Every finding on record at New Mark Rehab and Healthcare Center

Based on observation, interview, and record review the facility failed to provide a comfortable, home like environment when the facility's cooling system was not able to maintain comfortable temperatures for the residents, causing two residents with lung disorders to have increased difficulty breathing; and two residents to be uncomfortable in their rooms. This deficient practice affected four (Resident #3, #4, #5, and #6) of four sampled residents. The facility census was 172.Review of the facility policy titled, Extreme Weather, dated 10/24/22, showed:-The purpose of the policy was to provide residents, visitors, and staff with comfortable and safe environment during extreme weather; -The facility responds to extreme weather in a prompt manner to protect the health and safety of residents; -Nursing staff will assess residents for signs of heat related conditions, such as increased fatigue, dehydration, lethargy or decreased skin turgor and notify the Attending Physician of any concerns.1. Review of Resident #3's electronic medical record on 07/27/28 showed:-Diagnoses included: Multiple Sclerosis (A nervous system disorder causing fatigue, numbness, weakness, and balance issues), Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD: a lung disease that blocks airflow and makes it hard to breathe). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 05/09/26, showed:- The resident had adequate hearing, made self-understood and understood others;-Brief Interview of Mental Status score of 99 (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents), indicated the resident had a cognitive deficit. Review of the resident's comprehensive care plan, dated 07/24/26, showed:-He/She was at risk for respiratory distress because of his/her chronic obstructive pulmonary disease (COPD, lung disease that makes it difficult to breathe) and he/she used oxygen; -Monitor for signs and symptoms of respiratory distress such as restlessness, headache, sweating, skin color and notify the physician as needed.During an interview and observation on 07/27/26 at 4:15 P.M., the resident said: -It was very hot in his/her room yesterday (07/26/26);-He/She had not had a shower for a week, and no extra showers were offered due to the heat; -He/She felt it was harder to breathe because of the heat;-He/She was so hot it was hard to talk;-His/Her face was flushed and greasy; -Respirations were short and shallow;-He/She only had a sheet covering his/her body;-Room temperature by portable thermometer was 84.7 degrees Fahrenheit. 2. Review of Resident #5's electronic medical record on 07/27/26 showed: -Diagnoses included: COPD, Respiratory Failure, Muscle Weakness, dependence on supplemental oxygen, and Congestive Heart Failure (CHF: the heart's inability to pump blood effectively);Review of the resident's admission MDS, dated [DATE] showed:-He/She had clear speech, was able to make self-understood and understood others;-He/She scored 12 on the BIMS, indicating slight cognitive deficit;-He/She need partial to moderate assistance from staff for ADL's (Activities of Daily Living). Review of the resident's comprehensive care plan, dated 06/27/26, showed:-He/She will verbalize less difficulty breathing and be more comfortable; -He/She had altered respiratory status; -Monitor for signs and symptoms of respiratory distress, such as restlessness, skin color and increased heart rate, and report to the physician as needed.During an interview and observation on 07/27/26 at 4:05 P.M., the resident said:-He/She felt it was hard to breath in his/her room because it was hot; -Yesterday (07/26/26) his/her room was unbearable and terrible; -He/She was not aware of any staff checking the temperature of his/her room;-He/She did not report the room was hot because staff would say he/she complained and would be mean to him/her;-A portable air conditioning unit was in Resident #5's room, facing the closet; -One tower fan and one box fan were sitting on his/her bedroom floor;-The resident's face was pale, lips were pale and he/she had pursed lipped breathing (puckered lips used to assist in breathing for people who feel short of breath) -Room temperature by portable thermometer was 82.6 degrees Fahrenheit. 3. Review of Resident #4's electronic medical record on 07/27/26 showed:-Diagnoses included: Parkinson's Disease (a brain disorder causing tremors, balance problems and effects all body movements); syncope and collapse (sudden loss of consciousness and muscle control) dementia and anxiety. Review of the resident's annual MDS, dated [DATE], showed :-BIMS of 1, indicated significant cognitive loss; -He/She was dependent on staff for all ADL's. Review of the resident's comprehensive care plan, dated 06/26/26 showed:-He/She was at risk for yelling out behaviors; -Staff were to anticipate and meet the resident's needs;-Monitor behavior and attempt to determine underlying cause; -He/She had a communication problem; -His/Her needs will be anticipated and met by staff.Observation on 07/27/26 at 4:02 P.M. showed:-The resident was heard in the hallway outside his/her room, crying out; -He/She was lying in bed; -His/Her face was flushed and shiny; -His/Her bed linens were in disarray at the foot of his/her bed; -He/She was moving his/her legs back and forth pushing at linens with his/her feet; -He/She had nothing covering his/her lower body; -He/She had a t shirt on his/her upper body; -Room temperature by portable thermometer was 83.1 degrees Fahrenheit. 4. Review of Resident #6's electronic medical record on 07/27/26 showed: -Diagnoses included: Need for assistance with personal cares, muscle weakness, anxiety and convulsions. Review of the resident's annual MDS, dated [DATE] showed:-The resident had clear speech, was able to make self-understood and understood others; -He/she scored 13 on the BIMS, indicating very limited cognitive deficit;-Partial to moderate assistance from staff for ADL's. Review of the resident's comprehensive care plan, dated 05/21/26 showed:-He/She had ineffective breathing at rest or while lying flat; -He/She preferred to sleep in a recliner most times; -Assess for shortness of air;.During an interview and observation on 07/27/26 at 4:07 P.M., showed:-He/She said it was so hot in his/her room that he/she could not stand to have blankets on;-He/She was miserable due to the heat; -He/She was lying back in a recliner with a thin blanket over his/her lower body; -He/She kicked his/her legs, dislodging the blanket, and exposed his/her legs;-He/She had on a t-shirt and soiled incontinent brief; -His/her face was flushed and hair was disheveled;-Room temperature by portable thermometer, near the privacy curtain, was 83.8 degrees Fahrenheit. During an interview on 07/27/26 at 3:30 P.M., Certified Nurse Aide (CNA) Z said:-The facility was really hot; -Several residents had complained about the heat; -Sunday (07/26/26) was terribly hot, the portable air conditioners were not working to keep the facility cool.During an interview on 07/27/26 at 3:26 P.M.; the Director of Operations said:-Measures had been taken to maintain temperatures throughout the facility; -Portable air conditioners had been set up thought the facility; -The Regional Maintenance Director had been in the facility monitoring the temperatures and portable machines. During an interview on 07/27/26 at 5:00 P.M., the Regional Maintenance Director said: -He had been on site starting 07/24/26 because of cooling concerns for the facility; -Four portable air conditioners were installed 07/24/26; -Two time a day temperature checks were started on Sunday, 07/26/26;-The increased temperature procedure included resident interviews; -Monday, 07/27/26 at 2:00 P.M. interviews with residents had very few concerns brought up; -200 hall temperatures were elevated as they had water source units and did not work as well; -Residents had been instructed to keep room blinds closed, sliding doors and windows closed; -More wall mounted units should be added week of 08/03/26; -Four additional portable units were added to the facility on Monday, 07/27/26, one by the 200 hall nurse's station, and three on the 300 hall; -There have been no reported real concerns just discussions about the temperature in the facility.During an interview on 08/05/26 at 1:10 P.M. Nurse Practitioner A said:-She was in the facility Monday through Friday in the mornings for rounds; -She knew the facility was warm; -The facility heat was discussed in morning meetings; -No specific resident concerns were brought up in the morning meeting; -Some residents do have trouble breathing in the heat, such as residents with COPD, Emphysema (lung disease that effects the elasticity of the lungs and the ability to move air in and out of the lungs) and resident's on oxygen;-She was not aware Resident #5 had complaints of difficulty breathing;-She did not specifically see Resident #5 during the time of extreme heat 07/25/26 to 07/27/26; -Resident #3 was seen sometime after 07/23/26, she was unsure of the date, and the resident did not complain of any difficulty breathing; -She would expect to be notified if residents complained of increased shortness of breath. Intake 3117281

Based on interview and record review, the facility failed to report to the State Survey agency when one resident (Resident #1) was found with skin tears to his/her mouth, right arm and right ring finger of unknown origin. This affected one of seven sampled residents. The facility census is 172. Review of the facility's Abuse Prevention and Prohibition Program policy, dated 10/24/22, showed:-Unexplained injuries are promptly and thoroughly investigated by the Director of Nursing Services and/or other staff person designated by the Administrator, to ensure resident safety is not compromised and action is taken whenever, to avoid future occurrences. -Facility staff are mandatory reporters. -The Facility will report known or suspected instances of physical abuse to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations. -Immediately, but no later than two hours after forming the suspicion-if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement and the Ombudsman. 1.Review of Resident #1's electronic medical record on 07/28/26 showed diagnoses of dementia, dysphagia, falls, cognitive communication deficit, severe protein-calorie malnutrition, chronic obstructive pulmonary disease, normal pressure hydrocephalus, wandering, Alzheimer's disease, anemia, adult failure to thrive. Review of the quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated 06/24/26, showed he/she had adequate hearing, clear speech, sometimes made self understood and sometimes understood others. He/She scored 3 on the Brief Interview for Mental Status indicating severely impaired cognition. Review of the comprehensive care plan, dated 07/27/26, showed interventions related to risk for elopement due to wandering, behaviors related to wandering and picking up other resident's belongings, impaired cognition, risk for falls. Review of the resident's progress notes on 07/28/26 showed:-On 07/26/26 at 7:00 P.M., Registered Nurse (RN) A documented that at approximately 6:45 P.M., RN A witnessed Resident #1 exiting Resident #2's room, ambulating in the hallway. During assessment, Resident #1 was noted to have skin tear to the right forearm, skin tear to right ring finger, multiple bruises to right arm and skin tear inside of the lower lip. When questioned, Resident #2 stated Resident #1 refused to leave his/her room and was taking possession of Resident #2's things. 2. Review of Resident #2's electronic medical record on 07/28/26 showed diagnoses of dementia with behavioral disturbance, severe protein-calorie malnutrition, restlessness/agitation, falls, cognitive communication deficit. Review of the admission MDS, dated [DATE], showed he/she had moderate difficulty hearing, clear speech, sometimes made self understood and sometimes understood others. He/She scored 3 on the BIMS indicating severely impaired cognition. Review of the comprehensive care plan, dated 07/26/26, showed interventions related to behaviors (being argumentative, refusal of cares, combative with staff), wandering/elopement risk, communication, cognition, agitation/insomnia, mood. Review of the resident's progress notes on 07/28/26 showed:-On 07/26/26 at 7:00 P.M., RN A documented that at approximately 6:45 P.M., Resident #1 went into Resident #2's room and started touching Resident #2's things. Resident #2 asked Resident #1 to leave the room and Resident #1 refused. Staff witnessed Resident #1 leaving Resident #2's room. Resident #2 told staff what happened and he/she asked Resident #1 to leave. Resident #2 had no injuries. Review of the facility investigation, dated 07/28/26, showed:-On 07/26/26 Resident #1 was visualized coming out of Resident #2's room at approximately 6:45 P.M.-Resident #1 was calm and not in distress. -The nurse noticed Resident #1 had a small skin tear to his/her finger and arm and a small area to the inside of his/her lip. -Nothing was heard or visualized in the room by any staff. -Upon entering Resident #2's room, Resident #2 was sitting in his/her chair. -Resident #2 denied touching Resident #1. -Resident #2 said he/she wanted Resident #1 out of the room. -Resident #1 does have a history of falls and is able to get self up if he/she falls. -Resident #1 was placed on one-to-one monitoring and neurological assessments were initiated. During an interview on 07/28/26 at 11:12 A.M., Nurse Practitioner (NP) A said: -Resident #1 wandered into Resident #2's room. -Staff heard yelling and observed Resident #1 exit Resident #2's room. -Resident #1 had injuries to his/her right arm, right hand, and lip. During an interview on 07/29/26 at 11:39 A.M., Certified Medication Technician (CMT) A said:-He/She was at the medication cart when he/she heard screaming and a resident yelling get out of my room. -CMT A observed Resident #1 exiting Resident #2's room.-Resident #1 had blood on his/her mouth, right arm, and right hand. -The nurse was also coming toward the room after hearing the yelling. -The nurse assessed the residents. During an interview on 07/29/26 at 12:26 P.M., NP B said:-He/She was informed of Resident #1's injuries during morning meeting on 07/28/26, when the Director of Nursing (DON) asked him/her to assess the resident. -NP B is unsure how Resident #1 came to have the injuries. -Resident #1 frequently wanders into other resident's room and takes their belongings. -Resident #1's right ring finger appeared red and puffy and the resident was started on antibiotics.-No staff witnessed what happened. During an interview on 08/05/26 at 3:52 P.M., RN A said: -RN A walked down the hall when he/she witnessed Resident #1 exiting Resident #2's room.-RN A first thought the resident had red food or drink on his/her face. -When RN A looked closer at Resident #1, RN A realized Resident #1 had blood on his/her face. -Upon further assessment, it was found Resident #1 had injuries to his/her mouth, right arm and right ring finger. -When RN A asked Resident #1 what happened, Resident #1 said he/she didn't know. -RN A then entered Resident #2's room and Resident #1 followed RN A into the room. -Resident #2 became very upset, yelling for Resident #1 to get out of the room and stop touching his/her belongings. -Resident #1 was assisted from the room. -RN A assessed Resident #2, who had no injuries. -RN A then informed the residents' physician, responsible parties, and the DON of the incident. -RN A started neurological assessments on Resident #1, treated his/her injuries, and placed Resident #1 on one-to-one supervision for safety. -It was Resident #1's base line to frequently wander and touch/take other resident's belongings. During an interview on 07/29/26 at 1:40 P.M., the DON said:-It was his/her expectation that all residents were safe and remain free of injuries. -Injuries of unknown origin should be reported to the state survey agency. Intake 3119143Intake 3119148

Based on observation, interview, and record review the facility failed to provide a safe and comfortable home like environment when the facility's heating system was not able to maintain comfortable temperatures for the residents. This deficient practice affected four (Resident #2, #3, #4, and #5) of five sampled residents. The facility census was 158.Review of the facility policy titled, Extreme Weather, dated 08/25/23, showed:-The purpose of the policy was to provide residents, visitors, and staff with comfortable and safe environment during extreme weather; -The facility responds to extreme weather in a prompt manner to protect the health and safety of residents; -During extreme cold weather, the facility will provide extra blankets to whom desire them, obtain additional clothing for residents with insufficient warm clothing, provide additional warm beverages for resident who desire them, and facility staff will assess residents for comfort and take additional measures to promote a comfortable environment as necessary;-The Maintenance Department maintains a log of Facility temperatures, if the temperature is above 81 degrees Fahrenheit or below 71 degrees, the Maintenance Department will document measures to remedy the situation. 1. Review of Resident #2's electronic medical record on 01/26/26 showed:-He/She was admitted to the facility on [DATE]. -Diagnoses included: Lymphedema (swelling, most often in an arm or leg, caused by a lymphatic system blockage), repeated falls, cognitive communication deficit (a difficulty with communication that's caused by an underlying issue with cognition), asthma (a chronic lung condition that causes inflammation and narrowing of the airways, leading to symptoms such as wheezing, coughing, and shortness of breath), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing a significant impairment in daily life), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), bilateral osteoarthritis of knee (a chronic degenerative joint disease that causes cartilage in the joints to break down over time).Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 01/05/26, showed:- The resident had adequate hearing, clear speech, made self understood and understood others;He/She scored 15 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents) , indicating the resident did not have a cognitive deficit. Review of the resident's comprehensive care plan, dated 01/23/26, showed:-Interventions related to increasing lung function related asthma, participates in activities of choice, activities of daily living (ADLs) related to bilateral knee arthritis, atrial fibrillation, risk for falls, depression, nutrition, pain related to arthritis, skin integrity, occasional bladder incontinence. During an interview on 01/26/26 at 01:33 P.M., the resident said: -It was very cold in the facility on Sunday, 01/25/26;-He/She was very cold in his/her room, he/she had to put on extra blankets and a coat;-The staff came to the resident's room Sunday evening and said he/she could move to a room on a different hall, where it was warmer and the resident moved to a different room; -No one has come to speak to the resident about when he/she can move back to his/her original room;-It is still too cold in the facility;-He/She still had to wear a coat and blanket while out of his/her room. 2. Review of Resident #3's electronic medical record on 1/26/26 showed:-Diagnoses included: Multiple Sclerosis (a chronic autoimmune disease affecting the central nervous system that damages the myelin sheath protecting nerve cells, leading to a range of neurological symptoms like vision problems, numbness, weakness, balance issues and cognitive difficulties), dementia (a group of thinking and social symptoms that interferes with daily functioning), cognitive communication deficit (a difficulty with communication that's caused by an underlying issue with cognition), and bipolar disorder (a mental health condition characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function).Review of the resident's quarterly MDS, dated [DATE], showed the resident had adequate hearing, clear speech, was able to make self understood and understood others. He/She scored 12 on the BIMS, indicating moderately impaired cognition. Review of the resident's comprehensive care plan, dated 01/20/26, showed interventions related to choosing own activities, decreased mobility related to muscle weakness, ADL needs related to multiple sclerosis, dementia, risk for falls, bipolar disorder, depression, behaviors including anger/agitation towards staff/refusing cares at times, nutrition, epilepsy, multiple sclerosis, pain, skin integrity, incontinent of bowel and bladder. During an interview on 01/26/26 at 01:27 P.M., the resident said:-His/Her room was very cold on Sunday, 01/25/26. -Staff asked him/her to move rooms, but the resident didn't want to leave his/her belongings unattended; -He/She had to wear a coat, mittens and an extra blanket to keep warm while in his/her room; -The heating unit in his/her room was not working;-It was not coming on or blowing any air;-The resident did not know how long the heating unit has not been working.Observation of the resident's room on 01/26/26 at 01:27 P.M., showed:-The resident's room was very cool;- The resident was in bed wearing a coat and mittens;-The heating unit in the room was not blowing any air; -The control panel screen of the heating unit was blank;-The screen on the unit was blank when the on/off switch was flipped or the temperature buttons were pushed. 3. Review of Resident #4's Face Sheet on 01/26/26 showed: -Diagnoses included: polyneuropathy (occurs when multiple peripheral nerves become damaged), Diabetes Mellitus type 2, chronic respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period), weakness, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing a significant impairment in daily life). Review of the resident's quarterly MDS, dated [DATE] showed he/shehe had clear speech, was able to [NAME] self understood and understood others. He/She scored 14 on the BIMS, indicating intact cognition. Review of the resident's comprehensive care plan, dated 12/23/25, showed interventions related to choosing own activities, decreased mobility related to weakness, ADL needs, diabetes mellitus, risk for falls, enhanced barrier precautions related to wound care, depression, pain, alteration in mood and behaviors including anger/agitation towards staff/refusal of care, skin integrity, occasional bladder incontinence. During an interview on 01/26/26 at 03:22 P.M., the resident said:-It has gotten pretty cold inhis/her room;-Staff did not offer another room for the resident to move to temporarily or offered additional blankets;-He/She would have moved to at least sleep in a warmer room; -The heating unit in the room was working, but it didn't blow very warm air;-The maintenance staff checked on it this morning but didn't know what he/she did to it. Observation of the resident on 01/26/26 at 03:22 P.M. showed the resident was wearing a coat, gloves and blankets.4. Review of Resident #5's Face Sheet on 01/26/26 showed: -Diagnoses included: Congestive heart failure (CHF; a condition where the heart cannot pump blood effectively enough to meet the body's needs; causes include coronary artery disease, heart muscle damage/heart attack, high blood pressure, valve disease, myocarditis), alcohol-induced persisting dementia (a type of dementia caused when drinking an unsafe amount of alcohol damages the brain), tachycardia (a faster than normal heart rate ), seizures (a burst of uncontrolled electrical activity between brain cells (neurons, nerve cells) that causes temporary abnormalities in muscle tone or movements(stiffness, twitching or limpness), behaviors, sensations or states of awareness), major depressive disorder, generalized anxiety disorder (GAD, a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities).Review of the resident's quarterly BIMS, dated 01/01/26, showed the resident had clear speech, was able to make self understood and understood others. He/she scored 12 on the BIMS, indicating moderately impaired cognition. Review of the resident's comprehensive care plan, dated 01/13/26, showed interventions related to choosing own activities, court appointed guardian, increasing lung function related to CHF, ADL care related to dementia, risk for behaviors including yelling at staff/refusing medications/paranoia, risk for falls, depression, anxiety, nutrition, seizures, skin integrity. During an interview on 1/26/26 at 3:22 P.M., the resident said:-His/Her room was very cold overnight;-The heating unit feels like cool air; -He/She had to wear a sweater, coat and gloves to stay warm; -Staff members did not offer to move the resident to a warmer room or offer extra blankets;-He/She would have moved temporarily if he/she had been given the choice.During an interview on 01/26/26 at 01:01 P.M., Certified Medication Technician (CMT) A said:-He/She worked on Sunday, 1/25/26; -Something was wrong with the heating system and the building got very cold, especially the 200 hall; -The resident's in some of the rooms were offered to move to warmer rooms;-Two residents agreed to move and two residents decided to stay in their rooms; -CMT A was not involved in offering the residents to move rooms and doesn't know why all the residents affected by cold rooms were not offered to move rooms. During an interview on 01/26/26 at 1:53 P.M., the Maintenance Director, said:-One of the two boilers in the facility stopped working over the weekend;-While the technicians were in the facility working on the broken boiler, the other boiler stopped working;-The technicians were in the facility today, 01/26/26;-The first boiler was now working and they were working on the second; -The temperatures in the facility did get cool on Sunday 01/25/26 and today-The temperature in one of the resident rooms earlier this morning was 68 degrees Fahrenheit; -The Maintenance Director has been resetting the individual heating units in resident rooms this morning; -The temperatures in the building were now coming back to normal. During an interview on 01/26/26 at 03:55 P.M., the Director of Nursing (DON) said he/she expected the facility to be a comfortable temperature for the residents. The residents should be relocated to a warmer area if the rooms were too cold. During an interview on 1/26/26 at 3:40 P.M., the Administrator said:-He/She expected the facility to remain at a warm enough temperature, so the residents were comfortable;-It should be warm enough so residents don't have to wear mittens inside; -The temperature in the facility should remain between 71 and 81 degrees Fahrenheit;-If the noted temperature is colder than that range, the residents should be relocated to a warmer room and offered extra blankets;-Maintenance staff should try to find out why the building is too cold. Intake 2725600

Based on interview and record review, the facility failed to provide a discharge notice to the resident and his/her Durable Power of Attorney (DPOA) and follow appropriate discharge procedures and complete discharge documentation, for one resident (Resident #1) of five sampled residents. The census was 158.Review of the facility policy titled, Transfer and Discharge, dated 10/24/2022, showed:-The purpose of the policy is to ensure that residents are transferred and discharged from the Facility in compliance with state and federal laws and to provide complete, safe and appropriate discharge planning and necessary information to the continuing care provider; -The facility may transfer or discharge a resident for the following reasons: The discharge is necessary for the resident's welfare and resident's needs cannot be met in the facility; the discharge is appropriate because the resident's health has improved, the safety of individuals in the Facility is endangered by the resident's presence, the health of the individuals in the facility would otherwise be endangered by the resident's presence, and the resident has failed, after reasonable and appropriate notice, to pay for a stay at the Facility. -Residents are discharged based on physician order unless the resident signs themself out against medical advice; -Facility staff will provide the resident with reasonable advanced notice of the discharge before it occurs;-Unless exigent circumstances exist, the notice should be provided 30 days prior to the proposed date of discharge;-Situations that may prevent 30 days' notice include: the resident poses a threat to the health or safety of other individuals at the Facility, the resident's health improves sufficiently to allow for more immediate transfer/discharge or the resident is experiencing urgent medical needs.-In cases in which 30 days' notice is not possible, the notice of transfer or discharge should be provided to the resident or resident's representative as soon as practicable; -Documentation related to the resident's discharge will be maintained in the resident's medical record; -Discharge planning begins with the pre-admission process by identifying and assessing the resident's living and social support network prior to admission; -Discharge planning continues throughout the stay; -Prior to discharge, Social Services Staff or designee will provide the resident or resident representative with reasonable notice that the resident is going to be discharged ; -The Facility may use the Notice of Proposed Transfer/Discharge or another comparable form to provide the resident or his/her resident representative with advanced notice of the transfer or discharge. The notice will contain the following information: The reason the resident is being transferred/discharged , the effective date of the transfer/discharge, the name, complete address and telephone number to which the resident is being discharged , a statement the resident has the right to appeal the action to the state, contact information for the state entity which receives appeal hearing requests, and information on how to request an appeal, information on obtaining assistance in completing and submitting the appeal request, filing an appeal will allow a resident to remain in the Facility until the hearing is held unless a hearing official finds otherwise, the name, address, and telephone number of the State Long Term Care Ombudsman. -The notice must also be sent to any legally authorized representative of the resident and to at least one (1) family member; -The Facility will also send a copy of the Notice of Proposed Transfer/Discharge to the State Long Term Ombudsman for Facility-initiated discharges;-The copy of the Notice of Proposed Transfer/Discharge must be provided to the Ombudsman at the same time the Notice is provided to the resident/resident's representative; -When the Facility anticipates a resident's discharge to another nursing care facility, the Interdisciplinary Team (IDT), with the assistance of the resident and his/her resident representative, will develop a Discharge Summary and Post-Discharge Plan to assist the resident to adjust to his or her new living environment. Appropriate IDT members will educate the resident or his/her resident representative regarding the Discharge Plan issues and will assist the resident with discharge plans. Review of the Performance Improvement Plan provided by the facility, dated 1/20/26, showed:-Identified Area for Assessed Improvement: Completion of Notices of Proposed Discharge;-Plan: Education given to social services for non-emergent discharge notices, such as home health, facility transfer;-Action Steps to Implement the Plan: Audits will be completed on all Identified Areas for Improvement;-Identified areas post audits will be updated and/or fixed;-Objective Measures to Evaluate Plan Effectiveness: Audits will be completed weekly to ensure compliance for four weeks and then monthly thereafter;-Any concerns will be taken to Quality Assurance and Performance Improvement (QAPI); -Person Responsible for Oversite: Social Services Designee, Medical Records, and/or Administrator/Regional Designee; -Date to Be Completed: Education to be completed by 1/30/26 and ongoing;-Audits for four weeks to be completed by 2/20/26 and then monthly thereafter;-There was no indication the facility administered a discharge notice to the resident or resident representative once the failure was identified. 1. Review of Resident #1's Face Sheet on 01/23/26 showed:-The resident was admitted to the facility on [DATE] and discharged from the facility to another skinned nursing facility on 12/29/25;-Diagnoses included: Fluid overload (a condition where excessive water and sodium accumulate in the body's tissues and bloodstream), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), cognitive communication deficit (a difficulty with communication that's caused by an underlying issue with cognition), repeated falls, lack of coordination, dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning), heart disease (heart conditions that include diseased vessels, structural problems, and blood clots), urinary incontinence. Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated 11/03/25, showed:-The resident had adequate hearing, clear speech, made self-understood and understood others;-He/She scored 10 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents), indicating the resident had moderately impaired cognition;-He/She displayed no behaviors during the assessment behaviors. Review of the comprehensive care plan, dated 12/23/25, showed interventions related to increasing lung functioning related to smoking, Activities of Daily Living (ADLs), behaviors related to making inappropriate sexual comments to females, communication, cardiac status, edema/fluid overload, cognition related to dementia, risk for falls, mood problem related to new admit to long term care, nutrition, skin integrity, bladder incontinence.Review of the resident's Durable Power of Attorney, dated 05/20/24, showed the resident named his/her Family Member A as the Power of Attorney. The document outlines authority in areas including financial transactions, contractual agreements, medical matters, legal matters, and personal relationship and affairs. Review of the resident's Physician Order Sheet (POS), dated December 2025, showed no physician order to be discharged to a different skilled nursing facility. Review of the resident's progress notes showed:- On 10/28/25 at 12:28 P.M The resident was admitted to the facility from a local hospital;- On 12/17/25 at 07:22 P.M. The SSD Documented he/she spoke with a family member of the resident that was not the DPOA, to update on the progress of the resident's discharge form the facility; - On 12/24/25 at 04:49 P.M. The Admissions Director documented: The resident will discharge to another skilled facility within the company Monday and will be transported by an outside transportation service at 01:30 P.M. This facility will send all personal effects with the resident and family at time of discharge. He/she will discharge with all his/her all medications. Will send current documentation and discharge order; Review of the resident's electronic medical record showed the facility did not document a discharge notice, discharge summary, discharge care plan, or physician orders to discharge resident from this facility and admit to receiving facility. During an interview on 1/21/26 at 1:59 P.M., Family Member A said:-The facility contacted the resident's grandchild, Family Member B, and said the resident was being discharged to a different facility because the resident was wandering and bothering other residents and the new facility could meet the resident's needs;-Family Member A was never notified of the discharge to a different facility, even though Family Member A was the resident's DPOA;-The facility never provided any documentation to the family of why the resident was discharged or any discharge planning paperwork;-He/She did not receive a discharge notice form the facility;-HE/She would not have chosen to discharge the resident to the receiving facility; -The family was never contacted by the receiving facility and has not received or signed any admission paperwork for that facility. During an interview on 1/26/26 at 3:55 P.M., the Director of Nursing (DON) said:-He/She expected the staff to notify the resident's DPOA/representative, get approval or give a 30-day notice for discharge;-Staff need to make sure the DPOA/representative is on board with the discharge/transfer with clear communication;-The accepting facility should be able to take care of the resident's needs. During an interview on 1/26/26 at 3:40 P.M., the Administrator said:-A discharge notice was not completed as the facility believed it was a transfer to another skilled nursing facility, not a discharge; -Social services was responsible for documentation of discharge planning and providing discharge notices to residents/resident representatives;-He/She expected staff to provide discharge notices as is required by regulation. Intake 2722479

Based on interview and record review the facility failed to ensure that licensed staff's responsibilities were completed according to acceptable standards of professional clinical practice when two licensed nurses RN-A, LPN-A and the Social Worker (SSD) failed to document a change or update of one resident's condition in the clinical medical record (the clinical medical record is accessible to all facility nursing staff and providers) that would have allowed other clinical staff to know what changes or updates had been done for one Resident (Resident #1), when Resident #1 had a critical potassium lab level and refused to be taken to the hospital for potassium to be replaced, and then unexpectedly died three days later. Additionally, the facility failed to assure staff provided care and treatment in accordance with professional standards of practice for three sampled residents, (Resident #2, #3 and #4) when medications were not administered as ordered by the physician. This affected a total of 4 residents out of 4 sampled. The facility census was 159.Review of the facility's policy Nursing Care and Services, dated [DATE], showed: -All residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being that enhances quality of life in the long-term care facility. - The facility staff will provide appropriate and competent services to the residents to ensure safety and highest level of care. - Licensed nurses and staff will document refusal of treatment, changes in treatment, and changes in the resident's condition in the clinical record. This includes refusal of care and unusual circumstances. 1.Review Resident #1's re-admission MDS (Minimum Data Set) A federally mandated assessment completed by facility staff, for the month of [DATE]., showed: - Cognition was intact. - Dependent on nursing staff for all activities of daily living. - Was on hemodialysis (A machine and process that cleans the blood when kidneys no longer function.) three times a week in an outpatient clinic. - Was on two IV (Intravenous) antibiotics with hemodialysis three times a week and had infected chronic wounds with osteomyelitis (infection of the bone) and a previous amputation to lower extremity. - Diagnoses: Insulin dependent diabetic, kidney failure, atrial fibrillation (abnormal heartbeat) and congestive heart failure. Review of nursing progress notes for the month of [DATE], starting on [DATE] showed: -On [DATE] at 6:13 P.M. A one-time order for Potassium Chloride ER 80 mEq (milliequivalent) by mouth was ordered by the facility's Nurse Practitioner for potassium replacement. -On [DATE] at 5:46 A.M. resident refused to go to outpatient hemodialysis. -On [DATE] at 3:45 A.M. resident was repositioned in bed and provided a drink of water. -On [DATE] at 4:52 A.M. resident was found in bed with no respirations and no pulse. -On [DATE] at 3:00 P.M. resident's remains where picked up by the county medical examiner. Review of the resident's clinical record, including nursing progress notes from [DATE]th through [DATE]th showed the following items were not documented in the resident's facility chart: -On [DATE] the resident's code status was updated to a Do Not Resuscitate and was completed with the SSD. -On [DATE] labs drawn while resident was at an outpatient clinic doctor appointment. Clinic physician called the facility to report lab results to RN A regarding the critical potassium level and an order was given to RN A to send the resident to the local emergency room for treatment and was not documented. -RN A did not document or notify the ordering clinic physician what the resident's wishes were, and that resident refused to be sent to the hospital. -RN A did not notify the ordering clinic physician what the plan was as ordered by the nurse practitioner and did not document it. -RN A spoke to the resident regarding the lab results and the new order to be sent to hospital, the resident refused to be sent to the hospital and was not documented. -RN A notified facility nurse practitioner who ordered immediate dose of 80 mEq potassium with a repeat of STAT (immediate labs) to recheck the resident's potassium level and was not documented. -STAT potassium lab results not documented and not documented that provider was notified of the results. -On [DATE] no documentation regarding the dialysis clinic had been notified or if the physician was notified that the resident refused dialysis on the 13th. The resident was being treated with IV antibiotics at the dialysis appointments, and this was not documented as being a missed treatment. -On [DATE]-indication of a cough and yelling out. No documented assessment of the resident. -On [DATE]-found deceased 4:52 A.M. During an interview on [DATE] at 11:35 A.M. RN A said he/she received a phone call from the clinic physician's nurse regarding the resident's critical potassium lab and for the resident to be sent to the hospital for treatment. He/She notified the resident, who refused to be sent to the hospital. He/She notified the facility nurse practitioner and orders were obtained for potassium to be replaced at the facility with repeat lab. The clinic physician's office was not updated on the new plan. The potassium was given that night and labs repeated the next day and called to the nurse practitioner. The resident refused dialysis on the [DATE]th, and the resident was found deceased on the morning of [DATE]. RN A said he/she did not document any of this in the clinical record but should have. During an interview on [DATE] at 1:17 P.M. LPN A said he/she received a phone call from an outside clinic wanting to give orders for the resident and informed the clinic the resident had passed away, LPN A did not document the interaction with the provider or review the resident's clinic record to explain how the resident may have come to pass away, but should have. During an interview and record review on [DATE] at 12:20 P.M the SSD said she had spent lots of time with resident #1 but had not charted anything regarding their interactions in the resident's chart. She could not recall if she had completed a do not resuscitate (DNR) form with the resident but remembered the resident talking to her about the dialysis nurses discussing the resident changing her code status to a do not resuscitate. She said the resident wished to change her code status to DNR. She said if there was an updated DNR in the chart then it had been done, and that she also kept a notebook to keep her interactions with the resident's in, rather than in the resident's clinical record. A new DNR was completed with the resident on [DATE]. During an interview on [DATE] at 3:45 P.M. the Administrator said changes in a resident's condition, treatment plan, orders, labs, changes in code status, and resident's wishes should be documented in the resident's chart so other healthcare providers can stay up to date on how the resident is doing. He would expect all licensed providers to document in the resident's progress notes regarding their overall condition. The facility did not provide a policy for following physician's orders or medication administration. 2. Review of Resident #2's physician order sheet (POS), dated [DATE] showed: Start date [DATE] - Clopidogrel (Plavix) 75 milligrams (mg.) daily for coronary artery disease (CAD, narrowing or blockage of the coronary arteries which supply oxygen-rich blood to the heart). Start date [DATE] - Cyanocobalamin 500 micrograms (mcg.) two tablets daily for supplement. Start date [DATE] - Ezetimibe 10 mg. tablet daily for hyperlipidemia. Start date [DATE] - Folic Acid 1 mg. tablet daily for deficiency. Start date [DATE] - Klor-Con M20 extended-release tablet, two tablets daily for supplement. Start date [DATE] - Losartan Potassium 25 mg. on tablet daily for congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body). Start date [DATE] - Torsemide 20 mg., two tablets in the morning for CHF. Start date [DATE] - Dorzolamide HCL ophthalmic Solution 2%, instill one drop in both eyes twice daily for glaucoma. Start date [DATE] - Metoprolol tartrate 25 mg., give 0.5 mg. twice daily for high blood pressure. Hold for systolic blood pressure less than 110, and diastolic less than 50 or hear rate less than 60. Start date [DATE] - Ensure or equivalent supplement with meals for at risk of malnutrition. Start date [DATE] - Tramadol 50 mg. one tablet three times a day for pain. Review of the resident's medication administration record (MAR) dated [DATE] showed on [DATE], the following medications were documented with a 9 (a 9 indicated to see the progress notes): Clopidogrel (Plavix) 75 mg. daily for CAD. Cyanocobalamin 500 mcg. two tablets daily for supplement. Ezetimibe 10 mg. tablet daily for hyperlipidemia. Folic Acid 1 mg. tablet daily for deficiency. Klor-Con M20 extended-release tablets, two tabs daily for supplement. Losartan Potassium 25 mg. on tablet daily for CHF. Torsemide 20 mg., two tablets in the morning for CHF. Dorzolamide HCL ophthalmic Solution 2%, instill one drop in both eyes twice daily for glaucoma. Metoprolol tartrate 25 mg., give 0.5 mg. twice daily for high blood pressure. Hold for systolic blood pressure less than 110, and diastolic less than 50 or hear rate less than 60. Ensure or equivalent supplement with meals for at risk of malnutrition. Tramadol 50 mg. one tablet three times a day for pain. Review of the resident's progress notes dated [DATE] showed staff did not document why the medication was not administered. 3. Review of Resident #3's POS dated [DATE] showed: Start date [DATE] - Brexpiprazole (antipsychotic used to treat schizophrenia and depression) 0.5 mg. tablet daily for prophylaxis. Start date [DATE] - Cetirizine 5 mg tabled daily for allergies. Start date [DATE] - Cranberry oral tablet 450 mg. daily to reduce the risk for a urinary tract infection (UTI). Start date [DATE] - Magic cup in the afternoon for weight loss. Start date [DATE] - Pantoprazole Sodium delayed release 40 mg. tablet daily for gastroesophageal reflux disease (GERD). Start date [DATE] - Senna Plus oral tablet 8.6-50 mg. one tablet daily for constipation. Start date [DATE] - Sertraline HCL 50 mg. one tablet daily for dementia with behaviors related to major depression disorder. Start date [DATE] - Trazodone HCL 50 mg., give 0.5 mg. tablet every morning and at bedtime for restlessness and depression. Start date [DATE] - Acetaminophen oral tablet 325 mg. two tablets twice daily for pain not to exceed (NTE) 3 grams in 24 hours. Start date [DATE] - Ativan 0.5 mg. one tablet twice daily for agitation until [DATE]. Start date [DATE] - Carvedilol oral tablet 6.25 mg one tablet three times a day for high blood pressure. Hold if systolic blood pressure is less than 100 or pulse is less than 60. Start date [DATE] - Gabapentin capsule 300 mg. one capsule twice daily for anxiety. Start date [DATE] - Memantine HCL 10 mg. one tablet twice daily for dementia. Start date [DATE] - Quetiapine Fumarate 50 mg. one tablet twice daily for dementia. Start date [DATE] - Trazodone HCL 50 mg. give 0.5 mg. tablet every morning and at bedtime for restlessness and depression. Start date [DATE] - Buspirone HCL 10 mg. one tablet three times daily for anxiety. Start date [DATE] - Med Pass 2.0 120 milliliters (ml.) three times a day for supplement. Review of the resident's MAR dated [DATE] showed on [DATE], the following medications were documented with a 9: Brexpiprazole 0.5 mg. tablet daily for prophylaxis. Cetirizine 5 mg tabled daily for allergies. Cranberry oral tablet 450 mg. daily to reduce the risk for a UTI. Magic cup in the afternoon for weight loss. Pantoprazole Sodium delayed release 40 mg. tablet daily for GERD. Senna Plus oral tablet 8.6-50 mg. one tablet daily for constipation. Sertraline HCL 50 mg. one tablet daily for dementia with behaviors related to major depression disorder. Trazodone HCL 50 mg., give 0.5 mg. tablet every morning and at bedtime for restlessness and depression. Acetaminophen oral tablet 325 mg. two tablets twice daily for pain NTE 3 grams in 24 hours. Ativan 0.5 mg. one tablet twice daily for agitation until [DATE]. Carvedilol oral tablet 6.25 mg one tablet three times a day for high blood pressure. Hold if systolic blood pressure is less than 100 or pulse is less than 60. Gabapentin capsule 300 mg. one capsule twice daily for anxiety. Staff did not document it as administered at 8:00 A.M or 2:00 P.M. Memantine HCL 10 mg. one tablet twice daily for dementia. Quetiapine Fumarate 50 mg. one tablet twice daily for dementia. Trazodone HCL 50 mg. give 0.5 mg. tablet every morning and at bedtime for restlessness and depression. Buspirone HCL 10 mg. one tablet three times daily for anxiety. Staff did not document it as administered at 8:00 A.M or 2:00 P.M. Med Pass 2.0 120 milliliters (ml.) three times a day for supplement. Staff did not document it as administered at 8:00 A.M or 2:00 P.M. Review of the resident's progress notes dated [DATE] showed staff did not document why the medication was not administered. 4. Review of Resident #4's POS dated [DATE] showed: Start date [DATE] - Diltiazem HCL 30 mg. one tablet three times daily for high blood pressure. Start date [DATE] - 2 Cal four times a day for supplement. Review of the resident's MAR dated [DATE] showed on [DATE], the following medications were documented with a 9: Diltiazem HCL 30 mg. one tablet three times daily for high blood pressure. 2 Cal four times a day for supplement. Review of the resident's progress notes dated [DATE] at 3:07 P.M., showed neither the medication or the supplement had been administered. During an interview on [DATE] at 2:14 P.M., the Staffing Coordinator said: He/She did not cover any shifts but was responsible to get staff to cover the shifts when call ins happened. When a staff member called in, he/she would attempt to get the in-house staff to cover the shift. If the in-house staff were unable to cover the shift, then he/she would reach out to an agency to cover the shift. On Sunday, [DATE], the Certified Medication Technician (CMT) called in for the 100 halls. The Registered Nurse (RN) passed the medications. He/She attempted to get in-house staff to cover the shift, and no one was able to. He/She attempted to get agency to work and was unable to get anyone to pick up the shift. He/She notified the unit managers. Unit Manager A was unable to work, and Unit Manager B was working another job. He/She notified the Regional Associate who approved the premium shifts (higher rate of pay), but he/she was unable to get any staff to cover the shift until 2:00 P.M. During an interview on [DATE] at 4:40 P.M., RN B said: He/She worked on [DATE] on the 100 halls. When the CMT had not shown up for work, he/she contacted the staffing coordinator who said to go ahead and start passing the medications and he/she would try to get coverage. He/She had never passed medications in a long-term care facility before. He/She did not know which residents' medications should be crushed, placed in applesauce or pudding. He/She had a resident with a medical emergency, had to complete wound care and monitor the residents on the unit to ensure they did not fall or have any resident-to-resident altercations. He/She did get some medications passed but did not get them all passed. When the CMT arrived at 2:00 P.M., the CMT said he/she would not pass them because they were overdue, and the RN should document not administered. RN B said if the medications were not passed, he/she should have documented in the progress notes why the medications were not administered. Normally agency staff pick up any extra shifts. During an interview on [DATE] at 5:36 P.M., the Administrator and the Regional Nurse Consultant said: When the facility has a call in, the Staffing Coordinator is notified. The Staffing Coordinator calls the in-house staff first then calls for agency staff. The unit managers are also notified to see if they can cover the shift. The Administrator would expect to be notified if there was an emergency staffing issue. The Administrator said the medications should have been administered, even if the staff had to notify the physician and get an order for the medications to be administered late. The nurse should have reached out to the physician to see if the medications should have been administered late or held. The Regional Nurse Consultant said she would expect the medications to be administered as ordered and/or the physician to be notified. Intakes 2707044 & 2706879 & 2706685

Based on interview and record review, the facility failed to follow their policy and ensure an alleged allegation of sexual abuse of Resident #1 was reported to law enforcement and the state survey agency within two hours. The facility census was 161. Review of the facility policy titled, Abuse Prevention and Prohibition Program, dated 10/24/2022, showed:-The purpose of this policy is to ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Each resident has the right to be free from abuse;-The Facility has zero-tolerance for abuse of resident's;-Staff must not permit anyone to engage in sexual abuse of a resident; -The Facility is committed to protecting residents from abuse by anyone, including other residents;-The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems; -Reporting/Response: Facility staff are mandated reporters and will report reasonable suspicion of a crime against a resident when it is objectively reasonable physical abuse resulting in physical harm or pain or mental suffering; -The facility will not impede or inhibit a facility member's reporting duties, nor will facility staff be reprimanded or disciplined for reporting abuse;-The Administrator or his/her designee, as Abuse Coordinator: In order to facilitate reporting, ensure confidentiality, and promote order at the facility, the Administrator or his/her designee, shall be the individual who report known or suspected instances of abuse of residents at the facility to the proper authorities;-Facility staff will report known or suspected instances of abuse to the Administrator or his/her designee;-The facility will report known or suspected instances of physical abuse, including sexual abuse, and criminal acts to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations;-Immediately, but no later than 2 hours after forming the suspicion, if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement and the Ombudsman;-No later than 24 hours after forming the suspicion, if the alleged violation does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement and the Ombudsman;-Reporting requirements are based on real clock time, not business hours;-The administrator will provide the state survey agency, law enforcement and the Ombudsman with a copy of the investigation report within five days of the incident;-Failure to file a report within the required time frames may result in disciplinary action; -Special Considerations for Reporting Suspected Incidents of Criminal Sexual Abuse: Anyone who suspects that criminal sexual abuse has been committed against a resident must immediately report this information to the Administrator and Director of Nursing Services;-The facility will treat allegations as criminal sexual abuse wherein the facility determines that the resident does not have decision making capacity to consent to sexual act;-The Director of Nursing Services or designee will immediately report this information to the Attending Physician;-The Administrator then acts to ensure the following steps are taken: the proper authorities and individuals are notified immediately or within two hours, including but not limited to law enforcement/resident's representative/state survey agency/adult protective services;-A licensed nurse assesses the resident (victim) for possibly injuries;-The resident is provided with the medical treatment and emotional support necessary to prevent further deterioration of his/her health and wellbeing;-The area where the alleged incident occurred is not disturbed or accessed by anyone before law enforcement arrives;-The facility will reassess the resident following the abuse incident to determine if the resident's medical, nursing, physical, mental or psychosocial needs or preferences have changed as a result of the incident of abuse or initiate or update the care plans as indicated. 1. Review of Resident #1's electronic medical record on 12/31/25 showed: -Diagnoses included: Senile degeneration of the brain (a general term for a group of neurological disorders that cause a decline in cognitive function), dementia with agitation (a group of thinking and social symptoms that interferes with daily functioning), polyneuropathy (occurs when multiple peripheral nerves become damaged. Symptoms include problems with sensation, coordination, or other body functions), pain, urinary incontinence, anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing a significant impairment in daily life).Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 10/30/25, showed:-The resident had moderate difficulty hearing, clear speech, sometimes made self-understood and rarely/never understands others;-He/She scored zero on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents), indicated severely impaired cognition;-He/She displayed physical/verbal behaviors during the evaluation period; Review of the resident's comprehensive care plan, dated 11/25/25, showed:-Interventions related to receiving hospice services for senile degeneration of the brain;-The resident required assistance with Activities of Daily Living (ADLs) including bathing, dressing and personal hygiene;-The resident exhibited behaviors that included yelling and agitation with cares and overstimulation in large groups. Review of Resident #2's electronic medical records on 12/31/25 showed:-Diagnoses included: Edema (swelling from excess fluid trapped in body tissues), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), weakness, cognitive communication deficit (a difficulty with communication that's caused by an underlying issue with cognition), falls, dementia with other behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning), urinary incontinence.Review of the admission MDS, dated [DATE], showed:-The resident had moderate difficulty hearing, clear speech, made self understood and understands others;-He/She had a BIMS score of 10, indicating moderately impaired cognition;-He/She had displayed no behaviors during the assessment period.Review of the resident's comprehensive care plan, dated 12/23/25, showed:- Interventions related to assistance with bathing, dressing, personal hygiene;-The resident used a walker to walk;- He/She had behavior problems related to making inappropriate sexual comments to other residents;- He/She was placed on one-to-one supervision on 11/29/25 for making inappropriate sexual comments to other residents.During an interview on 12/29/2025 at 3:44 P.M., the Hospice Director said:-On 12/23/2025, the resident's family member reported to the Hospice Director that on 11/29/25, Registered Nurse (RN) A informed him/her that the Resident was sexually assaulted by another resident at the facility;-The other resident put his/her hands down Resident #1's pants, while he/she was sitting in his/her wheelchair in the common area near the nurses' station;-The family member told the Hospice Director that he/she had spoken with the Administrator of the facility, who stated he/she reviewed the camera footage of the incident and it could not be determined that the other resident actually put his/her hands down Resident #1's pants;-The family member then reported the other resident is now on one-to-one supervision and the facility was attempting to find other placement for that resident;-The hospice agency was not notified by the facility of this alleged event. During an interview on 12/31/25 at 11:15 A.M., Resident #1's family member said:- RN A called the family member on 11/29/25 at 4:54 P.M. and said that a mobile resident put his/her hands down Resident #1's pants;- RN A told Resident #1's family member that other staff and residents witnessed the event; - Approximately three hours later at 7:54 P.M., Licensed Practical Nurse (LPN) A called to speak with Resident #1's family member;- LPN A identified themselves as a unit manager;- LPN A informed Resident #1's family member the Administrator had reviewed the camera footage of the common area at the time of the event, and the other resident was not successful in getting his/her hands inside of Resident #1's pants;- A full assessment was completed on Resident #1 and no injuries were found and he/she did not display any signs of stress or anxiety; - Resident #1's family member spoke with the Administrator two weeks after the event who informed Resident #1's family member the other resident involved was on one-to-one supervision and the facility was seeking alternative placement for this resident. During an interview on 12/31/25 at 11:44 A.M., Hospice RN stated:- No one from the facility had notified the hospice agency that another resident attempted to put his/her hands down Resident #1's pants; - Resident #1's family member informed a hospice staff person of the event on 12/23/25; - Hospice RN went to the facility on [DATE] to assess the resident and attempt to gather additional information regarding the event;- Resident #1 appeared to be at his/her baseline and had no evidence of injury; - Hospice RN attempted to speak to the Director of Nursing (DON) and the Administrator, but they were in a meeting;- The Corporate Nurse Consultant (CNC) called Hospice RN later in the day who said the incident did not occur as reported;- The CNC reviewed the camera footage of the incident and observed that Resident #1 was sitting in his/her wheelchair in the common area near the nurses' station;- He/She was holding a teddy bear in his/her lap;- The other resident involved was holding one of the arms of the teddy bear;- Resident #1 dropped his/her hold of the teddy bear, and the other resident attempted to hold Resident #1's hand;- Hospice RN asked the CNC why the allegations were not reported to the state survey agency or the hospice agency, the CNC responded that the allegations did not occur and thus did not have to report the incident. During an interview on 12/31/25 at 11:58 A.M., RN A said:- RN A was working on 11/29/25;- At the time of the event, RN A was on a different unit than where Resident #1 resided, assisting another resident;- The staff notified RN A of the incident when he/she returned to Resident #1's unit; - RN A notified the manager on duty of the alleged incident involving Resident #1;- The manager on duty instructed RN A to call and notify the family of Resident #1 of the incident;- Later, LPN A, the unit manager, informed RN A that the Administrator reviewed the camera footage of the alleged event and determined that the other resident did not get his/her hands down Resident #1's pants;- RN A conducted an assessment on Resident #1 and he/she was found to have no injuries or display any signs of stress or anxiety. During an interview on 12/31/25 at 3:20 P.M., the Administrator said:- He was aware of the allegations that another resident put his/her hands down Resident #1's pants on 11/29/25;- The allegations were brought to his attention by LPN A, the unit manager on 11/29/25; - RN A originally thought the other resident's hands were in Resident #1's pants;- Assessments were completed for Resident #1 and there were no injuries;- The Administrator said he spoke with Resident #2, who denied the allegations; - The Administrator said there was no camera footage of the incident; - The Administrator did not need to report the allegations to the state survey agency or law enforcement, as he/she looked into the incident and determined the allegations were untrue. Intake 2703167

Based on interview and record review, the facility failed to follow their policy and ensure an alleged allegation of sexual abuse of Resident #1 was investigated. The facility census was 161.Review of the facility policy titled, Abuse Prevention and Prohibition Program, dated 10/24/2022, showed:-Each resident has the right to be free from abuse; -The Facility has zero-tolerance for abuse, staff must not permit anyone to engage in sexual abuse;-The Facility is committed to protecting residents from abuse by anyone, including other residents, -The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems. -Investigation: The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source or criminal acts;-If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, injuries of an unknown source or crime, the Administrator or designee may appoint a member of the facility's management team to investigate the alleged incident;-The investigator reviews all relevant documentation, reviews resident's medical record to determine events preceding the alleged incident, interviews person making the incident report, interviews any witnesses to the alleged incident, interviews resident (as medically appropriate), interviews staff members who have had contact with the resident during the period of the alleged incident;-Witness reports must be given in writing and signed and dated;-While the investigation is underway, accused individuals who are not facility staff may not have any unsupervised access to the resident; -The Administrator will provide initial and follow-up written reports of the results of all abuse investigations and consequent actions to the appropriate agencies; -Anyone who suspects that criminal sexual abuse has been committed against a resident must immediately report this information to the Administrator and Director of Nursing Services;-The facility will treat allegations as criminal sexual abuse wherein the facility determines that the resident does not have decision making capacity to consent to sexual act;-The Director of Nursing Services or designee will immediately report this information to the Attending Physician;-The Administrator then acts to ensure the proper authorities and individuals are notified immediately or within two hours, including but not limited to law enforcement/resident's representative/state survey agency/adult protective services;-A licensed nurse assesses the resident (victim) for possibly injuries;-The resident is provided with the medical treatment and emotional support necessary to prevent further deterioration of his/her health and wellbeing;-The area where the alleged incident occurred is not disturbed or accessed by anyone before law enforcement arrives;-The facility will reassess the resident following the abuse incident to determine if the resident's medical, nursing, physical, mental or psychosocial needs or preferences have changed as a result of the incident of abuse or initiate or update the care plans as indicated. The facility did not provide an investigation of the allegations of sexual abuse involving Resident #1 on 11/29/25. 1. Review of Resident #1's electronic medical record on 12/31/25 showed: -Diagnoses included: Senile degeneration of the brain (a general term for a group of neurological disorders that cause a decline in cognitive function), dementia with agitation (a group of thinking and social symptoms that interferes with daily functioning), pain, urinary incontinence, anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing a significant impairment in daily life).Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 10/30/25, showed:-The resident had moderate difficulty hearing, clear speech, sometimes makes self-understood and rarely/never understands others;-He/She scored zero on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents), indicating the resident had severely impaired cognition;-The resident received hospice services. Review of the resident's comprehensive care plan, dated 11/25/25, showed the resident had interventions in place for his/her Activities of Daily Living (ADLs) including bathing/dressing/personal hygiene, and communication. Review of Resident #2's electronic medical records on 12/31/25 showed:-Diagnoses included: Edema (swelling from excess fluid trapped in body tissues), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), weakness, cognitive communication deficit (a difficulty with communication that's caused by an underlying issue with cognition), falls, dementia with other behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning), urinary incontinence.Review of the admission MDS, dated [DATE], showed:-The resident had moderate difficulty hearing, clear speech, made self understood and understands others;-He/She had a BIMS score of 10, indicating moderately impaired cognition;-He/She had displayed no behaviors during the assessment period.Review of the resident's comprehensive care plan, dated 12/23/25, showed:- Interventions related to assistance with bathing, dressing, personal hygiene;-The resident used a walker to walk;- He/She had behavior problems related to making inappropriate sexual comments to other residents;- He/She was placed on one-to-one supervision on 11/29/25 for making inappropriate sexual comments to other residents.During an interview on 12/29/2025 at 3:44 P.M., Hospice Director said:-On 12/23/2025,the resident's family member reported to the Hospice Director that on 11/29/25, Registered Nurse (RN) A informed him/her the resident was sexually assaulted by another resident at the facility;-The other resident put his/her hands down Resident #1's pants, while he/she was sitting in his/her wheelchair in the common area near the nurses' station;-The family member told the Hospice Director that he/she had spoken with the Administrator of the facility, who stated he/she reviewed the camera footage of the incident and it could not be determined that the other resident actually put his/her hands down Resident #1's pants;-The family member then reported the other resident is now on one-to-one supervision and the facility was attempting to find other placement for that resident.During an interview on 12/31/25 at 11:15 A.M., Resident #1's family member said:- RN A called the family member on 11/29/25 at 4:54 P.M. and said that a mobile resident put his/her hands down Resident #1's pants;- RN A told Resident #1's family member that other staff and residents witnessed the event; -Approximately three hours later at 7:54 P.M., Licensed Practical Nurse (LPN) A called to speak with Resident #1's family member;- LPN A identified themselves as a unit manager;- LPN A informed Resident #1's family member the Administrator had reviewed the camera footage of the common area at the time of the event, and the other resident was not successful in getting his/her hands inside of Resident #1's pants;- A full assessment was completed on Resident #1 and no injuries were found and he/she was not displaying any signs of stress or anxiety; -Resident #1's family member spoke with the Administrator two weeks after the event;- The Administrator informed Resident #1's family member that the other resident involved is currently on one-to-one supervision and the facility was seeking alternative placement for this resident. During an interview on 12/31/25 at 11:58 A.M., RN A said:-He/she works at the facility part-time, approximately one to two times per month;-RN A was working on 11/29/25; -At the time of the alleged event, RN A was on a different unit than where Resident #1 resided, assisting another resident;-The staff notified RN A of the incident when he/she returned to Resident #1's unit; -RN A was unsure of that staff person's name or position, as he/she so rarely works at the facility; -RN A notified the manager on duty of the alleged incident involving Resident #1;-The manager on duty instructed RN A to call and notify the family of Resident #1 of the incident;-Later, LPN A, the unit manager, informed RN A that the Administrator reviewed the camera footage of the alleged event and determined that the other resident did not get his/her hands down Resident #1's pants;-RN A conducted an assessment on Resident #1 and he/she was found to have no injuries or display any signs of stress or anxiety. During an interview on 12/31/25 at 3:20 P.M., the Administrator said:-He was aware of the allegations that another resident put his/her hands down Resident #1's pants on 11/29/25;-The allegations were brought to his attention by LPN A, the unit manager on 11/29/25; -RN A originally thought the other resident's hands were in Resident #1's pants;-Assessments were completed on Resident #1 and no injury was noted;-The Administrator said he/she spoke with Resident #2, who denied the allegations; -The Administrator said there was no camera footage of the incident; -The Administrator did not have to report the allegations to the state survey agency or law enforcement, as he/she looked into the incident and determined the allegations were untrue;-Resident #2 was placed on one-on-one supervision because he/she made sexual comment towards other residents. Intake 2703167

Based on observation, interview and record review the facility failed to provide basic Activities of Daily Living (ADLs: tasks completed in a day to care for oneself) to ensure residents were clean, dry, and free of odor. The facility failed to provide incontinence care in a timely manner for four sampled residents (Resident #10, #1, #4, and #3); failed to ensure four residents were free of offensive body odor (Resident #10, #1, #4, #3) out of 28 sampled residents. The facility census was 158. Review of the facility provided policy titled, Perineal Care, dated October 24, 2022 showed: -Purpose is to maintain cleanliness, reduce odor and prevent skin breakdown;-Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need; Review of the facility provided policy titled, Care and Services, dated October 24, 2022 showed:-Purpose is to ensure that all residents receive the necessary care and services based on an individualized comprehensive assessment;-Residents are provided with the necessary care and services to maintain the highest practicable physical, mental and social well being; -Care and services are provided in a manner that consistently enhances self esteem and self worth. Review of the facility provided titled, Resident Rights, policy dated May 1, 2023 showed all residents have a right to a dignified existence. 1. Review of Resident #10's Significant Change Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 10/15/25 showed:-Brief Interview of Mental Status (BIMS) of 3 indicated significant cognitive loss;-Dependent on staff for ADL's;-Incontinent of bowel and bladder;-Diagnoses included: Dementia, heart failure, and Parkinson's disease ( a disease that causes nerve cells in parts of the brain to weaken, become damaged, and die, leading to symptoms that include problems with movement, tremor, stiffness, and impaired balance). Review of the resident's Comprehensive Care Plan dated 10/22/25 showed:-He/She had an ADL self care performance deficit because of limited mobility, dementia, and amputation of fingers;-He/She required assistance with mobility;-He/She required total assistance of staff for personal hygiene and toileting; -He/She was incontinent of bowel and bladder;-He/She required full assistance with toileting and perineal care; -The staff were to keep his/her skin clean and dry. Continuous observation on 11/18/25 beginning at 11:20 A.M. through 1:50 P.M. showed:-The resident was sitting in a wheelchair in the television (TV) room, he/she was wearing grey sweatpants, and grey sweatshirt; -At 11:22 A.M. the resident was taken to the dining room by staff and placed at the dining room table; -Staff did not offer the toilet or repositioning to the resident; -He/She remained at the dining room table until 12:57 P.M. when he/she was assisted by staff to the TV room; -At 1:50 P.M. the resident remained in the TV room, he/she had a foul body odor. Observation on 11/18/25 at 4:46 P.M. showed:-The resident was removed from the TV room and assisted to his/her room by Nurse Aide (NA) A; -The resident was placed in the sit to stand lift (a mechanical device used to move residents from one surface to another, such as from a bed to a chair or chair to bed) by NA A and Certified Nurse Aide B;-The resident was raised to a standing position, NA A removed the resident's grey sweatpants; -The resident's incontinent brief was saturated and hung to his/her mid-thigh, CNA B removed the brief, the removed brief had copious amounts of fluid dripping onto the floor, multiple brown fluids rings and a small smear of red to the right side; -NA A used a wipe to cleanse the resident from front to back; -The used wipe showed yellow/brown fluid and a smear of red fluid wiped away from the resident; the resident said the area hurt when it was wiped; -A clean incontinent brief was applied; -The resident was returned to his/her wheelchair and assisted to the dining room. During an interview on 11/18/25 at 4:46 P.M NA A said:-He/She had not changed or cleaned up the resident since the morning of 11/18/25; -There was not enough staff to provide care to all the residents and he/she was not able to change the resident's incontinent brief when needed. During an interview on 11/18/25 at 4:46 P.M. CNA B said:-He/She had not provided cares for the resident since the morning of 11/18/25; -He/She was busy and did not have time to assist the resident with his/her cares. 2. Review of resident #1's admission MDS, dated [DATE] showed:-Severe cognitive impairment;-Incontinent of bowel and bladder;-Dependent on staff for toileting;-Substantial assistance with personal hygiene;-Diagnosis included, traumatic brain injury (a brain injury that caused by an outside force), dementia and heart failure. Review of the resident's care plan dated 10/04/25 showed:-The resident was totally dependent on staff for toileting;-The resident was incontinent of bowel and bladder;-Check the resident routinely and as needed for incontinence;-Change clothing and provide incontinence care after each incontinent episode. During an observation beginning on 11/18/25 at 09:20 A.M. - 12:22 P.M., showed:-09:32 A.M., the resident sat in the TV area in his/her wheelchair; -09:45 A.M., the resident sat in the TV area in his/her wheelchair; -10:16 A.M., Nurse Aide (NA) A took the resident to the dining room for activities and did not toilet or change the resident;-10:20 A.M., the resident sat at the table in the dining room in his/her wheelchair;-10:40 A.M., NA A took the resident back to the TV area and did not toilet or change the resident;-10:56 A.M., the resident sat in the TV area in his/her wheelchair; -11:04 A.M., there were no staff near the resident's location;-11:08 A.M., the resident sat in the TV area in his/her wheelchair; -11:18 A.M., the resident sat in the TV area in his/her wheelchair;-11:21 A.M., the resident sat in the TV area in his/her wheelchair;-11:31 A M., the resident sat in the TV area in his/her wheelchair;-11:45 A.M., NA A took the resident to the dining room;-12:02 A.M., the resident the resident sat in the dining room in his/her wheelchair;-12:18 P.M., Certified Nurses Aide (CNA) A took the resident to his/her room;-12:19 P.M., the resident had a strong smell of urine;-12:20 P.M., CNA A and NA A transferred the resident to his/her bed;-12:22 P.M., the resident's wheel chair had liquid that smelled of strong urine in it and the seat of the wheel chair was wet and smelled of strong urine;-The resident's pants were wet in the groin area and smelled of strong urine;-CNA A and NA A removed the resident's pants and brief:-The brief was saturated with urine and had a strong smell of urine. During an interview on 11/18/25 12:41 P.M., NA A said: -The resident was dependent on staff for transfers and toileting;-The resident was incontinent;-The resident should be provided incontinent care and repositioned at least every two hours;-The resident should be changed before the mechanical lift pad becomes saturated with urine;-He/She did not provide incontinent care and reposition the resident every two hours because he/she had been busy helping other residents. During an interview on 11/18/25 12:55 P.M., CNA A said: -The resident was dependent on staff for transfers and toileting;-The resident was incontinent;-The resident should be provided incontinent care and repositioned at least every two hours. 3.Review of Resident #4's Quarterly MDS dated [DATE] showed:-Mild cognitive impairment;-Dependent on staff for toileting;-Dependent on staff for showers;-Substantial assistance from staff for personal hygiene; -Always incontinent of bowel and bladder;-Diagnoses included, dementia and depression. Review of the resident's care plan dated 11/07/25 showed:-The resident was totally dependent on staff for toileting;-The resident was incontinent of bowel and bladder;-Check the resident routinely and as needed for incontinence. During an observation beginning on 11/18/25 at 09:20 A.M. - 12:24 P.M., showed:-09:32 A.M., the resident sat in the TV area in his/her wheelchair; -09:45 A.M., the resident sat in the TV area in his/her wheelchair; -10:00 A.M., the NA A took the resident to the dining room for activities and did not toilet or change the resident;-10:20 A.M., the resident sat at the table in the dining room in his/her wheelchair;-10:31 A.M., CNA A took the resident back to the TV area and did not toilet or change the resident;-10:49 A.M., there were no staff near the resident's location;-10:58 A.M., the resident sat in the TV area in his/her wheelchair; -11:05 A.M., the resident sat in the TV area in his/her wheelchair; -11:13 A.M., the resident sat in the TV area in his/her wheelchair; -11:17 A.M., CNA A walked by the resident and did not toilet the resident;-11:18 A.M., the resident sat in the TV area in his/her wheelchair;-11:21 A.M., the resident sat in the TV area in his/her wheelchair;-11:27 A.M., the resident sat in the TV area in his/her wheelchair;-11:45 A.M., CNA A took the resident to the dining room;-11:46 A.M., the resident had a strong smell of urine; -12:02 P.M., the resident sat in the dining room in his/her wheelchair;-12:18 P.M., the resident the resident sat in the dining room in his/her wheelchair;-12:22 P.M., the resident sat in the dining room in his her/wheel chair;-12:24 P.M., the facility staff did not offer to toilet the resident during this continuous observation. During an interview on 11/18/25 12:41 P.M., NA A said: -The resident was dependent on staff for transfers and toileting;-The resident was incontinent;-He/She had not provided incontinent care since breakfast;-The resident should be provided incontinent care and repositioned at least every two hours;-He/She did not provide incontinent care and reposition the resident every two hours because he/she had been busy helping other residents. During an interview on 11/18/25 at 12:55 P.M., CNA A said: -The resident was dependent on staff for transfers and toileting;-The resident was incontinent;-He/She had not provided incontinent care or repositioned since breakfast;-The resident should be provided incontinent care and repositioned at least every two hours;-He/She did not provide incontinent care and reposition the resident every two hours because he/she had been busy helping other residents. 4. Review of Resident #3's Five Day MDS dated [DATE] showed:-Severe cognitive impairment;-Occasionally incontinent of bowel and bladder;-Substantial assistance for toileting;-Diagnoses included, anemia, dementia and respiratory failure. Review of the resident's care plan dated 10/18/25 showed:-The resident was totally dependent on staff for toileting;-The resident was incontinent of bowel and bladder;-Check the resident routinely and as needed for incontinence. During an observation beginning on 11/18/25 at 09:20 A.M. - 12:02 P.M., showed:-09:32 A.M., the resident sat in the TV area in his/her wheelchair; -09:45 A.M., the resident sat in the TV area in his/her wheelchair; -10:16 A.M., CNA A took the resident to the dining room for activities and did not toilet or change the resident;-10:20 A.M., the resident sat at the table in the dining room in his/her wheelchair;-10:40 A.M., Certified Nurses Aide CNA A took the resident back to the TV area and did not toilet or change the resident;-10:56 A.M., the resident sat in the TV area in his/her wheelchair; -11:12 A.M., the resident sat in the TV area in his/her wheelchair;-11:22 A.M., the resident sat in the TV area in his/her wheelchair;-11:35 A.M., the resident sat in the TV area in his/her wheelchair;-11:45 A.M., NA A took the resident to the dining room;-12:02 P.M., the resident the resident sat in the dining room in his/her wheelchair. During an interview on 11/18/25 12:41 P.M., CNA A said: -The resident was dependent on staff for transfers and toileting;-The resident was incontinent;-The resident should be provided incontinent care and repositioned at least every two hours. During an interview on 11/18/25 12:55 P.M., LPN B said: -The resident was dependent on staff for transfers and toileting;-The resident was incontinent;-He/She would expect the resident be provided incontinent care and repositioned at least every two hours;-All dependent residents who are incontinent should be provided incontinent care at least every two hours. During an interview on 11/18/25 03:17 P.M., the Director of Nursing said he expected staff to check and change incontinent residents at least every two hours and as needed. During an interview on 11/18/25 04:22 P.M., the Administrator said: -All dependent residents who are incontinent should be provided incontinent at least every two hours;-He expected staff to check and change incontinent residents at least every two hours and as needed. Intakes 2672337, 2672247, 2672338, 2652454

Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect when staff allowed Resident #7 to scream and yell in the halls and dining room of the facility. This affected two sampled residents (Resident #2 and Resident #5). The facility census was 158. Review of the facility's policy titled, Resident Rights, dated 5/1/23, showed:-All residents have a right to a dignified existence, self-determination;-The facility must treat each resident with respect and dignity;-The facility will protect the rights of the resident.Review of the facility's policy titled, Privacy and Dignity, dated 10/24/22, showed the facility will promote resident care in a manner that maintains or enhances dignity and respect, in full recognition of each resident's individuality.1.Review of Resident #7's admission Data Set Minimum Data Set, (MDS, a federally mandated assessment tool completed by facility staff) dated 10/15/25 showed:-Severe cognitive impairment;-Dependent on staff for Activities of Daily Living (ADL)s;-Verbal behavioral symptoms directed towards others (threatening others, screaming at others, and cursing at others);-Other behavioral symptoms not directed towards others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, and disruptive sounds);-Diagnoses included Parkinson's Disease, diabetes and anxiety.Review of the resident's care plan dated 7/24/25 showed:-The resident was at risk for a mood problem related to anxiety and depression;-Assist the resident with positive coping skills;-The resident will maintain a stable mood state.Observation on 11/18/25 at 12:13 P.M., showed:showed:-Resident #7 sat in the assisted dinging room in a wheel chair;-Resident #7 cried out and said Daddy, Daddy;-Licensed Practical Nurse (LPN) B repositioned the resident and offered him/her a cup of water;-Resident #7 continued to yell and cry out.Observation on 11/18/25 at 12:25 P.M., showed:-Resident #7 crying out loud and yelling;-Resident #1 sat across the table from Resident #7;-Nurse Aide (NA) A wheeled Resident out of the dining room;-Resident #7 yelled as he/she left the ding room.During an interview on 11/18/25 at 12:50 P.M., NA A said:-Resident #7 often yelled out loud;-Resident #7 used to live back on the rehab hall but was moved to this hall in hopes it would help the yelling;-The other residents became upset when resident #7 yells and that is why the staff took him/her back to his/room.During an interview on 11/18/25 at 12:59 P.M, Certified Nurses Aide (CNA) A said:-Resident #7 yelled and screamed often;-The staff did what they could to offer the resident food or drink and repositioning;-The staff notified the nurse if the resident does not calm down;-CNA A said he/she had not been given specific instructions on how to care for Resident #7.2.Review of Resident #2's Annual MDS dated [DATE] showed:-Mild cognitive impairment;-Impairment on one side upper and lower extremities;-Partial assistance with eating;-Dependent on staff for toileting;-Always incontinent of bowel;-Diagnosis of stroke, high blood pressure, and diabetes. Review of the resident's care plan dated 10/13/25, showed:-ADL self care deficit related to stoke;-The resident had depressive symptoms;-The resident would maintain a stable mood.During an interview on 11/18/25 at 2:22 P.M., the resident said:-Since the new company took over the care had became worse;-There is a lady that yelled constantly;-The constant yelling got on his nerves;-He/She said the staff and nurses knew because the yelling happened in front of them;-He/She cannot get up and leave to get away from the noise because he/she was paralyzed;-He/She hoped the facility would do something about the yelling soon because it made him/her depressed.During an interview on 11/18/25 at 2:47 P.M., Family Member A said:-He/She could hear another resident yelling when he/she was on the phone with Resident #2;-Resident #2 told him/her the yelling agitated him/her;-Resident #2 should not have to listen to the yelling all the time.3.Review of Resident #5's Quarterly MDS dated [DATE] showed:-Mild cognitive impairment;-Partial assistance with ADLs;-Diagnoses included, diabetes, bipolar disorder and anxiety.Review of the resident's care plan dated 10/8/25 showed:-The resident is at risk for a mood problem related to depression and anxiety.During an interview on 11/18/25 at 3:07 P.M., the resident said:-There was a resident that yelled from the time they got the resident up until staff all day long and part of the evening;-The staff sat the resident in his/her wheel chair in the tv room;-The resident yells and screams until they took the resident back to his/her room;-He/She could hear the resident yell from his/her room;-The staff are aware because the resident yelled most of the time;-The resident yells out daddy, daddy and just screamed;-The yelling got on his/her nerves;-The yelling made him depressed.During an interview on 11/18/25 3:45 P.M., LPN B said: -The resident #7 yelled and screamed often;-The staff do what they can to offer the resident food or drink and repositioning;-He/she had not been specific instructions for how to care for Resident #7.During an interview on 11/18/25 03:57 P.M., the Director of Nursing said:-He expected staff to address the needs of resident #7;-Resident #2 and #5 have the right to be treated with dignity and respect.During an interview on 11/18/25 04:22 P.M., the Administrator said: -He expected staff to address the needs of resident #7 as well as all residents;-The facility had been in contact with the family for ideas to decrease the resident's yelling;-Resident #2 and #5 have the right to be treated with dignity and respect.2652448

Based on observation, interview and record review, the facility failed to ensure one resident with potential for skin breakdown was free of preventable pressure ulcers when Resident #10 was not provided timely incontinent care and had open area to his/her buttocks. The facility census was 158. Review of the facility provided policy titled, Perineal Care, dated 10/24/2022 showed the purpose was to maintain cleanliness and prevent skin breakdown.Review of the facility provided policy titled, Care and Services, dated 10/24/2022 showed the facility will have sufficient staff to provide services to residents, to provide nursing and related services to assure resident's attain or maintain highest practicable physical well being.Review of the facility provided policy titeled, Wound Management, dated 10/24/2022 showed:- Residents will receive necessary services to promote healing, prevent infection and prevent new pressure ulcers from developing;- Upon identification of a new wound the licensed nurse wil measure the wound, initiate a Wound Monitoring Record Sheet and implement a wound treatment per physician's order.1. Review of Resident #10's Significant Change Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 10/15/25 showed:-Brief Interview of Mental Status (BIMS) of 3 indicated significant cognitive loss;-Dependent on staff for Activities of Daily Living (ADLs');-Incontinent of bowel and bladder;-At risk for pressure ulcers;-He/She had no wounds;- Diagnoses included: Dementia, heart failure, and Parkinson's disease ( a disease that causes nerve cells in parts of the brain to weaken, become damaged, and die, leading to symptoms that include problems with movement, tremor, stiffness, and impaired balance). Review of the resident's Comprehensive Care Plan date 10/22/25 showed:-He/She had an ADL self care performance deficit because of limited mobility, dementia, and amputation of fingers;-He/She required assistance with mobility;-He/She required complete assistance from staff for personal hygiene and toileting; -He/She was incontinent of bowel and bladder;-He/She had an actual impairment of skin integrity as evidenced by bowel and bladder incontinence; -He/She required full assistance with toileting and perineal care; -Staff were to keep his/her skin clean and dry.Review of the resident's Physician Order Sheets (POS) for November 2025 showed no orders for treatment to open area on buttocks.Review of the resident's Nurse Progress Notes dated 11/18/25 at 6:10 P.M. by Unit Manager A showed:-Reported the resident had loose stools and an area to the right buttocks; -Nurse Practitioner A was notified of the loose stools and moisture breakdown to his/her buttocks; -Orders received for Imodium and moisture barrier to buttocks. Review of Nurse Practitioner A Progress Notes for the resident dated 11/19/2025 at 5:40 P.M. showed:- The patient experienced loose stools on 11/19/25;- Imodium ordered and barrier cream to be applied to buttocks each shift and as needed.Continuous observation on 11/18/25 beginning at 11:20 A.M. through 1:50 P.M. showed:-The resident was sitting in a wheelchair in the television (TV) room, he/she was wearing grey sweatpants, and grey sweatshirt;-At 11:22 A.M. the resident was taken to the dining room by staff and placed at the dining room table; -Staff did not offer the toilet or repositioning to the resident; -He/She remained at the dining room table until 12:57 P.M. when he/she was assisted by staff to the TV room; -At 1:50 P.M. the resident remained in the TV room, he/she had a foul body odor.Observation on 11/18/25 at 4:46 P.M. showed:-The resident was removed from the TV room and assisted to his/her room by Nurse Aide (NA) A;-The resident was placed in the sit to stand lift (a mechanical device used to move residents from one surface to another, such as from a bed to a chair or chair to bed) by NA A and Certified Nurse Aide (CNA) B;-The resident was raised to a standing position, NA A removed the resident's grey sweatpants; -The resident's incontinent brief was saturated and hung to his/her mid-thigh, CNA B removed the brief;-The removed brief had copious amounts of fluid dripping onto the floor, multiple brown fluids rings and a small smear of red to the right side; -NA A used a wipe to cleanse the resident from front to back; -The used wipe showed yellow/brown fluid and a smear of red fluid wiped away from the resident; -The resident said the area hurt when it was wiped; -The resident had a pencil eraser sized open area, with pink tinged drainage to the right buttock; -The skin surrounding the open wound was red and inflamed; -A clean incontinent brief was applied; -The sweatpants were repositioned and the resident was returned to his/her wheelchair;-The resident was assisted to the dining room. During an interview on 11/18/25 at 4:46 P.M NA A said:-He/She was not aware of any open areas to the resident;-He/She noticed some red bloody drainage on the wipe when he/she cleaned up the resident the morning of 11/18/25; -He/She had not changed or cleaned up the resident since the morning of 11/18/25; -There was not enough staff to provide care to all the residents and he/she was not able to change the resident's incontinent brief as needed.During an interview on 11/18/25 at 4:46 P.M. CNA B said:-He/She had not provided cares for the resident since the morning of 11/18/25; -He/She was busy and did not have time to assist the resident.During an interview on 11/18/25 at 5:20 P.M. Licensed Practical Nurse (LPN) A said;-He/She was not aware of any open areas on the resident; -He/She could not evaluate the resident as the resident was in the dining room;-The resident has a history of open areas and wounds.During an interview on 11/18/25 03:17 P.M., the Director of Nursing said:-He expected staff to check and change incontinent residents at least every two hours and as needed, and report open areas immediately;-Resident #10 did not have an open area he was aware of.During a follow up interview on 11/18/25 04:22 P.M., the Administrator said: -All dependent residents who are incontinent should be provided incontinent at least every two hours;-He expected staff to check and change incontinent residents at least every two hours and as needed and report open areas to the nurse.-Resident #10 did not have an open area he was aware of. Intake 2672337

Based on interview and record review, the facility failed to protect Resident #1's safety when he/she eloped from the facility and was later found in the facility parking lot with a laceration to the forehead. The facility census was 152.On November 17, 2025 , the Administrator was notified of the past noncompliance incident which occurred on September 7, 2025. On September 7, 2025 facility administration was notified of the incident, an investigation immediately began and corrective actions were implemented to include:-All staff education on wandering/elopement, falls, door alarms, door checks, behaviors/dementia and abuse/neglect, verification that all door alarms were functioning, verification all residents were accounted for on the memory care unit, care plan meeting with family, audit and update of elopement book, and audit and updating of wandering assessments for residents on the memory care unit. The noncompliance was corrected on September 7, 2025. Review of the facility's Wandering & Elopement Policy, dated October 24, 2022, showed: -The purpose of this policy is to enhance the safety of residents of the facility; -The facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement; -If facility staff observes a resident leaving the premises without having followed proper procedures, he/she may: Try to prevent the departure in a courteous manner, get help from other Facility Staff int he immediate vicinity, if necessary, and director another Facility Staff member to inform the Charge Nurse or Director of Nursing Services that a resident is trying to leave the premises;-When an individual who departed without following proper procedures returns to the facility, the Director of Nursing Services or Licensed Nurse should: Examine the resident for any possible injuries, notify the Attending Physician, notify the resident's responsible party. The Licensed Nurse will initiate or update the resident's Care Plan and implement immediate interventions to prevent further wandering/elopement by the resident. The Interdisciplinary Team (IDT), with input from the Licensed Nurse, will conduct a thorough review of the elopement, document its findings in the IDT notes, and update the Care Plan to prevent a recurrence.1.Review of Resident #1's electronic medical record on 9/24/25, showed: -His/Her diagnoses included: Diffuse traumatic brain injury (TBI, brain disfunction caused by an outside source), traumatic subdural hemorrhage (a collection of blood between the dura mater (the outermost layer of the brain's covering) and the brain itself, often caused by head trauma), wedge compression fracture of thoracic (T) 11-T12 vertebra (a type of spinal fracture where the front part of a vertebra collapses, creating a wedge-shaped deformity), dementia with behavioral disturbance, agitation, mood disturbance (a group of thinking and social symptoms that interferes with daily functioning), dysphagia (difficulty swallowing), diabetes mellitus type II (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), pressure-induced deep tissue damage of right and left heels, anxiety disorder, major depressive disorder, congestive heart failure, restlessness and agitation. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 8/29/25, showed: -He/she scored zero on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents) indicating severely impaired cognition; -The resident requires substantial assistance with all activities of daily living, including dressing, bathing, and personal hygiene;-He/She required the assistance of staff for transfers and bed mobility;-He/She uses a wheelchair for mobility but will walk without it. Review of the resident's comprehensive care plan showed interventions related to history of trauma, behavior problem related to dementia, TBI, risk for elopement (including wandering, door seeking, wandering into other resident's rooms, moves quickly by using a wheelchair and walking), impaired cognitive and communication function related to dementia, TBI, risk for falls.Review of the resident's progress notes showed:-On 9/7/2025 at 1:28 P.M., the nurse documented that after lunch, the resident has agitation, demanding to go home. The resident has been up front with the nurse to maintain the resident's safety. The resident called his/her son, screaming I don't belong here. The son hung up on the conversation. The nursing supervisor was informed of the resident's continued demands to get out; -On 9/7/25 at 2:15 P.M., the nurse documented at 2:00 P.M., he/she was notified by another nurse that there was a resident in the parking lot on the west side of the building parking lot. The nurse arrived to the parking lot with another nurse and the resident was noted to be sitting on the ground with three visitors standing around her. The resident was noted to have a laceration to right side of forehead. The nurse entered the building through the west entrance while the other nurse stayed with the resident to inquire the resident's name. The certified nurses assistant (CNA) stated the resident's name and brought a wheelchair to the parking lot. The resident was brought back inside; -On 9/7/25 at 9:36 P.M., the nurse Licensed Practical Nurse (LPN) A documented that at 7:34 P.M., the resident returned from the local hospital with paramedics and assisted to bed. There was a dressing intact on the resident's forehead with three sutures, bruising to the right and left eye, an abrasion to the nasal bridge, and cotton ball and tape to the right wrist. The resident had a chest x-ray and cat scan of the head done at the hospital and both were negative for injury. Review of the facility investigation, dated 9/7/25, showed:-On 9/7/25 at 2:45 P.M., the Administrator was informed by the weekend nursing supervisor that the resident was observed in the facility parking lot, having fallen. The resident resided on the memory care unit; -The resident was last seen at 1:57 P.M. at the nurse's station. The resident then propelled the wheelchair down the hallway, and transferred self from the wheelchair, stood up and exited the door on the left side of the wing, sounding the alarm. The resident lost his/her balance, due to ambulating without staff assistance or assistive device. The nurse approached the resident in the parking lot and performed assessment. No significant injury was noted at the time and the resident denied pain. The nurse did not a small open area above the right brow. The resident was sent to the emergency room for further evaluation, as the resident has a history of traumatic subdural hemorrhage and current anticoagulant use. During an interview on 9/25/25 at 9:26 A.M., LPN A said: -He/She was the relief staff for the morning nurse on 9/7/2025. When LPN A arrived at the memory care unit, paramedics were already present and Resident #1 was being prepared to transfer to the emergency room; -LPN A was told by other staff that Resident #1 was found in the parking lot by another resident's family and he/she had a laceration to the forehead. The resident returned to the facility later that evening with stitches to the forehead. A computed tomography (CT) scan and chest x-ray were done at the hospital, both were negative for injury. During an interview on 9/25/25 at 10:00 A.M., Nurse Practitioner (NP) A said:-NP A is familiar with Resident #1 and his/her wandering and exit seeking; -The facility notified the on-call services the day of the incident, and NP A saw the note on Monday, 9/8/25; -NP A expected the facility to keep the resident safe and prevent him/her from eloping. Resident #1 frequently attempted to elope but staff were usually able to redirect him/her before he/she exited the facility. Resident #1 resides on the secure unit for his/her safety. NP A expected staff to be aware of the resident's location and monitor for the door alarm. During an interview on 9/26/25 at 11:02 A.M., the Administrator said:-He/She expected residents to be safe while residing on the secure unit. He/she expected staff to monitor the residents and monitor the door alarm; -Resident #1 frequently wanders the secure unit and attempts to open the exit doors;-Staff were aware of his/her behaviors; -The weekend nursing supervisor was on the secure unit at 1:57 P.M. on 9/7/25 and observed the resident at the nurses' station;-The weekend nursing supervisor then received a call at 2:00 P.M. from the nurse on the secure unit that the resident was found outside in the parking lot.Intake 2610018

Based on observation, interview and record review the facility failed to ensure appropriate wound dressing orders were obtained and in place for one resident (Resident #2), when a negative pressure wound dressing (Wound Vac) was left in place from September 9, 2025 until September 19, 2025, causing the wound to open and bleed excessively when the dressing was removed. This effected one of four sampled residents. Facility census was 152.Review of the facility provided policy titled, Wound Management, dated October 24, 2022 showed:-Purpose is to provide a system for treatment and management of residents with wounds including pressure and non-pressure ulcers; -A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing; -A licensed nurse will perform a skin assessment upon admission, readmission, weekly and as needed for each resident, and implement a wound treatment per physician's order;-Per attending physician order the nursing staff will initiate treatment. Review of Resident #2 Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated,9/2/25, showed:-Brief Interview for Mental Stats (BIMS) of 12, indicated very mild cognitive loss; -No refusal of cares;-Moderate to Maximum assistance of staff for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself);-Surgical wound;-Use of pressure reducing devices for the chair and the bed.-Diagnoses included: Left below the knee amputation (BKA), a surgical removal of the left lower leg below the knee, Parkinson's Disease, peripheral vascular disease (PVD, a condition that reduces blood flow to the legs). Review of the Resident's Comprehensive Care Plan updated 9/9/25 showed and order dated 9/9/25 for wound/incision care -Negative Pressure wound therapy to left BKA, cleanse with normal saline, apply granufoam (a special wound dressing to be used with negative pressure wound therapy) to wound beds, attach at 125 millimeters (mm) mercury (HG) secured with gauze.Review of Resident #2's physician orders showed and order dated 9/16/25 as no order for wound vac or wound vac change September 9, 2025 to September 16, 2025.Review of the resident's progress notes showed:-9/10/2025 at 11:15 A.M. wounds to left BKA, wound vac applied, pressure set to 125mm HG. Follow up with Nurse Practitioner to see if the resident is following up with in house wound care or outside wound clinic; -9/14/25 3:59 A.M. Wound vac in place, continuous 125mm HG; -9/19/25 2:05 P.M. Attempted to change wound vac dressing. Wound began bleeding profusely due to sponge adhered to the tissue. The resident had difficulty tolerating pain, asked to take frequent breaks. Pain medication given prior to wound care. Decision was made to send the resident to the emergency department. Excess bandage cut away, dressing applied and wrapped with gauze. Bleeding noted through the bandage after calling 911. Emergency Medical Services (EMS) arrived and the resident was transferred to an area hospital. Review of Physician Assistant (PA) note dated 9/19/25 at 3:05 P.M. showed:-Resident #2 was seen and examined; -Wound vac was changed, unfortunately during the dressing change, the patient experienced a significant amount of bleeding;-Licensed Practical Nurse (LPN) called EMS to have him/her transferred to the hospital;-The resident reported a burning sensation of his/her leg and mild dizziness. During an interview on 9/24/25 at 4:06 P.M. the PA said:-He/She did not see staff remove the dressing from Resident #2; there was a substantial amount of bleeding and staff were wrapping the wound up when he/she arrived; -He/She would not expect a dressing change to cause that kind of bleeding; -He/She would not expect a dressing to be stuck that badly if it was changed regularly; -He/She did not work with wound vacs typically.During an interview on 9/25/25 at 10:32 A.M. Nurse Practitioner A said:-He/She was the primary care provider for Resident #2; -The facility notified him/her of the issue with the dressing being adhered to the wound;-He/She had never known a wound vac dressing to adhere to a wound;-He/She would expect staff to call the primary care physician or wound care physician for wound vac orders. During an interview on 9/25/25 at 11:00 A.M. LPN B said:-Staff notified him/her on 9/19/25 that Resident #2 wound vac did not look right; -He/She assessed the dressing and looked for documentation of when it had been changed; -He/She was unable to find orders for the wound vac dressing change, or when it had been changed;-He/She was only able to find a note that showed the wound vac was in place on 9/10/25; -He/She used saline to soak the dressing to remove it; -There were three sponges and the third sponge was severely adhered to Resident #2's wound;-One area started to bleed significantly;-He/She wrapped the wound with roll gauze, discussed the situation with the Registered Nurse, and decided to call EMS; -He/She cut away the old dressing, applied thick padding, and wrapped the leg with gauze, as the wound was bleeding significantly; -The wound had bled through the thick dressing when EMS arrived;-Typically wound vac dressings should be changed twice weekly or more often if there was excessive drainage;-The wound nurse typically orders all the wound care supplies; -There was not a wound nurse currently; -He/She was not aware who would order supplies for wound care.During an interview on 9/26/25 at 12:04 P.M. the Administrator said:-He/She would expect staff to take orders from the hospital where the resident discharged or call the physician for orders; -There should have been orders for wound vac dressing changes for Resident #2;-He/She was aware there were no orders for the dressing change after the resident was sent to the hospital. Complaint 2622612

Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food safety when staff failed to dispose of expired food items, failed to properly label and seal opened food items, failed to wear hairnets and failed to maintain cleanliness in the refrigerators, freezer, and storerooms. This affected all residents by putting them at risk for food borne illness. The facility census was 162. Review of facility policy, Cleaning Schedule Dietary Services, revised 10/24/22, showed: - The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the Dietary Manager; - The cleaning schedule includes tasks assigned to specific positions within the dietary department; - Dietary staff will initial next to the assigned task once it is completed; - The Dietary Manager monitors the cleaning schedule to ensure compliance; Review of facility policy, Food Temperatures, revised 10/24/22, showed: - Record temperature readings taken in the Food Temperature Log; - Take the temperature of each pan of product before serving; Review of facility policy, Dietary Department General, revised 10/24/22, showed: - Food service staff must wear hairnets when cooking, preparing, or assembling food, such as stirring pots or assembling ingredients of a salad; Review of facility policy, Food Storage, revised 10/24/22, showed: - Freezer space should be available upon delivery of product; - Label and date all food items; - The walls, ceiling, and floor should be maintained in good repair and regularly cleaned; - Shelving should be sturdy and provided with a surface which is smooth and easily cleaned; - Shelving should be mounted at least six inches from the floor; Observation on 6/17/25 at 8:00 A.M., showed: Kitchen Area: - Kitchen cleaning schedule for June posted with no initials or staff members assigned indicating that areas has been cleaned by the staff; - Five-foot square area around the sink has dirt on the walls; - Between stand-up refrigerator and heater exhaust tower there is standing water on the floor with multiple two inch diameter patches of black growth underneath a cart holding food items; - In front of walk-in freezer door entrance there is a six-foot by three-foot patch of condensation and black growth on the floor; - Outside the walk-in freezer on the right side next to a boxed up ice machine is a puddle of condensation on the floor with heavy dirt and bacterial black growth covering a eight inch area; Stand Up Refrigerator: - No open date on resealed plastic container of beef base, one gallon container of Worchester sauce and minced garlic two pound container; - Inside ledge of refrigerator had six-inch area of food stain build up; - Tray with condiments has caked food debris and stains on tray surface; Walk-in Refrigerator: - Puddle of dried red substance covering eight-foot area under storage racks on floor; - Thermometer and various chunks of food debris under the racks on the floor; - Staff personal food bag stored on the top rack; - Storage rack surfaces throughout the refrigerator had dirt and food grime build-up; - Black mold like substance growing on a six-inch square piece of paper which is wedged behind an aluminum sheet located above the door on the inside of the refrigerator; - Back wall of refrigerator has deteriorated metal at base near floor covering a three foot section. There is also heavy dirt and black growth in the same area; - Standing water underneath right-side racks with black growth in the water covering the entire line of racking area of eight feet; - Single serving butter cups and single serving milk container underneath the storage racks lying in standing water; - Liquid whole eggs opened and not dated or resealed; - Buttermilk ranch dressing, one gallon container, opened and not dated; - Five, one half gallon unopened plastic containers of whipping cream expired as of 6/10/25; Walk-in Freezer: - Freezer door seals have a heavy buildup of black grim over entire seal area; - One palm sized ball of unpackaged raw cookie dough on the floor of the freezer; - Seven boxes of frozen meats and vegetables stored directly on the floor of the freezer; - One dead fly on the floor; - Pieces of plastic trash and dirt buildup underneath the racks of the freezer; - A water leak from the overhead condenser had formed a column reaching 10 inches of icicles ending in a frozen puddle of ice with a five inch diameter on top of a box of frozen meat; Dry Storeroom: - Rust and dirt buildup on racking metal shelf rods throughout the storeroom shelving; - Line of dirt and food debris along the walls under all racks; - Two cans of food and one Cheeto snack puff lying on the floor under the racks; Dishwashing Area: - Heavy grim and dirt on the wall and metal table siding covering a two-foot by six-inch area going into the loading station of the dishwasher; - Floor area under the dishwasher has heavy grim buildup covering a three-foot by one-foot area; During an interview on 6/17/25 at 8:30 A.M., the interim DM (Dietary Manager) said: - He been there a couple of days due to both current DMs being out sick; - The last delivery of food to the facility was on 6/16/25 and there is not enough space in the freezer to handle all the frozen items currently in stock at the facility. The boxes should not be on the ground in the freezer. The previous DM did a poor job of planning and ordering items which are not needed for the scheduled menu; - The corners and behind items in the kitchen need to be cleaned better and deep cleaning should be done on a weekly basis rotating areas so every part of the kitchen gets covered every month. His/Her plan would be for staff to sign off when they have completed work assignments to assure cleaning areas are addressed weekly; - The equipment in the kitchen is working as intended and there are no open work orders except for a light that is out in the storage area; Continuous observation of the kitchen on 6/18/25 starting at 10:23 A.M., showed: - No sanitizing buckets with cleaning rags stationed in the kitchen area for staff to use; - Freezer with ice cream stored in it has four inches of frost buildup on interior and needs defrosting; - Condensation dripping at a rate of one drop every 15 seconds from overhead air conditioning unit next to the steam line; - Heavy dust build up on air conditioning vent near the ceiling next to the steam line; - Steam line has several broken six-inch floor tiles coming away from the wall; - Food debris from previous meals not wiped up on the storage surface of where clean plates are placed under the steam line; - Sink near stove area is leaking to the floor and drain under the sink does not have a grate and is coated with food debris and bacterial growth over a six-inch diameter area; - 10:42 A.M. DM placed a bucket of fresh sanitizing liquid with rags onto a kitchen self underneath a food prep table; - Review of temperature logs from today's breakfast showed no temperature checks recorded on completed meal items; - 10:48 A.M. Dietary Aide (A) put on hair net after being observed for 25 minutes working in the kitchen doing various tasks including food preparation of vegetables without the hair net on; - Five-inch block of wood lying in standing water and black grease on the floor behind a steamer machine next to the stove; During an interview on 6/18/25 at 11:00 A.M., [NAME] (A) said he/she didn't have time this morning to record the temperatures on the food items prepared for breakfast on 6/18/25; Continuous observation of the steam line on 6/18/25 at 11:20 A.M., showed: - Clean plates put face down on a storage shelf beneath the steam line in preparation for lunch service. Same breakfast small food debris noted earlier in the observation still on storage surface, no sanitizing bucket in the steam line area; - No temperature checks of food items on the steam line prior to serving the first meal for lunch; - 11:47 A.M. Plate warmer cart covered in greasy hand prints and dried food stains along three-foot area on the surface of the door; During an interview on 6/19/25 at 9:50 A.M., the Administrator said: - He would expect the staff to have a routine deep cleaning plan in place for the storage areas and the kitchen; - He would not expect to see standing puddles of water in the walk-in [NAME] and in the storage areas; - He would expect drains to have covers and be cleaned; - Expired food items should be removed from the kitchen area immediately upon expiration; - Anyone entering the kitchen should have a hairnet on; - Personal food items should not be stored in the walk-in refrigerator; - Vents in the kitchen should be free of built-up dust; - He would not expect the condenser in the freezer to be leaking; - He would not expect to see icicles forming in the walk in freezer or to see frozen puddles of water on food boxes; - He would not expect to see boxes of frozen food stored on the floor or food debris and trash under the storage racks; - He would expect temperatures to be taken on foods before serving and after cooking; - Dates should be annotated on containers for any food items that are opened; During an interview on 6/19/25 at 10:30, the Registered Dietician (RD) said: - She would expect the staff to have a routine deep cleaning plan with sign offs for when the work has been done by each person; - She would not expect to see puddles of water in the walk in refrigerator or in storage areas; - She would not expect to see black bacterial growths in the storage areas; - Drains should have covers and be free of food debris; - Expired items should be removed and discarded; - Hairnets should be worn at all times in the kitchen; - Personal food items should not be stored in the walk-in refrigerator; - Storage racks should be free of rust and built-up grime or dust; - Vents should be free of built-up dust; - She would not expect the condenser in the freezer to be leaking or to see icicles handing down from the condenser onto food products; - She would expect boxes to be stored at least six inches off the floor; - She would not expect to see trash or food debris underneath storage racks in any area; - She would not expect to see a rusted out wall in the walk-in refrigerator; - All hot foods should be checked for temperature when they are completed with the cooking process; - Temperature checks should be done of foods before the first serving from the steam line; - Opened dates should be annotated on all opened food containers that are resealed for use; During an interview on 6/19/25 at 11:15 A.M., the interim DM said: - He would expect the staff to have a routine deep cleaning plan in place for the storage areas and the kitchen. Sign up sheets work best and keeping on top of them are vital to a good program. He is working on developing a new one for the kitchen; - He would not expect to see standing puddles of water in the walk-in [NAME] and in the storage areas; - He would not expect to see black bacteria growth in the storage areas; - Drains in the floor should have grates over them and be regularly cleaned of food debris and grime; - Expired food items should be removed from the kitchen area immediately upon expiration; - Anyone entering the kitchen should don a hairnet; - Personal food items should not be stored in the walk-in refrigerator; - Vents in the kitchen should be free of built-up dust; - He would not expect the condenser in the freezer to be leaking; - He would not expect to see icicles forming in the walk in freezer or to see frozen puddles of water on food boxes; - He would not expect to see boxes of frozen food stored on the floor or food debris and trash under the storage racks; - He would not expect to see rusted interior walls on the walk in refrigerator; - Food temperatures should be taken of foods before they are put on the steam line and before serving if they have been sitting there for over an hour; - Dates should be annotated on containers for any food items that are opened and intended for re-use.

Based on observation, interview and record review, the facility failed provide proper respiratory care when staff failed to document the date when oxygen tubing was cleaned and failed to properly store oxygen accesories at the bedside for three residents (Residents #119, #126, and #253) resulting in possible exposure to bacteria during oxygen usage. This affected three of 32 sampled residents. The facility census was 162. Review of the facility's Oxygen administration policy not provided; 1. Review of Resident #253's Care Plan, dated 6/9/25, showed: - Resident has COPD (lung disease) with risk of shortness of breath. Maintain resident's O2 levels with a flow rate of two liters per minute via a nasal cannula as needed to maintain oxygen saturation levels above 90%; - Check O2 saturation every shift and as needed; - Give medications, treatments, for COPD as ordered, monitor for effectiveness; Review of Resident's Physician Order Summary Report, dated 6/19/25, showed: - Diagnoses: stroke, dementia, COPD, and diabetes; - O2 at two liters per minute to keep oxygen saturation levels above 90%; Observation on 6/16/25 at 3:08 P.M., showed: - Oxygen tubing attached to the oxygen concentrator lying on the floor next to resident's bed under a pair of dirty slippers. There are no dates on the tubing or the concentrator indicating when the tubing was last cleaned or changed; 2. Review of Resident #119's admission Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 6/2/25, showed: - Resident is cognitively intact; - Diagnosis: cirrhosis (liver disease), renal failure, asthma, and depression; Review of Resident's Care Plan, revised 6/9/25, showed: - Resident has Adult Daily Living (ADL) performance issues due to respiratory failure and COPD; - Resident is a smoker; - Resident uses oxygen therapy due to COPD, shortness of breath, and chronic hypoxic respiratory failure (lack of oxygen delivery to the blood); Review of Resident's Physician Order Summary Report, dated 6/19/25, showed: - Cleanse oxygen concentrator filters with water, let dry and replace twice weekly; - Oxygen orders, check bubble humidifier daily and fill as needed every night shift; - Oxygen orders check oxygen saturation levels and apply two liters per minute nasal cannula to maintain saturation at or greater than 90%; - Oxygen orders if present, dispose of all oxygen tubing, humidifier, and plastic bag once a week; Observation on 6/16/25 at 1:13 P.M. showed: - No dates on oxygen tubing attached to the oxygen concentrator showing when last cleaned or tubing changed; Observation on 6/19/25 at 9:18 A.M., showed; - Oxygen tubing from oxygen concentrator lying on the floor next to resident's bed with no date of when last cleaned or changed; 3. Review of Resident #126's admission MDS, dated [DATE], showed: - Cognition is moderatly impaired; - Diagnoses: diabetes, hypertension, and peripheral vascular disease (narrowing of the blood vessels); Review of Resident's Care Plan, revised 5/15/25, showed: - Resident has ADL self-care performance deficit due to acute respiratory failure; - Resident has acute respiratory failure with COPD and uses as needed oxygen therapy to maintain oxygen saturation great than 92% and is at risk for shortness of breath; - Administer oxygen per physician's orders; Review of Physician's order summary report, dated 6/19/25, showed: - Cleanse oxygen concentrator filters with water, let dry and replace twice weekly; - If present change nebulizer, tubing, and bag weekly; - Oxygen three liters per nasal cannula as needed to maintain oxygen saturation greater than 92%; - Oxygen orders to check bubble humidifier daily and fill as needed; - Oxygen orders to check oxygen saturation every shift; - Oxygen orders to change all oxygen tubing, humidifier and plastic bag weekly; - Oxygen orders if present, dispose of all oxygen tubing, humidifier, and plastic bag monthly; Observation on 6/16/25 at 1:51 P.M., showed: - Oxygen tubing in resident's room next to bed has no date documented on oxygen tubing to show when last changed or cleaned by staff; - Oxygen concentrator on and has water in it, nebulizer is lying on the bedside table and not stored hygienically in a plastic bag; Observation on 6/18/25 at 8:45 A.M., showed: - Nebulizer in plastic bag, oxygen tubing from oxygen concentrator lying on the ground with no date of when last changed or cleaned, water is in the concentrator tank; During an interview on 6/19/25 at 9:45 A.M., the Director of Nursing said: - Oxygen concentrator tubing should be kept in a plastic protective barrier, labeled with tape around the tubing to show when it was cleaned or changed out. This should be done weekly, and the filter cleaned weekly; - When nebulizers are not in use they should be stored in a plastic baggie for protection. The mouthpiece should be cleaned. This is monitored by the nursing staff to ensure proper storage; During an interview on 6/19/25 at 10:58 A.M., CMT (A) said: - The CNAs will wipe off any dust and change the tubing once a week for the oxygen concentrators and they will document the disinfect date on the tubing with tape while also checking the water levels; - The tubing and nebulizer should be placed in plastic bags when not and they should not be stored on the ground. There should never be bedroom slippers lying on the tubing;

Based on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff failed to ensure they provided perineal to meet the needs of three residents (Resident #72, #56, and #103), out of the sampled 32 Residents. The facility census was 162. Review of the facility's Care and Services Policy, revised 10/24/22, showed: -Care and services are provided a in manner that consistently enhances self esteem and self worth. Review of the facility's Perineal Care Policy, revised 10/24/22, showed: -Perineal care is provided to maintain cleanliness of the resident and to reduce odor, prevent infection and reduce skin breakdown; -Perineal care is provided as part of a resident's care; -Perineal care is provided a minimum of once daily and as needed per resident. 1. Review of Resident 72's quarterly MDS dated [DATE], showed: -Severe cognitive impairment; -Always incontinent of bowel and bladder; -Dependent on staff for toileting; -Diagnoses included: Alzheimer's disease and a thyroid disorder. Review of the resident's care plan dated 05/21/25, showed: -ADL self-care deficit related to advanced dementia; -Incontinent of bowel and bladder; -Check and change the resident every two to three hours for incontinence. During an observation beginning on 06/18/25 at 09:20 A.M. - 12:22 P.M., showed: -09:32 A.M., the resident sat in the TV area in his/her wheelchair; -09:45 A.M., the resident sat in the TV area in his/her wheelchair; -10:16 A.M., CNA G took the resident to the dining room for exercise class and did not toilet or change the resident; -10:20 A.M., the resident sat at the table in the dining room in his/her wheelchair; -10:40 A.M., Certified Nurses Aide CNA G took the the resident back to the TV area and did not toilet or change the resident; -10:56 A.M., the resident sat in the TV area in his/her wheelchair; -10:58 A,M, the resident looked around the room and aid help, help; -11:04 A.M., there were no staff near the resident's location; -11:08 A.M., the resident sat in the TV area in his/her wheelchair; -11:18 A.M., the resident sat in the TV area in his/her wheelchair; -11:21 A. M., the resident sat in the TV area in his/her wheelchair; -11:31 A. M., the resident sat in the TV area in his/her wheelchair; -11:45 A.M., CNA F took the resident to the dining room; -12:02 A.M., the resident the resident sat in the dining room in his/her wheelchair; -12:18 P.M., CNA F took the resident to his/her room; -12:19 P.M., the resident had a strong smell of urine; -12:20 P.M., CNA F and CNA G transferred the resident to his/her bed; -12:22 P.M., the resident's wheel chair had liquid that smelled of strong urine in it and the mechanical lift pad was wet around the groin area and smelled of strong urine; -The resident's pants were wet in the groin area and smelled of strong urine; -CNA G and CNA F removed the resident's pants and brief: -The brief was saturated with urine and had a strong smell of urine. During an interview on 06/18/25 12:41 P.M., CNA F said: -The resident was dependent on staff for transfers and toileting; -The resident was incontinent; -The resident should be provided incontinent care and repositioned at least every two hours; -The resident should be changed before the mechanical lift pad becomes saturated with urine; -He/She did not provide incontinent care and reposition the resident every two hours because he/she had been busy helping other residents. During an interview on 06/18/25 12:55 P.M., CNA G said: -The resident was dependent on staff for transfers and toileting; -The resident was incontinent; -The resident should be provided incontinent care and repositioned at least every two hours. 2. Review of Resident #56's care plan dated 02/13/25, showed: -ADL self-care deficit related to stroke and dementia; -Incontinent of bowel and bladder; -Check the resident frequently for needs and incontinent care. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/23/25, showed: -Moderate cognitive impairment; -Always incontinent of bowel and bladder; -Dependent on staff for toileting; -Diagnoses included: stroke, dementia and seizure disorder. During an observation beginning on 06/18/25 at 09:20 A.M. - 12:24 P.M., showed: -09:32 A.M., the resident sat in the TV area in his/her wheelchair; -09:45 A.M., the resident sat in the TV area in his/her wheelchair; -10:00 A.M., the Activities Aide A took the resident to the dining room for exercise class and did not toilet or change the resident; -10:20 A.M., the resident sat at the table in the dining room in his/her wheelchair; -10:31 A.M., Certified Nurses Aide (CNA) F took the the resident back to the TV area and did not toilet or change the resident; -10:55 A.M., the resident had facial grimacing and said help and help; -10:56 A.M., the resident leaned to the right and tried to push himself/herself up off of the seat of the wheel chair; -10:58 A,M, the resident looked around the room and said help, help; -10:49 A.M., there were no staff near the resident's location; -11:04 A.M., the resident said help; -11:05 A.M., the resident's left arm hung over the left side of his/her wheel chair and the resident said help; -11:08 A.M., Certified Medication Technician (CMT) B lifted the resident's left arm and put it on the resident's lap; -11:09 A.M., CMT B did not toilet the resident; -11:13 A.M., the resident sat in the TV area in his/her wheelchair; -11:17 A.M., CNA F walked by the resident and did not toilet the resident; -11:18 A.M., the resident sat in the TV area in his/her wheelchair; -11:21 A.M., the resident sat in the TV area in his/her wheelchair; -11:27 A.M., the resident sat in the TV area in his/her wheelchair; -11:45 A.M., CNA G took the resident to the dining room; -11:46 A.M., the resident had a strong smell of urine; -12:02 P.M., the resident sat in the dining room in his/her wheelchair; -12:18 P.M., the resident the resident sat in the dining room in his/her wheelchair; -12:22 P.M., the resident sat in the dining room in his her/wheel chair; -12:24 P.M., the facility staff did not offer to toilet the resident during this continuous observation. During an interview on 06/18/25 12:41 P.M., CNA F said: -The resident was dependent on staff for transfers and toileting; -The resident was incontinent; -He/She had not provided incontinent care or repositioned since breakfast; -The resident should be provided incontinent care and repositioned at least every two hours; -He/She did not provide incontinent care and reposition the resident every two hours because he/she had been busy helping other residents. During an interview on 06/18/25 at 12:55 P.M., CNA G said: -The resident was dependent on staff for transfers and toileting; -The resident was incontinent; -He/She had not provided incontinent care or repositioned since breakfast; -The resident should be provided incontinent care and repositioned at least every two hours; -He/She did not provide incontinent care and reposition the resident every two hours because he/she had been busy helping other residents. 3. Review Resident 103's Significant change MDS dated [DATE], showed: -Severe cognitive impairment; -Always incontinent of bowel and bladder; -Dependent on staff for toileting; -Diagnoses included: dementia and high blood pressure. Review of the resident's care plan dated 06/16/25, showed: -ADL self-care deficit related to dementia; -Incontinent of bowel and bladder; -Total assistance with toileting; -Check and change the resident routinely for incontinence. During an observation beginning on 06/18/25 at 09:20 A.M. - 12:02 P.M., showed: -09:32 A.M., the resident sat in the TV area in his/her wheelchair; -09:45 A.M., the resident sat in the TV area in his/her wheelchair; -10:16 A.M., CNA F took the resident to the dining room for exercise class and did not toilet or change the resident; -10:20 A.M., the resident sat at the table in the dining room in his/her wheelchair; -10:40 A.M., Certified Nurses Aide CNA G took the the resident back to the TV area and did not toilet or change the resident; -10:56 A.M., the resident sat in the TV area in his/her wheelchair; -11:12 A.M., the resident sat in the TV area in his/her wheelchair; -11:22 A.M., the resident sat in the TV area in his/her wheelchair; -11:35 A.M., the resident sat in the TV area in his/her wheelchair; -11:45 A.M., CNA F took the resident to the dining room; -12:02 P.M., the resident the resident sat in the dining room in his/her wheelchair. During an interview on 06/18/25 12:41 P.M., CNA F said: -The resident was dependent on staff for transfers and toileting; -The resident was incontinent; -The resident should be provided incontinent care and repositioned at least every two hours. During an interview on 06/18/25 12:55 P.M., Licensed Practical Nurse (LPN) I said: -The resident was dependent on staff for transfers and toileting; -The resident was incontinent; -He/She would expect the resident be provided incontinent care and repositioned at least every two hours; -All dependent residents who are incontinent should be provided incontinent care at least every two hours. During an interview on 06/18/25 02:45 P.M., the resident's family said: -He/She expects the resident to be checked and changed at least every two hours if not more; -He/She had found the resident soaking wet on several occasions; -He/She had told the staff about changing the resident but noting had changed. During an interview on 06/18/25 03:17 P.M., the Director of Nursing said she expects staff to check and change incontinent residents at least every two hours and as needed. During an interview on 06/18/25 03:28 P.M., the Administrator said: -All dependent residents who are incontinent should be provided incontinent at least every two hours; -He expects the staff to check and change incontinent residents at least every two hours and as needed.

Based on interview, and record review, the facility failed to, provide supportive services, or develop a care plan that directed interventions for facility staff to utilize to protect the resident and prevent trauma from recurring for one resident who was identified as having a past traumatic life event (Resident #26), out of 32 sampled residents. The facility census was 162. Review of the facility's Care and Services Policy, revised 10/24/22, showed: -Care and services are provided a in manner that consistently enhances self esteem and self worth; -Behavior health encompasses and residence whole emotional and mental well-being which includes the identification of needed care and services; -A resident who is diagnosed with mental disorder or psychosocial adjustment difficulty will receive appropriate treatment in accordance with assessed behavioral needs. The facility did not provide a Trauma Informed Care Policy. 1. Review of Resident #26's Quarterly Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/22/25, showed: -Moderate cognitive impairment with difficulty speaking; -Resident experienced little interest or pleasure in doing things nearly everyday; -Resident felt down, depressed, or hopeless nearly everyday; -The resident received antipsychotics (a class of medications primarily used to treat mental health disorders) daily; -Diagnoses included, PTSD (post traumatic stress disorder a mental health condition that can develop after experiencing or witnessing a traumatic event), anxiety and depression. Review of the resident's undated care plan did not address the resident's diagnosis of PTSD and did not address staff interventions to manage the resident's PTSD triggers or needs. Review of the resident's admission trauma informed care screening assessment, dated 01/27/25., showed the resident had experienced a traumatic life event. Review of the resident's documented history and physical, dated 01/30/25 showed the resident had a history of PTSD. Review of the resident's trauma informed care screening dated, 02/28/25 showed the resident had experienced a traumatic life event. During an interview on 06/18/25 at 01:15 P.M., Certified Nurses Aide (CNA) G said: -He/She did not know if the resident had a diagnosis of PTSD or any past trauma; -He/She would expect PTSD to be in the resident's care plan; -He/She would expect the resident's triggers or any interventions to be on the care plan; -The staff should know the resident's triggers as not to retraumatize the resident; -He/She had no special training or instructions on now to take care of the resident. During an interview on 6/18/25 at 01:25 P.M., CNA F said: -He/She did not know if the resident had any past trauma or PTSD; -He/She did not know what the resident's triggers were or are how to mitigate them; -It is important to not trigger resident's with PTSD because it brings up past memories of trauma. During an interview on 6/19/25 at 09:12 A.M., Licensed Practical Nurse (LPN) I said: -There are no residents that he/she was aware that had a diagnosis of PTSD; -He/She would expect the PTSD to be included in the resident's care plan along with triggers and interventions to avoid triggers; -It is important for all staff that provide care to the resident, know the triggers and to avoid triggers that can escalate the resident's behaviors; -He/She does not know who is responsible to complete the trauma assessments at the facility. During an interview on 6/19/25 at 10:55 A.M., the Social Services Designee (SSD) said: -She is responsible for doing the trauma assessments; -She completes a trauma assessment upon admission and quarterly; -The resident was not able to tell her what his/her trauma was and the family did not mention any trauma; -The resident came from the hospital with the diagnosis PTSD; -She should have followed up with the family on the resident's PTSD; -She would expect PTSD to be in the resident's care plan; -She would expect the resident's triggers or any interventions to be on the care plan; -The staff should know the resident's triggers as not to retraumatize the resident. During an interview on 06/19/25 at 11:18 A.M., the Director of Nursing (DON) said: -He/She was not aware that the resident had past trauma and a diagnosis of PTSD; -Trauma history should be documented on admission using the trauma screening; -A plan should be in place for the resident to address the resident's triggers and a plan to mitigate them; -The staff should know the resident's triggers so they do not retraumatize the resident; -The family should be involved in obtaining the history of past trauma upon admission if possible; -If trauma history is discovered later or a new traumatic event occurs this information should be added to the plan of care as soon as possible; -The facility should offer counseling or psychiatric services if needed; -She was not aware of any counseling or therapy the resident was attending. During an interview on 06/19/2025 at 11:30 A.M., the Administrator said: -He would expect the resident's care plan to address trauma and provide interventions; -He would expect the facility to address the resident's PTSD and history of trauma; -He would expect staff to know the triggers and know how to mitigate them.

Based on interviews and record review, the facility failed to provide an appropriate discharge when staff failed to provide written notice of discharge that included the date and location the resident would be discharge to, statement of appeal rights and the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities) to one sampled resident (Reisdent #1). The facility's census was 161. Review of facility policy regarding Transfer and Discharge, revised 10/24/22, showed: - The facility may not transfer or discharge a resident while the appeal to the notice of transfer/discharge is pending, unless it is documented that failure to transfer or discharge the resident would endanger the health or safety of the resident or other individuals; - In cases in which 30 days' notice is not possible, the notice of transfer or discharge should be provided to the resident or resident representative as soon as practicable; - Documentation of written or telephone acknowledgement of the resident's transfer by the resident's representative may occur after the transfer in an emergency; - Documentation relating to resident's transfer/discharge will be maintained in the resident's medical record; - The Notice of Proposed Transfer/Discharge must be completed by the facility and sent to any legally authorized representative of the resident and to at least (1) family member; - Before the facility transfers a resident to a hospital the facility will provide written information to the resident or his/her resident representative which covers the bed hold policy and it's duration; - In an emergency transfer/discharge to a hospital the facility will: notify the attending physician, notify the receiving facility that the transfer is being made, notify the resident's representative; - Prior to discharging the resident, the facility will prepare a Discharge Summary and will document the summary in the resident's medical record; - The medical record will contain written documentation from the resident's attending physician that the resident is transferred/discharged because it is necessary for the resident's welfare and resident's needs cannot be met in the facility; - Documentation and education provided to a resident or his/her resident representative in preparation for transfer/discharge will be provide in a language that he/she understands; Review of Resident #1's admission Record, dated 5/2/25, showed: -admitted from acute care hospital on 4/8/25; - Resident has a DPOA invoked; - Diagnoses: Congestive heart failure, neurocognitive disorder with Lewy bodies (a neurodegenerative disorder characterized by progressive cognitive impairment, visual hallucinations, and motor symptoms like Parkinsons), repeated falls, difficulty in walking, unsteadiness on feet, restlessness and agitation, dementia, and acute kidney failure; Review of Resident's Care Plan, revised 4/22/25, showed: - Resident is on Hospice; - Resident is at risk for elopement and door seeking, hospice services to evaluate and adjust medications as needed; - Resident has trauma from working as a police officer and homicide detective. Evaluate recommendations of psychiatric/behavioral health professions and implement as appropriate; - Resident has a behavior problem related to Lewy Body Dementia having vivid hallucinations and delusions. Administer medications as ordered and monitor/document side effects. Psychiatry to evaluate and treat; Review of the residents progress notes in the Electronic Medical Record showed: - Progress Note: 4/23/25 Family member notified that EMS was at the facility to transfer resident to hospital facility; - Progress Note: 4/23/25 Resident transferred to hospital facility and family member notified; - Progress Note: 4/23/25 Bed hold policy sent with resident to ER; - No copy of bed hold policy found during review of electronic records; - Progress Note: 4/24/25 Behavior committee met on 4/24 to review that on 4/23 resident was very agitated, staff tried to use de-escalation techniques, which were not successful. Resident punched a staff member in the mouth, exit seeking, having strong delusions. Resident was transported to a hospital facility with family and provider involved and Hospice aware; - Progress Note: 4/29/25 Social Services department notified family member through Carefeed that resident was discharged from the facility; - No record of resident/representative involvement in the development of a discharge plan which would address the discharge needs of the resident; During an interview on 5/2/25 at 10:35 A.M., the Social Services Director said: - He/she had little involvement with the transfer of the resident from the facility. - This was a facility initiated unplanned transfer and the day after the transfer is when she was notified that it had occurred; - As far as she could remember no one had ever had a planned transfer to this hospital, it was only used for evaluation purposes and treatments; - Social services would not have handled this transfer but instead the Admissions department would have completed it; - Carefeed is a corporate communication system utilizing automated emails and phones calls to send out announcements or contact families with routine information. If Social Services was tasked to contact a family member about a transfer they would never use Carefeed because it's too informal and not reliable that information actually reaches the recipient; - The requirement for notifying a resident of a planned discharge is 72 hours advance notice and for a facility initiated non-emergency transfer, facility staff are required to provide 30 days advance notice to the resident and family; During an interview on 5/2/25 at 11:00 A.M., the DON (Director of Nursing) said: - On 4/23/25 he called 911 to have the resident transferred for medical health evaluation after the resident struck a staff member; - After the resident transferred to the hospital facility, the DON met with the Unit Manager, other team members and the Administrator and it was decided that the resident would not be accepted back to the facility because of the resident's aggression, exit seeking on an unlocked unit, and due to the resident refusing medications and treatments; - The initial call to the family of the resident was made by LPN A but the DON does not know who contacted the residents DPOA once the decision was made to not accept the resident back to the facility; During an interview on 5/2/25 at 11:45 A.M., LPN A said he/she told the family member that resident was being sent to the hospital for a medical evaluation due to behaviors. The family was given a choice on which hospital to send the resident for evaluation. LPN A did not know that the resident would not be accepted back at the facility. During an interview on 5/2/25 at 12:57 P.M. the facility Admissions Coordinator said: - He/She remembers the resident was initially screened with a yellow status which means more research needs to be done in order to approve them for admission to the facility. - The residents status was upgraded to green after research was completed, which means the facility had the capabilities to meet the needs of the resident; - Currently the admissions team is looking for another facility to accept the resident which has a locked unit capable of providing the necessary security and care. - He/She had no communication with the family with regards to discharge plans or placement. - No one had told him/her that the resident was not coming back to the facility at the time the reisdent was transferred to the hospital; During an interview on 5/2/25 at 1:36 P.M., the residents DPOA said; - He/she had not received a call or notification from facility staff regarding transferring the reisdent from the facility or notification of discharge. - Another family member had been communicating with the facility; During an interview on 5/3/25 at 10:15 A.M., a Family Member A said: - He/she was contacted by the facility just before resident was transferred out to the hospital. - He/she told the facility which hospital the resident should be sent to for evaluation and the facility staff member told him/her that the resident was being transferred was due to behavioral issues that day. - When the family member arrived at the hospital, he/she was told by hospital staff that the facility was not allowing the resident to return and they would not accept the resident back to the facility. - The family member confirmed that he/she never received a copy of the bed hold policy, Notice of Proposed Transfer/Discharge or information regarding the residents right to appeal; - It was not the family member's choice that the resident be discharged from the facility; - Since being discharged to the hospital, the reisdent has been confused because of their new surroundings, has experienced rigidity of their extremities, and has at times displayed bouts of fear; - The resident has experienced physical and psychosocial harm because the facility staff failed to provide appropriate planning and notice regarding discharge; During an interview on 5/6/25 at 10:15 A.M., the Administrator said: - At the time of transfer on 4/23/25 the facility was in the process of looking for alternate locations because of the resident's hallucinations and behaviors. Initially we just wanted the resident evaluated but looking at all the factors the resident needed a secure unit designed for him/her; - I think that the Charge Nurse LPN A notified the family of the transfer decision; - The goal of the transfer was to evaluate the resident and every family has the opportunity to appeal the decision but I do not know who told the family about their rights to appeal; - There was no conversation that she knew of with the hospital facility on agreeing to take on the resident full time; On 5/6/25 Review of record review of documents supplied by the facility on 5/6/25 showed: - Notice of Proposed Discharge/Transfer, dated 4/23/25 signed by the Social Services Director. - Proposed discharge date [DATE] to a hospital facility and that notification was provided to the resident and family via phone call and document given to resident. - Reason for discharge is listed as necessary for resident's welfare and the facility cannot meet individual's needs; - Bed Hold Policy for resident, signed by the Social Services Director, dated 4/23/25, provided to resident and family verbally and copy provided at the time of transfer (no persons name listed); During an interview on 5/6/25 at 3:00 P.M., Hospital Employee A said: - Resident #1 was not accepted back by the facility and remains in the hospital. - The hospital is not equipped to provide long-term care for patients. - The facility staff did not inform the hospital staff they would not be accepting Resident #1 back to the facilty until after the resident had been transferred to the hospital. - The hospital is not an appropriate level of care as they are unable to provide long-term care. - Hospital staff did not agree to accept the resident on a long term basis and had only intended to provide evaluative care. MO00252657

Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse when Resident #1 hit and restrained Resident #2 resulting in a scratch to Resident #2's left cheek, redness to his/her right eye, abrasion to right eyebrow, and redness and bruises to the right forearm and bicep. The facility census was 153. Review of the facility's Abuse Prevention and Prohibition Program, revised 10/24/22, showed: - Each resident has the right to be free from abuse. The facility has zero-tolerance for abuse. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse of residents; - The facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met; - The facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse; - Resident assessments and care planning are performed to monitor resident needs and address behaviors that may lead to conflict; - Resident to resident altercations must be reported if the altercation is caused by a willful action that results in physical injury, mental anguish or pain. 1. Review of Resident #1's admission record, dated 2/11/25, showed: - Diagnosis: frontal temporal neurocognitive disorder (affects cognitive functions for decision making, behavior, language and memory), dementia (decline in cognitive abilities), depression, and Pick's disease (rare neurodegenerative brain disorder); Review of Resident's Care Plan, dated 2/12/25, showed: - Resident has a behavior problem hitting and pulling peer's hair, -Staff should intervene as necessary to protect the rights and safety of others. Review of the Resident's care plan revised 3/10/25 showed the resident was combative with staff. Review of Resident order summary report, dated 3/18/25, showed: - 2/24/25 Brexplprazole 2 miligrams (MG), 1 x daily for Dementia with agitation; - 2/18/25 Divalproex Sodium 125 MG, 2 tablets 2 x daily for agitation; - 3/18/25 Divalproex Sodium 500 MG, 1 tablet 2 x daily for agitation; - 3/18/25 Risperdal 1 MG, 1 x daily for agitation. Review of Resident's progress notes, dated 3/17/25, showed: - Staff came into resident room to observe Resident #1 standing off to the side while Resident #2 was in bed visibly shaking and a scratch mark was noted on his/her cheek. Resident #2 said he/she was in bed when Resident #1 came over and hit and grabbed Resident #2. Resident #2 said he/she was struck on the right and left side of the face and his/her right arm was grabbed by Resident #1. During an observation on 3/26/25 at 1:15 P.M., showed the Resident was wandering the hallways back and forth and could only communicate in one or two word answers when questioned by staff; Review of Resident #2's admission record, dated 5/14/24, showed: Diagnosis: Alzheimer's disease (progressive brain disorder) and dementia. Review of Resident's Care Plan, dated 1/14/25, showed: - Resident has experienced trauma and has developed fear, terror, dread or helplessness following exposure to a traumatic event; - Resident has impaired cognitive function due to dementia and may have periods of confusion, poor safety awareness and memory deficits. Review of facility incident report, dated 3/17/25, showed: - Staff heard screaming from a resident room and immediately investigated. Resident #2 was crying and said that Resident #1 hit him/her on the right side of the face, slapped him/her on the left side of their head and grabbed their right arm; - Staff did not witness the actual altercation. Assessment of Resident #2 showed a scratch mark on left cheek, redness to right eye, a small abrasion to the right eyebrow, and redness and bruising to the right forearm and bicep. Review of Resident #2's progress notes, dated 3/17/25, showed: - Resident brought back to nurses' station after incident. Abrasion cleansed and medication applied. Resident placed on observation, right arm and left cheek iced. During an interview on 3/26/25 at 1:00 P.M., Registered Nurse (RN) B said: - Resident #1 has not shown any signs of agitation since their medications were changed by the physician following the hitting incident on 3/17/25; - Neither Resident #1 or Resident #2 can remember the incident, it happened on the night shift and he/she was not on duty at the time. During an interview on 3/26/25 at 3:15 P.M., Director of Nursing (DON) said the injuries noted in the report for resident #2 are accurate. During an interview on 4/4/25 at 2:00 P.M., Administrator said the injuries sustained by Resident #2 during the altercation with Resident #1 fit the definition of physical abuse as outlined in the facility's Abuse and Neglect policy. MO251256

Based on observation, interview, and facility policy review, the facility failed to ensure air vents were clean, stored food was dated after opening and sealed from contamination, and staff wore hair restraints while in the kitchen. This had the potential to affect 98 of 99 residents who resided in the facility and consumed food prepared from the facility's kitchen. Findings include: 1. During an initial tour of the kitchen on 04/08/24 at 8:40 AM, with the Dietary Director (DD), the following observations were made: Walk-in Freezer and kitchen: a. One large clear bag, containing pork sausage links, was observed open and undated. b. One bag of pepperoni with saran wraps around the outside was observed open and undated. c. One large bag of frozen cheese raviolis was observed undated. d. One large box of turkey breakfast sausage was observed open and exposed to the air. e. Two large clear bags of French toast were observed undated. f. One large clear bag of tater tots was observed undated. g. One large clear bag of shredded hash brown, was observed undated. Walk-in Refrigerator and kitchen: h. One large bag of lettuce mix was observed undated. g. Three bags of 2 pounds of liquid eggs were observed undated. i. Ten-pound buckets of hard cooked eggs were observed with the top open and exposed to the air. Three air vents above the kitchen entrance appeared visibly dirty with thick dust particles attached to it. Three air exhaust system vents above the exit back door appeared dirty with visible dust particles on it. During an interview on 4/08/24 at 8:40 AM, DD stated the air exhaust system was to keep the bugs out of the kitchen when the door was opened. DD stated the system was visibly dirty with visible dust particles on it. DD stated maintenance was responsible for cleaning the system. DM stated the dirty vents could contaminate the food coming in and out of the kitchen. DD stated their expectation was for all items to be labeled and dated as needed. DD stated all dietary staff were responsible to ensure food items were labeled with a visible open date and food delivered should be kept in its original box which was dated on the outside. for items to stored, labeled, and dated appropriately. During an interview on 04/09/24 at 12:41 PM, Maintenance Staff (MS) stated he was not aware of the vents being dirty in the kitchen until today by DD. MS stated he was not aware of who was responsible for cleaning the vents. During an interview on 04/09/24 at 12:44 PM, the Administrator stated she expected dietary staff to notify them directly if things such as the vents needed to be cleaned. The Administrator stated she expected the vents in the kitchen to be cleaned at least monthly. The Administrator stated the vents being dirty could contaminate food with dirt particles. Review of the facility's policy titled Storage of Dry Food and Supplies, dated May 2015, revealed The Dietary Department will store dry food and supplies according to facility guidelines and state regulation. 2. During a follow-up tour of the kitchen on 04/08/24 at 12:10 PM, Dietary Staff (D1) was observed on the food serving line plating food without a beard restraint. D1 was observed with a full beard that appeared about 1 inch long. During an interview on 04/08/24 at 12:14 PM, DD stated their expectation was for staff to wear beard restraints the whole shift unless they go outside of the kitchen for break. During an interview on 04/09/24 at 11:05 AM, D1 stated they removed their beard restraint on 04/08/24 due to being unable to breath with it on. D1 acknowledged they were supposed to wear the beard restraint at all times to prevent hair contaminating the food. Review of the facility's policy titled Dietary Personnel Guidelines, dated May 2015 revealed 4. Hairnets or bouffant disposable caps should be worn at all times and should cover the entire head of hair.

Based on interview and record review, the facility failed to ensure one resident and/or representative of five residents (Resident (R) 78) reviewed for unnecessary medications, out of a total sample of 25 residents, was informed of the risk and benefits of a physician ordered antipsychotic medication. This failure placed the resident and/or representative at risk of not knowing the risks and benefits of the use of medications. Finding included. Review of the Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R78 was admitted to the facility on [DATE] with Alzheimer's disease and major depressive disorder. Review of an 08/02/23 Physician Order located in the Orders tab of the EMR revealed, Abilify [an antipsychotic medication used as an add-on treatment for adults with major depressive disorder] 5 mg [milligrams] at bedtime. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/29/23 revealed R78 had a Brief Interview of Mental Status (BIMS) of 11 out of 15 which indicated she was moderately impaired in cognition for daily decision-making and was administered an antipsychotic medication daily during the observation period. Review of the Resident Documents tab and the Nursing Progress Notes tab of the EMR did not document that R78 or her representative was informed of the risks and benefits prior to initiating a new Physician Order for the Abilify. During an interview on 04/09/24 at 8:32 AM, R78 was asked if she was aware of the Physician Order for the Abilify and why she was being administered the medication. R78 stated, When I first came here, I was pretty depressed, but I am not aware of what Abilify is for. During an interview on 04/11/24 at 1:21 PM, Unit Manager (UM) 1 was asked if there had been documentation that the risks and benefits were explained to R78 or her representative when Abilify was initiated. UM1 stated, There is no consent obtained for the use of the medication. The facility did not provide a policy.

Based on observation, interview and record review, the facility failed to provide supervision and protective oversight for one sampled resident (Resident #1) when he/she was found with an acute oblique (break is at an angle) fracture to the right femur. The facility census was 105. Review of the facility's Positioning Policy/Procedure, dated March 2021, showed: -Any resident is an appropriate candidate for the Positioning Program if he/she: -Is unable to turn and get into position independently -Needs assistance in turning or positioning due to any mental or physical limitation. -Before determining which Positioning Program best meets the resident's needs, caregivers should assess: -Resident ability to assist with positioning and turning. -The need for learning specific positioning techniques. -Risk factors such as: contractures, fracture, confusion. 1. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 11/27/2023, showed: -He/She is usually understood and sometimes makes understands. He/She has moderately impaired vision. -He/She was unable to complete a Brief Interview for Mental Status (BIMS), a structured evaluation aimed at evaluated aspects of cognition in elderly persons, due to advanced dementia. -He/She is totally dependent on staff for all Activities of Daily Living (ADL's), including dressing, bathing, transfers, hygiene and eating. -He/She is always incontinent of bowel an bladder. -He/She has the following diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Chronic Obstructive Pulmonary Disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), chronic pain, right femur fracture (1/31/24), anxiety, insomnia, recurrent depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), spinal stenosis (the spaces inside the bones of the spine get too small), history of breast cancer. Review of the resident's Comprehensive Care Plan, dated 11/21/2023, showed: -He/She was at risk for alteration in comfort related to chronic pain. Staff will monitor for non-verbal signs/symptoms of pain, including moaning, facial expressions, crying, agitation, restlessness, body language. Nursing will evaluate and address severe pain issues for better pain management. -He/She was at risk for self-care/ADL deficit related to dementia, confusion, impaired mobility, impaired vision, spinal stenosis and chronic pain. He/She required assistance of two staff for bed mobility, dressing, transfers with mechanical lift. He/She used a Broda (a Broda chair provides supportive positioning through a combination of tilt, recline, adjustable leg rest angle, wings with shoulder bolsters and height adjustable arms) pedal wheelchair for mobility and positioning. -He/She was receiving hospice care related to progressing disease processes. Review of the resident's progress notes showed: -1/13/24 at 3:54 A.M.: Resident was combative with cares, hitting and scratching staff. Given pain medication due to facial grimacing. Required two staff for cares and transfers. -1/14/24 at 2:50 A.M.: Resident was combative with cares. Facial grimacing with care and transferring. Given pain medications. -1/30/24 1:04 P.M.: Resident lifting buttocks and sliding down Broda chair. Resident repositioned up in Broda chair. Resident was up and in dining room, appetite good. Hospice gave the resident a shower today. -1/31/24 at 5:54 P.M.: Resident yelling ouch when repositioned in Broda chair. Attempted to give oral pain medication, but the resident spit it out. Given liquid pain medication. The resident was still saying it hurts but unable to verbalize where it hurts. -1/31/24 at 6:35 P.M.: CNA called nurse in to asses resident's right leg/hip. Hip bone feels out of alignment. Called Registered Nurse (RN) in house to visualize. Hospice called. Hospice will send a nurse out to assess resident. -1/31/24 at 8:08 P.M.: Hospice nurse assessed the resident, observed with inverted right leg. Gave order to send to the emergency room for evaluation. Physician and family notified. -1/31/24 at 9:04 P.M.: Given another dose of pain medication. Emergency Medical Services (EMS) arrived. No bruising observed to right hip or groin. -2/1/24 at 4:25 P.M.: Hospice nurse practitioner here to see another resident. He/She informed the facility staff that Resident #1 was sent to a hospice house. -2/5/24 at 10:11 A.M.: Per email from resident's family, the resident passed away on 2/3/24 at the hospice house. Review of the resident's x-ray results, dated 1/31/24 at 10:37 P.M., showed: -There was an acute oblique fracture of the right femur. Review of the facility's internal investigation showed: -Narrative: On 1/31/24 around 3:00 P.M., the resident was noted to have complaints of pain, unable to report location. Able to move upper and lower extremities. Aide continued to prepare resident for a mechanical lift transfer to Broda chair. CNA A reports resident squirming in chair, needing repositioning during dinner. The resident was commonly observed to be squirming in wheelchair. Three aides repositioned the resident in his/her chair and the resident yelled out in pain. CNA A reported to the nurse. -On 2/1/24, the Administrator interviewed the resident's roommate. The roommate has not observed anyone being rough with the resident. The resident has not fallen in the last two weeks. The roommate had no concerns related to his/her care. -Statement obtained from CNA A: CNA A arrived at work and around 3:00 P.M., went to Resident #1's room on first rounds. The resident was in bed. His/Her right hip looked fine but the right leg was turned inward. He/She did not see any bruising and the resident was able to move their own leg. Put the resident in sling and used the mechanical lift to transfer the resident to his/her to wheelchair. The resident continued to say it hurts. -Statement obtained from Certified Medication Technician (CMT) A: Assisting aide with transfer, and the resident' right leg was turned inward, and he/she was yelling out in pain. CMT A attempted to straighten out the resident's leg and again he/she yelled out in pain. -Statement obtained from CMT B: In the morning, CMT B helped to pull up the resident in the wheelchair, using the mechanical lift sling, and the resident did not yell out at that time. During an interview on 2/13/24 at 1:05 P.M., CMT A said: -CMT A assisted CNA A in transferring the resident from the wheelchair to the bed on the afternoon of 1/31/2024. The resident's right leg didn't look normal, so CMT A attempted to straighten it out. The resident screamed out in pain. CMT A and CNA A then transferred the resident to the bed using the mechanical lift. CMT A then asked the charge nurse to come to the resident's room to assess the resident. During an interview on 2/13/24 at 2:01 P.M., CMT B said: -He/She worked on 1/31/24 and observed staff transferring the resident from her wheelchair to the bed, after lunch. -The resident did not cry out or make statements of pain at that time. During an interview on 2/13/24 at 2:01 P.M., the Director of Nursing (DON) said: -It was his/her expectation if a staff member noted a resident's leg was rotated or did not look normal, the staff should not proceed with transferring the resident and notify the charge nurse. -If staff note that a resident's leg was rotated, bent, or did not look normal, the staff member should not attempt to straighten the leg out and should notify the charge nurse. During an interview on 2/13/24 at 2:25 P.M., the Administrator said: -It was his/her expectation that if, when preparing to transfer a resident, it is noted the resident's leg looks abnormal, the staff should not transfer the resident and notify the charge nurse. -It was also his/her expectation that if a staff member notes the resident's leg is bent or did not look right, the staff member should not attempt to straighten the leg or bend it. The staff member should notify the charge nurse. MO231197

Based on interview and record review, the facility failed to assure staff monitored one of three sampled residents (Resident #1) with a change in condition. Staff failed to appropriately monitor the resident's low blood sugar and assess the resident's complaint of difficulty breathing, and contact the resident's physician in a timely manner regarding these changes. The facility census was 193. 1. Review of the Policy/Procedure, Physician Notification Guidelines, dated [DATE], showed: - Directions to staff to immediately notify the physician of blood glucose (sugar) level of less than 70 milligrams/deciliter (mg/dl) in a (resident who is) diabetic. - An acute onset of shortness of breath with other symptoms such as labored breathing, changes in vital signs or oxygen saturation (measure of the amount of oxygen carried in the blood) of less than 88%. Review of the American Diabetes Association current website, undated, showed: - The target blood glucose level before meals for most adults is 80 - 130 mg/dl , although more or less stringent goals may be appropriate for each individual. - [DIAGNOSES REDACTED] (low blood glucose) is usually less that 70 mg/dl. Some people may start to have symptoms of [DIAGNOSES REDACTED] when their blood glucose levels are higher than 70 mg/dl. Review of the Mayo Clinic current health information website entitled Hypoxemia, showed: - Hypoxemia is lower than normal amount of oxygen in the blood. - An approximate blood oxygen level can be estimated using a pulse oximeter (small device that clips on the finger). - Normal oxygen saturation readings range from 95 - 100% under most circumstances. - Values less than 90% are considered low. 2. Review of Resident #1's Medication Administration Record [REDACTED] - Accucheck (fingerstick test of blood glucose) before meals and at bedtime, related to diabetes mellitus diagnosis. - Humalog insulin (fast-acting type of insulin lowers blood glucose) subcutaneously (SQ/injection) 8 units before breakfast, 10 units before lunch and 9 units before dinner to treat diabetes mellitus. - [MEDICATION NAME] (long acting type of insulin/lowers blood glucose) six units SQ at bedtime to treat diabetes mellitus. - [MEDICATION NAME] tablet (oral medication given to lower blood glucose) 1000 milligrams (mg) twice daily for diabetes mellitus. Review of the care plan dated [DATE], showed: - The facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. - The resident planned to go home. - The resident was diabetic, and a goal was to maintain blood glucose levels within parameters without complications. - Staff were to monitor blood glucose before meals and at bedtime. - Staff were to monitor for signs or symptoms of hyper (high) and [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: - Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact. -[DIAGNOSES REDACTED]. Review of a Progress Note, written by Licensed Practical Nurse (LPN) B dated [DATE] at 1:15 P.M., showed: - In the facility for weakness from a perineal abscess s/p (status [REDACTED]. - Legs wrapped related to leg ulcers and [MEDICAL CONDITION]. - Alert, oriented and able to make needs known. - Refused to get out of bed most of the day because of diarrhea related to[DIAGNOSES REDACTED] ([MEDICAL CONDITION] - a bacterial infection in the colon that often follows antibiotic use, common in older adult in long term care facilities). - Complained of nausea and vomiting and stomach discomfort. - Seen by his/her physician that day with orders to treat the diarrhea. During an interview on [DATE] at 10:51 A.M., LPN B said: - He/she was one of the usual day shift charge nurses for the resident. - The resident had many health issues, including nausea from the [MEDICATION NAME] (medication ordered to treat[DIAGNOSES REDACTED]). - Physician A discontinued the [MEDICATION NAME] on [DATE] , because of the resident's nausea and ordered [MEDICATION NAME] (different antibiotic used to treat[DIAGNOSES REDACTED]). - The resident did not eat well the week before [DATE], sometimes refused medications. Review of a Progress Note, written by LPN A dated [DATE] at 1:07 P.M. showed: - Complains of nausea and abdominal pain, [MEDICATION NAME] (medication given to relieve nausea) suppository given with relief noted. Refused breakfast, ate one-half bowl of chicken noodle soup. - Family concerned, asking why he/she was not on intravenous (IV) fluids. Physician A to visit tomorrow. This information added to list of information for the physician. During an interview on [DATE] at 10:45 A.M., LPN A said: - He/she was charge nurse on the hall on the day shift on [DATE]. - The resident had some nausea, and his/her appetite had declined the last week. - He/she held the mealtime insulin that day (at breakfast and lunch) due to the resident not eating. - He/she thought he/she put in Physician A's book to see the resident when he came the next day. Review of the MAR indicated [REDACTED].M. Accucheck was 126. LPN A noted on the back of the MAR, the resident did not eat breakfast and LPN A held the breakfast dose of Humalog. Review of the meal intake record for breakfast on [DATE] showed staff documented the resident ate 25 % of the meal. Review of the MAR indicated [REDACTED].M. Accucheck was 125. On the back of the MAR indicated [REDACTED]. Review of the meal intake for lunch on [DATE] showed staff documented the resident consumed 25% of the meal. Review of the MAR indicated [REDACTED].M. the resident's blood glucose was 66. LPN C circled his/her initials in the space for the 4:30 P.M. dose of Humalog, indicating he/she did not give that dose. He/she wrote low BS (blood sugar) in the square below that. Review of Progress Notes, dated [DATE], showed one entry on the evening shift at 5:13 P.M., written by the Assistant Director of Nursing regarding a dressing change. There was no entry regarding monitoring of the resident's blood glucose. During an interview on [DATE] at 2:45 P.M., LPN C said: - He/she had been the evening shift charge nurse for the resident for several days leading up to [DATE] and was charge nurse that evening. - The resident had not wanted to eat for the last week. - On [DATE], at 4:30 P.M. the resident's Accucheck results were 66. - He/she took the resident apple juice and rechecked the blood glucose 30 minutes later. He/she did not record that action or the second reading, but thought it was better. - He/she thought he/she checked the blood glucose again between 8:00 P.M. and 9:00 P.M. and it was okay, but did not remember what it was. He/she did not record the 8:00 P.M. blood glucose on the MAR. - He/she was sure he/she gave the [MEDICATION NAME] scheduled at bedtime, but did not record that. - The resident complained of some difficulty breathing that evening. He/she checked the resident's oxygen saturation and it was 91%. Because it was above 90%, he/she did not do anything. The resident called his/her family member and asked them to bring his/her [MEDICAL CONDITION] (continuous positive airway pressure/used to overcome obstructions in the airway while sleeping) machine from home. He/she told the family member that they could not use it without a physician's orders [REDACTED].>- He/she told the family member that staff could ask Physician A for an order to use the [MEDICAL CONDITION] on his/her next visit. - He/she did not know if he/she assessed the resident's breathing complaints by listening to lung sounds. - He/she did not feel the resident was in any distress and his/her vital signs were stable, so he/she did not consider contacting the physician about the resident's poor intake all day, that staff held scheduled mealtime insulin all day and that the resident complained of difficulty breathing. Review of the MAR indicated [REDACTED].M. dose of [MEDICATION NAME] on [DATE]. He/she did not document giving the 8:00 P.M. [MEDICATION NAME] (the space for initialing that was blank/no explanation on the back). During an interview on [DATE] at 1:08 P.M., Registered Nurse (RN) A said: - He/she was the night shift charge nurse for the resident from 10:00 P.M. on [DATE] until 6:30 A.M. on [DATE]. - LPN C did not report any change in the resident's condition to him/her. - That night he/she was with the resident quite a bit. - The resident complained of indigestion. He/she offered the resident a PRN (as needed) medication at least twice, but the resident declined each time. - He/she attempted to assess the resident but the resident declined that. He/she asked the resident if he/she was hurting or short of breath and the resident said just had indigestion. - The resident did not look any different that night, he/she did not attempt any further assessment such as rechecking the resident's blood glucose. Review of the Progress Notes showed no documentation of the resident's condition on the night shift on [DATE] to [DATE]. During an interview on [DATE] at 10:51 A.M., LPN B said: - He/she was the resident's day shift charge nurse on [DATE]. - He/she checked the resident's blood glucose at 7:00 A.M. and it was 40. - He/she gave the resident apple juice with sugar (to raise blood glucose). - After a few minutes he/she rechecked there resident's blood glucose and it was 44. - He/she gave the resident glucose tablets and a [MEDICATION NAME] injection (both given to raise blood glucose), but the resident's blood glucose level remained low. - The resident was alert, talking, showed no difficulty breathing, but was beginning to look worse. He/she was not able to hear the resident's blood pressure reading and his/her oxygen saturation was low - Staff called 911 and when the paramedics arrived, they were not able to feel a radial pulse (at the wrist) or hear a blood pressure. They transported the resident to the hospital. Review of Progress Notes, written by LPN B, dated [DATE] at 8:26 A.M. showed: - At 7:00 A.M. the resident's blood glucose was 40. LPN B gave the resident juice with sugar. - At 7:15 A.M. the blood glucose was 44. LPN B gave a glucose tablet. - At 7:30 A.M. the blood glucose was 47. LPN B gave a [MEDICATION NAME] injection. The resident's oxygen saturation was in the 70's and he/she started oxygen at 2 liters per minute. - Staff called 911. Review of hospital Emergency Department (ED) records, dated [DATE], showed: -The resident arrived at the ED at 8:38 A.M. and was minimally responsive, pale, dry and cool to touch. - The complaint on arrival was [DIAGNOSES REDACTED] and [MEDICAL CONDITION] (low blood pressure). - The resident remained in the emergency room until 12:15 P.M. when staff transferred him/her to the ICU. During the time in the ED, staff attempted to gain IV access several times, intubated (tube inserted into the throat to maintain airway and assist breathing) the resident, administered emergency medications and obtained blood tests and a chest x-ray. - The ED physician's clinical impression was [DIAGNOSES REDACTED] (presence of bacteria in the blood). Review of the hospital Discharge Summary showed the resident progressed to multi-system organ failure and expired at 6:57 P.M. During an interview on [DATE] at 12:46 P.M. the Director of Nurses (DON) said: - Staff should have contacted Physician A about the need to hold the resident's mealtime insulins for the entire day due to not eating well and low blood glucose readings. - When the resident complained of difficulty breathing staff should have assessed the resident's respiratory status including listening to lung sounds and continued monitoring of the resident's oxygen saturations and contacted the physician about those findings if they felt there was a change or any abnormal findings with the resident's breathing, lung sounds or oxygen saturation results. - Nurses should document assessments including Accuchecks taken and medications administered or not administered and why not administered. During an interview on [DATE] at 2:00 P.M. , Physician A said: - Staff probably should have contacted him/her when staff held the mealtime insulins all day and the resident's blood sugar reached 66 mg/dl, to obtain directions on whether or not to administer the bedtime [MEDICATION NAME] and [MEDICATION NAME]. - Staff probably should have done an assessment of the resident's respiratory status (including lung sounds and more frequent oxygen saturation measurements) when the resident complained of difficulty breathing. - He/she could not say that not doing those things contributed to the resident's decline and death. MO 2