Every finding on record at Kimes Nursing and Rehab LLC

Based on closed medical record review, hospital documentation review, facility policy review, and interview, the facility failed to timely identify and obtain necessary medical intervention for Resident #160 following a fall. This resulted in Immediate Jeopardy and Actual Harm on 06/24/26 beginning at 4:00 P.M. when Resident #160 sustained an unwitnessed fall from bed. On 06/24/26 at approximately 6:00 P.M., Certified Nursing Assistant (CNA) #56 reported to Licensed Practical Nurse (LPN) #120 the resident appeared tired. No assessment was conducted, and Resident #160 was left to rest. On 06/24/26 at approximately 9:00 P.M., CNA #56 returned to the resident's room and notified LPN #120 Resident #160 appeared pale. On 06/25/26 at approximately 1:06 A.M., Resident #160's blood pressure was 80/51 mmHg (hypotensive) with a pulse of 52 beats per minute (bradycardic). Blood pressure medication was ordered to be held at that time and the physician instructed staff to send the resident (to the hospital) for evaluation if distress developed. However, no additional assessment, increased monitoring or further medical intervention was documented until 6:30 A.M. On 06/25/26 at 6:30 A.M. Resident #160 was observed in bed with pale appearance, blood around his mouth, making gurgling noises with respirations and he was unable to clear secretions. The resident appeared agitated. Vital signs included blood pressure was 82/40 mmHg (hypotensive), body temperature 92.4 degrees Fahrenheit (F) (hypothermic), respirations elevated at 21 breaths per minute, oxygen saturation (low) 88% on room air, and heart rate recorded as 100 beats per minute (tachycardic). The resident's pupils were pinpoint and non reactive. Resident #160 was transferred to a local hospital, where diagnostic imaging revealed an acute left C4 anterior fracture, a large abdominal wall hematoma, and acute respiratory failure. The resident required two units of blood for acute blood loss anemia. Resident #160 was subsequently transferred to another hospital, where the resident was intubated and admitted to the Intensive Care Unit. This affected one (Resident #160) out of four residents reviewed for injury of unknown origin and changes in condition. The facility census was 60. On 07/02/26 at 11:03 A.M., the Director of Nursing (DON) was notified Immediate Jeopardy began on 06/24/26 when the facility failed to identify, provide timely assessment and treatment and necessary medical intervention for Resident #160 following a fall. On 06/25/26 at 6:30 A.M. Resident #160 was transferred to the hospital where he was subsequently intubated and admitted to the Intensive Care Unit. The Immediate Jeopardy was removed on 07/06/26 when the facility implemented the following corrective actions:-On 07/02/26 Registered Nurse Clinical Consultant (RNCC) #320 conducted an investigation into Resident #160's cause of injuries (fall history, incident reports, nursing documentation, staff assignments, skin/body assessments review).-On 07/02/26 the DON and Assistant Director of Nursing (ADON) #238 completed a facility-wide audit of all 55 residents for injuries, bruising, and change in conditions after falls/incidents.-Beginning 07/02/26 the DON and ADON #238 would lead/participate in daily clinical Stand-up/Morning Meeting reviewing falls, injuries of unknown origin, and bruises.-On 07/02/26, the DON, ADON #238, and RN #182 conducted an in-service with all licensed nursing on skin and body assessments post-fall/injury.-On 07/02/26, the DON, ADON #238, and RN #182 completed an in-service for all nursing staff on investigations, timeframes, notification requirements, and documentation expectations.-Between 07/02/26 and 07/06/26, the DON, ADON #238, and RN #182 conducted competency validation/return demonstration/skills check-off with licensed nursing staff on post-fall assessment and injury of unknown origin investigations. Ongoing check offs for new hires and competencies during clinical orientation would be completed by the DON or designee. In addition, a plan for ongoing random staff interviews and chart audits to verify staff knowledge/compliance would be completed by the DON or designee.-Beginning 07/02/26 the DON would audit 100% of falls, injury of unknown origin and bruises (investigation completeness, timeliness, notifications, monitoring, documenting, care plan revision) daily for four weeks, weekly for eight weeks, and monthly for three months.-A plan for monthly audits to be reported to Quality Assurance and Performance Improvement (QAPI) committee was implemented. (QAPI included the Administrator, DON, and Medical Director (MD) #500). -On 07/02/26 the DON completed an impromptu QAPI review of the facility Immediate Jeopardy Abatement plan with MD #500.-On 07/06/26, the medical records for three additional residents (#50, #84, and #152) were reviewed for injuries of unknown origin and changes in condition with no concerns noted.-Interview on 07/06/26 from 12:00 P.M. to 12:30 P.M. with LPN #210, #222, #259 and CNA #72 and #70 confirmed they had received education as noted above.Although the Immediate Jeopardy was removed on 07/06/26, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include:Review of the closed medical record revealed Resident #160 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, need for assistance with personal care, atrial fibrillation, and cirrhosis of the liver. Review of Resident #160's care plans dated 06/08/26 revealed Resident #160 required (staff) assistance with activities of daily living including bed mobility, transfers, and ambulation due to muscle weakness and debility. Resident #160 was at risk for falls/injury related to decreased mobility, episodes of incontinence, medication use, and impaired awareness of deficits. Intervention dated 06/09/26 revealed to monitor, document, report for 72 hours post fall, report to physician for any signs and symptoms of pain, bruises, change in mental status and neuro checks as ordered. Additionally, Resident #160 was receiving anticoagulant therapy related to diagnosis of atrial fibrillation with intervention dated 06/08/26 to monitor, observe, report any adverse reactions, labs per order and notify physician of results.Review of Resident #160's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 was cognitively intact and was dependent on staff for toileting hygiene, personal hygiene, and bathing. The assessment revealed Resident #160 required substantial maximum assistance with transfers and bed mobility. Ambulation was not assessed on the MDS. Resident #160 was frequently incontinent with bladder function and occasionally incontinent with bowel function. Record review revealed Resident #160 had falls in the facility on 06/08/26 and 06/09/26.Review of an Incident Follow Up Note dated 06/09/26 at 10:36 A.M. created by Licensed Practical Nurse (LPN) #259 revealed Resident #160 had some bruising to his right side of the abdomen. However, there were no measurements or evidence of a thorough assessment of the bruising at this time. Review of MD #500's progress note revealed to check for labs. There was no mention of bruising to right abdomen and/or falls. Review of an Incident Follow Up Note dated 06/10/26 at 10:39 A.M. created by LPN #259 revealed Resident #160 had some bruising to his right side of the abdomen. However, there was no documentation of a comprehensive assessment including measurements or description of the bruise. There was no mention of any physician notification of bruising. Review of MD #500's progress notes dated 06/12/26 and 06/15/26 revealed no mention of falls and/or bruising to right abdomen. Review of lab work completed for Resident #160 dated 06/15/26 revealed a hemoglobin level of 8.5 with normal range 14.0-18.0 g/dL and a hematocrit level at 28.1 with normal range between 42.0 and 54 percent. Review of MD #500's progress note dated 06/17/26 revealed Resident #160 had two falls and questioned ataxia (a neurological condition that causes poor muscle control and clumsiness). There was no mention of bruising to right abdomen. Record review revealed Resident #160 had another unwitnessed fall on 06/24/26 at 4:00 P.M. The note included Resident #160 slid out of bed onto the floor. He denied hitting his head and stated he was trying to get up. Vital signs included blood pressure 106/60 mmHg, temp 96.6 degrees F, pulse at 70 beats per minute, respirations at 18 breaths per minute and oxygen saturations at 90 percent on room air. No skin assessment was completed. Neurological assessments (neuro check) were started; however, only one neuro check was completed. Review of a nursing progress note dated 06/25/26 at 1:06 A.M. created by LPN #120 revealed Resident #160 had a low blood pressure of 80/51 mmHg and a heart rate at 52 beats per minute. The note included MD #500 was notified and stated to discontinue the medication Diltiazem (a hypertension medication). The note also included if the resident becomes distressed, to send him to the emergency room. Review of a nursing progress note dated 06/25/26 at 6:30 A.M. created by LPN #210 revealed she was called to Resident #160's room via staff. Resident #160 was lying in bed, pale in color, with blood around his mouth. He had gurgling noises during respirations and was unable to clear his throat when cued. His speech was soft, low and garbled at this time. Resident #160 had agitation and attempted to remove the blood pressure cuff and pulse oximeter while obtaining vital signs. Resident #160's blood pressure was 82/40 mmHg, temp was 92.4 degrees F, respirations were 21 breaths per minute, pulse at 100 beats per minute and oxygen saturations at 88 percent. His pupils were pinpoint and non-reactive. Resident #160 was transferred to hospital. Review of a nursing progress note dated 06/25/26 at 1:30 P.M. created by LPN #210 revealed she received report from emergency room and Resident #160 had bilateral pleural effusions, acute blood loss and acute respiratory failure. Resident #160 was being transferred to another hospital. Review of laboratory testing for Resident #160 which was collected on 06/25/26 and resulted on 07/01/26 revealed his hemoglobin was now at 7.5 g/dL and his hematocrit was now 24.6 percent. Review of Resident #160's hospital record documentation dated 06/25/26 revealed the resident was assessed to have abdominal wall hematoma, bilateral pleural effusions, acute blood loss anemia, hemorrhagic disorder due to extrinsic circulating anticoagulants, acute respiratory failure with hypoxia, and a closed displaced fracture of the fourth cervical (C4) vertebra. Recommendations at that time included rewarming, broad spectrum antibiotics, abdominal binder, C collar, blood transfusion, and stabilized prior to transfer to another hospital. Review of Resident #160's hospital record documentation from the receiving/secondary hospital revealed Resident #160 was experiencing shock, presumed hemorrhagic, suspected acute hematoma within the right anterior rectus abdominus muscle, aspiration pneumonia, and a left C4 transverse process fracture involving the transverse foramen. Resident #160 was intubated for airway protection and admitted to the Intensive Care Unit. On 06/30/26 at 1:40 P.M., interview with LPN #210 revealed when she reported to work on 06/25/26 she received in report from LPN #120 that Resident #160 had experienced a fall on 06/24/26 with no injuries. The resident had a few low blood pressures during the night and after reaching out to MD #500 she was told to discontinue his blood pressure medication and to continue to monitor. LPN #120 claimed the resident's vital signs remained about the same. LPN #210 said the day shift CNA reported to her that she needed to come and see Resident #160 right away and that he did not look well. Upon entering the resident's room, he was pale, had blood around his mouth and was making gurgling sounds. The resident (who was previously noted to be cognitively intact) could not voice what was going on at that time. While attempting to obtain vital signs, the resident was agitated. Resident #160 did feel cool to the touch and when his temperature read 92.4 degrees F, she checked it on herself, and it came back normal. LPN #210 stated in her opinion Resident #160's condition did not appear to have been something that just occurred and she was surprised the night shift nurse did not send him to the emergency room. Emergency medical services (EMS) were then contacted and Resident #160 was transported to a local hospital. Review of an undated signed statement completed by CNA #56 (related to the fall on 06/24/26) revealed, When I arrived LPN #259, the day shift nurse informed me that Resident #160 had fallen and to get a floor mat for him. I went and got the floor mat and placed it on the right side of his bed. He was in bed at this time; I changed him because he was incontinent. He appeared tired so after incontinence care, I let him rest. Approximately 9:00 P.M. I returned to the room and alerted LPN #120 that Resident #160 looked pale. I took his vital signs and gave them to the nurse; she verbalized that she would communicate the results to MD #500. She then informed me that MD #500 requested us to monitor Resident #160 and not to send him to the emergency room at this time. At approximately 1:00 A.M. on 06/25/26, I took his vital signs again and they were the same as it was the first time. At approximately 5:45 A.M. I checked his vital signs again and it was similar so I reported that to LPN #120 and she verbalized that she would inform the day shift nurse. Interview on 06/30/2026 at 12:53 P.M. with Resident #160's sister revealed the resident had been living at home on his own prior to his nursing home admission. There had been concerns related to his inability to care for himself. The resident was hospitalized and then admitted to the facility for placement. During the interview, the family member voiced concerns the resident was supposed to receive therapy after being admitted , but that was never provided. Following admission (date not provided), family had visited and found the resident in bed wearing only an incontinence brief. At the time of this visit they observed a large bruise on the resident's side and had taken a photo of the bruise. The sister revealed on 06/24/26 she had a voicemail from the facility asking her to return the call at her earliest convenience, there was no urgency in the call. She stated she received another phone call on 06/25/26 (again no urgency) just asking her to call back when she could. The resident's sister stated she received a second call on 06/25/26 from the hospital for permission to administer blood to him. The sister stated this was how she learned of the fall that occurred on 06/24/26. The sister stated the resident had a large hematoma to his side, pneumonia and a fractured C4. He needed taken to a larger hospital for treatment. Upon her arrival to the hospital, the resident had been intubated due to difficulty breathing on his own. On 06/30/26 at 3:00 P.M., interview with the DON confirmed a lack of skin assessments following the fall on 06/09/26 when staff noted bruising to the abdominal/side area. Interview on 07/01/26 at 11:30 A.M. with LPN #120 revealed she worked on 06/24/26 from 6:00 P.M. until 06/25/26 at 6:00 A.M. At the beginning of her shift, the off-going nurse reported Resident #160 had slid out of the bed onto the floor. The LPN stated she did go in to see Resident #160 (unable to recall time) during the beginning of her shift, and she felt he appeared to be at his baseline (which included lethargy). The LPN revealed the CNA did report the resident seemed different from normal and she did call the physician (time not recalled) who told her to discontinue his blood pressure medication and monitor the resident. The LPN stated she did go back and check on the resident after speaking with the physician and did check his vital signs, although she verified there was no documented evidence of this. Review of the facility undated policy titled Change in a Residents Condition or Status, revealed the facility would promptly notify the physician of changes in resident's physical/mental condition. The charge nurse would notify the physician when there had been an accident involving the resident, discovery of injuries of unknown source, a need to alter resident's medical treatment significantly, and need to transfer resident to hospital. This deficiency represents non-compliance investigated under Complaint Number 3063687. This deficiency is an example of continued non-compliance from the survey dated 06/02/26.

Based on observation, record review, and interview, the governing body failed to ensure measures were in place to prevent the facility from being without a licensed nursing home administrator who had an active license to practice in the State of Ohio following the resignation of the previous administrator to maintain uninterrupted administrative oversight. This had the potential to affect all 60 residents residing at this facility. Findings include:Observation at the time entrance to the facility on [DATE] at 11:20 A.M. revealed there was no licensed nursing home administrator present in the facility. At the time of entrance, Corporate Staff #89 (who was licensed as an Administrator in another state but not licensed in Ohio) was available to assist the surveyor. On 06/26/26 at 11:20 A.M. interview with Corporate Staff #89 revealed the facility previous Administrator had resigned earlier on this date. During the interview, Corporate Staff #89 revealed the facility owner, Owner #51 was a licensed nursing home administrator in the State of Ohio, and he would be at the facility next week (06/29/26). During the interview Corporate Staff #89 also revealed the facility did not have a full-time onsite Director of Nursing but were using an Interim DON who was out of State who was reachable by phone. On 06/26/26 at 3:00 P.M. interview with the previous Administrator revealed he had resigned on this date and stated his resignation was due to multiple concerns he had identified including Owner #51's direction to terminate the facility DON the previous week leaving the facility with no full-time onsite nursing oversight and the use of a corporate clinical director who was in another state. Online licensure verification for Owner #51, completed on 06/26/26 and contained on Nursing Home Administrator License Detail (website) revealed Owner #51's nursing home administrator's license was inactive as of inactive as of 04/01/26. Information obtained from the Board of Executives of Long-Term Services and Supports (BELTSS) during the onsite investigation verified Owner #51 did not have an active administrator's license in the State of Ohio and that his license had been inactive since 04/01/26. A Board Executive provided evidence of communication with Owner #51 on 04/20/26 related to the license being inactive since 04/01/26. The Board Executive denied evidence of Owner #51's attempts to re-activate his administrator's license between 04/20/26 and 06/29/26. On 06/29/26 at 11:45 A.M. interview with Owner #51 revealed the previous Administrator had put in his 30-day notice on 06/19/26 with his last day to be 07/17/26. He stated the facility was in the process of hiring a new administrator for the facility and a few different people were contacted and on 06/23/26 a person had agreed to a 90-day contract to be an Interim Administrator beginning prior to 07/17/26. When the previous Administrator left of 06/26/26, they reached out to the Interim Administrator to see if she could start immediately, but the earliest she could start was on 07/07/26. During the interview, Owner #51 stated he was licensed in Ohio as an Administrator, but there was a misunderstanding/mistake about his licensing period and had reached out to the licensing board to follow-up. Owner #51 revealed he was currently in the process of getting his license active as of this date. During the interview, Owner #51 failed to provide evidence the facility had measures in place to ensure uninterrupted services of an administrator were in place. Additional observations throughout the onsite investigation on 06/30/26 revealed there was no licensed nursing home administrator with an active Ohio license onsite to provide administrative oversight. Owner #51 provided evidence his nursing home administrator's license was active on 07/01/26. This was verified by a Board of Executives of Long-Term Services and Supports (BELTSS) executive. This deficiency represents non-compliance investigated under Complaint Number 3056219.

Based on closed medical record review, hospital record review, and interview, the facility failed to ensure therapy services were provided as ordered for Resident #160 upon admission. This affected one (Resident #160) of four residents reviewed for therapy services. The facility census was 60. Findings include: Review of the closed medical record revealed Resident #160 was admitted on [DATE] with diagnoses including osteomyelitis, need for assistance with personal care, atrial fibrillation, and cirrhosis of the liver. Review of hospital records for Resident #160 dated 06/05/26 revealed the resident was ordered to discharge from the hospital on this date to a skilled nursing facility. Review of the discharge summary revealed under Activity Orders Resident #160 was to ambulate with assistance at least three times a day, out of bed to chair all day. Discharge orders included Physical and Occupational therapy to evaluate and treat. Review of Resident #160's physician's orders for June 2026 revealed no order was written (per discharge instructions) for physical and occupational therapy services. Review of Resident #160's care plans dated 06/08/26 revealed Resident #160 required (staff) assistance with activities of daily living including bed mobility, transfers, and ambulation due to muscle weakness and debility. The resident also had a plan of care identifying he was at risk for falls/injury related to decreased mobility, episodes of incontinence, medication use, and impaired awareness of deficits. Review of Resident #160's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 was cognitively intact and was dependent on staff for toileting hygiene, personal hygiene, and bathing. Resident #160 required substantial maximum assistance with transfers and bed mobility. Ambulation was not assessed on the MDS. Resident #160 was frequently incontinent with bladder function and occasionally incontinent with bowel function. Review of a nursing progress note dated 06/10/26 at 6:40 A.M. created by Licensed Practical Nurse (LPN) #210 revealed Resident #160 had required more than usual help with walking, transferring, toileting. The note included to be receiving therapy services with goal to return home. Review of a nursing progress note dated 06/10/26 at 6:55 A.M. created by LPN #210 revealed Resident #160 was not currently being treated by therapy. Interview on 06/30/2026 at 12:53 P.M. with Resident #160's sister revealed the resident had been living at home on his own prior to his nursing home admission. There had been concerns related to his inability to care for himself. The resident was hospitalized and then admitted to the facility for placement. During the interview, the family member voiced concerns the resident was supposed to receive therapy after being admitted , but that was never provided. Interview on 06/30/26 at 2:00 P.M. with Director of Rehab #610 confirmed Resident #160 did not receive therapy at any point during his stay at this facility (admission [DATE] to discharge on [DATE]). During the interview Director of Rehab #610 stated he was informed by Admissions #600 that Resident #160 had been admitted for wound care and medication management and did not need therapy evaluation. Interview on 06/30/26 at 3:07 P.M. with Admissions #600 revealed when a resident is newly admitting to the facility, most of the time she would receive a referral package from the discharging facility with expected care and orders for that resident. Admissions #600 stated she had spoken with the case manager from the discharging hospital and asked the case manager if Resident #160 was coming to the facility to receive wound care and medication management. Admissions #600 also revealed that due to Resident #160's young age, she did not figure he was going to receive therapy services and told the therapy department that they did not need to see this resident when he admitted because therapy services were not ordered or required. During the interview Admissions #600 verified she did receive the referral information for Resident #160 and verified there was information in this referral indicating this resident was to be evaluated by physical and occupational therapy and treat as needed. This deficiency represents noncompliance investigated under Complaint Number 3063687.

Based on closed record review, hospital record review, interview, and facility policy review, the facility failed to investigate an injury of unknown origin when Resident #160 was found to have an abdominal wall hematoma and a closed fracture (fx) of the left fourth cervical vertebrae ( C-4 ). This affected one (Resident #160) of four residents reviewed for injury of unknown origin and change in condition. The facility census was 60. Findings include:Review of the closed record revealed Resident #160 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, need for assistance with personal care, atrial fibrillation, and cirrhosis of the liver.Review of physician orders for June 2026 revealed an order to observe for bleeding, decolorization to skin, changes in mental status and vital signs. A progress note is to be made and physician notified.Review of Resident #160's care plans dated 06/08/26 revealed Resident #160 required (staff) assistance with activities of daily living including bed mobility, transfers, and ambulation due to muscle weakness and debility. Resident #160 was at risk for falls/injury related to decreased mobility, episodes of incontinence, medication use, and impaired awareness of deficits. Intervention dated 06/09/26 revealed to monitor, document, report for 72 hours post fall, report to physician for any signs and symptoms of pain, bruises, change in mental status and neuro checks as ordered. Additionally, Resident #160 was receiving anticoagulant therapy related to diagnosis of atrial fibrillation with intervention dated 06/08/26 to monitor, observe, report any adverse reactions, labs per order and notify physician of results.Review of Resident #160's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 was cognitively intact and was dependent on staff for toileting hygiene, personal hygiene, and bathing. The assessment revealed Resident #160 required substantial maximum assistance with transfers and bed mobility. Ambulation was not assessed on the MDS. Review of an incident follow-up note dated 06/10/26 at 10:39 A.M. created by Licensed Practical Nurse (LPN) #259 (from a fall on 06/08/26) revealed Resident #160 had some bruising to his right side of the abdomen. No complaints of pain or discomfort noted. There was no documentation pf the cause of the bruising or a comprehensive assessment including measurements or description of the bruise. There was no mention of any physician notification of bruising. There was no investigation started for the bruise to see if it was related to the fall that occurred. Review of Medical Director #500's progress notes dated 06/12/26 and 06/15/26 revealed no mention of falls and/or bruising to right abdomen.Review of a nursing progress note dated 06/25/26 at 6:30 A.M. created by LPN #210 documented she was called to Resident #160's room via staff. Resident #160 was lying in bed, pale in color, with blood around his mouth. He had gurgling noises during respirations and was unable to clear his throat when cued. His speech was soft, low and garbled at this time. Resident #160 had agitation and attempted to remove the blood pressure cuff and pulse oximeter while obtaining vital signs. Resident #160's blood pressure was 82/40 mmHg, temp was 92.4 degrees F, respirations were 21 breaths per minute, pulse at 100 beats per minute and oxygen saturations at 88 percent. HIs pupils were pinpoint and non-reactive. Resident #160 was transferred to hospital. There was no skin assessment or documentation of bruising contained in this note.Review of a nursing progress note dated 06/25/26 at 1:30 P.M. created by LPN #210 revealed she received report from emergency room and Resident #160 had bilateral pleural effusions, acute blood loss and acute respiratory failure. Resident #160 was being transferred to another hospital.Review of Resident #160's hospital notes dated 06/25/26 revealed he had abdominal wall hematoma, bilateral pleural effusions, acute blood loss anemia, hemorrhagic disorder due to extrinsic circulating anticoagulants, acute respiratory failure with hypoxia, and a closed displaced fracture of the fourth cervical (C-4) vertebra. Recommendations at that time included rewarming, broad spectrum antibiotics, abdominal binder, C collar, blood transfusion, and stabilization prior to transfer to another hospital.Review of Resident #160's hospital notes from the second hospital he was transferred to revealed Resident #160 was experiencing shock, presumed hemorrhagic, suspected acute hematoma within the right anterior rectus abdominus muscle, aspiration pneumonia, and a left C-4 transverse process fracture involving the transverse foramen. Resident #160 was intubated for airway protection.Interview on 06/30/26 at 3:00 P.M. with the Director of Nursing (DON) confirmed a thorough investigation (for injuries of unknown origin) had not been completed following the hospital identification that Resident #160 had an abdominal hematoma, and a C-4 fracture. Review of the facility undated policy titled Abuse, Neglect, Misappropriation policy and protocol revealed injuries of unknown source were a violation that requires reporting. The policy included the facility shall initiate investigation immediately including resident interview, witness interviews, staff interviews, record review, clinical assessment review, video/security review if available, environmental assessments, and a timeline reconstruction. Review of the facility undated policy titled Change in a Residents Condition or Status, revealed facility would promptly notify the physician of changes in resident's physical/mental condition. The charge nurse would notify the physician when there had been an accident involving the resident, discovery of injuries of unknown source, a need to alter resident's medical treatment significantly, and need to transfer resident to hospital. This deficiency represents non-compliance investigated under Complaint Number 3063687.

Based on closed record review, fall investigation review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized fall prevention program for Resident #160 and failed to ensure the resident was fully assessed and provided with timely, updated interventions to prevent additional falls from occurring. This affected one resident (Resident #160) of four residents reviewed for falls. The facility census was 60. Findings include:Review of the closed medical record revealed Resident #160 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, need for assistance with personal care, atrial fibrillation, and cirrhosis of the liver. Review of a Fall Risk Evaluation dated 06/07/26 revealed the resident was assessed to be at low risk for falls with a fall risk score of five (5). Review of a nursing progress note dated 06/08/26 at 8:30 A.M., created by Licensed Practical Nurse (LPN) #210 revealed the nurse was down the hall during medication administration and heard a loud thud along with the sound of a walker banging against the floor. Resident #160 was lying on the floor with his head and shoulders resting against the bathroom door with his walker to his right. Resident #160 stated he hit his head on the bathroom door. The resident's bed was soiled and Resident #160 said he could not find his urinal. The urinal was on the tray table to the right side of resident's bed. Resident #160 was assessed during this time. The note revealed the resident had no complaints of pain, and an assessment was within normal limits. Resident #160 was assisted from floor to a wheelchair with the assistance of two staff. The note revealed Resident #160 was provided education on the importance of using his call light and waiting for assistance. The resident was also provided signage to the bathroom door with a reminder to press call-light and ask staff for assistance for all transfers. Review of Medical Director (MD) #500's progress note dated 06/08/26 documented Resident #160 was status post fall without any injuries. A fall risk assessment dated [DATE] revealed the resident was assessed to be at high risk for falls with a score of 11. A plan of care dated 06/08/26 revealed Resident #160 required (staff) assistance with activities of daily living including bed mobility, transfers, and ambulation due to muscle weakness and debility. The resident also had a care plan related to risk for falls/injury related to decreased mobility, episodes of incontinence, medication use, and impaired awareness of deficits. Fall interventions dated 06/08/26 included call light was to be in reach and encourage the resident to use it for assistance as needed and keep commonly used items within reach. The care plan was updated on 06/09/26 to monitor, document, report for 72 hours post fall, report to physician for any signs and symptoms of pain, bruises, change in mental status and neuro checks as ordered. Review of an incident follow-up note dated 06/09/26 at 10:36 A.M. created by LPN #259 (from the fall on 06/08/26) revealed Resident #160 had with some bruising to his right side of the abdomen. The nurse documented the resident had no complaints of pain. Record review revealed there were no measurements or additional assessment of the bruising at this time and no information as to the cause of the bruising contained in the note. Record review revealed Resident #160 fell again on 06/09/26 at 9:25 P.M. Certified Nursing Assistant (CNA) #310 entered the resident's room to see Resident #160 slip off the bed. The note revealed a new intervention following this fall was to place the resident's bed in the lowest position when occupied. No vital signs post fall were documented nor was there a skin assessment completed. Review of a plan of care dated 06/09/26 revealed Resident #160 had an actual fall (did not identify if the plan was created prior to or after the fall on 06/09/26) with no injury due to poor balance, and unsteady gait. Interventions initiated on 06/09/26 included to check range of motion post fall and notify the Medical Director promptly for any negative findings, continue interventions on the at-risk plan, determine and address causative factors of the fall, monitor/document, and report as needed for 72 hours to the Medical Director any signs or symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, and agitation. Neuro checks as ordered, visual reminder to resident to use call light before getting up. Review of an Interdisciplinary Team note dated 06/10/26 revealed the root cause of the fall (not specific to the fall on 06/08/26 or 06/09/26) was that Resident #160 was weak, unsteady, and having delusions. Interventions included to monitor and document for 72 hours and any pain, bruising, and changes in mental status were to be reported to physician. There was no evidence the facility implemented any fall/safety interventions at this time to address the resident's weakness, unsteadiness or delusions. Review of MD #500's progress note dated 06/10/26 revealed no mention of bruising to right abdomen and/or falls/fall risk or safety needs. Review of a nursing progress note dated 06/10/26 at 6:40 A.M. created by Assistant Director of Nursing (ADON) #238 revealed Resident #160 required help with walking, transferring and toileting more than usual. Resident #160 had required staff assistance since admission to safely transfer and ambulate. There was no evidence of new fall risk and/or safety interventions being initiated at this time to address this change in the resident's condition. Review of an incident follow-up note dated 06/10/26 at 10:39 A.M. created by LPN #259 revealed Resident #160 had some bruising to the right side of his abdomen. However, there was no additional information as to what the bruising was from or measurements/description of the bruise. Review of Resident #160's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 was cognitively intact and was dependent on staff for toileting hygiene, personal hygiene, and bathing. The assessment revealed Resident #160 required substantial maximum (staff) assistance with transfers and bed mobility. Ambulation was not assessed on the MDS. Resident #160 was frequently incontinent with bladder function and occasionally incontinent with bowel function. Review of MD #500's progress notes dated 06/12/26 and 06/15/26 revealed no mention of falls and/or bruising to resident's right abdomen.Review of MD #500's progress note dated 06/17/26 revealed Resident #160 had two falls and questioned ataxia (a neurological condition that causes poor muscle control and clumsiness). There was no mention of bruising to right abdomen and no plan for treatment or follow-up related to possibly ataxia or other safety/fall risk needs. Record review revealed Resident #160 had an unwitnessed fall on 06/24/26 at 4:00 P.M. The note revealed Resident #160 slid out of bed onto the floor. He denied hitting his head. He stated he was trying to get up. Vital signs were blood pressure 106/60 mmHg, temperature at 96.6 degrees F, pulse at 70 beats per minute, respirations at 18 breaths per minute and oxygen saturations at 90 percent on room air. No skin assessment was completed. Neurological assessments (neuro check) were started; however, only one neuro check was completed. During an interview on 06/30/26 at 1:40 P.M., LPN #210 revealed she reported to work on 06/25/26 she received information from LPN #120 (the off-going nurse) that Resident #160 had experienced a fall on 06/24/26 with no injuries. LPN #210 said that the day shift Certified Nursing Assistant (CNA) reported to her that she needed to come and see Resident #160 right away and that he did not look well. Upon entering his room, the resident was pale, had blood around his mouth and was making gurgling sounds. Emergency medical services (EMS) were contacted and the resident was transported to a local hospital. During an interview on 06/30/26 at 3:00 P.M., the Director of Nursing (DON) confirmed fall investigations completed following the resident's falls on 06/08/26, 06/09/26 and 06/24/26 were not thorough/complete and failed to include comprehensive skin assessments and/or vital sign monitoring. In addition, the DON also confirmed there should have been additional details documented related to the fall that occurred on 06/09/26. There was a lack of evidence the facility thoroughly reviewed each fall to ensure timely, necessary and effective new fall risk/safety interventions were initiated to prevent additional falls likely contributing to the fall on 06/24/26 and subsequent hospitalization. During an interview on 07/01/26 at 1:09 P.M., MD #500 stated he could not say for sure if he was aware of Resident #160's bruise or the falls he sustained, but felt the nurses most likely told him. Review of the facility undated policy titled Falls, Fall Risk Managing, revealed staff would identify interventions related to resident specific risks and causes to try and prevent resident from falling and try to minimize complications from falling. Staff would monitor and document interventions. This deficiency represents non-compliance investigated under Complaint Number 3063687. This deficiency is also an example of continued non-compliance from the survey dated 06/02/26.

Based on record review, interview, observation, review of hospital records, and review of information from the National Library for Medicine, the facility failed to ensure residents with acute respiratory changes and decline in condition received comprehensive assessment and treatment in a timely manner. This affected two residents (#1,#21) of two residents reviewed for change in condition. The facility census was 56.Actual Harm occurred to Resident #21 on 05/04/26 when the resident was experiencing shortness of breath, had labored breathing, with oxygen levels desaturating into the 70's and 80's around 1:00 A.M. and Licensed Practical Nurse (LPN) #181 failed to complete a comprehensive assessment including checking vitals and lung sounds and failed to provide treatment to the resident. On 05/04/26 at 6:00 A.M. upon the arrival of dayshift, LPN #164, an immediate assessment was completed and Resident #21 was transferred to the hospital, where she was admitted with a diagnosis of bilateral pulmonary embolisms and remained in the hospital for nine days receiving treatment. Actual Harm occurred to Resident #1 on 02/17/26 when the resident, who had recently been diagnosed with COVID and pneumonia, had a significant change in condition and decline in respiratory status with continued low oxygen saturations without interventions and timely treatment in place until 02/28/26. The facility also failed to provide the resident's medical provider with abnormal lab results thereby not providing the resident's physician with the comprehensive condition of the resident which failed to provide the resident's physician with all the statistics to provide appropriate treatment to the resident. On 02/28/26 Resident #1 was sent to the hospital and admitted with diagnoses of multifocal pneumonia, acute on chronic hypoxic respiratory failure, and acute on chronic symptomatic anemia. The resident remained in the hospital for five days receiving treatment. Additionally, not rising to the level of harm, the facility failed to ensure resident skin impairments were identified and treated timely and failed to apply compression stockings used in the treatment of peripheral edema. This affected four residents (#2, #9, #15, and #28) of four residents reviewed for general skin concerns. The facility census was 56.Findings include: 1.Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including other pericardial effusion and cardiac tamponade. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21's memory was severely impaired, had no behaviors, and did not have oxygen or a bipap (a bilevel positive airway pressure which is a noninvasive ventilator to help you breathe)/cpap (continuous positive airway pressure). Review of a care plan dated 04/22/26 revealed Resident #21 had altered respiratory status/difficulty breathing related to sleep apnea. The goal was for Resident #21 to have no complications related to shortness of breath through the review date. Interventions included but were not limited to administer medications and puffers as ordered and monitor for effectiveness and side effects; assist resident in learning signs of respiratory compromise; CPAP settings: 04/13 via full facemask; encourage sustained deep breaths by using demonstration, using incentive spirometer, or asking resident to yawn; maintain a clear airway by encouraging resident to clear own secretions with effective coughing, if secretions cannot be cleared, suction as ordered/required to clear; nebulizer treatments as ordered. Review of documentation for Resident #21 revealed no notes, vitals or assessments were documented from 05/03/26 until 05/04/26 at 8:00 A.M. Review of a nursing note dated 05/04/26 at 8:00 A.M. by LPN #164 revealed the nightshift nurse (LPN #181) informed her during report that Resident #21's oxygen had been low all-night ranging from 70's to 80's. An aide (certified nurse aide (CNA) #152) obtained vitals which were out of normal range and the resident was lethargic. Upon assessment of lungs, rales were present bilaterally. Vitals were blood pressure of 150/122 (normal range 120/80 mm/Hg), pulse of 91, oxygen saturation still ranging from 80's to 90's and respiration of 25. Physician #195 was notified and gave new orders to send to the emergency room. An ambulance was called to transfer resident to the emergency room. Review of a hospital note dated 05/04/26 revealed Resident #21 presented to a local hospital prior to being sent to current tertiary hospital due to shortness of breath. Upon arrival, she was found to be hypoxic and computed tomography pulmonary angiography (CTPA) showed major thromboembolism with right heart strain which was also confirmed on an echocardiogram. Admitting diagnoses include acute hypoxic respiratory failure and acute pulmonary embolism. The cause of acute pulmonary embolism was unknown but may be in the setting of decreased mobility. Resident #21 was started on heparin drip and peripheral vascular was consulted for consideration of thrombectomy. Review of a hospital note dated 05/07/26 revealed there was no plan for a thrombectomy due to being too high risk for the procedure and would need to plan for indefinite continuation of blood thinners. Review of a hospital note dated 05/08/26 revealed Resident #21's fever was abating, she was still requiring heated high flow, and she wore a bi-pap overnight. The treatment plan was to continue heated high flow nasal cannula and wean flow to saturation greater than 90%; noninvasive positive pressure ventilation when sleeping; heparin drip; both peripheral vascular and structural heart signed off with no intervention planned; resident was too unstable for TEE (transesophageal echocardiogram) or cardiac MRI to evaluate for possible VSD (ventricular septal defect); hold off on additional diuresis; continue cefepime (antibiotic); monitor hemodynamics. Resident #21 was discharged from the hospital and readmitted to the facility on [DATE]. Interview on 05/17/26 at 2:49 P.M. with LPN #164 revealed she came to the facility on [DATE] and was told by LPN #181 that Resident #21's oxygen saturation had been low all night, she did not send her out, call the doctor or document anything. LPN #164 stated the first thing she and the CNA did was round and take vitals for Resident #21 which were abnormal. The physician was contacted and gave an order to send the resident out. Interview on 05/18/26 at 7:48 A.M. with CNA #152 revealed on the morning of 05/04/26, she received report that Resident #21 kept removing her c-pap mask and oxygen throughout the night and her oxygen levels were low. CNA #152 stated she took Resident #21's vitals which were unstable so she informed LPN #164 who took it from there. CNA #152 stated Resident #21 did not look like she felt well, she was pale, breathing rapidly, and her mannerisms were off. Interview on 05/18/26 at 11:52 A.M. with LPN #121 revealed on 05/04/26 she was asked to help assess Resident #21 due to LPN #164 being a newer nurse and the resident had abnormal vital signs. LPN #121 stated she could not recall what Resident #21's vitals were, just that they were all over the place. LPN #121 stated she noticed a surgical incision from prior to admission to resident's chest and recommended she be sent out due to potential cardiac issues. LPN #121 stated Resident #21 wasn't snow white but was pale in color and not feeling well. Interview on 05/18/26 at 2:13 P.M. with Physician Assistant (PA) #190 revealed the facility does not have an on-call service after hours because Physician #195 prefers to take care of his own orders. PA #190 stated the expectation if a resident is having abnormal vital signs would be to complete a comprehensive assessment of the resident and call him or Physician #195 for orders. PA #190 stated it would be abnormal for a resident who usually has oxygen saturations in the 90s to have saturation below 88%. The assessment should include checking all vitals, checking lung sounds, and checking for accessory muscle use. PA #190 stated abnormal vital signs would depend on the resident's baseline. PA #190 stated if a resident who was not alert and oriented would not wear their c-pap and had oxygen saturations in the 70's to 80's, the provider should be contacted and the resident should be sent out. PA #190 stated he would think a nurse should document incidents. Interview on 05/19/26 at 5:44 A.M. with LPN #181 revealed Resident #21 does not like to wear her c-pap and moves around a lot so it is hard to keep on. LPN #181 stated on nightshift 05/03/26 to 05/04/26, Resident #21 did not want to wear her c-pap and the CNA (#132) checked on her around 1:00 A.M. and noticed low oxygen saturations. The aide asked LPN #181 to go to the rehab unit to check on her and they were able to convince Resident #21 to wear her c-pap and her saturations started to rise. LPN #181 stated the lowest she saw Resident #21's saturations was 85%. LPN #181 stated she thought CNA #132 had checked all of Resident #21's vitals but she did not document anything. LPN #181 stated she did listen to Resident #21's lung sounds. LPN #181 confirmed she did not document anything at all for Resident #21on 05/03/26 to 05/04/26 and should have. Interview on 05/19/26 at 12:58 P.M. with the Administrator confirmed nightshift staff should have identified concerns with Resident #21's oxygen saturations and if Resident #21 was having low oxygen concentrations for an entire shift and no one did anything, it would be a delay in care. The Administrator stated if staff don't document it, it didn't happen. Interview on 05/19/26 at 1:36 P.M. with the Director of Nursing (DON) revealed she completed an investigation into the incident with Resident #21. The DON provided the information to the surveyor and it was a statement from LPN #181 and a record of disciplinary measure form. The DON verified this was the entire investigation. The DON stated she started the investigation because she knew the survey team would be looking into the concerns with Resident #21. The DON confirmed the nightshift nurse (LPN #181) did not complete any kind of assessment or progress note for Resident #21 during her shift (05/03/26-05/04/26). Review of a statement dated 05/19/26 by LPN #181 revealed she worked from 05/03/26 to 05/04/26 and when giving report to the dayshift nurse (LPN #164) had advised her to check Resident #21's oxygen saturations as the resident had a few times her oxygen dropped. The lowest number reported was 85% at which time a certified nursing assistant (CNA) and LPN #181 talked to Resident #21 who agreed to wear her c-pap mask to breathe better. After applying the c-pap and waiting approximately 15 minutes, Resident #21's saturations were reassessed and had increased to 93%. LPN #181's statement said she did not report anything in the 70's and if the saturations had remained in the 80's, she would have sent Resident #21 for emergency treatment. Interview on 05/20/26 at 1:30 P.M. with Physician #195 revealed he did not recall being notified of anything regarding Resident #21 on 05/04/26 nightshift. He stated he would want to be notified of oxygen saturations in the 70's and provide a full assessment of all vital signs and lung sounds. Interview on 05/20/26 at 2:30 P.M. with Registered Nurse (RN) #168 revealed she is the respiratory nurse for the facility and completes chest PT, box breathing, and incentive spirometers with residents, but does not work on the rehab side of the building. RN #168 stated if a resident oxygen desaturates into the 70's, it is an emergency and all nurses should be in the room preparing the resident to be sent out because there is a potential for the resident to code. Interview on 05/20/26 at 6:05 P.M. with CNA #132 revealed Resident #21 was having low oxygen saturations due to not wanting to wear her c-pap or oxygen during the night (05/03/26-05/04/26). CNA #132 stated Resident #21's oxygen saturation did read in the 70's at one point, but she would move the pulse oximeter to a different finger and get different readings in the 80's. CNA #132 could not remember an exact time the incident occurred but stated she retrieved LPN #181 who worked with her to convince Resident #21 to apply her c-pap. CNA #132 stated that once the c-pap was applied the oxygen saturation improved but was still fluctuating. CNA #132 stated the resident appeared to be breathing faster than normal. Review of an article titled Acute Pulmonary Embolism on the National Library of Medicine website (https://www.ncbi.nlm.nih.gov/books/NBK560551/) revealed pulmonary embolism (PE) leads to impaired gas exchange due to obstruction of the pulmonary vascular bed leading to a mismatch in the ventilation-to-perfusion ratio because alveolar remains the same. A timely diagnosis of PE is crucial because of the high associated mortality and morbidity which may be prevented with early treatment. 30% of untreated patients with Pes die while on 8% die after timely therapy. Diagnosing a PE can be difficult due to the variety of nonspecific clinical signs and symptoms in patients with acute PE. The most common symptoms include dyspnea, pleuritic chest pain, cough, hemoptysis, presyncope, and syncope. Dyspnea may be acute and severe in a central PE. In patients with pre-existing conditions including heart failure or pulmonary disease, worsening dyspnea may be the only symptom. 2. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including pneumonia due to mycoplasma pneumoniae and acute post-hemorrhagic anemia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and acute on chronic respiratory failure. Review of physician orders revealed Resident #1 had an order in place dated 02/01/26 for albuterol sulfate inhalation aerosol solution 108 (90 base) micrograms (mcg)/ACT two puffs every four hours as needed for chronic obstructive pulmonary disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had mildly impaired cognition, had no behaviors, and received continuous oxygen therapy. Review of a care plan dated 02/09/26 revealed Resident #1 required oxygen therapy related to chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and acute on chronic respiratory failure. The goal was for Resident #1 to have no signs or symptoms of poor oxygen absorption through the review date. Interventions included but were not limited to change resident's position frequently to facilitate lung secretion movement and drainage; give medications as ordered; monitor for signs and symptoms of respiratory distress and report to provider including respirations, pulse oximetry, increase heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage and skin color; oxygen setting at 2 liter per minute (lpm) via nasal cannula; promote lung expansion and improve air exchange by positioning with proper body alignment and elevate head of bed to 30 degrees. Review of a nursing note dated 02/12/26 at 10:18 A.M. by Licensed Practical Nurse (LPN) #222 revealed Resident #1 had a temperature of 101.3 degrees. Physician #195 was notified. New orders were received for a COVID test, flu test, and a complete blood count. Resident #1 tested positive for COVID. Resident #1's labs came back with a critical result of hemoglobin at 6.8 which was reported to the physician. New orders were received to send Resident #1 out for further evaluation. Review of hospital notes dated 02/12/26 revealed Resident #1 presented with a chief complaint of abnormal labs. His hemoglobin was 6.8. Resident #1 complained of a dry cough but denied other concerns. Guaiac results were negative. A computed tomography (CT) scan revealed bilateral lower lobe airspace opacities were suspicious for pneumonia. An x-ray revealed moderate infiltrate perhaps from pneumonia in the right lung base and slight pneumonitis in the right upper lobe. Resident #1 was given intravenous normal saline bolus, Rocephin, and azithromycin (both antibiotic medications) while in the emergency room. A repeat complete blood count (CBC) showed his hemoglobin at 7.1. Review of a nursing note dated 02/13/26 at 6:00 A.M. by Registered Nurse (RN) #123 revealed Resident #1 returned to the facility from the local hospital. The resident had antibiotic orders for diagnosis of pneumonia, and he was COVID positive. Resident #1 was receiving oxygen continuously via nasal cannula at two liters per minute (lpm). Review of orders revealed Resident #1 had an order place dated 02/13/26 for oxygen at four lpm via nasal cannula continuously every shift related to chronic obstructive pulmonary disease. The order was discontinued on 02/17/26. Review of oxygen saturation on 02/16/26 at 11:59 P.M. revealed Resident's oxygen was at 80% with oxygen in place via nasal cannula. There was no evidence that the resident's medical provider was notified of the change in the resident's condition. Review of a nursing note dated 02/17/26 at 5:13 A.M. by RN #225 revealed Resident #1's oxygen was in the low 70's this shift. RN #225 was teaching the resident to breathe in his nose and out his mouth. Resident #1 stated he could hardly take a deep breath. There was no evidence that the resident's medical provider was notified of the resident's change in condition. There was no additional information in the note that included a comprehensive respiratory assessment. Review of a nursing note dated 02/17/26 at 10:58 A.M. by the DON revealed Resident #1's oxygen saturation was at 80% which exceeded a low of 90%. The respiratory nurse was notified to evaluate Resident #1 on possible use of incentive spirometer. There was no evidence that the resident's medical provider was notified of the resident's decline in condition. Review of a nursing note dated 02/17/26 at 3:17 P.M. by RN #168 revealed per nursing report at 6:00 A.M., Resident #1's oxygen dropped to 80%, oxygen was increased to six lpm via nasal cannula and oxygen saturation increased to 90%. Upon assessment at 6:30 A.M., oxygen saturation was 89-90% on six lpm via nasal cannula. Lungs had scattered rhonchi and a nonproductive cough. Inhalers were administered per orders, and as needed nebulizer treatment was administered this shift. Resident was assessed and treated by the respiratory therapist. A call was received by infectious disease provider stating resident's hemoglobin was 6.3 and wanted to make sure Physician #195 was aware and treating. An urgent message was left for Physician #195 at 11:00 A.M.,(specific to the low hemoglobin) and the facility was awaiting a response. There was no evidence the medical provider was notified of the resident's declining respiratory status. Review of orders revealed Resident #1 had an order in place dated 02/17/26 for oxygen six lpm via nasal cannula continuously every shift. Review of a lab note dated 02/17/26 at 3:45 P.M. by RN #189 revealed Resident #1's lab tests which were drawn on 02/16/26 were abnormal including a critically low hemoglobin of 6.3 (normal 13.5-17.5), red blood count of 2.37 (normal 4.25-5.65), platelet count of 115, sed rate of 34 (normal less than 15), sodium of 132 (normal 136-145), albumin of 2.5 (normal 3.4-5.4), calcium of 8.3 (normal 8.5-10.2), CK of 32 (normal 22-198), blood urea nitrogen (BUN) of 42.1 (normal 6-24), creatinine of 1.72 (normal 0.7-1.3), and glucose of 230. Physician #195 was made aware and gave new orders for further lab work to be drawn tomorrow (02/18/26). There was no evidence the resident's physician was notified of the resident's decline in respiratory status and condition. There was no evidence Resident #1's lab tests ordered for 02/18/26 were completed or results received. Review of a nursing note dated 02/23/26 at 1:33 P.M. by DON revealed Resident #1 received a critical low lab result for hemoglobin of 6.7. (This specific lab result was called directly to the facility from the lab; no other lab results were provided at this time). Physician #195 was notified and stated he would be in shortly to review and had no new orders at this time.(Please note- subsequent interview of Physician #195 on 05/20/16 revealed he couldn't find his notes from this visit and there was nothing documented in the medical record regarding the visit). There were no additional notes or assessments of Resident #1 completed between 02/23/26 and 02/28/26 documented in the medical record. Review of a nursing note dated 02/28/26 at 4:41 A.M. by LPN #231 revealed a certified nursing assistant (CNA) checked Resident #1's oxygen status and stated his oxygen saturation was in the 70's at 3:00 A.M. via nasal cannula. Oxygen was checked at 3:30 A.M. and remained at 76% and his oxygen was changed from four lpm to six lpm. Oxygen was checked around 4:00 A.M. and had gone up to 80%. Raised the head of bed to 30 degrees and waited, checked oxygen again at 4:30 A.M. and it was till reading at 76%. The medical provider was called and an order was received to give albuterol treatment and if there were no changes, send to the emergency room. Will continue to monitor. Review of a nursing note dated 02/28/26 at 5:32 A.M. by LPN #231 revealed the breathing treatment was administered and oxygen saturation was still ready 77%. Resident #1 was sent to the emergency room. Review of oxygen saturation for 02/28/26 at 6:09 A.M. revealed Resident #1's oxygen was at 77%. Review of a nursing note dated 02/28/26 at 5:29 P.M. by RN #184 revealed Resident #1 was being admitted to the hospital for pneumonia. Review of hospital notes dated 02/28/26 revealed Resident #1 arrived to the hospital with reported shortness of breath. Resident #1 reported he had been short of breath and relates it to pneumonia. He reported a cough. Upon assessment, tachypnea was present and examination of the right and left lower fields revealed decreased breath sounds. A venous blood gas panel was completed and revealed Resident #1 had a high pH of 7.44 (normal 7.32-7.42), a low pCO2 of 37 (normal 41-51), a low hemoglobin of 7.6 ( normal 13.5-17.5), and a low hematocrit of 23 (normal 41-53). A CBC was also completed and revealed low red blood cells of 2.62 (normal 4.5-5.9), critically low hemoglobin of 6.8 (normal 13.5-17.5), low hematocrit of 23.1 (normal 41-51), and low MCHC of 29.4 (normal 31-37). Review of an additional hospital note dated 02/28/26 revealed Resident #1 was receiving oxygen at four lpm and was saturating at 94% but reports he usually receives two lpm. He was turned down to two lpm and desaturated to 88%. Bilateral lung exam revealed scattered rhonchi and wheezing with the left slightly worse than the right and decreased lung sounds at the bases. Resident #1 received two units of blood due to low hemoglobin but since it was not an abrupt decrease in hemoglobin it was not believed to have caused desaturation. Resident #1 had hypoxia and appreciable bilateral pleural effusions since being treated for pneumonia with an increasing oxygen requirement. It was prudent to admit him. Resident #1 was admitted to the hospital with diagnoses including multifocal pneumonia, acute on chronic hypoxic respiratory failure, and acute on chronic symptomatic anemia. Resident #1 received a one-time loading dose of Vancomycin (antibiotic) 1500 mg followed by a maintenance dose of 750 mg every 24 hours via PICC, Cefepime (antibiotic) 2000 mg every 12 hours. Review of a hospital Discharge summary dated [DATE] revealed Resident #1 Vancomycin transitioned to Daptomycin due to renal function; he was started on Azithromycin (antibiotic) and Levofloxacin (antibiotic) for multifocal pneumonia. The Azithromycin finished on 03/04/26 and the Levofloxacin was dosed every 48 hours due to renal function with the last dose scheduled for 03/09/26. Discharge medications included Daptomycin 50 mg/milliliters (ml) injection infuse 12 ml (600mg total) into a venous catheter daily for seven days and Levofloxacin 750 mg tablet take one tablet by mouth every other day for four days. Interview on 05/20/26 at 1:09 P.M. with Physician #195 revealed he should be notified at any time oxygen saturation is in the 70's and staff should document any rechecks of oxygen levels. Physician #195 did not recall being notified of Resident #1's oxygen dropping into the 70's or staff increasing oxygen to six lpm. Physician #195 stated they should notify him of that, not necessarily before due to it being emergency, but he should be made aware as soon as possible. Physician #195 stated he was not made aware of respiratory struggles with Resident #1 and if he had known about that in conjunction with the low hemoglobin, which he was aware of, he would likely have requested Resident #1 to be sent to the emergency department due to possible need of blood transfusion. Physician #195 stated he ordered iron levels and other labs on 02/17/26 to evaluate the cause of low hemoglobin and he does not know what happened to those lab results. Physician #195 stated he needs to know the results to try and figure out what is going on with Resident #1 to cause low hemoglobin. Interview on 05/20/26 at 2:30 P.M. with RN #168 revealed she is currently the respiratory nurse but was not in February (2026). RN #168 stated she does not give her own orders but will add recommendations in the online order system which have to be approved by a physician. RN #168 stated if a resident is having low oxygen saturation or other signs of respiratory distress on night shift, they should not wait for the respiratory nurse to arrive at the facility on dayshift because it is likely an emergency and should be an all hands-on deck. RN #168 stated if someone is oxygen saturated in the 70s, there is a chance a code could happen so the nursing staff should be working together to get the resident sent out to the hospital. RN #168 stated she could not recall notifying Physician #195 of Resident #1's oxygen desaturating on 02/17/26. RN #168 stated she documented what nightshift told her since they had not documented and then added on to her note what she did for the resident. RN #168 stated respiratory therapy did not actually see him as a patient but laid a second set of eyes on the resident to ensure there were no additional needs. Interview on 05/26/26 at 10:32 A.M. with the DON revealed when Resident #1 was desaturating to 80% on 02/17/26, she did not send him out or call the doctor because they tried to address concerns in-house first since he had COVID, pneumonia and low hemoglobin. The DON stated low hemoglobin can impact breathing. The DON stated she had not been aware of the nursing note prior to hers on 02/17/26 which stated Resident #1 was desaturating into the low 70's but stated she could not speak on behalf of the nurse for not calling the doctor. The DON stated at one point, Resident #1 was sent out to the emergency room for low hemoglobin but the hospital sent him right back without transfusing him. The DON stated she would attempt to locate the labs ordered on 02/18/26 along with occult stools. Review of the labs which were ordered on 02/18/26 revealed they were received by the facility on 05/26/26. The labs indicated Resident #1 had a low iron of 13 (normal 59-158), low TIBC of 141 (normal 170-500), high retic of 2.01 (normal 0.5-2), low hematocrit of 21.8 (normal 40-52), low red blood cells of 2.58 (normal 4.4-5.9), and a critically low hemoglobin of 6.7 (normal 13.3-17.7). The critically low hemoglobin was called in to LPN #227. The occult stools were not provided upon request. Interview on 05/26/26 at 11:53 A.M. with the Administrator confirmed the labs which were ordered on 02/18/26 were not received or reviewed by the facility until 05/26/26 and the occult stools were not provided. Review of a policy titled Change in a Resident's Condition or Status dated 12/2016 revealed the facility shall promptly notify the resident, the provider, and representative of changes in resident's medical/mental condition and/or status. The nurse will notify the attending physician or on-call when there's been a need to alter resident's medical treatment significantly and need to transfer to the hospital/treatment center. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, impacts more than one area of the resident's health status, requires interdisciplinary review and/or revision to the care plan, and ultimately is based on the judgement of the clinical staff and the guidelines outline the Resident Assessment Instrument. Prior to notifying the provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider including information prompted by the communication form. Except in medical emergencies, notifications will be made timely when a change occurs in the resident's medical/mental condition or status. The nurse will record in the medical record information relative to changes in the resident's medical/mental condition or status. 3. Review of the record for Resident #2 revealed an admission date of 02/17/23 and diagnoses including chronic kidney disease, diabetes, hydronephrosis with renal and ureteral calculous obstruction, and chronic pain. Resident #2 had a physician's order dated 04/20/26 to cleanse a skin tear on the right thigh with wound wash and pat dry. Then apply collagen powder to the wound bed, cover with methylene blue foam, and then cover with a gauze island border dressing on Monday, Wednesday, and Friday. Review of wound physician progress notes revealed on 05/13/26 the resident had a skin tear of the right thigh measuring 0.4 by 0.4 by 0.2 centimeters. Observation of the treatment to the right thigh on 05/18/26 at 1:30 P.M. revealed LPN #119 apply collagen powder to the wound bed, then foam, then a gauze dressing. The resident was observed to have a 0.4 centimeter by 0.4-centimeter sheared area on the right thigh. LPN #119 did not cleanse the area before applying the collagen powder and dressings. Interview with LPN #119 on 05/18/26 at 1:50 P.M. confirmed the wound was to be cleansed with wound wash prior to applying the new dressing and he did not. There was no evidence in the record that the area had worsened or had any signs of infection. 4. Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included malignant neoplasm (cancer) of the prostate, malignant neoplasm of the rectum, and anemia. Review of Resident #9's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and his cognition was moderately impaired. He had a functional limitation of his range of motion (ROM) in his upper and lower extremities bilaterally. He was dependent on staff for bed mobility and transfers. Review of Reside

Based on record review, observations, staff interview, policy review, and review of Legionella prevention maintenance records, the facility failed to implement their infection prevention and control program (standard precautions, enhanced barrier precautions and Legionella prevention) to prevent the spread of infection. This affected three residents (#2, #21, #57) of 27 residents reviewed for infection control concerns and had the potential to affect all 56 residents residing in the facility. Findings include: 1.Review of the record for Resident #57 revealed an admission date of 09/03/25 and diagnoses including diabetes, hypertension, and cerebral palsy. Resident #57 had deep tissue pressure ulcers to the left and right heels with a treatment order 05/06/26 to cleanse areas with wound wash, pat dry, apply betadine to wound and leave open to air every day. Observation of the treatment to the heels on 05/19/26 at 7:15 A.M. revealed Licensed Practical Nurse (LPN) #105 to place the treatment supplies, including bottle of wound cleanser, a package of gauze pads, a box of gloves, and a non-disposable tape measure on the resident's over bed table without any barrier. The overbed table was not cleaned first. LPN #105 did not wear a gown to complete the treatment to the heels. There was a sign on the door indicating Enhanced Barrier Precautions were to be followed by staff. (Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Multidrug-resistant organisms (MDROs) refer to microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents. Although the names of certain MDROs describe resistance to only one agent, these pathogens are frequently resistant to most available antimicrobial agents). LPN #105 applied gloves and used a non-disposable tape measure (with retractable coiled tape) to measure the wounds on the residents heels. She was observed to touch the heels with the tape measure. The left heel had a dark dry scab measuring 2.5 by 2.5 centimeters. The right heel had a dark dry scab measuring 5 by 4.5 centimeters. She cleansed the heels with wound cleanser spray then painted the areas with betadine swabs. LPN #105 then put the non-disposable tape measure in her pocket without cleaning it. She then put the bottle of wound cleanser and the package of gauze back into the treatment cart without cleansing after it had sat on the bedside table in the resident's room without any type of barrier. She set the box of gloves used in the treatment back on top of the treatment cart. LPN #105 then got the tape measure out of her pocket and laid it on top of the treatment cart without cleansing it first. Interview with LPN #105 on 05/19/26 at 7:35 A.M. confirmed Resident #57 was on EBP and she should have worn a gown to complete the treatment and she did not. She confirmed she did not use a barrier on the overbed to set the supplies on to prevent them from becoming contaminated. She stated she did not have a disposable measuring device available so she used the non-disposable tape measure. Interview with the Director of Nursing on 05/19/26 at 9:13 A.M. revealed Resident #57 should be on EBP (no physician's order for) and staff should wear a gown to provide treatments. She stated staff should set their treatment supplies on a barrier on the bedside table to prevent contamination. 2. Review of the record for Resident #2 revealed an admission date of 02/17/23 and diagnoses including hydronephrosis with renal and ureteral calculous obstruction, chronic kidney disease, diabetes, and chronic pain. Review of physician's orders revealed an order 06/30/25 to cleanse suprapubic catheter (a tube inserted directly into the urinary bladder through a small incision in the lower abdomen) site with normal saline, pat dry, cover with gauze dressing and secure with tape. There was a physician's order 09/04/25 for enhanced barrier precautions related to the suprapubic catheter. The resident also had a physician's order 04/20/26 for a treatment to a skin tear on the right thigh to include cleanse wound with wound wash, pat dry, apply collagen powder to wound bed, cover with methylene blue foam, and cover with gauze island border dressing. Observations on 05/18/26 at 11:15 A.M. revealed Resident #2 to be in bed. Urine was observed in a catheter bag on the side of the bed. Observation of the treatment to the right thigh on 05/18/26 at 1:30 P.M. included LPN #119 measuring the open area . The resident was observed to have a 0.4 centimeter by 0.4 centimeter sheared area on the right thigh. LPN #119 used a non-disposable tape measure (with retractable coiled tape) to measure the area. LPN #119 used an alcohol wipe to clean the tape measure after using it. He stated he was unable to find a disposable measuring tool to measure the wound with. Interview with the Director of Nursing on 05/18/26 at 3:30 P.M. revealed nurses should be using disposable measuring devices to measure wounds. She stated she would remove the non-disposable tape measure from the treatment cart. (However, a non-disposable tape measure was observed to be used for Resident #57 the next day). Observation of suprapubic catheter care for Resident #2 on 05/19/26 at 7:40 A.M. by LPN #105 revealed she dropped a multi pack of gauze sponges on the floor then picked them up and laid the package on top of the treatment cart (after it had touched the floor). LPN #105 applied gloves but did not put on a gown. A sign was observed on the door telling staff to follow EBP. (LPN #105 had just completed wound care for Resident #57 without wearing a gown for EBP). LPN #105 removed the soiled suprapubic catheter dressing, removed her gloves then, without washing her hands, applied clean gloves. She cleansed around the suprapubic catheter site with normal saline on gauze, applied a new dressing, removed her gloves, and washed her hands. Interview with LPN #105 on 05/19/26 at 7:50 A.M. confirmed she did not wear a gown to complete the treatment for Resident #2, who was on EBP. She confirmed she dropped the gauze on the floor then placed it on top of the treatment cart and she confirmed she did not wash her hands after removing soiled gloves and before applying clean gloves. Interview with the Director of Nursing on 05/19/26 at 9:25 A.M. confirmed staff are to wear a gown while performing a treatment for a resident on EBP. She confirmed staff should not place items on top of the treatment cart that have been dropped on the floor. She confirmed staff should wash their hands after removing gloves and before putting on clean gloves. Review of the undated facility policy titled Enhanced Barrier Precautions revealed the facility will implement EBP for residents identified with MDROs or residents with increased risk for transmission due to wounds or indwelling medical devices. to reduce transmission of MDROs while maintaining resident quality of life and participation in normal activities. The policy stated that staff will wear isolation gowns during high-contact resident care activities including wound care and device care. Review of the undated facility policy titled standard precautions revealed staff are to wash hands after removing gloves. It further stated to ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleansed and reprocessed. Review of the undated facility policy titled Dressings, Dry/Clean revealed staff are to clean the bedside stand and establish a clean field. It further stated to clean the bedside stand after the dressing change. 3. Review of the facility undated Water Management Procedure revealed areas susceptible to Legionella Growth (Legionellosis refers to two clinically and epidemiologically distinct illnesses: Legionnaires' disease, which is typically characterized by fever, myalgia, cough, and clinical or radiographic pneumonia; and Pontiac fever, a milder illness without pneumonia (e.g., fever and muscle aches). Legionellosis is caused by Legionella bacteria) included incoming water supply; domestic hot water heater and storage tanks; all hot and cold water outlets, including sinks and showers, even if not in use; air conditioning and air handling units; circulating pumps; external hose bibs; tempering valves; ice machine; water fountain; and patient care machines including C-pap and Bi-pap machines and oxygen concentrators. Monitoring and control measures in the procedure included: cleanse and disinfect all hot and cold water outlets in use weekly, including vacant rooms and chiller to be serviced monthly by a contractor. It further included maintaining appropriate water temperature and quality by random water sampling. The procedure did not specify what random meant. Review of Legionella Precautionary Maintenance and Inspection Frequency records revealed hot and cold water outlets were being maintained monthly, instead of weekly per procedure. In addition, there was no evidence the chiller was being serviced monthly by a contractor. There was no evidence of any check of the water quality by random water sampling. Interview with Maintenance Director #154 on 05/17/26 at 2:00 P.M. revealed he did not know if the water at the facility had been sampled to test for Legionella. He stated he felt that he needed training on the procedures for preventing Legionella in the facility. Interview with the Administrator on 05/20/26 at 11:40 A.M. and 3:30 P.M. confirmed the water management plan included random checks of water quality. He stated he did not know if the water at the facility had been sampled to test for Legionella. He stated he did not know how often the random sampling was to be done. He confirmed the hot and cold water outlets were being maintained monthly and not weekly per procedure. He confirmed the procedure called for the chiller to be serviced monthly by a contractor and he did not know if this had been done. 4.Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including pericardial effusion and cardiac tamponade. Review of a care plan dated 04/22/26 revealed Resident #21 had altered respiratory status/difficulty breathing related to sleep apnea. The goal was for Resident #21 to have no complications related to shortness of breath through the review date. Interventions included but were not limited to administer medication/puffers as ordered; CPAP setting 4/13 via full face mask; and nebulizer treatments as ordered. Review of orders revealed an order dated 05/06/26 for Resident #21 to have a CPAP/BIPAP in place at bedtime and nap times. Settings 4/13 and remove in the morning. Observation on 05/17/26 at 2:53 P.M. revealed Resident #21's CPAP was laying directly on her nightstand. Observation and interview on 05/20/26 at 8:42 A.M. with CNA #147 revealed Resident #21's CPAP mask was laying directly on the bedside table and not stored in a sanitary bag.

Based on review of the facility assessment, policy and procedure, and interviews, the facility failed to maintain an adequate quality assurance and program improvement program. This affected 56 of 56 residents residing in the facility. The facility census was 56. Findings include:Review of the facility assessment (dated 02/23/26) revealed the assessment would be shared with the quality assurance performance improvement (QAPI) committee at a to be determined (TBD) date. There was no evidence that the facility assessment had been shared with the QAPI committee at the time of the annual recertification survey that initiated on 05/17/26. In addition, the facility assessment identified the facility was licensed for 61 beds with a daily average census of 55-59 residents. Per the facility assessment policies and procedures were to be evaluated with each regulatory update and with new technologies being introduced to the facility staff. Interview on 05/27/26 at 11:04 A.M. with Director of Nursing (DON) and Administrator revealed the QA committee meets monthly. During quarterly meetings, they identify trends and go over information for the minimum data set (MDS) including falls, wounds, behaviors, pharmacy, weights, infections, rehab, and activities of daily living management. The Administrator stated trends that had been previously identified were falls, showers, grievance reporting, medication errors, infection control, and training requirements. When a trend is identified, they then create a performance improvement plan (PIP), find the root cause, and establish a timeframe for improvement. The Administrator stated there were no current PIPs in place. At this time, they had not identified current concerns for change in condition, notification to the physician, ADLs, staff training and evaluations, infection control, or documentation. The Administrator and DON stated they did not feel like QAPI was effective yet and they were concerns prior to them starting QAPI that no one else had done it because staff look at them like a deer in headlights when they run the meetings. The Administrator stated it is a work in progress at this time. Review of a policy titled Quality Assessment and Assurance Plan dated 12/2009 revealed the program is in place and designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems.

Based on record review, review of billing information, review of the facility assessment, review of the Administrator and Director of Nursing (DON) job descriptions, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently. This affected 56 of 56 residents residing in the facility. The facility census was 56. Findings include:1.The annual recertification and complaint survey was initiated on 05/17/26.Review of an undated governing body and facility organizational chart revealed the governing body consisted of: two owners, a holding company which is wholly owned by the facility owners, then the administrator who oversees department heads.Review of a tax bill prepared on 01/30/26 revealed property taxes would be due on 03/06/26 for the first half of the year, totaling $21,451.50.Review of a statement dated 05/14/26 from Gas provider revealed the facility owed $1,011.39 which needed to be paid immediately otherwise, shut-off was scheduled for 06/01/26. Additionally, $672.88 was due on 05/29/26.Review of an invoice dated 05/23/26 from a bakery vendor revealed the facility owed $1975.03 dating back to 01/12/26.Review of a receipt dated 05/26/26 revealed the Gas provider had been paid $1684.27.Review of an email from the owning company Senior Controller (SC) #201 dated 05/26/26 at 9:00 A.M. revealed for some vendors, the facility was carrying some invoices beyond terms which was not unusual for the industry. SC #201 stated they were in contact with vendors and have payment arrangements in place and there was no risk of service interruption for resident care.Interview on 05/26/26 at 11:53 A.M. with the Administrator confirmed the facility received a shut-off notice for gas. The Administrator verified it wasn't until today (05/26/26) that the overdue bill was paid.Review of an online payment receipt from the local Treasurer's office dated 05/26/26 at 12:35 P.M. revealed a payment of property taxes was paid for $23,597.15.Interview on 05/26/26 at 12:58 P.M. with a bakery vendor revealed the facility had not made a payment since March (2026) which was to pay some debt from 2025 and currently owe from 02/09/26 to current date. The bakery vendor stated the terms for payment are to be within 30 days but on average the facility doesn't pay until 82 days overdue. The bakery vendor stated the facility owed $1975.03.Review of an email from bakery vendor dated 05/26/26 at 1:10 P.M. revealed the facility needed to pay $1599.94 so their account would not be placed on cash on delivery (COD) status. The payment would be due by 06/01/26.Interview on 05/27/26 at 8:30 A.M. with Senior Controller (SC) #201 revealed property taxes were late being paid because they had a previous business office in Columbus so the bills were sent to the previous address instead of the current address. SC #201 stated once asked for evidence property taxes were paid, she realized what had happened and paid them. SC #201 stated with the bakery vendor, they were within terms of payment and a payment was made on 05/26/26. She stated they had never been notified they would be cash on delivery if they did not pay their bill. Regarding the gas, SC #201 stated you have to go into a portal to pull the invoice and her assistant accounts payable forgot to pull the bill until survey team requested evidence of payment. She confirmed that should not happen and it won't happen again in the future. Interview on 05/27/26 at 11:04 A.M. with Director of Nursing (DON) and Administrator revealed the QA committee meets monthly. During quarterly meetings, they identify trends and go over information for the minimum data set (MDS) including falls, wounds, behaviors, pharmacy, weights, infections, rehab, and activities of daily living management. The Administrator stated trends that had been previously identified were falls, showers, grievance reporting, medication errors, infection control, and training requirements. When a trend is identified, they then create a performance improvement plan (PIP), find the root cause, and establish a timeframe for improvement. The Administrator stated there were no current PIPs in place. At this time, they had not identified current concerns for change in condition, notification to the physician, ADLs, staff training and evaluations, infection control, financial solvency, or documentation. The Administrator and DON stated they did not feel like QAPI was effective yet and there were concerns prior to them starting QAPI that no one else had done it because staff would look at them like a deer in headlights when they run the meetings. The Administrator stated it is a work in progress at this time. The Administrator stated prior to the evening of 05/26/26, he did not have access to the facility's policy and procedure manual to know how to operate the facility per the company's policies.Review of a policy titled Quality Assessment and Assurance Plan dated 12/2009 revealed the program is in place and designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. Review of a policy titled Governing Body dated 06/13/26 revealed the governing body is legally responsible for the conduct of the facility. The governing body shall appoint a licensed nursing home administrator who is responsible for the day-to-day management of the facility who ensures the facility complies with all federal, state, and local laws and regulations governing the operation of a skilled nursing facility.2. Review of the personnel file for Activity Assistant #153 revealed a hire date of 01/29/25. There was no evidence the facility had checked the State nurse aide registry to check for any findings of abuse for Activity Assistant #153 upon hire. Interview with Human Resources staff #163 on 05/27/26 at 7:45 A.M. confirmed the State nurse aide registry had not been checked for findings of abuse for Activity Assistant #153 upon hire. Interview with Human Resources staff #163 on 05/27/26 at 9:15 A.M. revealed she had just started as the Human Resource staff in November 2025. Review of an Employee Dates Report revealed 30 employees had been hired since November 2025 who were not nurses or nursing assistants (Physical Therapy Assistants #141 and #144, Administrator #214 and #158, Hospitality aide #129, Housekeepers #219, #205, #206, #208, #172, #215, #102, and #116, Receptionist #207 and #117, Dietary Aides #156, #209, #178, #135, #187, #217, and #218, Cooks #114, #210, #211, #107, #212, #213, and #160, and Dietary Manager #142.Interview with Human Resources staff #163 on 05/26/26 at 3:30 P.M. revealed the facility had not checked the State nurse aide registry for findings of abuse for any staff except nurse aides and nurses, including the 30 listed above. She stated she was not aware that they needed to check for employees who were not nursing assistants or nurses. 3. Review of the personnel file for Registered Nurse (RN) #123 revealed a hire date of 11/14/25. Review of a Confirmation of State Residency form revealed RN #123 documented that she had not resided in the state for the previous five years. The form stated if the person had not resided in the state for the previous five years, they were giving consent to the facility to obtain a set of fingerprint impressions for criminal records check of the state, as well as providing a separate set of fingerprint impressions for the FBI. RN #123 had signed the form on 11/12/25. There was no evidence that an FBI background check had been completed for RN #123 (to check for crimes in other states that would disqualify the employee from working at the facility). Interview with Human Resources staff #163 on 05/27/26 at 7:45 A.M. confirmed there was no evidence an FBI background check had been completed for RN #123. She confirmed the FBI background check was required for RN #123.Review of the facility assessment (dated 02/23/26) revealed the assessment would be shared with the quality assurance performance improvement (QAPI) committee at a to be determined (TBD) date. There was no evidence that the facility assessment had been shared with the QAPI committee at the time of the annual survey that initiated on 05/17/26. In addition, the facility assessment identified the facility was licensed for 61 beds with a daily average census of 55-59 residents. Per the facility assessment policies and procedures were to be evaluated with each regulatory update and with new technologies being introduced to the facility staff.Review of a job description for Administrator revealed it was the primary purpose of his job to direct day-to-day functions of the facility in accordance with federal, state, and local standards, guidelines, and regulations to assure the highest degree of quality of care can be provided to residents at all times. Administrative functions included: review policies and procedures at least annually and make changes as necessary to assure continued compliance; ensure appropriate facility policies and procedures are followed when conducting background checks and when providing information to the Nurse Aide Registry; prepare an annual operating budget for approval by the governing body and allocate the resources to carry out programs and activities of the facility; assist in the establishment and maintenance of an adequate accounting system that reflects the operating cost of the facility; review and interpret the monthly financial statements and provide information to the governing body; and ensure adequate financial records and cost reports are submitted to authorized government agencies as required by current regulations.Review of a job description for the DON revealed the primary purpose of her position was to plan, organize, develop and direct overall operation of our nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations. Functions include make daily rounds of nursing service department to ensure all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards; perform background checks on nursing service personnel in accordance with established procedures; ensure all CNA's are verified through the State Nurse Aide Registry; review nursing notes to ensure they are informative and descriptive of the nursing care being provided, they reflect the resident's response to the care, and such care is provided in accordance with the resident's wishes; schedule daily rounds to observe residents and determine if nursing needs are being met in accordance with the resident's request.This deficiency represents non-compliance investigated under Complaint Number 3003957.

Based on observation and staff interview, the facility failed to maintain a clean/ sanitary environment in the dry storage room located in the facility's kitchen used for the storage of dry food goods. This had the potential to affect all residents residing in the facility. The facility's census was 56. Findings include:On 05/19/26 at 11:28 A.M., an observation of the kitchen while observing tray line for the lunch meal served noted cleanliness/ sanitation concerns in the dry food storage room. The dry food storage room was a separate room within the facility's main kitchen behind the food preparation and cooking area. The door to the dry food storage room was propped open despite it having a self-closing mechanism by use of a lanyard strap that was tied around the door knob on the outside of the door and to a metal shelf that was located in the dry food storage room behind the entry/ exit door to the dry food storage room. There was loose uncooked pasta noodles and a large uncooked and unpeeled potato that were found under a bottom rack of one of the metal storage shelves. There was also a rodent trap that was on the floor under that rack. Findings were verified by Dietary Manager #142. On 05/19/26 at 11:30 A.M., an interview with Dietary Manager #142 confirmed the door to the dry food storage room should not be propped open with it have a self-closing mechanism on it. She further confirmed leaving food products that had been dropped on the floor was not going to help any rodent problems that they may have as evidenced by the rodent trap in that same area. She removed the potato from the floor and was going to sweep under the shelf to clean up the uncooked pasta.

Based on review of personnel files, review of the director of nursing job description, and interviews, the facility failed to ensure annual nurse aide performance reviews were completed. This had the potential to affect 56 of 56 residents in the facility. Findings include:Review of the personnel file for Certified Nursing Assistant (CNA) #125 revealed she was hired on 10/12/23. Further review of her file revealed she had not received an annual performance evaluation. Review of the personnel file for CNA #106 revealed she was hired on 04/10/15. Further review of her file revealed she had not received an annual performance evaluation. Review of the personnel file for CNA #203 revealed she was hired on 07/24/87. Further review of her file revealed she had not received an annual performance evaluation. Interview on 05/27/26 at 9:07 A.M. with Human Resources (HR) #163 confirmed CNA #106, #125, and #203 did not have annual evaluations completed on or within 30 days of their due dates. Review of a job description for the Director of Nursing (DON) revealed it was her responsibility to assist HR in developing performance evaluation schedules, criteria, and annual reviews for the nursing service department.

Based on review of schedules, director of nursing job description, Staffing Data Report, facility assessment, and interviews, the facility failed to ensure they had Registered Nurse (RN) coverage daily for eight consecutive hours. This had the potential to affect 56 of 56 residents who resided in the facility. Findings include:Review of the Facility assessment dated [DATE] revealed staff members required for the care of residents included registered nurses (RN)s and licensed nursing staff. There should be three nurses for dayshift and two at night. Review of a staff schedule for 05/03/26 revealed the Director of Nursing (DON) worked from 2:00 P.M. to 6:00 P.M. and was the only RN scheduled to work for the day. Review of a Staffing Data Report dated 05/08/26 revealed for the first quarter of 2026, the facility had triggered excessively low weekend staff and one star staffing rating. Interview on 05/26/26 at 9:15 A.M. the DON confirmed there was not an RN for eight consecutive hours on 05/02/26. Review of the DON Job Description dated 01/08/26 revealed it is the responsibility of the DON to ensure a sufficient number of licensed practical and/or registered nurses for each tour of duty is assigned to ensure quality of care is maintained.

Based on review of employee personnel files, staff interview, and policy review, the facility failed to conduct thorough background checks of employees upon hire to ensure there were no findings of abuse, neglect, exploitation, or misappropriation of property. The facility failed to check the State nurse aide registry for findings of abuse for 30 employees hired since November 2025, failed to conduct an FBI background check for one nurse who had not lived in the the state for the past five years, and failed to check information from previous and/or current employers (reference checks) for 90 of 90 employees hired since November 2025. This affected 56 of 56 residents residing in the facility. Findings include:1.Review of the personnel file for Activity Assistant #153 revealed a hire date of 01/29/25. There was no evidence the facility had checked the State nurse aide registry to check for any findings of abuse for Activity Assistant #153 upon hire. Interview with Human Resources (HR) staff #163 on 05/27/26 at 7:45 A.M. confirmed the State nurse aide registry had not been checked for findings of abuse for Activity Assistant #153 upon hire. Interview with Human Resources staff #163 on 05/27/26 at 9:15 A.M. revealed she had just started as the Human Resource staff in November 2025. Review of an Employee Dates Report revealed 30 employees had been hired since November 2025 who were not nurses or nursing assistants (Physical Therapy Assistants #141 and #144, Administrator #214 and #158, Hospitality aide #129, Housekeepers #219, #205, #206, #208, #172, #215, #102, and #116, Receptionist #207 and #117, Dietary Aides #156, #209, #178, #135, #187, #217, and #218, Cooks #114, #210, #211, #107, #212, #213, and #160, and Dietary Manager #142). Interview with Human Resources staff #163 on 05/26/26 at 3:30 P.M. revealed the facility had not checked the State nurse aide registry for findings of abuse for any staff except nurse aides and nurses, including the 30 listed above. She stated she was not aware that they needed to check for employees who were not nursing assistants or nurses. 2. Review of the personnel file for Registered Nurse (RN) #123 revealed a hire date of 11/14/25. Review of a Confirmation of State Residency form revealed RN #123 documented that she had not resided in the state for the previous five years. The form stated if the person had not resided in the state for the previous five years, they were giving consent to the facility to obtain a set of fingerprint impressions for criminal records check of the state, as well as providing a separate set of fingerprint impressions for the FBI. RN #123 had signed the form on 11/12/25. There was no evidence an FBI background check had been completed for RN #123 (to check for crimes in other states that would disqualify the employee from working at the facility). Interview with Human Resources staff #163 on 05/27/26 at 7:45 A.M. confirmed there was no evidence an FBI background check had been completed for RN #123. She confirmed the FBI background check was required for RN #123. 3. Review of the personnel file for RN #123 revealed a hire date of 11/14/25. Review of the personnel file for Activity Aide #153 revealed a hire date of 01/29/25. There was no evidence that any attempts had been made to check information from previous and/or current employers prior to hiring the employees. Interview with Human Resources staff #163 on 05/26/26 at 3:30 P.M. revealed the facility does not do any reference checks on employees prior to hire. Interview with Human Resources staff #163 on 05/27/26 at 9:15 A.M. revealed she had just started as the Human Resource staff in November 2025. Review of an Employee Dates Report revealed the facility had hired 90 employees since November 2025 (RN's #255, #103, #248 and #239, Director of Nursing #125, Administrators #158 and #214, MDS nurse #175, LPN's #224, #256, #241, #243, #119, #161, #245, #181, #247, #250, #257, #121, #105, #164, and #236, Physical Therapy Assistant's #144 and #141, Occupational Therapy Assistant #107, Respiratory Therapist #230, Nursing Assistants #249, #112, #220, #221, #223, #179, #242, #251, #252, #110, #253, #182, #104, #220, #118, #133, #246, #226, #254, #155, #228, #233, #176, #131, #258, #165, #232, #259, #169, #108, #234, #152, #235, #237, #238, and #240, Housekeepers #219, #205, #206, #208, #172, #215, #116, and #102, Hospitality Aides #129, #140, #124, and #174, Receptionist #117 and #207, Dietary aides #187, #135, #156, #209, #178, and #217, Cooks #213, #160, #114, #210, #211, and #212, and Dietary Manager #142. Human Resources staff #163 confirmed on 05/26/26 at 3:30 P.M. that reference checks had not been completed for any of those employees. Review of the facility policy titled Abuse Prevention Program dated 2001 and revised December 2016 revealed our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. As part of the resident abuse prevention, the administration will: conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. The facility policy did not specifically address conducting reference checks with previous/current employers.

Based on review of personnel files and interviews, the facility failed to ensure facility staff received a minimum of 12 hours of in-services per year. This affected 56 of 56 residents living in the facility. Findings include:1.Review of the personnel file for Certified Nursing Assistant (CNA) #125 revealed she was hired on 10/12/23. Further review of her file revealed no evidence she had received at least 12 hours of in-service education annually. 2.Review of the personnel file for CNA #151 revealed she was hired on 08/14/23. Further review of her file revealed no evidence she had received at least 12 hours of in-service education annually. 3.Review of the personnel file for CNA #132 revealed she was hired on 09/16/21. Further review of her file revealed no evidence she had received at least 12 hours of in-service education annually. Interview on 05/27/26 at 9:07 A.M. with Human Resources (HR) #163 confirmed CNA #125, #151, and #132 had no evidence they had completed at least 12 hours of in-services annually.

Based on record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs including drugs used without adequate indication for use. This affected four residents (#7, #22, #53, #72) of five residents reviewed for unnecessary medications. The facility census was 56.1.Review of the record for Resident #7 revealed an admission date of 01/13/26 and diagnoses including acute and chronic respiratory failure, hypertension, anxiety disorder, morbid obesity, and status post pneumonia. Record review revealed a physician's order 05/04/26 for Prednisone ( a steroid medication) 40 milligrams in the morning for seven days for cold symptoms. Review of the medication administration record for May 2026 revealed the Prednisone 40 milligrams was given daily from 05/05/26 to 05/20/26 (16 days instead of 7). Interview with the Director of Nursing (DON) on 05/20/26 at 10:35 A.M. confirmed the Prednisone was ordered for seven days. She stated a stop date was not put into the computer system so the resident continued to receive the medication as of 05/20/26. She stated she called the physician and an order was given to taper the dose and discontinue the medication in five days. (Prednisone can not be stopped suddenly and must be tapered). 2. Review of the record for Resident #72 revealed an admission date of 04/07/26. Review of the facility infection surveillance report for April 2026 revealed Resident #72 had been taken to the hospital by his family for reports of ongoing weakness, agitation, and hallucinations with difficulty urinating. No other symptoms voiced. Diagnosed with urinary tract infection by the hospital and started on an antibiotic. Review of hospital records revealed he presented with increased falls, confusion, and concern for urinary tract infection (did not mention difficulty urinating). The assessment and plan stated: urinary tract infection with urinary incontinence. It stated a urine sensitivity was pending. On 04/06/26 it stated the urine was sensitive to the antibiotic Cipro. He was started on Cipro at the hospital on [DATE]. After admission to the facility on [DATE], the Cipro continued from 04/07/26 to 04/16/26 for a total of 18 doses. (the physician's order was for Cipro 500 milligrams twice daily for 9 more days). Review of the urine culture results from the hospital dated 04/06/26 revealed Resident #72 had 50,000-100,000 CFU/ml of Enterobacter cloacae. Review of nursing progress notes on 04/08/26 at 3:31 A.M. revealed the resident had no signs/symptoms of infection. Interview with Assistant Director of Nursing (ADON) #189 on 05/26/26 at 12:05 P.M. revealed the facility is supposed to complete an Infection Control Surveillance form for residents prescribed antibiotics to determine if the antibiotic is necessary. She confirmed the Infection Control Surveillance form was not complete for Resident #72. She confirmed that the Infection Surveillance form indicated that the criteria for a urinary tract infection included at least 100,000 CFU/ml of an organism and at least one of the following symptoms: acute dysuria or pain, swelling, or tenderness of testes, epididymis or prostate, fever or leukocytosis. She stated the results of urine culture and lack of symptoms were not discussed with the physician to determine if the resident should continue on the antibiotic after admission to the facility. Resident #72 was discharged home on [DATE]. 3. Review of the record for Resident #22 revealed an admission date of 05/03/26. Review of hospital records revealed the resident was admitted to the hospital 04/26/26 with chief complaint of confusion. Notes indicated the resident had urinary frequency and lower abdominal pain. Denied dysuria. Has had watery diarrhea for two weeks with abdominal cramping. Diagnosis of acute metabolic encephalopathy (a sudden disruption of brain function caused by a systemic illness, chemical imbalance, or organ failure) likely secondary to infection. Urine culture pending. Review of the urine culture results revealed 50,000 CFU/ml of Pseudomonas aeruginosa. Upon admission to the facility on [DATE], the resident had physician's orders for an antibiotic (Ceftriaxone sodium injection two grams daily by IV until 05/06/26. The resident received the medication on 05/04/26, 05/05/26, and 05/06/26). Review of nursing progress notes on 05/04/26 at 4:02 P.M. revealed the resident had no reports of urinary symptoms. Interview with Assistant Director of Nursing #189 on 05/26/26 at 12:05 P.M. revealed the facility is supposed to complete an Infection Control Surveillance form for residents prescribed antibiotics to determine if the antibiotic is necessary. She confirmed the Infection Control Surveillance form was not complete for Resident #22. She confirmed that the Infection Surveillance form indicated that the criteria for a urinary tract infection included at least 100,000 CFU/ml of an organism and at least one of the following symptoms: acute dysuria or pain, swelling, or tenderness of testes, epididymis or prostate, fever or leukocytosis. She stated the results of urine culture and lack of symptoms were not discussed with the physician to determine if the resident should continue on the antibiotic after admission to the facility. Record review revealed the resident was sent to hospital 05/14/26 with chest pain and did not return. 4.Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including radiculopathy, polyneuropathy, and rheumatoid arthritis. Review of a care plan dated 03/02/26 revealed Resident #53 was at risk for pain related to recent surgery, spinal stenosis, osteoarthritis, irritable bowel syndrome, gastro-esophageal reflux disease, and neuropathy. The goals included not having an interruption in normal activities due to pain through the review, will not have discomfort related to side effects related to analgesia through the review, and resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions included but were not limited to administer analgesia per orders' evaluate effectiveness of pain interventions; monitor for probable cause of pain for each episode; monitor and document side effects of pain medications; monitor and record pain characteristics; administer treatments as ordered; administer medications as ordered; and encourage small frequent position changes. Review of a MDS dated [DATE] revealed Resident #53's cognition remained intact and resident had frequent pain of eight through the review period. Review of an order dated 04/07/26 revealed Resident #53 was receiving acetaminophen extra strength oral tablet 500 mg give two tablets by mouth every six hours as needed for pain. There were no parameters to specify which pain level to administer the acetaminophen. Review of an order dated 04/07/26 revealed Resident #53 was receiving oxycodone oral tablet 5 mg give one tablet by mouth every six hours as needed for pain. There were no parameters to specify which pain level to administer the oxycodone. Interview on 05/19/26 at 9:38 A.M. with the director of nursing (DON) confirmed there were no parameters in place for neither acetaminophen nor oxycodone to instruct staff on which pain medication to give based on the resident's pain level. Review of an undated policy titled Pain- Clinical Protocol revealed the physician and staff will identify resident's who have pain or are at risk for pain. The physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain. Pain medications should be selected based on pertinent treatment guidelines.

Based on observation, review of meal tickets, review of the facility's menu/ spreadsheet for specialty diets, review of diet orders, interview, and policy review, the facility failed to ensure all residents receiving a carbohydrate controlled diet (CCD) received the appropriate serving size of the dessert food item served during the lunch meal on 05/19/26. This affected two residents (Resident #58 and #65) and had the potential to affect 19 other residents (Resident #1, #3, #4, #5, #6, #13, #16, #21, #26, #27, #29, #31, #39, #40, #42, #50, #53, #56, and #57), who the facility identified as receiving a carbohydrate controlled diet. Findings include: On 05/19/26 at 11:10 A.M., an observation of the tray line for the lunch meal being served to the residents was completed to ensure diets were provided as ordered and appropriate serving sizes were served. The facility served regular diets, mechanically altered diets, pureed diets, CCD's, renal diets, and large portion diets. Two residents' meal tickets were observed during the tray line that identified those two residents (Resident #58 and #65) as being on a CCD. Dietary [NAME] #160 was noted to dip the main food items onto the plates that included pork loin, Malibu blend vegetables, and a baked potato. The plates were then handed to another dietary aide, who placed them on a tray and added the additional items that were to be served with the meal, which included wheat bread, sour cream and chives, margarine, and a lemon bar. The lemon bars were pre-packaged and all of the same size. Once the other food items were added on the tray, it was loaded into a food cart to be delivered to the residents. All residents were given a pre-packaged lemon bar for dessert. Two resident meal tickets were noted to come through that identified those two residents (Resident #58 and #65) to be on CCD. Both residents received a full serving of the pre-packaged lemon bar that had been removed from a large plastic bowl and placed onto the food cart being delivered to the location they were eating in. Review of the specialty menu and spreadsheet for the CCD's revealed the residents receiving that type of diet were to receive the same food items, as residents on a regular diet, but was to receive half a serving of the lemon bars. Findings were verified by Dietary Manager #142. On 05/19/26 at 11:17 A.M., Dietary Manager #142 confirmed those residents on a CCD were only to receive half a serving size of the pre-packaged lemon bars. She acknowledged two residents (Resident #58 and #65) had already been served a full serving of the lemon bar that all the other residents received. She removed the full serving of the lemon bar that was placed on Resident #65's tray with one that she had cut in half and re-packaged in plastic wrap. She then went to the unit where Resident #58's tray was delivered to and retrieved her lemon bar before she ate it replacing it with one of proper serving size. She then cut up enough of the full size lemon bars to be able to give the remaining residents on a CCD the proper serving size per the menu. She confirmed the residents on a CCD were only supposed to receive half the serving of the dessert being served on that day, as was clearly indicated on the specialty menu's spreadsheet. Review of the facility's policy on Therapeutic Diets revised December 2008 revealed therapeutic diets should be prescribed by the attending physician and the facility would strive for the fewest possible dietary restrictions. Diets modified for medical or nutritional needs would be considered therapeutic diets. Routine menus were planned by the Food Service Manager, and approved by a Registered Dietitian for nutritional adequacy. The regular menu would be modified by the Registered Dietitian for therapeutic diets, with input from the dietary manager for feasibility of kitchen production. The Food Service Manager would establish and use a tray identification system to ensure that each resident received his or her diet as ordered. Residents that were on therapeutic diets would not receive extra or reduced portions or modifications that were not part of the diet, unless approved by the attending physician in conjunction with the Clinical Dietitian.

Based on record review, interview, observations, and policy review, the facility failed to ensure documentation in the medical record was completed accurately to reflect residents' status. This affected four residents (#4, #5, #13, and #56) of 27 residents reviewed for accuracy of medical records. The facility census was 56. Findings include: 1.Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including multiple fractures of the ribs and muscle weakness. Review of a minimum data set (MDS) dated [DATE] revealed Resident #4's cognition remained intact, he had no behaviors, and he had skin tears. Review of a care plan dated 04/23/26 revealed Resident #4 was at risk for bruising related to bruising currently to bilateral upper extremities (BUE)and torso due to fall at home. The goal was for bruising to fade and disappear without any complications. Interventions included but were not limited to observe area and document any noted concerns, remind resident to alert staff if they notice any areas themselves, and weekly skin assessment. Review of a weekly skin assessment dated [DATE] revealed Resident #4 had bruises to BUE and torso. Review of a weekly skin assessment dated [DATE] revealed Resident #4 had bruises to BUE and right side. Review of a weekly skin assessment dated [DATE] revealed Resident #4 had no bruising. Review of a weekly skin assessment dated [DATE] revealed Resident #4 had no bruising. Review of a weekly skin assessment dated [DATE] revealed Resident #4 had no bruising. Observation and interview on 05/18/26 at 8:07 A.M. with Resident #4 revealed he had a large amount of bruising to BUE. Resident #4 stated staff were not monitoring the bruising. Observation and interview on 05/26/26 with Licensed Practical Nurse (LPN) #164 verified Resident #4 had bruising to BUE and stated the bruises had been there since admission with no changes. LPN #164 stated she was taught to only document on the bruising if there were changes. Interview on 05/26/26 at 10:42 A.M. with the Director of Nursing (DON) confirmed Resident #4 had bruising to BUE and weekly skin assessments completed on 05/06/26, 05/13/26, and 05/21/26 did not contain information about the bruising. The DON confirmed information regarding location of bruising should be contained in the assessments even if the bruising was not new. The DON verified Resident #4's assessments were inaccurate. 2.Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and anemia. Review of a care plan dated 04/08/26 revealed Resident #5 had potential for impairment to skin integrity. The goal was to maintain or develop clean and intact skin by the review date. Interventions included but were no limited to educate resident of causative factors and measures to prevent skin injury; encourage good nutrition and hydration in order to promote healthier skin; and follow facility protocols for treatment of injury. Review of a skin assessment dated [DATE] revealed Resident #5 had bruises to BUE, left forehead, and eye. Review of a skin assessment dated [DATE] revealed Resident #5 had bruises to her face, right antecubital, left antecubital, right hand and left hand. Review of an MDS completed on 04/13/26 revealed Resident #5's cognition remained intact, she had no behaviors, and she had burns to her skin. Review of a skin assessment completed on 04/15/26 revealed Resident #5 had bruising to BUE and left side of forehead/eye. Review of a skin assessment dated [DATE] revealed Resident #5 had bruising to BUE. Review of a skin assessment dated [DATE] revealed Resident #5 had bruising to BUE. Review of a skin assessment dated [DATE] revealed Resident #5 did not have bruising. Review of a skin assessment dated [DATE] revealed Resident #5 did not have bruising. Review of a skin assessment dated [DATE] revealed Resident #5 did not have bruising. Observation on 05/17/26 at 3:10 P.M. revealed Resident #5 had scattered bruising to her right hand and forearm. Resident #5 stated the bruises were from the hospital. Interview on 05/26/26 at 9:35 A.M. with LPN #164 confirmed Resident #5 had scattered bruising to BUE. LPN #164 stated they were keeping an eye on the bruising. Interview on 05/26/26 at 10:39 A.M. with the DON confirmed Resident #5's assessments on 05/06/26, 05/17/26, and 05/25/26 indicated Resident #5 did not have bruises and the documentation was inaccurate. Review of a policy titled Charting and Documentation dated 08/2008 revealed all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. 3. Review of the record for Resident #56 revealed an admission date of 02/06/24 and diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, diabetes, and bipolar disorder. Record review revealed a physician's order 07/09/25 to change oxygen tubing and set up weekly on dayshift on Thursday and as needed. Observations on 05/17/26 at 9:10 A.M. revealed Resident #56 to have oxygen on per nasal cannula at two liters. The oxygen tubing was dated 04/02/26 and the humidifier bottle was dated 03/26/26. Interview with LPN #119 on 05/17/26 at 9:30 A.M. confirmed the oxygen tubing was dated 04/02/26 and the humidifier bottle was dated 03/26/26. Review of the oxygen administration record for Resident #56 revealed it was documented that the oxygen tubing and set up had been changed on 04/09/26, 04/16/26, 04/23/26, 04/30/26, 05/07/26, and 05/14/26. Interview with Assistant Director of Nursing #189 on 05/18/26 at 1:00 P.M. confirmed it had been documented six times that the oxygen tubing and set up had been changed when it was not (dated 04/02/26). She confirmed the record was not accurately documented. Interview with LPN #121 on 05/18/26 at 1:15 P.M. confirmed that she documented that Resident #56's oxygen tubing and set up was changed on 04/09/26, 04/23/26, and 05/07/26, when it was not. She confirmed the record was not accurately documented. Interview with LPN #105 on 05/19/26 at 9:43 A.M. confirmed that she documented that Resident #56's oxygen tubing and set up was changed on 04/16/26 and 05/14/26 when it was not. She confirmed the record was not accurately documented. 4. Review of the record for Resident #13 revealed an admission date of 05/07/25 and diagnoses including Parkinson's disease, hypertension, and anxiety disorder. Review of a Minimum Data Set assessment completed 05/07/26 revealed a brief interview for mental status score of 15, indicating intact cognition. It further indicated he was dependent upon staff for personal hygiene, dressing, and showers and required substantial/maximal assistance with transfers. Review of the plan of care revised 08/14/25 revealed Resident #13 required assistance with activities of daily living and mobility. Resident #13 had a physician's order 6/7/25 for nurses to trim and file nails every week on day shift with skin checks. Observations on 05/17/26 at 9:21 A.M. revealed Resident #13 to have long fingernails with a dark substance under the nails. He stated his fingernails needed cut. Observations on 05/18/26 at 8:00 A.M. and 11:19 A.M. revealed the resident to have long fingernails with a dark substance under the nails. He stated the nurses usually cut his nails and they need cut now. Review of the Treatment Administration Record for May 2026 revealed LPN #105 had documented that Resident #13's nails were trimmed and filed on 05/15/26 (2 days before originally noted to be long with dark substance underneath on 05/17/26). Observations on 05/18/26 at 2:20 P.M. revealed Resident #13 to be in bed with long fingernails with a dark substance under the nails. Interview with Assistant Director of Nursing #189 revealed nails are cut weekly by nurses if the resident is a diabetic. She confirmed they did not look like they had been trimmed on 05/15/26 as documented. She asked the resident if he preferred his nails long or short and he replied short. Interview with LPN #105 on 05/19/26 at 9:43 A.M. revealed she did not trim Resident #13's nails on 05/15/26 even though she documented on the treatment record that she did. She confirmed the record was not accurately documented.

Based on review of resident financial records, staff interview, and policy review, the facility failed to ensure residents had access to petty cash on an ongoing basis to include evenings and weekends. This could affect the seven residents whose personal funds were handled by the facility (#2, #6, #13, #25, #26, #27, and #43) of the seven residents reviewed for funds. The facility census was 56. Findings include: Review of resident personal funds records revealed the facility managed the personal funds for seven residents (Residents #2, #6, #13, #25, #26, #27, and #43). Interview with Business Office Manager #186 on 05/26/26 at 9:25 A.M. revealed residents, whose funds are handled by the facility, have access to petty cash at all times. She stated that business office staff are available Monday through Friday from 8:00 A.M. to 4:30 P.M. She stated that if a resident wanted money outside of those times, including weekends, there was a box behind the desk on the rehab unit that contained petty cash. She stated the rehab nurse had the key and would be able to get money out for the residents. Business Office Manager #186 further provided a paper that stated banking hours were from 8:30 A.M. to 4:30 P.M. Monday through Friday. It stated if you wish to request money from your personal funds held by the facility, please notify the rehab charge nurse. Interview with licensed practical nurse (LPN) #164, who was working as the rehab charge nurse on 05/26/26 at 10:30 A.M. (working 6:00 A.M. to 6:00 P.M.) revealed she was not aware of any petty cash box at the rehab desk. She stated she had not been trained on that and would not know how to get cash out for residents after hours when the business office was closed. Review of the facility undated policy titled Resident Trust Fund revealed after hours access to resident trust funds: In circumstances where a resident requires access to funds outside of normal business office or banking hours, the charge nurse on duty will be authorized to access the designated resident trust lock box containing limited petty cash funds.

Based on record review, staff interview, and resident interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team, to include the resident and resident representative and individuals who have knowledge of the resident and his/her needs, after each comprehensive and quarterly assessment. This affected four residents (#3, #5, #9, and #10) of 27 sampled residents reviewed for plans of care. The facility census was 56. Findings include:1.Review of the record for Resident #3 revealed an admission date of 03/07/24 and diagnoses including End Stage Renal Disease with dialysis, diabetes, and hypertension. An annual Minimum Data Set (MDS) assessment completed 03/14/26 documented a brief interview for mental status score of 15, indicating intact cognition. Interview with Resident #3 on 05/17/26 at 1:32 P.M. revealed he had not participated in a care plan meeting in the last six months. He stated he would like to have one and in previous meetings his daughter was present. Record review revealed the last care conference summary was 12/07/25 and it indicated only the resident and social service person was present at the meeting, (no other interdisciplinary team members). It stated an invitation was mailed to his daughter with no response. Interview with Social Worker (SW)#130 on 05/19/26 at 10:15 A.M. revealed care conference meetings are to be held 48 hours after admission, quarterly, annually, with a significant change, upon readmission, or as requested. She stated the care conferences should coincide with the completion of MDS's. She stated in addition to the resident and resident representative, other disciplines should attend or participate including social services, therapy, nurse, and activities. She stated she had taken over social services at the end of February 2026. She confirmed there was no evidence of a care conference in March 2026 when the annual MDS was done. She stated there should have been a care conference in March 2026. She confirmed that the previous care conference in December 2025 included only social services and the resident. 2. Review of the record for Resident #10 revealed an admission date of 11/21/25 and diagnoses including tremors, migraines, Schwannomatosis (multiple benign tumors on nerves throughout the body), bipolar disorder, parkinsonism, schizoaffective disorder, and normal pressure hydrocephalus. Record review revealed MDS assessments completed 11/27/25 (admission), 01/16/26 (quarterly), and 04/18/25 (quarterly). A brief interview for mental status score was unable to be done on 04/18/26 and it was noted the resident had long and short term memory problems. Interview with Resident #10's brother on 05/17/26 at 5:09 P.M. revealed there had been no care conferences since admission. He stated he would like to participate in one as he would like to know what is being done to try to figure out what is causing the resident to decline in mobility. Record review revealed a care conference summary on 11/23/25 that stated a care conference was held with the resident, passport, and family per phone (did not specify who). It indicated two staff were present (did not specify discipline). On 04/16/26 a care conference summary indicated a care conference was held with the resident and social services. It stated brother invited but chose not to participate. It did not indicate that any other interdisciplinary team members participated in the review of the care plan or care conference. Interview with SW #130 on 05/19/26 at 10:23 A.M. revealed she had called Resident #10's brother prior to the 04/16/26 care conference and left a voicemail. She stated he did not get back to her until after the meeting was held. She stated the other department heads did not go into the room for the conference but she did touch base with them prior. She confirmed the care conference summary did not indicate that any other team members participated in the review of the care plan or that the brother was given an opportunity for a care conference. 3.Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anemia, and depression. Review of an MDS dated [DATE] revealed Resident #5's cognition was intact. Review of a care conference dated 04/15/26 revealed the resident, her son, and Social Worker (SW) #130 were in attendance. No additional members of the interdisciplinary team were present. Interview on 05/17/26 at 2:57 P.M. with Resident #5 revealed she had not had a care conference yet. Interview on 05/18/26 at 4:51 P.M. with SW #130 revealed care conferences are completed within the first 48 hours of admission, quarterly, annually, as requested, or with significant changes. Attendees should include social worker, admissions, therapy, nursing, activities, and dietary. Interview on 05/26/26 at 8:23 A.M. with SW #130 revealed for Resident #5's care conference, her son did not get off work until five so she stayed late to meet with resident and her son. SW #130 stated the floor nurse who was working at the time was in attendance and she was not sure why she did not document that. SW #130 stated she went over as much information as she could and provided copies of the care plan and medication list. 4. Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of the prostate, malignant neoplasm of the rectum, and anemia. Review of Resident #9's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and his cognition was moderately impaired. He was not known to display any behaviors, nor was he known to reject care during the seven days of the assessment reference period. He had a functional limitation of his range of motion (ROM) in both his upper and lower extremities bilaterally. Review of Resident #9's active care plans revealed he had a care plan in place for being at risk for skin breakdown and infection related to his skin bruising easily and having thin, fragile skin. The interventions included encouraging the use of Geri-sleeves (specialized, non-compression tubular protectors designed to safeguard fragile, thin skin) to his bilateral upper extremities (BUE), except for hygiene. Review of Resident #9's active physician's orders revealed they also included the need to encourage the use of Geri-sleeves to BUE at all times, except during hygiene. That order originated on 06/23/25. On 05/18/2026 10:39 A.M., an observation of Resident #9 noted him to be lying in bed on an air mattress in a supine position with head of the bed elevated. He was noted to not be wearing any Geri-sleeves at that time. On 05/18/26 at 2:45 P.M., an interview with RN #170 revealed Resident #9 had not been wanting to wear his Geri-sleeves, as per his plan of care. She acknowledged his care plan was not revised to reflect he was known to be non-compliant with the use of Geri-sleeves that was ordered to help protect his skin.

Based on record review, interview, and policy review, the facility failed to ensure a resident receiving an anti-depressant received education on the risks and benefits of taking that medication to allow them to provide informed consent. This affected one resident (#44) of five residents reviewed for unnecessary medications. Findings include:Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with mood disturbance, depression, and anxiety disorder. Review of Resident #44's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. Review of Resident #44's contact list on her admission Record (Face Sheet) revealed her emergency contact/ resident representative was an attorney that was appointed her legal guardian. Review of Resident #44's active physician's orders revealed she had an order in place to receive Remeron (an anti-depressant) 7.5 milligrams (mg) by mouth (po) every night at bedtime for dementia. The order originated on 04/11/26. The resident was also receiving the following psychotropic medications: Zoloft (an anti-depressant) 100 mg po every morning for major depressive disorder, Ativan 0.5 mg po three times a day for anxiety/ agitation related to depression, and Ativan 0.5 mg po every four hours as needed (prn) for anxiety/ agitation. Review of Resident #44's Informed Consents for the Use of Psychotropic Medications provided for review by the facility's Director of Nursing (DON) revealed the resident's daughter was provided education on the risks and benefits associated with the use of Ativan on 03/27/26 and gave an informed consent for that medication to be used. An Informed Consent for Use of Psychotropic Medication pertaining to the use of Zoloft revealed informed consent was received from the resident for the use of that medication on 03/17/26. The form was not signed by the resident to provide evidence an informed consent was obtained. The resident's medical record was absent for any documented evidence that an informed consent was obtained from the resident's legal guardian for the use of Remeron, after it had been initiated as one of the resident's psychotropic medications on 04/11/26. On 05/20/26 at 2:40 P.M., an interview with the director of nursing (DON) confirmed there was no evidence of an informed consent being obtained from Resident #44's legal guardian for the use of Remeron, before it was initiated on 04/11/26. She acknowledged informed consent for the use of psychotropic medications should be obtained, prior to the initiation of the medication. Review of the facility's policy on Psychotropic Medication Consents (not dated) revealed the facility would ensure informed consent was obtained prior to the initiation of psychotropic medications, except in emergency situations consistent with applicable law and clinical standards. The purpose of the policy was to ensure residents or their representatives were informed of the risks, benefits, alternatives, and potential side effects associated with psychotropic medication use and to promote resident rights, safety, and appropriate medication management. The procedure for informed consent indicated the physician or licensed practitioner would discuss with the resident and/ or their representative the medication name and purpose, the target symptoms/ behaviors, risks and potential side effects, benefits and expected outcomes, non-pharmacological interventions attempted, alternative treatment options, and right to refuse treatment. The informed consent was to be obtained prior to initiating a psychotropic medication. The informed consent discussion and consent would be documented in the medical record.

Based on record review, review of an Emergency Medical Service (EMS) run report, review of the facility's incident and accident log for the past six months, review of a facility investigation, interview, and policy review, the facility failed to ensure Agency Licensed Practical Nurse (LPN) #100 followed proper medication administration procedures when preparing and administering medications to Resident #42 resulting in a significant medication error. This resulted in Immediate Jeopardy and Actual Harm on [DATE] at 8:23 P.M., when Resident #42 was erroneously given medications that included Xanax 2 milligrams (mg) by mouth (po), Oxycodone 10- 325 mg po, and Gabapentin 800 mg po during an evening medication administration pass that were physician ordered and intended for his roommate (Resident #15). Due to the significant medication error, Resident #42 had a serious change/deterioration in his condition (altered mental status and decreased level of consciousness). After it had been made known to the facility by Resident #15 that his and Resident #42's medications had been inadvertently mixed up and each received the other's ordered medications, the facility failed to timely identify and correlate the reported medication mix up with the change in Resident #42's condition. LPN #100 did not contact the physician to notify him of the reported medication error or to seek medical intervention/ guidance, when the resident was noted to be lethargic on [DATE] at 8:53 P.M. An on-call physician was not contacted and Resident #42 was not transferred to the hospital for an evaluation, until his condition further deteriorated, and he was found unresponsive, hypotensive, and bradycardic on [DATE] at 1:15 A.M. resulting in a delay in treatment. While hospitalized Resident #42 underwent an endotracheal intubation for airway compromise, had a central venous catheter placed for stable intravenous access, and was admitted to the Intensive Care Unit for ongoing monitoring and treatment. Resident #42 remained hospitalized through [DATE], before being readmitted back to the facility. On [DATE] at 4:04 P.M., the facility's Administrator was notified Immediate Jeopardy began on [DATE] at 8:23 P.M., when Resident #42 was given medications ordered and intended for his roommate (Resident #15). As a result of the significant medication error, Resident #42 was found to be lethargic beginning on [DATE] at 8:53 P.M. The resident continued to show signs of an altered mental status and decreased level of consciousness through [DATE] at 1:15 P.M. when he was found to be unresponsive, hypotensive, and bradycardic. It was not until this point the nurse reached out to the on-call physician to obtain an order for Resident #42 to be transferred to the hospital for an evaluation. The nurse did not make it known to the on-call physician, EMS personnel, or the receiving hospital that it was suspected Resident #42 received the wrong medication that evening, contributing to his change in condition delaying prompt and appropriate medical intervention.The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: - On [DATE] at approximately 4:15 P.M. the [NAME] President (VP) of Clinical Services created the performance improvement plan (PIP) which was presented to the Director of Nursing (DON). The DON was to start the PIP on [DATE] which would go through [DATE] and assign a designee to assist with the PIP. The DON assigned the Assistant Director of Nursing (ADON) to assist with medication audits. The medication audits were designed to address performance criteria for passing medications such as timing of administration, sanitation, security, resident identification per facility policy and procedure, resident privacy, medication pass, medication preparation, ensuring the medication administration record (MAR) was read prior to preparing medications, documentation, controlled substances, vital signs, interactions, directions for preparing/administering/manufactures specifications, oral medications, oral/intranasal inhalers, eye drops, patches, injectables, tube feeding, crushed meds, multi-dose containers, change of directions, and expired meds. - On [DATE] at approximately 5:00 P.M. the DON began an investigation for a possible medication error requiring Resident #42 to be sent to hospital. - On [DATE] at approximately 5:10 P.M. the DON interviewed LPN #100 and got LPN #100's statement of the incident.- On [DATE] at approximately 5:20 P.M. the DON interviewed LPN #135 working the night of the event and received LPN #135's statement.- On [DATE] at approximately 5:30 P.M. the DON interviewed Certified Nursing Assistant (CNA) #150 who worked with Resident #42 the night of the event. - On [DATE] at approximately 6:00 P.M. the DON interviewed Resident #42's roommate (Resident #15) to get his statement.- On [DATE] at approximately 7:00 P.M. the investigation of the incident showed an issue on how medication was prepared and administered. The medication was given in the dark and two residents, #42 and #15 medications were prepared at the same time. The corrective action taken was education on proper medication administration and the five rights of medication administration. - On [DATE] at approximately 8:00 P.M. the DON initiated an in-service on Safe Medication Administration Techniques and Change of Condition with nurses currently on shift regarding the possible medication error that occurred when LPN #100 possibly gave the wrong medications on [DATE] to Resident #42 and Resident #15 that resulted in Resident #42 being transferred to the hospital. - Beginning on [DATE], the facility implemented a plan for the DON/Designee to educate nurses on changes of condition and five rights of medication administration followed by medication administration audits. All current full time licensed nurses (9 LPN's and 10 Registered Nurses (RNs) education was completed by [DATE] (in person and via an education book). The facility implemented a plan for any new LPNs and/or RNs to be educated upon hire by unit manager(s). This education included agency nurses as they were scheduled. - On [DATE], the facility determined they would continue the process for an agency nurse resource guide binder to be available for agency staff to review. - Beginning on [DATE] the DON/ADON began auditing changes in condition daily in clinical meeting one time a day for two weeks, then two times a week for eight weeks and then weekly for three months. Audits were scheduled to continue through [DATE]. The results of the audits would be reviewed through the facility Quality Assessment and Performance Improvement (QAPI) process, and any issues would be addressed as needed. - Beginning on [DATE], the DON/ ADON began medication audits and would continue as stated in PIP; one time a day for two weeks, then two times a week for eight weeks and then weekly for three months. The DON would audit proper identification of residents to ensure picture identification was available on residents at this same frequency. These audits included agency nurses as scheduled. Audits were scheduled to continue through [DATE]. The results of the audits would be reviewed through the facility Quality Assessment and Performance Improvement (QAPI) process, and any issues would be addressed as needed.- On [DATE] at approximately 11:00 A.M. interviews were conducted by the DON with two RNs and two LPNs who had worked three days prior to the incident/event. - On [DATE] at approximately 11:00 A.M. skin checks and health assessment (mental status and level of alertness for changes outside of their baseline) were completed on nine of 23 residents with Brief Interview for Mental Status (BIMS) score of eight or less by the ADON to determine whether any resident(s) had a change in condition or medication adverse effects. - On [DATE] at approximately 1:00 P.M. the current policies and procedures for medication administration and change in condition were reviewed by VP of Clinical Services and DON.- On [DATE] at approximately 2:00 P.M. the physician saw and assessed Resident #15 with result of the visit showing no changes in condition related to medication adverse effects upon examination related to possible medication errors. Physician also reviewed medications for Resident #42 at this time.- A review was completed on [DATE] by the DON, on the process that was in place prior to the [DATE] event for agency staff, including resident rights. Report forms were given to all nursing staff at the beginning of shift that inform a nurse on how residents take their medication. After the review was completed areas identified that needed to be added to the process were the five rights of medication administration and change in condition policy/education. - On [DATE] at approximately 10:00 A.M. resident interviews were started by Social Services for residents with a BIMS of 9 or higher and completed at approximately 4:00 P.M. Fourteen of 23 residents were interviewed by the licensed social worker (LSW). The interview questions pertained to life satisfaction survey- abuse and neglect with last question focusing on whether residents feel comfortable reporting any issues or concerns? - On [DATE] at approximately 10:00 A.M. the DON completed a one-on-one in-service with LPN #100, the nurse involved with the incident on [DATE] on safe medication administration and change in resident conditions. - On [DATE] at approximately 11:00 A.M. the DON initiated an in-service with the nursing department which included (9 LPNs and 10 RNs) related to when to notify the DON of any accidents/incidents causing injury or no injury, significant physical, mental, or psychosocial changes, medication errors, any emergency that arises in the building or with residents. This education was completed on [DATE]. Any new LPNs and/or RNS would be educated upon hire by unit manager (s).- On [DATE] at approximately 2:00 P.M. LPN #100, who was responsible for the medication error involving Resident #42, was placed on the Do Not Return list to work at the facility. - On [DATE] at approximately 4:00 P.M., the medical director requested that all residents had a picture in their chart to prevent future medication errors. An immediate audit was completed on [DATE] at approximately 5:00 P.M. by the DON/ Designee. - On [DATE] at approximately 6:30 P.M. Resident #42 returned from the hospital and the physician reviewed medications for the resident at that time. - On [DATE] at approximately 3:00 P.M. Resident #42 was seen by the provider and all medications and documents were reviewed and approved. - On [DATE] at approximately 3:40 P.M. Social Services conducted an interview with residents on South Hall who had a BIMS score of nine or higher (14 of 23 residents) to see if they had any concerns with receiving any other residents' medications. - The facility implemented a plan for the incident that occurred on [DATE] to be discussed at the next QAPI meeting in [DATE] (undetermined date at this time). All audits would be reviewed during the facility QAPI process, and any issues would be addressed as needed.Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of Resident #42's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, neurocognitive disorders with Lewy Bodies, unspecified mood disorder, major depressive disorder, anxiety disorder, congestive heart failure, hypertension, cirrhosis of the liver, muscle weakness, lack of coordination, difficulty walking, and insomnia. Review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not known to display any behaviors and was not indicated to have received any anti-anxiety medications or opioids. Review of Resident #42's active physician's orders, as of [DATE], revealed the resident had orders to receive the following medications: Abilify (an anti-psychotic sometimes used as conjunctive therapy for major depression not receptive to antidepressants) two mg po every (q) morning (am) for depression, Aspirin Enteric Coated 81 mg po q am, Atorvastatin (cholesterol lowering medication) 80 mg po q night at bedtime (hs), Vitamin D 2,000 units po q am, Plavix (an antiplatelet) 75 mg po q am for blood clot prevention, Aricept 5 mg po q hs for dementia, Fluoxetine (an antidepressant) 30 mg po q am for depression, Lactulose 30 milliliters (ml) po three times daily, Magnesium Oxide 400 mg po q am, Melatonin 10 mg po q hs for insomnia, Remeron 7.5 mg po q hs for appetite stimulant, Potassium Chloride 20 milliequivalents (meq) po twice a day for hypokalemia, Sennosides (constipation medication) 8.6 mg (two tablets) po twice a day for constipation, and Tamsulosin HCL 0.4 mg po q hs for an enlarged prostate. The resident's medications ordered on an as needed (prn) basis active as of [DATE] included Acetaminophen for general discomfort, artificial tears prn for dry eyes, Mucinex prn for congestion, and Zofran prn for nausea. He was not ordered to receive a benzodiazepine for anxiety or a narcotic pain medication for pain. Review of Resident #42's nurses' progress note revealed a nurse's note by Agency LPN #100 dated [DATE] at 1:51 A.M. that indicated at approximately 8:00 P.M. the nurse checked on the resident and administered his medications to him. The resident complained of feeling tired from a room change that occurred earlier that day. The nurse helped prepare the resident for bed. The nurse's note further indicated at approximately 8:53 P.M. she went to do rounds on the resident, and his wife was at his bedside. The wife said he (Resident #42) was sleeping and hadn't woken up during the time she had been there. The nurse attempted to wake the resident, and he reacted to touch but was lethargic. The resident was able to grasp her hands and push his feet against her hands when requested showing the ability to follow command. The nurse obtained his vital signs which included blood pressure 108/72mm/Hg (normal 120/80), heart rate was 68 beats per minute (normal 80-100), respiration rate 17 per minute and temperature was 98.1 degrees Fahrenheit (F.). The wife indicated that she would just come back tomorrow and let the resident rest. The note included the nurse (LPN #100) documented she went back to check on the resident throughout the night, and he seemed to be sleeping peacefully. He was still reactive to touch but remained lethargic. At approximately 1:15 A.M., the nurse went to check on the resident again and he was more lethargic than previously noted throughout the night. The resident wasn't responding to stimuli. The nurse attempted a sternal rub (movement using the knuckles of your hand in an up and down motion to elicit a response from an unresponsive resident) on the resident with no reaction. The nurse obtained another set of vital signs and noted the resident's blood pressure was 96/62 mmHg (hypotensive, meaning low blood pressure) and the resident had a radial pulse rate of 62 beats/minute. His oxygen saturation was 92% on room air (lower side of normal). The on-call physician was contacted, and an order was received to transport Resident #42 to the emergency department (ED) for an evaluation. Emergency Medical Services (EMS) was contacted about the need for transport and arrived at the facility at approximately 1:45 A.M. The nurse gave report to EMS personnel upon their arrival. Review of Resident #42's Skilled Nursing Facility/ Nursing Facility to Hospital Transfer Form dated [DATE] at 1:45 A.M. completed by LPN #100 revealed Resident #42's reason for transfer was an altered mental status. Resident #42 was also noted to have a blood pressure reading of 96/62 mmHg (hypotensive). Relevant diagnoses included dementia and difficulty in walking. Review of Resident #42's EMS Run Report dated [DATE] revealed EMS responded to the facility after a call was received at 1:26 A.M. for an unconscious or fainting individual. They were on-site at 1:37 A.M. The chief complaint was bradycardia (slow heart rate), and a secondary complaint was hypotension (low blood pressure). The resident was noted to have a significant medical history for congestive heart failure, dementia, hypertension, cirrhosis of the liver, anxiety, tremors, myocardial infarction (MI), and encephalopathy. His current medications included Cholecalciferol (Vitamin D), Fluoxetine, Acetaminophen, Plavix, Tamsulosin, Lactulose, Donepezil, and Melatonin. He was assessed to be in moderate distress and there were no reported factors of drug use affecting care. The resident was unresponsive with a primary impression of unconsciousness. He responded to painful stimuli. His Glascow coma scale was seven (a total score of 8 or less is generally indicative of a severe brain injury or coma) with eye opening to painful stimuli, withdrawal from pain, and no verbal response. His vital signs revealed hypotension with a blood pressure of 80/52 mmHg. His blood sugar was 133 milligrams/ deciliter (mg/ dl). The resident was administered Narcan (a medication used to rapidly reverse an opioid overdose) four mg intranasally, due to the resident being assessed to have pinpoint pupils. Intravenous (IV) therapy was initiated into the resident's left forearm for IV administration of 0.9 Normal Saline. The resident was administered an additional 2 mg of Narcan IV and subsequently 1 mg of Atropine IV. Upon arrival at the hospital, the resident's condition was noted to have improved, but he was still unresponsive. Review of the facility's incident/accident log for the past six months revealed an incident dated [DATE] for Resident #42 included under other incidents. An interview with the DON on [DATE] at 2:54 P.M. clarified the other incident that was documented as having occurred with the resident on [DATE] at 1:15 A.M. pertained to the resident's transfer out to the hospital for unresponsiveness. The resident reportedly had a room change that occurred earlier that day and became tired/weak from that. She was asked if the resident's symptoms were possibly related to receiving the wrong medication(s) and she indicated that it was possibly medication related. She indicated the facility conducted an investigation into the incident, but she did not feel she was able to determine that was the cause. She was asked to provide the investigation for review. Review of the facility's investigation of the incident involving Resident #42's change in condition occurring on [DATE] at 1:15A.M. revealed it included incident statements the DON received from several employees, including an agency nurse (LPN #100), who all worked on the evening of [DATE] into the morning hours of [DATE]. The investigation file also included an investigation worksheet, hospital records pertaining to Resident #42, medication administration records (MARs) for Resident #15 and #42, and a performance improvement plan (PIP). Review of an incident statement from Agency LPN #100 obtained by the facility's DON dated [DATE] at 5:10 P.M. revealed the nurse indicated to the DON that she went into Resident #42's room to give him his evening/ bedtime medications, when the resident reported he was tired. After giving him his medications, she helped the resident put his feet up in bed and he laid down. The nurse did not bother him again until his wife informed her the resident did not wake up during her visit. The wife put her cold hands on the resident, but he still did not wake up. That was when the nurse reported she had become a little concerned. The resident was still alert at the time and could open his eyes. He was also able to squeeze her hands and everything. She just figured he was tired, so she left him alone but kept going back and checking on him. When he did not respond to verbal commands to squeeze her hand, or her shaking him, or to a sternal rub that was when she called the physician. The wife reportedly arrived at the facility around 8:53 P.M. The nurse did not know the wife was there until she went back to the room to inform the roommate (Resident #15) that he had already been given his pain medication. Resident #15 had complained to an aide earlier that he was still having pain and said his pain medications did not work. The aide had previously told him he had already got his medications, but the nurse was going to tell him the same. That was when the nurse said she saw Resident #42's wife and was told about the resident not waking up during her visit. The nurse assessed the resident, but the resident acted like he was just sleepy. She got another nurse (LPN #135) to check him, and they both just thought the resident was sleepy from moving earlier that day. She did not think anything about it until he stopped responding later in the evening. She was asked by the DON if she remembered when she originally went into the resident's room and indicated it was at the beginning of her shift, sometime around 8:00 P.M., when she gave him his medications and the resident told her he was tired. She denied she noticed anything else about the resident at that time. The DON then asked the nurse if the resident got worse and became more lethargic as the night went on. The nurse responded that was correct. Once he was like that, she called the provider because the resident was a full code. The wife saw that the resident was not awake after they tried to get him to drink his milkshake. The nurse reported the wife was like oh well, she would just come back tomorrow telling the staff to just let him rest. The nurse then left the resident's room and just returned routinely to check on him. He was still able to respond, at least a little bit, during her follow-up checks. Once he stopped responding, she called the provider. His vital signs remained around 108 (not clear what vital sign she was referencing). Since the nurse did not really know the resident, she asked the wife when she was there if the resident normally slept that deep. The wife responded sometimes, not really, but the nurse did not feel the wife seemed concerned and that he was just in a deep sleep. The nurse was asked by the DON how she prepared her medications for that room. The nurse admitted she prepared them at the same time pulling them both out and popping them both into medication cups that she wrote their names on. She crushed Resident #42's pills and mixed them with pudding before taking them to him. She then went back and gave his roommate (Resident #15) his pills whole. The DON asked the nurse if the roommate said anything about getting the wrong medications. The nurse admitted the room was dark when she gave Resident #15 his medications, but he took them. Twenty (20) minutes later he was complaining to his aide (CNA #150) that he didn't feel like he got his medications because he could normally tell 10 minutes after he took them and that time, he did not feel that way. Review of an incident statement from LPN #135 obtained by the facility's DON dated [DATE] at 5:19 P.M. revealed she was asked by Agency LPN #100 to come back to Resident #42's room to check on him. When she got back to the room, the resident's wife was there. The nurse reported she did not work with Resident #42 that much, but something just seemed off. His vital signs were stable, but he had just moved and they all thought maybe it was just the move or something like that. The aide (CNA #150) continued to do his rounds and the other nurse (Agency LPN #100) went back and checked on him every once in a while. The staff came and got her a second time to check on the resident. That time she said she was like somethings just not right. His vitals were low, but they were still you know he was, she just had a bad feeling so she looked up his code status, and he was a full code. She told the other nurse, Agency LPN #100 he was a full code, and he needed to go out because the resident was not even like he was the first time. She was only able to get the resident to kind of squeeze her hand, after a little time and he fluttered his eyes and moved his feet well the first time, but when they went in prior to calling the squad he would not do any of that. She told the other nurse there was something wrong with him and he needed to go out. She was asked if there was anything else she remembered. She told the DON the roommate was saying well she gave him (Resident #42) his (Resident #15's) pills. The other nurse responded and told her she swore that she did not. She replied she was not there, so she did not know but they did give him (Resident #42) Narcan. His pupils were pinpoint, but he had no response to the Narcan. The EMS only administered one dose of the Narcan while there. She was not sure if they gave him anymore after they left. The EMS did say it could take up to 15 minutes for a response. Even after he was loaded in the truck, the resident was still not responding. She then denied she heard anything directly from the roommate about his medications. What she heard about Resident #42 getting Resident #15's medications came from the nurse (Agency LPN #100). Review of an incident statement from CNA #150 obtained by the facility's DON dated [DATE] at 5:30 P.M. revealed Resident #42 was acting himself at first mumbling. He did not seem out of his normal and he was usually tired. It was usually hard to understand the resident but later he became more lethargic. His family brought him McDonalds, and the resident seemed like he was coming out of it, or so they thought. His vitals were fine. Around midnight, he started getting worse. The resident was not interacting with him as much. He denied he got anything in report about Resident #42, or that there was a resident that they really needed to watch. He was asked by the DON if there seemed to be anything abnormal for the resident when he first arrived on shift. He stated he could not tell anything different at first, but the resident took a drastic turn after his wife left and he thought that was sometime between or around midnight. Review of Resident #42's MAR's for [DATE] that was included in the facility's investigation file revealed Resident #42 should have been given the following medications ordered at bedtime (hs) on [DATE]: Atorvastatin 80 mg po, Donepezil HCL 5 mg po, Melatonin 10 mg po, Remeron 7.5 mg po, Tamsulosin HCL 0.4 mg po, Potassium Chloride 20 meq po, Senna 8.6 mg two tablets po, and Lactulose 30 ml po. The nurse administering those medications was identified as being Agency LPN #100. The medications given to the resident were his 6:00 P.M. medications, also noted to be his hs medications. A medication administration audit report showed he was documented as having received those medications on [DATE] at 8:44 P.M. Review of Resident #42's roommate's (Resident #15's) MAR for [DATE] revealed Resident #15 was scheduled to receive the following medications at bedtime on [DATE]: Atorvastatin 40 mg po, Xanax 2 mg po, Eliquis 5 mg po, Sinemet 10-100 mg po, Gabepentin 800 mg po, and Percocet 10-325 mg po. The medications were signed off as having been given by Agency LPN #100. A medication administration audit report revealed he was documented as having received those medications on [DATE] at 8:23 P.M. The controlled drug record for the Oxycodone- Acetaminophen (Percocet) 10-325 mg tablet and the Xanax 2 mg tablet were signed out of the controlled medication box on [DATE] at 8:00 P.M. (23 minutes prior to the controlled medication being documented as having been administered). Review of Resident #42's hospital records that were included in the facility's investigation file revealed they included Emergency Department (ED) notes, a hospital History and Physical (H&P), and a Discharge Summary from a local hospital. There were additional records from another hospital that Resident #42 had been transferred to. Review of Resident #42's ED Triage Note dated [DATE] at 2:31 A.M. revealed the resident arrived at the hospital from the nursing facility, after being found unresponsive. Per the EMS, the resident was responding to pain on arrival and had pinpoint pupils. His blood pressure was 80/50 (low) and heart rate was 45 beats per minute (bpm). He was administered at total of 6 mg of Narcan (medication given to reverse the effects of a drug overdose) and 1 mg of Atropine (medication used to treat a slow heart rate). Review of an ED Provider Note dated [DATE] at 4:51 A.M. revealed Resident #42's chief complaint was hypotension, bradycardia, and unresponsiveness. His reported last known well was around 8:00 P.M. (approximately six hours prior to his arrival to the ED). The resident was poorly responsive, but did have a gag reflex, and had some arousability to a sternal rub. He was spontaneously breathing with reasonable rate. EMS reported initial miotic pupils. Narcan was tried with some pupillary response and possibly some initial response in terms of arousability but not maintained and not responsive to additional doses. He was supported with low dose pressor therapy for borderline low pressures. A central line was placed for ICU stability. His social history indicated he was never known to use drugs. Pupils were equal at 3 millimeters, after multiple doses of Narcan (per EMS was reported to be miotic previously). Clinical impression was acute encephalopathy, unresponsiveness, abnormal cat scan (CT) of lung, sinus bradycardia. Other known diagnoses in his history included congestive heart failure (CHF), dementia with Lewy Bodies, and cirrhosis of the liver. He was released from the ED and admitted to the hospital ICU. A Urine Drug Screen collected on [DATE] at 5:03 A.M. revealed the resident tested positive for benzodiazepines (classification of a type of antianxiety medication to include Xanax) and Oxycodone (neither of which the resident had an order to receive but was consistent with what was ordered for his roommate at hs). Review of Resident #42's hospital history and physical (H&P) dated [DATE] at 5:52 A.M. revealed the resident presented from the nursing home with complaints of an altered mental status and unresponsiveness. He was admitted to the hospital ICU with risk variables including conventional mechanical ventilation, acute respiratory failure, pneumonia, and dementia. His hospital diagnoses included acute hypoxic (low oxygen levels in the blood) respiratory failure and multifocal pneumonia. He was mildly hypoxic requiring supplemental oxygen upon arrival, initially maintaining airway; however, he had progressive respiratory decline necessitating endotracheal intubation (plastic tube inserted through the mouth and down the throat for airway access) to maintain airway patency. He was also dia

Based on observation, resident interview, staff interview, review of the facility's Abuse policy, and review of a facility self-reported incident (SRI), the facility failed to ensure Resident #14 was protected from physical and verbal abuse/mistreatment. This resulted in actual harm to Resident #14 when her arm was twisted, causing her pain, and resulting in bruising to her arm as staff attempted to force her to put on a hospital gown and when the staff member cursed at her and threatened to leave her naked and exposed to everyone. This affected one of three residents reviewed for physical and verbal abuse. The facility census was 49. Findings include: Review of the facility Resident Abuse policy dated May 2010, revealed the facility strictly prohibits resident abuse, neglect and mistreatment by employees. This policy indicated the facility will do all that is within its control to assure that residents are free from mistreatment, verbal, sexual, physical and mental abuse, corporal punishment, non-therapeutic involuntary seclusion, and misappropriation of personal property. The facility employees are required to report, without fear of reprisal, all known/suspected occurrences of abuse, neglect, and mistreatment immediately to their immediate supervisors. All employees who are suspected of abusing a resident are to be automatically suspended from duty until the investigation is complete. The involved resident is be provided one on one supervision during the acute period. Review of the medical record for Resident #14 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 was alert and oriented to person, place and time and had no documented behaviors. This assessment indicated Resident #14 required extensive assistance of two people for bed mobility, transfers, walking in her room, dressing and toileting. This assessment indicated she was frequently incontinent of bowel and bladder and used a bedside commode for her toileting needs. An interview was conducted with Resident #14 on 06/30/16 at 9:40 A.M. The resident said a state tested nursing assistant (STNA), STNA #50, that worked at the facility had tried to make her put on a hospital gown and twisted her right arm. Resident #14 said this STNA then called her an[***] . Resident #14 said she reported this incident to the nurse when the nurse brought her medications in around 7:00 P.M. or 7:30 P.M. On 06/30/16 at 3:45 P.M., Resident #14 was interviewed again. She said her arm was getting better and described the pain as stinging. She said the incident happened about a week ago after dinner. When asked how the incident made her feel, Resident #14 said she felt bad. She said she never had any problems with anyone and she said STNA #50 was abusive to her. Review of the facility charting guidelines and acute plan of care for incidents dated 06/20/16 at 1:30 P.M. revealed STNA #44 reported to Licensed Practical Nurse (LPN) #2 concerns from Resident #14 about a nursing assistant, STNA #50, being rude and rough with her. Social Service (SS) #8 talked with Resident #14 on 06/20/16 at 1:30 P.M. and then LPN #2 went to check on Resident #14 on 06/20/16 at 1:30 P. M, 06/21/16 at 1:00 P.M., 06/22/16 at 3:00 P.M. and 06/24/16 at 2:00 P.M. Resident #14 reported to both SS #8 and LPN #2 she had areas on both of her forearms from the gown being put on. A skin check was completed on Resident #14 by LPN #2 on 06/20/16 at 1:30 P.M. There were several small scattered areas to both of her forearms that were purplish in color. Review of the facility self-reported incident (SRI) (# 3) dated 06/20/16 revealed an allegation of emotional/verbal abuse was made by Resident #14. The report revealed Resident #14 complained that STNA #50 was mean to her, called her names, and refused to put her on the bedside commode on 06/18/16 at 7:00 P.M. Resident #14 also said STNA #50 tried to put a hospital gown on her. Resident #14 said she told STNA #50 she did not wear hospital gowns, but this STNA insisted the resident wear a hospital gown. Resident #14 said the STNA called her an[***] and continued to put on the hospital gown in a rough manner, twisting her arm and causing her right arm to hurt. The charge nurse supervisor, LPN #25, indicated Resident #14 had discussed this situation with her on Saturday evening, 06/18/16, however she said this resident did not express to her the seriousness of the event. LPN #25 misunderstood at the time and thought the resident had called the aide an[***] and felt that she had taken care of the situation by speaking to the aide about the standard of care expected at the facility. LPN #25 failed to notify administrative staff of this incident immediately. The statements from the facility SRI were reviewed. A written statement from STNA #44 dated 06/20/16 revealed Resident #14 told her on 06/19/16 (no time indicated) that STNA #50 was mean to her by fighting her to put on one of the facility gowns. The resident told STNA #50 that she had her own gowns, but STNA #50 made her put on the facility gown, pulling on her arm. The resident then said she had to have a bowel movement and STNA #50 told her to go in her Depends (adult brief) and STNA #35, a different nursing assistant, could change her. STNA #50 then said she would remove Resident #14 ' s Depend and take her down the hall for people to make fun of her. STNA #44 said Resident #14 was very upset and that it was reported to LPN #2 on 06/20/16. A statement from LPN #2 dated 06/20/16 revealed that after she received this information from STNA #44, the LPN assessed Resident #14's arms. At that time the resident said she already had two bruises on her hand and arm from bumping things. The resident has a history of senile purpura, purplish skin discolorations. Resident #14 showed the LPN small bruises on her right forearm that she said happened when the STNA had pulled a night gown over her arm. No size or documentation of the bruising was documented. A statement from LPN #25 dated 06/21/16 revealed that while administering medications to Resident #14 around 7:00 P.M. on 06/18/16 the resident reported she did not like the new staff, STNA #50. The LPN asked why, what was going on. Resident #14 said she wanted her night gown on and STNA #50 put a hospital gown on her after she explained to this STNA that she had her own gowns to wear to bed. LPN #25 indicated Resident #14 called this STNA an[***] and told her to leave her room. A statement from STNA #35 dated 06/21/16 revealed Resident #14 reported on 06/19/16 (no time given) that on 06/18/16, STNA #50 tried to put a hospital gown on her and she told the STNA that she doesn't wear our gowns, that she has her own. Resident #14 said the STNA tried to force the gown on her but finally stopped. As the STNA was leaving the room, Resident #14 said she needed to use the bathroom and the STNA told her she could wait. Resident #14 then said she needed to have a bowel movement and STNA #50 said the resident could just go in her Depends. A statement from STNA #50 dated 06/21/16 revealed she worked over the weekend and there was a resident that always asked for a certain STNA and she would get the STNA for the resident. STNA #50 did not document any other information on her statement. An interview statement from Resident #14 dated 06/23/16 at 10:30 A.M. revealed the resident had been sitting in her wheelchair. She said STNA#50 came in and wanted to know what she wanted her to do. She told STNA #50 she wanted her gown on. Resident #14 emphatically stated that she does not sleep in a hospital gown but STNA #50 picked up the hospital gown and said that she was going to sleep in this gown. Resident #14 said No, I am not. Resident #14 reported STNA #50 twisted my arm and indicated to her right arm and put her arm in the gown. Resident #14 reported that she told the STNA she was a liar and the STNA told her she was an[***] . Resident #14 removed her arms from the gown and STNA #50 then told her I am going to let you sit here naked and let everyone come back the hall and see you and charge $5.00. Resident #14 then said STNA #50 said she would let STNA #44 take care of her. The SRI summary with the facility ' s conclusion/disposition section indicated abuse was substantiated. STNA #50 was terminated for physical and verbal abuse on 06/23/16. LPN #25 was given a corrective action for not recognizing potential resident abuse and not reporting the incident to management as soon as possible. An interview with STNA #35 on 06/30/16 at 5:00 P.M. revealed she provided care to Resident #14 the remainder of the shift because Resident #14 had said she did not want STNA #50 to take care of her. STNA #50 continued to work on the hall and provide care for the other residents. An interview with the DON on 07/01/16 at 8:20 A.M. confirmed that STNA #50 was not suspended timely, and continued to work until 10:00 P.M. on the hall that evening. An interview with the Director of Nursing (DON) on 06/30/16 at 4:05 P.M. revealed Resident #14 was assessed by the unit manager, LPN #2, and was found to have bruises and purpura noted to both arms. There was no swelling or pain reported. The physician was notified with no new orders. No further examination or assessment of Resident #14 ' s right arm was completed. An interview on 06/30/16 at 5:00 P.M. with STNA #35 revealed she has worked at the facility for about one year. STNA #35 was familiar with Resident #14 and said this incident happened on 06/18/16 and she was made aware of it on 06/19/16. STNA #35 said the resident required two person assistance with a gait belt for transfers. She said Resident #14 was mostly continent and would let staff know when she needed to use the bed side commode. On 06/18/16 at 6:45 or 7:00 P.M., STNA #50 had said Resident #14 wanted her to finish up in getting her ready for bed. When STNA #35 entered Resident #14's room, Resident #14 was seated in her recliner with a gown and pants on and seemed to be upset but didn't want to talk about it. STNA #35 said the resident needed to have a bowel movement and she and STNA #50 transferred Resident #14 to the bedside commode. STNA #35 reported to LPN #25 immediately after providing toileting needs that Resident #14 seemed upset, and STNA #35 did not ask what was wrong but said the resident would tell her when she was ready. LPN #25 said okay. On 06/19/16 (no time given) STNA #35 reported to LPN #25 that Resident #14 said STNA #50 had come in her room the night before and tried to put a hospital gown on her when she had her own gowns. STNA #50 forced the gown on the resident and twisted her arm and then got one of the resident ' s gowns out of the closet and put it on her. But before STNA #50 left her room, Resident #14 said she would let her sit there naked and charge $5.00 for people to see her. Then Resident #14 said she told STNA #50 to get her (STNA #35) to help her. When STNA #50 asked why, Resident #14 said she needed to use the bedside commode to have a bowel movement. At that time, STNA #50 told the resident to go in her pants or Depends (adult brief). LPN # 25 and STNA #35 agreed to tell management on Monday, which would have been 06/20/16. When asked if STNA #35 had worked with STNA #50 prior to the incident, STNA #35 said yes, on Wednesday, Thursday and Friday. She said STNA #50 was new and still in orientation. STNA #35 said she did not know of any problems between STNA #50 and any other residents. STNA #35 said STNA #50 continued to work after the incident happened until the shift ended at 10:00 P.M. An interview with the DON on 06/30/16 at 5:55 P.M. confirmed the investigation included only one interview with another resident (#12) on the same hall as Resident #14 resided because she was the only other cognitively intact resident. Resident #12 voiced no concerns about staff being abusive. The DON confirmed the investigation was not completed in a timely manner and that the staff did not promptly notify the administrative staff of the allegations made by Resident #14. The DON also confirmed STNA #50 worked the remainder of her shift, until 10:00 P.M. on 06/18/16. STNA #50 was not scheduled to work on 06/19/16. On 07/01/16 at 8:21 A.M., the DON verified STNA #50 verbally and physically abused Resident #14. She verified LPN #25 failed to properly notify administrative staff to begin an investigation and permitted STNA #50 to provide care to residents until 10:00 PM on 06/18/16. This deficiency substantiates the Self-Reported Incident Investigation, Control Number OH 200.