the administrator, DON, and assistant director of nursing (RN #2) were interviewed about Resident #2's allegations of inappropriate touching, along with staff and reporting of the resident's complaints/concerns about CNA #4 by RN #1, CNA #1 and CNA #3. The administrator stated that he was first advised of the allegations by adult protective services (APS) on 10/24/22, after an APS worker met with Resident #2 about another issue. The administrator stated no staff members had reported any allegations or concerns of Resident #2 regarding CNA #4. The DON responded that she interviewed Resident #2, who had reported inappropriate wiping in her peri-area and that the resident reported she had previously told CNA #1 and CNA #3 about the incident that occurred on the COVID unit. The DON stated when she talked with CNA #3 she stated she reported the allegations to LPN #2, but that LPN #2 stated CNA #3 did not report the allegations directly to her. The DON stated she was not aware that Resident #2 had requested not to have CNA #4 provide her care or that RN #1 was routinely not assigning CNA #4 to Resident #2. The DON stated that she had not been made aware of the reported concerns about CNA #4 made to RN#1, which should have been reported to her or the administrator. The administrator repeated that RN #1 should have reported to her supervisor about the resident not wanting care by CNA #4. During this interview, the administrator also stated that his staff interviewed other residents that were assigned to CNA #4 and found no other concerns following this incident. The administrator stated he was unable to firmly conclude that the allegations happened. The administrator stated he reviewed the abuse policy with CNA #4 and had been allowed to return to work on 10/26/22. 3. Resident #13 was subjected to non-consensual touching of the perineal/vaginal area by a staff member, that the facility identified as CNA #4. The 11/3/22 facility reported incident form sent to the state agency documented that Resident #13 reported to the ADON that she had been fingered by a dark skinned, short man and that she had not reported the incident when it happened, but probably should have. The facility identified the employee involved as CNA #4. A review of Resident #13's clinical record included a note written by the ADON dated 11/3/22 documenting, . this nurse spoke with resident regarding care needs, resident states she is comfortable with male staff members .resident states she has only had a problem with one male staff member .resident stated, 'I don't know his name, but he has dark skin, is short, and he hasn't been here for a few days.' This nurse again asked if resident was comfortable with female and/or male staff member assisting her with care, residient [resident] stated, 'yes, just not that one man'. On 11/9/22 at 2:20 p.m., Resident #13 was interviewed about her allegations. Resident #13 stated a dark-skinned man with a foreign accent came into her room just that one night and when changing her brief started fondling in her vaginal area. Resident #13 stated the man put his fingers in her vagina and she asked him to stop. Resident #13 stated he then stopped and put her brief back in place and left the room. Resident #13 stated that she did not report the incident to anyone when it happened because she was .scared to talk about private stuff. Resident #13 stated that was the only time he had provided her any care. Resident #13 stated, It bothered me. I didn't want him to do it to someone else. Resident #13 stated she reported the incident to the ADON when she interviewed her about any concerns with staff. Resident #13 stated she did not remember the exact date but that it had occurred . shortly before [CNA #4] was fired. On 11/10/22 at 10:35 a.m., the administrator, DON and ADON (RN #2) were interviewed about the allegation made by Resident #13. RN #2 stated Resident #13 had initially reported to the social worker that a male CNA had been rough with her during a brief change but did not mention inappropriate touching. RN #2 stated that when she went back and talked with the resident, she described a short, dark complexion man and said he stuck his fingers in her during a brief change. 4. Resident #15 had unwanted touching to her upper thigh, but thwarted efforts by a staff member to gain further access to her perineal area. The facility identified the staff member as CNA #4. During the facility investigation following Resident #8's allegations of non-consensual sexual touching, the staff conducted interviews with all cognitively intact residents. The ADON (RN #2) documented an interview with Resident #15 dated 11/1/22, which stated, .I asked [Resident #15] if any staff member had touched her inappropriately. [Resident #15] stated, 'No but I am afraid of that man who works at night' .[Resident #15] stated, 'I don't know his name, but he is short, dark complexion, with an accent, he worked last night' .[Resident #15] stated, 'He came into my room and said he needed to change me, I told him I did not wear a brief, but he would not listen, he said he needed to make sure I was clean, I again told him No, that I did not wear a brief .he then checked his paper and said oh, I need to check your roommate, and he left me alone . (Resident #15's roommate at this time was Resident #8). A review of the clinical record documented a social worker (SW) note dated 11/2/22 documenting that resident #15 stated she was inappropriately touched and 'made to feel very uncomfortable . The social worker note documented that Resident #15 was told that the perpetrator was currently suspended from the facility and that she declined services by the psychiatric nurse practitioner about the incident. There was no facility reported incident form sent to the state survey agency regarding Resident #15's comments/allegations regarding the unwanted touching by a staff member identified by the facility as CNA #4. On 11/14/22 at 11:55 a.m., Resident #15 was interviewed about her allegations regarding CNA #4. Resident #15 described the staff member as dark with a foreign accent that was not her usual CNA. Resident #15 stated that she did not remember the exact date, but she . woke up one morning and he [CNA #4] was standing beside my bed and said he was there to change me. Resident #15 stated that she did not wear a diaper or pull-up, but that this staff person insisted stating, Let me see. Resident #15 stated that he then put his hand under her upper thigh and said again he needed to check to see if she was wet. Resident #15 stated that she told him again that she wore underwear, not a brief, but the staff member went to the closet and stated, Let me see. Resident #15 stated that he went to the roommate's closet instead of her closet. Resident #15 stated he kept insisting and she told him she was calling the nurse. Resident #15 stated that she pushed the call bell several times and each time the male CNA turned off the call light and said he was the nurse. Resident #15 stated that she told him he was not the nurse and to get out of her room, but he then went to her roommate (Resident #8) and pulled the curtain around her. Resident #15 stated that she did not see what care he provided for the roommate, but that he left the room, and she did not see him again. When questioned further, Resident #15 stated that when the male CNA put his hand under her leg, she had pushed him away. Resident #15 stated that the male CNA did not touch her groin or perineal area but did reach under her leg against her wishes. Resident #15 stated that she was unable to go back to sleep that morning after the incident and . still wondered if he would be able to return to the building. Resident #15 stated, I'm sure he realizes why he was let go. He's scary. I was able to take care of myself, but it makes you wonder what he may have done to other residents. When questioned if she had told anyone about the incident, Resident #15 stated that she had told a night nurse, who she described as blonde with an accent, but she did not know her name. Resident #15's comprehensive care plan (revised 9/26/22) documented the resident as able to transfer to the toilet with limited assistance of one person and included a toileting intervention to provide an unobstructed path to the bathroom. The minimum data set (MDS - a cms assessment tool) dated 10/14/22 assessed Resident #15 as cognitively intact, always continent of bowel/bladder elimination, and as requiring limited assistance of one person for toileting. On 11/14/22 at 12:30 p.m., the administrator and DON were interviewed about Resident #15's allegation. The administrator stated he did not initiate a facility reported incident form and formal investigation about Resident #15's allegation because the resident reported that she was not physically touched. The DON stated no nurses had reported to her Resident #15's allegations about CNA #4 and she was not aware of a blonde night shift nurse with an accent mentioned by the resident. A review of facility records revealed that CNA #4 was originally suspended on 10/24/22 and returned to work on 10/26/22, with his last day worked in the facility listed as 10/31/22. Records also show that Residents #8, #13 and #15 resided on the same unit around the time of the allegations. A review of the work schedules documented that CNA #4 worked on these residents' unit during the night shift (11:00 p.m. to 7:00 a.m.) on 10/26/22, 10/27/22 and 10/31/22. The facility's policy titled Abuse/Neglect/Misappropriation/Crime (1/23/20) documented, There is zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient .Patients of the Center have the legal right to be free from verbal, sexual, mental and physical abuse, corporal punishment, involuntary seclusion .Any employee and/or covered agent of the Center, who willfully abuses .will be immediately subjected to corrective action . This policy documented that sexual abuse included sexual harassment, inappropriate touching, sexual coercion, sexual assault or inciting any of these actions. This policy described psychological/emotional (mental) abuse to include humiliation, harassment, malicious teasing and threats of punishment or deprivation. These findings were reviewed with the administrator, DON, regional director of clinical services on 11/10/22 at 10:35 a.m. and on 11/14/22 at 1:10 p.m. No further information was provided prior to the exit conference. This was a complaint deficiency.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure a safe bed environment for one of 38 residents in the survey sample. There was no assessment for Resident #260's bed safety prior to placement on a specialty air mattress with bed rails. Resident #260 rolled out of bed less than 24 hours after the air mattress was placed. The resident's left arm was entangled in the bed rail during the fall, resulting in a fractured left arm and dislocated left shoulder (harm). The findings include: Resident #260 was admitted to the facility on [DATE], was re-admitted on [DATE] and was discharged from the facility on 7/22/17. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #260 with severely impaired cognitive skills. Resident #260's clinical record documented the resident was readmitted to the facility following a hospital stay on 3/20/17. A nursing note dated 3/24/17 documented, daughter called and requesting that res (resident) have an air mattress. order received from (physician) and asked 3-11 to get mattress for res. Resident #260's clinical record documented a nursing note dated 3/27/17 at 3:30 p.m. stating, cna (certified nurses' aide) note res (resident) had his left arm through the assist bar and was on his knees at bedside. staff assist to remove arm from assist rail and lowered to floor. res c/o (complained of) left arm pain/discomfort, res assessed by (nurse practitioner). res lifted back to bed x 5 staff and lift. with staff supporting head and left arm. orders received to send res to (emergency room ) for eval. (evaluation). instructed by np (nurse practitioner) to give res pain med (medication) . (sic) The emergency room report dated 3/27/17 documented the resident was diagnosed with [REDACTED]. A fall committee meeting note dated 3/27/17 at 4:00 p.m. documented, .The resident is at risk for further falls r/t (due to) Unaware of safety needs .resident sustained [REDACTED].Resident had left arm through assist bar on left side of bed and rolled onto the floor. Resident has cognitive impairment - [MEDICAL CONDITION] .received verbal order to send to ER (emergency room ) for evaluation. Resident returned same evening with sling in place to L (left) arm due to L (left) humerus fx (fracture) and L shoulder dislocation and orders to follow up with Ortho (orthopedics) .assist bars and atmos 9k (9000 air mattress) were interventions in place before fall. New interventions post fall include concave air mattress and bilateral fall mats . The nurse practitioner's (NP's) progress note dated 3/28/17 documented, The resident fell last evening and was noted to have some deformity and significant pain in his left shoulder/arm .Notes returned which showed a left impaction type [MEDICAL CONDITION] head he was also noted to have a anterior sub-coracoid dislocation of the left humerus from the glenoid (shoulder blade cavity). He had the dislocation reduced and he was sent back for continued care .Will schedule [MEDICATION NAME] 3 times a day also add as needed [MEDICATION NAME] discontinuing the [MEDICATION NAME] staff stated that they are concerned that this may have contributed to his agitation and fall that occurred yesterday afternoon . Resident #260's clinical record documented prior to the fall of 3/27/17, the resident had severe cognitive impairment, required the extensive assistance of one person for bed mobility and was totally dependent upon one person for transfers. The resident's plan of care in place during (MONTH) (YEAR) documented the resident was at risk of falls due to poor safety awareness. Interventions for fall/injury prevention included anticipate needs, assistive devices, call light in reach, encouragement to use call light and encouragement to participate in activities. A device assessment dated [DATE] listed the resident's use of assist bars as non-restrictive and listed the bars were in place to promote bed mobility. There was no re-assessment of Resident #260's bed safety and bed rail use when the specialty air mattress (model 9000) was installed. The facility's investigation report to the state agency of Resident #260's fall dated 3/31/17 documented, .found kneeling on the floor next to his bed with his wrist tangled in the assist bar on his bed. Staff did not witness how the resident arrived on his knees .Based on his injuries of a fractured clavicle and how he was observed we determined that he had rolled out of bed. After a root cause analysis and discussing with staff, we had given him an air mattress 15 hrs (hours) prior which we believe is why he rolled out of bed . On 4/19/18 at 10:55 a.m., the registered nurse (RN) consultant was interviewed about Resident #260's fall/fracture on 3/27/17. The RN consultant stated the device assessment for assist bars dated 3/21/17 was with a standard 4000 model mattress. The RN consultant stated that on 3/24/17 the resident's family member demanded the resident be placed on an air mattress following his recent hospitalization . The RN consultant stated the resident did not have pressure ulcers but since the family member was adamant about the mattress, the physician entered an order for [REDACTED]. A copy of the safety precautions and installation instructions for the Atmos 9000 mattress was requested at this time. On 4/19/18 at 12:21 p.m., the licensed practical nurse (LPN #2) unit manger caring for Resident #260 at the time of the fall was interviewed. LPN #2 stated she was called to the room and found the resident on his knees with his left arm through the center of the assist rail. LPN #2 stated the resident's family member requested the air mattress to protect the resident's skin. LPN #2 stated the physician ordered the mattress after the family member's request. LPN #2 stated there was no re-assessment at the time of Resident #260's use of the Atmos 9000 air mattress with the assist rails. LPN #2 stated she had a physician's orders [REDACTED]. On 4/19/18 at 2:51 p.m., the RN consultant presented a sheet listing the 9000 model mattress dimensions and product specifications. The sheet listed no safety precautions or installation instructions. The RN consultant stated she did not have a copy of the safety and/or installation instructions but thought they were available online. The manufacturer's user guide for the AtmosAir mattress replacement system stated, .Use or non-use of restraints, including side rails, can be critical to patient safety. Serious or fatal injury can result from the use (potential entrapment) or non-use (potential falls) of side rails or other restraints .Bed frame and side rails (if used) must be properly sized relative to the mattress to help minimize any gaps that might entrap a patient's head or body. It is recommended that bed and side rails (if used) comply with all applicable regulations and protocols .Caregivers should assess risks and benefits of side rail/restraint use (including entrapment and patient falls from bed) in conjunction with individual patient needs, and should discuss use or non-use with patient and/or family. Consider not only the clinical and other needs of the patient but also the risks of fatal or serious injury from falling out of bed and from patient entrapment in or around the side rails, restraints or other accessories .refer to FDA's Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment . (1) These findings were reviewed with the administrator, nurse consultant and director of nursing during a meeting on 4/19/18 at 3:15 p.m. (1) AtmosAir Mattress Replacement System User Guide Instructions for Use. Revised 4/2015. Arjohuntleigh Getinge Group. 4/20/18. www.arjohuntleigh.com.

Based on observations, clinical record review, and staff interview, the facility staff failed, for two of 31 residents in the survey sample (Residents # 7 and 10), to implement safety measures to prevent or self injury or accidents. For Resident # 7, the facility staff failed to ensure a six-plug power strip, as well as various cords, were not available to Resident # 7, who had suicidal behaviors and was known to practice auto-erotic asphyxiation. The failure to ensure such items were not in use or available to the resident resulted in the identification of Immediate Jeopardy at a Level 4 isolated, which resulted in SQC (Substandard Quality of Care) in the area of QOC (Quality of Care). In addition, the facility staff failed to ensure for Resident # 10 that a fall mat was in place while the resident was in bed. The findings include: 1. Resident # 7 in the survey sample, a [AGE] year-old male, was admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. at T-9 and T-12. According to an Admission Minimum Data Set (MDS) following a prior readmission on 5/26/15, with an Assessment Reference Date (ARD) of 6/2/15, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. According to the most recent MDS, a Medicare 14-Day with an ARD of 1/11/16, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Review of a history and physical examination [REDACTED].o. (year old) male .who presents as a transfer from (Hospital Named) after presenting following a ground level fall on the morning of 12/23. He reports that he was sitting on the edge of his bed when he fell asleep causing him to fall and hit the top of his head on the floor. However, per outside hospital records, staff from the facility where he lives (Nursing home named) reported that he was performing auto-erotic asphyxiation in his chair when he fell backwards and impacted his head. They also reported that he endorsed passive suicidal ideation (stated he was 'on day 182 of a 1000-day suicide plan) and therefore sent him to the ED for psychiatric evaluation. CT there demonstrated C1 anterior arch fracture and C2 dens fractures An Orthopaedic Spine Surgery Discharge Summary, dated 12/29/15, noted the following, 59 y.o. male with multiple medical problems who suffered a fall when trying to strangulate self .imaging revealed a C1 and C2 injury and was transferred to UVA. He had no neurologic symptoms, but was also found to have T9 compression deformity and T12 deformity. During an interview with the resident at 10:00 a.m. on 2/24/16, a six-plug power strip was observed attached to the left quarter siderail at the head of the resident's bed. All six plugs on the strip were in use. Items plugged into the power strip included a small fan and charging units for electronic devices (i Pad, cell phone, etc.). There was also a power cord for a bed air mattress, a long call bell cord, a long cord for a light on the wall at the head of the bed, and a trapeze bar over the head of the bed. At approximately 11:45 a.m. on 2/24/16, a meeting was held that included the survey team, the facility Administrator, and DON. During the meeting, the Administrator and the DON were advised of the power strip, cords and trapeze bar. The survey team questioned the presence and use of the power strip and cords given the facility staff's knowledge of Resident # 7's prior suicide attempts, his ongoing suicidal ideations, and his auto-erotic asphyxiation practices. At 12:17 p.m. on 2/24/16, the Administrator and DON were notified that the facility was placed in Immediate Jeopardy Level 4 isolated, which resulted in SQC (Substandard Quality of Care) in the area of QOC (Quality of Care) based on the failure of the staff to ensure the six-plug power strip, various cords, and the trapeze bar were not available to the resident. In response to the identification of Immediate Jeopardy, the facility developed a Plan of Removal. After careful consideration, the survey team accepted the Plan of Removal, and the finding of Immediate Jeopardy was lifted at 5:35 p.m. on 2/24/16. The facility staff presented the following as their Plan of Removal: 5 Step POC (Plan of Correction) for (Resident # 7) 1. (Resident # 7) has items in room to potentially harm himself with. 2. All items that are potentially harmful to patient are to be removed from patient's room today, 2/24/2016, to include power cords, power strip, and call bell. Bell is given to resident in place of call bell. 3. Education to assigned nursing staff by ADON (Assistant Director of Nursing) or designee will be on going as they arrive to work until completed on monitoring patient according to his update care plan for suicide risk. Updated care plan includes low, medium, high risk for suicidal ideations. Monitor for suicidal behaviors every 2 hour. Low risk - pt alert in bed and any potential harming equipment is not in room and he voices no plan to harm himself. STAFF TO CONTINUE PLAN OF CARE. Moderate risk - pt in room alert and items not in normal place for patient, resident still voices no plan to harm himself. NOTIFY MD FOR AND/OR PSYCH MD FOR EVALUATION. High risk - pt in room with harmful equipment in possession, plan to harm self. STAFF TO IMMEDIATELY REMOVE PATIENT AND NOTIFY MD TO SEND TO ER. This education will also include monitoring of mood and/or symptoms of sadness or depression, inappropriate use of equipment (such as cords, handmade items, etc.), and/or inappropriate comment of suicidal ideation. 4. Care plan is updated specifically for patient and what to monitor for to include low, moderate and high risk levels with assigned interventions. 5. Completion date: 2/25/2016 Upon team review of the Plan of Removal, as well as observations of the changes to the resident's room, including the removal of all possible items the resident could potentially use to harm himself, Immediate Jeopardy was lifted at 5:35 p.m. on 2/24/16. In addition, observation of the resident's room at 9:00 a.m. on 2/25/16 confirmed all potentially dangerous items were removed from Resident # 7's room. After accepting the plan for removal of Immediate Jeopardy from the Administrator, and determining that the Immediate Jeopardy was removed, the deficiency was assigned a Scope and Severity level of Level Three - Isolated. 2. Resident #10's fall mat was not observed at the resident's bedside, while he was in bed, for safety interventions related to falls. The findings include: Resident #10 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/16 was a quarterly assessment. The resident was assessed as being a ten (10) for cognitive skills, moderately impaired in decision-making skills and able to make his needs known. On 2/23/16 at approximately 2:55 p.m., During the Resident Interview process with Resident #10, was observed in bed, an over-bed table was across the resident, while in bed. A bedside fall mat was observed folded and at the foot of the resident's bed. On 2/23/16 at approximately 2:55 p.m., a licensed practical nurse, who will be identified as LPN #4 entered the resident's room. LPN #4 was interviewed regarding the bedside fall mat being at the foot of Resident #10's bed and not at the bedside. LPN #4 stated, We only put that down at night. On 2/23/16 at approximately 2:57 p.m., as this Surveyor was interviewing LPN #4, a certified nursing assistant (CNA #3) entered the room. CNA #3 was interviewed regarding the bedside fall mat being folded at the foot of the resident's bed. CNA #3 stated, We check him during the day. When interviewed regarding the reason for the fall mat, CNA #3 stated, He is a fall risk. On 2/23/16 at approximately 3:00 p.m., the electronic clinical record for Resident #10 was reviewed a nursing note was reviewed to include the following: 10/30/15 22:25 (10:25 p.m.) Incident Note .Focus: The resident is at risk for further falls r/t (related to) Unaware of safety needs .The resident exhibits adverse behavioral symptoms States, I'm bored. : resident will crawl out of bed onto mat beside bed actual fall on 4/7/15 x2, 4/22/15) (fall 8/28/15) (observed on floor mat 10/30/15, 11/28/15) . A Fall Care Plan (CP) created on 4/2/15 and updated on 11/29/15 was reviewed to include the following: Focus .The resident is at risk for further falls r/t Unaware of safety needs .The resident exhibits adverse behavioral symptoms States, I'm bored. : resident will crawl out of bed onto mat beside bed actual fall on 4/7/15 x2, 4/22/15) (fall 8/28/15) (observed on floor mat 10/30/15, 11/28/15) .Interventions .Assistive Devices: . low bed with mats . On 2/23/16 at approximately 4:26 p.m., the administrator and director of nursing were made aware of the above findings. No further information was provided during the course of the survey regarding the resident's fall mat not being at the bedside, while the resident was observed in bed.

Based on observation, staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to ensure that the resident environment was free of accident hazards and that each resident received adequate supervision and assistive devices to prevent accidents for 3 of 27 residents in the survey sample, Resident #25, #22, and #1. 1. The facility staff failed to provide supervision to ensure the resident ' s wheel chair brakes were locked during unassisted transfers for the prevention of a fall, which resulted in a fractured right hip and a dislocated right ring finger for Resident #25. 2. The facility failed to provide supervision and to prevent the ingestion of a medicated lotion for Resident #1, and failed to properly store medications. A basket containing 38 Dimethicone skin protectant, 16 skin prep, and no-sting skin prep wipes was accessible to residents on one of one unit. 3. Resident #20 did not have a chair cushion in use for fall/injury prevention as required in his plan of care. The findings include: 1. Resident # 25 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/13 was an admission assessment. The resident was assessed as a zero (0) for cognitive skills indicating severe impairment and inability to make decisions.. On 11/7/13 at approximately 7:30 a.m., Resident #25's closed clinical record was reviewed to include the following: Hospital History and Physical: "DOS (Date of Service) 8/3/13 ...Chief Complaint / Nature of Presenting Problem: UTO (unable to obtain)...History of Present Illness: ...admitted to SNF (skilled nursing facility) following hospital for altered mental status/lethargy and CHF (congestive heart failure) exacerbation. He has underlying advanced dementia...Patient's baseline mental status does not allow him to participate meaningfully in the interview/review of systems/exam today...Decision Making Capacity: Resident IS NOT capable of understanding resident rights and IS NOT capable of making informed decisions. Resident is NOT aware of medical condition due to: Dementia." Nursing Home Admission: "8/3/13 1840 (6:40p.m.) Cognitive /Level of Consciousness Status: Awake, Alert, Confused, Disoriented to: Place, Time ...Pain Assessment: Unable to answer ...Behavior: Cognitive impairment with poor decision-making skills ...Clinical Findings: Friendly, Aggressive: Physically, Agitated/Restless ...Transferring: Total dependence." MDS (Minimum Data Set) Assessments: An MDS with ARD of 8/9/13, an initial admission assessment documented: Section G0110 Activities of Daily Living (ADL) Assistance: B. Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) (3/3). Extensive assistance-resident involved in activity, staff provide weight-bearing support with Two + persons physical assist. C. Walk in Room-how the resident walks between locations in his/her room (8/8). Activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period. D. Walk in corridor (same as C). E. Locomotion on unit: -how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair (3/3). Extensive assistance with the support of 2+ persons physical assist. F. Locomotion off unit: (7/2) Activity did occur but only once or twice with One person physical assist. G. Toilet Use: how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag. (3/3) Extensive assistance with 2 + persons physical assist. Section G0300 Balance During Transitions and Walking: A. Moving from seated to standing position (8) Activity did not occur. B. Walking (8) Activity did not occur. C. Turning Around and facing the opposite direction while walking (2) Not steady, only able to stabilize with staff assistance. D. Moving on and off toilet (8) Activity did not occur. E. Surface-to-surface transfer (transfer between bed and chair or wheelchair) (2) Not steady, only able to stabilize with staff assistance. Another MDS with an ARD of 8/19/13, an admission assessment after the fall, was reviewed to include the same ADL coding for Transfer, Walk in room/corridor, Locomotion on/off unit and Toilet Use as the MDS with ARD of 8/3/13. Section G0300 Balance During Transitions and Walking coding was reviewed to include: A. Moving from seated to standing position (2) Not steady, only able to stabilize with staff assistance. B. Walking (8) Did not occur. C. Turning around and facing the opposite direction while walking (2) D. Moving on and off toilet (8) and E. Surface to surface transfer (transfer between bed and chair or wheelchair) (2) Fall Risk Assessment: "8/3/13 Place a check in front of each item that applies to the resident. If any item triggers, check, the resident is considered to be 'At Increased Risk' for fall. If any item does not trigger, the resident is considered 'At Minimum Risk' for fall ...Admission Fall Risk Assessment ...Risk Areas checked were: Medications, Orthostatic Changes...Unable to stand was documented under comment, Vision, Unsafe Behavior and Other: Chair bound and requires assistance with toileting, Incontinent and New Environment was checked. There were six (6) items listed on the "Fall Assessment" form. Of the six items, five (5) were checked, which indicated that the resident was considered 'At Increased Risk' for falls. Rehabilitation Screen: "8/3/13 Physical Therapy Pt is a new admission significant for dementia and inconsistently follows commands with increased cues and extended time to complete. Pt is unable to provide PLOF (prior level of functioning) declines skilled PT intervention at this time despite encouragement and education on the purpose of PT. D/C skilled PT services." "8/4/13 Occupational Therapy Patient inconsistently following 1 step concrete commands with verbal and tactile cues to attend to task. Patient declining OT services at this time despite patient education on purpose and scope of OT. Patient is not a candidate for skilled OT." "8/19/13 Physical Therapy patient is unable to follow one step commands and unable to adhere to WB (weight-bearing) restrictions. Patient not a candidate for skilled PT services at this time." "8/19/13 Occupational Therapy Patient inconsistently following 1 step commands and requiring max verbal cues to remain alert. Patient is maximum assist for all aspects of care. Patient is not a candidate for skilled OT at this time." There were no other OT or PT notes in the clinical record for Resident #25. Nursing Notes: "8/5/13 8:41 p.m. Pt is alert and confused. Pt has been up in w/c this shift. At 1615 (4:15 p.m.), nurses at nurses station heard alarm sounding. I turned around and ran towards pt, as I was going towards pt, I observed pt slide from w/c to the floor. Pt did not hit his head and had no new wounds, bruises or trauma ...Pt was brought to the nurses station for close monitoring (sic). " "8/5/13 10:55 p.m. Resident has been restless throughout shift...Medicated for aggitiation (sic) without noted results. Resident positioned at the nurse's station for observations, CNA sitting with resident. At 2110 (9:10 p.m.) resident quickly stood up, w/c lock on left side of chair gave out and the chair slid out from under him. Resident fell to the floor onto his back ...W/C switched for a chair with working breaks to prevent further falls (sic)." "8/11/13 Pt attempted to get OOB (out of bed) x 1 and was gotten up in w/c. Pt has attempted to get out of w/c x. Pt has been in w/c this shift with staff or at nurses station for close monitoring ...Pt is up in w/c at nurses station for close monitoring." "8/15/13 02:01 a.m. Resident fell out of wheel chair around 1800 (6:00 p.m.), witnessed by CNA's. Resident did not hit head, but did have a skin tear to right elbow as well as an obvious deformity to his right ring finger. NP (nurse practitioner, named) notified and gave orders to send resident to ER for eval. Resident sent to ER around 1845 (6:45 p.m.)...Called ER to check on resident around 0100 and we were advised that resident was admitted to the 4th floor for a right hip fx (fracture)..." "8/15/13 02:26 p.m. Late Entry On 8/13/13 at 7:35PM Patient was sitting in w/c with wheel locked while in hallway in front of nurses station. Patient attempted to rise from w/c and alarms sounded. Patient attempted to sit back in w/c right side of chair gave out and tipped. patient slipped out of the bottom of the chair onto his bottom...(sic)." Post Fall Assessments: "8/5/13 4:15 p.m. Resident was sitting in w/c. He attempted to stand up and w/c lock gave out on the left side. The w/c slid out from under him and he fell on to his back...Immediate action taken to prevent further falls: Brought to nurses station for increased supervision." "8/5/13 9:10 p.m. Resident was sitting in w/c. He attempted to stand up and w/c lock gave out on the left side. The w/c slid out from under him and he fell on to his back ...Immediate action taken to prevent further falls: W/C exchanged for one with working locks." "8/13/13 7:35 p.m. Resident was sitting in w/c at nurses station, when patient attempted to rise alarms went off. He attempted to return to sitting position, while w/c locked, gave out on the right side. The w/c tipped out from under him and he fell on to his bottom...Immediate action taken to prevent further falls: toileted every two hours." "8/14/13 6:00 p.m. Resident was sitting in w/c in hallway, when patient attempted to rise to scoot himself back into w/c. Patient did not have w/c breaks (sic) locked...Immediate action taken to prevent further falls: Patient was sent to ER for evaluation." On 11/7/13 at approximately 7:45 a.m. the investigation reports for the above listed falls were requested. The only fall that was reviewed with a recommendation was as follows: "8/5/13 2210 (10:10 p.m.) ...Eval wheel chair (therapy), Add dysom, Eval footwear." On 11/7/13 at approximately 7:30 a.m., Resident #25's closed clinical record was reviewed to include an initial fall care plan dated 8/3/13 and updated on 8/19/13 to include the following: "Problem/Conclusions Measurable Goals: Resident will be free from injury related to a fall through next review...Approaches/Interventions: Remind resident to rise slowly to prevent dizziness and/or fainting...Ask/encourage/assist resident to toilet...Assistive devices (list): (nothing was listed on the care plan)...Call bell within reach. Educate resident on use of call bell and to wait until assistance arrives...Keep environment free of trip hazards...Observe for adverse reaction to medications (dizziness, drowsiness, orthostatic hypotension, changes in behavior, insomnia, etc,) and report." Under the section on the CP for "Evaluation" the following was reviewed: "8/5/13 Resident fell at 2110 when w/c lock gave out and chair slid out from under resident. No injuries..." "8/8/13 ... 8/5/13 patient slid out of w/c to floor..." "8/15/13 ... 8/14/13 fall out of w/c." This care plan was started on 8/3/13 and discontinued on 8/19/13 when the resident was admitted to the hospital for a fall with fracture. The care plan was not revised to reflect any new or updated interventions with each of the listed falls. Hospital History and Physical: "DOS (Date of Service) 8/19/13...Chief Complaint /Nature of Presenting Problem: Aftercare hip fracture ORIF (open reduction internal fixation). History of present illness: ..XXX[AGE] year old Caucasian man with dementia already had declining physical abilities, and was sent from the hospital here after acute treatment for [REDACTED].Decision Making Capacity: Resident IS NOT capable of understanding resident rights and IS NOT capable of making informed decisions. Resident is NOT aware of medical condition due to: Dementia. Resident #25 was readmitted back to the facility on [DATE] fell again on 9/21/13 and again on 10/2/13 from his wheel chair, no injuries were sustained from the falls. On 11/7/13 at approximately 11:15 a.m., the maintenance director, Other Staff (OS) #7 was interviewed regarding Resident #25's wheelchair and if a work order had been placed for a wheelchair repair during the month of August 2013, when the brakes on the left and then on the right gave out and the resident fell . OS #7 stated, "Not since I have been here but I have to look and see. I started May 20th and I was in training until September 10th so my first quarter for wheelchair inspections, lifts, and scales, do not start until December of this year. I have been doing minor things like if a wheelchair is rusty or worn or if the frames are bad. I take care of those things or either throw them away. The facility has an outside company doing the lifts and scales right now so I have not been doing those." OS #7 further stated, "I don't remember getting a work order for Resident (named), they (facility staff) put them in on an as needed basis but I will look and see." On 11/7/13 at approximately 11:40 a.m., the unit manager, a registered nurse (RN) #5, was interviewed regarding fall from the wheel chair resulting in the resident's finger being dislocated and the hip fracture. RN #5 stated, "I remember him (the resident) he was sitting at the nurse's station because he was in his room and he was trying to get out of bed. He went to scoot back in the chair and the wheel chair brakes were not locked and he fell ." RN #5 was asked why the wheel chair brakes were not locked. RN #5 stated, "The brakes were not locked because we did not want to restrain him, he could propel himself a little." RN #5 was asked if Resident #5 was attempting to propel himself when the wheel chair slid from under him. RN #5 stated, "I am so confused, I thought I was doing what was right. This is so frustrating. I am not sure when to consider a resident as being restrained." RN #5 was asked again if the resident was attempting to propel himself when the wheel chair slid from under him. RN #5 stated, "No, the wheel chair brakes were supposed to have been locked, he was at the nurse's station for observation because he would try to get up." On 11/7/13 at approximately 11:40 a.m. RN #5 was interviewed regarding the care plans and when they are updated. RN #5 stated, "I update the initial care plan and then the nurse's or myself can add anything else that needs to be added." RN #5 was made aware that Resident #25's care plan was not updated to reflect changes and interventions after each fall and recommendation according to the "Incident or Accident Report and the Post Fall Assessments." RN #5 was also made aware that the care plans were the same for 8/3/13 and 8/19/13, with the exception that on the 8/19/13 care plan, the assist bars, bed & alarm, wheelchair, low bed & floor mats were listed under the "Approaches/Interventions" for falls. Under the "Evaluation" section it was documented: 9/21/13 Resident fell out of his wheel chair this evening...10/2/13 Resident fell out of his wheel chair this evening... " RN #5 reviewed the resident's care plan and stated, "I see." On 11/7/13 at approximately 11:40 a.m., when interviewed and asked if Resident #25's care plan was appropriate for him, due to his cognitive status of zero (0) and his multiple falls out of his wheel chair and the care plan not addressing fall interventions for wheel chair safety, RN #5 stated, "Other than remind him (the resident) to rise slowly, No." This Surveyor asked RN #5 if Resident #25, having a cognitive status of zero (severely impaired and not able to make decisions), would remember to call for assistance, as the CP stated and / or "rise slowly" as RN #5 stated, RN #5 shook her head, "No." On 11/7/13 at approximately 1:45 p.m., OS #7 entered the conference room and stated in the presence of the Survey team, "I don't have a work order for Resident (named) wheel chair. Something like that would have been considered a life safety and taken care of immediately but I don't have anything." On 11/7/13 at approximately 2:05 p.m., the licensed practical nurse (LPN #8) who was on the unit when Resident #25 fell from the wheelchair, was interviewed regarding the fall. During the interview, LPN #8 stated, "I did not see him fall I heard the alarm sounding. I turned around and he was on the floor. I helped him up and I noticed his finger was deformed, at first I thought it was arthritis and then they (staff) told me, 'oh no it's broken.'" The witness statement attached to the 8/14/13 Post Fall Assessment given by LPN #8 was reviewed. The witness statement given to the facility stated that LPN #8 was doing an admission assessment and the resident was noted up walking and staggering, LPN #8 ran to the resident and attempted to catch the resident before the resident fell . The statement given in the interview with LPN #8 and the witness statement did not match. On 11/7/13 at approximately 2:45 p.m., LPN #8 was interviewed again regarding the resident's fall from the wheelchair and the witness statement. LPN #8 reviewed the witness statement and stated, "This is what happened." When asked the reason this Surveyor was told something different the first time, LPN #8 stated, "I don't know." On 11/7/13 at approximately 2:00 p.m. during the meeting with the administrator, director of nursing, assistant director of nursing and the nurse consultant, the above findings were mentioned. The DON stated, "We also had him, the resident, screened by therapy due to his falls." At this time, the administrator stated, "We did not want to restrain him and locking his brakes on his wheel chair would have been a restraint for him." The administrative staff was made aware that the resident nursing notes were documented that the resident was placed at the nurse's station for close monitoring due to the resident attempting to get either out of bed or out of his wheel chair; therefore locking the brakes on his wheel chair was a safety intervention. On 11/7/13 at approximately 2:15 p.m., the assistant physical therapy manager, OS #2 was interviewed regarding screenings and evaluations for Resident #25. OS #2 stated, "Other than what's in the computer that's all we have." On 11/7/13 at approximately 2:20 p.m., the administrator, director of nursing, assistant director of nursing and the nurse consultant were made aware of the above findings. The nurse consultant stated, "Well, it was worth a try." 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current MDS, a quarterly assessment with an assessment reference date (ARD) of 8/23/13, assessed the resident had both short and long term memory loss and the need for extensive assistance with decision making. The clinical record was reviewed on 11/6/13. The progress notes documented "8/25/13 at 05:44 PM - resident sitting at nurses station around 1615 (4:15 p.m.) and ate solosite wound gel. Poison control contacted and said to clean his mouth out, and then give him a couple of glasses of water to dilute any wound gel that may have gotten into his system. They also said to keep an eye on him for a couple of hours for any nausea and vomiting. Resident had 2 glasses of water, no S/S (signs or symptoms) of nausea. On call NP (nurse practitioner) (name) notified and stated to call her if any episodes of emesis. RP (responsible party) (name) notified by phone, message left for her to return call. RP (name) came to facility to visit so she was notified in person of the incident. RP seemed to be OK with actions taken. Incident report completed. VS (results). Will continue to monitor resident for nausea, vomiting, or any changes." An APS (adult protective services) report received in the state survey agency's office documented from their investigation "Client had an unfortunate incident/accident on 8/25/13. The nurses did not realize he would be strong enough to unscrew the cap on the solosite wound gel. The administrator, Director of Nurses, and unit manager have discussed the situation with this APS worker. The staff will be more diligent in finding activities for client so that he isn't constantly sitting next to the nurse's station, thus he won't have access to inappropriate things like medication." On 11/6/13 at 9:00 a.m., the unit manager (registered nurse) (RN) #5 was asked about the incident Resident #1 had on 8/25/13 with the consumption of medicated lotion. RN #5 stated "there was an issue with the resident and medicated lotion." When asked if the medicated lotion was in a tube or a cup, RN #5 stated "I'm not sure if it was in a cup or a tube." When asked how the resident got in the nurse's station, if he was brought there or self-propelled, RN #5 stated "There was an investigation done, I am not sure where he was." The facility's "Incident or Accident Report" documented "Description of incident - resident sitting at nurses station with aides and ate solosite wound gel. Unknown amount ingested." The only staff statement as part of the investigation was by the unit manager dated 8/27/13 that documented "Upon investigation, resident sitting at nurses station around 8/25/13 at 1615 and ate solosite wound gel. Poison control contacted and said to clean his mouth out, and then give him a couple of glasses of water to dilute any wound gel that may have gotten into his system. They also said to keep an eye on him for a couple of hours for any nausea or vomiting. Resident had two glasses of water, no S/s of nausea. NP (name) was notified and stated to call her if any episodes of emesis. RP (name) notified first by voicemail to return call to facility and then when she came in to visit. Nurse was provided individual education and all staff on the unit were inserviced on no patients behind the desk and no medications are to be left unsupervised." The only other information provided as the investigation were three nurse's progress notes regarding the incident and two follow ups. There was no information from the aides on the unit at the time of the incident. The facility's policy titled "Storage and Expiration of Medications, Biologicals, Syringes and Needles" documented under section procedure "3.3 - Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors." On 11/7/13 at 8:55 a.m., this surveyor and another surveyor observed a black plastic basket on the counter on the side of the nurses station that went to the activities room. The basket contained 38 Dimethicone skin protectant, 16 skin prep, and no-sting skin prep wipes. These medications stated on the packages "For External Use Only." The second surveyor stated that the basket was in the same spot on 11/6/13 as well. On 11/7/13 at 9:10 a.m., certified nurses assistant (CNA) #10 was asked about the basket and it's contents. CNA #10 stated "we are to fill up our pockets every shift with the skin prep and Dimethicone." When asked where the basket is usually kept, CNA #10 stated "right over here" and pointed to the area the basket was found. On 11/7/13 at 9:15 a.m., licensed practical nurse (LPN) #7 was asked about the basket and if it was usually kept in the spot CNA #10 had indicated. LPN #7 stated "yes, it is kept here." She went on to state "I asked the question if it was okay to keep it here and was told yes." She then asked this surveyor "Is it okay not okay? I'll put it over here" and proceeded to put it underneath the counter out of resident reach. When asked if residents would be able to access the contents of the basket where it was located before she moved it she stated "Yes, in reality they can." On 11/7/13 at 10:40 a.m., RN #4 was asked about the investigation process. RN #4 stated "the nurse present at the time of the incident starts the investigation. The investigation then goes to the unit manager and they review and would be responsible for getting witness statements." When asked about this investigation and the lack of written statements from the aides and that the only statement was the one she provided, RN #4 stated "Oh crap" looked through the investigation that had been provided to this surveyor and stated "I remember more to it. I will check my office and with the director of nurses." On 11/7/13 at 11:00 a.m., RN #4 stated "There were no other written statements." She then went on to state "I just spoke to the CNA (certified nurses assistant) that was here and she said that she brought the resident up to the nurse's station because the nurse was sitting at the station and she (the aide) had to go change other residents and could not have Resident #1 stay with her the entire time." She then stated "the CNA stated she did not fill out a written statement." When asked who received the inservice training, RN #4 stated "the staff that work on this unit." On 11/7/13 at 2:45 p.m., the administrative team was asked who received the inservice training after Resident #1's 8/25/13 incident, to which the director of nurses stated "the staff on that unit (unit 3)." The administrative team was made aware of the findings during a meeting with the survey team. No other information was provided to this surveyor prior to the exit conference on 11/7/13. This is a complaint deficiency. 3. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #20 with severely impaired cognitive skills. On 11/6/13 at 2:30 p.m. and 4:25 p.m. Resident #20 was observed seated in a reclining chair with a mechanical lift sling under the resident but no chair cushion in use. Resident #20's clinical record was reviewed on 11/7/13. Resident #20's plan of care (reference date 6/17/13) documented the resident was at risk for falls due to decreased mobility and poor balance. Included as an intervention to prevent injuries from a fall was "...broda chair with cushion..." On 11/7/13 at 8:45 a.m. the certified nurses' aide (CNA #6) routinely caring for Resident #20 was interviewed about the use of a chair cushion. CNA #6 stated the resident frequently "scooted" down in the reclining chair. CNA #6 stated, "He (Resident #20) does it (slides down in chair) all the time." CNA #6 stated they had tried some cushions but she was not sure if he still had one in use. Accompanied by CNA #6 the resident's reclining chair was observed on 11/7/13 at 8:45 a.m. There was no cushion in place in the chair. CNA #6 looked in the resident's room and did not locate a chair cushion. CNA #6 stated they frequently pulled the resident up in his reclining chair because he "scoots" down. On 11/7/13 at 9:00 a.m. the registered nurse (RN #1) unit manager was interviewed about Resident #20 seated without a chair cushion. RN #1 stated Resident #20 frequently "scooted" down when in the reclining chair. RN #1 stated the resident was transferred using a mechanical lift so a lift pad would be under the resident when seated. RN #1 stated she thought the resident also used an anti-slip cushion in his chair. On 11/7/13 at 9:00 a.m. accompanied by RN #1, Resident #20's reclining chair was observed. There was no cushion in the chair. RN #1 searched the resident's room and closet and did not locate a cushion. These findings were reviewed with the administrator, director of nursing and corporate nursing consultant during a review meeting on 11/7/13 at 2:45 p.m. This was a complaint deficiency.

Based on observation, staff interview, resident interview, clinical record review, and facility document review, the facility staff failed to prevent an accident that resulted in harm for one of 31 residents (Resident # 20) and failed to ensure safety devices were in place for three of 31 residents in the facility, Resident #'s 13, 16, and 1. 1. Resident # 20 fell out of a w/c (wheelchair) that was the incorrect height, as a result Resident # 20 sustained a fracture to the right wrist from the fall. 2. The facility staff failed to ensure that multiple safety devices were in place to prevent accidents for Resident # 13. 3. The facility staff failed to implement interventions from the care plan of Resident #16 resulting in multiple falls. 4. Resident # 1 did not have a floor mat in place for injury prevention. Findings include: 1. Resident # 20 was admitted to the facility on [DATE], with the most recent readmission on 09/22/12. [DIAGNOSES REDACTED]. The most recent full MDS (minimum data set) was an annual assessment dated [DATE]. Resident # 20 was assessed as having short term memory impairment and severe impairment in daily decision making skills. The resident was assessed as requiring limited assistance with ambulation and also assessed as using/requiring a wheelchair for mobility. Resident # 20 was additionally assessed as "not steady, but able to stabilize without human assistance" in balance during transitions and ambulating and as having no impairment for "functional limitation in range of motion." On 01/09/13 at approximately 11:00 a.m., Resident # 20 was observed in her room, in a w/c, both feet resting on the floor, the resident's eyes were closed. No chair alarms or restraints were observed at this time. During clinical record review at approximately 11:15 a.m. on 01/09/13, nursing notes were reviewed and documented the following: 9/06/12 (4:28 p.m.)- "7-3 Note: At 12:15, resident sitting in w/c in hallway and fell to floor. Found sitting on floor with right side leaning against wall...Assisted to feet with two staff...skin tear on right knee...Resident able to walk with assist as prior to fall...Noted post fall that w/c is too tall for resident and feet do not reach the floor...therapy notified and shorter w/c obtained for resident..." 09/07/12 (2:35 p.m.)- "Pt (patient) has had bruised raised area around right wrist. Area is swollen and is warm to touch...ordered X-ray...right wrist injury believed to be from previous fall yesterday..." 09/07/12 (7:52 p.m.)- "Pt's X-ray results were returned and pt had a right wrist hairline fracture...brace to right wrist..." Further review of the clinical record revealed and was documented through out nursing notes, that Resident # 20 was frequently independently ambulatory and had a history of [REDACTED]. and ambulating...devices as written...ensure that hallways are free from spills, clutter, and other hazards...walk with resident frequently...Monitor for any signs and symptoms of unsteady gait-resident ambulates independently...chair alarms on while in w/c..." On 01/09/13 at 4:20 p.m., a meeting with the survey team was held with the administrator, DON (director of nursing) and nurse consultant. The above information, along with concerns regarding Resident # 20's injury were shared with the facility staff at this time. A copy of the CCP (comprehensive care plan) that was in effect at the time of the fall from the w/c was requested at this time, as well as information regarding the w/c (specifically when the w/c came in use by the resident). Additionally, the investigation regarding this fall was requested for review. On 01/10/13 at approximately 9:00 a.m., the DON presented the investigation and the prior CCP in effect. The DON stated that the resident had been supplied with a w/c some time ago, which was only used PRN (as needed) because the resident was primarily ambulatory. The DON was asked about the w/c being too tall for the resident and was that particular w/c Resident # 20's designated w/c. The DON stated, "No" and that the w/c the resident fell out of was not the designated w/c for the resident and she (the DON) did not know if the resident's w/c had been taken out of resident's room or moved. The DON stated, "...got a w/c for her, but wasn't her regular one...just got one for her..." The DON could not explain why the resident was given a w/c that did not fit the resident appropriately, who gave her the w/c or where the resident's designated w/c was. The "Post Fall Assessment", along with additional documentation (investigation) was reviewed and documented the following: "...changes in sensorium/behavior related to medication...unsteady gait/poor balance...problems with mobility...unsteady gait/poor balance...unsafe behaviors...wandering without regard for fatigue...attempts to rise/ambulate/transfer unsafely...other...incontinent...memory loss...disorientation...DEVICE CHANGE: SHORTER W/C OBTAINED FROM THERAPY...IMMEDIATE ACTION TAKEN TO PREVENT FURTHER FALLS: SHORTER W/C OBTAINED FROM THERAPY FOR RESIDENT..." The investigation did not provide specific details to facilitate identification or determination of why the resident was supplied with a w/c that was not appropriately fitted for the resident. Resident # 20's CCP in effect at the time (dated 05/30/11) of the fall with injury documented: "...Monitor adverse reaction to medications (dizziness, drowsiness, orthostatic hypertension, changes in behavior, insomnia, etc.)...Keep environment free of potential obstacles...assistive devices assist bars, w/c as needed...Educate resident to rise slowly to prevent a sudden drop in blood pressure...encourage frequent rest periods...therapy screen for positioning...lock wheels on w/c...instruct resident to call for assistance when getting out of bed or out of chair...ambulate with assistance as indicated...assistive devices as indicated...supervise and assist with transfers as indicated..." On 01/10/13 at 12:10 p.m., the administrator was again informed of the concerns regarding Resident # 20's fall from the ill fitting w/c, which resulted in the resident sustaining a fracture to the wrist. The administrator stated that a lot of times, the resident would "walk further than normal and tire significantly..." The administrator further stated that at times, "...a close w/c (not the resident's designated w/c) was brought to her (by staff) to let her sit down...I'm not sure if that was the situation here..." The administrator was informed that the investigation did not provide any details as to why the resident was sitting in a w/c that was not an appropriate fit. The administrator was asked if the investigation provided should have specific details attempting to identify why the resident was using a w/c that was not the resident's designated w/c; the administrator stated that, "an investigation would be more thorough." The administrator stated that the investigation that was completed for Resident # 20 was more focused on prevention for the future, not necessarily what the root cause was or why it actually happened; the administrator stated that is why the shorter w/c was obtained from therapy. Safety concerns were shared with the administrator regarding the resident's known history of recurrent falls with an unsteady gait, the resident was in a w/c that did not belong to the resident, the resident's feet did not touch the floor while sitting in the w/c, and the resident fell from the chair and sustained a fracture to the wrist. The administrator was asked why the resident did not have a w/c that was appropriately fitted for the resident to start with or why the resident's designated w/c was not available to the resident; no comment was provided. No further information or documentation was provided prior to the exit conference prior to exit conference on 01/10/13 at 12:45 p.m. 2. Resident #13 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 11/06/2012. Resident #13 was coded as having a cognitive summary score of 06, indicating her cognitive status was severely impaired. On 01/08/2013 at approximately 10:30 a.m., Resident #13 was observed inside the doorway of her room. She was up in her wheelchair, a lap buddy was across the front of the wheelchair and Resident #13 had her head down on the lap buddy. Her eyes were closed. A tab alarm was observed on the back of the wheelchair but it was not attached to Resident #13. CNA (certified nursing assistant) #1 was in the room and was asked about the tab alarm. She stated, "We don't use the alarm when we use the lap buddy and we only use the lap buddy if she is agitated." CNA #1 was asked if Resident #13 was agitated at that time and she stated, "No, she is asleep right now and leaning forward on it...I am going to get her up and in the shower in a little bit." The electronic clinical record was reviewed on 01/08/2013 at approximately 2:00 p.m. A device assessment dated for 04/27/2012 was observed which listed the following devices as needed for Resident #13: Assist bars, bed alarm, chair alarm, lap buddy, low bed with mats, and other." The purpose of the devices was documented as: To assist with mobility, to alert staff of resident's attempts to rise unassisted, bed against wall, Lap buddy to prevent patient from attempting to rise unassisted r/t (related to) dementia and poor safety awareness." Another device assessment dated [DATE] and also 12/07/2012 contained the same information. On 01/08/2013 at approximately 3:15 p.m., this surveyor entered Resident #13's room. She was lying in bed, call bell in her hand, tab alarm hooked to her shirt. The left side of her bed was against the wall, there was no fall mat on the right side of her bed. This surveyor and the unit manager entered the room at 3:30 p.m. and a fall mat had been placed beside Resident #13's bed. The unit manager was asked about the use of the lap buddy, the tab alarm and the fall matt. RN (registered nurse) #5 stated, "She is suppose to have the fall mat down when she is in the bed. She is also suppose to have her alarms on at all times and her lap buddy is used when she is in the chair." RN #5 was asked about CNA #1's statement that the lab buddy was only used when Resident #13 is agitated, she stated, "We use it whenever she is up in her wheelchair." The above information was shared with the administrative team during an end of the day meeting on 01/08/2013 On 01/09/2013 at approximately 11:30 a.m. Resident #13 was observed sitting in her wheelchair. Her lab buddy was in place but her tab alarm was hooked onto the alarm cord and hanging on the back of the chair. It was not attached to Resident #13. RN #5 was notified of the observation. On 01/09/2013 at approximately 2:00 p.m., the progress notes section of the electronic clinical record were reviewed. On 09/16/2012 the following note was written: "5:52 p.m. Resident alert, continues to sit at nursing desk conversing with residents, lab buddy continues to be removed at this time, resident with out (sic) agitation. Lab buddy was not needed, resident sitting pleasantly in chair, alert with no anxiety, was not attempting to crawl from chair, or stand on own. fell ow residents witnessed resident drift off to sleep, lean forward and fell to floor, bumping right side of head. Resident denies pain or discomfort at time of fall. Hematoma to right side of head, ice applied..." On 09/20/2012 the following notes were written: "3:19 p.m. Falls, meeting for fall on 09/16/2012 at 1715 (5:15 p.m.) Resident in W/C (wheelchair) fell asleep and leaned forward and fell . Educated staff that resident must have lap buddy when unattended by staff....3:39 p.m. Device meeting, resident continues with lap buddy. Removal of lab (sic) buddy while in hall with staff attendance. Decrease in falls since placement.." A copy of the accident/incident report for the fall on 09/16/2012 was requested from the DON (director of nursing) at approximately 3:00 p.m. on 01/09/2013. The "Incident or Accident Report" was received at approximately 3:30 p.m. During an end of the day meeting on 01/10/2013 the administrator and the DON the above information was discussed. The DON was asked why the lap buddy was off of Resident #13 at the time of her fall in September. She stated, "We were trying to see how she would do with out it. The DON was asked if there was any assessment indicating that a restraint reduction trial was in progress. She stated, "I didn't see anything." The DON was asked if the alarm was on at the time of the fall and she stated, "It should say that on the report." The DON and this surveyor reviewed the report and no area was observed to address whether or not the alarm was on at the time of the fall. The DON stated, "I don't know." On the morning on 01/10/2013 the DON and the nurse consultant came to the conference room at approximately 9:00 a.m. The DON was asked if any information had been found addressing the reduction of the lap buddy for Resident #13. The DON stated, "We discuss it in meetings...nothing is written down, it all verbal communication. We didn't revise the care plan or do any documentation." The nurse consultant stated, "We see a problem with the system." No further information was obtained prior to the exit conference on 01/10/2013. 3. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/02/2012. Resident #16 was assessed as being severely impaired in her short and long term memory and in her cognitive skills for daily decision making. On 01/09/2013 at approximately 9:00 a.m., Resident #16's clinical record was reviewed. During this review several progress notes documented resident falls. The progress notes were dated as follows: 08-16-12 at 2:10 p.m., "...resident slid herself out of w/c (wheelchair) on the floor, call bell not on." 08-16-12 at 10:49 p.m., "At 1600 (4:00 p.m.) another res (resident) reported to this nurse and other nurse that res had slid out of chair onto the floor in front of HR room. Alarm was not on." On 08/21/2012 during a care plan meeting Resident #16's husband gave consent for a lap buddy to be used for resident's safety. 09-10-12 at 11:34 p.m., "CNA (certified nursing assistant) reported to this nurse that res was observed on the floor at 1715 (5:15 p.m.) with alarm sounding at the end of short hall at front entrance." 09-13-12 at 3:26 p.m., "Fall meeting for 9/10/12 at 1715, Patient in East hallway, lap buddy was not in place at the time of incident." 01-03-13 at 7:09 p.m., "... CNA from east observed pt (patient) laying on the floor in the dining room beside her w/c around 1520 (3:20 p.m.). Fall was unwitnessed." 01-04-13 at 2:17 p.m., "Falls meeting for fall on 1/3/13 @ (at) 1520 when found in dining room floor... Placed lap buddy back on her. Interventions are lap buddy and diversion. Interventions alarms." Resident #16's "Plan of Care" was reviewed. During this review a care plan was noted for falls. "Onset 03-06-2012, FALL: At increased risk for falls R/T (related to) cognitive impairment with agitation and aggressive behaviors, weakness, requires assistance with transfers, ambulation." The care plan listed "Approaches/Interventions" of "Keep call bell in place, ... low bed, concave mattress, pressure alarm in bed, tab alarm in chair, fall mats..." On 08/21/2012 an intervention of lap buddy was added after a care plan meeting with Resident #16's husband. Resident #16 was observed by this surveyor in the activities room at 10:05 a.m. on 01/09/2013, chair alarm in place, but no lap buddy. At 1:35 p.m. on the same day this surveyor observed Resident #16 in the dining room with lap buddy in place, but no chair alarm. RN #3 was interviewed on 01/09/2013 at approximately 2:20 p.m. She was asked by this surveyor if bed/chair alarms need a physician's orders [REDACTED]. RN #3 stated, "No doctor's order is needed. Bed/chair alarms are a nursing decision and are care planned." RN #3 also stated that once alarms are initiated they should always be used until they are removed from the care plan. RN #3 was asked by this surveyor if a resident has a lap buddy and alarms ordered should or would they be used simultaneously. RN #3 stated, "Depends on the resident, but I would say yes. I don't trust the residents not to remove the lap buddy and try to get up. It's a double safety thing for the resident." The administrator and DON (director of nursing) were notified of the above findings during a meeting with the survey team on 01/09/2013 at approximately 4:30 p.m. No further information was given to the survey team prior to the exit conference on 01/10/2013. 4. Resident #1 was admitted to the facility on [DATE] with a re-admission on 12/15/12. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #1 as having severely impaired cognitive skills for decision-making. On 1/8/13 at 9:20 a.m. and 10:00 a.m. Resident #1 was observed unattended in bed. A folding chair was positioned beside the resident's bed during these observations. There was no protective floor mat by the resident's bed during either of these observations. Resident #1's clinical record and care plan documented the resident had a history of [REDACTED]. The resident's care plan interventions included the use of a protective floor mat by his bed to prevent injury. On 1/9/13 at 7:50 a.m. the registered nurse unit manager (RN #5) was interviewed about the missing floor mat. RN #5 stated the resident was supposed to have the floor mat in place and she did not know why it was not down. These findings were reviewed with the administrator, director of nursing and regional nurse consultant on 1/9/13 at 4:15 p.m.