Every finding on record at Majora Lane CTR for Rehab & NSG Care Inc

Based on medical record review, Self-Reported Incident review, witness statements, policy review, and interview, the facility failed to ensure staff immediately reported an allegation of mistreatment to the Administrator. This affected one (Resident #27) of four residents reviewed for abuse and had the potential to affect all 14 residents (#2, #6, #7, #8, #9, #17, #20, #26, #27, #28, #29, #30, #34, and #47) who resided on the Speret hall (the secured memory care unit) whom the alleged perpetrator cared for. The census was 52. Findings include: Review of the medical record for Resident #27 revealed an admission date of 01/31/26 with diagnoses of dementia without behavioral disturbance, neurocognitive disorder with Lewy bodies, anxiety, fracture of femur, depression, and anemia. Resident #27 resided on the secured-memory care unit. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #27 was severely cognitively impaired, had physical behaviors four to six days during the assessment, rejected care one to three days during the assessment and required substantial/maximal assistance with all activities of daily living except eating. Review of the Self-Report Incident #274881 dated 05/23/26 revealed one aide alleged that another aide was sometimes rough with care and tone when she spoke to residents. The category of allegation/suspicion was physical abuse and emotional/verbal abuse. The alleged perpetrator was Certified Nursing Assistant (CNA) #69. CNA #68 felt like CNA #69 was rough by rushing the transfer and change in plane, from standing-to-sitting, with Resident #27. Review of the witness statement dated 05/23/26 authored by the Administrator revealed the Administrator had received a voicemail to return a call back to CNA #68. The Administrator called CNA #68 and CNA #68 felt uneasy on a couple things and wanted to tell someone. CNA #68 stated she witnessed CNA #69 and another aide (unnamed) putting Resident #27 in recliner and CNA #68 felt they did it in a rough manner. The Administrator asked for a date, or what nurse was on; CNA #68 could not remember. The Administrator educated CNA #68 that if CNA #68 felt something wasn't right, to notify nurse right away so the nurse could look into it and if needed, the nurse could call the Administrator. Review of the witness statement dated 05/23/26 authored by CNA #68 revealed CNA #68 stated one time she felt CNA #69 was rough, when putting Resident #27 in a recliner in the Speret hall dining room (secured memory care unit), but couldn't remember a date or time, or what nurse was on, but stated probably Registered Nurse #66, as she was the nurse on back there. Interview on 05/27/26 at 1:55 P.M. with CNA #68 revealed initially upon talking to Assistant Director of Nursing (ADON) #74 and the Administrator, CNA #68 felt a previous incident needed reported from a couple of weeks ago involving a tiny, Amish man [indicating Resident #27] who had behaviors such as being combative. CNA #69 and CNA #72 arm-in-arm transferred Resident #27 to change his incontinence brief. CNA #69 and CNA #72 flung him forward and swung him backwards into a recliner. CNA #68 felt the incident with Resident #27 was abusive. When CNA #68 was asked why she waited to report the incident involving Resident #27, CNA #68 stated it was her first couple of weeks working at the facility, she didn't know the people, didn't want confrontation, didn't know how to go about it, and she was scared. Interview on 06/01/26 at 12:25 P.M. with the Administrator verified CNA #68 should have immediately reported the allegation of abuse if CNA #68 felt abuse had occurred. Review of the facility's Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation policy dated 2016 revealed mistreatment was defined as inappropriate treatment or exploitation of a resident. All incident and allegations of abuse, neglect, exploitation, mistreatment and misappropriation of resident property and all injuries of unknown source must be reported immediately to the Administrator or designee. This deficiency represents non-compliance investigated under Complaint Number 3024629.

Based on observation, medical record review, Centers of Disease Control guidance, policy review and interview, the facility failed to implement written infection control policies and procedures for Enhanced Barrier Precautions (EBP) during a two-person staff transfer of Resident #27 within the resident's room. This affected one (Resident #27) of three residents reviewed for transfers. The census was 52. Findings include: Review of the medical record for Resident #27 revealed an admission date of 01/31/26 with diagnoses of dementia without behavioral disturbance, neurocognitive disorder with Lewy bodies, anxiety, fracture of femur, depression, and anemia. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #27 was severely cognitively impaired, had physical behaviors four to six days during the assessment, rejected care one to three days during the assessment and required substantial/maximal assistance with transfers. Resident #27 resided on the secured-memory care unit. Review of the infection care plan revised on 03/18/26 revealed Resident #27 required enhanced barrier precautions (EBP) related to a chronic wound with interventions which included to utilize the use of personal protective equipment (PPE) gowns and gloves during high contact resident care activities when in room, shower room or in therapy. Review of the wound care nurse practitioner progress note dated 06/01/26 revealed Resident #27 had a stage-three pressure ulcer to the right buttock and sacrum. Review of the June 2026 physician orders revealed Resident #27 was ordered EBP's; the order began 03/16/26. Observation on 06/01/26 at 1:00 P.M. revealed the Centers of Disease Control (CDC) Enhanced Barrier Precautions sign was posted on the wall out of Resident #27's room. The sign indicated to, wear gloves and a gown for the following high-contact resident care activities which included transferring. There was a door caddy hanging within Resident #27's room with PPE within the door caddy. Certified Nursing Assistant (CNA) #60 and CNA #78 donned gloves only, and each CNA arm-in-arm transferred Resident #27 from his wheelchair to his bed; CNA #60 and #78 did not don gowns before or during the transfer. Interview, after the observation, with CNA #60 and CNA #78 verified they did not don a gown during the transfer. Both CNA's believed they didn't need to don a gown anymore because the resident's buttock wound was closed and CNA's didn't think Resident #27's EBP order had been updated to reflect that. Interview on 06/01/26 at 1:05 P.M. with Assistant Director of Nursing (ADON) #74 revealed Resident #27's had a stage-three pressure ulcer on his buttock and the wound was not closed. ADON #74 verified CNA #60 and CNA #78 should have donned a gown when transferring Resident #27 within his room. Interview on 06/01/26 at 1:08 P.M. with Regional Registered Nurse (RRN) #76 verified the CNA's should have donned a gown when transferring Resident #27 within his room. Review of the facility's EBP policy revised 05/01/25 revealed EBP were used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provided opportunities for transfer of Multidrug-resistant Organisms (MDROs) to staff hands and clothing. EBP were indicated for resident's with any of the following: chronic wounds and/or indwelling medical device even if the resident was not known to be infected or colonized with a MDRO. For the purpose of this policy, chronic wounds did not include shorter-lasting wounds . Examples of chronic wounds included pressure ulcers. For residents identified requiring EBP's, staff would wear gloves and gowns when performing the following high-contact resident care activities while in a resident room, shower room and during therapy: transferring. Review of the CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) guidance revised 04/02/24 revealed expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: transferring. This deficiency is based on an incidental finding discovered during the course of this complaint investigation.

Based on observation, medical record review, Self-Reported Incident review, witness statement review, policy review, and interview, the facility failed to ensure Resident #21, who was diagnosed with dementia with behaviors, was assessed as severely cognitively impaired and had a history of sexually inappropriate behaviors, had appropriate care-planned interventions in place to protect Resident #23's right to be free from alleged sexual abuse by Resident #21. This affected one resident (#23) of four residents reviewed for abuse. The census was 52. Findings include: Review of the medical record for Resident #21 revealed an admission date of 04/24/25 with diagnoses of dementia with behavioral disturbances, Alzheimer's disease, restlessness and agitation, altered mental status, vascular dementia, diastolic congestive heart failure, chronic obstructive pulmonary disease (COPD), anxiety disorder, diabetes, and malaise. Resident #21's responsible party was his daughter. Resident #21 was initially admitted to the Speret hall (the secured memory-care unit) then was moved off the secured memory-care unit to the 300-hall on 10/08/25. Review of the skilled nursing facility (SNF) documents in the electronic medical record (EMR) dated 04/24/25 revealed Resident #21 had been admitted from another SNF. Review of the nurse practitioner progress note dated 04/05/26 revealed Resident #21 was a poor historian due to cognitive/psychiatric impairment. Resident #21 had history of Alzheimer's disease and dementia with behaviors. The resident was alert and oriented times one to two (alert to person and/or place). He was able to answer some questions during history and physical interview, but most answers were nonsensical. Per staff, the resident did make comments about where his wife was and all these pretty women. The assessment/plan for the dementia with behavioral disturbance revealed the behaviors included sexually inappropriate behaviors (verbal comments/hand holding attempts). Review of the physician orders revealed Resident #21 was ordered Tagamet HB (Cimetidine) oral tablet 200 milligrams (mg) (a medication used off label to manage hypersexuality or inappropriate sexual behaviors) with instructions to give one tablet by mouth two times a day related to dementia with other behavioral disturbance, which was started on 04/16/25. Review of the physician orders from April 2025 revealed Resident #21 was ordered Tagamet HB (cimetidine) tablet 200 mg one tablet oral twice a day for dementia. Review of the Nursing admission - Clinical admission Documentation assessment dated [DATE] revealed Resident #21 was admitted from another skilled nursing facility (SNF). Resident #21 was alert and oriented to place only and was admitted with a psychiatric diagnosis, behaviors and/or medications. Review of the Social Service - Social History assessment dated [DATE] authored by Licensed Practical Nurse (LPN)/Social Service Coordinator (SSC) #65 revealed Resident #21 was alert and oriented to person only, forgetful/confused and lacked safety awareness. Resident #21 had physical, verbal, other behaviors not directed towards others and was impulsive. Review of the nursing progress note dated 05/11/25 timed 5:13 A.M. authored by Registered Nurse (RN) #66 revealed an unnamed Certified Nurse Aide (CNA) reported to this nurse increased inappropriate sexual behaviors such as commenting on the CNA's appearance and attempting to touch the staff member while providing routine care. Redirection and distraction attempted, somewhat effective. Resident's safety ensured, noted to be in bed at this time with call light within reach. Care plan continued. Review of the nursing progress note dated 05/13/25 authored by the Speret Hall Program Director (SHPD) #79 revealed Resident #21 was discussed in the weekly behavior meeting yesterday. Target behaviors were discussed which included: restlessness and tearfulness. Medications were reviewed. Recent behaviors were discussed related to being inappropriate and making inappropriate comments to staff with no recommendations noted. Care plans reviewed and updated as needed. Resident to follow-up with psychiatric services. There was no evidence of what specific inappropriate sexual behaviors were exhibited by Resident #21. Review of Physician #80's progress note dated 07/15/25 revealed Resident #21 was diagnosed with dementia and to watch for worsening behaviors. Review of the pharmacy Note To Attending Physician/Prescriber dated 08/13/25 revealed Resident #21 was triggering for falls at the facility. The note stated to please review the following medications that could be contributing to falls which included: Cimetidine 200 mg twice a day which caused dizziness and drowsiness. The pharmacist recommended to discontinue Cimetidine 200 mg twice a day and start 300 mg in the morning or 100 mg twice a day. Review of the physician orders from August 2025 revealed Resident #21 was ordered Cimetidine tablet 100 mg twice a day. Review of the nursing progress note dated 09/26/25 timed 7:36 A.M. authored by SHPD #79 revealed Resident #21 was discussed in the weekly behavior meeting this week. Target behaviors discussed included: tearfulness. Medications were reviewed. Recent behaviors discussed related to inappropriate sexual behaviors. There were no recommendations noted. The care plan was reviewed and updated as needed. The resident continued with psychiatric services. There was no evidence of what specific inappropriate sexual behaviors were exhibited by Resident #21. Review of the nursing note dated 10/06/25 timed 5:34 P.M. authored by SHPD #79 revealed interdisciplinary (IDT) meeting was held today and discussed the resident needing a specialized unit. The IDT meeting recommended to transfer the resident off the unit with a compatible roommate on the 300-hall. The Nurse practitioner was updated and agreeable with the transfer. It noted they spoke with the resident, his daughter, and family, related to the resident not meeting requirements for the unit and would like to transfer to another unit. Resident and family agreeable to transfer tomorrow to a new room. Review of the psychiatric nurse practitioner progress note dated 01/13/26 revealed Resident #21's had recent and remote memory impairment, limited insight and limited judgement. Per staff, the resident was more restless and agitated around bedtime. Diagnoses were noted as dementia with behavioral disturbance and he was ordered Zoloft 75 mg (an antidepressant medication) orally once a day and Tagamet 100 mg twice a day. The plan was to start Remeron 7.5 mg orally at night for restlessness. Review of the nurse practitioner progress note dated 01/15/26 revealed Resident #21 had anxiety/depression with occasional inappropriate sexual behaviors. The resident was on Zoloft as well as cimetidine. Review of the cognitive loss/dementia care plan updated 02/03/26 revealed Resident #21 had impaired cognition related to Alzheimer's disease, dementia, impaired decision making, short-term memory loss, long-term memory loss, poor safety awareness, disorientation to time and place, confusion, brief interview for mental status less than 13 and unable/unwilling to participate with Minimum Data Set (MDS) interview. The interventions were generalized and not individualized to Resident #21 such as being more restless and agitated around bedtime and monitoring for worsening behaviors. There was no documentation in this care plan about Resident #21's sexually inappropriate behaviors, and no evidence of comprehensive, individualized care planned interventions for sexually inappropriate behaviors. Review of the behavioral symptoms care plan updated 03/12/26 revealed Resident #21 exhibited the following symptoms of physical aggression, verbal aggression, wandering and other which included: argumentative and yelling at peers for items; expressed delusions related to people being present when not here, agitation, shouting at times, and he used bedside table to lean on at times. The interventions were generalized and not individualized to Resident #21 such as being more restless and agitated around bedtime and monitoring for worsening behaviors. There was no documentation in this care plan about Resident #21's sexually inappropriate behaviors, and no evidence of comprehensive, individualized care planned interventions for sexually inappropriate behaviors. Review of the nursing progress note dated 05/02/26 timed 12:41 A.M. authored by RN #66 revealed the front nurse notified this nurse that Resident #21 was observed in a peer [Resident #23's] room on an opposing unit, without clothing. The nurse promptly responded, approached the resident and assisted him back to his assigned unit. Safety was ensured and reassurance was provided. A skin assessment was completed with no new issues noted. The resident's family was contacted. The Administrator and DON were notified by an unnamed LPN and 15-minute checks were initiated. Review of the MDS 3.0 annual assessment dated [DATE] revealed Resident #21 was severely cognitively impaired, and required partial/moderate assistance with dressing, oral hygiene, toileting, bathing, personal hygiene, bed mobility and transfers. There was no documentation that Resident #21 displayed any behaviors. Review of the medical record for Resident #23 revealed an admission date of 09/03/25 with diagnoses of Alzheimer's disease, cognitive communication deficit, obesity, episodic tension-type headache, and noninfective gastroenteritis and colitis. Resident #23's brother was her emergency contact. Resident #23 resided on the 300-unit in a private room upon admission and on 03/11/26 was moved to the 200-hall in a private room. Review of the Social Service - Social History assessment dated [DATE] revealed Resident #23 was alert and oriented to person, place and time, forgetful/confused and lacked safety awareness. Resident #23's was assessed as being moderately cognitively impaired. Resident #23 was a missionary for 29-years and traveled on a ship to multiple countries and was never married. Review of the nursing and social services progress note from September 2025 to April 2026 revealed there was no evidence Resident #23 exhibited sexual behaviors. Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #23 was severely cognitively impaired, required set-up or clean-up assistance with eating and oral hygiene, and required supervision or touching assistance with dressing, putting on/taking off shoes, toileting, bathing, personal hygiene, bed mobility, transferring and walking 10 feet, 50 feet and 150-feet. Review of the social service progress note dated 05/01/26 timed 10:45 P.M. authored by LPN/SSC #65 revealed at 7:30 P.M., this nurse was informed that when staff entered Resident #23's room to pass snacks, the aide noted there was a box of pop behind the door and Resident #23 and a male peer [Resident #21] were both lying in the resident's bed, undressed and lying side by side. Resident #21 was assisted in redressing and escorted out of room and returned to his room with no incident. Undersigned spoke to Resident #23 who denied having felt pressured into the situation, she voiced consent and smiled stating, that was the first time I was going to have sex and we didn't get that far. Resident #23 denied having had either resident touch the other in any way. A head-to-toe assessment was completed with no issues noted. The resident stated, I feel embarrassed, and was reminded that physical urges and intimacy were normal and natural for all adults. The Administrator, Assistant Director of Nursing (ADON) #74 and Physician were notified of the situation with no new orders. Resident #23 would be monitored every 15 minutes for 24 hours. A message was left for the resident's brother to return the call for an update. The brother had not returned the call as of the end of the shift. Review of the nursing progress note dated 05/02/26 timed 5:04 P.M. revealed staff called and updated the resident's brother about an incident yesterday. The brother voiced understanding and thanked staff for the update. Review of Self-Reported Incident #274054 dated 05/01/26 revealed a sexual abuse allegation involving Residents #21 and #23, found naked in a room together. The sexual abuse allegation was unsubstantiated. Review of the witness statement dated 05/01/26 authored by Hospitality Aide (HA) #73 revealed upon passing snacks, this aide knocked and entered the resident's room to find two residents (unnamed) appearing to be naked lying side-by-side in bed, uncovered. HA #73 immediately notified a Certified Medication Aide (CMA)/nurse. Review of the witness statement dated 05/01/26 authored by CMA #67 revealed HA #73 was passing snacks to find two residents (unnamed) in a resident room and appearing to be naked. CMA #67 immediately got the nurse to report the event. Review of the witness statement dated 05/01/26 authored by MDS RN #75 revealed this RN was approached by CMA #67. CMA #67 alerted MDS RN #67 that Hospitality Aide (unnamed) was passing night snacks and knocked on the resident's room and then entered. Upon entering, she noted that there were two residents in the room, naked and lying in bed together. MDS RN #75 went to resident's room and knocked on door and then entered. The door noted to have been barricaded with a box of soda. The male resident (unnamed) opened the door. Both residents were noted to be naked. The female resident (unnamed) noted to be lying in bed and the male resident was at the door talking to this nurse. MDS RN #75 then asked the aide to retrieve the other nurse on the floor. Other nurse came to the room to separate them and ensure safety. The male resident was taken back by his nurse (unnamed) to his hall. Review of the undated witness statement authored by LPN/SSC #65 revealed on Friday, 05/01/26 at approximately 7:00 P.M. to 7:15 P.M., LPN/SSC #65 was notified that while passing snacks, a HA attempted to enter Resident #23's room and noted that a box was behind the door making opening it more difficult than normal. The staff member entered to find the resident and a male peer (unnamed) lying in Resident #23's bed side-by-side and neither were dressed. Undersigned entered the room to note the same observation and encouraged the male peer (unnamed) to be assisted to redress by a staff member and the female resident (unnamed) was encouraged to redress. The female resident reported that she had never had sex and was about to for the first time, but they didn't get that far. The female denied having felt coerced into the situation and was a consenting participate in the intended activities. A head-to-toe was completed while the resident (unnamed) went into bathroom to redress. Resident's (unnamed) most recent BIMS was noted at a five (severely cognitively impaired). It noted the undersigned went to the back hall to locate the male resident's nurse to assist with returning him to his unit and to ensure complete understanding and assessment of the situation to ensure that both families were provided clear details on events as noted. Upon the undersigned's return to the front hall, the male resident was redressed and seated in his wheelchair that was in the female resident's room. The undersigned spoke to the male peer. Undersigned inquired of the resident who he believed he was with and he responded, my girlfriend, [Resident #21's wife's name]. The male resident was returned to his room on the other unit with both resident's stating that they were consenting to the intended activity and that neither felt pressured or forced in any way. Male resident's most recent BIMS was four (severity cognitively impaired). LPN/SSC #65 notified the Administrator and ADON #74 of incident and notified Physician #80 of the situation and both resident's were placed on 15-minute checks for 24-hours. Interview on 05/26/26 at 3:15 P.M. with CNA #60 revealed Resident #21 displayed sexual behaviors and said weird things to women about body parts, such as nice boobs and nice butt. When Resident #21 resided on the secured memory care unit, he would try to grab staff and rub their back. Resident #21 hadn't displayed sexual desires towards any other resident beside Resident #23. Resident #21 was confused, could walk and self-propel himself in his wheelchair. Interview on 05/26/26 at 3:20 P.M. with CNA #61 revealed Resident #23 used to reside on the 300-unit until she got a private room on the 200-unit. Residents #21 and #23 saw each other in the dining room and Resident #23 would come to the 300-unit to sit and talk to Resident #21. Interview on 05/26/26 at 3:25 P.M. with RN #62 revealed Resident #23 used to reside on the 300-unit and recently moved to the 200-unit. Observation on 05/26/26 at 3:35 P.M. revealed Resident #21 was in bed with a blanket covering his body including his head. Interview, during the observation, with Resident #21 revealed when asked if he had a friend named [Resident #23's name], Resident #21 stated, that name sounds familiar. When asked if he remembered getting into bed with Resident #23, Resident #21's response was unclear. Interview on 05/26/26 at 3:45 P.M. with CNA #63 revealed CNA #63 had seen the residents talk in the dining room and by the nurses station. Interview on 05/26/26 at 4:30 P.M. and on 05/27/26 at 4:40 P.M. with LPN/SSC #65 revealed LPN/SSC #65 was working as a floor nurse the evening of 05/01/26 when a newer aide (unnamed) was passing snacks. The newer aide observed the residents and retrieved CMA #67, then CMA #67 retrieved LPN/SSC #65. Residents #21 and #23 were side-by-side, shoulder-to-shoulder lying in Resident #23's bed, completely naked. LPN/SSC #65 retrieved the 300-hall nurse since that was where Resident #21 resided. Resident #21 and #23 were friends, sat together in the dining room and were both confused. Resident #21 thought Resident #23 was his wife as Resident #23 looked like Resident #21's wife. Residents #21 and #23 were both embarrassed. Resident #23 stated, I'm quite embarrassed, it was the first time I was going to have sex but I didn't get to. LPN/SSC #65 did a head-to-toe assessment on Resident #23 with no concerns. LPN/SSC #65 stated both Residents #21 and #23 were unable to make their own decisions. LPN/SSC #65 notified Resident #21's daughter who consented to the relationship. LPN/SSC #65 asked Resident #21's daughter if there were any grounds Resident #21's daughter was uncomfortable with, Resident #21's daughter responded, no not really. Resident #23's brother returned the facility's call the next morning (05/02/26), and spoke to RN #62 and couldn't believe people their age wanted to have sex. LPN/SSC #65 stated she did not have a conversation with Resident #23's brother about consent. LPN/SSC #65 stated she had last observed Resident #23 entering the dining room for dinner between 4:00 P.M. and 4:30 P.M. on 05/01/26. Interview on 05/27/26 at 8:40 A.M. and 4:50 P.M. with RN #66 revealed on 05/01/26, RN #66 was working in the back [300 and 400-unit] and LPN/SSC #65 came to get RN #66 to notify her of what happened with Residents #21 and #23. The residents were dressed when RN #66 arrived to Resident #23's room and both were very embarrassed. RN #66 did a skin assessment on Resident #21 with no concerns and Resident #21 stated he was down there for a visit with his girlfriend and we didn't get to touch. Resident #21 had a history of asking female staff members if they were married and typical old man things. Residents #21 and #23 were friends and would hang out and read magazines together in the common areas. RN #66 called Resident #21's daughter and the daughter was embarrassed on Resident #21's behalf. RN #66 had last observed Resident #21 sitting by the 300-400 unit nurses station at approximately 6:00 P.M. to 6:30 P.M. when RN #66 arrived to work then received nurse-to-nurse report. Observation and interview on 05/27/26 at 9:10 A.M. revealed Resident #23 was lying in bed, awake. When asked about the male resident who got into bed with her a couple of weeks ago, Resident #23 responded, that was weird and she didn't know who he was and he just came in; Resident #23 could not remember the male resident's name. When asked if he got into bed with her, Resident #23 stated, he didn't get into bed with me. Interview on 05/27/26 at 9:25 A.M. with Resident #21's daughter revealed she was notified that Resident #21 had wandered into another resident's room, Resident #21 thought the female resident was Resident #21's wife, they were both naked and nothing happened. Resident #21's daughter revealed Resident #21 had dementia and didn't know where he was at. Interview on 05/27/26 at 10:05 A.M. with CMA #67 revealed she was working with a trainee aide (unnamed) and the trainee aide was passing snacks when the trainee aide looked at CMA #67 and stated, you should probably get the nurse. CMA #67 got LPN/SSC #65. Residents #21 and #23 were naked and embarrassed. CMA #67 stated Resident #21 did not have an erection. Interview on 05/27/26 at 11:55 A.M. with Resident #23's brother revealed he was notified that Resident #23 and a male resident were in the same bed and planning on having sex. Resident #23 stated, at their age, I couldn't comprehend that but again, I don't know what to make of it and he mentioned there was not a lot he could do. Interview on 05/27/26 at 2:10 P.M with Hospitality Aide (HA) #73 revealed on 05/01/26, HA #73 was passing snacks for the evening and knocked on Resident #23's door around 7:00 P.M., and there was a box behind the door and HA #73 proceeded in. Residents #21 and #23 were lying side-by-side, not touching, naked in her bed. HA #73 notified the nurse (unnamed). The nurse went into the room to talk to them. HA #73 and the nurse assisted the residents to get dressed. HA #73 stated Resident #21 did not have an erection. Interview on 06/01/26 at 11:15 A.M. with CNA #77 revealed Resident #21 was able to dress and undress her upper body however Resident #21 needed assistance dressing and undressing her lower body. Interview on 06/01/26 at 11:35 A.M. with Regional Registered Nurse (RRN) #76 verified Resident #23 had a history of sexually inappropriate behaviors and verified his sexually inappropriate behaviors were not documented in his care plans to ensure appropriate individualized interventions were implemented. Review of the facility's Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation policy dated 2016 revealed abuse was defined as, the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse and mental abuse. Exploitation was defined as taking advantage of a resident for personal gain through manipulation, intimidation, threats or coercion. Sexual abuse was defined as non-consensual sexual contact of any time with a resident. Willful was defined as meaning the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's procedure would include: the assessment, care planning and monitoring of resident's with needs and behaviors which might lead to conflict or neglect such as resident's with a history of aggressive behaviors, or if resident had behaviors such as entering other resident's rooms. This deficiency represents non-compliance investigated under Complaint Number 3024629 and Incident Number 3021070.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on review of a closed medical record, review of a self-reported incident, facility investigation, and interviews, the facility failed to ensure residents were free of misappropriation when a staff member accepted financial gifts from Resident #65. This affected one (Resident #65) out of three residents reviewed for misappropriation. Facility census was 60. Findings include:Review of the medical record revealed Resident #65 was admitted on [DATE] with diagnoses that included sepsis, hypertension, type 2 diabetes mellitus, end stage renal disease, anxiety disorder, blindness to left eye, bipolar disorder, and polyneuropathy. The facility contact information did not have anyone listed. Resident #65 was discharged on 02/10/26 to an independent living facility. A text message (no date) Housekeeper #150 wrote, No I can't I need to get a tire and rents coming up again Resident #65 replied, How much the tires cost. How much a (is) rent. Housekeeper #150 replied, I'm not sure I half (have) to find some where that as (has) that size. I give my mom 450 for rent. Resident #65 replied, You need $600 then.A text message dated 11/28/25 revealed Housekeeper #150 wrote, I feel bad taken anymore money from you, you have gave me so much all ready. Resident #65 replied, I don't care I'm hoping (helping) you out you need a new tire and rent money. Housekeeper #150 replied, I know but that's not your job. Resident #65 replied, Yes it is. A text message (no date) Housekeeper #150 wrote, The part is order now be in tomorrow I will get it Thursday after work. Resident #65 replied, Get it tomorrow you're my debit card. Housekeeper #150 replied, No I can't you have gave me way to much. And it's $160 way to much you all ready gave me 200 today. Resident #65 replied, Why can you give you no money Housekeeper #150 replied, You can call now. A text message dated 11/29/25 revealed Housekeeper #150 texted, Are you sure you have that to give. I will take it this time for the part and no more for awhile ok. Good night sweet dreams see you in the morning.A text message dated 11/30/25 revealed Housekeeper #150 wrote, I put your card under them papers on your table. Resident #65 replied, Ok where you put your lips at. Housekeeper #150 wrote, On my face. Resident #65 replied, I've written this morning you kissed me but you didn't it's okay The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #65 was cognitively intact. Review of the progress notes revealed no evidence of cognitive impairment. Multiple parts of text messages without dates were provided and conversations included:Housekeeper #150: Just remember no one can know we talk out of work not even my kid she lets it slip wrong person and it's back to my boss I won't have a jobResident #65 responded I know no one knowsResident #65: I like this is our business nobody else Housekeeper #150 responded, That's I don't give a (expletive) we aren't doingHousekeeper #150: So I guess some of the nurse went and told my boss you have the hots for me lol Resident #65: She say to you. Housekeeper #150: I just laughed and I said who would that be lol. She didn't say anything, she would tell me who said it which I don't care they aren't going to tell me who I can and can't talk toResident #65: They are jealousHousekeeper #150: Yep and I don't careResident #65: Don't care. I like this is our business nobody elseHousekeeper #150: That's I don't give a (expletive) we aren't doing anything bad well I'm working so (expletive) them all. Housekeeper #150: Who would ever thought I would become friends are even meet someone where I got a job atResident #65 responded, meHousekeeper #150: Who is your housekeeper todayResident #65 texted back a female's name. Housekeeper #150: Oh she your favorite oneResident #65: No you are. The beautiful one is my favorite. Sorry for itHousekeeper #150: Awe you are so sweet. A Facebook link was sent from Housekeeper #150 to Resident #65. Resident #65: Didn't answer my questionHousekeeper #150: What questionResident #65: Put your hand in my handHousekeeper #150: And how am I supposed to do that at workResident #65: You see tomorrowHousekeeper #150: I can't get in trouble I will lose my jobResident #65: You sweet. Housekeeper #150: Awe I saved on my phone. And thanks for offering to buy me beef sticks. They are $12 that's to much to take. Resident #65: It ok I care about uHousekeeper #150: I just never had a guy offer to buy me anything before always done it on my own. Housekeeper #150: What are you going to tell them if you ask for moneyResident #65: I have money in the roomHousekeeper #150: Oh why does the office have everybody else money. Don't let anyone see you give it to me that way we don't get in troubleResident #65: One way hold your hand and a youtu.be link. Housekeeper #150: Ya just got hereResident #65: Look how much I give youHousekeeper #150: I did that's way to muchResident #65: NoHousekeeper #150: Yes I thought maybe 20 not 50Resident #65: It okHousekeeper #150: I'm given you the change backResident #65: NoHousekeeper #150: I get paid from this job and car payments I'm broke for 2 weeks Resident #65: YesHousekeeper #150: Use to be making 16 a hour and dropping down to 13 is a big pay cut. Resident #65: Yes. Do you need some money Housekeeper #150: No you all ready gave me to muchResident #65: So. Do it who you care aboutHousekeeper #150: Ok took a hot shower. Resident #65: Ok Housekeeper #150: Love that song got it on my playlistResident #65: Yes. Do you have me on you phone Housekeeper #150: Not your picture because everyone gets on my phone. Housekeeper #150: Half to see if I got paid. Resident #65: I help you Housekeeper #150: I know you will but I don't want to take all your money you might need something. I will let you help me Resident #65: Ok. Housekeeper #150: Will you be happy if I do that. Resident #65: What Housekeeper #150: If I let you help me will that make you happy Resident #65: yesHousekeeper #150: It's $40 I can get it tomorrow Resident #65: I have 50. Housekeeper #150: That's all your money Resident #65: No Housekeeper #150: I don't know how I would get it since I left Resident #65: True Housekeeper #150: Unless you meet me in the dining room Resident #65: Ok. I'm in the dinner room Housekeeper #150: Pulling inResident #65: K Housekeeper #150: I owe you this money backResident #65: Thank you. For pick up your pills Housekeeper #150: You are welcome and thank you for getting them for me Resident #65 sent a snapchat link and replied no problemHousekeeper #150: Trying to find somewhere to go to get a shower Resident #65: oh see. Housekeeper #150: We have no hot water for some reason. Resident #65: That suck. Housekeeper #150: Yes it does I need a shower I feel nasty. Resident #65: I know. Call around and see how much the water tank cost and see how much it cost.Housekeeper #150: Cleaning the nursing station right now Resident #65: I'm next right.Housekeeper #150: Taken smokers out side. I can see your window when I take them out Resident #65: Can you see me Housekeeper #150: If you was in your window I probably couldResident #65: I want to see a pretty faceHousekeeper #150: It's not your responsibility to give me that much Resident #65: Yes it is I need a diet mountain dew and a can of grizzly long cuts rate if you want anything get it Housekeeper #150: Ok promise me this if I take it from you will let me pay you back Resident #65: No Housekeeper #150: I can run up to the bank Resident #65: OkayHousekeeper #150: How much money do you have I'm not taken all your money Resident #65: Have a lot of money don't worry about it okay I'm hoping you out Housekeeper #150: I know I feel bad I hate asking for help always done it on my own Housekeeper #150: You want me to bring the money to you are just leave it in my car Resident #65: Bring it here please. Housekeeper #150: Ok. Be in a fewHousekeeper #150: I had to use some of that money to go buy pull ups and diapers Because they are worthless and there dad won't buy them any Resident #65: You need help I'm here for you Housekeeper #150: I know you are. I was saving that to go see my son next month for a hotel room Resident #65: YesHousekeeper #150: And I'm not taken that much money from you to go if I don't get to go I will plan another time Resident #65: Yes you willHousekeeper #150: Its to much money to take from you its so high up thereResident #65: Sent a TikTok link and replied, It's okay with me you know I care about you I'm hoping you out. Housekeeper #150: The last time we went there it coast me all most 500 for two nights and food. I won't take that much from you that's way to much Resident #65: NotHousekeeper #150: Wish I could go to the hotel tonight I need to get away from here I'm so stressed outResident #65: Me too. You can go Housekeeper #150: I can't till I get paid Resident #65: I'll give you your money if for a hotel room you know that Housekeeper #150: I know I'm just stress out about wanting to go see my son and don't know if I'm going to be able to go Resident #65: Yes. Do you want me to buy you a roomHousekeeper #150: I don't know what I want to do right now Resident #65: OkayHousekeeper #150: I might and just borrow money off my daily pay. Why aren't you talkingResident #65: I am talking honey when you done clean the rooms come down and my debit card if you borrow money off of me okay. You busy that's why I'm not talking either. You did that not me Housekeeper #150: Be down in a minute Housekeeper #150: Hey how much you want me to take off Resident #65: How much you need Housekeeper #150: You tell me. You tell me how much Resident #65: 200 Housekeeper #150: You don't half to give me that much. I'm going to owe you my life Housekeeper #150: I half to run to Walmart on lunch Resident #65: Ok. Do you need money Housekeeper #150: I half to go get a bag of diapers and looking at work clothes they have Resident #65: Do you need some money yes or no Housekeeper #150: I have a little bit Resident #65: Okay I'll give you my debit card to youHousekeeper #150: I half to buy everything for these boys Resident #65: Buy them a toy for them Housekeeper: I don't have money for a toy not till Thursday Resident #65: Yes you do you have my debit card. Housekeeper #150: Ok I will see what I can find Housekeeper #150 sent a picture of Megalodon truck and a picture of a truck and sport trailer with lights and sound. Resident #65: What you want to buy them. Housekeeper #150: Those are the only things I see Resident #65: Get it Self-reported incident (SRI) Tracking Number 271600 dated 03/02/26 and completed on 03/06/26, revealed the Licensed Nursing Home Administrator (LNHA) received a call from an old friend of Resident #65. The friend informed the LNHA Resident #65 had passed away over the weekend. The friend had the resident's phone and found communication between Resident #65 and Housekeeper #150. The friend stated there had allegedly been money exchanged and wanted LNHA to be aware. The LNHA asked the friend to send any information she had. Housekeeper #150 was asked to come into the facility to give a statement. Housekeeper #150 admitted Resident #65 had helped her with a couple car payments. Housekeeper #150 asked Resident #65 about paying him back but he would not accept the repayment. Housekeeper #150 stated Resident #65 asked her to go to Walmart and other places and had voluntarily given Housekeeper #150 his card to buy stuff while he was at the facility and after he was discharged . Housekeeper #150 was immediately suspended. The LNHA and Director of Nursing (DON) reviewed resident records, provided education to all staff, and staff and residents were interviewed with no negative finding. LNHA received the text message communication between Resident #65 and Housekeeper #150, and the interactions appeared to be voluntary. The facility unsubstantiated the allegation of misappropriation. A handwritten statement signed by Housekeeper #150 on 03/02/26 revealed she had started talking to Resident #65 a couple of days after starting to work at the facility. Resident #65 and herself became good friends and started talking more. Resident #65 then gave Housekeeper #150 his phone number and asked if Housekeeper #150 would be his girlfriend. Housekeeper #150 told Resident #65 she would not be his girlfriend. Housekeeper #150 stated she got behind on a car payment and Resident #65 helped her out a couple of times. Resident #65 gave her his card to get money off of and to also get things at the store that the resident wanted. Housekeeper stated she remembered buying Resident #65 beef sticks, underwear, socks, pop, chips, candy, hair clippers, shampoo, toothpaste and cough drops. A typed statement dated 03/02/26 by LNHA of an interview with Housekeeper #150 revealed Resident #65 paid her car payment twice or just a portion of it. Housekeeper #150 offered to pay the resident back, but he declined. Housekeeper #150 stated the resident never gave her cash, but she was given Resident #65's card to take cash out and put on her account. A typed note by LNHA (no date) revealed the police came to the facility and asked if Resident #65 was mentally stable. The police were shown the resident's Brief Interview Mental Status with a score of 15 (out of a possible 15) which indicated the resident was cognitively intact. The resident had not shown any signs of mental instability and did not see a psychiatric doctor while at the facility. The police officer stated that due to the preliminary findings (Resident #65 was mentally competent) the case would be closed. A typed statement of an interview with Resident #65's daughter on 03/03/26 revealed the daughter wanted to make sure the facility was aware a staff member was having a relationship with Resident #65 and taking money from him. LNHA reported she had been made aware of the allegation on 03/02/26. An interview on 04/04/26 at 8:47 A.M. with the LNHA verified the facility staff were not aware of Housekeeper #150 taking money from Resident #65 until 03/02/26. LNHA stated the facility immediately began an investigation and suspended Housekeeper #150. The LNHA verified the Housekeeper was terminated for accepting money from Resident #65 as stated in the SRI and investigation.An interview on 04/04/26 at 11:47 A.M. with Resident #65's daughter verified that text messages were discovered on Resident #65's phone after he expired. The text messages between Housekeeper #150 and Resident #65 revealed Housekeeper #150 took money from Resident #65 while at the facility (from 09/23/25 through 02/10/26) and after the resident was discharged to an independent living facility. The daughter stated a nurse at the independent living facility had to stop Housekeeper #150 from entering Resident #65's apartment to get the residents debit card after he was hospitalized . An interview on 04/04/26 at 8:12 A.M. with Housekeeping Supervisor #105 verified she was made aware of Housekeeper #150 taking money from Resident #65 on 03/02/26. An additional interview with LNHA on 04/04/26 at 10:05 A.M. revealed Resident #65 had been homeless and did not have any money and very limited belongings that staff went and got from the homeless shelter. LNHA verified Resident #65 did not have any money in a personal funds account. LNHA verified every resident that could be interviewed, was interviewed and no residents reported giving money or debit cards to staff members.An interview on 04/04/26 at 11:26 A.M. Resident #34 verified she knew Resident #34 gave his debit card to Housekeeper #150 to buy things for him and heard that he paid bills for Housekeeper #150 after he was discharged from the facility. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice on 04/02/26: On 03/02/26 Housekeeper #150 was interviewed and suspended pending an investigation. On 03/02/26, the DON implemented all staff in-service training on abuse, mistreatment, neglect, misappropriation of resident property and exploitation. On 03/02/26, LNHA and DON interviewed all interviewable residents about staff asking for money and/or residents giving staff money or gifts. No negative findings were identified. On 03/03/26 the quality assurance performance improvement committee met to provide education on abuse, neglect, and misappropriation. The focus was on the process of reporting and forms of misappropriation. Housekeeper #150 was terminated on 03/06/26 for breaking company policy employees conduct by accepting money, gifts, gratuities, etc. from the residents, families, or visitors. Audits were conducted on 03/09/26, 03/12/26, 03/16/26, 03/19/26, 03/25/26, 03/27/26, 03/31/26, and 04/02/26. Residents were asked if any staff member had asked the resident to buy anything or had asked the resident for money. Audits were conducted on 03/09/26, 03/12/26, 03/16/26 03/19/26, 03/25/26, 03/27/26, 03/31/26, and 04/02/26. Staff were asked if they had witnessed another staff member asking a resident for money. As of 04/02/26 there had been no further incidents or concerns identified. Interviews on 04/04/26 from 7:53 A.M. to 8:10 A.M. with Certified Nursing Assistant (CNA) #101, CNA #102, CNA #103, CNA #104, Housekeeper #106 revealed they had received additional training about not being permitted to take any gifts from residents, to refer residents to the activities department if the resident wanted to purchase items at the store, and to report any concerns with residents giving gifts to employees.This deficiency represents non-compliance investigated under Complaint Number 2799617.

Based on record review, observation and interview, the facility failed to monitor and record dishwasher temperatures and Quatinary sanitizer solution levels. This had the potential to affect 61 residents receiving meals from the facility. The facility further failed to ensure appropriate drying times after cleaning equipment prior to preparing pureed meals for two residents. The facility census was 62.Findings Include: 1. Review on 01/05/25 during the initial kitchen tour between 8:55 A.M. and 9:20 A.M. of the facilities monthly dishwasher temperature check log revealed for the month of January 2026 three slots each day (breakfast, lunch, and dinner) to record temperature checks of the high temperature dishwasher. Further review revealed no temperatures recorded for breakfast, lunch, or dinner on 01/02/26 and 01/03/26. There was no temperature recorded for breakfast on 01/04/26.Review of the facilities monthly sanitizer tracking log revealed for the month of January 2026 three slots each day (breakfast, lunch, and dinner) to record sanitation testing levels used for the Quatinary sanitizer solution in the cleaning buckets. There was no sanitation level recorded for dinner on 01/01/26. Further review revealed no sanitation testing levels recorded for breakfast, lunch, or dinner on 01/02/26 and 01/03/26. Interview on 01/05/2025 at 9:20 A.M. with the Dietary Coordinator (DC) #21 revealed verification that the dishwasher temperature tracking log for January 2026 was missing data entries for breakfast, lunch, and dinner services on 01/02/26 and on 01/03/26 as well as breakfast service on 01/04/25. Further interview with DC #21 revealed verification that the sanitizer tracking logs were missing data entries for dinner on 01/01/25, and breakfast, lunch, and dinner on 01/02/25 and 01/03/25. The DC #21 revealed that he was told by his boss that if a couple days or times are missed during the month it was okay. Review of the Ohio Food Code 3717-1-04.2 and 317-7-04.4 effective 09/05/24 revealed temperature monitoring devices are to be calibrated in accordance with the manufacturer ' s specifications and in a hot water mechanical dishwasher, an irreversible registering temperature indicator is provided and readily accessible for measuring utensil surface temperatures.2. Observation and interview on 01/07/26 between 09:45 A.M. and 10:15 A.M. of the puree food preparation revealed cook (CO) #16 prepared chicken and noodle puree then removed the Robot Coup (special blender used to make pureed dishes) bowl and lid to run it through dishwasher prior to beginning broccoli puree. CO #16 then went to the dishwasher and obtained the bowl and lid which were still wet and brought them to the preparation area. While walking to the preparation area CO #16 vigorously waved the bowl and lid back and forth with her arms to increase the drying time of the equipment. The water on the bowl and lids was splashed throughout the vicinity of the preparation station. This was verified by RDC #101 who observed CO #16 swinging bowl and lid to dry and attempted to intervene to make sure the bowl was dry prior to beginning the broccoli puree.Review of the Ohio Food Code 3717-1-04.8 effective 09/05/24 revealed equipment and utensils after cleaning and sanitizing are to be air dried after adequate draining and not to be cloth dried. Further review revealed that clean equipment and utensils are to be stored in a self-draining position to allow for air drying.

Based on observations, record review, interview, and policy review, the facility failed to ensure the secured unit provided meaningful activities to meet Resident #9's needs. The facility also failed to ensure Resident #11 received preferred activities. This affected two residents (Resident #9 and #11) of three residents reviewed for activities but had potential to affect all 14 residents (#9, #10, #18, #20, #28, #31, #36, #37, #38, #40, #45, #49, #58, and #61) who resided on the secured unit. The facility census was 62. Findings include: 1. Review of the medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included chronic congestive heart failure, cellulitis of right lower limb, venous insufficiency, dementia, type 2 diabetes, major depressive disorder, and anxiety. Review of a quarterly activity note dated 07/11/25 at 10:47 A.M. revealed Resident #9 continued to participate in most group activities. The resident liked to play bingo, do outdoor games, watch entertainers, and some of the crafts and church services. The resident interacted daily with other residents and staff. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9 had a brief interview for mental status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of the plan of care revised 11/12/25 revealed Resident #9 needed encouragement to engage in structured leisure pursuits. Interventions revealed Resident #9 felt it was important to listen to music, to be around animals, watch television, play bingo, socialize with staff and peers, go outside during good weather, and participate in religious services. Resident #9 was to be invited, encouraged, and assisted to activities of interest. If the resident preferred to engage in independent leisure activities, staff would provide the resident with supplies for the resident ' s choice of independent activity preference. Review of the December 2025 Activity Calendar revealed music activities were scheduled twice, religious activities were scheduled eight times, food activities were scheduled 13 times, and bingo was scheduled 17 times. Review of the activity participation record for December 2025 revealed Resident #9 did not attend any of the music activities or religious activities. The resident attended four of the party and food activities, and eight bingo activities. Review of the January 2026 activity calendar revealed on 01/07/26 activities included bible study at 10:15 A.M., bread day at 1:15 P.M., and bread pass at 2:30 P.M. An observation on 01/06/26 at 1:07 P.M. revealed the resident was in the hallway, seated in her wheelchair. An interview with the resident was attempted however, the resident was not interviewable. An observation on 01/07/26 at 10:09 A.M. revealed Resident #9 was in the dining area on the secured unit. The resident was not involved in an independent or group activity. Attempts were made during the onsite survey to interview Resident #9 regarding activities on the secured unit however, the attempts were unsuccessful. An interview on 01/07/26 at 10:50 A.M. with Activity Coordinator #31 verified the activity staff did not go to the secured unit to do activities. Activity Coordinator #31 stated three or four residents who could sit for 15 to 30 minutes could be brought off the secured unit to participate in activities. Activity Coordinator #31 verified the residents on the secured unit did not participate in the bread day activity but bread would be passed to the residents on the secured unit. An interview on 01/07/26 at 4:27 P.M. Program Director #28 for the secured unit stated the A.M. and P.M. Social Circle on the activity participation log could be puzzles, crafts, coloring, or other various activities. Program Director #28 verified movies and watching television were the same because there were movies on the television. Program Director #28 stated music was played during meals, and the television was on the rest of the time so those were activities that Resident #9 was involved in every day. Resident #9 participated in talking/conversation and resident-to-resident interaction because Resident #9 spent time out in the common areas and would speak to staff and other residents. Program Director #28 verified there was not an activity person assigned to the secured unit and the nursing staff did activities when able however, there were no daily, structured activities on the secured unit.2. Review of Resident #11 ' s medical record revealed an admission date of 12/11/25 with diagnoses including but not limited to legally blind, cognitive communication deficit, difficulty walking, and high blood pressure. Review of Resident #11 ' s activity care plan dated 12/12/25 revealed Resident #11 engages in leisure activities of choice with approaches including things important to him to listen to music and keep up with the news, to do group activities, go outside, religious services and having snacks between meals. Review of Resident #11 ' s daily activity logs dated 12/12/25 to 01/07/26 revealed the only time Resident #11 listened to music was when there was musical entertainment performing at the facility. The only entry for participating in crafts was marked on 01/06/26. There were no entries for listening to music and/or keeping up with the news. Observation on 01/05/26 at 2:20 P.M. revealed Resident #11 lying in a recliner in the common area near the front desk and the facility main entrance. Resident #11 was lying at an angle with his bilateral legs hanging off the footrest to the left and his head was hanging off the headrest and leaning against the handrail. Resident #11 was not covered with a blanket and there was no music playing. Observation on 01/06/2026 at 1:04 P.M. revealed Resident #11 was sitting in a recliner in the common area at the front nurse desk near the facility ' s main entrance. Resident #11 was reclined back with his head leaning to his right side, up against the handrail. Resident #11 was restless with his bilateral feet hanging off the left side of the footrest. There was no music playing and no TV playing. Observation on 01/07/26 at 10:15 A.M. revealed Resident #11 requested to go to his room and lay down in bed. Resident #11 was assisted into bed by Assistant Director of Nursing (ADON) and Certified Nursing Assistant (CNA) #61. Resident #11 was resting in bed with no music playing or his TV on. Interview on 01/07/26 at 10:23 A.M. with the Activity Coordinator (AC) #31 confirmed Resident #11 was seated in the recliner in the common area for the past two days with no music or news playing despite this being an important activity of choice for him. Review of the facility policy titled Resident Activity Preferences dated 03/21/19 revealed the facility will accommodate resident activity preferences through the comprehensive assessment and care planning process. This deficiency represents non-compliance investigated under Master Complaint Number 2696509 and Complaint Number 2623247.

Based on record review, observation, and interview, the facility failed to ensure Resident #11 was provided accommodations to ensure appropriate and dignified seating and had access to fluids if needed This affected one resident (#11) out of three residents reviewed for dignity. The facility census was 62.Findings Include: Review of Resident #11's medical record revealed an admission date of 12/11/25 with diagnoses including legally blind, cognitive communication deficit, difficulty walking, and high blood pressure.Review of Resident #11's physician orders revealed an order dated 12/12/25 for a regular texture diet with thin liquids.Observation on 01/05/26 at 2:20 P.M. revealed Resident #11 was lying in a recliner in the common area near the front desk and the facility main entrance. Resident #11 was lying at an angle with his bilateral legs hanging off the footrest to the left of the chair and his head hanging off the headrest and leaning against the hand rail. Resident #11 was not covered with a blanket. Observation on 01/06/2026 at 1:04 P.M. revealed Resident #11 was seated in a common area recliner at the front nurses' desk, near the facility's main entrance. Resident #11 was reclined back with his head leaning to his right side and against the hand rail. Resident #11 was restless with his bilateral feet hanging off the left side of the footrest. There was no music or TV playing. Resident #11 had nothing available if a drink was needed.Observation on 01/06/2026 at 1:56 P.M. Resident #11 continued lying at an angle in the common area recliner. He attempted to hold his right leg up on the footrest but it continued to fall off the footrest. Resident #11's head continued to be at an angle on the headrest and was still touching the hand rail. Facility staff, seated at the desk across from Resident #11, did not reposition Resident #11 in the recliner or offer a pillow for his use. There were several visitors walking past Resident #11 while he was lying in the recliner.Observation on 01/06/2026 at 2:19 P.M. Assistance Director of Nursing (ADON) stopped and talked with Resident #11 but did not offer to reposition the resident in the recliner. The Activities Coordinator (AC) #31 was passing ice cream and cake for residents. Resident #11 was not offered either cake or ice cream while he was seated in the common area recliner. There continued to be no water cup available for Resident #11 to use if needed. Observation on 01/06/2026 at 2:48 P.M. revealed Resident #11 requested to get out of the recliner and into the wheelchair. Staff members assisted Resident #11 into the wheelchair and he remained in the common area, next to the recliner. Resident #11 had nothing available if a drink was needed.An interview on 01/06/26 at 3:00 P.M. with the ADON confirmed Resident #11 had been lying in the recliner at an angle, was not repositioned and had no food or fluids within his reach if he needed them. The ADON stated Resident #11 was brought to the common area for safety reasons (for staff to keep the resident within their sight)This deficiency represents non-compliance investigated under Complaint Numbers 2660576 and 2623247.

Based on record review, self-reported incident review, interviews, facility assessment review, and dementia training review, the facility failed to ensure staff had the skills necessary to provide direct care in a way to relieve and accommodate Resident #38's distress. The facility also failed to ensure staff approached Resident #59 appropriately after a behavior occurred. This affected two (Residents #38 and #59) of two residents reviewed for dementia care. The facility census was 62. Findings include: 1. Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses that included dementia, depression, anxiety, insomnia, Meniere's disease, osteoarthritis, osteoporosis, psychosis, and mood disorder. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #38 had psychosis, physical and verbal behaviors directed towards others, behaviors not directed towards others, and rejection of care. Plan of care dated 10/20/25 revealed Resident #38 refused bathing at times. Interventions included to offer resident alternatives when refusals occur, allow resident to choose options when able, allow resident to have some control over situations when possible and allow the resident to make choices/decisions regarding care as able. Resident has the right to refuse care and treatments. Maintain a calm environment and approach the resident in a calm manner. Convey an attitude of acceptance toward the resident. Plan of care dated 10/21/25 revealed Resident #38 had alteration in communication related to being hard of hearing (wears hearing aids), impaired ability to express and comprehend verbal communication related to Alzheimer ' s disease, dementia, and Meniere ' s disease. Interventions included to approach the resident slowly and face resident when speaking, establish and maintain a consistent care routine for the resident, observe for any signs of frustration during daily routine and redirect with calm gentle verbal tones.Plan of care dated 10/22/25 revealed Resident #38 exhibited behavioral symptoms of physical aggression towards staff. Interventions included to encourage the resident to accept assistance with care as needed. If the resident becomes combative during care .stop, allow that choice, make sure resident is safe. Explain to the resident you will return later and try again. The resident had the right to refuse care and treatment. When the resident ' s behaviors begins or escalate, move the resident to a quiet, calm environment to promote safety and prevent injury.A progress note dated 10/17/25 at 1:16 A.M. revealed Resident #38 was confused and resistive to care at times. A progress note dated 10/21/25 at 12:45 A.M. revealed Resident #38 had been combative during care. A progress note dated 10/28/25 at 4:10 P.M. revealed Resident #38 had increased periods of restlessness, anxiety, and verbal aggression towards staff. The physician was notified and a new order was received for Vistaril (for anxiety) as needed. Review of Self-Reported Incident (SRI) #267145 dated 11/04/25 revealed staff alleged the nurse forced the aides to provide a shower. A written statement (no date) by Licensed Practical Nurse (LPN) #37 revealed during report with Registered Nurse (RN) #41 on 11/03/25, Resident Assistant (RA) #99 reported Resident #38 agreed to take a shower but was now being combative and pulled RA #99 ' s hair. RN #41 stated Resident #38 had dementia and told RA #99 to talk to the resident and change the subject. RN #41 told the staff to shower Resident #38 because the resident would usually calm down once the shower started. RA #99 went back to the shower room. After getting report, LPN #37 started passing medication. Certified Nursing Assistant (CNA) #100 (a trainee) came out of the shower room and stated under her breath, this is (expletive) ridiculous. CNA #100 went to the nurse ' s station and grabbed something and returned to the shower room. As CNA #100 was walking into the shower room, she stated the nurse should be taking care of this. LPN #37 then moved onto another resident to administer medications. LPN #37 was talking to a resident when CNA #100 stuck her head out of the shower room and stated we need help in here. LPN #37 ignored CNA #100 because LPN #37 was talking with a resident. CNA #100 then stated, hello, I said we need help. LPN #37 told CNA #100 she was going to have to wait. LPN #37 finished up with the resident she was talking to and went to the shower room. LPN #37 spoke to Resident #38 and told the resident if she stood up, LPN #37 would take the resident back to her baby. Resident #38 stood up, the staff dried the resident and applied an incontinence brief. LPN #37 took the resident out to the medication cart and administered Resident #38 ' s medications. LPN #37 called the Director of Nursing (DON) to notify her RA #99 and CNA #100 would call the DON because LPN #37 made them mad. Staff Coordinator #8 called LPN #37 and said RA #99 messaged Staff Coordinator #8 threatening to go to the hospital because her hair was pulled. LPN #37 verified RA #99 had reported Resident #38 had pulled her hair. Later in the shift, RA #99 asked for acetaminophen (pain reliever) because of a headache. LPN #37 gave RA #99 the acetaminophen. After Resident #38 was showered, LPN #37 did not speak to RA #99 or CNA #100 before they left for the night. The facility investigation revealed on 11/03/25 three calls were made to CNA #100. CNA #100 did not answer the phone but texted Staff Coordinator #8 and stated she felt her safety was at risk and did not want to work at the facility anymore. A handwritten statement by CNA #57 dated 11/03/25 revealed RA #99 was with a new girl and had Resident #38 on their assignment. RA #99 and CNA #100 stated Resident #38 hit, bit, and broke a necklace. CNA #57 put Resident #38 to be with no behaviors.An interview on 11/03/25 with CNA #57 by Administrator and DON revealed RA #99 and CNA #100 had an attitude and stated they had given a resident a shower and they got beat up. CNA #57 put Resident #38 to bed and had no concerns. CNA #100 stated she was calling the state because LPN #37 forced them to give (Resident #38) a shower. CNA #57 stated LPN #37 did not force RA #99 and CNA #100 to give Resident #38 a shower. CNA #57 stated RA #99 and CNA #100 had an attitude about giving Resident #38 a shower before they even started the shower. CNA #100 was mad before Resident #38 was even showered. CNA #57 stated she had no concerns with Resident #38. An interview on 11/03/25 with LPN #37 by Administrator and DON revealed she was getting report from RN #41 when RA #99 came in and stated Resident #38 said she would get a shower but was now combative and the resident was already in the shower room. LPN #37 and RN #41 told RA #99 to try again later. LPN #37 went in at the end of the shower and Resident #38 was fine and had no behaviors when LPN #37 was in the shower room. LPN #37 stated she was talking with another resident when RA #99 and CNA #100 asked for help. RA #99 and CNA #100 were rude, and she told them she was with another resident and then needed to stop with the attitude. LPN #37 did not tell the staff to hold down Resident #38 ' s hands and did not tell the staff they had to shower Resident #38.A handwritten statement by RN #41 dated 11/04/25 revealed RA #99 came into the conference room while RN #41 was giving report to LPN #37. RA #99 reported Resident #38 was getting combative during the shower and asked what to do. RN #41 suggested giving Resident #38 a moment to calm down but to have two aides in the shower room to be safe. RN #41 encouraged one aide to watch/hold Resident #38 ' s hands so the resident did not grab, hit, or pull staff ' s hair. RA #99 said okay and left the conference room. RN #41 demonstrated how to hold a resident ' s hand as a distraction and not a restraint. A progress note dated 11/04/25 at 1:06 A.M. authored by Licensed Practical Nurse (LPN) #37 revealed Resident #38 received a scheduled shower and became physically aggressive with staff. The resident was hitting, pulling staff ' s hair, and attempted to spit on and bite staff. The resident was given space and another staff provided care with no issues. Resident #38 continued to be confused and was not easily redirected at times. The resident was incontinent of bladder and was cooperative with care. A progress note dated 11/12/25 at 8:15 A.M. revealed Resident #38 ' s behaviors were discussed in the weekly meeting. The targeted behaviors included restlessness, verbal and physical aggression with spitting, exit seeking, and tearfulness. Medications were reviewed and no recommendations were noted. An interview on 01/08/26 at 6:02 A.M. CNA #94 revealed Resident #38 was combative at times but was easily redirected. An interview on 01/08/26 at 6:38 A.M. LPN #37 revealed RA #99 notified her that Resident #38 did not want to be showered. CNA #100 then came out of the shower room and was cursing under her breath. LPN #37 stated she had finished report, passed medications to a resident, and then was talking to another resident when CNA #100 stated they needed help. LPN #37 verified she did not know why she was needed in the shower room. When LPN #37 entered the shower room, RA #99 stated they could not do anything with Resident #38. LPN #37 stated Resident #38 was facing the wall. LPN #37 asked if she could dry Resident #38 off and take Resident #38 to her baby. LPN #37 stated Resident #38 was not aggressive but was agitated. LPN #37 stated RA #99 and CNA #100 were also agitated. A different CNA provided care for Resident #38 the rest of the shift and there were no other concerns. LPN #37 verified she did not ask another staff member to provide care, but RA #99 or CNA #100 must have asked CNA #57 to provide the care for Resident #38. LPN #37 verified that Resident #38 was usually easily redirected. LPN #37 stated RA #99 frequently worked the dementia unit and CNA #100 was new and was being trained. LPN #37 verified she knew that RA #99 and CNA #100 reported Resident #38 did not want to be showered, and she had been asked three times by RA #99 and CNA #100 for help before she entered the shower room. LPN #37 verified she did not know if there had been a change in Resident #38 ' s condition when CNA #100 had asked for help. LPN #37 verified the staff were agitated and were providing care for Resident #38 who they reported being aggressive. LPN #37 verified if a resident became combative or agitated the staff should stop what they were doing. LPN #37 verified she did not immediately enter the shower room when staff were agitated to make sure Resident #38 was safe. The facility assessment dated [DATE] revealed all new and existing staff, including individuals providing services to residents under contract and volunteers, consistent with their expected roles, will receive training based on the conditions of the populations served. The facility uses an on-line education tool called Relias and/or in person education for the facility staff. Staff, contractors and volunteers receive training in the following core areas: communication, resident rights and facility responsibility, and abuse/neglect/exploitation. The nursing staff (RN ' s and LPN ' s) will also receive core training in the following areas, consistent with their roles: person-centered care and dementia management training and resident abuse prevention training, and care of the cognitively impaired. Nurse aides will also receive the following core training: dementia management training and resident abuse prevention training, care of the cognitively impaired, person-centered care. The resident acuity is determined by a review of evidence based on MDS data from the time of the last assessment. The average number of resident with behavioral symptoms and cognitive performance was 12.66%. Dementia Management Training Inservice Outline for Caring for the Patient with Dementia included to be patient, supportive, and friendly. Pay close attention to your non-verbal language and your tone of voice.Review of the job description for RN/LPN Charge Nurse revealed the nurse insured resident ' s personal hygiene regimen was completed as indicated. Monitors and talks with residents to be sure that they have been given appropriate care. Review of the job description for State Tested Nursing Assistant (aka CNA) revealed the CNA provides all basic care services as required by the resident, assists new employees in following established facility policies and procedures, identified special resident problems and reports them immediately to the charge nurse, provides nursing care to residents without violating resident rights, seeks assistance when confronted with a resident problem that requires special assessment, controls angry feelings appropriately, and demonstrates warm, caring feelings about resident by responding appropriately to the needs expressed. 2. Resident #59 was admitted [DATE] with diagnoses that included type 2 diabetes mellitus, congestive heart failure, paroxysmal atrial fibrillation, depression, chronic kidney disease, history of transient ischemic attack, generalized anxiety disorder, and dementia without behavioral disturbance. Plan of care dated 12/10/24 revealed Resident #59 exhibited verbal aggression, hallucinations, making false accusations, yelling and argumentative with staff, made insulting comments about staff and other residents, and made threatening statements. Interventions included to resident from group activities when behavior was unacceptable, observe and report socially inappropriate or wandering behaviors that were disruptive to other residents. When resident began to become socially inappropriate/disruptive or was wandering, provide comfort measures for basic needs. When the resident ' s behavior begins or escalate move resident to a quiet, calm environment to promote safety. Avoid over-stimulation (noise, crowding, large groups, or other noted behavioral residents), if not tolerated by the resident. Observe for behavior that endangers the resident and/or others, staff to carefully intervene to promote safety of resident, other residents and staff. A handwritten statement dated 10/26/25 by Licensed Practical Nurse (LPN) #32 revealed her daughter was visiting LPN #32, staff, and residents on 10/26/25. The child wanted to go outside to get fresh air in the center courtyard during the resident ' s smoke time with Certified Nursing Assistant (CNA) #58. LPN #32 ' s child was running circles out and around the pavilion playing kind of a game of BOO in the dark. During this time, Resident #59 became suddenly agitated and swung her arm with a closed fist and intentionally hit/punched her (LPN #32 ' s) child in the stomach. The child entered the facility crying and holding her stomach. LPN #32 asked what happened and the child stated the lady with red streaky hair punched her in the stomach. LPN #32 looked at the child ' s stomach and there was a bright red mark across her abdomen. LPN #32 verified with CNA #58 that Resident #59 did punch the child. Resident #59 was wheeling into the building and LPN #32 approached the resident beside the nurse ' s station and asked the resident if she punched her daughter. Resident #59 confirmed with a smirk and stated she told the child to go inside before she hit her. LPN #32 told Resident #59 that a lot of children come into the facility and the resident did not have the right to hit children. Resident #59 could be charged with assault and potentially taken to jail. LPN #32 also stated that because she was a staff member she would not pursue any criminal charges, but if it was someone else ' s child Resident #59 may not be as fortunate. LPN #32 reassured Resident #59 she would make sure her daughter was not around Resident #59 again. A timeline typed up by the facility revealed on 10/27/25 Administrator received a message from Resident #59 ' s daughter stating a staff members daughter was running around outside and when the resident told her to stop, the child ran in and told her mother the resident hit her. The mother of the child told Resident #59, you are lucky you are in here. The Administrator talked with Resident #59 about the incident. The resident stated a little girl, around 12, was running around and on the chairs and Resident #59 told her to stop. The little girl ran inside and got her mom/grandma who was a nurse. The nurse (LPN #32) came out and stated you are lucky you are here. The resident stated the child had been outside for all the smoke breaks on 10/26/25. Administrator talked with Resident #7 who stated they saw a little girl outside when they went to smoke but did not see anything happen. Administrator talked with CNA #58 who reported the child went out with her when the residents went out to smoke. CNA #58 stated the child did not do anything wrong and Resident #59 hit the child in the belly. CNA #58 stated the child went inside and CNA #58 pushed Resident #2 back to her room. CNA #58 was walking back when she heard LPN #32 say to Resident #59, If I wasn ' t a staff member here, you would be leaving in a cop car because it was assault. Administrator interviewed Resident #2 who stated they witnessed Resident #59 hit the child and did not hear LPN #32 say anything other than, she was close to pressing charges, you do not hit other people ' s kids. Administrator called LPN #32. LPN #32 stated she was upset but did not yell at Resident #59 but was stern. LPN #32 told the resident You did not know whose kid that was and if I was not an employee someone could press charges on you for assault. You do not put your hands on someone else ' s kid. Administrator talked with CNA #77 who revealed LPN #32 was upset but did not do anything unprofessional other than say, you are lucky I do not call the cops and press charges. As LPN #32 went back to the unit she was working on, she said she was (expletive for being mad).Review of SRI #266837 dated 10/27/25 revealed a reported allegation of emotional/verbal abuse to Resident #59 by LPN #32. The SRI revealed Resident #59 had a brief interview for mental status (BIMS) score of 12 which indicated cognitive impairment. A handwritten statement dated 10/27/25 of an interview with Resident #59 with Administrator and Director of Nursing (DON) revealed the little girl was out at all smoke breaks. Resident #59 stated the little girl had no business out there and that the little girl was all over the chairs and running around. Resident #59 denied anything happening between her and the child but stated the child ran in and told her mom (LPN #32) she had been hit. Resident #59 stated when she came into the facility, LPN #32 said you are lucky you are here. Resident #59 stated it did not matter because LPN #32 did not scare her. A handwritten statement dated 10/27/25 by CNA #77 revealed it was a little before 8:00 P.M. when LPN #32 came up and was very upset. LPN #32 went to talk to another staff member and was being a little louder due to anger but did not say anything inappropriate. When LPN #32 came back down the hall, CNA #77 asked what happened. LPN #32 stated Resident #59 just punched her daughter, and the resident was lucky that LPN #32 did not call the cops and press charges. LPN #32 stated she was (expletive meaning mad) and went back down the hallway. A statement by Resident #2 dated 10/27/25 revealed the residents were outside smoking. Resident #59 did not like it that LPN #32 ' s daughter (seven years old) was out there because Resident #59 was trying to talk to CNA #77. Resident #59 told the child to go in and see her mother and to quit bothering them. Resident #59 then told the child Come over here so I can pop ya. The child ended up close enough to Resident #59 and her arm hit the child in the stomach. A handwritten statement dated 10/28/25 by CNA #58 revealed she was outside with the residents smoking at 7:00 P.M. LPN #32 ' s daughter followed CNA #58 outside and was running around playing. Resident #59 got very frustrated with the child running around and hit the child in the stomach. CNA #58 was pushing residents back inside and saw LPN #32 approach Resident #59 and asked if she hit LPN #32 ' s daughter. Resident #59 said she did. LPN #32 then said Resident #59 was lucky LPN #32 was a staff member or the resident would be leaving in a cop car with assault charges. A handwritten statement dated 10/29/25 by Resident Assistant (RA) #99 revealed RA #99 was sitting at the nurse ' s station when LPN #32 approached her and asked where Resident #59 was. RA #99 stated Resident #59 was outside. LPN #32 walked back down the hall and when LPN #32 saw Resident #59, LPN #32 told Resident #59 you ' re lucky I am a staff member and not a visitor because I ' d call the cops on you. It ' s not okay for you to hit other people ' s children at all. If she was bothering you that much, you should ' ve told CNA #58. Resident #59 started back talking to LPN #32, so LPN #32 walked away and RA #99 took Resident #59 to her room. An interview on 01/07/26 at 11:11 A.M. LPN #32 stated her daughter was only at the facility for an hour to visit herself and other residents. LPN #32 stated her daughter was seven years old and went outside when staff took residents out to smoke. LPN #32 verified that CNA #58 was outside to monitor residents that were smoking to ensure they were safe and not to monitor LPN #32 ' s child. LPN #32 verified she was not outside and did not witness the interaction between her child and Resident #59. LPN #32 also verified she was not Resident #59 ' s nurse but did confront the resident about hitting her child. LPN #32 stated she was not threatening the resident but educating the resident about hitting children. LPN #32 verified that Resident #58 had dementia and the facility was considered the resident ' s home. An interview on 01/07/26 at 2:23 P.M. Administrator stated LPN #32 stated she was not threatening Resident #59 but was just educating the resident about hitting children. The facility assessment dated [DATE] revealed all new and existing staff, including individuals providing services to residents under contract and volunteers, consistent with their expected roles, will receive training based on the conditions of the populations served. The facility uses an on-line education tool called Relias and/or in person education for the facility staff. Staff, contractors and volunteers receive training in the following core areas: communication, resident rights and facility responsibility, and abuse/neglect/exploitation. The nursing staff (RN ' s and LPN ' s) will also receive core training in the following areas, consistent with their roles: person-centered care and dementia management training and resident abuse prevention training, and care of the cognitively impaired. Nurse aides will also receive the following core training: dementia management training and resident abuse prevention training, care of the cognitively impaired, person-centered care. The resident acuity is determined by a review of evidence based on MDS data from the time of the last assessment. The average number of resident with behavioral symptoms and cognitive performance was 12.66%. Dementia Management Training Inservice Outline for Caring for the Patient with Dementia included to be patient, supportive, and friendly. Pay close attention to your non-verbal language and your tone of voice.Review of the job description for RN/LPN Charge Nurse revealed they are to interact with all residents, families, visitors, and employees in a mature, responsible manner to ensure a positive and professional living and working environment. Conduct all work activities in resident areas with respect for the rights and wishes of residents, including the maintenance of a pleasant and quiet environment. Consistently remains calm during stressful situations and vents emotions and frustrations appropriately. This deficiency represents non-compliance investigated under Master Complaint Number 2696509 and Complaint Number 2623247.

Based on record review, observation, interview and facility policy review, the facility failed to maintain transmission-based precautions. This deficient practice affected two residents (#17 and #70) out of three residents reviewed for transmission-based precautions. The facility census was 62.Findings Include: 1. Review of Resident #17 ' s medical record revealed admission date 04/30/24 with diagnoses including but not limited to stroke, contractures, vascular dementia, high blood pressure, depression and anxiety. Resident #17 required assistance from staff to complete Activities of Daily Living (ADL) tasks and had intact cognition.Review of Resident #17 ' s physician orders revealed an order dated 11/04/25 for enhanced barrier precautions (EBP) related to chronic wounds and urinary catheter use.Review of Resident #17 ' s EBP care plan dated 01/05/25 revealed Resident #17 requires EBPs related to chronic wound and indwelling medical device of urinary catheter use, with approaches including but not limited to EBP supplies may be placed in resident room, post signage to alert caregivers of the need for enhanced barrier precautions, and utilize the use of personal protective equipment (PPE) gowns and gloves during high contact resident care activities when in room, shower room, or in therapy.Observation on 01/06/26 at 9:02 A.M. revealed on the wall beside Resident #17 ' s room door a notification sign for EBP during high contact resident care and hanging on the door was PPE storage with gowns and gloves available for use. Resident #17 was observed being transferred via mechanical lift from bed to wheelchair by Certified Nursing Assistants (CNAs) #61 and #65. Neither CNA #61 and #65 were wearing PPE gowns or gloves.Interview on 01/06/26 at 9:30 A.M. with CNA #61 confirmed neither CNA #61 nor #65 were wearing gowns or gloves while transferring Resident #17 from bed to wheelchair via a mechanical lift. CNA #61 stated we should have put on the gowns and gloves before transferring her.2. Review of Resident #70 ' s medical record revealed admission date 12/31/25 with diagnoses including but not limited to Covid, intracranial hemorrhage, and fall with injuries at home.Review of Resident #70 ' s physician orders revealed an order dated 01/01/26 for Airborne transmission-based precautions; resident to remain in room and all services brought to the room.Observation on 01/05/26 at 11:15 A.M. revealed Resident #70 ' s door was closed and there was an airborne precautions notification sign visible on the wall beside the room door. Notification sign indicated everyone must: clean hands when entering and before leaving room and to wear gown, gloves, mask and eye protection when entering the room. Healthcare professionals must in addition to the above precautions, use an N95 mask. There was a PPE hanging storage device on the door which included gowns, gloves, masks and eye protection.Observation on 01/05/26 at 2:10 P.M. Resident #70 ' s room revealed there was no hand sanitizer available to clean/sanitize hands after exiting the room. The nearest hand sanitizer dispenser was down the hallway from Resident #70 ' s room. There was no disinfectant wipes available and no designated area to remove and disinfect the used eyewear. There was no used eyewear devices observed in the room or in the PPE storage device hanging on the door.Interview on 01/05/26 at 2:15 P.M. with the Assistant Director of Nursing (ADON) confirmed the lack of hand sanitizer available once exiting the room, the lack of disinfectant wipes and an area to clean/disinfect used eyewear and the lack of used eyewear noted in the PPE hanging storage device. The ADON stated there should be disinfectant wipes to clean the eyewear and the cleaned eyewear can be placed in the PPE storage for future use.Review of the facility ' s policy titled Isolation - Categories of Transmission-Based Precautions dated 07/01/25 revealed it is the facility ' s policy that appropriate precautions shall be used either al all times (Standard Precautions) or for individuals who are documented or suspected to have infections or communicable diseases that can be transmitted to others (Transmission-based Precautions).This deficiency represents non-compliance investigated under Master Complaint Number 2696509.

Based on medical record review and staff interview the facility failed to maintain accurate medical records. This affected three residents (Resident #10, Resident #41, and Resident #43) of twenty-five residents reviewed for accurate medical records. The facility census was 62.Findings include: 1. Review of the medical record for Resident #41 revealed admission to facility on 12/10/25 with diagnoses including morbid obesity, depression, chronic venous stasis (poor blood return in lower legs), lymph edema (chronic swelling related to poor fluid movement in body), anemia, pulmonary hypertension (elevated blood pressures related to air pressures in lungs), Review of Resident #41's initial Minimum Data Set (MDS) completed on 12/16/25 revealed a brief interview for mental status (BIMS) score of 15/15 (no impaired memory and cognition). Further review revealed Resident #41 was dependent and requiring maximum assistance of two persons for bed mobility (turning), transferring, showering, and dressing lower body. Review of Resident #41 orders by the Nurse Practitioner dated for 12/15/25 revealed Aquaphor to be applied to bilateral lower extremities three times a day. Further review of the Medication Administration Record (MAR) revealed Aquaphor application times of 7:00 A.M. to 11:00 A.M., 2:00 P.M. to 4:30 P.M., and 7:00 P.M. to 11:00 P.M. Review of the MAR on 01/06/25 at 1:59 P.M. revealed the Aquaphor had not been signed off as being administered for the 7:00 A.M. to 11:00 A.M. time frame. Review of the MAR on 01/06/26 at 4:10 P.M. revealed the Aquaphor being signed off as administered by Registered Nurse (RN) #42. Observation and interview on 01/06/26 at 4:20 P.M. of Resident #41 revealed no visible Aquaphor present on bilateral lower legs. Resident #41 reported no one had applied any Aquaphor to her legs all day. Observation and interview on 01/06/26 at 4:22 P.M. with the Administrator revealed verification that Resident #41 did not have any Aquaphor visible on lower legs and that the MAR was signed off as being administered already for the 2:30 P.M. to 4:30 P.M. time slot. Interview on 01/06/26 at 4:24 P.M. with RN #42 revealed she had just signed off the Aquaphor administration for Resident #41 and had not yet administered it and was getting ready to go apply the Aquaphor to Resident #41 legs. 2. Review of medical record for Resident #43 revealed admission to facility on 12/30/23 for diagnoses including heart failure, stroke affecting right side with paralysis, concentration and memory deficits following stroke, language deficits following stroke, morbid obesity, depression, incontinence of feces and urine, and high blood pressure. Review of the most recent annual comprehensive assessment on the MDS completed on 12/25/25 revealed Resident #43 to have a BIMS score of 3/15 indicating severe cognitive/memory impairment. Further review of the MDS assessment revealed Resident #43 to be on a bladder and bowel incontinence program for frequent urinary and fecal incontinence. Review of the most recent care plan updated on 12/25/25 for Resident #43 revealed a care plan initiated on 01/19/24 for Resident #43 to be on a routine bowel and bladder program including to have staff check and offer toileting assistance every two hours. Review of the Bladder Program Service Delivery Record for November 2025, December 2025, and January of 2026 revealed numerous blank areas to identify if Resident #43 was checked for incontinence or assisted to the toilet. Further review for December 2025 revealed no documentation on 12/06/25, 12/09/25, 12/11/25, 12/12/25, 12/14/25, 12/15/25, 12/17/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, 12/24/25, 12/25/25, 12/29/25, and 12/30/25 on the Bladder Program Service Delivery Record. Interview on 01/07/26 at 1:55 P.M. with Certified Nursing Assistant (CNA) #57 revealed that the CNAs are to perform incontinence checks and toileting assistance every two hours and record if the resident is incontinent or not in the logbook at the nurses desk. CNA #57 demonstrated the location of the logbook containing residents who are bowel and bladder programs. CNA #57 reviewed the Bladder Program Service Delivery Record for December of 2025 for Resident #43 and verified missing documentation for several dates. CNA #57 reported that sometimes the aides forget to sign the logs including herself. 3. Review of the medical record revealed Resident #10 was admitted on [DATE] with diagnoses that included Alzheimer's disease, schizoaffective disorder, bipolar, severe protein-calorie malnutrition, anxiety, paranoid schizophrenia, cerebral palsy, and major depressive disorder. The plan of care dated 10/25/23 revealed Resident #10 was at risk for altered nutrition. Resident #10 liked sweets, pop, milk, ice cream, pudding, and yogurt. The resident had variable oral intakes from zero to 100%. The resident accepts supplements. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a brief interview for mental status (BIMS) score of seven which indicated severe cognitive impairment. Interventions included supplements as ordered and offer menu alternatives as needed On 11/05/25, Resident #10 weighed 90 pounds.On 12/01/25, Resident #10 weighed 87 pounds. A dietician note dated 12/03/25 at 10:46 A. M. revealed Resident #10 had a significant weight loss of 8.4% in the last 90 days and 13% in the last 180 days. The resident ' s meal intakes remained variable. Resident #19 received a house supplement four times a day, fortified ice cream with lunch and dinner, and preferred milk at meals. Review of the meal intake documentation revealed on 12/06/25 and 12/07/25 the only meal documented was dinner. There was no documentation for meal intakes on 12/20/25. On 12/25/25,12/31/25, 01/02/26, 01/03/26, 01/04/26 the only meal documented was at dinner. A dietician note dated 01/07/26 at 12:30 P.M. revealed Resident #10 ' s body mass index was 14.93 and was below healthy range for age. Resident #10 ' s intakes were widely variable from one percent to a hundred percent. An interview on 01/07/26 at 1:23 P.M. Regional Dietician Consultant #98 verified the meal intakes were not always documented. If a resident refused a meal, the documentation should reflect the refusal. Regional Dietician Consultant #98 stated she would interview the staff to see how Resident #10 was eating. The lack of documentation had been addressed with the certified nursing assistants in the past. An interview on 01/07/26 at 4:08 P.M. Director of Nursing verified meal documentation for Resident #10 was missing in the electronic record. This deficiency represents non-compliance investigated under Master Complaint Number 2696509.

Based on record review, observation, interview and facility policy review, the facility failed to store portable oxygen tanks in an oxygen storage area. This deficient practice affected one resident (#1) out of two residents reviewed for respiratory care. The facility census was 62.Findings Include: Review of Resident #1 ' s medical record revealed admission date 11/01/25 with diagnoses including but not limited to cerebral infarction, dysphagia, hemiplegia, Chronic Obstructive Pulmonary Disease (COPD), and anemia.Review of Resident #1 ' s physician orders revealed no orders for oxygen use.Review of Resident #1 ' s care plan dated 11/07/25 revealed no implementation of oxygen use for any disease process.Observation on 01/05/26 at 10:15 A.M. revealed in Resident #1 ' s room two portable oxygen tanks with regulators in place, separately secured in transport carts located in the closet area of the room, behind the door. Further observation revealed a portable oxygen tank unsecured in a canvas bag, for use on a wheelchair, leaning upright in a chair near the window of the room.An interview on 01/05/26 at 10:40 A.M. with Certified Medication Assistant (CMA) #53 confirmed the two secured oxygen tanks in the portable carts in the closet behind the door and the unsecured portable oxygen tank in the canvas bag leaning up right in the chair by the window. CMA #53 stated the portable oxygen tanks are to be stored in the oxygen storage room and not in a resident ' s room.Review of the facility's policy Oxygen- Use/Storage dated 05/01/25 revealed when oxygen is discontinued or is ordered as needed (PRN), oxygen concentrators and liquid oxygen no longer in use will always be stored and secured in the oxygen storage area.

Based on record review, observation, interview, and facility policy review, the facility failed to implement fall interventions for a fall risk resident. This affected one resident (#50) out of six residents reviewed for falls. The facility census was 62.Findings Include: Review of Resident #50 ' s medical record revealed admission date 09/02/25 with diagnoses including but not limited to high blood pressure, hallucinations, weakness and cognitive communication deficit. Review of Resident #50 ' s Falls Risk Observation dated 09/02/25 revealed Resident #50 was at moderate risk for falls with a score of eight, (a score of 10 or higher represents a high risk for falls). Further review revealed Resident #50 ' s Falls Risk Observation dated 10/09/25 revealed Resident #50 was at a high risk for falls with a score of 14.Review of Resident #50 ' s Safety Event - Fall Without Injury Event dated 10/21/25 at 12:14 A.M. revealed Resident #50 was observed lying on the floor beside the bed. Fall interventions in place at the time of the fall included bed in lowest position.Review of Resident #50 ' s fall care plan revised 10/21/25 revealed fall intervention implemented for a perimeter mattress to the bed to assist in defining edges of the bed.Observation on 01/08/26 at 9:46 A.M. revealed Resident #50 ' s bed had a regular flat mattress in place with no perimeter sides observed.An interview on 01/08/26 at 9:53 A.M. with the Assistant Director of Nursing (ADON) confirmed Resident #50 ' s bed did not have a perimeter mattress in place, instead had a regular flat mattress. The ADON stated Resident #50 had moved into the room sometime in October.Review of the facility policy titled Fall Investigation dated 05/01/25 revealed a member of the interdisciplinary team will review current interventions and implement additional fall interventions based on residents' risk factors. This deficiency represents non-compliance investigated under Master Complaint Number 2696509.

Based on record review, observation and interviews, the facility failed to maintain range of motion for a resident with contracture. This affected one resident (#17) out of three residents reviewed for range of motion and positioning. The facility census was 62.Findings Include: Review of Resident #17 ' s medical record revealed an admission date 04/30/24 with diagnoses including but not limited to stroke, contractures, vascular dementia, high blood pressure, depression and anxiety. Resident #17 required assistance from staff to complete Activities of Daily Living (ADL) tasks and had intact cognition.Review of Resident #17 ' s physician orders revealed an order dated 11/08/24 for a Left hand palm protector to be applied in A.M. and removed at bedtime (HS). Check skin integrity every shift with application and removal notify nurse with any concerns and an order dated 07/31/25 patient to tolerate hand roll splint or palm protector nightly for decreased risk of worsening contracture and increased hand hygiene. Left hand is to be thoroughly washed and dried prior to donning splint and after removal.Review of Resident #17 ' s Activities of Daily Living (ADL) functional status care plan dated 11/06/24 revealed Resident #17 was to wear a palm protector to left hand for contracture.Review of Resident #17 ' s Treatment Administration Record (TAR) dated 12/01/25 to 01/06/26 revealed the order for a left-hand palm protector to be applied in A.M. and removed at bedtime (HS). Check skin integrity every shift with application and removal notify nurse with any concerns had been marked as being completed. The order for patient to tolerate hand roll splint OR palm protector nightly for decreased risk of worsening contracture and increased hand hygiene. Left hand is to be thoroughly washed and dried prior to donning splint and after removal had also been marked as being completed as ordered.Observation on 01/05/26 at 11:30 A.M. revealed Resident #17 sitting in a wheelchair in her room watching TV. There was no palm protector visible in Resident #17 ' s left hand.Observation on 01/06/26 at 9:10 A.M. revealed Resident #17 sitting in a wheelchair finishing breakfast meal. There was no palm protector visible in Resident #17 ' s left hand.Observation on 01/06/26 at 3:30 P.M. revealed Resident #17 participating in activities in the dining room. There was no palm protector visible in Resident #17 ' s left hand.Observation on 01/07/26 at 8:02 A.M. revealed Resident #17 was sleeping in bed and there was no palm protector or hand roll splint visible in Resident #17 ' s left hand.Interview on 01/07/26 at 9:35 A.M. with Registered Nurse (RN) #42 confirmed Resident #17 did not have a palm protector placed in her left hand. RN #42 stated the nurse or Certified Nursing Assistants (CNAs) will place the palm protector in Resident #17 ' s left hand. RN #42 further stated Resident #17 ' s palm protector could not be found in the room and had not been in the room for several days.This deficiency represents non-compliance investigated under Master Complaint Number 2696509.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure the residents' environment in the secured unit was clean and homelike. This had the potential to affect all 17 residents (#6, #9, #11, #19, #22, #24, #26, #27, #28, #33, #35, #38, #41, #44, #46, #51, and #57) residing in the secured unit. The facility census was 62. Findings include: 1.Record review for Resident #35 revealed an admission date of 06/20/23. Diagnosis included vascular dementia unspecified severity, muscle weakness, age related physical mobility, lack of coordination, and need for assistance with personal care. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] for Resident #35 revealed Resident #35 was moderately cognitively impaired. Resident #35 required extensive assistance with bed mobility, transfers, and toilet use. Resident #35 used a raised toilet seat. Observation on 11/24/25 at 11:09 A.M. revealed the shared bathroom of Resident #35 and Resident #38 had a plastic toilet seat riser (used to elevate the height of the standard toilet bowl reducing the amount of effort needed to sit and stand). The toilet seat riser had areas of smeared stool. The rim under the seat, (used to hold the seat in place) was broken and dangling in the toilet bowl with black/grey discoloration and dried urine. The area had a foul odor. Resident #35 wheeled himself in the bathroom and began to transfer himself onto the raised toilet seat. CNA #210 entered and assisted Resident #35 onto the raised toilet seat to toilet. CNA #210 verified the broken raised toilet seat that had dried stool and urine. 2. Record review for Resident #38 revealed an admission date of 02/20/24. Diagnosis included unspecified dementia without behavioral disturbances, muscle weakness, and need for assistants with personal care.Review of the significant change in status MDS assessment dated [DATE] revealed Resident #38 was rarely or never understood, was frequently incontinent of bowel and bladder, required partial/moderate assistance with toileting hygiene, and supervision or touch assistance with chair/bed to chair transfer, and ambulation. Observation and Interview on 07/24/25 at 7:43 A.M. with Certified Nursing Assistant (CNA) #210 revealed the toilet in the shower room (located in the secured unit) was not flushing consistently, and it hadn't been for about two weeks. CNA #210 revealed they used the toilet in the shower room every day to assist residents with toileting after meals and revealed maintenance had been notified on several occasions. Observation of the toilet in the shower room with CNA #210 confirmed the toilet was not working properly and did not flush. Observation revealed the floor surrounding the toilet appeared dirty with a large amount of dirt/grime build up. Inside the shower, the caulking on the floor was grey/black. Observation revealed there was only one shower room on the secured unit.Observation and interview on 07/24/25 at 4:29 P.M. with CNA #308 confirmed she was the CNA for the second shift. First shift CNAs had left for the day. Observation of the raised toilet seat in Resident #35 and #38's shared bathroom revealed the raised toilet seat was still present, broken and uncleaned. The bathroom also still had a foul strong odor of urine. CNA #308 lifted the riser. The bottom of the riser had stained dried stool/urine along with a black/grey substance. CNA #308 confirmed the observation. Interview on 07/28/25 at 12:09 P.M. with Program Director #204 verified both residents, Residents #35 and #38 used the same raised toilet seat. Program Director #204 confirmed Resident #38 did not have an order or care plan for the raised toilet seat but again verified he does use it daily. Program Director #204 confirmed all residents residing in the secured unit use the shower. Observation and interview on 07/28/25 at 12:20 P.M. with Maintenance Coordinator #263 confirmed staff reported the toilet in the secured unit shower room was not working. Maintenance Coordinator #263 revealed when he checked it, it was working. Observation of the shower room in the secured unit revealed the toilet flushed. Maintenance Coordinator #263 confirmed surrounding the toilet and on the base was dirt/grime build up. There was also rust build up on the base of the toilet and on the floor surrounding the toilet. Maintenance Coordinator #263 revealed the rust was from water. Maintenance Coordinator #263 verified in the shower stall there was black/grey mold along the caulking on the floor and revealed he recently cleaned and repaired the wall in the shower stall where there was also a large amount of mold.Review of the facility policy titled, Environmental Services updated 07/01/25 revealed it is the facilities policy to maintain the resident's environment is a clean and sanitary condition.This deficiency represents non-compliance investigated under Complaint Number 1373625 (OH00167388).

Based on interview, record review, and review of the facility policy, the facility failed to ensure Resident #35 was free from physical restraints. This affected one resident (#35) of one resident reviewed for physical restraints. The facility census was 62. Findings include: Record review for Resident #35 revealed an admission date of 06/20/23. Diagnosis included vascular dementia unspecified severity, muscle weakness, age related physical mobility, lack of coordination, and need for assistance with personal care. Review of Resident #35's care plan dated 09/21/23 revealed Resident #35 had impaired ability to perform or participate in activities of daily living (ADL) care. Interventions included to assist Resident #35 with toileting if needed, encourage the resident to participate with care as tolerated, and provide nail care and shampoo hair with showers per weekly schedule. Continued review of Resident #35's care plan dated 01/19/25 and 05/09/25 included Resident #35 will maintain daily routine that promotes maximum mental health and wellbeing; Report any increase or exacerbation of behaviors or conditions to physician, remove resident to a quiet area and allow time to re-focus. Encourage Resident #35 to voice concerns, identify factors that may cause exacerbation of behaviors such as overstimulation, and involve the resident in daily care and decision making as much as possible. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] for Resident #35 revealed Resident #35 was moderately cognitively impaired. Resident #35 required extensive assistance with bed mobility, transfers, toilet use, and supervision with eating. Observation on 07/24/25 at 7:43 A.M. revealed Resident #35 was seated in his wheelchair. Resident #35 propelled himself without difficulty using his upper and lower extremities. Resident #35 was pleasant and was able to converse appropriately. Interview on 07/24/25 at 7:45 A.M. with Certified Nursing Assistant (CNA) #210 revealed she and CNA #277 came in one day in June 2025 to start their shift. Resident #35 rolled out of his room in his wheelchair crying. Resident #35 said a CNA and a nurse sat on top of him and trimmed his nails and cut him. CNA #210 recalled Resident #35 had a band aid on his thumb. Interview on 07/24/25 at 11:13 A.M. with CNA #277 revealed she and CNA #210 came into work one morning, this was sometime during the beginning of June 2025, and observed Resident #35 crying. Resident #35 was crying, complaining of his finger, and I asked what was wrong. Resident #35 stated staff the night prior cut his nail. Resident #35's thumb nails were always long, he stated he liked them long as it helped him open things, and staff left them long. CNA #277 revealed the night shift CNA the night prior had reported Resident #35 was being combative that night. Resident #35 had reported he was on the toilet the night prior and they (night shift staff) came in, cut his nails. Resident #35 reported staff were holding him down, cutting his nails, and cut his thumb. CNA #277 revealed she had observed Resident #35 with a band aid on his thumb and she reported this to Program Director #204 the same morning it occurred. Interview on 07/24/25 at 3:24 P.M. with Program Director #204 revealed she was the coordinator for the secured unit. Program Director #204 reported she was told the staff trimmed Resident #35's nails because he had been clawing at them. Staff had reported Resident #35 was soaked and they went in to change him when he started grabbing them and digging his nails into them. Program Director #204 questioned if he had actually allowed the staff to trim his nails as she knew how he was about his fingernails and he preferred long thumb nails. Staff reported the nurse trimmed one hand while the CAN held the other hand. Program Director #204 reported that was all she had been told. She was not sure if staff had applied a band aid, but a CNA from another shift may have said something about putting a band aid on but she could not remember for sure. Program Director #204 recalled the nurse involved was Licensed Practical Nurse (LPN) #223 and the aide involved was CNA involved was CNA #202. Review of Resident #35's medical record from 01/01/25 to 07/24/25 with Program Director #204 at the time of the interview confirmed there was no documentation including in the physician orders, progress notes, or evidence of skin assessments related to the occurrence or injury to Resident #35's thumb. Record review of the incident reports with Program Director #204 confirmed there was no report of the incident for Resident #35. Interview on 07/24/25 at 4:13 P.M. with Resident #35's family member revealed she recalled the day when the night shift staff trimmed Resident #35 ' s nails. When she came into the facility that morning, she saw the band aid on his thumbnail. The family member stated, I got there, it was a month or two ago, he was upset, he did get teary eyed talking about it, he did have a band aid on it, they cut back too far, I guess it bled quite a bit so that' s why. The family member additionally reported she now comes in and trims Resident #35's nails herself. Resident #35 had reported to her that one staff member held his arms down while another trimmed his nails, and he was upset. Program Director #204 had told her it was night shift who had trimmed the nails, that she was unsure what happened but was sorry and asked the family member to trim the nails from then on. The family member reported she had been trimming the resident's nails before that incident, but they must have gotten longer than she had thought. Interview on 07/24/25 at 4:24 P.M. with Resident #35 stated, I was in the bathroom, I don't know why they came in they were hurrying me, the one sat on my legs and the other held my arms, it was my left nail, I told her to stop, she didn't, and she cut back to far it cut in and bled everywhere. Resident #35 reported after they let him go, the staff member cleaned up the blood. Resident #35 reported to his family member he was so upset. Resident #35 reported he liked his thumb nails long and stated he used to work construction and with wood and would use the nail kind of like a putty knife and always kept his thumb nails long. Interview on 07/25/25 at 6:58 A.M. with CNA #202 confirmed she recalled the night when she assisted in trimming Resident #35 ' s nails. A #202 stated Resident #35 did not want staff to cut his nails. CNA #202 was trying to change him and he was scratching, hitting, and kicking her. CNA #202 went to retrieve LPN #223. LPN #223 got her fingernail clippers, came into Resident #35's bathroom where he was seated on the toilet. She held his arm and trimmed his nails while CNA #202 held his other arm down. CNA #202 reported she had to hold the resident's other arm down so the nurse could trim the resident's nail as he was fighting so bad. CNA #202 stated LPN #223 clipped his finger and it did bleed. LPN #223 cleansed it and then applied a band aid. Resident #35 was cussing and fussing. After his nails were trimmed, Resident #35 stood up, care was completed, and CNA #202 proceeded to care for another resident. Review of the facility policy titled, Restraint - Physical revealed the facility's policy is to provide safety or postural support of a resident to prevent injury to the resident or others when the resident has medical symptoms that warrant the use of restraints. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation undated revealed the facility will not tolerate Abuse, Neglect, Misappropriation of Resident Property or Exploitation of its residents. The definition of abuse included the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain, or mental anguish. This deficiency represents non-compliance investigated under Master Complaint Number 2569408 and Complaint Number 2566715.

Based on interview, record review, and review of the facility policy, the facility failed to notify the physician and/or responsible party of a change in condition. This affected three residents (#7, #35, and #46) of four residents reviewed for notification of change in condition. The facility census was 62.Findings include:1.Record review for Resident #35 revealed an admission date of 06/20/23. Diagnosis included vascular dementia unspecified severity, muscle weakness, age related physical mobility, lack of coordination, and need for assistance with personal care. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] for Resident #35 revealed Resident #35 was moderately cognitively impaired. Resident #35 required extensive assistance with bed mobility, transfers, toilet use, and supervision with eating. Review of the care plan for Resident #35 dated 05/09/25 revealed Resident #35 had depression and anxiety. The goal included Resident #35 will maintain a daily routine that promotes maximum mental health and well being. Interventions included to report any increase or exacerbation of behaviors or conditions to physician, remove resident to a quiet area and allow time to re-focus. Notify the physician, encourage the resident to voice concerns, and identify factors that may cause exacerbation of behaviors such as overstimulation, time of day. Interview on 07/24/25 at 7:45 A.M. with Certified Nursing Assistant (CNA) #210 revealed she and CNA #277 came in one day in June 2025 to start their shift. Resident #35 rolled out of his room in his wheelchair crying. Resident #35 said a CNA and a nurse sat on top of him and trimmed his nails and cut him. CNA #210 recalled Resident #35 had a band aid on his thumb. Interview on 07/24/25 at 11:13 A.M. with CNA #277 revealed she and CNA #210 came into work one morning, this was sometime during the beginning of June 2025, and observed Resident #35 crying. Resident #35 was crying, complaining of his finger, and I asked what was wrong. Resident #35 stated staff the night prior cut his nail. Resident #35's thumb nails were always long, he stated he liked them long as it helped him open things, and staff left them long. CNA #277 revealed the night shift CNA the night prior had reported Resident #35 was being combative that night. Resident #35 had reported he was on the toilet the night prior and they (night shift staff) came in, cut his nails. Resident #35 reported staff were holding him down, cutting his nails, and cut his thumb. CNA #277 revealed she had observed Resident #35 with a band aid on his thumb and she reported this to Program Director #204 the same morning it occurred. Interview and record review on 07/24/25 at 3:24 P.M. with Program Director #204 of Resident #35's medical record from 01/01/25 to 07/24/25 confirmed there was no documentation of Resident #35's physician being notified of the incident when staff trimmed his nails on night shift. Interview on 07/24/25 at 4:13 P.M. with Resident #35's family member revealed she recalled the day when the night shift staff trimmed Resident #35's nails. When she came in to the facility that morning, she saw the band aid on his thumbnail. The family member stated, I got there, it was a month or two ago, he was upset, he did get teary eyed talking about it, he did have a band aid on it, they cut back too far, I guess it bled quite a bit so that's why. The family member additionally reported she now comes in and trims Resident #35's nails herself. Resident #35 had reported to her that one staff member held his arms down while another trimmed his nails, and he was upset. Program Director #204 had told her it was night shift who had trimmed the nails, that she was unsure what happened but was sorry and asked the family member to trim the nails from then on. The family member reported she had been trimming the resident's nails before that incident, but they must have gotten longer than she had thought. Interview on 07/24/25 at 4:24 P.M. with Resident #35 stated, I was in the bathroom, I don't know why they came in they were hurrying me, the one sat on my legs and the other held my arms, it was my left nail, I told her to stop she didn't she cut back to far it cut in and bled everywhere. Resident #35 reported after they let him go, the staff member cleaned up the blood. Resident #35 reported to his family member he was so upset. Resident #35 reported he liked his thumb nails long and stated he used to work construction and with wood, and would use the nail kind of like a putty knife and always kept his thumb nails long. Interview on 07/25/25 at 6:58 A.M. with CNA #202 confirmed she recalled the night when she assisted in trimming Resident #35's nails. CNA #202 stated Resident #35 did not want staff to cut his nails. CNA #202 was trying to change him and he was scratching, hitting, and kicking her. CNA #202 went to retrieve LPN #223. LPN #223 got her fingernail clippers, came into Resident #35's bathroom where he was seated on the toilet. She held his arm and trimmed his nails while CNA #202 held his other arm down. CNA #202 reported she had to hold the resident's other arm down so the nurse could trim the resident's nail as he was fighting so bad. CNA #202 stated LPN #223 clipped his finger and it did bleed. LPN #223 cleansed it and then applied a band aid. Resident #35 was cussing and fussing. After his nails were trimmed, Resident #35 stood up, care was completed, and CNA #202 proceeded to care for another resident. 2. Record review for Resident #46 revealed an admission date of 06/12/24. Diagnosis included metabolic encephalopathy, Alzheimer's disease, history of falling, muscle weakness and need for assistance with personal care. Review of the care plan for Resident #46 dated 10/23/24 revealed Resident #46 frequently thinks he is working, tinkers with items, crawls on the floors and under furniture at times to work. Interventions included providing a fidget board. Review of the MDS quarterly assessment dated [DATE] revealed Resident #46 was rarely or never understood. Resident used a walker or wheelchair for mobility. Resident #46 required supervision or touching assistance with eating, bed mobility, substantial/maximal assistants with sit to stand, transfers, toileting, bathing, and personal hygiene and partial/moderate assistance with walking. Resident #46 had no falls since admission.Review of the medical record for Resident #46 for June 2025 revealed no documentation of Resident #46 having a bruised left eye prior to going to the hospital.Review of the progress note dated 06/18/25 at 10:11 A.M. completed by Program Director Licensed Practical Nurse (LPN) #204 revealed she spoke with Resident #46's daughter who voiced understanding and acknowledged she was aware Resident #46 was transferred to the hospital. Review of the progress note dated 07/04/25 at 11:30 A.M. completed by Registered Nurse (RN) #316 revealed Resident #46 returned to the facility from a hospital stay. Resident #46 had no skin concerns except for a bruised left under eye area. Review of the wound summary report from 05/01/25 through 07/24/25 to include bruises revealed Resident #46 had no documentation related to the bruise left eye. Interview on 07/24/25 at 1:18 P.M. with Program Director #204 revealed Resident #46 went to the hospital on 6/17/25 due to unmanageable behaviors. Resident #46's family lived out of state and rarely visited. Program Director #204 revealed Resident #46 had a bruised left eye before going to the hospital stating, It was swollen, mushy, we used ice packs on it. Program Director #204 confirmed there was no documentation in Resident #46's medical record about the bruised and swollen left eye that was treated with ice packs and revealed she was unsure how the incident occurred. Program Director #204 confirmed Resident #46's physician nor Guardian was notified of Resident #46's bruised and swollen left eye.Interview on 07/24/25 at 2:21P.M. with DON revealed she happened to be back on the secured unit on 06/12/25 and witnessed Resident #46 hitting his eye with the siderail as he was trying to scoot himself out of bed. DON confirmed the shower record dated 06/13/25 revealed Resident #46 had a bruised left eye. DON confirmed there was no documentation in the entire medical record regarding the incident, or the black eye that required ice packs until Resident #46 returned from the hospital on [DATE] when he still had residuals of the black eye. DON confirmed Resident #46's family and physician should have been notified of the incident, bruise, and treatment of ice packs provided. Interview on 07/24/25 at 2:52 P.M. with Resident #46's emergency contact revealed she was Resident #46's Guardian of health. Resident #46's Guardian revealed she received a call from the Hospital Social Worker after Resident #46 was transferred to the hospital on [DATE] who revealed to her Resident #46 arrived to the hospital with a black eye. Resident #46's Guardian stated, This was the first time I heard about it. 3. Record review for Resident #7 revealed an admission date of 04/30/24. Diagnosis included type two diabetes mellitus with diabetic neuropathy, personal history of urinary tract infections, hemiplegia and hemiparesis following cerebral infarction, obstructive and reflux uropathy, presence of urogenital implants, need for assistance with personal care, and muscle weakness. Review of the care plan dated 05/01/24 for Resident #7 revealed Resident #7 had urinary obstruction, urinary retention, cystitis, unspecified hydronephrosis, right urinary stent placement, overactive bladder, and bloody urine at times. Interventions included to report UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning pain, foul odor, concentrated urine, blood in urine). Review of the MDS quarterly assessment dated [DATE] for Resident #7 revealed Resident #7 was moderately cognitively impaired. Resident #7 was always incontinent of bowel and bladder, was dependent for toileting hygiene, lower body dressing, bed mobility, chair/bed to chair transfers, and toilet transfer. Resident had no pain in the previous five days. Observation on 07/25/25 at 4:10 P.M. of incontinence care for Resident #7 with Certified Nursing Assistant (CNA) #239 and #281 revealed Resident #7's brief was saturated with a mixture of foul-smelling blood and urine. Resident #7 stated I have a UTI. CNA #239 and #281 confirmed the large amount of foul-smelling blood and urine in the brief and revealed the blood and urine has been in Resident #7's briefs when they change her for more than a month. CNA #281 revealed she remembered because that was when she started working at the facility and Resident #7 was bleeding then and has been ever since. Observation revealed as the CNA wiped Resident #7s vaginal area to clean her, the cloth had bright red smears of blood after each wipe. Interview and record review of Resident #7's medical record on 07/25/25 at 4:24 P.M. with the Director of Nursing (DON) and Administrator from 06/01/25 through 07/25/25 revealed Resident #7 had no documentation in the medical record of having blood in her urine. The DON revealed Resident #7 had a history of UTI's with blood in the urine but none recently. The DON revealed she was unaware of Resident #7 currently having blood in the urine and confirmed if Resident #7 had blood in the urine, the nurses should have assessed Resident #7 when the bleeding started, notified the physician, and documented the assessment and notification. Phone interview on 07/25/25 at 4:47 P.M. with Resident #7's Primary Physician/Medical Director #320 with the DON and Administrator present revealed she was not aware Resident #7 had blood in her urine recently. Primary Physician/Medical Director #320 stated, She has had that in the past but not recently; I do need to be made aware when that happens so we can address that, no one made me aware. Interview on 07/28/25 at 12:40 P.M. with Certified Nurse Practitioner (CNP) #321 revealed she worked with Primary Physician/Medical Director #320 and Resident #7. CNP #321 confirmed she was not told about Resident #7's blood in the urine. CNP #321 revealed Resident #7 had a history of blood in the urine but none active since her last UTI several months ago. CNP #321 revealed she would have wanted to be informed and was not. Review of the facility policy titled, Change in the Resident's Condition or Status updated 05/01/25 revealed the nurses will immediately notify the resident; consult with the resident's attending physician, on call physician, nurse practitioner, physician assistant, or clinical nurse specialist and notify the residents authorized representative or interested family member when there is a significant change in the resident's physical, mental, or psychosocial status in either life threatening condition or clinical complications. This deficiency represents non-compliance investigated under Master Complaint Number 2569408.

Based on observation, interview, record review, and review of the facility policy, the facility failed to timely assess and notify the physician when Resident #7 was noted to have blood in her urine. This affected one resident, Resident #7 of three resident reviewed for incontinence care. The facility census was 62. Findings include: Record review for Resident #7 revealed an admission date of 04/30/24. Diagnosis included type two diabetes mellitus with diabetic neuropathy, personal history of urinary tract infections, hemiplegia and hemiparesis following cerebral infarction, obstructive and reflux uropathy, presence of urogenital implants, need for assistance with personal care, and muscle weakness. Review of the care plan dated 05/01/24 for Resident #7 revealed Resident #7 had urinary obstruction, urinary retention, cystitis, unspecified hydronephrosis, right urinary stent placement, and overactive bladder, bloody urine at times. Interventions included to report UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning pain, foul odor, concentrated urine, blood in urine). Review of the physician order for Resident #7 dated 06/26/24 revealed Resident #7 received Macrodantin (an antibiotic) 50 milligrams (mg) orally once a day for urinary tract infection (UTI) prophylactic (Intended to prevent UTI). Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #7 was moderately cognitively impaired. Resident #7 was always incontinent of bowel and bladder, was dependent for toileting hygiene, lower body dressing, bed mobility, chair/bed to chair transfers, and toilet transfer. Resident #7 had no pain marked in the past five days. Observation on 07/25/25 at 4:10 P.M. of incontinence care for Resident #7 with Certified Nursing Assistant (CNA) #239 and CNA #281 revealed Resident #7's brief was saturated with a mixture of foul-smelling blood and urine. Resident #7 stated I have a UTI. CNAs #239 and #281 confirmed the large amount of foul-smelling blood and urine in the brief and revealed the blood and urine has been in Resident #7's briefs when they change her for more than a month. CNA #281 revealed she remembered because that was when she started working at the facility; Resident #7 was bleeding then and has been ever since. Observation revealed as the CNAs wiped Resident #7's perineal area to clean her, the cloth had bright red smears of blood after each wipe. Interview and record review of Resident #7's medical record on 07/25/25 at 4:24 P.M. with the Director of Nursing (DON) and Administrator from 06/01/25 through 07/25/25 revealed Resident #7 had no documentation in the medical record of having blood in her urine. The DON revealed Resident #7 had a history of UTIs with blood in the urine, but none recently. The DON revealed she was unaware of Resident #7 currently having blood in the urine and confirmed if Resident #7 had blood in the urine, the nurses should have assessed Resident #7 when the bleeding started, notified the physician, and documented the assessment and notification. Phone interview on 07/25/25 at 4:47 P.M. with Resident #7's Primary Physician/Medical Director #320 with the DON and Administrator present revealed she was not aware Resident #7 had blood in her urine recently. Primary Physician/Medical Director #320 stated, She has had that in the past but not recently; I do need to be made aware when that happens so we can address that, no one made me aware. Interview on 07/28/25 at 11:14 A.M. with Registered Nurse (RN) 221 confirmed she was the charge nurse on day shift on 07/25/25. RN #221 revealed she was not told at any time during the previous month that Resident #7 had blood in her brief when being changed. RN #221 revealed CNAs do not always tell the nurses when something is going on, they know they are supposed to, but they just don't. Phone interview on 07/28/25 at 11:30 A.M. with Primary Physician/Medical Director #320 revealed a person could still have a UTI even if they were on a prophylactic antibiotic if the antibiotic was resistant. Primary Physician/Medical Director #320 revealed she ordered labs including a urinalysis and a complete blood count, a bladder/kidney ultrasound, and a gynecology consult for Resident #7 due to the blood in the urine reported on 07/25/25. Primary Physician/Medical Director #320 revealed she cannot be sure what is going on, until the culture and ultrasound results are back and the consultation with the gynecologist is completed. Interview on 07/28/25 at 12:40 P.M. with Certified Nurse Practitioner (CNP) #321 revealed she worked with Primary Physician/Medical Director #320 and Resident #7. CNP #321 confirmed she was not told about Resident #7's blood in the urine. CNP #321 revealed Resident #7 had a history of blood in the urine but none since her last UTI several months ago. CNP #321 revealed she would have wanted to be informed and was not. Review of the facility policy titled, Change in the Resident's Condition or Status updated 05/01/25 revealed the nurses will immediately notify the resident; consult with the resident's attending physician, on call physician, nurse practitioner, physician assistant, or clinical nurse specialist and notify the residents authorized representative or interested family member when there is a significant change in the resident's physical, mental, or psychosocial status in either life threatening condition or clinical complications. This deficiency represents non-compliance investigated under Master Complaint Number 2569408 and Complaint Number 2566715.

Based on observation, interview, and record review, the facility failed to ensure one resident, Resident #7, was provided with timely incontinence care. This affected one resident, (Resident #7) of three residents reviewed for incontinence care. The facility census was 62. Findings include: Record review for Resident #7 revealed an admission date of 04/30/24. Diagnosis included personal history of urinary tract infections, hemiplegia and hemiparesis following cerebral infarction, need for assistants with personal care, and muscle weakness. Review of the care plan dated 05/15/24 revealed Resident #7 was incontinent of bladder and was at risk for altered dignity, skin breakdown, and urinary tract infections (UTI). Interventions included to check and provide incontinence care as needed. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #7 was moderately cognitively impaired. Resident #7 was always incontinent of bowel and bladder, and was dependent for toileting hygiene, chair/bed to chair transfers, and toilet transfer. Interview on 07/25/25 between 7:12 A.M. and 9:48 A.M. with Assistant Director of Nursing (ADON) #207 and Registered Nurse (RN) Supervisor #316 revealed residents should be checked and changed if needed every two hours and as needed. Observation on 07/25/25 at 10:00 A.M., 12:10 P.M., and 3:07 P.M. revealed Resident #7 was up in her wheelchair. Interview on 07/25/25 at 3:12 P.M. with Certified Nursing Assistant (CNA) #239 confirmed she was Resident #7's primary CNA. CNA #239 revealed Resident #7 liked up in the morning between 9:00 A.M. and 10:00 A.M., and revealed she provided incontinence care for Resident #7 before she got her up that morning. CNA #239 confirmed she had not checked or changed Resident #7 since she got her up earlier that morning. Interview on 07/25/25 at 3:50 P.M. with Resident #7 revealed the staff got her up before 10:00 A.M. Resident #7 remembered the time because 10:00 A.M. was the scheduled smoking time. Resident #7 stated after the staff get her up into her chair in the morning, the staff do not check to see if she needs to be changed again until she goes to bed in the evening. Resident #7 stated, They never ask to check me, yes I am wet, I am incontinent, and they never check or change me during the day. Requested observation on 07/25/25 at 4:10 P.M. of incontinence care for Resident #7 with CNAs #239 and #281 revealed Resident #7 was transferred to bed via a mechanical lift. CNAs #239 and #281 reported Resident #7 usually goes to bed after the scheduled 7:00 P.M. smoke break. Resident #7 reported during the observation that her buttocks area felt sore. Observation revealed after removing Resident #7's pants, the brief underneath was bulging, saturated, and had a foul odor. Observation revealed after removing the brief, Resident #7's buttocks ware red. Resident #7 confirmed this was the first time she was changed since she got up that morning.

Based on interview, record review, and review of the facility policy, the facility failed to ensure injuries for two residents (#35 and #46) were recorded in each resident's medical record. This affected two (#35 and #46) of three residents reviewed for documentation. The facility census was 62.Findings include: 1. Record review for Resident #35 revealed an admission date of 06/20/23. Diagnosis included vascular dementia unspecified severity, muscle weakness, age related physical mobility, lack of coordination, and need for assistance with personal care. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] for Resident #35 revealed Resident #35 was moderately cognitively impaired. Resident #35 required extensive assistance with bed mobility, transfers, toilet use, and supervision with eating. Interview on 07/24/25 at 7:45 A.M. with Certified Nursing Assistant (CNA) #210 revealed she and CNA #277 came in one day in June 2025 to start their shift. Resident #35 rolled out of his room in his wheelchair crying. Resident #35 said a CNA and a nurse sat on top of him and trimmed his nails and cut him. CNA #210 recalled Resident #35 had a band aid on his thumb. Interview on 07/24/25 at 11:13 A.M. with CNA #277 revealed she and CNA #210 came into work one morning, this was sometime during the beginning of June 2025, and observed Resident #35 crying. Resident #35 was crying, complaining of his finger, and I asked what was wrong. Resident #35 stated staff the night prior cut his nail. Resident #35's thumb nails were always long, he stated he liked them long as it helped him open things, and staff left them long. CNA #277 revealed the night shift CNA the night prior had reported Resident #35 was being combative that night. Resident #35 had reported he was on the toilet the night prior and they (night shift staff) came in, cut his nails. Resident #35 reported staff were holding him down, cutting his nails, and cut his thumb. CNA #277 revealed she had observed Resident #35 with a band aid on his thumb and she reported this to Program Director #204 the same morning it occurred. Interview and record review on 07/24/25 at 3:24 P.M. with Program Director #204 of Resident #35 ' s medical record from 01/01/25 to 07/24/25 confirmed there was no documentation of Resident #35 ' s physician being notified of the incident when staff trimmed his nails on night shift. 2. Record review for Resident #46 revealed an admission date of 06/12/24. Diagnosis included metabolic encephalopathy, Alzheimer ' s disease, history of falling, muscle weakness and need for assistance with personal care. Review of the care plan for Resident #46 dated 10/23/24 revealed Resident #46 frequently thinks he is working, tinkers with items, crawls on the floors and under furniture at times to work. Interventions included providing a fidget board. Review of the MDS quarterly assessment dated [DATE] revealed Resident #46 was rarely or never understood. Resident used a walker or wheelchair for mobility. Resident #46 required supervision or touching assistance with eating, bed mobility, substantial/maximal assistants with sit to stand, transfers, toileting, bathing, and personal hygiene and partial/moderate assistance with walking. Resident #46 had no falls since admission. Review of the progress note dated 06/18/25 at 10:11 A.M. completed by Program Director Licensed Practical Nurse (LPN) #204 revealed she spoke with Resident #46 ' s daughter who voiced understanding and acknowledged she was aware Resident #46 was transferred to the hospital. Review of the progress note dated 07/04/25 at 11:30 A.M. completed by Registered Nurse (RN) #316 revealed Resident #46 returned to the facility from a hospital stay. Resident #46 had no skin concerns except for a bruised left under eye area. Review of the medical record for Resident #46 for June 2025 revealed no documentation of Resident #46 having a bruised left eye prior to going to the hospital. Review of the wound summary report from 05/01/25 through 07/24/25 to include bruises revealed Resident #46 had no documentation related to the bruise left eye. Interview on 07/24/25 at 1:18 P.M. with Program Director #204 revealed Resident #46 went to the hospital on 6/17/25 due to unmanageable behaviors. Resident #46 ' s family lived out of state and rarely visited. Program Director #204 revealed Resident #46 had a bruised left eye before going to the hospital stating, It was swollen, mushy, we used ice packs on it. Program Director #204 confirmed there was no documentation in Resident #46 ' s medical record about the bruised and swollen left eye that was treated with ice packs and revealed she was unsure how the incident occurred. Program Director #204 confirmed Resident #46's physician nor Guardian was notified of Resident #46 ' s bruised and swollen left eye. Record review on 07/24/25 at 2:19 P.M. with Program Director #204 who presented a QAA document dated 06/12/25 naming Resident #46 as the person involved. The form was signed by the Director of Nursing (DON) and stated the resident purposefully attempted to get out of bed and down to the floor. Resident #46's head was near the handrail as he tried to lower himself. The documentation included the resident became agitated when the DON tried to assist and continued trying to get out of bed using the handrail. Interview on 07/24/25 at 2:21P.M. with DON revealed she happened to be back on the secured unit on 06/12/25 and witnessed Resident #46 hitting his eye with the siderail as he was trying to scoot himself out of bed. DON confirmed she did not complete an incident report because since she witnessed it, it was not a fall. DON revealed she did a skin assessment, but did not document it, and Resident #46's eye was not red at that time. The DON stated, It wasn't a hard hit so my main goal wasn't his face. The DON demonstrated how Resident #46 hit his eye on the side rail by repeating her hand/head motion with the hands holding the side rail and resident #46's head repeatedly hitting the siderail in the location of the left eye. DON confirmed there were no neurochecks done, no vital signs, no skin assessment documented and no documentation in the entire medical record regarding the incident, or the black eye that required ice packs until Resident #46 returned from the hospital on [DATE] when he still had residuals of the black eye. DON confirmed the bruise and how it occurred with assessments and any treatment orders should have been documented in Resident #46's medical record. Review of the facility policy titled, Change in the Resident's Condition or Status updated 05/01/25 revealed the nurse will record in the resident's medical record information relative to changes in the resident's medical /mental condition or status. This deficiency represents non-compliance investigated under Master Complaint Number 2569408.

Based on observation, interview, and facility policy review, the facility failed to ensure appropriate food storage in the kitchen's dry storge area. Additionally, the facility failed to ensure the Robo-coupe (food processor) was clean and dry prior to pureeing Resident #21 and #23 meals and ensure a contained spoon was not placed into the mixture. This affected two residents (#21 and #23) and had the potential to affect 56 of 56 residents who received meals from the kitchen. The facility identified two residents (#1 and #30) who received nothing by mouth (NPO) and had NPO diet orders The facility census was 58. Findings include: 1. Observation on [DATE] at 8:10 A.M. of the facility's dry food storage in the kitchen revealed six loafs of expired wheat bread. The expiration date was noted to be [DATE]. Upon further examination all six loafs of bread were observed to have visible mold growing on the bread. Interview on [DATE] at 8:10 A.M. Dietary Coordinator (DC) #507 confirmed the findings and removed the bread from the storage areas. Continued interview with DC #507 revealed all residents would have the potential to receive this bread except for Resident #1 and Resident #30 who did not receive any food by mouth. Review of the undated facility policy titled Dry Storage and Supplies revealed all non-perishable food shall be stored in a manner that optimized food safety and quality. Stock in dry storage (areas) shall be rotated such that new deliveries are placed behind existing stock. 2. Observation on [DATE] at 10:15 A.M. revealed [NAME] #415 washed her hands and prepared to puree au gratin potatoes. After ensuring a proper consistency she placed the potatoes into a serving dish and took the food item to the steam table. She returned and placed the Robo-coupe in the facility high temperature dish washer at 10:22 A.M. [NAME] #415 returned with the Robo coupe which was observed to still wet from the dishwasher placed it on the counter. Remains of visible mashed potatoes could be seen on the side of the Robo-coupe. [NAME] #415 then placed meatloaf, beef broth, and bread into the machine and pureed until it met the correct consistency. She placed the puree meatloaf into a serving dish and took it to the steam table. At 10:26 A.M. the Robo-coupe was taken to the dishwasher. At 10:27 A.M. it was brought back to the counter with visible signs of wetness and [NAME] #415 placed mixed vegetables, bread and margarine into the machine to blend. After the mixture was blended, [NAME] #415 placed the mixed vegetables into serving dish and taste tested the mixture with a plastic spoon. After placing the spoon in her mouth to test the food she placed the same plastic spoon into the mixture and stirred the vegetables checking the consistency. After stirring the mixture with the dirty spoon, she went to place it on the steam table to be served. Interview on [DATE] at 10:27 A.M. with Dietary Coordinator (DC) #507 (who was present for the observation) and [NAME] #415 confirmed the Robo-coupe was not properly cleaned and left to air dry prior to pureeing the meat loaf and mixed vegetables. Both also confirmed [NAME] #415 placed her spoon into the vegetable mixture after it was already in her mouth. DC #507 revealed the facility had two residents who received puree meals (Resident #21 and Resident #23). Review of the facility policy titled Puree Diets, dated ,d+[DATE] revealed puree food was to be prepared in a clean food processor for each item being prepared. Puree items were to be taste tested to ensure that the consistency was correct and hold their shape.