Every finding on record at Nathaniel Witherell, The

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the care plan was updated with interventions that specified directions for staff regarding how to prevent a resident-to-resident altercation. The findings include: Resident #1 had a diagnosis of dementia, anxiety, and adjustment disorder. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of three (3) indicating severely impaired cognition, no behaviors, and was independent with transfers and ambulation. The Resident Care Plan (RCP) dated 4/24/26 identified aggressive behaviors, and the potential to be physically aggressive related to dementia, and paranoia. Interventions directed independent ambulation, administer medications as ordered, intervene as necessary to protect the rights and safety of others, remove from situations and walk to alternate location as needed. Resident #2 had a diagnoses of dementia without behavior disturbances and agitation. admission MDS dated [DATE] identified Resident #2 had a BIMS of three (3), indicating severe cognitive impairment and no behaviors, and was independent with transfers and ambulation. The RCP dated 3/26/26 identified risk for harm self-directed or other directed. Interventions directed if resident poses a threat to self or others to notify the provider. Reportable Event dated 6/30/26 at 9:45 AM identified Resident #2 was found on the floor in the dining room. RN assessment identified no injuries. Facility investigation identified Resident #1 took hold of Resident #2 and pulled on him/her whereby he/she slowly went down on the floor. Once on the floor, Resident #1 walked away. Additional information identified prior to the incident Resident #1 and #2 were seated at the same table, and the new intervention was to keep the residents apart in common areas. Facility RE summary dated 7/7/2026 identified Resident #1 and Resident #2 were seated at a table when Resident #2 walked to the window behind Resident #1. Resident #1 then took hold of Resident #2 by the arm and pulled on him/her, whereby he/she went down on the floor and lay down. Then Resident #1 walked away. Nursing note dated 6/30/26 at 9:30 AM identified Resident #1 had an episode of aggressiveness toward another resident in the dining room after breakfast. Resident #1 pulled Resident #2 by his/her hand and walked the resident backward in the dining room, and Resident #2 fell. Record review identified Resident #1's care plan was updated on 6/30/26 to include a potential for physical aggression related to dementia, with interventions that directed the resident's triggers for physical aggression are (SPECIFY). The resident's behaviors is de-escalated by (SPECIFY), assess and address for contributing sensory deficits, and psychiatric/psychogeriatric consult as indicated. Further review failed to identify the care plan was updated with specific interventions to direct staff how to prevent further resident-to-resident incidents after the incident that occurred on 6/30/26. Resident #3 had a diagnosis of dementia and anxiety. The annual MDS dated [DATE] identified Resident #3 had a BIMS of 0 indicating severely impaired cognition, physical behaviors, and was independent with transfers and ambulation. The RCP dated 7/16/26 identified a potential to be aggressive related to dementia, and resistive or combative with care. Interventions directed to analyze triggers and what de-escalates behaviors. Facility RE dated 7/15/26 identified at 3:45 PM Resident #3 was found lying on the floor in the dining room on his/her right side. Facility investigation identified Resident #1 had pushed Resident #3 who lost his/her balance and fell. Resident #3 had gone to the table that Resident #1 was seated at with other residents, and Resident #1 got up and tried to nudge Resident #3 away from the table and pushed him/her. Resident #3 sustained a small skin tear on her/his right elbow. APRN note dated 7/16/26 at 5:56 PM identified Resident #1 had dementia, paranoia, delusions, and resistiveness to care, and was seen for an increase in behavioral symptoms due to a reported resident-to-resident altercation. The residents were separated with safety measures initiated and nursing was directed to assess both residents for injury. A psychiatric referral was requested for evaluation of worsening behaviors. Facility RE summary dated 7/28/26 identified resident will be monitored when in the dining room to ensure personal space is respected. Review of facility surveillance video on 8/13/26 at 12:57 PM identified on 7/15/26, Resident #3 walked up to a table in the dining room where Resident #1 was seated. Resident #1 then stood up and grabbed both of Resident #3's upper arms/shoulders and turned Resident #3 away from him/her and then pushed Resident #3 away. Then Resident #3 fell to the floor and fell sideways onto his/her buttocks/right side and then continued to lay flat on the floor on his/her right side. Record review identified although Resident #1 had a history of aggressive behaviors, review failed to identify the care plan included what Resident #1's behavior triggers were, and how staff should intervene if they were to witness a possible triggering event. Review identified the RCP was updated on 6/30/26 (date of the prior resident-to-resident altercation) and included the following interventions: the resident's triggers for physical aggression are (SPECIFY). The resident's behaviors was de-escalated by (SPECIFY), assess and address for contributing sensory deficits, and psychiatric/psychogeriatric consult as indicated.The RCP failed to identify what Resident #1's physical aggression triggers were and how staff would de-escalate those behaviors when they occur. Although additional record review identified the facility RE directed a new intervention to monitor residents in the dining room to ensure personal space, record review failed to identify Resident #1's care plan was updated with the intervention. The facility failed to supervise Resident #1 while in the dining room with other residents, to prevent the resident-to-resident altercation that occurred on 7/15/26. Interview and record review with the Director of Nursing (DON) on 8/13/26 at 12:20 PM identified no staff were in the dining room on 7/15/2026 when the incident occurred between Resident #1 and Resident #3. Further, the interventions added to Resident #1's RCP on 6/30/26 after the resident-to-resident incident did not address directions for staff regarding how to prevent potential further related incidents. Review of facility Care Planning Policy (undated) directed ongoing changes in residents status, shall be updated as needed (in the care plan).

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #3) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment, and failed to provide adequate supervision in a common area for a resident with a history of dementia and known aggressive behaviors to prevent a resident-to-resident altercation. The findings include: Resident #1 had a diagnosis of dementia, anxiety, and adjustment disorder. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of three (3) indicating severely impaired cognition, no behaviors, and was independent with transfers and ambulation. The Resident Care Plan (RCP) dated 4/24/16 identified aggressive behaviors, and the potential to be physically aggressive related to dementia. Interventions directed independent ambulation, monitor behavior episodes and triggers for physical aggression, assess and address for contributing sensory deficits, and psychiatric/psychogeriatric consult as indicated. Resident #2 had a diagnoses of dementia without behavior disturbances. Record review identified Resident #2 had a BIMS of one (1), indicating severe cognitive impairment. Reportable Event dated 6/30/26 at 9:45 AM identified Resident #2 was found on the floor in the dining room. RN assessment identified no injuries. Facility investigation identified Resident #1 took hold of Resident #2 and pulled on him/her whereby he/she slowly went down on the floor. Once on the floor, Resident #1 walked away. Additional information identified prior to the incident Resident #1 and #2 were seated at the same table, and the new intervention was to keep the residents apart in common areas. Facility RE summary dated 7/7/2026 identified Resident #1 and Resident #2 were seated at a table when Resident #2 walked to the window behind Resident #1. Resident #1 then took hold of Resident #2 by the arm and pulled on him/her, whereby he/she went down on the floor and lay down. Then Resident #1 walked away. Review of facility surveillance video identified Resident #2 did not hit his/her head when he/she fell. a. Resident #3 had a diagnosis of dementia and anxiety. The annual MDS dated [DATE] identified Resident #3 had a BIMS of 0 indicating severely impaired cognition, physical behaviors, and was independent with transfers and ambulation. The RCP dated 7/16/26 identified a potential to be aggressive related to dementia, and resistive or combative with care. Interventions directed to analyze triggers and what de-escalates behaviors. Facility RE dated 7/15/26 identified at 3:45 PM Resident #3 was found lying on the floor in the dining room on his/her right side. Facility investigation identified Resident #1 had pushed Resident #3 who lost his/her balance and fell. Resident #3 had gone to the table that Resident #1 was seated at with other residents, and Resident #1 got up and tried to nudge Resident #3 away from the table and pushed him/her. Resident #3 sustained a small skin tear on her/his right elbow. APRN note dated 7/16/26 at 5:56 PM identified Resident #1 had dementia, paranoia, delusions, and resistiveness to care, and was seen for an increase in behavioral symptoms due to a reported resident-to-resident altercation. The residents were separated with safety measures initiated and nursing was directed to assess both residents for injury. A psychiatric referral was requested for evaluation of worsening behaviors. Facility RE summary dated 7/28/26 identified resident will be monitored when in the dining room to ensure personal space is respected. Review of facility surveillance video on 8/13/26 at 12:57 PM identified on 7/15/26, Resident #3 walked up to a table in the dining room where Resident #1 was seated. Resident #1 then stood up and grabbed both of Resident #3's upper arms/shoulders and turned Resident #3 away from him/her and then pushed Resident #3 away. Then Resident #3 fell to the floor and fell sideways onto his/her buttocks/right side and then continued to lay flat on the floor on his/her right side. Record review identified although Resident #1 had a history of aggressive behaviors, review failed to identify what Resident #1's behavior triggers were, how staff should intervene if they were to witness a possible triggering event, and failed to supervise Resident #1 while in the dining room with other residents. No staff were visible on the video - there were three (3) residents visible sitting at the table when Resident #3 walked over to the table. Observation of the facility identified the dining room is located beyond the nursing station, not within view of the nursing station, and had windows that allowed view of the dining room from the hallway for anyone walking past the dining room. Interview and record review with the Director of Recreation on 8/13/26 at 12:04 PM identified there were no recreation activities occurring in the dining room at the time of the incident. Interview and record review with the Director of Nursing (DON) on 8/13/26 at 12:20 PM identified review of facility surveillance video footage had identified on 7/15/26 around 3:45 PM while in the dining room, Resident #3 went to the table where Resident #1 was sitting. Resident #1 then got up and pushed Resident #3 who then fell to the floor and sustained an abrasion to the right elbow and bruise to the right forearm. After the incident, both residents were evaluated by psychiatry and deemed not a danger to self or others. The DON stated no staff were in the dining room when the incident occurred. The interview failed to identify why Resident #1 was in the dining room with other residents without staff supervision. Review of facility Elder Abuse, Neglect and Prevention Policy (undated) directed in part, residents had the right to be free from abuse. Resident Right Policy directed in part, residents have the right to be free from physical, verbal, mental abuse and misappropriation.

Based on observations, review of clinical records, review of facility policy, review of facility documentation, and interviews, the facility failed to review the infection prevention control program policies and procedures at least annually; the facility failed to provide documentation of infection surveillance data collection and analysis of infection trends within the facility reports that were completed on a routine basis; the facility failed to provide documentation of environmental/infection control rounds; the facility failed to ensure appropriate disinfectant solution was used when cleaning areas and surfaces within the facility consistently by the housekeeping staff; the facility failed to ensure biohazards were emptied when filled and two sampled resident (Resident #3, Resident #17 and Resident #60) with a pressure injury, the facility failed to ensure the resident was placed on Enhanced Barrier Precautions (EBP) to ensure the appropriate PPE was utilized when providing wound care. The findings include:Review of the facility's Infection Control Program Policies and Procedure manual for the past one year and ten months with the Infection Preventionist (RN #1) on 6/10/26 at 10:36 AM PM identified that the policies and procedures manual was reviewed on 5/29/26 by the Administrator and the DNS; and on 6/1/26 by the Medical Director; and on 6/2/26 by the Infection Preventionist (IP), but failed to provide any documentation that the Infection Control Program Policies and Procedure manual was reviewed in 2025.Interview with the RN #1 on 6/10/26 at 10:36 AM identified the policy and procedure manual should have been updated and reviewed annually with a signature page attesting that it was completed, however, none was completed for 2025 as she was not in the role of the IP until June of 2025. She further identified when she started in June of 2025, she had begun to review and update a few of the policies, but not all policies were reviewed. Interview with the DNS on 6/16/26 at 6:50 AM identified it is the responsibility of the DNS, the Administrator, the Medical Director and the IP nurse to review the infection and control policies and procedures annually. He further identified the signature page would attest to the review of the existing policy, however, he was not the DNS in 2025 as he started in this position in February 2026.A request for a policy for annual review of the policy and procedure infection control program manual was not provided. The DNS identified on 6/17/26 he is not sure if there is such a policy, however, it is the practice to review and revise the infection and control program policies and procedures manual annually. Review of the facility's Infection Control Surveillance for the past one year and ten months with the Infection Preventionist (RN #1) on 6/10/26 at 10:36 AM failed to provide documentation that identifies routine surveillance infection and analysis of infection trends reports that were completed for the period of August 7, 2024, through June 2025.A request was made throughout the survey period to the IP and the DNS for the infection control quarterly meetings held during the period of August 7, 2024, through June 2025 and it was not provided.Interview with the RN #1 on 6/16/26 at 12:03 PM identified surveillance and analysis of infection trends report within the facility is complete monthly. RN #1 identified that she had not completed the June 2025 surveillance report as that was her orientation month as the position was vacant prior to her starting and she was assessing where to start. RN #1further identified she was unable to locate any documentation of monthly surveillance for the period of August 2024 through May 2025. She identified that she had called for the infection control quarterly reports presented at quarterly reports but had not received them and had only a copy of the reports she completed during her time. She further identified those reports would be the responsibility of the previous IP nurse to complete.Interview with the DNS on 6/16/26 at 6:50 AM identified typically when the IP position is vacant the DNS would take on the role to ensure the documentation is completed and the program continues, however, he could not speak for the prior DNS as to whether this was the case as he had only started working at the facility in February of 2026. He further indicated that he will be searching through to locate the infection control program documentation.Interview with the DNS on 6/16/26 at 12:15 PM identified he was unable to locate any infection control program documentation for the period of August 2024 through May 2025 as requested.Interview with RN #1 on 6/17/26 at 9:24 AM identified once policies are changed the old policy is removed from the system and Information Technology (IT) team will have to locate the older policy and she will have to find out from the DNS, however, not provided by the DNS.Request was made to the DNS on 6/17/26 for Infection Surveillance policy in placed prior to the update and he identifies that the policy should be similar, but he will find out, however, it was not provided, only the current and in effect policy.Review of the Survellance of Infections policy identified it is the facility's policy to ensure ongoing systematic collection, analysis and dissemination of data regarding community acquired and healthcare-associated infections and to determine risk factors and reduce development and transmission of infections among residents and staff. The policy and procedures further identified that the IP is responsible for tracking, monitoring and reporting healthcare associate infections in the facility, and findings and results of the surveillance process will be communicated to the multi-disciplinary team during Infection Control Committee Meetings, QAPI meetings and Medical Board meetings. Review of the facility's infection control environmental round documentation for the past one year and ten months with the Infection Preventionist (RN #1) on 6/10/26 at 10:36 AM failed to provide documentation that identifies monthly infection control/environmental rounds that were completed for the period of August 7, 2024, through June 2025.Interview with the Infection Preventionist (RN #1) on 6/17/26 at 9:24 AM identified infection control environmental/rounds are completed monthly by the infection preventionist nurse. RN #1 identified she was unable to locate any documentation of monthly infection control environmental/rounds for the period of August 2024 through May 2025. RN#1 identified she had not completed an infection control/environmental round in the kitchen and has completed on other areas in the facility. She further identified she had not completed an infection control/environmental round in June of 2025 as that was her orientation month. Interview with the DNS on 6/16/26 at 6:50 AM identified typically when the IP position is vacant the DNS would take on the role to ensure the documentation is completed and the program continues, however, he could not speak for the prior DNS as to whether this was the case as he had only started working at the facility in February of 2026. He further indicated that he will be searching through to locate the infection control program documentation.Interview with the DNS on 6/16/26 at 12:15 PM identified he was unable to locate any infection control program documentation for the period of August 2024 through May 2025 as requested.A request was made to the DNS on 6/17/26 for Infection Control Rounds policy in placed prior to the update and he identifies that the policy should be similar, but he will find out, however, it was not provided only current and in effect policy.Interview with RN #1 on 6/17/26 at 9:24 AM identified once policies are changed the old policy is removed from the system and Information Technology (IT) team will have to locate the older policy and she will have to find out from the DNS, however, not provided by the DNS.Review of the Infection Control Rounds policy and procedures identified the Infection Preventionist (IP) holds primary responsibility for designing the schedule, choosing priority area or practices to inspect/audit during clinical rounds, deciding which rounding tool to use, documenting findings and corrective actions. The policy and procedures further identified the IP (or clinical designee) will perform infection control rounds at least once a month, the rounds may be conducted by the IP alone or a team of representatives from two or more disciplines may be gathered to conduct the IC rounds together. If tools or checklist will not be used, observations or findings should be written down, and this document should be kept on file. Observation of the housekeeping cart and interview with Housekeeper #1 on 6/16/26 at 8:00 AM identified he uses the Sani-clean all-purpose cleaner to clean tables, beds, sinks in the bathroom, odor control product in the rooms and bathroom, fast glass cleaner to clean the mirrors and Zep to clean the toilet and for resident with a precaution sign outside of the room. Review of the Sani-clean multipurpose cleaner for the EPA (Environmental Protection Agency) number and it was not listed on the product; he then refers to his supervisor. He further identified this is what he uses.Review of the housekeeping supplies used to clean and disinfect the facility surfaces with the Director of Housekeeping/Housekeeping Supervisor on 6/16/26 at 8:58 AM identified he identified that they use Chlorox and Zep when there is an outbreak in the facility. A tour of the dispenser located in the housekeeping closet identified the following products Sani-clean multipurpose cleaner and sanitizer- (used to clean surfaces), Cleanse all Orange neutral all-purpose cleaner (used to clean the floors) solution bottles that did not show the EPA number (Environmental Protection Agency) which tracks hazardous materials to ensure regulatory compliance and public safety and the list of organisms which the solution kills, and fast glass (used to clean mirrors and glass). The Director of Housekeeping identified he will provide the information as it is in his office. He then provided the surveyor with another product EPA number that was not used in the facility, he then indicated that he would have to contact the supplier for the number. He identified the facility had recently changed product about 4 months ago and he is aware that when surfaces are cleaned, it should also be disinfected after it has been cleaned. Interview with Person #3 (Vice President (VP) of Sales and Operations) on 6/16/26 at 10:36 AM in the presence of the Director of Facility's and the Director of Housekeeping/ housekeeping supervisor identified his company supplies most of the cleaning products uses by the facility. He further identified that the products supplied to the facility do not have an EPA number but meet the standard. He further identified some of the products have a quad based, so it can disinfect surfaces if mixed appropriately, and does not know off the top what organism the products are effective against. The Director of Housekeeping identified he was not aware that the products the facility was utilizing for cleaning were not able to disinfect surfaces and will have to switch the products immediately to Lysol and Chlorox until the vendor can provide them with an approved EPA product. The Director of Facility also identified that the products used by the facility should have EPA number and efficacy information.Interview with the Infection Preventionist (RN #1) on 6/17/26 at 9:24 AM identified she had checked the products used for cleaning the facility and identified that the products did not have an EPA number in August of 2025 and had informed the housekeeping supervisor and others via an email, and they indicated that they were going to change the product. RN #1 identified that the purpose of using disinfectants for cleaning is to prevent infection.Interview with the Director of Facilities on 6/17/26 at 2:30 PM identified the Housekeeping Supervisor misspoke as the facility been using/order the product since January 2025 and he was not working at the facility during that time and was not aware that the products used for cleaning does not have an EPA number.Review of the Complete Room Cleaning policy identified resident rooms for dressers to clean all sides with a disinfectant cleaner, remove mattress and disinfect. In the bathroom for the sink use the proper germicide solution for cleaning, scrub and disinfect toilet bowl, clean and disinfect safety bar and paper holder, clean and disinfect light cover. Observation of the first-floor medication cart with LPN #11 on 6/9/26 at 10:30 AM identified the sharps container/biohazard was filled above the fill line indicated on the container to the actual top of the container.Interview with LPN #11 on 6/9/26 at 10:30 AM identified someone from the maintenance department would be called to remove and place a new container on the cart and it should not be filled above the line.Observation of the second-floor medication cart with RN #7 on 6/9/26 at 12:59 PM identified the sharps container/biohazard was filled above the fill line indicated on the container to the top, which she had difficulty closing the lid.Interview with RN #7 on 6/9/26 at 12:59 PM identified that the sharp container should not be filled above the line indicated on the container and she will have to call to have the container replaced.Observation of the fourth-floor medication room with RN #8 on 6/15/26 at 6:30 AM identified the sharps container/biohazard was filled above the fill line indicated on the container.Interview with RN #8 on 6/15/26 at 6:30 AM identified when the sharp container is filled it should be emptied and it done by the maintenance, she will have to let them know.Interview with the Infection Preventionist (RN #1) on 6/16/26 at 10:36 AM identified the nurses are responsible for emptying the sharps container on their cart. She further identified that the is a standard line on the container which indicates when it is filled and once it reaches that line the container should be changed.Review of the Handling of Sharps, Sharps/Sharps Containers policy identifies sharp containers are located on each medication cart, medication room, soiled utility room, laundry and clinic. The policy further identified that sharps containers will be easily accessible and must not be overfilled. Replacement containers are available by calling the clinic or supervisor. Resident #3's diagnosis included type 2 diabetes, dementia, methicillin resistant staphylococcus aureus infection, and chronic kidney disease.The quarterly MDS assessment dated [DATE] identified Resident #3 had severely impaired cognition, dependent on care with dressing, personal hygiene, chair transfers, bed mobility and non-ambulatory. The assessment further identified Resident #3 was at risk for pressure ulcers with treatments that included pressure reducing devices for chair and bed, nutrition and hydration intervention and applications of ointments/medications other than to feet.The care plan dated 3/26/26 identified Resident #3 had potential for pressure ulcer development related to immobility, bowel and bladder incontinence, refusal to get out of bed and diabetes. The interventions directed for administer treatments as ordered and monitor for effectiveness, blue foam boot to right foot for diabetic right ankle while in bed and follow facility policies/protocols for prevention/treatment of skin breakdown. Additionally, the care plan identified Resident #3 had potential/actual impairment to skin integrity of the right ankle open scabbed and right heel darkened scabbed area offload both heels at all times while in bed, and to apply ankle/heel booties at all times except for hygiene purposes.The physician order dated 5/13/26 directed for the right plantar heel pressure injury to cleanse wound with 0.125% Dakin's (1/4 strength), then apply calcium alginate with silver and cover with clean dressing daily and every 8 hours as needed.Observation on 6/15/26 at 7:00 AM failed to identify posted signage outside the resident's room identifying the need for Enhanced Barrier Precautions (EBP) which noted the need for everyone to clean their hands before entering and when leaving the room, providers and staff to wear gloves and a gown for high-contact resident care activities such as dressing, bathing, changing linens, changing briefs or assisting with toileting, showering, wound care: any skin opening requiring a dressing. Interview with the wound APRN #1 on 6/16/26 at 10:50 AM identified the area on Resident #3's right plantar heel was a chronic wound. She further identified that she received an email from the facility which indicates that residents with significant drainage, infected wounds, and wounds with purulent drainage are to be placed on EBP. APRN #1 further identified that typically the infection preventionist nurse would decide which resident is place on EBP but at this facility she was told to decide even though she was not an expert for the EBP placement.Interview and review of the EBP list with RN #1 (Infection Preventionist) on 6/17/26 at 9:24 AM failed to identify that Resident #3 was placed on EBP. RN #1 identified that the wound care specialist (APRN #1) would decide who is placed on EBP and APRN #1 is aware of the EBP guidance. She further identified that Resident #3 did not require EBP because his/her wound is stable, improved and had moderate drainage. RN #1 identified she is aware of the CMS memo and resident with chronic wounds are not place on EBP they should have a combination of drainage from the wound, a chronic wound and an infected wound. Resident #17's diagnoses included dementia with other behavioral disturbance, anxiety disorder and left hip pain.The quarterly MDS assessment dated [DATE] identified Resident #17 had moderately impaired cognition (decisions poor, cues/supervision required), was dependent for all self-care and mobility, and was always incontinent of bowel and bladder.Observation on 6/16/26 at 1:58 PM identified Resident #17 lying on the bed in his/her room. APRN#1 and NA #10 were in the room for the purpose of providing wound care. The resident's door did not contain signage indicating the resident was on EBP and personal protective equipment is required for personal care and dressing changes. Interview with APRN #1 on 6/16/26 at 10:50 AM identified Resident #17 had a chronic, worsening coccyx wound. She further identified that she received an email from the facility which indicates that residents with significant drainage, infected wounds, and wounds with purulent drainage are to be placed on EBP. APRN #1 further identified that typically the infection preventionist nurse would decide which resident is place on EBP but at this facility she was told to decide even though she was not an expert for the EBP placement.Resident #60's diagnoses included Type 2 Diabetes, Congestive heart failure, and Dementia. The admission MDS assessment dated [DATE] identified Resident #60 was moderately cognitively impaired, required partial moderate assistance with bed mobility, transfers, substantial maximal assistance with dressing and personal hygiene. The assessment further identified that the resident utilized a wheelchair for mobility and was at risk for developing pressure ulcers/injuries. The care plan dated 5/27/26 identified Resident #60 was at risk for pressure ulcer development related to decreased mobility from weakness and history of pressure ulcer with interventions that included administer treatments as ordered and monitor for effectiveness, educate the resident/family/caregivers as to causes of skin breakdown, good nutrition and frequent repositioning and to follow the facility policies/protocols for the prevention treatment of skin breakdown. On 6/2/26 the Wound care APRN#1 note identified that there was a stage #3 pressure ulcer present on the left buttocks measuring 1cm x1.5cm x0.2cm with a moderate amount of serosanguinous exudate (fluid.) Interview on 6/17/26 at 8:00AM with RN#5 identified that Resident #60 was not on EBP precautions although he/she should be for a resident with an open wound. This was missed either by herself or the charge nurse. According to RN#5 there should also have been a sign posted by the door of the resident. Interview on 6/17/26 at 9:10AM with RN#1 (Infection Prevention) that Resident #60 was not on EBP due to the fact pressure ulcers that were chronic and had copious amounts of drainage that could not be contained are who needed to be on EBP. Interview on 6/17/26 at 9:30AM with the DNS identified that Resident #60 with a stage #3 pressure ulcer should be on EBP precautions and would ensure that the resident is placed on EBP. Review of the CMS memo dated 3/20/24 identified EBP is indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds (not short-lasting wounds such as skin breaks or skin tears. Examples are chronic wounds include but are not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers.Review of the Enhanced Barrier Precautions policy directed that EBP is not indicated for all wounds. It is only indicated for those wounds that are chronic/non healing, infected, and copiously draining. EBP is discontinued when the wounds improve, infections resolve and drainage becomes containable.

Based on observations, review of clinical records, review of facility policy/procedures and interviews for 3 of 5 sampled residents (Resident #70, Resident #74 and Resident #127) reviewed for involuntary seclusion, the facility failed to ensure that nursing units not designated as secure/specialized care units allowed residents the freedom to independently exit the nursing units. The findings include: Observations on all days of the survey 6/9, 6/10, 6/15, 6/16 and 6/17/26 identified that all six nursing units in the facility were secured and required a numerical code to exit the unit. The third-floor nursing unit (capacity of 40) was identified as the secured dementia unit and had specific criteria in place for admission and care on the unit. The remaining five nursing units were not identified as secure nursing units. Interview with the DNS on 6/17/26 at 7:38 AM identified the nursing units are secured to ensure the safety of all residents and to prevent potential elopements. The DNS indicated that the facility is the residents' home and he was unaware of any resident that had a problems or concern with the process. He identified that it is in the best interest of the residents to require a numerical code to be typed into the keypads in order to leave the units. Further, he indicated that residents are not restricted in any way and simply have to ask the staff to open the door. The DNS identified that residents who are physically able to leave the unit independently have the code. Resident #70Resident #70 was admitted to the facility with diagnoses including adjustment disorder, and muscle weakness.The quarterly MDS assessment dated [DATE] identified Resident #70 had intact cognition, utilized a walker for mobility, was independent with personal hygiene, and did not exhibit wandering behaviors.The care plan dated 3/17/26 identified Resident #70 identified Resident #70 had impaired thought processes related to difficulty making decisions and the potential for adjustment issues to admission and long-term care living with interventions that included involve resident in activities that match interests and provide resident with as many situations as possible which give the resident control over the resident's environment and care delivery.a physician's order dated 5/27/26 directed that Resident #70 could go on leave of absence (LOA) with staff, family, and friends. The elopement evaluation dated 6/2/26 identified Resident #70 did not have a history of elopement or elopement attempts. Interview with Resident #70 on 6/17/26 at 9:25 AM identified that he/she is not able to leave the unit on his/her own. Resident #70 indicated that he/she did not have the code to enter into the keypad and would need help with managing the door.A review of Resident #70's clinical record failed to identify a consent to reside on a locked unit, a care plan that addressed residing on a locked unit, a physician's order directing the placement on a secured unit and/or physician's documentation that the secured unit was the least restrictive housing option for Resident #70. Resident #74Resident #74's diagnoses included mild dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.The elopement evaluations dated 2/8/26 and 5/10/26 at 10:06 AM identified Resident #74 did not have a history of elopement or attempts to leave the facility and had not verbally expressed the desire to go home or packed belongings to go home or stayed near an exit door and did not wander. The quarterly MDS assessment dated [DATE] identified Resident #74 had intact cognition, utilized a walker for mobility, and did not exhibit wandering behaviors.The care plan dated 5/26/26 identified Resident #74 had impaired social interaction and indicated impaired cognitive function related to dementia with impaired decision-making, and short-term memory loss. Physician's orders dated 6/16/26 directed Resident #74 was able to go out on therapeutic leave with medications, transfers independently with rolling walker, Review of Resident #74 clinical record failed to identify a consent, care plan, physician's order or physician documentation that the secured unit is the least restrictive housing option.Interview with Resident #74 on 6/17/26 at 9:35 AM identified that he/she does not have the code to exit the First Floor Unit. Resident #74 indicated that someone has to be with him/her to leave the unit and that staff sometimes take him/her to other parts of the building for recreation. Resident #74 identified that even if he/she had the code, he/she would need assistance because he/she is not able to physically open the door with the doorknob, the walker and the oxygen tank.Resident #127Resident #127's diagnoses included adjustment disorder with depressed mood, and dementia without behavioral disturbance.The elopement evaluation dated 1/27/26 identified Resident #127 did not have a history of elopement and did not wander. The MDS assessment dated [DATE] identified Resident #127 had intact cognition, did not exhibit wandering behavior, utilized a walker and a wheelchair for mobility, and was independent with toileting, personal hygiene and all transfers, The care plan dated 5/12/26 identified Resident #127 self-propels in the wheelchair throughout the community and may lack sense of initiative/involvement related to admission and need for adjustment to long term care living situation with interventions including attempt to involve resident with individuals who seem to bring out a more positive optimistic side of the resident and encourage independent activity and escort or transport to programs as accepted.The Physician's orders date 5/27/26 directed Resident #127 may go on leave of absence (LOA) with staff, family and friends. Review of Resident #127's clinical record failed to identify a consent, care plan, physician's order or physician's documentation that the secured unit was the least restrictive housing option for Resident #127.Interview with Resident #127 on 6/17/26 at 9:15 AM identified that he/she did not have the code to exit the nursing unit (first floor). Resident #127 indicated that he/she asks someone at the desk to let him/her out but only if he/she has something to do. Resident #127 further identified he/she needs assistance with opening the door and usually has someone with him/her when he/she leaves the unit.Interview with LPN #11 on 6/9/26 at 10:45 AM identified that the only designated secured unit is the third floor, but the first-floor unit and other unit also require a code to exit the unit. LPN #11 indicated that staff members have the code to the doors, but the residents do not have the code to the doors, and staff and visitors should not allow residents to leave the unit.Interview with the DNS on 6/9/26 at 11:43 AM identified the only secured unit is the third-floor unit but that all other units need a code to exit the floors. The DNS indicated that any resident who is alert and oriented and ambulatory can have the code to leave. Additionally, the DNS identified families have the code to exit the units if they visit the facility a lot.Interview with NA #7 on 6/10/26 at 1:00 PM identified that no resident should have the code to exit the unit. NA#7 indicated that staff know who is allowed to leave and who needs someone with them by knowing the residents. NA#7 identified that no residents on the first floor should have the code to leave the unit.Interview with LPN #8 and LPN #11 on 6/15/26 at 7:48 AM identified that if a resident is allowed to have the code to the keypad for exiting the unit, it should be designated in the resident care plan. LPN #8 and LPN #11 indicated that none of the residents on the first floor have the code for leaving because the unit is a secured unit and if a resident wanted to leave the unit they would need an escort.Interview with the Psychiatric APRN on 6/15/26 at 9:50 AM identified that the units in the facility are secured and indicated that no resident should have the code and that she is not allowed to let any resident out of the units.Interview with the Director of Social Service on 6/16/26 at 10:35 AM identified that all residents are able to leave the units but residents who have dementia will be escorted off of the units. The Director of Social Service identified that the residents do not have the code for their safety.Interview with the DNS on 6/17/26 at 7:38 AM identified there is no security at the exits of the building and they are secured or coded areas to ensure the safety of all residents and prevent potential elopement. The DNS indicated that the facility is the residents' home and he was not aware that any residents had problems or concerns with the process. The DNS identified it is in the residents' best interest that there are keypads to leave the units and indicated that residents are not restricted in any way and simply have to ask the staff to open the door. The DNS identified that residents who are physically able to leave the unit independently have the code.Interview with the DNS on 6/17/26 at 11:07 AM identified all units in the facility are secured units but only the third-floor unit is designated as the dementia unit. The DNS indicated that all units require a keypad entry to leave the unit. ]The facility policy for Resident Access/Exit, and Escort identified residents have the right to move freely within and outside the facility to the extent that such movement is consistent with the resident's assessed abilities, cognitive status, safety needs and individualized care plan and indicated that general nursing units utilize keypad access systems and access codes are available to staff and may be provided to residents, families and visitors as appropriate. The policy identified that residents who are alert, oriented, cognitively intact and assessed as capable of independent mobility may leave their unit and move throughout the facility independently. Additionally, residents who require assistance due to physical, cognitive, behavioral, or medical limitations shall be encouraged to have an escort and may require supervision as identified in their care plan. The policy indicated that resident assessments, supervision requirements, escort needs, and any restrictions on movement shall be documented in the medical record and care plan.

Based on observations, review of facility documentation, review of facility policy and interviews, for three of six medication carts, and one of six medication storage rooms, the facility failed to ensure that expired medications were removed from the medication carts and medication storage rooms and failed to ensure that medications were labeled with an open date when opened. The findings include:Observation of the first-floor medication cart with LPN #11 on 6/9/26 at 10:30AM identified that the top-drawer of the cart contained Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 base) microgram (mcg) with an open date of 5/31/25 and an expiration date of 5/31/26. Interview with LPN #11 on 6/9/26 at 10:30AM identified the night shift (11:00 PM to 7:30 AM) nurse is responsible for checking and removing expired medications from the cart. Observation of the third-floor medication cart with RN #6 on 6/9/26 at 11:20 AM identified the following:An opened bottled of Akums Antacid Tablets without an open date and a manufacture expiration date of 5/2026. An opened canister of Thick and Easy for swallowing difficulty instant food and beverage thickening powder without an opening date. The manufacturer's label on the cannister identified to store in a cool dry place and the shelf-life is stable up to 2 years from the opening date. An opened bottle of Fiber Powder Psyllium Husk without a label containing the date the medication was opened.Observation of the third-floor medication storage room with RN #6 on 6/9/26 at 11:40 AM identified in the cabinet on the wall to the right 2 boxes of Covid 19 antigen (rapid test for home use) with an expiration date of 5/31/26. Further observation identified in the fridge an open bottle of Tuberculin Purified Protein vial with an open date of 4/16/26 and a manufacture label on the container which indicates to discard opened product after 30days, which means it should have been discarded on 5/16/26. Interview with RN #6 on 6/9/26 at 11:40 AM identified the night shift (11:00 PM to 7:30 AM) identified that the pharmacy comes in and checks the medication cart for expired medication and the nurses also check for expired medications. She further identified that expired medications should not be kept in the medication cart. RN #6 identified that when medications are opened it should have a date label on the container as to when it was opened, however, it depends on the nurse who opens the container as some would place the date while some do not label the medication with the opened date. Observation of the second-floor medication cart with RN #7 on 6/9/26 at 12:59 PM identified the following:Tylenol suppository box containing 10 suppositories with an open date of 4/25/26 and a manufacture's expiration date of 1/2026, which was 5 months past the expiration date. Pantoprazole Sodium 40 milligram (mg) packets containing 6 packets with an expiration date of 1/2026, which was 5 months past the expiration date. Ketotifen Fumarate ophthalmic solution 0.035% with an expiration date of 2/2026, which was 4 months past the expiration date. Interview with RN #7 on 6/9/26 at 12:59 PM identified the medication cart is checked by the night shift nurse for expired medication and the nurses on the unit. She further identified that the residents do not use those medications; however, they should not be in the cart. Review for the Medication Cart Daily Audit completed for the first, second, and third floor medication cart from 6/7/26 to 6/8/26 identified the medication cart was checked for as needed expired medications. Interview with RN #4 (the night shift nursing supervisor) on 6/16/26 at 6:40 AM identified that the night shift nurse checks the cart nightly for expired medications and completes an audit that the cart was checked. Interview with the DNS on 6/16/26 at 6:50AM identified that medications when opened should have a date when opened on the side or top of the container such as medications in a vial as they are often expired after 30 days. The DNS further identified if the medication carts are checked nightly for expired medications then there should not have been any expired medications in the cart. Review of the Storage and Expiration Dating of Medications and Biologicals policy identified once any medications or biologicals package is opened, facility should follow manufacture/supplier guidelines with respect to expiration dates for opened medications. Facility should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. The policy further identifies if a multi-dose vial of an injectable medication has been opened or accessed (example needle-punctured), the vial should be dated and discarded within 28 days unless the manufacture specified a different date for that opened vial. The policy identifies that facility should ensure medications and biologicals that have an expired date on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier.

Based on observations, review of facility documentation, review of facility policy, and interviews the facility failed to ensure refrigerated foods were stored under sanitary conditions, failed to ensure open food items were dated to include opened/expired/use by dates, failed to ensure food temperatures were obtained in a manner to prevent cross contamination, and failed to maintain accurate dishwasher logs. The findings include:A tour of the kitchen with the Director of Dietary on 6/9/2026 starting at 10:20AM identified the following: An opened and undated 1/4 full 5-pound (lb.) bag of shredded parmesan cheese was stored in the dairy refrigerator.An opened and undated 3/4 full 5-pound (lb.) bag of shredded mozzarella cheese was stored in the dairy refrigerator.An opened and undated 1/8 full 5-pound (lb.) bag of shredded Swiss cheese was stored in the dairy refrigerator.A water puddle, approximately 12 inches x 6 inches in size, was on the floor of the dairy refrigerator near the door.Debris and dirt were on the floor of the dairy refrigerator under and behind the food storage shelves.A dust covered fan was blowing on food in the produce refrigerator. Insulation on a pipe was unraveling and had buildup of a white substance on the insulation wrap.Debris and dust were covering the food shelves inside the produce refrigerator.A brown substance was on the walls and coating the seams inside the produce refrigerator.Shelves of the walk-in refrigerator were coated with dust and debrisBrown patches of dried liquid were on the floor of the walk-in refrigerator.A staff lunch box was sitting on the left-hand middle shelf of the walk-in refrigerator.A container of raw chicken was uncovered, undated, and sitting on a shelf.One 10 lb. bag of diced celery 1/2 full was opened and not dated in the freezer.One bag of hamburger patties containing 12 patties was opened and not dated in the freezer. One bag containing 25 breakfast sausages was open and not dated in the freezer.One bag containing 20 pizza crusts was open, not sealed, and not dated in the freezer.One bag containing 10 hash browns was open and not dated in the freezer.1/2 case of frozen pancakes was open, not sealed, and not dated in the dessert freezer.1/4 bag of frozen pretzels was open, not sealed, and not dated in the dessert freezer.A white Styrofoam cup containing a liquid was sitting on a shelf of the dessert freezerA brown substance was dripping down the walls and on the seams of the cook's refrigerator.Food debris was on the floor behind the dishwasher areaFood debris and dried brown liquid were located under the gas stove Tour of the dry foods closet with the Head Chef on 6/10/2026 at 12:39 PM identified the following:2 #10 dented cans of fruit cocktail.A commercial cooking appliance approximately 4-foot x 3 foot in size and waist high, contained hot steaming water and was not covered.A dirty rag was wrapped around the pipe of a steamer unit and was approximately 18 inches from an open flame of the gas stove. Interview with the Director of Dietary identified that the facility's cooks are responsible for labelling and dating opened food stored in the dairy refrigerator and they forgot to date the bags of cheese. Additionally, he identified the puddle was from a leak in the refrigerator and a porter would be called to clean and mop the floor.Interview with the Director of Facilities identified he was not aware the refrigerator needed to be cleaned and stated the refrigerator was cleaned on a quarterly schedule. He stated rounds are conducted daily to assess issues and a work order would be placed if anything needed attention. The Director of Facilities stated no work orders for the kitchen related to cleaning of the refrigerators/freezers had been placed.Interview with the Head Chef identified that staff should not be storing their personal food items in the food storage refrigerators. She failed to identify why the lunchbox was in the walk-in refrigerator and stated that staff have their own place for their food and shouldn't be using resident food storage areas.Interview with the Head Chef identified the staff responsible for cleaning the kitchen floor and noted they cleaned today but must have missed a few spots.Interview with the Director of Dietary identified the steamer was broken and the dirty rag was to keep water from dripping on the floor. He stated due to the proximity of the open flame; the rag should have been removed and the steamer unit tagged out (of service).A request for copies of the weekly cleaning logs identified the facility failed to keep cleaning logs. Interview with the Dietary Director and Head Chef on 6/09/2026 at 11:58 AM identified a list of what needs to be cleaned within the kitchen is posted on the wall, but no sign-off sheets are utilized. He indicated that staff are instead trusted to do the work. Observation of the breakfast food tray line on 6/10/2026 at 7:41 AM with Dietary Aide #1 identified that she was not wiping her thermometer with an alcohol wipe between taking the temperatures of the items on the food line.Interview with Dietary Aide #1 identified that she should be wiping the thermometer with an alcohol wipe between taking the temperature of different food items. She stated the reason she did not clean the thermometer probe between uses was that she was nervous.Interview with the Head Chef on 6/10/2026 at 8:04 AM identified that all Dietary Aides should be cleaning the thermometer probe with an alcohol wipe or probe wipe to prevent the risk of cross contamination. Review of dishwasher logs on 6/10/2026 identified that the breakfast, lunch, and dinner dishwasher logs had been filled out for the dates 6/1/2026 through 6/20/2026 (11 days in the future had been prefilled with temperatures and signoffs). Interview on 6/10/2026 at 8:01 AM with Dietary Aide #2 identified that temperatures should be taken and recorded for the dishwasher once per shift. He was unable to identify why the dishwasher logs had already been filled out from 6/10/2026 through 6/20/2026 when those dates had not yet occurred. Interview on 6/10/2026 at 8:04 AM with the Head Chef identified her staff should be filling out the temperature logs for the dishwasher once per shift. She failed to identify why the dishwasher logs had already been filled out from 6/10/2026 through 6/20/2026 when those dates had not yet occurred and stated she would address the dishwasher logs with her staff. The facility's Kitchen Cleaning and Sanitation Program policy dated May 2026 identified, in part, that all kitchen and food preparation areas shall be maintained in a clean, sanitary, and pest-free condition at all times to prevent contamination of food, equipment, and food contact surfaces. The facility's Food Temperature Control policy dated May 2024 identified, in part, that thermometers must be sanitized before and after each use. The facility's Dishwashing policy dated May 2024 identified, in part, that food service staff are to follow all washing procedures exactly, monitor and document required temperatures and sanitizer levels, and report equipment malfunction immediately. The food service manager should review logs weekly.

Based on review of facility documentation, review of facility policy and interviews, during a review of the facility antibiotic stewardship program, the facility failed to provide documentation of the antibiotic utilization and outcome report that was collected for review at the quality assurance meetings. The findings include: Review of the antibiotic stewardship program for the past year and 10 months with the Infection Preventionist (RN #1) on 6/10/26 at 10:36 AM failed to provide any documentation related to antibiotic utilization and outcomes for the period of August 7, 2024, through June 2025. A request was made throughout the survey period to the IP and the DNS for the infection control quarterly meetings held during the period of August 7, 2024, through June 2025 and it was not provided. Interview with RN #1 on 6/10/26 at 10:36 AM identified she was not working at the facility in August of 2024 through May of 2025 and was unable to locate any infection control reports including the antibiotic utilization reports. RN #1 indicated this was the responsibility of the prior infection preventionist nurse and she was not there, so she was unable to speak to that timeframe. She identified that she had called the secretary requesting the quarterly reports as she only had the ones, she completed during her time. RN #1 further identified she had not completed the June 2025 antibiotic report because she was working part-time and that was her orientation month. RN #1 identified that this report would include the antibiotic prescribed to ensure there is an indication, duration for stop and start dates, frequency, dosage and any laboratory findings and x-ray results are included. She identified this information would be presented quarterly to the quality assurance committee and infection control committee. Interview with the DNS on 6/16/26 at 6:50 AM identified that typically when the IP position is vacant the DNS would take on the role to ensure the documentation is completed and the program continues, however, he could not speak for the prior DNS as to whether this was the case as he had only started working at the facility in February of 2026. He further indicated that he will be searching through to locate the infection control program documentation. Interview with the DNS on 6/16/26 at 12:15 PM identified he was unable to locate any infection control program documentation for the period of August 2024 through May 2025 as requested. Request was made to the DNS on 6/17/26 for Antibiotic Stewardship policies in placed prior to the update and he identifies that the policy should be similar, but he will find out, however, was not provided only current and in effect policies. Interview with RN #1 on 6/17/26 at 9:24 AM identified once policies are changed the old policy is removed from the system and Information Technology (IT) team will have to locate the older policy and she will have to find out from the DNS, however, not provided by the DNS. Review of the Antibiotic Stewardship Program policy and procedures (last annual review dated 5/29/2026) identified reports on antibiotic utilization on a monthly basis are prepared by the Infection Preventionist and Consultant Pharmacist. Antibiotic use and resistance data are reviewed in quality assurance meetings. The policy and procedure further identified the quality assurance committee (QAPI), and the Infection Prevention and Control (IPC) committee monitor whether antibiotic stewardship policies are being followed.

Based on facility documentation, and interviews, the facility failed to have a consistent designated Infection Preventionist (IP) with the required specialized training in infection control, that was responsible for the facility's Infection Control Program from the period of March 7, 2025, through June 9, 2025. The findings include:Based on facility documentation, and interviews, the facility failed to have a consistent designated Infection Preventionist (IP) with the required specialized training in infection control, that was responsible for the facility's Infection Control Program from the period of March 7, 2025, through June 9, 2025. The findings include:Review of the infection control program on 6/10/26 at 10:36 AM failed to identify any documentation with relation to monthly infection surveillance and analysis, environmental rounds, MDRO tracking, antibiotic stewardship, and quarterly infection reports for the period of August 7, 2024, through June 2025. Interview with the Infection Preventionist (IP) (RN #1) on 6/10/26 at 10:36 AM identified she had started working part-time in the role as the facility's Infection Preventionist in June of 2025. RN #1 further identified when she started in the role, the position was empty and there was no overlapping of IP. She further identified that she was unable to locate any documentation of infection control monthly surveillance and analysis reports, environmental round reports, MDRO's tracking, the annual review of policies document, and antibiotic stewardship reports. RN #1 further identified she had to start over from fresh as there was nothing there that she had to work from. She further identified that the previous IP was responsible for the infection control program and documentation. A request was made on 6/16/26 for the previous Infection Preventionist (IP) specialized training and hire dates. The facility provided on 6/16/26 a document that indicated the previous IP started working at the facility in 2020 and was separated from service on 3/7/25, when RN #1 was hired as part-time staff RN on 6/10/25. The document further identified the position for the IP was posted from 3/2025 to 9/2025 and after 6 months the job was taken down, updated and re-posted with new description in 12/2025. Interview with the DNS on 6/16/26 when this document was provided to the surveyor the DNS indicated the IP listed was the same IP at the previous survey so her certificate was checked and he was not sure if human resource would still have her paperwork. Review of the Job bulletin provided by the facility on 6/17/26 identified the IP position was posted on the following dates: an opening date of 3/11/25 and a closing date of 7/7/25; then opening date of 7/8/25 and a closing date of 9/9/25; another posting with an opening date of 12/18/25 and a closing date of 1/28/26 and last posting with an opening date of 3/25/26 and a closing date of 6/30/26. Interview with the DNS on 6/16/26 at 6:50 AM identified that typically when the IP position is vacant the DNS would take on the role to ensure the documentation is completed and the program continues, however, he could not speak for the prior DNS as to whether this was the case as he had only started working at the facility in February of 2026. He further indicated that he will be searching through to locate the infection control program documentation. Interview with the DNS on 6/16/26 at 12:15 PM identified he was unable to locate any infection control program documentation for the period of August 2024 through May 2025 as requested. Interview with the Administrator on 6/17/26 at 7:00 AM in the presence of the DNS identified they are aware that the facility should have an IP with specialized training. The Administrator identified that the position was vacant and they were actively recruiting for the position. When asked who was covering the absence of the IP, he indicated the former DNS and was unsure if she had specialized training and that he would have to ask the former DNS about the infection control reports as the facility did have an IP for some of the periods requested. When asked if the facility had an IP nurse for the period of August 2024 through March of 2025, then where is the documentation to reflect that the infection control program was being implemented, no response was provided. A request was made to the Administrator and the DNS for the former DNS contact information to obtain an interview on 6/17/26 and it was not provided. Review of the job bulletin identified in the general statement of duties that the IP is to perform professional and administrative work directing and supervising the compliance with Infection Control policies and the quality assurance policies in accordance with Federal and/or State laws and regulations and Department policy. The duties also include providing extensive program development and accurate statistical record keeping, from which required reports are compiled on a regular scheduled basis. A request for a policy regarding having a designated Infection Preventionist with specialized training on 6/17/26 and was not provided.

Based on review of clinical record, review of facility policy and procedure, review of facility documentation, and interviews for 3 of 5 sampled residents (Resident #39, Resident #102, and Resident #136) reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was assessed and offered and for 2 of 5 sampled residents, the facility failed to offer the influenza vaccine to residents (Resident #39, and Resident #102). The findings include:Resident #39 was admitted to the facility in January of 2026 with diagnoses that included non-traumatic intracerebral hemorrhage, anxiety and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #39 had intact cognition. The assessment further identified that Resident #39 pneumococcal vaccination was not up to date as the vaccine was not offered.Review of Resident #39's immunization report and clinical record failed to identify a history of receiving the pneumococcal vaccine(s) was assessed or that he/she was offered/refused the vaccine while at the facility.Interview with the Infection Preventionist (IP) (RN #1) on 6/16/26 at 12:03 PM identified she was unable to provide documentation that the pneumococcal vaccine was offered or had declined by the resident. RN #1 identified vaccines are offered to residents on admission by the admitting nurse and during the various seasons when certain vaccine is being offered such as influenza and covid-19 by nursing staff. She further identified that vaccination history is obtained on admission and if the resident is unable to provide the information their primary care physician is contacted. She further identified Resident #39 was in and out of the hospital, however, the pneumococcal vaccine (PCV 20) should have been offered to the resident and if he/she had refused the vaccine it should be documented in the record. RN #1 identified she had completed an audit which identified that this resident had not received the vaccine, which she had provide this information to nursing administration, so they are aware that the resident did not receive the vaccine. Resident #102 was admitted to the facility in April of 2024 with diagnoses that included adult failure to thrive, adjustment disorder and abnormal posture. The annual MDS assessment dated [DATE] identified Resident #102 had intact cognition. The assessment further identified that Resident #102 pneumococcal vaccination was not up to date as the vaccine was not offered.Review of Resident #102's immunization report and clinical record failed to identify a history of receiving the pneumococcal vaccine(s) was assessed or that he/she was offered/refused the vaccine while at the facility.Interview with the Infection Preventionist (IP) (RN #1) on 6/16/26 at 12:03 PM identified she was unable to provide documentation that the resident's pneumococcal vaccine history was obtained, nor was she able to locate any documentation that the vaccine offered or had declined by the resident while in the facility. RN #1 identified vaccines are offered to residents on admission by the admitting nurse and during the various seasons when certain vaccine is being offered such as influenza and covid-19 by nursing staff. She further identified that vaccination history is obtained on admission and if the resident is unable to provide the information their primary care physician is contacted. RN #1 identified she had completed an audit which identified that this resident had not received the vaccine and had provided the information of the audit to nursing administration, so they are aware that the resident did not receive the vaccine. RN #1 further identified she had only started working in the role of IP part time starting in June of 2025 and it was the responsibility of the then IP nurse and nursing to ensure this resident was offered the pneumococcal vaccine (PCV 20). Resident #136 was admitted to the facility in March of 2021 with diagnoses that included Alzheimer's disease, major depressive disorder and hypothyroidism. The annual MDS assessment dated [DATE] identified Resident #136 had severely impaired cognition. The assessment further identified that Resident #136 pneumococcal vaccination was not up to date as the vaccine was not offered.Review of Resident #139's immunization report and clinical record failed to identify a history of receiving the pneumococcal vaccine(s) was assessed or that he/she was offered/refused the vaccine while at the facility.Interview with the Infection Preventionist (IP) (RN #1) on 6/16/26 at 12:03 PM identified she was unable to provide documentation that the resident's pneumococcal vaccine history was obtained, nor was she able to locate any documentation that the vaccine offered or had declined by the resident while in the facility. RN #1 identified vaccines are offered to residents on admission by the admitting nurse and during the various seasons when certain vaccine is being offered such as influenza and covid-19 by nursing staff. She further identified that vaccination history is obtained on admission and if the resident is unable to provide the information their primary care physician is contacted. RN #1 identified she had completed an audit which identified that this resident had not received the vaccine and had provided the information of the audit to nursing administration, so they are aware that the resident did not receive the vaccine. RN #1 further identified she had only started working in the role of IP part time starting in June of 2025 and it was the responsibility of the then IP nurse and nursing to ensure this resident was offered the pneumococcal vaccine (PCV 20). Interview with the DNS on 6/16/26 at 6:50 AM identified that in May of 2026 the IP nurse (RN#1) had brought to his attention that residents were not receiving and offering the vaccine including the pneumococcal vaccine, which he had put in place for new admission to be offered and provide education about the vaccine on admission and the unit manager will validate the vaccine consent. The DNS further identified he had started working in this role at the facility in February 2026 and was not aware of what happened prior, but he knows that vaccine should have been offered with education to resident, and if the resident/responsible party declines the vaccine it should be documented. Interview with LPN #4 on 6/17/26 at 11:00 AM identified the admitting nurse or nursing supervisor is responsible for obtaining consent from resident/resident responsible party on admission. She further identified that the nursing supervisor/nurse would obtain vaccination history from the hospital discharge paperwork or from the resident's family member (responsible party). LPN #4 identifies that once consent is obtained, a physician's order is obtained, and the vaccine is ordered from pharmacy then administered to the resident when received. She further identifies if the resident refuses the vaccine or is given the vaccine it would be documented in the immunization tab in the electronic medical record.Request was made to the DNS on 6/17/26 for Resident Pneumococcal Vaccine policies in placed prior to the update and he identifies that the policy should be similar, but he will find out, however, was not provided. Interview with RN #1 on 6/17/26 at 9:24 AM identified once policies are changed the old policy is removed from the system and Information Technology (IT) team will have to locate the older policy and she will have to find out from the DNS, however, not provided by the DNS. Review of the Resident Pneumococcal Vaccination (last annual review dated 5/29/2026) identifies that the facility policy is to offer the pneumococcal vaccine to all residents as part of routine vaccination. The policy and procedure further identified that a consent form will be used to document consent or declination, and refusals will be documented in the progress notes as well as in the immunization tab of the electronic medical record. Resident #39 was admitted to the facility in January of 2026 with diagnoses that included non-traumatic intracerebral hemorrhage, anxiety and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #39 had intact cognition. The assessment further identified that Resident #39 had not received the influenza vaccine with none of the given reason was selected. Review of Resident #39's immunization report and clinical record failed to identify an influenza vaccine consent was obtained for the 2025 to 2026 formula. In addition, the clinical records failed to identify that he/she had received the influenza vaccination at the facility or had refused the vaccine in the fall when the facility was providing the vaccine to the residents. Interview with the Infection Preventionist (IP) (RN #1) on 6/16/26 at 12:03 PM identified the resident was not offered the vaccine when admitted to the facility as at the time the resident was a short-term rehab patient. RN #1 further identified the influenza vaccine should have been offered to all residents, however, they had not received clear guidance from management on offering all residents within facility the influenza vaccine, as at the time short-term residents were not being offered the influenza vaccine, hence why he/she was not offered the vaccine to the resident.Interview with the DNS on 6/16/26 at 6:50 AM identified he had only started working as the DNS in February of 2026 and every resident should be offered the influenza vaccine even the short-term residents. The DNS further identified that vaccination status of the resident was unknown and family would provide the resident's vaccine information, but moving forward they are planning to use one form to include all vaccines that are being offered by the facility. Resident #102's diagnoses included adult failure to thrive, adjustment disorder and abnormal posture. The annual MDS assessment dated [DATE] identified Resident #102 had intact cognition. The assessment further identified that Resident #39 had not received the influenza vaccine with none of the given reason was selected.Review of Resident #102's immunization report and clinical record failed to identify an influenza vaccine consent was obtained for the 2025 to 2026 formula. In addition, the clinical records failed to identify that he/she had received the influenza vaccination at the facility or had refused the vaccine in the fall when the facility was providing the vaccine to the residents. Interview with the Infection Preventionist (IP) (RN #1) on 6/16/26 at 12:03 PM identified the resident was not offered the influenza vaccine even though the resident was in the facility. RN #1 identified she had completed a vaccine audit, which had indicated that Resident #102 had not received/offered the influenza vaccine and had told the then DNS and ADNS. RN #1 further identified it was their responsibility to follow-up on the information as the facility hosted a vaccination drive, which those nurses who were apart of the drive was responsible for offering, obtaining and administering the influenza vaccine. Interview with the DNS on 6/16/26 at 6:50 AM identified he had only started working as the DNS in February of 2026 and every resident should be offered the influenza vaccine even the short-term residents and this was done prior to his employment start time. Request was made to the DNS on 6/17/26 for Resident Pneumococcal Vaccine policies in placed prior to the update and he identifies that the policy should be similar, but he will find out, however, was not provided. Interview with RN #1 on 6/17/26 at 9:24 AM identified once policies are changed the old policy is removed from the system and Information Technology (IT) team will have to locate the older policy and she will have to find out from the DNS, however, not provided by the DNS. Review of the Resident Influenza Vaccination policy (last annual review dated 5/29/2026) identified the facility policy is to offer influenza vaccine to all residents during the months of October to May. The policy and procedure further identify to document a consent or declination to vaccination; a consent form will be used.

Based on review of the clinical record, review of facility documentation, facility policy/procedures, and interviews for 2 of 5 residents (Resident #39 and Resident #102) reviewed for immunizations, the facility failed to ensure that the COVID-19 booster vaccination was offered to residents. The findings include:Resident #39 was admitted to the facility in January of 2026 with diagnoses that included non-traumatic intracerebral hemorrhage, anxiety and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #39 had intact cognition. The assessment further identified that Resident #39 was not up to date with his/her covid-19 vaccine.Review of Resident #39's immunization report and clinical record failed to identify a covid-19 vaccination consent was obtained for the 2025 to 2026 formula. In addition, the clinical records failed to identify that he/she had received the covid-19 vaccination outside of the facility or at the facility or had refused the vaccine.Interview with the Infection Preventionist (IP) (RN #1) on 6/16/26 at 12:03 PM identified the resident was not offered the vaccine when admitted to the facility as at the time the resident was a short-term rehab patient. RN #1 further identified the covid-19 vaccine should have been offered to all residents, however, they had not receive clear guidance from management on offering all residents within facility the covid-19 booster vaccine as at the time short-term residents were not being offered the covid-19 booster, hence why he/she was not offered the vaccine.Interview with the DNS on 6/16/26 at 6:50 AM identified he had only started working as the DNS in February of 2026 and every resident should be offered the covid-19 booster vaccine even the short-term residents. The DNS further identified that vaccination status of the resident was unknown and family would provide the resident's vaccine information, but moving forward they are planning to use one form to include all vaccines that are being offered by the facility. Resident #102's diagnoses included adult failure to thrive, adjustment disorder and abnormal posture. The annual MDS assessment dated [DATE] identified Resident #102 had intact cognition. The assessment further identified that Resident #39 was not up to date with his/her covid-19 vaccine.Review of Resident #102's immunization report and clinical record failed to identify a covid-19 vaccination consent was obtained for the 2025 to 2026 formula. In addition, the clinical records failed to identify that he/she had received the covid-19 vaccination outside of the facility or at the facility or had refused the vaccine.Interview with the Infection Preventionist (IP) (RN #1) on 6/16/26 at 12:03 PM identified the resident was not offered the influenza vaccine even though the resident was in the facility. RN #1 identified she had completed a vaccine audit, which had indicated that Resident #102 had not received/offered the covid-19 vaccine and had told the then DNS and ADNS. RN #1 further identified it was their responsibility to follow-up on the information as the facility hosted a vaccination drive, which those nurses who were apart of the drive was responsible for offering, obtaining and administering the influenza vaccine to residents. Interview with the DNS on 6/16/26 at 6:50 AM identified he had only started working as the DNS in February of 2026 and every resident should be offered the influenza vaccine even the short-term residents and this was done prior to his employment start time. Request was made to the DNS on 6/17/26 for Resident Covid-19 Vaccination policies in placed prior to the update and he identifies that the policy should be similar, but he will find out, however, was not provided. Interview with RN #1 on 6/17/26 at 9:24 AM identified once policies are changed the old policy is removed from the system and Information Technology (IT) team will have to locate the older policy and she will have to find out from the DNS, however, not provided by the DNS. Review of the Resident Covid-19 Vaccination policy (last annual review dated 5/29/2026) identified the facility policy is to offer COVID-19 vaccination to all residents as a part of the facility's Resident Routine Vaccination Program. The policy/procedure further identifies that a consent form will be used to document a consent or declination to vaccination.

Based on review of facility documentation, review of facility policy/procedures and interviews for 3 of 6 medication carts reviewed for medication storage and labeling, the facility failed to ensure that controlled medications were reconciled (assurance of the medication count being correct) with each shift change, failed to ensure controlled medications were kept under double lock, and failed to implement a system for controlled substance reconciliation to ensure accurate reconciliation on controlled substances in the facility. The findings include:Review of the Narcotic Drug Change of Shift Audit for the first-floor medication cart for the month of June/2026 with LPN #11 on 6/9/26 at 10:30AM identified she did not sign the oncoming day shift nurse section of the narcotic drug change of the shift audit. LPN #11 identified that she had gotten busy and had not signed that she and the off-going nurse counted and reconciled the controlled medication count. She identified that she should have signed because it indicates that the controlled medication count was accurate and the medications were reconciled. Review of the Narcotic Drug Change of Shift Audit for the third-floor medication cart for the month of June/2026 with RN #6 on 6/9/26 at 11:20 AM identified she did not sign the oncoming day shift nurse section of the narcotic drug change of shift audit. RN #6 identified she should have signed the narcotic controlled-drug change of shift audit in the day shift on-coming nurse section when she and the off going nurse counted and reconciled the medication. She further identified that at the start of the shift she had a resident that was found with a laceration, and they counted so she should have signed. Observation on 6/9/26 at 11:20 AM of the third-floor medication cart with RN #6 after the completion of her morning medication administration identified the medication cart parked next to the nurse's station and RN #6 seated at the nurse's station. RN #6 then unlocked the medication cart and proceeded to open the narcotic/controlled substance box within the cart identified the lid was not secured with a key. Interview with RN #6 on 6/9/26 at 11:20 AM identified she had locked the medication cart and was nearby hence why she did not lock the narcotic box within the medication cart. RN #7 when asked should the narcotic controlled box within the cart be kept under double and she responded yes and identified she should have locked the narcotic controlled boxReview of the medication cart Narcotic Drug Change of Shift Audit for the 3rd floor for the period of March 2026 through June 9, 2026, identified a total of nine missed signatures. The signatures are used to indicate that the controlled medication count was conducted and reconciled. Review of the Narcotic Drug Change of Shift Audit for the fourth-floor medication cart for the month of June/2026 with RN #8 on 6/15/26 at 6:30 AM identified in the section of the audit for the off-going nurse for nights was already signed by RN #8. She identified she was not supposed to sign yet as she should have signed at the end of the shift when she reconciles the medication with the oncoming nurse for the day shift. She further identified that her shift ended at 7:30 AM and she was not working the next shift. Review of the medication cart Narcotic Drug Change of Shift Audit for the 4th floor for the period of March 2026 through June 9, 2026, identified a total of four missed signatures. The signatures are used to indicate that the controlled medication count was conducted and reconciled. Interview with the DNS on 6/15/26 at 6:47 AM identified the narcotic drug change of shift audit should be signed when the off going and oncoming nurses count and reconcile the controlled medications. He identified he was new to the facility, but the practice is typically to sign the audit when the off-going and oncoming nurse count and reconcile the controlled medications not before to indicate the count is correct. Review of the Storage and Expiration Dating of Medications and Biologicals policy identified controlled substances storage the facility should store Schedule II-V controlled substances in a separate compartment within the locked medication carts and should have a different key or access device. The policy further identified that controlled medications must be counted with another designated staff member when there is an exchange of keys.Observation with RN#2 of the 1st floor medication room and emergency-controlled substances on 6/15/26 at 7:48 AM identified that 4 of 33 Controlled Substance Disposition Records (CSDR) were not reconciled which is the process by which the facility tracks the usage and destruction of controlled substance medication that is received into the facility. These include:Alprazolam 0.25 mg tablets received into the facility 7/30/34 and should have one remaining. Lorazepam Concentrate 2mg/1ml 30 milliliters (ml) received into the facility 2/25/25 with no documented administrations on the CSDR.Zolpidem 5mg tablets received into the facility on 7/30/24 and should have one remaining.Hydromorphone 2mg tablets should have 2 remaining and received into the facility 7/30/24. Interview with the ADNS on 6/15/26 at 8:30 AM identified that her process for the bi-monthly reconciliation (twice per month) of the controlled substances includes counting each controlled medication in the Omnicell with another supervisor and if there is a discrepancy the computer will alert them. The ADNS indicated that the night supervisor conducts the reconciliations for the controlled substances medication in use on the units. The ADNS identified that the pharmacy identified that the reconciliation process was not being completed at the facility and she had been taught by the previous ADNS how to complete the destruction of the meds and the Omnicell reconciliation. This process started in April 2025, as should not speak to previous process. Interview with RN#2 on 6/15/26 at 9:00 AM identified that the ebox (emergency) controlled medication are reconciled by the night shift supervisor. RN#2 indicated there was a pharmacy change (unable to date) and the medication was removed and then destroyed. RN#2 could not identify why the outstanding CSDRs were still present in the in use-controlled substance book. RN#2 indicated that the nurses were told to only leave the liquid medication sheets in the book so that when they take the medication from the ebox they can use the CSDR to document administration.A request was made on 6/15/26 for the bimonthly control drug audit for the period of August 7, 2024, through June 15, 2026, completed throughout the facility. The facility only provided bimonthly audits completed of the Omnicell (emergency-controlled drug storage) for the period of April 2025 through June 2026. Interview with RN supervisor (RN#4) on 6/16/26 at 6:40 AM identified the bimonthly controlled substance medication reconciliations are completed on the 1st and the 15th of every month (twice every month in the beginning and the ending usually) by the nurse on the floor and the supervisor. RN#4 indicated the process for reconciliation was to count the controlled substance medications on each of the carts with the nurse on shift. RN#4 identified that she does not take the binder of the duplicate CSDR when completing the audit, and if there is a controlled substance that had been completed or needed to be destroyed, she collects the sheet and the medication and turns the medication over to the DNS with both CSDR sheets and matches any zeroed paper with the duplicate CSDR in the binders. RN#4 indicated the reconciliation process was new for the facility because they were told that the reconciliation must be done, so she does not have past audits.Observation of the Controlled Substance Disposition Record binder with the Nursing Supervisor (RN#2) on 6/17/26 at 12:30 PM identified the binder was organized by unit with duplicate CSDRs and contained several CSDRs that were old CSDRs that should be completed or belonged to residents no longer at the facility. A sample of 25 CSDRs out of 170 CSDRs from the reconciliation binder were pulled for reconciliation. The facility was not able to provide documentation of reconciliation for the 25 CSDRs reviewed during the survey period. The outstanding CSDRs were as follows:Pregabalin 300 mg capsules 20 caps received into the facility 11/6/24Hydromorphone HCL 2mg tablets 30 tablets received into the facility 12/12/24Pregabalin 25 mg capsule 14 capsules received into the facility 9/5/24Oxycodone IR 5 mg tablet 30 half tabs received into the facility 8/25/24Oxycodone HCL IR 5 mg tab 30 tabs received into the facility 2/21/26Acetaminophen Codeine #3 300mg-30mg 30 tabs received 1/28/25Lorazepam 0.5 mg tablets 30 tabs received 6/19/25Oxycontin tablet 10 mg ER 30 tabs received 8/6/23Oxycodone 5mg IR 30 half tablets received 6/17/25Hydromorphone HCL 1mg/1ml 7ml received 12/09/25Oxycodone tab 5mg 20 tabs received 2/24/24Methylphenidate ER 18 mg 30 tabs received 12/17/25Lorazepam 2mg tablet 30 tabs received 11/21/25Methylphenidate ER 18mg tab 30 tabs received 11/21/25Tramadol HCL 25mg tab 21 tabs 1/20/26Pregabalin 100mg capsule 60 caps received 2/5/26Tramadol 50mg tablets 30 tabs received 10/13/25Alprazolam tab 0.5 mg 30 tabs received 2/2/24Pregabalin capsule 300 mg 30 caps received 5/10/24Alprazolam tablet 0,5mg 30 tablets received 4/28/24Tramadol HCL 25 mg tablet 30 tabs received 9/23/25Tramadol HCL 25 mg tablet 60 tabs received 8/8/25Tramadol HCL 50 mg 30 tabs received on 6/3/24Tramadol HCL tablet 50 mg 30 half tabs received (no received date and no signature under received by)Tramadol HCL tablet 50 mg 60 tablets received 6/20/24Interview with the DNS on 6/17/26 at 12:45 PM identified that he was not accustomed to the process of the reconciliation done at the facility and was not aware that the reconciliation process was not done using the duplicate CSDR binder to verify medications brought into the facility were accounted for. The DNS indicated that the reconciliation should include taking the duplicate CSDR binder to each unit and verifying each controlled substance is still in use in the facility and the count and date documented on the duplicate CSDR.Review of the Routine Reconciliation of Controlled Substances policy identified that to conduct a routine reconciliation of controlled substances, the facility staff should compare the total number of doses originally dispensed by the pharmacy to the number of doses remaining to the number of doses recorded as remaining on the medication-specific declining inventory sheet to the number of doses administered according to the resident's medication administration record. The policy further identified when conducting the reconciliation, one nurse should perform the actual count while the second nurse records the resident name, room number, name, strength, and dosage form of the controlled substance, prescription number and quantity dispensed by the pharmacy, the number of tablets, capsules, volume (i.e., milliliters), or other dosage units remaining in the current inventory, the number of tablets, capsules volume (i.e., milliliters), or other dosage units remaining according to documentation on the declining inventory sheet, the number of tablets, capsules, volume (i.e., milliliters) or other dosage units administered according to the resident's medication administration record, both nurses should sign the reconciliation worksheet and retain the worksheet per facility policy for controlled substance records.

Based on observations, review of the clinical records, review of facility documentation, review of facility policy/procedures and interviews for 2 of 6 sampled residents (Residents #3 and #17) reviewed for pressure injuries, the facility failed to ensure wound care orders were transcribed and implemented, failed to ensure accurate skin and pressure risk assessments and failed to ensure interventions were implemented (turning and repositioning) and documented to prevent the development and worsening of a pressure ulcer. The findings include: Resident #3's diagnoses included type 2 diabetes, dementia, methicillin resistant staphylococcus aureus infection, and chronic kidney disease. The quarterly MDS assessment dated [DATE] identified Resident #3 had severely impaired cognition, was dependent on staff for dressing, personal hygiene, transfers, and bed mobility. The assessment further noted the resident was non-ambulatory, was at risk for pressure ulcers, did not have any current pressure ulcers and had pressure reducing devices for the chair and bed. The Braden Scale (determines the risk of developing pressure ulcers) dated 3/4/26 identified Resident #3 scored 13 which indicated Resident #3 was at moderate risk for the development of a pressure ulcer (a score of 9 or below indicates very high risk, 10 to 12 indicates high risk, 13 to 14 indicates moderate risk, 15-18 indicates mild risk and 19-23 indicates no risk). The care plan dated 3/26/26 identified Resident #3 had the potential for developing and/or actual pressure ulcers present related to immobility, bowel and bladder incontinence, refusal to get out of bed and diabetes. The interventions directed to administer treatments as ordered, monitor for effectiveness, apply blue foam boot to right foot for diabetic ulcer to the right ankle while in bed and to follow facility policies/protocols for prevention/treatment of skin breakdown. Additionally, the care plan identified Resident #3's right ankle had a scabbed area, and the right heel had a darkened scabbed area. Interventions directed to offload both heels at all times while in bed, and to apply ankle/heel booties at all times except for hygiene purposes. The Wound APRN's progress note dated 3/20/26 at 3:54 PM identified Resident #3 was seen on 3/17/26 for an initial wound assessment of the right plantar heel and identified the wound was an unstageable pressure ulcer measuring 1.0 centimeter (cm) in length by 1.5cm in width with 50-74% slough in the wound base with a moderate amount of serosanguinous yellow exudate. The note further identified the resident had a reopened stage 2 pressure ulcer to the right lateral ankle measuring 0.5cm in length by 0.6 cm in width by 0.2 cm in depth with moderate amount of serosanguineous drainage. The Wound APRN's progress note dated 3/24/26 at 7:22 PM identified the pressure ulcer to the right lateral ankle had resolved (healed). The physician's orders for the month of June/2026 directed to apply a protective foam dressing to the right lateral ankle as needed every 3 days for redness, keep bilateral heel and ankle booties on at all times and remove for care every shift for offloading pressure, off load right foot on pillow, perform weekly skin assessments on shower days every Tuesday. Observation on 6/9/26 at 10:45 AM identified Resident #3 lying in bed and appeared to be sleeping with his/her feet hanging off the bed without the use of the ankle/heel boots. Observation on 6/10/26 at 9:45 AM identified Resident #3 lying in bed and appeared to be sleeping with his/her feet on the bed without the benefit of the ankle/heel boots. Observation on 6/15/26 at 9:09 AM identified Resident #3 lying in bed with his/her feet off loaded with a pillow without the benefit of the ankle/heel boot. Review of the Treatment Administration Record (TAR) for the period of May/2026 through June 16, 2026, identified the order for the protective boots. The TAR indicated Resident #3 had the boots in place on 5/8/26 (day shift), on 5/17/26 (night shift), there was no notation documented for 6/3/26. All other days were notated as administered. Further review of the TAR for the period of April 2026 through June 16, 2026, identified that the protective foam dressing had not been applied to the right lateral ankle for redness. Review of the nurse's notes for the period of May 2026 through June 16, 2026, did not contain documentation that Resident #3 refused to wear the heel protection boots. The weekly skin assessment dated [DATE] at 7:16 AM did not identify any new skin impairments. Observation with the Charge Nurse (LPN #3) on 6/16/26 at 7:20 AM identified Resident #3 lying in bed. The resident had a sock in place to the right foot that covered the ankle and the heel of the sock was padded. The resident did not have the protective boots in place as ordered. LPN #3 removed the sock and noted a reddened area to the right ankle with a small tan colored area towards the center of the redness, and a dressing was in place to the right heel. LPN #3 identified that there was a treatment ordered for the right ankle. LPN #3 further identified Resident #3 should have the protective boots on, and noted the boots were in the resident's bathroom. Interview with LPN #3 on 6/16/26 at 7:25 AM identified Resident #3 should be wearing the protective boots but noted that he/she refuses to wear the boots at times. LPN #3 who is the regular charge nurse on the day shift identified, after reviewing the TAR that he had not documented the resident's refusals to wear the heel protective boots, and the TAR reflected documentation that the boots were in place on a consistent basis. LPN #3 further noted that last Monday (6/8/26) he noticed redness to the right ankle where the resident had previously had a pressure ulcer wound. LPN #3 further identified that he applied the foam dressing to the area but was unable to provide documentation in the TAR that he applied the treatment as ordered for redness. LPN#3 identified that he has documented on the TAR that the protective boots were applied but should have noted when the resident refused the boots. LPN #3 identified that the boots should be utilized to aide in the healing of the wounds on the heel and ankle. LPN #3 further identified that he noticed redness to the right ankle last Monday and believes the APRN was made aware. When asked to show the communication about the redness to the resident's right ankle. LPN #3 identified it should be written in the APRN's communication book and in the nurses' note. Upon review of the APRN's communication book and the nurse's note, they both failed to reflect that Resident #3 had increased/redness to the right ankle. LPN #3 further identified that he had applied the foam dressing to the area but was unable to provide documentation in the TAR that he had applied the treatment as ordered for redness. Subsequent to surveyor's inquiry on 6/16/26 the boots were applied to the resident's feet and observation throughout the day on 6/16/26 at 9:00AM, 11:30 AM and 2:20 PM identified the resident kept the boots in place. Interview with LPN #2 on 6/16/26 at 10:04 AM identified that she noticed the redness prior to that day and had applied skin prep to the area, however, the resident does not have a physician's order to apply skin prep to the right ankle. She further identified the right ankle looks redder today than before and the resident will be seen by the wound APRN today. LPN #2 identified Resident #3 should be wearing the blue boots and the resident has been wearing the padded sock since his/her. She further identified that the boots are used to prevent openings and should be worn all the time. Interview with the wound APRN (APRN #1) on 6/16/26 at 10:50 AM identified Resident #3 currently has a stage three pressure ulcer to the right plantar heel which was first identified on 3/17/26. APRN #1 further identified that she is not aware of Resident #3 having an opened area to the right ankle currently as it was healed. APRN #1 further identified that the heel sock would not prevent openings to the ankle but wearing the boots would prevent the resident from developing wounds to the ankle. Observation with APRN #1 on 6/16/26 at 2:20 PM identified Resident #3 lying in bed. APRN #1 performed hand hygiene, donned gloves, assessed the area to the right ankle and noted redness measuring 1.0 centimeter in length by 1.5 cm in width, slough and classified the wound as an unstageable pressure ulcer. The wound progress note written by APRN #1 dated 6/16/26 at 11:37 PM identified Resident #3 was evaluated for a wound to the right lateral anklet that was determined to be an unstageable pressure injury measuring 1.0cm in length by 1.5cm in width, the wound base was 50% fibrin and 50% epithelial, the peri wound had erythema with no amount of drainage to the wound. The Prevention of Pressure Ulcers/Injuries policy directed to review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The policy further identified to inspect skin on a daily basis when performing or assisting with personal care or ADLs and to evaluate, report and document potential changes in the skin. Resident #17 was admitted to the facility with diagnoses including dementia with other behavioral disturbance, depressive episodes, anxiety disorder and age-related osteoporosis and left hip pain. Review of the Nutritional assessment dated [DATE] identified Resident #17 had intact skin. The Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #17 had moderately impaired cognition (decisions poor, cues/supervision required), had impairment on both sides of the lower extremities, was dependent for all self-care and mobilities and was always incontinent of bowel and bladder. The MDS identified Resident #17 was at risk for pressure injury development but did not have any pressure injuries and indicated Resident #17 had pressure reducing devices for the chair and bed and had an application of ointments/medications other than to the feet. Review of APRN progress note by APRN dated 2/16/26 at 6:35 PM identified Resident #17 denied skin breakdown, rashes or wounds. The Care plan dated 2/17/26 identified Resident #17 had a communication problem r/t dementia, anxiety and dx of dysphonia and had a potential or actual impaired skin integrity related to a decline in ability to perform activities of daily living and bladder incontinence related to impaired mobility and dementia with interventions including anticipate and meet needs and be conscious of resident position when in groups/activities for communicating, assist to turn and position every 2 hours as needed and a pressure relief mattress and wheelchair cushion (this was initiated on the care plan on 5/9/18). Physician's orders dated 2/26/26 directed to apply zinc ointment to buttocks and intergluteal folds with incontinent care every shift and directed use of a Pressure reduction mattress originally ordered 7/23/23. Observation of Resident #17 on 6/10/26 at 9:40 AM identified Resident #17 was laying primarily on the back with a pillow propped under the right side back and buttock. Observation of Resident #17 on 6/15/26 at 10:45 AM identified no EBP signage on the resident room door. Resident #17 was laying primarily on the back with pillows propped under the right side back and buttock and a pillow between the legs. Observation of Resident #17 on 6/16/26 at 1:58 PM with the wound care specialist APRN#1 and NA #10 with wound care. Wound care provided included cleansing wound with Dakin's solution and application of Santyl and calcium alginate to the wound bed covered by a foam bordered dressing. Wound Care Orders and Treatments Review of APRN#2 (facility medical APRN) progress note dated 3/11/26 at 12:42 PM identified Resident #17 was seen for an evaluation of a wound to the coccyx region likely related to pressure and moisture exposure measuring approximately 0.5 cm x 0.5 cm and indicated an early pressure injury at stage 2 with treatment orders to cleanse wound with normal saline during dressing changes and apply calcium alginate dressing to coccyx wound and to cover with foam dressing for protection. The treatment orders directed to reposition patient every 2 hours while in bed, pressure redistribution cushion while sitting and avoid prolonged sitting greater than 1 hour without repositioning and maintain skin barrier cream (zinc oxide) to surrounding area to protect from moisture, prompt incontinent care and monitor wound size, drainage, erythema and pain. The note identified Resident #17 was at increased risk for skin breakdown with directions for a daily skin inspection. The note indicated that staff were educated on pressure injury prevention protocol, repositioning schedule, and wound monitoring, increase in wound size, drainage, redness or signs of infection. Review of nursing progress note dated 3/13/26 at 1:34 PM identified Resident #17 had a superficial pin size open area to coccyx and indicated a new treatment in place of triad paste to buttocks and coccyx every shift and as needed until re-evaluated by wound care but failed to include the wound care orders directed by APRN #2 for cleansing with normal saline and applying calcium alginate and cover with foam dressing. Review of nursing progress note dated 3/13/26 at 1:52 PM identified an addendum note indicating Resident #17 had an ongoing treatment already in place of calcium alginate daily and as needed until re-evaluated by wound care. Review of Physician's order dated 3/13/26 directed turning and repositioning every 2 hours every shift and continued order to apply zinc ointment to the buttocks and intergluteal folds with incontinent care every shift. The orders failed to direct wound care as ordered on 3/11/26 by APRN#2. Review of nursing progress note dated 3/16/26 at 11:41 AM identified additional care for skin issues included pressure reducing device for bed, turning/repositioning program and treatment in progress to buttocks. Review of the weekly skin assessment dated [DATE] identified Resident #17 had a pressure reducing device for the bed and was on a turning and repositioning program. The assessment indicated that pressure injuries were not assessed/no information Review of the Wound Care specialist progress note dated 3/17/26 identified this was Resident #17's first evaluation for a coccyx pressure wound measured 1 cm x 0.8 cm with an undetermined depth and a moderate amount of serosanguinous exudate. Treatment recommendations directed to cleanse with normal saline, apply Santyl, Calcium alginate to base of the wound, secure with dry clean dressing and to change daily and as needed and identified the wound as unstageable. The wound specialist plan included a dietician consultation, PT to re-evaluate support surfaces, avoid friction/shear/traumatic forces and offload pressure/reposition patient every 2 hours. Physician's order dated 3/18/26 directed to cleanse coccyx wound (0.8 cm x 1 cm) with normal saline, apply Santyl, calcium alginate followed by foam dressing daily and as needed. Review of the wound care specialist progress note dated 3/24/26 identified wound size as 1 cm x 1.2 cm x 0.2 cm with a moderate amount of serosanguinous drainage. Wound care treatment recommendations to cleanse with normal saline, apply Santyl, Calcium alginate to base of the wound and secure with dry clean dressing daily and as needed. Review of the Treatment Administration Record (TAR) dated March 2026 identified Resident #17 had wound care provided daily from 3/19/26 through 3/30/26 of cleanse with normal saline, apply Santyl and Calcium Alginate to wound base followed by foam dressing daily and as needed. Review of wound care specialist progress note dated 3/31/26 identified Resident #17 coccyx wound size of 1.8 cm x 1.5 cm x 0.2 cm with a moderate amount of serosanguinous drainage with treatment recommendations to cleanse with 0.125% Dakin's (1/4 strength), apply Santyl, calcium alginate to base of the wound and secure with dry clean dressing daily and as needed. Review of wound care specialist progress note dated 4/7/26 identified Resident #17's coccyx wound with wound healing stalled and wound size 2 cm x 1.5 cm x 0.2 cm with a moderate amount of serosanguineous drainage. Treatment recommendations directed cleanse with 0.125% Dakin's (1/4 strength) apply Santyl, Calcium alginate to base of wound and secure with dry clean dressing daily and as needed. Physician's order dated April 2026 directed to cleanse with normal saline, apply Santyl, Calcium alginate followed by foam dressing daily and as needed. This order was active 4/1/26 through 4/21/26 and did not reflect the change from normal saline to Dakin's for wound cleansing as directed by the wound care specialist on 3/31/26. Review of the TAR dated April 2026 identified Resident #17's wound care from 4/1/26 through 4/21/26 was marked as completed daily for cleansing wound with normal saline, apply Santyl, Calcium alginate to the wound bed followed by foam dressing daily and as needed. This treatment did not reflect the wound treatment recommendations to cleanse the wound with Dakin's. Review of wound care specialist progress note dated 4/21/26 identified Resident #17's coccyx wound size 2 cm x 1 cm x 0.2 cm with treatment recommendations directing cleanse with 0.125% Dakin's (1/4 strength) apply Calcium alginate with silver to base of wound. Review of wound care specialist progress note dated 4/28/26 identified Resident #17's coccyx wound size 2 cm x 1.5 cm x 0.2 cm with treatment recommendations directing cleanse with 0.125% Dakins (1/4 strength) apply Santyl, Calcium alginate to base of the wound and secure with dry clean dressing daily and as needed. Review of the TAR dated 4/22 through 5/3/26 identified Resident #17's wound care completed daily to cleanse coccyx with Dakin's 1/4 strength, pat dry and apply calcium alginate with silver followed by clean dry dressing daily and as needed. This treatment did not reflect the change made on 4/28/26 back to calcium alginate (without silver). Review of the wound care specialist progress note dated 5/5/26 identified Resident #17's coccyx wound healing was stalled and measured 2 cm x 1.5 cm x 0.2 cm with moderate serosanguineous drainage and treatment recommendations to cleanse with 0.125% Dakin's (1/4 strength) apply Santyl, Calcium alginate to base of the wound and secure with dry clean dressing and change twice a day and as needed. Physician's order dated 5/6/26 directed Santyl External ointment 250 unit/gm applied to the coccyx topically every day shift for pressure ulcer cleanse coccyx (stage 3 measurement 2cm x 1.5cm x 0.2cm) with Dakin's 1/4 strength pat dry apply Santyl, calcium alginate with silver followed by clean dry dressing daily and as needed. The order did not reflect the increase in treatment to twice daily. Review of the TAR dated May 2026 identified Resident #17 received coccyx wound care of cleanse coccyx with Dakin's 1/4 strength, pat dry, apply Santyl, calcium alginate with silver followed by clean dry dressing daily and as needed one time daily from 5/7/26 through 5/31/26. This treatment failed to identify the change to plain calcium alginate (without silver) made on 4/28/26 and failed to identify the increase to wound care to twice a day and as needed. Review of subsequent wound care specialist progress notes dated 5/19/26, 5/26/26, 6/2/26, 6/9/26 and 6/16/26 identified Resident #17's wound treatment recommendations were to cleanse with 0.125% Dakin's (1/4 strength) apply, Calcium alginate to base of the wound and secure with dry clean dressing and change twice a day and as needed. Review of TAR dated June 2026 identified Resident #17 received wound care treatment to the coccyx pressure ulcer to cleanse with Dakin's 1/4 strength, pat dry, apply Santyl, calcium alginate with silver followed by clean dry dressing daily and as needed. This treatment did not reflect the wound care ordered by the wound care specialist to use calcium alginate without silver and complete wound care twice daily. Interview with the wound care specialist APRN#1 on 6/16/26 at 11:15 AM identified the expectation is for wound care to be completed as ordered. APRN#1 indicated that the development of the pressure area is probably from not getting turned and repositioned, poor nutrition and other medical conditions. Interview with the DNS on 6/17/26 at 10:45 AM identified that orders should be completed as they are ordered. The DNS indicated that orders should be verified and transcribed accurately with changes. The facility policy for wound care included to verify that there is a physician's order for the procedure and documentation in the resident's medical record would include the position in which the resident was placed, all assessment data obtained when inspecting the wound. The policy additionally identified there should be a disposable cloth next to the resident (under the wound) to serve as a barrier for the bed linen and other body sites. Skin Assessments Review of the Braden assessment dated [DATE], completed by LPN#9 who is a charge nurse, identified Resident #17 was at risk for development of a pressure injury with a score of 16 indicated Resident #17 had no sensory impairment, was rarely moist, was chairfast, had very limited mobility, adequate nutrition and a problem with friction and shear. A score of 15-16 indicates that the resident has a mild risk of developing a pressure injury. This assessment did not accurately reflect Resident #17's status as being completely dependent for all mobility and position changes, always incontinent of bowel and bladder, mostly in bed with turning and repositioning every 2 hours. The score should have been less than 11 which would indicate a severe risk of developing a pressure injury. Review of nursing progress note dated 3/9/26 at 11:19 AM identified Resident #17 had no skin issues noted. Review of weekly skin assessment dated [DATE] identified Resident #17 pressure injuries was not assessed and there was no information. This Is the only box checked off on the assessment. Review of APRN#2 (facility medical APRN) progress note dated 3/11/26 at 12:42 PM identified Resident #17 was seen for evaluation of a wound to the coccyx region likely related to pressure and moisture exposure measuring approximately 0.5 cm x 0.5 cm and indicated a pressure injury at stage 2. The note identified Resident #17 was at increased risk for skin breakdown with directions for a daily skin inspection. Review of weekly skin assessment dated [DATE] identified Resident #17 had no skin issues with no additional care and unhealed pressure injuries not assessed/no information. Review of the Braden assessment dated [DATE] identified Resident #17 was at risk for pressure injury development with a score of 17 and indicated Resident #17 had no sensory impairment, was rarely moist, was chairfast, with very limited mobility, adequate nutrition and a problem with friction and shear. Interview with LPN#9, charge nurse on 6/17/26 at 8:45 AM identified he had completed the Braden scale dated 1/27/26 and reviewed the selections that made up the mild risk score of 16. LPN#9 identified that he signs and locks the information and had not been educated by the facility on how to fill out the assessment. LPN#9 indicated that he usually goes into see the resident after care is provided and identified that the resident was dry at that time. LPN#9 indicated that Resident #17 does not move and cannot communicate and is incontinent of bowel and bladder. LPN#9 identified that Resident #17 should be checked on every two hours and is changed or turned and repositioned at that time. LPN#9 indicated that when completing the Braden, he did not consider how long the resident might stay wet or incontinent of bowel in that 2-hour period. Additionally, LPN#9 identified that he knew Resident #17 and was able to understand the resident's needs by moans but could not identify if all staff did the same. Interview with NA #11 on 6/17/26 at 8:50 AM identified that Resident #17 should be checked on every two hours. NA#11 indicated that Resident #17 is full care and requires the NAs to change positions. NA#11 identified that although she checks resident #17 every two hours while she is working, she has not documented the turning and repositioning and does not know how long Resident #17 remains wet or soiled before getting changed. Interview with the DNS on 6/17/26 at 10:41 AM identified that the electronic health record did not allow for a second signature of LPN documentation. The DNS indicated that this was a known problem but that the supervisors were responsible for reviewing the LPN documentation and that it was expected that the assessments accurately reflect the resident status. Turning and Repositioning Review of the positioning plan for Resident #17 identified a 2 hour alternating system and 12a/p-2a/p facing the door, 2a/p-4a/p facing the window, 4a/p-6a/p facing the door, 6a/p-8a/p facing the window, 8a/p-10a/p facing the door, 10a/p-12a/p facing the window with direction to position on back for meals only. Observation of Resident #17 on 6/10/26 at 9:40 AM identified the resident room door. Resident #17 was laying primarily on the back with a pillow propped under the right side back and buttock so Resident #17 was facing the window. According to the positioning plan the 8a/p-10a/p time frame should have Resident #17 facing the door. Observation of Resident #17 on 6/15/26 at 10:45 AM identified Resident #17 was laying primarily on the back with pillows propped under the right side back and buttock and a pillow between the legs which had Resident #17 facing the window (which would be appropriate). Observation of Resident #17 on 6/15/26 at 1:32 PM identified Resident #17 in bed primarily on the left side with pillows propped under the right side which had Resident #17 facing the window. 12a/p-2a/p time frame would have Resident #17 facing the door. Interview with wound care specialist APRN#1 on 6/16/26 at 11:15 AM identified that pressure injury probably started by not getting turned and repositioned and poor nutrition. APRN#1 indicated that she had implemented the air mattress, turn and reposition and ordered a dietician assessment. APRN#1 identified she expected orders to be completed as ordered. Observation of Resident #17 on 6/16/26 at 1:58 PM with the wound care specialist APRN and NA #10 who started wound care prior to notifying this surveyor and Resident #17 was positioned on the right side with Dakin's gauze soaking in the wound. The original position of Resident #17 was not observed. Wound bed was grey and black in color with slough and measurements of 3.0 cm x 2.5 cm unstageable with moderate amount of serosanguineous drainage. After wound care, Resident #17 was positioned with pillows propped under the right side back and buttock with the left leg also propped on a pillow due to new redness found by the wound care specialist APRN. Positioning from 12a/p-2a/p would have the resident facing the door. Interview with LPN#9, charge nurse on 6/16/26 at 2:09 PM identified that NAs should be documenting the turning and repositioning in a 3-ring binder that is kept at the nurses' station on the unit. At this time, LPN#9 was not able to locate the binder. LPN#9 indicated that although the NAs are responsible for the turning and repositioning, the documentation is also completed by the nurses and that the binder is to reference to make sure the turning and repositioning is being completed for all residents that require it. Interview with APRN#2, medical APRN, on 6/17/26 at 10:33 AM identified all care should be provided as ordered. APRN#2 indicated that orders should be placed in the computer by nursing staff and should follow what is written by the ordering doctor. APRN#2 identified that she expects assessments to be completed accurately and could not identify if LPN documentation should be reviewed by an RN. Observation of Resident #17 on 6/16/26 at 2:29 PM identified Resident #17 was still positioned on the left side with pillows under the right side facing the window as left after wound care. 2a/p-4a/p time frame would have Resident #17 facing the window. Observation of Resident #17 on 6/17/26 at 8:40 AM identified Resident #17 laying on the back with pillows propped under the right side and Resident #17 facing the window. The 8a/p-10a/p time frame would have Resident #17 facing the door. Interview with LPN#9 and NA#11 on 6/17/26 at 8:45 AM identified there used to be a binder that the nurse aides had to document the turning and repositioning. LPN#9 indicated that this binder had gone missing and was located last night and had not been in use since 1/29/26. LPN#9 identified that Resident #17 had not had any documentation by nurse aides to confirm repositioning schedule. NA#11 indicated that she had not documented in the binder and did not have a spot in the clinical record tasks to document turning and repositioning. LPN#9 indicated that although the turning and repositioning was checked off in the EHR by the nurse, there would not be a way to confirm it was completed, but it was expected to be completed. LPN#9 identified that he had been proud that the unit only had one pressure injury this year and had noticed an increase in pressure. LPN#9 indicated that he, as the charge nurse, was responsible for reviewing the turning and repositioning log, but it had escaped him. Interview with the DNS on 6/17/26 at 10:41 AM identified if there is a treatment or order for the resident to be turned and repositioned then it should be completed. The DNS was not aware that the NA documentation was not being completed on the 1st floor unit for the turning and repositioning. The facility policy for wound care included to verify that there is a physician's order for the procedure and documentation in the resident's medical record would include the position in which the resident was placed, all assessment data obtained when inspecting the wound. The policy additionally identified there should be a disposable cloth next to the resident (under the wound) to serve as a barrier for the bed linen and other body sites. Subsequent information from the DNS on 6/23/26 identified the facility did not have a skin policy, nor a turning and repositioning policy as requested.

Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident with a diagnosis of amyotrophic lateral sclerosis (Resident #97) reviewed for respiratory care, the facility failed to ensure a physician's order for a respiratory therapy assessment was completed thus resulting in a lack of orders for consistent respiratory assessments. The findings include:Resident #97 was admitted in April of 2026 with diagnoses including amyotrophic lateral sclerosis (ALS), dysphagia oropharyngeal phase, and adult failure to thrive.The Clinical admission assessment dated [DATE] identified Resident #97 had an oxygen saturation of 95% (normal parameters are 95% to 100%), lungs clear bilaterally with no difficulty breathing, no cough noted, no shortness of breath and no oxygen use. The assessment indicated there were no safety or comfort concerns.The physician's order dated [DATE] directed for a respiratory therapy evaluation and treatment as indicated.The Care Plan dated [DATE] identified Resident #97 was non-verbal, had expressive aphasia and communicated through writing and using thumbs up and down method and indicated the resident's preference of wearing tape across the mouth to reduce infections to mouth and stomach with interventions to acknowledge resident's preference and offer support as needed. The care plan further identified muscle weakness deterioration related to ALS and that the resident received nutrition through a feeding tube. APRN #2's admission note dated [DATE] at 7:47 PM identified Resident #97's lungs were clear to auscultation bilaterally with non-labored breathing and indicated the assessment and plan addressing bulbar-onset ALS (an aggressive form of ALS that first attacks the brainstem motor neurons, controlling facial and neck muscles) was to continue supportive care, therapy services, secretion management and monitoring of respiratory status. Respiratory monitoring was not reflected in the physician orders nor the care plan.APRN#2's progress note dated [DATE] at 3:18 PM identified Resident #97's lungs were clear with non-labored respirations and to monitor respiratory status.The admission MDS assessment dated [DATE] identified Resident #97 had intact cognition, required substantial/maximal assistance with oral hygiene and personal hygiene, rolling left to right, lying to sitting on the side of the bed, chair and toilet transfers, did not experience shortness of breath with exertion, when sitting at rest or when lying flat and did not exhibit signs and symptoms of possible swallowing disorder but had a gastric tube for feeding and received 51% or more of total calories through parenteral or tube feeding with an average fluid intake per day of 501 cc/day or more through tube feeding. APRN#2's progress note dated [DATE] at 4:21 PM identified the assessment and plan for Resident #97 included to reinforce aspiration precautions due to neuromuscular weakness. The plan indicated Resident #97 was an aspiration risk with reinforced education to avoid mouth taping and directed monitoring for coughing, desaturation, fever, or increased secretions. However, none of the plan monitoring was reflected in the physician's orders or the care plan.Observation of Resident #97 in bed on [DATE] at 10:44 AM identified Resident #97 had tape covering the mouth and lips. Resident #97 does not appear to have any breathing difficulty at this time. Interview with Resident #97 and Person #3 identified Resident #97 preferred to have the tape covering the mouth because of the resident's infection concerns. Resident #97 was able to demonstrate removal of the tape independently.Observation of Resident #97 on [DATE] at 10:12 AM identified tape in place on the resident's mouth. Resident #97 appeared to intermittently gasp but was able to give a thumbs up when asked if his/her breathing was okay with the tape over the mouth.Interview with LPN#8 and LPN#11 on [DATE] at 7:48 AM identified it was Resident #97's preference to have the tape covering the mouth due to fear of getting a mouth infection because it is always open due to weak musculature. Both LPNs identified that Resident #97 places the tape independently and they were not aware of when it gets changed. Interview with the Director of Rehabilitation on [DATE] at 11:03 AM identified there is a respiratory therapist on staff and if there is an order for an assessment, the therapist should assess the resident. After reviewing Resident #97's clinical record, the Director of Rehabilitation identified there were no respiratory therapy notes or evaluations.Interview with Resident #97 on [DATE] at 12:00 PM identified the resident preference to keep the tape over the mouth and does not want to try other covers.Observation on [DATE] at 6:39 AM identified Resident #97 appeared to have labored breathing with use of ancillary muscles and increased respiratory rate of 24 respirations per minute. Observation with LPN#8 and RN#6 on [DATE] at 6:39 AM (after Surveyor request) identified Resident #97 had labored breathing, increased respirations and accessory muscle use with respirations. LPN#8 and RN#6 identified that the resident was breathing in the normal pattern for the resident and denied the need for intervention, thus no respiratory assessment was completed by RN #6. Review of the clinical record for the time period of [DATE] through [DATE] failed to identify that a respiratory therapy assessment was completed.Interview with the Respiratory Therapist on [DATE] at 10:46 AM identified that she had not evaluated Resident #97. She indicated that the nursing staff call her if an evaluation is needed. She further noted that she doesn't check the orders and she doesn't evaluate someone unless she is called. Additionally, the Respiratory Therapist identified that anyone with increased respirations or use of accessory muscles to breathe should have a respiratory assessment completed.APRN#4's progress note dated [DATE] at 10:47 AM identified Resident #97 was transported to the emergency room related to increased work of breathing and hypoxemia (abnormally low level of oxygen in the blood) requiring supplemental oxygen. The note further indicated that the nursing staff had reported an oxygen saturation of 87% on room air requiring 4 liters of oxygen via nasal canula and then titrated to 2 liters as oxygen saturation improved. The progress note identified Resident #97 had demonstrated increased difficulty with breathing, including accessory muscle use and was non-responsive to verbal commands. Review of the nursing progress note dated [DATE] at 2:32 PM identified Resident #97 was admitted to the ICU (intensive care unit) for respiratory failure.Interview with APRN #2 on [DATE] at 10:22 AM identified that she refers to respiratory therapy if she assesses the resident and feels that deep suctioning is needed. APRN#2 indicated that if there is an order to be evaluated by respiratory therapy then the resident should be evaluated by respiratory therapy. APRN#2 identified that any increased difficulty with breathing or use of accessory muscles should be evaluated immediately and respiratory therapy should follow anyone who has a potential airway compromise.Subsequent to surveyor inquiry on [DATE] it was relayed by the DNS that Resident #97 had expired at the hospital. Hospital admission notes dated [DATE] identified Resident #97 was admitted for hypercapnic (too much carbon dioxide in the blood) respiratory failure. The note further indicated Resident #97 passed away peacefully on [DATE] at 4:59 PM.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedure and interviews for 1 of 2 sampled residents (Resident #14) reviewed for pain management, the facility failed to ensure the resident's preference to see a community pain management physician was honored and failed to re-evaluate routine ordered pre-hospitalization medication when resident was readmitted to the facility following a hospitalization. The findings include:Resident #14's diagnoses include disease of the spinal cord, Pressure ulcer of sacral region stage 4 and pressure ulcer of right buttock stage 4, quadriplegia and osteomyelitis of vertebra, sacral and sacrococcygeal region and polyneuropathy.The nursing admission note dated 10/20/25 at 7:41 PM identified Resident #14 was alert and oriented and had vocal complaints of pain with protective body movements with a pain level of 8 out of a scale of 1 to 10. The note identified Resident #14 was admitted to the facility with right lower quadrant bruising, left outer forearm bruising, stage 1 pressure injury to the right heel, Stage 1 pressure injury to the left heel, Stage 4 pressure ulcer to the sacrum and a stage 4 pressure ulcer to the right gluteus.The nursing note dated 10/21/25 at 5:37 AM identified Resident #14 was seen by the pain management doctor and started on Gabapentin 300 mg three times daily and Robaxin 750 mg three times daily.The physician's orders dated 10/21/25 directed administration of:Alprazolam 0.5 mg tablet twice a day for anxiety disorderBaclofen 10mg oral tablet three times a day for painFentanyl transdermal patch 72-hour 25 mcg/hr. one time a day every 3 days related to polyneuropathyLidocaine external patch 4% to lower back in the morning for 12 hours.Lidocaine-Prilocaine external cream 2.5-2.5 % apply to sacrococcygeal area topically every Mon, Wed, Fri for pain prior to wound dressing change MWF.Oxycodone HCL oral tablet 10 mg by mouth every 4 hours as needed for breakthrough pain.Gabapentin 300mg 1 capsule by mouth three times a day.]The admission MDS dated [DATE] identified Resident #14 had intact cognition, was dependent on staff for toileting, personal hygiene, dressing, position changes and transfers. The MDS assessment further indicated Resident #14 received scheduled and as needed pain medication. Review of APRN progress note dated 10/29/25 at 3:46 PM identified Resident #14 was seen by the APRN for pain management. The note indicated that Resident #14 reported that current pain regimen was not adequately controlling pain and requested stronger medication. The note identified that due to prior adverse reaction to opioids the pain medication would not be increased.Review of the APRN progress note dated 11/9/25 at 4:37 AM identified Resident #14 was seen for chronic pain syndrome with ongoing pain despite current regimen not adequately controlled with recommendations to review current pain regimen and assess for potential dose adjustment to comfort and consider consulting pain management for further recommendations.Review of the APRN progress note dated 11/15/25 at 8:38 AM identified Resident #14 continued to express dissatisfaction with the current pain regimen expressing it is ineffective. The note identified that although the current pain regimen reportedly is ineffective per Resident #14 it was not corroborated by observed discomfort and therefore there is no indication for dose escalation.Review of APRN progress note dated 11/24/25 at 5:36 PM identified Resident #14 requested to see the pain management doctor to discuss pain medication regimen. The note did not indicate that the pain doctor was notified.The care plan dated 11/25/25 identified Resident #14 had chronic pain related to disease process of osteomyelitis, and poly neuropathy with interventions to administer analgesics as per orders, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, monitor/document for side effects of medications and notify physician if interventions are unsuccessful.Review of Resident #14's clinical record identified Resident #14 was transported for evaluation at the hospital on [DATE] with diagnoses of urinary tract infection, sepsis, acute kidney injury and pneumonia and fecal impaction of the rectum with stercoral proctitis and development of a rectovaginal fistula requiring a fecal diversion (colonoscopy) and returned to the facility 1/2/26Review of the Psych APRN progress note dated 1/8/26 identified Resident #14 had been in pain despite receiving pain medications and indicated staff was aware.Review of the Psych APRN progress note dated 1/12/26 identified Resident #14 was experiencing pain which was causing mood fluctuations and indicated an as needed dose of Xanax added to address anxiety. The note did not identify any follow up for pain complaints.Review of APRN progress note dated 1/16/26 at 11:36 AM identified Resident #14 had requested to be seen by a pain doctor in the community for chronic pain management. The progress note indicated Resident #14 reported persistent but stable pain, currently rated 3/10, primarily involving the lower back/sacral region and was described as chronic and aching with intermittent exacerbations with current pain regimen providing partial relief without reported side effects. The note identified that the facility would assist with navigating and scheduling appointment.Review of APRN progress note dated 1/17/26 at 3:03 PM identified Resident #14 demonstrated improved pain management with addition of gabapentin but failed to identify any coordination with a physician, pain management or a community pain management appointment.Review of APRN progress note dated 1/22/26 at 9:40 PM identified Resident #14 reported overall improvement of neuropathic pain control after starting on gabapentin 100mg three times daily. The note does not identify any update on pain management appointment.Review of APRN progress note dated 1/26/26 at 11:54 PM identified Resident #14 was seen for continued reports of chronic pain with a request to increase gabapentin. The note further identified that kidney function was impaired, and the gabapentin could not be increased for that reason and indicated that pain would be reassessed after renal stabilization and repeat labs.Review of APRN progress note dated 1/27/26 at 9:03 PM identified Resident #14 had ongoing complaints of pain with an underlying kidney issue that would not support an increase to gabapentin. The note indicated this concern was discussed with the facility's pain doctor and identified that Resident #14 was asking for a consult with the pain specialist in the community.Review of APRN progress note dated 1/29/26 at 6:04 PM identified Resident #14 was recently evaluated by pain management (no date was listed) and indicated a baclofen dose was increased to 15 mg three times a day for improved control of muscle spasms.Review of APRN progress note dated 2/8/26 at 7:29 PM identified Resident #14 reported severe pain localized to the sacral area that was persistent and limiting comfort at rest. The note indicated the renal function was reviewed and situation discussed with the facility pain doctor and gabapentin was increased from 100mg to 200mg three times daily. The note failed to identify any update of the community pain management appointment.Review of APRN progress note dated 2/17/26 at 7:15 PM identified Resident #14 had persistent pain in sacrum and new pain and stiffness in bilateral ankles/feet with directions to increase Tylenol dose to 1000mg for 6 weeks and ordered Lidocaine patches for bilateral ankles. The note failed to identify any update to follow up with pain management or notification to the MD of new pain complaints.Review of APRN progress note dated 2/18/26 at 9:43 AM identified Resident #14 continued to report persistent sacral pain and increasing stiffness in feet and ankles and requested physical therapy. The note further identified persistent sacral discomfort likely a combination of prolonged sitting, deconditioning and history of significant spinal infectious process. The note indicated Resident #14 was started on fungal medication by the wound team and added Lidocaine anesthetic tetracaine gel for the sacral area and encourage frequent repositioning and pressure offloading. The note failed to identify any notification to the pain doctor or any update regarding the community pain management referral.Review of Psych APRN progress note dated 3/2/26 identified Resident #14 was still in pain at times and the note indicated that staff was aware and identified anxiety was better controlled with Xanax.Review of APRN progress note dated 3/3/26 at 4:17 PM identified Resident #14 requested an appointment with an outside pain management specialist. The note indicated Resident #14 had not been receiving gabapentin due to insurance non-approval. The note identified that Resident #14 was still under the care of the facility pain doctor so the request for an appointment with a community pain specialist was deferred to the medical director.Review of APRN progress note dated 3/11/26 at 2:22 PM identified Resident #14 had multiple concerns regarding care and intermittent chronic pain and interest in specialty evaluation. The progress note indicated that Resident #14 would have a pain management consultation and identified that a pain management appointment was previously scheduled but rescheduled. The note failed to identify a date of the appointment and indicated that the case was discussed with the Nursing team, but did not identify if a doctor was notified.Review of the APRN referral sheet for medical referrals identified an entry dated 3/25/26 indicating Resident #14 had an increase in delusional thoughts (due to a vaginal complaint) and complained of feet being burnt from below.Review of APRN progress note dated 3/26/26 at 1:33 PM identified Resident #14 complained of burning pain to bilateral feet, worse at heels, and indicated it was consistent with neuropathic pain with a plan to continue gabapentin 200mg three times daily, titrate if necessary and increase dose gradually as tolerated. The note failed to identify any update on pain management appointment or consultation with the doctor. The note did indicate additional problems that required follow-up with gynecology.Review of the APRN referral sheet for medical referrals identified entry on 3/29/26 complaints of burning under feet and left hip.Review of the APRN progress note dated 4/3/26 at 12:41 AM identified Resident #14 was being treated for a UTI with a short course of antibiotic but did not make changes to the current chronic pain management and failed to identify consultation with any pain doctor.Review of APRN progress note dated 4/8/26 at 6:45 PM identified Resident #14 was seen for bilateral foot burning pain that is chronic but persists despite current regimen and identified a plan of care to continue gabapentin 200 mg three times daily, consider gradual titration and increase by 100-300 mg increments every 3-7 days as tolerated. The note additionally added Magnesium 400mg and indicated a re-evaluation in 1 week for pain control response but failed to identify a notification to the doctor or update on pain management appointment.Review of the APRN progress note dated 4/18/26 at 7:18 PM identified Resident #14 was seen for severe headache, pain management and care coordination and indicated Resident #14 requested a pain evaluation with the community pain management doctor. The progress note identified the plan for suboptimal control of chronic pain included to consider pain management consult.Review of APRN progress note dated 4/19/26 at 1:30 PM identified Resident #14 had complaints of persistent severe headache consistent with prior migraines, vaginal complaint and new complaint of left foot numbness and continued discomfort and requested to be transported to the emergency room for evaluation. The not indicated a specialist referral was pending but did not indicate what specialist and identified a new neurological symptom of foot numbness warranted an ER evaluation.Review of APRN progress note dated 4/24/26 at 5:08 PM identified Resident #14 returned from a hospital admission with a plan that included pain management until outside consult is available.Review of APRN progress note dated 4/27/26 at 7:01 PM identified Resident #14 reported ongoing lower extremity weakness, stiffness, and burning sensations in the soles of the feet. The progress note failed to identify any pain management in the assessment/plan or notification to the physician regarding the continued pain complaint.Review of the Social Work progress notes dated 5/8/26 at 3:04 PM identified Resident #14 continued to perseverate about what is below the room causing his/her feet to be hot. The progress note indicated SW#2 was unable to rationalize this with Resident #14 but did not identify any report to nursing or the physician regarding continued complaints of pain or with psych for alleged delusions.The care plan dated 5/12/26 identified Resident #14 used psychotropic medication r/t delusions, hallucinations, cognitive impairment with interventions to administer as ordered and to consult with pharmacy/MD to consider dosage reduction when clinically appropriate.Review of the Social Work progress note dated 5/12/26 at 12:23 AM identified Resident #14 had the tendency to perseverate on symptoms that are reported to be because of neuropathy and can be delusional and paranoid why symptoms are experienced indicating feeling hot or feet having a burning sensation. The progress note did not identify any communication with nursing or the physician regarding pain complaints.Review of APRN note dated 5/26/26 at 5:26 identified Resident #14's chronic pain was stable with plan and interventions to continue fentanyl patch, baclofen acetaminophen, reassess pain control routinely and monitor for sedation or constipation.Review of Social Services progress noted dated 6/10/26 at 1:56 PM identified Resident #14 reported to SW#1 he/she was still having some pain and experiencing headaches and mentioned wanting to see the community pain management doctor. The progress note failed to identify any plan for follow through or reporting to the provider requests.Interview with LPN#9, First Foor Unit Charge nurse, on 6/15/26 at 7:56 AM identified Resident #14 always wants more pain medication. LPN#9 indicated that the pain doctor saw Resident #14 several times but Resident #14 requested to see a different pain doctor and was not satisfied with the pain management in place although Resident #14 does not appear to be in pain with the medications in place. LPN#9 identified Resident #14 does still complain about burning and as a nurse, I have to do something about the pain. LPN#9 was not able to identify if Resident #14 was referred or seen by an outside provider.Interview with the Psych APRN, APRN #3, on 6/15/26 at 9:27 AM identified Resident #14 had a long history of anxiety and pain. APRN #3 indicated that she spoke with the facility pain doctor (unknown date and not documented) initially regarding the amount of medications Resident #14 was taking. APRN#3 identified Resident #14 leg burning complaints were more recent and had been referred to psych because of how Resident #14 was presenting the pain, perceived as delusions, but indicated that Resident #14 had continued complaints of pain and APRN #3 was under the impression that Resident #14 was being followed by pain management.Interview with LPN#8 on 6/16/26 at 6:48 AM identified complaints of burning should be referred to the pain doctor. LPN#8 indicated that if there is something identified in the APRN notification book, there should be a corresponding progress note to identify how the problem was handled.Review of APRN progress note dated 6/16/26 at 4:10 PM identified Resident #14 reported not being see by the outpatient pain specialist and the progress note indicated that per nursing, the appointment was cancelled due to Resident #14 being in the hospital and identified the appointment had been rescheduled but failed to identify a date. The plan and interventions indicated Resident #14 had a pain specialist appointment rescheduled and the facility should ensure attendance but failed to identify specifics of the appointment.Interview with APRN#2, facility medical APRN, on 6/17/26 at 9:48 AM identified that the facility pain management doctor collaborates with the APRNs when there are changes to the medications and then if the pain continues to not be controlled. APRN#2 indicated that she did not know where the pain doctor documented and identified that collaboration is via phone call or text and could not provide documentation of the collaboration. APRN#2 indicated that she asked that an appointment be made with a community pain doctor on 1/16/26 but could not identify the date of the appointment but indicated that the resident was not seen by the community pain doctor. APRN#2 could not identify why this was not followed up on and indicated there was a scheduler responsible to make appointments.Interview with the DNS on 6/17/26 at 10:41 AM identified that if a resident has chronic pain or any pain, it is subjective and should be assessed and treated. The DNS indicated that any complaints of pain should be communicated to the APRN.Interview with the ADNS on 6/17/26 at 12:27 PM identified that the facility scheduler passed away a couple of weeks ago and she was filling in for that position. The ADNS indicated that she had just made an appointment for Resident #14 to be seen by the community pain doctor but could not identify the actual date of the appointment. The ADNS reviewed a handwritten calendar book and indicated that on 3/5/26 there was an appointment scheduled for pain management that Resident #14 did not attend but could not identify the reason for the missed appointment but indicated transportation problems.Review of Resident #14's clinical record identified that Resident #14 was present in the facility on 3/5/26.The facility policy for pain management identified pain is assessed on admission and ongoing and focused on person-centered care identifying residents' preferences for care and indicated pain management is integrated into each resident's comprehensive care plan reflecting the resident's condition, preferences and functional goals consistent with professional standards and resident preference.

Based on observation, interviews, and Facility policy, the facility failed to ensure a kitchen steamer unit was maintained in safe operating condition, and the facility failed to visibly tag equipment as out of use. The findings include:Observation of the kitchen on 6/09/2026 at 11:58 AM identified the steamer unit located next to the gas stove, had the upper pot 1/3 full of water, and water from the steamer unit's faucet was dripping into the pot. A dirty cloth rag was wrapped around and tied to the junction of the upper pot and the steamer's water pipe, and a cloth rag was intertwined between electrical wires within the steamer unit's electrical box. No maintenance tags were observed on the steamer unit.Interview on 6/09/2023 at 11:58 AM with the Dietary Director and Head Chef identified the steamer unit was broken. The upper water pot required emptying several times a day because the faucet dripped into the pot, and the dirty rag was wrapped around the water pipe to keep water from leaking onto the ground around and under the gas stove. The Dietary Director stated the water supply to the steamer unit could not be shut off. Additionally, he indicated that having a cloth rag in the electrical box of the steamer unit was not a fire hazard because the electricity had been turned off to the steamer unit. The Dietary Director identified that the steamer unit had been out of service since 3/04/2026 and the facility had failed to place an out of service tag on it. He was unable to identify why the steamer unit was not tagged out.A request for a copy of the steamer unit's service maintenance request or work order was made to the Dietary Director, but the facility failed to provide a copy of the maintenance request.The facility's Food Service Equipment policy dated May 2024, and revised May 2026 identified in part that all food service equipment shall be maintained in safe, sanitary, and operational condition. Any equipment that is not functioning properly poses a food safety risk, or fails to meet temperature, sanitation, or operational standards shall be immediately removed from service, clearly identified, and not used until repaired, inspected, and approved for return to service. All affected equipment must be immediately labeled OUT OF SERVICE - DO NOT USE. Equipment must be physically removed from operational areas when possible or secured to prevent accidental use. A work order must be submitted immediately upon identification of malfunction.

Based on observations, and interviews, the facility failed to ensure the dumpster area was maintained in a clean manner, failed to ensure used cooking oil was disposed of appropriately and failed to ensure refuse was appropriately contained. The findings include:Observation of the facility's dumpster area and exterior of kitchen garbage exit area with the Dietary Director on 6/9/2026 at 11:52 AM identified the following items littered on the ground in front of the dumpster area and kitchen exit door:one wheelchairtwo sit to stand liftsfive broken air handling unitstwo four wheeled cartstwo five-gallon laundry chemical buckets filled with oil, open to air through missing screw tops and overflow of oil onto the lid of the container and surrounding ground area, stored under multiple black milk crates, next to the exit door against the building's exterior wall An approximate 8 foot by 8-foot square concrete patio with an area of oil spillage covering a 4 foot by 3-foot square area near the exit door.Multiple used facemasks, used gloves, paper scraps, plastic bottle screw tops, and empty plastic water bottles were also noted near the exit door. An interview with the Director of Food Service on 6/9/2026 at 11:52 AM identified that he was unaware of the used cooking oil being stored in laundry chemical containers and that the kitchen was responsible for putting used kitchen oil in a black metal drum for disposal, Additionally he indicated it was not the responsibility of the kitchen staff to keep the area outside the kitchen trash exit door free from garbage on the ground as that was the responsibility of the cleaning staff.An interview with the Director of Housekeeping and Building Maintenance Supervisor on 6/9/2026 at 11:57 AM identified that neither department is responsible for picking up trash on the ground outside of the building, as the landscapers should pick it up, and stated that the dumpsters are emptied on Wednesdays or Thursdays by a contracted company. The Director of Maintenance indicated the wheelchairs, sit to stand lifts, and broken air handling units were next to the dumpster because the facility is under construction and he would transfer the items to a dumpster for pickup.An interview on 6/9/2026 at 11:58 AM with the Head Chef identified kitchen staff are aware that used cooking oil should be dumped in the black drum and not be dumped into unapproved containers. She was unable to identify why kitchen staff did not follow facility procedure and placed the oil in empty laundry chemical containers instead.The facility's Disposal of Cooking Oil Policy, dated May 2024 and revised May 2026, identified in part that all used cooking oil shall be managed through approved collection systems. Improper handling or disposal of used cooking oil presents significant operational, environmental, and safety risks including slip hazards, chemical contamination from improper storage or mixing with cleaning chemicals, and fire hazards of grease ignition from improper handling or proximity to heat sources Only approved grease containers, leak-proof and clearly labeled USED COOKING OIL ONLY should be used and stored in an exterior storage area away from building entrances and food preparation zones. Containers must be closed at all times.The facility's Kitchen Cleaning and Sanitation Policy, dated May 2026, identified in part that outdoor waste areas should be maintained to prevent overflow and pest attraction.

Based on record review, facility documentation review and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to provide supervision for a resident with dementia and known risk of falls to prevent a fall with injury. The findings include:Resident #1 had a diagnosis of metabolic encephalopathy, dementia, and glioblastoma. Nursing admission Note dated 12/19/2025 at 6:48 PM identified Resident #1 had a fall prior to admission to the facility, had impaired cognition and required assistance with personal hygiene. Physician order dated 12/19/2026 directed Aspirin (prevents blood clots) 81 mg daily. Facility incident report dated 12/19/2025 at 10:20 PM identified Resident #1 was observed sitting on the floor and sustained an abrasion to his/her mid back, was able to perform active and passive range of motion to all extremities and had no discomfort. The Resident Care Plan dated 12/19/2025 identified a high risk for falls. Interventions directed to ensure the call light was in reach and to ensure appropriate footwear (brown leather shoes and non-skid socks) when ambulating (walking). The admission Minimum Data Set, dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 5, indicating severely impaired cognition, and required maximal assistance with toileting and transfers. Facility incident report dated 1/7/2026 at 5:10 AM identified Resident #1 was found on the floor in a prone (face down) position in his/her room with no visible injury noted and denied pain. The report directed the RCP was updated to ensure Resident #1 had non-skid socks on every shift. Nursing note dated 1/7/2026 at 5:27 AM identified Resident #1 was wearing regular socks at the time of the fall, hit his/her head, and was transferred to the hospital for further evaluation. Nursing note dated 1/7/2026 at 10:30 AM identified the hospital notified the facility that Resident #1 was returning to the facility, and had no injuries identified (CT scan and x-rays were negative). Record review identified Resident #1 returned to the facility. Facility incident report dated 1/19/2026 at 4:50 PM identified Resident #1 was observed on the floor on his/her left side and reported he/she hit their head. Resident #1 was assessed, had no bumps or redness to the head, was able to perform active and passive range of motion, and a left ankle abrasion was noted. Resident #1 was transferred to the hospital for evaluation. Nursing note dated 1/19/2026 at 5:52 PM identified Resident #1 was found on the floor around 4:50 PM, stated that he/she hit his/her head and had vomited, and Resident #1 was transferred to the hospital for evaluation. Record review identified Resident #1 was readmitted to the facility. Facility reportable event dated 1/25/2026 at 11 PM identified during rounds, a NA heard a loud sound and found Resident #1 lying on the floor. Resident did not call for assistance prior to getting up, complained of pain on the back of his/her head, and was transferred to the hospital for evaluation. Facility reportable event summary dated 1/25/2026 identified Resident #1 was admitted to the hospital with an acute (new) subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane), a subdural hemorrhage (bleeding between the brain and the membrane covering of the brain), and bifrontal contusion (bruising on both frontal lobes of the brain). Record review identified Resident #1 had the following falls: 12/19/2025 at 10:20 PM, 1/7/2026 at 5:10 AM, 1/19/2026 at 4:50 PM and 1/25/2026 at 11 PM. Additional review identified Resident #1 was not readmitted to the facility after the fall on 1/25/2026. Interview and record review with Director of Nursing (DNS) #2 and Assistant Director of Nursing (ADNS) on 3/2/2026 at 10:52 AM identified the care plan was updated after falls occurred on 12/19/2025 and 1/7/2026 to direct use of non-skid socks. Interview failed to identify additional measures were put into place to prevent additional falls after the fall on 1/19/2026, and failed to identify additional supervision was provided to prevent the fall with injury on 1/25/2026. No facility policy was provided for surveyor review.

Based on resident record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to develop new fall interventions timely following a fall. The findings include:Resident #1 had a diagnosis of metabolic encephalopathy, dementia, and glioblastoma. Nursing admission Note dated 12/19/2026 at 6:48 PM identified Resident #1 had a fall prior to admission to the facility, had impaired cognition and required assistance with personal hygiene. Physician order dated 12/19/2026 directed Aspirin (prevents blood clots) 81 mg daily. Facility incident report dated 12/19/2025 at 10:20 PM identified Resident #1 was observed sitting on the floor and sustained an abrasion to his/her mid back, was able to perform active and passive range of motion to all extremities and had no discomfort. The Resident Care Plan dated 12/19/2025 identified a high risk for falls. Interventions directed to ensure the call light was in reach and to ensure appropriate footwear (brown leather shoes and non-skid socks) when ambulating (walking). The admission Minimum Data Set, dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 5, indicating severely impaired cognition, and required maximal assistance with toileting and transfers. Facility incident report dated 1/7/2026 at 5:10 AM identified Resident #1 was found on the floor in a prone (face down) position in his/her room with no visible injury noted and denied pain. The report directed the RCP was updated to ensure Resident #1 had non-skid socks on every shift. Nursing note dated 1/7/2026 at 5:27 AM identified Resident #1 was wearing regular socks at the time of the fall, hit his/her head, and was transferred to the hospital for further evaluation. Record review identified Resident #1 returned to the facility. Facility incident report dated 1/19/2026 at 4:50 PM identified Resident #1 was observed on the floor on his/her left side and reported he/she hit their head. Resident #1 was assessed, had no bumps or redness to the head, was able to perform active and passive range of motion, and a left ankle abrasion was noted. Resident #1 was transferred to the hospital for evaluation. Nursing note dated 1/19/2026 at 5:52 PM identified Resident #1 was found on the floor around 4:50 PM, stated that he/she hit his/her head and had vomited, and Resident #1 was transferred to the hospital for evaluation. Record review identified the RCP was updated to indicate Resident #1 was transferred to the hospital, directed neurological checks and to provide treatment to the abrasion. Additional review failed to identify an intervention was put into place to attempt to prevent another fall. Record review identified Resident #1 was readmitted to the facility. Record review identified after Resident #1 was readmitted from the hospital, review failed to identify any additional interventions were put into place to mitigate a risk of falls. Interview and record review with Director of Nursing (DNS) #2 and Assistant Director of Nursing (ADNS) on 3/2/2026 at 10:52 AM identified Resident #1 had an abrasion after the 12/19/2025 fall, and had no injuries identified after the falls on 1/7 and 1/19/2026. Resident #1 was care planned on 12/19/2025 to wear non-skid socks, and he/she was not wearing the non-skid socks at the time of the fall on 1/7/2026. Interview indicated Resident #1 should have been wearing non-skid socks on 1/7/2026, but failed to identify why staff did not follow the care plan to ensure Resident #1 was wearing the non-skid socks in accordance with the plan of care. Further, the care plan was updated after the 1/7/2026 fall with a repeat intervention, that directed use of the non-skid socks. Although the DNS and ADNS stated after the 1/19/2026 fall the care plan was updated to conduct neurological checks and to treat the abrasion, they were unable to provide documentation that a new intervention was put into place after the fall on 1/19/2026 to reduce the risk of another fall. Interview identified new interventions should be put into place after each fall to attempt to reduce the risk of falls. Review of Facility Falls, Management and Prevention Policy dated 1/16/2026 directed in part, if a fall does occur, the care plan was to be updated with appropriate interventions.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed ensure staff did not move a resident after a fall resulting in resident complaint of pain. The findings include: Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed ensure staff did not move a resident after a fall resulting in resident complaint of pain. The findings include: Resident #2 had diagnoses that included a history of dementia, falls, muscle weakness, and difficulty in walking. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #2 had a BIMS of 10, indicating moderately impaired cognition, had no behaviors, required maximal assistance with toileting and ambulation, partial assistance with transfers, and was independent with mobility in a wheelchair. The Resident care plan dated 1/2/26 identified a self-care deficit and risk for falls. Interventions directed to encourage to use the call bell and assist of one (1) with transfers (stand and pivot). Facility reportable event form dated 1/3/26 at 4:10 PM identified the charge nurse heard a loud noise from the shower room. Upon entering the shower room, Resident #2 was observed lying on the floor, his/her right leg bent at the knee and under his/her left leg and the commode frame was on top of Resident #2. Resident #2 had wheeled him/herself into the shower room to use the toilet and did not call for assistance. the right hip appeared to be dislocated and the hip area was swelling. Resident #2 complaint of right hip pain. NA #1 was observed standing over Resident #2 and lifted the commode frame off Resident #2, and proceeded to kick his/her right foot which made him/her call out in pain. The Report indicated NA #1 was directed to stop what she was doing and was sent home pending an investigation. Nursing note dated 1/3/26 at 6:04 PM identified Resident #2 fell while attempting to self-transfer in the shower room, the fall was not witnessed by staff, and the APRN was notified and Resident #2 was transferred to the hospital for evaluation. The facility investigation summary dated 1/6/26 identified Resident #2 was wearing sneakers, and after the fall, staff observed Resident #2 attempt to re-position him/herself. NA #1 placed the sole of her sneaker on the sole of his/her left foot and helped him/her move his/her leg. When the nurse observed the action, NA #1 was directed to not move Resident #2 and to wait for Emergency Medical Services (EMS). NA #1 denied kicking Resident #2. Interview and record review with the Director of Rehabilitation on 1/15/26 at 9:43 AM identified Resident #2 was independent with wheelchair mobility, was unstable when standing without assistance, had the ability to independently enter the shower room, and required assist of one (1) staff for transfers. Interview and record review with RN #2 on 1/15/26 at 11:15 AM identified she was the supervisor on shift when Resident #2 fell on 1/3/26. RN #2 observed NA #1 remove the commode frame from Resident #2, and directed NA #1 to not move Resident #2. After NA #1 was directed to not move Resident #2, RN #2 observed NA #1 try to move Resident #2's foot/leg using her foot, and Resident #2 then called out in pain. NA #1 was removed from the room, and Resident #2 was transferred to the hospital for evaluation. Interview with NA #1 on 1/15/26 at 11:30 AM identified Resident #2 fell in the shower room on 1/3/26. The commode chair over Resident #2's right side, the wheelchair was on left side of the toilet, and Resident #2 stated his/her waist and head hurt. NA #1 removed the wheelchair and took the commode off Resident #2. NA #1 stated Resident #2's legs were crossed and he/she was trying to move Resident #2' legs by uncrossing his/her legs using her foot on his/her left foot to guide Resident #2's left foot/leg off of his/her right leg. NA #1 denied kicking the resident, and stated she was not supposed to move the resident after a fall. Interview failed to identify why NA #1 attempted to move the resident, and why she used her foot to attempt to move the resident. Interview with the Director of Nursing (DNS) on 1/15/26 at 1:13 PM identified around 4 PM on 1/3/26 staff observed Resident #2 on the floor in the shower room. NA #1 saw Resident #2 was trying to move his/her legs and NA #1 tried to move Resident #2's legs to uncross them in an attempt to make the resident more comfortable. Moving Resident #2's leg caused the resident pain and the nurse told her not to move the resident after they saw NA #1 trying to move his/her legs. The DNS stated NA #1 should not have moved Resident #2. Further, the DNS stated NA #1 should not have used her foot to move Resident #2, instead she should have used her hands. Interview failed to identify why NA #1 attempted to move Resident #2 and failed to identify why NA #1 would use her foot in an attempt to move Resident #2 after the fall. Review of Falls, Management and Prevention Policy dated 2/7/23 directed in part, following a fall, not to move the resident prior to an assessment from the nurse. the nurse.

Based on record review, facility documentation, facility policy review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure a comprehensive care plan was developed to include a resident's transfer status. The findings include:Resident #1 had a diagnosis of hemiplegia (paralysis), hemiparesis (muscle weakness) affecting the left non-dominant side, and muscle weakness. The annual Minimum Data Set (MDS) dated [DATE] identified Resident #1 was alert and oriented (Brief Interview for Mental Status - BIMS - score of 15 out of 15) and was dependent for transfers. The Resident Care Plan (RCP) dated 6/17/2025 identified a deficit in activities of daily living (ADLs) and a risk for falls. Interventions directed to praise all efforts at self-care, and to ensure the resident's call light was in reach. Facility reportable event dated 7/2/2025 at 7:45 PM identified Nurse Aide (NA) #1 transferred Resident #1 into bed with use of a mechanical lift without a second staff member present and Resident #1 fell to the floor. Record review failed to identify a physician order for transfer status or use of a mechanical lift. Record review failed to identify the RCP directed use of a mechanical lift for transfers. Additional review failed to identify any transfer status was noted in the care plan. Interview and documentation review with the Director of Nursing (DNS) on 7/28/2025 at 2:41 PM identified Resident #1 required use of a mechanical lift since admission in 2021, and stated the care plan should include a resident's transfer status. The DNS stated Resident #1's care plan did not include use of a mechanical lift, or any type of transfer status, and she did not know why. Although the DNS stated the NA assignment sheet directed use of a mechanical lift, the DNS was unable to provide a copy of the NA assignment sheet. Review of the undated facility Care Planning policy directed in part, the facility was to develop and implement comprehensive and individualized care plans for all residents to ensure the needs are being met.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #8 and 371) reviewed for accidents, for Resident #8 the facility failed to use the appropriate size sling during a mechanical lift transfer which resulted in the resident falling out of the sling onto the floor during a mechanical lift transfer and sustaining a [CONDITION(S)] that required 8 staples to close. For Resident #371 who was being transported in a vehicle, the facility failed to adequately secure the wheelchair the resident was seated, which resulted in the wheelchair sliding and bumping the resident's leg causing a displaced distal femur fracture. The findings include: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbances and stroke. The nurse aide assignment, undated, identified Resident #8 required the assistance of 2 staff via mechanical lift (Maxi lift) for transfers. Review of February 2022 physician's orders directed to get the resident out of bed as tolerated. The physician's orders failed to reflect how Resident #8 was to be transferred. The quarterly MDS dated [DATE] identified Resident #8 had severely impaired cognition and required total 2-person assistance with transfers. A reportable event form dated 2/19/22 at 4:20 PM identified Resident #8 fell from the Maxi lift while being transferred from the wheelchair to the bed and sustained a laceration to the back of the head and multiple abrasions. The physician was notified, and the resident was transferred to the hospital for evaluation. The investigation identified the wrong size sling was used during the Maxi lift transfer. Resident #8 returned to the facility at baseline with 8 staples to the back of the head. Review of the safety event fall dated 2/19/22 identified Resident #8 fell from the Maxi lift during transfer. [CONDITION(S)] and abrasion to leg. Neurological check identified Resident #8 was alert, wakefulness, in pain, blood pressure 177/61, temperature 97.4, pulse 66, respiration 16, oxygen saturation 98% on room air. A fall investigation form dated 2/19/22 identified NA #1 indicated during the transfer from the wheelchair to bed she operated the Maxi lift and hooked the slings onto the lugs to the right, and NA #2 hooked the slings onto the lugs to the left side. When the resident was lifted, and the mechanical lift was moved towards the bed, 3 of the slings let go from the latch and Resident #8 fell to the floor. NA #1 indicated it happened so quick she was unable to grab the resident to prevent the fall. A fall investigation form dated 2/19/22 identified NA #2 was assisting NA #1 during the transfer. NA #2 indicated she fastened the left side of the slings to the lugs. NA #2 indicated she moved the wheelchair out of the way and NA #1 maneuvered the Maxi lift towards the bed. NA #2 indicated she was at the foot of the resident and suddenly all 3 slings came off from the lugs. The resident fell and they were unable to break the fall as it happened so quickly. The care plan dated 2/19/22 identified Resident #8 sustained a laceration to the back of head. Interventions included to monitor for bleeding, signs and symptoms of infection, and pain. Remove sutures as ordered by the physician. Review of hospital emergency course notes dated 2/19/22 at 11:28 PM identified Resident #8 was status post a fall during a mechanical lift transfer and fell ,d+[DATE] feet. On arrival, resident has a laceration to head and abrasion noted on bilateral legs, more on the right inner leg. Skin tear on the left shin. Resident is nonverbal at baseline and has dementia. No loss of conscious. CT scan brain/c-spine were negative for acute pathology. Knee negative for fracture. Laceration to left occiput was deep to scalp, repaired with staples. Interview with NA #1 on 3/1/22 at 4:08 PM identified she was assigned to Resident #8 and NA #2 was assisting with the Maxi lift. NA #1 indicated Resident #8 was sitting on the blue sling and she hooked the right-side of the sling onto the lugs and pulled the strap down. NA #2 hooked the left side of the sling onto the lugs and pulled the strapped down. NA #1 indicated the blue sling was used during the Maxi lift transfer. NA #1 indicated she was controlling the Maxi lift and NA #2 was at the resident legs. NA #1 indicated after lifting the resident up she opened the Maxi lift legs and turned the Maxi lift toward the bed. Quickly the 2 shoulder slings and the left leg sling latch came off the lugs, a total of 3 sling came off, and the resident fell on the floor. NA #1 indicated only the right sling was still attached to the Maxi lift. NA #1 indicated the resident was not moved and she went and got the nurse. NA #1 indicated she was aware that the wrong sling was used because the blue sling was too big for the resident. NA #1 indicated the sling color goes with the resident weight. NA #1 indicated she stayed at the resident side until the paramedics arrived. Interview with LPN #8 on 3/2/22 at 1:56 PM identified NA #1 notified her of Resident #8's fall. LPN #8 indicated Resident #8 was lying on his/her back on the floor and only one sling on the Maxi lift was still latched to the lug. LPN #8 indicated she assessed the resident and saw blood on the floor near his/her head. LPN #8 indicated she did not move the resident and called RN #8 and grabbed the first aid kit. LPN #8 indicated she took vital signs and initiated neurological check. Resident #8 was alert, non-verbal at baseline and never lost consciousness. LPN #8 indicated RN #8 arrived and completed an assessment and neurological checks and pressure was applied to the resident's head. LPN #8 indicated she remained with the resident until the paramedics arrived. Interview with the DNS on 3/2/22 at 2:43 PM indicated after a thorough investigation and a returned demonstration she identified the staff used the wrong sling for Resident #8's weight and height which caused the fall. The DNS indicated the blue sling that was used was too big for Resident #8. The DNS indicated an audit of all residents that transfer via Maxi lift was completed. Interview with RN #8 on 3/2/22 at 3:50 PM identified LPN #8 called her to report the fall. RN #8 indicated she observed Resident #8 on the floor on his/her back in front of the bed. RN #8 indicated Resident #8 was alert and an assessment was done. RN #8 noticed blood coming from the back of the resident's head and pressure was applied to the area. The resident was not moved, neurological checks were initiated, and the resident never lost consciousness. RN #8 immediately called 911 and started the paperwork. RN #8 indicated LPN #8 and the 2 nurse aides were at the resident side. RN #8 indicated the paramedics came and assessed Resident #8, placed a neck collar and lifted the resident to the stretcher. RN #8 indicated the resident was alert and non-verbal when he/she left the facility. RN #8 indicated she and the DNS started the investigation and returned demonstration. RN #8 identified at the conclusion of the investigation it was identified that the wrong sling was used. The staff used a blue sling which was too big for Resident #8's weight. Review of the Arjo sling color/size guide identified adults' size small weighing 77-132 lbs. (35-60kg) is to use the red sling. Review of the Maxi Move manual identified the standard range of Maxi Move slings will support 227 kg (500 lbs.), the pediatric spreader bar range will support 125 kg (275 lbs.). All slings are sized-coded with different colored edge binding or attachment strap coloring: Pediatric rated: teal or grey - extra small - XXS. Brown or white - extra small - XS. Red - small - S. Standard Range: Yellow - medium - M. Green - large - L. Purple - large, large - LL. Blue extra-large - XL. Terracotta - extra extra large - XXL. Always refer to the label on the sling being used to make sure of its actual safe working load (SWL). A label is placed on the spreader bar for a quick color-to-size reference. Arjo standard sling profile that can be used with the Maxi Move - Four-point padded sling. To lift from a chair: Attach the shoulder strap attachment clips to the sling attachment lugs on the spreader bar. Apply the leg clips of the sling onto the lugs so that they become positioned vertically. Review of the mechanical lift policy identified a hoyer lift is a lifting device or hydraulic lift that is commonly used to help transfer patients from beds to wheelchairs and back again. Special care and attention need to be used when transferring any resident using a hoyer lift as injuries, even death, may result from improper techniques or use of the lift. The hoyer lift should always be used with two people. It is the policy of the facility to ensure proper mechanical lift training for all clinical employees prior to using the equipment. Staff must be trained/educated during orientation, on the units and annually for proper/safe use and compliance. The mechanical lift comes in different sizes and shapes. Each comes with a manual that designates weight capacity and guidelines for correct use. Before transferring anyone using a hoyer lift, individuals must ensure that the proper canvas/sling is utilized for the resident being transferred. Selection and use of the proper size canvas sling is based on each resident's weight. 2. Resident #371's diagnoses included [CONDITION(S)], [CONDITION(S)]. The quarterly MDS dated [DATE] identified Resident #371 had moderately impaired cognition, exhibited verbal behaviors directed towards others (1 - 3-day occurrence), was totally dependent on staff for transfers between surfaces i.e., to/from wheelchair, and required extensive assistance with all activities of daily living (ADLs) including locomotion off unit. The care plan dated 10/27/20 identified Resident #371 had a problem with falls due to impaired physical mobility related to [CONDITION(S)] and a history of tibial fracture related to [CONDITION(S)]. Interventions included to transfer Resident #371 via a mechanical lift with assistance of two (2) staff. A nurses note dated 1/7/21 at 11:10 PM identified Resident #371 was to have an appointment with MD #2 this morning. A nurses note dated 1/7/21 at 2:10 PM identified that on the way to MD #2's appointment, Resident #371's wheelchair slid forward slightly, and the resident's right foot hit the empty chair in front of him/her. Further, Resident #371 was seen and examined by MD #2 and additionally examined by RN #3. No bruising or redness was identified, and the plan was to continue to monitor. A physicians' order dated 1/7/21 directed to monitor the resident's right foot for any bruising or redness every shift for three (3) days. A reportable event form dated 1/8/21 identified on 1/7/21 at 11:15 AM, during transport via facility motor vehicle to a physician's appointment, Resident #371's wheelchair slid forward, and his/her right foot struck the chair in front of him/her. Interventions included repositioning the resident in the vehicle and that Resident #371 was seen by Neurologist MD #2 during appointment. The report identified that APRN #1 was notified on 1/7/21 at 1:00 PM and that no bruising or redness was noted. A nurses note dated 1/8/21 at 7:10 PM identified that Resident #371 requested Tylenol 650 mg for general discomfort and right foot discomfort. The note further identified no bruises were noted on resident's right foot. A nurses note dated 1/9/21 identified that at about 12:40 AM the resident was awake, vital signs were stable and that some swelling was noted to bilateral lower extremities. The resident requested Tylenol for sleep and all over pain /discomfort. The note further identified no bruises or redness noted on resident's right foot. A nurses note dated 1/9/21 at 8:07 AM identified right knee discoloration, slightly swollen and warm to touch. The resident did not express any acute pain. MD #1 was notified and directed to obtain an x-ray of right lower extremity. A radiology report dated 1/9/21 identified an acute moderately displaced fracture of the distal right femur involving its supracondylar region. An orthopedic consultation was recommended. A physician's orders dated 1/9/21 directed to apply a knee immobilizer at all times, can remove for care. A reportable event form dated 1/11/21 identified subsequent to the 1/7/21 transport vehicle incident, Resident #1 complaint of pain and an x-ray identified a right femur fracture. Interview with NA #4 (transport companion) on 3/8/22 at 11:59 AM indicated that on the day of the incident, although she had locked the resident's wheelchair brakes after the incident, Resident #371 had told her that the brakes were not locked. A return demonstration utilizing Resident #371's wheelchair on 3/8/22 at 12:35 PM with transport driver (TD #1) and the Assistant Director of Nursing (ADNS) present observing, noted that there were no seats located in front of the location where wheelchairs are secured. TD #1 indicated that at the time of the incident, it was actually the passenger chair on the right side (of the aisle) of the wheelchair location. Proper strapping was demonstrated by TD #1 and the wheelchair was noted unable to shift sideways. As straps were loosened some was movement noted and with significant loosening of the straps the wheelchair (with occupant) noted to move more but continued to retain the wheelchair and occupant from engaging the adjacent passenger chair. Interview with TD #1 with ADNS present at the time of the demonstration, identified that although the securing straps were loose, he was unable to explain how the resident's wheelchair could have moved and impacted the adjacent passenger chair. Interview with the ADNS on 3/8/22 at 12:53 PM identified that for the wheelchair (with occupant) to come in contact with the adjacent chair, the straps must have been loose and could not have occurred as originally described. Interview with the radiologist (MD #3) on 3/9/22 at 11:50 AM identified that the femur fracture was the result of full body weight impact or from a traumatic forceful event. Interview with the DNS on 3/9/22 identified that although there was no documented formal training for TD #1, when he was hired seven (7) years ago, he was trained by the preceding driver, and this was the first incident. The DNS indicated that TD #1 was provided education at the time of the incident in January of 2021, that included direction for drivers to ensure residents are securely fastened into vehicle prior to leaving to and from destination. The education further identified that the wheelchair /transport chair must be secured in a manner where it does not shift during transportation. Although requested, a facility vehicle transport policy was not provided.

Based on clinical record review, review of facility documentation, review of facility policies, and interviews for one of three sampled residents (Resident #1) reviewed for elopement risk, the facility failed to ensure adequate supervision was provided to prevent an elopement resulting in immediate jeopardy. The immediate jeopardy was verified as corrected during the onsite visit on 1/23/20. The finding includes: Resident (R) #1's diagnoses included Diabetes Mellitus (DM), [CONDITION(S)] of the right thumb, and dementia An admission elopement risk assessment was completed on 8/20/19 and indicated R#1 was not at risk for elopement. The five day Minimum Data Set (MDS) assessment dated [DATE] identified R#1 had moderately impaired cognition, required extensive assistance with bed mobility, transfers and personal hygiene, and required limited one person assistance with ambulation in his/her room and corridor with the assistance of a rolling walker. Additionally, the MDS identified that R#1 had a history of falls in the previous six months. A nurse's note dated 8/31/19 at 2:56 PM identified that R#1 had been wandering on the unit with his/her clothes in a bag. The clinical record lacked documentation an elopement risk assessment was completed however, the Physician was notified, a wander guard was placed on the Resident's right ankle, and a physician's order dated 8/31/19 directed to check the wanderguard every shift for placement on R#1's right ankle. The Resident Care Plan (RCP) dated 9/3/19 identified R#1 was at risk for impaired decision making related to dementia. Interventions directed to determine if decisions made by R#1 endangered the Resident or other residents and to intervene when necessary, and to check the wanderguard every shift for placement on R#1's right ankle. A nurse's note dated 9/6/19 at 12:17 AM indicated that on 9/5/19 at 7:05 PM, R#1 was not in his/her room and could not be located in the facility. According to the nurse's note the Resident left the facility in a taxi cab to go home and returned to the facility on [DATE] at 7:20 PM. R#1 stated that s/he wanted to go home. A complete body assessment was completed and no injuries were noted. The Physician was notified and no new orders were obtained. Review of the facility's investigation of the incident on 1/21/2020 at 11:00 AM with the Interim Administrator identified that on 9/5/19 the facility's receptionist called a taxi for Resident #1 who indicated s/he needed a cab home and provided the address to the Receptionist. R#1's wander guard activated the alarm at the facility's main entrance and Housekeeper #1 silenced the alarm without checking to see if a Resident had left the facility, triggering the alarm. Housekeeper #1 did not notify anyone that the alarm had sounded. The Receptionist, whose desk was located in the lobby, indicated she did not hear the alarm. When it was identified that R#1 had left the building the Taxi cab service was notified and the Resident was returned to the facility. Interview on 1/21/2020 at 11:15 AM with the Receptionist, on duty at the time of the incident, identified that she thought R#1 was a visitor, called for a taxi, and did not hear the alarm sound. Additionally she indicated that prior to the incident she knew who was at risk for eloping because all the residents who were at risk had a wander guard that would sound an alarm if they attempted to leave the facility, and pictures of residents at risk for elopement were posted at the receptioon desk in the lobby. Interview on 1/21/2020 at 12:15 PM with Registered Nurse (RN) #1, the nurse on duty at the time of the incident, identified that once she noticed that R#1 was not in his/her room she notified the supervisor, an announcement indicating a resident was missing was made and the staff began a search of the facility, as directed by the facility Missing Person policy. RN#1 could not recall the last time she observed the Resident prior to noticing he/she was not in his/her room. Interview with the shift Supervisor on 1/21/2020 at 12:25 PM identified that when the Facility's Missing Person Policy was initiated and the receptionist notified her that a taxi was had been called for someone who could have possibly been R#1. Interview on 1/21/2020 at 12:45 PM with Housekeeper #1 identified that when the main entrance alarm sounded he turned off the alarm. Although he indicated that there was not a resident standing near the door at the time, he did see a Taxi driver holding the door open for a man getting into the taxi who he believed to be a visitor. Additionally the housekeeper stated that he searched the surrounding area near the door, inside the facility, and failed to notify licensed staff the alarm had sounded. Review of the clinical record, facility documentation and interview with the Director of Nurses (DON) on 1/23/2020 at 11:00 AM identified that although other residents who were determined to be at risk for elopement had their picture posted at the reception desk as a visual reminder for reception staff, R #1's picture was not included and should have been. The facility policy at the time of the incdent identified resident photos for second floor residents would be posted at the reception desk however the policy did not include posting of resident photos for the residents at risk for elopement on the first floor. The facility failed to ensure a resident at risk for elopement was properly identified at the reception desk, and ensure that facility staff (Housekeeper #1) reacted appropriately when the door alarm was activated by notifying a licensed staff member. The Facility's Elopement Risk Prevention and Management of a Missing Resident policy identified it is the responsibility of all staff, regardless of the department they work in to respond to activated door alarms and to return residents to their unit. During the onsite visit, on 1/23/20, it was verified that IJ was abated on 9/10/19 when the facility implemented the following: The facility policy related to wander guard/elopement procedures was revised on 9/9/19 and retraining of all staff was initiated on 9/10/19 on wander guard/elopement procedures. The wander guard system at the main entrance was modified on 9/16/19 to prevent the exterior doors from opening when the alarm is activated until the nursing unit staff or supervisor is notified of a potential elopement and the alarm is then silenced. An elopement drill was conducted on 9/27/19 during the 7:00 AM-3:00 PM shift and will be conducted randomly thereafter. Photo Identification will be taken on admission and when there is a change in condition. Photos of all Resident's at risk for elopement were posted at the nurse's stations and the main reception area, while maintaining resident privacy.

Based on review of the clinical records, review of facility documentation and interviews for one of three sampled resident (Resident #377) who were at risk for dehydration, the facility failed to monitor and/or assess the resident to ensure the resident consumed a sufficient amount of fluids. The findings include: Resident #377's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified Resident #377 had memory and cognitive deficits, required extensive one person assistance with eating, and received a diuretic daily. The resident care plan dated 8/31/16 identified Resident #377 was at risk for dehydration. Interventions directed to monitor blood work and report abnormal results, assess for signs and symptoms of dehydration, encourage fluids and assist with fluids. An admission physician's orders [REDACTED]. Review of the Intake and Output Record from 8/22/16 through 9/6/16 identified that the resident's twenty-four (24) hour fluid goal was 1650 cubic centimeters and the intake and output (I & O) monitoring was discontinued on 9/6/16. A physician's orders [REDACTED]. The laboratory results dated [DATE] identified abnormal values: the Blood Urea Nitrogen (BUN) was 91 (normal 7-25 mg/dL); the Creatinine was 4.26 (normal range 0.70-1.11 mg/dL); Sodium level was 150 (normal range 135-146 mmol/L); and the Chloride was 115 (normal range 98-110 mmol/L). Review of the clinical record from 9/16/16 through 9/22/16 failed to reflect documentation the resident had been monitored for signs and/or symptoms of dehydration. The Advanced Practice Registered Nurse (APRN) progress note dated 9/22/16 identified Resident #377 was seen for acute mental status changes, inability to swallow, the mucosa was slight dry and the resident was hypotensive. Subsequently on 9/22/16, Resident #377 was transferred to the hospital and admitted with [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 10/5/16 identified on admission the resident was found to have severe [MEDICAL CONDITION] with a creatinine level of 8.7 on 9/22/17. The report identified the resident received four (4) to five (5) days of intravenous fluids and a gastrostomy tube was inserted for nutrition due to the resident's high risk of aspiration. Review of the clinical record and interview with the Director of Nursing (DON) on 7/26/17 at 11:30 AM identified that the resident's twenty-four (24) hour fluid goal was 1650 cubic centimeters and the intake and output (I & O) monitoring was discontinued on 9/6/16 because the resident had reached his/her intake goals. Upon further review, the clinical record failed to reflect documentation the resident had been monitored for signs and symptoms of dehydration. The Intake and Output/Hydration policy identified, in part, residents will be placed on intake and output for seventy-two (72) hours on admission and poor intake [MEDICATION NAME] more than three (3) days.

Based on review of the clinical record, facility policy, and interview for 1 of 3 sampled residents, (Resident #213), reviewed for accidents, and for the only hydrocollator in the therapy department, the facility failed to ensure adequate supervision to prevent a fall and/or maintain equipment to prevent an accident, according to the facility policy. 1. Resident #213 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician's order dated 2/16/17 directed the use of a bed and chair alarm. The care plan dated 2/17/17 identified Resident #213 had impaired cognition, was at risk for falls related to Parkinson's disease, and was non-compliant with safety measures due to dementia. Additionally, the care plan identified Resident #213 could walk without staff assistance. Interventions directed the use of a wheelchair alarm and bed alarm, and the provision of close supervision while allowing for privacy. Additionally, the NA care card identified the resident was at high risk for falls. The admission MDS dated [DATE] identified Resident #213 had moderately impaired cognition, and required extensive assistance for transfers, ambulation, and toileting. An OT progress note dated 3/16/17 identified Resident #213 required supervision (standby assistance, contact guard assist) for standing and/or transfers to ensure safety. Physician's order dated 3/22/17 directed orthostatic blood pressures be obtained twice daily and the results faxed weekly to the physician. The MAR dated 3/23/17 during the 3:00 PM to 11:00 PM shift identified orthostatic blood pressures as follows; Sitting 106/63 mm/Hg Standing 87/50 mm/Hg, (19/13 mm/Hg lower). The MAR dated 3/24/17 during the 7:00 AM to 3:00 PM shift identified orthostatic blood pressures as follows; Sitting 119/65 mm/Hg Standing 73/49 mm/Hg, (46/16 mm/Hg lower). Nurse's note dated 3/24/17 at 1:55 PM identified a nurse aide assisted Resident #213 to the bathroom, and instructed the resident to call for assistance when done. At 2:00 PM the nurse aide returned to the bathroom and found Resident #213 on the floor, lying on his/her right side. Upon assessment, Resident #213 complained of right hip pain, had limited ROM, and shortening of the right lower extremity. The physician was notified and Resident #213 was transferred to the hospital for evaluation. Resident #213 returned to the facility on [DATE]. Review of the hospital discharge summary dated 3/29/17 identified a non-displaced distal clavicle fracture, (collarbone), and an intertrochanteric fracture of the right hip. The care plan dated 3/29/17 was revised to include the use of a floor matt next to Resident #213's the bed, and a sign was posted in the bathroom to remind Resident #213 to call for assistance. Review of the clinical record identified on 4/27/17 and 5/22/17 Resident #213 attempted to transfer and/or stand without calling for assistance, and was found on the floor. Nurses note dated 6/26/17 identified the interdisciplinary team directed the staff to keep Resident #213's walker out of reach to prevent the resident from walking without assistance due to poor safety awareness. Interview and review of the clinical record on 7/26/17 at 6:50 AM with RN #1 identified although Resident #213 required the use of a wheelchair alarm and bed alarm for poor safety awareness, on 3/24/17 at 1:55 PM the resident was left unassisted on the toilet for privacy. Interview and review of the clinical record on 7/27/17 at 10:00 AM with APRN #1 identified Resident #213's orthostatic blood pressures were being monitored due to a [DIAGNOSES REDACTED]. Interview and review of the clinical record on 7/27/17 at 7:45 AM with the DNS identified that although Resident #213 had transferred and/or attempted to stand on 3 occasions (3/24, 4/27, and 5/22/17), which resulted in falls, it was still appropriate for the resident to be unsupervised in the bathroom, because he/she would use the call light to call for assistance. Review of the facility policy on fall management identified when assessing a resident, staff weighs identified risk factors against autonomy issues and resident choice. Risk factors include prior falls, medications with potential hypotensive effects, dementing illnesses, observed ambulation problems, conditions that may impact balance, continence and the need for assistance with toileting. 2. Review of facility documentation identified a hydrocollator was ordered for the therapy department on 11/11/16, and was received by the facility on 11/29/16. Observation on 7/27/17 at 8:12 AM identified the hydrocollator unit was noted in the therapy department. Review of the hydrocollator log failed to reflect temperatures had been monitored between 1/1/17 through 7/27/17, Interview with Rehabilitation Aide #1 on 7/27/17 at 8:20 AM identified the hydrocollator was new. Additionally, Rehabilitation Aide #1 indicated he/she checks the temperature, and documents the temperature on the hydrocollator log monthly. Interview with Rehabilitation Director on 7/27/17 at 8:20 AM indicated the hydrocollator temperature should be check daily. Observation and interview with the Rehabilitation Director on 7/27/17 at 9:05 AM identified there was no thermometer located in the rehabilitation department. The hydrocollator cleaning procedure directed to regulate the temperature between 160 and 165 degrees F.

Based on clinical record review and staff interview for one of six residents in the survey sample reviewed for accidents (R #92), the facility failed to protect a combative resident during care resulting in multiple injuries. The findings include: Resident #92's [DIAGNOSES REDACTED]. The care plan dated 6/9/15 identified a problem with dementia, delusions with verbal abuse and resistance to care. The care plan identified that the resident experiences sudden spikes in aggressive behaviors at times with little or no warning. Interventions included that when resident begins to resist care, stop and try task later. Nurse ' s notes dated 8/7/15 identified R#92 was extremely combative, scratching staff, throwing a meal tray and punching staff. Nurse's notes dated 9/1/15 at 12:30 AM identified that NA#4 reported that Resident #92 became combative (during care), tried to grab NA#4, missed and grabbed his/her own left forearm causing a skin tear that required steri-strips and a dressing. Nurse ' s notes dated 9/17/15 at 2:00 AM noted that NA#4 called the nurse to the resident ' s room where the resident was found with a large laceration with copious amounts of blood on the left forearm. Facility report/ investigation dated 9/17/15 identified that R#92 sustained laceration left forearm at 1 AM irregular shape. Length 10 cm. Resident was very combative, resistive while given care . NA#4 again reported that R#92 became combative and attempted to strike/grab NA#4 and instead the resident struck his/herself inflicting the large laceration. The resident was transferred to the hospital where sutures had to be placed in the muscle to re-connect the lacerated muscle in his/her arm. Interview and review of R#92's clinical record on 12/16/15 at 10:05 AM with RN#7 failed to provide documentation that the plan of care was reviewed and/or revised after the first injury occurred on 9/1/15 and/or that NA#4 had provided care to the resident in accordance with the plan of care for combative residents. Subsequent to the second injury, the resident ' s care was to be provided with 2 staff members.