Every finding on record at Mallard Bay Nursing and Rehab

Based on interviews and record reviews, it was determined that the facility failed to; notify the resident's responsible party in writing, of the reason for a resident's transfer, to provide the resident and/or resident's responsible party with the bed-hold policy, and to notify the local ombudsman's office of a resident's transfer/discharge. This was evident for 4 (#103, #106, #11, #2) out of 4 residents reviewed for hospitalizations during the facility's annual recertification survey.Findings include: 1. A medical record review was conducted for resident # 103 on 8/25/26 at approximately 10:35 AM and upon review it revealed the resident was sent to the hospital on 6/1/26 for unresponsiveness. A medical record review was conducted for resident # 106 on 8/25/26 at approximately 11:35 AM and upon review it revealed the resident was sent to the hospital on 4/13/26 for further evaluation. An interview was conducted with the DON on the same date at approximately 3:33 PM related to the transfer of Residents #103 and #106. She was asked to provide a copy of the transfer documentation that was provided to the resident responsible party, and she stated that the facility does not have the required hospital transfer documentation or bed-hold policy and that the Ombudsman was not notified of the transfers. The DON acknowledged that the transfer documentation and bed-hold policy are required to be given to the resident and /or responsible party, and that the Ombudsman is to be notified as well. She stated that education will be provided regarding this concern. 2. On 08/26/2026 at 11:19 AM, the surveyor interviewed the Director of Nursing (DON) #2. During the interview, the DON #2 informed the surveyor that Resident #11 was transferred/discharged to the hospital on 6/3/26, 7/9/26, 8/4/26, and 8/5/26. On 08/26/2026 at 11:54 AM, the surveyor conducted a record review. During the record review, the surveyor could not locate a signed bed hold policy for when Resident #11 was hospitalized on [DATE], 7/9/26, 8/4/26, and 8/5/26. Also, the surveyor could not locate documentation indicating that Resident #11's responsible party was notified in writing of the reason for the 6/3/26, 7/9/26, 8/4/26, and 8/5/26 transfers. On 08/26/2026 at 12:21 PM, the surveyor interviewed the DON #2. During the interview, the surveyor asked the DON #2 to provide a bed hold policy for when Resident #11 was hospitalized on [DATE], 7/9/26, 8/4/26, and 8/5/26. The surveyor also asked the DON #2 to provide documentation indicating that Resident #11's responsible party was notified, in writing, of the reason for Resident #11's transfer/discharge to the hospital on 6/3/26, 7/9/26, 8/4/26, and 8/5/26. Also, the surveyor asked the DON #2 to provide documentation indicating that the local ombudsman's office was notified of Resident #11's transfer/discharge to the hospital on 6/3/26, 7/9/26, 8/4/26, and 8/5/26. On 08/26/2026 at 2:30 PM, the surveyor interviewed the Director of Nursing (DON) #2. During the interview, the DON #2 stated that the facility does not have a signed bed hold policy for when Resident #11 was hospitalized on [DATE], 7/9/26, 8/4/26, and 8/5/26. The DON #2 also mentioned that the facility does not have documentation indicating that Resident #11's responsible party was notified in writing of Resident #11's reason for being transferred to the hospital on 6/3/26, 7/9/26, 8/4/26, and 8/5/26. Also, the DON #2 mentioned that the facility does not have documentation indicating that the local ombudsman's office was notified of Resident #11's transfer/discharge to the hospital on 6/3/26, 7/9/26, 8/4/26, and 8/5/26. 3. On 8/27/2026 at 3:00 p.m., Review of Resident #2's medical record revealed the resident was transferred to the hospital in December 2025 for severe shortness of breath (SOB), tachycardia, and hypertension. Review of the medical record failed to reveal evidence that the resident's RP or contact person was provided with the facility's transfer/bed-hold policy at the time of the hospital transfer. Further review failed to reveal evidence that the transfer/bed-hold policy was subsequently mailed to the RP or contact person. During interview on 8/27/2026, the Director of Nursing (DON) was unable to provide documentation demonstrating that the RP or contact person was provided with the transfer/bed-hold policy at the time of the resident's transfer to the hospital. The DON was also unable to provide evidence that the documents were mailed to the RP or contact person. All concerns were discussed with the Administration team at the exit conference on 8/28/26.

Based on observations and interviews it was determined that the facility failed to ensure residents' right to dignified experience was maintained. This was evident for 2 (#42, # 97) of 3 residents investigated for dignity and neglect during the facility's annual Medicare/Medicaid survey. The findings include: 1. During an interview on 08/24/2026 at 7:50 am, Resident #42 stated We have to make our own beds around here because staff doesn't offer to help. It has been two weeks since I got my bed changed and I've had the same linen on it for the entire time. I have a hard time reaching across from my chair to remove the sheet and put a new one on and when I go to the laundry cart, I sometimes think that the staff doesn't like me doing that. Resident #42 additionally stated that staff will help if asked but does not offer until Resident #42 says something. At the time of the conversation with Resident #42 the surveyor observed that Resident #42 was sitting up dressed in his/her wheelchair and the bed was disheveled and unmade. During an interview on 08/24/2026 at 8:20 am, Registered Nurse Staff #28 was notified of Resident #42's concern about needing assistance to make the bed and stated that staff was expected to offer this assistance daily to Resident #42. During an interview on 08/24/2026 at 2:30 pm the Director of nursing was made aware of Resident #42's concern and verified that staff should be offering assistance to make the bed. During an interview on 08/26/2026 at 8:05 am Geriatric Nursing Assistant (GNA) Staff #26 was asked by the surveyor if Resident #42 receives assistance with making his/her bed. GNA Staff #26 responded No, the resident makes his/her own bed and that staff knows this by looking at the resident information in the Kardex. (A nursing Kardex is a quick-reference summary sheet or digital screen that nurses use to see essential patient information at a glance.) On 08/26/2026 at 8:10 am a record review of Resident #42's plan of care revealed a self-care performance deficit, a risk for falls-anticipate and meet the resident's needs, impaired mobility, poor safety awareness, left sided hemiparesis/hemiplegia- (paralysis and or weakness). During an interview on 08/26/2026 at approximately 8:30 am Unit Manager Licensed Practical Nurse (LPN) Staff # 29 was made aware that staff stated Resident #42 makes his/her own bed. Unit Manager LPN Staff #29 verified that staff should be offering to do this and it will be investigated. 2. During an observational tour of the clinical unit on 08/27/2026 at 2:23 PM the surveyor observed that Resident #97 was in bed with lights out, bare-chested lying-in bed. The resident stated that the bedside cabinet located on the left side of the bed had three broken drawers and that she/he had asked the nursing staff to replace the bedside cabinet several times. The three broken cabinet drawers were in the resident's chair located on the right side of the resident's bed. Also, the surveyor observed that the room's curtains were drawn, the floor unclean, the walls had several areas of scuffed and/peeled drywall. The surveyor informed the resident they would contact the unit manager to follow up regarding the broken cabinet. At 2:30PM on 08/27/2026 the unit manager was located and advised of broken cabinet prior to entering the resident's room with the surveyor. The unit manager asked the resident how long the cabinet had been broken and whether he/she had reported the broken item to any staff members. The resident responded yes that he/she had informed staff members. The unit manager was asked by the surveyor what was the reporting process for staff regarding broken furniture or equipment. The unit manager stated that the staff are to enter the information into TELS system for the notification of the maintenance director. The unit manager stated that she would enter the broken cabinet into the TELS system. At approximately, 3:15 PM on 08/27/2026 the surveyor notified the DON of the observation of the broken bedside cabinet in room [ROOM NUMBER] and advised her that the unit manager was present and aware of the situation. On 08/28/2026 at 10:00 AM the surveyor observed that the broken bedside cabinet in room [ROOM NUMBER] had been replaced with a functional, clean bedside cabinet. Additionally, Resident #97 reported that his/her room had been cleaned including the floors and his/her personal possessions were now within reach. The resident also shared with the surveyor that he/she had not received incontinence care from 12 noon until 11PM on 08/27/2026. Resident stated that his/her call bell was not responded to in a timely manner and that the GNA for evening shift had not introduced herself at the beginning of shift (3PM) on 08/27/2026. This information was shared with the unit manager and the surveyor was present when Resident #97 retold the information regarding neglect to the unit manager. At approximately 11:00 AM on 08/28/2026 the surveyor was notified by the DON that a facility incident report had been initiated by the facility related to Resident # 97's complaint of not receiving incontinence care from approximately 12 noon until 11 PM on 08/27/2026.

Based on observations, interviews, and record reviews, it was determined the facility failed to consult with the resident's physician; and notify, consistent with his or her authority, the resident representative following significant change in the resident's conditions and/or a need to alter treatment significantly. This was evident for 3 (#17, #89, #75) of 11 residents reviewed for nutrition and medication during the facility's annual Medicare/Medicaid survey.Findings include: 1. Resident #17 was admitted with, but was not limited to, the following diagnoses: traumatic brain injury (TBI), morbid obesity, and mild protein-calorie malnutrition. A medical record review of Resident #17 was conducted on 08/24/2026 at approximately 10:50 AM. The record revealed the following documented weights: -08/07/2026: 212 pounds -08/11/2026: 191 pounds During an interview with the DON on 08/27/2026 at approximately 3:00 PM, the DON was asked to explain the facility's expectations when a resident's weight is obtained, and weight loss is identified. The DON stated that when weight loss is noted, the physician is to be notified. The DON explained that the 212-pound weight documented on 08/07/2026 was the resident's hospital weight. The DON subsequently provided the survey team with a copy of Resident #17's nutritional assessment, which was completed on 08/26/2026. Review of the assessment revealed a weight of 198 pounds on 08/26/2026. Further review of the nutritional assessment revealed that the original admission weight documented as 212 pounds on 08/07/2026 was the hospital weight. According to the assessment, Resident #17 received intravenous Lasix at the hospital for fluid overload, and the hospital weight of 212 pounds was used as the resident's admission weight. The assessment identified the resident's post-admission weight baseline as approximately 191 to 198 pounds. The DON acknowledged that a nutritional assessment should have been completed within 14 days of admission, that the physician should have been notified when the subsequent weight of 191 pounds was obtained, and that an actual admission weight should have been obtained rather than using the hospital weight. The DON further stated that the facility's dietitian was no longer employed at the facility and that a dietitian from another facility assisted with completion of nutritional assessments. The DON stated that education would be provided to facility staff. 2. Resident #89 was admitted to the facility with, but not limited to, diagnoses of rheumatoid arthritis and spondylosis (age-related degenerative changes of the spine). An interview was conducted with Resident #89 during the initial screening process on 8/24/26 at approximately 11:05 AM. The resident stated that they receive an Enbrel weekly injection and that the medication was not administered until Sunday, 8/23/26. The resident further stated that, prior to receiving the medication on 8/23/26, they had gone more than 10 days without receiving the medication. Review of Resident #89's medical record on 8/25/26 at approximately 1:10 PM revealed a physician order for Etanercept (Enbrel) subcutaneous solution, 50 mg, to be administered subcutaneously once weekly every Sunday for pain. The resident also had a physician order for Naprosyn (Naproxen) 500 mg oral tablet that the resident received for pain twice daily. Review of the facility's medication administration audit report for Resident #89 revealed the following documentation for Etanercept (Enbrel) 50 mg/mL subcutaneous prefilled syringe: -8/5/26: Scheduled for 7:00 AM; documented as administered at 12:29 PM. -8/12/26: Scheduled for 7:00 AM; documented as administered at 11:17 AM. -8/19/26: Scheduled for 7:00 AM; documentation indicated the medication was not administered on this date. -8/23/26: Scheduled for 11:00 AM; documented at 12:56 PM as administered at 11:00 AM. An interview was conducted with the Director of Nursing (DON) on 8/25/26 at approximately 1:40 PM. The DON was asked to explain the facility's expectations when a resident's medication is administered late or when a resident refuses a medication. The DON stated that when a resident refuses a medication, staff are expected to initial the Medication Administration Record (MAR), enter the numeric code 9 to indicate refusal, and complete a corresponding progress note. She further stated that when a medication is administered late, staff are expected to contact the physician for an updated order and complete a corresponding progress note documenting the updated medication administration. The DON was made aware that there were no corresponding progress notes for 8/19/26, when the medication was not administered as scheduled. The DON stated that the facility has experienced problems with the pharmacy delivering medications when ordered. 3. During interview on 08/25/2026 at 11:00 a.m., Resident #75's daughter stated that she was contacted by the nurse at approximately 6:20 p.m. on 06/25/2026 and informed that Resident #75 had experienced a seizure while eating dinner. The daughter stated that, when she arrived at the facility, the nurse informed her that the resident had not received his/her prescribed anti-seizure medication for approximately two days because the pharmacy was out of the medication. The daughter stated she had not been notified prior to the seizure that Resident #75 had missed his/her prescribed anti-seizure medication. She requested that the matter be entered as a formal complaint and that another pharmacy be contacted. The daughter stated that the nurse informed her there was no backup pharmacy. The daughter further stated that she was later informed that the NP had contacted the pharmacy and that the medication was expected to arrive that evening. However, when she left the facility at approximately 10:00 p.m. on 06/25/2026, the medication had not arrived, and she was not subsequently notified when the medication was delivered. During interview with the Director of Nursing (DON) on 08/26/2026 at 2pm, the DON was unable to present documentation demonstrating that Resident #75's daughter/responsible party (RP) had been notified that the resident had missed prescribed anti-seizure medication or that the medication remained unavailable. The facility failed to notify Resident #75's representative of the need to alter treatment (lack of prescribed anti-seizure medication) and significant change in condition (subsequent seizure).

Based on review of complaint #3134428, record reviews, and interviews, it was determined that the facility failed to ensure accurate documentation of resident records. This was found to be evident for 1(Resident #107) out of 1 resident complaint reviewed, and 1 (Resident # 75) out of 1 resident reviewed for medication administration during the facility's annual recertification survey. The findings include: 1. On [DATE] at 5:26 PM, the surveyor reviewed complaint #3134428 which indicated that there is inadequate documentation related to Resident #107's death. On [DATE] at 8:02 AM, the surveyor conducted a record review. The record review revealed that there is an eINTERACT Change in Condition Evaluation V5 - Rev 2.0 form, dated [DATE], which indicates that on [DATE], Resident #107 was observed staring off and seemed to be breathing abnormal. The physician was notified of Resident #107's change in condition at 9:20 AM on [DATE], and an order was placed to have Resident #107 transferred to the hospital. On [DATE] at 9:46 AM, the surveyor conducted a record review. The record review revealed that there is a Health Status Note progress note, dated [DATE] at 11:53 PM, that indicates that Resident #107 was found unresponsive in bed on [DATE] at 9:00 AM, without respirations and a pulse. Also, it states that Resident #107's death was verified at 9:05 AM on [DATE]. On [DATE] at 10:46 AM, the surveyor interviewed the Director of Nursing (DON) #2. During the interview, the surveyor mentioned to the DON #2 that there is an eINTERACT Change in Condition Evaluation V5 - Rev 2.0 form, dated [DATE], which indicates that on [DATE] Resident #107 was observed staring off and seemed to be breathing abnormal. The physician was notified of Resident #107's change in condition at 9:20 AM on [DATE], and an order was placed to have Resident #107 transferred to the hospital; however, there is a Health Status Note progress note, dated [DATE] at 11:53 PM, that indicates that Resident #107 was found unresponsive in bed at 9:00 AM on [DATE], without respirations and a pulse, and that Resident #107's death was verified at 9:05 AM on [DATE]. The surveyor then asked the DON #2 to verify Resident #107's time of death. The DON #2 mentioned that she believes that Resident #107's time of death listed in the Health Status Note progress note, dated [DATE] at 11:53 PM, is an error, because Resident #107 discharged from the hospital and returned to the facility on [DATE]. The surveyor then asked the DON #2 to provide a copy of Resident #107's Certificate of Death. The DON #2 indicated that she would follow up with the surveyor. On [DATE] at 10:53 AM, the surveyor conducted a record review. The record review revealed that there is a Health Status Note progress note, dated [DATE] at 11:59 AM, that indicates that EMS arrived at the facility at 10:00 AM on [DATE] and transported Resident #107 to the hospital. On [DATE] at 11:03 AM the surveyor interviewed the DON #2. During the interview, the DON #2 mentioned that Resident #107's time of death, that is listed in the Health Status Note progress note, is incorrect. The DON #2 mentioned that Resident #107 died at night on [DATE], and the correct time of death was 9:05 PM not 9:05 AM. On [DATE] at 4:19 PM, the surveyor interviewed the Medical Director (MD) # 30. The MD #30 provided the surveyor with Resident #107's Certificate of Death along with Resident #107's Supplemental Report of Cause of Death. The MD #30 mentioned that Resident #107's time of death was incorrectly reported on the Certificate of Death as 9:05 AM instead of 9:05 PM; therefore, a Supplemental Report of Cause of Death was completed on [DATE] to list Resident #107's correct time of death. 2. Review of Resident #75's medical record on [DATE] at 11:00AM revealed that on [DATE] at approximately 5:51 p.m., the resident experienced a seizure while eating dinner. The seizure lasted approximately 40 seconds. Review of the [DATE] Health Status Note, documented by nursing at 7:23 p.m., revealed that the provider was notified immediately following the seizure and ordered emergency medication. The nurse documented that 4 mg of IM Ativan was administered at approximately 6:00 p.m. in the right deltoid. The nurse further documented that the resident tolerated the medication without complication and that neurological checks were initiated following the seizure. However, review of the Medication Administration Record (MAR) revealed that the Ativan administration was not documented/signed off until approximately 7:30 p.m. Therefore, the medical record contained a discrepancy between the documented time of medication administration (6:00 p.m.) and the time the medication was documented on the MAR (7:30 p.m.). During interview, staff confirmed that the Ativan was administered following the resident's seizure and that the administration was documented on the MAR at approximately 7:30 p.m. The facility's failure to accurately and contemporaneously document the administration of an emergency medication resulted in an inaccurate medication administration record and created the potential for uncertainty regarding whether and when the medication had been administered. Accurate medication documentation is necessary to ensure continuity of care and to allow subsequent staff and providers to determine the resident's medication history and make informed clinical decisions.

Based on medical record review and interview, it was determined the facility staff failed to assess and monitor residents' nutrition needs and intervene in a timely manner. This was evident for 3 (Resident #3, #6 and #4) of 5 residents reviewed during a complaint survey. The findings include: 1) Review of Complaint 3040167 was conducted on 6/24/26 regarding Resident #3's care at the facility. Review of Resident #3's medical record on 6/24/26 revealed the Resident was admitted to the facility in 2023 with a diagnosis to include dysphagia. Dysphagia is the medical term for difficulty swallowing. Further review of Resident's medical record revealed on 2/16/26 the Resident was seen and assessed by Nurse Practitioner (NP) #17 for weight loss. At that time NP #17 documented: the Resident was 106.6 pounds on 12/3/25 and 100.3 pounds on 2/6/26 with albumin 3.2 and prealbumin < 10 on 1/16/26 on puree/thin diet. Initiate nutrition consult and add oral nutrition supplements. Further review of Resident #3's medical record revealed the Resident was not seen by the Dietitian until 3/8/26, 3 weeks later. At that time the Dietitian documented: supplement liquid protein added twice a day for depressed prealbumin in the presence of skin wounds. There was no documentation regarding the weight loss. Further review of Resident #3's medical record revealed the staff documented the Resident weighed 99 pounds on 3/19/26, 94 pounds on 4/14/26 and 96.2 pounds on 5/9/26. The Resident had a significant weight loss from 3/19/26 until 4/14/26 of 5 pounds or 5.05%. The Resident was not seen again by the Dietitian until 6/3/26. At that time the Dietitian documented: Resident with skin wounds and weight loss trend. Currently on a Pureed diet with liquid protein twice a day, Juven twice a day for 30 days for wound healing. Med Pass twice a day for increased calories and protein. Interview with the Dietitian on 6/24/26 at 1:59 PM, the Dietitian was asked why the Resident was not assessed for prealbumin after NP #17's note on 2/16/26 until 3/8/26, not assessed for weight loss at that time per NP #17's note on 2/16/26, and not after the significant weight loss from 4/14/26 until 6/3/26. The Dietitian stated she only works in the facility 12 hours a week, unable to get all assessments done in a timely manner due to time constraints and was not made aware of NP #17's request for consult for weight loss on 2/16/26 by the facility staff and also stated the Resident's weight did increase in May to 96.2 pounds. Interview with the Director of Nursing (DON) on 6/25/26 at 12:30 PM confirmed the Dietitian did not assess and order liquid protein supplements for Resident #3 timely after the NP #17 2/16/26 note for nutritional consult. The DON also confirmed the Dietitian did not assess the Resident for weight loss until 6/3/26 and add nutritional interventions timely. 2) Review of Complainant 3033039 was conducted on 6/24/26 regarding Resident #6's care at the facility. Review of Resident #6's medical record on 6/24/26 revealed the Resident was admitted to the facility in November 2025 with a diagnosis to include dysphagia. Dysphagia is the medical term for difficulty swallowing. Further review of Resident #6's medical record revealed the Resident was not assessed by the Dietitian until 12/10/25, 3 weeks after admission. Further review of the Resident's medical record revealed the facility documented the Resident's weight as 242 pounds on 11/24/25 at time of admission and 247.8 on 12/18/25. The Resident was not weighed in January 2026. Interview with the Dietitian on 6/24/26 at 1:59 PM the Dietitian asked what the expectation for a nutritional assessment on admission is and why the delay in the Resident's admission nutrition assessment. The Dietitian stated ideally a resident would be assessed within 72 hours but due to the Dietitian's limited time in the facility she has to prioritize residents with wounds and significant weight loss first. The Dietitian was asked what are the expectations for residents to be weighed. The Dietitian stated every week for 4 weeks then once a month unless the resident has a significant change. Review of the facility's Weight Monitoring policy implemented on 2/15/24 and provided by the Regional Nurse was conducted on 6/25/26. It stated A weight monitoring schedule will be developed upon admission for all residents: Newly admitted residents-monitor weekly for 4 weeks. All others-monitor weight monthly. Interview with the Director of Nursing (DON) on 6/25/26 at 8:45 AM confirmed the delay in Resident #6's admission nutrition assessment, the Resident was not weighed weekly times four and should have had a monthly weight in January 2026. 3) On 6/24/26 at 11:14 AM a review of complaint 3023641 was conducted along with a review of Resident #4's medical record. Review of the complaint revealed concerns regarding Resident #4's blood sugars, insulins, and the circumstances of the resident's transport to the hospital in Diabetic Ketoacidosis. Diabetic Ketoacidosis (DKA) is a life-threatening condition of diabetes that occurs when the body doesn't produce enough insulin. Proper nutrition management plays a key role in keeping blood sugar stable and preventing DKA. On 6/24/26 at 11:14 AM a review of Resident #4's medical record revealed a 5/14/26 progress note from internal medicine documenting that Resident #4 had highly variable blood glucose levels with multiple readings from 191-540 mg/dl. Normal blood glucose levels before eating in the morning should be between 80 to 130 mg/dl for individuals with diabetes and less than 180 mg/dl after meals. A blood sugar reading over 500 mg/dl can lead to DKA. Review of nutritional assessments for Resident #4 revealed the last comprehensive nutritional assessment was dated 7/10/25. There were no nutritional assessments for the past 11 months. Review of nutrition/dietary notes revealed the last note was 6/18/26 that documented, currently on a renal, thick liquid diet. RD (registered dietician) from dialysis is requesting double protein with meals. Order updated. The previous dietary note was dated 9/25/25 regarding a weight warning. There were no dietary notes between 9/25/25 and 6/18/26 in which another dietician recommended the upgrade. On 6/24/26 at 12:39 PM an interview was conducted with Nurse Practitioner (NP)#5, who confirmed that Resident #4 was a brittle diabetic. On 6/25/26 at 9:52 AM an interview was conducted with the Medical Director (MD) #3, who confirmed that Resident #4's blood glucose levels were all over the place. MD #3 was asked if nutritional assessments should be done regularly since the resident has had issues with blood glucose control and DKA. MD #3 stated it was unacceptable that there were no recent nutritional assessments from the dietician and that he expected the resident would be followed closely due to his/her diabetes and renal status. On 6/25/26 at 11:18 AM an interview was conducted with Dietician #9. Dietician #9 stated that she had talked to Resident #4 several times and that the resident was very noncompliant, snacked, and had progressive kidney failure. Dietician #9 stated, I have seen [him/her] and have talked to [him/her] several times. When asked where her documentation was she said, I try to document. When I am here on Thursdays I get pulled. It is challenging. This is a high acuity building in terms of resident care. When I come in I try to prioritize. I look up wounds and weight losses. I do new assessments on admission and then quarterly. Usually for a quarterly assessment I may just do a note. If there is no quarterly note then it probably was not done. If [he/she] is not losing weight and doesn't have wounds, then I wouldn't see because the wound patients and weight loss patients would take precedence. I work 12 hours a week and that is not enough. They have not offered me more hours. I am still doing MDS assessments care plans, care plan meetings, QAPI, weight audits, and checks. I am doing the best I can with the time that I am here. [He/She] would be much more of a priority about educating about the kidney disease. Dietician #9 did confirm that there was not an assessment since July 2025 and there were no dietary assessments or notes since September 2025. On 6/25/26 at 11:34 AM the Director of Nursing and Regional Nurse were informed of the findings and expressed that they understood the surveyor's concerns.

Based on review of complaint 3027850, observations, and interviews conducted during a complaint survey, it was determined that the facility failed to provide maintenance services necessary to maintain resident rooms and equipment. This issue affected 5 of 12 residents reviewed (#8, #9, #10, #11, #12) and 3 of 3 nursing units observed.The findings include: On 6/24/26 at 9:00 AM a review of complaint 3027850 was conducted regarding environmental concerns. On 6/24/26 at 10:05 AM the following observations were made during environmental walking rounds: Resident Wheelchairs in Disrepair: Damage or missing components (including torn vinyl covering, missing foam padding, and missing armrests) were noted on wheelchairs for Residents #8, #9, #10, #11, and #12. Additionally, two unattended wheelchairs in the 300 hallway had damaged or missing armrests. Ceiling Tiles in Disrepair: [NAME] water stains of various sizes were observed on ceiling tiles in the main lobby, the 300 hallway, and rooms 103, 104, 125, 130, 218, 220, 307, 315, and 317. Missing and loose wood trim around the sink was also noted in room [ROOM NUMBER]. Interviews conducted on June 24, 2026, revealed a breakdown in the maintenance reporting process: - At 10:20 AM: Housekeeper #8 stated she reported repairs verbally to maintenance rather than using the electronic system (TELS).- At 10:46 AM: Maintenance Director #6 stated his expectation was for staff to use TELS for non-emergency repairs. He noted that wheelchair armrests are considered emergencies that require immediate reporting and acknowledged that the stained ceiling tiles were due to roof leaks. The Director of Nursing and the Regional Nurse were informed of these findings on June 25, 2026, at 11:34 AM.

Based on review of a complaint, record review, and interview, it was determined the facility failed to provide timely medication to meet the needs of a resident. This was evident for 1 (Resident #6) of 5 residents reviewed for complaints during a complaint survey.The findings include: On 6/24/26 a review of complaint 3033039 was conducted for Resident #6's care at the facility. Review of Resident #6's medical record on 6/24/26 revealed the Resident was admitted to the facility in November 2025 following a hospitalization. Further review of the Resident's medical record revealed on 2/6/26 Nurse Practitioner (NP) #5 ordered the Resident to have Ertapenem 1 Gram intravenously 1 time a day for UTI (Urinary Tract Infection) for 10 days. Review of Resident #6's February 2026 Medication Administration Record revealed the Resident did not receive Ertapenem until 2/10/26, 4 days later. Further review of Resident #6's medical record revealed the following nurses' notes: On 2/7/26 at 9:47 PM a nurse's note stated: Ertapenem 1 gram intravenously one time a day for UTI for 10 days. Awaiting pharmacy delivery. Provider aware. On 2/8/26 at 9:17 PM a nurse's note stated: Ertapenem 1 gram intravenously one time a day for UTI for 10 days. Awaiting pharmacy delivery. On 2/9/26 at 4:13 PM a nurse's note stated: Ertapenem 1 gram intravenously one time a day for UTI for 10 days. Waiting from pharmacy. Interview with the Regional Nurse on 6/25/26 at 11:29 AM confirmed the Resident did not receive Ertapenem 1 gram as ordered by provider on 2/6, 2/7, 2/8 and 2/9/26.

Based on medical record review, review of facility reported incident 3015069, and interviews, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff. This was evident for 1 (Resident#1) of 4 residents reviewed for abuse during a complaint survey.The findings include: On 6/24/26 at 1:25 PM a review of Resident #1's medical record was conducted and revealed Resident #1 was admitted to the facility on [DATE] from the hospital for rehabilitation following joint replacement surgery and an infection and inflammatory reaction due to internal right knee prosthesis. On 6/24/26 at 1:25 PM a review of facility reported incident #3015069 was conducted and revealed a witnessed event regarding a (GNA) geriatric nursing assistant's verbal conduct toward Resident #1, specifically the use of profanity. The facility's documentation revealed on 5/14/26 at 12:45 PM the facility did an interview with Resident #1 who stated, I just go back in my room so I can get some ice in my bag because my knee has been bothering me and I pressed the buzzer. She (GNA#13) came in and said what do you want, you were just in the wheelchair, you can get it your damn self. Then she came back in and started saying F (expletive language) this and F (expletive) that and then said F (expletive) it I got it. The report documented that licensed practical nurse (LPN) #15 documented that GNA #13 came down to the nurse's station upset and said she quit and put her badge down and walked out. Review of a written statement from the Director of Rehabilitation (DOR) documented the DOR was in the therapy gym. The entry door to the 100 unit was open. All of a sudden there was a loud statement in the hallway. The GNA said the patient wheeling around could get [his/her] own ice. Then she said, F (expletive) it I quit. Review of the facility's investigation revealed GNA #13 was terminated, the facility staff were re-educated on abuse and professional conduct. The Director of Nursing (DON) documented that facility wide resident audits/interviews would be done weekly times 4 weeks and the issue would be reviewed in QAPI. Review of the investigation revealed only 8 residents were interviewed about abuse.Further review of the facility's investigation failed to produce the weekly audits. There were no skin assessments provided to the surveyor for residents who were cognitively impaired. Review of the May 2026 QAPI meeting minutes that were given to the surveyor from the DON failed to produce documentation that verbal abuse or results from resident audits was discussed.On 6/25/26 at 9:05 AM the DON was interviewed and stated that she did not do the weekly audits that they said they were going to do.On 6/25/26 at 10:01 AM the DON was interviewed and stated that she did the initial audit on the facility report and it was an oversight and they were going to start the audits. The DON could not find the education provided to staff but stated she went around and personally educated staff.On 6/25/26 at 10:46 AM Certified Occupational Therapy Assistant (COTA) #12 was interviewed and stated that he was going down to the resident's room to get the resident for therapy. The aide and the resident were arguing about the ice pack. Resident #1 was being a little rude to the GNA, but she did cuss at the resident. She said, F U. COTA #12 said he was just standing there trying to get the resident for therapy and the GNA walked away. The resident said to him, did you hear that and the COTA said, yes. COTA #12 stated he filled out an incident report after it happened. On 6/25/26 at 11:09 AM LPN #15 was interviewed and stated that the resident had the call light on and the GNA went down to answer it and she came back screaming F (expletive) this place, I quit, they were looking for a reason to fire me anyway. LPN #15 stated she checked on the resident to see how the resident was doing and the resident was distraught and upset. The resident stated that GNA #13 was rude to the resident and cussed at him/her. The resident calmed down and came down to the nurse's station to talk to the doctor.On 6/25/26 at 2:15 PM the concerns were discussed with the Regional Nurse, DON, and the Nursing Home Administrator.

Based on medical record review and interview, it was determined the facility failed to report two injuries of unknown origin to the Office of Health Care Quality (OHCQ) as required. This was evident for 1 (Resident #3) of 7 residents reviewed during a complaint survey. The findings include:Review of Complaint 3007212 regarding 2 injuries of unknown origin for Resident #3 was conducted on 5/20/26. Review of Resident #3's medical record on 5/20/26 revealed the Resident was admitted to the facility in 2025 with diagnosis to include anoxic brain injury and quadriplegia.During interview with Resident #3's representative (RP) on 5/20/26 at 1:45 PM, the RP stated the Resident had 2 injuries recently that he/she is unaware of how they happened. The RP stated one was a fracture of the right great toe in March 2026 and the second one was a large bruise on the left ankle. The RP stated he/she found out about the fracture of the great toe when the Wound Clinic wanted the toe X-rayed. The RP stated he/she was told about the second injury when he/she called by the facility a few days after going to the Wound Clinic on 4/8/26 and was told the Resident had a new left ankle wound. The RP stated he/she took the Resident to the Wound Clinic on 4/22/26 and that is when he/she saw it was a large bruise and not a wound.1.Review of Resident #3's medical record on 5/20/26 revealed on 3/9/26 the Resident was seen at the Wound Clinic for a new right great toe wound. At that time the Wound Clinic ordered an X-ray of the right great toe.Further review of Resident #3's medical record revealed the X-ray was completed on 3/10/26 with the results received on 3/11/26. The X-ray result was possible nondisplaced age indeterminate fractures through the base of the proximal phalanx of the fifth digit.Interview with the Director of Nursing on 5/21/26 at 11:30 AM confirmed the facility staff did not report the injury of unknown origin to Resident #3's right great toe to OHCQ on 3/11/26.2.Review of Resident #3's medical record on 5/20/26 revealed the Resident had a change in condition documented by Nurse #13 on 4/11/26 at 6:34 AM. Review of Resident #3's change in condition revealed it stated the Resident had a new left ankle pressure area and the Resident's provider and RP were notified.During interview with Nurse #13 on 5/21/26 at 8:35 AM, Nurse #13 stated she was assisting Nurse #15 documenting for Resident #3 on 4/11/26 and couldn't remember what the Resident's left ankle looked like.During interview with Nurse #15 on 5/21/26 at 10:13 AM, Nurse #15 stated she was providing wound care for Resident #3 on 4/11/26 when she removed both the Resident's socks. At that time, she assessed the Resident to have a bruise around the entire left ankle, and it was a little swollen. Nurse #15 stated she reported the injury to day shift.During interview with the Director of Nursing (DON) on 5/21/26 at 11:30 AM, the DON confirmed both Resident #3's injuries were not reported to OHCQ and she was not aware of the left ankle injury until 4/22/26 when the Resident returned from the Wound Clinic.

Based on review of a complaint, medical record review and interviews, it was determined the facility staff failed to 1) notify the Resident's case manager of discharge location and 2) ensure home health services were set up for a resident at time of discharge. This was evident for 1 (Resident #5) of 3 residents reviewed for discharge during a complaint survey.The findings include:Review of Complaint 3008101 was conducted on 5/19/26 for a concern Resident #5 was discharged without home health services.Review of Resident #5's medical record on 5/19/26 revealed the Resident was admitted to the facility from the hospital on 4/29/26 with a diagnosis to include cellulitis of right lower limb.1.The facility staff failed to notify the Resident's representative (RP) of discharge location.During interview with Resident #5's community Case Manager/Resident's RP on 5/19/26 at 10:20 AM, the Case Manager stated the Resident was discharged from the facility on 5/6/26 and facility failed to notify her where the Resident was being discharged and failed to set up home health services. The Community Case Manager stated the Resident called her on 5/6/26, told her he/she had been discharged and where he/she was.Further review of Resident #5's medical record revealed the facility staff held a care plan meeting with the Case Manager on 4/30/26 and discussed potential discharge on [DATE] but had not finalized discharge location. On 5/4/26 the Social Services Assistant documented the Case Manager was called and given a discharge date of 5/6/26.During interview with Social Services Assistant (SSA) on 5/19/26 at 10:40 AM, the SSA stated she had called the Resident's Case Manager on 5/4/26 and told her the Resident was being discharged on 5/6/26. SSA stated the Case Manager asked where the Resident was being discharged to. The SSA stated she gave the Case Manager a few options. The SSA stated the Resident was not assigned to her but to the facility's Social Worker so she then notified the Social Worker of the call.During interview with the Social Worker on 5/19/26 at 10:49 AM the Social Worker was asked if he/she notified the Case Manager of the Resident's discharge location and the Social Worker stated no.2. The facility staff failed to set up home health services for Resident #5 at discharge.Review of Resident #5's medical record on 5/19/26 revealed a 5/5/26 Physician #9's Discharge Summary note that stated discharge with home health for continued wound care.Further review of Resident #5's medical record revealed a nurses note on 5/6/26 at 5:27 PM that stated, Resident discharged home without home care.During interview with the facility's Social Worker on 5/19/26 at 10:49 AM, the Social Worker was asked why home health services were not set up for Resident #5 at discharge. The Social Worker stated because the Resident was discharged to a shelter, the Resident was educated on wound care and given wound care supplies at discharge.During interview with Physician #9 on 5/19/26 at 11:40 AM, Physician #9 was asked if he was aware Resident #5 was discharged without home health services. Physician #9 stated no, the Resident should have been set up with home health, and he would assist in making sure the Resident got home health services now.Interview with the Director of Nursing (DON) on 5/19/26 at 2:25 PM confirmed the Resident's Case Manager was not notified of the Resident's discharge location and home health services were not set up at discharge.During interview with the DON on 5/20/26 at 10:55 AM, the DON told the Surveyor home health services have now been set up for Resident #5.

Based on review of a complaint, medical record review and interviews, it was determined the facility staff failed to include the discharge instructions and prescriptions in the resident's medical record. This was evident for 1 (Resident #5) of 3 residents reviewed for discharge during a complaint survey.The findings include:Review of Complaint 3008101 was conducted on 5/19/26 related to the discharge of Resident #5. Review of Resident #5's medical record on 5/19/26 revealed the Resident was discharged from the facility on 5/6/26.Further review of Resident #5's medical record revealed a nurse's note that stated, Resident discharged home without home care, all personal belongings and prescriptions sent with resident.Review of both the Resident's electronic and paper medical records revealed no discharge instructions or prescriptions given to Resident #5 at discharge.Interview with the Director of Nursing on 5/19/26 at 1:53 PM confirmed Resident #5's medical record does not include any discharge instructions or prescriptions that were given to the Resident at discharge on [DATE].

Based on medical record review and interviews, it was determined the facility failed to administer medications as ordered (Resident #2) and failed to administer wound treatments as ordered (Resident #6). This was evident for 2 of 7 residents reviewed during a complaint survey. The findings include:1.The facility staff failed to administer medications as ordered for Resident #2.Review of Complaints 2979772 and 3002392 regarding medication administration was conducted on 5/20/26. Review of Resident #2's medical record on 5/20/26 revealed the Resident was admitted to the facility in April 2025 with a diagnosis to include Ankylosing Spondylitis of the spine. Ankylosing Spondylitis (AS) is and inflammatory form of arthritis that primarily affects the spine, causing chronic pain and stiffness.During interview with Resident #2 on 5/20/26 at 12:45 PM, the Resident stated he/she is not receiving his/her Etanercept injections as ordered.Review of the Resident's physician orders revealed the Resident is ordered to receive Etanercept 50 mg/ml every week. Etanercept is an injection used to treat the signs and symptoms of autoimmune diseases such as Ankylosing Spondylitis.Review of Resident #2's April and May 2026 Medication Administration Records revealed the facility staff failed to administer Resident #2's Etanercept injection on 4/9/26 and 4/23/26.Interview with the Director of Nursing on 5/21/26 at 4:10 PM confirmed Resident #2 did not receive his/her Etanercept injection on 4/9/26 and 4/23/26.2.The facility staff failed to administer wound treatments as ordered to Resident #6.Review of Complaint 3004313 regarding wound care was conducted on 5/19/26 for Resident #6. Review of Resident #6's medical record on 5/19/26 revealed the Resident was admitted to the facility in July 2025 with a diagnosis to include Necrotizing Fasciitis. Necrotizing Fasciitis is a rare but severe bacterial infection that destroys the tissue beneath the skin, including fat and the fascia covering muscles.During interview with Resident #6 on 5/20/26 at 8:13 AM, the Resident stated the facility staff do not always do his/her wound dressings.Review of Resident #6's wound care for March, April and May 2026 revealed the Resident is ordered daily wound treatment to the Resident's right leg and right foot. Review of the Resident's March, April and May 2026 Treatment Administration Records revealed the facility staff failed to administer the treatment ordered to the Resident's right leg and right foot on 3/6, 3/9, 3/16, 3/18, 3/19, 3/26, 3/27, 4/9, 4/10, 4/16, 4/17, 4/23, 4/24, 4/26, 4/29 and 5/6/2026.Interview with the Director of Nursing on 5/20/26 at 9:50 AM confirmed the facility staff did not administer wound treatment as ordered for Resident #6.

Based on medical record review and interviews it was determined the facility failed to provide treatment/services to prevent/heal pressures ulcers as ordered for a resident. This was evident for 1 (Resident #3) of 3 residents reviewed during a complaint survey.The findings include: A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed).Review of Complaint 3007212 regarding pressure ulcer care was conducted on 5/20/26. Review of Resident #3's medical record on 5/20/26 revealed the Resident was admitted to the facility in 2025 with diagnosis to include anoxic brain injury and quadriplegia. During interview with Resident's representative (RP) on 5/20/26 at 1:45 PM, the RP stated he/she takes the Resident to an outside Wound Clinic and is concerned that the Resident's pressure ulcer dressings are not always being done.Review of Resident #3's medical record on 5/20/26 for pressure ulcer care in March, April and May 2026 revealed the Resident went to the Wound Clinic on 3/9/26. Review of the 3/9/36 Wound Clinic discharge instructions revealed the Resident had a sacral Stage IV pressure ulcer and a right great toe Stage III pressure ulcer. The Wound Nurse Practitioner ordered for the sacral pressure ulcer: wound cleanser, normal saline and dressing every day and for the right great toe pressure ulcer: wound cleanser, Iodosorb and dressing every day.Review of Resident #3's March, April and May 2026 Treatment Administration Records revealed the facility staff failed to administer treatment to the Resident's sacral pressure ulcer on 3/10, 3/11, 3/16, 3/26, 3/31, 4/13, 5/11, 5/17, 5/18 and 5/19/2026 and to Resident's right great toe on 3/26, 3/31, 5/1, 5/11, 5/17 and 5/18/2026.Interview with the Director of Nursing on 5/21/26 at 11:30 AM confirmed the facility staff failed to administer treatment to Resident #3's sacral and right great toe pressure ulcers as ordered.

Based on interviews and record reviews, it was determined that the facility failed to ensure its Infection Preventionist met the mandatory qualifications for the position.The findings include:An Infection Preventionist (IP) is responsible for the facility's Infection Prevention and Control Program. This position requires specialized training in infection control.On 3/24/26 at 10 AM, during an interview with the Director of Nursing (DON), confirmed she/he was the Infection Preventionist for the facility. The DON reported that she/he hasn't completed specialized training in infection control and the facilities staff has no one else who is currently qualified for the position. Further investigation revealed that the previous Infection Preventionist for the facility left in October 2025.On 3/24/26 at 1:30PM the Administrator and DON confirmed that they are currently looking to fill the position of Infection Preventionist for the facility staff. Cross reference F880

Based on observation during tour and interview with facility staff, it was determined that the facility staff failed to ensure that resident medications and supplies, including oxygen were maintained in a secure fashion. This was an observation on 2 occasions and 2 additional times after the implementation of education by the facility DON and occurred on 3 of 3 units.The findings include:On 3/23/26 at 10:50 AM an oxygen tank was observed sitting on the floor with no supporting device present. The oxygen tank was located to the left behind the bed of Resident #12 who resides on unit 1.RN #1 was notified of the observation and concern and immediately proceeded to get a tank holder and secure the oxygen tank.Tour of the facility on the 3rd unit on 3/25/26 at 7:31 AM noted a treatment cart with a Collagenase Santyl cream on top labeled for Resident #17. This surveyor observed 2 residents wheeling past in power wheelchairs and staff sitting at the nursing station. Staff RN #7 was notified of the observation and concern and upon looking at the cream stated that it was just delivered and whoever received it did not put it away, and she immediately put it away.The DON was notified of the observations when at approximately 8:10 AM on 3/25/26 and she stated she would put education in place immediately.While touring the facility on 3/25/26 at 1:53 PM with the DON, NHA and Corporate VP of Clinical Services, we all simultaneously observed an unattended and unlocked treatment cart upon arriving at the unit 2 nursing station. The Corporate VP immediately locked it.On 3/30/26 at 9:36 AM on the top of a treatment cart, Diclofenac gel for Resident #19 was found with multiple packs of dressings. At 9:38 AM the DON happened to walk past and was notified of the concerns and observations.

Based on the review of a complaint related to a new admission diet, staff and resident interviews, and medical record review, it was determined that the facility failed to employ sufficient staff to ensure all residents with dietary concerns were met. This was evident during the review of 3 of 3 (Resident #16, #26, #27) residents related to complaints about diet. The findings include:On 3/25/26 at 10:30 AM, review of the complaint 2962212 regarding admission assessments, revealed Resident #16 was admitted to the facility over 2 weeks ago in addition to other comorbidities for diabetic management with an A1C level of 11.5%. (A1C measures average blood sugar levels over the past 2-3 months, normal levels are below 5.7%). A review at this time of the hospital discharge orders, included a recommendation for a carbohydrate-controlled diet. Further review, however, revealed that upon admission, Resident #16 was ordered a regular diet with no acknowledgement of the need for the carbohydrate-controlled diet until 3/17/26, 1 week after the resident's admission, when s/he asked for larger portions. This review also revealed that as of 3/25/26 the dietitian had yet to see or review the resident's medical record.On 3/25/26 at 1:15 PM the facility dietitian, staff # 16, was interviewed regarding her process for visiting and assessing new residents. She said that she only has 12 hours at this facility a week and therefore needs to prioritize who she sees. The priority list was clarified. She stated residents that are new admissions with tube feedings for example would be seen first. The concerns relating to Resident #16 were reviewed with staff #16, that s/he was here specifically for her assistance with diet and modifications. She stated that Resident #16 would not have been a priority to be seen, however, she stated Resident #16 should have been admitted on the recommended diet from the hospital. At this time, she reviewed Resident #16's weight and stated that it's stable. This surveyor reviewed that the resident has only had 1 weight since admission 2 weeks ago. She again stated that she must prioritize who she sees and it is also determined in the risk meetings if there is a resident that needs to be seen. Surveyor met with Resident #16 in his/her room on 3/25/26 at 1:55 PM. S/he stated that they were very frustrated with the meals. S/he was asked if they had seen a dietitian yet and they stated 'no.'Additionally, for a new admission and a resident admitted for diabetic monitoring for the first 2 weeks of admission, there was only 1 weight completed, although the physicians continued to document on their visits that the resident's weight was 'stable.'A review of other recently admitted residents revealed the additional following concerns:Resident #26 readmitted to the facility on [DATE] was last seen by the dietitian on 9/19/25 secondary to a significant weight loss of 6.4 lbs. over 30days, there was no documented follow up since then. A review of Resident #26's weights noted that s/he has continued to lose weight and was currently 22lbs. less than when reviewed by the dietitian in September. Resident #27, admitted to the facility at the end of February 2026 with diagnosis including severe protein-calorie malnutrition, a month ago, still has had no review by the facility dietitian as of 3/25/26. Additionally, according to the documented weights, Resident #27 has had a 14 lb. weight loss, since admission (2 weeks) which equates to a 7% significant weight loss, that has not been assessed by the facility dietitian. The overall concerns related to the failure of the dietitian to see all new admissions to the facility timely and revisit as needed with the appropriate and timely implementation of interventions as needed was reviewed with the DON on 3/25/26 at 2:42 PM. A meeting held with the facility medical director, NHA, DON and Corporate VP of Clinical Services at 3:30 PM on 3/25/26 to review the concerns related to the lack of dietitian coverage and inability to timely see all the admissions and other residents as their diagnosis and acuity determined was reviewed at this time.

Based on observations and interviews and medical record review, it was determined that the facility failed to ensure infection control orders were followed and consistent throughout the facility. This was evident during the review of a complaint related to residents on transmission-based precautions.The findings include:Contact precautions involve full-time gown/glove use and resident isolation for acute, infectious, or draining infections, usually time limited.Enhanced Barrier Precautions (EBP) use gowns/gloves only for high-contact care (e.g., dressing, transfers) for residents with known MDRO (multi-drug-resistant organism) colonization, allowing room sharing and social participation. Resident #17 at 8:24 AM was observed in the room with physical therapy. There were no signs up identifying the need for any personal protective equipment (PPE), however, a foley catheter could be seen from the doorway.At 8:25 AM, Resident #18 was observed in bed. The facility nurse practitioner (NP) was in the room on her personal phone, with no PPE and the assigned GNA, staff #13 was currently repositioning the resident, pulling him/her up in bed and wearing only gloves. Staff RN #8 at this time, was at the doorway to the room preparing the residents' medications. There was a sign to the right of the door stating, 'contact precautions.' When GNA #13 exited the room, she was asked by this surveyor about the care she provided, who the sign belonged to, as it was a double occupancy room and how she cleaned her hands as they were not observed washed. The NP, RN and GNA all stated that Resident #18 was not on any contact precautions. GNA #13 proceeded to state that the signs were hanging at all the doors, and this resident was 'just wrong.' This surveyor stayed in the vicinity for another 6 minutes making notes and observations until GNA #13 returned to the room and turned the sign around at the room entrance showing that there was no one in the room with the requirement of staff to wear PPE.The identified concerns were reviewed with the DON on 3/30/26 at 12:37 PM. She followed up at 1:29 PM and stated that Resident #17 was a new admit and should have had a contact precaution sign posted for the foley catheter and in addition the resident had the foley placed related to wounds. Additionally, she stated that Resident #18 was supposed to be on contact precautions as well and the staff would be addressed.Interview on 3/30/26 at 2:30 PM with occupational therapy staff #15 revealed that they rely on the signs posted outside of the resident rooms and stated that if the sign is wrong the PPE is wrong.The overall concerns with signage and staff awareness of resident diagnosis were reviewed with the facility DON and Corporate VP of Clinical Services on 3/30/26.

Based on medical record review and interview with facility staff, it was determined that the facility staff failed to thoroughly investigate allegations related to potential abuse and injuries of unknown origin. This was evident during the review of 2 of 8 facility reported incidents (Residents #3). The findings include:1. The surveyor reviewed the facility investigation for Resident #3 on 3/23/26 at 1:54 PM. Resident #3 had 2 separate allegations of abuse, on 2/5 or 2/6 and again on 2/8. The facility provided the investigation packets which contained interviews of staff who cared for or were scheduled the days of the allegations. Although both incidents were investigated with a focus on Resident #3, the facility investigation did not contain any other resident interviews inquiring about abusive or neglectful treatment from facility staff, specifically the staff that were working on the days the allegations of abuse from Resident #3 were reported. During interview with the DON and Corporate [NAME] President of Clinical Operations on 3/24/26 as to the concern that there was no type of interview or assessment done for the other residents on the unit to ensure that they too were safe from potential abuse. As of 3/30/26, no further documentation was provided to the survey team regarding these incidents and investigations. The overall concern that although the allegations were not validated, no other residents were interviewed if able or assessed for any signs and symptoms of injury was reviewed with the facility. 2. Resident #6 whose medical record was reviewed on 3/25/26 at 10:15 AM, revealed the facility's' identification of a bruise on 3/4/26 on the right eye. The facility documented a change in condition and awareness of a new bruise on Resident #6's right eye on 3/4/26 at 4:09 AM. According to the facility report and subsequent record review on 3/24/26 at 1:35 PM, Resident #6 had a brief interview for mental status (BIMS) of '99,' meaning that Resident #6 was unable to complete the interview and therefore report how the injury occurred. A review of the facility investigation revealed that they identified how the injury potentially occurred, however, there was no definitive resolution. Additionally, there were no other interviews of other residents on the unit related to concerns of abuse or assessments of residents for potential injuries of unknown origin for those unable to speak for themselves, as in the case for Resident #6.

Based on a complaint related to the oral status of residents with tracheostomies and percutaneous endoscopic gastrostomy (PEG) tubes, observations, interviews with residents and staff, it was determined that the facility failed to provide oral care to a resident that was dependent on staff for activities of daily living (ADL). This was evident during the review of a complaint for 1 of 3 (#23) residents related to quality of care. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. Resident #14 was observed and interviewed on 3/24/26 at 11:09 AM. S/he was noted with a tracheostomy and a behavior of intermittently chewing on the comforter, towel or blanket nearby. This resident made good eye contact with the surveyor and so s/he was interviewed. S/he was noted with a thicker white substance in the mouth that had a thick sticky appearance. S/he was asked if the staff brush [residents] teeth. S/he nodded left to right. S/he then mouthed and stated that the staff 'need to.'Resident # 14, according to the 2/11/26 minimum data set, was dependent on staff for oral care. Resident # 23 was then observed in his/her room on 3/24/26 at 11:58 AM. Resident #23 was sitting propped up in bed and was able to respond to the surveyors' questions at this time only with smiles. This surveyor noted that the resident's mouth inside the lips had a thick clear white milky substance that was observed to be on the upper and lower teeth and his/her lips as s/he tried to open their mouth when they smiled. Resident #23 was asked about oral care and would just smile. The roommate asked this surveyor to look in the nightstand and although there was the presence of oral care supplies, at this time, Resident #23's teeth and mouth were not clean. Resident # 23, according to the 3/11/26 minimum data set, was dependent on staff for oral care.The following observations occurred on 3/25/26 with the facility DON, NHA and Corporate VP of clinical services:Secondly, at the request of Resident #14's family, we all started at his/her room. The family was concerned about the residents' status and wanted to be updated. This surveyor notified the family member of Resident #14 the purpose of the room visits and proceeded to assess Resident #14's mouth and reminded him/her of my visit to the room yesterday. Resident #14 did not recall my visit or the discussion. The observation of Resident #14's mouth and dentition on 3/25/26 did not show any significant concerns of build up or accumulation at this time. Resident #23 was observed next at 1:55 PM. S/he was observed in bed and was responsive to the surveyor and DON when we spoke to [resident] with smiles. However, when the resident attempted to smile you could visibly see the same thick clear milky substance between the lips and caking the teeth and would string between the teeth when the resident tried to open his/her mouth. The concern related to the lack of consistent oral care provided to residents that are dependent on staff for oral care was reviewed with the administration staff at this time in addition to the lack of oral care provided to a resident dependent on staff for activities of daily living was also reviewed at this time again during exit.

Based on medical record review, observation and interview with facility staff, it was determined that the facility staff failed to ensure that the residents' medical records were maintained and documentation was complete. This was evident for 3 of 22 (#2, #7 and #16) medical records reviewed during a complaint survey. The findings include:1. Review of the complaint and medical record for Resident #7 on 3/23/26 at 9:50 AM revealed concerns related to wound care. However, according to the medication administration record (MAR) for the specific dates reported the wound care and subsequent treatments were signed off. During a face-to-face meeting with Resident #7 and the facility DON on 3/25/26 at 11:15 AM s/he had continued complaints about wound care and staff not changing the bandages. This surveyor reviewed that the MAR was reviewed for the dates that s/he had complained about and that staff had signed off that they completed the tasks. Resident #7 then stated that it occurred again this past weekend. This surveyor stated they would review the MAR for the identified concerns. The DON also stated that she would speak to the staff as well. This surveyor then proceeded to exit the room and review the MAR for other dates of concern for wound care treatment. This review on 3/25/26 at 2:50 PM revealed missing sign off from staff for wound care on 3/18/26 and 3/23/26. There were also 3 days out of 24 where staff failed to sign off the application of A&D ointment on Resident 7's feet. These concerns were reviewed with the facility DON on 3/25/26 during the exit conference. 2. Review of the medical record for Resident #2 on 3/25/26 at 9:43 AM revealed that there was a new injury of unknown origin, a bruise on the residents' left hand. The assigned GNA let the nurse know, and according to the facility documentation a change in condition was initiated at 11:30 AM on 1/8/26. However, a pain evaluation was not initiated and completed until 9:11 PM. According to a brief interview for mental status (BIMS a standardized, 15-point assessment used in long-term care to screen cognitive function, typically assessing orientation, memory, and attention) completed 12/2025 for Resident #2, revealed that s/he had a score of '00' showing severe cognitive impairment. Resident #2 could not tell how the injury occurred according to the investigation or verbalize pain using a standard pain score assessment. The concern that an official pain assessment was not completed for a cognitively impaired resident timely after the finding of an injury of unknown origin according to documentation was reviewed during exit on 3/25/26. 3. The medical record of Resident #16 was reviewed on 3/25/26 at 10:35 AM regarding complaints surrounding his/her admission process. Part of the complaint noted that the resident did not receive the admission PPD (purified protein derivative is a screening tool for tuberculosis (TB) infection) skin test. However, according to the medication administration record (MAR) although there was a '9' on 3/18/26 for the administration meaning see nurses note, which there was none, for the read date on 3/20/26, staff documented 'negative,' even though the injection was not signed off as administered.This surveyor met with Resident #16 in his/her room on 3/25/26 at 1:55 PM. S/he stated that they never received the PPD injection.This surveyor then met with the DON and reviewed the concerns on 3/25/26 at 2:41 PM. She stated that the facility was out of the PPD solution so 'no' they would not have administered the PPD test to Resident #16 on 3/18/26 and they will do it now. The concern remained that staff proceeded to document 'negative' on a test that was not administered.

Based on observation and staff interview, the facility staff failed to monitor water temperatures to ensure that water in resident areas was maintained at a temperature that prevents the risk of scald injury. Water temperatures exceeding 120 degrees Fahrenheit were identified in five of ten resident rooms that were checked. (101, 103, 205, 206, 214) during the initial investigation. The findings included: 1. On March 11, 2014, at 10:15 AM, a surveyor found that water temperatures in an employee restroom were excessively hot. As a result, the Environmental surveyor, accompanied by the assistant Maintenance Director, began checking temperatures of water in resident rooms at hand sinks. Thermometers were calibrated in an ice water slurry and found to be accurate, both reading 32 degrees Fahrenheit (F). Between 10:30 AM and 11:15 AM, water temperatures were checked in all wings of the building. Temperatures exceeding 120 degrees F were observed in the following rooms: Room 101- 126 degrees F Room 103-128 degrees F Room 205- 128 degrees F Room 206-130 degrees F Room 214-124 degrees F Water temperatures were checked in rooms 119, 120, 229, 329 and 318 and found to be at or under 120 degrees F. At about 11:00 AM, the assistant Maintenance Director made adjustments to the mixing valve near the Unit 1 Nurse's station. The mixing valve is a device that prevents excessively hot water from reaching resident areas. The surveyor requested that the assistant Maintenance Director notify the Administrator and the Maintenance Director about the findings of high water temperatures. At about 12:00 PM, the Environmental surveyor notified the receptionist and the Director of Nursing that the Maintenance Director had not made contact with the survey team concerning the excessively hot water temperatures. At 12:25 PM, the surveyor checked the temperature in the employee restroom and found that it was 134 degrees F, an increase of four degrees from the 10:30 AM reading. Based on the above findings, it was determined that the excessively high water temperatures presented an immediate jeopardy to the residents in the facility. The Administrator was notified at 12:50 PM on March 11, 2014. At 1:15 PM, they surveyor checked the temperature of the water in room 200 and found it to be at 130 degrees F. Review of the facility temperature logs revealed that temperatures had been recorded weekly until February 22, 2014. Interview of the Maintenance Director verified that he had not completed water temperature checks since that date, greater than two weeks prior to the survey date. After further adjustment was made to the hot water heaters, at 3:00 PM, the surveyor, accompanied by the Maintenance Director and Assistant Maintenance Director measured water temperatures in room 200 at 108 degrees F and room 203 at 122 degrees F. Facility staff presented a written Plan of Correction which included turning off the hot water heater that services the 100 and 200 wings until repairs could be made by a licensed plumber. The plan also included immediate staff education to prevent injury to residents in the interim. The Immediate Jeopardy was abated at 3:17 PM on March 11, 2014. 2. The Speech Language Pathologist (SLP) failed to communicate the need of a resident to have one on one supervision during meals due to her inability swallowing food and fluids safely. Speech-language pathologists (SLP) assess, diagnose, treat, and help to prevent speech, language, communication, and swallowing disorders. Speech language pathologists are college educated and specially trained to use a variety of diagnostic skills to assess an individual's ability to swallow safely. Resident #37 was admitted to the facility with multiple [DIAGNOSES REDACTED]. This resident is dependent upon staff for her care, comfort and safety. Observation of this resident during lunch on 03/11/2014 from 12:20 p.m. to 12:45 p.m., revealed this resident seated in her room consuming her meal without any staff supervision. The resident ate her puree food in an undignified manner, using her fingers. Interview with the geriatric nursing assistant (GNA) #1 on 03/11/2014 at 12:20 p.m., revealed that this resident only required that her meal tray be set up, that she feed herself and only needed assistance to feed if she became fatigued. Interview with the 200 unit charge nurse #2 on 03/11/2014 at 12:45 p.m., revealed that she was also unaware that this resident required one on one supervision during meal consumption to ensure safe swallowing. Review of the medical record revealed no indication that this resident was to be supervised during meals to ensure safe swallowing. Interview with the SLP on 03/12/2014 at 2:15 p.m., revealed that based on her assessment that this resident was to have direct supervision during all meals to ensure safe swallowing but did not communicate this feeding need to the physician or nursing staff. The SLP failed to communicated the need of a resident to have one on one supervision during meals due to her inability swallowing food and fluids safely.