Every finding on record at Mckinley Nursing

Based on record review and interview, the facility failed to ensure certified nursing assistants (CNA) had yearly performance evaluations. This had the potential to affect all residents residing in the facility. The facility census was 151. Findings include:Review of the employee files for Certified Nursing Assistant (CNA) #325, CNA #386 and CNA #425 revealed they had not received yearly performance evaluations. CNA #325 was hired on 03/13/25, CNA #386 was hired on 01/15/25 and CNA #425 was hired on 03/04/25. Interview on 04/28/26 at 1:15 P.M. with Human Resources Director (HR) #307 verified yearly performance evaluations had not been completed as required. HR #307 acknowledged the delay and stated they were behind on evaluations but were working to get caught up.

Based on resident interviews, lunch meal observations, staff interview, and review of diet spreadsheets, resident council minutes and facility policy, the facility failed to ensure appropriate portion sizes were served and all components of the meal were served to meet resident needs and preferences. This affected all residents receiving meals from the kitchen. The facility identified no residents with a nothing by mouth (NPO) diet. The facility census was 151.Findings include:1. Interview on 04/19/26 at 9:30 A.M. with Resident #75 revealed the menus were not always posted in common areas and the aides were not taking down alternate choices to the kitchen. Resident #75 reported the portion sizes are child-like and he was not receiving enough food. Interview on 04/19/26 at 10:09 A.M. with Resident #99 revealed there were no food substitutions available. Interview on 04/19/26 at 10:12 A.M. with Resident #124 revealed there were no food substitutions available. Interview on 04/19/26 at 12:47 P.M. with Resident #51 revealed he was not receiving enough food at each meal. Interview on 04/19/26 at 1:54 P.M. with Resident #94 revealed the dietary staff or nursing staff do not come to ask residents what they would like to eat for meals. Resident #94 stated the menus posted were old. Resident #94 stated she had offered to post menus each week on every unit for the kitchen. Observation on 04/22/26 at 12:06 P.M. with [NAME] #462 revealed for regular texture ham and beans the residents were served with a six-ounce ladle. There was no mechanical soft texture available to be served. The scoop sizes were confirmed by [NAME] #462. Interview on 04/22/26 at 12:15 P.M. with Dietary Manager (DM) #458 revealed there was an alternative menu item listed on the menu and spreadsheets. DM #458 indicated they were not serving the alternate menu in addition to the main menu. DM #458 stated many of the residents were confused by this. DM #458 stated they send menus every week to each unit and nurse aides were expected to ask residents if they would like a substitution. DM #458 stated resident orders needed to be submitted by 10:00 A.M. for lunch and 3:00 P.M. for dinner. DM #458 stated only two units returned their list of alternates on 04/22/26 for lunch. DM #458 was unable to provide a list of always available/alterative menu items upon request. Observations on 04/22/26 from 12:27 P.M. to 2:13 P.M. of the lunch meal service revealed there was no pureed cornbread or pureed fruit cobbler dessert available for puree diets. The fruit cobbler was substituted for pudding. There was no substitute for cornbread. At 1:43 P.M. the kitchen staff ran out of fruit cobbler for all other textures or diet modifications. Applesauce was served as a substitute. There were three units out of 6 units who did not receive fruit cobbler. The alternates served were observed to be hamburgers or hot dogs. Interview on 04/22/26 at 2:40 P.M. with DM #458 confirmed the kitchen had run out of fruit cobbler and served applesauce or pudding. DM #458 confirmed there was no puree cornbread served to residents on puree diet. Follow up interview on 04/22/26 at 3:02 P.M. with DM #458 confirmed the ham and beans portion size served to regular and mechanical soft textures was inadequate and did not follow the spreadsheet recommendations. DM #458 stated resident food preferences were mostly obtained if something was reported to therapy or nursing staff. DM #458 stated there are forms for food preferences but the last one she could locate was completed by the former DM. DM #458 was unable to describe a system for maintaining current food preferences to meet each resident's needs. Interview on 04/28/26 at 1:07 P.M. with Dietitian #468 revealed she was only at the facility every other week for one day. Dietitian #468 stated the rest of her work was completed offsite. Dietitian #468 stated she had minimal oversight in the kitchen and generally just completed a monthly sanitation audit. Dietitian #468 stated she was unaware of the issues identified in the kitchen. Review of Diet Spreadsheet for Spring/Summer menu dated 2024 revealed for a regular texture diet and mechanical soft diet residents would be served with an 8-ounce ladle. The spreadsheet revealed all residents were to receive meal components of the appropriate texture for ham and beans, seasoned spinach, cornbread with a fruit cobbler dessert. Review of Resident Council Meeting minutes from 11/25/25 revealed residents complained nurse aides were not asking them if they wanted an alternate menu item. Review of facility policy titled Resident Food Preferences Policy undated revealed nutrition assessments would include an evaluation of individual food preferences. The dietitian was expected to complete initial food preferencing within 72 hours of admission and periodically to determine if revisions were needed. The food service department would offer a limited number of food substitutes for individuals who do not want to eat the primary meal. The facility's Quality Assessment and Assurance (QAA) program would periodically review issues related to food preferences and meals to identify widespread concerns. This deficiency represents non-compliance investigated under Complaint Number 2593029.

Based on observation, interview, and review of food committee minutes, the facility failed to serve appealing meals at palatable temperatures. This had potential to affect all residents receiving meals from the kitchen. The facility identified no residents with a nothing by mouth (NPO) diet order. The facility census was 151.Findings include:Review of the food committee meeting minutes from 11/25/25, 02/24/26, and 03/31/26 revealed residents complaining of cold food.An interview on 04/19/26 at 11:25 A.M. with Resident #12 revealed the food was not served hot enough and was not appealing. An interview on 04/19/26 at 12:26 P.M. with Resident #91 revealed the food was never hot. An interview on 04/19/26 at 1:16 P.M. with Resident #117 revealed the food was not hot. An observation on 04/22/26 at 12:06 P.M. revealed temperatures taken with [NAME] #462 prior to lunch service using a facility digital thermometer revealed the ham and beans were 187 degrees Fahrenheit (F), turnip greens were 190 degrees F, and cornbread was at room temperature. Observations on 04/22/26 of lunch meal service revealed the service began at 12:27 P.M. through 2:13 P.M. Nurse aides completed passing trays at 2:38 P.M. It was noted the facility had run out of insulated dome lids, and insulated plastic bowls. There was no use of heated or insulated bases. Lunch service ended 38 minutes after the scheduled mealtime and the last residents received their lunch trays one hour and three minutes after the scheduled mealtime. Observation on 04/22/26 at 2:38 P.M. of a test tray with Dietary Manager (DM) #458 revealed temperatures were taken using the facility's digital thermometer. The ham and beans were in a ceramic bowl, and the temperature was 115 degrees F. The turnip greens were 125 degrees F and were on a plate with a piece of cornbread. The juices from the turnip greens were pooled on the plate and soaking in to the cornbread. Taste test of the ham and beans revealed a lukewarm temperature and food was not palatable due to temperature. An interview on 04/22/26 at 2:40 P.M. with DM #458 confirmed the ham and beans were not at a palatable temperature. DM #458 confirmed the cornbread was soggy. DM #458 confirmed they had run out of the plastic insulated bowls and dome lids. An interview on 04/28/26 at 1:07 P.M. with Dietitian #468 revealed she was only at the facility every other week for one day. Dietitian #468 stated the rest of her work was completed offsite. Dietitian #468 stated she had minimal oversight in the kitchen and generally just completed a monthly sanitation audit. Dietitian #468 stated she was unaware of the issues identified in the kitchen. This deficiency represents non-compliance investigated under complaint number 2677432.

Based on observation, interview and record review, the facility failed to ensure meals were served at regularly scheduled times. This affected all residents receiving meals from the kitchen. The facility identified no residents with a nothing by mouth (NPO) diet order. The facility census was 151.Findings include:Review of the Resident Meal Times, undated, revealed breakfast was from 8:15 A.M. to 9:20 A.M., lunch was from 12:30 P.M. to 1:35 P.M., and Dinner was from 5:15 P.M. to 6:20 P.M. Service order was [NAME] Unit, Grant Unit, [NAME] Unit, Presidential Unit, Taft Unit, and [NAME] Unit. Review of Food Committee Meeting minutes from 02/24/26 revealed residents complaining of late lunches and trays being left to sit for 15 minutes after arriving to the unit before staff passed them out. The meeting minutes from 11/25/25 revealed meals were not on time. Observation on 04/19/26 from 1:40 P.M. to 2:37 P.M. revealed the lunch meal was delivered late to each of the six units as followed: Observation at 1:40 P.M. revealed a nurse aide was passing trays on Grant Unit. Observation at 1:43 P.M. revealed nurse aide staff were passing lunch trays on [NAME] Unit. Observation at 1:45 P.M. revealed Certified Nursing Assistant (CNA) #418 was picking up finished lunch trays. An interview on 04/19/26 at 1:45 P.M. with CNA #418 confirmed [NAME] Unit lunch trays were over an hour late. CNA #418 indicated it was hit or miss on if meals were on time. An interview on 04/19/26 at 1:47 P.M. with CNA #383 confirmed lunch trays were late on Grant Unit. CNA #383 stated it varied if the lunch meal was on time from day to day. An interview on 04/19/26 at 1:53 P.M. with Medical Records #344 confirmed the [NAME] Unit had not received lunch trays. An interview on 04/19/26 at 1:56 P.M. with CNA #301 confirmed Presidential Unit had not received lunch trays. An interview on 04/19/26 at 1:58 P.M. with Licensed Practical Nurse (LPN) #437 confirmed Taft Unit had not received lunch trays. LPN #437 did not answer if late meals were a normal occurrence. Observation on 04/19/26 at 1:59 P.M. revealed Resident #36 commented to staff that the food was late, and staff told him it would be coming. Resident #120 asked when she would be able to have a smoke break and was told she needed to wait until lunch was over. Observation at 2:19 P.M. revealed lunch trays arrived at Taft Unit. An interview on 04/19/26 at 2:07 P.M. with Resident #28, #45, and #54 complained lunch was late. Residents #28, #45, and #54 were sitting in the dining room on [NAME] Unit. An observation on 04/19/26 at 2:22 P.M. revealed lunch trays arrived at Presidential Unit. Follow up interview on 04/19/26 at 2:21 P.M. with Medical Records #344 revealed the dietary director had come to [NAME] Unit. Medical Records #344 reported the lunch trays were late because the dietary director reported that the cooler had broke and all the prepped food for the lunch meal had to be thrown away. Interview on 04/19/26 at 2:29 P.M. with Resident #119 revealed the food was always delivered late. An observation on 04/19/26 at 2:35 P.M. in the [NAME] Unit dining room revealed Resident #141 stated he had not had lunch yet. An observation on 04/19/26 at 2:37 P.M. revealed lunch trays arrived at [NAME] Unit. An observation on 04/22/26 from 12:06 P.M. to 2:38 P.M. of lunch tray service revealed [NAME] Unit lunch trays left the kitchen at 12:47 P.M., Grant Unit lunch trays left kitchen at 1:08 P.M., [NAME] Unit lunch trays left kitchen at 1:20 P.M., Presidential Unit lunch trays left kitchen at 1:43 P.M., Taft Unit lunch trays left kitchen at 1:59 P.M., and [NAME] Unit lunch trays left kitchen at 2:13 P.M. Lunch tray pass was not completed until 2:38 P.M. An interview on 04/22/26 at 2:40 P.M. with Dietary Manager (DM) #458 confirmed lunch meals were late on 04/19/26 and 04/22/26. An interview on 04/28/26 at 1:07 P.M. with Dietitian #468 revealed she was only at the facility every other week for one day. Dietitian #468 stated the rest of her work was completed offsite. Dietitian #468 stated she had minimal oversight in the kitchen and generally just completed a monthly sanitation audit. Dietitian #468 stated she was unaware of the issues identified in the kitchen.

Based on observation, interview and review of facility policy, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all residents receiving meals from the kitchen. The facility identified no residents with a nothing by mouth (NPO) diet order. The facility census was 151.Findings include:Observation on 04/19/26 from 8:24 A.M. to 9:05 A.M. of the facility kitchen revealed upon entering the kitchen it was observed that the walk-in refrigerator's temperature gauge was at 60 degrees Fahrenheit (F). Food stored inside was warm to touch.Observation of the dish machine area revealed the floors and walls had dried splatter and debris. There were four rubber floor mats that were sticky with various debris stuck to them. There was noted dust on the walls and ceiling by air vents and lights. There were three fans with dust covering the fans. The dish machine had dried splatters and a white colored build up. There was a dried, soiled rag sitting on top of dish machine. There was a notable sour, spoiled odor in the dish machine area. Observation of the main kitchen area revealed there was a stove with six burners. The stove had burnt food debris and dark grease build-up on it. The wall across from the stove and prep table had dried food splatter. The prep table holding the juice machine had dried red juice on shelves and splattered on the ground in front of the table. There was a dried spill on the floor in front of the three-compartment sink. Observation of a deep fryer revealed the frying oil was empty with significant amounts of dried yellow grease in the frying well. There were dried grease drips down the front and sides of the fryer. Observation of a reach-in refrigerator by the tray line revealed there was a container of peanut butter mixed with grape jelly with no date or label. There was a plastic wrapped partial package of sliced deli ham without label or date. There was a plastic wrapped chunk of deli turkey without label or date. There was a cut cucumber covered with plastic wrap with no label or date. There was a container of hard-boiled eggs with no label or date. There was a container of sliced tomatoes with no label or date. There was a container of mixed fruit cocktail with no label or date. There was a fan across from tray line that was over a prep area table that was coated with dust. Observation of the walk-in freezer revealed significant ice buildup from the condenser. The ice was built up on the food storage rack below with ice in two empty metal trays. There was also ice on a covered tray of beef tips and a tray of pineapple crisp. There was ice built up on the ceiling and the door. Observation of the dry storage room revealed an open box of powdered sugar that was not sealed. There was various debris on floors throughout the dry storage area. The floors and walls throughout the kitchen had various food debris/splatters and the floors were sticky. An interview on 04/19/26 at 8:26 A.M. with Dietary Aide (DA) #326 confirmed the walk-in cooler was at 60 degrees F. Dietary Aide #326 stated the staff were not using anything from the cooler because all the food was warm. DA #326 stated she was in the kitchen until about 8:00 P.M. last night and it was working fine. DA #326 stated when she came in this morning it was warm. DA #326 stated Dietary Manager (DM) #458 was aware. An interview on 04/19/26 at 8:35 A.M. with [NAME] #462 confirmed findings in the reach-in refrigerator. [NAME] #462 reported leftovers were kept for seven days. [NAME] #462 confirmed findings related to cleanliness in the kitchen area. [NAME] #462 stated they have not used the fryer since she started in January 2026. An interview on 04/22/26 at 8:45 AM DM #458 revealed DM #458 had arrived and completed a tour. DM #458 reported she had become the manager about two months ago. DM #458 confirmed findings in the walk-in freezer and cooler. DM #458 stated the ice had been building up for a while in the freezer. DM #458 stated her staff were supposed to clean the floors everyday including sweeping and mopping. DM #458 stated maintenance was aware of the fryer, and they needed to remove it and cap off the gas line. DM #458 stated the deep fryer had not been used in over a year. DM #458 confirmed findings in the stove area and prep areas. DM #458 confirmed findings in the dish machine area. Observations on 04/22/26 from 12:06 P.M. to 2:38 P.M. of lunch tray service revealed DA #934 had picked up spilled plastic lids off the floor with bare hands and disposed of them in a trash can in the dish machine area. DA #934 touched the lid of the trash can and returned to tray line without performing hand hygiene. DA #934 was observed to drink out of a cup and continue assisting on tray line without performing hand hygiene. DA #934 was observed to adjust his hair net and clothing without performing hand hygiene before continuing to assist on tray line. DA #934 was observed to have facial hair that was not secured with a beard net. Certified Nursing Assistant (CNA) #433 entered the kitchen area to fill an ice cooler from the ice machine. CNA #433 was not wearing a hair net or perform hand hygiene. DA #349 was fixing desserts on trays and dropped a dessert in a plastic cup with lid on the floor and it did not break open so DA #349 picked the dessert up and put it on a lunch tray. DA #349 took dirty trays to the dish machine area and returned to tray line without performing hand hygiene. [NAME] #368 was preparing desserts and was observed to rinse hands in a preparation sink without using soap and dried her hands on her pants. [NAME] #368 was observed to prepare three different desserts without performing hand hygiene between tasks or when leaving her preparation area. [NAME] #368 was observed to handle her cellphone and return to her task without performing hand hygiene. [NAME] #368 returned to the kitchen area from the breakroom to remove cakes from the oven. [NAME] #368 did not perform hand hygiene. [NAME] #368 was observed to cough without covering her mouth and did not perform hand hygiene. An interview on 04/22/26 at 2:40 P.M. with DM #458 revealed concerns with hand hygiene and hair net/beard guard use were reviewed and confirmed by DM #458. An interview on 04/28/26 at 1:07 P.M. with Dietitian #468 revealed she was only at the facility every other week for one day. Dietitian #468 stated the rest of her work was completed offsite. Dietitian #468 stated she had minimal oversight in the kitchen and generally just completed a monthly sanitation audit. Dietitian #468 stated she was unaware of the issues identified in the kitchen. Review of the facility policy titled Kitchen Sanitation and Cleanliness Policy, undated,j revealed all kitchen equipment would be kept clean and in working condition, floors would be cleaned regularly, and refrigeration/freezers would be monitored daily. Review of facility policy titled Proper Food Storage dated 10/22/03 revealed all ready-to-eat foods stored should be discarded if not consumed within seven days. Proper storage included a label including the contents, a date, and initials. Foods stored should be covered and secured with plastic wrap or foil. Review of facility policy titled Hand Washing Policy undated revealed staff must wash hands with soap and water when hands were visibly dirty, after using restroom, before and after eating or handling food, and after removing gloves. Review of facility policy titled Why the Hairnet? undated revealed a hair restraint was part of the dress code. Hair restraints should be worn by anyone in the kitchen including guests and staff. Hands should be washed following handling of the hair restraint. Hair restraints included a hat that covers all hair, a fine net, a beard or facial hair covering, or a piece of clothing that covers body hair.

Based on observation, staff interview, and policy review, the facility failed to properly dispose of garbage and refuse. This had the potential to affect all residents residing in the facility. The facility census was 151. Findings include:Observation on 04/19/26 at 9:00 A.M. with Dietary Manager (DM) #458 revealed there were multiple dumpsters in an enclosed, indoor space. There was a very strong, pervasive, foul odor in the room. There were various debris including plastic gloves, dried leaves, and a tied black trash bag on the floor. In the dumpster area there was also various equipment including two floor cleaners and a plastic wrapped recliner on a wooden pallet. An interview on 04/19/26 at 9:00 A.M. with DM #458 confirmed the pervasive foul odor and garbage and refuse not being properly disposed. DM #458 stated all staff were responsible for keeping the area clean and free of debris. An interview on 04/28/26 at 1:07 P.M. with Dietitian #468 revealed she was only at the facility every other week for one day. Dietitian #468 stated the rest of her work was completed offsite. Dietitian #468 stated she had minimal oversight in the kitchen and generally just completed a monthly sanitation audit. Dietitian #468 stated she was unaware of the issues identified in the kitchen. Review of the facility policy titled Policy for Dumpster Area/Refuse undated revealed the dumpster area must be kept clean, secure, and accessible for waste removal services. The policy stated the dumpster area would be inspected daily for cleanliness and loose trash or spills would be cleaned. The area would be pressure washed periodically to control odor.

Based on observation, record review, review of facility job descriptions and interview the facility failed to ensure effective administration to manage the facility and identify care concerns, implement appropriate and sustainable corrective actions to prevent reoccurrence and attain or maintain the highest practicable physical, mental and psychosocial well-being of all 151 residents residing in the facility.Findings include: Review of the Administrator job description, signed by the Administrator but not dated, revealed the position would establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet resident's needs in compliance with state and local requirements. The administrator would develop a monitoring system to assure compliance with federal, state and local requirements. The administrator would establish systems to enforce facility policies and procedures, establish operating procedures for physician responsibilities, participate in the scheduling, planning and procuring of materials and information of staff meetings and in-service education programs, observe all infection control policies and procedures, assume responsibility for implementation of an effective quality assurance program, assume responsibility for notifying appropriate state and local agencies of the transfer, temporary or permanent discharge or death of any resident receiving medicaid funds, consistently work cooperatively with residents, resident's representatives, facility staff, physicians, consultants and ancillary service providers, observe all facility safety policies and procedures and remain positive and caring and act in the best interest of the residents.Review of the Director of Nursing (DON) job description signed by the DON on 11/14/01 revealed the DON was responsible for organizing and directing activities in the nursing department to ensure proper resident care. The DON attends various meetings to initiate a collaborative working environment in the organization. Investigates possible neglect and abuse incidents. Resolves operational issues throughout the day regarding nursing care application. Maintains open communication with the administrator, medical director, quality assurance committee and related departmental heads to ensure proper operation of nursing department.Interview on 05/05/26 at 9:13 A.M. with the Administrator, DON and Regional Director (RDI) #449 revealed the Administrator had assumed his position on 12/08/25.During the onsite investigation, the following concerns were identified related to a lack of comprehensive and effective administrative oversight:1. Review of personnel files revealed a lack of a Licensed Social Worker (LSW) since LSW #360 had been terminated on 01/09/26. Social Service Designee (SSD) #373 remained the only current employee in the social services department and was not a LSW. The facility had brief LSW coverage from LSW #451 from 02/12/26 until she separated from the facility on 02/27/26. Review of census data revealed the facility census remained over 120 residents, with a census of 151 residents upon survey entry on 04/19/26.Interviews with Human Resource Director (HRD) #307, LSW #360, SSD #373 and the Administrator verified the social service concerns identified during the survey.2. Review of multiple self-reported incidents (SRIs) in conjunction with medical record, Medication Administration Record (MAR), controlled substance administration record and controlled medication shift change log review revealed misappropriation of controlled medications between November 2025 and April 2026 affecting Resident #1, Resident #3, Resident #47 and Resident #154. Not all instances of the medication misappropriation were reported to the state agency as required and staff were not re-educated on medication administration or narcotic handling in response to the misappropriation events.Interviews with Registered Nurse (RN) #457, the DON and Licensed Practical Nurse (LPN) #431 verified the medication misappropriation concerns identified during the survey.3. Observations of the kitchen environment and meal service on 04/19/26 and 04/22/26 revealed concerns with kitchen sanitation, disposal of garbage, following the menu (items and portion sizes), appropriate food temperatures, appropriate food consistencies and delays in meal service to the resident units. While the facility had taken dietary concerns to Quality Assurance and Performance Improvement (QAPI) during their meetings on 04/24/25, September 2025, 12/18/25 and 03/19/26, the issues continued to recur without resolution. Interviews with the Administrator, Dietary Manager (DM) #458, Dietary Aide (DA) #326, [NAME] #462 and Registered Dietitian (RD) #468 verified the dietary service concerns identified during the survey.4. Review of the facility's infection control program documentation revealed a lack of a comprehensive legionella water management program. Observations during the survey indicated additional infection control concerns were identified relative to handwashing, contact isolation and the provision of personal care.Interviews with the Administrator, DON and Infection Preventionist (IP)/LPN #445 verified the infection control concerns identified during the survey.5. Review of QAPI meeting minutes dated 04/24/25 revealed action plans for the physical environment/pest control, care plan revisions, falls, leave of absence and dietary services. The plans indicated the department responsible for the corrective action but did not specify a point person on most of the plans. The columns under monthly progress were blank for most of the plans and if not blank, did not contain dates or other information to show when the plan would be completed by. There was no additional information provided to verify the correction plan was completed.During the current annual survey, deficiencies were identified related to the physical environment, care plan revisions, falls, inappropriate discharge and dietary services.6. Review of QAPI meeting minutes dated 06/26/25 revealed action plans for leave of absence, therapy/equipment, falls, smoking policy, dietitian services and dietary department staffing. The plans indicated the department responsible for the corrective action but did not specify a point person on most of the plans. The columns under monthly progress were blank for most of the plans and if not blank, did not contain dates or other information to show when the plan would be completed by. There was no additional information provided to verify the correction plan was completed.During the current annual survey, deficiencies were identified related to inappropriate discharge, falls and nutrition.7. Review of QAPI meeting minutes dated September 2025 (date not specified) revealed action plans for pharmacy services, dietitian services, infection control, wound care, discharge documentation, dietary services, physical environment and Minimum Data Set (MDS) 3.0 assessments. The plans indicated the department responsible for the corrective action but did not specify a point person on most of the plans. The columns under monthly progress were blank for most of the plans and if not blank, did not contain dates or other information to show when the plan would be completed by. There was no additional information provided to verify the correction plan was completed.During the current annual survey, deficiencies were identified related to pharmacy services, nutrition, infection control, wound care for pressure and non-pressure wounds, discharge documentation, dietary services, physical environment and MDS assessments.8. Review of QAPI meeting minutes dated 12/18/25 revealed an action plan in place for workplace culture change. There was no evidence that previous QAPI action items (pharmacy services, nutrition, infection control, wound care for pressure and non-pressure wounds, discharge documentation, dietary services, physical environment and MDS assessments) were revisited, followed up with if needed or determined to have corrective actions completed.During the current annual survey, deficiencies were identified related to pharmacy services, nutrition, infection control, wound care for pressure and non-pressure wounds, discharge documentation, dietary services, physical environment and MDS assessments. 9. Review of QAPI meeting minutes dated 03/19/26 revealed action plans for falls with major injury, MDS assessments, nursing point of care documentation, dietary services, abuse reporting and prevention, laundry services and Preadmission Screening and Resident Review (PASRR). The plans indicated the department responsible for the corrective action but did not specify a point person on most of the plans. The columns under monthly progress were blank for most of the plans and if not blank, did not contain dates or other information to show when the plan would be completed by. There was no additional information provided to verify the correction plan was completed.During the current annual survey, deficiencies were identified related to falls, MDS assessments, dietary services, abuse reporting and investigation and PASSR.During an interview on 05/05/26 at 9:13 A.M. the Administrator was made aware none of the QAPI meeting minutes had a full PIP developed including dates and a point person to ensure follow-through, evidence of auditing, education or other corrective measures completed to address the facility-identified concerns or for ongoing monitoring to prevent reoccurrence. The Administrator verified during the interview he was unaware the PIPs were not completed from any of the QAPI meetings prior to his start of employment in December 2025. This deficiency represents noncompliance investigated under Complaint Number 2992799, Complaint Number 2668600 and Complaint Number 2593029.

Based on record review and interview, the facility failed to ensure the facility assessment was accurately completed. This had the potential to affect all 151 residents residing in the facility. The facility census was 151. Findings include:Review of the facility assessment revised 08/01/25 revealed Former Administrator (FA) #448 was listed as the current administrator for the facility.Additional review of the facility assessment revealed under the section for 'Staffing Plan,' there was a table listing positions including licensed nurses providing direct care, nurse aides, other nursing personnel, other staff needed for behavioral healthcare and services, dietitian or other clinically qualified nutrition professional, food and nutrition services staff and respiratory care services staff. Under the adjacent column 'Total Number Needed or Average or Range' the area was blank. A second table in this section listed staff including licensed nurses, direct care staff and other staff with a notation 'refer to Centers for Medicare and Medicaid Services (CMS) minimum staffing rule.' Both sections did not specify numbers or ranges of staff required to meet resident needs.Interview on 04/27/26 at 9:23 A.M. with the current Administrator revealed he had looked at the facility assessment twice since starting his employment with the facility on 12/08/25 and indicated the assessment was due to be reviewed again in August 2026. When asked about the 'CMS minimum staffing rule' written in the staffing plan section, the Administrator stated he could not speak to that and acknowledged the assessment was not done how he would do it. The Administrator shared staffing levels for Certified Nursing Assistants (CNAs) were 14 CNAs for first and second shift, with nine on third shift and staffing levels for Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) together were six on first and second shift and four on third shift and confirmed this information was not located within the facility assessment and should have been.

Based on personnel record review, review of the job description for social services, and staff interview, the facility failed to employ a full-time Licensed Social Worker (LSW). This had the potential to affect all residents residing in the facility. The facility census was 151.Findings include:Review of the personnel file for Social Services Director (SSD) #373 revealed a hire date of 03/11/25. Review of her employee application as well as her resume revealed she did not have a degree in social services.Review of the personnel file for LSW #360 revealed a progressive discipline action form dated 01/09/26 which revealed he had been terminated on 01/09/26. Review of the personnel file for LSW #451 revealed she was hired by the facility on 02/12/26 and separated from the facility on 02/27/26. Interview on 04/20/26 at 9:39 A.M. with Human Resources Director (HR) #307 verified SSD #373 was the only employee in the social services department. She stated SSD #373 was not a Licensed Social Worker (LSW) nor held a bachelor's degree in a human services field.Interview on 04/20/26 at 10:36 A.M. with SSD #373 verified she was not a LSW nor held a bachelor's degree in a human services field. She stated she had been the Social Services Director since LSW #360 was fired on 01/09/26.Interview on 04/20/26 at 11:17 A.M. with the Administrator verified the facility did not have a LSW and had not had one in the social services department since 02/27/26. He stated they were interviewing candidates for the position, but had not completed the hiring process yet.Review of the facility document titled Job Description for social services, undated, revealed the purpose of the position was to provide services to meet the social and/or emotional needs that affected the residents' abilities to achieve their highest level of function. There was no verbiage included in the job description that the Social Services Director would be required to be a Licensed Social Worker if the facility census was over 120 residents as required.

Based on record review, interview, and review of the facility policy and procedure, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) committee was in place to identify and address concerns timely and effectively. This had the potential to affect all 151 residents in the facility. The facility census was 151. Findings include: Review of the facility QAPI minutes and Performance Improvement Plan (PIP) documentation revealed the following plans without continued corrective action or evidence the plan was revised when necessary or changed once identified to be ineffective:1. Review of QAPI meeting minutes dated 04/24/25 revealed action plans for the physical environment/pest control, care plan revisions, falls, leave of absence and dietary services. The plans indicated the department responsible for the corrective action but did not specify a point person on most of the plans. The columns under monthly progress were blank for most of the plans and if not blank, did not contain dates or other information to show when the plan would be completed by. There was no additional information provided to verify the correction plan was completed.During the current annual survey, deficiencies were identified related to the physical environment, care plan revisions, falls, inappropriate discharge, and dietary services.2. Review of QAPI meeting minutes dated 06/26/25 revealed action plans for leave of absence, therapy/equipment, falls, smoking policy, dietitian services, and dietary department staffing. The plans indicated the department responsible for the corrective action but did not specify a point person on most of the plans. The columns under monthly progress were blank for most of the plans and if not blank, did not contain dates or other information to show when the plan would be completed by. There was no additional information provided to verify the correction plan was completed.During the current annual survey, deficiencies were identified related to inappropriate discharge, falls and nutrition.3. Review of QAPI meeting minutes dated September 2025 (date not specified) revealed action plans for pharmacy services, dietitian services, infection control, wound care, discharge documentation, dietary services, physical environment, and Minimum Data Set (MDS) 3.0 assessments. The plans indicated the department responsible for the corrective action but did not specify a point person on most of the plans. The columns under monthly progress were blank for most of the plans and if not blank, did not contain dates or other information to show when the plan would be completed by. There was no additional information provided to verify the correction plan was completed.During the current annual survey, deficiencies were identified related to pharmacy services, nutrition, infection control, wound care for pressure and non-pressure wounds, discharge documentation, dietary services, physical environment and MDS assessments.4. Review of QAPI meeting minutes dated 12/18/25 revealed an action plan in place for workplace culture change. There was no evidence that previous QAPI action items (pharmacy services, nutrition, infection control, wound care for pressure and non-pressure wounds, discharge documentation, dietary services, physical environment and MDS assessments) were revisited, followed up with if needed, or determined to have corrective actions completed.During the current annual survey, deficiencies were identified related to pharmacy services, nutrition, infection control, wound care for pressure and non-pressure wounds, discharge documentation, dietary services, physical environment and MDS assessments. 5. Review of QAPI meeting minutes dated 03/19/26 revealed action plans for falls with major injury, MDS assessments, nursing point of care documentation, dietary services, abuse reporting and prevention, laundry services and Preadmission Screening and Resident Review (PASRR). The plans indicated the department responsible for the corrective action but did not specify a point person on most of the plans. The columns under monthly progress were blank for most of the plans and if not blank, did not contain dates or other information to show when the plan would be completed by. There was no additional information provided to verify the correction plan was completed.During the current annual survey, deficiencies were identified related to falls, MDS assessments, dietary services, abuse reporting and investigation and PASRR.Interview on 05/05/26 at 9:13 A.M. with the Administrator, Director of Nursing (DON), and Regional Director (RDI) #449 revealed QAPI was a mechanism in place to identify and resolve issues. During the interview, the Administrator was made aware none of the QAPI meeting minutes had a full PIP developed and there was no evidence of auditing or education or other corrective measures completed to address the facility-identified concerns or for ongoing monitoring to prevent reoccurrence. The Administrator verified during the interview he was unaware the PIPs were not completed from any of the QAPI meetings prior to his start of employment in December 2025. The Administrator also verified during the interview there was not yet a mechanism in place for residents and staff to report issues to the facility's QAPI program and hoped to have related education out to staff within the next 30 days.Review of the undated policy, Quality Assurance and Performance Improvement (QAPI) Policy, revealed the QAPI program would ensure the delivery of safe, effective and high-quality care to all residents. This program provides a systematic, data-driven approach to maintaining and improving resident outcomes, care processes and organizational performance. The facility is committed to ongoing quality assessment and performance improvement, identifying opportunities for improvement through data analysis and implementing corrective actions and monitoring outcomes. The QAPI committee was responsible for reviewing performance data and trends, overseeing performance improvement projects (PIPs), ensuring compliance with regulatory standards and reporting findings to leadership. Leadership was responsible for fostering a non-punitive culture that encourages reporting and improvement. PIPs are initiated based on identified areas needing improvement. All QAPI activities should be documented.

Based on observation, interview, record review, and policy review, the facility failed to ensure infection control standards were maintained during medication administration for Resident #50 and during incontinence care for Resident #24. The facility failed to ensure contact precautions were in place for Resident #1. The facility failed to ensure the infection control policy was reviewed annually. Additionally, the facility failed to ensure the Legionella water management program comprehensively assessed risk measures for their elderly population. This had the potential to affect all residents residing in the facility. The facility census was 151.Findings include: 1.Review of the facility's Legionella risk assessment, undated, revealed the facility had a municipal water source. The assessment evaluated the risk of Legionnaires' disease associated with the facility's water systems and supports compliance with the Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, and American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE). The assessment did not reveal any resident risk profile or the overall risk level. Based on system condition, population, and control measures revealed no overall risk determination. There were no control measures or monitoring plan in place per the assessment. There was no attached water management diagram. The assessment revealed the program was not reviewed annually nor were monitoring logs reviewed. Review of the facility's water temperature logs for April 2026 and May 2026 revealed water temperatures and call light functioning were measured in rooms. Interview on 04/28/26 at 11:15 A.M. with Maintenance Director (MD) #399 revealed the facility does not do water flushing but does take water temperatures. He indicated the city tests the water for Legionella. Interview on 05/04/26 at 12:48 P.M. with Maintenance Director #399 revealed information on risk assessment was what was available. There was no water schematic map. Per Maintenance Director #399, he was new to the maintenance role. Review of the facility's Legionella policy, undated, revealed the facility would establish a comprehensive water management program that reduced the risk of growth and transmission of Legionella bacteria within the facility's water systems. The facility would implement and maintain a water management program consistent with industry standards. The team would identify high-risk populations and routine flushing faucets at least weekly. If control limits were not met: there would be immediate investigation of cause, system flushing or thermal disinfection, and documentation of all corrective action. Review of the Center for Disease Control's Legionella Control Toolkit, dated 02/17/26, revealed developing and maintaining a water management program was a multi-step process that required continuous review including establishing a team, describing building water systems, identifying areas or devices where Legionella might grow or spread to people, determining control measures, monitoring control measures, establishing remediation activities and interventions when control measures are not met, ensuring the program was running as designed and was effective, and documenting all program activities. Flush low-flow piping runs and dead legs at least weekly and flush infrequently used fixtures regularly as needed to maintain water quality parameters within control limits. 2. Review of Resident #1's medical record revealed an admission date of 01/20/22 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, bacteremia, pseudomonas, methicillin resistant staphylococcus aureus, chronic bronchitis, and congestive heart failure. Review of Resident #1's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/09/26, revealed intact cognition and the presence of a multi-drug-resistant organism (MDRO). Review of Resident #1's physician orders revealed an order for contact isolation for Carbapenem-resistant Acinetobacter baumannii (CRAB, an infectious MDRO) that started on 03/31/26. Review of Resident #1's comprehensive care plan did not indicate the resident required contact isolation. This was verified in an interview with the Director of Nursing (DON) on 05/04/26 at 2:51 P.M. Observation on 04/20/26 at 10:20 A.M. of Resident #1's room revealed no isolation supplies outside of room. At the time of observation, confirmation with Licensed Practical Nurse (LPN) #456 revealed Resident #1 should be on contact isolation for CRAB in his blood, but there was no signage indicating isolation was required and there was no personal protective equipment (PPE) available outside of the room. Interview on 04/27/26 at 11:44 A.M. with Assistant Director of Nursing (ADON) #445 revealed the facility used a gown and gloves for residents on contact isolation. For a resident on contact isolation, there were red barrels in their room, carts outside their rooms for personal protective equipment, and a sign on the door which showed what kind of isolation the resident was on for staff notification. Observation on 04/29/26 at 9:38 A.M. revealed staff donned gown and gloves prior to going into Resident #1's room with contact isolation in place. Review of the facility's Isolation Categories and Transmission-Based Precautions Policy, undated, to prevent and control the transmission of infectious organisms within the facility by implementing standard precautions, transmission-based precautions, and enhanced barrier precautions when indicated. Contact precaution indications for MDROs private room preferred or cohorting. Gloves and gowns were to be worn upon room entry. Dedicated or disposable equipment was to be used. The policy noted to limit resident movement unless necessary. 3. Interview on 04/27/2026 at 11:44 A.M. with ADON #445 revealed their infection control policy was last reviewed in 2020 and had not been reviewed annually. Review of the facility's Infection Prevention and Control and Stewardship Program Policy, revised date 01/15/20, revealed the facility had established an infection control program which addressed all phases of the organization's operation to reduce or prevent the risks of nosocomial infections in residents and healthcare workers. All infection control policies and procedures would be reviewed annually by the Quality Assurance Committee and revised as needed. 4. Review of the medical record for Resident #24 revealed an admission date of 08/30/22 with diagnoses including dementia, chronic kidney disease, repeated falls and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 had severely impaired cognition and was dependent on staff for toileting. Observation on 04/27/26 at 9:46 A.M. of incontinence care to Resident #24 by Certified Nursing Assistant (CNA) #426 revealed concerns with infection control. CNA #426 assisted the resident to her bed, removed her shoes, and placed them on the floor by the foot of the bed and started providing perineal care. When CNA #426 removed Resident #24's brief, she placed it on the ground by Resident #24's shoes. She then utilized disposable wipes to wash the resident and after wipes were soiled, including with bowel movement, she attempted to place them on top of the soiled brief on the floor with some landing directly on the floor. During the observation, it was noted a trash can was by the resident's head of the bed but there was no trash bag in it. CNA #426 stated there was usually a bag in the can and she stated she should have opened a bag before started providing care. CNA #426 stated she had trash bags in her pocket. Review of the facility policy titled, Perineal Care, revised August 2008, revealed staff were to throw disposable items into a designated container. 5. Review of the medical record for Resident #50 revealed an admission date of 10/28/25 with diagnoses including schizophrenia, anxiety, depression and hypertension. Review of the physician's orders for April 2026 revealed Resident #50 received Aspirin 81 milligrams (mg), calcium carbonate (supplement), Coenzyme Q10 (supplement) 30 mg, Effexor (anti-depressant) 37.5 mg, Magnesium (supplement) 200 mg, Omeprazole (antacid) 40 mg, Oxybutynin (medication for over-active bladder) 2.5 mg, Potassium Chloride (supplement) 20 milliequivalents (meq), Seroquel (anti-psychotic) 25 mg, Thiamine (supplement) 100 mg, Zestoretic (medication for high blood pressure) 20-12.5 mg, Aso D Mannose (medication for urinary tract infections) 500 mg, Tylenol extra strength (pain medication) 500 mg, and Carbidopa-Levodopa (medication for Parkinson's Disease) 25-100 mg every morning. Observation on 04/27/26 at 9:28 A.M. of LPN #406 revealed she was performing medication administration for Resident #50. She was observed to be popping the resident's medications out of the medication card into her ungloved hand and then into a medication cup. There was a total of 17 pills in the medication cups on her medication cart when she had completed gathering Resident #50's medications. LPN #406 stated she was in a hurry and did not notice she was popping the pills into her hands first and then placing them into the medication cups. Review of the facility policy titled, Medication Dispensing System, revised August 2008, revealed staff were not to touch the medication when opening a bottle or unit dose package.

Based on personnel file review, review of the facility assessment, and interviews, the facility failed to conduct mandatory training to all staff on the facility's quality assurance and performance improvement (QAPI) program. This affected five out of 11 personnel files reviewed and had the potential to affect all 151 residents residing in the facility. The facility census was 151. Findings include: Review of Certified Nursing Assistant (CNA) #464's personnel file revealed a hire date of 12/23/25. There was no documented evidence that CNA #464 had received QAPI training as required.Review of CNA #465's personnel file revealed a hire date of 01/06/26. There was no documented evidence that CNA #465 had received QAPI training as required.Review of CNA #466's personnel file revealed a hire date of 02/26/26. There was no documented evidence that CNA #466 had received QAPI training as required.Review of Licensed Practical Nurse (LPN) #338's personnel file revealed a hire date of 09/16/25. There was no documented evidence that LPN #338 had received QAPI training as required.Review of Human Resource Director (HRD) #307's personnel file revealed a hire date of 04/21/25. There was no documented evidence that HRD #307 had received QAPI training as required.Interview on 04/30/26 at 10:23 A.M. with HRD #307 revealed the facility had not provided any QAPI training or in-services to staff since she started her employment with the facility in April 2025. HRD #307 stated she believed the Administrator would handle that area and confirmed he had not provided any QAPI in-servicing to staff, including herself.Interview on 04/30/26 at 11:05 A.M. with the Administrator verified the facility needed to complete QAPI training and it had not been completed yet since he started his employment with the facility on 12/08/25.Review of the facility assessment revised 08/01/25 revealed the facility would train its staff on communications, residents' rights, abuse, infection control, culture change, identification of changes in condition and cultural competency. The assessment did not include education for staff on QAPI as required.

Based on record review and interview, the facility failed to ensure Certified Nursing Assistants (CNA) had at least 12 hours of in-service training annually as required. This had the potential to affect all residents residing in the facility. The facility census was 151.Findings include:Review of the employee file for Certified Nursing Assistant (CNA) #325 revealed a hire date of 03/13/25. Continued review of the employee file revealed CNA #325 had not received 12 hours of in-service training annually as required. Review of the employee file for CNA #386 revealed a hire date of 01/15/25. Continued review of the employee file revealed CNA #386 had not received 12 hours of in-service training annually as required. Review of the employee file for CNA #425 revealed a hire date of 03/04/25. Continued review of the employee file revealed CNA #425 had not received 12 hours of in-service training annually as required. Interview on 04/29/26 at 2:26 P.M. with Human Resources Director (HR) #307 verified the CNA's had not completed the 12 hours of in-service training annually as required. She stated the facility was in the process of setting up an online education system.

Based on record review, interview and review of the facility policy, the facility failed to conduct care conferences at least quarterly as required. This affected nine residents (#6, #62, #65, #66, #74, #75, #119, #138, and #139) of nine residents reviewed for care planning. Facility census was 151. Findings include: 1. Review of Resident #139's medical record revealed an admission date of 09/05/24 and diagnoses including dementia with other behavioral disturbance, depression, anxiety, hypertension, and osteoarthritis. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #139 was cognitively impaired. Further review of Resident #139's medical record for the last twelve months revealed one care conference completed on 07/31/25. Telephone interview on 04/19/26 at 11:20 A.M. with Resident #139's guardian revealed she was concerned Resident #139 had not had a care conference since July 2025. Interview on 04/21/26 at 2:45 P.M. with MDS/Licensed Practical Nurse (LPN) #379 during review of Resident #139's chart revealed the last care conference conducted for Resident #139 was during July 2025. MDS/LPN #379 confirmed this was the last care conference done for Resident #139 and verified the facility was to be completing care conferences at least quarterly for all residents. 2. Review of the medical record for Resident #119 revealed an admission date of 11/22/19 and diagnoses including chronic respiratory failure, anxiety disorder, diabetes mellitus, and recurrent major depressive disorder. Review of quarterly MDS assessment dated [DATE] revealed Resident #119 was cognitively intact. Review of plan of care meeting notes from 10/02/25 revealed the care plan meeting was held however Resident #119 did not attend the meeting. Further review of the medical record for Resident #119 revealed there was no evidence of additional care plan meeting held since 10/02/25. Interview on 05/05/26 at 8:10 A.M. with Director of Nursing (DON) confirmed she was unable to locate any additional care plan meetings for Resident #119 held since 10/02/25. Review of facility policy Care Conference Resident/Family Participation undated revealed each resident and their family members were encouraged to participate in the development of the resident's comprehensive assessment and care plan. The social services director or designee was responsible for arranging care planning conferences. The policy did not address requirements for frequency of care planning conferences. 3. Review of the medical record for Resident #138 revealed an admission date of 11/25/24 and diagnoses including dementia with mood disturbance, chronic kidney disease, generalized anxiety disorder, hyperlipidemia, osteoarthritis, and essential hypertension. Review of plan of care meeting notes from 07/31/25 revealed the meeting needed to be re-scheduled. Review of MDS assessment dated [DATE] revealed Resident #138 had short- and long-term memory problems and severely impaired decision-making ability. Resident #138 was noted to have delusions. Review of Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #138 was unable to participate in interview resulting in score of 99. Further review of the medical record for Resident #138 revealed there was no evidence of a care plan meeting held since 04/10/25. There was no evidence the care plan meeting on 07/31/25 was re-scheduled as indicated. Interview on 04/27/26 at 3:17 P.M. with Social Services Designee (SSD) #373 confirmed Resident #138 had not had a care plan meeting since April of 2025. Review of facility policy Care Conference Resident/Family Participation undated revealed each resident and their family members were encouraged to participate in the development of the resident's comprehensive assessment and care plan. The social services director or designee was responsible for arranging care planning conferences. The policy did not address requirements for frequency of care planning conferences. 4. Review of Resident #62's medical record revealed an admission date of 09/05/24 with diagnoses including cerebral infarction, seizures, depression, anxiety, chronic kidney disease, neurocognitive disorder, insomnia, and alcohol-induced dementia. Review of Resident #62's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/13/26, revealed Resident #62 was cognitively impaired. Review of the weekly schedules of plan of care meetings dated back to 01/22/26 revealed Resident #62 had no scheduled care plan meetings. Interview on 04/21/26 at 12:00 P.M. with Resident #62 revealed the facility does not include her in care plan meetings or follow any preferences or wishes she had. Interviews on 04/21/26 at 2:44 P.M. with the Resident Council revealed residents were invited to care plan meetings but there have not been any care plan meetings lately. Interview on 04/21/26 at 2:55 P.M. with the DON revealed residents were involved with their plan of care. There was a meeting schedule and the staff would bring residents to the meetings if they wished to attend. Interview on 04/22/26 10:22 A.M. with the DON revealed care plan meetings were currently not being done. Review of the facility's care conference policy, undated, revealed the resident and family are invited to attend and participate in the residents assessment and care planning conference. Advance notice of the care planning conference was provided to the resident and authorized representative. 5. Review of Resident #6's medical record revealed he was admitted on [DATE] and his diagnoses Included but were not limited to personal history of traumatic brain injury acute and chronic respiratory failure, tracheostomy, unspecified kidney failure, and cerebral vascular disease. Review of Resident #6's quarterly MDS 3.0 assessment dated [DATE] revealed he had a Brief Interview Mental status score of 15 indicating he was intact cognition and he was his own responsible party. Review of Resident #6's progress notes revealed the last Plan of Care Care Conference was dated 09/21/25. Progress notes from 09/22/25 to 05/01/26 /22 did not reveal any documented evidence that a quarterly care conference was completed. Interview on 04/22/26 at 2:03 P.M. with SSD #373 revealed many of the care conferences were missed/not done recently including Resident #6's care conference. 6. Review of Resident #65's medical record revealed he was admitted on [DATE] and his diagnoses included but were not limited to Schizoaffective disease, major depressive disorder, anxiety disorder, chronic kidney disease, and peripheral vascular disease Review of Resident #65's quarterly MDS 3.0 assessment dated [DATE] revealed he had a Brief Interview Mental status score of five indicating he was severely cognitively impaired. The medical record revealed Resident #65 had a legally appointed Guardian. Review of Resident #65's progress notes revealed the last Plan of Care Conference was dated 10/30/25. Resident #65's Care Plan documentation and his medical record Progress notes from 10/30/25 to 05/01/26 did not reveal any documented evidence that a quarterly care conference was completed. Interview on 04/22/26 at 2:03 P.M. with SSD #373 revealed many of the care conferences were missed/not done recently including Resident #65's care conference. 7. Review of Resident #66's medical record revealed he was admitted on [DATE] and his diagnoses included but were not limited to Schizoaffective disease, major depressive disorder, anxiety disorder, chronic kidney disease, and peripheral vascular disease Review of Resident #66's quarterly MDS 3.0 assessment dated [DATE] revealed he had a Brief Interview Mental status score of five indicating he was severely cognitively impaired. The medical record revealed Resident #66 had a legally appointed Guardian. Review of Resident #66's progress notes revealed the last Plan of Care Conference was dated 10/30/25. Resident #66's Care Plan documentation and his medical record Progress notes from 01/01/25 to 05/01/26 did not reveal any documented evidence that a quarterly care conference was completed. Interview on 04/22/26 at 2:03 P.M. with SSD #373 revealed many of the care conferences were missed/not done recently including Resident #66's care conference. 8. Review of Resident #74's medical record revealed he was admitted on [DATE] and his diagnoses included but were not limited to Parkinson's disease, chronic respiratory failure, chronic obstructive pulmonary disease, hypertensive chronic kidney disease, and generalized weakness. Review of Resident #74's quarterly MDS 3.0 assessment dated [DATE] revealed he had a Brief Interview Mental status score of eight indicating he was severely cognitively impaired. The medical record revealed Resident #74's brother was responsible party. Review of Resident #74's progress notes revealed the last Plan of Care Conference was dated 10/30/25. Resident #74's Care Plan documentation and his medical record Progress notes from 10/31/25 to 05/01/26 did not reveal any documented evidence that a quarterly care conference was completed. Interview on 04/22/26 at 2:03 P.M. with SSD #373 revealed many of the care conferences were missed/not done recently including Resident #74's care conference. 9. Resident #75 was admitted to the facility on [DATE] with diagnosis motor and sensory neuropathy schizoaffective disorder type 2 diabetes Mellitus, varicose veins of left lower extremity with ulcer on other part of lower leg, non pressure chronic ulcer on right heel, and major depressive disorder. Review of Resident #75's annual MDS assessment dated [DATE] revealed the resident had a brief interview mental status score of 12, indicating mild to moderate cognitive impairment. Review of Resident #75's progress notes revealed the last Plan of Care Conference was dated 10/08/25. Resident #75's Care Plan documentation and his medical record Progress notes from 10/09/25 to 05/01/26 did not reveal any documented evidence that a quarterly care conference was completed. Interview on 04/22/26 at 2:03 P.M. with SSD #373 revealed many of the care conferences were missed/not done recently including Resident #75's care conference. Review of the undated policy, Care Conference Resident/Family Participation, revealed the resident and his/her family members are encouraged to participate in the development of the resident's assessment and care planning conference. A baseline care plan is completed within 48 hours of admission and a summary of the baseline care plan will be provided to the resident and/or representative upon request. Advance notice of the care planning conference is provided to the resident and authorized representative. The Social Service director/designee is responsible for contacting the resident's family and/or maintaining records for such notices. A comprehensive care plan is developed within seven days of completing the resident assessment by the interdisciplinary team. This deficiency represents non-compliance investigated under Complaint Number 2593029.

Based on record review, interview and review of the facility policy the facility failed to timely notify the responsible party and physician of changes. This affected four residents (#2, #56, #138 and #153) of five residents reviewed for notification of change. Facility census was 151. Findings include:1.Review of Resident #56's medical record revealed an admission date of 01/30/24 and diagnoses including schizoaffective disorder bipolar type, generalized anxiety disorder, depression, type two diabetes, dementia with mood disturbance and chronic kidney disease stage three. Review of an annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had severe cognitive impairment and had two or more falls since the previous assessment without injury. Review of a fall investigation dated 12/31/25 at 2:45 A.M. revealed Resident #56 tried to transfer herself from her wheelchair to her toilet and fell to the floor. The report indicated the nurse practitioner (NP) was notified. Under the report section, 'Agencies/People Notified,' Resident #56's family member was documented as having been notified regarding her fall on 01/02/26 at 1:57 P.M. Review of a hand-written investigation follow-up form included with the fall investigation dated 12/31/25 revealed Licensed Practical Nurse (LPN) #327 notified Resident #56's family regarding her fall on 01/02/26 at 1:50 P.M. Review of a progress note dated 01/07/26 at 6:56 A.M. revealed NP and [Resident #56's] family updated on resident's fall with no new orders. Family updated on room change recommendations. Interview on 04/30/26 at 2:40 P.M. with the Director of Nursing (DON) revealed if a fall occurred after hours, she expected staff to notify the family and physician within the shift the incident occurred in. During the interview the DON verified that notification to Resident #56's family two days after she fell was not timely notification as required. 2. Review of Resident #153's closed medical record revealed an admission date of 04/23/25 and diagnoses including dementia with other behavioral disturbance, unspecified protein-calorie malnutrition, type two diabetes, unspecified psychosis, hypertension, delusional disorders, altered mental status and depression. Resident #153 discharged to the hospital and then on to another facility on 09/19/25. Review of a quarterly MDS 3.0 assessment dated [DATE] revealed Resident #153 was cognitively impaired and displayed other behaviors one to three days over the seven day look-back period. Review of a progress note dated 05/11/25 at 9:31 A.M. revealed Resident #153 continued to remove his wanderguard (device used to alert staff of unauthorized leave of absence). Wanderguard replaced this morning. Resident #153 became upset and speaking Spanish when replaced to left ankle. Review of a progress note dated 05/14/25 at 11:11 A.M. revealed Resident #153 removed his wanderguard again. New one replaced to left extremity. Review of a progress note dated 05/14/25 at 2:00 P.M. revealed despite much encouragement, explanation of need and possible adverse effects given, [Resident #153] refused Depakote (medication) three times stating, I am not a child, I know what you are doing. Review of a progress note dated 05/24/25 at 1:53 P.M. revealed Resident #153 was without his wanderguard to left lower extremity. When asked, Resident #153 stated he was unsure where the wanderguard was. New wanderguard was placed. Review of an electronic Medication Administration Record (e-MAR) note dated 05/27/25 at 2:23 P.M. revealed there was no wanderguard present on Resident #153. Review of an e-MAR note dated 05/31/25 at 2:04 P.M. revealed there was no wanderguard present on Resident #153 and the supervisor was made aware. Review of an e-MAR note dated 06/01/25 at 2:30 P.M. revealed Resident #153 keeps removing [the wanderguard] and cannot find it in his room. Review of a progress note dated 06/27/25 at 1:54 P.M. revealed despite much encouragement and explanation of need given, refused shower three times. Resident #153 repeatedly stated 'no.' Further review of Resident #153's medical record revealed no evidence the physician and Resident #153's family member were notified regarding Resident #153's above refusals of his wanderguard, showers and medications. Interview on 04/29/26 at 4:20 P.M. with the DON verified there was no evidence the facility notified the physician or Resident #153's family member regarding Resident #153 removing his wanderguard on 05/11/25, 05/24/25, 05/27/25, 05/31/25 and 06/01/25, refusing medications on 05/14/25 and refusing showers on 06/27/25. 3. Review of the medical record for Resident #2 revealed an admission date of 03/02/26 and diagnoses including dementia, fracture of first lumbar vertebra, multiple fractures of ribs on left side, repeated falls, contusion of scalp, unsteadiness on feet, generalized muscle weakness, adult failure to thrive, and need for assistance with personal care. Review of Weight Summary revealed Resident #2 had an admission weight on 03/02/26 of 184.0 pounds. Additional weights were obtained: on 03/12/26 at 175.0 pounds, on 03/13/26 at 173.0 pounds, on 03/19/26 at 173.0 pounds, on 03/27/26 at 172.0 pounds, on 04/10/26 at 172.2 pounds, on 04/17/26 at 128.5 pounds, and on 04/22/26 at 129.6 pounds. Review of a Medicare MDS admission assessment dated [DATE] revealed Resident #2 had a brief interview for mental status (BIMS) score of 03 indicating severe cognitive impairment. Resident #2 had significant weight loss not on prescribed weight loss regimen. Further review of the medical record for Resident #2 revealed no evidence Resident #2's son who was identified as an emergency contact was notified of the weight changes including significant weight loss. Interview on 04/30/26 at 7:39 A.M. with DON confirmed there was no evidence Resident #2's family was notified of significant weight changes. Review of facility policy Nutrition (Impaired)/Unplanned Weight Loss – Clinical Protocol dated August 2008 revealed staff would notify the resident's family of significant weight losses, weight gains, decline of appetite, or decline in food intake. 4. Review of the medical record for Resident #138 revealed an admission date of 11/25/24 and diagnoses including dementia with mood disturbance, chronic kidney disease, generalized anxiety disorder, hyperlipidemia, osteoarthritis, and essential hypertension. Review of Medicare MDS assessment dated [DATE] revealed Resident #138 required substantial/maximal assistance from staff for personal hygiene, bathing, and upper body dressing and was dependent on staff assistance for lower body dressing and toileting hygiene. Resident #138 had short- and long-term memory problems and severely impaired decision-making ability. Resident #138 was noted to have delusions. Review of Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #138 was unable to participate in interview resulting in score of 99. Review of progress note dated 03/27/26 at 2:20 P.M. revealed Resident #138's right wrist was red and swollen. Resident #138 complained of pain when moving the wrist. NP was notified and gave new orders for x-ray and two tablets of Tylenol 500 milligrams twice daily for three days for pain. There were no noted accidents or events related to the redness, swelling, and pain. Review of NP progress note dated 03/27/26 revealed Resident #138 was seen for evaluation of right wrist pain. There was noted redness and swelling. There were no related falls and resident was unable provide details other than the area was painful. Resident #138 noted to be an irritated mood. Noted right forearm bruising on physical exam. New orders for an x-ray and addition of 1000 milligrams of Tylenol twice daily for three days. Review of radiology result dated 03/28/26 at 12:00 A.M. revealed x-ray resulted with no evidence of acute fracture or dislocation of right wrist. Review of NP progress note dated 03/30/26 revealed the NP was unable to determine an underlying reason for swelling, redness, and pain. A new order for Voltaren one percent two grams applied twice daily for seven days. Review of progress note dated 03/30/26 at 12:11 P.M. revealed Resident #138's son who was identified as her resident representative was notified of redness, swelling, and pain to Resident #138's right wrist and results of an x-ray. Interview on 04/30/26 at 7:39 A.M. with Director of Nursing (DON) confirmed there was no evidence Resident #138's resident representative was notified of the redness, swelling, and pain to Resident #138's right wrist, need for x-ray, and medication change until 03/30/26. Review of facility policy titled Notification of Resident Change in Condition Policy dated August 2015 revealed a licensed nurse would promptly inform the resident's legal representative of a significant change in the resident's physical, mental, or psychosocial status, need to alter treatment significantly or begin a new treatment, and any injury/accident that could require nursing or medical intervention. This deficiency represents non-compliance investigated under Complaint Number 2626558.

Based on record review, interview, review of self-reported incidents (SRI) and review of the facility policy, the facility failed to ensure residents were free of misappropriation of controlled medications. This affected four residents (Residents #1, #3, #47 and #154) of five residents reviewed for controlled substances. The facility census was 151. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 01/20/22 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, heart failure and arthritis. Review of the physician's orders for Resident #1 revealed an order for Oxycodone (opioid medication for pain) 10 milligrams (mg) every four hours dated 03/27/26. The medication was to be administered at 1:00 A.M., 5:00 A.M., 9:00 A.M., 1:00 P.M., 5:00 P.M. and 9:00 P.M. daily. Review of the Medication Administration Record (MAR) for April 2026 for Resident #1 revealed Oxycodone 10 mg was administered on 04/27/26 at 1:00 A.M., 5:00 A.M., 9:00 A.M., 1:00 P.M., 5:00 P.M. and 9:00 P.M. Review of the Patient Controlled Substance Administration Record for Resident #1's Oxycodone 10 mg revealed nursing staff had administered the medication on 04/27/26 at 1:00 A.M., 5:00 A.M., 10:00 A.M., 4:52 P.M., 4:00 P.M. and 10:00 P.M. The record revealed medication times were out of order and did not match the MAR. It was also noted there was an extra dose of medication signed out of the record but not administered to the resident. Interview on 04/29/26 at 11:13 A.M. with the Director of Nursing (DON) revealed she was alerted on 04/28/26 there were discrepancies with Resident #1's Oxycodone administration for 04/27/26. She stated Licensed Practical Nurse (LPN) #338 had documented on the patient controlled substance administration record that she administered Resident #1's Oxycodone 10 mg at 4:00 P.M. However, LPN #338 was not working at that time. She stated LPN #338 did not clock into work until 6:46 P.M. The DON stated the facility initiated an investigation and filed a self-report incident with the State Agency. She stated LPN #338 and LPN #456, who was the nurse on duty on 04/27/26 at 4:52 P.M., were both sent for drug tests which were negative. Interview on 04/29/26 at 11:45 A.M. with Registered Nurse (RN) #457, who is the Assistant Director of Nursing, stated she identified an inconsistency on Resident #1's patient controlled substance administration record on 04/28/26. She stated LPN #456 was working the 7:00 A.M.–7:00 P.M. shift on 04/27/26 and had correctly administered Resident #1's scheduled 5:00 P.M. dose of Oxycodone 10 mg at 4:52 P.M., which matched the MAR. RN #457 reported that the next entry on the controlled substance record showed an additional administration of Oxycodone at 4:00 P.M., documented and signed by LPN #338, who was not working at that time. She confirmed the signature on the 4:00 P.M. entry matched LPN #338's other signatures on the page. RN #457 verified that Resident #1 did not receive an extra dose of Oxycodone on 04/27/26. However, she was unable to account for the medication associated with the incorrect 4:00 P.M. entry. Interviews were attempted on 04/29/26 at 1:33 P.M. and at 3:34 P.M. with LPN #338 without success. Messages were left with no return contact made. Interview on 04/29/26 at 2:20 P.M. with Resident #1 revealed he was concerned about getting his pain medications timely. He stated he was worried that he would not be able to remember if he got his medications as ordered. Review of the facility policy titled, Medication Dispensing System, undated, revealed nursing staff were to verify each medication preparation that the medication was the right drug, right dose, right route, right rate, right time and for the right customer. Review of the facility policy titled, Abuse Prevention Program, dated February 2017, revealed misappropriation of resident property meant the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings without the resident's consent. The facility was to ensure the residents were free from abuse, neglect, exploitation, misappropriation of property or mistreatment. 2. Review of the medical record for Resident #154 revealed an admission date 05/13/25 with diagnoses including malignant neoplasm of the lung (cancer), chronic obstructive pulmonary disease, diabetes mellitus and back pain. She was discharged home on [DATE]. Review of the physician's orders for Resident #154 revealed she had an order for Oxycodone (opioid medication for pain) 5 milligrams (mg) every eight hours as needed for pain dated 12/01/25. Review of the Patient Controlled Substance Administration Record for Resident #154's Oxycodone 5 mg Rx #206039493 revealed 30 tablets had been received on 12/02/25. The first dose was administered on 12/13/25 at 8:15 P.M. and the last dose on the card was administered on 12/25/25 at 8:30 P.M. There were 23 tablets remaining on the card. Review of the Controlled Medication Shift Change Log dated 12/26/25 revealed Registered Nurse (RN) #452, the Assistant Director of Nursing, had removed Resident #154's card of Oxycodone 5 mg Rx #206039493 with 23 remaining tablets from the medication cart. Her signature was the only one noted with the removal of the medication. Review of the witness statement by Licensed Practical Nurse (LPN) #327 revealed on 12/26/25 RN #452 had come to her medication cart to check the narcotic book. She stated RN #452 stated there were errors on Resident #154's Oxycodone card so she removed the signature sheet along with the card of remaining pills. LPN #327 asked if she wanted her to assist in destroying the medication with RN #452, but RN #452 had responded she could only do it with another department head. Review of the witness statement dated 12/29/25 by LPN #317, Assistant Director of Nursing, revealed she was doing audits on 12/29/25 of the narcotic count sheets and noted Oxycodone for Resident #154 was removed from the medication cart on 12/26/25. She stated she could not find the patient controlled substance administration record or the reason it was removed. LPN #317 stated she interviewed LPN #327 who stated RN #452 removed Resident #152's Oxycodone card with the medications stating there were discrepancies on the card. LPN #327 stated RN #452 did not want her to waste the remaining narcotics with her. LPN #317 stated she then interviewed RN #452 about the discrepancy and she became nervous and flustered and her hands were shaking. RN #452 stated she had wasted the Oxycodone with LPN #327. LPN #317 stated she had spoken to LPN #327 who denied wasting the medication with her. RN #452 then began to pull papers out of her personal back pack and then wanted to go to her car to look for the narcotic card. RN #452 could not explain why she had removed the card and was unable to produce the medication. RN #452 provided the patient controlled substance administration record to LPN #317 for Resident #154's Oxycodone 5 mg which revealed there were 23 tablets remaining. Review of the emailed statement dated 12/30/25 by RN #452 revealed she was notified by the floor nurse there was an error on the patient controlled substance administration record for Resident #154's Oxycodone. She stated she reviewed the record and updated pharmacy who stated they were sending a new card of Oxycodone to the facility. RN #452 stated she took the card of medication out of the medication cart and placed it in her office. She stated before she left the facility for the day she destroyed the medication prior to leaving because she did not want them in her office over the weekend. She did not identify any other staff having assisted her in destroying the Oxycodone for Resident #154. Interview on 04/22/26 at 9:11 A.M. with the DON verified the facility had not filed a self-reported incident (SRI) incident for misappropriation with the State Agency related to Resident #154's Oxycodone 5 mg. The DON verified RN #452 was unable to produce the Oxycodone 5 mg with the 23 remaining tablets. Interview on 05/04/26 at 8:35 A.M. with the DON revealed nursing staff were not re-educated on medication administration or narcotic handling since their orientation on hire to the facility. Review of the facility policy titled, Schedule II Controlled Substance Medication, undated, revealed all controlled dangerous substances would be stored under double lock. If the controlled medication could not be accounted for, the DON should be notified immediately and a report of theft or loss of controlled form would be forwarded to the appropriate authorities. All medication destruction in the facility should be witnessed by at least two persons (an RN, LPN or pharmacist consultant). A record of each instance of the drug destruction should be maintained. Review of the facility policy titled, Abuse Prevention Program, dated February 2017, revealed misappropriation of resident property meant the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings without the resident's consent. The facility was to ensure the residents were free from abuse, neglect, exploitation, misappropriation of property or mistreatment. 3. Review of the medical record for Resident #47 revealed an admission date of 05/15/25 with diagnoses including schizoaffective disorder, depression, anxiety, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had impaired cognition. Review of Resident #47's physician orders revealed an order for Lyrica (anticonvulsant controlled substance) 100 milligrams twice a day that started on 06/06/25. Review of Resident #47's medication administration record (MAR) for November 2025 revealed the morning dose on 11/12/25 was not administered since it was not available. Review of Resident #47's Lyrica count sheets revealed no doses were signed out on 11/12/25. Review of SRI tracking number 267482 dated 11/12/25 revealed the facility staff reported that Resident #47's Lyrica was misplaced. A new order of Lyrica was ordered from the pharmacy. The facility immediately initiated an investigation. The physician and police were notified. The facility unsubstantiated the SRI stating evidence was inconclusive that misappropriation occurred. Review of the facility investigation for SRI tracking number 267482 revealed Resident #47 was not interviewed. There were no interviews with like residents related to the SRI. Resident #47's family was not notified. The Alleged Perpetrator, a witness, and other staff were interviewed regarding the SRI. Interview on 05/04/26 at 8:35 A.M. with the DON revealed the nurses has had no additional competencies for medication administration since hire even though there were concerns with misappropriation and possible narcotic diversion. The DON stated the in-services provided were the competencies the nurses were set up to complete. Interview on 05/04/26 at 11:01 A.M. with the DON revealed a previous administrator handled the SRI and indicated the SRI was unsubstantiated due to the Alleged Perpetrator not having the intent to steal the medication. The DON indicated she was notified of the missing medication and assisted in trying to locate the medication. The Alleged Perpetrator that misplaced the medication was training and it was lost due to being busy with the nurse trainee. The Alleged Perpetrator was drug tested on [DATE] with a negative result. The DON confirmed Resident #47 was not interviewed nor were other residents since it was a missing medication card. The DON confirmed Resident #47's family was not notified of the misplaced medication. Also, there was no education provided to the facility staff in regard to misappropriation. Interview on 05/04/2026 at 12:30 PM with the DON revealed Resident #47 did not receive Lyrica on 11/12/25 even though a dose was marked on the MAR as given for the evening dose. Review of the facility's abuse policy, dated 02/07/17, revealed any incident involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property result in an investigation. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident if interviewable. Any written statements that have been submitted will be reviewed along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed. Review of the facility's controlled substance medication policy, undated, revealed when the licensed staff member/nurse receives a controlled dangerous substance medication from the pharmacy, he/she will verify the contents with the label and will note the date received and quantity on the declining inventory form. 4. Resident #3 was admitted to the facility at 01/12/26, with diagnosis including cellulitis, non-pressure chronic ulcer of unspecified part of right lower leg , type two diabetes mellitus with diabetic neuropathy, and peripheral vascular disease. Resident #3 Quarterly Minimum Data Set, dated [DATE] revealed the resident had a Brief Mental Status of 15, revealing the resident was mentally intact. Resident was independent on bed mobility, independent with upper and lower dressing, independent on transfers, could ambulate with a walker for 150 feet independently. Review of Resident #3's care plan dated revised 04/18/26 revealed Resident #3 can be resistant of care including physical therapies, goes out for long leave of absences, (LOA), refuses to elevate leg than complains of pain, and can be verbally aggressive. Review of Resident #3's physician orders for April 2026 revealed orders for Oxycodone HCI tablet five milligrams orally on wound care day, assess for pain, Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) give one tablet by mouth every 24 hours as needed for pain on wound care days one hour prior to appointment, do not give as needed (PRN) dose within one hour other PRN dose. All Oxycodone orders had been discontinued by 04/09/26. Review of the Resident#3's MAR and Resident #3's Narcotic Medication Administration Log revealed on 04/01/26 LPN #393 signed the controlled substance administration sheet stating she gave Oxycodone to resident but did not document in electronic MAR. On 04/05/26 LPN #425 signed the controlled substance administration sheet stating she gave Oxycodone to Resident #3 but did not document in electronic MAR. Interview on 04/30/26 at 11:58 A.M. with DON regarding Resident #3 Oxycodone not being administered on 04/01/26 and 04/05/26 but the medication being removed revealed on 04/01/26 the nurse was LPN #393 and nurse on 04/05/26 was LPN #425. DON revealed they would begin an investigation and submit a SRI Interview on 04/30/26 at 1:32 P.M. with Resident #3 revealed he was received Oxycodone medication when his wound was worse, but feel his wound was better, his pain was no longer as intense, his Oxycodone was no longer needed and he did not recall if he received his Oxycodone on 04/01/26 and 04/05/26. Review of the facility's SRI dated 04/30/26 revealed on 04/01/26 LPN #425 signed the controlled substance administration sheet stating she gave Oxycodone to Resident #3 but did not document in electronic MAR. On 04/05/26 LPN #393 signed the controlled substance administration sheet stating she gave Oxycodone to same resident but did not document in electronic MAR. The nurse practitioner and the resident's family were notified. Both LPNs were suspended pending investigation. Resident #3 was at his normal baseline; no ill effects were noted. The Ohio Department of Health surveyor and the Ohio Attorney General were aware. Review of the facility's abuse policy, dated 02/07/17, revealed any incident involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property result in an investigation. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident if interviewable. Any written statements that have been submitted will be reviewed along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed. Review of the facility's controlled substance medication policy, undated, revealed when the licensed staff member/nurse receives a controlled dangerous substance medication from the pharmacy, he/she will verify the contents with the label and will note the date received and quantity on the declining inventory form. This deficiency represents non-compliance investigated under Complaint Number 2668600 and 2990856.

Based on record review, interview, review of self-reported incidents (SRI) and review of the facility policy, the facility failed to implement and follow their policy for allegations of abuse for residents. This affected four residents (Residents #47, #98, #138, #154) of fifteen residents reviewed for abuse. The facility census was 151. Findings include:1. Review of the medical record for Resident #154 revealed an admission date 05/13/25 with diagnoses including malignant neoplasm of the lung (cancer), chronic obstructive pulmonary disease, diabetes mellitus and back pain. She was discharged home on [DATE]. Review of the physician's orders for Resident #154 revealed she had an order for Oxycodone (opioid medication for pain) 5 milligrams (mg) every eight hours as needed for pain dated 12/01/25. Review of the Patient Controlled Substance Administration Record for Resident #154's Oxycodone 5 mg Rx #206039493 revealed 30 tablets had been received on 12/02/25. The first dose was administered on 12/13/25 at 8:15 P.M. and the last dose on the card was administered on 12/25/25 at 8:30 P.M. There were 23 tablets remaining on the card. Review of the Controlled Medication Shift Change Log dated 12/26/25 revealed Registered Nurse (RN) #452, the Assistant Director of Nursing, had removed Resident #154's card of Oxycodone 5 mg Rx #206039493 with 23 remaining tablets from the medication cart. Her signature was the only one noted with the removal of the medication. Review of the witness statement by Licensed Practical Nurse (LPN) #327 revealed on 12/26/25 RN #452 had come to her medication cart to check the narcotic book. She stated RN #452 stated there were errors on Resident #154's Oxycodone card so she removed the signature sheet along with the card of remaining pills. LPN #327 asked if she wanted her to assist in destroying the medication with RN #452, but RN #452 had responded she could only do it with another department head. Review of the witness statement dated 12/29/25 by LPN #317, Assistant Director of Nursing, revealed she was doing audits on 12/29/25 of the narcotic count sheets and noted Oxycodone for Resident #154 was removed from the medication cart on 12/26/25. She stated she could not find the patient controlled substance administration record or the reason it was removed. LPN #317 stated she interviewed LPN #327 who stated RN #452 removed Resident #152's Oxycodone card with the medications stating there were discrepancies on the card. LPN #327 stated RN #452 did not want her to waste the remaining narcotics with her. LPN #317 stated she then interviewed RN #452 about the discrepancy and she became nervous and flustered and her hands were shaking. RN #452 stated she had wasted the Oxycodone with LPN #327. LPN #317 stated she had spoken to LPN #327 who denied wasting the medication with her. RN #452 then began to pull papers out of her personal back pack and then wanted to go to her car to look for the narcotic card. RN #452 could not explain why she had removed the card and was unable to produce the medication. RN #452 provided the patient controlled substance administration record to LPN #317 for Resident #154's Oxycodone 5 mg which revealed there were 23 tablets remaining. Review of the emailed statement dated 12/30/25 by RN #452 revealed she was notified by the floor nurse there was an error on the patient controlled substance administration record for Resident #154's Oxycodone. She stated she reviewed the record and updated pharmacy who stated they were sending a new card of Oxycodone to the facility. RN #452 stated she took the card of medication out of the medication cart and placed it in her office. She stated before she left the facility for the day she destroyed the medication prior to leaving because she did not want them in her office over the weekend. She did not identify any other staff having assisted her in destroying the Oxycodone for Resident #154. Interview on 04/22/26 at 9:11 A.M. with the Director of Nursing (DON) verified the facility had not filed a self-reported incident (SRI) incident for misappropriation with the State Agency related to Resident #154's Oxycodone 5 mg. She verified a thorough investigation was not completed and the facility did not follow their policy. Review of the facility policy titled, Abuse Prevention Program, dated February 2017, revealed misappropriation of resident property meant the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings without the resident's consent. The facility stated it was to report immediately or no later than 24 hours to the State Agency, local law enforcement and the resident's representative. The facility policy stated upon learning of the allegation of misappropriation of resident properly it would initiate an incident and investigation. 2. Review of the medical record for Resident #138 revealed an admission date of 11/25/24 and diagnoses including dementia with mood disturbance, chronic kidney disease, generalized anxiety disorder, hyperlipidemia, osteoarthritis, and essential hypertension. Review of progress note dated 11/22/25 at 8:15 A.M. revealed Resident #138 had grayish black ecchymosis areas to left outer upper arm, left outer wrist area, and right inner arm. Resident #138 did not complain of any pain. Resident #138 was noted to have fragile skin and was on a daily aspirin. Resident #138 was noted to ambulate independently. There were no noted accidents or events related to bruising. Review of Self-Reported Incident (SRI) Form number 267836 dated 11/22/25 revealed the facility reported to the State Agency an injury of unknown origin for Resident #138. Staff noted bruising on Resident #138's left upper outer arm, left outer wrist, and right inner wrist. Resident #138 was unable to report what had happened. It was noted the facility did not suspect abuse due to location and shape of bruising. It was noted Resident #138 can be combative with care and independently ambulates on the unit. The facility was unable to determine the origin of bruising. The SRI was unsubstantiated as evidence indicates abuse, neglect, or misappropriation did not occur. Review of the facility's investigation for SRI number 267836 revealed no identification of root cause. There was no evidence of any environmental inspection. There was no evidence of staff re-training related to the occurrence and investigation of an injury of unknown origin. Review of Nurse Practitioner (NP) progress note dated 11/24/25 revealed Resident #138 seen for evaluation for contusion to the arm. NP ordered long sleeves to protect skin. Resident #138 noted to be poor historian and pleasantly confused. Nursing staff reported Resident #138 had intermittent bruising. Plan to continue monitoring for ongoing occurrences and monitor for symptoms suggestive of anemia. Review of progress note dated 01/23/26 at 10:00 P.M. revealed Resident #138 had a lump with bruising on right forearm. There was also bruising noted to inner right forearm. Resident #138 denied pain. Resident #138 was unable to report what had happened. Resident #138 was noted to have a history of being combative with care. There were no noted accidents or events related to bruising or a lump. Review of progress note dated 01/23/26 at 10:30 P.M. revealed Resident #138 had order for x-ray to the right forearm and new order for antibiotics. Review of Self-Reported Incident (SRI) Form number 270153 dated 01/23/26 revealed the facility reported to the State Agency an injury of unknown origin for Resident #138. Staff noted a lump with bruising on Resident #138's lateral right forearm and bruising on medial forearm. Resident #138's family and NP were notified. The facility initiated 15-minute checks. Resident #138 was unable to provide a description of what had happened to her arm. The SRI was unsubstantiated as evidence indicates abuse, neglect, or misappropriation did not occur. Review of the facility's investigation for SRI number 270153 revealed no identification of root cause. There was no evidence of any environmental inspection. There was no evidence of additional residents being evaluated for bruising. There was no evidence of staff re-training related to the occurrence and investigation of an injury of unknown origin. Review of radiology result dated 01/24/26 at 11:57 A.M. revealed no evidence of acute fracture. There was noted soft tissue swelling over the latera aspect of proximal shaft of the radius consistent with hematoma. Review of progress note dated 01/24/26 at 12:45 P.M. revealed a new order to elevate and ice area on right forearm. Staff were to monitor area and call NP if the area had additional spread. Review of NP progress note dated 01/26/26 revealed Resident #138 seen for evaluation of bruise to right forearm. The bruise was of unknown etiology per nursing and Resident #138. There was no noted trauma or injury. New orders for Doxycycline 100 mg twice daily for seven days, elevate and ice area, and x-ray. Physical exam revealed poor strength, range of motion was normal to right arm and wrist, and there was no erythema. Resident #138 remained pleasantly confused. NP unable to identify etiology of bruising. Review of progress note dated 01/28/26 at 10:19 P.M. revealed Resident #138 had a doppler test completed to the bruised and swollen right forearm area. There was no evidence of deep vein thrombosis. Review of radiology result dated 01/28/26 at 8:48 P.M. revealed a doppler scan resulted with no evidence of deep venous thrombosis in right upper extremity veins. Review of Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #138 required substantial/maximal assistance from staff for personal hygiene, bathing, and upper body dressing and was dependent on staff assistance for lower body dressing and toileting hygiene. Resident #138 had short- and long-term memory problems and severely impaired decision-making ability. Resident #138 was noted to have delusions. Review of Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #138 was unable to participate in interview resulting in score of 99. Review of progress note dated 03/27/26 at 2:20 P.M. revealed Resident #138's right wrist was red and swollen. Resident #138 complained of pain when moving the wrist. NP was notified and gave new orders for x-ray and two tablets of Tylenol 500 milligrams twice daily for three days for pain. There were no noted accidents or events related to the redness, swelling, and pain. Review of facility's SRIs revealed no evidence an SRI was reported to the State Agency on or around 03/27/26 for an injury of unknown origin for Resident #138. There was no evidence of investigation to determine root cause of redness, swelling, and pain to Resident #138's wrist. Review of NP progress note dated 03/27/26 revealed Resident #138 was seen for evaluation of right wrist pain. There was noted redness and swelling. There were no related falls and resident was unable provide details other than the area was painful. Resident #138 noted to be an irritated mood. Noted right forearm bruising on physical exam. New orders for an x-ray and addition of 1000 milligrams of Tylenol twice daily for three days. Review of radiology result dated 03/28/26 at 12:00 A.M. revealed x-ray resulted with no evidence of acute fracture or dislocation of right wrist. Review of NP progress note dated 03/30/26 revealed the NP was unable to determine an underlying reason for swelling, redness, and pain. A new order for Voltaren one percent two grams applied twice daily for seven days. Interview on 04/30/26 at 7:39 A.M. with Director of Nursing (DON) revealed Resident #138 was supposed to walk with assistance from staff, however, did not always remember to ask for help. Resident #138 was not known to get into altercations with other residents. Resident #138 had impaired cognition. SRIs #267836 and #270153 were reviewed and the DON confirmed she was unable to locate evidence to support a root cause was identified to sufficiently rule out abuse. DON confirmed an SRI was not filed Resident #138's wrist presenting with redness, swelling, and pain despite history with injuries of unknown origin presenting in a similar manner. DON reported there was no bruise, so an SRI was not filed. Review of facility policy titled Abuse Prevention Program dated February 2017 revealed an appointed investigator would at a minimum interview the person reporting the incident, interview anyone with direct knowledge of the incident, obtain written statements, and gather any pertinent medical records. An injury would be classified as an injury of unknown source when both conditions were met: the source of injury was not observed or could not be explained and the injury is suspicious due to location, extent, or incidence of injuries over time. The injury would be reported to the State Agency and investigated following the abuse policy. 3. Review of the medical record for Resident #47 revealed an admission date of 05/15/25 with diagnoses including schizoaffective disorder, depression, anxiety, and bipolar disorder. Review of Resident #47's physician orders revealed an order for Lyrica (anticonvulsant controlled substance) 100 milligrams twice a day that started on 06/06/25. Review of Resident #47's medication administration record (MAR) for November 2025 revealed the morning dose on 11/12/25 was not administered since it was not available. Review of Resident #47's Lyrica count sheets revealed no doses were signed out on 11/12/25. Review of SRI tracking number 267482 dated 11/12/25 revealed the facility staff reported that Resident #47's Lyrica was misplaced. A new order of Lyrica was ordered from the pharmacy. The facility immediately initiated an investigation. The physician and police were notified. The facility unsubstantiated the SRI stating evidence was inconclusive that misappropriation occurred. Review of the facility investigation for SRI tracking number 267482 revealed Resident #47 was not interviewed. There were no interviews with like residents related to the SRI. Resident #47's family was not notified. Interview on 05/04/26 at 11:01 A.M. with the DON revealed a previous administrator handled the SRI and indicated the SRI was unsubstantiated due to the Alleged Perpetrator not having the intent to steal the medication. The DON indicated she was notified of the missing medication and assisted in trying to locate the medication. The Alleged Perpetrator that misplaced the medication was training and it was lost due to being busy with the nurse trainee. The Alleged Perpetrator was drug tested on [DATE] with a negative result. The DON confirmed Resident #47 was not interviewed nor were other residents since it was a missing medication card. The DON confirmed Resident #47's family was not notified of the misplaced medication. Also, there was no education provided to the facility staff in regard to misappropriation. Review of the facility's abuse policy, dated 02/07/17, revealed any incident involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property result in an investigation. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident if interviewable. Any written statements that have been submitted will be reviewed along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed. 4. Review of the medical record for Resident #98 revealed an admission date of 05/21/25 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, anxiety, depression, and chronic kidney disease. Review of SRI tracking number 271768 dated 03/05/26 revealed Resident #98 alleged a certified nurse assistant spoke to her in an unfriendly way and cursed at her. The certified nurse assistant was suspended pending investigation. No known witnesses noted. Resident questioned with no known issues noted. Staff questioned with no known issues noted. Based on the facility's investigation the allegation was unsubstantiated. Evidence indicated abuse, neglect or misappropriation did not occur. Review of the facility investigation for SRI tracking number 267482 revealed Resident #98 was interviewed but no statement provided. There were interviews with residents but they were not dated and did not cover all the resident in the area of the alleged incident. There was no assessment completed on Resident #98 following the allegation. There were staff interviews but it was not specific to the allegation and not dated. Also there was no education provided to the staff regarding abuse. Interview on 04/30/26 at 12:26 P.M. with the Administrator revealed resident statements were obtained but not dated and not all residents from the area of the alleged incident. There was no resident assessment completed. There was no abuse training completed for the staff. Staff statements were included in the investigation but they were not specific to the allegation and no dates listed. Review of the facility's abuse policy, dated 02/07/17, revealed any incident involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property result in an investigation. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident if interviewable. Any written statements that have been submitted will be reviewed along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed. This deficiency represents non-compliance investigation under Complaint Number 2668600, 2990856, and 2992799.

Based on record review, interview, review of self-reported incident (SRI) and review of the facility policy, the facility failed to thoroughly investigate an allegation of abuse, misappropriation and injury of unknown origin for residents. This affected four (Residents #47, #98, #138, #154) of fifteen residents reviewed for abuse. The facility census was 151. Findings include: 1. Review of the medical record for Resident #154 revealed an admission date 05/13/25 with diagnoses including malignant neoplasm of the lung (cancer), chronic obstructive pulmonary disease, diabetes mellitus and back pain. She was discharged home on [DATE]. Review of the physician's orders for Resident #154 revealed she had an order for Oxycodone (opioid medication for pain) 5 milligrams (mg) every eight hours as needed for pain dated 12/01/25. Review of the Patient Controlled Substance Administration Record for Resident #154's Oxycodone 5 mg Rx #206039493 revealed 30 tablets had been received on 12/02/25. The first dose was administered on 12/13/25 at 8:15 P.M. and the last dose on the card was administered on 12/25/25 at 8:30 P.M. There were 23 tablets remaining on the card. Review of the Controlled Medication Shift Change Log dated 12/26/25 revealed Registered Nurse (RN) #452, the Assistant Director of Nursing, had removed Resident #154's card of Oxycodone 5 mg Rx #206039493 with 23 remaining tablets from the medication cart. Her signature was the only one noted with the removal of the medication. Review of the witness statement by Licensed Practical Nurse (LPN) #327 revealed on 12/26/25 RN #452 had come to her medication cart to check the narcotic book. She stated RN #452 stated there were errors on Resident #154's Oxycodone card so she removed the signature sheet along with the card of remaining pills. LPN #327 asked if she wanted her to assist in destroying the medication with RN #452, but RN #452 had responded she could only do it with another department head. Review of the witness statement dated 12/29/25 by LPN #317, Assistant Director of Nursing, revealed she was doing audits on 12/29/25 of the narcotic count sheets and noted Oxycodone for Resident #154 was removed from the medication cart on 12/26/25. She stated she could not find the patient controlled substance administration record or the reason it was removed. LPN #317 stated she interviewed LPN #327 who stated RN #452 removed Resident #152's Oxycodone card with the medications stating there were discrepancies on the card. LPN #327 stated RN #452 did not want her to waste the remaining narcotics with her. LPN #317 stated she then interviewed RN #452 about the discrepancy and she became nervous and flustered and her hands were shaking. RN #452 stated she had wasted the Oxycodone with LPN #327. LPN #317 stated she had spoken to LPN #327 who denied wasting the medication with her. RN #452 then began to pull papers out of her personal back pack and then wanted to go to her car to look for the narcotic card. RN #452 could not explain why she had removed the card and was unable to produce the medication. RN #452 provided the patient controlled substance administration record to LPN #317 for Resident #154's Oxycodone 5 mg which revealed there were 23 tablets remaining. Review of the emailed statement dated 12/30/25 by RN #452 revealed she was notified by the floor nurse there was an error on the patient controlled substance administration record for Resident #154's Oxycodone. She stated she reviewed the record and updated pharmacy who stated they were sending a new card of Oxycodone to the facility. RN #452 stated she took the card of medication out of the medication cart and placed it in her office. She stated before she left the facility for the day she destroyed the medication prior to leaving because she did not want them in her office over the weekend. She did not identify any other staff having assisted her in destroying the Oxycodone for Resident #154. Interview on 04/22/26 at 9:11 A.M. with the Director of Nursing (DON) verified the facility had not filed a self-reported incident (SRI) incident for misappropriation with the State Agency related to Resident #154's Oxycodone 5 mg. She verified a thorough investigation was not completed. Review of the facility policy titled, Abuse Prevention Program, dated February 2017, revealed misappropriation of resident property meant the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings without the resident's consent. The facility stated it was to report immediately or no later than 24 hours to the State Agency, local law enforcement and the resident's representative. The facility policy stated upon learning of the allegation of misappropriation of resident properly it would initiate an incident and investigation. 2. Review of the medical record for Resident #138 revealed an admission date of 11/25/24 and diagnoses including dementia with mood disturbance, chronic kidney disease, generalized anxiety disorder, hyperlipidemia, osteoarthritis, and essential hypertension. Review of progress note dated 11/22/25 at 8:15 A.M. revealed Resident #138 had grayish black ecchymosis areas to left outer upper arm, left outer wrist area, and right inner arm. Resident #138 did not complain of any pain. Resident #138 was noted to have fragile skin and was on a daily aspirin. Resident #138 was noted to ambulate independently. There were no noted accidents or events related to bruising. Review of SRI Form number 267836 dated 11/22/25 revealed the facility reported to the State Agency an injury of unknown origin for Resident #138. Staff noted bruising on Resident #138's left upper outer arm, left outer wrist, and right inner wrist. Resident #138 was unable to report what had happened. It was noted the facility did not suspect abuse due to location and shape of bruising. It was noted Resident #138 can be combative with care and independently ambulates on the unit. The facility was unable to determine the origin of bruising. The SRI was unsubstantiated as evidence indicates abuse, neglect, or misappropriation did not occur. Review of the facility's investigation for SRI number 267836 revealed no identification of root cause. There was no evidence of any environmental inspection. There was no evidence of staff re-training related to the occurrence and investigation of an injury of unknown origin. Review of Nurse Practitioner (NP) progress note dated 11/24/25 revealed Resident #138 seen for evaluation for contusion to the arm. NP ordered long sleeves to protect skin. Resident #138 noted to be poor historian and pleasantly confused. Nursing staff reported Resident #138 had intermittent bruising. Plan to continue monitoring for ongoing occurrences and monitor for symptoms suggestive of anemia. Review of progress note dated 01/23/26 at 10:00 P.M. revealed Resident #138 had a lump with bruising on right forearm. There was also bruising noted to inner right forearm. Resident #138 denied pain. Resident #138 was unable to report what had happened. Resident #138 was noted to have a history of being combative with care. There were no noted accidents or events related to bruising or a lump. Review of progress note dated 01/23/26 at 10:30 P.M. revealed Resident #138 had order for x-ray to the right forearm and new order for antibiotics. Review of Self-Reported Incident (SRI) Form number 270153 dated 01/23/26 revealed the facility reported to the State Agency an injury of unknown origin for Resident #138. Staff noted a lump with bruising on Resident #138's lateral right forearm and bruising on medial forearm. Resident #138's family and NP were notified. The facility initiated 15-minute checks. Resident #138 was unable to provide a description of what had happened to her arm. The SRI was unsubstantiated as evidence indicates abuse, neglect, or misappropriation did not occur. Review of the facility's investigation for SRI number 270153 revealed no identification of root cause. There was no evidence of any environmental inspection. There was no evidence of additional residents being evaluated for bruising. There was no evidence of staff re-training related to the occurrence and investigation of an injury of unknown origin. Review of radiology result dated 01/24/26 at 11:57 A.M. revealed no evidence of acute fracture. There was noted soft tissue swelling over the latera aspect of proximal shaft of the radius consistent with hematoma. Review of progress note dated 01/24/26 at 12:45 P.M. revealed a new order to elevate and ice area on right forearm. Staff were to monitor area and call NP if the area had additional spread. Review of NP progress note dated 01/26/26 revealed Resident #138 seen for evaluation of bruise to right forearm. The bruise was of unknown etiology per nursing and Resident #138. There was no noted trauma or injury. New orders for Doxycycline 100 mg twice daily for seven days, elevate and ice area, and x-ray. Physical exam revealed poor strength, range of motion was normal to right arm and wrist, and there was no erythema. Resident #138 remained pleasantly confused. NP unable to identify etiology of bruising. Review of progress note dated 01/28/26 at 10:19 P.M. revealed Resident #138 had a doppler test completed to the bruised and swollen right forearm area. There was no evidence of deep vein thrombosis. Review of radiology result dated 01/28/26 at 8:48 P.M. revealed a doppler scan resulted with no evidence of deep venous thrombosis in right upper extremity veins. Review of Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #138 required substantial/maximal assistance from staff for personal hygiene, bathing, and upper body dressing and was dependent on staff assistance for lower body dressing and toileting hygiene. Resident #138 had short- and long-term memory problems and severely impaired decision-making ability. Resident #138 was noted to have delusions. Review of Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #138 was unable to participate in interview resulting in score of 99. Review of progress note dated 03/27/26 at 2:20 P.M. revealed Resident #138's right wrist was red and swollen. Resident #138 complained of pain when moving the wrist. NP was notified and gave new orders for x-ray and two tablets of Tylenol 500 milligrams twice daily for three days for pain. There were no noted accidents or events related to the redness, swelling, and pain. Review of facility's SRIs revealed no evidence an SRI was reported to the State Agency on or around 03/27/26 for an injury of unknown origin for Resident #138. There was no evidence of investigation to determine root cause of redness, swelling, and pain to Resident #138's wrist. Review of NP progress note dated 03/27/26 revealed Resident #138 was seen for evaluation of right wrist pain. There was noted redness and swelling. There were no related falls and resident was unable provide details other than the area was painful. Resident #138 noted to be an irritated mood. Noted right forearm bruising on physical exam. New orders for an x-ray and addition of 1000 milligrams of Tylenol twice daily for three days. Review of radiology result dated 03/28/26 at 12:00 A.M. revealed x-ray resulted with no evidence of acute fracture or dislocation of right wrist. Review of NP progress note dated 03/30/26 revealed the NP was unable to determine an underlying reason for swelling, redness, and pain. A new order for Voltaren one percent two grams applied twice daily for seven days. Interview on 04/30/26 at 7:39 A.M. with DON revealed Resident #138 was supposed to walk with assistance from staff, however, did not always remember to ask for help. Resident #138 was not known to get into altercations with other residents. Resident #138 had impaired cognition. SRIs #267836 and #270153 were reviewed and the DON confirmed she was unable to locate evidence to support a root cause was identified to sufficiently rule out abuse. DON confirmed an SRI was not filed Resident #138's wrist presenting with redness, swelling, and pain despite history with injuries of unknown origin presenting in a similar manner. DON reported there was no bruise, so an SRI was not filed. Review of facility policy titled Abuse Prevention Program dated February 2017 revealed an appointed investigator would at a minimum interview the person reporting the incident, interview anyone with direct knowledge of the incident, obtain written statements, and gather any pertinent medical records. An injury would be classified as an injury of unknown source when both conditions were met: the source of injury was not observed or could not be explained and the injury is suspicious due to location, extent, or incidence of injuries over time. The injury would be reported to the State Agency and investigated following the abuse policy. 3. Review of the medical record for Resident #47 revealed an admission date of 05/15/25 with diagnoses including schizoaffective disorder, depression, anxiety, and bipolar disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 had impaired cognition. Review of SRI tracking number 267482 dated 11/12/25 revealed the facility staff reported that Resident #47's Lyrica was misplaced. A new order of Lyrica (anticonvulsant controlled substance) was ordered from the pharmacy. The facility immediately initiated an investigation. The physician and police were notified. The facility unsubstantiated the SRI stating evidence was inconclusive that misappropriation occurred. Review of the facility investigation for SRI tracking number 267482 revealed Resident #47 was not interviewed. There were no interviews with like residents related to the SRI. Resident #47's family was not notified. The Alleged Perpetrator, a witness, and other staff were interviewed regarding the SRI. Interview on 05/04/26 at 8:35 A.M. with the DON revealed the nurses have had no additional competencies for medication administration since hire even though there were concerns with misappropriation and possible narcotic diversion. The DON stated the in-services provided were the competencies the nurses were set up to complete. Interview on 05/04/26 at 11:01 A.M. with the DON revealed a previous administrator handled the SRI and indicated the SRI was unsubstantiated due to the Alleged Perpetrator not having the intent to steal the medication. The DON indicated she was notified of the missing medication and assisted in trying to locate the medication. The Alleged Perpetrator that misplaced the medication was training and it was lost due to being busy with the nurse trainee. The Alleged Perpetrator was drug tested on [DATE] with a negative result. The DON confirmed Resident #47 was not interviewed nor were other residents since it was a missing medication card. The DON confirmed Resident #47's family was not notified of the misplaced medication. Also, there was no education provided to the facility staff in regard to misappropriation. Review of the facility's abuse policy, dated 02/07/17, revealed any incident involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property result in an investigation. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident if interviewable. Any written statements that have been submitted will be reviewed along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed. 4. Review of the medical record for Resident #98 revealed an admission date of 05/21/25 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, anxiety, depression, and chronic kidney disease. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #98 had intact cognition. Review of SRI tracking number 271768 dated 03/05/26 revealed Resident #98 alleged a certified nurse assistant spoke to her in an unfriendly way and cursed at her. The certified nurse assistant was suspended pending investigation. No known witnesses noted. Resident questioned with no known issues noted. Staff questioned with no known issues noted. Based on the facility's investigation the allegation was unsubstantiated. Evidence indicated abuse, neglect or misappropriation did not occur. Review of the facility investigation for SRI tracking number 267482 revealed Resident #98 was interviewed but no statement provided. There were interviews with residents but they were not dated and did not cover all the resident in the area of the alleged incident. There was no assessment completed on Resident #98 following the allegation. There were staff interviews but it was not specific to the allegation and not dated. Also there was no education provided to the staff regarding abuse. Interview on 04/30/26 at 12:26 P.M. with the Administrator revealed resident statements were obtained but not dated and not all residents from the area of the alleged incident. There was no resident assessment completed. There was no abuse training completed for the staff. Staff statements were included in the investigation but they were not specific to the allegation and no dates listed. Review of the facility's abuse policy, dated 02/07/17, revealed any incident involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property result in an investigation. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident if interviewable. Any written statements that have been submitted will be reviewed along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed. This deficiency represents non-compliance investigated under Complaint Number 2668600, 2990856, and 2992799.

Based on record review and interview, the facility failed to ensure assessments were accurately completed. This affected five (Residents #5, #9, #15, #35 and #107) of 48 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 151. Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 06/25/25 with diagnoses including multiple sclerosis, dementia and obstructive reflux uropathy (a blockage in the urinary tract that stops urine from flowing). Review of Resident #5's physician's orders from March of 2026 revealed she had an indwelling catheter related to obstructive reflux uropathy dated 12/02/25. Review of the nursing progress notes from 03/01/26 through 03/31/26 revealed Resident #5 had a foley catheter. There was no evidence she had any other indwelling devices. Review of the quarterly modified Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed under section H that Resident #5 had an indwelling catheter. It was also documented she had an ostomy (a surgical opening in the abdomen that would allow waste or urine to exit the body). Interview on 05/04/26 at 1:40 P.M. with Licensed Practical Nurse (LPN) #304 verified Resident #5 did not have an ostomy and the MDS was inaccurate. 2. Review of the medical record for Resident #15 revealed an admission date of 02/11/26 with diagnoses including Alzheimer's Disease, hypertension and depression. Review of Resident #15's physician's orders from February of 2026 revealed he had no orders for restraints. Review of the nursing progress notes from 02/11/26 through 02/24/26 revealed Resident #15 had no restraints in place. Review of the quarterly modified Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed under section P that Resident #15 had other restraint used in bed daily. Interview on 04/22/26 at 9:16 A.M. with LPN #379 verified Resident #15 did not have restraints and the MDS was inaccurate. 3. Review of the medical record for Resident #35 revealed an admission date of 06/23/17 with diagnoses including Schizoaffective disorder, hypertension and unsteadiness on feet. Review of the fall investigation follow-up dated 10/29/25 revealed Resident #35 was pushed by another resident and fell to the ground. She had no injuries. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed under section J that Resident #35 had not had any falls since the prior assessment which was 09/29/25. Interview on 04/30/26 at 8:50 A.M. with LPN #379 verified Resident #35's MDS dated [DATE] was inaccurate as she had a fall on 10/29/25. 4. Review of the medical for Resident #107 revealed an admission date of 03/06/26 and diagnoses including chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure with hypoxia, heart failure, shortness of breath, and dependence on supplemental oxygen. Review of physician order dated 03/08/26 revealed Resident #107 received continuous oxygen therapy at two liters per minute via nasal canula. Review of Treatment Administration Record (TAR) for March 2026 revealed Resident #107 was evaluated for oxygen therapy use three times per day and was documented as receiving as ordered. Review of Medicare Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #107 was coded to not be receiving oxygen therapy. Interview on 04/22/26 at 9:26 A.M. with LPN #379 confirmed Resident #107's admission MDS assessment on 03/12/26 was coded incorrectly for oxygen therapy. 5. Review of the medical record for Resident #9 revealed an admission date of 04/13/23 with diagnoses including Type 2 Diabetes Mellitus. Review of Resident #9's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 was taking hypoglycemic medication. Review of Resident #9's physician orders revealed no active anti-diabetic medications. Interview on 04/22/26 at 3:17 P.M. with LPN #379 revealed Resident #9 last received Metformin on 03/14/26 and the assessment reference date (ARD) was 03/25/26 so no diabetic medications were received seven days prior to 03/25/26.

Based on record review, interview and review of the facility policy, the facility failed to formulate a complete baseline care plan timely after admission. This affected 22 residents (#2, #3, #4, #9, #12, #15, #48, #50, #53, #56, #62, #81, #91, #95, #98, #100, #107, #113, #117, #139, #154 and #160) of 62 residents reviewed for care plans. Facility census was 151.Findings include:1. Review of Resident #53's medical record revealed an admission date of 08/29/25 and diagnoses including Alzheimer's disease, dementia, depression anxiety and Crohn's disease. Review of a significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 had severe cognitive impairment. Further review of Resident #53's medical record revealed no baseline care plan could be found. Interviews on 04/22/26 at 9:16 A.M. and on 04/27/26 at 9:28 A.M. with MDS/Licensed Practical Nurse (LPN) #379 revealed she was not responsible for the baseline care plan as floor nurses created this. MDS/LPN #379 verified she was unable to locate a baseline care plan for Resident #53. 2. Review of Resident #56's medical record revealed an admission date of 01/30/24 and diagnoses including schizoaffective disorder bipolar type, generalized anxiety disorder, depression, type two diabetes, dementia with mood disturbance and chronic kidney disease stage three. Review of an annual MDS 3.0 assessment dated [DATE] revealed Resident #56 had severe cognitive impairment and had two or more falls since the previous assessment without injury. Further review of Resident #56's medical record revealed no baseline care plan could be found. Interviews on 04/22/26 at 9:16 A.M. and on 04/27/26 at 9:28 A.M. with MDS/LPN #379 revealed she was unable to locate a baseline care plan for Resident #56. 3. Review of Resident #81's medical record revealed an admission date of 09/26/24 and diagnoses including dementia with other behavioral disturbance, anxiety, depression, hypertension and hyperlipidemia. Review of a quarterly MDS 3.0 assessment dated [DATE] revealed Resident #81 had moderate cognitive impairment and displayed disorganized thinking. Review of the interim care plan for Resident #81 dated 11/30/24 revealed the document was in assessment form and did not identify interventions. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #81 looked like an assessment and confirmed it did not have interventions as it should. 4. Review of Resident #139's medical record revealed an admission date of 09/05/24 and diagnoses including dementia with other behavioral disturbance, depression, anxiety, hypertension, and osteoarthritis. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #139 was cognitively impaired. Review of the interim care plan for Resident #139 dated 09/05/24 revealed the document was in assessment form and did not identify interventions. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #139 looked like an assessment and confirmed it did not have interventions as it should. 5. Review of Resident #160's medical record revealed an admission date of 04/17/26 and diagnoses including end stage renal disease, chronic obstructive pulmonary disease, mild protein-calorie malnutrition, dementia and Alzheimer's disease. Review of the interim care plan for Resident #160 dated 04/17/26 revealed the document was in assessment form and did not identify interventions. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 revealed the baseline care plan for Resident #160 looked like an assessment and confirmed it did not have interventions as it should. 6. Review of the medical record for Resident #4 revealed an admission date of 10/05/25 with diagnoses including paraplegia, chronic obstructive pulmonary disease, diabetes mellitus, and schizophrenia. Review of the quarterly modified MDS 3.0 assessment dated [DATE] for Resident #4 revealed he had depression and a suprapubic catheter (a tube inserted through the lower abdomen into the bladder to drain urine). Further review of Resident #4's medical record revealed no baseline care plan could be found. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #4 looked like an assessment and confirmed it did not have interventions as it should. 7. Review of the medical record for Resident #12 revealed an admission date of 02/07/26 with diagnoses including malignant neoplasm of endometrium (cancer), diabetes mellitus and hypertension. Review of the admission MDS 3.0 assessment dated [DATE] for Resident #12 revealed she had depression, had obvious or likely cavity or broken natural teeth, was on a mechanical diet and had pain. Further review of Resident #12's medical record revealed no baseline care plan could be found. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #12 looked like an assessment and confirmed it did not have interventions as it should. 8. Review of the medical record for Resident #15 revealed an admission date of 02/11/26 with diagnoses including Alzheimer's disease, dementia, depression, anxiety and hypertension. Review of the quarterly modified MDS 3.0 assessment dated [DATE] for Resident #15 revealed he had impaired cognition, inattention and disorganized thinking that comes and goes, depression, was occasionally incontinent of bowel and bladder and utilized a walker. Further review of Resident #15's medical record revealed no baseline care plan could be found. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #15 looked like an assessment and confirmed it did not have interventions as it should. 9. Review of the medical record for Resident #117 revealed an admission date of 09/17/25 with diagnoses including chronic obstructive pulmonary disease, pain, depression, hypertension and edema. Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #117 revealed he had depression and pain. Further review of Resident #117's medical record revealed no baseline care plan could be found. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #117 looked like an assessment and confirmed it did not have interventions as it should. 10. Review of the medical record for Resident #154 revealed an admission date of 05/13/25 with diagnoses including malignant neoplasm of the lung (cancer), chronic obstructive pulmonary disease, back pain and depression. Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #154 revealed she had impaired cognition, rejected care, was dependent for most activities of daily living and had frequent pain. Further review of Resident #154's medical record revealed no baseline care plan could be found. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #154 looked like an assessment and confirmed it did not have interventions as it should. 11. Review of the medical record for Resident #2 revealed an admission date of 03/02/26 and diagnoses including dementia, fracture of first lumbar vertebra, multiple fractures of ribs on left side, repeated falls, contusion of scalp, unsteadiness on feet, generalized muscle weakness, and need for assistance with personal care. Review of Interim Care Plan dated 03/12/26 revealed at admission Resident #2 had impaired skin integrity, was cognitively impaired, required assistance with bed mobility, transfers, eating, was dependent on staff for assistance with ambulation, locomotion, dressing, personal hygiene, toileting use, and bathing, was incontinent of bowel and bladder, used an assistive device for mobility, and used anti-psychotic/psychotropic medications. The assessment indicated once completed the staff member should navigate to the care plan and add triggers identified on the assessment to build the interim care plan. Review of Medicare MDS admission assessment dated [DATE] revealed Resident #2 had brief interview for mental status (BIMS) score of 03 indicating severe cognitive impairment. Resident #2 was experiencing hallucinations, inattention, and disorganized thinking. Review of the care plan for Resident #2 revealed no evidence baseline care plan was initiated. Further review of the medical record for Resident #2 revealed no evidence a baseline care plan was developed and was provided to the resident and their representative as required. Interview on 04/21/26 at 11:21 A.M. with Director of Nursing (DON) revealed the MDS staff complete the baseline care plans. Interview on 04/22/26 at 9:16 A.M. with MDS Licensed Practical Nurse (LPN) #379 reported nursing staff completed the baseline care plans upon admission. MDS LPN #379 stated she was responsible for the comprehensive care plan. MDS LPN #379 confirmed she was unable to locate a baseline care plan for Resident #2. Interview on 04/22/26 at 10:22 A.M. with DON confirmed the baseline care plans were not being completed appropriately and residents were not provided with a copy of the baseline care plan. 12. Review of the medical for Resident #107 revealed an admission date of 03/06/26 and diagnoses including chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure with hypoxia, heart failure, shortness of breath, and dependence on supplemental oxygen. Review of Medicare MDS admission assessment dated [DATE] revealed Resident #107 was cognitively intact. Review of the care plan initiated on 03/06/26 revealed at admission Resident #107 was a smoker, desired to be a full code, was admitted for short term rehab, was independent for meeting emotional/social needs, required assistance for activities of daily living, was at risk for falls, had nutritional problems, was at risk for pain, had skin impairments, was on oxygen therapy, experienced shortness of breath. There were goals and interventions initiated for each area of concern. Further review of the medical record for Resident #107 revealed no evidence Resident #107 was provided with a copy of the baseline care plan developed. Interview on 04/22/26 at 9:16 A.M. with MDS LPN #379 confirmed she was unable to locate evidence Resident #107 was provided with a copy of baseline care planning. 13. Review of the medical record for Resident #9 revealed an admission date of 04/13/23 with diagnoses including type 2 diabetes mellitus, bipolar disorder, dementia, depression, and schizoaffective disorder. Review of Resident #9's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed impaired cognition and non-traumatic brain dysfunction. Further review of Resident #9's medical record revealed no baseline care plan could be found. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #9 looked like an assessment and confirmed it did not have interventions as it should. 14. Review of the medical record for Resident #48 revealed an admission date of 09/02/25 with diagnoses including benign neoplasm of meninges, chronic obstructive pulmonary disease, depression, heart failure, anxiety, and chronic kidney disease. Review of Resident #48's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed intact cognition and mood issues noted. Further review of Resident #48's medical record revealed no baseline care plan could be found. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #37 stated the baseline care plan for Resident #48 looked like an assessment and confirmed it did not have interventions as it should. 15. Review of Resident #62's medical record revealed an admission date of 09/05/24 with diagnoses including cerebral infarction, seizures, depression, anxiety, chronic kidney disease, neurocognitive disorder, insomnia, and alcohol-induced dementia. Review of Resident #62's quarterly MDS 3.0 assessment, dated 03/13/26, revealed Resident #62 was cognitively impaired and mood issues present. Further review of Resident #62's medical record revealed no baseline care plan could be found. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #62 looked like an assessment and confirmed it did not have interventions as it should. 16. Review of Resident #91's medical record revealed an admission date of 04/17/25 with diagnoses of right femur fracture, type 2 diabetes mellitus, weakness, chronic kidney disease, anxiety, heart failure, and major depression. Review of Resident #91's annual MDS 3.0 assessment, dated 04/01/26, revealed intact cognition. For activities of daily living, Resident #91 was dependent for toileting hygiene and substantial assistance for transfers. Also, pain noted that affected sleep occasionally. Further review of Resident #91's medical record revealed no baseline care plan could be found. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #91 looked like an assessment and confirmed it did not have interventions as it should. 17. Review of the medical record for Resident #95 revealed an admission date of 04/13/23 with diagnoses including type 2 diabetes mellitus, bipolar disorder, dementia, depression, and schizoaffective disorder. Review of Resident #95's quarterly MDS 3.0 assessment dated [DATE] revealed impaired cognition and was dependent on staff for toileting and transfers. Also required substantial assistance for showering. Further review of Resident #95's medical record revealed no baseline care plan could be found. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #95 looked like an assessment and confirmed it did not have interventions as it should. 18. Review of the medical record for Resident #98 revealed an admission date of 05/21/25 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, anxiety, depression, and chronic kidney disease. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #98 had intact cognition and required hypoglycemic medication for diabetes management. Further review of Resident #98's medical record revealed no baseline care plan could be found. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #98 looked like an assessment and confirmed it did not have interventions as it should. 19. Review of Resident #100's medical record revealed an admission date of 01/07/25 with diagnoses of malnutrition, cellulitis of the bilateral lower extremities (BLE), type 2 diabetes mellitus, peripheral vascular disease, failure to thrive, and chronic ulcers of the BLE. Review of Resident #100's five-day MDS 3.0 assessment, dated 03/13/26 revealed impaired cognition. Also, Resident #100 had two deep tissue injuries and six vascular ulcers. Further review of Resident #100's medical record revealed no baseline care plan could be found. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #100 looked like an assessment and confirmed it did not have interventions as it should. Interview on 04/22/26 at 10:22 A.M. with the Director of Nursing (DON) verified baseline care plans were not being done appropriately and no interventions were in place until the comprehensive care plan. The DON also verified residents were not being given a copy of the baseline care plan as required. 20. Review of Resident #50's medical record revealed resident was admitted to the facility on [DATE] with admitting diagnoses that included Schizophrenia, bipolar disorder, anxiety disorder, Parkinson's disease, and hypertension. Review of Baseline/Interim Care Plan dated 10/28/25 had no care plan interventions. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #50 looked like an assessment and confirmed it did not have interventions as it should. 21. Review of Resident #3's medical record revealed resident was admitted to the facility at 01/12/26, with diagnosis including cellulitis, non-pressure chronic ulcer of unspecified part of right lower leg , type two diabetes mellitus with diabetic neuropathy, and peripheral vascular disease. Review of the medical record revealed no evidence of an appropriate Baseline Care Plan with care plan interventions. Interview on 04/22/26 at 9:16 A.M. with MDS/LPN #379 stated the baseline care plan for Resident #3 looked like an assessment and confirmed it did not have interventions as it should. 22. Resident #113 was admitted to the facility at 02/27/26, with diagnosis including schizoaffective disorder, generalized weakness, type two diabetes, and generalized anxiety disorder. Baseline/Interim Care Plan dated 02/27/26 had no care plan interventions. Interviews on 04/22/26 at 9:16 A.M. and on 04/27/26 at 9:28 A.M. with MDS/Licensed Practical Nurse (LPN) #379 revealed she was not responsible for the baseline care plan as floor nurses created this. Interview on 04/22/26 at 10:22 A.M. with the Director of Nursing (DON) verified baseline care plans were not being done appropriately and no interventions were in place until the comprehensive care plan. The DON also verified residents were not being given a copy of the baseline care plan as required. Review of facility policy Care Conference Resident/Family Participation undated revealed a baseline care plan would be completed within 48-hours of admission. A summary of the baseline care plan would be provided to the resident and/or representative upon request.

Based on closed record review, hospital record review, facility policy review and interview the facility failed to implement comprehensive and individualized fall/safety interventions to prevent falls including a fall with injury for Resident #200. Actual Harm occurred on 09/27/23 when Resident #200, who had moderate cognitive impairment and required extensive two-person assistance for bed mobility and transfers was transferred to the emergency room per family request due to changes in condition. Record review revealed the resident sustained three falls between 09/25/23 and 09/27/23 without evidence of adequate interventions being in place at the time of the falls. Following a second fall on 09/27/23, the resident was picked up off the floor by Central Supply #808, an employee who was not qualified/trained to provide direct resident care. The resident was subsequently diagnosed with non-displaced left rib fractures and re-injury of a previous pelvic fracture. This affected one resident (#200) of three residents reviewed for falls. Findings include: Review of Resident #200's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including a fracture of the superior rim of the left pubis, weakness and major depressive disorder. Hospital documentation dated 09/15/23 (prior to admission) revealed the resident had presented to the hospital with pain following a fall at home on 09/14/23. The resident was diagnosed with a left superior pubic ramus fracture and possible left inferior pubic ramus fracture. Review of Resident #200's hospital admission orders dated 09/18/23 indicated she had a primary diagnosis of left pelvic fracture with a secondary diagnosis of falls. A fall risk assessment, dated 09/18/23 revealed the resident was at high risk for falls. A plan of care, created 09/19/23 revealed Resident #200 was at risk for falls due to her history of falls prior to admission, her mental status and her general weakness. The goal developed was for the resident to remain free from significant injury due to her risk of falls. Interventions included the resident needed assistance with transfers, does reposition in wheelchair and does try to ambulate without assistance; staff to report any falls to family/physician and fall interventions, which may include vital signs, neurological exams, medication reviews, lab work, x-rays and any intervention that may be ordered by the physician. Review of Resident #200's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment and required extensive two person assist for bed mobility, dressing, toilet use, personal hygiene and bathing as well as limited two person assist for transfers. Review of Resident #200's progress note dated 09/25/23 at 6:00 P.M. indicated the STNA reported the resident was sitting in front of the bathroom. The note indicated no injuries were noted. The resident had no change in range of motion (ROM) to extremities, neurological checks were initiated and the supervisor was notified. Record review revealed no comprehensive investigation was completed related to this fall or the circumstances of the fall. In addition, record review revealed no evidence comprehensive or individualized fall/safety interventions were initiated following this incident. Following the fall, the resident was encouraged to call for (staff) assistance. Review of Resident #200's progress note dated 09/26/23 at 9:15 A.M. indicated the resident was extremely confused, stated she had $25.00 under her breakfast tray for her groceries. The son indicated the resident did not have money. Review of Resident #200's progress note dated 09/26/23 at 2:26 P.M. indicated the resident was confused and forgetful and propelled herself in the wheelchair without difficulty. Review of Resident #200's progress note dated 09/26/23 at 4:15 P.M. indicated the police officer came to the facility due to the resident calling them and she had reported that her children were stealing her clothing and her belongings. The staff were unable to redirect the resident and the supervisor was aware. Review of Resident #200's progress note dated 09/26/23 at 5:02 P.M. indicated the resident called the police and stated her children were taking her belongings and selling them. The resident was confused to the month but was aware of the year and that she was at the nursing facility. Record review revealed no evidence of new fall/safety interventions being initiated following the changes in behavior/increased confusion exhibited by the resident on 09/26/23. Review of Resident #200's progress note dated 09/27/23 at 7:29 A.M. indicated at 4:00 A.M. the resident came out of her room and thought it was morning. The resident was re-educated, and she had returned to her room. At 5:00 A.M. the resident came out of the room and stated the STNA kicked her a**. When questioned, the resident stated it happened right at the time of the interview. The resident then lowered herself to the floor and started to crawl across the floor. Staff tried to encourage the resident to return to the wheelchair. She refused and started to roll down the hall. The Registered Nurse (RN) Supervisor was notified and able to get the resident back to her room. The resident refused the 6:45 A.M. neurological check and refused lab work. Record review revealed no evidence this incident was investigated or evidence interventions were initiated to prevent additional falls/promote resident safety. Review of Resident #200's progress note dated 09/27/23 at 11:52 A.M. revealed the resident was sent to the hospital via the emergency technicians (EMT) per the family's request for evaluation and treatment (due to the resident not acting herself). The resident did not return to the facility after being transferred to the emergency room . Review of Resident #200's hospital documentation dated 09/27/23 indicated the resident arrived to the emergency roiagnom on [DATE] at 12:30 P.M. and was evaluated in the trauma bay by the physician. The resident was able to move all of her extremities but had decreased range of motion in the bilateral lower extremities secondary to pain. X-ray of the chest did show possibility of rib fractures as well as a re-injury of her known pelvic fracture. Dedicated rib x-rays were obtained which showed evidence of non-displaced left rib fractures. Review of the hospital radiology report (one view chest x-ray), dated 09/27/23 at 12:38 P.M. indicated a slight cortical step-off of the left lateral 6th through 8th ribs. The impression included findings were suspicious for a nondisplaced left lateral 6th through 8th ribs and consider a rib series for further evaluation. Review of the hospital radiology report (two view rib x-ray), dated 09/27/23 at 2:15 P.M. indicated the resident had a slight cortical step-off of the left lateral second rib. Subtle cortical irregularity of the left lateral 4th and 5th ribs may be overlap of adjacent ribs on the x-ray. Previously described left lateral 6th through 8th rib step-off was not appreciated on this exam. The impression was a nondisplaced left lateral second rib fracture and questionable left 4th and 5th rib fractures versus artifacts. This finding correlated with point tenderness. Interview on 11/03/23 at 6:26 A.M. with Licensed Practical Nurse (LPN) #803 indicated she took care of Resident #200 on (09/27/23) the day that she was sent out. She confirmed around 4:00 A.M., the resident came out of the room and was observed putting herself on the ground from the wheelchair. LPN #803 indicated both herself, STNA #804 and STNA #805 picked the resident back up and put her in a wheelchair. LPN #803 indicated she had assessed her following this incident and indicated the resident had no concerns with pain or injuries. LPN #803 indicated around five minutes later, the resident placed herself on the floor again and was screaming (this incident was not documented in the medical record progress note). LPN #803 stated the resident would not allow the STNAs and the nurse to pick her up to place her back in the wheelchair following the second fall. LPN #803 indicated she called the nursing supervisor to come see the resident, but Central Supply #808 came to the floor first and picked the resident up and placed her back in the wheelchair. Interview on 11/03/23 at 6:30 A.M. with STNA #804 indicated Resident #200 had come out of her room (on 09/27/23) in her wheelchair and stated STNA #805 had beat her up. She indicated the resident then placed herself on the floor and was yelling. STNA #804 confirmed Central Supply #808 put Resident #200 back in the chair the second time the resident was on the floor (on this date). Interview on 11/03/23 at 6:36 A.M. with STNA #805 indicated on 09/27/23 Resident #200 threw herself on the floor and LPN #803, STNA #804 and STNA #805 picked the resident up and placed her in the wheelchair. STNA #805 indicated five minutes later the resident was on the floor again and would not let the nursing staff pick her up so Central Supply #808 came and picked her up and put her back in the wheelchair. Interview on 11/03/23 at 7:09 A.M. with Central Supply #808 indicated he went upstairs to deliver linens and observed Resident #200 on the floor screaming. He stated at that point, he observed the nursing staff standing near the resident and the resident on the floor. He stated he went over and picked the resident up and placed her in the wheelchair. When questioned, he stated he picked up Resident #200 from the floor under both arms and placed her in her wheelchair. Interview on 11/03/23 at 7:17 A.M. with LPN Unit Manager (UM) #810 indicated she was called to the second floor because Resident #200 was crawling around on the floor. She indicated when she got to the unit, Resident #200 was already in her wheelchair, and she took the resident back to her room and completed neurological checks on the resident. She stated she did not observe any injuries. LPN UM #810 indicated later in the day, Resident #200's daughter wanted to take the resident home and requested the resident go to the emergency room for treatment. LPN UM #810 confirmed the resident did not return to the facility after being transferred to the hospital. Interview on 11/03/23 at 7:45 A.M. with the Administrator indicated Resident #200's son came to the facility and wanted to know about the fall as well as the rib fracture that was sustained following the fall on 09/27/23 per the hospital documentation. The Administrator indicated the resident had a history of falls and he felt it was an old rib fracture. Interview on 11/03/23 at 9:25 A.M. with the Administrator confirmed the facility did not identify the gradual change in Resident #200's mental status (following admission) and the facility did not have a fall investigation for resident falls that occurred after her admission on 09/18/23. The Administrator verified the lack of evidence of new fall/safety interventions being initiated for the resident and also indicated he was not aware Central Supply #808 had picked the resident up off the floor when she sustained the second fall on 09/27/23. Review of the Fall Clinical Protocol policy revised 08/2008 indicated the staff and physician would continue to collect and evaluate information until either the cause of the fall was identified, or it was determined that the cause could not be found or that finding a cause would not change the outcome or the management of falling and fall risk. This deficiency represents non-compliance investigated under Complaint Number OH00147385.

Based on record review, interview, policy review, and hospice contract review, the facility failed to ensure pain was addressed for Resident #74, a hospice resident. This affected one of one resident reviewed for hospice services. Actual Harm occurred when Resident #74 was admitted to the facility into hospice services with complaints of pain. Resident #74 continued to complain of pain and did not receive effective pain medication until approximately 30 hours following admission. Findings include: Review of Resident #74's record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 08/19/17 hospital discharge instructions timed 12:35 P.M. revealed Resident #74's rehab potential and prognosis was poor and the resident was being admitted to the facility under hospice care. Resident #74 was discharged from the hospital with a printed prescription for [MEDICATION NAME] (an antianxiety medication) 1.0 milligram (mg) one tablet by mouth, four times a day, for seven days, as needed. Review of the 08/19/17 nursing progress notes timed 6:15 P.M. revealed Resident #74 arrived from the hospital at 2:40 P.M., alert and requesting pain medication but did not have a physician order [REDACTED]. Review of the 08/19/17 untimed hospice nursing progress note revealed Resident #74 was readmitted to hospice with end stage [MEDICAL CONDITION]. Resident #74 was alert and oriented to time, place, person and situation, her pulse was slightly [MEDICAL CONDITION] (fast) at 90 beats per minute. Resident #74 was having pain all over, 5 out of 10 on the pain scale, and medications were reordered by Resident #74's physician. The nursing staff were to call the hospice service with any concerns or changes. Review of the 08/19/17 physician orders [REDACTED]. revealed Resident #74 had a telephone order to admit to hospice care and for [MEDICATION NAME] 5-325 mg orally every four hours, as needed, for pain. Review of the notes on the physician order [REDACTED]. Review of the 08/19/17 nursing progress note timed 9:26 P.M. revealed Resident #72 was requesting [MEDICATION NAME] and sleeping medication; however, [MEDICATION NAME] was not available and sleeping medication was not ordered. LPN #4 indicated she would advise the supervisor of Resident #74's request. Review of the 08/19/17 pain monitoring flow sheet for day and afternoon shifts revealed Resident #74 had facial wrinkling and grimacing and pain all over which was rated 9 out of 10 on the pain scale. Staff tried to listen and talk to Resident #74 which was ineffective and the flow sheet indicated a drug intervention was given. Review of the 08/19/17 Medication Administration Record [REDACTED]. Review of the 08/20/17 nursing progress note timed 7:21 A.M. revealed Resident #74 had high anxiety and had an incontinent bowel episode. Resident #74 was requesting medications and pharmacy had not delivered the medication. [MEDICATION NAME] was given at 6:30 A.M. Review of the 08/20/17 nursing progress note timed 2:58 P.M. revealed Resident #74 complained of pain all over and Tylenol 500 milligrams two tablets were given at 9:40 A.M. When LPN #3 shook Resident #74 to wake her up, Resident #74 said the pain medicine was ineffective. Review of the August, 2017 MAR indicated [REDACTED].M. and 3:14 P.M. on 08/20/17 and Tylenol Extra Strength 500 mg two tablets on 08/20/17 at 9:40 A.M. which was ineffective. Review of the stock medication/contingency supply log revealed four tablets of [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 5-325 mg were dispensed on 08/20/17 at 6:28 P.M. Review of the August, 2017 MAR indicated [REDACTED].M. Review of the 08/21/17 nursing progress note timed 2:51 A.M. revealed Resident #74 had no complaints of pain or discomfort and was asleep in bed. Review of the 08/26/17 Minimum Data Set (MDS) 3.0 admission assessment revealed Resident #74 was cognitively intact, needed extensive assistance with bed mobility and transferring, had almost constant, moderate pain which made it hard for her to sleep at night and was receiving hospice care. Review of the 07/01/11 hospice contract revealed all physician orders [REDACTED]. Review of the August 2008 pain - clinical protocol revealed the staff would discuss significant changes in levels of comfort with the attending physician who would adjust interventions accordingly. Interview with Resident #74 on 10/16/17 at 10:51 A.M. was unsuccessful. Resident #74 answered the questions in a nonsensical manner. Interview on 10/18/17 at 4:30 P.M. with Hospice Registered Nurse (HRN) #2 revealed HRN #2 was not aware there was a delay on Resident #74's pain medication administration. Interview on 10/18/17 at 5:28 P.M. with LPN #1 revealed LPN #1 notified the nursing supervisor Resident #74 was requesting medication for pain. LPN #1 offered Resident #74 Tylenol but Resident #74 didn't want it because it wasn't going to work. LPN #1 stated LPN #4 did not call the hospice service after the hospice nurse wrote the telephone orders on 08/20/17 at 6:30 P.M. LPN #4 thought the [MEDICATION NAME] was coming from the pharmacy; however, when the [MEDICATION NAME] did not come on LPN #1's shift, LPN #1 relayed that information to the night shift nurse. Interview on 10/19/17 at 11:08 A.M. with LPN #302 and the Director of Nursing verified Resident #74 did not receive [MEDICATION NAME] in a timely manner and continued to complain of pain.

Based on observation, record review and interview, the facility failed to ensure adequate supervision during resident care. This resulted in Actual Harm when Resident #1 rolled from the bed during resident care and onto the floor, sustaining a fracture of the right tibia (leg). This affected one (Resident #1) of three residents reviewed for falls. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a physician order [REDACTED].#1 was to have two staff for care at all times. Review of Resident #1's care plan dated 05/02/17 relative to a self-care deficit revealed individualized interventions included dependent on staff for Activities of Daily Living (ADLs). Review of Resident #1's progress note dated 06/10/17 at 6:00 A.M. revealed the resident rolled out of bed during care and hit her head. Review of Resident #1's x-ray dated 06/10/17 revealed the resident sustained [REDACTED]. Review of Resident #1's progress note dated 06/10/17 at 8:43 P.M. revealed the resident was sent to the hospital. Review of the hospital record dated 06/10/17 revealed the resident was treated for [REDACTED]. Review of an occurrence statement dated 06/10/17 completed by State tested Nurse Aide (STNA) #20 revealed Resident #1 rolled out of bed when she was trying to turn the resident during care. Review of an incident report dated 06/10/17 revealed Resident #1 rolled out of bed and sustained a small abrasion on her forehead. The resident reported a headache and foot pain with no other obvious injury. Interview on 08/01/17 at 9:30 A.M. with Resident #1 revealed she had a fall when she rolled out of bed and hit her head on the bedside table. Resident #1 stated the STNA was in the room helping her and just let her roll out of the bed. Resident #1 revealed she had a cast put on her foot but could not recall the exact date of the fall or why she had a protective boot on her foot. She did recall going to the hospital after the fall for monitoring. Observation on 08/01/17 at 9:32 A.M. revealed Resident #1 had a hard plastic protective boot with padding on her right foot. Interview on 08/01/17 at 9:52 A.M. with the Director of Nursing (DON) confirmed Resident #1 rolled out of bed during care. Resident #1 sustained a leg fracture from the fall and STNA #20 was educated on supervision and assist with care and bed mobility. Interview on 08/01/17 at 12:34 P.M. with STNA #2 verified Resident #1 sustained a fall with injury because she attempted care without another STNA to assist. Review of the Falls and Falls Risk, Managing policy, dated August 2008, revealed staff should implement and monitor fall interventions to reduce the risk and/or prevent resident falls. This deficiency substantiates Complaint Number OH 494.

Based on observation, medical record review, family and staff interview, review of the facility's Self Reported Incident (SRI) and investigations of reported allegations of abuse, review of the police report, review of behavior grids, and review of the facility's Resident Abuse policy and procedure, the facility failed to protect Resident #140 from sexual abuse from Resident #139. This placed one of 12 female residents on the Dementia Unit (Resident #140) in Immediate Jeopardy when Resident #139 sexually abused her and had the potential to affect 11 additional female residents (#138, #143,#144, #147, #148, #149, #152, #153, #154, #155 and #156) on the Dementia Unit at risk for harm from sexual abuse because they were unable to communicate their needs to staff and lived on the same unit with Resident #139 who was able to wander throughout the unit. On 07/28/11 at 5:30 P.M., the administrator and director of nursing were notified that Immediate Jeopardy began on 06/20/11 at 11:30 P.M., when State tested Nurse Aide (STNA) #10 found Resident #139 kneeling beside Resident #140 ' s low bed with one hand fondling Resident #140's breast and the other hand fondling Resident #140 ' s vaginal area. The Immediate Jeopardy was removed on 06/21/11 at 3:20 P.M. as there were no other residents in the facility ' s Dementia Unit who exhibited sexually aggressive behaviors, and the facility implemented the following corrective actions: ? On 06/21/11 at 12:00 A.M., Resident #139 and Resident #140 were placed on every 15 minute checks. Motion sensors were applied to Resident #139 ' s door and Resident #140 ' s door. ? On 06/21/11 at 3:20 P.M., Resident #139 was transferred to the hospital for evaluation and did not return to the facility. ? On 06/22/11, Resident #140 was transferred to another facility. ? On 06/30/11, six employees (STNA #10, STNA #11, STNA #14, Licensed Practical Nurse (LPN) #15, Registered Nurse Supervisor (RNS) #9, and Social Worker (SW) #12) were interviewed and demonstrated knowledge of the facility ' s Routine Resident Check and Abuse policy to monitor and maintain resident safety. ? On 06/30/10 between 6:30 P.M. and 8:30 P.M., two STNA ' s (#10 and #20) were observed supervising residents on the Dementia Unit. ? On 06/30/11 between 6:30 P.M. and 8:30 P.M., the surveyor observed chair and bed alarms were functioning correctly for six residents (#141, #144, #145, #150, #151 and #153).on the Dementia Unit. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing the following corrective actions: ? By 07/19/11, all staff will be in-serviced on a new protocol that is being developed to address the supervision and monitoring of residents to ensure resident safety, and reporting observations of inappropriate resident behaviors and allegations of inappropriate resident touch and sexual abuse. ? The Quality Assurance Committee will develop and implement procedures to ensure staff follow the new facility protocol. Findings include: Review of Resident #140's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #140 was blind. Review of the quarterly MDS assessment dated [DATE] indicated Resident #140 had short/long-term memory loss and exhibited modified impairment in decision making skills. She required extensive assistance for transfer, ambulation, dressing, eating, and bathing. Additionally, her assessment indicated she could make noises but could not consistently communicate her wants and needs and was unable to call for help. Review of Resident #139 's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #139 had minimal short/long-term memory loss and displayed no behavioral symptoms. The assessment indicated Resident #139 was independent with transfers, ambulation, dressing, eating, and bathing. Review of facility ' s SRI and Investigation Reports revealed there were three incidents where Resident #139 was found attempting to touch or inappropriately touching two female residents. On 02/02/11 Resident #139 was found attempting to climb into bed with Resident #138. Resident #138 was able to get out of the bed, go to the bathroom and call for help from the bathroom. When STNA #25 arrived to the room, Resident #138 was holding the bathroom door shut and Resident #139 was getting up from Resident #138 ' s bed. Resident #139 was redirected to his room. Resident #139's plan of care dated 02/02/11 documented the resident was at risk for wandering. Interventions included observe and redirect as needed from touching other residents and the placement of a motion sensor on the resident's bedroom door for 48 hours, and discontinue on 02/04/11. On 06/10/11 at 10:15 P.M., Resident #139 was found with Resident #140 in the hallway. Resident #140 ' s gown was raised above her brief and Resident #139's hand was on her right thigh. Resident #139 said to STNA #10 that he was trying to hold Resident #140 ' s hand, and then he left the hallway and went to his room. On 06/11/11 at 4:30 P.M., Resident #139 was transferred to the hospital for evaluation for being a threat to others and being sexually inappropriate. Resident #139 returned to the facility on [DATE]. Review of a written statement dated 06/12/11 by STNA #10, who was assigned to Resident #139 at the time of the incident, documented Resident #139 and Resident #140 were in the hallway in their wheelchairs. Resident #140 had finished her shower and was being provided time to calm down before being placed in bed. STNA #10 walked out of another room and observed Resident #139 with his hand on Resident #140's right leg, with her gown up above the brief and her blankets removed. STNA #10 asked Resident #139 what he was doing and the resident " jumped, moved his hand, stuttered and said ' I was just touching her hand. ' " STNA #10 told Licensed Practical Nurse (LPN) #16 about the incident, and LPN #16 completed a physical examination after the incident. STNA #10 documented that Resident #140 said she was fine and STNA #10 put her to bed. Resident #139 left the area and went to his room. Resident #139's plan of care which was updated on 06/13/11 indicated he inappropriately touched another resident's leg. Care plan interventions dated 06/13/11 included engage resident in meaningful activities; monitor the resident for behavior and redirect; encourage resident to become involved with physical activities; refer to psychiatrist services and monitor for mood indicators. There was no evidence in the plan of care to indicate when and how staff were to monitor and supervise Resident #139 to prevent subsequent incidents of inappropriate touch. The plan of care lacked specific interventions for redirection of Resident #139 if he continued to display behaviors of inappropriate touch. Review of Resident #140 ' s clinical record revealed a late entry in the nurse ' s notes dated 06/12/11 at 3:30 P.M., written by LPN #16 for 06/10/11. LPN #16 was notified by STNA #10 that she witnessed Resident #139 "feeling on " Resident #140's leg. Resident #140 ' s gown was "pushed up. " Resident #140 was removed from the area and brought to the nurse ' s station. Resident #139 went back to his room. Resident #140 was calm and not able to tell staff what happened. Review of Resident #140 ' s clinical record revealed social service notes dated 06/13/11 (no time) and written by Social Worker (SW) #12 documented the director of nursing (DON) reported Resident #139 touched Resident #140's leg. The family was notified and was offered a room change off the Dementia Unit, but the family declined the room change. Resident #140's cognitive status remained poor and SW #12 ' s interview with Resident #140 was not successful. Nursing staff reported no unusual change in Resident #140 ' s mood and behavior. Resident #140's plan of care dated 06/13/11 identified a male resident touched her right leg on 06/10/11. The care plan interventions included support and reassure the resident in new situations; provide the resident opportunities to make decisions as appropriate; encourage the resident to verbalize feelings, concerns and fears; involve the responsible party in decision making; monitor the resident; and keep her involved as she was able. Review of SW #12's social service notes dated 06/16/11 (no time) documented SW #12 followed up with nursing staff. The nursing staff indicated Resident #140's routine was as usual and her mood and behavior were unchanged. Interview with STNA #10 on 06/30/10 at 4:10 P.M., verified she was on duty on 06/10/11 at 10:00 P.M. when Resident #139 inappropriately touched Resident #140. STNA #10 said Resident #140 was given a shower and was positioned in a special chair in the hallway afterward to provide her time to calm down after the shower. STNA #10 described Resident #140 as blind, requiring total care, unable to call for help, unable to provide consent, and was unable to protect herself from Resident #139. STNA #10 said 06/10/11 was a busy night and both residents were in the hallway. STNA #10 said around 10:00 P.M., she came out of a resident room and found Resident #139 had his hand on Resident #140's right thigh. STNA #10 said her blanket was off and her gown was up over the top of her brief. STNA #10 said she asked Resident #139 what he was doing and the resident jumped up, moved his hand and while stuttering said he was only holding Resident #140's hand. STNA #10 said she felt Resident #139 "stalked" Resident #140. STNA #10 said Resident #139 constantly flirted with Resident #140. Resident #139 always wanted to know where Resident #140 ' s whereabouts, was constantly outside her bedroom door, and following her around the unit. STNA #10 said Resident #139 acted like he had a "crush" on Resident #140. STNA #10 said before this incident Resident #139 was on every two hour checks, which was the facility ' s policy and procedure for routine resident checks. After the incident Resident #139 was placed on every 15 minute checks with a motion sensor to the door, a bed alarm, and wheelchair cushion alarm. STNA #10 said she did not report her "stalking" suspicion to the charge nurse, DON or administrator. Review of an SRI report and facility's Investigation Report dated 06/21/11 revealed on 06/20/11 at 11:30 P.M., STNA #14 stated she went to Resident #140's room and observed Resident #139 kneeling by Resident #140's low bed. Resident #139 had his left hand on Resident #140's breast and his right hand on her vaginal area. STNA #14 called for LPN #15. Resident #139 placed himself back in his wheelchair and went to his room. LPN #15 came to Resident #140 ' s room and STNA #14 went to the nurse station and obtained Registered Nurse Supervisor (RNS) #9. LPN #15 and RNS #9 completed an assessment of Resident #140 and found no injuries. A motion sensor was placed on Resident #140 ' s bedroom door. Both Resident #139 and Resident #140 were placed on every 15 minute checks. Resident #139 was transferred to the hospital on [DATE] at 3:20 P.M. for inappropriate sexual behavior and did not return to the facility. Interview with the administrator on 07/01/11 at 12:10 AM confirmed Resident #139 was discharged to another long term care facility. Review of Resident #139 ' s every (q) 15 minute checks for inappropriate sexual behavior flow sheet, dated 06/21/11 from 10:30 A.M. to 06/21/11 at 3:20 P.M., revealed no written evidence nurses or STNAs supervised Resident #139 ' s whereabouts on the Dementia Unit. The facility provided no documented evidence Resident #139 's motion sensor, bed or wheelchair alarms, that were initiated on 06/21/11 at 12:00 A.M., were in place and functional from 10:30 A.M. to 3:20 P.M. before he was transferred to the hospital for evaluation. Review of a local police report dated 06/21/11 at 2:10 A.M., completed by Patrolman #17, revealed the reporting party was the granddaughter/ power of attorney for Resident #140. The granddaughter stated the suspect, a resident at the facility, fondled the victim (grandmother) about the chest and vaginal area. The report documented the offense as gross sexual imposition. The report identified the suspect as Resident #139. Review of Resident #140 ' s nurse ' s notes written by LPN #15 on 06/21/11 at 1:45 A.M., revealed Resident #140 was in bed in her room when STNA #14 "found a male resident in her room fondling her," and was at the bedside kneeling beside her. LPN #15 witnessed the male get up from the bedside and go back to his wheelchair. At 2:00 A.M., LPN #15 documented the police arrived to discuss the incident with the resident. On 06/21/11 at 12:00 P.M. LPN #18 indicated a full body assessment was completed on Resident #140 with no injuries noted. Review of a late entry nurse's notes written by LPN #15 dated 06/30/11 for 06/20/11, revealed RNS #9 went into Resident #140's room and checked the resident for vaginal bleeding. The peri-anal area showed no signs of injury. Resident #140 showed no outward signs of discomfort. LPN #15 documented the resident ' s breasts were checked because the sports bra had been removed. LPN #15 documented there were no signs, marks or evidence of discomfort. LPN #15 documented an alarm was placed on Resident #140 ' s door (no time indicated) and monitoring of the resident was completed by LPN #15, RNS #9, and STNA #14. Review of RNS #9 's nurse's notes dated 06/30/11, and identified as a late entry for 06/20/11, revealed RNS #9 agreed with LPN #15' s documented assessment. LPN #15 and RNS #9 documented a physical assessment was completed to check for signs and symptoms of injury. RNS #9 did not observe any bruising, scratches or bleeding. RN #9 documented Resident #140 was looking at LPN #15 and RNS #9 with her eyes open and was calmly lying in bed. RNS #9 documented Resident #140 displayed no sign or symptoms of pain. Review of LPN #16 ' s nurse ' s notes dated 06/21/11 at 3:20 P.M. revealed Resident #139 was transported to the hospital and was discharge from the facility. Interview with STNA #14 on 06/30/11 at 11:15 P.M. verified she was on duty on 06/20/11 at 11:00 P.M. STNA #14 said she was assigned to Resident #139. At 11:30 P.M., STNA #14 went to Resident #140's room. STNA #14 said the lights were off and she observed Resident #139 kneeling down by Resident #140's low bed. STNA #14 said to Resident #139, "What are you doing ?" According to STNA #14, Resident #139 never answered her. STNA #14 said she observed Resident #140 ' s hospital gown was above her incontinence brief, her sports bra was pulled up off her breasts and her incontinence brief was open. STNA #14 said Resident #139 had his left hand on Resident #140's breast and his right hand on her vaginal area, with his fingers moving in a massaging motion. STNA #14 stated Resident #139 was fully clothed at the time of the incident. STNA #14 stated she called for LPN #15, who came to the room and STNA #14 went to get RNS #9. STNA #14 stated she obtained a motion sensor and placed it on Resident #140's bedroom door. STNA #14 stated both Resident #139 and Resident #140 were placed on every 15 minute bed checks. STNA #14 stated Resident #139's bed alarm and wheelchair cushion alarms were not sounding at the time of this incident because he had turned the alarms off, disconnected the alarms from his bed and wheelchair and placed the alarms on the bedside table. Interview with LPN #15 on 06/30/11 at 11:30 P.M. she verified she was on duty on 06/20/11 at 11:00 P.M., and said STNA #14 called her to Resident #140's room. On entrance to the room, LPN #15 observed Resident #139 at the side of Resident #140's low bed, and he was in the process of placing himself back in his wheelchair. LPN #15 stated Resident #140's brief was pulled off to the side of the resident. LPN #15 said she was told by STNA #14 that Resident #139 had his left hand on Resident #140's breast and his right hand on her vaginal area. LPN #15 stated STNA #14 informed her Resident #140 ' s gown was pushed up to Resident #140's sleeves and the sports bra was pulled up above the breasts. LPN #15 said she sent STNA #14 to obtain RNS #9 for assistance. LPN #15 said although she did not document a physical assessment on 06/20/11, she documented it as a late entry dated 06/30/11 and provided the assessment to the surveyor. LPN #15 said she completed a physical assessment and did not observe any injuries to Resident #140 ' s vaginal area or breasts. She said RNS #9 assisted with the physical assessment of Resident #140. LPN #15 said Resident #140 was not sent to the hospital for an evaluation. LPN #15 said the police came to the facility around 2:00 A.M. and completed their report. LPN #15 stated Resident #139 alarms were disconnected before the incident occurred at 11:30 P.M., and were placed back on around 12:00 A.M. LPN #15 stated Resident #139 was transferred to the hospital on [DATE] for evaluation and was discharged from the facility. LPN #15 stated Resident #140 ' s power of attorney transferred her to another nursing home. On 06/30/11 at 11:45 P.M., RNS #9 verified she assisted LPN #15 with the physical assessment of Resident #140 after the incident of inappropriate sexual touch by Resident #139. RNS #9 said she completed a head to toe assessment of Resident #140. RNS #9 stated she did not find any marks or scratches on Resident #140's breasts, arms, genital area or legs. RNS #9 verified Resident #140 was not sent to the hospital for examination. RNS #9 said the police arrived on the Dementia Unit at approximately 2:00 A.M. and made a report of the incident. RNS #9 verified she did not chart her initial assessment on 06/21/11 and wrote a late entry notation on 06 /30/11 at 10:20 P.M. at the request of the assistant director of nursing. Interview with the administrator on 07/01/11 at 12:10 A.M. revealed this was the first investigation RNS #9 and LPN #15 had completed of an alleged incident of sexual abuse. The administrator said the late assessments completed by RNS #9 and LPN #15 should have been written on the night of the alleged incident on 06/21/11, and not nine days after the incident occurred. The administrator said STNA #14 failed to ensure Resident #139 was supervised and had the motion sensor, bed alarm and wheelchair alarm on and functioning prior to the 06/20/11 incident. The administrator verified this was the third incident involving Resident #139. Observation of the Dementia Unit on 06/30/11 from 6:00 P.M. to 6:30 P.M. revealed Resident #139' s room was located on the same side of the hall approximately 60 feet from the entrance to Resident #140's room. Interview with Detective #28 on 07/05/11 at 9:35 A.M. revealed a warrant had been issued and would be served on 07/06/11 to Resident #139 for gross sexual imposition. Review of the facility's policy and procedure on Abuse Prohibition Program (no date or revision date) revealed the facility does not sanction nor would permit residents to be abused by anyone, including staff, other residents, visitors, family members, volunteers or personnel from outside agencies. It was the practice of the facility that the Administrator and Director of Nursing would be notified immediately of abuse, neglect or knowledge or suspicion of abuse, neglect or misappropriation of resident property. All reports would be thoroughly investigated and reported as required by the State of Ohio and Federal Government. Sexual Abuse was defined as including inappropriate sexual contact (sexual assault), sexual harassment, or coercion. The policy lacked interventions for staff to implement to prevent resident to resident sexual abuse. The policy and procedure did not address what steps the facility would take to prevent further incidents of sexual abuse, the type of monitoring and supervision to be implemented, and the implementation of an immediate plan of action to ensure the safety of other residents residing in the facility. This deficiency substantiated Complaint Number #OH 313.

Based on record review and interview, the facility failed to ensure Residents #88 and #116 were transferred according to their plan of care. Actual harm occurred to Resident #88 who sustained a dislocated left shoulder. The facility also failed to ensure Residents #62 and #135 were transferred safely when a mechanical lift was used. This affected four of four residents who were reviewed related to falls and two of 23 residents who required mechanical lift transfers. Facility census was 138. Findings include: 1. Medical record review revealed Resident #88 was admitted to the facility on [DATE]. Resident #88 had [DIAGNOSES REDACTED]. A minimum data set (MDS) assessment dated [DATE] revealed Resident #88 required extensive assistance of one to transfer. A Resident Information Sheet dated 12/27/10 indicated Resident #88 required the assistance of one to transfer. In bold print was direction to use gait belt for all transfers. emergency room discharge instructions dated 12/29/10 included a discharge [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) #2 on 01/12/11 at 4:00 P.M. revealed the following. On 12/29/10 a day shift state tested nurse aide (STNA) reported Resident #88 had bruising to her left arm and shoulder area. RN #2 said she assessed Resident #88 and immediately recognized the bruising was consistent with an improper transfer technique. In addition to the bruising RN #2 noted a lump in the area. Resident #88 complained of pain when range of motion was attempted to the left arm. The family and physician were notified of the injury. The physician ordered further evaluation at an emergency center where [DIAGNOSES REDACTED]. RN #2 said an investigation was completed related to the injury and the conclusion was that STNA #1 and STNA #3 improperly transferred Resident #88 by "hooking" her arms. They had not used a gait belt. 2. Medical record review revealed Resident #62 was admitted to the facility on [DATE]. Resident #62 had [DIAGNOSES REDACTED]. Nurses notes dated 12/09/10 at 3:45 P.M. revealed STNA #1 reported while putting Resident #62 in bed via a mechanical lift, the lift tipped over and Resident #62 fell on to her back on the floor. The physician was notified and ordered transport to an emergency room for evaluation. Resident #62 refused to go to the emergency room . During an interview with Resident #62 on 01/12/11 at 11:15 A.M., she said she was "dropped" to the floor while being transferred from a geriatric chair to her bed with a mechanical lift. Resident #62 explained STNA #1 did not operate the mechanical lift properly. STNA #1 attached the lift pad to the arm of the lift then raised the arm until she cleared the chair. STNA #1 and STNA #5 then began to move her from the chair toward the bed. STNA #1 did not use the handles of the lift when pushing it over to the bed but used the lift arm. Resident #62 tried to tell STNA #1 she was doing it wrong but she would not listen. The lift tipped over, Resident #62 dropped to the floor and the lift landed on top of her. Resident #62 said she sustained bruising to her legs, back, and buttock, a skin tear to her right arm and her neck snapped. Resident #62 showed the surveyor her right arm which had a gauze dressing wrapped around the forearm. Resident #62 confirmed she refused to go to the emergency room but did allow an x-ray of her back. Resident #62 said the x-ray showed no fractures. An interview with STNA #5 on 01/13/11 at 10:20 A.M., confirmed she assisted STNA #1 to transfer Resident #62 on 12/09/10. STNA #5 confirmed STNA #1 used improper hand placement during the transfer. STNA #5 said she was supporting Resident #62's legs when the lift tipped over and Resident #62 fell to the floor. STNA #5 said Resident #62 sustained a skin tear to her right arm and bruising to her back and bottom. Interview with the director of nursing on 01/13/11 at 1:10 P.M. revealed the facility's investigation of the fall revealed STNA #1 used improper hand placement during the transfer which caused the lift to tip over. 3. Medical record review revealed Resident #116 was admitted to the facility on [DATE]. Resident #116 had [DIAGNOSES REDACTED]. Review of an MDS assessment dated [DATE] revealed Resident #116 required maximum assist with two plus persons for transfers. Resident #116 was 72 inches tall and weighed 180 pounds. A fax sheet in the medical record dated 11/26/10 revealed an STNA had Resident #116 in the shower room and tried to transfer her from the wheelchair to the shower. Resident #116's knees buckled and the STNA lowered her to the floor. No injury was noted. Review of an Employee Education Log dated 11/26/10 revealed STNA #11 attempted to transfer Resident #116 by herself. Resident #116 had a physician order for [REDACTED]. STNA #11 had to lower Resident #116 to the floor because the resident's knees buckled. 4. Review of an undated Investigation Follow-Up revealed on 10/28/10 at approximately 7:15 P.M., Resident #135 was being put to bed by two STNAs and the mechanical lift tipped. The resident fell to the floor and hit the bed on the way down. The resident complained of back and shoulder pain. Resident #135 was sent to the emergency room . The investigation documented the lift was pulled from service. Review of witness statements dated 10/29/10 that were written by STNA #7 and STNA #9 revealed the following. On 10/28/10 at approximately 7:15 P.M., they were transferring Resident #135 from a recliner to her bed. The legs of the mechanical lift were in the wide position but when STNAs #7 and #9 attempted to turn the mechanical lift, the legs closed causing Resident #135 and the lift to tip over. Resident #135 complained of left shoulder and back pain. Interview with the director of nursing on 01/13/11 at 1:15 P.M., revealed the mechanical lift was removed from service immediately after the incident. The director of nursing said that upon inspection of the mechanical lift, it was found that when the legs of the lift were open and an object was bumped, the legs would pop closed. Interview with Resident #135 on 01/13/11 at 1:40 P.M., revealed she fell during a mechanical lift transfer. Resident #135 denied any injury as a result of the fall. This deficiency substantiates Complaint Numbers OH 984M, OH 961 and OH 934.