Every finding on record at Heritage Hills Nursing & Rehabilitation Center

Based on clinical record review and staff interview, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 3 residents reviewed for pressure ulcers (an injury to the skin and underlying tissue caused by prolonged pressure on the skin over a bony prominence), Resident ID #2. Specifically, the resident was admitted to the facility without any skin impairments and while at the facility s/he developed a stage III pressure ulcer (an ulcer that has completely broken through the top 2 layers of skin and into the fat layer below) and an unstageable pressure ulcer (an ulcer that occurs when the wound bed is completely covered by dead tissue, slough, or eschar, preventing clinicians from assessing the depth and extent of tissue damage accurately). Findings are as follows:Review of a community reported complaint received by the Department of Health on 6/5/2026 alleged in part that the facility staff left the resident in a single position for entire shifts.Record review of a facility policy titled, Pressure Injuries Overview reveals in part, . 'Avoidable' means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed.Evaluation of the resident's clinical condition and risk factors.Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice.monitoring or evaluation of the impact of the interventions.Record review revealed the resident was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, quadriplegia (paralysis that affects all four limbs and the body from the neck down). The resident was discharged from the facility on 3/20/2026.Record review of a document titled Admission/ readmission Screener dated 3/2/2026 revealed a skin assessment indicating that the resident's skin color was normal, the skin was intact and had abnormalities had not been identified.Record review of a skin check dated 3/2/2026 revealed the resident had no skin impairments noted.Record review of a document titled Braden Scale- for Predicting Pressure Ulcer Risk Evaluation dated 3/2/2026 revealed that the resident was confined to a bed, and his/her mobility is very limited, able to make occasional slight changes in body or extremity position, but s/he is unable to make frequent or significant changes independently.Record review of a document titled, .Skin Issues, dated 3/5/2026, revealed a new coccyx wound described as a .stage 2 pressure ulcer/injury: partial-thickness skin loss with exposed dermis. The wound measurements were 3.53 centimeters (cm) by 0.68 cm by 0 cm.Record review revealed a physician's order dated 3/5/2026 to cleanse the wound on the resident's coccyx with wound cleanser, pat dry, to apply medihoney (a treatment to support wound healing) to the open area and cover with a foam dressing daily and as needed.Record review of a care plan initiated on 3/5/2026 revealed a focus area, The resident has a pressure ulcer or has the potential for pressure ulcer development [related to] immobility. Interventions included, but were not limited to, avoid positioning the resident on the area of wound, and to monitor, remind, and assist to turn and reposition at least every 2 hours, or more often as needed or requested.Record review of the Nursing Assistant (NA) Kardex (a resident information system that summarizes a patient's care requirement details for quick reference) revealed that the resident was dependent on 2 staff members and a sheet for turning and repositioning, and that the resident required monitoring, reminding, and assistance to turn and reposition at least every 2 hours.Further Record review revealed the resident was hospitalized from [DATE] until 3/9/2026.Record review of a Minimum Data Set assessment dated [DATE] revealed that at the time of this assessment the resident was at risk of developing pressure ulcers or injuries, and had one actual pressure ulcer, which was a stage 2 pressure ulcer.Record review of a document titled Admission/ readmission Screener, dated 3/10/2026, revealed that a skin assessment was completed upon the resident's return from the hospital and the resident's skin color was normal, the skin was intact and there were no abnormalities.Record review of a skin check dated 3/11/2026 revealed an unstageable pressure ulcer to the gluteal cleft with eschar and slough (types of dead tissue within the wound bed). The wound measured 6 cm by 1.5 cm. Additionally; the facility documented an open wound on the right buttock measuring 3 cm by 2.5 cm. This wound on the right buttock is documented on the skin check as being acquired in house.Record review of a wound care progress note dated 3/11/2026 by the Wound Nurse Practitioner (NP) revealed the following wounds:1) Right buttock, Stage 3 pressure ulcer, the wound was measured to be 3 cm by 2.5 cm by 0 cm.2) Gluteal cleft (the groove between the buttocks), unstageable, the wound was measured to be 6 cm by 1.5 cm by 0 cm. The wound contained 50-74% granulation (the formation of new connective tissue typically appears red or pink and moist) 50-74% slough (dead tissue that appears yellow, tan or white which can impede the healing process).Further review of the wound care progress note authored by the Wound NP, dated 3/11/2026 revealed that new wound orders were obtained and under the section titled Assessment /Plan it indicated that the resident should be repositioned every 2 hours.During a surveyor interview on 6/16/2026 at approximately 10:00 AM with NA, Staff A, she revealed that the NAs document resident care including turning and repositioning in the electronic record using an iPad.Record review of the resident's tasks failed to reveal documentation that the NAs were turning and repositioning the resident every 2 hours during his/her time at the facility, as was indicated in the resident's care plan and the wound care progress note.Further review of the resident's record from 3/2/2026 through discharge on [DATE] failed to reveal evidence that the resident was assisted to turn and reposition at least every 2 hours per the care plan.During a surveyor interview on 6/15/2026 at 1:40 PM with the Wound NP, she revealed that she would expect that the resident would be turned and repositioned every two hours to aid in healing the pressure ulcers.During a surveyor interview on 6/15/2026 at 1:13 PM with the Director of Nursing Services, she revealed that at the facility they do not get orders to turn and reposition resident's every 2 hours because that is a standard of practice. She revealed that turning and repositioning would be written in the task section of the NA documentation. However, she could not provide evidence from the resident's record that the resident was turned and repositioned at least every 2 hours per the resident's care plan or the Wound NP assessment. Additionally, she could not provide evidence that the resident was provided with the necessary treatment and services to promote wound healing and prevent new pressure areas from forming.During a surveyor interview on 6/16/2026 at approximately 10:45 AM with the Regional Director of Clinical Services, she acknowledged that the documentation on the Admission/readmission Screener skin checks completed on 3/2/2026 and 3/10/2026, upon the resident's returns from the hospital indicated that the resident's skin was intact with no irregularities, despite documentation from the wound care NP dated 3/11/2026 indicating that the resident had an unstageable pressure wound to the gluteal cleft and a stage 3 pressure wound to the right buttock. Additionally, she acknowledged that she could not provide evidence that the resident was turned and repositioned every 2 hours as per his/her care plan.The facility's failure to ensure the resident was turned and repositioned at least every two hours in accordance with the care plan, wound care recommendations, and the facility's policy resulted in the resident developing multiple facility-acquired pressure injuries, including the progression of a stage 2 pressure ulcer to an unstageable pressure ulcer and the development of a stage 3 pressure ulcer, causing actual harm.Cross reference F 656

Based on record review and staff interview, the facility failed to provide care in accordance with a resident's plan of care for 3 of 3 resident's relative to turning and repositioning, Resident ID #s 1, 2, and 4.Findings are as follows:1) Record review revealed that Resident ID #1 was readmitted to the facility in March of 2026 with diagnoses including, but not limited to, Parkinson's disease (a progressive neurological disease that primarily affects movement) and adult failure to thrive.Record review of a care plan dated 12/19/2025 revealed in part, .The resident has a pressure ulcer or has the potential for pressure ulcer development. interventions include, but are not limited to, .I require monitoring, reminding, and assistance to turn and reposition at least every 2 hours, more often as needed or requested.Review of the record failed to reveal evidence that the resident was assisted to turn and reposition at least every two hours per the plan of care.2) Record review revealed that Resident ID #2 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, quadriplegia (paralysis that affects all four limbs and the body from the neck down).Record review of a care plan dated 3/5/2025 revealed in part, .The resident has a pressure ulcer or has the potential for pressure ulcer development [related to] immobility. Gluteal cleft -unstageable (a full-thickness wound whose true depth and severity cannot be determined because the wound bed is completely covered by dead tissue) [right] buttocks pressure unstageable. Interventions include, but are not limited to, .I require monitoring, reminding, and assistance to turn and reposition at least every 2 hours, more often as needed or requested.Review of the record failed to reveal evidence that the resident was assisted to turn and reposition at least every two hours per the plan of care.3) Record review revealed that Resident ID #4 was readmitted to the facility in March of 2026 with diagnoses including, but not limited to, aftercare for circulatory system surgery and transient ischemic attack (a temporary blockage of blood flow to the brain).Record review of a care plan dated 11/19/2025 revealed in part, .The resident has a pressure ulcer or has the potential for pressure ulcer development [related to] immobility. Interventions include, but are not limited to, .I require monitoring, reminding, and assistance to turn and reposition at least every 2 hours, more often as needed or requested.Review of the above resident records failed to reveal evidence that the residents were assisted to turn and reposition at least every two hours per their plan of care.During a surveyor interview on 6/16/2026 at approximately 11:45 AM with the Director of Nursing Services and the Regional Director of Clinical Services, they were unable to provide evidence that the above residents were assisted to turn and reposition at least every two hours per their care plans.Cross reference F 686

Based on clinical record review and staff interview, the facility failed to ensure that assessments accurately reflect the resident's status for 1 of 3 residents reviewed related to pressure ulcers (an area of localized damage to the skin and/or underlying tissue that develops as a result of prolonged pressure), Resident ID #2.Findings are as follows:Record review revealed the resident was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, quadriplegia (paralysis that affects all four limbs and the body from the neck down).Record review of a document titled Skin Issues dated 3/5/2026 revealed that the resident had a Stage 2 pressure ulcer (is a partial -thickness loss of the skin where the dermis is exposed, forming a shallow, red or pink wound or blister without visible fat or deeper tissues) on his/her coccyx measuring 3.53 centimeters (cm) by 0.68 cm by 0 cm.Record review of the Minimum Data Set (MDS) assessment dated [DATE] inaccurately coded that the resident did not have a pressure ulcer.During a surveyor interview on 6/15/2026 at 12:53 PM with the MDS Coordinator, she revealed that the MDS dated [DATE] should have been accurately coded to indicate that the resident had a pressure ulcer.During a surveyor interview on 6/15/2026 at approximately 1:15 PM with the Director of Nursing Services she indicated that she would expect the MDS assessment dated [DATE] to indicate that the resident had a stage 2 pressure ulcer, as documented on the skin check from 3/5/2026.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to care of a peripherally inserted central catheter (PICC line- is a type of Central Venous Catheter (CVC), inserted peripherally, typically in the upper arm. It is a long thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) for 2 of 2 residents reviewed with a PICC line, Resident ID #s 1 and 2. Findings are as follows:According to Lippincott Nursing Procedures, Ninth Edition page 657, states in part, .Performing a CVC [central venous catheter- dressing change .Use a sterile measuring tape or the incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter hasn't migrated .Review of a facility policy titled, Central Venous Catheter Care and Dressing Changes dated October 2024 states in part, .Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion.Change the dressing if it becomes damp, loosened or visibly soiled and at least every 7 days.1. Record review revealed that Resident ID #1 was admitted to the facility on [DATE] with a diagnosis including, but not limited to, acute myeloblastic leukemia (cancer).Record review of a hospital document titled PICC insertion Record dated 1/12/2026, revealed the resident had a PICC placed in his/her left arm. The baseline external length of the catheter was 0 centimeters (cm).Further record review revealed that s/he would be receiving chemotherapy to be administered via the PICC catheter.Record review of the January 2026 Medication Administration Record (MAR) revealed a physician's order dated 1/30/2026 to change the central line dressing every 7 days and to measure the external length of the catheter with each dressing change. Further record review revealed that the dressing change was signed off as completed on 1/31/2026. Additionally, the documentation for the catheter length was left blank.During a surveyor observation on 2/6/2026 of Resident ID #1's PICC line dressing change at approximately 2:00 PM with Licensed Practical Nurse Staff, A she measured the external catheter length to be 1 cm.During a surveyor interview on 2/6/2026 at 2:12 PM with Staff A, she acknowledged that the external catheter length was not documented in the resident's record. She further revealed that she will document the external length that she observed.2. Record review revealed that Resident ID #2 was admitted to the facility on [DATE], with a diagnosis including, but not limited to, malignant neoplasm (cancer).Record review of a hospital document titled PICC insertion Record dated 1/28/2026, revealed the resident had a PICC placed in his/her right arm. The baseline external length of the catheter was 0 cm.Further record review revealed that s/he would be receiving chemotherapy to be administered via the PICC catheter.Record review of the January 2026 MAR revealed a physician's order dated 1/29/2026 to change the central line dressing every 7 days and to measure the external catheter length. Further record review revealed that the order was signed off as incomplete indicating the resident was absent from the facility.Further record review revealed that the PICC dressing was not changed on admission and was completed on 2/6/2026, 9 days later. Additional record review failed to reveal evidence that the external length was measured per the facility policy and physician's order.During a surveyor interview with the Nurse Practitioner, on 2/6/2026 at 2:40 PM, she revealed that it would be her expectation that a PICC dressing would be changed as ordered and if the resident was not available at the scheduled time it would be completed upon their return. Additionally, she would expect that the external catheter length be measured per policy with each dressing change and reported to her if it was different from the baseline insertion record.During a surveyor interview with the Director of Nursing Services on 2/6/2026 at 3:05 PM, she was unable to provide evidence that the PICC dressing was completed as ordered for Resident ID #2 and that the external catheter length was measured and documented until it was brought to the facility's attention by the surveyor for Resident ID #s 1 and 2.

Based on record review and staff interview, the facility failed to keep residents free from abuse for 1 of 5 residents reviewed, Resident ID # 4.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 1/10/2026, revealed that at approximately 2:00 PM on 1/10/2026 while sitting in the South Unit Day room, Resident ID #2 was observed touching Resident ID #4's lower private area, both residents were immediately separated, and they were assessed without any injuries. Further review of the report revealed Resident ID #2 was then placed on continuous observation while out of bed, and that s/he will resume his/her 15-minute checks while in bed. Resident ID #4 was also placed on 15-minute checks.Record review revealed Resident ID #4, was admitted to the facility in June of 2016, with a diagnosis including, but not limited to, Alzheimer's disease and major depressive disorder. Review of Resident ID #4's Quarterly MDS assessment dated [DATE], revealed s/he has severe cognitive impairment. During a surveyor interview on 1/13/2026 at 1:41 PM with the Activities Aide, Staff B, he revealed that on 1/10/2026 at 2:00 PM he was walking by the South Unit day room and when he looked in the room, he observed Resident ID #2 in his/her wheel chair sitting on the side of Resident ID #4's chair and observed Resident ID #2 touching Resident ID #4's lower private area. Staff B immediately intervened and removed Resident ID #2 from the room and notified the nurse. Review of Resident ID #2's care plan, initiated on 1/23/2025, revealed a focus area related to a history of sexually inappropriate behavior, and a history of inappropriate touching towards other residents and staff. The care plan indicated that the resident was subsequently involved in further incidents of inappropriately touching other residents on 8/30/2025, 10/14/2025, 12/19/2025 and lastly on 1/10/2026 (with Resident ID #4).Further review of Resident ID #2's care plan revealed an intervention implemented after the 1/10/2026 incident with Resident ID #4 to provide 1:1 observation. Record review indicated that the incident on 1/10/2026 involving Resident ID #2 and Resident ID #4 occurred in the day room on the South Unit. However, the 15-minute observation sheet dated 1/10/2026 documented that at the time of the incident, Resident ID #2 was observed at the nurse's station on the [NAME] Unit.Despite interventions implemented following each inappropriate sexual incident involving other residents including two prior incidents with Resident ID #4 on 8/30/2025 and 10/14/2025, Resident ID #2 continued to engage in inappropriate touching of other residents. During a surveyor interview conducted on 1/13/2026 at approximately 3:00 PM, the Administrator acknowledged that Resident ID #2 had previously inappropriately touched other residents, including three incidents involving Resident ID #4, and that interventions were implemented. However, he was unable to provide evidence that the facility ensured Resident ID #3 and Resident ID #4 were free from abuse by Resident ID #2.

Based on surveyor observations, clinical record review, and staff interview, the facility failed to maintain medical records on each resident that are complete and accurately documented, for 1 of 2 residents reviewed for falls, Resident ID #7. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/13/2026 revealed in part, the complainant had safety and care practice concerns surrounding the resident's fall on 1/12/2026. Record review revealed the resident was admitted to the facility in April of 2023 with diagnoses including, but not limited to, dementia and neuromuscular dysfunction. Record review of a nursing progress notes indicated that the resident had a witnessed fall in his/her room while care was being provided. The resident was assisted with turning in bed by one staff member; s/he fell out of the bed landing onto the floor. Record review of the Quarterly Minimum Data Set assessment dated [DATE] revealed the resident is dependent with rolling in bed from his/her back, to the left and right side, and returning to his/her back. Record review of the resident's care plan initiated 4/14/2023 with a focus area for activities of daily living (ADL) related to physical limitations due to impaired mobility, revealed the following conflicting interventions for bed mobility: -Date initiated 6/7/2024, I require the assist of 2 staff and a sheet for turning and repositioning. -Date initiated 12/23/2025, I require the assist of 1 staff and a sheet for turning and repositioning. The above care plan failed to indicate a complete and accurate description of what the resident required for assistance when turning and repositioning in bed. During a surveyor interview with the Regional Clinical Director in the presence of the Director of Nursing Services on 1/14/2026 at 4:50 PM, when asked about the above-mentioned care plan with the two different interventions for rolling the resident in bed, she revealed that when the 12/23/2025 intervention was implemented, the 6/7/2024 intervention should have been removed. She was unable to provide evidence the care plan accurately reflected the resident's needs.

Based on clinical record review and staff interview, the facility failed to ensure that services provided meet professional standards of quality relative to following physician's orders for medication administration, for 1 of 3 residents reviewed, Resident ID #2. Findings are as follows:Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients.Record review revealed that Resident ID #2 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, dementia with behavioral disturbances and major depressive disorder.Record review revealed a physician's order with a start date of 12/20/2025 for Seroquel (a medication prescribed to treat several types of mental health conditions) 50 milligrams (mg), administer one tablet by mouth twice daily.Record review revealed a physician's order with a start date of 12/19/2025 for Seroquel 25 mg once daily at bedtime.Record review revealed an additional physician's order to re-evaluate the Seroquel orders with the provider on 1/2/2026. Record review of the January 2026 Medication Administration Record (MAR) revealed that on 1/2/2026 the order to re-evaluate the resident's Seroquel medication was signed off as completed by Licensed Practical Nurse (LPN) Staff X, indicating the Seroquel medications were re-evaluated with the provider. Record review of the progress notes failed to reveal evidence that the Seroquel medication was re-evaluated with the provider on 1/2/2026.During a surveyor interview on 1/14/2026 at 3:30 PM with LPN, Staff C, she revealed that she had signed that she re-evaluated the resident's Seroquel order with the provider, but she acknowledged that she had not. Additionally, she revealed that when the Seroquel orders were initially entered into the resident's record, they were entered for only 14 days.Additional review of the January 2026 MAR indicated that the last time the Seroquel order for twice daily was administered on 1/2/2026 at 1:00 PM and that the last time the Seroquel order for bedtime was administered was 1/1/2026 and both medication orders were no longer in place. Further review of the MAR indicated that the same Seroquel order for twice daily administration was ordered again, starting on 1/11/2026 and the same Seroquel order for bedtime administration, was ordered again on 1/10/2026.Review of the January 2026 MAR indicated that the resident failed to receive his/her Seroquel, as ordered, for a total of 8 days. During a surveyor interview on 1/14/2026 at 4:50 PM with the Director of Nursing Services, she acknowledged that the Seroquel orders were initially entered into the resident's record for only 14 days. Additionally, she indicated that when she reviewed the resident's record on 1/10/2026, she realized that the Seroquel orders were no longer in place, and that she had contacted the provider.

Based on surveyor observation, record review, and resident and staff interview, it has been determined that the facility failed to provide and prepare food in a form designed to meet individual needs for 2 of 4 residents reviewed with a physician's order for moderately thickened (honey) consistency fluids, Resident ID #s 49 and 19. Findings are as follows:Record review of the facility's diet manual states in part, .Thickened Liquids.Honey-like: Sticks to sides of a cup like honey. Pours very slowly, such as honey and cream soup.1. Record review revealed Resident ID #49 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, aspiration pneumonia (infection of the lungs caused by inhaling saliva, food, liquid, or vomit) and stroke.Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating s/he has severely impaired cognition. Additional review revealed that s/he was coughing or choking during meals and had complaints of difficulty with swallowing during the review period.Review of the care plan revealed a focus area initiated on 4/24/2025 indicating Resident ID #49 has a nutritional problem related to a swallowing issue which requires honey thickened fluids.Review of a physician's diet order dated 4/19/2025 revealed that Resident ID #49 requires honey thickened fluids.During a surveyor observation on 9/15/2025 at approximately 12:30 PM, Resident ID #49 was observed eating lunch in his/her room. S/he was observed picking up an 8-ounce (oz) mug of liquid off of the meal tray, which then spilled over the top of the mug along with a dry, white, powdery substance. S/he then proceeded to take a drink from the mug and immediately started coughing. The call light was immediately activated by the surveyor for staff assistance. Nursing Assistant (NA), Staff A, entered the room.During a surveyor interview immediately following the above observation with Staff A, she was unable to identify the consistency of the liquid provided to the resident to drink and requested to go ask the nurse. Staff A was observed mixing in the white, powdery substance as she brought the drink to Licensed Practical Nurse (LPN), Staff B to be observed. Staff B was asked by the surveyor what the consistency of the drink was, and she stated, I'm not sure, maybe nectar [mildly thickened fluid, a thinner consistency than honey thickened].Record review of a nursing progress note dated 9/15/2025 states, Resident observed coughing with nectar liquids at lunch. Liquids downgraded to pudding thickness [extremely thick fluids that hold their shape on a spoon and do not flow], speech eval [evaluation] requested with therapy team. Residents [family] made aware. Director of rehab aware and awaiting speech therapist eval at this time.Record review of a nursing progress note on 9/15/2025 states in part, .ordering a chest x-ray to rule out aspiration pneumonia.2. Record review revealed Resident ID #19 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, dysphagia (difficulty swallowing), acute respiratory failure, and aspiration pneumonia.Review of an MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15, indicating moderately impaired cognition.Review of the care plan revealed a focus area initiated on 6/9/2025 indicating Resident ID #19 has a potential for aspiration due to dysphagia with an intervention to provide a therapeutic diet as ordered, including the prescribed fluid consistency.Review of a hospice recommendation dated 6/2/2025 revealed that Resident ID #19 had a recommendation approved by the physician that states, please downgrade elder to honey thick for reoccurring aspiration pneumonia.Review of a physician's diet order dated 6/9/2025 revealed that Resident ID #19 requires honey thickened fluids.During a surveyor observation and interview on 9/15/2025 at approximately 12:50 PM, Resident ID #19 was observed eating lunch in his/her room. S/he was observed with an 8 oz clear plastic cup with a lid and a tea bag inside.Immediately following the above observation, the surveyor went a retrieved LPN, Staff C. Staff C poured the liquid out of the cup and was noted to pour freely and did not appear to be honey thickened. At that time, Staff C revealed that the drink appeared thickened at the bottom, the liquid on top was not, indicating it required mixing. She further revealed that the NAs prepare and thicken the drinks at bedside.Record review of a nursing progress note dated 9/15/2025 states, At approximately 12:50pm, resident observed with un-thickened fluid in mug near [him/her]. fluid removed, resident assessed with no visible signs of aspiration. lung sounds clear, will continue to monitor for any signs of aspiration x 72 hours. Fluid does not appear to have been consumed. monitoring ongoing.During a surveyor interview on 9/15/2025 at 12:58 PM with NA, Staff D, she revealed that she prepared the beverage for Resident ID #49 and mixed 1 packet of Thick & Easy into the mug of apple juice. Additionally, she indicated that when prepares the beverages for Resident ID #19, who also requires a honey thickened consistency liquid, she uses only a 1/2 packet of Thick & Easy. Furthermore, she did not know the number of fluid ounces contained in the beverage cups supplied by the facility, indicating she was unaware of how much thickening agent was required to achieve the desired consistency for Resident ID #s 19 and 49. Record review of a packet of thickener agent provided by the facility titled, THICK & EASY states in part, Directions: Add 1 packet.to 4fl oz of liquid. Stir with a spoon or fork for approximately 15 seconds or until thickener is dissolved. Allow 1-4 minutes for product to reach desired thickness.Honey-like Consistency: Add one packet to 4fl oz of liquid.During a surveyor interview on 9/15/2025 at 2:17 PM with the Director of Nursing Services, she revealed that she would expect the staff to prepare the beverages according to the prescribed orders and manufacturer's instructions.The facility's failure to provide and prepare foods in a form designed to meet individual needs for Resident ID #s 19 and 49 placed the residents at risk for more than minimal harm, impairment, injury, or death. Cross reference F 726.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident received adequate supervision for 1 of 1 resident reviewed who was able to successfully elope from the facility, Resident ID #15.Findings are as follows:Record review of a facility policy titled, Wandering and Elopements states in part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintain the least restrictive environment for residents.If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the residents' safety.If an employee observes a resident leaving the premises, he/she should.attempt to prevent the resident from leaving.get help from other staff members .inform charge nurse or director of nursing services.During a surveyor observation on 9/15/2025 at approximately 8:00 AM during the initial tour, revealed that the facility is equipped with a wander guard system which indicates that when a resident is wearing a wander guard device and attempts to exit the facility, an alarm will sound, alerting the staff.Record review revealed the resident was admitted to the facility in January of 2025 with diagnoses including, but not limited to, mild neurocognitive disorder, dementia, and anxiety.Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 5 out of 15, indicating s/he has severely impaired cognition. Additional review of the MDS revealed the resident requires the use of a wheelchair for ambulation.Record review of a progress note dated 9/1/2025, states in part, .resident found self wheeling in the parking lot. [S/he] was brought back to the unit by activity staff. [S/he] is currently in the dining room and on 15-minute checks.Record review of an assessment titled, Interim Elopement/Wandering Risk Evaluation dated 9/2/2025, revealed that the resident was at risk for Wander/Elopement.Record review of the resident's care plan revealed a focus area initiated on 9/3/2025 which states in part, I am at actual/potential risk for elopement [related to] wandering, with an intervention to apply a wanderguard device.Record review of a physician's order dated 9/3/2025 which states, Wander Bracelet: Check Placement of Wander Bracelet on wheelchair on every shift.During a surveyor observation on 9/16/2025 at approximately 12:30 PM, the resident was observed self-propelling in the parking lot away from the front door. During this observation, there were no staff observed to be supervising the resident. Further observation revealed there was no wander guard located on the resident's wheelchair, per the physician's order.During a surveyor interview on 9/16/2025 at approximately 1:00 PM with Nursing Assistant (NA), Staff L, she revealed that the resident was participating in activities in the main dining room. When the surveyor informed Staff L that there were no residents in the main dining room, she proceeded to ask multiple staff where the resident was. She then exited the facility from the main entrance to look outside and found him/her in the parking lot. Staff L introduced the surveyor to the resident and immediately went back into the facility, leaving the resident outside without staff supervision. During a subsequent interview with Staff L at approximately 1:40 PM, she revealed that she was unaware that the resident had an order for a wander guard bracelet and should not be outside without supervision.Review of the September 2025 Treatment Administration Record (TAR) revealed the physician's order to check the placement of the Wander Bracelet was documented as completed by Licensed Practical Nurse (LPN), Staff F, on the 7:00 AM to 3:00 PM shift on 9/16/2025, the day the resident was observed outside of the facility without his/her wander bracelet fastened to his/her wheelchair.During a surveyor interview on 9/16/2025 at approximately 2:00 PM with the Director of Nursing Services, she acknowledged that Resident ID #15 did not have a wander guard on his/her wheelchair and should not be outside unsupervised. Additionally, she could not provide evidence that the facility ensured that the resident received adequate supervision to prevent an elopement.During a surveyor interview with LPN, Staff F on 9/16/2025 at approximately 2:15 PM, she acknowledged signing off the order for the wander bracelet in the TAR as she had seen it attached to a wheelchair earlier in the day. However, she was unable to provide evidence that it was fastened to the wheelchair the resident was using at the time s/he exited the building.The facility's failure to provide adequate supervision and implement interventions for a cognitively impaired resident who is at risk for elopement and who has successfully eloped, placed him/her at risk for more than minimal harm, injury, impairment, or death.

Based on surveyor observation, and resident and staff interviews, it has been determined that the facility failed to maintain a safe and clean environment relative to 3 of 3 nursing units observed and the main building.Findings are as follows:During a surveyor observation on 9/15/2025 at approximately 8:00 AM, upon entrance to the main building, the state agency survey team was met with a noticeable foul and unpleasant odor that smelled distinctly of urine.Multiple surveyor observations on 9/15/2025, during the state agency survey team's initial tour, revealed the following observations, on the following units:South Unit:-8:31 AM: room [ROOM NUMBER] had a strong, unpleasant odor consistent with urine.East Unit:-9:57 AM: room [ROOM NUMBER] had a strong, unpleasant odor consistent with urine.West Unit:-10:33 AM: room [ROOM NUMBER] had a strong, unpleasant odor consistent with urine. The resident was observed with a saturated bed comforter and clothing. Additionally, a brownish discoloration was noted on the white bed linen.-10:56 AM: room [ROOM NUMBER] had a strong, unpleasant odor consistent with urine. Additionally, the bed linens were noted to have a brownish discoloration and dried tan/yellow stains. Further, particles of food that resembled scrambled eggs were scattered on the comforter and bed linens while the resident remained in his/her bed.-11:16 AM: room [ROOM NUMBER] had a strong, unpleasant odor consistent with urine. Additionally, the resident was observed resting in his/her bed and was noted to have a dried, tan/yellow colored stain on his/her white bed linens.Surveyor interviews on 9/15/2025 at 10:38 AM and 11:31 AM with Licensed Practical Nurse, Staff F, she acknowledged the above observations on the [NAME] Unit. During a surveyor interview on 9/16/2025 at approximately 3:45 PM with a small group of residents following the conclusion of the Resident Council task, the surveyor asked if they noted any unpleasant odors within the building and/or on the units, one resident who resides on the [NAME] unit stated, Yeah, It smells like pee!Additional surveyor observations throughout the survey process from 9/15/2025 through 9/18/2025, strong and unpleasant odors were noted in the main building and on all three nursing units.During a surveyor interview on 9/18/2025 at approximately 9:00 AM with the Administrator, he was unable to provide evidence that the facility maintained a safe and clean environment relative to the main building and the three nursing units.

Based on record review and staff interview, it has been determined that the facility failed to implement and maintain an effective, comprehensive, data-driven, Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. Additionally, the facility failed to make a good faith attempt to correct the identified concerns of patient care relative to call lights being answered, incontinence care, and morning care being provided.Findings are as follows:Review of a facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program last revised in February 2020, states in part, This facility shall develop, implement, and maintain an ongoing, facility wide, data driven QAPI program that is focused on indicators of outcomes of care and quality of life for our residents.identifying and prioritizing quality deficiencies.developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed.Review of a document titled, Quality Assurance Performance Improvement Action Plan initiated on 9/16/2024, revealed a problem that states, Surveyor identified one instance of a resident being saturated in urine in the morning, 4 instances of residents not being provided morning care until well after 12-2 PM and call bells not being answered timely.Further review revealed actions or interventions implemented as follows:- Reeducation was provided to facility leadership and scheduler to the sufficient nursing staff guidelines.- The facility assessment has been updated according to include a contingency plan for staffing.- Nursing staff re-educated to answer call lights timely and providing incontinent care before and after meals and as needed.- Audits will be completed to ensure timely incontinence care and morning care is being provided at a reasonable time.Review of the 2025 QAPI binder failed to reveal evidence that the QAPI committee discussed any of the above concerns after the January 2025 QAPI meeting.During a surveyor interview on 9/18/2025 at approximately 12:00 PM with the Administrator, he was unable to provide evidence of a good faith attempt to correct the identified concerns brought forth by the 2024 annual recertification survey and was unable to provide evidence of a comprehensive QAPI program that addressed the criteria to monitor nursing services and care concerns.Cross reference F 550, F 677, F 725, F 726, F 838 and F 919.

Based on record review and staff interview, it has been determined that the facility failed to implement the facility-wide assessment that is used to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.Findings are as follows:Record review of the facility's undated document Facility Assessment states in part, Staffing Guidelines.Our staffing pattern is further developed based on the assessed nursing care needs of our residents, acuity [the severity of an illness], and census [unit population]. The base staffing pattern represents typical staffing based upon the average daily census of the facility. The facility adjusts staffing based upon multiple factors, including but not limited to, shifts in resident census, acuity, communicable disease outbreaks, and admission or discharge volume.Staffing assignments are determined by looking at both census and acuity of the residents.The staffing pattern fluctuates when it is determined that one unit or shift needs additional assistance.Our staffing process includes ensuring that resident needs are met in the face of challenges related to call outs or emergent situations.1. During the resident council task completed on 9/16/2025 at approximately 2:00 PM, multiple residents complained about waiting long periods of time for staff to respond to their call lights, with an average wait time between 30 minutes to 1 hour. Additionally, one resident indicated it can take up to two hours. Further, the council complained about not receiving showers and/or care as needed, and the odor in the building, revealing it smelled like urine.Review of the staffing guidelines for the facility revealed there is a total of 9 Nursing Assistants (NA) on the 7:00 AM to 3:00 PM shift.Review of the nursing schedule from 9/15/2025 to 9/17/2025 revealed a total of 3 NAs scheduled to work on the South Unit, for a census of 30 residents, and 4 NAs to work on the [NAME] Unit, for a census of 40 residents.Review of the NAs' assignments for the South Unit revealed a total of 14 residents that require the use of a Hoyer lift (a mechanical lift requiring the use of two staff members to transfer a resident with limited mobility). Further review revealed 7 residents that requiring the use of a Hoyer are on one assignment.Review of an untitled document provided by the facility revealed that on the South Unit, 6 residents require assistance with meals.During surveyor observations from 9/15/2025 during the initial tour of the facility, multiple residents were noted to be in urine saturated sheets with dried, amber colored stains. Additionally, the observation revealed several residents appeared unkempt with food noted on their bedding.2. During the resident council task completed on 9/16/2025 at approximately 2:00 PM, the council complained about not receiving showers and/or care as needed.During a surveyor interview on 9/17/2025 at approximately 1:10 PM with Licensed Practical Nurse, Staff K, she revealed that no residents received a shower on the [NAME] Unit because they only have 3 NAs.During a surveyor observation and simultaneous interview on 9/17/2025 at 1:29 PM with NA, Staff N, she was observed providing morning care to a resident. Additionally, she revealed that the facility was short staffed.Surveyor observations from 9/15/2025 through 9/17/2025 failed to reveal evidence of residents receiving showers on the [NAME] and South Units.3. A surveyor observation on 9/16/2025 at 12:46 PM revealed, Resident ID #15 self-propelling out in the parking lot without supervision.Record review revealed that Resident ID #15 was at risk for elopement.During a surveyor interview on 9/16/2025 at approximately 2:00 PM with the Director of Nursing Services, she acknowledged that Resident ID #15 did not have a wander guard on his/her wheelchair and should not be outside unsupervised. During a surveyor interview on 9/17/2025 at 1:49 PM with the Director of Nursing Services (DNS), she was notified of the concerns related to the acuity of the residents and the staffing pattern.Review of the nursing staffing schedule on 9/18/2025, after the facility was notified of the concerns regarding the residents' acuity levels, revealed 4 NAs were scheduled for the South and [NAME] Units.During surveyor observations of the [NAME] and South Units on 9/18/2025 revealed residents receiving showers and morning care. During a surveyor interview on 9/18/2025 at 11:49 AM with the DNS, she was unable to provide evidence that the staffing pattern was adjusted based on the needs of the residents according to the facility assessment, until after it was brought to the facility's attention by the surveyor. Cross reference F 550, F 677, F 725 and F 689.

Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity (the severity of an illness), and diagnoses of the facility's resident population in accordance with the facility assessment as required for 4 staff members observed, affecting Resident ID #s 4, 19, 46, and 49.Findings are as follows:1A. Record review of the facility's diet manual titled, Thickened Liquids states in part, .Honey-like: Sticks to sides of a cup like honey. Pours very slowly, such as honey and cream soup.Record review revealed Resident ID #49 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, aspiration pneumonia (infection of the lungs caused by inhaling saliva, food, liquid, or vomit) and stroke.Review of a physician's diet order dated 4/19/2025 revealed that Resident ID #49 requires honey thick fluids.During a surveyor observation on 9/15/2025 at approximately 12:30 PM, Resident ID #49 was observed eating lunch in his/her room. S/he was observed picking up an 8-ounce (oz) mug of liquid off his/her meal tray, when the liquid with a dry white powdery substance spilled over the top of the mug. S/he then proceed to take a drink from the mug and immediately started coughing. The call light was immediately activated by the surveyor for staff assistance. Nursing Assistant (NA), Staff A entered the room.During a surveyor interview immediately following the above observation with Staff A, she was unable to identify the consistency of the liquid provided to the resident. Staff A was observed mixing in the white powdery substance as she brought the drink to Licensed Practical Nurse (LPN), Staff B to be observed. Staff B was asked by the surveyor what consistency the drink was, and she stated, I'm not sure, maybe nectar.1B. Record review revealed Resident ID #19 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, dysphagia (difficulty swallowing), acute respiratory failure, and aspiration pneumonia.Review of a physician's diet order dated 6/9/2025 revealed that Resident ID #19 requires honey thick fluid.During a surveyor observation and interview on 9/15/2025 at approximately 12:50 PM, Resident ID #19 was observed eating lunch in his/her room. S/he was observed with an 8 oz clear plastic cup with a lid and a tea bag inside. The liquid poured freely and did not appear to be thickened.Immediately following the above observation, the surveyor went a retrieved LPN, Staff C. Staff C poured the liquid out of the cup and was noted to pour freely and did not appear to be honey thickened. At that time, Staff C revealed that the drink appeared thickened at the bottom, the liquid on top was not, indicating it required mixing. She further revealed that the NAs prepare and thicken the drinks at bedside.During a surveyor interview on 9/15/2025 at 12:58 PM with NA, Staff D, she revealed that she prepared the beverage for Resident ID #49 and mixed 1 packet of Thick & Easy into the mug of apple juice. Additionally, she indicated that when she prepares the beverages for Resident ID #19, who also requires a honey thickened consistency liquid, she uses only a 1/2 packet of Thick & Easy. Furthermore, she did not know the number of fluid ounces contained in the beverage cups supplied by the facility, indicating she was unaware of how much thickening agent was required to achieve the desired consistency for Resident ID #s 19 and 49. Record review of a packet of the thickener agent provided by the facility titled, THICK & EASY states in part, Directions: Add 1 packet.to 4fl [fluid] oz of liquid. Stir with a spoon or fork for approximately 15 seconds or until thickener is dissolved. Allow 1-4 minutes for product to reach desired thickness.Honey-like Consistency: Add one packet to 4fl oz of liquid.During a surveyor interview on 9/15/2025 at 2:17 PM with Director of Nursing Services (DNS) she revealed that she would expect the staff to prepare the beverages according to the prescribed orders and manufacturer's instructions.2. Review of a facility policy titled, Administering Medications last revised in April of 2019, states in part, Medications are administered in a safe and timely manner, and as prescribed.Record review revealed that Resident ID #4 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia and intellectual disabilities.2A. Record review revealed a physician's order for Biotene Dry Mouth/Throat Liquid (Mouthwash) give 15 milliliters (ml) three times a day for comfort measures/dry mouth.Review of the Biotene Dry Mouth Oral Rinse label revealed a warning label that states, Do not swallow.During the medication administration task on 9/17/2025 at approximately 8:50 AM with Certified Medication Technician (CMT), Staff G, he was observed administering medication to Resident ID #4, he was observed to put a straw into the medicine cup with the mouth wash. The resident drank and swallowed the mouth wash.During a surveyor interview immediately following the above observation with Staff G, he indicated that the resident was given the mouth wash to drink due to the resident's inability to swish and spit out the mouth wash.2B. Record review revealed a physician's order for Haloperidol Lactate (antipsychotic) Concentrate 2 milligrams/milliliters (mg)/(ml), administer 0.25 ml to equal 0.5 mg two times a day. During a surveyor observation on 9/17/2025 at approximately 8:50 AM of CMT, Staff G was preparing medications to administer to the resident; he utilized the dropper for the liquid Haloperidol and put two full droppers into a medicine cup to equal 10 mg. When questioned by the surveyor about the dose being administered, he poured half the liquid Haloperidol into a second medicine cup to equal 2.5 ml or 5 mg. When questioned a second time about the dose being administered, Staff G acknowledged that the dose measured was 2.5 ml and not 0.25 ml, as ordered. He then threw both cups away and went to get assistance from the nurse. During a surveyor observation on 9/17/2025 at approximately 9:10 AM of LPN, Staff I she was observed to utilize the dropper for the liquid Haloperidol and measure between 0 and 1 mg of the liquid. When questioned by the surveyor about the dose being administered, Staff I acknowledged that there was no line to accurately measure 0.5 mg on the dropper. At this time Staff I got a smaller syringe and accurately drew up the 0.25 ml to equal 0.5 mg, as ordered.During a surveyor interview on 9/17/2025 at approximately 10:00 AM with the DNS, she acknowledged that Resident ID #4 should not have been given a straw to drink mouthwash and acknowledged that the mouthwash should not be swallowed. Additionally, the DNS revealed that she would expect Staff G and Staff I to utilize the appropriate size syringe to measure an exact dose of liquid medication to ensure proper dosage. 3. Review of a policy titled, Assistance with Meals dated 3/2022 states in part, .All employees who provide resident assistance with meals will be trained and shall demonstrate competency.During the entrance conference on 9/15/2025 at 8:58 AM, with the Administrator and the DNS, it was revealed that the facility does not have a paid feeding assistant program.Record review revealed that Resident ID #46 was readmitted to the facility in February of 2025 with a diagnosis including, but not limited to, dysphagia (difficulty swallowing).Record review revealed the resident requires a pureed textured diet.Review of the care plan for Resident ID #46, dated 6/9/2023 revealed that the resident is at risk for aspiration (medical term for when a fluid or solid accidentally enters your windpipe and lungs), due to a diagnosis of dysphagia and a history of a choking episode while eating breakfast. S/he is therefore at risk for pneumonia, malnutrition and/or dehydration. Additionally, the care plan revealed that Resident ID #46 has been noted to pocket foods (holding food in his/her mouth without swallowing it, increasing his/her risk for choking or pneumonia).During a surveyor observation on 9/17/2025 at 8:19 AM, the Life Enrichment Director, was observed assisting Resident ID #46 with his/her breakfast meal. Additionally, the Life Enrichment Director revealed that she has not been in a role that would have trained her to assist with meals and has not attended a state approved training program.During a surveyor interview on 9/17/2025 at 8:56 AM with the Staff Development Coordinator, she revealed that the Life Enrichment Director has not completed a competency for feeding assistance.Review of the Life Enrichment Director's online training failed to reveal evidence of training related to feeding assistance.During a surveyor interview on 9/17/2025 at 9:45 AM with the DNS, she was unable to provide evidence that the Life Enrichment Director received state approved training in feeding assistance. Additionally, she revealed that she would expect staff to receive specialized training prior to assisting a resident with meals.During a surveyor interview on 9/18/2025 at 11:49 AM with the DNS, she was unable to provide evidence that the above-mentioned staff provided competent care to Resident ID #s 4, 19, 46, and 49.Cross reference F-726, F-805, and F-811

Based on surveyor observation, record review, and resident and staff interviews, it has been determined that the facility failed to have sufficient nursing staff to assure resident safety and attain the highest practicable, physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care relative to providing care and responding to each resident's basic and individual needs for 1 of 3 nursing units reviewed, the South Unit. Findings are as follows:Record review of the Facility Assessment States in part, Staffing Guidelines.Our staffing pattern is further developed based on the assessed nursing care needs of our residents, acuity [the severity of an illness], and census [unit population]. The base staffing pattern represents typical staffing based upon the average daily census of the facility. The facility adjusts staffing based upon multiple factors, including but not limited to, shifts in resident census, acuity, communicable disease outbreaks, and admission or discharge volume.Staffing assignments are determined by looking at both census and acuity of the residents.The staffing pattern fluctuates when it is determined that one unit or shift needs additional assistance.Our staffing process includes ensuring that resident needs are met in the face of challenges related to call outs or emergent situations.Review of the nursing schedule from 9/15/2025 to 9/17/2025 revealed a total of 3 Nursing Assistants (NA) scheduled to work on the South Unit with a total census of 30 residents.Review of the NA's assignments for the South Unit revealed a total of 14 residents who require Hoyer lifts (a device designed to assist caregivers in safely transferring individuals with limited mobility. It is commonly used in healthcare settings and nursing homes, allowing caregivers to move residents from one place to another, such as from a bed to a wheelchair, a bath, or a chair.). Further review of this document states, .Reminder: 1) you need 2 assists when using a Mechanical lift [Hoyer lift] .Review of an untitled document provided by the facility revealed that on the South Unit, 6 residents require assistance with meals.During a surveyor interview on 9/18/2025 at 9:10 AM with the Staffing Coordinator, she revealed that 3 NAs is the base staffing for the South Unit.During the resident council task completed on 9/16/2025 at approximately 2:00 PM, multiple residents complained about waiting for long periods of time for staff to respond to their call lights with an average wait time between 30 minutes to 1 hour. Additionally, one resident indicated it can take up to two hours.1A. Record review revealed Resident ID #30 was admitted to the facility in October of 2023 with diagnoses including, but not limited to, osteoarthritis and adult failure to thrive.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Additionally, s/he is coded as dependent on staff for his/her activities of daily living (ADLs).During a surveyor interview on 9/15/2025 at approximately 8:31 AM with Resident ID #30, s/he revealed that s/he has been waiting for personal care for over an hour and is currently sitting in a puddle of piss. At this time, the resident rolled to his/her side to reveal a sheet noted with both dried and wet tan/yellow stains, a strong odor of urine was also noted. Additionally, s/he revealed that s/he is scheduled to receive a shower every Tuesday, on the 7:00 AM to 3:00 PM shift and s/he could not recall when s/he last received a shower. Further, the resident revealed that the facility staff provides his/her personal care while in their bed and only uses dry shampoo to wash his/her hair. The resident also indicated, in the past s/he would receive two showers per week.Record review of a facility document titled, South Unit 3 CNA [certified nursing assistants] Assignments provided by the facility revealed that Resident ID #30 was to receive a shower every Tuesday on the 7:00 AM to 3:00 PM shift and every Friday on the 3:00 PM to 11:00 PM shift.During a surveyor observation and subsequent interview on 9/16/2025 at 3:12 PM with Resident ID #30 s/he appeared ungroomed, with greasy hair and a strong odor of urine. S/he revealed that s/he did not receive a shower that day, which was his/her scheduled shower day. Record review failed to reveal evidence that Resident ID #30 received a shower on 9/16/2025, his/her scheduled shower day. Additionally, the record failed to reveal evidence that s/he was offered, received, and/or refused showers on his/her scheduled shower days.1B. Record review revealed Resident ID #73 was admitted to the facility in February of 2021 with a diagnosis including, but not limited to, osteoarthritis.Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. Additionally, s/he requires assistance from staff for his/her activities of daily living.During a surveyor interview on 9/17/2025 at 1:14 PM, with Resident ID #73, s/he revealed that s/he had not been provided with personal care during this shift. S/he further revealed that they came in to change his/her brief in the morning, but the staff did not wash him/her at that time.Record review of Resident ID #73's shower schedule revealed that s/he is to receive a shower twice a week, every Wednesday during the 7:00 AM to 3:00 PM shift and every Saturday during the 3:00 PM to 11:00 PM shift.Record review failed to reveal evidence that s/he was offered, received, and/or refused a shower on his/her shower days.During a surveyor interview on 9/17/2025 at 1:38 PM with NA, Staff J, she revealed that she was still trying to complete morning care for the residents on her assignment and would be completing Resident ID #73's morning care shortly. She further revealed that she had not completed any showers today on the South Unit because they only have 3 NAs scheduled and would not have the time2. Record review revealed Resident ID #15 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, mild neurocognitive disorder, dementia, and anxiety.Record review revealed that Resident ID #15 was at risk for elopement.A surveyor observation on 9/16/2025 at 12:46 PM revealed, Resident ID #15 was self-propelling out in the parking lot without supervision.During a surveyor interview on 9/16/2025 at approximately 2:00 PM with the Director of Nursing Services, she acknowledged that Resident ID #15 did not have a wander guard on his/her wheelchair and should not be outside unsupervised. Record review failed to reveal evidence that the staffing pattern fluctuates when it is determined that one unit or shift needs additional assistance as evidenced by the failures above which indicates that residents were not being provided with personal care and supervision as the facility did not have sufficient staff coverage. Cross reference F-550, F-677, F-689, and F-838.

Based on surveyor observation, record review, and resident and staff interviews, it has been determined that the facility failed to provide the necessary services to a resident who is unable to carry out Activities of Daily Living (ADLs) relative to bathing and personal hygiene for 6 of 6 residents reviewed, Resident ID #s 30, 34, 41, 69, 73, and 75. Findings are as follows:1. Record review revealed Resident ID #30 was admitted to the facility in October of 2023 with diagnoses including, but not limited to, osteoarthritis and adult failure to thrive.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Additionally, s/he is coded as dependent on staff for his/her ADLs. During a surveyor interview on 9/15/2025 at approximately 8:31 AM with Resident ID #30, s/he revealed that s/he has been waiting for personal care for over an hour and is currently sitting in a puddle of piss. At this time, the resident rolled to his/her side to reveal a sheet noted with both dried and wet tan/yellow stains, a strong odor of urine was also noted. Additionally, s/he revealed that s/he is scheduled to receive a shower tomorrow on the 7:00 AM to 3:00 PM shift and s/he could not recall when they last received a shower. Further, the resident revealed that the facility staff provides his/her personal care while in their bed and only uses dry shampoo to wash his/her hair. Record review of a facility document titled, South Unit 3 CNA [Certified Nursing Assistant] Assignments sheet provided by the facility revealed, Resident ID #30 was to receive a shower every Tuesday on the 7:00 AM to 3:00 PM shift and every Friday on the 3:00 PM to 11:00 PM shift.During a surveyor observation and subsequent interview on Tuesday, 9/16/2025 at 3:12 PM with Resident ID #30, s/he appeared ungroomed with greasy hair and a strong odor of urine was noted. S/he revealed that s/he did not receive a shower that day which was their scheduled shower day.Record review failed to reveal evidence that Resident ID #30 received a shower on 9/16/2025, his/her scheduled shower day. Additionally, the record failed to reveal evidence that s/he was offered, received, and/or refused showers on his/her scheduled shower days.2. Record review revealed Resident ID #34 was admitted to the facility in July of 2025 with a diagnosis including, but not limited to, legal blindness.Review of the admission MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15, indicating intact cognition.During a surveyor interview on 9/16/2025 at 2:36 PM with Resident ID #34, s/he revealed that they have only received two showers since July. Further, s/he indicated that the staff do not offer showers and only provide basic hygiene care in the room.Record review of the resident's shower schedule revealed s/he is to receive a shower every Wednesday, on the 7:00 AM to 3:00 PM shift.During a surveyor interview on 9/18/2025 at 11:30 AM with Resident ID #34, s/he revealed that s/he did not receive his/her scheduled shower on Wednesday, 9/17/2025.Record review failed to reveal evidence that Resident ID #34 received a shower on 9/17/2025, his/her scheduled shower day. Additionally, the record failed to reveal evidence that s/he was offered, received, and/or refused showers on his/her scheduled shower day.3. Record review revealed Resident ID #41 was admitted to the facility in May of 2024 with a diagnosis including, but not limited to, anxiety.Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15, indicating intact cognition. Additionally, s/he requires substantial assistance from staff for his/her ADLs.During a surveyor observation and subsequent interview on 9/17/2025 at 1:00 PM, with Resident ID #41, s/he was in bed, wearing a johnny. The resident revealed that s/he cannot remember the last time s/he received a shower. Additionally, s/he revealed that the staff have not provided personal care during the 7:00 AM to 3:00 PM shift. Record review of Resident ID #41's shower schedule revealed that s/he is to receive a shower twice a week, every Wednesday during the 7:00 AM to 3:00 PM shift, and every Saturday during the 3:00 PM to 11:00 PM shift. Record review failed to reveal evidence that Resident ID #41 received a shower on 9/17/2025, his/her scheduled shower day. Additionally, the record failed to reveal evidence that s/he was offered, received, and/or refused showers on his/her scheduled shower days.4. Record review revealed Resident ID #69 was admitted to the facility in August of 2025 with a diagnosis including, but not limited to, osteoarthritis.Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. Additionally, s/he requires substantial assistance from staff for ADLs and receiving showers is somewhat important to him/her.During a surveyor interview on 9/17/2025 at 1:00 PM, with Resident ID #69, s/he revealed that s/he has not received a shower at this facility since his/her admission in August. Additionally, s/he revealed that s/he had his/her brief changed but staff have not provided personal care during this shift. Record review of Resident ID #69's shower schedule revealed that s/he is to receive a shower once a week, every Monday during the 3:00 PM to 11:00 PM shift.Record review failed to reveal evidence that s/he was offered, received, and/or refused showers on his/her scheduled shower day.During a surveyor interview on 9/17/2025 at 1:08 PM with Licensed Practical Nurse, (LPN) Staff I, she revealed that morning care should have been completed for Resident ID #41, prior to 1:00 PM.5. Record review revealed Resident ID #73 was admitted to the facility in February of 2021 with a diagnosis including, but not limited to, osteoarthritis.Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. Additionally, s/he requires assistance from staff for ADLs.During a surveyor interview on 9/17/2025 at 1:14 PM, with Resident ID #73, s/he revealed that s/he had not been provided personal care during this shift. S/he further revealed that they came in to change his/her brief in the morning, but the staff did not wash him/her at that time.Record review of Resident ID #73's shower schedule revealed that s/he is to receive a shower twice a week, every Wednesday during the 7:00 AM to 3:00 PM shift and Saturday during the 3:00 PM to 11:00 PM shift.Record review failed to reveal evidence that s/he was offered, received, and/or refused showers on his/her scheduled shower days.During a surveyor interview on 9/17/2025 at 1:38 PM with NA, Staff J, she revealed that she was still trying to complete morning care for the residents on her assignment and would be completing Resident ID #73's morning care shortly. She further revealed that she had not completed any showers on the South Unit because they only have 3 NAs and would not have the time.6. Record review revealed Resident ID #75 was admitted to the facility in June of 2025 with a diagnosis including, but not limited to, Alzheimer's.Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 out of 15, indicating severely impaired cognition. Additionally, s/he requires substantial assistance from staff for ADLs.Record review of Resident ID #75's shower schedule revealed that s/he is to receive a shower once a week, every Wednesday during the 7:00 AM to 3:00 PM shift.Record review failed to reveal evidence that s/he was offered, received, and/or refused showers on his/her scheduled shower days.During a surveyor interview on Wednesday, 9/17/2025 at approximately 1:15 PM with LPN, Staff K, she revealed that no residents on the [NAME] Unit received showers on 9/17/2025 because they only had 3 NAs scheduled, and residents would only receive showers if there were 4 NAs scheduled to work.During a surveyor interview on 9/17/2025 at approximately 2:27 PM with the Director of Nursing Services, she revealed that residents should receive showers on their scheduled shower days. If a shower is missed or the resident refuses, the NA is expected to reattempt, and if unsuccessful, notify the nurse, who is expected to document that information in a progress note. Additionally, she revealed that staff should accommodate a resident who did not receive a shower on their scheduled shower day or if a resident requests an additional shower. Furthermore, she was unable to provide evidence that the above-mentioned residents were offered, received, and/or refused showers on their scheduled shower days.

Based on surveyor observation, record review, and staff and resident interviews, it has been determined that the facility failed to ensure that a resident's right to communication to promote a dignified existence was promoted for 1 of 1 resident reviewed whose primary language is [NAME], Resident ID #86. Additionally, the facility failed to ensure that a resident's right to a dignified existence was promoted for 4 of 4 residents observed with soiled bed linens, Resident ID #s 12, 26, 30, and 37.Findings are as follows:Review of the Facility's admission document last revised in 2021 states in part, .Resident rights.The resident has a right to be treated with respect and dignity.The resident has the right to receive notices orally.and in writing.in a format and a language he or she understands.The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide.Clean bed and bath linens that are in good condition.1. Record review revealed Resident ID #86 was admitted to the facility in December of 2021 with a diagnosis including, but not limited to, depression.Review of his/her care plan revealed a focus area dated 6/13/2023 indicating his/her primary language is [NAME].Additional review of the care plan revealed a focus area dated 3/11/2025 that indicated s/he is independent fulfilling his/her leisure time and will pursue personal interests with an intervention that includes to provide him/her with the daily chronicle.Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed, Section F - Preferences for Customary Routine and Activities was coded as Very important for him/her to have books, newspapers, and magazines to read.During a surveyor observation and simultaneous interview on 9/15/2025 at approximately 10:45 AM with the resident, s/he was observed seated in his/her room watching television. Additionally, a newsletter titled, THE DAILY CHRONICLE dated 9/15/2025 was observed on his/her bedside table, however, it was written in English. When questioned, the resident gestured to the surveyor that s/he speaks some English. Further, s/he indicated that s/he is unable to read the THE DAILY CHRONICLE newsletter and would like to receive it in his/her primary language.During an additional surveyor observation on 9/16/2025 at approximately 10:30 AM, the resident was noted to receive another newsletter of THE DAILY CHRONICLE dated 9/16/2025, in English.During a surveyor interview immediately following the above observation with Certified Medication Technician, Staff E, she acknowledged that the resident received THE DAILY CHRONICLE in English and indicated that she was unsure if the resident can read it.During a surveyor interview on 9/16/2025 at approximately 11:00 AM with the Life Enrichment Director, she revealed that the resident's primary language is [NAME] and would expect him/her to receive the newsletter in his/her primary language. During a surveyor interview on 9/18/2025 at approximately 12:30 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that Resident ID #86 received the newsletter in a language that s/he can understand to help promote a dignified existence.2a. Record review revealed Resident ID #30 was admitted to the facility in October of 2023 with diagnoses including, but not limited to, osteoarthritis and adult failure to thrive.Review of an admission MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Additionally, s/he is coded as dependent on staff for his/her activities of daily living (ADLs).During a surveyor observation and simultaneous interview on 9/15/2025 at approximately 8:31 AM, Resident ID #30 was observed lying in bed in his/her room. S/he revealed that s/he has been waiting for personal care for over an hour and is currently sitting in a puddle of piss. Additionally, s/he rolled to his/her side exposing the bed linens underneath him/her that revealed a tan/yellow stain and a strong odor of urine.2b. Record review revealed Resident ID #37 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, alcohol abuse and major depressive disorder.Review of an MDS assessment dated [DATE] revealed s/he is coded as dependent on staff for his/her ADLs.Review of a care plan focus area dated 3/25/2024 revealed that s/he refuses care at times with an intervention that includes to return in 5-10 minutes if s/he refuses ADL care.During a surveyor observation on 9/15/2025 at approximately 10:36 AM, Resident ID #37 was observed lying in his/her bed. Additionally, an overpowering, unpleasant odor that smelled of urine was noted. Further observation revealed the resident's clothing and bed linens were noted to be saturated and there was a brown colored discoloration observed on the sheet beneath him/her.During a surveyor interview immediately following the above observation with Licensed Practical Nurse (LPN), Staff F, she acknowledged the above observation. She revealed that Resident ID #37 often refuses care, and she was present when the Nursing Assistant (NA), Staff G, attempted to provide ADL care around 7:30-8:00 AM and the resident refused.During an additional surveyor observation on 9/15/2025 at approximately 11:32 AM of the resident, approximately one hour after the surveyor's initial observation, the resident was observed lying in bed with all linens stripped except for the fitted sheet, in which a large tan/yellow stain was observed. Further, the edges of the stain appeared to have dried, and the center remained saturated.During a follow up surveyor interview on 9/15/2025 at approximately 11:48 AM with Staff F, she acknowledged the above observation and revealed that she spoke with Staff G who informed her that Resident ID #37's care had been completed.During a surveyor interview on 9/15/2025 at approximately 12:03 PM with Staff G, he revealed that he was assigned to care for Resident ID #37 on 9/15/2025 during the 7:00 AM - 3:00 PM shift. He revealed that he attempted to provide ADL care for the resident around breakfast time and s/he refused. He further revealed that at 11:30 AM, he reattempted to provide ADL care to the resident, and s/he complied. He was unable to provide evidence that he reattempted to complete ADL care for the resident after s/he initially refused until approximately three and a half hours later, after the resident initially refused.2c. Record review revealed Resident ID #12 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, morbid obesity and cognitive communication deficit.During a surveyor observation on 9/15/2025 at approximately 10:56 AM, Resident ID #12 was observed lying in his/her bed. Additionally, the bed linens were observed to have dried tan/yellow discolorations. Further, particles of food that resembled scrambled eggs were scattered on the comforter and bed linens while the resident remained in his/her bed.During a surveyor interview on 9/15/2025 at approximately 11:47 AM with LPN, Staff F, she acknowledged the above observation.2d. Record review revealed Resident ID #26 was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, dementia.During a surveyor observation on 9/15/2025 at approximately 11:16 AM, Resident ID #26 was observed lying in his/her bed. Additionally, the bed linens were observed to have dried tan/yellow discolorations, and a strong odor of urine was noted.Record review revealed that Resident ID #26's care had been documented as completed, on 9/15/2025 at 11:12 AM.During a surveyor interview on 9/15/2025 at approximately 11:32 AM with NA, Staff H, she acknowledged the above-mentioned observation. Additionally, she revealed that she was assigned to care for Resident ID #26 at that time. Further, she acknowledged that she documented that she had completed his/her care although it was not completed and revealed it is not her normal practice to document tasks as completed if they are not done.During a surveyor interview on 9/18/2025 at approximately 12:30 PM with the DNS, she revealed that sometimes the bed linens they provide to residents are clean but are stained. She further revealed that she would expect that staff would reattempt to provide ADL care to a resident that refuses every 5-10 minutes if that's what the care plan indicates. Additionally, she was unable to provide evidence that Resident ID #s 12, 26, 30, and 37 received timely assistance with ADL care and clean bed linens to promote a dignified existence.

Based on record review, and resident and staff interview, it has been determined that the facility failed to explain the arbitration agreement to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands, for 2 of 12 residents reviewed for arbitration agreements, Resident ID #s 20 and 42.Findings are as follows:Review of a policy titled, Binding Arbitration Agreements last revised November 2023, states in part, .Upon admission, or any time during the resident's stay, the resident (or representative) may be presented with the opportunity to utilize a binding arbitration agreement to resolve disputes as long as the terms and conditions of the agreement comply with federal regulations.Binding arbitration agreements are voluntary for the residents. Residents are not compelled, pressured or coerced to enter into a binding arbitration agreement. It is unambiguously communicated to residents (or representatives) that binding arbitration agreements are optional and not required as a condition of admission or to receive care at this facility.The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a form and manner that he or she understands, taking into consideration the resident's (or representative's) language, literacy and stated preference for learning.A. Record review revealed Resident ID #20 was admitted to the facility in August of 2025 with a diagnosis including, but not limited to, stroke.Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.Review of a facility document titled, admission Packet, dated 8/26/2025 with an attachment titled, Alternative Dispute Resolution [ADR] Agreement Between Resident and Facility, revealed Resident ID #20 accepted and signed to enter into an arbitration agreement with the facility on 8/29/2025. Further review revealed a question which states, Facility representative has presented and explained the ADR to the Resident and/or Legal Representative, which was documented as No.During a surveyor interview on 9/17/2025 at 12:40 PM, with Resident ID #20, s/he revealed that s/he could not recall a facility representative explaining the arbitration agreement to him/her. Additionally, s/he was unaware that s/he had agreed to enter into a binding arbitration agreement with the facility and indicated that s/he would not have agreed to it.B. Record review revealed Resident ID #42 was admitted to the facility in July of 2025 with a diagnosis including, but not limited to, legal blindness.Review of an MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15, indicating intact cognition.Review of a document titled, admission Packet, dated 7/28/2025 with an attachment titled, Alternative Dispute Resolution Agreement Between Resident and Facility, revealed Resident ID #42 accepted and signed to enter into an arbitration agreement with the facility on 7/29/2025. Further review revealed a question which states, Facility representative has presented and explained the ADR to the Resident and / or Legal Representative, which was documented as No.During a surveyor interview on 9/17/2025 at 11:48 AM with Resident ID #42, s/he revealed that s/he could not recall a facility representative explaining the arbitration agreement to him/her. Additionally, s/he was unaware that s/he had agreed to enter into a binding arbitration agreement with the facility and indicated that s/he would not have agreed to it.During a surveyor interview on 9/17/2025 at 12:29 PM with the Admissions Director, she acknowledged that Resident ID #s 20 and 42's Alternative Dispute Resolution Agreement Between Resident and Facility forms documented that it was not explained to the residents. Further, she was unable to provide evidence that the facility explained the Alternative Dispute Resolution Agreement Between Resident and Facility, form to Resident ID #s 20 and 42, per policy and regulation, prior to both residents entering into a binding arbitration agreement.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 26 opportunities for errors observed during the medication administration task. Two errors occurred, resulting in an error rate of 7.69%, involving Resident ID #4.Findings are as follows:Review of a facility policy titled, Administering Medications last revised in April of 2019, states in part, Medications are administered in a safe and timely manner, and as prescribed.Record review revealed that the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia and intellectual disabilities.A. Record review revealed a physician's order for Biotene Dry Mouth/Throat Liquid (Mouthwash) give 15 milliliters (ml) three times a day for comfort measures/dry mouth.Review of the Biotene Dry Mouth Oral Rinse label revealed a warning label that states, Do not swallow.During a surveyor observation on 9/17/2025 at approximately 8:50 AM of Certified Medication Technician (CMT), Staff G, he was observed administering medications to Resident ID #4, he was observed to put a straw into the medicine cup with the mouth wash, and the resident swallowed the mouth wash.During a surveyor interview immediately following the above observation with Staff G, he indicated that the resident was given the mouth wash to drink, due to the resident's inability swish and spit out the mouth wash.During a surveyor interview on 9/17/2025 at approximately 10:00 AM with Licensed Practical Nurse (LPN), Staff I, she revealed that the resident is not able to swish and spit the mouth wash and it should be administered using a mouth swab.B. Record review revealed a physician's order for Haloperidol Lactate (antipsychotic) Concentrate 2 milligrams/milliliters (mg)/(ml), administer 0.25 ml to equal 0.5 mg two times a day. During a surveyor observation on 9/17/2025 at approximately 8:50 AM of CMT, Staff G was preparing medications to administer to the resident he utilized the dropper for the liquid Haloperidol and put two full droppers into a medicine cup to equal 10 mg. When questioned by the surveyor about the dose being administered, he poured half the liquid Haloperidol into a second medicine cup to equal 2.5 ml or 5 mg. When questioned a second time about the dose being administered, Staff G acknowledged that the dose measured was 2.5 ml and not 0.25 ml, as ordered. He then threw both cups away and went to get assistance from the nurse. During a surveyor observation on 9/17/2025 at approximately 9:10 AM of LPN, Staff I, she was observed to utilize the dropper for the liquid Haloperidol and measured between 0 and 1 mg of the liquid. When questioned by the surveyor about the dose being administered, Staff I, acknowledged that there was no line to accurately measure 0.5 mg on the dropper. At this time Staff I, got a smaller syringe and accurately drew up 0.25 ml to equal 0.5 mg, as ordered.During a surveyor interview on 9/17/2025 at approximately 10:00 AM with the Director of Nursing Services (DNS), she acknowledged that Resident ID #4 should not have been given a straw to drink the mouthwash. Additionally, the DNS revealed that she would expect Staff G and Staff I to utilize the appropriate size syringe to measure an exact dose of liquid medication. The DNS was unable to unable to provide evidence that the facility ensured each resident's medication regimen is free from a medication error rate of 5% or greater.Cross reference F 726

Based on record review, surveyor observation, and staff interview it has been determined that the facility failed to provide care that meets professional standards for 1 of 1 resident reviewed with a Peripherally Inserted Central Catheter (PICC line, a thin tube inserted into a vein in the upper arm and advanced to a large vein near the heart to deliver long-term intravenous treatments), Resident ID #79 and for 1 of 3 residents observed for wound care, Resident ID #83.Findings are as follows:1. Review of a facility policy titled, Central Venous Catheter Flushing and Locking last revised 10/2024 states in part, .Flush the catheter and aspirate [the procedure of drawing blood or fluid the procedure of drawing blood or fluid] for blood return prior to each infusion to assess catheter function.Record review revealed that Resident ID #79 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, sepsis (a life-threatening medical condition that occurs when the body's response to an infection becomes dysregulated and causes widespread inflammation, leading to tissue damage, organ failure, and potentially death) and peripheral vascular disease.During a surveyor observation on 9/17/2025 at 9:26 AM, Licensed Practical Nurse, Staff F, flushed both lines of the resident's PICC line with normal saline but failed to aspirate for blood return. After flushing the lines, she infused an antibiotic through the line.During a surveyor interview immediately following the above observation with Staff F, she acknowledged that she did not aspirate for blood return and was unaware if it was the facility's policy.During a surveyor interview on 9/17/2025 at 9:52 AM with the Director of Nursing Services (DNS), she revealed that she would expect Staff F, to aspirate for blood return on a PICC line prior to administering medication per the facility policy.2. Record review revealed that Resident ID #83 was readmitted to the facility in February of 2025 with diagnoses including, but not limited to, multiple sclerosis and anxiety.According to, [NAME], et al. (2007). Skin adhesives and their role in wound dressings. https://wounds-uk.com, states in part, Tissue trauma caused by the removal of adhesive tapes and dressings is known to increase the size of wounds, exacerbate wound pain and delay healing.Record review revealed a physician's order to cleanse his/her coccyx with normal saline, pat dry, apply zinc, and a bordered gauze to the excoriation on his/her buttocks daily.During a surveyor observation on 9/16/2025 at 10:11 AM of LPN, Staff I, and the Assistant Director of Nursing, during wound care they cleansed the wound with normal saline, applied zinc and then covered with a bordered gauze. The bordered gauze did not cover the excoriation on Resident ID #83's buttocks and the adhesive was applied directly to the excoriated skin.During a surveyor interview directly following the above observation of wound care with Staff I, she acknowledged that she applied the bordered gauze to the excoriated skin on the resident's buttocks and acknowledged that she should not have.Record review revealed that the resident was evaluated by the wound physician on 9/17/2025 and the order was changed to omit the dressing.During a surveyor interview on 9/18/2025 at 12:44 PM with the DNS, she was unable to provide evidence that the facility provided care that meets professional standards relative to wound care for Resident ID #83.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident with a known complicated feeding problem is assisted by a qualified staff member for 1 of 2 residents observed being assisted with feeding, Resident ID #46.Findings are as follows:Review of a policy titled, Assistance with Meals dated 3/2022 states in part, .All employees who provide resident assistance with meals will be trained and shall demonstrate competency.During the entrance conference on 9/15/2025 at 8:58 AM with the Administrator and the Director of Nursing Services (DNS), it was revealed that the facility does not have a paid feeding assistant program.Record review revealed that Resident ID #46 was readmitted to the facility in February of 2025 with a diagnosis including, but not limited to, dysphagia (difficulty swallowing). Record review revealed the resident requires a pureed textured diet.Review of the resident care plan dated 6/9/2023 revealed that the resident is at risk for aspiration (inhalation of something into the airway) due to a diagnosis of dysphagia and a history of a choking episode while eating breakfast. S/he is therefore at risk for pneumonia, malnutrition, and/or dehydration. Additionally, the care plan revealed that Resident ID #46 has been noted to pocket foods (holding food in his/her mouth without swallowing it, increasing his/her risk for choking or pneumonia).During a surveyor observation and simultaneous interview on 9/17/2025 at 8:19 AM with the Life Enrichment Director, she was observed assisting Resident ID #46 with his/her breakfast meal. Additionally, the Life Enrichment Director revealed that she has not been in a role that would have trained her to provide feeding assistance to residents and has not completed a state approved paid feeding assistant program.During a surveyor interview on 9/17/2025 at 8:56 AM with the Staff Development Coordinator, she revealed that the Life Enrichment Director has not completed a competency for feeding assistance.Review of the Life Enrichment Director's online training failed to reveal evidence of training related to feeding assistance.During a surveyor interview on 9/17/2025 at 9:45 AM with the DNS, she was unable to provide evidence that the Life Enrichment Director received state approved training for feeding assistance. Additionally, she revealed that she would expect staff to receive specialized training prior to assisting a resident with meals.

Based on record review and resident and staff interview, it has been determined that the facility failed to ensure that residents receive adequate supervision to prevent an elopement for 1 of 1 resident reviewed who successfully eloped from the facility, Resident ID #2. Findings are as follows: Review of a facility policy titled, Wandering and Elopement dated March 2019, states in part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .If identified as at risk for wandering, elopement, or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety . Record review failed to reveal evidence of a facility policy relative to escorting residents to medical appointments. Review of a community reported complaint dated 5/6/2024 alleged that the resident went to an appointment in the community on 5/3/2024 unaccompanied by facility staff and his/her whereabouts were unknown. Record review revealed that the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, mild cognitive impairment, schizoaffective disorder, and unsteadiness on feet. Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 11 out of 15, indicating moderately impaired cognition. Review of a care plan dated 12/21/2023, revealed I am at actual/potential risk for elopement r/t [related to] attempt to leave the building without informing staff. Record review revealed the following physician's orders: 2/27/2024 - resident may go on a leave of absence with a responsible party 3/13/2024 - Wander Bracelet (WanderGuard): Check function of wander bracelet (left ankle) every day, one time a day for elopement risk Review of a Elopement/Wandering Risk Evaluation dated 3/16/2024 revealed s/he is at risk for elopement with an intervention for a wander bracelet. Review of a Neuropsychological Evaluation dated 1/11/2024 revealed that the resident lacks the capacity to make decisions for his/her medical care. Additionally, that his/her cognitive difficulties with functional decline are consistent with a diagnosis of major neurocognitive disorder. Further review revealed recommendations that include, but are not limited to, a surrogate for medical decision making should be activated, s/he requires supervision that would best be achieved through a residential setting such as a nursing facility and the resident is strongly encouraged to abstain from drug use. Record review failed to reveal evidence that interventions were implemented relative to the facility providing a responsible party for the resident during a leave of absence. Review of a progress note dated 2/24/2024 revealed that the resident was found outside of the facility on a main road attempting to catch the bus. Additionally, the progress note indicated the staff were unaware that the resident was not in the building at the time. The resident was then placed on 15-minute checks for 5 days. Review of a community reported allegation dated 5/3/2024 states in part, .[Resident] has noted cognitive deficits, baseline confusion, and incapacity, as well as various other concerns. [Resident] requires walker to ambulate but frequently does not use it .on today's date 5/3/24 .upon arrival, [Resident] was sitting in the waiting area of [Facility] They indicated they had an appointment .[Resident] had attempted to abscond from [Facility] a few months ago and this [Worker] recommended to facility that [Resident] not be transported to appointments at this time .Several hours later .received a phone call that [Resident] never attended their appointment .their current whereabouts are unknown .[Resident] was reportedly spotted at their apartment complex but is not believed to be there presently. At this time, [Residents] whereabouts are unknown . During a surveyor interview on 5/7/2024 at approximately 9:55 AM with the resident s/he revealed that s/he was transported to his/her appointment alone and when s/he arrived at the appointment s/he was informed that it was cancelled. S/he revealed that s/he took three buses to go to his/her home and then went to eat at a restaurant. During a surveyor interview with the Assistant Director of Nursing on 5/7/2024 at 10:40 AM she revealed that prior to the resident leaving for his/her appointment in the community on 5/3/2024 his/her wanderguard was removed in case something happened and s/he was admitted to the hospital, so that the facility would have possession of the device, because wanderguards are expensive. During a surveyor interview on 5/7/2024 at 12:10 PM with the Administrator she acknowledged that the resident was dropped off for an appointment without facility staff accompanying him/her. Additionally, she acknowledged that the resident had previously left the building without staff knowledge and was care planned as an elopement risk. During a surveyor interview on 5/8/2024 at 10:26 AM with Social Worker, Staff A, she revealed that she drove to Resident ID #2's apartment on 5/3/2024 and s/he was not there. Additionally, she revealed that she was driving around and found the resident standing on the corner of a highly traveled main road approximately 8 miles from the facility. Staff A indicated that she located the resident at 1:24 PM. During a surveyor interview on 5/7/2024 at 3:05 PM with the Medical Director he revealed that he was unaware that the resident had been dropped off for an appointment alone and was unaware that s/he had been missing for several hours. Additionally, he revealed that he would expect a resident who is care planned as an elopement risk be accompanied by a staff member when leaving the building. During a surveyor interview on 5/7/2024 at approximately 2:00 PM with the Administrator she was unable to provide evidence that Resident ID #2 received appropriate supervision to prevent an elopement. Due to the facility's failure to provide adequate supervision to a cognitively impaired resident who was assessed as an elopement risk resulted in this resident to be unsupervised in the community. The resident left an appointment and took several buses to multiple locations. This resident was found by facility staff standing on the corner of a highly traveled main road approximately 8 miles from the facility which placed the resident at risk for more than minimal harm, impairment, or death. 46338

Based on record review and staff and resident interview it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 1 of 4 residents reviewed, Resident ID #6. Findings are as follows: Review of a community reported complaint sent to the Rhode Island Department of Health on 6/28/2023 alleges that Resident ID #6 had not been receiving his/her medication as ordered. Review of the packaging insert for Keppra, last revised in January 2023, states in part, Medication Guide .Do not stop KEPPRA without first talking to a healthcare provider. Stopping KEPPRA suddenly can cause serious problems. Stopping a seizure medicine suddenly can cause seizures . 1A. Record review revealed the resident was admitted to the facility in May of 2023 with diagnoses including, but not limited to, urinary tract infection (UTI) and Parkinson's disease. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident is cognitively intact. Record review revealed that on 6/8/2023 the resident was found to have seizure activity for approximately 2 minutes and sent to the hospital for an evaluation. Further record review revealed the resident was diagnosed with a UTI and started on oral antibiotics. Record review of a progress note authored by the Nurse Practitioner, dated 6/13/2023 revealed a new order was received from the resident's neurologist to .start Keppra 500 milligram (mg) tablet at bedtime for seven days, then 500 mg tablet twice daily for seizure management . Record review of the June 2023 Medication Administration Record (MAR) revealed the following physician's orders: - levetiracetam (Keppra) 500 mg by mouth at bedtime for seizure for 7 days, with a start date of 6/13/2023 - levetiracetam (Keppra) 500 mg by mouth two times a day for seizure, with a start date of 6/21/2023 Further review of the June 2023 MAR revealed the resident did not receive the above mentioned medication on 6/20/2023 or the morning of 6/21/2023. Record review revealed that on 6/26/2023 the resident was found to have seizure activity lasting approximately 2 minutes and a fall. Further record review revealed the resident was sent to the hospital for treatment related to the seizure and fall. Record review of the hospital documentation dated 6/26/2023 revealed the resident was evaluated and a CT scan (imaging that helps detect disease and injury) was performed. Further review revealed recommendations for the resident to follow up with his/her primary care provider in 1-2 days. During a surveyor interview on 6/28/2023 at 4:29 PM with Registered Nurse, Staff D she indicated that she transcribed the above mentioned medication order incorrectly. She further indicated that the Keppra 500 mg twice a day order should have started on 6/20/2023 in the morning instead of 6/21/2023 in the evening. Additionally, she acknowledged that the resident missed 3 doses of the medication. During a surveyor interview on 6/28/2023 at 3:37 PM with the Nurse Practitioner, she indicated that the Keppra 500 mg twice a day should have started on 6/20/2023 in the morning and would expect the medication to be administered as ordered. She further indicated that she was unaware that the resident missed 3 doses of the seizure medication and would have expected to be notified of the missed doses. During a surveyor interview on 6/28/2023 at approximately 5:00 PM with the Regional Director of Nursing Services, she acknowledged the above mentioned order was transcribed incorrectly and that the resident missed 3 doses of the seizure medication. 1B. Record review of a care plan dated 6/9/2023 revealed that the resident was receiving antibiotic therapy related to a UTI with an intervention to administer medications as ordered. Review of a physician's order dated 6/12/2023 for Imipenem-Cilastatin (antibiotic) Intravenous (IV) Solution 500 milligrams (mg) intravenously every 8 hours for ESBL (a bacteria in the urine) for 21 days. The above order was discontinued on 6/27/2023 and a new order for Imipenem-Cilastatin was ordered on 6/27/2023 with a new end date. Review of a physician's order dated 6/27/2023 for Imipenem-Cilastatin Intravenous Solution 500 milligrams intravenously every 8 hours for ESBL until 7/4/2023. Review of the June 2023 MAR revealed the medication was not administered as ordered on the following dates and times: -6/25/2023 at 2200 (10 PM) -6/26/2023 at 1400 (2 PM) -6/26/2023 at 2200 -6/27/2023 at 0600 (6 AM) -6/27/2023 at 1400 -6/27/2023 at 2200 During a surveyor interview on 6/28/2023 at approximately 1:00 PM with the resident, s/he revealed that s/he recently missed several doses of his/her IV antibiotics and was concerned about his/her health related to the missed doses. During a surveyor interview on 6/28/2023 at approximately 1:35PM with Registered Nurse, Staff D she acknowledged the resident missed several doses of the above medication as ordered. She further indicated that a physician was not notified of the missed dosed until 6/27/2023. During a surveyor interview on 6/28/2023 at 3:37 PM with the Nurse Practitioner, she indicated that she wasn't made aware of the first 4 missed doses until the morning of 6/27/2023 and would have expected to be notified after the first missed dose. She indicated that subsequently on 6/27/2023, the order's end date was adjusted for the missed doses. Additionally, she revealed that she was contacted regarding the resident on 6/26/2023 however was not made aware that the ordered medication was unavailable and not administered. During a surveyor interview on 6/28/2023 at 5:40 PM with the Director of Nursing Services, she could not provide evidence that the resident received the above mentioned doses of the medication as ordered or that the physician was notified of the missed doses.

Based on record review and staff interview, it has been determined that the facility failed to ensure residents are free from accident hazards for resident's who require assistance devices to prevent accidents for 1 of 3 resident's reviewed, Resident ID #1. Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/18/2023 alleges, per EMS [emergency medical services] on February 17, 2023 while patient was being transferred to a bed in a nursing home [his/her] right leg was caught between the rail and was twisted and also sustained an open compound wound. Findings are as follows: Review of a facility policy titled, Safe Patient Handling states in part, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .2. Manual lifting of residents shall be eliminated when feasible . Record review revealed that the resident was admitted to the facility in June of 2018 and has diagnoses including, but not limited to, lack of coordination, difficulty walking, osteoarthritis, other abnormalities with gait and mobility, and localized edema of the lower extremities. Review of the quarterly Minimum Data Set (MDS) Assessment (entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated 2/7/2023 revealed a Brief Interview for Mental Status score of 13 indicating that the resident is cognitively intact. The MDS further indicates that the resident is totally dependent, requiring the assistance of two persons for transfers. Review of a Safe Patient Handling assessment dated [DATE] revealed that the resident is dependent and requires more than 50% assistance or is unpredictable in the amount of assistance offered and assistive devices should be used. The assessment further revealed in part, .if any caregiver is required to lift more than 35 pounds of a patient's weight, then the patient should be considered to be fully dependent, assistive devices should be used .Patient is cooperative, stand and pivot technique with a powered stand assist lift with 2 caregiver . Record review revealed a progress note dated 2/17/2023 at 9:21 PM that states in part, .writer was calling to help two staff members with a transfer, elder right leg got twisted during transfer while [s/he] tried to turn to seat in bed, elder screamed my leg when checked writer noticed blood and skin tear . Review of a hospital document dated 2/17/2023 states in part, .Per EMS, patient was at NH [nursing home] being transferred from bed to bed when [his/her] R [right] foot got stuck in the rail, [his/her] leg twisted, and [his/her] leg broke. Patient has open tib-fib [tibia/fibular] fracture to RLE [right lower extremity] . During a surveyor interview with Certified Nursing Assistant (CNA) Staff A on 2/21/2023 at 12:01 PM, she revealed that she, another CNA and the nurse were transferring the resident from the wheelchair to the bed when the resident screamed and she noted that the resident had a large skin tear. Staff A further indicated that the resident requires a two person assist and the staff do not use any mechanical devices for transfers for this resident. During a surveyor interview with CNA Staff B on 2/21/2023 at 1:03 PM, she revealed that she, another CNA and the nurse were transferring the resident from the wheelchair to the bed, the resident screamed and was bleeding. Staff B further indicated that they did not use a mechanical device to assist with the transfer. During a surveyor interview with Licensed Practical Nurse Staff C on 2/21/2023 at 10:05 AM, she revealed that she and two CNA's transferred the resident from the wheelchair to the bed without the use of a mechanical device for assistance. Staff C further indicated that during the transfer, the resident reported that his/her leg was twisted and there was a lot of blood noted. During a surveyor interview with the Director of Nursing Services (DNS) on 2/21/2023 at 10:15 AM, she acknowledged that the Safe Patient Handling assessment indicated that the resident required a stand and pivot technique with the use of a powered stand assist lift and two caregivers for transfers. The DNS further indicated that the staff did not utilize any mechanical devices for the transfer and the resident was sent out to the hospital for an open leg wound.