Every finding on record at Huntington Health and Rehabilitation Center

Based on observation and staff interviews, the facility failed to provide respiratory care in accordance with professional standards of practice, by not properly labeling and/or storing respiratory equipment. This failed practice was found true for (3) three of (4) four residents reviewed for respiratory compliance during the Long-Term Care Survey Process. Resident identifiers #92, #1, and #14. Facility Census 181. Findings include: a) Resident #92 The initial observation on 04/05/26 at 1:30 PM, revealed an oxygen concentrator in Resident #92's room. The oxygen tubing was on the resident. Neither the tubing nor the storage bag was dated. Further observation revealed a breathing treatment machine lying in a Geri chair with a mask not in a bag, as well as a Continuous Positive Airway Pressure (CPAP) machine with the mask lying on the nightstand, not in a bag. During an interview on 04/06/26 at 1:30 PM, Registered Nurse (RN) #76 stated, Respiratory Therapy takes care of the labeling and changing the bags. I think they do that on Wednesday. RN #76 further confirmed that the oxygen tubing was not labeled and none of the respiratory equipment was stored properly. b) Resident #1 physician orders read: Change and date oxygen tubing, and clean filter once a week. As needed if soiled or broken. c) Resident #14 physician orders read: Change and date oxygen tubing, and clean the filter weekly, every day shift every Monday Resident #1, 4/06/2026 3:04 PM Observation: Oxygen tubing has no date indicating when it was changed. Baggie on concentrator has a date of 03/25/26. Registered nurse (45) verified that there was not date of change on tubing. Resident #14 4/06/26 2:50 PM Observation: Oxygen tubing has no date indicating when it was changed. Baggie on concentrator has a date of 03/25/26. Registered nurse (45) verified that there was not a date of change on tubing.

Based on observation, record review, and staff interview, the facility failed to record the disposition of all controlled drugs within accepted standards of practice. This was a random opportunity for discovery. Additionally, the facility failed to provide pharmaceutical services to meet the needs of each resident. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: #62. Facility Census: 181. Findings included: a) Controlled substances The facility's policy titled, Controlled Substances, with effective date September 2018 and Revision Date August 2020, stated when a controlled substance is administered, the licensed nursing personnel administering the medications should immediately enter the removal of the medication on the accountability record. On 04/08/2026 at 9:14 AM, the fourth floor A cart was inspected with Licensed Practical Nurse (LPN) #88 in attendance. LPN #88 had just completed her morning medication pass from the cart. As part of the inspection, the surveyor asked to compare the amount of medication indicated on the Controlled Drug Administration Record with the amount of medication actually contained in the locked controlled substance drawer in the cart. Each controlled substance has a Controlled Drug Administration Record for the nurse administering the medication to record the date and time of the medication administration, the amount of medication used, and the amount of medication remaining in the locked controlled substance drawer in the cart. The medication is also signed out on the Medication Administration Record (MAR) after the resident has taken the medication. For Resident #62, the Controlled Drug Administration Record showed 16 tablets of lorazepam (Ativan) 1 milligram (mg) should be remaining in the drawer. However, only 15 Lorazepam 1 mg tablets were remaining in the controlled substance drawer in the cart. LPN #88 stated she had administered an Ativan tablet to Resident #62 that morning but did not sign it out on the administration record. LPN #62 stated, I'm going to be honest. I haven't signed out any [controlled substances] that I gave this morning.On 04/08/2026 at 9:27 AM, the Director of Nursing confirmed controlled substances should be signed out on the Controlled Drug Administration Record when removed from the controlled substances drawer for administration to the resident. No further information was provided through the completion of the survey process. b) Resident #62 Review of Resident #62's physician's orders showed an order written on 07/10/25 for Ritalin (methylphenidate), 5 mg, three (3) tablets, two (2) times a day for restlessness related to anxiety disorder related to dementia with psychotic disturbance. The medication was scheduled to be given at 6:00 AM and 12:00 PM. Review of Resident #62's MAR for March 2026. showed the notation 9 for Ritalin administration on the following dates and times: - 03/04/26 at 12:00 PM- 03/04/26 at 6:00 AM - 03/10/26 at 6:00 AM- 03/15/26 at both 6:00 AM and 12:00 PM- 03/16/26 at both 6:00 AM and 12:00 PM- 03/17/26 at both 6:00 AM and 12:00 PM- 03/28/26 at both 6:00 AM and 12:00 PM According to the MAR legend, the notation 9 means see progress note. A progress note written on 03/04/26 at 2:30 PM stated Awaiting from pharmacy. A progress note written on 03/05/26 at 8:47 AM stated Unavailable in Omnicell, on order from pharmacy. A progress note written on 03/10/26 at 11:01 AM stated, Awaiting from pharmacy.A progress note written on 03/15/26 at 10:48 AM stated Awaiting from pharmacy. A progress note written on 03/15/26 at 3:17 AM stated Awaiting from pharmacy. A progress note written on 03/16/26 at 8:45 stated, On order from pharmacy, unavailable in Omnicell. A progress note written on 03/16/26 at 12:24 PM stated, New script signed by [physician] and faxed to pharmacy. Unavailable in omnicell. A progress note written on 03/16/26 at 12:41 PM stated Awaiting pharmacy, no supply. A progress note written on 03/17/26 at 8:14 AM stated On order. A progress note written on 03/17/26 at 12:41 PM stated Awaiting pharmacy, no supply. Additionally, Resident #62's MAR for April 2026 also showed the notation 9 for the resident's morning administration of Ritalin on 04/08/26. A progress note written on 04/08/26 at 9:00 AM stated Resident's Ritalin is out of stock at this time. Awaiting from pharmacy. Provider notified. Additonally, the Controlled Drug Administration Records for Resident #62's Ritalin showed the medication had been signed out twice on 03/05/26 and 03/10/26 at 1:00 PM and 9:00 PM. The MAR only shows one (1) administration of Ritalin for those days. On 04/08/2026 at 2:06 PM, the Director of Nursing (DON) stated she was unable to explain why Ritalin was not available from the pharmacy on the above-referenced days. The DON also stated the provider should have been contacted when the medication was not given and on 03/05/26 and 03/10/26 to provide orders to administer the medication outside of the scheduled times. No further information was provided through the completion of the survey process.

Based on observation, resident interview, record review (recipes, production sheets) and staff interviews, this facility failed to ensure menus, recipes and production sheets are being followed. This was found during the Long term Care Survey Process. Facility census: 181. Findings include:A review of the menu for day 11 of the cycle revealed the following for Lunch: For regular consistency diets- Ziti with meat sauce, Italian blend vegetables, vanilla pudding.For Consistent carbohydrate diets (CCD) -Ziti with meat sauce, Italian blend vegetables, diet vanilla pudding. For Renal diets- Hamburger on bun, Italian blend vegetables, vanilla pudding. Review of menu for day 17 of the menu cycle: Lunch- For regular consistency diets- Baked fish, sweet potatoes, collard greens, angel food cake. For CCD diets- Baked fish, sweet potatoes, collard greens, angel food cake. For renal diets: Baked fish, buttered pasta, mixed vegetables, angel food cake. Review of recipe for ziti with meat sauce- ingredients- oil olive, pasta penne, oil salad, garlic chopped natural, onion fresh yellow, carrot diced frozen, tomatoes crushed, tomato diced in juice, salt, oregano leaves, fresh basil, sugar, beef ground, pork ground. Review of recipe for baked fish- Pangasius fish, margarine, black pepper, and paprika. Observations during meal preparation in the kitchen: Observation resumed in the department for meal service at 11:15 AM on 04/08/26. The surveyor observed [NAME] #124 and questioned them regarding the ingredients used to prepare this meal. He reports I ground the hamburger so I did not have to worry about the chopped diets, added some seasoning, poured tomato sauce over the noodles and baked it. Adding cheese at the end. Questioned if he reviewed recipe prior to meal preparation and he denied reporting I didn't see one. Reviewed the recipe for today's meal-ziti with meat sauce-with the manager; the dietary manager verified that the recipe had not been followed. Tray line service began- 12:10 PM. During this time, Server #118 did not use the correct scoop size; it needed 8 oz and 12 oz per the production sheet. The surveyor observed that all 10 trays were incorrect. At 12:25 PM, the manager corrected each one and then took over the tray line. Server #118 assisted in ensuring all other components of the meal were ready for service : chopped vegetables and puree meal. Observation continues in the department for meal service on 04/13/2026 at 11:00 AM. Observed Regional Dietary Manager assisting with meal being prepared for day as the day shift cook left. Menu for day- baked fish observed a breaded fish was being prepared for all diets. Questioned Dietary manager regarding the use of breaded fish for all diets and not the baked fish per recipe. The manager reported They like this pub style fish better, but I should have used the un-breaded for the CCD and renal diets. Dietician in facility, this surveyor questioned her regarding using the pub style breaded fish for all diets, she reported I did not realize they were not using the un-breaded for these diets.

Based on observation, resident interview, record review, and staff interview the facility failed to ensure meals were served in a palatable manner and a safe and appetizing temperature to ensure resident satisfaction. This was found during the Annual Survey Process.(Resident indicators- #1, #13, #31, #48 #125) (Census181) Findings include: Review of the Food Temperature Policy and Procedure Manual revealed The temperature of all food items will be taken and properly recorded prior to service of each meal. Procedures read in part: All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit (F). All cold food items must be stored at a temperature of 41 degrees (F) or below.Temperatures should be taken periodically to ensure hot foods stay above 135 degrees (F) and cold foods stay below 41 F during the holding and plating process and until food leaves the service area. Foods sent to the units for distribution (such as meals) will be transported and delivered to the unit to maintain temperatures at or below 41 degrees (F) for cold foods and at or above 135 degrees (F) for hot foods. On 04/06/26 at 2:00 pm the surveyor observed the lunch meal service being served. The meal consisted of the following:Herbed breaded pork chop, stuffing, diced carrots, and Jell-O. Meal served: nonbreaded pork chop to all residents on the unit. During an interview with Resident #149 the resident reported, This pork chop is not even breaded and it is really tough. Resident #31 reported, I don't see any breading on the pork chop, I was hoping for some and I hoped it wouldn't be so tough.Resident #125 reported, They did not even bread these tough chops. I can't chew thisReviewed with the dietary manager, she verified they did not prepare the breaded pork chop. On 04/07/26 at 2:05 PM observation of the served lunch meal revealed it consisted of grilled chicken, mashed potatoes, and cauliflower. Menu for lunch for regular consistency diet: grilled chicken, smashed red potatoes, cauliflower. Resident #31 reported, The chicken is rubbery; I cannot chew it. I asked for something else just waiting.Resident #125 reported, The chicken is too tough to chew, I have plenty of snacks, I'll be okay. Staff interview with [NAME] #116 reported, Once I baked the chicken I put it in the steamer to keep it warm. [NAME] #116 also reported, Sometimes the chicken breast get tough 04/09/2026 12:36 PM Review of the resident council meeting minutes regarding food revealed: 10/31/25- resident complaint- meals sometimes late, meals some issues with cold temps. 12/05/25 (for November)-resident complaint-some issues with cold temps. 1/30/26 -resident complaint-cold temps at times 2/27/26-resident complaint-meal service late at times, cold food temps Observation of the tray line at 11:45 AM on 04/14/26 revealed the following:Pre-service temperatures: Regular fish-172 degrees (F)Chopped fish-168 degrees (F)Puree fish-170 degrees (F)Collard greens-166 degrees (F)Puree greens-162 degrees (F)Sweet potatoes-168 degrees (F) The observation on 04/14/26 revealed that the tray line started at 12:00 PM. A test tray was sent to a cart at 1:50 PM. The test tray was delivered to the unit at 1:55 PM. The test tray was checked at 2:10 PMResults:Chopped fish-122 degrees (F)Greens-130 degrees (F)Sweet potatoes- 128 degrees (F)Pineapple tidbits- 60 degrees (F)04/06/26 3:30 PM Resident #13 reported, The food is usually cold when we get it, I don't like the taste. When I ask for something different I don't get anything. 04/06/26 2:51 PM Resident #1 reported, The food is horrible; it's not hot when it needs to be. I don't get what I want a lot. When I ask for something else sometimes I get it sometimes I don't.

Based on observations, staff interviews, and record reviews facility failed to follow proper sanitation and food handling practices to prevent the potential outbreak of foodborne illness. This was found during the Long Term Care Survey process and had the potential to affect all residents who receive nutrtion from the kitchen area. Facility census: 181. Findings include: Review of policy for Cold and frozen food storage. For cold and frozen food storage reads in part. All refrigerated and frozen foods shall be stored at safe temperatures and conditions to prevent spoilage and contamination. Procedure: 5- defrost and sanitize units per manufacturer recommendation or as needed. Dietary staff shall monitor and record refrigerator and freezer temperatures at least twice daily (AM/PM).Review of policy for Dry Food Storage: Dry storage areas shall be maintained in clean, organized, and pest-free condition to ensure safe preservation of non-perishable food. Clean shelving and floors weekly. Inspect for pests each shift.Policy review: Cleaning and Sanitation of Dining and Food Service Areas.-Policy reads: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule.Policy review: Cleaning instructions for Food Preparation Appliances.-Policy reads: Small appliances (such as mixers and food processors) will be cleaned and sanitized after each use.Policy review: Employee Hygiene for Food SafetyPolicy reads: All food and nutrition services employees will practice good personal hygiene and safe food handling procedures.Procedures read in part as:All employees will- 1.Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. Wash hands before handling food Avoid touching mouth or face while preparing food (wash hands if contaminated).8. Use these guidelines in handling clean dishware, glasses and flatware: Use clean hands. Pick flatware and cups with their handles. Pick dishes up by their rims.Policy review: Food Safety and Sanitation.Policy reads: All local, state, and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department.Procedure reads in part: Employees All staff will practice good personal hygiene and use safe food handling practices.All staff are required to have hair restraints and should cover all hair on the head.Beard nets are required when facial hair is visible. Employees will wash their hands just before they start to work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes, smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes, and touching face, hair, other people or surfaces or items with potential for contamination.G)Policy review: General Sanitation of Kitchen.Policy reads: Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.Policy review: Personal Hygiene and Health Reporting-Policy reads: All food and nutrition services employees will be trained in appropriate personal hygiene and health reporting.-Procedure reads in part.:Personal hygiene criteria to follow include the following: Hands should be washed in the designated hand-washing sinks. Refer to the Hand-Washing policy on the next page.Hair should be neat and clean. Hair restraints must be worn around exposed foods, in the kitchen or food service area and dining areas.Beards and mustaches should be closely cropped and neatly trimmed. When near exposed foods, beards must be restrained using beard covers.Policy review: Hand WashingPolicy reads: Employees will wash their hands as frequently as needed throughout the day using proper hand washing procedures (and surrogate prosthetic device washing procedures as appropriate). Hand washing facilities will be readily accessible and equipped with hot and cold running water, paper towels and/or automatic hand dryer, soap, trash cans and signage outlining hand washing procedures. If chemical sanitizing gels are used, staff must first wash their hands as outlined below.Procedure reads: Hands and exposed portions of arms (or surrogate prosthetic devices) should be washed immediately before engaging in food preparation.When to wash hands When entering the kitchen at the start of a shift, after touching bare human body parts other than clean hands and wrists. After using the bathroomAfter handling soiled equipment or utensils. During food preparation, as often as necessary to remove soil or contamination and prevent cross contamination when changing tasks. When switching between working with raw food and working with ready to eat food.Before donning disposable gloves for working with food and after gloves are removed.After engaging in other activities that contaminate the hands (e.g., answering a phone call, using a computer, tablet, or smartphone, handling trash etc.) 2. How to wash hands:Turn on the faucet using a paper towel to avoid contaminating the faucet. Wet hand and forearms with warm water (minimum 85 degrees Fahrenheit) and apply an antibacterial soap. Scrub well with soap and additional water as needed, scrubbing all areas thoroughly. Pay close attention to the fingernails using a brush as needed. Scrub for a minimum of (10) to (15) seconds within the (20) seconds hand washing procedure. Apply vigorous friction between the fingers and fingertips. Rinse with clean, running water.Rinse04/06/26 11:15 AM during an initial walk through with Dietary manager (DM) the door to the kitchen entrance was propped open with a broom.At 4:30 PM same day, remained propped open. DM reported, We generally leave it open because it is so hot. On all flooring large amounts of food debris, dish room as well. dietary manager verified Table on clean side of dish room bottom shelf with moderate amount of food debris. Dietary manager verified Ice cream freezer- outside- moderate amount of liquid residue dried but sticky. Observation revealed food debris on the ice cream freezer's bottom shelves. Three sherbet containers- with melted, sticky, orange debris. On one container the lid was torn exposing the sherbet to air. Dietary manager was verified. Temperatures for the ice cream freezer are missing the PM temperatures for 04/04/26 and 04/05/26. Dietary manager verified it.Observation of the able that held the large coffee makers had large amount of bedrivs on the table. Table that holds the coffee makers-large amount of debris on the table, on the floor along with trash debris. The doors from the table are sitting on the floor. Outer aspects of the table have dried sticky debris. Dietary manager verified. Nesting occurred in eight of the eleven coffee cups observed. Dietary manager verified.Cleaning rag not in sanitation/cleaning bucket. Laying on prep table. Dietary manager verified. Microwave- outside moderate amount of food debris. Inside, there was a large amount of food debris. Dietary manager verifiedWarming unit- large amount of food debris on the bottom aspect outside, inside with food debris on bottom of shelf. Dietary manager verified.Mixer tabletop- not covered, moderate amount of food debris. Dietary manager verified it.Slicer tabletop- not covered, moderate amount of food debris. Dietary manager verified. Gas stove-handle to oven large amount of greasy, debris. Dietary manager verified and informed this surveyor, This stove does not work. Not in use Gas stove is in working condition. However, the backsplash above the stove has a large amount of sticky, yellowish-brown substance on the shelf. The stovetop edges and the area between the burners have built-up, dark black, flaking debris. Dietary manager verified. The reach-in refrigerator had a large amount of dried, sticky liquid residue. Inside there was a large amount of food debris. Dietary manager verified. Food debris and butter cups were on the floor of the walk-in refrigerator, along the wall. Dietary manager verified. Walk in freezer- floor along seems-reddish substance. Case of Beyond Meat, veggie patties, waffles open to air, bag also open Ice formed from the fan along the shelves under the fans. On floor large amount of ice .On shelf near door a bag of breaded meat-open to air, no dates-open, use by date. Dietary manager verified. Review of Food temperature logs revealed missing temperatures for the dinner meal on 04/03/26. Missing temperatures were observed for the dinner meal on 04/04/26. Dietary manager verified these findings. On 04/07/26 at 10:12 AM the surveyor revisited the area:Door to entrance observed propped open. The dietary manager reported, We always leave it propped, it's hot in here.On the floor behind ice machine with trash debris-cups and food debris along with a moderate amount of dark grey sticky build up. Dietary manager verified the need for cleaning.On the floor between ice cream freezer and coffee maker stand-same food debris-coffee grounds, paper trash. Dietary manager verified the need for cleaning.Pellet warmer-observation revealed food debris and a dried sticky substance on the outside and inside of the unit. The dietary manager verified it.Warming unit observation revealed food debris remained on outside and bottom of the unit. Dietary manager verified it.Top of working stove and backsplash large amount of greasy sticky film remains. The Dietary manager verified it.04/08/2026 10:30 AM Observation by the sruveyor upon entering the department for observations noted [NAME] (#124) did not have a beard guard on, manager verified and instructed him to apply one. Spoke with dietary manager regarding lunch being all white from the previous day. Asked to review sub logs- nothing charted for any days since 04/01/26. Manager showed the surveyor the packages of instant red bit potatoes they used.During observation of meal preparation for lunch today noted Diet Aide (#118) removed his gloves, took bare hand opened trash can lid (does not have one that is either with an opening cut or peddle to open without using hands) threw gloves away then wiped face and hands on shirt, went back to station did not wash hands, and went to apply new set of gloves. Dietary Manager stopped Diet Aide (#118) and had him wash his hands. Observation of his handwashing revealed that he did not turn off the faucet with a clean, dry cloth. After washing, he wiped his hands on his shirt and pants before going to the station to apply gloves. The Dietary Manager stopped him again and educated him on proper handwashing technique.Surveyor observed [NAME] #124 stirring pasta and with gloved hands, wiping his face, scratching his arm then threw the gloves away after taking lid off trash can, then immediately turned to apply gloves without hand washing. Dietary Manager stopped him and instructed him to wash his hands and apply gloves correctly. Once [NAME] (#124) applied gloves he immediately wiped his face and arm. Dietary Manager again stopped him and instructed him on proper glove usage. 04/08/26 11 15 AM Observation resumed in department. Deli ham wrapped in syran wrap no dates placed on prep table. Dietary Manager verified no dates and could not give approximate time it was left out, temperature read 61 degrees Fahrenheit, and the Dietary Manager then threw the ham out. [NAME] (#124) and Diet Aide (#118) were observed again touching clothing, wiping face with gloves, lifting the trash can lid with gloves then threw away gloves, attempted to apply clean gloves without washing hands. Dietary Manager verified and stopped the [NAME] and Diet Aide instructing them to wash hands. Observed Diet Aide (117), setting up trays online noting wet nesting and aide wiping off with cleaning cloth. Manager verified and stopped aide. Reviewed meal delivery carts (6) six of (6) six with excessive amount of dried red/white sticky liquids and food debris. Dietary Manager verified and instructed aide to wipe these down.04/08/26 at 1:30 PM continued surveyor observation of meal line service, ran out of food, did not have the extra requests prepared example: grilled cheese, tossed salad, dessert for lactose intolerant, [NAME] (124) working to ensure enough food is being prepared for remainder of meal service. As of 2:30 PM continued to wait on the vegetables to be done. Tray line finished at 2:50 PM.04/13/2026 9:40 AM Follow up kitchen tour:Ice machine the vent on front was very dusty with rust on the panels, and the side had broken pieces. Inside where ice level is there is a grey dried substance on inside of door and along edges. Reviewed maintenance cleaning schedule to be cleaned this date. 04/13/26. Dietary Manager verified needing cleaned and repaired.Excessive ice buildup was present in the walk-in freezer on the shelves along the back wall, on the floor under a shelf, and on the pipe coming from the fan. The Dietary Manager verified reports they are supposed to clean the fan and defrost periodically. Three shelf cart (with clean glasses and trays on it) with excessive dried red and white liquid, sticky to touch and food debris on each shelf. Dietary Manager verified.04/13/26 12:36 PM follow up in the kitchenDish machine temperature not filled in Dietary Manager verified not being done.On 04/13/26 2:25 PM during a staff interview with the Maintenance Director (MD) the surveyor asked how often the walk-in freezer got defrosted and cleaned. The Maintenance Director (MD), At least 3 months and as needed. The surveyor asked the Maintenance Director (MD) how often the ice machine was cleaned or repaired. MD reported, We do these every three months and verified that the freezer had an excessive amount of ice on the floor, walls, pipes, and shelves. The Maintenance Supervisor verified the ice machine needs a new vent cover.On 04/13/26 at 3:16 PM the Maintenance director (MD) reported, I called the company that worked on our walk-ins, and they are here now to review and repair.On 04/14/26 at 11:00 AM continued observations in the kitchen area revealed ice buildup remained in the walk-in freezer, Regional Account Manager (RAM) reported, The company had to order a part for the motor, and maintenance informed us they would defrost then.The dunnage rack (low profile, heavy duty storage platform) that held the clean dessert bowls had a large amount of food debris and dried sticky substances on the sides and edges. Dietary Manager verified it needed cleaned.The surveyor observed food delivery carts in hall (6) six of (6) six with dried red and white liquid on outside of doors, inside on the shelves and along sides and back. D(DA) #113 confirmed these carts were ready for service. Dietary Manager verified carts needed to be wiped down. Observations revealed that handwashing/glove use remained incorrect. Diet Aide (DA) #113 lifted the trash can lid, then went to perform another task. The Dietary Manager (DM) stopped the aide and reminded her to wash her hands.

Based on observation, staff interview and resident interview, the facility failed to ensure a homelike environment by keeping rooms clean and maintaining a comfortable and safe room temperature. This included Resident's #202 and #23. Findings included: a) Resident #23 During an interview with Resident #23 on 04/06/26 at 2:29 PM the resident reported feeling cold at night when the temperature drops and the heat is off. b) Resident #202 During an interview with Resident #202 at 2:35 PM he was observed wearing a coat with his wife, who was also wearing a coat. Resident reported the room had been cold since the temperature dropped last night. They reported this to staff and were told there was no way to adjust the heat individually in rooms, and nothing had been done. On 04/06/26 at 3:00 PM, Maintenance Director measured the room temperature in Resident #23's room to be 62.8 degrees Fahrenheit and the hallway outside the room at 61.5 degrees Fahrenheit. He stated he could turn the heat back on but it would take 5 hours for the boiler system to heat up. He said he planned to turn it back on tonight anyway because the temperature was supposed to be cold again. Review of facility policy titled Homelike Environment. Specific Procedures /Guidance sections 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: h. comfortable and safe temperatures (71 degrees Fahrenheit - 81 degrees Fahrenheit.) Review of the policy for cleaning and disinfecting environmental surfaces reads as follows: Environmental surfaces will be cleaned and disinfected according to current Center for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard. Definitions read in part: Cleaning refers to the removal of dirt and impurities, including germs, from surfaces. Cleaning alone does not kill germs but, by removing the germs it decreases their number and therefore any risk of spreading infection. Specific procedures and guidance read in part: 9. Housekeeping surfaces (floors, tabletops etc.) will be cleaned on a regular basis (daily, (3)three times a week etc.) and when surfaces are visibly soiled. 12. Disinfecting (or detergent) solutions will be prepared as needed and replaced frequently with fresh solution. Floor mopping solution will be replaced every three resident rooms or changed no less often than at (60) minute intervals.) On 04/06/26 at 2:32 PM in room [ROOM NUMBER], an observation was made of a sticky substance on the floor near the bed. Wheel chair cushion with sticky substance, cushion is cracked and has odor. Nurse assistant #196 verified. Reporting I will let the nurse know about the chair cushion On 04/06/26 at 2:35 PM an observation in room [ROOM NUMBER] revealed a sticky substance on the floor near the beds. Debris along edges of walls, under beds, trash on floor. Nurse aide registered (#196) verified. Reports We have not seen a housekeeper today here, we try to pick up as we have time to do On 04/06/26 at 3:23 PM an observation in room [ROOM NUMBER] revealed that the floor had trash debris and sticky substances, and a dark grey sticky substance had built up along the wall. Air conditioner filter had an excessive amount of dust debris. Nurse aide #196 reported, I only see house keeping every other day in here and have not seen anyone change these filters. On 04/06/26 at 3:27 PM observation in room [ROOM NUMBER] revealed the air conditioner's front cover had cracked plastic and would not stay on the unit. Along wall rust noted with paint peeling. Floor has trash debris and a sticky substance. Overall needing cleaned. Licensed Nurse supervisor #8 confirmed and reported, I will let maintenance know about the air conditioner. On 04/06/26 at 3:49 PM in room [ROOM NUMBER], an observation noted a large amount of dust and debris on the air conditioner filter. Debris along wall at baseboards grey build up. Trash can without liner, trash in can and along floor. In front of closet debris observed. Nurse aide #207 and #200 verified reporting, housekeeping usually comes every other day. Reports also we have been here since February I don't recall maintenance being in at all At 3:50 PM on 04/06/26 in room [ROOM NUMBER], an observation revealed that the floor had debris with a sticky substance. Nurse aide #196 verified this observation. A revisit on 04/07/26 at 10:09 AM revealed that although the rooms were swept, grey, sticky buildup remained along the edges of the floors near the walls. Rooms had an odor of stagnant water. Trash cans in rooms (#317, #319, #325, and #327) had no liners. Trash debris was on the floor in Rooms #309 and #317. The floor had a sticky substance. Regional director of maintenance (RDOM) #230 and Housekeeping Manager (HM) #172 toured with this surveyor and verified the findings. Housekeeping manager (#172) reported, The person assigned to this floor was off; I had someone covering. On 04/07/26 at 10:30 AM the surveyor observed that the microwaves in the pantry were not cleaned and had a large amount of food debris and sticky substance on each one. Housekeeping manager #172 informed this surveyor, I believe dietary is supposed to clean these, we do the floors and the cabinet tops. Spoke with Dietary manager (#212) she informed this surveyor, I don't think we do the microwaves, just the refrigerators. Attempted to pull policy for review however could not find one. Informed this surveyor I will call my regional person and get back with you 04/07/26 11:30 AM Dietary manager #212 reported, My regional person (name) said we do not have a clear policy; however, after speaking with the housekeeping manager, they will begin to ensure these are cleaned daily as well. On 04/08/26 at 8:45 AM during observations on unit 300 odor persisted throughout, including stagnant water, human body odor, and urine, 04/13/26 10:00 AM Continued observations of pantries: microwave on unit (1) one with dried liquid debris and some food debris, in refrigerator food debris and dried white sticky liquid on shelving. A case of styrofoam cups on floor certified nursing assistant (#75) verified and picked up the case of cups.

Based on observation, staff interview and resident interview, the facility failed to keep an accurate medical record in the area of blood pressure documentation for Resident #8. Findings Included:a) Resident #8 During an interview with Resident #8 on 04/06/26 at 1:26 PM, he reported having a fistula in his left arm. He stated no one ever tried to take his blood pressure in that arm. On 04/09/26, a review of resident's blood pressure summary since 01/01/26 show the following blood pressures documented to have been taken in the left arm in 2026: 3/7/26 122/68 l/arm Licensed Practical Nurse (LPN) #1873/16/26 127/77 l/arm LPN #823/20/26 124/66 l/arm Registered Nurse (RN) #744/3/26 112/62 l/arm RN #744/4/26 104/67 l/arm LPN #614/8/26 111/69 l/arm l/arm LPN #123 c)Review of Facility Performance Improvement Project dated 04/02/26. The plan To eliminate incidents related to improper blood pressure documentation on residents with limb restrictions. Licensed Practical Nurse #123 was educated on 04/06/26 and documented blood pressure in the wrong arm two (2) days later. d) An interview was conducted on 04/13/26 at 1:00 PM with the Director of Nursing (DON) who acknowledged Licensed Practical Nurse (LPN) #123 was re-educated on the 04/06/26 Performance Improvement Project to include proper blood pressure limb documentation. DON acknowledged documentation the resident documented blood pressure for Resident #8 in the left arm on 04/08/26.

Based on resident interview, record review and staff interview, this facility failed to ensure reasonable accommodation of needs, a residents touch call light was to be accessible to the resident at all times. This was found during the Long Term Care Survey Process. This was true for (1) one of (1) one resident observations. Resident identifier#: 14. Facility census: 181. Findings include:a) Resident #14 Record review of care plan states in part, (Resident to have touch call light due to diagnosis multiple sclerosis. B) Diagnosis review: Functional quadriplegia, quadriplegia, unspecified, contracture right elbow, contracture left hand, multiple sclerosis. On 04/06/26 at 4:05 PM observation revealed Resident #14's call light lying on the floor, missing the clip to attach it to the bed linens. Registered nurse (#45) verified this and stated, It needs to stay on her chest, she cannot move enough to reach out. -04/08/2026 9:00 AM Resident (#14) Observation: Call light out of reach on the floor. Resident reports I don't know where my light is; I need a nurse. This surveyor went to the desk and reported to Licensed Practical nurse (#95) that the resident could not locate her call light and needed a nurse. Licensed practical nurse (#95) reported she would let her nurse know. On 04/08/26 at 9:30 AM the surveyor entered the room to follow up for the resident. The surveyor observed that the call light remained on the floor. Resident reports, He came in and cleaned my eyes and put eye drops in, I still don't have my call light and I can't move. Registered Nurse (#137) was brought in. This surveyor questioned her where the call light should be, as the resident is unable to actively move her arms to reach or move the call light. Registered nurse (#137) reports, It should be lying on her chest close to her chin so she can use it as needed. This surveyor informed Registered nurse (#137) that the call light was on the floor ,Registered nurse (#137) verified it was on the floor and placed it back on the resident's chest. And reported I will make sure her nurse knows, On 04/08/26 at 10:30 AM during an interview with the Director of Nursing (#29) regarding Resident #14's inaccessible call light, it was discussed that there was not a clip to attach to linens and that this was an ongoing observation since Monday. DON #29 reported, Oh, I did not know that, I thought it was today. We then went to the room and observed her call light was accessible with a clip to ensure it was attached to the bed linen. Reports, I had them put this on once I knew the issue.

Based on resident interviews, record review, and staff interviews, the facility failed to promote and facilitate resident self-determination by supporting resident choice regarding bathing. This failure was found in (1) one of (6) six residents reviewed for choices during the Long-Term Care Survey Process. Resident identifier #136. Facility Census: 181.Findings Include:a) Resident #136During the initial interview on 04/06/26 at 2:01 PM, Resident #136 stated, I want to take showers, but always on my day at the last minute they come and give me a bed bath, saying they haven't had time. They just don't want to get me up in the lift.A record review on 04/08/26 at 4:00 PM, of an Activities Preference Evaluation dated 06/09/25, question 3 indicates that it's very important for Resident #136 to choose between a tub bath, shower, bed bath or sponge bath. Question 3a indicates that Resident #136 prefers showers. indicates that Resident #136 prefers showers. A review of Resident #136's bathing task from 02/02/26 to present revealed that he had four showers and the rest were documented as bed baths. One shower refusal was listed. During an interview, on 04/09/26 at 9:30 AM, the Director of Nursing (DON) confirmed that Resident #136 indicated a preference for showering and that he had mostly received bed baths.

Based on Electronic Medical Record (EMR) review and staff interview, the facility failed to update PASARR's when Resident #150 had a diagnosis of Post Traumatic Stress Disorder (PTSD) and Resident #54 had a new diagnoses of major depressive disorder and anxiety. This failed practice was true for two (2) of nine (9) residents reviewed for PASARR's. Resident identifiers: Resident #54, #150. Facility census: 181. Findings included:a) Resident #54On 04/07/26 at 10:20 AM a review of the EMR for Resident #54 found a PASARR dated 04/24/16 noted the resident would be able to be discharged in 3-6 months. Resident #54 currently resides at the facility. In addition, the diagnosis of Major Depressive Disorder was added on 07/11/16. Anxiety diagnosis was added on 02/28/19. Bipolar Disorder was added to the diagnoses on 05/12/20. No evidence was found of an updated PASARR.In an interview with admission Coordinator #36 on 04/08/26 at 1:21 PM, she stated that she had resubmitted the updated PASARRs but could provide no evidence to substantiate that the PASARRs had been updated. No evidence was provided at the time of exit from the facility.b) Resident #150 On 04/07/26 at 9:42 AM a review of the EMR found the resident was admitted on [DATE]. A diagnosis of PTSD was found on the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/21. No evidence was found in the EMR that the PASARR was updated. In an interview with the admission Coordinator (AC) #36 on 04/08/26 at 1:21 PM, AC #36 stated that she had resubmitted the updated PASARR's but could provide no evidence to substantiate the PASARR's had been updated. No evidence was provided at the time of exit of the facility.

Based on record review and staff interviews, the facility failed to include diagnoses of Post-Traumatic Stress Syndrome (PTSD), Bipolar disorder, and Major Depressive Disorder and anxiety on the Pre-admission Screening and Resident Review PASARR. This deficient practice was found true for (3) three of (9) nine residents reviewed for PASARR accuracy during the Long-Term Care Survey Process. Resident identifiers: #6, #54, and #150. Facility Census: 181. a) Resident #54 On 04/07/26 at 10:20 AM a review of the EMR for Resident #54 found a PASARR dated 04/24/16 noted the resident would be able to be discharged in 3-6 months. Resident #54 is currently resides at the facility. In addition, on 07/11/16 the diagnosis of Major Depressive Disorder was added. Anxiety diagnosis was added on 02/28/19. Bipolar Disorder was added on 05/12/20 to the diagnoses. No evidence was found of an updated PASARR. In an interview with the admission Coordinator #36 on 04/08/26 at 1:21 PM, stated that she had resubmitted the updated PASARR's but could provide no evidence to substantiate the PASARR's had been updated. No evidence was provided at the time of exit of the facility. b) Resident #150 On 04/07/26 at 9:42 AM a review of the EMR found the resident was admitted on [DATE]. A diagnosis of PTSD was found on the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/21. No evidence was found in the EMR the PASARR was updated. In an interview with the admission Coordinator #36 on 04/08/26 at 1:21 PM, stated that she had resubmitted the updated PASARR's but could provide no evidence to substantiate the PASARR's had been updated. No evidence was provided at the time of exit of the facility. c) Resident #6 A record review on 04/07/26 at 9:27 AM, revealed that Resident #6 was admitted on [DATE] with a diagnosis of Bipolar. Further record review revealed a PASRR dated 01/19/26, section 3, question 30, did not indicate Bipolar disorder. During an interview on 04/08/26 at 11:00 AM, admission Coordinator (ac) #36 confirmed that the diagnosis of Bipolar was not indicated on the admission PASARR.

Based on observation, record review, and staff interview the facility failed to develop a resident-centered care plan for activities for Resident #16, and the use of side rails for Resident #13. This failed practice was found true for (2) two of 41 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers #16, and #13. Facility Census:181. Findings Include: a) Resident #16 The initial observation on 04/06/26 at 2:50 PM, found Resident #16 lying in bed, hollering out. No stimulation was on in the room. A record review on 04/09/26 at 9:00 AM, revealed a diagnosis of Autism for Resident #16. Further record review revealed an initial activities assessment for Resident #16 dated 07/30/25, under section C, Number 6 comments reads as follows: Per former caregiver, resident enjoys being up and active even if she is unable to meaningfully participate. Staff will involve in group activities when resident is up to wheelchair, and provide with coloring materials and fidget toys for leisure stimulation . Will monitor for signs of satisfaction. The last Quarterly Activity Assessment completed on 03/09/26, Section B {Attendance and Participation Summary is as follows1. Describe the resident's attendance preferences and participation level with activiteies(Resident #16 name) had no changes to activity preferences this review. She refuses most group activity invitations but staff will continue to encourage.2. Describe resident's favorite activities, special accomplishments, and/or interests(Resident #16 name) continues to prefer to spend leisure time in her room resting, watching TV, and listening to music at times. At time enjoys coloring but not always.3. Additional comments: Activities staff visit on a regular basis to ensure leisure and social needs are being met.04/09/2026 9:15 AM A record review revealed an activity care plan, with no added activity interventions since 07/30/25 Resident #16's Activity Care plan reads as follows:Focus: (Resident #16 name), is non-verbal and unable to communicate activity preferences, but would likely benefit from attending groups for socialization, She enjoys watching TV and listening to music in her room during leisure time. Goals: (Resident #16 name) will pursue self-initiated activities that are meaningful to her on a daily basis through next review date. (Resident #16 name) will attend/participate in group activities of her choosing 1-3 times weekly through next review date.04/09/2026 9:33 AM Interview with the activity Director AD stated, They used to be more personalized, but now we have this new system and our company wants them simple. Interventions: Assist the resident to perform self directed activities as needed Initiated 07/30/25 Invite/assist the resident to group activities, assist as needed and monitor for signs of satisfaction. Initiated 07/30/25 Modify activities treatment plan to accommodate in room or preferred place for the resident. Initiated 07/30/25 Provide activities calendar. Initiated 07/30/25 Provide materials for self directed activities as needed/available. Initiated 07/30/25Visit on a regular basis to ensure needs are being met. Initiated 07/30/25 Reviewing the activity record revealed that Resident #16's activity participation had changed since initial admission. No new care plan interventions have been added have been implemented since 07/30/25, and no personalized interventions exist to assist in leisure activities. During an interview on 04/09/26 at 10:30 AM, the Activity Director confirmed that Resident #16's care plan had not updated interventions since her admission and stated, We have a care plan library that we go by. The AD further confirmed that the activity care plan was not personalized. b) Resident #13 The facility's policy titled, Proper Use of Side Rails, with creation date 04/26/23 and no revision date given, stated the use of side rails as an assistive device would be addressed in the resident care plan. Review of Resident #13's physician's orders showed the following order written on 10/17/25: Device: Side Rail: Bilateral One Fourth Side Rails up at all times while in bed to promote independence with bed mobility. Check placement Q [every] shift. Upon observation on 03/09/26 at 12:35 PM, the resident had quarter side rails on both sides of his bed. Resident #13's comprehensive care plan did not contain a focus or interventions related to side rail use for bed mobility. On 04/13/2026 at 2:37 PM, the Director of Nursing confirmed Resident #13 was not care planned for side rail use. No further information was provided through the completion of the survey process.

Based on Electronic Medical Record (EMR) review and staff interview, the facility failed to ensure residents were given the opportunity to attend care plan conferences and failed to revise a care plan after a resident had all teeth extracted. This was true for two (2) of 41 residents reviewed for care plans. Resident identifiers: #54, # 48. Facility census: 181. Findings included: a) Resident #45 A review of the care plan for Resident #45, on 04/08/26 at 10:45 AM, found the following: Focus: Oral/dental: (Resident name) requires assistance with their oral and/or dental care. Has natural teeth in poor repair with obvious caries and missing teeth. Date initiated: 02/01/25. Revision on: 02/11/25. Goal: (Resident name) will be free from dental complications thru review period. Date initiated: 02/01/25. Revision on: 10/18/25. Target date: 04/06/26. An interview with the Care Plan/MDS Coordinator #46 on 04/08/26 at 10:45 AM confirmed the care plan had not been updated after the resident had all teeth extracted on 10/08/25. b) Resident #48 During an interview with Resident #48 at approximately 1:30 PM the resident stated that he had not been involved in a care plan since his admission. During an interview with the MDS Coordinator #46 at approximately 2:30 PM the Minimum Data Set (MDS) Coordinator stated that Resident #48 did not want to be involved in his care plan. The surveyor asked MDS Coordinator #46 for documentation verifying resident #48 did not want to be involved. No evidence was available or provided before the facility exit.

Based on observation, record review, and staff interviews, the facility failed to provide an activities program to meet the needs and interests of each resident. This failed practice was found true for (1) one of (2) two residents reviewed for activities during the Long-Term Care Survey Process. Resident identifier #16. Facility Census: 118. Findings Include:a) Resident #16The initial observation on 04/06/26 at 2:50 PM, found Resident #16 lying in bed, hollering out. No stimulation was on in the room.A record review on 04/09/26 at 9:00 AM, revealed a diagnosis of Autism for Resident #16.Further record review revealed an initial activities assessment for Resident #16 dated 07/30/25, under section C, Number 6 comments reads as follows: Per former caregiver, resident enjoys being up and active even if she is unable to meaningfully participate. Staff will involve in group activities when resident is up to wheelchair, and provide with coloring materials and fidget toys for leisure stimulation . Will monitor for signs of satisfaction.The last Quarterly Activity Assessment completed on 03/09/26, Section B {Attendance and Participation Summary is as follows1. Describe the resident's attendance preferences and participation level with activiteies(Resident #16 name) had no changes to activity preferences this review. She refuses most group activity invitations but staff will continue to encourage.2. Describe resident's favorite activities, special accomplishments, and/or interests(Resident #16 name) continues to prefer to spend leisure time in her room resting, watching TV, and listening to music at times. At time enjoys coloring but not always.3. Additional comments: Activities staff visit on a regular basis to ensure leisure and social needs are being met.04/09/2026 9:15 AM A record review revealed an activity care plan, with no added activity interventions since 07/30/25Resident #16's Activity Care plan reads as follows:Focus: (Resident #16 name), is non-verbal and unable to communicate activity preferences, but would likely benefit from attending groups for socialization, She enjoys watching TV and listening to music in her room during leisure time.Goals: (Resident #16 name) will pursue self in initiated activities that are meaningful to her on a daily basis through next review date. (Resident #16 name) will attend/participate in group activities of her choosing 1-3 times weekly through next review date.04/09/2026 9:33 AM Interview with the activity Director AD stated, They used to be more personalized, but now we have this new system and our company wants them simple.Interventions: Assist the resident to perform self directed activities as needed Initiated 07/30/25 Invite/assist the resident to group activities, assist as needed and monitor for signs of satisfaction. Initiated 07/30/25 Modify activities treatment plan to accommodate in room or preferred place for the resident. Initiated 07/30/25 Provide activities calendar. Initiated 07/30/25 Provide materials for self directed activities as needed/available. Initiated 07/30/25Visit on a regular basis to ensure needs are being met. Initiated 07/30/25A review of the activity record shows that through assessment Resident #16 has had a change in her activity participation since initial admission, with no new care plan interventions since 07/30/25, and no personalized interventions to assist in leisure activities.A review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/30/25, Section F, under F0800, indicates that Resident #16 enjoys doing things with groups of people.Further record review of Resident #16's Activity Participation record from 02/01/26 to present revealed that the resident has only participated in one group activity and no one-to-one visits are indicated.During an interview on 04/09/26 at 10:30 AM, the Activity Director confirmed that Resident #16's care plan had not updated interventions since her admission and stated, We have a care plan library that we go by. The AD further confirmed that the participation record does not indicate one-to-one visits are being provided for the resident who is not attending group activities.

Based on record review, resident interview, and staff interview, the facility failed to provide care and services in accordance with professional standards of practice. For one (1) of five (5) residents reviewed for the care area of unnecessary medications, the facility failed to implement physician's orders for blood glucose monitoring and failed to administer medication as ordered. For one (1) of three (3) residents reviewed for the care area of pain management, the facility failed to provide medication for hemorrhoid pain relief. Resident Identifiers: #62 and #136. Facility Census: 181. Findings included: Findings include: a) Resident #136 During an interview on 04/08/26 at 3:45 PM, Resident #16 stated, My hemorrhoids have been hurting constantly for two weeks. They used to be infrequent but not anymore. Finally a young nurse spread'em and put some on there, but only once. I can't even eat hotcake. During an interview on 04/09/26 at 9:30 AM, The Director of Nursing (DON) stated, I will call the unit manager and let her know what is going on. A record review on 04/09/2026 at 10:49 AM found a Nurses note dated for today at 10:19 AM that reads as follows: This nurse manager spoke with the APRN regarding resident hemorrhoids. Order received to schedule hemorrhoid rectal cream three times a day x 7 days. Resident notified and in agreement with plan of care. This note confirmed that Resident #136 had hemorrhoids. b) Resident #62 Review of Resident #62's physician's orders showed an order written on 11/05/24 for monthly Accu-chek blood glucose monitoring (fingerstick blood glucose monitoring) on the fifth (5th) of every month due to antipsychotic use. Antipsychotic medication can cause the side effect of elevated blood glucose levels. Resident #62 was prescribed the antipsychotic medication Risperdal (risperidone) for bipolar disorder with psychotic features. Review of Resident #62's physician's orders showed no Accu-chek blood glucose monitoring results. On 04/08/2026 at 1:07 PM, the Director of Nursing (DON) confirmed Accu-chek blood glucose monitoring had not been obtained for Resident #13 monthly as ordered by the physician. The DON stated the order had been entered incorrectly and the order had not carried over to the resident's medication administration record (MAR) for implementation. No further information was provided through the completion of the survey process. Review of Resident #62's physician's orders showed an order written on 03/02/25 for Risperdal (risperidone) intramuscular injection, 25 milligrams (mg) every 14 days for bipolar disorder with psychotic features. The Risperdal injection was given on 03/04/26 and 03/18/26 and was due again on 04/01/26. Resident #62's medication administration record (MAR) for April showed the notation 9 for the Risperdal injection on 04/01/26. According to the MAR legend, the notation 9 means see progress note. The progress note for 04/01/26 stated the facility was waiting for the pharmacy to deliver the medication. There was no documentation the medication was ever administered. According to the MAR, Risperdal was to be next administered on 04/15/26. On 04/08/2026 at 1:38 PM, the Director of Nursing (DON) confirmed Resident #62's Risperdal injection had not been administered for 04/01/26. She stated Resident #62's Risperdal injection had been delivered to the facility on [DATE], according to the medication label, and was still in the medication cart. The DON stated when the Risperdal arrived to the facility on [DATE], the nurse should have contacted the physician for an order to administer the medication late. The DON stated Resident #62 would be receiving the Risperdal injection today. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to provide a discharge/ transfer notice in writing to resident or resident representative. This was true for two (2) of five (5) residents reviewed. Resident identifiers: # 4 and #24. Census: 181 Findings included: a) Resident #24 A review of Resident #24's electronic health record (EHR) showed the resident was transferred to the hospital on [DATE] for altered mental status. A notice of transfer form was not located in the EHR. The Administrator was asked to provide a copy of Resident #24's written notice of transfer form, detailing the reason for transfer or discharge, a statement of the resident's appeal rights and how to appeal, and the Ombudsman's contact information. On 04/09/26 at 12:26 PM, the Administrator stated, We don't do that. b) Resident #4 Review of Resident #4's electronic health record (EHR) showed the resident was transferred to the hospital on [DATE] due to altered mental status. The resident did not have capacity to make his own medical decisions. A progress note written on 12/15/25 at 2:36 PM stated, Resident out of facility with [emergency medical service] via 2 attendants. Resident sent to [hospital] for evaluation and treatment. Resident sent with appropriate paperwork including bed hold policy. All parties made aware of transfer. A notice of transfer form was not located in the EHR. The Administrator was asked to provide a copy of Resident #4's written notice of transfer form, giving the reason for transfer or discharge, a statement of the resident's appeal rights and how to appeal, and the Ombudsman's contact information. On 04/09/26 at 12:26 PM, the Administrator stated, We don't do that. No further information was provided through the completion of the survey process.

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to implement the correct transmission based precautions for a resident being treated for an active multidrug-resistant organism (MRDO). This was true for one (1) of three (3) residents reviewed for the care area of transmission based precautions. Resident Identifier: #182. Facility Census: 181. a) Resident #182 The facility's policy titled, Transmission-based Precautions, dated 02/01/22 and reviewed on 10/24/22, stated that contact precautions may be implemented for residents known or suspected to be infected with microorganisms transmissible by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Also, according to the policy, with contact precautions, staff must wear gloves and gowns when entering the room for all interactions with the resident or the resident's environment. On 03/06/26 at 10:00 AM, Resident #182 was observed to have an enhanced barrier precautions sign in his room, indicating gowns and gloves should be worn during high-contact resident care. Review of Resident #182's physician's orders showed an order written on 02/26/26 for Enhanced Barrier Precautions every shift for history of MRSA [Methicillin-resistant Staphylococcus aureus]. Further review of the resident's physician's orders showed an order written on 04/02/26 for the antibiotic Cephalexin, 500 mg, three (3) times a day for seven (7) days for an abscess. An order was also written on 04/07/26 for the antibiotic doxycycline monohydrate, 100 mg, two (2) times a day for five (5) days for secondary bacterial coverage for the abscess. Review of Resident #182's past physician's orders showed additional antibiotic orders as follows: - Ceftriaxone intramuscular injection, one time for abscess, written on 04/02/26- Ceftriaxone intramuscular injection, one time for abscess, written on 04/03/26- Doxycycline monohydrate for two (2) days for secondary bacterial coverage for abscess, written on 04/05/26 A physician progress note written on 04/05/26 at 10:32 AM noted, H/O [history of] MRSA and multiple abscess/skin infections .today noted to have a new abscess to the right shin. On 04/08/26 at 11:15 AM, the Infection Preventionist (IP) confirmed Resident #182 should be on contact precautions instead of enhanced barrier precautions due to abscesses with a history of MRSA. The IP stated the facility did not have a list of all conditions requiring contact precautions, but the facility followed Centers for Disease Control (CDC) guidelines. According to the CDC publication, Infection Control Guidance: Preventing Methicillin-resistant Staphylococcus aureus (MRSA) in Healthcare Facilities, available on-line, contact precautions should be followed for residents with MRSA infections. On 4/8/26, an order was written for Resident #182 for Transmission Based (Contact) Isolation every shift for MRSA in wounds.

Based on observation and staff interview, the facility failed to ensure residents were dressed in a manner to promote dignity. This was a random opportunity for discovery. Resident Identifier: #62. Facility Census: 181. Findings included:a) Resident #62 On 04/06/2026 at 11:56 AM, Resident #62 was observed sitting in a wheelchair in the fourth-floor day room. She was wearing a hospital gown that was not tied in the back. She was wearing no socks, slippers, or shoes. The resident was noninterviewable. The resident's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 01/13/26 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. Resident #62 continued to sit in the day room attired only in a hospital gown. Unit Manager #86 was notified about this on 04/06/26 at 1:35 PM. Unit Manager #86 stated, I'll take care of that immediately. On 04/06/2026 at 1:38 PM, Resident #62 was noted to be sitting in the day room wearing a hospital gown, which was tied in the back. The resident also had on socks. On 04/06/2026 at 4:12 PM, the resident was noted to be in the hallway in her wheelchair. She was wearing pajamas. No further information was provided through the completion of the survey process.

Based on observation and resident and staff interview, the facility failed to ensure call lights were within reach and accessible to Residents #166, 487, 184, 38. This was a random opportunity for discovery. Resident identifiers: 166, 487, 184, 38. Facility census: 184. Findings include: A) Resident #166 At approximately 2:25 PM on 3/17/2025, during an interview with Resident #166, she stated she was unable to ring her call light for help because she did not know where it was. Upon further inspection, Resident #166 ' s call light was found to be lying on the floor to the left side of her bed. At approximately 2:37 PM on 3/17/2025, the call light was confirmed to be in the floor and out of reach of Resident #166 by Licensed Practical Nurse (LPN) #75. B)Resident #487 At approximately 2:55 PM on 3/20/2025, during observation of the lunch meal pass, Resident #487 stated to the surveyor, I need to go to the bathroom but I can ' t find my button (call light). Upon further inspection, Resident #487 ' s call light was found to be on the floor, to the left side of her bed. At approximately 2:58 PM on 3/20/2025, the call light was confirmed to be lying on the floor by LPN #108. C) Resident #184 At approximately 2:55 PM on 3/20/2025, following the discovery of Resident #487 ' s call light on the floor next to her bed, the status of Resident #184 ' s call light was checked, in the same room. Resident #184 ' s call light was found to be wrapped around the arm of a chair, to the left side of the resident ' s bed, with the button itself lying on the floor, out of reach of the resident. At approximately 2:58 PM, on 3/20/2025, the call light was confirmed to be out of reach of the resident by LPN #108. 51553 d) On 03/17/25 at 12:30 PM, during the initial resident interview process, Resident #38 reported she was wet and needed changed. The resident stated, Can you please get my bottom dry? The resident's call light was lying in the floor out of reach. Registered Nurse #30 confirmed the Resident #38's call light was in the floor on the left side of the bed and the resident's water pitcher had been knocked over and into the floor on the right side of the bed.

Based on Record Review and Staff Interview, the facility failed to ensure the Resident and/or Power of Attorney (POA) was notified of a change in condition/order. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents. Resident Identifiers: #7, #151, #169, #48, #8, #80, #97, #59, #34, #58, #111, #152, #124, #116, and #33. Facility Census: 184 Findings included: -The Facility's Policy and Procedure for Change in a Residents Condition stated, The facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident's medical/mental condition and/or status. a) Resident #7's Resident #7's order was revised on 03/19/25. Aspiration Precautions were removed from the resident's dietary order. b) Resident #151 Resident #151's order was revised on 03/19/25. Double portions of protein with lunch and dinner, Full upright position with PO, Alternate bites and drinks were removed from the resident's dietary order. c) Resident #169 Resident #169's order was revised on 03/19/25. Resident prefers plastic water bottle provided by family, filled 1/4 full or approximately 4 oz. to assist with rate and bolus control were removed from the resident's diet order. A two-handled mug was added. d) Resident #48 Resident #48's order was revised on 03/19/25. Resident straw with all liquids was removed from the dietary order. e) Resident #80 Resident #80 order was revised on 03/19/25. Three (3) second hold with ALL drinks, small bites. sips, alternate bites/sips and aspiration precautions were removed from the resident's diet order. g) Resident #97 Resident #97's order was revised on 03/19/25. Set up assistance, Alternate solids and liquids, small bites/drinks, make sure the resident is upright during all PO intake and for 30 minutes following PO intake were removed from the resident's dietary order. h) Resident #59's order was revised on 03/19/25. Aspiration precautions were removed from the resident's dietary order. i) Resident #34's order was revised on 03/19/25. Strict aspiration precautions were removed from the resident's diet order. j) Resident #58's order was revised on 03/20/25. No straws was removed from the resident's diet order. K) Resident #111 Resident #111's order was revised on 03/19/25. Fill upright position for all PO intake, no talking while food is in mouth, Chew food thoroughly before swallowing, alternate bites/drinks (every 1-3 bites) were removed from the resident's diet order. l) Resident #152 Resident #152's order was revised on 03/20/25. No straws and set-up with meals were removed from the resident's dietary order. m) Resident #124 Resident #124's order was revised on 03/19/25. Ground meat was removed from her diet order. n) Resident #116 Resident #116's diet order was revised on 03/19/25. Aspiration precautions were removed from the resident's diet order. o) Resident #33 Resident #33's diet order was revised on 03/19/25. NO STRAWS was removed from the resident's diet order. Additional documentation was requested by the State Surveyor for documentation of the notifications regarding the change in condition/order. No additional information was provided. On 03/24/25, Corporate Life Enrichment Staff #224 confirmed there was no additional documentation.

Based on interview and record review, the facility failed to implement written policies and procedures to prohibit neglect for one resident (resident #28) of 3 residents sampled from 8 residents identified by the facility to have had a fall and/or fracture in the last 30 days. Findings Include: Resident #28 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was totally dependent on two or more staff for physical assistance with transfers. Review of the care plan for Transfers dated August 3, 2011 revealed the resident has a potential for injury and impaired ability to self-transfer. The resident requires use of full body mechanical lift and 2 person assistance with transfers to/from bed and chair. The care plan goal was for the resident to be transferred with identified transfer devices/assistance through next review on July 10, 2012. Review of the Resident Care Cardex which outlines relevant resident care needs revealed the resident requires use of a LBGC (Lean Back Geri-Chair). A change of condition form was completed on April 29, 2012 due to increased pain and decreased range of motion. A physician's orders [REDACTED]. Nurse's Notes on April 29, 2012 also document the change of condition. The radiological report, dated April 29, 2012, could not exclude a fracture/dislocation. Recommended were repeat images or a CT (computed tomography). Documented on the report was notification to the physician and his instructions to continue to monitor. A change of condition form was completed on May 2, 2012 due to redness and warmth of the right leg. Physician orders [REDACTED]. [MEDICAL CONDITION] was ruled out. Physician orders [REDACTED]. Nurse's notes on May 3, 2012 documented increased pain to right hip and decreased range of motion. A physician's orders [REDACTED]. The CT report, dated May 4, 2012, revealed the presence of a spiral type fracture involving the distal tibial diaphysis with mild medial angulation distally and an additional oblique fracture involving the distal fibular diaphysis also demonstrating mild medial angulation distally. Following the confirmation of an injury of unknown origin, the facility initiated an investigation. The preliminary investigation revealed on April 27, 2012, a Certified Nursing Assistant (CNA) employee #110 had inappropriately transferred the resident during a shower. Furthermore, it was discovered the employee had failed to assess for correct placement of the right foot and the resident's foot was caught under the footrest of the geri-chair. At the time of the incident, the employee reported to the nurse the resident complained of pain to the foot, yet, but did not report the incident of the foot getting caught in the chair. Observations of the resident on May 14 and 17, 2012 were conducted. The resident was observed in bed with a geri-chair next to the bed. An interview with Certified Nursing Assistant (CNA) employee #110 was conducted on May 17, 2012. Employee #110 stated on April 27, 2012 he gave resident #28 a shower. At the time of the shower, he failed to transfer the resident per her plan of care. Specifically, he failed to use a mechanical lift during transfers. Employee stated he had not verified resident #28's care requirements on her care plan nor on the resident care cardex prior to the transfer. Also, employee #110 stated when he changed the position of the Lean Back Geri-Chair, the resident got her foot caught under the footrest of the geri-chair. Employee #110 stated the resident complained of pain to her "boot" (understood to mean foot). He reported to the Licensed Practical Nurse (LPN), employee #170, the resident had complained of pain, however, he failed to report the resident had caught her foot under the footrest of the geri-chair. Furthermore, during same interview, employee #110 shared his perception that he failed to provide the necessary care and services the resident required for proper transferring and failed to report to the nurse an accident/incident involving the resident's foot. An interview with LPN employee #170 was conducted on May 17, 2012. She stated on April 27, 2012, employee #110 reported to her resident #28 complained of pain during the shower. She stated she then assessed the resident's foot and it appeared within normal limits. She then medicated the resident with her routine scheduled pain medication. Interviews were conducted with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) on May 17, 2012. The DON and the ADON summarized the results of the investigation into the injury (fracture) of unknown origin and concluded on April 27, 2012, employee #110 did not use a mechanical lift for transfers as indicated and had not verified placement of the foot prior to changing the position of the Lean Back Geri-Chair. The resident caught her foot in the gap of the footrest which likely resulted in the fracture identified days later. Staff also concluded employee #110 had failed to report the incident to the nurse at the time. Review of the facility's Abuse & Neglect Prohibition policy states each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. Neglect means failure to provide goods and services neccessary to avoid physicial harm, mental anguish, or mental illness. .

Based on interview and record review and review of a preliminary investigative report, the facility failed to prevent a fracture and multiple falls for two residents (residents #28 and #120) out of three residents sampled of eight residents identified by the facility for falls/and or fractures in the last 30 days. Findings include: 1. Resident #28 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was totally dependent on two or more staff for physical assistance with transfers. Review of the care plan for Transfers dated August 3, 2011, revealed that the resident has a potential for injury and impaired ability to self-transfer. The resident requires use of full body mechanical lift and 2 person assistance with transfers to/from bed and chair. The care plan goal was that the resident be transferred with identified transfer devices/assistance through next review on July 10, 2012. Review of the Resident Care Cardex which outlines relevant resident care needs revealed that the resident requires use of a LBGC (Lean Back Geri-Chair). A change of condition form was completed on April 29, 2012, due to increased pain and decreased range of motion. A physician's orders [REDACTED]. Nurse's Notes on April 29, 2012 also document the change of condition. The radiological report, dated April 29, 2012, could not exclude a fracture/dislocation. Recommended were repeat images or a CT (computed tomography). Documented on the report was notification to the physician and his instructions to continue to monitor. A change of condition form was completed on May 2, 2012, due to redness and warmth of the right leg. Physician orders [REDACTED]. Deep vein thrombosis was ruled out. Physician orders [REDACTED]. Nurse's notes on May 3, 2012, documented increased pain to right hip and decreased range of motion. A physician's orders [REDACTED]. The CT report, dated May 4, 2012, revealed the presence of a spiral type fracture involving the distal tibial diaphysis with mild medial angulation distally and an additional oblique fracture involving the distal fibular diaphysis also demonstrating mild medial angulation distally. Following the confirmation of an injury of unknown origin, the facility initiated an investigation. The preliminary investigation revealed that on April 27, 2012, a Certified Nursing Assistant (CNA) employee #110 had inappropriately transferred the resident during a shower. Furthermore, it was discovered that the employee had failed to assess for correct placement of the right foot and the resident's foot was caught under the footrest of the geri-chair. At the time of the incident, the employee reported to the nurse the resident complained of pain to the foot, yet, did not report the incident of the foot getting caught in the chair. Observations of the resident on May 14 and 17, 2012 were conducted. The resident was observed in bed with a Geri-Chair next to the bed. An interview with Certified Nursing Assistant (CNA) employee #110 was conducted on May 17, 2012. Employee #110 stated on April 27, 2012, he gave resident #28 a shower. At the time of the shower, he failed to transfer the resident per her plan of care. Specifically, he failed to use a mechanical lift during transfers. Employee stated he had not verified resident #28's care requirements on her care plan nor on the resident care cardex prior to the transfer. Also, employee #110 stated when he changed the position of the Lean Back Geri-Chair, the resident got her foot caught under the footrest of the geri-chair. Employee #110 stated the resident complained of pain to her "boot" (understood to mean foot). He reported to the Licensed Practical Nurse (LPN) employee #170, the resident had complained of pain. However, he failed to report the resident had caught her foot under the footrest of the geri-chair. An interview with LPN employee #170 was conducted on May 17, 2012. She stated on April 27, 2012, employee #110 reported to her resident #28 complained of pain during the shower. She stated she then assessed the resident's foot and it appeared within normal limits. She then medicated the resident with her routine scheduled pain medication. Interviews were conducted with the Director of Nurses and the Assistant Director of Nurses on May 17, 2012. The DON and the ADON summarized the results of the investigation into the injury (fracture) of unknown origin and concluded on April 27, 2012, employee #110 did not use a mechanical lift for transfers as indicated and had not verified placement of the foot prior to changing the position of the Lean Back Geri-Chair. The resident caught her foot in the gap of the footrest which likely resulted in the fracture identified days later. Staff also concluded that employee #110 had failed to report the incident to the nurse at the time. . . 2. Resident #120 had [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) on 4/27/12 listed no falls. The MDS indicated the resident was an extensive assist for activities of daily living including locomotion and transfers. The plan of care for falls dated 5/14/12 revealed the resident was at risk for falls related to mental status, history of falls, balance problems, arthritis and the use of psychotropic medications. The plan of care revealed the resident was on a falling star program, therapeutic rest after breakfast, chair alarm, call light within reach and a low bed with floor mats next to the bed. The Interdisciplinary Team (IDT) Post Fall Review dated 5/5/12 with a fall at 9:50 a.m. revealed the resident scooted to middle of room beyond floor mats from bed with no injury. At 12:05 p.m., the resident scooted out of bed again beyond the floor mats into middle of the floor. The fall reviews indicated the resident had an unassisted fall. There were no new interventions on the first review. The Summary of the Interdisciplinary Team was to continue current interventions for falls and to cleanse under breasts with warm soapy water, rinse, pat dry and apply Nystatin powder under breasts three times a day for seven days. After the second fall on 5/5/12, there were no new interventions for falls, except an order for [REDACTED]. The Intervention Recommendations on the fall reviews (check all that apply) was to do a care plan revision. On 5/7/12 at 5:00 p.m., the resident had another fall. The fall review indicated the resident was up in the Day Room in a wheelchair with a chair alarm. The staff heard the alarm sounding and the resident was found sitting in floor in front of the wheelchair. The Summary of the Interdisciplinary Team was to continue the current interventions of falls and a physician's orders [REDACTED]. The laboratory blood work and urinalysis was not collected until 5/9/12 after the Interdisciplinary Team met to review the falls. There were no nursing staff interventions after the falls. The only new interventions on the review forms after the Interdisciplinary Team met was to do the X-ray and laboratory work. Observations were made of the resident on 5/15/12 at 12:35 p.m.. The resident was sitting in a wheelchair in the hallway with pommel cushion in the wheelchair with an alarm. On 5/15/12 at 1:10 p.m., the resident was observed in the main dining room sitting in her wheelchair. On 5/16/12 at 10:50 a.m., observations were made of CNA #36 in the resident's room to provide a.m. care. The CNA was knowledgeable of the care plan interventions, such as, allowing the resident to sleep in late and provide a.m. care after breakfast. On 5/17/12 at 7:40 a.m., the resident was observed lying in bed with 1/4 side rails up on both sides of the bed. The CNA #36 stated she has never seen the resident use the side rails to get out of bed, but is able to reposition herself in bed. She stated she tries to push herself up when she wants to get up. During an interview on 5/16/12 at 6:45 p.m. with RN #32 about her falls, the RN stated the resident was on the floor crawling when found on both times on 5/5/12. The RN stated the x-ray was questionable with a fracture of the femoral neck. The family wished for no treatment other than pain medication. The RN stated the resident fell on [DATE] out of the wheelchair and had no injury. The resident had not fallen since January, 2012. She did have labs done on 5/9/12 that revealed a yeast infection in her urine. The DON was interviewed on 5/16/12 at 4:15 p.m. and stated the resident could have been confused when she had the falls on 5/5 and 5/7, but there was no evidence in the chart that he could find to support the resident was having an increase in confusion or any physical symptoms that would have caused the falls. An interview with the physician 5/17/12 at 10:35 a.m. was conducted. The physician stated he could not verify the femoral neck was fractured unless a CT Scan was done and the family declined any invasive procedures since she is on Hospice and they only wanted to keep her comfortable. The physician stated the urinalysis revealed a yeast infection in the urine, but was not a contributing factor for the resident's falls on 5/5 and 5/7. The post fall meeting that was held on 5/9/12 by the IDT team failed to implement any additional interventions to decrease falls. .