Every finding on record at Mid-Town Oaks Post-Acute

Based on interview and record review, the facility failed to ensure three out of four sampled residents (Resident 1, Resident 3, and Resident 4) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's orders when Resident 1, Resident 3, and Resident 4's pain medication orders were not consistently followed.This failure had the potential for Resident 1, Resident 3, and Resident 4 to experience unrelieved pain and/or over-medication and not attain their highest practicable well-being.Findings:1a. A review of Resident 1's clinical record indicated Resident 1 was admitted June of 2026 and had diagnoses that included fracture (a break in the continuity of a bone) of vertebra (an individual irregular bone that forms the backbone), lung cancer, and diabetes (elevated sugar in the blood).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 6/10/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 10 out of 15 which indicated Resident 1 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 1's MDS Health Conditions, dated 6/10/26, indicated Resident 1 received as needed pain medications.A review of Resident 1's Care Plan Report, initiated 6/6/26, indicated, Pain: Experiencing .chronic pain .due to: general body, recent injury .Administer medications as ordered .During an interview on 7/29/26 at 1:04 p.m. with Resident 1, Resident 1 stated she was taking pain medications for her pain, but she was not sure how often. Resident 1 further stated the pain medications sometimes are not effective.A review of Resident 1's active physician's order, dated 6/9/26, indicated, Acetaminophen [a potent pain reliever] Extra Strength Oral Capsule 500 MG [milligrams- unit of measurement] .Give 500 mg by mouth every 4hours as needed for Pain rating (1-4) [numeric pain scale from 1 to 10] .A review of Resident 1's medication administration record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of June and July 2026 indicated Resident 1 received 500 mg of Acetaminophen which was indicated for a pain rating of 1-4 on the following occasions:6/16/26 at 8:03 a.m.- pain level was 8 (severe pain)6/17/26 at 10:27 a.m.- pain level was 5 (moderate pain)6/19/26 at 8:01 a.m.- pain level was 5 (moderate pain)6/22/26 at 7:55 a.m.- pain level was 7 (moderate pain)6/25/26 at 7:47 a.m.- pain level was 5 (moderate pain)6/25/26 at 8:26 p.m.- pain level was 0 (no pain)7/3/26 at 8:14 p.m.- pain level was 0 (no pain)7/7/26 at 7:39 a.m.- pain level was 5 (moderate pain)7/10/26 at 8:43 p.m.- pain level was 0 (no pain)7/15/26 at 7:51 a.m.- pain level was 5 (moderate pain)A review of Resident 1's active physician's order, dated 6/6/26, indicated, Hydrocodone [a controlled pain medication] -Acetaminophen Oral Tablet 5-325 MG . Give 1 tablet by mouth every 4 hours as needed for Moderate pain (4-7 on painscale [sic]) .A review of Resident 1's MAR for the month of July 2026 indicated Resident 1 received 1 tablet of Hydrocodone-Acetaminophen which was indicated for moderate pain on the following occasion:7/5/26 at 6:52 p.m.- pain level was 3 (mild pain)A review of Resident 1's physician's order, dated 6/6/26, indicated, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG . Give 2 tablet by mouth every 4 hours as needed for severe pain (8-10 on painscale [sic]) .A review of Resident 1's MAR for the month of June 2026 indicated Resident 1 did not receive 2 tablets of Hydrocodone-Acetaminophen which was indicated for severe pain even though Resident 1 had a recorded pain level of 8 (severe pain) on 6/16/26 at 8:03 a.m.During a concurrent interview and record review on 7/29/26 at 3:39 p.m. with Licensed Nurse (LN) 2, Resident 1's clinical records were reviewed. LN 2 confirmed that Resident 1's pain medication orders were not consistently followed. Resident 1's progress notes were also reviewed and LN 2 further confirmed that there was no documentation as to why Resident 1's pain medication orders were not followed.1b. A review of Resident 3's clinical record indicated Resident 3 was admitted June of 2026 and had diagnoses that included fracture (a break in the continuity of a bone) of right hip, bone cancer of the lower right leg, cancer of connective and soft tissue, and pain in right leg.A review of Resident 3's MDS Cognitive Patterns, dated 6/29/26, indicated Resident 3 had a BIMS score of 12 out of 15 which indicated Resident 3 had a moderately impaired cognition. A review of Resident 3's MDS Health Conditions, dated 6/29/26, indicated Resident 3 received scheduled and as needed pain medications.A review of Resident 3's Care Plan Report, revised 7/1/26, indicated, Pain: Experiencing .acute pain due to: cancer diagnosis .Administer treatment as ordered.During an interview on 7/29/26 at 1:15 p.m. with Resident 3, Resident 3 stated she was taking pain medications but sometimes it would not work and she would still be in pain.A review of Resident 3's active physician's order, dated 6/23/26, indicated, HYDROmorphone HCl [a potent controlled pain medication] Oral Tablet 4 MG . Give 1 tablet by mouth every 4 hours as needed for moderate pain (4-7 on painscale [sic]).A review of Resident 3's MAR for the month of July 2026 indicated Resident 3 received 1 tablet of hydromorphone which was indicated for moderate pain on the following occasions:7/10/26 at 11:13 p.m.- pain level was 9 (severe pain)7/18/26 at 4:43 a.m.- pain level was 9 (severe pain)7/22/26 at 4:43 a.m.- pain level was 9 (severe pain)7/10/26 at 5:03 a.m.- pain level was 8 (severe pain)A review of Resident 3's physician's order, dated 6/23/26, indicated, HYDROmorphone HCl Oral Tablet 4 MG . Give 2 tablet by mouth every 4 hours as needed for severe pain (7-10 on painscale [sic]).A review of Resident 3's MAR for the month of July 2026 indicated Resident 3 received 2 tablets of hydromorphone which was indicated for severe pain on the following occasions:7/2/26 at 8:42 p.m.- pain level was 0 (no pain)7/9/26 at 4:17 p.m.- pain level was 3 (mild pain)7/10/26 at 4:19 p.m.- pain level was 3 (mild pain)7/12/26 at 5:35 p.m.- pain level was 6 (moderate pain)7/14/26 at 12:04 p.m.- pain level was 6 (moderate pain)7/14/26 at 4:24 p.m.- pain level was 6 (moderate pain)7/14/26 at 8:37 p.m.- pain level was 6 (moderate pain)7/15/26 at 2:39 p.m.- pain level was 2 (mild pain)7/15/26 at 8:03 p.m.- pain level was 2 (mild pain)7/23/26 at 8:45 p.m.- pain level was 6 (moderate pain)7/25/26 at 4:36 p.m.- pain level was 6 (moderate pain)During a concurrent interview and record review on 7/29/26 at 3:39 p.m. with LN 2, Resident 3's clinical records were reviewed. LN 2 confirmed that Resident 3's pain medication orders were not consistently followed. Resident 3's progress notes were also reviewed and LN 2 further confirmed that there was no documentation as to why Resident 3's pain medication orders were not followed.1c. A review of Resident 4's clinical record indicated Resident 4 was admitted January of 2026 and had diagnoses that included osteoarthritis (a deteriorating disease that causes pain, stiffness, and swelling where two or more bones meet), difficulty walking, and depressive episodes.A review of Resident 4's MDS Cognitive Patterns, dated 7/10/26, indicated Resident 4 had a BIMS score of 15 out of 15 which indicated Resident 4 had an intact cognition. A review of Resident 4's MDS Health Conditions, dated 7/10/26, indicated Resident 4 received scheduled pain medications, as needed pain medications, and non-medication intervention for pain.A review of Resident 4's Care Plan Report, revised 4/16/26, indicated, Pain: at risk for .pain or discomfort due to: depression, BL [bilateral- both sides] osteoarthritis, left hand discomfort/tingling .4/12/26 Pain to R [right] foot near pinky toe .Administer treatment as ordered. ( . oxycodone [a strong controlled pain medication] .).A review of Resident 4's physician's order, dated 6/3/26, indicated, oxyCODONE HCl Oral Tablet 5 MG . Give 1 tablet by mouth every 4 hours asneeded for Moderate pain.A review of Resident 4's MAR for the months of June and July 2026 indicated Resident 4 received 1 tablet of oxycodone which was indicated for moderate pain on the following occasions:6/8/26 at 8:34 a.m.- pain level was 0 (no pain)A review of Resident 4's physician's order, dated 6/3/26, indicated, oxyCODONE HCl Oral Tablet 5 MG . Give 2 tablet by mouth every 4 hours as needed for Severe pain.A review of Resident 4's MAR for the months of June and July 2026 indicated Resident 4 received 2 tablets of oxycodone which were indicated for severe pain on the following occasions:47 times when Resident 4's pain level was at 0 (no pain)1 time when Resident 4's pain level was at 1 (mild pain)5 times when Resident 4's pain level was at 2 (mild pain)1 time when Resident 4's pain level was at 3 (mild pain)20 times when Resident 4's pain level was at 4 (moderate pain)15 times when Resident 4's pain level was at 5 (moderate pain)21 times when Resident 4's pain level was at 6 (moderate pain)During a concurrent interview and record review on 7/29/26 at 3:39 p.m. with LN 2, Resident 4's clinical records were reviewed. LN 2 confirmed that Resident 4's pain medication orders were not consistently followed. Resident 4's progress notes were also reviewed and LN 2 further confirmed that there was no documentation as to why Resident 4's pain medication orders were not followed. LN 2 stated nurses should always follow the physician's order, and the severity of assessed pain would indicate which medication would be given to the resident. LN 2 also stated the resident would be at risk for unrelieved pain or the resident would have over medication which could cause dependence on pain medications or other medical condition if the physician's orders were not followed. During an interview on 7/29/26 at 4:20 p.m. with the Director of Nursing (DON), the DON stated he would expect nurses to administer as needed pain medications to residents depending on the assessed pain severity to provide effective pain management. The DON also stated that the assessed 0 pain levels were probably the follow up assessment after pain medication. The DON then stated that their policy is for nurses to document the initially assessed pain level to determine which pain medication should be given. The DON further stated if the patient request other pain medication, it should be documented in the progress notes and would be communicated to the doctor. A review of the facility's P&P titled, Administering Medications, revised 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame .6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training.A review of the facility's P&P titled, Pain Assessment and Management, revised 10/2022, indicated, 1. The pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. Pain management interventions reflect the sources, type and severity of pain .When opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose. a. Any resident who uses opioids for long-term management of chronic pain is at risk for opioid overdose .6. The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications .

Based on interview and record review, the facility failed to protect the privacy of one of six sampled residents (Resident 1) when Resident 1's private health information was entered into Resident 2's chart. This failure gave Resident 2 access to Resident 1's personal health history.Findings:Resident 1 was admitted to the facility in early 2026 with diagnoses that included brain dysfunction caused by a chemical imbalance, anxiety, depression, back pain, and a urinary tract infection.Resident 2 was admitted to the facility in early 2026 with diagnoses that included degenerative joint disease in the knee and difficulty walking.During a review of Resident 2's electronic health record (EHR), the EHR included an entry dated 2/6/26 by a nurse practitioner (NP). The NP entered a progress note for Resident 1 into Resident 2's EHR, which included Resident 1's name, date of birth , medical history, medical diagnoses, physical examination information, and treatment plan.During a concurrent interview and record review on 5/14/26 at 11:34 a.m. with the Director of Nursing (DON), the DON was asked to review the entry dated 2/6/26. The DON confirmed Resident 1's information was inaccurately documented in Resident 2's EHR and stated it was a violation of Resident 1's privacy. The DON stated they expected resident information to be documented under the correct resident.During a concurrent interview and record review on 5/14/26 at 11:57 a.m. with the Medical Record Director (MRD), the MRD confirmed that on 2/6/26 the NP incorrectly documented Resident 1's information in Resident 2's chart. The MRD stated it was important to have correct information in a medical record.During an interview on 5/14/26 at 12:45 p.m. with Resident 2 in her room, Resident 2 stated she had requested copies of her own health record and, upon reviewing them, found a progress note for Resident 1. Resident 2 stated the progress note included personal information about Resident 1.During a review of the facility's policy and procedure (P&P) titled Confidentiality of Information and Personal Privacy, dated 2/01, the P&P indicated, Our facility will protect and safeguard resident confidentiality and personal privacy. The facility will safeguard the personal privacy and confidentiality of all residents' personal and medical records. The facility will strive to protect resident's privacy regarding his or her. medical treatment. Access to resident personal and medical records will be limited to authorized staff and business associates.

Based on interview and record review, the facility failed to report an allegation of abuse to the Department for one of six sampled residents (Resident 3) when Resident 3 told staff that Resident 4 threw a comb at him, striking him in the head. This failure had the potential for an allegation of abuse not being investigated.Findings:Resident 3 was admitted to the facility in early 2025 with diagnoses that included major depressive disorder, difficulty walking, and muscle weakness.During a review of Resident 3's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 1/29/26, the MDS showed a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) score of 15/15, which indicated no cognitive impairment.Resident 4 was admitted to the facility in late 2025 with diagnoses that included difficulty walking and deafness.During a review of Resident 4's MDS dated [DATE], the MDS showed a BIMS score of 13/15, which indicated no cognitive impairment.During a review of Resident 3's Progress Notes (PN) dated 4/9/26 at 10:24 a.m. the PN indicated, At around 7 am, this writer was doing her rounds/check and observed that [Resident 3] was involved in altercation with roommate [Resident 4]. This writer was asked to flip TV so he [Resident 3] can watch the news, this his roommate [Resident 4] woke up and mumbles and said NO. [Resident 4] then grabhis (sic) comb, and threw it towards him, striking [Resident 3] head. Triter assessed immediately.Per [Resident 3] he had asked to this writer to call 911, and this writer responded that it is a minor issue that we can all figure and resolved (sic).At approx. (sic) 7:15am, Police came and investigate, DON [Director of Nursing] present.During a review of Resident 4's PN dated 4/9/26 at 3:30 p.m. the PN indicated, At approx. 7 am during nursing rounds, this writer witnessed [Resident 4] was upset that is roommate [Resident 3] TV was on, and he [Resident 4] threw a comb towards his roommate [Resident 3] writer tried to communicate and his roommate [Resident 3] was frightened and threatened and stated that he is vulnerable and could get himself hurt again from is roommate's [Resident 4] behavior.During a telephone interview on 5/13/26 at 2:51 p.m. with Resident 3, Resident 3 stated that on 4/9/26, in front of a nurse, Resident 4 threw a hard plastic brush that hit him on the forehead.During an interview on 5/14/26 at 10:41 a.m. with Licensed Nurse (LN 1), LN 1 stated she was the nurse working on 4/9/26. LN 1 stated Resident 3 was screaming that Resident 4 threw a comb at him. I was not sure it happened, but [Resident 3] was claiming it happened. LN 1 confirmed a resident who stated they were abused made an allegation that should be reported to the Department.During an interview on 5/14/26 at 11:34 a.m. with the Director of Nursing (DON), the DON stated he was notified of the incident and confirmed the progress notes indicated an incident occurred between Resident 3 and Resident 4, and that Resident 3 called the police after the incident occurred.During an interview on 5/14/26 at 1:20 p.m. with Resident 4 in his room, a tablet was used to communicate with Resident 4. Resident 4 confirmed he threw a comb at his previous roommate and that his previous roommate [Resident 3] called the police. Resident 4 stated Resident 3 was angry about the television.During an interview on 5/14/26 at 2:04 p.m. with the Administrator (ADM), the ADM stated any allegations of abuse should be reported to the Department within two hours. The ADM stated it was not reported as they had treated this incident as a grievance.During a review of the facility policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 9/22, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The local/state ombudsman; The resident's representative; Adult protective services (where state law provides jurisdiction in long-term care); Law enforcement officials; The resident's attending physician; and the facility medical director. 'Immediately' is defined as within two hours of an allegation involving abuse.

Based on interview and record review, the facility failed to ensure the order for Restorative Program (designed to help residents maintain their highest level of physical function and prevent decline after rehabilitation) was followed for one of three sampled residents (Resident 1).This failure had the potential for Resident 1 to experience further decline in mobility and function.A review of the admission Record indicated Resident 1 was admitted early January 2026 with diagnoses including bilateral primary osteoarthritis (progressive condition causing pain, stiffness, swelling and reduced mobility) of knee and difficulty in walking.A review of Resident 1's RNA (Restorative Nurse Assistant) program indicated the following orders:- an order for RNA ambulation/mobility program (3-5 days a week) FWW (front wheel walker) for 50-100 feet as tolerated on 2/27/26;-an order for exercises UE/LE's (upper extremity/lower extremity), FWW/SPC (single point cane) ambulation 3x a week on 3/19/26;-an order for RNA ambulation/mobility program (3-5 days a week) FWW for 50-100 feet as tolerated with quad cane (four-pronged base) on 4/2/26; and-an order for RNA ambulation/mobility program (1 day a week) FWW for 50-100 feet as tolerated with quad cane on 4/14/26.A review of Resident 1's care plan initiated 1/5/26 indicated Resident 1 was at risk for ADL (Activities of Daily Living)/mobility decline and requires assistance related to pain, weakness. The intervention included, Ambulation: Assist .A review of Resident 1's care plan revised 4/15/26 indicated, Resident 1 has the potential for decline in functional mobility and gait related to balance deficit, bed mobility/transfer deficit, decrease strength, gait difficulty. The intervention indicated RNA for ambulation/mobility (1 day a week) for 50-100 feet as tolerated with FWW/Quad cane.During an interview on 4/16/26 at 1:54 p.m. with the RNA, the RNA stated he provided assistance to Resident 1 for two weeks. The RNA further stated Resident 1 insisted on using the quad cane instead of the FWW for ambulation. The RNA added if a resident refuses the RNA program, the refusal will be documented. During a concurrent interview and record review on 4/16/26 at 4:49 p.m. with the Director of Rehabilitation (DOR), Resident 1's Nursing- RNA Weekly Summary was reviewed. The DOR stated Resident 1 had three weekly summaries for 3/28/26, 4/4/26, and 4/10/26. The DOR further stated there was a Restorative Nursing Note dated 3/5/26 that Resident 1 refused RNA program today. There was no documented evidence Resident 1 was seen by RNA from 2/28/26 to 3/4/26 and from the second to third week of March. During an interview on 4/16/26 at 5:09 p.m. with the Administrator (ADM), the ADM stated there was no RNA Weekly Summary prior to 3/28/26 for Resident 1. During a follow up interview on 4/16/26 at 5:13 p.m., the DOR stated Resident 1's RNA order was dated 2/27/26 and RNA program should be offered the following day. The DOR further stated attempts should be made to offer the RNA program and if resident refused, the refusals should be documented.A review of the facility's undated policy and procedure and titled, Restorative Nursing Services indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Residents may be started on a restorative nursing program .during the course of stay or when discharged from rehabilitative care .Restorative goals and objectives are individualized and resident-centered .

Based on observation, interview, and record review, the facility failed to implement infection control and prevention practices when staff provided care to residents under contact isolation without the use of appropriate personal protective equipment (PPE) for two out of five sampled residents (Resident 1 and Resident 2). This failure increased the potential for the spread of infections among residents for a census of 97.Findings: During a review of Resident 1's admission Record (AR), dated 2/27/26 (print date), the AR indicated, Resident 1 was admitted to the facility in May of 2025 with diagnoses which included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and sepsis (a life-threatening blood infection). During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse (LN) to document medications and treatments given to a resident) for February of 2026, dated 2/27/26 (print date), the MAR indicated an order for isolation on contact precautions (a type of isolation requiring staff to apply gown and gloves prior to room entry and provision of care) for Clostridium difficile infection (C. diff- a highly contagious bacteria that causes severe diarrhea) for the period of 2/27/26 to 3/15/26. During a review of Resident 2's AR, dated 3/3/26 (print date), the AR indicated, Resident 2 was admitted to the facility in January of 2026 with diagnoses which included diabetes mellitus and colostomy status (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body). During a review of Resident 2's Care Plan History, a care plan initiated on 2/1/26 indicated, Resident has potential for C. Diff infection and is at risk for complications.Use principles of infection control and contact precaution(s) as indicated. During a concurrent observation and interview on 2/27/26 at 7:58 a.m. with Certified Nursing Assistant 1 (CNA 1) in the hallway near Resident 1's and Resident 2's room (roommates), a sign near the room door indicated that the room was on contact precautions, and providers had to apply a gown and gloves prior to room entry. CNA 1 was observed entering the room without a gown and gloves, bringing a breakfast tray to Resident 1 and setting it up on the bedside table. Per Resident 1's request, CNA 1 also pulled on the light cord with his bare hands to turn on the light. Upon leaving the room, CNA 1 confirmed that he touched surfaces in the room and that the room had an isolation sign at the door. CNA 1 indicated he wasn't sure for which resident the isolation was applied to which resident, Resident 1 or Resident 2. CNA 1 stated that if he was bringing the tray to Resident 2, he would have used a gown and gloves. During a concurrent observation and interview on 2/27/26 at 8:29 a.m. with CNA 2 and CNA 3 near Resident 2's room. CNA 2 and CNA 3 entered the room without gowns and pushed Resident 2's bed closer against the wall. Upon exiting the room, CNA 2 and CNA 3 confirmed they did not use gowns for the room entry, and both CNAs indicated that they needed gowns only for close contact care when handling Resident 2's urinary catheter. During an observation on 2/27/26 at 8:34 a.m. near Resident 1's room entrance, LN 1 entered the room without a gown and administered two injectable medications to Resident 1, one shot given to the arm and another shot to the belly. Resident 1 was in his bed, and as LN 1 worked around him, her pants were touching Resident 1's mattress and sheets. During an interview on 2/27/26 at 8:41 a.m. with LN 1, LN1 confirmed that she entered Resident 1's room without a gown, and as she administered injectable medications, she touched Resident 1's bed. LN 1 further confirmed that Resident 1 was on contact isolation for C. diff, and she should have used a gown and gloves when working with Resident 1. During an interview on 2/27/26 at 10:53 a.m. with the Director of Nursing (DON), the DON confirmed that Resident 1 had a C. diff infection and his roommate, Resident 2, was also exposed, and both residents were considered to be under contact isolation precautions. The DON indicated that the expectation was for all staff entering the room and providing care to both residents had to use gowns and gloves. The DON further stated that not using appropriate PPE would increase the risk of the spread of infection among residents. During a review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment, dated 10/2018, the P&P indicated, Personal protective equipment appropriate to specific task requirements is available at all times.Not all tasks involve the same risk of exposure, or the same kind or extent of protection. The type of PPE required for a task is based on: a. the type of transmission-based precaution.

Based on the interview and record review, the facility failed to provide the requested medical records within two working days following a written request for one of four sampled residents (Resident 1), when electronic copies of medical records were requested on 1/22/26, and the request was fulfilled on 1/27/26, and a second request was made on 2/5/26 and fulfilled on 2/10/26.This failure resulted in the delayed provision of medical records to Resident 1, which decreased the likelihood of Resident 1 making informed medical decisions regarding her care.Findings:During a review of Resident 1's admission record (AR), dated 2/19/26 (print date), the AR indicated Resident 1 was admitted to the facility in early 2026 with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the knees and anxiety (fear, worry) disorder. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/9/26, the MDS indicated that Resident 1 had moderate cognitive impairment. During an interview on 2/18/26 at 2:41p.m. with Resident 1, Resident 1 stated that she emailed facility staff multiple requests for medical records and they were not fulfilled timely. Resident 1 stated that she had to hold staff's feet to the fire to get anything done. During a concurrent interview and record review on 2/19/26 at 11:35 a.m. with the Director of Rehabilitation (DOR), Resident 1's email dated 1/22/26 at 5:31 p.m. [After business hours, but before the morning of the next business day, Friday of 1/23/26] to the DOR was reviewed, and the email indicated that Resident 1 was following up on previously requested medical records. The DOR stated that Resident 1 was requested therapy records that day, and the DOR informed the medical records director about the request on the same day. During a concurrent interview and record review on 2/19/26 at 1:29 p.m. with the Medical Records Assistant (MRA), Resident 1's progress note (PN) dated 1/23/26 at 1:10 p.m. written by the MRA was reviewed. The PN indicated, I Received a Medical Records Request from Rehab Department at around noon of 1/23/26 dated 1/22/26 and i send it right away to our Legal Department. I Received a response from them at around 4:37 on Friday, I am out of Office. The MRA confirmed that the first request for records from Resident 1 was received by the medical records on 1/23/26, and it was successfully fulfilled on 1/27/26. The MRA provided a copy of the email to Resident 1 dated 1/27/26 at 4:46 p.m., sent by the Director of Nursing [DON] with the attachments of the records. [Request time 1/22/26 after hours to fulfillment time of 1/27/26 at 4:46 p.m., with no state-approved holidays during that time period, constituted more than 2 business days]. The MRA further stated that the second request for records, Resident 1 emailed directly to her on 2/5/26 and Resident 1 was refusing to fill out the facility-approved request form, and that request was fulfilled on 2/10/26 after Resident 1 signed the facility-approved form on 2/9/26. The MRA provided a copy of the initial email request dated 2/5/26 at 11:51 a.m., and a copy of the progress note written by MRA dated 2/19/26 at 11:07 a.m., which indicated, [Resident 1] sent an email on 2/5/26 @2:33 pm. Requesting for Medical Records. and she has her own format to request. The following day 2/6/26 I went to her room to give her the authorization form for the Release of the Health Information which is a Protocol in the Facility. She accepted the form, but she said that she will do it if she has time. She's threatening us/me she said that we violated under the Federal law that did not provide the records that she wanted right away. Last 2/9/26 Monday I received an email from her again attached is the Medical Records form that I given (sic) to her last Friday 2/6/26. She signed and back dated 2/5/26. My Supervisor talked to her and explained the protocol that we need to follow and fill out the records that she wants to request because it was not properly filled out when i (sic) received it thru email but she didn't comply. Regardless, we Immediately e-mailed our legal team for the approval. They responded right away that we can release the records. The time was 4:28 pm. We released her records the following day thru email 2/10/2026. [Request time 2/5/26 at 11:51 a.m. to fulfillment date 2/10/26, with no state-approved holidays during that time period, constituted more than 2 business days]. During a review of the facility's policy and procedure (P&P) titled, Access to Personal and Medical Records, revised 5/2017, the P&P indicated, Each resident has the right to access and/or obtain copies of his or her personal and medical records upon request. A resident may submit his/her request either orally or in writing for access to personal or medical information pertaining to him/her. The resident may obtain a copy of his or her personal or medical record within two business days of an oral or written request and completion of the Authorization form for the release of health information.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan to monitor and timely address clinical symptoms and complications for one of four sampled residents (Resident 1), when Resident 1 reported decreased left-hand strength, and when Resident 1 had a broken tooth and developed a tongue ulcer. These failures had the potential for Resident 1 to receive delayed and inadequate care.Findings: During a review of Resident 1's admission record (AR), dated 2/19/26 (print date), the AR indicated Resident 1 was admitted to the facility in early 2026 with diagnoses which included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the knees and anxiety (fear, worry) disorder. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/9/26, the MDS indicated that Resident 1 had moderate cognitive impairment. During a concurrent observation and interview on 2/18/26 at 2:41p.m. with Resident 1 in her room. Resident 1 showed her left hand with the thumb overextended backwards and stated that she had nerve issues with her left hand and was seeking referral to a specialist. Resident 1 also demonstrated an ulcer on the right side of her tongue [approximately 1 centimeter (cm) wide and 2 cm long] and stated that it developed after her tooth on that side was broken and had sharp edges, and nobody was looking at it or monitoring the progression of the ulcer. During a concurrent interview and record review on 2/19/26 at 2:13 p.m. with the Director of Nursing (DON), Resident 1's progress notes (PN) were reviewed, and a PN dated 1/27/26 indicated, [Resident 1] had ongoing concern with cracked/molar tooth that was bothering resident and stated it to cause sores on tongue. A review of a physician's note dated 1/7/26 indicated, [Resident 1] has c/o [complaints of] left hand thumb weakness . Resident 1's current orders and care plans were reviewed, and no monitoring orders or care plans were found addressing the issues with the left hand or tongue ulcer. The DON confirmed that the facility was aware of Resident 1's issues with left hand and tongue ulcer, and he expected these issues to be monitored and care planned. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure safety for two of six sampled residents (Resident 1 and Resident 2), when: 1. Resident 1 eloped twice to a nearby hospital without facility's knowledge; and 2. Resident 2 eloped from facility and was found outside the front door on the ground near her wheelchair. These failures decreased the facility's potential to maintain residents' safety and prevent injuries. Findings: 1. A review of Resident 1's Facesheet, indicated he was admitted to the facility in September 2024 with diagnoses including metabolic encephalopathy (brain dysfunction caused by systemic illness rather than direct brain trauma), cognitive communication deficit (impairment in communication due to underlying thinking disruptions), psychotic disorder with hallucinations (severe mental health condition causing a loss of contact with reality). A review of Resident 1's Minimum Data Set (MDS; an assessment tool), dated 12/1/25, indicated Brief Interview of Mental Status (BIMS) score was 11 out of 15 with moderate cognitive impairment. A review of Resident 1's Change of Condition, dated 1/20/26, indicated one of the nurses at the facility received a call from the nearby hospital who informed them Resident 1 was in the emergency room (ER). A review of Resident 1's Progress Notes, dated 1/21/26, indicated Resident 1 exited the facility without staff authorization. A review of Resident 1's Nurse's Notes, dated 2/1/26, indicated Resident 1 took himself to the ER during lunch. The note further indicated staff from the nearby hospital notified the facility that Resident 1 was in the ER. During an interview on 2/10/26 at 10:30 a.m. with Director of Nursing (DON), DON confirmed Resident 1 had two separate elopement incidents that occurred on 1/20/26 and 2/1/26. DON stated a wander guard (an electronic alarm device that is placed on residents who are at risk for elopement) was ordered and implemented after the second elopement occurred. DON also stated both elopements occurred without facility's knowledge and the nearby hospital contacted facility staff to inform them of Resident 1's location. 2. A review of Resident 2's Facesheet, indicated she was admitted to the facility in July 2024 with diagnoses including unspecified dementia (cognitive decline and memory loss), cognitive communication deficit, and difficulty in walking. A review of Resident 2's MDS, dated [DATE], indicated BIMS score was three out of 15 with severe cognitive impairment. A review of Resident 2's Progress Notes, dated 1/21/26, indicated on 1/20/26 at 11:30 a.m., Resident 2 had an unwitnessed fall and was found by staff sitting on the ground next to the sloped walkway outside the front door. The record also indicated Resident 2 was noted to have a bluish colored bump to her left cheek and left temporal area, a skin tear to left elbow with moderate bleeding, and a skin abrasion to left knee. The record further indicated Resident 2 was crying and complaining of pain when she was found. During an interview on 2/11/26 at 2:59 p.m. with Licensed Nurse (LN) 1, LN 1 stated she saw Resident 2 sitting on the ground next to her wheelchair outside of the front door at the top of the sloped walkway crying. LN 1 further stated she observed a bleeding from Resident 2's elbow and a bump forming on the left side of her face. A review of Resident 2's undated record titled, Investigation Summary Report Unwitnessed Fall Elopement, indicated the most likely contributing factor to Resident 2's elopement was the reception area (located near front door) being unattended for a brief period. During an observation on 2/10/26 at 1:36 p.m. in front of Resident 2's room, Resident 2 was observed sitting in her wheelchair with faded bluish colored bruising to the left side of her face from the left temporal area and spread across left cheek. During an interview on 2/10/26 at 1:59 p.m. with DON, DON confirmed the three elopements occurred within a short span of time with two of the three occurring on the same day. DON expected facility staff to do everything they can to prevent elopements and injuries to residents from occurring. A review of the facility's policy titled, Wandering and Elopements, dated 3/2019, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintained the least restrictive environment for residents . If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility's policy titled, Falls and Fall Risk, Managing, dated 12/2007, indicated, . the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident form falling and to try to minimize complications from falling. These findings represent past noncompliance with this regulatory requirement. Observations, interviews, and records' review, confirmed Resident 1 and Resident 2 who had eloped were safely back in facility. The residents' care plans were updated post elopement and fall. Resident 1 was placed on new interventions (wanderguard) post second elopement, and care plans were updated. Resident 2 was assessed post fall/elopement and change of condition and elopement risk assessment was done. Elopement Performance Improvement Project (PIP) was updated, a facility led investigation and root cause analysis was conducted, and an elopement in-service training was conducted on 1/23/26. There was sufficient evidence that the facility corrected the violation as of 2/3/26, and no other occurrences of noncompliance were identified. At the time of the survey, the facility was in substantial compliance with this regulatory requirement and therefore, this violation does not require a plan of correction.

Based on interview and record review, the facility failed to ensure a current copy of advance directive (a legal document indicating resident preference on end-of-life treatment decisions) was available in the medical records for three out of 31 sampled residents (Resident 47, Resident 10 and Resident 85). This failure decreased the facility's potential to provide health care to residents when incapacitated (a state where you don't have the capacity or ability to accomplish something).Findings: A review of Resident 47's admission Record, indicated Resident 47 was admitted to the facility in July 2024 with a diagnosis of cognitive communication deficit. A review of Resident 47's Physician Orders for Life-Sustaining Treatment (POLST), dated 7/2/24, indicated Resident 47's advance directive was not available. A review of Resident 47's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/26/25, indicated Resident 47's advance directive was available and reviewed. During a concurrent interview and record review on 12/3/25 at 4:12 p.m. with the Director of Nursing (DON), Resident 47's medical record was reviewed. DON confirmed a copy of Resident 47's advance directive was not available and stated if Resident 47's MDS indicated an advance directive was available and reviewed then a copy of the advance directive should have been placed in Resident 47's medical record. A review of an admission record indicated Resident 10 was readmitted to the facility in June 2025 with a diagnosis of cognitive communication deficit. A review of Resident 10's POLST, dated 6/25/25, indicated an advance directive was available and reviewed by a staff member. During a concurrent interview and record review on 12/2/25 at 4 p.m. with the MDS Coordinator (MDSC), Resident 10's medical records and quarterly MDS assessment, dated 9/26/25 were reviewed. MDSC confirmed Resident 10's advance directive was unavailable. During an interview on 12/3/25 at 8:01 a.m. with DON, DON stated Resident 10's advance directive should have been obtained from the resident's responsible party and maintained by staff to ensure the residents' wishes are honored in times of disability. A review of an admission Record indicated Resident 85 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a complex mental illness that includes hallucinations) and bipolar disorder (a brain disorder causing extreme mood swings). A review of Resident 85's MDS, dated [DATE], indicated an advance directive was available and reviewed. During a concurrent interview and record review on 12/2/25 at 12 p.m. with the Medical Records Assistant (MRA), Resident 85's health record was reviewed. MRA was unable to locate Resident 85's advance directive in the electronic health record or physical chart. MRA stated Resident 85's advance directive should have been placed in the chart. During an interview on 12/3/25 at 7:53 a.m. with DON, DON stated if Resident 85's MDS indicated the advance directive was available and reviewed, then it should have been readily available in the medical record. A review of the facility's policy titled, Advance Directives, revised in 4/2013, indicated, Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. A review of the facility's policy titled, Advance Directive, revised in 9/2022, indicated, If the resident or the resident's representative has executed . advance directive . upon admission copy of this document are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff . The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive . The resident's wishes are communicated to the resident's direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record .

Based on interview and record review, the facility failed to ensure two of 31 sampled residents (Resident 18 and Resident 86) were free from unnecessary psychotropic medications (drugs that alter brain chemistry to affect mood, thinking, and behavior), when:A Gradual Dose Reduction (GDR - tapering of dose to determine if symptoms can be managed at a lower dose or if a medication can be discontinued) was not attempted for Resident 18's olanzapine (an antipsychotic medication used to treat symptoms of psychosis).Resident 86's lorazepam (an antianxiety medication) as needed (PRN; pro re nata) order was beyond 14 days from 9/25/25; andResident 86's sertraline (an anti-depression medication) was administered without a manifestation.These failures increased the residents' potential to receive unnecessary medications.Findings: 1- A review of Resident 18's admission Record, indicated he was admitted to the facility in September 2024 with diagnoses including psychotic disorder (a severe mental illness causing distorted reality) with hallucinations and recurrent major depressive disorder with severe psychotic symptoms. A review of Resident 18's Order Summary Report (OSR), dated 6/12/25, indicated, an order for olanzapine 15 milligrams (mg; unit of measurement) to be administered at bedtime for auditory hallucinations (sensory experiences of hearing sounds, often voices, that aren't actually present). The OSR further indicated monitoring Resident 18's hallucinations started in September 2025. A review of Resident 18's Medication Administration Record (MAR), indicated Resident 18 experienced no episodes of auditory hallucinations in September 2025. The MAR further indicated Resident 18 had two episodes of hallucinations in October 2025 and seven episodes in November 2025. A review of the facility's Medication Regimen Review (MRR), dated November 2025, indicated a GDR recommendation by the pharmacist regarding Resident 18's use of olanzapine. The recommendation was unmarked with no actions written in response. During a concurrent interview and record review on 12/3/25 at 2 p.m. with the Director of Nursing (DON), Resident 18's MAR and MRR, dated July-November 2025 were reviewed. DON confirmed Resident 18 started to receive olanzapine in June 2025 and a GDR was not attempted. DON also confirmed Resident 18's pharmacist recommendation for a GDR in November 2025 was not addressed. DON stated the pharmacist recommendation should have been fulfilled and discussed with the physician in order to properly determine if Resident 18 would benefit from taking the medication. A review of the facility's policy titled, Tapering Medications and Gradual Dose Reduction, revised in 2/2025, indicated, After the resident has been started on psychotropic medications, the staff and practitioner will attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated . All medications are considered for possible tapering/GDR. 2- A review of Resident 86's admission Record, indicated Resident 86 was admitted to the facility in 2025 with diagnoses including depression and anxiety. A review of Resident 86's Order Summary Report, dated 12/2/25, indicated an order for lorazepam 0.5 mg one tablet by mouth every 12 hours PRN for anxiety manifested by restlessness and inability to relax. The OSR further indicated Resident 86 was started on lorazepam on 9/25/25 with no stop date. A review of Resident 86's Consultant Pharmacist's Medication Regimen Review, dated 11/1/25 to 11/18/25, indicated the pharmacist's comment was to add a 14 day stop date to the PRN lorazepam order or have the provider document the need for extended therapy and add the extend stop date. The record indicated no response from the physician. A review of Resident 86's Note to Attending Physician/Prescriber, dated 11/18/25, indicated the last risk/benefit medications review was completed in August 2024. The note indicated no further response from the physician. During a concurrent interview and record review on 12/4/25 at 10:23 a.m. with the DON, Resident 86's medical record was reviewed. DON confirmed Resident 86's lorazepam 0.5 mg PRN order had no stop date and stated it should have an end date after 14 days of start. A review of the facility's policy titled, Psychotropic Medication Use, revised in 2/25, indicated, PRN orders for psychotropic medications are limited to 14 days. 3- A review of Resident 86's Order Summary Report, dated 12/2/25, indicated an order for sertraline 50 mg by mouth one time a day for depression. The OSR further indicated Resident 86's sertraline was started on 4/28/25 without a manifestation. A review of Resident 86's Consultant Pharmacist's Medication Regimen Review, dated 10/1/25 to 10/16/25, indicated the pharmacist's comment was to add a manifestation to the sertraline order. The record indicated no response from the physician. During a concurrent interview and record review on 12/4/25 at 10:23 a.m. with the DON, Resident 86's medical record was reviewed. DON stated psychotropic medication like sertraline should have a manifestation listed in the order. A review of the facility's policy titled, Psychotropic Medication Use, revised in 2/25, indicated, Psychotropic medication may be considered appropriate when a resident's behavioral symptoms present a danger to the resident or others . The policy further indicated, The clinical rationale for the use of psychotropic medication . is documented in the medical record. Diagnosis alone does not necessarily warrant the use of psychotropic medication.

Based on interview and record review, the facility failed to follow the monthly pharmacist medication regimen reviews (MRR) for two of 31 sampled residents (Resident 18 and Resident 86), when:A Gradual Dose Reduction (GDR - tapering of dose to determine if symptoms can be managed at a lower dose or if a medication can be discontinued) was not attempted for Resident 18's olanzapine (an antipsychotic medication used to treat symptoms of psychosis); Resident 86's lorazepam (an antianxiety medication) as needed (PRN; pro re nata) order was beyond 14 days from 9/25/25; andResident 86's sertraline (an anti-depression medication) was administered without a manifestation.These failures decreased the facility's potential to follow the pharmacist recommendations and prevent residents from receiving unnecessary medications. Findings: 1- A review of Resident 18's admission Record, indicated he was admitted to the facility in September 2024 with diagnoses including psychotic disorder (a severe mental illness causing distorted reality) with hallucinations and recurrent major depressive disorder with severe psychotic symptoms. A review of Resident 18's Order Summary Report (OSR), dated 6/12/25, indicated, an order for olanzapine 15 milligrams (mg; unit of measurement) to be administered at bedtime for auditory hallucinations (sensory experiences of hearing sounds, often voices, that aren't actually present). The OSR further indicated monitoring Resident 18's hallucinations started in September 2025. A review of Resident 18's Medication Administration Record (MAR), indicated Resident 18 experienced no episodes of auditory hallucinations in September 2025. The MAR further indicated Resident 18 had two episodes of hallucinations in October 2025 and seven episodes in November 2025. A review of the facility's Medication Regimen Review (MRR), dated November 2025, indicated a GDR recommendation by the pharmacist regarding Resident 18's use of olanzapine. The recommendation was unmarked with no actions written in response. During a concurrent interview and record review on 12/3/25 at 2 p.m. with the Director of Nursing (DON), Resident 18's MAR and MRR, dated July-November 2025 were reviewed. DON confirmed Resident 18 started to receive olanzapine in June 2025 and a GDR was not attempted. DON also confirmed Resident 18's pharmacist recommendation for a GDR in November 2025 was not addressed. DON stated the pharmacist recommendation should have been fulfilled and discussed with the physician in order to properly determine if Resident 18 would benefit from taking the medication. A review of the facility's policy titled, Tapering Medications and Gradual Dose Reduction, revised in 2/2025, indicated, After the resident has been started on psychotropic medications, the staff and practitioner will attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated . All medications are considered for possible tapering/GDR. 2- A review of Resident 86's admission Record, indicated Resident 86 was admitted to the facility in 2025 with diagnoses including depression and anxiety. A review of Resident 86's Order Summary Report, dated 12/2/25, indicated an order for lorazepam 0.5 mg one tablet by mouth every 12 hours PRN for anxiety manifested by restlessness and inability to relax. The OSR further indicated Resident 86 was started on lorazepam on 9/25/25 with no stop date. A review of Resident 86's Consultant Pharmacist's Medication Regimen Review, dated 11/1/25 to 11/18/25, indicated the pharmacist's comment was to add a 14 day stop date to the PRN lorazepam order or have the provider document the need for extended therapy and add the extend stop date. The record indicated no response from the physician. A review of Resident 86's Note to Attending Physician/Prescriber, dated 11/18/25, indicated the last risk/benefit medications review was completed in August 2024. The note indicated no further response from the physician. During a concurrent interview and record review on 12/4/25 at 10:23 a.m. with the DON, Resident 86's medical record was reviewed. DON confirmed Resident 86's lorazepam 0.5 mg PRN order had no stop date and stated it should have an end date after 14 days of start. A review of the facility's policy titled, Psychotropic Medication Use, revised in 2/25, indicated, PRN orders for psychotropic medications are limited to 14 days. 3- A review of Resident 86's Order Summary Report, dated 12/2/25, indicated an order for sertraline 50 mg by mouth one time a day for depression. The OSR further indicated Resident 86's sertraline was started on 4/28/25 without a manifestation. A review of Resident 86's Consultant Pharmacist's Medication Regimen Review, dated 10/1/25 to 10/16/25, indicated the pharmacist's comment was to add a manifestation to the sertraline order. The record indicated no response from the physician. During a concurrent interview and record review on 12/4/25 at 10:23 a.m. with the DON, Resident 86's medical record was reviewed. DON stated psychotropic medication like sertraline should have a manifestation listed in the order. A review of the facility's policy titled, Psychotropic Medication Use, revised in 2/25, indicated, Psychotropic medication may be considered appropriate when a resident's behavioral symptoms present a danger to the resident or others . The policy further indicated, The clinical rationale for the use of psychotropic medication . is documented in the medical record. Diagnosis alone does not necessarily warrant the use of psychotropic medication.

Based on observation, interview, and record review, the facility failed to ensure medications were safely stored and secured for a census of 96 residents, when:A medication refrigerator temperature log for December 2025 was found incomplete in the medication room at station-3;An expired and discontinued medication was found inside a medication refrigerator in the medication room at station-3;Eight loose tablets and three loose bubble packs were found in and behind medication cart 2's drawers at station-2; andFour over the counter (OTC) medications were stored insecurely inside Resident 89's room.These failures decreased the facility's potential to safely store and secure medications for its residents. Findings: 1- During a concurrent observation and interview on 12/3/25 at 11:22 a.m. with Licensed Nurse (LN) 3 in the medication room at station-3, an incomplete temperature log was observed posted at the door of a medication refrigerator. LN 3 confirmed the refrigerator temperature was not recorded for three days from 12/1/25 to 12/3/25 for the morning shift. 2- During a concurrent observation, interview, and record review on 12/3/25 at 11:32 a.m. with LN 3 in the medication room at station-3, a partially used box of formoterol fumarate (a medicine used to treat breathing difficulties) 20 micrograms (mcg-a unit of measurement)/two milliliters (ml-a unit of measurement) nebulizer vials (single use plastic container filled with drug used for inhalation) was found stored beyond its expiration date 10/22/25 inside a medication refrigerator. LN 3 confirmed the medication expired on 10/22/25. LN 3 reviewed the facility's electronic health records and stated the medication was prescribed for a resident who was discharged from the facility on 8/1/25. 3- During a concurrent observation and interview on 12/4/25 at 8:33 a.m. with LN 4 at station-2, medication cart 2 was inspected. LN 4 confirmed eight loose tablets were found in a drawer and three loose bubble packs were stored behind the bottom drawer. LN 4 stated the loose tablets were unidentifiable and needed to be discarded in a pill buster immediately. LN 4 also stated two out of three loose bubble packs were discontinued and belonged to residents who were discharged from the facility. During an interview on 12/4/25 at 9 a.m. with Director of Nursing (DON), DON stated staff should have checked the temperature of medication refrigerator twice in 24 hours and recorded in the log as instructed to maintain the medications' safety and potency. DON confirmed expired, discontinued and loose medications were stored in a medication refrigerator and medication cart 2. DON expected staff to check and remove expired and discontinued medications from the storage to reduce the chances of medication diversion and misuse. 4- A review of Resident 89's admission Record, indicated Resident 89 was admitted to the facility in 2024. During a concurrent observation and interview on 12/1/25 at 9:06 a.m. with Resident 89 and LN 1 inside Resident 89's room, LN 1 confirmed four OTC medications were stored insecurely on top of Resident 89's cabinet. The medications were famotidine (medication used to decrease stomach acid production), a stool softer, fiber gummies, and stimulant laxative tablets. LN 1 stated the medications needed to be locked up. During an interview on 12/1/25 at 9:43 a.m. with DON, DON stated Resident 89's medications should be stored safely to prevent misuse. A review of facility's policy titled, Storage of Medications, dated 2001, indicated, The facility stores all drugs . in a safe, secure, and orderly manner .

Based on observation, interview, and record review, the facility failed to provide a clean environment for a census of 96 residents, when one out of four garbage dumpsters located outside the facility was not closed securely due to a gap between the lids.This failure decreased the facility's potential to maintain a safe environment and prevent pest infestation.Findings:During a concurrent observation and interview on 12/2/25 at 10 a.m. with the Dietary Services Supervisor (DSS), four dumpsters used by the facility were inspected. One dumpster's lids did not fully cover the dumpster and had a two-inch gap in the middle. DSS stated the dumpster lid should be replaced.During an interview on 12/3/25 at 2 p.m. with the Director of Nursing (DON), DON stated the dumpsters where all the trash was disposed should always be kept closed by ensuring the lids fit properly. DON further stated it was necessary to maintain such a safe practice to prevent pests from entering and potentially spreading disease.A review of the facility's undated policy titled, Food-Related Garbage and Rubbish Disposal, indicated, Food-related garbage and rubbish shall be disposed of in accordance with current state laws . Outside dumpsters provided by garbage pick-up services will be kept closed . Garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin.

Based on observation, interview, and record review, the facility failed to administer a medication according to professional standards of quality for one of 31 sampled residents (Resident 86), when Resident 86's metoprolol succinate (a medication used to treat high blood pressure and heart failure) was not administered as ordered by the physician.This failure decreased the facility's potential to follow physician's orders and safely administer medications to residents as prescribed.Findings:A review of Resident 86's admission Record, indicated Resident 86 was admitted to the facility in July 2023 with a diagnosis of hypertensive heart disease with heart failure (a long-time high blood pressure weakens the heart and reduces its ability to pump blood effectively).During a concurrent observation and interview on 12/2/25 at 8:55 a.m. with Licensed Nurse (LN) 2, LN 2 was observed preparing and administering Resident 86's morning medications. LN 2 stated metoprolol succinate tablet was withheld because Resident 86's blood pressure (BP) and heart rate (HR) were lower than the physician's ordered values. LN 2 further stated Resident 86's BP was 108/58 and HR was 59.A review of Resident 86's Order Summary Report (OSR), dated 12/4/25, indicated a 75 milligrams (mg - a unit of measurement) tablet of metoprolol succinate was to be administered by mouth once daily for high BP and to be held for a BP less than 90/50 and a HR less than 50.During a concurrent interview and record review on 12/2/25 at 1:33 p.m. with LN 2, Resident 86's Medication Administration Record (MAR) and OSR were reviewed. The MAR indicated the 8 a.m. scheduled dose of metoprolol succinate was withheld by LN 2 on 12/2/25. LN 2 documented Resident 86's vital signs (BP and HR) were out of parameters. LN 2 confirmed she did not administer Resident 86's scheduled dose of metoprolol and stated she misread the physician's order.During a concurrent interview and record review on 12/2/25 at 1:45 p.m. with the Director of Nursing (DON), Resident 86's OSR and MAR were reviewed. DON confirmed LN 2 did not administer Resident 86's metoprolol succinate on 12/2/25 and stated Resident 86's BP and HR were within the ordered values. DON expected LN 2 to read the orders correctly to avoid drug errors. DON further stated a missed dose of metoprolol succinate might increase Resident 86's potential to develop high blood pressure or heart attack.A review of the facility's policy titled, Administering Medications, revised in 2019, indicated, . Medications are administered in accordance with the prescriber orders .

Based on observation, interview, and record review, the facility failed to ensure two out of 31 sampled residents (Resident 9 and Resident 61's) environment was safe and free of accident hazards, when: 1. Licensed Nurse (LN) 5 did not check Resident 61's wanderguard (a device that activates sensors on doors to alarm, alerting staff to intervene when wandering residents attempt to elope) functionality; and2. Resident 9 was smoking without supervision.These failures decreased the facility's potential to maintain residents' safety.Findings: 1- A review of Resident 61's admission Record, indicated she was admitted to the facility in October 2022 with diagnoses including dementia (a progressive state of decline in mental abilities) with agitation and history of falling. During an observation on 12/2/25 at 2:49 p.m., Resident 61 was observed pacing up and down the hallway going to the nurses' station. Resident 61 was redirected by staff to keep her from wandering to other residents' rooms. During a concurrent observation and interview on 12/2/25 at 3:49 p.m. with LN 5 inside Resident 61's room, LN 5 confirmed Resident 61 was wearing a wanderguard on her right ankle. LN 5 stated she checked Resident 61's wanderguard placement during her shift, but not its functionality. LN 5 further stated the wanderguard's functionality was checked monthly by the nurses. A review of resident 61's Medication Administration Record (MAR), dated 12/4/25, indicated an order to check Resident 61's wanderguard placement and functionality every shift for safety. LN 5 signed the MAR on the evening shifts of 12/1/25 and 12/2/25. During a concurrent interview and record review on 12/2/25 at 4:15 p.m. with LN 5, Resident 61's MAR, dated 12/25 was reviewed. LN 5 confirmed Resident 61's wanderguard placement and functionality should have been checked every shift as ordered. LN 5 stated she was unsure of the proper method to check the wanderguard's functionality and considered the wanderguard functional if Resident 61 passed by the door and the door alarm sound was activated. A review of a facility's document titled, Transmitter Testing, revised in 1/20, indicated, Testing the patient transmitters is an integral part of your facility's patient security program and should be done on a regular basis . You must test all wander management transmitters prior to use . Failure to test the transmitters can result in system failure or elopement. The document further indicated, Never take a patient to a door to test their transmitter. During an interview on 12/3/25 at 2 p.m. with the Director of Nursing (DON), DON stated LN 5 was not properly trained to check the residents' wanderguards functionality. DON further stated staff should know the method of checking the wanderguards in order to properly monitor the safety of residents with exit seeking behaviors. A review of the facility's undated policy titled, Elopement and Wandering, indicated, This facility ensures that residents who exhibit wandering behavior or are at risk for elopement receive supervision to prevent accidents and receive care in accordance with their person-centered plan of care . The facility shall establish and utilize systematic approach . Implementing interventions . monitoring for effectiveness and modifying interventions when necessary. 2- A review of Resident 9's admission Record, indicated Resident 9 was admitted to the facility in August 2025 with diagnoses including encephalopathy (disease that affects the brain) and respiratory failure. A review of Resident 9's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/24/25, indicated Resident 9 had a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of nine out of 15 with moderate cognitive impairment. During an interview on 12/1/25 at 3:36 p.m. with Resident 9, Resident 9 stated she was a smoker and kept a lighter and cigarettes in her room. Resident 9 further stated she had no smoking schedule and would smoke whenever she wanted. During a concurrent observation and interview on 12/2/25 at 1:47 p.m. with Resident 9 in her room, an oxygen concentrator (a medical device that provides supplemental oxygen) was found at the bedside. Resident 9 stated she occasionally used oxygen. A review of Resident 9's Order Summary Report, dated 12/4/25, indicated Resident 9 had an order for oxygen at 2.5 liters (L, a unit of measurement) per minute via nasal cannula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed. During an observation on 12/2/25 at 2:05 p.m., Resident 9 was observed in the smoking patio area. Resident 9 lit a cigarette and started to smoke without staff supervision. During a concurrent observation and interview on 12/2/25 at 2:10 p.m. with the Staffing Coordinator (SC), Resident 9 was observed smoking at the smoking patio area. SC confirmed Resident 9 was smoking without staff supervision. A review of Resident 9's Nursing – Smoking Observation/Assessment, dated 11/24/25, indicated Resident 9 required smoking supervision. During a concurrent interview and record review on 12/3/25 at 3:59 p.m. with DON, Resident 9's Nursing – Smoking Observation/Assessment, dated 11/24/25 was reviewed. DON confirmed Resident 9's smoking assessment indicated Resident 9 required smoking supervision. DON stated Resident 9 should not have smoked without supervision, as there was a risk of self-injury, damage to clothing, or potential fire hazard when smoking unsupervised. A review of the facility's policy titled, Smoking Policy – Resident, revised in October 2023, indicated, Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

Based on observation, interview, and record review, the facility failed to ensure respiratory care was consistent with professional standards of practice for one of 31 sampled residents (Resident 42), when Resident 42's nasal cannula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not changed weekly.This failure decreased the facility's potential to prevent the risk of lung infection for Resident 42. Findings:A review of Resident 42's admission Record, indicated Resident 42 was admitted to the facility in October 2024 with diagnoses including chronic obstructive pulmonary disease (a chronic lung disease causing difficulty breathing) and respiratory failure.During an observation on 12/1/25 at 10:40 a.m. in Resident 42's room, Resident 42 was wearing NC. The NC was labeled with a date of 11/18.A review of Resident 42's Order Summary Report, dated 12/4/25, indicated Resident 42 had an active order for continuous oxygen at one liter (a unit of measurement) per minute via NC and to change NC every Sunday and as needed.During a concurrent observation and interview on 12/1/25 at 11:57 a.m. with Licensed Nurse (LN) 1 in Resident 42's room, Resident 42's NC was observed. LN 1 confirmed the NC was labeled with a date of 11/18. LN 1 stated the NC was supposed to be changed weekly. During an interview on 12/3/25 at 4:09 p.m. with Director of Nursing (DON), DON stated it was important to change the NC weekly and as needed to prevent the risk of lung infection for Resident 42. A review of the facility's policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised November 2011, indicated, Change the oxygen cannula [NC] and tubing every seven (7) days, or as needed.

Based on observation, interview, and record review, the facility failed to safely store food for a census of 96 residents, when an expired food item was available for use in the facility's kitchen.This failure decreased the facility's potential to prevent foodborne illness among residents.Findings:During a concurrent observation and interview on 12/1/25 at 8:12 a.m. with the Dietary Services Supervisor (DSS) in the kitchen, DSS confirmed a loaf of bread with expiration date of 11/30/25 was stored on the bread rack.During an interview on 12/3/25 at 2 p.m. with the Director of Nursing (DON), DON stated kitchen staff should not store expired food items that can be served to residents which might make them sick.A review of the facility's undated policy titled, Food-Related Garbage and Rubbish Disposal, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices.

Based on observation, interview, and record review, the facility failed to ensure one of 31 sampled residents (Resident 87's) call light was within reach, when Resident 87 was in bed and could not reach the call light.This failure decreased the facility's potential to provide Resident 87 with assistance when needed.Findings:A review of Resident 87's admission Record, indicated Resident 87 was admitted to the facility in 2025 with diagnoses including anxiety and inability to sleep.A review of Resident 87's Minimum Data Set (MDS, a federally mandated assessment tool), dated 10/27/25, indicated Resident 87 had moderate memory impairment.During a concurrent observation and interview on 12/1/25 at 9:27 a.m. with Resident 87 inside his room, Resident 87 stated he could not reach the call light and could not find it. The call light was hanging off the left side of bed. During a concurrent observation and interview on 12/1/25 at 9:34 a.m. with the Director of Nursing (DON) inside Resident 87's room, DON confirmed the call light was hanging off the bed and stated it should have been within arm-reach of Resident 87.A review of the facility's policy titled, Answering the Call Light, dated 10/2010, indicated, When the resident is in bed or in a chair be sure the placement of the call light is within reach of the resident.

Based on observation, interview, and record review, the facility failed to ensure staffing information was posted daily for a census of 96 residents, when staffing information was not updated for two days during the weekend.This failure decreased the facility's potential to have staffing information available for residents and visitors.Findings:During an observation on 12/1/25 at 7:07 a.m. near the facility's main entrance door, the posted staffing information was found with a date of 11/28/25.During an interview on 12/3/25 at 9:35 a.m. with Staffing Coordinator (SC), SC stated the supervisor during the weekend should have updated the staffing information. SC further stated staffing information should be posted daily. During an interview on 12/3/25 at 1:14 p.m. with Director of Staff Development/Infection Preventionist (DSD/IP), DSD/IP stated staffing information should be posted daily to show the residents and visitors the facility's compliance with staffing to provide care to residents. A review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised 8/22, indicated, Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.

Based on observation, interview, and record review, the facility failed to accurately document and replace emergency medication kits (E-Kit: a kit/box containing medications and supplies for immediate use during a medical emergency) for a census of 95. This failure decreased the facility's potential for having accurate accountability of emergency medications, availability of emergency medications when needed, and meeting the residents' therapeutic needs. Findings: During a concurrent observation and interview on 11/4/24 at 9:35 a.m. with Licensed Nurse 3 (LN 3) in the medication room on the second floor, it was observed that an intravenous (IV; Injectable medication to be administered into the vein) E-kit was found to be opened on 10/16/24 at 10:25 p.m. LN 3 stated, one liter (L, a unit of measure) of dextrose (a type of sugar solution) was taken out of the E-kit and was not replaced. LN 3 further stated the medication sticker should have been faxed on 10/16/24 to the pharmacy to replace the E-kit and the faxed order should have been documented in a binder in the nursing station. During a concurrent observation and interview on 11/4/24 at 9:40 a.m. with LN 3 in the medication room on the second floor, a refrigerated E-kit was found to be opened on 8/16/24. LN 3 stated a 10 milliliters (ml; a unit of measure) vial of insulin (medication used to lower blood sugar level) was taken out of the E-kit, but pharmacy was not notified, and the E-kit box was not replaced. LN 3 stated if the E-kit was not replaced, then residents will be at risk when emergency medications were needed. During an interview on 11/6/24 at 9:40 a.m. with the Director of Nursing (DON), DON stated her expectation was nurses and pharmacy should have followed the process to replace the E-kits within 72 hours to ensure all emergency medications were available for residents in case of an emergency. A review of the facility's policy and procedure titled, Emergency Pharmacy and Emergency Kits, dated September 2021, indicated, As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the kit by transmitting the entire order for the resident and indicating the first dose was used from the kit . The nurse opening the kit also records use of the kit in the Emergency kit logbook. The nurse records the date, time, resident name, medication name, strength, and dose . If exchanging kits, open kits are replaced within 72 hours.

46995 Based on observation, interview, and record review, the facility failed to provide treatment for one of 27 sampled residents (Resident 15) when Resident 15 did not receive preventative treatment (low air loss mattress- a mattress designed to distribute body weight over a large surface, used to help prevent skin breakdown) to prevent pressure ulcer (PU-injury to the skin and underlying tissue from prolonged pressure on the skin). This failure resulted in Resident 15 developing a Stage 4 (full thickness skin loss, wound can extend to muscle and bone) pressure ulcer to her sacrococcyx area (tailbone area). Findings: Resident 15 was admitted to the facility on [DATE] with diagnoses that included right femur fracture (broken thigh bone), difficulty in walking, pressure-induced deep tissue damage (purple or maroon localized area of discolored intact skin due to damage from pressure) to sacral region (tailbone area), Alzheimer's disease (progressive disease that affects memory). During a record review of Resident 15's Surgical Consult (SC), dated 8/31/22, the SC indicated, .WOUND LOCATION: Sacrococcyx (tailbone area) .Wound is epithelialized (covered with skin cells) . During a record review of Resident 15's Care Plan History (CP), the CP indicated, .PRESSURE ULCER CARE PLAN .Sacro coccyx ., was discontinued on 9/27/22, Dc Reason: Problem Discontinued. During a record review of Resident 15's MDS (Minimum Data Set, an assessment tool), dated 12/20/22, Section M, Skin Conditions .Determination of Pressure Ulcer/Injury Risk . Check all that apply ., the box for, Resident has a pressure ulcer/injury, a scar over bony prominence . was not checked. During a record review of Resident 15's 12/20/22 MDS question, Unhealed Pressure Ulcer/Injuries .Does this resident have one or more unhealed pressure ulcers/injuries? the MDS indicated, No. During a record review of Resident 15's 12/20/22 MDS question, Skin and Ulcer/Injury Treatments .check all that apply, the MDS indicated pressure reducing device for chair and bed were used. During a record review of Resident 15's Progress Notes, Type: Skin/Wound Note (PN), dated 1/6/23, the PN indicated, .The wound is now 99% intact black eschar [dead tissue]. The eschar is measuring 5cm [centimeter, a unit of measurement] X 3.8cm and is irregular shaped .Pt [patient] is reporting pain in the area as well . During a record review of Resident 15's SC, dated 1/12/23, the SC indicated, The patient has developed a recurrent stage 4 sacrococcyx injury. She has recently been returned to a low air loss mattress when the wound was identified .continue low air loss mattress . During a record review of Resident 15's MDS dated [DATE], Section M, Skin Conditions .Determination of Pressure Ulcer/Injury Risk . Check all that apply ., the box for, Resident has a pressure ulcer/injury, a scar over bony prominence . was checked. During a record review of Resident 15's 3/15/23 MDS question, Unhealed Pressure Ulcer/Injuries .Does this resident have one or more unhealed pressure ulcers/injuries? the MDS indicated, Yes. During a record review of Resident 15's 3/15/23 MDS question, Current Number of Unhealed Pressure Ulcer/Injuries at Each Stage .Stage 4 .Number of Stage 4 pressure ulcers ., The MDS indicated, 1. During a record review of Resident 15's 3/15/23 MDS question, Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry, the MDS indicated, 0. During a record review of Resident 15's 3/15/23 MDS question, Skin and Ulcer/Injury Treatments .check all that apply, the MDS indicated pressure reducing device for chair and bed were used. During a record review of review of Resident 15's Order Summary Report OSR, dated 9/14/23, the OSR indicated, treatment: LAL mattress ., with an order start date of 10/5/22. During an interview on 9/13/23 at 9:10 a.m., with Licensed Nurse (LN 4) 4, LN 4 was asked about Resident 15's PU. LN 4 stated, She [Resident 15] admitted with a wound, it healed and then the scar broke down. The wound healed while she was upstairs, when they moved her to long term, they did not move the low air loss mattress with her .it has definitely turned into a 4 now . When asked if Resident 15 had pain with wound care LN 4 stated, Yes. During an observation on 9/13/23 at 10:17a.m., in Resident 15's room of the PU dressing change, the PU was circular in appearance, pale pink in color. The PU extended through the subcutaneous (layer of fat) tissue, able to visualize undermining (tissue loss under the skin surface). During an interview on 9/23/23 at 2:20 p.m., with the Director of Nursing (DON), the DON confirmed Resident 15's PU had developed in the facility. During an interview on 9/14/23 at 10:05 a.m., with LN 4, LN 4 was asked if she felt Resident 15's PU was unavoidable. LN 4 stated, No, I think it could have been avoided if she had an air mattress .I told [DON's name] that [Resident 15] needed an air mattress . During an interview on 9/14/23 at 12:20 p.m., with the DON, the DON was asked if Resident 15's PU was unavoidable. The DON stated, .it can be avoidable if the interventions are in place .I have to be honest with you, there was some delay in getting her low air loss mattress from the short-term unit to the long-term unit . When asked the expectation for wound prevention the DON stated, In her [Resident 15] case the use of the low air loss mattress was effective .the low air loss mattress should have been there .ready and inflated .before the resident was moved. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol, dated April 2018, the P&P indicated, .the nurse shall describe and document .Current treatments, including support surfaces .Treatment/Management .the physician will order pertinent wound treatments, including pressure reduction surfaces .

Based on interview and record review, the facility failed to provide adequate supervision and assistance for one resident (Resident 1), who required two-person assistance for bed mobility, for a census of 85. This failure resulted in Resident 1 having an avoidable fall with injury, a left femur (thigh bone) fracture. Findings: During a review of Resident 1's medical records, the medical records indicated Resident 1 was admitted to the facility in early 2018, with diagnoses that included functional [CONDITION(S)] (inability to move with or without spinal damage) and [CONDITION(S)] (inability of a person to communicate effectively with others due to damage in a specific area of the brain). During a review of Resident 1's Minimum Data Set (MDS, standardized assessment and care planning tool), the MDS indicated in Section G (Functional Status), dated 5/13/20, 1. ADL (Activities of Daily Living) Self-Performance . A. Bed Mobility (how resident turns side to side, and positions body while in bed) was scored with a 3 (requires two or more persons physical assistance). During a review of Resident 1's ADL Care Plan, dated 3/14/18, the MDS indicated .[name of Resident 1] @ Risk for Decline in functional ADL activity such as, .Bed Mobility .Requires Extensive/Max/Total Dependence .1-2 person .to assist with bed mobility (e.g. get out of bed, turning and repositioning .during care) . During a review of Resident 1's record titled Observation Detail Report dated 4/12/20, the Observation Detail Report indicated The CNA [Certified Nursing Assistant] stated, 'She was changing the patient's soiled brief. The patient fell off the bed while she was trying to hold on but couldn't. She stated she found her laying on the floor with her head near the wheels of the bed. The patient was showing signs of distress and difficulty breathing due to her condition, I moved her head out; underneath the bed and elevated her 90 degrees. I noticed that her left leg was turned to the left .The CNA also stated that she does not know if the patient hit her head . During a review of Resident 1's IDT (Interdisciplinary Team) Progress Note, dated 4/14/20, the Progress Note indicated, .Re-educate nursing staff [Resident 1] requires two persons to assist during ADL care . During an interview with the Director of Nursing (DON) on 2/23/22, at 3 p.m., the DON stated, Resident 1 was found to have a fracture in her left femur (thigh bone). She was discharged from the hospital after 3 days, back to the facility with a cast. The DON also stated, The CNA does not work for the facility anymore. During an interview with the Licensed Nurse (LN) on 2/24/22, at 5:42 p.m., LN stated, . I heard someone calling from inside of the room and saw the CNA and [Resident 1] on the floor. LN stated she observed that Resident 1 grimaced in pain. LN called 911 and Resident 1 was transferred to the hospital. LN also stated, .Because of Resident 1's diagnosis of functional [CONDITION(S)], two people should assist her at all times. During a review of the facility Policy and Procedure titled Falls and Fall Risk, Managing revised March 2018, the Policy and Procedure indicated .Resident-Centered Approaches to Managing Falls and Fall Risk .the staff .will implement a resident-centered fall prevention plan to reduce the specific risk .of falls for each resident . During a review of the facility Policy and Procedure titled Activities of Daily Living (ADLs), Supporting, revised March 2018, the Policy and Procedure indicated, .Residents who are unable to carry out activities of daily living independently, will receive the services .a resident's ability to perform ADLs will be measured using the clinical tool, including the MDS (a measuring tool) .

Based on interview and record review, the facility failed to implement measures for the prevention of pressure ulcers for one resident (Resident 1) of two sampled residents when, Resident 1 developed a stage 3 pressure ulcer (an ulcer that has extended through dermis [second layer of skin] into the fatty subcutaneous [below the skin] tissues) on her coccyx (tailbone). This failure resulted in Resident 1 acquiring a preventable pressure ulcer and a delay in recovery. Findings: According to the Resident Face Sheet, Resident 1 was admitted in early March 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's clinical record included the following documents: A Nursing Admission Note, dated 3/7/22, by Licensed Nurse 1 (LN 1), indicated Resident 1 did not have a pressure sore upon admission. A Care Plan for At Risk for Altered Skin Integrity, dated 3/9/22, included interventions to monitor the resident's skin for any signs of breakdown (sore, tender, red, or broken areas), weekly skin checks, pressure relieving device for bed and turn and reposition frequently. A MDS (Minimum Data Set, an assessment tool), dated 3/10/22, indicated Resident 1 had no memory impairment and no pressure sores. It further indicated Resident 1 required extensive assistance to turn and be repositioned in bed. A review of point of care history, dated 3/7/22 through 5/28/22 indicated Resident 1 was turned and repositioned 12 times during his entire stay at the facility. A nursing note, dated 4/8/22, by the treatment nurse (Tx. Nurse), indicated she had assessed Resident 1's skin and found worsened spot-on coccyx area measuring 1.8c.m (unit of measurement) X 1cm X UTD (Unable to Determine). It also indicated lal (low air loss) mattress had been placed that day, a month after admission to the facility. In an interview on 8/4/22 at 12:28 p.m., the Director of Nursing (DON) referred to the nursing note written by Tx. Nurse on 4/8/22 and stated the wound had been staged incorrectly. The DON also stated as per description wound was already stage 2 (partial thickness loss of dermis) pressure ulcer. A weekly wound note, dated 4/21/22, by the Tx. Nurse, indicated, Coccyx reclassified as stage 3 pressure injury, measures 2.1 cm x 0.6 cm x 0.2 cm . In an interview on 7/17/22 at 10:34 a.m., Tx. Nurse stated Resident 1 had potential for skin breakdown and the care plan was not followed for preventive measures. She also confirmed the facility failed to place Resident 1 on a low air loss mattress upon admission to prevent further skin breakdown. In an interview on 7/17/22 at 12:48 p.m., the DON stated Resident 1's coccyx pressure sore was avoidable (if preventive measures and interventions had been in place and followed) and the facility failed to identify interventions such as turning, positioning, and monitoring for Resident 1. She further stated the facility failed to monitor the progress of the wound. A review of the facility's policy titled, Prevention of Pressure Ulcers/Injuries, last revised 7/17, stipulated, Inspect the skin daily when performing or assisting with personal care .Identify any signs of developing pressure injuries .Reposition resident as indicated on the care plan .evaluate, report and document potential changes in the skin.

Based on observation, interview, and record review, the facility failed to adequately supervise and prevent abuse for two of four sampled residents (Resident 1 and Resident 2) when Resident 2 sexually abused Resident 1. This failure had the potential to cause physical harm and emotional distress to Resident 1. Findings: Resident 1 was admitted to the facility in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's Minimum Data Set (MDS - an assessment tool), dated 9/15/20, documented her BIMS (a brief screening that aids in detecting cognitive impairment) score was 0 which indicated she had severe cognitive impairment. Resident 2 was admitted to the facility in 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 2's MDS, dated [DATE], documentation on his BIMS score was left blank and not fully completed. The MDS described Resident 2 as having moderately impaired (decisions poor, cues/supervision required) cognitive skills for daily decision making. During a phone interview on 12/07/20 at 1:57 p.m., with Certified Nurse Assistant (CNA), the CNA stated on 11/28/20, she saw Resident 2's hand underneath the covers over Resident 1 who was in bed and his hand was moving back and forth. She further stated she pulled the covers back and saw Resident 2's hand touching Resident 1's genitals. The CNA stated she grabbed Resident 2's wrist and told to him to get out of the room. The CNA stated she reported the incident to the Nurse. During a review of Resident 1's Resident Progress Notes, dated 11/28/20 at 8:00 a.m., the note indicated, .[CNA] found patient [Resident 2] in [Room #] put his finger in patient in [room #] [Resident 1's] anus. CNA redirected [Resident 2] to get out of the room. During a review of Resident 2's Resident Progress Notes, dated 11/28/20 at 10:45 a.m., the note indicated, [Resident 2] was found in a female [Resident 1's] pts (sic) room hunched over her bed with his fingers in her vagina going in and out. During concurrent observation and interview on 12/1/20 at 3:08 p.m., with Resident 2, he was seen sitting in his wheelchair outside his room. He stated he does not remember anything. During observation on 12/1/20 at 3:25 p.m., Resident 1 was sleeping comfortably. She opened her eyes when called and went back to sleep. Review of the facility's Abuse Prevention Program, revised 01/2011 indicated, Our residents have the right to be free from abuse by . Our facility is committed to protecting our residents from abuse by . other residents . or any other individual.