Every finding on record at Lebanon Veterans Home

Based on observation and interview it was determined the facility failed to ensure proper food temperatures were maintained for meals served from 2 of 12 facility kitchens reviewed for food service. This placed residents at risk for unpalatable and unpleasant meals. Findings include:1. On 9/2/25 at 11:55 AM, Resident 130 stated the ground up food was completely unpleasant. On 9/3/25 at 8:12 AM, Resident 15 stated the food was tasteless, and always cold. On 9/3/25 at 10:09 AM, Resident 2 stated the food was not palatable and she/he did not like to eat it. During an observation of the lunch meal service on 9/5/25 at 12:24 PM, a meal of lemon pepper tuna, rice pilaf, and broccoli was served to residents of the [NAME] 200 house. The meal service also included an alternate texture option for the lemon pepper tuna. The temperatures of the meal components when delivered from the kitchen were as follows: - Lemon pepper tuna: 160 degrees F. - [NAME] pilaf: 149 degrees F. - Broccoli: 135 degrees F. The broccoli was reheated in the microwave multiple times until it reached a temperature of 165 degrees F. - Mechanical soft texture (ground up) lemon pepper tuna: 125 degrees F. This tuna was placed in an oven set to 200 degrees F until served. Throughout the meal service the following were observed: - The lemon pepper tuna, rice pilaf, and broccoli were kept in separate foil covered metal containers on the kitchen counter and were opened repeatedly while being served. - All plates of food were reheated in the microwave prior to serving them to the residents. On 9/5/25 at 12:45 PM, Staff 37 (CNA) stated the residents' plates were microwaved nearly every lunch and dinner service to get the food warm enough to serve. The surveyor test meal was served at 12:47 PM directly after the last resident meal. The texture of the lemon pepper tuna was rubbery, the mechanical soft texture tuna was dry, the rice pilaf was dry and crunchy, and the broccoli was mushy and unpalatable. The lemon pepper tuna, the mechanical soft texture tuna, and the rice pilaf were lukewarm to touch, and the broccoli was cold. The following temperatures were noted: - Lemon pepper tuna: 121 degrees F. - Mechanical soft texture lemon pepper tuna: 136 degrees F. - [NAME] pilaf: 123 degrees Fahrenheit. - Broccoli: 87 degrees Fahrenheit. On 9/5/25 at 3:20 PM, Staff 6 (Dietary Manager) stated the drop in temperatures for resident meals was a known issue, and the facility administration was working on a plan of correction. Further education was forthcoming for staff. She stated the required holding temperature for most foods was 140 degrees F, and staff were instructed to use the oven set to 200 degrees F or the microwave to bring resident food up to the proper temperature before serving. On 9/5/25 at 5:06 PM, Staff 1 (Administrator) acknowledged the drop in temperatures and the unpleasantness of the surveyor test tray. He stated the drop in resident meal temperatures was a known issue, and the administrative team was working on a correction plan. 2. On 9/5/25 at 11:39 AM, the posted lunch menu included lemon pepper tuna. On 9/5/25 at 11:49 AM, the meal cart was delivered to the Alpha 200 house. The tuna was placed in the oven. Staff 7 (CNA) removed the tuna from the oven, and it was observed at a temperature of 131 F. Staff 7 referenced a temperature guide for the food and stated it was close to the required temperature for other meats. On 9/5/25 at 12:16 PM, after all other meals were delivered to residents a test tray was sampled, and the tuna was lukewarm. On 9/5/25 at 12:28 PM, Staff 6 (Dietary Manager) stated the required holding temperature was 140 F. Staff were instructed to return food to the oven uncovered or use a microwave if temperatures were below the threshold.

Based on observation and interview it was determined the facility failed to ensure medications were not expired for 2 of 4 sampled houses reviewed for medication storage. This placed residents at risk for altered medication effectiveness. Findings include: 1. On 9/5/25 at 3:03 PM, an open bottle of Prednisolone 1% eye drops was observed with Staff 19 (LPN) in the medication storage in room [ROOM NUMBER]. The bottle of Prednisolone had an open date which was unreadable and was dispensed on 6/13/25. Staff 19 stated eye drops were expired after being open for 30 days. On 9/5/25 at 3:05 PM, an open bottle of acetaminophen was observed with Staff 19 in the medication storage in room [ROOM NUMBER] which expired in 2/2025. Staff 19 stated medications were to be destroyed when they were expired. On 9/5/25 at 3:14 PM, two open insulin pens (an injection device that allows you to deliver preloaded insulin into the body) were observed with Staff 19 in the medication storage in room [ROOM NUMBER]. Both pens did not have an open date on them and were dispensed on 7/1/25. Staff 29 stated insulin pens were expired after being open for 28 days. On 9/5/25 3:19 PM, Staff 20 (RNCM) stated medications needed to be removed from medication storage when expired. Staff 20 stated eye drops were to be labeled when opened and discarded after 30 days. Staff 20 stated insulin pens were to be labeled when opened and discarded after 30 days. 2. During an observation of the resident medication storage cabinets in the [NAME] House 100 unit on 9/5/25 at 6:05 PM, the following was found in room [ROOM NUMBER]: - One box of Ondansetron 4mg tablets with an expiration date of 8/2025. On 9/5/25 at 6:05 PM, Staff 34 (LPN) acknowledged the expired medication and stated the expectation for resident medications was for nursing staff to remove and replace medications before they expired. On 9/8/25 at 5:28 PM, Staff 2 (DNS) acknowledged the expired medications and stated the expectation for resident medications in the medication cabinets was they were not expired while in use. 3. During an observation of the resident medication storage cabinets in the [NAME] House 200 unit on 9/5/25 at 6:25 PM, the following was found in room [ROOM NUMBER]: - One tube of triple antibiotic ointment with an expiration date of 7/2025. On 9/5/25 at 6:25 PM, Staff 35 (LPN) acknowledged the expired medication and stated the expectation was for all expired medications to be removed from resident storage cabinets. On 9/8/25 at 5:28 PM, Staff 2 (DNS) acknowledged the expired medications and stated the expectation for resident medications in the medication cabinets was they were not expired while in use.

Based on observation, interview, and record review it was determined the facility failed to ensure infection control standards were followed in 1 of 4 houses reviewed for infection control. This placed residents at risk for spread of infection. Findings include: During an observation of the COVID precautions in the [NAME] House 100 unit on 9/3/25 at 10:25 AM, it was noted the frosted glass door to the unit did not have signage, PPE (Personal Protective Equipment), trash cans, or hand sanitization supplies on either side of the door. On 9/4/25 at 11:26 AM, Staff 5 (Infection Control RN) stated units with active COVID outbreaks were to have signage, PPE, trash cans, and hand sanitization supplies for staff and visitors on all doors to the unit. During an observation of the COVID precautions in the [NAME] House 100 unit on 9/4/25 at 12:57 PM, two visitors were seen exiting the unit through the frosted glass door. The two visitors removed their masks after exiting, put the masks in their pockets, and opened multiple doors with their hands while exiting the building. During an observation of the COVID precautions in the [NAME] House 100 unit on 9/5/25 at 6:55 PM, a staff member was observed to exit the unit through the frosted glass door, take off their mask, walk across the lobby to throw the mask away, and then sanitize their hands. On 9/8/25 at 3:21 PM, Staff 5 stated staff and visitors were not supposed to use the frosted glass door to the [NAME] House 100 unit. He stated he did not put any signage, PPE, trash cans, or hand sanitization supplies by that door because it was not supposed to be used by anyone. On 9/8/25 at 5:28 PM, Staff 2 (DNS) acknowledged the lack of COVID precautions for the frosted glass door on the [NAME] House 100 unit. She stated the expectation for any unit during a COVID outbreak was for signage, PPE, trashcans, and hand sanitization supplies to be at every door for that unit.

Based on observation and interview it was determined the facility failed to ensure carpeting was clean for 1 of 3 houses (Delta 3). This placed residents at risk for an unhomelike environment. Findings include: On 9/3/25 at 10:41 AM on Delta 3 the following were observed: -The carpet between the fireplace and the dining room had three large brown stains that were approximately one foot in diameter. -The carpet in front of the recliners located by the television had dark brown stains that were approximately four feet long by one foot wide. -The carpet between the dining room and room [ROOM NUMBER] had a dark brown stain approximately one- and one-half feet in diameter. On 9/3/25 at 10:45 AM Staff 8 (CNA) stated the carpets were cleaned approximately two weeks prior but the brown spots resurfaced a few days later. On 9/8/25 at 10:10 AM Staff 9 (Housekeeping Manager) stated the stains surrounded the dining room for at least two years. The carpet was cleaned at least every two weeks, but the stains were not able to be removed.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was not started on a psychotropic medication without indication for use and failed to monitor a resident for side effects of psychotropic medications for 1 of 5 sampled residents (#123) reviewed for mood and unnecessary medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 123 was admitted to the facility in 2/2024 with a diagnosis of dementia and stroke.a. A Behavioral Management Program Policy and Procedure last updated 8/2014 revealed all non-pharmacological interventions were to be exhausted and acute medical conditions including pain and environmental factors were to be ruled out prior to obtaining any orders for psychoactive medications. Resident 123's 9/16/24 physician visit note revealed she/he was sitting at the exit door waiting to visit her/his spouse. Resident 123 appeared to be in good spirits. Staff did not report concerns. Staff previously reported on 8/19/24 Resident 123 kicked a staff when she/he was unable to leave the facility. Resident 123's Interdisciplinary Care Conference forms revealed:-10/2/24 Resident 123 visited her/his spouse on campus and enjoyed eating meals with her/him.-12/26/24 staff reported Resident 123 was agitated and hit staff. Resident 123 was frustrated from her/his inability to visit her/his spouse.Resident 123's 3/10/25 External Visit indicated Resident 123 had worsening behaviors. Staff reported after Resident 123 visited her/his spouse, she/he appeared to be calm and content. The note indicated Resident 123 was on daily oxycodone (narcotic pain medication) for pain. The use of Seroquel (antipsychotic medication) was discussed with family and agreed with implementation. Resident 123's physician orders dated 3/10/25 revealed Seroquel was to be administered at bedtime.Resident 123's 3/2025 MAR revealed she/he was administered Seroquel at bedtime from 3/11/25 for agitation/behaviors.Resident 123's clinical record revealed laboratory tests were not obtained prior to the initiation of Seroquel on 3/11/25. On 9/9/25 at 9:47 AM Staff 11 (LPN Resident Care Coordinator) stated Resident 123 was angry and depressed because she/he was not able to visit her/his spouse. Staff 12 (LPN Resident Care Coordinator) stated the antipsychotic was not appropriate for use and her/his behaviors did not improve. On 9/8/25 at 2:40 PM Staff 2 (DNS) stated Resident 123 sat by the door and wanted to see her/his spouse. The staff tried to assist the resident, but she/he hit and banged on the door. Resident 123 and her/his spouse were on different sleep schedules, and it was difficult for Resident 123 to understand the reason she/he could not visit her/his spouse. Staff 2 acknowledged labs were not obtained until 3/27/25, after the Seroquel was started. Staff 2 also indicated the Seroquel did not work.b. Resident 123's 6/24/25 Psychotropic Pharmacy Review form revealed she/he was on Seroquel (antipsychotic).Resident 123's care plan initiated on 2/29/24 was not updated to include the use of Seroquel and to monitor for side effects of the medication. Resident 123's clinical record did not indicate she/he was monitored for side effects of Seroquel. On 9/5/25 at 1:22 PM Staff 11 (LPN Resident Care Coordinator) stated a care plan for Seroquel was not developed and there was no monitoring for the side effects of the antipsychotic.

Based on interview and record review it was determined the facility failed to complete a trauma assessment for residents with post-traumatic stress disorder (PTSD) for 2 of 7 sampled residents (#s 3 and 11) reviewed for psychotropic medications and unnecessary medications. This placed residents at risk for triggers related to PTSD. Findings include: 1. Resident 3 was admitted to the facility in 11/2019 with diagnoses including post-traumatic stress disorder (PTSD).A 11/19/19 care plan indicated Resident 3 had a history of trauma related to childhood deprivation and abuse. The goal indicated Resident 3 would identify individual strengths by the review date. An intervention indicated Resident 3 needed assistance, supervision, and support to identify precipitating factors and stressors.A review of Resident 3's medical record revealed no indication of a completed trauma screen.On 9/9/25 at 8:21 AM, Staff 30 (Social Service Designee) stated usually upon admission she completed a trauma screen to identify specific types of trauma and triggers for the trauma. With that information she put the type of trauma and triggers in the residents' care plan. Staff 30 stated she was unaware Resident 3 did not have a trauma screen to identify triggers of her/his diagnosis of PTSD and the triggers for Resident 3's PTSD were not on the care plan.On 9/9/25 at 10:46 AM Staff 2 (DNS) stated every resident was to have a trauma screen completed to identify types of trauma and triggers. Staff 2 stated the information obtained in the trauma screen was to be placed on the residents' care plan, so staff were aware of the type of trauma and triggers to watch for.2. Resident 11 was admitted to the facility in 1/2020 with diagnoses including post-traumatic stress disorder (PTSD).On 9/5/25 at 1:54 PM, Staff 31 (CNA) stated Resident 11 was aggravated at times and just wanted to be left alone sometimes.On 9/5/25 at 2:00 PM, Staff 32 (LPN) stated Resident 11 got aggravated at times and she was unsure what made her/him get aggravated.On 9/9/25 at 9:51 AM, Staff 33 (Social Service Designee) stated he was unable to locate a completed trauma screen for Resident 11.A review of Resident 11's medical record revealed no indication of a completed trauma screen or a PTSD care plan.On 9/9/25 at 10:46 AM Staff 2 (DNS) stated every resident was to have a trauma screen completed to identify types of trauma and triggers. Staff 2 stated the information obtained in the trauma screen was to be placed on the residents' care plan, so staff were aware of the type of trauma and triggers to watch for.

Based on interview and record review it was determined the facility failed to monitor medications for 2 of 10 sampled residents (#s 3 and 4) reviewed for nutrition and unnecessary medications. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 3 was admitted to the facility in 11/2019 with diagnoses including arterial fibrillation (an irregular heartbeat).A review of Physician Orders revealed an 8/29/25 order for warfarin (a blood thinning medication).A review of Resident 3's care plan revealed no evidence of a blood thinning medication care plan or monitoring for adverse side effects of blood thinning medications.On 9/9/25 at 8:40 AM Staff 14 (RCM) stated adverse side effects for warfarin should be listed in a warfarin care plan. Staff 14 acknowledged Resident 3 had no care plan for blood thinning medications and no monitors in place to monitor for adverse side effects of blood thinning medications.On 9/9/25 at 10:52 AM Staff 2 (DNS) acknowledged Resident 3 was not care planned for blood thinners and had no monitors in place to monitor for adverse side effects of blood thinners.2. Resident 4 was admitted to the facility in 2/2025 with diagnoses including heart failure.A review of Physician Orders revealed an 4/10/25 order for furosemide (a diuretic medication used to treat heart failure by removing excess fluid from the body).A review of Resident 4's weights revealed the following: 7/19/25 218 lbs. 8/28/25 229 lbs. 8/30/25 228.2 lbs. 9/7/25 229.2 lbs.A review of Resident 4's care plan revealed no evidence of a diuretic medication care plan.On 9/8/25 at 2:33 PM, Staff 17 (CNA) stated Resident 4 had a little weight gain but was unsure how much. Staff 17 stated Resident 4 had some edema (swelling) in her/his feet and used compression socks for the edema.On 9/8/25 at 2:48 PM, Staff 19 (LPN) stated she was unsure if Resident 4 had any weight gain or if Resident 4 took any diuretics. Staff 19 stated Resident 4 had edema to both legs, and the physician was to be notified for a weight gain of five pounds or more in three days.On 9/9/25 at 9:07 AM, Staff 20 (RNCM) stated Resident 4's weight gain was not identified until this interview. Staff 20 acknowledged Resident 4 did not have a care plan for diuretic medications and was not being monitored for weight gain.On 9/9/25 at 10:42 AM, Staff 2 (DNS) stated a resident diagnosed with heart failure and taking a diuretic was to be monitored for weight gain and the doctor was to be notified for a gain of two to three pounds. Staff 2 stated Resident 4 should have had a head-to-toe assessment to see if the weight gain was related to heart failure and fluid retention. Staff 2 stated Resident 4 needed to be monitored for weight gain.

Based on observation, interview and record review it was determined the facility failed to ensure residents received services to prevent accidents for 2 of 5 sampled residents (#s 9 and 74) reviewed for falls and rehabilitation. This placed residents at risk for injury. Findings include: 1. Resident 9 was admitted to the facility in 10/2020 with a diagnosis of dementia. Resident 9's 4/13/25 Post Fall Assessment revealed on 4/13/25 at 6:25 PM she/he had a witnessed fall in the dining room. Resident 9 was in her/his wheelchair, was wiggling her/his legs, leaned to the left, fell to the floor, and sustained a forehead laceration. The assessment indicated the armrest was not properly latched after staff transferred her/him into the chair with a mechanical lift. On 9/8/25 at 10:25 Staff 12 (LPN Resident Care Coordinator) verified staff did not latch Resident 9's wheelchair armrest correctly and her/his movement and lack of trunk control, caused her/him to fall out of the wheelchair when she/he leaned to the left. 2. Resident 74 was admitted in 1/2025 with diagnoses including stroke, cognitive communication deficit, and a history of repeated falls. A fall risk assessment dated [DATE] identified Resident 74 as confused, with multiple diagnoses and medications, and a history of falls. The 5/13/25 revised care plan required Resident 74 to have two-person assistance with a mechanical sit-to-stand lift for transfers. On 9/5/25 at 6:42 AM, Staff 7 (CNA) entered Resident 74's room with a sit-to-stand lift with the resident observed in bed. At 6:55 AM, Staff 7 exited the room with the sit-to-stand lift. No other staff were observed in the room during the transfer. Resident 74 was in her/his electric wheelchair. At 8:30 AM, Staff 7 stated if a resident was care planned for two staff, she should have another staff member present during the transfer, and she did not have another staff present during Resident 74's transfer. Staff 7 stated she was confused about whether all sit-to-stand transfers required two staff or only some. On 9/9/25 at 8:20 AM, Staff 2 (DNS) stated she expected staff to follow residents' care plans. Staff 2 confirmed all sit-to-stand lift transfers required two staff.

Based on interview and record review it was determined the facility failed to obtain copies of advanced directives for 1 of 3 sampled residents (#13) reviewed for advanced directives. This placed residents at risk for not having their health care decisions honored. Findings include: Resident 13 was admitted to the facility in 2023 with diagnoses including anxiety and heart failure. From 7/23/23 through 7/9/25, Interdisciplinary Care Conference notes revealed Resident 13 would look for a copy of her/his advance directive.The 10/15/24 care conference reflected Resident 13 would look for a copy of the document and expressed interest in receiving assistance with completing it.A review of Resident 13's medical record revealed no indication staff assisted Resident 13 with completing an advance directive. On 9/8/25 at 11:33 AM, Staff 22 (Social Service Designee) acknowledged no one followed up on Resident 13's request to complete an advance directive.

Based on interview and record review it was determined the facility failed to ensure residents' neurological assessments were completed for 1 of 7 sampled residents (#135) reviewed for falls and rehabilitation. This placed residents at risk for unidentified head injuries. Findings include: Resident 135 was admitted to the facility in 4/2023 with diagnoses including dementia.An 4/27/25 incident report indicated Resident 135 was found on the floor in the activity room. According to the incident report, Resident 135 took 10 minutes to fully arouse, was unable to follow simple commands, and her/his right pupil was not responding to light at first. The on-call doctor was notified as well as the resident's Power of Attorney (POA) and it was decided to keep Resident 135 in the facility and monitor her/his neurological status closely.The 4/27/25 Neurological Flow Sheet indicated checks were to be completed every 15 minutes for an hour, every 30 minutes for two hours, every hour for four hours, every four hours for 16 hours, and every eight hours for 48 hours. The 4/27/25 Neurological Flow Sheet for Resident 135 was incomplete with missing assessment areas and stopped after three hours.On 9/8/25 at 3:11 PM, Staff 21 (LPN) stated on 4/27/25 Resident 135 was found in the activity room laying on the ground with a pillow under her/his head. Staff 21 stated it took approximately an hour for Resident 135 to get back to baseline neurologically after the fall.On 9/8/25 at 3:11 PM, Staff 11 (RNCM) stated neurological checks were to be initiated after an unwitnessed fall or a head injury. Staff 11 stated neurological checks were to be completed every 15 minutes for an hour, every 30 minutes for two hours, every hour for four hours, every four hours for 16 hours, and every eight hours for 48 hours. Staff 11 acknowledged Resident 135's neurological checks were incomplete with missing assessment areas. Staff 11 acknowledged the neurological checks stopped after every 30-minute checks and was to be continued until completed.

Based on observation, interview, and record review it was determined the facility failed to update resident care plans for 2 of 3 sampled residents (#s 9 and 74) reviewed for ROM and infection control. This placed residents at risk for skin break down and inaccurate records. Findings include: 1. Resident 9 was admitted to the facility in 10/2020 with a diagnosis of dementia. Resident 9's 4/11/25 Annual MDS revealed she/he had decreased ROM and a left-hand contracture. On 9/8/25 at 9:47 AM Resident 9 was observed in the dining area with a soft lamb wool Velcro wrap to the left hand. Resident 9's Care Plan initiated 10/2020 did not have a Velcro wrap on the care plan. On 9/4/25 at 9:18 AM Staff 28 (CNA) stated Resident 9 had a contracture and her/his fingers were hard to bend at times, and she/he had her/his wrap for quite a while. On 9/8/25 at 12:04 PM Staff 12 (LPN Resident Care Coordinator) stated staff used to place a towel in her/his hand to prevent her/his hand from forming a tight grip due to her/his contracture but she/he pulled the towel out. Staff 12 stated she ordered a new soft splint approximately one month ago but did not update the care plan. 2. Resident 74 was admitted to the facility in 1/2025 with diagnoses including urinary tract infection and cancer. Review of physician orders revealed Resident 74 was placed on Enhanced Barrier Precautions (EBP) on 4/23/25 due to chronic ulcers on the right ankle and heel. No end date was documented. On 9/2/25 at 1:52 PM, Resident 74 stated her/his shoulder wound was basically healed, but she/he still had wounds on her/his leg. On 9/3/25 at 11:30 AM, a nurses note indicated there was no wound on Resident 74's right lateral foot so no wound care was provided; the wound was resolved. From 9/2/25 through 9/5/25 observations revealed staff were not implementing EBP for Resident 74. On 9/8/25 at 7:06 AM, Resident 74's care plan was reviewed and EBP was listed on the care plan. On 9/8/2025 10:55 AM, Staff 5 (Infection Control RN) reported Resident 74's catheter was removed and her/his wounds were resolved. Staff 5 stated Resident 74's pressure ulcer resolved on 8/19/25 and the care plan was not updated. On 9/9/25 at 8:20 AM, Staff 2 (DNS) confirmed Resident 74 was placed on EBP for wounds which since resolved, and confirmed the care plan was not updated.

Based on interview and record review it was determined the facility failed to protect a resident's right to be free from physical abuse by a resident for 1 of 1 sampled resident (#68) reviewed for abuse. This placed residents at risk for injury. Findings include: Resident 68 was admitted to the facility in 9/2025 with a diagnosis of dementia. Resident 68's care plan initiated 12/12/24 revealed she/he had a history of wandering into other residents' rooms. Staff were to attempt to redirect Resident 68 before she/he entered another resident's room and offer food. Resident 135 was admitted to the facility in 4/2023 with a diagnosis of dementia. Resident 135's care plan initiated 12/28/23 revealed she/he had verbal and physical aggression. Interventions included to not invade Resident 135's space and staff were to monitor her/him when in close proximity of other residents. An 8/28/25 Resident to Resident /Staff Assessment form revealed on 8/28/25 at 5:10 PM CNAs witnessed Resident 68 walk into Resident 135's room while Resident 135 was in the dining room eating. Resident 135 stood up from the dining table, went into her/his room, and started to speak to Resident 68. Resident 135 then looked toward the dining room at staff, pushed Resident 68 hard which caused Resident 68 to fall. Resident 68 did not hit her/his head when she/he fell and did not sustain an injury. On 9/5/25 at 4:27 PM Staff 10 (CNA) stated Resident 68 wandered into other residents' rooms and did not have boundaries. Staff usually redirected her/him out of other residents' rooms. On 8/28/25 Resident 135 was eating dinner in the dining room when Resident 68 walked into Resident 135's room. Resident 135 finished eating and walked into her/his room and started to talk to Resident 68. The conversation was in normal tones and did not appear to be a concern. Resident 135 looked toward the dining room, then looked back at Resident 68 and pushed Resident 68 causing her/hm to fall. Staff 10 stated it was difficult to read Resident 135's mood. Some days Resident 135 was happy and other days she/he woke up upset. Staff 10 stated she did not intervene and initially just observed the interaction. Staff 10 stated the care plan indicated staff were to monitor Resident 135 from a distance because she/he did not like when people were in her/his bubble.On 9/8/25 at 8:40 AM Staff 36 (CNA) stated Resident 135 was usually very sweet and friendly but over the last few months she/he became very angry and unpredictable. Resident 135 could be in a normal interaction with a resident and in just a second would change into a different person. Staff had to distract Resident 135 when she/he became aggressive. Staff 36 stated you never knew what Resident 135 would do, at times she/he allowed residents in her/his room and other times it upsets her/him. Staff 36 stated on 8/28/25 initially Resident 135 did not seem to be upset Resident 68 was in her/his room, but all of a sudden her/his voice changed. Staff 36 stated when she/he heard Resident 135's voice change she/he headed to Resident 135's room but it was too late, and Resident 135 pushed Resident 68. Resident 68 was not upset and was not hurt. On 9/5/25 at 1:08 PM Staff 11(LPN Resident Care Coordinator) stated Resident 68 wandered, and on 8/28/25 she/he wandered into Resident 135's room. Staff 11 acknowledged the care plan directed staff to be in close proximity when Resident 135 was with other residents.

Based on observation and interview it was determined the facility failed to post complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information. Findings include:Observations of the Direct Care Staff Daily Reports (DCSDR) from 9/2/25 through 9/8/25:-On 9/3/25 at 7:00 AM, the DCSDR posted was dated 9/2/25. It did not include evening or night shift staff numbers or hours,-On 9/4/25 at 7:11 AM, the DCSDR posted was dated 9/3/25. It did not include evening or night shift staff numbers or hours,-On 9/5/25 at 6:07 AM, the DCSDR posted was dated 9/4/25. It did not include evening or night shift staff numbers or hours,-On 9/8/25 at 6:45 AM, the DCSDR posted was dated 9/7/25. It did not include evening or night shift staff numbers or hours, On 9/9/25 at 8:16 AM, 10:34 AM and 11:04 AM Staff 2 (DNS) stated they needed to improve the timing of documenting evening shift and night shift information on the DCSDR.

Based on interview and record review it was determined the facility failed to document and conduct a Significant Change MDS assessment within the required timeframe for 1 of 5 sampled residents (#118) reviewed for nutrition. This placed residents at risk for unassessed needs. Findings include: Resident 118 admitted to the facility in 2023 with diagnoses including diabetes, pressure ulcer and dementia. A 9/13/24 Admission MDS revealed Resident 118's BIMS score was 15 which indicated she/he was cognitively intact. There were no concerns with Resident 118's mood and she/he did not have any behaviors. Resident 118 was frequently incontinent of bowel and had occasional pain presence with PRN pain medications. Resident 118 had one Stage 3 (a deep wound that has broken through the top two layers of skin into the fatty tissue) pressure ulcer and moisture associated skin breakdown. Medications administered to Resident 118 included insulin and antidepressants. A 3/13/24 Quarterly MDS revealed Resident 118's BIMS was nine which indicated moderate cognitive impairment. Resident 118 felt down, depressed or hopeless two to six days during the look back period. Behaviors included physical symptoms towards others such as hitting or kicking, verbal behaviors such as threatening others, and behavioral symptoms not directed toward others such as pacing. Resident 118 also rejected care one to three days. Resident 118 was always incontinent of bowel. Pain levels were frequent pain with scheduled and PRN pain medications with a pain presence of eight on a one to 10 scale. Resident 118 had one Stage 4 (a deep wound that impacts muscle, tendons, ligaments, and bone) pressure ulcer and moisture associated skin breakdown. Medications administered to Resident 118 included insulin, antipsychotic, antianxiety, anticoagulant, and opioid medications. There was no documentation found in Resident 118's clinical records to indicate a significant change assessment was considered or ruled out. On 5/3/24 at 7:35 AM Staff 21 (RCM) stated she did not know why a significant change assessment was not completed for Resident 118.

Based on interview and record review it was determined the facility failed to timely investigate abuse for 1 of 3 sampled residents (#38) reviewed for abuse. This placed residents at risk for abuse and neglect. Findings include: Resident 38 admitted to the facility in 2018 with diagnoses including panic disorder, dementia, and PTSD (Post-Traumatic Stress Disorder). Resident 141 admitted to the facility in 2024 with a diagnosis of Alzheimer's Disease. An 4/4/24 Investigation revealed an investigation timeframe 4/4/24 through 4/10/24. On 4/4/24 while Resident 38 was on a video call with Witness 1 (Family Member) Resident 141 was sitting next to Resident 38 and reached over and rubbed Resident 38's chest area. Witness 1 stated Keep your hands to yourself. The facility determined sexual abuse was substantiated. On 5/3/24 at 8:57 AM Staff 21 (RCM) confirmed the investigation was not completed timely. Refer to F600

Based on interview and record review, it was determined the facility failed to ensure residents were free from sexual and physical abuse for 2 of 5 sampled residents (#s 38 and 108) reviewed for abuse by Resident 139 and Resident 141. This placed residents at risk for abuse. Findings include: 1. Resident 38 admitted to the facility in 2018 with diagnoses including panic disorder, dementia, and PTSD (Post-Traumatic Stress Disorder). Resident 141 admitted to the facility in 2024 with a diagnosis of Alzheimer's Disease. An 10/11/23 Annual MDS indicated Resident 38 was rarely understood. An 4/4/24 Investigation revealed on 4/4/24 while Resident 38 was on a video call with Witness 1 (Family Member), Resident 141 was sitting next to Resident 38 and reached over and rubbed Resident 38's chest area. Witness 1 stated, Keep your hands to yourself. Staff moved Resident 38 into her/his wheelchair to the nurses' station to complete the video call. Resident 141 was escorted back to her/his unit. The facility substantiated sexual abuse. On 5/1/24 at 10:10 AM Witness 1 stated Resident 38 was seated in a recliner while engaged in a video call with her. Witness 1 stated she saw a hand and forearm reach across and touch Resident 38's chest and was rubbing the area. Witness 1 yelled at Resident 141 and Resident 141 quit. On 5/2/24 at 7:49 AM Staff 17 (CNA) stated she was in a resident's room and Resident 141 was sitting next to Resident 38. Staff 17 stated she heard Witness 1 state leave [her/him] alone. Resident 141 touched Resident 38's chest two times. Staff 17 stated she stood between the two recliners until Resident 38 could be removed from the area. On 5/3/24 at 8:57 AM Staff 21 (RCM) confirmed the facility substantiated sexual abuse by Resident 141 to Resident 38. 2. Resident 108 admitted to the facility in 2024 with diagnoses including depression. Resident 139 admitted to the facility in 2023 with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, and PTSD (Post-Traumatic Stress Disorder). A 2/15/24 care plan indicated Resident 108 had a history of trauma to remain safe and stable. A 2/22/24 Annual MDS indicated Resident 108 had a BIMS score of 11 indicating moderate cognitive impact. A Nurse's Note on 4/17/24 at 8:30 PM indicated Resident 108 was struck by a thrown object on the side of her/his face. No injuries were identified on Resident 108, and the staff would continue to monitor her/him for any abnormalities. An 4/18/24 Investigation report revealed on 4/18/24 (incident occurred 4/17/24) around 7:30 PM Resident 139's behaviors escalated, she/he went into the kitchen and picked up a hand-held game in its packaging. Resident 139 threw the game into Resident 108's room and struck Resident 108 on the left side of her/his face. On 5/2/24 at 7:31 AM Staff 15 (CNA) stated around 7:30 PM on 4/17/24 she witnessed Resident 139's behaviors escalate, and she/he was upset. Resident 139 was yelling, Resident 108's door was open, and Resident 139 threw a handheld game into the room. Staff 15 went into the room and Resident 108 stated the game hit her/him in the face. On 5/1/24 at 12:21 PM Staff 14 (CNA) stated on 4/17/24 he observed Resident 139 pick up a hand-held game and throw it into Resident 108's room. Staff 14 stated he heard a sound of impact and Resident 108 reported to him that she/he was struck in the head by the game. Staff 14 did not get a chance to observe Resident 108's head at the time as he was attempting to keep other residents safe from 108's behaviors. On 5/3/24 at 8:54 AM Staff 40 (RCM) stated the facility did not substantiate abuse during the investigation. The facility determined Resident 139's PTSD was triggered, and she/he was agitated and did not believe Resident 139 was aware of her/his actions.

Based on interview and record review it was determined the facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) for 1 of 1 sampled resident (#248) reviewed for notices. This placed residents at risk for lack of appeal information. Resident 248 was admitted to the facility in 2024 with diagnoses including heart attack and dehydration. A NOMNC documented the last covered day as 4/3/24. The NOMNC was signed by Resident 248 on 4/2/24. On 5/2/24 at 2:44 PM Staff 4 (Social Services Designee) confirmed the notice was not provided in the required timeframe to Resident 248.

Based on interview and record review it was determined the facility failed to notify a resident's physician of a change in condition for 1 of 3 sampled residents (#36) reviewed for UTIs. This placed residents at risk for delayed treatment. Findings include: Resident 36 admitted to the facility in 2021 with a diagnoses including dementia, urinary retention, and an irregular heart beat. A 2/2024 annual CAA indicated Resident 36 had a diagnosis of dementia, was able to communicate, transfer to the toilet, and was incontinent of urine. Resident 36's 3/2024 MAR revealed she/he was administered a blood thinner daily. Progress Notes revealed the following: -2/24/24 Resident 36 was observed to have small amounts of red-tinged urine during her/his incontinent care. The resident denied pain or painful urination. The not indicate the resident would be monitored. There was no indication Resident 36's physician was notified of the red-tinged urine. -2/25/24 Resident 36 did not have red or pink-tinged urine or discharge. -2/26/24 through 3/8/29 revealed Resident 36's urinary status was not assessed. -3/9/24 at 5:46 PM a note by Staff 23 (Agency RN) indicated the resident continuously took her/himself to the bathroom. Resident 36 reported a stomach ache at approximately 2:30 PM and was administered an antacid which was noted to be effective. The resident was also noted to have a small amount of blood on her/his incontinent brief and genitalia. Resident 36 reported she/he had to pee every time. Staff were to monitor the resident. There was no indication Resident 36's physician was notified of the blood, abdominal pain, or frequent urination. -3/10/24 at 7:11 AM a note revealed Resident 36 reported stomach cramping which was alleviated with PRN medication. -3/10/24 at 11:13 AM revealed Resident 36 had severe abdominal pain, was shaking, and crying. The note indicated the pain could be from bowel care. The resident's physician was not able to be reached and the resident was transported to the hospital. A 3/12/24 hospital Orders At Discharge form revealed the resident was admitted to the hospital on 3/10/24 and was diagnosed with urinary retention, UTI with hematuria (blood in urine), and sepsis (potentially life-threatening complication of an infection) with sudden onset of kidney failure without septic shock (a serious condition when the body does not respond to an infection which causes a dramatic drop in blood pressure that can damage other organs). On 5/1/24 at 12:30 PM Staff 23 stated at times when a resident had symptoms of a UTI it was difficult for staff to obtain orders from the physician for UAs. Staff 23 stated she did not recall the note she wrote on 3/9/24, would review the note, and provide additional information if able. No additional information was provided. On 5/2/24 at 3:00 PM Staff 32 (LPN) stated if a resident had blood in her/his urine it could be signs of a UTI. Staff should also look at the medications the resident was administered and if the resident was on a blood thinner it could be related to the medication and the physician should be notified. The physician may or may not order a UA or other labs but staff should still notify the physician. On 5/2/24 at 4:33 PM Staff 2 (DNS) reviewed Resident 36's clinical record and stated during 2/24/24 through 3/8/24 she was not able find information to indicate Resident 36's physician was notified of the blood on the genitalia on 2/24/24 or 3/9/24. Staff 2 acknowledged the resident's blood could have been from the blood thinner or a possible UTI. Staff 2 stated she would provide documentation if Resident 36's physician was notified. No additional information was provided.

Based on interview and record review it was determined the facility failed to provide risk and benefits for the use of an antipsychotic medication to a resident/responsible party before administration and communicate changes in ROM services for 2 of 6 sampled residents (#s 80 and 118) reviewed for medications and positioning. This placed residents and responsible parties at risk for lack of appropriate information. Findings include: 1. Resident 80 admitted to the facility in 2020 with diagnoses including multiple sclerosis (disease of the central nervous system) and degeneration of the spine. A 1/10/24 Restorative Assessment and Referral indicated to utilize a standing frame (a device which allows an impaired individual to stand) for Resident 80 three times each week for 10 minutes for improved quality of life. Precautions required two staff present for set-up and one staff present during standing. A 2/29/24 revised Restorative Assessment and Referral indicated Resident 80 was to direct the frequency of the use of the standing frame. A 3/6/24 revised Task indicated staff were to facilitate Resident 80's ability to stand in the standing frame as needed for improved quality of life. On 4/25/24 and 4/27/24 the document indicated Resident 80 refused the standing frame and the task was not offered any additional days from 4/3/24 through 5/2/24. A 3/12/24 Interdisciplinary Care Conference indicated assistance would be provided to Resident 80 to have access to the standing frame per her/his request. Staff 5 (Resident Care Manager) was not in attendance. On 4/29/24 at 11:03 AM Resident 80 stated facility staff were to provide assistance to allow her/him to be in the standing frame three days each week, but the therapy was no longer offered by staff. On 5/1/24 at 9:01 AM Staff 12 (CNA) stated because Resident 80's standing frame task was PRN, staff no longer provided the standing frame service unless she/he asked. On 5/2/24 at 12:28 PM Staff 5 stated Resident 80 was able to advocate for herself/himself and could ask to use the standing frame. On 5/2/24 at 2:53 PM Resident 80 stated she/he was not aware she/he needed to ask staff to provide the standing frame service since the service was routine in the past. Resident 80 stated she/he only refused the standing frame services when she/he was too tired. On 5/3/24 at 9:42 AM Staff 2 (DNS) stated she trusted Resident 80's statement if she/he indicated she/he was not notified of the changes to her/his standing frame services. Staff 2 stated Resident 80 should be informed when changes were made to her/his therapy service plan. 35855 2. Resident 118 admitted to the facility in 2023 with diagnoses including bipolar disorder (mental illness with extreme mood swings) and dementia. A 3/11/24 signed physician order instructed staff to administer 50 mg Seroquel (an antipsychotic used to treat bipolar disorder) one time a day for bipolar disorder at bedtime with a start date of 2/29/24, and discontinue date of 3/18/24. Seroquel was increased on 3/19/24 to 100 mg two times a day in the morning and evening. An 4/2024 MAR instructed staff to administer 100 mg Seroquel two times a day for bipolar disorder and hold if blood pressure was 90/60 or she/he was overly drowsy with a start date of 4/18/24. No documentation was found in clinical records that risk and benefits were provided to Resident 118's responsible party and no consent was received for use of Seroquel. On 5/2/24 at 10:59 AM Staff 22 (Assistant DNS) confirmed consent was not received for use of Resident 118's Seroquel.

Based on interview and record review it was determined the facility failed to develop a sufficient grievance policy and a timely grievance response for 1 of 4 sampled resident (#128) reviewed for activities. This placed residents at risk for unaddressed concerns and grievances. Findings include: A 12/2023 revised facility Grievances policy indicated staff were to assist residents with the grievance process, a resolution to a grievance was as soon as possible, and the policy did not indicate a reasonable expected timeframe for the facility to complete the review of grievances. The facility policy neglected to include that a resident had the right to file a grievance orally or anonymously and obtain a written decision. An 4/12/24 hand-written letter from Resident 128 to Staff 6 (Recreation Director) indicated dissatisfaction with recent rule changes to a game activity because of her/his skills for the game. The letter also indicated activity staff were prejudice against Resident 128. On 4/29/24 at 10:00 AM Resident 128 stated she/he filed a complaint about activities and received no communication about her/his concerns since the letter was written (15 days ago). On 5/1/24 at 10:09 AM Staff 3 (Assistant Administrator) stated he (the Grievance Officer) did not read Resident 128's letter until 4/28/24. Staff 3 stated Staff 8 (Social Service Designee) observed Resident 128's letter on 4/12/24 when Resident 128's letter was shared by Staff 6. Staff 3 stated there was a delay in response to Resident 128 due to a team effort to determine the best way to handle information in the letter. On 5/1/24 at 12:43 PM Staff 8 stated he believed Resident 128's 4/12/24 letter was written to express her/his feelings and Staff 8 did not consider the letter a grievance because it was not on the grievance form. On 5/1/24 at 4:40 PM and 5/3/24 at 10:39 AM Staff 3 indicated a late conversation with Resident 128 regarding her/his concerns with activities was conducted on 5/1/24 and the facility Grievance policy was insufficient when updated in 12/2023.

Based on interview and record review it was determined the facility failed to ensure treatments and services related to wound care were provided for 2 of 3 sampled residents (#s 1 and 3) who had pressure injury wounds. Resident 1 developed an unstageable pressure injury with resultant [CONDITION(S)] (occurs when the body's response to an infection damages its own tissues) and [CONDITION(S)] (bone infection) and required hospitalization . Findings include: 1. Resident 1 was admitted to the facility in ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's wound Care Plan, last updated on [DATE] revealed the resident was at risk for actual skin impairment/pressure ulcer related to immobility, atrophy (wasting away) of muscles and polyneuropathy (nerve damage). The Care Plan indicated updates as follows [DATE]: Unstageable wound to right heel, [DATE]: Stage 3 right buttock and [DATE]: right heel unstageable with eschar (dry, dark scab). All wound care interventions, including methods of pressure relief, pain, referral to dietitian and wound referral were last updated on [DATE]. A [DATE] PN (Progress Note) indicated Resident 1 had a right heel wound identified as a deep tissue decub (DTPI - Deep Tissue Pressure Injury: intact or non-intact skin with localized area of persistent non-blanchable [discoloration of the skin that does not turn white when pressed], deep red, maroon, purple discoloration or [MEDICATION(S)] [thin outer layer of the skin] separation revealing a dark wound bed or blood filled blister). An [DATE] PN indicated the right heel wound worsened and Resident 1 stated her/his heel does not bother [her/him] much and she/he can not feel [her/his] feet too much. An [DATE] PN revealed Staff 8 (Facility Physician) documented Resident 1 had a pressure lesion of the right heel, treated with dressings and weight offloading (pressure reduction). Staff 8 indicated the resident had a 7 cm black scab with local [CONDITION(S)] (redness) and warmth. Staff 8 ordered X-rays to look for osteomeylitis (bone infection), a wound clinic consult and antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] An [DATE] VA (Veteran's Administration) After Visit Summary from the wound clinic included new right heel wound care orders. The summary indicated Resident 1 required a [NAME] (Peripheral Artery Exam: determines blood supply to lower extremities), X-rays, lab tests and instructions for bathing: Ok to shower off the (right foot) wound in the shower as long as the foot does not touch the bottom of the shower. The resident's Care Plan revealed no update with the wound clinic instructions to ensure the resident's foot did not touch the floor of the shower while bathing. A [DATE] VA Nursing Outpatient Note included updated wound care orders and results of the right heel X-ray. The [DATE] X-ray findings indicated early [CONDITION(S)] is not excluded. A [DATE] VA Nursing Outpatient Note described Resident 1's right heel wound as an Unstageable PI (Full-thickness skin and tissue loss, extent of tissue damage within the ulcer cannot be confirmed because it is covered by slough [yellow/white material] or eschar [dry, dark scab or loose dead skin]). According to a [DATE] PN facility staff contacted the VA wound clinic about the status of the resident's right heel wound and orders were provided for antibiotic treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] VA Wound Care PNs indicated Resident 1's right heel wound was examined and required debridement (removal of damaged or dead tissue). The PN revealed the wound was now 1.2 cm deep (increased from 0.1 cm on [DATE]) and when probed with a cotton swab it went close to the bone. X-rays results were consistent with [CONDITION(S)] of the heel, near the heel wound and new from when compared to the prior X-ray exam on [DATE]. The [DATE] VA wound care PNs indicated Resident 1 had a [NAME] completed on her/his lower extremities. On [DATE] wound care physician documented: Based on this study, the wound should have adequate arterial (blood) flow to close. The physician indicated more of a concern is probably [CONDITION(S)] impairing wound healing. According to [DATE] VA wound clinic PNs the resident's right heel wound continued to have a lot of dead tissue needing debridement. The PNs included updated wound care instructions and repeated the instructions it was OK to shower off the wound in the shower as long as (the resident's) foot does not touch the bottom of the shower. The PNs revealed a bone biopsy was scheduled to confirm the presence of [CONDITION(S)] in the right heel bone. The Care Plan revealed no update regarding the shower instructions to ensure the resident's right foot did not touch the floor. On [DATE] VA wound clinic PNs revealed Resident 1's right heel wound was debrided and a bone biopsy of the heel bone was done. Wound care orders were updated and a wound VAC (vacuum-assisted closure of wounds) was added to the wound treatment. The [DATE] VA Infectious Disease PNs indicated a video Telehealth consult was held with Resident 1, Staff 9 (LPN) and Staff 4 (Social Services). The VA physician revealed the findings of the right heel bone biopsy were consistent with [CONDITION(S)]. Staff 9 confirmed the facility could provide support for IV (intravenous) therapy with a PICC (peripherally inserted central catheter) line. The physician documented it makes sense to treat this aggressively with antibiotics and ordered placement of a PICC line to administer IV antibiotics for six weeks and an oral antibiotic twice a day for seven weeks. A follow-up wound care appointment in four to six weeks would be scheduled. On [DATE] Staff 4 documented a PN indicating she was contacted by the VA Infectious Disease staff and the physician ordered a PICC line and oral antibiotics to treat suspected bone infection. Staff 4 noted a STAT (immediate) consult was submitted requesting VA authorization for the PICC line placement at the local hospital. On [DATE] the VA Infectious Disease physician provided the facility with updated orders for Resident 1's wound care treatment, including: -IV antibiotics start date: [DATE], stop date: [DATE]. -Oral antibiotics start date: [DATE], stop date: [DATE]. -Lab orders to be completed weekly. -Facility to provide weekly PICC line care. An [DATE] PN revealed the wound VAC was discovered off Resident 1's right heel wound and the dressing had heavy saturation that soaked the resident's bedding. The wound was noted to have extreme odor and the area around the wound was macerated (occurs when skin is exposed to moisture for too long) with the skin peeling off. Redness and warmth was noted to the right foot up to the mid-calf and the physician was notified. From [DATE] through [DATE] there was no documentation regarding the delayed placement of the PICC line or administration of the IV and oral antibiotics ordered on [DATE]. The medical record revealed no documentation the VA wound clinic or the family was notified. According to an [DATE] PN Staff 5 (RN Resident Care Manager) documented the infusion center was called on [DATE] to request an appointment for Resident 1's PICC line insertion. The infusion center called to confirm an appointment on [DATE] at 1:30 PM and transportation was notified. On [DATE] Staff 5 documented in the PNs that antibiotic orders were faxed to the pharmacy to be delivered prior to the PICC line insertion on [DATE]. Staff 4 was notified of the need to ensure the procedure authorization was transferred to the local infusion center. The PNs on [DATE] revealed Resident 1's PICC line was not placed because the transport vehicle was unable to accommodate her/his electric wheelchair. The medical record revealed no documentation of notification to the wound clinic regarding Resident 1's status including the failure to facilitate placement of the PICC line for administration of IV and oral antibiotics ordered on [DATE]. On [DATE] at 2:14 AM Staff 5 documented a PN that indicated she received a message Resident 1 was unable to get [her/his] wheelchair into the van and the transportation service would follow-up and reschedule the appointment as soon as possible. According to the [DATE] VA wound clinic PNs, during Resident 1's follow-up appointment the ,d+[DATE] facility MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was called to find out more information and the documentation indicated the facility responded they did not receive the orders for IV medication administration or the PICC line and the wrong transportation came to pick up the resident for an appointment to place the PICC line. The [DATE] VA wound clinic PNs included an assessment of Resident 1's right heel wound: the skin around the wound was described as boggy (spongy texture), macerated and there was a new lesion over the Achilles tendon about 1 cm in diameter. The wound bed was described as: 100% gray and yellow boggy liquefacted necrotic tissue (a liquid viscous mass). The odor of the wound could be smelled outside the door of the room. Measurements of the wound revealed it was 8 cm in length, 5 cm in width and was 1.5 cm deep increased from 5 cm in length, 3.5 cm in width and 0.8 cm deep on [DATE]. The [DATE] wound clinic PNs revealed the physician documented Resident 1's right heel wound had greatly worsened since last visit and it was due to not receiving antibiotics after debridement and biopsy on [DATE]. The physician indicated the healing ability of the wound was poor - high risk of amputation and Resident 1 was informed of need for hospitalization today. The physician notified Witness 2 (Family) of Resident 1's status and informed him the resident was immediately seen by the surgeon, directly admitted to the hospital and is receiving the IV antibiotics [she/he] needs to save [her/his right] leg. A facility PN dated [DATE] at 2:55 PM indicated the resident went to her/his VA wound care appointment and would be admitted to the hospital due to the failure to get the PICC line placed. On [DATE] VA Discharge information revealed Resident 1's right heel wound was debrided on [DATE] and the tendon and bone were exposed and there was necrotic tissue scattered throughout the wound bed. No measurements of the wound were taken due to the goal was palliative with possible hospice care. PNs revealed Resident 1 returned to the facility on [DATE], she/he was admitted to hospice services and subsequently died on [DATE]. On [DATE] a public complaint was received that alleged there was negligence which resulted in Resident 1's death. The complaint indicated the resident went to the VA wound clinic on [DATE] and physicians determined the right heel wound had significantly worsened and the resident developed [CONDITION(S)] (occurs when the body's response to an infection damages its own tissues). The complaint further alleged the wound clinic was not contacted when the facility failed to administer antibiotics ordered on [DATE]. On [DATE] at 4:30 PM Witness 1 (Complainant) stated he became aware of Resident 1's right foot wound infection when he was at the facility on [DATE] and a nurse showed him the wound and he could smell the odor. Witness 1 stated on [DATE] he visited the resident who told him about not getting the PICC line placed. Witness 1 said he requested a copy of the facility's investigation related to what occurred when Resident 1 did not get the PICC line or the antibiotics. Witness 1 stated he received a document that was a timeline of the events that occurred and it was not an investigation. On [DATE] Staff 6 (Assistant Administrator) sent an email to Witness 1 regarding setting up a meeting with family and facility staff. Staff 6 indicated Staff 7 (Facility Physician) revealed she did not closely follow Resident 1's wound care because it was referred out to the wound clinic. On [DATE] at 12:04 PM Staff 4 stated there was confusion about the PICC line and where the resident could receive the services. Staff 4 indicated after the appointment was confirmed with the correct provider the resident was unable to make it to the appointment because she/he was unable to access the transportation vehicle. Staff 4 stated no one, including the VA wound clinic was notified regarding the failure to get the PICC line placed. Staff 4 stated if a resident was their own responsible party the facility was not obligated to notify family. On [DATE] at 12:42 PM Staff 5 stated Staff 4 was responsible for ensuring the appointment for the PICC line placement was set up. Staff 5 stated there was confusion with the antibiotic orders that required clarification and there were problems with where the PICC line could be placed. Staff 5 indicated no one was notified when the PICC line was not placed and she was not aware of anyone who would have received a call from them. On [DATE] at 6:58 PM Witness 2 (Family) stated he was not contacted by the facility regarding Resident 1's care needs, the status of her/his left heel wound or the problems with placing the PICC line and giving antibiotics for a bone infection. Witness 2 further stated he was never notified or invited to care plan meetings with the resident. Witness 2 indicated it was the VA wound clinic who notified him that the wound worsened after not receiving the antibiotics. During interviews on [DATE] at 3:26 PM and [DATE] at 3:27 PM Staff 9 (LPN) acknowledged on [DATE] she confirmed the facility was able to care for a PICC line for the resident during the meeting with the VA Infectious Disease physician. Staff 9 indicated it was appropriate to notify the wound clinic if there were problems with the resident's wound. Staff 9 revealed she was still learning about wound care and did no wound care prior to working at the facility. On [DATE] at 4:00 PM this surveyor made a second request to Staff 2 (DNS) for the investigation completed related to Resident 1 not receiving the PICC line and antibiotics. Staff 2 stated the investigation was not completed and she was still collecting information. On [DATE] at 3:00 PM Staff 2 provided a document titled [Resident 1's last name] confidential quality assurance review. Staff 2 stated this was the facility's response for a requested investigation related to what occurred with the resident not receiving a PICC line and antibiotics. The documentation consisted of facility PNs and information from the VA wound clinic from [DATE] through [DATE]. The documentation included no staff interviews or conclusions to determine causative factors. On [DATE] at 4:02 PM Staff 10 (CNA) revealed she cared for Resident 1 and was not aware of any special instructions when giving her/him a shower. Staff 10 stated staff used a lift to place him on the shower chair and there were no special instructions for the right heel wound during showers. Resident 1's Death Certificate, dated [DATE], revealed the Immediate cause of death was [CONDITION(S)] due to [CONDITION(S)] of right heel and non-healing heel ulcer. On [DATE] at 2:18 PM Staff 13 (LPN) indicated she cared for Resident 1's wound and noted the wound changed over time and the wound clinic was doing debridements. Staff 1 stated she would have contacted the wound clinic for any questions regarding the wound. On [DATE] at 10:30 AM Staff 14 (RN) acknowledged he cared for the resident's right heel wound and utilized the wound VAC. Staff 14 stated he did not have much wound care training and followed what other nurses did. Staff 14 confirmed he was present on [DATE] when the resident was unable to access the transport vehicle to have the PICC line placed. Staff 14 stated the infusion center called and said they had to cancel the resident's appointment. On [DATE] at 2:18 PM Staff 11 (CNA) acknowledged providing Resident 1 with bathing assistance and indicated it required two staff. Staff 11 revealed the resident's feet touched the floor of the shower when she/he was placed in the shower chair. Staff 11 was not aware of the instructions from the wound clinic for keeping the resident's feet off the floor of the shower. On [DATE] at 2:32 PM Staff 12 (CNA) stated she helped with the resident's showers and she was not aware of the wound clinic instructions to keep her/his feet from touching the floor. In an interview on [DATE] at 2:39 PM Staff 4 revealed a VA community care member communicated incorrect information about the PICC line needed causing confusion about where the procedure could be provided. Staff 4 stated she thought it was on [DATE] when she was notified regarding the inability to place the PICC line at the local infusion center. Staff 4 did not think this was documented in the resident's record. Staff 4 stated she did not know who talked to the wound clinic on [DATE] and reported no orders were received for the PICC line or antibiotic orders. On [DATE] at 11:43 AM Staff 5 indicated she was unaware of who talked to the wound clinic on [DATE] and reported the facility did not receive orders for the PICC line and antibiotic orders. Staff 5 stated she was not aware of the wound care instructions to keep the resident's feet off the floor in the shower or that it was not added to the Care Plan. On [DATE] at 3:00 PM in an interview with Staff 1 (Administrator), Staff 3 (Assistant DNS) and Staff 6 (Assistant Administrator) the preliminary results of the complaint survey were reviewed. Findings related to failure to ensure treatments and services were carried out as ordered and ensure other entities and family were notified appropriately were discussed with Staff 1, Staff 3 and Staff 6. No additional information was received. 2. Resident 3 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] wound clinic notes revealed Resident 3 had bilateral Stage 2 (partial-thickness skin loss with exposed dermis [the thick layer of living tissue below the skin]) wounds on her/his buttocks. An [DATE] Wound Clinic After Visit Summary indicated Resident 3 received care for the Stage 2 wounds on her/his buttocks. A physician's [DATE] 60 day visit indicated the resident's wounds were followed by wound care and were improving. On [DATE] the wound clinic documented updated specific wound care to the resident's bilateral buttocks wounds. A [DATE] Wound Clinic After Visit Summary indicated the resident was seen for the pressure ulcers of the buttocks. There was no descriptive documentation of the wounds. The summary included a note: OK to cancel [DATE] visit if healed. Weekly Skin and Wound Evaluations on [DATE] did not indicate the resident's bilateral buttock wounds were healed. The resident's medical record did not include documentation of Wound Clinic visits after [DATE]. An [DATE] physician's progress note revealed the last wound clinic visit for Resident 3's Stage 2 pressure injuries to her/his bilateral buttocks was on [DATE]. The physician documented they asked RCM (Resident Care Manager) to reschedule a wound clinic appointment. The resident's medical record revealed the physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] the resident's medical record revealed no documentation of a wound care visit for her/his bilateral buttocks pressure injuries as ordered on [DATE]. During an interview on [DATE] at 1:03 PM Staff 15 (RN Resident Care Manager) acknowledged Resident 3 was not seen by the wound clinic since [DATE]. Staff 15 stated she would have the resident's Resident Care Manager check for current Wound Clinic information. On [DATE] at 1:34 PM Staff 16 (RN Resident Care Manager) reviewed the resident's wound care information with this surveyor. Staff 16 acknowledged she needed to check for the Wound Clinic referral and follow up with staff to schedule an appointment for the resident.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 4 sampled residents (#4) reviewed for abuse and resident rights. Resident 4 experienced psychosocial harm as a result of the abuse. Findings include: Resident 4 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/22/21 Admissions MDS revealed Resident 4's cognition was moderately impaired with a BIMS score of eight out of 15. The 4/2/21 updated care plan revealed Resident 4 was on hospice, incontinent of bowel and bladder and conversations were to be intitiated before ADL care was provided. Review of a FRI form dated 4/17/21 revealed on 4/16/21 Staff 44 (Licensed Nurse) administered a suppository and performed digital stimulation (a method of stimulating a bowel movement by inserting a gloved finger into the rectum) without asking Resident 4's permission or explaining the procedure. Resident 4 verbalized stop your hurting and killing me. On 7/1/21 at 4:30 PM Staff 15 (CNA) stated on 4/16/21 she was asked by Staff 44 to help turn and hold Resident 4 to her/his right side in the resident's bed. Staff 15 stated Staff 44 inserted a suppository into Resident 4's rectum and did not tell Resident 4 what he was about to do before or during the procedure. Staff 15 explained the resident asked Staff 44 to stop and had facial expression of pain during the procedure. On 7/1/21 at 4:32 PM Staff 14 (CNA) stated on 4/16/21 she went into Resident 4's room soon after the suppository was given to Resident 4. Staff 44 returned to the room and performed digital sitmulation without lubrication to the glove or an explanation of the procedure to Resident 4. Staff 14 stated blood was present on Staff 44's glove after the procedure and Resident 4 stated it hurts and your raping me. Staff 14 added Resident 4 could not sleep that night and had increased agitation. The 4/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No further lorazepam was administered until 4/27/21 which was a day before her/his passing. On 7/13/21 at 11:16 AM Staff 4 (Social Services Designee) stated she was not involved in the investigation but stated an increased use of lorazepam for a resident after an incident of that kind indicates something was wrong. On 7/15/21 at 11:41 AM Staff 45 (CNA) stated Resident 4 was more agitated and jerky during care after the incident on 4/16/21. A 4/19/21 nursing progress note revealed Resident 4 showed signs of distress during routine brief changes and stated her/his butthole was burning even though no bowel movement took place. A 4/20/21 nursing progress note revealed Resident 4 was nervous, shaky, and scared during brief change. On 7/20/21 at 2:26 PM Staff 2 (DNS) stated Staff 44 admitted he did not stop the digital stimulation when Resident 4 asked him to stop.

Based on interview and record review it was determined the facility failed to follow physician's orders for 2 of 3 sampled residents (#s 1 and 2) reviewed for following physician's orders. Resident 1's wound became infected and required acute care intervention. Findings include: 1. Resident 1 admitted to the facility in 2/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/24/21 admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/24/21 Nursing Admission Assessment indicated Resident 1 had a dressing to her/his left foot on admission from a left great toe amputation. The resident's 3/1/21 care plan indicated the resident had a wound and wound care was to be done per physician's orders. A review of the 2/2021 and 3/2021 TAR revealed wound care was provided as ordered from 2/24/21 through 3/11/21. According to Resident 1's electronic medical record, she/he was admitted to the hospital from 3/12/21 through 3/25/21 for reasons unrelated to the wound. A 3/25/21 Hospital Discharge Summary noted skin healing nicely at left great toe. The Summary instructed staff to continue wound care to left big toe. The 3/25/21 Nursing Re-Admission Assessment indicated Resident 1 had no wounds or skin concerns. There was no documentation related to the left great toe. A review of the 3/2021 and 4/2021 TAR revealed no entries related to wound care from 3/12/21 through 4/2021. The only documentation related to Resident 1's wound was a 4/3/21 progress note which indicated the resident had a shower and the dressing to her/his left foot was saturated. The note revealed the nurse was unable to locate wound care orders in the resident's chart so she used supplies she found in the resident's room to redress the wound. The note further revealed the skin around the wound was macerated (soft, wet or soggy to the touch). The last progress note in Resident 1's electronic medical record was on 4/6/21 and revealed the resident had a medical appointment the following day, 4/7/21. The resident discharged on [DATE] with no further documentation. A 4/7/21 hospital General Surgery Admission History and Physical revealed the resident was admitted to the hospital for wound breakdown with exposed bone and required a revision (an additional surgical amputation of a limb after skin closure) of the great left toe amputation. On 7/16/21 at 1:56 PM Witness 11 (Family Member) reported when she brought the resident to her/his surgical follow up appointment, it was determined the wound was infected. She reported she called the facility immediately to ask when the last time the wound was addressed and the nurse could not answer. On 7/19/21 at 4:54 PM Staff 46 (Licensed Nurse) reported when the resident returned from the hospital the wound care orders went wrong and the family moved the resident to another facility. On 7/19/21 at 6:53 PM Staff 47 (Licensed Nurse) reported wound care orders were not present when Resident 1 returned from the hospital in 3/2021. He stated during that time there was not consistent nursing staff working on the unit to recall the resident had a wound prior to her/his hospitalization . On 7/20/21 at 12:41 PM Staff 19 (Licensed Nurse) reported the resident's daughter called her from the resident's surgical follow up appointment and informed her the wound was mushy. Staff 19 stated she was on a different unit since before Resident 1 went to the hospital in 3/2021 and did not know anything about her/his wound care. Staff 19 reported the day Resident 1 went to the appointment with her/his daughter was her first day back on the unit. She stated she did not change the resident's dressing on that day. On 7/20/21 at 2:22 PM Staff 5 (RCM) reported Resident 1's wound was not healed when she/he returned from the hospital. She stated there were pieces missed with the re-admission process and the resident's missing wound care orders were not identified. Staff 5 confirmed the resident did not receive wound care after returning to the hospital on 3/25/21 except for the one time noted in the progress notes on 4/3/21. 2. Resident 2 admitted to the facility in 4/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A 4/14/21 physician's order instructed staff to administer one liter of normal saline via IV (intravenous). A review of the resident's 4/2021 MAR/TAR did not reveal documentation related to the fluid administration. A 4/15/21 Physician Visit note revealed Resident 2 had a fever, was unresponsive and appeared dehydrated. The resident was sent to the Emergency Department. On 7/16/20 at 12:30 PM Staff 2 (DNS) confirmed Resident 2 did not receive the IV fluids the physician ordered.