Every finding on record at Murray Woods of Journey LLC

Based on observations, staff and resident interviews, record review, review of the facility's policy titled Notification of Changes, and Your Rights and Protections as a Nursing Home Resident, the facility failed to notify the emergency contact and/or responsible party after a fall for two of 11 sampled residents (R) (R1 and R2). This deficient practice had the potential to compromise the residents' rights to have their representatives informed of significant changes in condition and to participate in decisions regarding the residents' care and treatment.Findings include:1. Review of the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE], with pertinent diagnoses including, but not limited to, morbid obesity with current weight of 368 pounds, chronic respiratory failure with hypoxia and hypercapnia, chronic obstructive pulmonary disease (COPD), chronic diastolic congestive heart failure, generalized weakness/deconditioning, chronic pain syndrome, and type 2 diabetes mellitus.Review of the Medicare 5-day Minimum Data Set (MDS) assessment for R1 dated 04/17/2026, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment. Section GG revealed impairment to lower extremities requiring wheelchair and lift use. Review of the care plan for R1 dated 07/01/2026, documented a problem of risk for fall with injury related to decreased mobility. Goals included, but not limited to, assistance with bed mobility and transfers; may use mechanical lift with a two staff assist as needed; educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; follow facility fall protocol; provide resident/family education as needed and as indicated; sent to ER (Emergency Room) for eval and treatment effective 07/01/2026.Review of the EMR progress notes for R1 dated 07/01/2026, revealed a change in condition related to a fall from lift and sent to the ER. MD {Medical Doctor} notified by RCC {Resident Care Coordinator}. Resident is her own RP {Responsible Party}.Review of the progress notes for R1 dated 07/02/2026, revealed the facility contacted the local hospital and was informed that R1 had been transferred to another hospital.Review of the progress notes for R1 revealed no documentation which indicated R1's emergency contact was notified of the fall or the transfer to the emergency room until 07/02/2026, when the emergency contact contacted the facility to inquire about R1's condition and what had occurred.Interview on 07/21/2026 at 4:07 PM with R1's emergency contact, via telephone, revealed she was not notified by facility staff that R1 had sustained a fall resulting in hospitalization. The emergency contact stated she first became aware of hospitalization when hospital staff contacted her on 07/02/2026 to discuss treatment decisions. She stated she then contacted the facility and spoke with the Director of Nursing (DON), who apologized that no one from the facility had notified her of the incident.Interview on 07/28/2026 at 1:01 PM, with the Assistant Director of Nursing (ADON), revealed she responded after being notified that R1 had fallen. The ADON stated she assessed R1, obtained vital signs, and observed the resident to be alert, talking, and complaining of back pain following the fall. She stated emergency medical services responded and transported R1 to the hospital for evaluation. Regarding residents' notifications, the ADON stated, Normally, any kind of change in condition, any kind, we report to the responsible party. ADON stated she was unsure of the process when the residents were their own responsible party.Interview on 07/28/2026 at 1:51 PM with Licensed Practical Nurse (LPN) BB revealed she was the nurse assigned to the floor at the time of R1's fall but was not present when the incident occurred. LPN stated Unit Manager CC initiated notifications, including contacting the physician and hospital. LPN stated she did not believe R1's emergency contact was notified, explaining that R1 was her own responsible party (RP) and was alert and oriented at the time of transfer. LPN stated she had never contacted R1's emergency contact for any reason.Interview on 07/29/2026 at 12:16 PM with Unit Manager (UM) CC revealed she was at the nurses' station when staff notified her that R1 was on the floor following a fall. The Unit Manager stated she contacted the physician and emergency services only. She stated she did not document making the calls and instructed the nurse to complete the documentation to record the information.2. Review of the EMR revealed R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, displaced comminuted fracture of the shaft of the right femur, subsequent encounter with routine healing, generalized muscle weakness, impaired mobility, severe dementia with mood disturbance/Alzheimer's disease, morbid obesity, osteoporosis with history of pathological fractures, chronic pain syndrome, and recurrent falls. Resident R2 required extensive assistance with activities of daily living and was dependent on staff for mobility and care needs. Her medical history was significant for multiple chronic conditions requiring ongoing nursing support, including COPD/chronic bronchitis, hypertension, hypothyroidism, and chronic pain management.Review of the 5-day MDS assessment for R2 dated 07/01/2026, revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated severe cognitive impairment. Section GG revealed impairment to lower extremities requiring wheelchair and lift use. Review of the care plan for R2 dated 07/01/2026, documented a problem of risk for fall with injury related to decreased mobility, safety awareness, unsteady gain requiring assistance with ambulation and transfers. Goals included but not limited to educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; orient to surrounding/environment as needed; follow facility fall protocol; provide resident/family education as needed and as indicated; provide verbal cues for safety and sequencing when needed.Review of the EMR progress notes for R2 revealed that on 06/16/2026, R2 sustained an unwitnessed fall after rolling out of bed and landing on her knees. Nursing documented that R2 complained of knee pain, a right small toe injury with bleeding, with wound care was provided. The fall was identified as a change in condition, and the physician and hospice were notified; however, review of documentation revealed no evidence that R2's RP was notified of the fall at that time.Review of the EMR progress notes for R2 revealed that on 06/20/2026, R2's son reported that the resident's right leg was swollen and painful with touch or movement. Nursing notified the physician and responsible party, and an x-ray was ordered. Subsequent documentation revealed continued assessment and treatment related to the injury, including orthopedic follow-up and hospitalization.Review of the EMR for R2 revealed on 06/21/2026, x-ray results were reviewed with the physician, and the responsible party was contacted regarding treatment recommendations, including possible emergency room evaluation.Interview on 07/30/2026 at 11:02 AM with LPN Unit Manager CC revealed that if the physician cannot be reached, staff were expected to contact the after-hours physician service, and if the night shift nurse was unsuccessful in notifying the physician or resident representative, the day shift nurse was expected to continue those notification attempts.Interview on 07/30/2026 at 11:29 AM with LPN BB revealed she was the day shift nurse and was not on duty when R2's fall occurred during the night shift. LPN BB explained that during shift change, staff receive reports on outstanding issues, and that following a fall the nurse typically contacted the physician. She stated she was not instructed to notify anyone regarding the incident and did not review the nursing documentation related to the fall.Interview on 07/30/2026 at 11:58 AM with LPN FF revealed she was the nurse on duty when R2 rolled out of bed. LPN FF stated she found R2 on her knees, staff used a mechanical lift to return her to bed, and she completed an assessment, observing a bleeding right toe, which she treated. LPN FF stated R2 was on hospice, so she notified the hospice on-call service rather than the physician because the fall occurred late at night. She stated she did not notify the resident representative and did not ask the day shift nurse to make notification attempts and believed the hospice nurse would notify the representative.Interview on 07/30/2026 at 12:15 PM with a hospice provider representative for R2 revealed the facility contacted the hospice answering service on the night of 06/16/2026 to report the fall; however, the on-call message was not relayed to the assigned hospice nurse. The hospice nurse stated she was not made aware of the fall until she visited R2 on 06/19/2026. She explained that the usual process is for the triage nurse to notify the assigned hospice nurse for follow-up, but this did not occur.Interview on 07/28/2026 at 2:30 PM with the Director of Nursing (DON) revealed it was her expectation that staff follow the facility's policies regarding residents who sustain falls. Regarding R1, the DON stated that following the incident, R1 appeared alert, was answering questions, and was alert and oriented at her baseline. She stated R1 was not complaining of pain while she was present. Regarding notification, the DON stated R1 had been her own responsible party for years, and the family had not attended care plan meetings. Regarding R2, the DON stated that we follow our standard policy and procedures. The nurse completed her assessment and called me regarding the discoloration, with these new pieces of information, we proceeded with our protocol. The DON stated R2 was receiving hospice services at the time of the fall, hospice was notified, and the hospice nurse recommended continued monitoring and notification of any changes.Review of the facility policy titled, Notification of Changes reviewed 03/20/2025, documented in section Compliance Guidelines that The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 1. Accidents. a. Resulting in injury. b. Potential to require physician intervention. Further review indicated in section Additional Considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify resident's representative, if known. b. A family that wishes to be informed would designate a member to receive calls. c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the care of sudden illness or accident. 2. Resident incapable of making decisions: a. The representative would make any decisions that have to be made. b. The resident should still be told what is happening to him or her.Review of the facility document titled, Your Rights and Protections as a Nursing Home Resident undated, indicated in section Have Your Representative Notified that The nursing home must notify your doctor and, if know, your legal representative or an interested family member when the following occurs: You're involved in an accident and are injured and/or need to see a doctor.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, and Exploitation, the facility failed to prevent sexual abuse by another resident for one of three residents (R) (R2 and R1) reviewed. This failure allowed R1 to continue to potentially sexually abuse other residents after his behavior of getting in bed with other residents was first identified.Findings include: Review of the facility policy titled Abuse, Neglect, and Exploitation revised 3/5/2024 revealed under Definitions: Non-consensual sexual contact of any type with a resident. Under Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 1. Review of the electronic medical records (EMR) for R1 revealed he was admitted with diagnoses of major depressive disorder, persistent mood disorders, vascular dementia, bipolar disorder, anxiety disorder, and dementia with behavioral disturbances. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of 08, indicating a significant cognitive impairment. Observation on 02/16/2026 at 11:16 AM revealed R1 lying in bed moving his legs like he was riding a bicycle. A Certified Nursing Assistant (CNA) walked by and stated, R1, I'll be back in a minute to take you to lunch. He did not respond. Observed on 02/17/2026 at 9:31 AM revealed R1 in bed. He had been recently shaved and was sleeping soundly with the call light nearby. Review of a nurse note dated 08/6/2025 at 10:00 PM by Licensed Practical Nurse (LPN) AA revealed, Resident attempting to go into dietary room to use the restroom and climbing into other resident's beds with them. Review of a nurse note dated 10/06/2025 at 3:27 AM by LPN BB revealed, Resident continuously up and down, ambulatory on hallway, knocking on doors, and attempting to enter other resident's rooms. R1 waking other residents. Redirection attempts made by staff unsuccessful. Review of a nurse note dated 10/10/2025 by LPN CC revealed, R1 was found earlier in shift in another patient's room lying asleep on top of another patient. R1 assisted off top of other patient. Review of a nurse note dated 10/10/2025 at 2:02 AM by LPN CC revealed, Another patient in R2's room and laid down on top of her and went to sleep. Other patient removed and put into their room. Review of a nurse note dated 10/13/2025 by LPN DD revealed, R1 continues to try and get into bed with residents, male and female. He has been redirected back to his bed several times and continues to get up and try to get into bed with them. Review of a nurse note dated 10/17/2025 by LPN CC revealed, Earlier in shift R1 was wandering up and down the hallways and going in and out of other resident's rooms. Review of a progress note on 10/26/2025 at 4:07 AM by LPN BB revealed, R1 continues to be up and down throughout the majority of shift so far. R1 continues to attempt to enter a specific female resident's room. Redirection attempts mad by staff are unsuccessful. 2. Review of the most recent quarterly MDS dated revealed R2 had a BIMS score of 99, which indicates R2 could not complete/answer questions. Review of a nurse note dated 10/17/2025 at 12:33 AM by LPN CC, R2's daughter came in and was concerned about R2. She states she had blood all over her bottom lip and is not herself. Review of a nurse note dated 10/26/2025 at 8:00 PM by LPN AA revealed, R2's responsible party was notified of another resident being found in the bed with her, with his pants down and lips on hers. Responsible party voiced understanding. She requested that curtain be kept open. Review of the facility's investigation dated 10/28/2025 revealed a hand-written statement from CNA II regarding the incident on 10/26/2025. She stated that after entering R2's room, We found R1 in the bed with his pants and underwear off on top of R2 holding her by both arms attempting to kiss her. R2 was fully clothed and covered up but R2 was screaming because R1 was on top of her. Interview on 02/17/2026 at 8:48 AM with CNA HH revealed that she remembered finding R1 on top of R2 on 10/26/2025. R2 had her arms pinned down by her side. His face was really close to her, almost kissing. R2 couldn't talk, but she was making noises. It looked like R1 was just close to her. His brief was definitely on, but his pants were pulled way down. Interview on 02/18/2026 at 9:23 AM with CNA GG revealed that it was normal for R1 to get in and out of bed with other residents. R1 iwas a constant redirect. R1 went and got in bed with people. R1 laid right on top of people sometimes. I've seen R1 in R2's room curled up in bed with her. Interview on 02/18/2026 at 9:34 AM with the Social Services Assistant stated that staff was to redirect R1 when he got into bed with others. R2's responsible party was upset about what happened to her mother. In the event of the incident with R2, that's not normal. It's abuse. I agree that the other people here are at risk. We're supposed to keep an eye on R1. Interview on 02/17/2026 at 1:41 PM with LPN DD stated, To me these behaviors shouldn't be commonplace. Up until two weeks ago, we had a locked dementia unit. He was on the locked unit when these behaviors occurred. We removed the doors a couple weeks ago. He's all over the place in and out of other resident's rooms. Interview on 02/17/2026 at 2:05 PM with LPN CC, she stated, R1 is very confused. You can't redirect him. CNA's report to me when R1 would be in bed with another resident, and it was common for him to do so. At one-point R1 was moved out away from the lock-down unit, but then they moved him back. R1 no longer wanders up and down the hallways, but now that the unit is unlocked, there's the potential he could get around. He still ambulates. Interview on 02/18/2026 at 8:49 AM with the Administrator, he stated, Knowing R1 and knowing his history, that's normal behavior of him getting into other resident's beds. I'm aware I have a two-hour window to report abuse. R1 generally is redirected and not harmful. In my opinion, R1's behaviors are random. My perspective is that Mr. Long has severely impaired cognition and that his behavior is passive.

Based on observations, interviews, record review, document review and review of the facility policy titled, the facility failed to provide sufficient staff to meet the residents' needs timely. This failure to provide Activities of Daily Living (ADL) care, assistance with dressing and transported to the dining room for meals, timely incontinence care, program of activities, services to prevent further decrease in range of motion/mobility for a resident with contracture had the potential to negatively impact quality of life for all residents.Findings include:Review of the undated Facility Assessment revealed, .Staffing plan: staffing is based on the consideration of all or some of the following: diagnoses, conditions, physical and psychosocial limitations, resident acuity, or any other factor that may affect the services the facility must provide. 1.During the initial tour on 9/28/2025 at 9:00 am, there were no residents in the dining room. [NAME] 1 was asked why no residents were eating in the dining room and stated that the residents had to eat in their rooms because there wasn't enough nursing staff to bring the residents to the dining room.Interview with R43's family member (F)43 stated that the residents had to eat all three meals in their rooms on Saturday and again this morning (Sunday) due to being short staffed. R43 stated that she visits daily, and the conditions present this Sunday morning was, unfortunately, the norm. She stated the facility is always short-staffed.Interview on 9/28/0225 at 9:50 am with Registered Nurse (RN)1 confirmed F43's concerns were accurate.Interview with Resident (R)39 during the initial tour on 9/28/2025 at 10:15 am revealed she had been waiting more than two hours to get changed. Her brief was saturated with urine, and she wanted assistance to use her bedside commode. She stated an unnamed Certified Nurse Aid (CNA) came in over an hour ago and said they were short staffed, and she would be back to assist R39 after trays were passed on the hallways. She did not return and R39 remained soiled for another hour.Review of R39's admission Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 9/20/2025 and a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R39 was cognitively intact. The MDS indicated R39 was dependent on staff for assistance with toileting.Interview with CNA1 and CNA2 on 9/28/2025 at 12:15 pm, they stated that the CNAs do not stay on the same halls for their assignments because there's not enough staff for that, so we always work different halls. The CNAs stated there are days that they just can't keep up but they couldn't be more specific.Review of the PBJ Staffing Data Report CASPER Report - FY Quarter 3 2025 (April 1 - June 30) revealed the facility triggered for excessively low weekend staffing and a one-star (out of five possible stars) staffing rating. During an interview on 9/28/2025 at 11:30 am, the Administrator was asked for the facility's nurse staffing policy. He stated that there was no magic number or specific policy for staffing but that they always staff to meet the needs of the residents. The Administrator confirmed that he had reported excessively low staffing on the weekends in the required (PBJ) report. He also confirmed the facility was rated one star out of five possible stars for staffing.Registered Nurse (RN)1 was present when the survey team entered on 9/28/2025 at 9:00 am. She stated the schedule had one CNA and one nurse scheduled on each of the four halls to provide residents' care, and it wasn't doable, but it was always like that on the weekends. A copy of the assignments for staff working that day confirmed there was one CNA and one nurse on each hall to care for 111 residents. RN1 confirmed that anyone requiring a mechanical lift (like R39) to transfer from their bed had to wait for two staff to be able to take care of them and there were many residents that required a mechanical lift.Review of R108's quarterly MDS assessment with an ARD of 9/9/2025 indicated R108 was cognitively intact.Interview on 9/30/2025 at 12:00 pm, the interim Resident Council President (R108) stated that staffing is a problem in the facility and the resident's lives are negatively impacted by that. She stated they don't do many activities because there isn't enough staff for that, and residents eat in their rooms most of the time because they don't get them dressed and to the dining room for that socialization/interaction with other residents.2. The facility failed to provide timely incontinence care for two of three residents (R)39 and R8) reviewed for Activities of Daily Living (ADL) in the sample of 31 residents. (See F677-D)3. The facility failed to provide a program of activities to support residents in their choice of activities for four resident (R53, R60, R74, and R97) and failed to provide an ongoing program of activities designed to support the physical, mental, and psychosocial well-being of residents in the facility. (See F679-E)4. The facility failed to ensure residents admitted to the facility with a contracture were provided with the services and/or treatment to increase range of motion/mobility and/or to prevent further decrease in range of motion/mobility for R59 reviewed for contractures. (See F688-D)

Based on observation, interview, and review of the facility policy titled, the facility failed to ensure refrigerated foods in the walk-in cooler were stored and labeled correctly and dish wear stored under the air conditioner [NAME] were covered and the dish wear inverted. This deficient practice had the potential to affect 107 of 111 residents who received meals prepared in the facility's only kitchen. Findings include:Review of the facility's policy titled, Food Procurement and Storage dated 03/02/23 revealed all leftover food in the cold storage should be dated with an open and discard date, clearly identifying the container contents.During an initial kitchen tour observation on 9/28/2025 at 9:15 am, with the weekend dietary aid , the walk-in cooler contained a large bowl that appeared to be a lettuce salad that was not labeled and/or dated, an open container that appeared to be cream of chicken soup with no label or date, large containers with what appeared to be leftover vegetable soup and leftover tomato soup, with no label or date. The dietary aid stated the food items should have been labeled or removed from the cooler. A four-level rack for drying kitchen dish wear was located under an air conditioner overhead vent and contained bowls that were not covered but were inverted, however, the rack also contained saucers that were not covered and were not inverted on the rack.During an interview on 9/30/2025 at 10:35 am, the Dietary Manager stated that dietary employees were to properly label stored foods in the cooler.During an interview on 9/30/2025 at 10:35 am, the District Dietary Manager stated that he knew the leftover food must be labeled and dated and that the dishware needed to be inverted or covered standing under the air conditioning vent. He stated that he would provide a covering over the rack to shield it from the air-conditioning vent.

Based on observations, interviews, record review and facility policy, Administration failed to ensure residents' environment on two of four halls (200, and 400) was clean, in good repair and homelike. Administration failed to ensure residents (R33 and R14) were free from sexual and physical abuse. Administration failed to ensure allegations of sexual abuse were thoroughly investigated for R33 and reported timely to the State Survey Agency (SSA) (R14 and R12). Administration failed to ensure residents (R53, R59, R12 and R2) care plans were developed for activities with interventions for residents that required diversional activities, activities in their rooms and activities that were appropriate for residents with dementia on the secure unit. Administration failed to ensure residents were provided with activities to meet their needs (R53, R60, R74 and R97). Administration failed to ensure the facility's ice machine and range oven were repaired and functioning which had the potential to affect all residents' mental, physical psychosocial outcomes.Findings include: 1.The facility failed to provide a safe, clean, comfortable, and home-like environment for residents on two (200 and 400) of four halls in the facility. This failure could negatively impact resident due to not having a sanitary, homelike living environment. (See F584-D)During an interview on 10/2/2025 at 1:40 pm, the Administrator was questioned about the condition of the two halls that were observed on 9/28/2025. The Administrator stated once the remodeling is completed many of these issues will be resolved once the sale of the facility is finalized by the end of October 2025.2. The facility failed to ensure R33 and R14 were free from abuse; R33 from sexual abuse and R14 from physical abuse by another resident. The failure by the facility to identify that R33 was sexually abused by another resident (R57). (See F600-D)During an interview on 9/30/2025 at 10:00 am, the Administrator was asked why the incident was not substantiated for sexual abuse for R33. He stated .because neither resident remembered the incident.3. The facility failed to report allegations of resident-to-resident abuse to the State Survey Agency (SSA) within the two hours once the facility was aware of the abuse allegation for two residents, (R14 and R12). (See F609-D)Interview with the Administrator on 9/29/2025 at 11:05 am confirmed the investigation report was submitted as the five-day report instead of within two hours to the SSA after becoming aware of the allegations of abuse.4. The facility failed to thoroughly investigate an alleged allegation of sexual abuse for R33 and physical abuse for R14. (See F610-D)Interview with the Administrator on 9/29/2025 at 11:05 am, he confirmed the investigation did not include an interview from R14, from other residents or staff members.5. The facility failed to develop a comprehensive care plan for R53, R59, R12 and R2) that identified care needs. This failure placed the resident at risk for unmet care needs, and the inability to meet their maximum practicable level of functioning. (See F656-D)During an interview with the Administrator on 9/30/2025 at 2:30 PM, he stated that he assumed the Activity Director and the Minimum Data Set (MDS) Coordinator were completing or updating the care plan for activities to include activity preferences and choices of each resident and implementing new interventions as residents' care needs were identified.6. The facility failed to provide, based on the comprehensive assessment and care plan and the preferences, a program of activities to support residents in their choice of activities for (R53, R60, R74, and R97) and failed to provide an ongoing program of activities designed to support the physical, mental, and psychosocial well-being of residents in the facility. (See F679-E)During an interview on 9/30/2025 at 2:30 pm, the Administrator stated that he assumed the Activity Director (AD) was providing an ongoing activity program and were documenting the activity preferences and choices of each resident, developing resident care plans for activities/interventions, implementing new interventions comprehensively discussed, and documenting, according to the resident rights to participate or refuse activity involvement. He said he did not implement measures in place to prevent the possibility of falsified documentation of the resident medical records pertaining to activities.7. The facility failed to provide sufficient staff to meet the residents' needs. This failure to provide Activities of Daily Living (ADL) care, assistance with dressing and transported to the dining room for meal, timely incontinence care, program of activities, services to prevent further decrease in range of motion/mobility for a resident with contracture had the potential to negatively impact quality of life for all residents. (See F725-F)During an interview on 9/28/2025 at 11:30 am, the Administrator was asked for the facility's nurse staffing policy. He stated that there was no magic number or specific policy for staffing but that they always staff to meet the needs of the residents. The Administrator confirmed that he had reported excessively low staffing on the weekends in the required (PBJ) report. He also confirmed the facility was rated one star out of five possible stars for staffing.8. The facility to maintain the ice machine and primary oven in working order. Specifically, the ice machine did not provide the ice needed to meet the needs of the residents and family members had to buy ice for the residents, and the primary range oven did not work and could not be used. This deficient practice had the potential to affect all residents who received meals prepared in the facility's only kitchen. (See F908-F)During an interview on 9/30/2025 at 10:35 am, the Dietary Manager stated he had reported to the Administrator that the ice machine and the primary range oven were not working but was not informed when or if the equipment would be repairedDuring an interview on 9/30/2025 at 10:35 am, the District Dietary Manager stated that he was aware of the ice machine and the primary range oven not working for the past six months He could not provide an order or invoice to indicate the equipment was in the process of being repaired or that new equipment had been purchased.

Based on interview and review of the facility policy titled, Equipment the facility to maintain the ice machine and primary oven in working order. Specifically, the ice machine did not provide the ice needed to meet the needs of the residents and family members had to buy ice for the residents, and the primary range oven did not work and could not be used. This deficient practice had the potential to affect 107 of 111 residents who received meals prepared in the facility's only kitchen.Findings include:Review of the undated facility policy titled Equipment, stipulated that all foodservice equipment will be clean, sanitary, and in proper working order.During an initial kitchen tour interview on 9/28/2025 at 9:15 am, the weekend Dietary Aid reported that the ice machine had been broken and that many times, staff or family members had purchased bagged ice for the residents' the Dietary Aid also stated that the primary range oven in the kitchen was not working for several months and did not know when or if it would be repaired.During an interview on 9/30/2025 at 10:35 am, the Dietary Manager stated he had reported to the Administrator that the ice machine and the primary range oven were not working but was not informed when or if the equipment would be repairedDuring an interview on 9/30/2025 at 10:35 am, the District Dietary Manager, stated that he was aware of the ice machine, and the primary range oven not working for the past six months he could not provide an order or invoice to indicate the equipment was in the process of being repaired or that new equipment had been purchased.

Based on observation, record review, interview, and review of the facility policy titled, Activities the facility failed to provide, based on the comprehensive assessment and care plan and the preferences, a program of activities to support residents in their choice of activities for four of four residents (Resident (R)53, R60, R74, and R97) in the sample of 31 residents and failed to provide an ongoing program of activities designed to support the physical, mental, and psychosocial well-being of residents in the facility. This failure had the potential to negatively impact quality of life for the affected residents.Findings include:Review of the facility's policy titled, Activities dated 2/28/2023 indicated, .facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community.l. Each resident's interest and needs will be assessed on a routine basis. b. Activity assessment to include resident's interest, preferences and needed adaptations 2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. b. Create opportunities for each resident to have a meaningful life. c. Promote or enhance physical activity. d. Promote or enhance cognition' e. Promote or enhance emotional health f, promote self-esteem, dignity, pleasure, comfort, education, creativity, success, and independence. g. Reflect resident's interests and age h. Reflect cultural and religious interests of the residents i. Reflect choices of the residents. 4. Activities may be conducted in different ways.b. person.large and small groups, one-to-one, and self-directed as the resident desires to attend. 5. Scheduled activities are posted in the resident's room, where appropriate, and in a prominent place in the facility. 6. Residents are encouraged, but not mandated, to participate in scheduled activities.8. Activities will include individual, small and large group activities as well as: a. Indoor and Outdoor Activities. b. Activities away from the facility. c. Religious Programs. d. Exercise Programs. e. Community Activities. f. Social Activities. g. In-Room Activities. h. Individualized Activities. i. Educational Programs. 9. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. These include, but are not limited to, considerations for: a. Residents who exhibit unusual amounts of energy or walking without purpose, b. Residents who engage in behaviors not conducive with a therapeutic home like environment, c. Residents who exhibit behaviors that require a less stimulating environment to discontinue behaviors not welcomed by others sharing their social space, d. Residents who go through others' belongings, e. Residents who have withdrawn from previous activity interest/customary routines, and isolates self in room/bed most of the day. f. Residents who excessively seek attention from staff and/or peers, g. Residents who lack awareness of personal safety, h. Residents who have delusional and hallucinatory behavior that is stressful to themselves.1.Review of R53's Care Plan located under the Care Plan tab of the Electronic Medical Record (EMR) dated 2/5/2024 did not identify resident's preference for activities.Review of R53's Quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 1/21/2025 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. The MDS indicated that preferences for customary routine and activities revealed were very important to her and to do her favorite activities.During an interview with R53 on 9/28/2025 at 2:30 pm, she confirmed staff never ask her to attend activities and staff never come to her room to provide activities or supplies. During an observation on 9/28/2025 at 2:33 pm and on 9/29/2025 at 1:30 pm, revealed no activities occurred in R53's room.Review of the September 2025 Activity Interaction/ Attendance record indicated that no activities were highlighted on the calendar as being provided. 2.Review of R60's Face Sheet located under the Profile tab of the EMR revealed R60 was admitted to the facility with the diagnoses of idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, schizophrenia, bipolar disorder, dementia, anxiety disorder, heart failure, and chronic pain syndrome. R60 resided on the secure unit.Review of R60's quarterly MDS with an ARD date of 8/19/2025 located under the MDS tab with a BIMS score of 15 out of 15 which indicated R60 was cognitively intact. The MDS indicated that R60 was independent with ambulation.3.Review of R74's Face Sheet located under the Profile tab of the EMR revealed R74 was admitted to the facility with the diagnoses of hemiparesis and hemiplegia following cerebral infarction affecting the right dominant side, cognitive communication deficit, heart failure, heart disease, chronic obstructive pulmonary disease, seizures, vascular dementia, bipolar disorder, psychotic disorder, major depressive disorder, and aphasia. R74 resided on the secure unit.Review of R74's significant change MDS with an ARD date of 8/8/2025 located under the MDS tab indicated R74 was the MDS indicated a BIMS score of nine out of 15 indicating R74 was moderately cognitively impaired. The MDS indicated resident required moderate assist with ambulation.4.Review of R97's Face Sheet located under the Profile tab of the EMR revealed R97 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, dementia, falls, and chronic pain. R97 resided on the secure unit.Review of R97's quarterly MDS with an ARD dated 9/16/2025 located under the MDS tab indicated a BIMS score of 99 which indicated R97 was severely cognitively impaired. The MDS indicated resident required supervision with ambulation.Review of the residents Care plan under the Care Plan tab in the EMR indicated for R60 little activity involvement related to little interest or pleasure in doing things dated 9/9/2025; for R74 potential for limited activity participation related to diagnosis of depression and little interest dated 8/18/2025; for R97 the was nothing mentioned regarding activities and for R118 limited activity involvement related to signs and symptoms of depression, anxiety and little interest dated 8/8/2025.During an observation on 10/1/2025 at 2:05 PM through 3:25 PM on the secure unit, the October Activities schedule was taped on a door in the dining room which indicated that the activity titled Church was scheduled for 2:30 pm. During the time period between 2:05 pm through 3:00 pm, no church activity was observed on the secure unit. At 3:16 pm, the Activities Aid (AA) arrived on the unit with a cart and offered snacks and juice to the residents.Review of the Activity Calendar for September 2025 indicated activities were not marked as being provided for residents on the secure unit on the following dates: 9/1/2025, 9/2/2025, 9/3/2025, 9/4/2025, 9/5/2025, 9/6/2025, 9/7/2025, 9/10/2025, 9/11/2025, 9/12/2025, 9/13/2025, 9/14/2025, 9/15/2025, 9/16/2025, 9/17/2025, 9/19/2025, 9/20/2025, 9/21/2025, 9/22/2025, 9/23/2025, 9/24/2025, 9/25/2025, 9/26/2025, 9/27/2025, 9/28/2025 (a total of 25 days).During an interview on 9/29/2025 at 10:10 am, Certified Nursing Assistant (CNA) 7 and CNA8 were asked about activities being provided for residents on the secure unit. They both laughed. CNA7 and CNA8 stated activities occasionally provided ice cream or did a balloon toss activity for the residents. During an interview on 9/30/2025 at 10:30 am, Licensed Practical Nurse (LPN) 1 stated that she was the primary nurse on days for the secure unit. LPN1 stated there were no activities offered to residents on a daily basis. LPN1 said when the activities staff did come to the unit they might paint a few nails or hand out snacks then leave. During an interview on 10/2/2025 at 10:03 am, the Activities Director (AD) and AA stated they did a [NAME] toss, provided snacks, and took residents outside for activities on the secure unit. AA said she had a difficult time getting the secure unit residents to interact with her. AA stated she completed the activities listed on the calendar with the secure unit residents. AA confirmed she kept a resident log in a binder that was located on MCU in a dining room cabinet. During an interview on 10/2/2025 at 10:40 am, LPN1 pulled a white binder from the cabinet above the sink in the dining room on the secure unit. Review of the binder with LPN1 indicated each resident had a section with their name with the monthly activities calendar included. LPN1 confirmed there was an October calendar for each resident and the highlighted activities for 10/1/2025 were: 11:00 am morning exercise, 12:00 gospel music, 3:30 snacks LPN1 located R118's Activity Calendar dated September 2025 which indicated that for R118, activities were provided on 9/8/2025 (coke floats), 9/9/2025 (balloon toss), 9/18/2025 (balloon toss), 9/29/2025 (balloon toss, classic country, birthday Monday) 9/30/2025 (morning exercise, country music), however, R118 was discharged on 08/31/25. During an interview on 10/2/2025 at 10:55 am, the AD was speechless when shown that the Activity Aide (AA) had marked providing activities on 10/1/2025 for R118 who was discharged from facility on 9/10/2025. During an interview on 9/30/2025 at 1:30 pm, the AD stated that a monthly activity calendar is provided to each resident in the facility but was not based on the comprehensive assessment, care plan, social history, and preferences designed to meet the interests of each resident She stated that the activity calendar list of daily and weekly activities were not specialized specific to residents with dementia and/or special needs, and that the secure unit is provided the same activity calendar that is provided to all residents in the facility.During an interview on 10/02/2025 at 10:03 am, the AD stated that activities are provided two times a day every day. She stated that the activities provided are BINGO, church, and happy hour. She stated that one-to-one in-room activities are provided once a week. When asked what types of activities she provides for one-to-one activities, she stated that she reads them a devotion. She revealed church is the only activity provided on the weekend because there are no staff to provide activities on the weekends. She revealed there are games in the dining room residents have access to and can play. She confirmed residents who do in-room activities don't receive activities on the weekend.During an interview with the Administrator on 9/30/2025 at 2:30 pm, he stated that he assumed the AD was providing an ongoing activity program and documenting the activity preferences and choices of each resident, and implementing new interventions comprehensively discussed, documented, according to the resident rights to participate or refuse activity involvement.

Based on observations, interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure two of 31 Residents (R)(R39 and R41) were treated with dignity and respect. Specifically, the facility failed to ensure R39 was provided with incontinence care when requested and allowed to remain in a soiled brief for over two hours, the facility also failed to ensure R41 was able to have visitation in her room that was free from offensive odors. Findings include:Review of the facility policy Abuse, Neglect and Exploitation revised 3/5/2024 revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident.Review of R39's undated face sheet, found under the ''admission Record'' tab located in the Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE] for short-term rehabilitation after a traumatic fall at home with fractures and operative repair of her right elbow, wrist and right knee. Review of R39's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/20/2025 and a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R39 was cognitively intact. The MDS indicated R39 was dependent on staff for assistance with toileting. During observation and interview on 9/28/2025 at 10:30 am, R39's call light was on when the room was entered. R39's mother was visiting and they both stated this was the second time they had engaged the call light in two and a half hours requesting that R39 be provided with incontinent care. R39 said, .I'm embarrassed to lay here like this with people in the room. I'm here because I can't do it myself yet. She stated she pushed her call light two hours ago and after approximately 30 minutes a Certified Nurse Aid (CNA) entered the room, silenced the alarm and said she would be back as soon as breakfast trays were passed on the 100-hall. R39 stated she reengaged the call light about 20 minutes prior to this interview. After another 10 minutes had passed a CNA entered the room and without speaking to R39 to ask what was needed, the CNA silenced the alarm and left the room without explanation. R39 was clearly upset that she had been waiting more than two hours for the assistance she required, and that she remained soiled while her visitor was in her room. Review of R41's undated face sheet found under the admission Record tab of the EMR revealed R41 was admitted to the facility with diagnoses including bipolar disorder and chronic kidney disease. Review of her annual MDS with an ARD of 8/5/2025 revealed a BIMS score of 15 out of 15 which indicated R41 was cognitively intact. She was ambulatory with a rollator and required stand-by and set-up assist only from staff. Observation and interview on 9/28/2025 at 11:05 am, R41 was standing in the doorway to her shared room. R41 stated that her daughter was coming to visit her soon. She looked up to indicate her call light was on. She stated, she needed somebody to change her roommate before her daughter arrives. Approximately 20 minutes later, R41 continued to stand in her doorway with the call light still engaged. She said no one had stopped to help her since our earlier conversation. On 9/28/2025 at 11:30 am, Registered Nurse (RN)1 was near the 100-hall medication cart and stated they (facility) are short staffed on the weekends so they (nurses) are trying to help the CNAs as they can between medication passes. She stated she would send a CNA to assist R41 at 11:33 am.On 9/28/2025 at 11:45 am, R41 was observed ambulating toward the lobby. She stated that no one had assisted her, so she was coming up to the front to meet her daughter there instead of in her room because of the odor from her roommate's incontinence.Interview on 9/30/2025 at 8:35 am, the Administrator stated that the facility did not have a specific policy for dignity, but that it was a part of the abuse policy that residents should be treated with dignity and respect at all times. He confirmed that staff ignoring the residents' needs for timely incontinence care was not treating them with dignity and respect.

Based on observations, interviews and review of the facility policy titled, Resident Environmental Quality, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents on two of four halls (200 and 400) in the facility. This failure could negatively impact resident due to not having a sanitary, homelike living environment. Findings include:Review of the facility's policy titled, Resident Environmental Quality dated 2/16/2024 indicated, .facility to be designed, constructed, equipped and maintained to provide a safe, functional, sanitary and comfortable environment for resident.During a tour of the facility on 9/28/2025 at 10:25 am the following was observed: 1. room [ROOM NUMBER] in the bedroom, the baseboard was missing on the wall that held the sink leaving an open space between the floor and the sheetrock,2. room [ROOM NUMBER] bathroom had floor tile around the base of the toilet that was stained black in color and there were floor tiles that were missing,3. Secure unit (200 Hall) in the dining area was a blanket under the air conditioning unit to absorb liquid that was draining from the unit, a buildup of a brown/black substance around the door jams and in the corners of the wall throughout the unit, especially in the day room, During an interview on 10/02/2025 at 1:04 pm, the Maintenance Director (MD) stated that they make rounds throughout the facility to monitor for items that need to be repaired. The MD was shown the stained, cracked floor tiles and stated that they tried to replace the tiles as needed. During an interview on 10/02/2025 at 1:40 pm, the Administrator was questioned about the condition of the two halls that were observed on 9/28/2025. The Administrator stated once the remodeling is completed many of these issues will be resolved once the sale of the facility is finalized by the end of October 2025.

Based on observations, interviews, record review and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure two of four residents (R) (R33 and R14) were free from abuse; R33 from sexual abuse by R57 and R14 from physical abuse by R2.Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation revised 03/2024 revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of all residents.'Abuse' means the willful infliction of injury, confinement, or punishment with resulting harm or mental anguish.Instances of abuse, irrespective of any mental or physical condition, can cause physical harm, pain or mental anguish.This includes verbal abuse, physical, mental or sexual abuse.this includes sexual abuse with a resident who does not have the capacity to decline to participate in the sexual act.1.Review of the Administrator's investigation file revealed a written statement by Licensed Practical Nurse (LPN5) which indicated that on the secure unit on 3/25/2025 at 6:30 am, LPN5 documented, .staff went into resident's [R33] room during rounds to find male resident [R57] standing beside bed working to get his pants buttoned. Residents separated.[R33] crying and undressed.dressed by staff.when asked what happened [R33] stated, he thinks I am his wife, but I am not, I know what it's like to love someone, but I am sorry I am not his wife. When asked if she was touched R33 stated yes and pointed to her breasts and peri-area.when asked if they had sex, R33 said almost. R33 tearfully asked if she would have to leave the facility so he (R57) would leave her alone. Continued review of the facility's investigation file revealed after being discovered in R33's room on 3/25/2025, the two residents (R33 and R57) were separated and redressed by staff following the incident. A skin assessment was performed with no new findings for R33. There was no emergency room evaluation conducted for potential sexual abuse of R33. The facility investigation indicated that both residents were seen for a telehealth psychiatric evaluation the following day, and both were monitored by staff for repeated behaviors for 48 hours. No repeat behaviors were reported. The residents' representatives and their physician were notified of the incident. Review of the electronic medication record (EMR) Face Sheet under the Profile tab indicated R33 was admitted to the facility's secure unit with diagnoses of dementia with behavioral disturbance, cognitive communication deficits, and psychotic disorder. Review of R33's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 8/29/2025 indicated a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated R33 was severely cognitively impaired.During an interview with Certified Nurse Aid (CNA)1 on 9/28/2025 at 2:10 pm, CNA1 stated that both residents still wander into other residents' rooms and that R57 does at times believe the female residents are his wife. Review of R57's EMR Face Sheet under the Profile tab revealed R57 was admitted to the facility with diagnoses dementia with behaviors, visual hallucinations, and cognitive communication deficits. R57 also had severe cognitive impairment with an admission MDS with an ARD of 8/05/2025-and a BIMS score of three out of 15 which indicated R57 was severely cognitively impaired.The Medical Director (MD) was interviewed on 9/30/2025 at 4:00 pm and stated he saw both residents the following day after the incident and that he discussed the proposed medication Provera (a hormone therapy) recommended by telehealth psych consult on 3/26/2025 with R57's wife who opposed starting the new medication to repress R57's sexual urges. The MD stated he felt they were able to attain a similar positive result with another medication Rexulti (an antipsychotic medication for depression and agitation associated with Alzheimer's disease). During an interview on 9/30/2025 at 10:00 am, the Administrator was asked why the incident was not substantiated for sexual abuse for R33. He stated .because neither resident remembered the incident. 2. Review of R2's Face Sheet in the EMR under the Profile tab, revealed R2 was admitted to the facility with diagnoses of cognitive communication deficit, dementia sever, with agitation, early onset of Alzheimer's disease, and abnormalities of mobility.Review of R2's admission MDS with an ARD of 7/30/2025 located under the MDS tab of the EMR with a BIMS score of three out of 15, indicating R2 was severely cognitively impaired. Review of R14's Face Sheet in the EMR under the Profile tab revealed R14 was admitted to the facility with diagnoses of arthritis, multiple sites, unsteadiness on feet, muscle weakness, other specified polyneuropathies, morbid obesity, restless legs syndrome, conversion disorder with seizures, generalized anxiety disorder, and cardiac arrhythmias Review of R14's Quarterly MDS with an ARD of 8/05/2025 located under the MDS tab of the EMR and a BIMS score of 15 out of 15, indicating R14 was cognitively intact. Review of R2's Progress Note dated 8/23/2025 and located under the Progress Notes tab of the EMR revealed on 8/23/2025 at 17:51 (5:21PM), R2 slapped R14 on the left buttock. R14 was assessed with no redness to left buttock and returned to her room. R2 was redirected and became verbally aggressive with staff. Review of the facility's investigation report indicated that when R14 was at the nurses' station to get ice and R2 took the water pitcher from R14. The two residents got into a brief verbal argument and then R2 grabbed R14's left buttock. Staff immediately intervened and redirected R2 back to his room. The report documented that R14 was able to ambulate with the assistance of a rolling walker. R2 ambulates himself in a wheelchair and has a history of getting angry and becomes difficult to redirect. Interview with the Administrator on 9/29/2025 at 11:05 am, he indicated no resident-to-resident abuse because R2 was cognitively impaired. Interview with R14 confirmed that R2 did not harm her when he slapped her left buttock and that her buttock was a little sensitive with no redness.

Based on interviews, record reviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to report allegations of resident-to-resident abuse to the State Survey Agency (SSA) within the two hours once the facility was aware of the abuse allegation for two of four residents, Resident (R) (R14 and R12). The failure of the facility to report these incidents timely has the likelihood to lead to future unreported allegations of resident abuse.Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised on 3/5/2024, revealed the facility would implement policies and procedures to prohibit and prevent all types of abuse and neglect, Notify the appropriate agencies immediately: as soon as possible, but no later than.2 hours after discovery or forming suspicion.1.Review of R2's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed R2 was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit, dementia with agitation, early onset of Alzheimer's disease, and abnormalities of mobility.Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/30/2025 located under the MDS tab of the EMR with a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating R2 was severely cognitively impaired.Review of R2's Progress Note dated 8/23/2025 under the Progress Notes tab of the EMR, revealed the incident occurred on 8/23/2025 at 17:51 (5:21PM) and was reported to the Director of Nursing (DON). No documentation was provided to validate when the Administrator was notified of the incident.Review of R14's Face Sheet located in the EMR under the Profile tab revealed R14 was admitted to the facility with diagnoses of arthritis, unsteadiness on feet, muscle weakness, other specified polyneuropathies, morbid obesity, restless legs syndrome, conversion disorder with seizures, generalized anxiety disorder, and cardiac arrhythmias Review of R14's Quarterly MDS with an ARD of 8/5/2025 located under the MDS tab of the EMR revealed a BIMS score of 15 out of 15, indicating R14 was cognitively intact.Interview with the Administrator on 9/29/2025 at 11:05 am, he confirmed the investigation report was submitted to the SSA as the 5 Day Follow-up report submitted on 9/1/2025, nine days after the incident occurred on 8/23/2025. 2.Review of R55's Face Sheet in the EMR, Profile tab revealed R55 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, Alzheimer's disease with early onset, hearing loss, depressive episodes, dementia, moderate, with agitation, dysphagia, major depressive disorder, single episode, with psychotic features, and moderate intellectual disabilitiesReview of R55's Quarterly MDS in the EMR, MDS tab with an ARD of 9/23/2025 revealed a BIMS score of 99, indicating R55 was severely cognitively impaired and unable to complete the assessment.Review of R55's Progress Note in the EMR Progress Notes tab, dated 2/11/2025, revealed on 2/11/2025 at 6:40 am, R55's was lying in bed when his roommate, R12 was observed with his hand down R55's pants and had to be removed. An assessment of R55 was completed with no signs or symptoms of distress or discomfort. The responsible party, physician, and Administrator were notified.Review of R12's Face Sheet in the EMR Profile tab revealed R12 was admitted to the facility on [DATE] with diagnoses of generalized anxiety disorder, dementia with psychotic disturbance, other Alzheimer's disease, adult neglect or abandonment, confirmed, subsequent encounter, other persistent mood disorders, and neurocognitive disorder with Lewy bodies.Review of R12's quarterly MDS in the EMR MDS tab with an ARD of 8/26/2025, revealed a BIMS score of three out of 15, indicating R12 was severely cognitively impaired.Review of R12's Progress Note in the EMR Progress Notes tab dated 2/11/2025 revealed on 2/11/2025 at 6:40 am, R12 was observed at the bedside of his roommate. R55 had his hand down R55's pants of R55 and had to be removed by staff member. The responsible party, physician, and Administrator were notified.Interview with the Administrator on 9/29/2025 at 11:05 am confirmed the investigation report was submitted to the SSA as the 5 Day Follow-up report submitted 2/17/2025, six days after the incident occurred on 2/11/2025. He could not provide evidence that the allegation of sexual abuse was reported within two hours.

Based on resident record reviews, interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to thoroughly investigate an alleged allegation of sexual abuse for one of one resident (R) (R33) and physical abuse for one of one resident (R14) in the sample of 31 residents. The failure by the facility to failure to thoroughly investigate allegations of abuse had the potential to negatively impact residents in the facility.Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation revised 3/2024 revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of all residents.Instances of abuse, irrespective of any mental or physical condition, can cause physical harm, pain or mental anguish.this includes sexual abuse with a resident who does not have the capacity to decline to participate in the sexual act.V: Investigating abuse: An immediate investigation is warranted with any report or allegation of abuse.B: The investigation will include: 4. Identifying and interviewing all involved persons, including the alleged victim, the alleged perpetrator, and any staff or residents that may have knowledge of the allegations.1.Review of the facility's investigation completed by the Administrator dated 4/1/2025 regarding potential sexual abuse between two residents indicated R57 entered R33's room and was found by staff trying to put his pants back on. R33 was lying naked on her bed and stated, .he thinks I'm his wife and I'm not. When asked if R57 had touched her she stated yes and pointed to her breasts and peri area. When asked if they had sex she stated Almost. Review of Licensed Practical Nurse (LPN)1's written statement dated 3/25/2025 indicated, Staff went into resident's room during rounds to find male patient standing beside bed working with button to pants. Residents separated at this time, [R33 name] was crying and undressed. Staff began asking her what happened, and she stated, He thinks I am his wife, and I am not. I know what it is like to love someone, and I am sorry I am not his wife. Asked this resident if he touched her she stated yes. Asked her to point to where and she pointed to her breasts and peri area. Asked her if they had sex and she stated almost. She asked staff if she would have to leave now so he [R57] would leave her alone. Explained to her that this is not her fault and staff would make sure he didn't come back in her room.The facility's investigative file failed to include interviews with staff. There were no interviews with R33 or R57 or with other residents on the secure unit about concerns of resident-to-resident abuse. During an interview on 9/30/2025 at 10:00 am, the Administrator was asked why he did not obtain statements from other residents as a part of his investigation, and he stated because it happened on the dementia secure unit and even the residents involved (R33 and R57) said they didn't remember it.2. Review of R2's Progress Note dated 8/23/2025 under the Progress Notes tab of the electronic medical record (EMR) revealed on 8/23/2025 at 17:51 (4:21PM), R2 slapped R14 on the left buttock. R14 was assessed with no redness to left buttock and returned to her room. R2 was redirected and became verbally aggressive with staff. The investigative file lack documentation as to who reported the allegation and when the Administrator was notified of the incident.Review of R2's Face Sheet in the EMR under the Profile tab revealed R2 was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit, dementia sever, with agitation, early onset of Alzheimer's disease, and abnormalities of mobility.Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/30/2025, located under the MDS tab of the EMR, revealed R2 had a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating R2 was severely cognitively impaired. Review of R14's Face Sheet in the EMR under the Profile tab revealed R14 was admitted to the facility with diagnoses of arthritis, multiple sites, unsteadiness on feet, muscle weakness, other specified polyneuropathies, morbid obesity, restless legs syndrome, conversion disorder with seizures, generalized anxiety disorder, and cardiac arrhythmias Review of R14's quarterly MDS with an ARD of 8/5/2025 located under the MDS tab of the EMR revealed a BIMS score of 15 out of 15 which indicated R14 was cognitively intact. Review of the facility's investigation file lack statements from staff or residents that may have witnessed the incident, statement from the staff who reported the incident and did not provide evidence of further interviews of other residents or staff in the facility. Interview with the Administrator on 9/29/2025 at 11:05 am, he confirmed the investigation did not include an interview from R14, from other residents or staff members.

Based on interview, record review, and review of the facility policies titled, Transfer and Discharge, and Bed Hold Policy, the facility failed to ensure for two of two Resident (R) (R59 and R74) and Resident Representative (RR) received a written notice of transfer, and a written bed hold notice that included all the required information. In addition, the facility failed to ensure the Long-Term Care Ombudsman was notified of R59 and R74's hospital transfers.Findings include:Review of the facility's policy titled, Transfer and discharge date d 3/20/2025 indicated, .3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include the following at the time it is provided: a. The specific reason and basis for transfer or discharge.The specific location.to which the resident is to be transferred.d. An explanation of the right to appeal the transfer.to the State. e. The name, address.and telephone number of the State entity which receives such appeal hearing requests.h. The name, address, and phone number of the Office of the State Long-Term Ombudsman.10. Emergency Transfers to Acute Care.g. Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative as indicated.i. The resident will be permitted to return to the facility upon discharge from the acute care setting.Review of the facility's undated policy titled, Bed Hold Policy indicated, , It is the policy of this Center to charge the established daily rate for holding a vacant bed due to a hospital or therapeutic leave based on the criteria.The Resident and a family member or legal representative of the Resident will be notified of the Center's Bed Hold Policy at the time of admission and upon transfer from the Center.1.Review of R59's Progress Notes located under the Prog Note tab in the Electronic Medical Record (EMR) dated 9/5/2024 at 11:29 pm revealed the resident was transported to the emergency room (ER). Progress note dated 9/13/2024 at 1:30 pm confirmed the resident was readmitted back to the facility from the hospital after hip surgery. Review of R59's EMR revealed no documentation that R49 or the RR were provided with the transfer notice or bed hold policy for the hospital transfer dated 9/5/2024. During an interview with the Business Office Manager (BOM) on 10/2/2025 at 11:48 am, the BOM stated she looked in the resident's file and was unable to locate the transfer notice/ bed hold notice dated 9/5/2024.2.Review of R74's Face Sheet located under the Profile tab of the EMR revealed R74 was admitted on [DATE]. Review of R74's EMR under the Progress Notes tab dated 7/29/2025 indicated, Resident ambulating up the hallway to nurse's station. His skin noted to be pale in color. SOB [shortness of breath] with rapid respirations that were audibly heard from down the hall.Bilateral lungs with wheezing. New orders to send to ER [Emergency Room] for eval [evaluation] and TX [treatment]. EMS [Emergency Medical Services] called at 0230 [2:30 AM].EMS arrived at 0248 [2:48 AM].Review of R74's EMR under the Progress Notes tab dated 8/6/2025 indicated, Returned from.hospital via EMS.During an interview on 10/2/2025 at 11:40 am, the Administrator confirmed that the facility did not send the bed hold policy/notice to R74's resident representative (RR). The Administrator said he was not aware that the information needed to be provided to the resident and RR. During an interview on 10/2/2025 at 11:49 am, the Administrator confirmed the facility did not notify the Ombudsman of the residents being transferred to the hospital.

Based on interviews, record review, and review of the facility policy titled, Resident Assessment- RAI, the facility failed to ensure the comprehensive assessment accurately reflected Pre-admission Screening and Resident Review (PASSR) level II for one (Resident (R) 1) of two residents reviewed for PASSR level II and to ensure the comprehensive assessment accurately reflected contractures for one resident (R59) of one resident reviewed for contractures in the sample of 31 residents. R1's annual Minimum Data Set (MDS) assessment failed to document PASSAR level II. This failure had the potential to lead to a lack of services. R59's quarterly MDS assessment failed to document limited range of motion in upper extremity. This failure had the potential to lead to further worsening of contractureFindings include:Review of the facility's policy titled, Resident Assessment- RAI dated 12/24/2023 noted, this facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences using the resident assessment instrument (RAI) specified by CMS.1.Review of R1's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted with diagnoses of bipolar disorder, depression, and post-traumatic stress disorder (PTSD).Review of R1's Annual MDS located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 1/8/2025 revealed the resident did not require PASSAR level II.Review of R1's PASSAR level 1 completed on 5/8/2023 was provided by the facility and revealed the resident required a PASSAR level II that was provided by the facility and had been completed on 5/30/2024.During an interview with the MDS Coordinator (MDSC) 2 on 10/1/2025 at 4:18 pm, she confirmed R1's PASSAR II was not correctly documented on her MDS.2.Review of R59's admission Record located under the Profile tab of the EMR revealed the resident was admitted with complete paralysis (hemiplegia) and partial weakness or paralysis (hemiparesis) on his right dominant side.Review of R59's quarterly MDS located under the MDS tab of the EMR with an ARD of 8/19/2025 revealed no functional limitation in range of motion with upper extremities.During an observation of R59 on 9/28/2025 at 2:12 pm, R59's right hand was contracted. During an interview with Licensed Practical Nurse (LPN)4 on 10/1/2025 at 2:45 pm, she confirmed the resident cannot open his right hand and that it was contracted. During an interview with LPN5 on 10/1/2025 at 2:50 pm, she revealed R59 entered the facility with the contracted right hand after his stroke.During an interview with the Director of Nursing (DON) on 10/1/2025 at 2:52 pm, she confirmed the resident cannot open his hand due to contracture. During an interview with the MDSC 2 on 10/1/25 at 4:18 pm, she confirmed R59's MDS should indicate he has an impairment to his upper extremity.

Based on interview, record review and review of the facility policy titled, Comprehensive Care Plans , the facility failed to develop a comprehensive care plan for four of 31 Resident (R) (R53, R59, R12 and R2). This failure placed the resident at risk for unmet care needs, and the inability to meet their maximum practicable level of functioning.Findings include:Review of facility's policy titled, Comprehensive Care Plans with a revision date of 03/20/2025 noted, .facility to develop and implement a comprehensive person-centered care plan for each resident.ALL services that are identified in the resident's comprehensive assessment.other factors identified by the-interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, 6. The comprehensive care plan will include.to meet the resident's needs as identified in the resident's comprehensive assessment.Alternative interventions will be documented, as needed.1.Review of R53's Care Plan located under the Care Plan tab of the Electronic Medical Record (EMR) dated 2/5/2024 did not address resident's activity preference.Review of R53's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 1/21/2025 and a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicates she was cognitively intact. The MDS indicated that it was very important for R53 to do her favorite activities.During an interview with R53 on 9/28/2025 at 2:30 pm, she confirmed staff never ask her to attend activities and that they don't provide activity supplies for her to do in her room. During an observation on 9/28/2025 at 2:33 pm and 9/29/2025 at 1:30 pm, no activities occurred with R53 in her room.During an interview with MDS Coordinator 2 on 10/2/2025 at 10:28 am, she confirmed that R53's care plan failed to identify the resident's preference for activities. She confirmed that the Activities Director should document activities on the care plan.2.Review of R59's admission Record located under the Profile tab of the EMR revealed the resident was admitted on [DATE] with complete paralysis (hemiplegia) and partial weakness or paralysis (hemiparesis) on his right dominant side.Review of the R59's Care Plan located under the Care Plan tab in the EMR dated 4/24/2023 revealed the resident was not care planned for his right-hand contracture.Review of R59's quarterly MDS located under the MDS tab of the EMR with an ARD of 11/26/2024 revealed the resident has a functional limitation in range of motion with upper extremities.During an observation on 9/28/2025 at 2:12 pm, R59's right hand was contracted without a device. During an interview at this time, R59 confirmed that staff do not put a device in his hand.During an observation of R59 on 9/29/2025 at 9:58 am, he was observed with his right hand contracted without a device.During an interview with the Director of Nursing (DON) on 10/1/20025 at 2:52 PM, she confirmed the resident cannot open his hand due to contracture and that no device was present in his hand. During an interview with the MDSC2 on 10/01/25 at 4:18 PM, she confirmed R59 has impairments on his upper and lower extremities. She confirmed R59's should be care planned for his right-hand contracture and include intervention of a device be placed in the palm of his right hand.3.Review of the facility's investigation report for an incident of resident-to-resident abuse dated 2/17/2502 indicated that R12 inappropriately touched another resident. The report indicated an intervention to be immediately implemented as part of his care was for staff to provided R12 diversional activities.Review of R12's care plan revealed no diversional activities with interventions that identified what were the diversional activities to be provided as part of his care.Review of the facility's investigation report for an incident of resident-to-resident abuse dated 8/29/2025 indicated that R2 inappropriately touched another resident. The report indicated an intervention to be immediately implemented as part of his care was for staff to provided R2 diversional activities.4.Review of R2's care plan revealed no diversional activities with interventions that identified what were the diversional activities to be provided as part of his care.During an interview with the Activity Director and Activity Aid on 9/30/2025 at 1:30 pm, the Activity Director stated that she attended care plan meetings every week only to answer questions. She stated that she was not educated on the purpose of the resident's care plan or revising the care plan as resident's care needs were identified.During an interview with the Administrator on 9/30/2025 at 2:30 pm, he stated that he assumed the Activity Director was completing or updating the care plan for activities to include activity preferences and choices of each resident and implementing new interventions as residents' care needs were identified.

Based on observations, interviews, record review and review of the facility policy titled, Activities of Daily Living (ADL), the facility failed to provide timely incontinence care for two of three Residents (R) (R39 and R8) reviewed for Activities of Daily Living (ADL) in the sample of 31 residents. The facility's failure could negatively impact residents' overall feelings of wellbeing, and their willingness to socialize or participate in activities and other residents and/or staff.Findings include:Review of the facility's policy titled, Activities of Daily Living (ADL) dated 3/2025 revealed, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate.3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene.1. Review of R39's undated face sheet under the ''admission Record'' tab located in the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] for short-term rehabilitation after a traumatic fall at home with fractures and operative repair of her right elbow, wrist and right knee.Review of R39's admission Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 9/20/2025 and a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R39 was cognitively intact. The MDS indicated R39 was dependent on staff for assistance with toileting. She could help with positioning but required one staff assistance to use her bedside commode.Observation on 9/28/0225 at 10:30 am, R39's call light was on when the room was entered. R39 stated that this was the second time she had engaged the call light in two and a half hours requesting that she receive incontinent care. R39 stated, that she pushed her call light two hours ago and after approximately 30 minutes a Certified Nurse Aid (CNA) entered the room, silenced the alarm and said she would be back as soon as breakfast trays were passed on the 100-hall. R39 stated she re-engaged the call light about 20 minutes prior to this interview. After another 10 minutes had passed a CNA entered the room and without speaking to R39 to ask what was needed, the CNA silenced the alarm and left the room without explanation.Review of R39's admission care plan dated 9/15/2025 revealed she required one person assist for transfers and toileting. had a bedside commode in her room but required staff assist to transfer from the bed to the commode.2. Observation on 9/28/2025 at 11:05 am, R41 was standing in the doorway and looked up to indicate her call light was on. She stated, she needed somebody to change her roommate (R8) before my daughter arrives. There was a strong urine odor in the room and hallway. Approximately 20 minutes later, R41 continued to stand in her doorway with the call light still engaged. She said no one had stopped to help her since our earlier conversation.Review of R8's undated face sheet, found under the ''admission Record'' tab located in the EMR revealed she was admitted to the facility with diagnoses including dementia, psychotic disorder, and end stage renal disease (ESRD).Review of R8's quarterly MDS'' with an ARD of 8/5/2025 revealed a BIMS score of four out of 15 which indicated R8 was severely cognitively impaired the MDS indicated R8 was completely dependent on staff for all ADL care. She had a colostomy and wore incontinent briefs. She was care planned for incontinence care as needed.Interview on 10/1/2025 at 9:45 am, the Director of Nursing (DON) stated, she would be addressing staffing concerns first to improve the residents' overall care and their perception of wellbeing.

Based on observation, interviews, and record review, the facility failed to ensure residents admitted to the facility with a contracture were provided with the services to prevent further decrease in range of motion/mobility for one of two Resident (R) (R59).Findings include:During an observation of R59 on 9/28/0225 at 2:12 pm and on 9/29/2025 at 9:58 am, R59's right hand was contracted without a device in the palm of his hand. During an interview with R59 on 9/28/2025 at 2:12 pm, he confirmed that staff do not put a device in his contracted right hand.Review of R59's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with complete paralysis (hemiplegia) and partial weakness or paralysis (hemiparesis) on his right dominant side.Review of the R59's Care Plan located under the Care Plan tab in the EMR dated 4/24/2023 revealed there was not a care plan for resident's right-hand contracture.Review of R59's quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/26/2024 revealed a Staff Interview for Mental Status (SAMS) score of two which indicated the resident was moderately cognitively impaired. The resident had a functional limitation in range of motion with upper extremities.During an interview with Certified Nursing Assistant (CNA)5 on 10/1/2025 at 2:40 pm, she confirmed the resident cannot open his right hand and that it was contracted due to a stroke. CNA5 confirmed that the resident had no device in his hand, and that R59 should have a device in his hand to keep it open.During an interview with Licensed Practical Nurse (LPN)4 on 10/1/2025 at 2:45 pm, she confirmed the resident cannot open his right hand and that it was contracted with no device in his hand. LPN4 confirmed the resident should have a device in his hand to prevent his fingernails from leaving an imprint on the skin and to leave space in his hand.During an interview with LPN5 on 10/1/2025 at 2:50 pm, she revealed R59 entered the facility with the contracted right hand after his stroke.During an interview with the Director of Nursing (DON) on 10/1/2025 at 2:52 pm, she confirmed the resident cannot open his hand due to the contracture, and that no device was present. She confirmed the resident should have a device in his hand to keep the contracture from getting worse and to prevent injury to the palm.During an interview with the MDS Coordinator (MDSC)2 on 10/1/2025 at 4:18 pm, she confirmed he should have a care plan for his right-hand contracture and the intervention of a device placed in the palm of his hand.

Based on staff and family interviews, and review of facility documents titled, Facility Assessment Tool 2024 and the PBJ (payroll-based journal) Staffing Data Report Quarter 1 2024 (October 1, 2023, through December 31, 2023), the facility failed to ensure that the facility had adequate nursing staff. The deficient practice had the potential to affect the care provided to the 116 residents that resided in the facility. Findings include: Review of The Facility Assessment Tool (FAT) 2024 revealed the average daily census in the facility was 112 residents. The FAT revealed the average hourly staffing needs per day were 84 hours of licensed nurses providing direct care, 233 hours for nurses' aides. Review of the PBJ Staffing Data Report Quarter 1 2024 (October 1, 2023, through December 31, 2023) revealed based on the data submitted, the facility triggered Excessively Low Weekend Staffing and for a One-Star Staffing Rating (Failure to submit PBJ data by the deadline, more than 4 days in the quarter without RN (Registered Nurse) Staffing hours, failure to respond to, submit documentation for, or failure to pass a CMS (Centers for Medicare and Medicaid Services) audit designed to discover discrepancies in PBJ data). Interview on 5/30/2024 at 7:40 pm with the Director of Nursing (DON) and the Human Resources Director/Nursing Scheduler (NS) CC revealed they were both not aware of the PBJ's one-star staffing and excessively low weekend staffing rating the facility received for the first quarter of 2024. The DON stated that they stack the weekend with extra staff to help with call offs. NS CC stated that they use agency staff that helps the staffing numbers. Interview on 5/30/2024 at 7:53 pm with the Administrator, he acknowledged he was aware of the PBJ's one-star staffing rating and excessively low weekend staffing the facility received for the first quarter of 2024. He stated that they were trying to subsidize with agency staff.

Based on observations, staff interviews, record review, and review of the facility policy titled, Menus, the facility failed to serve the meal listed on the cycled menu for residents who received an oral diet from the kitchen. Specifically, the cycled menu stated ham and California vegetable blend was to be served for dinner, but instead, a sloppy joe was served. The deficient practice affected 115 of 116 residents who received an oral diet from the kitchen. Findings include: 1. Review of facility policy titled Menus updated February 2017 revealed under Policy: All residents are to receive the meal stated on the weekly menu. Meals should be prepared and served based on the cycled menu. Review of the weekly menu cycle for the week of Sunday, 5/26/2024, revealed residents were to receive glazed baked ham, pinto beans, broccoli, and cornbread. Interview on 5/29/2024 at 11:33 am with the Regional Dietitian revealed that she was aware of the residents in the facility not liking the food. 47946 2. Review of the quarterly Minimum Data Set (MDS) assessment from 4/30/2024 for R85 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating little or no cognitive impairment. Review of the admission MDS assessment from 3/4/2024 for R114 revealed a BIMS score of 14, indicating little or no cognitive impairment. Initial screening interview on 5/28/2024 at 12:02 pm with R85 revealed that on Sunday night, 5/26/2024, they were served a bag of potato chips and a spoon of watered-down sloppy joe chili on a slice of white bread. R85 revealed a time-dated photo on 5/26/2024 at 5:42 pm of the food received for dinner. The photo showed a piece of white bread with a meat sauce and a bag of chips. Initial screening interview on 5/28/2024 at 12:51 pm with R114 they stated, Sunday night's dinner was absolutely despicable, and the alternative sandwiches were thrown together in a plastic trash bag with ham deli meat that was sticky and tasted spoiled. During a Resident Council meeting on 5/28/2024 at 2:05 pm with seven alert and oriented residents (R) (R1, R5, R41, R54, R57, R70, and R89), they confirmed they received sloppy joe on a slice of bread instead of glazed ham for Sunday (5/26/2024) dinner. Interview on 5/30/2024 at 9:03 am with the Corporate Registered Nutritionist confirmed that a lot of residents were complaining about the food this past Sunday. She stated the new Dietary Manager was trying to come up with a menu committee that consists of several residents to help with menu food choices. Interview on 5/30/2024 at 4:31 pm, the Administrator confirmed he received several cellphone pictures and calls from residents and their family members regarding the dinner served on 5/26/2024. He stated when he did a walk through in the kitchen, they had plenty of ham in the cooler. He further stated they had plenty of hamburger buns to serve the sloppy joes in a decent manner. He stated when he spoke to the Cook that was responsible for serving the meal, she did not have an answer to why she served an unsuitable dinner meal. He stated, I was shocked and disappointed in her behavior because she is a seasoned kitchen cook.

Based on observations, staff interviews, and review of the facility policy titled, Resident Environmental Quality, the facility failed to provide a safe, clean, comfortable, and homelike environment in nine of 53 resident rooms on two of four halls, and in the lobby media common area. Specifically, these rooms and halls contained pests (flies), damaged floor fall strips, dirty wall sheetrock, dirty privacy curtain with missing hanging hooks, stained, brown, and damaged floor tiles, damaged bathroom toilet commodes, damaged baseboard, dirty, broken packaged terminal air conditioner (PTAC) unit vent covers, damaged soap dispensers, and crowded furniture (beds with crank adjustment) in the lobby media common area. Review of the facility policy titled Resident Environmental Quality dated 2/1/2022 indicated under Policy: It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Policy Explanation and Compliance Guidelines: 10. Maintain an effective pest control program so that the facility is free of pests and rodents. Initial screening observations on 5/28/2024 at 11:00 am in room [ROOM NUMBER] revealed flies on resident's pillow and floor, dirty wall, damaged floor fall strips, soap dispenser was unattached from the wall, sitting on the floor, dirty PTAC unit, and the bedroom sink was missing paint. Initial screening observations on 5/28/2024 at 11:15 am in room [ROOM NUMBER] revealed the floor behind the bed was dirty, flies on the bed, a big hole in the wall, sheetrock damage with a big hole next to bed B, and the bathroom toilet paper dispenser was sitting on the floor. Initial screening observations on 5/28/2024 at 11:25 am in room [ROOM NUMBER] revealed a dirty privacy curtain with brown, reddish stains, a dirty bathroom ceiling fan, damaged bathroom toilet commode with constantly running water, and flies in the room. Initial screening observations on 5/28/2024 at 11:35 am in room [ROOM NUMBER] revealed a damaged bedside cabinet dresser with missing bottom door, flies in the room, and a damaged bathroom toilet commode with constantly running water. Initial screening observations on 5/28/2024 at 11:45 am in room [ROOM NUMBER] revealed a stopped-up sink with slow drainage, flies in the room, spider webs in the windowsill, wall damage with a hole between the residents' beds, dirty wall above the soap dispenser with brownish, orange stains, and a damaged sink, detached from the countertop. Initial screening observations on 5/28/2024 at 11:55 am in room [ROOM NUMBER] revealed a broken PTAC unit vent cover, a damaged baseboard strip that was taped to the wall, and damaged wall sheetrock protruding from the wall. Initial screening observations on 5/28/2024 at 12:06 pm in room [ROOM NUMBER] revealed bugs (flies) on the mattress and dirty privacy curtains with brown stains hanging with missing hooks. Initial screening observations on 5/28/2024 at 1:06 pm in room [ROOM NUMBER] revealed damaged bathroom floor tiles with brownish, black stains. Initial screening observations on 5/28/2024 at 1:29 pm in room [ROOM NUMBER] revealed in the bathroom that the back of the toilet was removed, and missing parts were lying on the floor. Initial screening observations on 5/28/2024 at 2:15 pm in the lobby media common area revealed four residents in wheelchairs and two in geri-chairs watching television with five crank beds pushed against the wall located below the mounted television. Interviews during walking rounds on 5/31/2024 at 11:15 am with the Administrator, Assistant Maintenance Director (AMD) and Housekeeping/Laundry Director (HLD) confirmed pests (flies), damaged fall floor strips, dirty wall sheetrock, privacy curtain dirty and missing hanging hooks, damaged and stained floor tiles, damaged bathroom toilet commodes, damaged taped baseboards, dirty and broken PTAC unit vent covers, damaged soap dispensers, and crowded furniture (crank beds) in the lobby media common area. The HLD mentioned his team had completed a cleaning audit of privacy curtains on the 100-hall and were currently addressing the ones that needed attention on the 200-hall. The AMD stated the pest control service came out that week to exterminate the building, but did not know exactly what was being done for the flies. The Administrator stated due to the building being old, they have experienced a lot of flies, but never knew the pests were infesting the residents' rooms at that level. The AMD also confirmed the missing back of the commode top in room [ROOM NUMBER]. The AMD fixed the back of the toilet commode with a top cover during the walk-through. The Administrator stated the conditions of the room were unacceptable and asked the Environmental Services Director and HLD to immediately address the issues and concerns in the resident's rooms.