Every finding on record at Kirkwood Wellness & Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (skin damage caused by prolonged pressure usually occurring over boney areas) when staff failed to report a new skin issue to the Wound Nurse in a timely manner, and when staff failed to implement pressure-reducing interventions timely upon identification of a new skin integrity issue for one resident (Resident #505). The census was 66. The sample was 33. Review of the Wound Management policy, dated 7/1/25, showed:-Policy: To promote healing of wounds in accordance with standards of practice;-Procedure: Wound documentation:--Location of the wound;--Pressure injury and stage;--Size;--Volume and exudate (drainage);--Pain evaluation;--Presence of infection;--Condition of the wound bed and edges, condition of the peri-wound (tissue around wound edges);--Resident goals;-Guidelines:--Physician order;--Review wound care formulary to assist in treatment decision process. 1. Review of Resident #505's medical record, showed:-admitted [DATE];-Severe cognitive impairment;-Required full staff assistance for hygiene, bathing and bed mobility;-Diagnoses included epilepsy (seizures), difficulty swallowing, kidney disease and dementia. Review of the resident's care plan, in use during the survey showed:-Focus: At risk for self care deficit related to dementia;-Goal: Maintain current level of function;-Interventions: The resident requires assistance with hygiene. Review of the resident's active physician order sheet (POS), showed no physician orders for specialty mattress or heel protectors. Observations on 3/23/26 at 9:50 A.M. and 12:50 P.M., showed the resident reclined in bed on his/her left side on a standard mattress. The resident appeared thin and frail and had no heel protectors or pillows in use with his/her feet. During an interview on 3/24/26 at 10:15 A.M., Certified Nurse Aide (CNA) GGGG said the resident was more independent a few months ago. The resident became weaker and needed more care. The resident was incontinent and needed staff assistance for bed mobility. CNA GGGG observed a dark area on the resident's left outer foot on 3/23/26. He/She reported the area to the nurse on 3/23/26. The resident often lay on his/her left side in bed. During an interview on 3/24/26 at 10:55 A.M., Licensed Practical Nurse (LPN) HHHH said he/she had not been notified of changes in the resident's skin condition. He/She worked at the facility occasionally and expected the aides to report changes in skin condition. He/She was unaware of the facility's skin care or reporting policy. The resident relied on staff for repositioning and care. His/Her mattress was not a low air loss mattress. During an observation and interview on 3/24/26 at 11:10 A.M., the Wound Care Nurse said she worked for a staffing agency. At times, she is scheduled to work as a charge nurse. When she is scheduled to work as the Wound Nurse, she administered the wound care treatments. She had not been notified the resident had a change in skin condition on 3/23/26. The Wound Nurse removed the resident's sock and noted an intact dark purple area of skin to the left outer foot. The area measured 1.5 centimeters (cm) length by (x) 0.6 cm width x 0.0 cm depth. The Wound Nurse said the area was a deep tissue injury (DTI, an area of dark colored skin caused from extended pressure). The area should have been reported and pressure relieving measures should have been put in place, such as a low air loss mattress, heel protectors, a turn and reposition program, and increased monitoring. The Wound Nurse applied skin prep to the area and said the resident will be scheduled to be seen by the Wound Care Physician, and an order for a low air loss mattress will be placed. Review of the resident's progress note, dated 3/24/26 at 11:51 A.M., showed staff documented informed the resident had a wound to the left lateral (outer) foot and identified as a DTI. The area measured 1.5 cm x 0.6 cm and no depth. The resident had pain/tenderness to the area. Area cleaned and skin prep applied. The physician notified and a new order received for an x-ray and wound care to follow. The resident is in the wheelchair and writer took the resident to lunch. Observations on 3/25/26, showed:-At 9:16 A.M., the resident lay on a standard mattress on his/her left side in bed, with no heel protectors or positioning devices noted;-At 2:11 P.M., the resident lay in bed on a low air loss mattress. There were heel protectors in the resident's wheelchair and not in place on the resident's feet. Review of the resident's progress note, dated 3/25/26 at 4:55 P.M., showed staff documented the resident seen by the wound physician today. The resident is to continue current treatment and add off-loading boots and keep the resident off the left lateral foot. Review of the resident's initial wound evaluation and management physician visit note, dated 4/1/26, showed:-Chief complaint: The resident has a wound to the left lateral foot, and left fifth toe;-Wound 1: Unstageable DTI of the left lateral foot, undetermined thickness;--Etiology (cause): Pressure; --Duration: More than 16 days;--Size: 0.7 cm x 1.3 cm x no measurable depth;--Exudate (fluid that has seeped out of tissue): None;--Skin: Intact with purple/maroon discoloration;--Dressing: Apply skin prep once daily and as needed (PRN);-Wound 2: Unstageable DTI of the left fifth toe, undetermined thickness;--Etiology: Pressure;--Duration: More than nine days; --Size: 1.3 cm x 0.7 cm x no measurable depth; --Exudate: None; --Skin: Intact with purple/maroon discoloration; --Dressing: Apply skin prep once daily and PRN.-Recommendations:--General: Off-load wounds, float heels in bed, reposition per policy and turn side to side;--Specific visit recommendations: Continue offloading measures with wedge and off left side, use multi podus boot (relieves pressure and enhances circulation) when out of bed, use pressure off loading boot at all times unless out of bed and low air loss mattress. During an interview on 3/25/26 at 2:20 P.M., Director of Nursing (DON) III said when a change in resident's skin occurred, the aide should immediately report the change to the nurse. The nurse should assess the resident's skin and document the findings. Dependent residents need more frequent turning and repositioning. Pressure reducing devices should be in place to residents at risk to develop pressure injuries to aid in prevention of pressure. Staff should ensure heel protectors, wedges, and a turn and reposition program are implemented once ordered by the physician.

Based on observation, interview, and record review, the facility failed to follow physician orders pertaining to the nutritional requirements for one resident, which included no monthly weight since September 2025 and not administering a nutritional supplement as ordered. The resident had a 5.49% weight loss in four months (Resident #27). The sample was 21. The census was 91.Review of the facility's Weight Variance policy, dated July 2025, showed:-All residents who experience significant, insidious and/or unintentional/unplanned weight loss or gains shall be assessed for nutritional status by Registered Dietitian (RD). Recommendations from RD to include but not limit to adding calorie rich/preferred snacks between meals, fortification, supplements, liberalizing diet, and plan for expected weight changes;-Residents receiving supplements shall be monitored for acceptance by the Dietary Manager (DM)/nursing staff. Residents at risk for unintentional/unplanned weight variance may be monitored with weekly weights. Weights shall be reviewed by the RD for review and assessment;-Residents shall be weighed, and weights reported monthly to the RD. If significant, insidious, or unintentional/unplanned weight variances are identified or, if low body weight or malnutrition is identified, the RD shall be notified by the DM or nursing staff;-The RD shall assess the resident and submit a request for monitoring and/or intervention;-Once the order is obtained, the nutrition intervention is communicated to the DM and/or designee through nursing and/or Nutrition Management;-Residents assessed at risk may be weighed weekly;-Residents shall be assessed for progress monthly or as needed by the RD and adjustments to care made according to resident progress;-Resident progress may be reviewed with the Director of Nursing (DON) and/or DM;-All progress or any changes made shall be documented in the medical records and care plan updated accordingly. Review of Resident's #27's hospital medical record, dated 1/24/25, showed diagnoses included Alzheimer's disease, anxiety, severe protein-calorie malnutrition, and diabetes. During review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/3/25, showed:-Mild cognitive impairment;-Set-up or clean up assistance required for eating;-Malnutrition and diabetes not coded as an active diagnosis;-Weight: 107 pounds (lbs.);-Weight loss: No or unknown. Review of the resident's electronic physician's order sheet (ePOS), showed:-An order, dated 2/25/25, for dietary supplement, Med Pass (calorically-dense nutritional supplement) 90 milliliters (mL) three times daily (TID) at 8:00 A.M., 12:00 P.M., and 5:00 P.M;-An order, dated 4/14/25, for monthly weight monitoring. Review of the resident's weights on the facility's weight report, dated 1/27/26 at 5:31 P.M., showed:-On 7/9/25, 107 lbs.;-On 8/15/25, 109 lbs.;-On 9/15/25, 113.2 lbs.;-No further weights documented. Review of the resident's quarterly MDSs, dated 9/24/25 and 12/24/25, showed 113 lbs. Review of the resident's nutrition progress note, dated 12/23/25 at 11:28 A.M., showed supplements included Med Pass 90 mL TID. Current diet supports needs, will continue. Review of the resident's care plan, in use during the time of survey, showed it did not address the diagnosis of severe protein-calorie malnutrition or reasons for the ordered nutrition supplements. Review of the resident's December 2025 medication administration record (MAR), showed Med Pass 90 mL TID documented as not available 57 out of 93 opportunities. Observation on 1/26/26 at 9:15 A.M., showed the resident ate his/her entire breakfast. During an interview on 1/26/26 at 3:01 P.M., the Assistant Director of Nursing (ADON) said the resident was just weighed today and his/her weight was 106.8 lbs. During an interview on 1/23/26 at 1:07 P.M., Certified Medication Technician (CMT) W said staff weighed all residents in the beginning of each month, between the 1st and the 5th. The residents were weighed, but the nurses must put the weights into the computer. During an interview on 1/27/26 at 4:50 P.M., the RD said the weights available in the medical record were all the weights available for the residents. The facility called and asked if the RD had the resident's weights. The facility switched from one electronic medical record system to another. The transition has been tough and there have been minor issues. They tried to pull the weight report from the prior electronic medical record system but were unsuccessful. During an interview on 1/26/26 at 4:29 P.M., the Medical Director (MD) said staff should always follow physician orders. He expected staff to follow orders and obtain weights as indicated.

Based on observation, interview, and record review, the facility failed to provide medically related social services to assist a resident (Resident #507) lacking decision-making capacity in obtaining a legal representative, despite hospital documentation identifying the need for guardianship. The facility failed to ensure admission agreements and Do Not Resuscitate (DNR, no life saving measures) code status was signed upon admission and in the medical record for two residents (Resident #507 and Resident #505). The facility failed to ensure care plan meetings were conducted quarterly and updated with the goals, medical needs, and daily living support of one resident (Resident #94). The sample size was 33. The census was 66. Review of the facility's undated Social Services Director job description, showed:-Purpose: The primary purpose of your position is to plan, organize, develop, and direct the overall operation of the Facility's Social Services Department in accordance with current federal, state, and local standards, guidelines, and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that the medically related emotional and social needs of the residents are met and maintained on an individual's basis;-Administrative Functions: Plan, develop, organize, implement, evaluate, and direct the social services programs of the facility; -Review department policies and procedures, at least annually, and participate in making recommended changes; -Develop and implement policies and procedures for the identification of medically related social and emotional needs of the resident; -Interview resident and families in a private setting, as necessary; -Refer resident and families to appropriate social service agencies when the facility does not provide the services or needs of the resident in a private setting; -Interview residents or family members as necessary, in a private setting to obtain social history;-Care plan and assessment functions: Develop preliminary and comprehensive assessments of the social service needs of each resident; -Develop a written plan of care for each resident that identifies social problems and needs of the resident and the goals to be accomplished for each problem or need identified; -Encourage the resident or family to participate in the development and review of resident's plan of care; -Assist in the scheduling of care plans and assessments to be presented and discussed at each committee meeting; -Ensure that all social services personnel are aware of the care plan and that care plans are used in providing daily social services to the resident;-Resident Rights: Provide residents with information concerning resident rights, living wills, etc. Explain as necessary; -Participate in resident and group council meetings as requested and provide support services to such council. 1. Review of Resident #507's hospital record, showed:-admitted : 11/13/25;-discharged : 11/19/25;-History of Present Illness: Presenting trauma consult status post fall down eight stairs. Found in his/her underwear on his/her back by his/her friend. Exam with posterior head laceration, otherwise neurologically intact. Found to have bilateral 6 millimeter (mm) hypodense extra-axial collections (collection of fluid within the skull) and acute T12 (vertebral) compression fracture with approximately 20% height loss with mild canal stenosis (narrowing of the spinal canal);-Moderate dementia: Lack capacity; -Social work engaged for update. Social work consult; will contact Adult Protective Services (APS) and request state-appointed guardian for this unrepresented patient who lacks capacity;-Surrogate decision maker: Friend;-Psychiatric: Cognition and Memory: Cognition is impaired, memory is impaired. Review of the resident's physical medicine and rehabilitation consultation, showed:-Date of service: 11/14/25;-History of present illness: admitted on [DATE] after a fall down eight stairs. He/She was found to have bilateral 6 mm hypodense extra-axial collections, T12 compression fracture with 20% height loss, acute L1 compression (spinal column of the lower back) fracture with 10% height loss, minimal T5 (shoulder blade) and T6 (mid back) height loss, right L3 (middle of lumbar spine) transverse process compression fracture. Neurosurgery was consulted and was managed non operatively;-Interval history: Per geriatric medicine note from 8/26/25 and 10/26/25, there are concerns about the patient living on their own and he/she has been looking into Assisted Living Facility (ALF) versus Skilled Nursing Facility (SNF). Concern about his/her ability to manage finances, is unable to drive or make meals. He/She has friends bring groceries and receives food from Meals on Wheels. He/She manages his/her own medications, he/she recently had pills scattered all over the floor in his/her home;-Living situation: No local family support according to patient. Friend is emergency contact;-Assessment and Plan: Dementia: Geriatric medicine note indicating that he/she is not safe to live at home, does not have capacity. Social work is following and request for state-appointed guardian has been made according to chart. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 11/19/25, showed:-Diagnoses included fractures and other multiple trauma, anemia, hypertension (high blood pressure), hyperlipidemia, aphasia (communication disorder), Non-Alzheimer's dementia, traumatic brain injury, depression, and syncope and collapse (fainting);-Severe cognitive impairment;-Unclear speech pattern;-Sometimes understood;-Sometimes understands;-Required moderate assistance with personal hygiene, upper body dressing, shower/bathe;-Required maximal assistance with lower body dressing. Review of the resident's electronic medical record showed no documentation of the resident's signed admission agreement. Review of the resident's care plan, in use during the survey, showed:-Focus: Resident is prescribed regular diet, texture, regular/thin consistency liquids;-Focus: Resident/Responsible party has elected to be a full code;-Focus: Resident is prescribed a medication carrying a Food and Drug Administration (FDA) black box warning, placing the resident at increased risk for serious adverse effects requiring enhanced monitoring and interdisciplinary oversight;-Focus: The resident has hypertension;-Focus: Utilize fall interventions;-No documentation of the resident's brain injury and compression fractures or inability to make medical decisions. Review of the resident's Neurosurgery notes, dated 3/13/26, showed:-History of present illness: Patient presents today with a driver from his/her facility who is able to serve as somewhat of a historian. Per Electronic Medical Record (EMR), patient was admitted in November of 2025 for a fall. Imaging demonstrated concern for subdural hematomas (a life-threatening accumulation of blood between the brain surface usually caused by severe head trauma) for which the patient presents for evaluation of today. Of note, patient is only able to answer yes and no questions, although his/her yes and no do seem appropriate;-Assessment and Plan: In reviewing his/her most recent head Computed Tomography (CT, imaging procedure), he/she does have a significant increase in the size of his/her previously noted SDH (subdural hematoma). I do not know any worsening MLS (brain midline shift), but I think there may be some mild mass effect on the right parietal side. I was able to discuss his/her imaging with physicians for consideration of Middle Meningeal Artery embolization (treatment for chronic subdural hematoma). As the patient is not having any active symptoms related to this change, we recommended evaluation and discussion with vascular neurosurgery physician, for discussion of the procedure moving forward. I have attempted to call the patient's emergency contact which is the social worker from his/her facility, and per the patient's van driver, the social worker may not be in today. I have also not able to leave a voicemail. I have asked physician's nurse to reach out of the social worker to attempt to set up a time that he/she can discuss with the patient's decision maker/healthcare power of attorney and need for possible procedure. This was communicated to the patient and the van driver, as well as typed up for them so that they can give this to his/her facility;-Instructions: We will call Social Worker next week to set up appointment with the resident to see one of our neurosurgeons, to discuss a tentative procedure that is likely needed because resident's hematoma or blood collection in his/her head has increased from 5 mm to 2 centimeters (cm). He/She does not appear to have symptoms, which is good, but I would like him/her and his/her power of attorney to discuss with a surgeon the utility or need to have this taken care, sooner rather than later. Review of the resident's progress notes, showed:-On 3/18/26 at 2:14 P.M., spoke with resident's friend, who is listed as his/her first contact. Friend states that his/her family member is the power of attorney (POA). Writer called family member, no answer, voicemail left to return phone call;-On 3/20/26 at 2:47 P.M., returned call to neurosurgery at hospital. Resident does not need surgery but will most likely need a procedure. If not handled timely, this could result in a neurologically detrimental situation, but most likely would not as this is not an emergent issue. Resident needs a family member to provide consent to the procedure as the resident is not able to give consent at this time due to cognition. Family is persistently unresponsive despite multiple attempts to reach out. Resident has a friend who assist him/her at times, but he/she is not comfortable providing consent for this procedure. Neurosurgery states he/she will escalate this to his/her risk department and see if they have any other ideas. At this time, neurosurgery states that there is no need to send resident to the hospital as this is not an emergent issue at this time. Observation and interview on 3/23/26 at 10:06 A.M., showed the resident was in his/her room. Resident stood with his/her wheeled walker. He/She was able to answer questions; however, he/she took long pauses before answering questions. He/She was able to tell his/her name. He/she was asked if he/she ate breakfast and responded yes but was unable to say what he/she ate. During an interview on 3/23/26 at 1:05 P.M., the Social Worker said the resident had friends, but the facility had not been able to contact the family. The friends were involved and come frequently. He/She had one interaction with the resident since he/she first started in December 2025. The resident did not have a care plan meeting since he/she was admitted . He/She confirmed the resident was not able to make decisions and needed people to assist. He/She was not aware the resident needed a POA. It was just brought to his/her attention this past Friday, 3/20/26. Guardianship through the state was also an option discussed on 3/20/26. He/She spoke to the Administrator about the resident's need for POA and would let the Administrator guide. During an interview on 3/23/26 at 2:22 P.M., the Admissions Coordinator said when a resident was admitted , the liaison worked on getting the admission agreement signed, but it was defaulted to the Social Worker, but it depended on if he/she was in the building. Admissions Coordinator was the liaison between the facility and the hospital and he/she reviewed referrals. Admissions Coordinator was not sure if him/herself reviewed the resident's referral or a former employee. If the resident could not make a decision, they would find someone who could at that time. He/She was aware the resident was not able to make decisions. He/She would have to ask what the policy was for resident's who required a POA or public administrator. He/She does admissions and did not know. The Social Worker was responsible for that and the care planning. During an interview on 3/23/26 at 2:00 P.M., the Social Worker confirmed he/she could not find the resident's signed admission agreement. During an interview on 3/24/26 at 2:45 P.M., Director of Nursing (DON) IIII said the facility tried to reach out to everyone on the resident's contact list. His/Her friend did not want to make big decisions. They needed a care plan meeting, but the Interdisciplinary Team (IDT) discussed guardianship. DON IIII would expect the resident to have a care plan meeting quarterly and as needed. He/She would expect hospital referrals to be reviewed thoroughly so the needs of the resident could be identified. In December 2025, the resident's neurology department sent a clearance that stated he/she could resume normal activities, so there was no guidance or anything put in place related to his/her injury. Neurology said the resident's condition was not urgent, but eventually it was imperative the resident have the procedure done. 2. Review of Resident #505's face sheet, showed:-admitted on [DATE];-Diagnoses included ileus (non-mechanical stoppage of intestinal movement), constipation, chronic kidney disease, and dysphagia (speech impairment);-Advance Directive: Do not Resuscitate. Review of the resident's care plan, showed:-Focus: Resident/responsible party has elected to be a DNR;-Goal: Code status will be known; -To honor/uphold resident preference;-Interventions: Do not send to hospital for no pulse/respirations; -Provide comfort measures to resident if applicable; -Review with IDT team as needed and quarterly to maintain preferences;-Focus: The resident has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's dementia;-Goal: The resident will be able to communicate basic needs on a daily basis;-Interventions: Ask yes/no questions in order to determine the resident's needs; -Communicate with the resident/family/caregiver regarding resident's capabilities and needs. Review of the resident's Physician's Orders Sheet (POS), dated March 2026, showed:-An order, dated 12/30/25, for DNR;-An order, dated 3/24/26, for full code (all possible life saving measures). During an interview on 3/24/26 at 2:38 P.M., the Admissions Coordinator confirmed the resident's code status was changed from DNR to full code because the form was not signed. There was a form, but when he/she went out to a past hospital visit, the form was gone. The Social Worker called the family but also notified the physician. The physician made the decision for the resident to be a full code since the DNR was not signed. Review of the resident's progress notes, dated 3/24/26 at 3:25 P.M., showed a call placed to family to inform of fall and to discuss needing to review code status. No answer at this time. 3. Review of Resident 94's face sheet, showed:-He/She was admitted on [DATE];-Diagnoses included essential tremor, benign prostatic hyperplasia (BPH, enlarged prostate), bipolar disorder (a chronic mental health condition characterized by intense, fluctuating mood swings), vascular dementia, chronic kidney disease, and pneumonia. Review of the resident's quarterly MDS, dated [DATE], showed:-Mild cognitive impairment;-Has hearing aid;-Moderate difficulty - speaker has to increase volume and speak distinctly. Review of the resident's inventory sheet, dated 5/9/25, showed:-Upper and lower dentures;-Hearing aid and batteries. Review of the resident's POS, dated March 2026, showed:-An order, dated 2/2/26, may have audiology, dental, optometry, and/or podiatry consult and treatment;-An order, dated 12/11/25, please be sure patient has hearing aids placed in bilateral ears in AM (morning) and monitor, so they do not get lost;-An order, dated 12/11/25, please check that hearing aids are placed on charger at bedtime and monitor, so they do not get lost at bedtime;-An order, dated 12/11/25, Universal Serial Bus (USB) headset needs plugged in nightly. Please make sure it is plugged in at bedtime. Observation and interview on 3/24/26 at 10:30 A.M., showed the resident in his/her wheelchair. The resident wore a large pair of headphones that was connected to a charger pack that was inside the resident's shirt pocket. The resident did not have dentures in his/her mouth. The resident did not have upper or lower teeth. The resident said he/she did not have proper hearing aids or dentures. They were missing shortly after being admitted to the facility. He/She was tired of wearing the headphones because they made his/her ears sweat. The resident was able to eat meals; however, meat could be difficult if it was not tender. Review of the resident's progress notes showed no documentation in the current electronic medical record prior to 12/11/25. During an interview on 3/27/26 at 3:30 P.M., the resident's progress notes were requested. Administrator JJJJ said he/she would contact corporate because he/she did not have access to resident records in the previous electronic medical record. Review of the resident's previous electronic medical record's progress notes, received 3/30/26, showed:-Progress notes from 5/6/25 through 12/26/25;-On 5/7/25, patient's spouse brought resident's hearing aid in. The left one was lost at the hospital, and family is working with them to get a new one. Patient can hear slightly better, but still very hard of hearing. During an interview on 3/24/26 at 11:42 A.M., the Admissions Coordinator said the Social Worker would set up the appointments for the dentist or the audiologist. They would put up a post and residents signed up. During an interview on 3/24/26 at 12:56 A.M., the Social Worker said he/she organized the dental appointments and audiologist if the resident needed hearing aid. The resident was on the list for hearing, vision, and dental care. They came out every three months. The Social Worker was not aware of the resident's need for dentures and hearing aid, or they were lost. There was no care plan meeting for the resident. The resident approached the Social Worker and requested to be seen. 4. During an interview on 3/30/26 at 1:29 P.M., Administrator JJJJ said social services was responsible for ensuring the admission agreement was signed by the resident. If the resident was unable to sign it, he/she would expect social services to ensure it was signed by a responsible party or POA. It was expected to be signed within 72 hours of admission. Social services was also responsible for ensuring code status forms were signed for residents who choose to have DNR code status. Social services also ensured the physician signed the DNR code status. Administrator JJJJ would expect the code status to be in the medical record. The code status forms were reviewed quarterly. Residents were expected to have care plan meetings at least quarterly, change in condition or by request. Social services was responsible for scheduling the care plan meeting and take the lead on them. Administrator JJJJ agreed that care plans were necessary to ensure the facility was meeting the needs of the resident and those needs also included on-going medical issues, need for hearing aids or dentures, and code status. If a resident was admitted to the facility without the capacity to make decisions, staff was to confirm that the resident could not make decisions and identify a surrogate to make decisions. The IDT was responsible, but social services could lead it. Administrator JJJJ said he/she would expect social services to know how to start or seek the resource of obtaining a public administrator for a resident. There had been no update regarding Resident #507's need for POA or guardianship. They reached out with his/her family members, but no returned call. The neurosurgeon had gone back and forth on the urgency. It was believed to be important but could not say life threatening or detrimental. The facility emailed the neurosurgeon, and it was debated whether or not to send the resident to the hospital to see if there was an ethics committee for decision making, but the hospital decided it was not appropriate. They were not consistent with urgency. It would take several months for a public administrator. They were talking to the resident's friend who could make small decisions. The friend helped with medication decisions; however, this magnitude was too big. Administrator JJJJ would have expected the resident to have had a decision maker. 2809357

Based on observation, interview and record review, the facility failed to ensure payments were issued or issued in a timely manner, to the facility's food supplier, staffing agency, dietician, and other necessary vendors utilized to provide services for the needs of residents, placing residents at risk for interruption of services and inadequate care. This deficient practice had the potential to affect all residents. The census was 91. Review of the facility's Facility Assessment, undated, showed:-Purpose: The facility assessment is a complete review of internal human and physical resources required by the facility to care for residents competently during day to day (including nights and weekends) and emergency operations. The facility assessment identifies your capabilities as a skilled nursing services provider;-The assessment is not intended as a static tool but is intended to be a living document. It should include the business plan, staffing plan, the types of residents served, and the resources and physical plant required to competently care for the identified population;-Facility resources needed to provide competent resident support and care daily and during emergencies:--Nursing services staff, food and nutrition staff (e.g., Registered Dietician);--Physical environment and building plant needs:---Services, such as barber/beauty;--Facility contracts list included vendors for food and water supplies and oxygen medical supplies. 1. During an interview on 1/23/26 at 8:12 A.M., Certified Nurse Aide (CNA) QQQ said they run out of everything; wipes, towels, plates, etc. Staff try to make do with what they have. Observation and interview on 1/26/26 at 945 A.M., showed Housekeeper F lifted an empty container of the brand P&G Proline 3.78 liter/1 gallon container. During an interview, he/she said the facility stopped purchasing the mop water stuff, so now they use an all purpose cleaner. They used to have a hook up that would pour it out into the bucket. They ran out of the cleaner a while ago, but he/she kept the bottle. Housekeeper K pointed to a bottle that read, Medorra Limpreza All Purpose Cleaner Lavender scent. The facility purchased Medorra Limpreza all purpose cleaner. Without using the hook up, Housekeeper F was not sure how much to use. He/She poured cleaner into the cap and put it into the bucket. He/She said the bottle of the Medorra Limpreza is the last one they have. During an interview on 1/26/26 at 11:35 A.M., the Plant Operations Manager said they had a person in corporate that ordered the supplies. Staff did not have a say of what is approved. They used to have a census of 85, and now it is over 100 so they used more supplies. They dropped all the maintenance vendors. Before the change in ownership, every department had their own budget. He/She used to be able to go to a hardware store, but now it goes to corporate. Sometimes the items ordered did not come at once. During an interview on 1/28/26 at 10:46 A.M., the Regional Nurse Consultant said they ordered supplies from a platform called On-Care. It picked whichever was cheapest. During an interview on 1/28/26 at 2:39 P.M., Licensed Practical Nurse (LPN) Z said they ran out of wipes, paper towels, and tissue. During an interview on 1/29/26 at 10:00 A.M., Central Supply PPP said he/she worked in the building for several years. On 9/1/25, when the new management took over, he/she was given duties of medical records and accounts payable in October 2025. He/She tried to do everything, but it was a lot. Before the management change, there was never a problem. When the new management took over, there was a budget issue, and they went from having supplies to limited supplies. They were told five cases of gloves, which has 10 boxes of gloves to a case, was enough. They ordered them in large and medium. A case of wipes had 12 packs in each case. They ordered 1500 gloves and corporate said it was enough, but they were not looking at the fact they had 10 boxes. They only focused on the 1500 gloves part. He/She tried to add another box, but corporate said no. They said five cases would do. Corporate has been told it was not enough. Administrator A said to copy him/her in the e-mails to corporate, he/she did not have any luck with corporate, either. The quality of the gloves went down. They ordered gloves that ripped once put on. Central Supply PPP did not know about if there were money problems, and did not know what the budget was. He/She had a budget of $4000.00, and now there's no department budget anymore. He/She sent the order out and hoped they received what was ordered. The residents are aware of the issues and they did not like it at all. They complained about the briefs. Before the residents had fit ultra, which was the best. Now they buy fit basic, and the staff ran right through it because urine goes right through the briefs. He/She believed it contributed to odors or residents soiled in the facility. They ordered chucks/liners now, and they never had to order them prior to the management change. There were only four residents using liners at first. The aides told the residents they did not have a supply of briefs, pull-ups, or liners. He/She used to deliver them the briefs for residents to the units, but since he/she had new responsibilities, he/she could not or would fall behind. Before the facility was sold, they stocked up and bought a lot of supplies, so they did not need a lot other than gloves. Personal Protective Equipment (PPE) was in the basement. The face masks, briefs, and face shields are all in the basements. The new company had not completed inventory. They were supposed to do it with the Assistant Director of Nurses, but he/she left. It had not been stable. The had not ordered PPE since 9/1/25. They had ordered only gloves and wipes. During an interview on 1/29/26 at 1:43 P.M., Administrator B said there were extra supplies in the basement, so the Administrator told staff to educate someone on where to find it. He/She expected housekeeping to use appropriate supplies to clean all areas of the facility. He/She expected housekeeping staff to know how much chemicals to use. 2. Review of the facility's resident council minutes, dated 11/26/25, showed residents in attendance requested regular plates and bowls at meals, not plastic or Styrofoam. During an interview on 1/22/26 at 11:51 A.M., Dietary Aide U said the facility had not had the chemicals required to wash dishes in the dish machine for about two months. During an interview on 1/22/26 at 11:59 A.M., the Dietary Manager said the dish machine worked, but it did not have soap or rinse. It had been out for over a month. The new owners did not want to use a particular brand of chemicals because it was too expense, so they needed a new dispenser. Staff were washing dishes by hand. Observation on 1/22/26 at 12:43 P.M., showed the Assistant Dietary Manager plated the residents' food on Styrofoam plates and covered the plates with plastic lids. During an interview on 1/22/26 at 4:19 P.M., Administrator A said corporate ordered a new dispenser. It did not need to be repaired. They wanted cheaper products for dish machine. There was a monthly fee for the previous supplier, so they are changing the vendor. During an interview on 1/23/26 at 1:12 P.M., CNA V said they were on a tight budget. The residents went from having plastic cups to foam cups. During an interview on 1/26/26 at 3:04 P.M., the Dietary Manager said she placed the supply order with corporate. Food orders were based off the menu, so it was ordered weekly. For produce, the Dietary Manager ordered two cases of bananas in the past, and corporate asked, do you really need two? They gave push back on all the ordering. They could order bananas and they used to order grapes, but it was too expensive. They could get honeydew and cantaloupe. At times, they could get two cases, but most of the time, it was only one. Dietary asked for onions and heads of lettuce for burgers, but it was not ordered for them. The Dietary Manager would take the romaine lettuce from the bag and pair it with tomato and pickles for their burgers. Another example is ordering scalloped potatoes, but they will substitute it for hash browns with cheese on it. They used to order beef 81/19 fine, and now they get 73/27 fine raw beef. The 73 means there is more fat than 81. There is loss in protein/nutrients. Last week, she found out the facility owes Vendor A, the food supplier, $51,000.00. A representative from Vendor A informed her last week. They will email corporate and the Administrator. The company that delivered the bread also informed her that they need to be paid. During an interview on 1/27/26 at 4:50 P.M., the Registered Dietician (RD) said he/she was the current dietician and he/she went into the facility once or twice a month. Prior to the new ownership, the dietary budget was high. They fed everyone, including staff for years. Going from that to this budget.now, the residents wanted things on the menu that they could not afford to do. They had a person in corporate that ordered the food. The RD asked corporate to make changes and sometimes he/she did them. The RD was not sure the corporate person that placed orders ever worked in food service. It was hard communicating with them. The RD had never been paid by the facility for services since the new ownership took over. He/She informed Administrator A that he/she needed to be paid. During an interview on 1/28/26 at 1:43 P.M., Administrator B said he/she was not aware the residents used Styrofoam plates and cups instead of reusable dishware. He/She was not privy to that information, but it was not appropriate to suspend using the dish machine due to not purchasing sanitizer and rinse. He/She was not aware the dish machine was previously not in use. During an interview on 2/6/25 at 1232 P.M., representative from Vendor A confirmed the facility had a balance of $65,541.13. A large portion was past due, in the amount of $49,000.00. 3. During an interview on 1/23/26 at 8:12 A.M., CNA QQQ said they tried to call in agency staff, but they didn't show up all the time. It was hard for the facility to accommodate the needs of residents. When he/she started in October 2025, his/her first two paychecks bounced. During an interview on 1/23/26 at 9:03 A.M., LPN O said in December 2025/New Year's, he/she was told the facility would pay him/her for 12 hours instead of 20 hours. He/She had issues getting a paycheck. During an interview on 1/22/26 at 4:19 P.M., Administrator A said the payroll issues were confusing. They switched the time clock in December 2025, but if an employee missed a punch, it would not count the whole time. They fixed it immediately and issued paper checks. During an interview on 1/23/26 at 1:12 P.M., CNA V said he/she worked at the facility for five months. The paychecks were not right and his/her most recent check was incorrect. He/She worked over the weekend and was supposed to receive a $2 differential. Instead of receiving $25/hour (hr), it was $2/hr. He/She spoke to the facility yesterday about the issue, but they did not have an explanation. Staff have asked management for copies of their time, but they give them the run around. CNA V showed his/her paystub, which showed weekend hours were 14.75 hours. The hourly rate showed $2.00. The total amount was $29.50. During an interview on 1/23/26 at 1:23 P.M., CNA EEE said he/she worked at the facility for six months. The most recent check had one shift, which was about eight hours. He/She informed the facility and they said they would either pay them on the next check or cut a check. It had only been the last two checks. When staff asked the facility about it, they tell them it is coming from New York. There was an issue with the time clock. It showed they clocked in an hour later, and he/she had the time fixed when it happened. During an interview on 1/26/26 at 9:30 A.M., a representative from Vendor B, a staffing agency, said after the change in ownership, it was decided agency staffing would not be used; however, after two weeks, they wanted to give it a try until they no longer needed them. They were aware it was a transition change and people were quitting. The contract did not change, only the name of the facility. There are a total of 10 invoices. The company made zero payments. The facility's previous accounts receivable person was someone they had worked with for years and they tried to contact someone. The Administrator at the time told them everything had been approved to send to corporate for payment in an e-mail. This was right before it was decided to stop staffing the facility. Previously, he/she spoke to the facility on the phone and they said a payment would be made. The payment was not made because it was a holiday and then they asked what the minimum payment would be. A Regional Manager complained about the contract and the rates, so the facility received an adjustment of $10,000.00. The Regional Manager texted Vendor B and asked for all invoices, which were given to the facility. After that contact, the Regional Manager had not returned any phone calls and they lost contact with them. They stopped providing staff for the facility in early November 2025. He/She emailed the company on 1/5/26 to get payment. He/She was also privy to other staffing agencies that had not been paid. He/She confirmed the total amount before late fees is approximately $179,000.00. During an interview on 1/28/26 at 2:39 P.M., LPN Z said since the new management took over, they have been short staffed. The wound nurse quit several weeks ago because they were at the facility for 20 hours. The nurses did not know if they would have relief, so they did not come in. They called management and asked when they can leave. If they leave, management will say it is job abandonment. They have lost so many nurses because they did not know when they could go home. They had trouble with pay checks bouncing and they take an hour out of his/her check daily. He/She worked 12 hours and they took an hour from him/her. He/She used to work regularly at the facility until he/she was stuck for 23 hours. After that occurred, he/she switched to as needed (PRN). Another LPN got stuck overnight. Director of Nursing (DON) D worked the floor more than doing the DON duties. He/She got burned out. The residents complain about staffing. 4. During an interview on 1/22/26 at 11:05 P.M., the Beautician said he/she was paid on Friday, but it was not everything owed by the facility. He/She was not paid in December 2025. He/She received $25 per Medicaid resident. He/She was responsible for getting money from private pay residents, but the facility would not help with contacting the residents' families. 5. During an interview on 2/6/26 at 1:44 P.M., a representative from Vendor C, an oxygen supply company, said the facility had a current balance of $789.11. It was well beyond the 60 day term. The last payment made by the facility was 8/26/25, before the new management acquired the facility. They have not made a payment. 6. During an interview on 2/10/26 at 11:35 A.M., a representative from Vendor G, a food vendor, said the facility had an unpaid balance of $8,053.13. It included September 2025 through the end of January 2026. No payment had been made for September 2025 through January 2026. 7. During an interview on 2/10/26 at 1:50 P.M. a representative from Vendor I, a pest control company, said they provided service to the facility twice a month. The facility had two outstanding bills for the months of November 2025, December 2025, and January 2026. The facility owed a balance of $1,050.00. 8. During an interview on 1/28/26 at 2:05 P.M., the Plant Operations Manager said housekeeping and maintenance staff got cut. There were three additional maintenance staff, but now there was one. Everything was ordered from corporate, including the floor cleaner. He was also filling in for housekeeping. Staffing and supplies were an issue. There was so much going on and he was pulled in different directions. The transition has been hard on the residents and families. Some of the residents have been there for years. There are multiple vendors that had not been paid. Pest control and snow removal services did not receive a payment; however, the snow removal service came today. They were paid, but they are waiting for another payment. 9. During an interview on 1/29/26 at 1:43 P.M., Administrator B said the DON had a daily staffing sheet for nurse hours. He/She did not know if it was tracked. The past weekend was the issue for the Registered Nurses (RNs). They use quite a bit of agency staff and spend approximately $20,000.00 a month. They currently have two RNs on staff that just started. Since the change in ownership, there had been three Administrators and two DONs. The Assistant Administrator or Administrator would be responsible for compliance during each transition as well as corporate staff. Regulatory duties were not handed off between Administrators. They used agency staffing to ensure minimum staffing requirements were met. Administrator B said the DON was currently working on a system for everyone to abide by to ensure continuity of care with frequent staff turnover. 10. On 2/5/26 at 10:08 A.M. and 2/6/25 at 11:05 A.M., Department of Health and Senior Services (DHSS) attempted to reach the facility's Corporate Business Office Manager. Messages were left requesting returned calls, but the calls were unreturned. 272126227209122684730

Based on interview and record review, the facility failed to have a complete and thorough facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. The facility assessment did not include a monthly average number of residents who required assistance with activities of daily living. The census was 91. Review of the facility's Facility Assessment, updated 12/18/25, showed:-People involved in completing: Administrator A, Director of Nursing (DON) C, and Director of Maintenance;-Date reviewed with Quality Assurance Performance Improvement (QAPI) committee: 12/18/25;-Number of licensed beds: 117;-Average daily census: 100;-Average weekday admissions by shift: 3-4;-Average weekend admissions by shift: 0-1;-Average weekday discharges by shift: 3-4;-Average weekend discharges by shift: 0-1;-Assistance with activities of daily living monthly average:-Bed mobility sit to lying: --Set up: blank;--Supervision/partial/moderate assistance: blank;--Dependent/max assistance: blank;-Mobility sit to stand: --Set up: blank;--Supervision/partial/moderate assistance: blank;--Dependent/max assistance: blank;-Bathing: --Set up: blank;--Supervision/partial/moderate assistance: blank;--Dependent/max assistance: blank;-Transfer: --Set up: blank;--Supervision/partial/moderate assistance: blank;--Dependent/max assistance: blank;-Eating: --Set up: blank;--Supervision/partial/moderate assistance: blank;--Dependent/max assistance: blank;-Toileting: --Set up: blank;--Supervision/partial/moderate assistance: blank;--Dependent/max assistance: blank;-Other care, describe: blank;-Staff assignments: Describe how you determine and review individual staff assignments for coordination and continuity of care for residents within and across these staff assignments: -The facility meets this requirement by considering census, individual and overall unit acuity, routine/consistent staffing assignments per unit for both licensed nurses and Certified Nursing Assistants (CNAs), and resident preferences for staff assignments.-Describe how you evaluate if your infection prevention and control program includes effective systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, that follow accepted national standards: -Utilize acceptable infection control program, tracking and trending program infections by type, location, and antibiotic used. We provide transmission-based precautions. Annual infection control and handwashing competency training and as needed. Staff and volunteers participate in annual training. Visitors are observed for signs and symptoms of contagious infections. Signage is used to communicate isolation and any other necessary information to visitors and/or vendors. During the course of the survey process, problems were identified which included:-Staffing and training, to include:--No required CNA 12-hour in competencies abuse and neglect and/or dementia care training for 10 out of 10 CNAs who were employed for more than one year;--Insufficient nursing staff available to meet the needs of residents, as evidenced by staff interviews, residents with missed treatments, and residents with missed activities of daily living (ADL) care;-No restorative program or speech therapy;-Infection control practices, to include:--Tuberculosis testing not completed for 5 out of 5 residents sampled;--Residents on enhanced barrier precautions (EBP) did not have signage or a supply of personal protective equipment (PPE);--Housekeeping staff failed to have Environmental Protection Agency (EPA)-registered hospital disinfectant solution to clean floors. During an interview on 1/28/26 at 1:43 P.M., Administrator B said he/she expected the facility assessment to be fully completed with the total numbers of all residents who required assistance. The Administrator is responsible for ensuring the facility assessment is completed.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The sample was 21. The facility census was 91. Review of the facility's QAPI policy, dated 7/1/25, showed:-Policy: The QAPI plan will describe how the facility will ensure care and services delivered meet accepted standards of quality, identify problems and opportunities for improvement, and ensure progress towards improvement is achieved and sustained. The QAA Committee will meet monthly to assess and monitor the quality of services provided to residents and identify potential problems or areas of opportunity for improvement. The QAA Committee will implement and systematically evaluate programs and processes to identified problems in order to proactively improve health care delivery;-Procedure: The QAA committee will meet monthly; -Team Members: Administrator, Director of Nursing (DON), medical director/designee, Infection Preventionist, Social Services Designee (SSD), Activities Director, Environmental Services, Dietary Manager, Medical Records, Human Resources, and Pharmacy; -Review results from prior audits and identify action items for areas with opportunity for improvement; -Utilize monthly facility QA committee template for meeting minutes. Discuss and review items in template categories: Quality Measures, falls, wounds, weight loss; -Discuss concerns identified by resident council and grievances; -Identify quality improvement opportunities and assign committee members audits to areas of concern; -Provide staff training and education as needed for areas of opportunity; -Conduct root cause analysis: Identify trends and implement action items for improvement; -Develop a Performance Improvement Plan (PIP) for systems or processes that need further action. During the course of the survey process, problems were identified, which included:-Insufficient nursing staff available to meet the needs of residents, as evidenced by staff interviews, residents with missed treatments, and residents with missed activities of daily living (ADL) care;-Insufficient documentation on the Facility Assessment, reviewed by the QAPI committee on 12/18/25, regarding monthly average number of residents who required assistance with activities of daily living;-No restorative program or Speech therapy;-Residents on Enhanced Barrier Precautions (EBP) did not have signage or a supply of Personal Protective Equipment (PPE);-Residents without on-going documentation of daily, weekly, or monthly weights;-Dignity concerns regarding meals served on Styrofoam plates. During an interview on 1/28/26 at 1:43 P.M., Administrator B said he/she expected the facility assessment to be fully complete with all number of residents who require assistance. The Administrator was responsible for ensuring the facility assessment was completed. There was a recent QAPI meeting, but the Administrator would have to check if it was reviewed at that time. They attempted to have a QAPI meeting, but it was on the first day of survey. During the ownership transition, they shut down the previous management's e-mail, so a lot of information was lost. Families were told if they had problems, they could report them to him/her to ensure they prioritized certain concerns.

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and as required by the Centers for Medicare and Medicaid Services (CMS) for six residents (Residents #13, #12, #63, #4, #108, and #7). The facility failed to use appropriate infection control practices during perineal care (cleaning of the genitals and rectal area) for four residents (Residents #13, #63, #4, and #11). The facility failed to disinfect a Hoyer lift (mechanical lift) in between use on two residents (Residents #7 and #91). The facility failed to complete a tuberculin test (a test to determine if exposed to tuberculosis (TB, a contagious lung disease)) on five of five sampled residents (Residents #13, #12, #6, #9 and #8). The facility failed to complete a tuberculin test on 9 out of 10 newly hired employees and failed to use a proper disinfecting chemical to clean the floors. The sample was 21. The census was 91. Review of the facility's Incontinent Care policy, dated 7/1/25, showed:-Policy: The facility will provide incontinent care as directed in the plan of care;-Procedure:-Gather supplies;-Perform hand hygiene and apply gloves;-Assist with positioning resident in a safe and comfortable position;-Remove soiled brief and under pad by rolling the brief and under pad;-Cleanse Perineal (genital and rectal area) with perineal cleanser; --Females: Separate labia (part of the female genitalia), cleanse one side and then the other. Cleanse center of labia wiping towards the rectal area. Cleanse perineal area from front to back. Cleanse thighs, rectal area, and buttocks;--Males: Retract foreskin if uncircumcised, cleans the penile tip using a circular motion, starting with the urethra (opening that drains the urine from the body) working outward. Cleanse penile shaft, scrotum, and rectal area, thighs and buttocks;-Use a clean surface are of the cloth for each wipe' Use multiple cloths, if necessary, to maintain, infection control;-Remove soiled gloves, perform hand hygiene and appl clean gloves;-Apply clean brief and clothing;-Discard contaminated items in a plastic liner;-Remove gloves and perform hand hygiene. Review of the facility's EBP policy, dated 7/1/25, showed:-Policy: The facility may expand the use of personal protective equipment (PPE, gowns and gloves) and refer to the use of gowns and gloves during high contact resident care activities that provides opportunities for transfer of MDRO to hands and clothing. The use of gown and gloves for high contact resident care activities is indicated, when contact precautions do not otherwise apply, for facility residents with wounds and or indwelling medical devices regardless of MDRO colonization (presence of bacteria but does not cause and infection), as well as for residents with MDRO infection or colonization;-Steps: Post signage on the door or wall outside of the resident's room indicating the use of EBP, post signage in the resident's room with information on use of EBP and required PPE. PPE should be available inside of the resident's room. Alcohol-based hand rub should be available for hand hygiene .Position a trashcan inside the resident's room near exit for discarding PPE after removal and prior to exiting the resident's room;-Residents with the following: Infection or colonization MDRO, wounds, or and indwelling medical devices such as urinary catheter, (a tube that drains the bladder), central line, (a surgically inserted thin tube inserted into a large blood vessel), tube feeding (a surgically inserted tube in the abdomen that provides liquid nutrition and medications), and tracheostomy (surgically inserted tube into the windpipe to assist with breathing), regardless of MDRO status;-PPE situations: During high contact resident care activities, such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs and toileting, device care, and wound care, and skin openings requiring a dressing;-PPE required: Gloves and gown prior to high contact care activity. 1. Review of Resident #13's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/6/26, showed diagnoses included heart disease, kidney disease, and high blood pressure. Review of the resident's medical record, showed:-An order, dated 12/9/26, for urinary catheter;-No order for EBP. Observation on 1/22/25 at 10:00 A.M., showed on the outside of the resident's door, there was no EBP sign or PPE in the 200 hallway or available in the resident's room. The resident was incontinent of stool and requested to be cleaned. Certified Nurse Aide (CNA) BB and CNA Y performed hand hygiene and applied gloves. CNA BB loosened the resident's brief and rolled the front of the brief between the resident's legs. CNA BB cleansed the resident's genitals and performed urinary catheter care. CNA BB and CNA Y turned the resident to his/her left side. CNA BB cleansed the resident's buttocks and rectal area, removed the resident's soiled brief and bed pad. With the same gloved hands, CNA BB applied a new brief and bed pad. CNA BB pulled back on the privacy curtains with the same gloved hands and adjusted the resident's gown and bedding. CNA Y and CNA BB did not wear isolation gowns while providing direct care. 2. Review of Resident #12's quarterly MDS, dated [DATE], showed diagnoses included heart failure, hip fracture, diabetes, and kidney disease. Review of the resident's medical record, showed:-A physician order, dated 1/16/26, for left anterior leg, cleanse with wound cleaner or normal saline, apply skin prep around the wound, apply xeroform gauze (a special non-adherent dressing), collagen powder (a treatment that absorbs fluid and increases healing), apply gauze, wrap with Kerlix (specialized wrap), and secure with tape;-An order, dated 1/16/26, for left lateral leg, cleanse with wound cleaner or normal saline, apply skin prep around the wound, apply xeroform gauze, collagen powder, apply gauze, wrap with Kerlix gauze roll and secure with tape. Observation on 1/23/26 at 7:35 A.M., showed outside the resident's room, there was no EBP sign posted. There were no PPE supplies outside or inside the resident's room. As the resident was seated his/her wheelchair, Licensed Practical Nurse (LPN) JJ removed the resident's left leg dressings that were dated 1/21/26, and the dressings were saturated with serous (clear, yellow) drainage. LPN JJ cleaned the resident's left leg wounds with wound cleanser. LPN JJ applied a Mepilex dressing (a specialized foam dressing) over the left leg wounds. He/She did not wear an isolation gown while providing direct care. Observation on 1/27/26 at 1:30 P.M., showed outside the resident's room, there was no EBP sign posted. There were no PPE supplies outside or inside the resident's room. The resident sat in his/her wheelchair with his/her left leg dressings saturated with serous drainage. The Assistant Director of Nursing (ADON) gathered supplies off the treatment cart. The ADON removed the resident's dressings and completed the resident's left leg treatments. She did not wear an isolation gown while providing direct care. During an interview, the ADON said she should have worn a gown for the resident's dressing change because the resident is on EBP. She had not seen any gowns in the facility for a while. There should have been a sign posted and PPE supplies outside the resident's room. 3. Review of Resident #63's admission MDS, dated [DATE], showed:-Diagnoses included diabetes, hypertension (high blood pressure), hyperlipidemia (high cholesterol).-Cognitively intact;-Presence of indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine). Review of the resident's POS, dated 1/2026, showed no orders for EBP to be worn during close contact care. Observation on 1/22/26 at 8:28 A.M., showed no EBP sign on the resident's door. Observation on 1/26/26 at 10:55 A.M., showed CNA S walked into the resident's room, put on gloves, and pulled the resident's bed covers down, exposing the resident. He/She rolled the resident to the left side, leaning up against the bed and the resident. He/She wiped the resident from the front to the back. He/She pulled the catheter to the front and out of the brief from the right side. He/She attempted to put the catheter in the resident's pant leg while leaning against the resident. He/She did not wear an isolation gown while providing direct care. During an interview on 1/29/26 at 10:31 A.M., LPN H said PPE should be worn during close contact care if a resident has a catheter. Gown and gloves should be worn. During an interview on 1/28/2026 at 2:50 P.M., Director of Nurses (DON) C said gown and gloves should be worn when handling catheters to prevent germs and infection. 4. Review Resident #4's admission MDS, dated [DATE], showed:-Moderate cognitive impairment;-Physical assistance required for hygiene, transfers, and daily care. Review of resident's medical record, showed,-admission date 12/5/25;-Diagnoses included aphasia (inability to comprehend or express self), dementia (memory loss), hemiplegia and hemiparesis (paralysis and weakness), kidney disease, diabetes, anxiety, mood disorder, and hypertension; Review of the resident's electronic physician's order sheet (ePOS), showed:-No orders for EBP;-No orders for urinary catheter care. Review of the resident's medical record, showed no baseline care plan to direct staff on the care needs of the resident or need for maintenance care for catheter care. Observation on 1/22/26 at 2:50 P.M., showed CNA DDD drained the resident's urinary leg bag without wearing PPE while providing direct care. Observation on 1/26/26 at 9:20 A.M., showed CNA DDD did not wear PPE while performing personal care on the resident. He/She did not perform catheter care after cleaning stool from the resident's rectum. During an interview, CNA DDD said he/she guessed he/she should clean a resident's catheter and genitals. 5. Review of Resident #108's quarterly MDS, dated [DATE], showed:-admission date 7/1/25;-Cognitively intact;-Indwelling catheter;-Diagnoses included heart disease, kidney disease, neurogenic bladder (difficulty urinating), obstructive uropathy (difficulty urinating due to a stricture), and depression. Review of the resident's ePOS, dated 1/23/26, showed:-An order, dated 12/30/25, for dressing changes to nephrostomy tubes. Change dressing to right and left nephrostomy tubes on posterior back. Cleanse sites with wound cleanser, apply split gauze to right side and split gauze to left daily. Special Instructions: monitor for redness, swelling, drainage and irritation daily, once a day, one time a day for dressing changes;-An order, dated 12/30/25, for gentamicin sulfate external cream (antibiotic cream) 0.1%, apply to nephrostomy sites topically one time a day for dressing change. Special Instructions: Apply ointment to left and right nephrostomy tube site once daily at night shift. Apply with dressing change;-An order, dated 1/19/26, to flush nephrostomy tube with 10-20 milliliters (ml.) normal saline daily as needed (PRN);-An order, dated 1/26/26, for EBP related to nephrostomy tubes every day and night shift. Observations of the resident's room, showed:-On 1/22/26 at 11:23 A.M., no EBP signage on the door nor any PPE on or outside the door.-On 1/23/26 at 1:05 P.M., no EBP signage on the door nor any PPE on or outside the door.-On 1/23/26 at 2:54 P.M., no EBP signage on the door nor any PPE on or outside the door. Observation on 1/27/26 at 12:30 P.M., showed the resident in his/her wheelchair in his/her room. Employee VVV walked into the room and told the resident that he/she would not like it, but he/she had to change to the dressings on his/her nephrostomy tubes. The staff member put gloves on and proceeded to change the resident's dressings. He/She did not wear an isolation gown while providing direct care. 6. Review of Resident #7's medical record, showed:-Diagnoses included hyperlipidemia (high cholesterol), hypertension (high blood pressure), dementia, malnutrition, anxiety disorder, and depression;-A physician order, dated 12/18/25, for gentamicin sulfate external ointment 0.1%, apply to coccyx wound topically one time a day for wound;-No physician order for EBP. Review of the resident's care plan, in use during the survey, showed resident has pressure ulcers and is at risk for worsening of pressure ulcers due to incontinence and inability to offload and position change; Observations of the resident's room, from 1/22/26 to 1/26/26, showed no EBP signage on the resident's door, or any PPE in or outside the room. 7. During an interview on 1/2826 at 8:07 A.M., LPN OOO said he/she wasn't really exactly sure what or why residents required EBP. He/She thought the PPE supplies were in the basement. During an interview on 1/29/26 at 10:15 A.M., CNA PP said when there was an EBP sign on a resident's door, it meant that staff were to wear gowns and gloves when providing care. He/She had not seen isolation gowns for a couple of weeks. Residents that required EBP were expected to have a sign on their door and PPE supplies readily available. 8. Review of Resident #11's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Dependent on staff for personal and toilet hygiene;-Diagnoses include dementia, heart disease and heart failure. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident is incontinent of bowel and bladder at times. The resident has dementia that limits her ability to communicate his/her needs;-Intervention: Provide incontinence care after each incontinent episode. Observation on 1/26/26 at 8:26 A.M., showed LPN Y entered the resident's room, performed hand hygiene and applied gloves. He/She removed the resident's soiled brief and cleaned the resident's perineum. With the same gloved hands, LPN Y applied a new brief, helped the resident get dressed and out of bed, into his/her wheelchair. He/She propelled the resident to the dining room with the same gloved hands. During an interview on 1/29/26 at 10:15 A.M., CNA PP said when providing perineum care, a staff member should remove their gloves and perform hand hygiene. Once that is done, a new pair of gloves should be applied when proving a new brief and bedding. Staff should not be touching the resident or items in their rooms with soiled gloves. 9. Review of Resident #7's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Mobility device: Wheelchair;-Dependent on staff for transfers. Review of the resident's care plan, in use during the survey, showed:-Problem: The resident required extensive to total assist with activities of daily living (ADLs) due to generalized muscle weakness;-Approaches included: Hoyer lift for transfers, extensive to total assist with bed mobility and wheelchair locomotion. Review of Resident #91's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Mobility device: Wheelchair;-Dependent on staff for transfers;-Diagnoses included traumatic brain dysfunction, hypertension, hyperlipidemia, dementia, and anxiety disorder. Review of the resident's care plan, in use during the survey, showed:-Problem: The resident required staff assistance with ADLs and utilized a Hoyer lift for transfers;-Approaches included Hoyer lift for transfers with two staff members. Observations of Residents #7 and #91 on 1/28/26, showed:-At 11:13 A.M., CNA MMM and CNA XX used a Hoyer lift to transfer Resident #7 from the bed to his/her wheelchair;-At 11:18 A.M., immediately following the transfer of Resident #7, CNA XX took the Hoyer lift to Resident #91's room;-At 11:21 A.M., CNA NNN and CNA XX used the Hoyer lift to transfer Resident #91 from the bed to the Hoyer lift to weight him/her, then transferred the resident back to his/her bed;-The CNAs did not wipe the Hoyer lift and/or sanitize it in between use on the two residents. During an interview on 1/29/26 at 11:41 A.M., LPN ZZZ said the Hoyer lifts should be cleaned and wiped down in between residents' use. Before the new company took over, this was part of what the infection control nurse had staff doing. Staff should be following proper hand hygiene protocol, and their gloves should be changed when transferring a resident. During an interview on 1/29/26 at 12:30 P.M., CNA XX said the Hoyer lift should have been wiped down in between use on the residents. During an interview with Administrator B and DON C on 1/29/26 at 2:14 P.M., DON C said she expected for the Hoyer lift to have been cleaned and sanitized in between use on the two residents. 10. Review of the facility's Resident Screening for Tuberculosis policy, undated, showed:-Policy: The facility screens residents for TB in accordance with state requirements as part of the facility's overall infection prevention and control program;-Policy explanation and compliance guidelines:-New resident screening: Prior to or at the time of admission, all new residents will receive TB screen and testing and or chest x-ray in accordance with state requirements. The preferred method of TB testing shall be conducted as a two-step process unless contraindicated, then a chest x-ray will be performed. All initial and following TB tests shall be administered and interpreted within 48-72 hours, by a trained health care provider on our staff, or any licensed physician-Current resident screening: All residents previously TB tested negative will be rescreened in accordance with state requirements. In the absence of state requirements, rescreening will be completed as per the facility's infection control plane based upon their TB risk assessment. Follow up testing shall be the same type as initial testing for consistency. Review of Resident #13's medical record, showed:-admission date 8/29/25;-No two-step TB test documented as administered;-No TB screening completed. Review of Resident #12's medical record, showed:-admission date 4/27/25;-No two-step TB test documented as administered;-No TB screening completed. Review of Resident #6's medical record showed:-admission date 12/3/25;-No two-step TB test documented as administered;-No TB screening completed. Review of Resident #9's medical record showed:-admission date, 6/1/25;-No two-step TB test documented as administered;-No TB screening completed. Review of Resident #8's medical record showed:-admission date 10/29/25;-No two-step TB test documented as administered;-No TB screening completed. 11. During an interview on 1/29/26 at 12:57 P.M., the Regional Nurse Consultant said he is the facility's Infection Preventionist (IP). He expected staff to remove soiled gloves and perform hand hygiene after providing perineum care. He expected staff to put on clean gloves when placing a clean brief and bedding on a resident. Wearing soiled gloves and touching a resident and a resident's things is unacceptable. He expected catheter care to be completed every time perineum care is done, especially if a resident has had a bowel movement. He expected EBP signs to be on the resident room doors and supplies be readily available. He expected staff to wear PPE when providing direct care to the residents who are on EBP. It is expected for a resident to have a two-step tuberculin test upon admission, and a TB screening tool should be used on the residents that already had TB tests. 12. Review of the facility's Employee Tuberculosis Test policy, revised 7/1/25, showed:-TB screening and testing is conducted in this facility for the purpose of earlyidentification, evaluation, and treatment of employees with latent TB infection (LTBI, positive without symptoms) or TB disease;-Follow state or local requirements regarding TB screening and testing of employees. In the absence of state or local requirements, follow CDC recommendations below;-New Staff Screening: At the time of employment, all new staff shall undergo pre-placement screening for TB, including an individual risk assessment, TB symptom screen, and a TB test;-All new staff shall receive two Mantoux TB Skin Tests given two weeks apart (two-step testing) unless:-A previously positive TB skin test reaction or positive TB blood test is reported, or;--Evidence of completion of adequate therapy for active TB is reported, or;--Two negative TB skin tests within the past twelve months, the more recent within the last three months, can be documented, or;--The employee has previously received the BCG vaccine. In this case, the employee shall be tested using a blood test;-All initial and follow-up TB tests shall be administered and interpreted (48-72 hours for skin tests) by a trained healthcare provider on our staff, or any licensed physician;-No one may interpret his/her own test. Tests shall be interpreted according to current CDC guidelines;-If a designated reader detects redness, swelling, or anything other than an injection-site bruise at the testing site, they must refer the staff member to the Medical Director for a confirmation reading;-If the first test is positive in an employee at low-risk for TB infection, conduct the second test;-New staff with a documented history of a positive TB test, adequate treatment for active TB, or preventive therapy for latent TB infection shall be exempt from further TB testing. A chest radiograph will be required at the time of hire unless, within the last six months, a chest radiograph with no evidence of active pulmonary disease can be documented;-It is the responsibility of any such TB-test exempt staff member to immediately reportsymptoms suggestive of TB (persistent cough, bloody sputum, night sweats, weight loss,anorexia, or fever) to the DON or IP. Review of Employee AAAA's employee file, showed a hire date of 11/5/25. No documentation that a TB test was administered or read prior to his/her hire date, or a chest x-ray was completed. Review of Employee BBBB's employee file, showed a hire date of 11/5/25. No documentation that a TB test was administered or read prior to his/her hire date, or a chest x-ray was completed. Review of Employee CCCC's employee file, showed a hire date of 10/29/25. No documentation that a TB test was administered or read prior to his/her hire date, or a chest x-ray was completed. Review of Employee DDDD's employee file, showed a hire date of 11/24/25. No documentation that a TB test was administered or read prior to his/her hire date, or a chest x-ray was completed. Review of Employee EEEE's employee file, showed a hire date of 12/30/25. No documentation that a TB test was administered or read prior to his/her hire date, or a chest x-ray was completed. Review of Employee FFFF's employee file, showed a hire date of 11/19/25. No documentation that a TB test was administered or read prior to his/her hire date, or a chest x-ray was completed. Review of Employee GGGG's employee file, showed a hire date of 10/16/25. No documentation that a TB test was administered or read prior to his/her hire date, or a chest x-ray was completed. Review of Employee HHHH's employee file, showed a hire date of 9/30/25. No documentation that a TB test was administered or read prior to his/her hire date, or a chest x-ray was completed. Review of Employee IIII's employee file, showed a hire date of 12/5/25. No documentation that a TB test was administered or read prior to his/her hire date, or a chest x-ray was completed. Review of Employee JJJJ's employee file, showed a hire date of 11/26/25. No documentation that a TB test was administered or read prior to his/her hire date, or a chest x-ray was completed. During an interview on 1/29/26 at 1:43 P.M., Administrator B and DON C said Human Resources is responsible for conducting background checks. They expect all employees to have a TB test or submit a chest x-ray. DON C said it is important to test employees to know if they are a carrier of TB, so they do not infect residents. 13. Review of the facility's Cleaning Procedures policy, undated, showed:-Policy: Facility maintains a clean and sanitary environment throughout our building. The Environmental Protection Agency (EPA)-registered hospital disinfectant (disinfecting solution) used is approved by Quality Assurance Committee in accordance with CDC guidelines;-Procedures: Mop buckets: Mop buckets are cleaned after each shift;---Scrub inside and outside of bucket with clean pad, appropriately diluted disinfectant and hot water;--Rinse and dry with cloth. Review of the facility's Cleaning Resident Rooms policy, undated, showed:-Resident rooms at the facility are maintained in a clean and sanitary manner and are cleaned on a daily and weekly schedule. Cleaning procedures are detailed in separate policies;-Daily Cleaning: Equipment needed:--EPA-registered hospital disinfectant (disinfecting spray). Observation and interview on 1/26/26 at 945 A.M., showed Housekeeper F said the facility stopped purchasing the mop water stuff, so now they use an all-purpose cleaner. They used to have a hook up that would pour the cleaner out into a bucket. Housekeeper F lifted an empty container of the brand P&G Proline 3.78 liter/1 gallon container. He/She said they ran out of it a while ago, but he/she kept the bottle. Housekeeper K pointed to a bottle that read, Medorra Limpreza All Purpose Cleaner Lavender scent. The facility purchased Medorra Limpreza all-purpose cleaner. Without using the hook up, Housekeeper F was not sure how much to use. He/She poured cleaner into the cap and put it into the bucket. He/She said bottle of the Medorra Limpreza is the last one they had. During an interview on 1/26/26 at 10:24 A.M., DON C said the facility did not have a Housekeeping Director. During an interview on 1/26/26 at 11:35 A.M., the Plant Operations Manager said staff gave their supply order to corporate and they ordered the supplies. The facility staff did not have a say of what is approved and ordered for them by corporate. During an interview on 1/26/26 at 3:04 P.M., the Dietary Manager said they had a corporate person that ordered supplies for them. During observation and interview on 1/28/26 at 2:19 P.M., Housekeeper T said he/she used the Medorra Limpreza All Purpose Cleaner Lavender scent for the floors. He/She poured enough cleaner to cover the bottom of the bucket. They used to have a hook up that poured water and cleaner out of a hose. He/She liked that set up better. Observation on 1/28/26 at 3:11 P.M., showed a bottle of Medorra Limpreza All Purpose Cleaner Lavender scent. There was no EPA-registered number on the bottle. There was no documentation of EPA approved or hospital grade disinfectant. Review of EPA-approved, certified products on EPA.gov, reviewed 2/6/25, showed no result for Medorra Limpreza All Purpose Cleaner Lavender scent. Review of the Medorra Limpreza official website, reviewed1/28/26, 1/29/26, 2/5/26, and 2/6/26, showed the website had a critical error. The product or EPA registration could not be verified on the website. During an interview on 1/29/26 at 10:00 A.M., Central Supply PPP said he/she worked in the building for several years. On 9/1/25, when the new management took over, he/she was given duties of medical records and accounts payable in October 2025. He/She tried to do everything, but it is a lot. They never had issues with the supplies, but it changed drastically. Before the management change, there was never a problem with supplies. When they took over, there was a budget issue, and the facility went from having supplies to limited supplies. During an interview on 1/29/26 at 1:09 P.M., the Regional Nurse Consultant said housekeeping did their own ordering. They did not have a Housekeeping Director. There was no training for staff on how much floor chemicals to use. During an interview on 1/29/26 at 1:43 P.M., Administrator B said there were extra supplies in the basement, so he/she told staff to educate someone on where to find it. He/She expected housekeeping to use appropriate supplies to clean all areas of the facility. He/She expected housekeeping staff to know how much chemicals to use. 27209122703232271295626798782724850

Based on interview and record review, the facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The census was 91. Review of the facility's Antibiotic Stewardship policy, dated, 7/1/25, showed:-Intention: It is the policy of this facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use;-Policy: The Medical Director, Director of Nursing (DON), Infection Prevention Control (IPC) Nurse, and Consultant Pharmacist serve as leaders of antibiotic stewardship program and receive support from the Administrator and governing officials at the facility. During an interview on 1/23/26 at 2:19 P.M., Administrator A said the antibiotic stewardship program had not been updated since March 2025. The IPC Nurse recently quit, and the facility just started the program back up on 1/22/26. Administrator A said he/she expected the antibiotic stewardship program to be in place.

Based on interview and record review, the facility failed to offer the COVID-19 vaccine for five out of five residents reviewed (Resident # 12, #13, #8, #9, and #6). The census was 91.Review of the facility's COVID Vaccine policy, dated, 7/1/25, showed:-Policy: The facility will offer the COVID vaccine to assist in mitigating the spreads of COVID-19;-Procedure: COVID-19 vaccinations shall be offered to all residents unless such immunization is medically contraindicated; Residents shall be educated on the COVID-19 vaccine they are offered, in a manner they can understand, including the information of the benefits and risks with the Centers for Disease Control and Prevention (CDC) or Food and Drug administration (FDA); Residents shall be offered the opportunity to ask questions about the risk and benefits of the vaccination; The facility shall maintain documentation of COVID-19 vaccine for all residents in the medical record. 1.Review of Resident #12's medical record showed:-Diagnoses that included heart failure and kidney disease;-No documentation that the resident was offered or received the COVID-19 vaccine. 2.Review of Resident #13's medical record showed:-Diagnoses that included asthma and kidney disease;-No documentation that the resident was offered or received the COVID-19 vaccine. 3.Review of Resident #8's medical record showed:-Diagnoses that included diabetes and osteomyelitis (bone infection) of the foot;-No documentation that the resident was offered or received the COVID-19 vaccine. 4.Review of Resident #9's medical record showed:-Diagnoses that included heart failure and stroke;-No documentation that the resident was offered or received the COVID-19 vaccine. 5.Review of Resident #6's medical record showed:-Diagnoses that included stroke, dysphagia (difficulty swallowing) and kidney disease;-No documentation that the resident was offered or received the COVID-19 vaccine. 6. During an interview on 1/29/26 at 12:57 P.M., the Regional Nurse Consultant said he is also the facility's Infection Preventionist (IP). He would expect the COVID-19 vaccinations be offered to the residents on admission or when the resident requests one. Refusals of the vaccines and any education provided is expected to be documented in the resident's medical record. All vaccines administered to the resident are expected to be documented in the resident's medical record.

Based on interview and record review, the facility failed to ensure they had a system in place to track the required Certified Nurse Aide (CNA) 12 hours annual education (in-services). The facility identified 10 CNAs who worked for the facility for at least one year and all ten were sampled. Three out of 10 CNAs did not have any documented training hours, and seven out of 10 CNAs did not have the required training hours. The facility failed to ensure all CNAs were in-serviced on dementia care and abuse and neglect. In addition, there were no CNAs that received education after September 2025. The census was 91.Review of the Facility Assessment, updated and reviewed on 12/18/25, showed Staff Training/Education and Competencies:-Abuse, neglect and exploitation: training that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property. Procedures for reporting incidents of abuse and neglect, exploitation, or the misappropriation of resident property. Care/management for persons with dementia and resident abuse prevention. Upon Hire, quarterly, as needed, and all staff in-services:-Caring for people with dementia, Alzheimer's disease and cognitive impairments. Completed annually and as needed, including all staff in-services. 1. Review of CNA BB's in-service records showed:-A hire date of 11/5/14;-No documentation of the total in-service training hours;-No documentation of annual competency in-service on Abuse and Neglect Prevention and Dementia Care. 2. Review of CNA CC's in-service records showed:-A hire date of 6/22/23;-No documentation of total in-service training hours;-No documentation of annual competency in-service on Abuse and Neglect Prevention and Dementia Care. 3. Review of CNA I's in-service records showed:-A hire date of 2/8/22;-No documentation of total in-service training hours;-No documentation of annual competency in-service on Abuse and Neglect Prevention and Dementia Care. 4. Review of CNA DD's in-service records showed:-A hire date of 8/26/15;-In-service record, dated 5/8/25 through 5/30/25, showed 8.75 hours;-No documentation of annual competency in-service on Dementia Care. 5. Review of CNA EE's in-service records showed:-A hire date 5/9/24;-In-service record, dated 4/22/25 through 7/3/25, showed 8.75 hours;-No documentation of annual competency in-service on Dementia Care. 6. Review of CNA FF's in-service record showed:-A hire date of 7/5/23;-In-service record, dated 4/29/25 through 6/18/25, showed 8.75 hours;-No documentation of annual competency in-service on Dementia Care. 7. Review of CNA HH's in-service record showed:-A hire date of 11/5/98;-In-service record, dated 4/29/25 through 6/26/25, showed 8.5 hours;-An in-service, dated 11/9/23, showed Dementia 2 - Communication. No other Dementia Care was documented on the annual competency in-service. 8. Review of CNA J's in-service record showed:-A hire date of 9/27/24;-In-service record, dated 3/25/25 through 6/27/26, showed 11 hours;-No documentation of annual competency in-service on Dementia Care. 9. Review of CNA II's in-service record showed:-A hire date of 3/29/18;-In-service record, dated 4/23/25 through 6/29/25, 8.75 hours;-An in-service, dated 4/25/23, showed Dementia 2 - Communication. No other Dementia Care was documented on the annual competency in-service. 10. Review of CNA GG's in-service record showed:-A hire date of 4/8/15;-In-service record, dated 3/21/25 through 6/26/25, showed 9 hours. 11. During an interview on 1/29/26 at 1:43 P.M., Administrator B and Director of Nursing (DON) C said they recently educated the facility staff on the abuse and neglect policy on Monday (1/26/26). DON C completed an abuse in-service. They would expect all staff to receive education on the facility's policies, including abuse and neglect. DON C was aware there was no record of in-service training after August 2025. DON C is responsible for ensuring aides receive their required minimum training.

Based on observation, interview and record review, the facility failed to update records of residents' personal possessions per facility policy for two sampled residents (Residents #44 and #12). The facility failed to ensure one resident received an admission packet (Resident #124). In addition, the facility failed to ensure that residents were provided an accurate admission agreement that reflected financial terms related to refundable deposits following a change in management (Resident #129). The sample size was 21. The census was 91.Review of the facility's Grievance and Missing Property policy, dated, 7/1/25, showed:-Policy: Residents and their representatives have to right to report missing items or property;-Procedure: Grievances may be presented to any staff member and the staff member may resolve the issue immediately; If unable to resolve immediately, follow the grievance procedure; Supervisory personal will be responsible for notifying the resident and their representative of outcome of missing property investigation. 1 .Review of Resident #44's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated,1/6/26, showed:-admission date 6/3/25;-Cognitively intact. Review of the resident's medical record, showed:-Diagnoses included arthritis and spinal stenosis;-No inventory of personal belongings sheet. Observation on 1/22/26 at 9:30 A.M., showed the resident's room with multiple personal items, including a stereo, pictures, personal hygiene products and clothing in his/her closet. During an interview, the resident said he/she had some clothing missing. He/She told multiple staff members, but no one got back with the resident. He/She was missing an off-white lined quilted vest, flannel night shirt with rose flowers, black pair of pants, and new white turtleneck shirt from Land's End. He/She was never provided an inventory sheet to fill out on admission or any time after. 2. Review of Resident #12's quarterly MDS, dated , 11/18/25, showed:-admission date 4/27/25;-Cognitively intact;-Diagnoses included heart failure, hip fracture, diabetes, and kidney disease. Review of the resident's medical record, showed no inventory of personal belongings sheet. Observation on 1/22/26 at 8:10 A.M., showed the resident's room with multiple clothing items in his/her closet and a chest drawer full of socks and short sleeved t-shirts. During an interview, the resident said he/she had multiple tops missing. The clothing went to laundry, and they never returned. He/She never filled out an inventory sheet of personal belongings. 3. During an interview on 1/26/26 at 11:50 A.M., Certified Medicine Technician (CMT) P said there were paper inventory sheets on each of the halls. On admission and anytime residents had new personal property brought to their rooms, an inventory sheet needed to be filled out and updated. The forms should be given to the nurse so that they could be scanned into the residents' medical record. During an interview on 1/26/26 at 12:40 P.M., the Laundry Supervisor said an inventory of personal belongings sheet should be filled out on every resident. The inventory sheet was located in the resident's medical record or in the resident's room. The Laundry Supervisor had not seen an inventory sheet for Resident #44 or Resident #12 and had been unable to locate the residents' missing clothing. During an interview on 1/29/26 at 1:27 P.M., Administrator B and Director of Nursing (DON) C said they expected staff to fill out inventory sheets on admission and update the sheet when new items were brought in by the resident or their family. They expected staff to try to find the missing clothing and if they were not found, then an investigation would be started. 4. Review of Resident's #124's hospital medical record, dated 1/5/26, showed diagnoses included anxiety, diabetes, and open angle glaucoma (visually impairment).Review of the resident's medical record, showed:-admission date 1/5/26;-No baseline care plan to direct staff on the care needs of the resident. During an interview on 1/22/26 at 9:21 A.M., the resident said he/she never received a welcome/admission packet. Review of the resident's admission packet, reviewed 1/29/26 at approximately 1:00 P.M., showed it was signed by the resident 1/23/26. During an interview on 1/29/26 at 12:56 P.M., Administer B said admission packets should be given to residents on the day of admission. He/She was unaware why the resident did not receive the admission packet upon admission. The resident was admitted on [DATE]. 5. Review of the facility's admission agreement under the previous management company, revised on 3/22/23, showed:-To reserve a room, I agree to pay in advance:--A $6,000 deposit interest free security deposit, which is refunded within 45 days after discharge, less balances from Medicare, insurance and hospice companies. The deposit is viewed as an asset by Medicaid and must be applied toward monthly charges to qualify for Medicaid. The monthly charge for room and board starts the first day a bed is held in reserve. If the resident passes away before the admission, charges will be assessed for every day the room was held in reserve. Review of the Facility's current admission agreement, received 1/23/26, showed: -Nursing Facility, Financial, and Resource Agreement:---Receipt of Agreement: Resource hereby acknowledges that Resource has received a complete copy of the Agreement, together with all Exhibits thereto;--Disclosure of Income and Resources: Resources hereby represents and warrants that Appendix 1 which is attached to and hereby made a part of this Resource Agreement constitutes a complete, full and accurate list of all the income and other resources of resident which are known to Resource;-Payment from Residents: Resources hereby agree to pay Facility all charges incurred by resident under the terms of the Agreement only to the extent of the income or resources of Resident;-Limitation: Nothing in this Agreement shall be interpreted to require Resource to make any payment to Facility out of the personal assets of Resource or to incur other financial liability to Facility except as provided in paragraph three;-Miscellaneous:-Agreement: This agreement contains and merges all agreements, representations and understandings of the parties;-Notices: All notices under this Agreement shall be in writing and shall be deemed given when mailed or delivered in person to a party at the address shown above, or at another address as may be designated in writing by that party;-No documentation that addressed the previous contract, and previous deposits made under the previous management's contract/agreement. 6. Review of the Resident #129's admission MDS, a federally mandated assessment instrument completed by facility staff, dated 7/5/25, showed:-Severe cognitive impairment;-Diagnoses included hypertension, acid reflux, thyroid disorder, hyperlipidemia, non-Alzheimer's dementia, and asthma. Review of the resident's application and invoices, received from family on 1/15/26, showed:-Date of application: 4/2/25;-Payment receipt deposit: $6,000.00;--Room and Board: $7,398.00;--Total due at signing: $13,398.00. Review of the resident's progress notes, showed:-On 10/29/25 at 6:00 P.M., staff documented spoke with family member regarding resident transferring tomorrow and pick up at 10:00 A.M.;-On 10/20/25 at 10:36 A.M., resident was transported via at 10:10 A.M. Report was called to transferring facility at 8:30 A.M. Resident's daughter followed via personal transportation with resident's medications as well as resident's belongings. Review of the resident's invoices, received 1/29/26, showed no documentation of a deposit refund of $6,000.00. During an interview on 1/28/26 at 12:59 P.M., Regional Nurse Consultant said Business Office Manager's (BOM) last day at the facility was yesterday. There was a Regional BOM. He was unaware of the contract under the previous management company that required a deposit of $6,000 and the refund of the $6,000 upon being discharged from the facility. The new management does not require a deposit. If a resident had a $6,000 deposit and they were discharged from the facility, he would try and get that deposit back to them. They could contact the previous management company. He was not aware of the resident's situation and the attempts to refund the deposit. There was an increase of residents who were discharged , but they were admitting a lot of short-term residents. They had 10-15 skilled residents and they bumped it up to 30. Regional Nurse Consultant said they are still under the previous management company until the change in ownership was completed. They were still honoring the original contract. They wanted to make as few changes as possible. During an interview on 1/29/26 at 1:43 P.M., Administrator B said the funds were not turned over during acquisition by the new ownership. They have requested all information from the previous ownership. He/She was not aware of the resident's deposit; however, the corporate BOM was aware. The corporate BOM put in a request to refund the deposit. 27162942712809

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate activities of daily living (ADL) care to meet their needs, including showers, nail care, and assisting residents out of bed for four residents (Residents #93, Resident #12, Resident #17, and Resident #13). The sample was 21. The census was 91.Review of the facility's ADL policy, dated 7/21/25, showed the nursing staff will assist in bathing the residents to promote cleanliness and dignity. The Charge Nurse will be made aware of residents who refuse bathing. Review of the facility's Oral Hygiene policy, revised 7/1/25, showed the facility will provide oral hygiene to residents as directed by the care plan. Oral care will include cleansing the oral cavity and removing food and debris. This may reduce odors and infection and provide comfort. 1. Review of Resident #93's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/8/25, showed:-Diagnoses included chronic kidney disease, major depressive disorder (mood disorder), and anxiety;-Moderately impaired cognition. Review of the resident's medical record, showed the resident did not have a baseline care plan. Observation on 1/22/26 at 8:49 A.M., showed the resident in the dining room finishing up breakfast. The resident's hair appeared oily and stringy. His/Her fingernails were long and jagged. During an interview on 1/22/26 at 9:00 A.M., the resident said he/she had not received a shower yet that week. He/She believed this to be because not enough staff were working. He/She would like his/her nails trimmed. 2. Review of Resident #12's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Dependent on staff for personal hygiene, lower body dressing and putting on and taking off footwear;-Independent with showers and bathing;-Always incontinent of urine and occasionally incontinent of stool;-Diagnosis included heart failure, hip fracture, diabetes, and kidney disease. Review of the resident's care plan, in use at the time of survey, showed:-Problem: ADL functional performance related to the resident's hip fracture;-Approaches: Hands on assist with bathing, dressing, toileting, incontinence care, locomotion with wheelchair, transfers and bed positioning. Observation on 1/22/26 at 8:10 A.M., showed the resident in his/her wheelchair in his/her room. The resident's clothing had food stains and his/her hair appeared frizzy and messy. During an interview, the resident said he/she is supposed to get showers on Wednesdays and Saturdays. Since he/she is incontinent of urine, he/she would like a shower more than once a week because he/she sometimes has an odor. He/She also has visitors and is embarrassed that he/she may have an odor around his/her visitors. He/She requires assistance with showers. He/She cannot complete a shower by him/herself. Review of the resident's shower sheets showed:-Showers documented as completed on 1/3/26, 1/8/26, and 1/28/26;-No shower sheets provided by the facility for the month of December 2025. During an interview 1/26/26 at 8:26 A.M., Licensed Practical Nurse (LPN) Y said the resident requires assistance and supervision with his/her showers. 3. During an interview on 1/29/2026 at 7:08 A.M., Certified Nursing Assistant (CNA) I said he/she expected residents to receive at least two showers or bed baths a week. He/She expected the resident's nails to be clean and trimmed. During an interview on 1/29/26 at 10:22 A.M., LPN H said he/she expected residents to receive at least two showers a week. He/She expected the resident's hair to be washed during the shower. During an interview on 1/29/26 at 9:49 A.M. and at 1:43 P.M., Director of Nursing (DON) C said he/she expected residents to receive two showers or bed baths a week. If the resident refused a shower, the DON was to be notified and he/she would talk with the residents. If the resident still refused, then the shower needed to be rescheduled for the next day. 4. Review of Resident #17's admission MDS, dated [DATE], showed:-Diagnoses included muscle weakness and diabetes;-Cognitively intact. Review of the resident's care plan, in use at the time of the survey, showed the care plan did not include ADL care needs. Observation on 1/27/26 at 1:16 P.M., showed the resident in bed. His/Her toenails on both feet measured approximately an eighth of an inch long and appeared jagged. His/Her front teeth had a whitish-yellow substance caked on them. Observation on 1/28/26 at 1:16 P.M., showed the resident in bed. His/Her toenails on both feet appeared approximately an eighth of an inch long and jagged. His/Her front teeth had a whitish yellow substance caked on them. During an interview, the resident said he/she had asked for help trimming his/her nails and no staff would assist him/her. His/Her children have had to come and help brush his/her teeth because the staff are too busy to assist him/her. During an interview on 1/29/26 at 7:08 A.M., CNA I said nail care should be provided after the resident is showered. Lack of staffing was the reason the resident was not being assisted with oral hygiene. The resident required staff assistance with showers and personal hygiene. 5. During an interview on 1/29/26 at 10:22 A.M., LPN H said CNAs and nurses can trim residents' toenails unless the resident is diabetic, and then only the nurse or podiatrist can trim them. He/She expected CNAs to document on the shower sheet and alert the nurse if the resident needs his/her nails trimmed. He/She expected CNAs to assist residents with oral hygiene. During an interview on 1/29/26 at 9:49 A.M., DON C said he/she expected residents to have clean, trimmed toenails. He/She expected staff to assist residents with oral hygiene. 6. Review of Resident #13's quarterly MDS, dated [DATE], showed:-Cognitively intact;-No rejection of care behavior exhibited;-Substantial to maximum assistance from staff required for rolling from left to right and movement from bed to chair and chair to bed;-Diagnosis included heart disease, kidney disease, and high blood pressure. Review of the resident's medical record, showed no care plan completed. Observation 1/22/26 at 10:00 A.M. and 1/27/26 at 8:55 A.M., showed the resident in bed on his/her back, wearing a green hospital gown. During an interview on 1/27/26 at 8:55 A.M., the resident said he/she would like to get out of bed and wear clothing. He/She was reluctant to ask staff to place him/her in a chair because they leave him/her up in the chair for too long. He/She had a special chair but did not know where it was. Observation on 1/28/26 at approximately 2:00 P.M., showed the resident in bed, wearing a green hospital gown. During an interview, the resident said he/she had not gotten out of bed today and thought he/she was too much work for the staff since he/she required a Hoyer lift (full body mechanical lift). The resident would like to see things outside of his/her four walls. During an interview on 1/28/26 at approximately 2:30 P.M., the Director of Therapy said the resident had no restrictions and staff were to use a Hoyer lift to get the resident out of bed. A special high-back wheelchair had been ordered and was in the resident's room. During an interview on 1/29/26 at 10:05 A.M., CNA BB said the resident was offered to get out of bed, but the resident would refuse. The resident required a Hoyer lift to get out of bed. During an interview on 1/29/26 at 2:14 P.M., the DON said the resident was expected to get out of bed every day and as requested. If the resident refused, then the nurse should be notified. He/She expected refusals of care to be documented in the medical record and on the resident's care plan. 272126227168752703232271336527128092697912270539926883552688456268171327248502724974

Based on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner when staff wore earbuds while providing care for one resident (Residents #11) and one resident reported that staff frequently have earphones in (Resident #44). In addition, the facility failed to ensure all residents were served meals on reusable dishware and utensils instead of Styrofoam. The sample was 21. The facility census was 91.Review of the facility's Resident Rights policy, reviewed 7/1/25, showed the facility shall treat residents with kindness, respect, dignity, and ensure residents rights are being followed. The resident/resident representative will be informed of their rights upon admission. Review of the facility's employee handbook, undated, showed non-negotiable expectations: Use of cell phones for any purpose in any resident care areas including resident rooms, halls, nurse's stations and common areas is strictly prohibited. Cell phones are not to be heard or seen in these areas. This is the same expectation with headphones and/or Bluetooth devices. 1. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/6/25, showed:-Severe cognitive impairment;-Dependent on staff for personal hygiene and toilet hygiene;-Required maximum assistance from staff for dressing lower and upper body;-Diagnoses included dementia, heart disease, and heart failure. Observation on 1/26/26 at 8:26 A.M., showed Licensed Practical Nurse (LPN) Y walked down the 200 hall with earphones in his/her ears, attached to his/her phone. LPN Y entered the resident's room with the earphones in his/her ears. Music could be heard coming from the earphones approximately six feet away. LPN Y changed the resident's brief, dressed the resident, and assisted the resident to the wheelchair while LPN Y had earphones his/her ears, connected to his/her phone, and playing music. During an interview on 1/26/26 at 8:37 A.M., Resident #44 said staff are always on the phone when providing care. You can also see the earbuds in their ears. During an interview on 1/28/26 at 2:16 P.M., Certified Nursing Assistant (CNA) NN said cell phone use was not allowed in any resident care areas or when providing care to the residents. Earphones and earbuds are not allowed to be worn by staff. Staff should not be listening to music on their phones when providing care. During an interview on 1/29/26 at 1:41 P.M., Administrator B and Director of Nursing (DON) C said it was expected that employee cell phones were not seen or used while on duty for any reason. Having music playing through earphones while providing care to a resident was not acceptable. 2. Review of the facility's resident council minutes, dated 11/26/25, showed residents in attendance requested regular plates and bowls at meals, not plastic or Styrofoam. Review of the facility's resident council minutes, dated 12/29/25, showed residents in attendance requested to speak with the Administrator/Executive Directive and owners of the management company. The meeting was adjourned after speaking with the residents about re-scheduling to speak with the owners. During an interview on 1/22/26 at 11:51 A.M., Dietary Aide U said the facility had not had the chemicals required to wash dishes in the dish machine for about two months. During an interview on 1/22/26 at 11:59 A.M., the Dietary Manager said the dish machine worked, but it did not have soap or rinse. It had been out for over a month. The new owners did not want to use a particular brand of chemicals because it was too expense, so they needed a new dispenser. Staff were washing dishes by hand. Observation on 1/22/26 at 12:43 P.M., showed the Assistant Dietary Manager plated the residents' food on Styrofoam plates and covered the plates with plastic lids. During an interview on 1/22/26 at 4:19 P.M., Administrator A said corporate ordered a new soap dispenser. They wanted cheaper products for dish machines. There was a monthly fee for the previous supplier, so they were changing the vendor. During an interview on 1/23/26 at 1:12 P.M., CNA V said they were on a tight budget. The residents went from using plastic cups to foam cups. During the resident council meeting on 1/26/26 at 11:20 A.M., five out of five residents, who represented the resident council, said the dishwasher had been broken for at least a month. When the residents started getting plastic cutlery, they knew the dishwasher was broken. They preferred to use normal dishes and silverware. They did not feel like plastic cutlery was homelike. During an interview on 1/28/26 at 10:45 A.M., the Regional Nurse Consultant said the facility ordered from a platform that picked whatever was the cheapest. During an interview on 1/28/26 at 1:43 P.M., Administrator B said he/she was not aware the residents used Styrofoam plates and cups instead of reusable dishware. He/She was not privy to that information, but it was not appropriate to suspend using the dish machine due to not purchasing sanitizer and rinse. He/She was not aware the dish machine was previously not in use. 3. During an interview on 1/28/26 at 1:43 P.M., Administrator B said he/she expected all residents to be treated with dignity and respect. 271280926979122705399268616226837542724850

Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable food requests of offering fresh fruit for one resident (Resident #13), and five of five residents representing the resident council who said they wanted fresh fruit. Fresh fruit was listed on the facility menu as an option for breakfast. The facility census was 91.Review of the facility's Resident Rights policy, reviewed 7/1/25, showed:-Policy: The facility shall treat residents with kindness, respect, dignity, and ensure resident rights are being followed. The resident/resident representative will be informed of their rights upon admission;-Resident rights included the right to:--Exercise rights;--Planning/implementing care;--Make decision/choices;--Self-determination. Review of the facility's weekly menu showed fresh fruit offered with breakfast. During an interview on 1/22/26 at 9:30 A.M., Resident #13 said fresh fruit or salads are not offered any longer on the meal trays. Only canned fruit is offered. He/She does not like canned fruit and prefers fresh fruit. Observation and interview on 1/22/26 at 9:51 A.M., showed no fresh fruit in the walk-in cooler. The vegetables in the walk-in cooler included four bags of lettuce, two boxes of tomatoes, and two boxes of potatoes. During an interview on 1/22/26 at 10:00 A.M., Dietary Aide U said their food delivery days are on Wednesdays. They received their delivery yesterday. They are not always told what will be delivered. During the resident council meeting on 1/26/2026 at 11:20 A.M., 5 out of 5 residents, who represent the resident council, said they would like more fresh fruit. Seldom do they receive fresh fruit during meals or for snacks. During an interview on 1/26/26 at 3:04 P.M., the Dietary Manager said she placed the food order with corporate. She ordered food based off the menu and it is ordered weekly. For produce, the Dietary Manager ordered two cases of bananas in the past, and corporate asked, Do you really need two? Corporate gives push back on all the food ordering. The facility can order bananas and they used to order grapes, but it was too expensive. They could get honeydew and cantaloupe. At times, they could get two cases of fruit, but most of the time, it is only one. During an interview on 1/27/26 at 4:50 P.M., Registered Dietician (RD) said prior to the new ownership, the dietary budget was high. They fed everyone, including staff, for years. Going from that to this, the residents wanted things on the menu that the facility could not afford. If fresh fruit was on the menu, it should have been ordered and served. A person from corporate ordered the food. During an interview on 1/28/26 at 2:39 P.M., Licensed Practical Nurse (LPN) Z said he/she overheard residents complain that the facility stopped serving fresh fruit. During an interview on 1/29/26 at 7:16 A.M., Certified Nursing Assistant (CNA) G said the residents do not get fresh fruit anymore. They used to get fresh fruit all the time. Review of the facility's purchase order, dated 1/27/26, showed the following fresh fruits and vegetables ordered:-Honeydew;-Bananas;-Other fruit on the invoice showed was in can or bag form. During an interview on 1/29/26 at 1:43 P.M., Administrator B said the facility would try to accommodate food requests. He/She was not aware of the residents' requests for fresh fruit. There were budget cutbacks.

Based on interview and record review, the facility failed to maintain an effective grievance process for residents and family members to voice grievances and prompt the facility to resolve grievances for one resident (Resident #44). In addition, five out of five residents who represent the resident council said the facility failed to properly follow up on grievances. The failure has the potential to affect all residents with grievances. The sample was 21. The census was 91.Review of the facility's Grievance and Missing Property policy, dated 7/1/25, showed:-Policy: Residents and resident representatives have the right to voice concerns or grievances, which affect their lives at the facility, without fear of discrimination or reprisal; All residents, resident representatives, and families also have the right to report missing items or property.-Purpose: To provide an opportunity for residents, resident representatives, and families to present concerns or grievances to the proper authorities at the facility and to receive a response;-Procedure: Grievances may be presented to any staff member. The staff member may resolve the issue immediately. If unable to resolve immediately, follow the grievance procedure; -The Administrator, Grievance Official and department heads will follow up on issues noted; -Grievances may be presented to any staff member who will then report the issue utilizing the grievance form to his/her supervisor and an Interdisciplinary Department Team (IDT) member; -The supervisor will discuss the concerns and grievances and solutions with the appropriate department; -Grievance will be shared with other involved departments as needed; -IDT members are responsible for reviewing the grievance form within 10 working days; Department heads are responsible for reviewing, signing, and forwarding the completed complaint form to the Administrator and Social Service Director (SSD); -Social Service or Grievance Official is responsible for notifying the resident's representative, and Ombudsman (a neutral resident advocate), as appropriate of resolutions. IDT members shall be responsible for notifying the resident of the resolution and indicate on the grievance form. Should resolutions not me satisfactory and or if the grievance re-occur, Social Service or the Grievance Official will notify the Administrator and schedule a meeting with the involved parties. 1. Review of Resident #44's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/6/26, showed the resident cognitively intact. During an interview on 1/22/26 at 9:30 A.M., the resident said he/she filed a grievance on 1/5/26 related to the shower room on the 200 hall and has not heard back from the facility regarding a resolution. He/She feels as though no one cares at the facility. Review of the facility's grievance book showed:-A grievance form dated 1/5/26 with the resident's name listed;-A description of an incident that occurred in the 200 hall shower room;-Investigative findings: Blank;-Resolution: Blank;-Results report to: Blank;-Date due: Five days after the date of grievance was filed. 2. During the resident council meeting on 1/26/2026 at 11:20 A.M., five out of five residents who represent the resident council, said very seldom do staff get in contact with the residents when they file a grievance. It takes months to hear back from staff after filing a grievance. Observation on 1/26/26 at approximately 12:00 P.M., showed no grievance forms available for residents and resident representatives in the facility lobby or on the 200 hall. During an interview, the Admissions Coordinator said there used to be grievance forms and a locked box to place the grievance forms in on each floor and in the lobby. She did not know what happened to them. 3. During an interview on 1/28/26 at 1:40 P.M., Licensed Practical Nurse (LPN) BBB said he/she made the Director of Nursing (DON) aware of any concerns that he/she could not take care of. He/She was not familiar with the grievance process. During an interview on 1/29/26 at 10:15 A.M., Certified Nursing Assistant (CNA) PP said he/she just lets the Charge Nurse know about any concerns the residents may have. He/She was not familiar with the grievance process. 4. During an interview on 1/29/26 at approximately 1:00 P.M., the Social Worker said she was named the official Grievance Official on 1/28/26. Administrator A and Administrator B were the previous Grievance Officials. She expected grievances to be thoroughly investigated and to have findings of the investigation within five days. The residents and their families should have free access to grievance forms and a secure box to place them in. The Social Worker was not aware of Resident #44's grievance. 5. During the interview on 1/29/26 at 1:43 P.M., Administrator B said he/she was not aware of Resident #44's grievance. He/She would expect grievances to be acted on immediately and to have a conclusion of the findings reported to the family and their representative within five days. 27164582681713

Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable homelike environment for three residents (Residents #78, #91 and #93). The facility also failed to keep the 200 hall shower room clean and odor free. The sample was 21. The census was 91.Review of the facility's Cleaning Resident's Rooms policy, undated, showed: -Policy: -Resident rooms at the facility are maintained and cleaned on a daily and weekly schedule; -Procedure: -Daily cleaning: -Clean the bathroom; -Dust the furniture, windowsill television and pictures; -Clean chairs, tables, and handrails with disinfection spray; -Clean door know, light switches and telephone with disinfecting spray; -Sweep and mop floors. Review of the facility's Bathroom and Shower Cleaning policy, undated, showed: -Policy: The bathrooms and showers rooms are maintained in a clan and sanitary manner and are cleaned on a daily basis; -Procedure: -Daily cleaning includes: -Emptying waste cans, -Servicing toilet paper holders; - Sweeping and moping floors; -Daily cleaning and sanitizing of toilets includes: -Raise the seat and flush toilet; -With a brush, brush inside the bowl including areas under the rim; -If soiled are around the rim of bowl is not loosed, put on rubber gloves and use cleaning solution to clean by hand; -Wash the outside on the toilet bowl and hinges. 1. Review of Resident #78's annual Minimum Data Set (MDS), federally mandated assessment instrument completed by facility staff dated,12/17/25, showed: -Diagnoses included acute kidney failure, major depressive disorder, and type two diabetes; -Cognitively intact. Observations on 1/22/26 at 11:21 A.M., 1/23/26 at 6:33 A.M., and 1/27/26 at 7:33 A.M., of the resident's room, showed the wall surrounding the windowsill was broken and crumbling, and outside air came through the cracks in the wall. The ceiling tile above the window was stained yellow/orange. During an interview on 1/22/26 at 11:21 A.M., the resident pointed at the window from his/her bed and said he/she could feel cold air coming from the cracked wall. He/She was unable to get out of bed without assistance and was cold due to the draft. He/She would like the stained ceiling tile replaced. During an interview on 1/29/26 at 10:18 A.M., Licensed Practical Nurse (LPN) H said the cracks in the resident's wall were not homelike. He/She expected the resident's wall to be fixed to prevent outside air from coming in the resident's room. During an interview on 1/29/26 at 2:15 P.M., Maintenance Associate E said the resident's window and wall had been in the current condition for at least two months. He/She expected the wall to be in a working condition to prevent drafts from entering the resident's room. During an interview on 1/29/26 at 2:18 P.M., the Plant Operations Manager said he was aware of the wall and window's condition. He said the wall and window should be fixed and there should not be a draft coming into the resident's room. 2. Review of Resident #91's quarterly MDS, dated , 11/3/25, showed: -admission date: 3/18/22; -readmission date: 6/6/23; -Severe cognitive impairment; -Upper/lower extremity: No impairment; -Mobility device: Wheelchair; -Dependent on staff with toileting, bathing, dressing, and transfers; -Substantial/maximal assistance from staff with personal hygiene and dressing; -Supervision or touching assistance only from staff with eating; -Diagnoses included traumatic brain dysfunction, high blood pressure, dementia, and anxiety disorder. Observation on 1/28/26 at 11:34 A.M., showed the resident's family member showed a time stamped picture, dated for 1/26/26 at 10:13 A.M., on his/her phone. The window was opened in the resident's room, and he/she lay in bed under the cover and his/her feet were not covered. During an interview on 1/28/26 at 11:34 A.M., the resident's family member said the resident lived at the facility for the past five years. The family member was upset because he/she went to visit the resident (on 1/26/26) and found the resident's window opened. It had snowed on that previous Saturday and Sunday (1/24/26 and 1/25/26). On 1/26/26, the resident lay in bed with no socks on, and he/she was shivering and cold to the touch. The resident's tray/plate of food was wrapped with aluminum foil. The plate had mashed potatoes and gravy on it from the night before and was untouched. During an interview on 1/29/26 at 12:30 P.M., Certified Nurses Aide (CNA) XX said he/she had opened the window. He/She did not know if it was opened two minutes or twenty minutes, but he/she apologized to the resident's family member. He/She opened the window because there was a smell in the room, and it was hot. CNA XX understood why the resident's family member was upset. Staff had just cleaned up the resident prior to the family member's visit, and the resident was completely covered with one sheet and two blankets when CNA XX left the room. During an interview on 1/29/26 at 2:14 P.M., Director of Nursing (DON) C, said the resident's family member told him/her about the situation. The resident's window should not have been opened. During an interview via email on 2/5/26 at 12:09 P.M., Regional Nurse Consultant Infection Preventionist (IP) said he did not have a policy that explicitly covered safe and homelike environment. 3. Review of Resident #93's admission MDS, dated [DATE], showed: -Diagnoses included chronic kidney disease, major depressive disorder, and anxiety; -Moderately impaired cognition. Observations on 1/23/26 at 6:35 A.M., 1/26/26 at 8:43 A.M., 1/27/26 at 7:37 A.M., and 1/27/26 at 2:53 P.M., of the resident's room, showed the floors surrounding the bed were dusty and covered with a white power substance. A large wood floor board was missing under the resident's bed. The resident's fall mats were covered with food debris and trash. During an interview on 1/29/26 at 10:18 A.M., LPN H said she expected the floors in the resident's room to be clean and free from debris and trash. During an interview on 1/29/2026 at 2:04 P.M., Administrator B said he/she expected resident rooms to have clean floors. He/She expected the flooring to be intact. During an interview on 1/29/26 at 2:18 P.M., the Plant Operations Manager said he expected the floors in the residents' rooms to be cleaned by housekeeping once a day. He was aware of the flooring missing under the resident's bed. 4. Observations on 1/22/26 at 9:40 A.M., 1/23/26 at 7:36 A.M. and 12:35 P.M., and 1/26/26 at 8:45 A.M., showed the second-floor shower room with used briefs in trash cans with no trash liner, toilet riser seats smeared with stool and beneath the toilet riser seats, there was brown matter. There was no toilet paper in the toilet paper dispensary. The floor had puddles of clear liquid near the toilets. The shower room had a strong odor of urine. During an interview on 1/28/26 at 1:30 P.M., Housekeeper T said the shower rooms were cleaned once a day. Staff cleaned the toilets, mopped the floors, refilled the toilet paper, and emptied the trash. During an interview on 1/29/26 at 1:43 P.M., the Administrator B and DON C said the resident's shower room on the second floor should be clean, odor free and with adequate supplies. 2716875 2688456 2681691 2681713

Based on interview and record review, the facility failed to ensure grievances raised by resident council members were acted upon in a timely manner and failed to give a rationale as to why the grievances were not acted upon. This deficient practice had the potential to affect all residents in the facility. The sample was 21. The census was 91. Review of the facility's Grievance policy, dated 7/1/25, showed:-Policy: Residents and resident representatives have the right to voice concerns or grievances, which affect their lives at this facility, without fear of discrimination or reprisal;-Procedure: Grievances may be presented to any staff member; the staff member may resolve the issue immediately. If unable to resolve immediately, follow the grievance procedure;-Social Service/Grievance Official is responsible for notifying the resident representative, and ombudsman, as appropriate, of resolution. Interdisciplinary team (IDT) members shall be responsible for notifying the resident of resolution and indicate on the grievance form. Should resolution(s) not be satisfactory and/or grievances re-occur, Social Service/Grievance Official will notify the Administrator and schedule a meeting with the involved parties. Review of the resident council meeting minutes, dated 11/26/25, showed:-Staff representative: Activity Director;-Old business/outstanding issues: late medication pass, showers not being done on day shift, headphone usage from staff. Review of the resident council meeting minutes, dated 12/31/25, showed:-Staff representative: Activity Director;-Old business/outstanding issues: see November resident council minutes;-No documentation to show how the concerns identified at the 11/26/25 meeting were addressed or resolved. During a group interview on 1/26/2026 at 11:20 A.M., five out of five residents, whom the facility identified as alert and oriented, said very seldom do staff get in contact with the residents when they file a grievance. They said it takes months to hear back from staff after filing a grievance. Most of the time, their grievances are not acted upon. The staff do not inform them or give them a rationale as to why they are not acting upon their grievances. At the most recent resident council meeting, the group raised the concern of staff wearing headphones while providing care and medication pass being late. These grievances were not acted upon. Staff did not respond to these concerns or inform the resident council members if their concerns would be acted upon. They do not have access to resident council minutes to ensure their grievances are being written down. During an interview on 1/29/26 at 11:55 A.M., Administrator B said resident council grievances had not been acted upon in a timely manner, or in some cases at all. He/She expected grievances to be acted upon in a timely manner. He/She expected the resident council to be informed of the outcome of any grievance investigation during the resident council meeting. He/She expected a rationale to be given to the resident council if a grievance was not being acted upon.

Based on observation and interview, the facility failed to post the federal survey results for all residents and visitors to view. The sample was 21. The census was 91. Observation of the front desk area on 1/23/26 at 10:30 A.M., showed no sign indicating the location of the facility's survey results. No survey results documentation was visible. During a group interview on 1/26/26 at 11:30 A.M., five out of five residents, whom the facility identified as alert and oriented, said they did not know where the survey results were located. During an interview on 1/29/26 at 2:07 P.M., Director of Nursing (DON) C said he/she expected the facility's survey results to be readily available to residents and family members. During an interview on 1/29/26 at 11:54 A.M., Administrator B said he/she updated the survey result binder this week and it was located at the front desk. There was no sign posted indicating where residents and family members could find the survey binder. He/She expected the survey binder to be readily available to residents and their family members.

Based on interview and record review, the facility failed to complete all required background checks for newly hired employees prior to hiring for 10 out of 10 employees sampled. The facility failed to check the Nurse Aide (NA) Registry (checks for Federal Indicators (FI) given to individuals found guilty of abuse, neglect, and misappropriation of resident property) for seven out of 10 employees and failed to check either a criminal background check or the Family Care Safety Registry (FCSR, checks both the criminal background check (CBC) and employee disqualification list) for eight out of 10 employees. The census was 91.Review of the facility's Employee Background Checks policy, undated, showed:-The facility is committed to maintaining high quality care and service while protecting its residents from abuse, neglect, and exploitation. Accordingly, this policy sets forth the facility's process for conducting a thorough pre-hire background check of relevant individuals to ensure that relevant individuals:--Have not been found guilty of abuse, neglect, exploitation, or mistreatment or misappropriation of property by a court of law;--Do not have a finding in the state NA registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property;--Do not have a disciplinary action in effect taken against their professional license. 1. Review of Driver UU's employee file, showed:-Hire date 10/16/25;-No CBC check completed;-A FCSR check, dated 12/11/25;-No NA registry check. 2. Review of Admissions Coordinator's employee file, showed:-Hire date 9/30/25;-No CBC check completed;-A FCSR check, dated 12/16/25;-No NA registry check. 3. Review of Dietary Aide TT's employee file, showed:-Hire date 11/19/25;-No CBC check completed;-A FCSR check, dated 11/17/25;-No NA registry check. 4. Review of Activity Director's, employee file, showed:-Hire date 11/24/25;-No CBC check completed;-A FCSR check, dated 12/19/25;-No NA registry check. 5. Review of Director of Rehab's employee file, showed:-Date of hire 11/26/25;-No CBC check completed;-A FCSR check, dated 12/15/25;-No NA registry check. 6. A review of Social Worker's employee file, showed:-Date of hire 12/5/25;-No CBC check completed;-A FCSR check, dated 12/4/25;-No NA registry check. 7. Review of Licensed Practical Nurse (LPN) SS's, employee file, showed:-Hire date 12/30/25;-No CBC check completed;-A FCSR check, dated 12/17/25;-No NA registry check; 8. Review of Certified Nursing Assistant (CNA) RR's employee file, showed:-Hire date 10/29/25;-No CBC check completed;-A FCSR check, dated 12/16/25. 9. Review of CNA QQ's employee file, showed:-Hire date 11/5/25;-No CBC check completed;-A FCSR check, dated 12/19/25. 10. Review of CNA NN's employee file, showed:-Hire date 11/5/25;-No CBC check completed;-A FCSR check, dated 12/17/25. 11. During an interview on 1/28/26 at 1:43 P.M., Administrator B said Human Resources is responsible for conducting background checks. The background check is the first thing that is expected to be completed before staff start working. He/She expected the NA registry to be checked for all staff.

Based on observation, interview and record review, the facility failed to ensure residents received care that met professional standards of quality when staff failed to obtain weights as ordered for one resident (Resident #13) and failed to administer Vitamin D as ordered for one resident (Resident #78). The sample was 21. The census was 91. 1. Review of Resident #13's quarterly Minimum Data Set (MDS), federally mandated assessment instrument completed by facility staff, dated 10/17/25, showed:-admission date 8/29/25;-Diagnoses included heart disease, kidney disease, and high blood pressure. Review of the resident's medical record, showed:-An order, dated 10/21/25, for monthly weights;-An order, dated 12/17/25, weekly weights;-No weights documented August 2025 through January 2026. During an interview on 1/23/26 at 12:25 P.M., Certified Medication Technician (CMT) W said he/she helped obtain resident weights in January 2026. He/She documented the resident's weight on a piece of paper and handed the weights to a nurse. The nurse was to enter the information in the resident's electronic medical record (EMR) because CMT W did not know how to do that. At 1:07 P.M., CMT W said they weighed all the residents in the beginning of the month, between the 1st and the 5th. During an interview on 1/27/26 at 4:50 P.M., the Dietician said the facility called and asked if he/she had the resident's weights. The facility switched from EMR 1 to EMR 2. The transition has been tough and there have been minor issues. They tried to pull the weight report from EMR 1 to EMR 2, but it was unsuccessful. During an interview on 1/29/26 at 1:43 P.M., Director of Nursing (DON) C said staff was expected to follow physician orders and obtain the resident's weights as ordered. All weights were expected to be documented in the resident's medical record. 2. Review of Resident #78's annual MDS, dated [DATE], showed:-Diagnoses included diabetes, major depressive disorder, and chronic kidney disease;-Cognitively intact. Review of the resident's physician order sheet (POS), dated 1/2026, showed an order, dated 12/20/25, for Vitamin D3 oral tablet 25 micrograms (mcg). Give two tablets by mouth one time a day related to vitamin D deficiency. Review of the resident's Vitamin D3 medication administration record (MAR), dated 1/2026, showed:-On 1/1/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/2/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/4/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/5/26, the dose scheduled for 8:00 A.M., was left blank;-On 1/6/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/8/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/9/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/10/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/11/26, the dose scheduled for 8:00 A.M., was left blank;-On 1/12/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/13/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/15/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/17/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/18/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/20/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/21/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/22/26, the dose scheduled for 8:00 A.M., was coded 9;-On 1/23/26, the dose scheduled for 8:00 A.M., was coded 9. Review of the resident's progress notes, showed on 1/1/26 through 1/23/26, the resident's Vitamin D3 was not administered due to being unavailable, as indicated with (9) or blank on the MAR. During an interview on 1/29/26 at 10:25 A.M., Licensed Practical Nurse (LPN) H said medication should be administered per the physician's orders. If a medication was unavailable, the nurse should call the physician and obtain an order or call the pharmacy. He/She expected for the resident to receive his/her Vitamin D as prescribed.

Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #9) who had a history of [REDACTED].#25) environment remained as free of accident hazards as possible due to the resident's history of falls and risk for choking. Facility staff failed to ensure staff transferred four residents (Residents #44, #48, #54, and #57) during mechanical lift transfers, safely and effectively. Facility staff also failed to ensure the resident environment remained free of accident hazards by failing to ensure sharps were not accessible to residents. The facility census was 100 with 45 residents in certified beds. 1. Review of Resident #9's Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/20/18, showed the following staff assessment: -Severely impaired cognitive impairment; -Able to make him/herself understood; -Able to understand others; -Extensive assistance by one staff for bed mobility, transfers, dressing, toilet use, and hygiene; -Limited assistance by one staff for walking in his/her room; -Used a walker. Review of the resident's plan of care, showed a plan addressing the resident's fall risk, last reviewed/revised 2/19/19, where staff noted the resident was at risk for falls related to dementia, compromised mobility with the need for assistance with transfers related to unsteady gait and use of [MEDICAL CONDITION] medications that may have adverse effects such as increased confusion, dizziness, and lethargy. Staff documented the resident fell on [DATE] and 2/13/19. The approaches for care to address the resident's fall risk directed staff to: -Assess for adverse reactions to [MEDICAL CONDITION] medication use such as increased confusion, dizziness and lethargy and report to the physician for followup (dated 12/21/18); -Assure the resident is wearing eyeglasses; Assure eyeglasses are clean and in good repair; -Assure the floor is free of glare, liquids, foreign objects (dated 12/21/18); -Encourage the resident to use environmental devices such as hand grips, hand rails, etc. (dated 12/21/18); -Give the resident verbal reminders not to ambulate/transfer without assistance (dated 12/21/18); -Keep call light in reach at all times (dated 12/21/18); -Keep personal items and frequently used items within reach (dated 12/21/18); -Obtain physical therapy consult for strength training, toning, positioning, transfer training, gait training, mobility devices, etc per physician's orders [REDACTED]. -Occupy the resident with meaningful distraction such as activities, one on one conversation, music, etc (dated 12/21/18); -Provide the resident an environment free of clutter (dated 12/21/18); -Provide proper, well-maintained footwear (dated 12/21/18); -Provide toileting assistance every two hours and as needed (dated 12/21/18). Review of the plan showed staff did not update the plan after the resident's falls on 2/11/19 and 2/13/19, except to add the date of the falls. Review showed staff did not update the care plan to specifically address any determined causal factors related to the falls and any revised interventions after the two falls. During an interview on 4/18/19 at 10:00 A.M., MDS Coordinator K said the resident's most recent care plan is his/her admission care plan, dated 12/27/18 (care plan conference date). Review of a progress note dated 2/11/19 at 9:01 P.M. showed staff observed the resident on the floor. The resident was alert and oriented times two (knows who he/she is and where he/she is but unable to determine time). The resident was assessed, physician notified, and message left for his/her spouse. Staff did not note any change to the resident's care plan to prevent further falls. Review of a progress note dated 2/13/19 at 7:33 P.M. showed the resident was noted on the floor in his/her room next to the bed. The resident's wheelchair was noted behind the resident, the resident was lying on his/her back, was alert and oriented times two. The resident was unable to state what happened. Staff noted they assessed the resident who denied complaints of pain or discomfort, and assisted the resident to bed. Staff noted a faint light green/purple bruising to right buttock. The physician was notified. Staff did not note any change to the resident's care to prevent further falls. Observation on 4/1/19 at 3:03 P.M., showed the resident stood at the sink in his/her room alone, holding onto the sink. Observation showed Certified Nurse Aide (CNA) B entered the room and assisted the resident to walk to the restroom. Observation on 4/4/19 at 10:30 A.M. showed the resident sat in his/her wheelchair in his/her room, facing his/her television, which was off. The resident occasionally looked off to the right to his/her roommate's television, which was on. The resident's call light was not in reach at this time. Continued observation on 11:04 A.M. showed the resident continued to sit in his/her wheelchair looking ahead at his/her mirror or television that was off, and occasionally looked far to the right to his roommate's television that was on. The resident's call light continued to be out of reach. Observation on 4/4/19 at 3:35 P.M. showed the resident lay in bed. The resident said he/she hurt his/her leg, but couldn't describe what had happened. Review of a progress note dated 4/4/19 showed staff documented the resident was attempting to get up from his/her wheelchair and fell on to the floor on his/her bottom. The resident was assessed and stated he/she had pain of three out 10 in the left hip. The resident was able to move both lower extremities within normal limits with no added pain. The resident was assisted from the floor with assistance by two staff. The resident was alert and oriented times three. The physician was notified and an X-ray was ordered. Family was also notified. The resident was educated on the need to use the call light when assistance is needed to further prevent fall and possible injuries. Review of a progress note dated 4/4/19 at 3:27 P.M. showed staff documented they spoke with the resident's spouse, updated him/her on the resident's fall and complaints of left hip pain, informed her that X-ray had been ordered and staff would notify him/her of results. Staff noted they asked the resident's spouse for approval to use a personal safety alarm on a trial basis, as the resident could not recall what he/she was attempting to do before he/she fell . Staff noted the resident complained of left hip pain with passive range of motion. Review of an X-ray of the resident's left hip, unilateral with pelvis, dated 4/4/19, showed: -A fracture through the femoral neck is identified. Minimal displacement is identified. Inferior angulation is noted. The fracture does not involve the articular surface. The femoral head is well-seated within the acetabulum. Moderate [MEDICAL CONDITION] changes are noted. The surrounding soft tissues are normal. -Impression: Femoral neck fracture, as detailed above. Clinical correlation and follow-up are recommended. Review of a physicians order, dated 4/4/19 showed an order directing staff to send the resident to the emergency room for evaluation and treatment. During an interview on 4/5/19 at 11:20 A.M., CNA A said the resident hasn't fallen a lot. The CNA said he/she makes sure his/her leg rests are on the wheelchair, and ensure the resident has his/her fall alarm in place. When asked to clarify if the resident had a fall alarm prior to his/her fall the day before, the CNA said he/she thought the resident had a fall alarm in use prior to the fall and should've had it on. The CNA did not see the fall occur the day before, but staff told him/her the resident tried to scoot him/herself to the sink and stand up. The CNA said he/she had assisted the resident to the toilet after lunch and before the resident's fall. During an interview on 4/5/19 at 11:59 A.M., Licensed Practical Nurse (LPN) C said the resident has [MEDICAL CONDITION] so his/her gait is very unsteady. The resident used to walk with a walker before he/she developed the wounds, but uses a wheelchair now until the wounds heal. The resident does occasionally try to get up and walk on his/her own. After the fall yesterday, staff discussed with the resident's spouse, trialing a period with a personal body alarm for the resident's wheelchair. Staff were unable to figure out why the resident was trying to get up yesterday, but his/her guess was the resident tripped over his/her foot pedals. The resident said he/she didn't remember what he/she was trying to do. The resident had been toileted right before the fall and the call light was in reach. The LPN said the resident doesn't use the call light very often. He/she did not have a personal alarm prior to the fall yesterday. During an interview on 4/5/19 at 11:59 A.M., LPN C said any nurse can update the care plan, but the MDS coordinator, social service director, and the DON update the care plan when things change with the resident, quarterly. LPN C said staff should update the care plans with new interventions if needed after a fall. During an interview on 4/5/19 at 1:54 P.M., the Director of Nurses (DON) said any nurse can update a resident's care plan. The nurses and supervisors update the care plan on the resident's door and the MDS Coordinators update the care plan in the computer. Care plans should be updated at least quarterly, and with any status change, transfer change, or if the resident has a fall. After a resident falls, staff should document on the care plan that the resident had an actual fall and the date of the fall, whether or not the resident had any injury, and what happened, for example if the resident slipped in water. Staff should analyze the fall and then add interventions as needed, typically try to update the care plan within 24 hours. If staff review a resident's care plan after a fall and no new interventions are needed, it would be documented in the nurses notes. The DON said she was not sure of the resident's fall interventions, but staff should follow his/her plan of care. 2. Review of Resident #25's most recent MDS, dated [DATE], showed staff assessed the resident: -Had severe cognitive impairment; -Required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Did not walk; -fell since the prior assessment; -Had one fall with no injury; -Had one fall with injury (not major). Review of the resident's plan of care addressing his/her risk for falls, last reviewed/revised 3/16/19, showed the following: -Staff noted the resident was at risk for falls related to impaired mobility secondary to poor safety awareness and dementia. -The resident is a retired social worker and likes to stay busy. Nursing can usually keep the resident busy with papers doing paper work. -The plan directed staff to place the resident's bed in the lowest position with a fall mat in place while the resident is in bed. -The plan showed the resident fell on ce on 3/14/19. Review of the resident's care plan showed no plan to direct staff of the resident's potential for choking, due to the resident putting non-edible items in his/her mouth. Review of the resident's physician's orders [REDACTED]. -CHOKING HAZARD!!!! RESIDENT PUTS NON-EDIBLE ITEMS IN MOUTH; PLEASE KEEP OUT OF HIS/HER REACH ([MEDICATION NAME], PAPER, PUZZLES, ETC); -Low bed with mat for poor safety awareness; -PSA (Personal Safety Alarm) in wheelchair for safety. Review of the resident's record showed on 12/20/18, staff documented the resident was found in his/her room on the floor mat. The resident was found in urine, sitting up and trying to put on his/her gown; no injury noted. Review of the resident's record showed on 1/21/19, staff documented the resident was observed putting non-edible items in his/her mouth such as wooden puzzles, wedding ring, paper, [MEDICATION NAME] etc; Staff were made aware of the resident's choking risk. The resident's physician and responsible party were updated. The resident's wedding rings were removed and the spouse was asked to pick up the rings. Review of the resident's record showed on 2/2/19, staff documented the resident was observed standing from his/her wheelchair, lost his/her balance and fell to the floor onto his/her left side. Review of the resident's record showed on 3/14/19, an LPN documented he/she found the resident up from his/her wheelchair, walking and pushing an office chair. The resident's PSA was on his/her wheelchair, the string was detached and the alarm sounded. Before the LPN was able to reach the resident, he/she lost his/her balance and fell to the floor hitting his/her right hip and right side of his/her head against the wall. Observation on 4/3/19 on 9:18 P.M. showed the resident lay in his/her low bed. The bed was pushed against the wall on one side, and a fall mat lay beside the other side of the resident's bed on the floor. Observation on 4/3/19 at 10:28 P.M., showed Certified Medication Technician (CMT) G and CNA H checked the resident for incontinence while the resident lay in bed. After the CNAs provided incontinence care, they lowered the resident's bed and placed the fall mat next to the bed. CMT G then placed the resident's bedside table completely on top of the fall mat across from the resident's head and upper body, at a point that if the resident were to fall out of bed, he/she could fall directly onto the legs/wheels of the bedside table. Observation on 4/3/19 at 10:58 P.M. showed LPN I and the night shift charge nurse made rounds through the hallway and residents' rooms prior to LPN I leaving for the evening. The night shift nurse entered the resident's room to check on the resident; the charge nurse did not move the bedside table off of the fall mat and away from the resident's head and upper body in case of a fall to the mat. Observation on 4/4/2019 at 12:18 P.M., showed the resident sat at the dining room table. The resident tore his/her napkin apart and put a piece in his/her mouth, put the rest down and took a drink. Observation showed CNA A sat at the same table feeding another resident. During an interview on 4/5/19 at 11:20 A.M., CNA A said he/she was not aware the resident had any risk for choking hazards. The CNA said she was not aware that the resident puts things in his/her mouth that are not food. However, the CNA said once, the resident did put a Lego in his/her mouth, but this was not an every day thing. The CNA said he/she did not notice the resident took a bite of his/her napkin at lunch yesterday. The CNA said it would never be a good idea to put a bedside table up against a bed for residents with low bed and fall mat because they are at risk for falls and could fall off the bed and and hit the table. During an interview on 4/5/19 at 11:59 A.M., LPN C said for a resident with a low bed and fall mat, staff should not put a bedside table on top of a fall mat next to the resident while in bed. During an interview on 4/5/19 at 1:54 P.M., the DON said a resident should not have a bedside table on top of the fall mat next to their bed. 3. Review of the facilities stand up lift usage policy and procedure, dated 7/27/08, showed to use the stand up lift the resident must be able to partially bear weight and follow simple directions and must be able to hold on to the hand bars of the lifts. The stand up lift may be used by one person. Staff are directed to:-Inform the resident what they will be doing; -Have the resident's chair in positron and locked; -Place the resident on the edge of the bed; -Place the lift in front of the resident and place the resident's feet on the foot board; -Place waist strap around the resident and buckle into place. Pull strap until it is snug; -Make sure the resident's legs are against the leg rest and place the Velcro strap around the resident's calves; -Ask the resdient to place their hands on the hand bar; -Once the resident is positioned over the chair staff may press the down arrow on the hand control mechanism and lower the resident to the chair. 4. Review of Resident #44's quarterly MDS, dated [DATE], showed staff assessed the resident as the following: -Severe cognitive impairment for daily decision making; -Dependent on two or more staff for transfers; -Dependent on one staff for bed mobility, dressing, eating, toileting, personal hygiene, and bathing; -Incontinent of bowel and bladder; -Received as needed pain medication. Review of the resident's comprehensive care plan, last updated 3/1/19, showed staff assessed the resident as at risk for falling related to compromised mobility and need for assistance with transfers, the use of antibiotics, and cognitive impairment. The resdient fell on [DATE]. Facility staff were directed to: -Use hoyer lifts for transfers; -Assess for adverse reactions to [MEDICAL CONDITION] medication; -Explain transfer procedure use hoyer lift during transfers to ensure the resident feels safe and secure; -Provide toileting assistance; -Staff will use wedge cushion for positioning when in bed. Review of the resident's nursing care plan, last updated 3/7/19, showed staff assessed the resident as oriented to self only and was a fall risk. Staff were directed to: -Assist with two staff using the hoyer lift for transfers; -Use a wedge cushion in bed for positioning; -Provide toileting every two hours; -Provide a puree no concentrated sweets diet with honey thickened liquids; -Use aspiration precautions; -Turn from right to left to back. Review of the resident's nurse's notes, dated 9/28/18, showed facility staff documented the nurse entered the shower room and observed the resident on the floor with the hoyer lift under him/her. The two CNAs stated the resident slid out of the toileting sling that they had on the lift. The resident complained of his/her head hurting. The resident had a 5 centimeter (cm) by 4 cm lump to the left side of his/her head, abrasions to his/her left thigh, middle of the back, and abrasions with bruising to several areas on his/her head. The physician was notified and the resident was sent to the emergency room for evaluation and treatment. Observation on 4/3/19 at 01:41 P.M., showed CNA H and L tucked and positioned the hoyer pad under the resident, turning the resident side to side. CNA H lifted the resident with the remote and pulled the resident with the machine away from the bed. CNA L guided the resident with his/her feet to his/her wheelchair. The CNA did not provide support behind or under the resident while transferring the resident to the wheelchair. CNA H lowered the resident into his/her wheelchair and CNA L propelled the resident out of the room. 5. Review of Resident #54's annual MDS, dated [DATE], showed staff assessed the resident as the following: -Severe cognitive impairment; -Requires extensive assistance of one staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; -Has limited range of motion (ROM) to one side of the upper extremity; -Always incontinent of bowel and bladder. Review of the resident's comprehensive care plan, last updated 3/17/19, showed the resident requires extensive assistance with activities of daily living (ADLs) and requires the use of a stand up lift for transfers. The resident has a history of an ileus (a painful obstruction of the ileum or other part of the intestine) and may have two bowel movements in a 24 hour period. Staff were directed to: -Ensure the resident is positioned properly in the stand up lift and explain proper procedure as they are lifting him/her; -Staff will use proper transfer techniques to reduces the risk of skin tears; -Ensure resident is allowed extra time in the restroom when needing to have a bowel movement; -Staff will provide toileting assistance every two hours and as needed. Review of the resident's nursing care plan, review date 3/7/19, showed staff were directed to: -Limit sitting on toilet to 15 minutes; -Stand up lift with one assist; -Broda chair; -Must have two bowel movements per 24 hours, monitor and report to nurse; -Toilet every two hours. Observation on 04/02/19 at 01:49 P.M., showed CNA M positioned the resdient over the toilet removed his/her wet brief and lowered the resident onto the toilet. Observation showed the CNA left the resident unattended attached to the stand up lift in the restroom, while stating, It'll take around 15 minutes for him/her to go to the bathroom. The resident continued to repeat help me. Observation showed CNA M entered the restroom at 1:55 P.M. The CNA lifted the resident off the toilet with the sit to stand and transferred the resdient to his/her Broda chair. 6. Review of Resident #57's significant change MDS, dated [DATE], showed facility staff assessed the resident as the following: -Severe cognitive impairment for daily decision making; -Dependent on one staff for bed mobility, dressing, toileting, eating, personal hygiene, and bathing; -Dependent on two or more staff for transfers; -Always incontinent of bowel and bladder. Review of the resident's comprehensive care plan, dated 3/20/19, showed the resident required total assistance to complete all ADL's related to the [DIAGNOSES REDACTED]. The resident required the use of a hoyer lift for transfers. Staff are directed to use a hoyer lift when transferring the resident, ensure he/she is properly positioned in the lift prior to the transfer, and explain the procedure as they are transferring the resident. Observation on 4/3/19 at 2:00 P.M., showed the resident sat up in his/her Broda chair. CNA M attached the hoyer pad loops to the hoyer lift and CNA N began to lift the resident. CNA N guided the machine over to the bed, while CNA M held onto the resident's feet. CNA M did not provide support to the resident by holding unto the resident's sling or under the resident. 7. Review of Resident #48's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Minimal cognitive impairment; -Requires extensive assistance of one staff for bed mobility, transferring, dressing, toileting, and bathing; -Requires limited assistance of one staff for personal hygiene; -Frequently incontinent of bowel and bladder; -Limited range of motion to one side of the upper and lower extremities; -Had one non-injury fall. Review of the resident's comprehensive care plan, dated 3/8/19, showed the resident has left sided [MEDICAL CONDITION] (total or [DIAGNOSES REDACTED] on one side to the body). The resident fell on [DATE]. The resident requires limited to extensive assist of one to complete ADL's such as transfers, toileting, transfers, and dressing. The resident will continue to use a stand up lift for transfers. Staff are directed to: -Remind the resdient not to transfer without staff assistance; -Offer toileting every two hours and as needed; -Instruct the resident in proper transfer techniques using the stand up lift. Observation on 04/02/19 at 09:27 A.M., showed CNA M assisted the resident into a sitting position. The CNA assisted the resident in dressing his/her upper body and placed the stand up lift sling around the resident's torso, connecting the sling to the machine. The resident was only able to hold on with his/her right hand. Observation showed the resident only had his/her right foot on the stand up lift base. The resident's left foot was dragging on the ground as the CNA transferred the resdient to his/her wheelchair from the bed. The CNA continued to transfer the resident to his/her wheelchair lowering the resident into the wheelchair and unattached the sling from the lift. The resident was unable to hold onto the lift with his/her left hand and the CNA did not ensure the resident's left foot was positioned onto the lift. 8. During an interview on 04/05/19 at 11:20 A.M., CNA A said during a hoyer lift transfer staff are to use two people, the right size sling, and ensure the battery is charged. The CNA said one staff controls the lift and one staff guides the resident. Staff are to make sure the resident's feet do not hit. Staff are not supposed to guide the resident by their feet, but with their hands on the resident's back. 9. During an interview on 04/05/19 at 11:25 A.M., CNA M said when transferring a resident using a hoyer lift staff are expected to use two people. Both staff are supposed to help guide the resident to ensure they do not hit anything. Staff should be holding onto the resident, one holding onto the sling on the back of the resident to help guide them. CNA A said staff should not guide the resident using their feet. When transferring a resident using a stand up lift, one staff can transfer the resident. Staff are to cue the resident and ensure the resident has a hold of the lift with both hands and both feet are on the lift base before transferring. 10. During an interview on 04/05/19 at 11:59 A.M., LPN C said staff are to ensure safety with lift transfers. Staff are to lock the wheelchair, move foot pedals, move to closest position, secure hoyer - two staff for hoyer lift and one to two staff for the stand up lift, depending on the resident. Apply the belt/sling for the stand up lift, ensuring that it is tight enough, have the resident hold onto the hand rail, and stand up with the lift. For the hoyer lift, have the resident cross their arms, open the lifts legs, approach wheelchair during transport with the hoyer. One staff is responsible to ensure the feet are going the right direction, one controls the lift movement. Staff should guide the resident at the feet - so they don't bump into anything. 11. During an interview on 04/05/19 at 01:54 P.M., the DON said, the stand up lift only requires one staff per the facility policy and the hoyer lift requires two staff for transfers. During a hoyer lift transfer one staff should be at the resident's side or back to guide the resident and the other staff should be guiding the machine. Staff should protect the feet from getting hit, but staff should be normally be on the back side of the resident to help guide and align them. 12. Observation on 4/01/19 at 2:31 P.M., on 4/2/19 at 3:43 P.M., on 4/3/19 at 9:12 P.M., and on 4/4/19 at 10:06 A.M., showed the medication cart on the 200 hall had a plastic container that contained lancets and insulin (a medication used to treat high blood glucose) pen needles. Observation showed the plastic container did not have a lock and was unattended. 13. Observation on 4/1/19 at 1:30 P.M., on 4/2/19 at 10:00 A.M., on 4/3/19 at 1:46 P.M., and on 4/4/19 at 10:27 A.M. showed the medication cart on the Medicare hall had a plastic box that contained lancets and insulin pen needles. Observation showed the box did not have a lock, was easily opened, and was unattended. 14. During an interview on 4/5/19 at 11:59 A.M., LPN C said sharps should be kept locked in the medication cart or medication room at all times. LPN C said the insulin supplies are in a plastic box kept on top of the medication cart unlocked. 15. During an interview on 4/5/19 at 1:54 P.M., the DON said the insulin supplies are kept on top of the medication cart in a closed container. The DON said the insulin supplies have lancets that could cause injury in them.