Every finding on record at Meadows of Delphos the

Based on employee file reviews and staff interview, the facility failed to complete annual performance reviews for Certified Nursing Assistants (CNA). This affected three (#10, #13, and #69) CNAs out of four CNAs reviewed for annual performance evaluations. This had the potential to affect all the residents. The facility census was 52.Findings include: 1.Review of the employee file for CNA #10 revealed a hire date of 11/14/23. Further review of the file revealed no documentation to support an annual performance evaluation had been completed. 2. Review of the employee file for CNA #13 revealed a hire date of 12/12/24. Further review of the file revealed no documentation to support an annual performance evaluation had been completed. 3. Review of the employee file for CNA #69 revealed a hire date of 04/22/25. Further review of the file revealed no documentation to support an annual performance evaluation had been completed. Interview on 08/20/26 at 1:00 P.M. with Employee Experience Manager #61 confirmed the facility had not completed annual performance for CNA #10, #13, and #69.

Based on record review, interview, and policy review, the facility failed to follow its Legionella water management plan; the facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for Resident #9; and the facility failed to store nebulizer tubing properly for Resident #29. This affected two (#9 and #29) residents and had the potential to affect all residents in the facility. The facility census was 52. Findings include: 1.Review of the undated facility water management plan revealed the facility will check and record daily water temperatures. Review of the facility temperature logs revealed the facility did not have evidence that water temperatures were checked daily. Interview on 08/20/2026 at 1:00 P.M. with The Director of Plant Operations #44 confirmed the facility did not have evidence staff were monitoring water temperatures daily and thought they only need to record the temperatures weekly. Review of the facility policy, Guidelines of Water Management last reviewed 12/19/25 confirmed the Director of Plant Operations will maintain documentation of all the activities related to the water management program. 2.Record review for Resident #9 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: anterior dislocation of right humerus; sequela, paraplegia, aphasia, homonymous bilateral field defect, disorders of bone density and structure. Review of Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 00. This resident was assessed to be dependent on toileting, dressing, eating, and bathing. Review of the care plan dated 08/04/26 revealed Resident had a pressure ulcer. Observation on 08/17/26 at 10:00 A.M. revealed no Enhanced Barrier Precautions (EBP) sign in place or personal protective equipment (PPE) in place for Resident #9. Interview on 08/17/26 at 10:23 A.M. with Regional Nurse #91 verified no EBP was in place for Resident #9's pressure ulcer. Facility policy, Enhanced Barrier Precautions Standard Operating Procedure, dated 12/03/25, revealed Enhanced Barrier Precautions (EBP) will be in place during high-contact care activities for resident with chronic wounds, including but not limited to, pressure ulcers, diabetic food ulcer, unhealed surgical wounds and venous stasis ulcers. 3.Record review for Resident #29 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: acute and chronic respiratory failure with hypoxia, congestive heart failure, type two diabetes mellitus, and pneumonia. Review of Minimum Data Set (MDS) finalized assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to be independent with toileting and dressing, and supervision bathing. Review of the care plan dated 07/22/26 revealed potential shortness of breath when lying flat due to congestive heart failure and chronic respiratory failure. Medication Administration Review revealed that ipratropium-albuterol solution for nebulization (0.5 mg–3 mg per 3 mL) was initiated on 04/17/26 as needed for wheezing or shortness of breath. Documentation showed the medication was ordered twice daily from 08/01/26 through 08/18/26. Observation on 08/19/26 at 10:50 A.M. revealed on Resident #29's bed, a nebulizer machine was lying on the bed. Mask, tubing and chamber was lying beside the machine but was not attached and was not in a bag. Interview on 08/19/26 at 10:53 A.M. with Resident #29 revealed Resident #29 had not had breathing treatment yet. Interview on 08/19/26 at 11:04 A.M with Director of Nursing revealed Resident #29 did not have nebulizer tubing, mask, and chamber in a bag. Facility policy Respiratory Equipment, dated 07/28/26, revealed the circuit (tubing, mask, and chamber) was to be stored in plastic bag, marked with date and resident's name.

Based on interview and record review, the facility failed to ensure provider visit notes were signed and closed at the time of the visit. This affected four residents (#7, #10, # 28, and #29) of four residents reviewed for provider visit notes. The facility census was 52.Findings include: 1. Record review for Resident #7 revealed this resident was admitted to the facility on with the following diagnoses: sepsis with septic shock, end stage renal disease, and type two diabetes mellitus. Review of Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to be supervision with toileting hygiene and showering. Medications are antianxiety, insulin, antidepressant, anticoagulant, diuretic, antiplatelet, and anticonvulsant. Review of the care plan dated 08/06/26 revealed Resident #7 has renal failure resulting in need for dialysis. Review of the provider progress note for Resident #7 revealed a date of service of 07/30/26 and the note was signed and dated 08/12/26, date of service 07/23/26 and the noted was signed and dated 08/02/26, and date of service 07/21/26 and the noted was signed and dated 07/31/26. 2. Record review for Resident #10 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: dementia, chronic obstructive pulmonary disease, unspecified psychosis, and delusional disorders. Review of Minimum Data Set (MDS) annual assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to be maximal assistance with toileting, bathing, and moderate assistance with dressing. Medications include antidepressants and anticonvulsants. Review of the care plan dated 06/16/23 revealed Resident #10 presents with a diagnosis of unspecified psychosis and delusional disorder. Review of the provider progress note for Resident #10 revealed a date of service of 08/10/26 and the note was signed and dated 08/16/26, da10te of service 07/10/26 and the noted was signed and dated 07/19/26, and date of service 07/13/26 and the noted was signed and dated 07/18/26. 3. Record review for Resident #28 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: acute neurologic, history of delusional disorders, depressive disorder, and anxiety. Review of Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 16. This resident was assessed supervision with bathing, toileting and dressing. Review of the care plan dated 07/30/26 revealed resident presents with a diagnosis which is treated with anti-psychotic meds and will remain free from falls with major injury. Review of the provider progress note for Resident #28 revealed a date of service of 08/03/26 and the note was signed and dated 08/15/26, date of service 07/30/26 and the noted was signed and dated 08/11/26, and date of service 07/31/26 and the noted was signed and dated 08/02/26. 4. Record review for Resident #29 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: acute and chronic respiratory failure with hypoxia, congestive heart failure, type two diabetes mellitus, and pneumonia. Review of Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to be independent with oral care, toileting and dressing. Supervision with bathing. Review of the care plan dated 05/11/26 revealed potential for shortness of breath while lying flat related to chronic obstructive pulmonary disease. Review of the provider progress note for Resident #29 revealed a date of service of 08/10/26 and the note was signed and dated 08/16/26, date of service 07/03/26 and the noted was signed and dated 08/15/26, and date of service 07/30/26 and the note was signed and dated 08/12/26. Interview on 08/19/26 at 2:12 P.M. with Regional Nurse #91 at time of findings confirmed the provider's notes should be closed on the date of service provided and all notes for the residents listed above were closed late and not at the time of service.

Based on record review and staff interview, the facility failed to ensure the Medical Director (MD) visited the residents once every 60 days. This affected four (#9, #10, #20, and #24) of four reviewed for physician visits. The census was 52. Findings include: 1. Record review for Resident #9 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: anterior dislocation of right humerus; sequela, paraplegia, aphasia, homonymous bilateral field defect, disorders of bone density and structure. Review of Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 0. This resident was assessed to be dependent on toileting, dressing, eating, and bathing. Review of the medical record for Resident #9 revealed MD visits on 12/03/25, 03/30/26, and 07/20/26. Interview on 08/18/26 at 3:45 P.M. with the Regional Nurse #91 confirmed that Resident #10 had documented physician visits on 12/03/25, 03/30/26 and 07/20/26. 2. Record review for Resident #10 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: dementia, chronic obstructive pulmonary disease, unspecified psychosis, and delusional disorders. Review of Minimum Data Set (MDS) annual assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to be maximal assistance with toileting, bathing, and moderate assistance with dressing. Medications include antidepressants and anticonvulsants. Review of the medical record for Resident #10 revealed MD visits on 05/22/26 and 01/12/26. Interview on 08/18/26 at 3:45 P.M. with the Regional Nurse #91 confirmed Resident #10 had documented physician visits on 05/22/26 and 01/12/26. Regional Nurse #91 confirmed no additional physician visits were documented for Resident #9 from 05/22/26 to today. 3. Review of Resident #20 medical records revealed an admission date of 04/08/25 with medical diagnoses of kidney disease, type two diabetes, and congestive heart failure. Review of Resident #20 Minimum Data Set (MDS) last updated 06/15/26 revealed a Brief Interview of Mental Status score of 08 consistent with significant cognitive decline. Review of Resident #20's provider notes revealed the resident was seen by the facility physician on 08/12/25, 01/05/26, and 05/08/26. Interview on 08/20/26 at 1:11 P.M. with Regional Nurse #91 confirmed Resident #20 was not seen by their physician every 60 days as required. 4. Review of the medical record for Resident #24 revealed an admission date of 03/24/20 with medical diagnoses of left hemiparesis, hypertensive heart and chronic kidney disease with heart failure and diabetes mellitus. Review of Resident #24's quarterly MDS assessment, dated 07/02/26, revealed Resident #24 was cognitively intact and required substantial/maximum assistance with toilet hygiene, bathing and bed mobility and was dependent upon staff for transfers. Review of Resident #24's medical record revealed physician visits were conducted on 09/30/25, 01/29/26, and 05/22/26. Interview on 08/19/26 at 9:02 A.M. with Clinical Support #93 confirmed physician visits are to occur every 60 days and that Resident #24 was not seen by the physician every 60 days.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a Resident Representative was informed and consented of psychotropic medication use. This affected one (#15) resident out of five reviewed for psychotropic medication use. The facility census was 52.Findings include: Review of the medical record for Resident #15 revealed an admission date of 07/06/26 with medication diagnoses of severe dementia with mood disturbances, right femur fracture, hypothyroidism, hyperlipidemia, anxiety, and hypertension. Review of Resident #15's admission Minimum Data Set (MDS) assessment, dated 07/10/26, indicated Resident #15 had severely impaired cognition and required partial/moderate staff assistance with toilet hygiene, bathing, bed mobility and transfers. Review of Resident #15's physician orders revealed orders dated 07/06/26 for aripiprazole (antipsychotic) 10 milligram (mg) one tablet by mouth daily and lorazepam (antianxiety) 1 mg one tablet by mouth daily. Review of Resident #15's psychotropic medication informed consent forms for the antipsychotic and antianxiety medications revealed the consents were signed by Resident #15. Review of Resident #15's progress notes revealed no documentation Resident #15's representative consented to antipsychotic medication use for Resident #15. Interview on 08/18/26 at 10:39 A.M. with Director of Nursing (DON) confirmed Resident #15 had severely impaired cognition and could not make healthcare decisions independently. DON stated Resident #15's son made health care decisions. Interview with Clinical Support #93 confirmed the Resident #15 had signed the consents for psychotropic medication use and that the consents should have been signed by Resident #15's representative due to Resident #15's severely impaired cognition. Review of the facility policy titled, Medication Use and Gradual Dose Reduction Guidelines, revised 03/10/25 stated to ensure every effort was made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team. The policy stated the consent must be obtained by the Resident/Resident Party prior to initiating a new psychotropic medication, increasing the dose of a psychotropic medication, or changing a current psychotropic medication to an alternate psychotropic medication.

Based on medical record review, staff interview, and policy review, the facility failed to have documentation to support code status. This affected one (#08) resident out of three residents reviewed for advanced directives. The facility census was 52.Findings include: Review of the medical record for Resident #08 revealed an admission date of 04/17/24 with medical diagnoses of Alzheimer's disease, dementia with psychotic disturbances, adjustment disorder with mixed disturbances of emotions and conduct, major depressive disorder, and hypertension. Review of Resident #08's medical record revealed a quarterly Minimum Data Set (MDS) assessment which indicated Resident #08 had severely impaired cognition and was dependent upon staff for activities of daily living. Review of Resident #08's physician orders revealed an order dated 07/23/24 for Do Not Resuscitate (DNR). Review of Resident #08's electronic health record (EHR) revealed on Resident #08's home page a Do Not Resuscitate Comfort Care (DNRCC) status had been entered. Review of Resident #08's Advanced Directive, signed 07/25/24, revealed both the DNRCC and the Do Not Resuscitate Comfort Care Arrest (DNRCCA) appeared to be checked and the form was not legible to determine Resident #08's code status. Interview on 08/18/26 at 3:38 P.M. with Clinical Support #93 confirmed Resident #08's signed Advanced Directive was not legible and was not able to determine if Resident #08 had a DNRCC or DNRCCA code status. Clinical Support #93 also confirmed Resident #93 had an order for DNR code status and the EHR showed on Resident #08 had a DNRCC code status. Review of the facility policy titled, Guidelines for Advanced Directives, revised 09/26/24 stated the purpose was to ensure facility staff obtain and follow resident's advanced directives regarding end-of-life care. The guidelines stated the nursing staff would confirm the desired code status and obtain an order from the physician. The DNR form would be completed documenting these desires and scanned into the medical record. The guidelines stated the designation of code status and obtainment of physician order would be part of the medical record.

Based on observation, interview, and policy review, the facility failed to maintain an environment that promoted dignity. This deficient practice affected one (Resident #13) of fourteen on the 400 hall observed for homelike environment. The facility census was 52. Findings Include: Review of Resident #13's medical record revealed an admission date of 07/31/26 and included medical diagnoses of dementia, mood disturbance, major depressive disorder, and muscle weakness. Review of Resident #13's Minimum Data Set (MDS) last updated 08/06/26 revealed a Brief Interview for Mental Status (BIMS) score of 5 which is consistent with severe cognitive impairment. Further review confirmed the resident was dependent on staff for toileting hygiene and toilet transfers. Review of Resident #13's care plan last revised 08/17/26 revealed the resident was at risk for bowel and bladder incontinence due related to an impaired ability to recognize and communicate needs secondary to cognitive loss and need for assistance to transfer to the toilet. Interventions included to offer and assist with toileting. Further review revealed the resident has impaired ability to perform and complete Activities of Daily Living (ADL) related to cognitive loss and impaired endurance. Interventions include provide incontinent care after each incontinence episode. Observation on 08/17/26 at 4:46 P.M. revealed a pervasive smell of stool coming from Resident #13's private bathroom. Observation of the toilet revealed multiple large formed pieces of stool in the toilet. Interview at the time of observation with Certified Nurse Aide (CNA) #46 confirmed the pervasive smell of stool coming from Resident #13's private bathroom. The CNA attempted to flush the resident's toilet, the attempt was unsuccessful. CNA #46 confirmed the toilet was clogged and they would notify housekeeping to unclog the toilet. CNA #46 further confirmed that Resident #13 requires assistance from staff for all toileting, and that the resident's had not had a bowel movement on their shift and the stool was left from a previous shift. Interview on 08/20/26 with the Director of Nursing (DON) confirmed the facility's expectation if a resident's toilet is clogged that staff are to unclog the toilet and/or notify housekeeping if unable to unclog the toilet. Review of the facility policy, Resident Rights Guidelines, last reviewed 12/08/25 revealed the facility will ensure residents rights are respected and protected and provided and environment in which they can be exercised and resident shall not leave their individual personalities or basic human rights behind when moving to the health campus.

Based on medical record reviews, staff interviews, and policy reviews, the facility failed to ensure dose reduction was completed as ordered. The facility also failed to complete Abnormal Involuntary Movements Scale (AIMS) for a resident on antipsychotic medication. This affected two (#08 and #15) residents out of five residents reviewed for psychotropic medications. The facility census was 52.Findings include: 1.Review of the medical record for Resident #08 revealed an admission date of 04/17/24 with medical diagnoses of Alzheimer's disease, dementia with psychotic disturbances, adjustment disorder with mixed disturbances of emotions and conduct, major depressive disorder and hypertension. Review of Resident #08's medical record revealed a quarterly Minimum Data Set (MDS) assessment which indicated Resident #08 had severely impaired cognition and was dependent upon staff for activities of daily living. The MDS indicated Resident #08 received antipsychotic, antianxiety, and antidepressant medications. Review of Resident #08's physician orders revealed an order dated 09/17/25 for Zoloft (antidepressant) 100 milligram one tablet by mouth daily. Review of Resident #08's 07/14/26 pharmacy medication review revealed a recommendation to consider a gradual dose reduction of Resident #08's Zoloft from 100 mg to 50 mg daily. Review of the recommendation revealed a handwritten note by the physician which stated to start the trial dose reduction which was signed on 08/05/26. Interview on 08/18/26 at 3:04 P.M. with Regional Nurse #91 confirmed the facility had not initiated the Zoloft dose reduction as ordered on 08/05/26. 2.Review of the medical record for Resident #15 revealed an admission date of 07/06/26 with medication diagnoses of severe dementia with mood disturbances, right femur fracture, hypothyroidism, hyperlipidemia, anxiety, and hypertension. Review of Resident #15's admission MDS assessment, dated 07/10/26, indicated Resident #15 had severely impaired cognition and required partial/moderate staff assistance with toilet hygiene, bathing, bed mobility and transfers. Review of Resident #15's physician orders revealed orders dated 07/06/26 for aripiprazole (antipsychotic) 10 milligram (mg) one tablet by mouth daily. Review of Resident #15's medical record revealed no documentation to support the facility completed an AIMS assessment upon admission. Interview on 08/19/26 at 1:56 P.M. with Regional Nurse #91 confirmed Resident #15 received an antipsychotic medication upon admission and the facility had not completed an AIMs assessment. Review of the facility policy titled, Abnormal Involuntary Movement Scale (AIMS), revised 05/22/18 stated a licensed nurse would complete an AIMS scale assessment on all residents on antipsychotic medications or other medication known to cause Tardive Dyskinesia. The policy stated the AIMS assessment would be completed, if possible, prior to the resident beginning this type of medication, or at the earliest possible time; either after admission, after medications listed above are prescribed, and with dosage changes. Review of the facility policy titled, Medication Use and Gradual Dose Reduction Guidelines, revised 03/10/25 stated to ensure every effort was made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team. The policy stated the consent must be obtained by the Resident/Resident Party prior to initiating a new psychotropic medication, increasing the dose of a psychotropic medication, or changing a current psychotropic medication to an alternate psychotropic medication.

Based on record review and staff interview, the facility failed to complete post dialysis assessments. This affected one resident (#7) of one resident reviewed for dialysis. The census was 52. Record review for Resident #7 revealed the resident was admitted to the facility with the following diagnoses: sepsis with septic shock, end stage renal disease, type two diabetes mellitus. Review of Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of the care plan dated 08/06/26 revealed Resident #7 had renal failure resulting in need for dialysis. Review of medical record for Resident #7 revealed post dialysis assessments were not completed for dates of 08/07/26, 08/10/26, and 08/17/26 when Resident #7 went to dialysis. Interview on 08/18/26 at 10:42 A.M. with the Director of Nursing (DON) verified post dialysis assessments were not completed.

Based on medical record review, staff interview, and policy review, the facility failed to administer medications as ordered. This affected one (#15) resident out of five residents reviewed for psychotropic medications. The facility census was 52.Findings include: Review of the medical record for Resident #15 revealed an admission date of 07/06/26 with diagnoses of severe dementia with mood disturbances, right femur fracture, hypothyroidism, hyperlipidemia, anxiety, and hypertension. Review of Resident #15's admission Minimum Data Set (MDS) assessment, dated 07/10/26, indicated Resident #15 had severely impaired cognition and required partial/moderate staff assistance with toilet hygiene, bathing, bed mobility and transfers. Review of Resident #15's physician orders revealed an order dated 07/06/26 for lorazepam (antianxiety medication) 1 milligram (mg) one tablet by mouth every evening. Review of Resident #15's July 2026 Medication Administration Record (MAR) revealed no documentation to support lorazepam was administered from 07/06/26 through 07/12/26. Review of the MAR revealed documentation which stated the lorazepam was not available. Review of the medical record revealed no documentation to support the facility notified the physician the lorazepam was not available for administration. Interview on 08/18/26 at 1:26 P.M. with Clinical Support #93 confirmed the facility had not administered Resident #15's lorazepam as ordered on 07/06/26 through 07/12/26 or notified the physician that the medication was not available to administration. Review of the facility policy titled, Medication Administration, revised November 2018, stated medication are administered as prescribed in accordance with good nursing principles and practices and only by the persons legally authorized to do so.

Based on medical record review, staff interview, and policy review, the facility failed to ensure pharmacy medication regimen reviews were reviewed by the physician. This affected one (#08) resident out of five residents reviewed for psychotropic medications. The facility census was 52.Findings include: Review of the medical record for Resident #08 revealed an admission date of 04/17/24 with medical diagnoses of Alzheimer's disease, dementia with psychotic disturbances, adjustment disorder with mixed disturbances of emotions and conduct, major depressive disorder and hypertension. Review of Resident #08's medical record revealed a quarterly Minimum Data Set (MDS) assessment which indicated Resident #08 had severely impaired cognition and was dependent upon staff for activities of daily living. The MDS indicated Resident #08 received antipsychotic, antianxiety, and antidepressant medications. Review of Resident #08's medical record revealed no documentation to support the pharmacy medication review recommendations were reviewed by a physician on 10/20/25, 11/16/25, and 04/16/26. Interview on 08/18/26 at 3:50 P.M. with Regional Support #93 confirmed the facility had no documentation to support the pharmacy recommendations for 10/20/25, 11/16/25, and 01/29/26 were reviewed by the physician. Regional Support #93 stated Resident #08 received psychiatric services through a consultant company and that service managed any psychotropic dose reductions. Regional Support #93 confirmed Resident #08's physician should have reviewed the pharmacy recommendations. Review of the facility policy titled, Medication Use and Gradual Dose Reduction Guidelines, revised 03/10/25 stated to ensure every effort was made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team. The policy stated the pharmacy reviews would be conducted monthly by a consultant pharmacist and would notify the physician and the nursing staff whenever a psychotropic medication was due for review.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident was free from significant medication errors. This affected one (#15) resident out of five residents reviewed for unnecessary medications. The facility census was 52.Findings include: Review of the medical record for Resident #15 revealed an admission date of 07/06/26 with medication diagnoses of severe dementia with mood disturbances, right femur fracture, hypothyroidism, hyperlipidemia, anxiety, and hypertension. Review of Resident #15's admission Minimum Data Set (MDS) assessment, dated 07/10/26, indicated Resident #15 had severely impaired cognition and required partial/moderate staff assistance with toilet hygiene, bathing, bed mobility and transfers. Review of Resident #15's physician orders revealed an order dated 07/06/26 for clonidine 0.1 milligram (mg) one tablet by mouth as needed and to give if systolic blood pressure (SBP) was greater than 160-180 millimeters of mercury (mmHg) or diastolic blood pressure (DBP) was greater than 100-110 mmHg. Review of Resident #15's medical record revealed the following blood pressure readings 07/08/26 at 7:15am 166/81, 07/08/26 at 2:10pm 183/81, 07/10/26 at 8:16am 166/80, 07/11/26 at 9:19am 166/74, 07/19/26 at 6:56am 161/76, 07/20/26 at 10:24am 166/72, 07/23/26 at 2:47pm 161/79, 07/27/26 at 11:17am 165/76, 07/29/26 at 2:53pm 190/72, 08/01/26 at 11:58am 167/74, 08/08/26 at 10:21am 176/83, 08/09/26 at 12:51pm 181/77, 08/10/26 at 7:38am 173/81, 08/14/26 at 7:26am 173/67, 08/16/26 at 6:53am 170/80. Review of Resident #15's Medication Administration Record (MAR) for July and August 2026 revealed no documentation to support clonidine was administered as ordered for SBP greater than 160-180 mmHG or DPB greater than 100-110 mmHG. Interview on 08/18/26 at 11:17 A.M with Clinical Support #93 confirmed that facility had not administered clonidine as ordered in July or August 2026. Review of the facility policy titled, Medication Administration, revised November 2018, stated medication are administered as prescribed in accordance with good nursing principles and practices and only by the persons legally authorized to do so.

Based on medical record, resident interview, staff interview, and facility policy, the facility failed to provide three meals a day to a resident. This had affected one resident (#7) out of sixteen residents reviewed for documentation. The census was 52. Findings include: Record review for Resident #7 revealed this resident was admitted to the facility with the following diagnoses: sepsis with septic shock, end stage renal disease, type two diabetes mellitus. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to be supervision with toileting hygiene and showering. Review of the care plan dated 08/06/26 revealed Resident #7 had renal failure resulting in need for dialysis. Review of medical records for Resident #7 revealed the following meal intake documentation: On 08/14/26 at 9:26 A.M., 'not taken' was documented. On 08/12/26 at 2:13 P.M., 'none' was documented. On 08/07/26 at 12:17 P.M., 'not taken' was documented. On 08/05/26, 'not taken' was documented. On 07/22/26 at 10:55 A.M., 'not taken' was documented. Record review indicated Resident #7 was out of the facility at dialysis during the above times and typically returned between approximately 1:30 P.M. and 2:00 P.M. Interview on 08/17/26 at 2:50 P.M. with Resident #7 revealed the kitchen does not send a lunch with her on dialysis days. Resident #7 stated she typically returns to the facility between approximately 1:30 P.M. and 2:00 P.M. She reported it is not her request to skip lunch. Resident #7 stated there were times lunch was delivered to her room after she returned from dialysis. She further stated that on a couple of occasions she asked for lunch and was told that dinner would be served in a few hours. Interview on 8/17/26 at 2:59 P.M. with Licensed Practical Nurse (LPN) verified Resident #7 was not offered a meal when she returned from dialysis. Interview on 8/17/26 at 3:00 P.M. with Certified Nursing Assistant (CNA) #63 verified Resident #7 was not offered a meal when she returned from dialysis. Interview on 08/17/26 at 3:35 P.M. with Dietary Staff #56 revealed the kitchen holds Resident #7's lunch until she returns from dialysis. Dietary Staff #56 stated nurses and aides should come to the kitchen and obtain the meal when Resident #7 returns. The kitchen is open throughout the day and can prepare food for Resident #7 as needed. Interview on 08/17/26 at 4:16 P.M. with Regional Nurse #91 and Director of Nursing (DON) verified multiple days lunch was documented not given and unsure if Resident #7 received a meal. Review of facility policy, Meal Times revealed breakfast is from 7:00 A.M. to 9:00 A.M., lunch at 11:45 A.M., and supper at 4:45 A.M. meals are served in the dining room. Cafe menu items are available all day 7:00 A.M. to 7 P.M. with fresh fruit is available twenty-four hours a day.

Based on observation, medical records, and staff interview, the facility failed to maintain infection control while assisting Resident #26 with eating. This affected one (#26) of two residents observed for eating. The facility census was 52. Findings include:Record review for Resident #26 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: dysphagia, Alzheimer's, and dementia Review of Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 02. This resident was assessed to be dependent on toileting, eating, and bathing and maximal with dressing. Observation on 08/17/26 at 12:30 P.M. revealed Certified Nursing Assistant (CNA) #63 placed a cut up piece of fish onto a fork, then placed the fork, food side down, onto the table before feeding the piece to Resident #26. CNA #63 continued to place the fork on a dirty napkin and fed Resident #26 in this manner two additional times. Interview on 08/17/26 at 12:43 P.M. with CNA #63 verified that the fork, with food, had been contaminated three times and was then used to feed Resident #26.

Based on staff interview, record review, review of the facility's Self-Reported Incidents (SRI), and policy review the facility failed to report an allegation of abuse to the state agency. This affected one (#53) of the three residents reviewed. The facility census was 51. Findings include: Review of the closed medical record of Resident #53 revealed an admission date of [DATE] and expired in the facility on [DATE]. Diagnoses included rhabdomyolysis, chronic kidney disease, traumatic ischemia of muscle and hard of hearing. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #53 was cognitively impaired and dependent on staff for Activities of Daily Living (ADL). Review of the facility's Self-Reported Incidents (SRI) in the Certification and Licensure System (CALS), revealed no SRI being created on or around [DATE] related to allegations of abuse by staff members towards Resident #53. During an interview on [DATE] at 10:35 A.M., the Administrator stated she received a video from the former Director of Health Services (DHS) which alleged a resident was being verbally abused by staff in early [DATE]. The Administrator stated she immediately responded to the facility, as she only lives minutes away. The Administrator stated upon entering the facility, she could hear yelling from Resident #53's room. The Administrator stated that former Licensed Practical Nurse (LPN) #101and Certified Nursing Assistant (CNA) #100 were identified as being in the resident's room. The Administrator stated she immediately intervened and suspended the two staff members and began her investigation. The Administrator stated when she questioned the two staff members in the room and a CNA who was in the hallway, she didn't feel as if any abuse occurred. The Administrator stated Resident #53 was very hard of hearing and LPN #101 and CNA #100 were in the room and stated they were attempting to reposition Resident #53 and were talking loudly to get him to understand, and they admitted to getting frustrated. Review of the video with the Administrator on [DATE] at 11:15 A.M., revealed it was the same video recording she received in early [DATE]. The Administrator verified LPN #101 and CNA #100 were in Resident #53's when LPN #101 was heard yelling expletives towards Resident #53. The Administrator stated she did not need to create an SRI since she didn't feel the situation was abuse. The Administrator verified she did not create an SRI. Review of the policy tilted Abuse and Neglect Procedural Guidelines dated [DATE], revealed all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but not later than two hours after the allegation is made to the State Survey Agency.This deficiency represents non-compliance investigated under Complaint Number 3009685.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure care plans were accurate and current. This affected two residents, (#10 and #20) out of five residents reviewed for care plans. The current census was 53. Findings include: 1. Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included fracture of right humerus, unspecified intellectual disabilities, depression, anxiety, insomnia, and pain. Review of Resident #10's Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident had impaired cognition. Review of the psychiatric diagnostic evaluation dated 02/17/23 revealed the Psychiatric Licensed Social Worker (PLSW) documented Resident #10 had a history of past trauma involving the murder of her brother, abuse by her parent, and abuse by her partner. Per the evaluation ongoing counseling and evaluation from a psychiatrist for medication management was recommended. Review of Resident #10's care plans dated, 01/13/25, revealed a focus added to the care plans for of history of traumatic experiences. No care plan for trauma was added the the resident's care from 11/29/22 to 01/13/25. Interview on 01/15/24 at 3:33 P.M. with the Administrator and Director of Nursing (DON) revealed Resident #10 had reported her past trauma to the social worker sometime during 12/2024. Per the Administrator upon the report the care plan for trauma was not initiated until 01/13/25. Per the DON, Resident #10 did not report the type of trauma and/or any triggers of trauma to anyone prior to 12/2024 per her knowledge. Interview on 01/16/24 at 8:33 A.M. with Social Worker (SW) #380 revealed on 01/03/25 Resident #10 reported to the social worker she had a past trauma of abuse from her family, including her ex-husband. SW #380 stated she reported the trauma to the Administrator but did not document the report. SW #380 denied knowledge of the psychiatric evaluation dated 02/17/23, and stated she was not made aware of the details regarding the resident's trauma until 01/03/25. 2. Review of the medical record for Resident #20 revealed the resident admitted to the facility on [DATE]. Diagnoses included multiple rib fractures post fall, urinary retention, heart disease, and spinal stenosis. Review of Resident #20's MDS admission assessment dated [DATE] revealed the resident had intact cognition and was admitted to the facility without an indwelling catheter. Review of Resident #20's nursing admission assessment dated [DATE] revealed when the resident readmitted to the facility on [DATE] he did not have an indwelling urinary catheter. Review of Resident #20's orders revealed the resident was scheduled for an outside appointment with a urologist on 12/23/24. Per the order dated 12/23/24 the resident was ordered to receive indwelling catheter care each shift for the Foley catheter placed. Review of Resident #20's care plans dated from 12/23/24 to 01/13/25 revealed no focus was added to the care plans for the indwelling urinary catheter. On 01/14/25 the staff updated the care plans to add the catheter focus. Interview on 01/16/24 at 10:48 A.M. with Medical Director (MD) 408 revealed when Resident #20 was admitted he was not admitted with an indwelling catheter. Per MD #408, Resident #20 shows signs of urinary retention and was seen by an outside urologist for the issue. MD #408 stated when he returned to the facility from the appointment he had an indwelling catheter placed and the facility staff were caring for the catheter. MD #408 stated the outside urologist is managing the care for the catheter. Interview on 01/16/25 at 11:05 A.M. with Registered Nurse (RN) #350 revealed Resident #20 has had an indwelling catheter for over a month. Interview on 01/16/25 at 11:35 A.M. with the Director of Nursing (DON) verified the care plan was not updated on 12/23/24 when Resident #20 returned to the facility with the indwelling catheter. Per the DON, the care plan was revised after MD #408 had ordered new care orders for the catheter care on 01/14/25. Review of the facility policy titled Comprehensive Care Plans, dated 05/22/18, revealed the facility will ensure all care plans are accurate and current to ensure proper care is provided.

Based on observation, staff interviews and review of facility policy, the facility failed to ensure proper infection control measures wre followed for nephrostomy collection bag. This affected one Resident #144 of two reviewed for urinary catheter care. The facility census was 53. Findings included: Review of medical record for Resident #144 revealed an admitted [DATE]. Diagnoses included hydronephrosis with renal and ureteral calculous obstruction with a nephrostomy. Observation on 01/16/25 at 6:57 A.M revealed the resident was lying on his left side with the nephrostomy drainage bags hanging off the left side of the bed touching the ground. Interview with Certified Registered Care Associate (CRCA) # 329 on 01/16/25 at 7:15 A.M. verified the drainage bags were over the left side of the bed and touching the floor. Review of the policy titled Urinary Catheter Care, dated 12/16/24, revealed the urinary drainage bag should be held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on medical record review, observation, resident and staff interview, and review of facility policy, the facility failed to ensure resident smoking supplies were stored in a locked area. This affected one (Resident #7) out of one resident reviewed for smoking and had the potential to affect three additional residents (#4, #9, and #28) who were identified by the facility as being cognitively impaired and independently mobile. The facility census was 47. Findings include: Review of the medical record revealed Resident #29 was admitted on [DATE]. Diagnoses included but were not limited to hypertensive [CONDITION(S)] with heart failure, acute respiratory failure with [CONDITION(S)], and type two diabetes mellitus without complications. Review of Resident #29's Minimum Data Set assessment, dated 07/01/22, revealed Resident #29 was cognitively intact. Interview on 08/22/22 at 2:07 P.M. with Resident #29 revealed Resident #29 stored cigarettes and a lighter in his dresser drawer. Observation on 08/24/22 at 8:35 A.M. revealed Resident #29's resident room door was open and State tested Nursing Assistant (STNA) #182 was observed to open Resident #29's unlocked dresser drawer and hand Resident #29 his cigarettes and lighter. Interview on 08/24/22 at 8:40 A.M. with STNA #182 verified Resident #29's cigarettes and lighter were stored unlocked in the resident's room. Review of the facility policy titled Smoke Free Environment, last reviewed 12/01/21, revealed it is the policy of the facility to provide a Smoke Free Environment for employees, residents, and visitors. The facility and grounds have been designated tobacco free. Smoking and the use of tobacco products is prohibited anywhere on the facility property.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure medications were not left unattended at bedside. This affected one (Resident #34) out of one resident reviewed for self-administration of medication and had the potential to affect three additional residents (#4, #9, and #28) who were identified by the facility as being cognitively impaired and independently mobile. The facility census was 47. Findings include: Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included polyneuropathy, unspecified protein-calorie malnutrition, [CONDITION(S)], hypertensive [CONDITION(S)] with heart failure, acute on chronic systolic (congestive) heart failure, [CONDITION(S)], [CONDITION(S)], and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 07/06/22, revealed Resident #34 was cognitively intact. Review of Resident #34's physician order, dated 07/28/22, revealed an order for [MEDICATION(S)] one gram four times a day. Additional review of Resident #34's medical record revealed the Resident #34's medical record was silent for a self-medication assessment, physician order for self-administration of medication, and plan of care interventions for self-administration of medication. Observation on 08/22/22 at 1:30 P.M. of Resident #34's room revealed a medication cup on Resident #34's tray table with a single large white pill in the cup. Resident #34 was in bed with bedding over his face and body, and Resident #34 was not responding to questions. Interview on 08/22/22 at 1:37 P.M. with Licensed Practical Nurse (LPN) #103 verified he/she left a [MEDICATION(S)] (antacid medication) pill on Resident #34's bedside table. LPN #103 stated Resident #34 instructed her to leave it and that he would take it later. Review of the policy titled Medication Administration, revised November 2018, revealed residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. In addition, the resident is always observed after administration to ensure that the dose was completely ingested.

Based on medical record review and staff interview, the facility failed to ensure a care plan was developed to address resident medical diagnoses. This affected three (Resident #18, #23, and #103) out of 11 residents reviewed for care plans. The facility census was 47. Findings include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's admission Minimum Data Set (MDS) assessment, dated 08/17/22, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's most recent care plan, last updated 08/22/22, revealed there were no interventions for CHF, [CONDITION(S)], hypertension, or headache syndrome in the care plan. Interview on 08/24/22 at 1:18 P.M. with Registered Nurse (RN) #139 and RN MDS Support #185 verified Resident #18's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of the medical record for Resident #23 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #23's admission MDS assessment, dated 06/20/22, revealed Resident #23 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's care plan, last updated 08/22/22, revealed there were no interventions for CHF, [CONDITION(S)], or diabetes mellitus in the care plan. Interview on 08/25/22 at 1:33 P.M. with RN #139 verified Resident #23's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of the medical record for Resident #103 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #103's admission MDS assessment, dated 07/27/22, revealed Resident #103 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #103's care plan, last updated 07/27/22, revealed there were no interventions for unspecified heart failure or seizures in the care plan. Interview on 08/24/22 at 1:18 P.M. with Registered Nurse (RN) #139 and RN MDS Support #185 verified Resident #103's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .