Every finding on record at Oakland Manor Nursing and Rehabilitation Center LL

This citation relates to Intake #3010953 Based on interview and record review, the facility failed to protect the resident's right to a safe, homelike environment by not properly inventorying and securing their valuables for one Resident (R803) of one resident reviewed. Findings include: Review of an intake received by the State Agency on 4/29/26 revealed: Resident (R803) reported to The Director of Nursing (DON)) that his golden chain with a cross and two rings were missing. (R803) stated that while he was playing (Name of card game) with the Activities Director (Staff E), she took his chain off of his neck, and stated that she had to use the bathroom, and would be right back. When she came back, (R803) stated that he requested for his chain but (Staff E) claimed that she did not have it. (R803) insisted that (Staff E) give him back his jewelry, but she maintained that she did not have it. The (Nursing Home) Administrator (NHA) received a call from The Director of Nursing (DON) reporting the incident. The administrator (NHA) initiated the investigation as it relates to this matter. Review of the report Investigation summary revealed: Resident (R803) admitted to the facility on [DATE] and lives with the following diagnosis: other seizures.cerebral infarction (stroke)., adjustment disorder with anxiety.It was reported to the administrator (NHA) that (R803) was missing some jewelry and money and that the activity supervisor (Staff E) had the items. After inquiring with the activity's supervisor (Staff E), she stated that the previous administrator had kept the items in the safe. Upon returning to work, the administrator (NHA) opened the safe and saw two envelopes with (R803's) jewelry and money. The resident was informed that his items were in the safe and he was satisfied. On 4/29/2026, the resident (R803) asked for his jewelry and it was presented to him. He, however, informed the administrator (NHA) that he needed the chain, not the rings. When asked about the chain, which was not part of the jewelry in the envelope, the resident stated that on the day it was reported, while he was playing (Name of card game) with the activity supervisor (Staff E), she had removed his chain and since then he had not seen it. There was more jewelry than just the rings and that was inconsistent with what the activities supervisor (Staff E) had stated days before. This writer contacted the activity supervisor (Staff E) for an interview regarding the chain. Activity supervisor (Staff E) when queried if she was playing (Name of card game) on 4/24/2026 (date of incident) with (R803), she declined (sic) and stated that she had not worked closely with the resident and that the resident actually did not play (Name of card game) on that day. When asked if she (Staff E) had (R803's) chain, she denied and stated that all she knew was what was held by the previous administrator. The activity supervisor (Staff E) was suspended pending investigation. The administrator (NHA) continued the investigation and retrieved footage from the video recording around the area that the resident (R803) alleged the incident occurred. Upon review, it was evident that (R803) played (Name of card game) with the activity director (Staff E). Also, the employee (Staff E) was seen taking (R803's) necklace and was not seen returning it. Facility concludes that the activity director (Staff E) took (R803's) chain and was the last one in possession of the necklace. Although (Staff E) vehemently denies possession of the necklace, this matter has been referred to the.(Name) County Sheriff's Office. The facility is determining the value of the missing necklace to replace it for (R803). He (R803) was informed and was satisfied about replacement. The report further revealed the incident occurred on 4/24/26 at 1:58 p.m. and the police were notified on 4/29/26, and the incident was not witnessed. On 5/04/26 at 1:43 p.m., the NHA was asked via email if they had an inventory sheet for R803's belongings. No inventory sheet was received from admission or afterwards. On 5/04/26 at 3:40 p.m., R803 agreed to an interview with this Surveyor in his room via use of phone interpreter services provided by the facility Director of Nursing (DON), who was present during the interview. R803 reported during the interview their gold chain with a religious medal was taken off of them by Staff E on 4/24/26. Review of the Electronic Medical Record (EMR) showed R803 scored 15/15 on the Brief Interview for Mental Status (BIMS) assessment, dated 2/11/26, indicating they were cognitively intact. R803's profile showed they were their own responsible party.On 5/05/26 at 10:16 a.m., the NHA was asked a second time via email if they had an inventory sheet for R803's belongings. None was received from admission or afterwards. On 5/05/26 at 3:56 p.m., the NHA provided an inventory sheet for R803's belongings, dated 4/29/26, and confirmed they had no prior inventory sheet from R803's admission.Review of R803's inventory sheet titled, Resident Personal Belongings Inventory, dated 4/29/26, revealed an admission dated of 2/05/26, and the following items, Jewelry: (handwritten) 3 golden rings, 1 silver ring, 100 dollars cash. No other items were noted. Signed 4/29/26. It was noted that the gold necklace and cross pendant were not on the inventory list. On 5/04/26 at 6:05 p.m., Staff E called this Surveyor regarding the investigation. Staff E conveyed they took R803's necklace off when they were in the TV room on 4/24/26 at about 2:30 or 3:00 p.m. and put the necklace in R803's room on their bedside table. Staff E reported they were the staff that handled R803's rings upon admission and put them in the administrator's office. Staff E indicated they were terminated by the NHA, who told them R803's chain was missing. Staff E said she wished she would have documented the necklace (on an inventory sheet) and said she was on overtime and I was ready to go. Staff E confirmed they did not inventory R803's necklace when they took the necklace from them, and said, I wish there would have been a witness. Staff E said she did not know the process (for securing valuables in the facility), despite acknowledging they had handled R803's valuables (jewelry and money) upon their admission and said they had a witness at that time. On 5/05/26 at 8:15 a.m., the NHA said they spoke to Staff E on the phone on 4/24/26, who denied the incident occurred at that time and said R803's jewelry was stored in the facility safe. The NHA said when they returned to work on 4/27/26, they found four rings in the facility safe and $100 and said they were satisfied with that, after reaching out to the prior Administrator as well. The NHA reported facility nursing staff had done a room search when the incident occurred and had not found the necklace or cross pendant after R803 reported their necklace was missing. The NHA confirmed that the incident was not reported to the police or State Agency until 4/29/26, when they received and watched the video footage of the incident on 4/29/26, as R803 reported to them on 4/29/26 they were specifically missing a necklace with a cross on it. The NHA said R803 had not mentioned anything about a missing necklace until Wednesday (4/29/26) and said he wanted his jewelry. Once received, the NHA reported R803 said, My chain is not here, and the cross. The NHA confirmed they terminated Staff E after they watched the video and had concerns about Staff E who was observed taking R803's necklace, and inconsistencies during their interviews with Staff E. The NHA said R803's description of the incident had stayed consistent. On 5/05/26 at approximately 8:20 a.m., the NHA clarified Staff E should have inventoried the necklace, taken the necklace to a higher authority, and not handled the necklace themselves. The NHA shared they had concerns when Staff E denied taking R803's necklace and said they never played cards with him on 4/24/26, when video observations clearly showed they took R803's necklace and played cards with him. Review of the Policy, Resident Belongings and Personal Property, dated 6/4/25, provided by the NHA, revealed, Policy: It is the policy of this facility to protect the resident's right to possess personal belongings, such as clothing and furnishings, for their use while in the facility. Policy Explanation and Compliance Guidelines:Facility staff must support residents in the exercise of the right to have personal items of their choice to the extent practicable.It is the policy of the facility that residents have the right to personal items and be free of interference, coercion and discrimination and reprisal from facility staff in exercise of this right.All resident possessions, regardless of their apparent value to others, will be treated with respect.The facility will support the residents' right to retain and use personal possessions to promote a homelike environment and maintain their independence.All resident personal items will be inventoried at the time of admission by the social services designee, or another designated staff member and documentation shall be retained in the medical record. Additional possessions brought in during the duration of the individual's stay shall be added to the existing personal belongings inventory listing.9. The facility will exercise reasonable care for the protection of the resident's property from loss or theft. 14. Inventories of all items are to be reviewed and examined by Social Services or designee and the resident's representative.14. The facility will take reasonable measures to safeguard the residents' personal property. 2. Difficult to monitor items such as: cash, jewelry, family heirlooms, cellular phones, expensive clothing, collectibles, check books, credit and ATM cards and other personal identification cards (driver's licenses, Michigan issued identification and social security cards,) should not be left in the possession of the resident, but rather, be left at home or placed in the facility's designated safe keeping area.Cash, cellphones, and other valuables will not be replaced by the facility unless it is determined that a staff member's actions directly contributed to the loss.

This citation relates to Intake #3010953 Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from misappropriation for one Resident (R803) of four residents reviewed for abuse. Findings include: Review of an intake received by the State Agency on 4/29/26 revealed: Resident (R803) reported to The Director of Nursing (DON)) that his golden chain with a cross and two rings were missing. (R803) stated that while he was playing (Name of card game) with the Activities Director (Staff E), she took his chain off of his neck, and stated that she had to use the bathroom, and would be right back. When she came back, (R803) stated that he requested for his chain but (Staff E) claimed that she did not have it. (R803) insisted that (Staff E) give him back his jewelry, but she maintained that she did not have it. The (Nursing Home) Administrator (NHA) received a call from The Director of Nursing (DON) reporting the incident. The administrator (NHA) initiated the investigation as it relates to this matter. Review of the report Investigation summary revealed: Resident (R803) admitted to the facility on [DATE] and lives with the following diagnosis: other seizures.cerebral infarction (stroke)., adjustment disorder with anxiety.It was reported to the administrator (NHA) that (R803) was missing some jewelry and money and that the activity supervisor (Staff E) had the items. After inquiring with the activity's supervisor (Staff E), she stated that the previous administrator had kept the items in the safe. Upon returning to work, the administrator (NHA) opened the safe and saw two envelopes with (R803's) jewelry and money. The resident was informed that his items were in the safe and he was satisfied. On 4/29/2026, the resident asked for his jewelry and it was presented to him. He, however, informed the administrator (NHA) that he needed the chain, not the rings. When asked about the chain, which was not part of the jewelry in the envelope, the resident stated that on the day it was reported, while he was playing (Name of card game) with the activity supervisor (Staff E), she had removed his chain and since then he had not seen it. There was more jewelry than just the rings and that was inconsistent with what the activities supervisor (Staff E) had stated days before. This writer contacted the activity supervisor (Staff E) for an interview regarding the chain. Activity supervisor (Staff E) when queried if she was playing (Name of card game) on 4/24/2026 (date of incident) with (R803), she declined (sic) and stated that she had not worked closely with the resident and that the resident actually did not play (Name of card game) on that day. When asked if she (Staff E) had (R803's) chain, she denied and stated that all she knew was what was held by the previous administrator. The activity supervisor (Staff E) was suspended pending investigation. The administrator (NHA) continued the investigation and retrieved footage from the video recording around the area that the resident (R803) alleged the incident occurred. Upon review, it was evident that (R803) played (Name of card game) with the activity director (Staff E). Also, the employee (Staff E) was seen taking (R803's) necklace and was not seen returning it. Facility concludes that the activity director (Staff E) took (R803's) chain and was the last one in possession of the necklace. Although (Staff E') vehemently denies possession of the necklace, this matter has been referred to the.(Name) County Sheriff's Office. The facility is determining the value of the missing necklace to replace it for (R803). He (R803) was informed and was satisfied about replacement. The report further revealed, When (date and time) did the problem occur? 04/24/2026 1:58 PM (date of incident). Are law enforcement agencies involved? Yes. Police agency/precinct contacted: (Name) Sheriff's Office. Date contacted: 04/29/2026. (Date reported to State Agency). Time contacted: 12:15 PM. Were There Any Witnesses? No. Were Other Agencies Notified? No. The report confirmed the incident occurred on 4/24/2026 and was not reported to the State Agency until 4/29/2026, five days later. On 5/04/26 at 12:20 p.m., R803 was observed dressed and well-groomed, seated in a manual upright wheelchair in the dining room at a table eating lunch, feeding himself. Review of R803's Minimum Data Set (MDS) assessment, dated 2/11/26, revealed R803 was admitted to the facility on [DATE], with diagnoses including stroke. R803 required set-up with eating and grooming and moderate assistance with bed mobility and transfers. The assessment showed R803 was cognitively intact and had no behaviors. Review of the Electronic Medical Record (EMR) showed R803 scored 15/15 on the Brief Interview for Mental Status (BIMS) assessment, dated 2/11/26, indicating they were cognitively intact. R803's profile showed they were their own responsible party. Review of R803's typed witness statement, received from the NHA via email on 5/04/26, revealed, I (NHA) talked to (R803) in person, and he said that his jewelry and money was missing and that (Staff E) had it. When asked what happened, (R803) mentioned that he was playing (Name of card game) with (Staff E) in the common area of the dining room lounge when she took it off of him. After taking it off, he (R803) said she (Staff E) told him that she needed to use the bathroom and would be right back. When she (Staff E) came back, he (R803) asked for it (his necklace) but she said she did not have it. Review of Staff E's typed witness statement, received via email from the NHA on 5/04/26, revealed, I (NHA) spoke to employee on phone, and this was what they said: (Staff E): I never touched his chain, and he never played (Name of card game) that day. His jewelry and money was locked in the safe by the previous administrator (NHA) at the request of (R803's) sister. Later on, through the investigation, I asked the employee what happened to (R803's) chain, as it was last seen in her possession on the (video camera) footage. This was her response: (Staff E): I don't know, (NHA name). I don't know what happened to the chain after that. The employee was made aware that the police were involved and she (Staff E) said, It's okay. On 5/04/26 at 12:38 p.m., Certified Nurse Aide (CNA) D was asked about the incident between R803 and Staff E on 4/24/26. CNA D confirmed the incident occurred on 4/24/26, when R803 came to the nurse's station on Friday, 4/24/26, and said, My necklace, my necklace.It's gone. CNA D said R803 spoke very clearly, despite English being their second language. CNA D described R803 always wore the gold chain, and described it had his wife's ring on it, and a cross. R803 reportedly explained to CNA D that Staff E took off his necklace and pointed to his ring on (his hand) and said, I just didn't get back the necklace and cross. CNA D reported they saw R803 did not have their gold necklace on or after the incident. CNA D said that afternoon they saw Staff E enter R803's room prior to R803 saying anything about their necklace, and knocked their urinal over, and rushed out frantically afterwards, which they found unusual. CNA D said they believed the Director of Nursing (DON) witnessed this also. CNA D said they noticed Staff E clings to (R803) and is always with him (prior to being terminated). Surveyor asked CNA D if they had reported this to anyone in management and said they had not. CNA D said R803 had never removed their necklace. CNA D said they understood misappropriation was a form of abuse and reported the incident to the DON, who was at the nurse's station with them on 4/24/26. Review of CNA D's typed witness statement, dated 4/30/26 at 9:51 a.m., revealed, On Friday, April 24, 2026, (R803- initials) approached the nurse's station while the UM (Unit Manager, LPN H), DON, and I (CNA D) were all there. (R803) asked about his necklace. He stated that (Staff E) had taken it off of him to put a ring on it. (The ring that is/was on his left hand). He (R803) said that after she (Staff E) took if off he never got it back. And the ring was never put on the necklace; it was still on his finger. (R803) was very upset and sad about the situation. Making comments like, I thought (Staff E) was my friend, referring to (Staff E). As we all know there is a language barrier between (R803) and most; he can be very hard to understand. However, he was very clear about the statements he made and gave great details on how the situation went. And (R803) was sure that (Staff E) was the one who had taken it. They had sat together for majority of the time that day. (Staff E and R803). Also, I might add that I (CNA D) was the CENA that got (R803) dressed and up in his chair that day and I believe he had his necklace on that morning. On 5/04/26 at 3:40 p.m., R803 agreed to an interview with this Surveyor in his room via use of phone interpreter services provided by the facility Director of Nursing (DON), who was present during the interview. R803 was asked what happened on Friday, April 24th (2026). R803 said he was playing (Name brand) cards with my friend (in English). R803 described, .She (Staff E) took the chain off of me and (the) little (religious) medal and she (Staff E) put in on the table and came back; I didn't saw (see) it anymore. She (Staff E) took the chain and she went to the bathroom. R803 was asked if they knew her name, and R803 responded, (Staff E), and said, .Only me and her were there. R803 also reported Staff E kept coming in their room (prior to the incident). Then R803 became emotional, appeared upset, and began crying. It did not appear they could answer more questions, so they were not interviewed further about the incident. R803 was asked if they felt safe at the facility and said he was Ok. On 5/04/26 at approximately 4:15 p.m., the DON was asked about R803 becoming tearful during the interview. The DON explained that the necklace had sentimental value to him and said it was difficult for him to discuss. The DON confirmed R803 was their own responsible party. The DON said they did not know until this interview Staff E had been coming to their room, as he nor staff had reported this to them. On 5/04/26 at 4:55 p.m., video footage of the incident was reviewed with the Nursing Home Administrator (NHA) and the Human Resources representative, Staff F. It was noted there was no audio of the footage. The NHA reported they had no written timeline of the incident, as the video (times) stood for itself. It was observed on 4/24/26, with a video timestamp beginning at 1:55 p.m., R803 was dressed and seated in their manual upright wheelchair in the dining room lounge, with Staff E seated on an orange couch on their right side, with a table in front of both of them. There was a resident in the lounge with them seated in a tall wheelchair, with his back to them. Staff E leaned over and reached forward for R803's necklace and then walked behind R803 and unfastened it. Staff F sat back down on the orange couch and appeared to place the necklace on the table where they were playing cards and continued playing cards with R803. Staff E appeared to pick the necklace up and left shortly afterwards and walked out of the camera view at 1:59 p.m. Review of a second video at 1:59 p.m. showed Staff E entered R803's room from the hallway and then quickly exited. The room was unable to be visualized. Review of a third video at 2:00 p.m. showed Staff E had returned to where R803 was seated in the lounge area again with R803 and continued playing cards with them. Staff E was observed to be looking over their shoulders during the video, appearing unsettled or distracted shortly after the incident. Surveyor requested Staff E's employee file in its entirety after reviewing the videos. Review of Staff E s employee file, with the NHA and Human Resources representative, Staff F, revealed Staff F cleared a complete background check and had abuse training upon hire, on 2/04/26, and had no written disciplinary action in the file since their date of hire, which the NHA confirmed. The file showed Staff E was certified as an Activity Director. Both confirmed Staff E's last date of working was on 4/27/26, and she was suspended and terminated on 4/29/26. A letter of termination was provided. On 5/04/26 at 6:05 p.m., Staff E called this Surveyor regarding the investigation. Staff E stated at about 2:30 or 3:00 p.m. on 4/24/26 they were sitting with R803 in the TV room and R803 asked her to take the necklace off and put on the ring that was on his finger so she took the necklace off and handed it to him and he took the rings off and handed it to her and then he asked her to put the necklace in his room. Staff E described at that time she set the necklace onto the table (in the lobby) and said afterwards they finished playing the game. Staff E said left to do something and when she returned, she picked up the necklace and put it in on the table in R803's room, on the side of his bed. Staff E said when she came back out, R803 told her he told he had to go to the bathroom and she took him to his room and she asked if he wanted her to put the necklace on him and he said, No. Staff E said then R803 kept talking about his rings and Staff E told R803 they were locked up in the administrators office. Staff E said she was the one who took the rings from him (upon admission) and put them back in the office. Staff E said they wheeled R803 back out to the TV room. On 5/24/26 at approximately 6:10 p.m., Staff E said shortly afterwards one of the nurses came up to the nurse's station and said nobody knew where R803's necklace was. Staff E said the necklace was in his room on the side of his bed and it had been placed there before. Staff E clarified when R803 asked for anything to come off (prior to 4/24/26) they put it on the bedside table and (in) the drawers. Staff E said when you put it on, it only had one ring on it and he put one ring on the necklace and then one ring on his finger. Staff E continued, There were two rings off and he put the wedding band on his finger on the necklace, and he wanted it back in his room and said, Just put it in my room for now. Staff E reported they were terminated by the NHA who told them R803's chain was missing. Staff E then asked, Did they say anything about missing money in the safe? I don't know what is going on. Staff E then said they never had access to the safe with his ring. Staff E said she wished she would have documented the necklace (on an inventory sheet) and said she was on overtime and I was ready to go. Staff E said with the rings (upon admission) I did the progress note and his sister came to the building and insisted on them being taken off. Staff E said at that time she put them in the office and said, I guess there was a witness (prior). I wish there would have been a witness (in this situation). Staff E said she did not know the process (for securing valuables in the facility) and had nothing further. On 5/05/26 at 8:15 a.m., the NHA acknowledged R803 spoke to Licensed Practical Nurse (LPN) G when the incident occurred (on 4/24/26) and confirmed the DON was in the facility. The NHA said they spoke to Staff E on the phone on 4/24/26, who denied the incident occurred at that time and said R803's jewelry was stored in the facility safe. The NHA said when they returned to work on 4/27/26, they found four rings in the facility safe and (cash amount) and said they were satisfied with that, after reaching out to the prior Administrator as well. The NHA reported LPN G and CNA D had done a room search when the incident occurred and had not found the necklace or cross pendant after R803 reported their necklace was missing. The NHA confirmed that the incident was not reported to the police or State Agency until 4/29/26, when they received and watched the video footage of the incident on 4/29/26, as R803 reported to them on 4/29/26 they were specifically missing a necklace with a cross on it. The NHA said R803 had not mentioned anything about a missing necklace until Wednesday (4/29/26) and said he wanted his jewelry. Once received, the NHA reported R803 said, My chain is not here, and the cross. The NHA confirmed they terminated Staff E after they watched the video and had concerns about Staff E who was observed taking R803's necklace, and inconsistencies during their interviews with Staff E. The NHA said R803's description of the incident had stayed consistent and there were no witnesses. On 5/05/26 at approximately 8:20 a.m , the NHA explained they became concerned as Staff E said she never played (Name of card game) on that day (4/24/26) during their phone interview on 4/24/26. The NHA said to Staff E on Monday (4/27/26), when she worked, (R803) said you took his necklace. The NHA said they had to suspend Staff E at that time and requested the footage from corporate and by Wednesday (4/29/26) they reviewed it and confirmed Staff E took R803's necklace from them and it had not been found since. The NHA continued after reviewing the video they called Staff E and said, I talked to you earlier and you said he never played (Name of card game), and Staff E said, I never touched his necklace and the only thing I ever know was about (is) his money. The NHA described they said You (Staff E) played (Name of card game) with him in the lounge on Friday, the 24th, and from what I see in the video, you placed it (the necklace) on the table and before you stood up, you picked it up and you left with the necklace in your hands and according to R803 you told him you had to use the bathroom and he hasn't changed his story. You said you never used the bathroom, and you used his bathroom, and it makes me think you had a motive going to his room and to the bathroom. The NHA said per camera footage after the incident, Staff E was observed looking over their shoulders nervously. The NHA clarified Staff E should have inventoried the necklace and taken the necklace to a higher authority and not handled themselves. The NHA shared they had concerns when Staff E denied taking R803's necklace, saying they never played cards with him, and said they never used the bathroom, which they told R803 they were doing. The NHA said the police came to the facility Wednesday (4/29/26) at noon the same day they confirmed the necklace was taken, and Staff Es reporting of the incident was not what they observed on video. On 5/05/2026 at 9:35 a.m., LPN G said they recalled the incident between R803 and Staff E on 4/24/26 when they were working. LPN G said they saw the necklace earlier that day around R803's neck, midway through the day, and R803 said he couldn't find his gold necklace, around 3:30 p.m . LPN G described R803 wore the necklace regularly around his neck with his wife's wedding rings and reported R803 said to LPN G, The lady who I played (Name of card game) took if off. and said R803 was upset and crying. LPN G explained they and the nursing staff searched R803's room and could not find his necklace and said they reported his concerns to all the necessary parties (management) at that time, including the Unit Manager, LPN H, who was there at the nurse's station when the incident was reported. LPN G said there were no witnesses reported. LPN G said R803 was a reliable reporter as he was always alert and fully oriented and had no psych or behavioral issues nor had any accusations prior. Review of LPN G witness statement, dated 4/29/26 at 3:14 p.m., received from the NHA on 5/05/26, revealed: On 4/24/26, a resident's (R803's) necklace was reported missing. The resident (R803) notified staff that the necklace could not be located. A thorough search was conducted by me, the CNA, and the Unit Manger in the resident's room, including the bed area, closet, dresser, and all personal belongings and clothing. The dining areas were also searched. The necklace was not found during the search. The resident stated that the one he plays (Name of card game) with took it off him. On 5/05/26 at 11:38 a.m., Unit Manager, LPN H, reported they were at the nurse's station on 4/24/26 with the DON, LPN G, and CNA D when the incident occurred. LPN H described R803 came up to them and said, My necklace is missing.She took my necklace off for my ring and I did not get it back. LPN H said they asked R803 who and he said, (Staff E) from activities, and explained, I asked her to take my necklace off to put my ring on (it) and it is missing; I did not get it back. R803 said this happened when they were playing cards with Staff E, and kept saying, I thought she was my friend. LPN H said they texted Staff E at 3:04 p.m. and showed Surveyor a text message from their cell phone and said they asked Staff E what happened. LPN H reported Staff E said they never played cards with R803 and LPN H said to Staff E they saw them playing cards with R803, and Staff E never responded back after. LPN H said they found this concerning since they had directly witnessed Staff E playing cards with R803 that afternoon. LPN H said they and CNA D searched for the necklace including in R803's room, tray table, and dresser and never found the necklace. LPN H said R803's description stayed consistent. LPN H said Staff E was in the facility the following Monday (4/27/26) working and again denied the incident occurred as described by R803. When asked if this was a concern to them, LPN H said it was a form of abuse and said the DON was aware and they understood the NHA was made aware on 4/24/26, per a phone call made to the NHA after the incident.During the interview on 5/05/26 at approximately 11:45 a.m., LPN H said they sent Staff E a text message to see what occurred, right after R803 reported the concerns. Staff E showed Surveyor their phone and a copy of the text message. Review of LPN H's text message to Staff H, dated 4/24/26 at 3:04 p.m., read as follows: LPN H asked (blue font), Hey, (Staff E), this is (LPN H), do you have (R803) necklace? Staff E responded (black font), No, he said it was taken off to put his ring on. He's got rings in the safe but I haven't seen his necklace. He kept saying something about praying. LPN H said (blue font), Okay. He is saying you have it. That you took if off to put his ring on but did not give it back. Staff E responded, No, he already has that ring on in (sic) ever (sic) took his necklace off at all. LPN H said (blue font). He said this morning you took it off while playing (Name of card game). Staff E did not respond to this last message. The text thread ended there. Review of LPN H's witness statement, dated 4/29/26 at 3:07 p.m., revealed, A resident came to the nursing station asking about his necklace and stated that (Staff E) had it. (R803) states she took it off so he could place his ring on it but she never gave it back and that she took it while they were playing (Name of card game). I called (Staff E) and she stated she did not have the necklace and never took it off of him. Perhaps his family, who stopped by to bring him clothes, took it off him. I asked (R803) if his family came to see him today and he stated, 'yes', but they were not here long. They stopped by to bring him clean clothes. Then he goes back to staying, (Staff E), my friend in activities has it. She took it off when we were playing (Name of card game). On 5/05/26 at 12:45 p.m., the DON was asked about R803 reporting their necklace was missing. The DON confirmed they were working on 4/24/26 in the 3:00 (p.m.) hour when the incident was reported to them by R803. The DON said they were at the nurse's station with LPN H, LPN G, and CNA D when R803 came up to them in their wheelchair and told them (Staff E) took his necklace off while they were playing (name of card game) and said, Where's my necklace? The DON further described R803 pointed at their own cross they were wearing, and they said to R803, What happened?. The DON reported R803 described they were playing (Name of card game) with (Staff E) (which they mispronounced) and said (Staff E) took my necklace off, and said in Spanish, Mi amiga, mi amiga (my friend, my friend).She was my friend. The DON said they and staff searched in the facility, and in the area where R803 and Staff E played cards, and in R803's room, and never found the necklace. The DON confirmed they called the NHA who was the abuse coordinator after R803 reported the incident to them and told the NHA R803 reported Staff E had taken off their necklace when they were playing (Name card game). The DON said the incident would be considered misappropriation. When asked about R803's cognition, The DON said R803's BIMS score was 15 (of 15), and they were alert and oriented times four (to person, place, time, and situation). During the interview, the DON was shown a copy of their typed witness statement, received via email from the NHA, and acknowledged this was their statement and signature. Review of the DON's witness statement, provided on 5/05/26 by the NHA, typed and dated 4/24/26 1500 (3:00 p.m.), revealed, .The resident (R803) came to the nursing station and asked where his necklace was. This writer (DON) told the resident that she did not know where his necklace was at the time but recalled that he (R803) does usually wear one with a cross around his neck but that the necklace was not evident at that time. This writer asked the resident when was the last time he recalled having the necklace around his neck. He (R803) stated that earlier, he and Staff E were playing (Name of card game) and that she had taken it from around his neck after pulling on it. He (R803) stated that he had told her not to pull on it and that when he asked her for the necklace again, she said that she did not have it. This writer asked the CENA (CNA D) to go into the resident's room and look for the resident's necklace. She (CNA D) could not find it. Writer went to check the dining room where the activities usually occur and could not find the necklace. At this time the writer called the NHA to report what the resident had reported to her and that is sounded like a possible allegation of misappropriation. The resident (R803) stayed near the nursing station and continued to ask that staff help him find the necklace. He (R803) stated that he was surprised that Staff E had his necklace and had not returned it as he believed her to be a friend of his. Having not found the necklace, this writer and the other nursing staff (LPN G, CNA D, LPN H) stated to the resident that we would continue to look for his necklace and report it to the Administrator (NHA). The Administrator (NHA) phoned this writer and asked that the phone be taken to the bedside of the resident for an interview. Review of Staff E's Time Card, received via email from the NHA on 5/04/26, revealed from 4/23/26 through 5/07/26, Staff E worked on Thursday, 4/23/26 from 7:15 a.m., to 3:45 p.m., on Friday, 4/24/26, from 6:23 a.m., to 3:00 p.m, and on Monday, 4/27/26, from 5:30 a.m. to 3:18 p.m., confirming Staff E worked after the allegation of misappropriation was made by R803 to four nursing staff and the NHA on 4/24/26. Review of a letter, on facility letterhead, received via email from the NHA on 5/04/26, dated 4/29/26, revealed, Dear (Staff E). Per our conversation, we have reached a conclusion on your suspension pending investigation due to the allegation made against you for the missing jewelry from one of our residents at (the facility). Your employment at (the facility) is terminated, effective immediately. Signed by Staff F . Review of the policy, Abuse, Neglect, and Exploitation, dated 1/14/26, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions:. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body 3. Physical injury of a resident, of unknown source 4. Resident reports of theft of property, or missing property.V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation. F. Providing emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal; 3. Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. This facility will post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint. 4. Reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions

This citation relates to Intake 3010953. Based on interview and record review, the facility failed to report an allegation of misappropriation timely for one Resident (R803) of four residents reviewed for abuse. Findings include:Review of an intake received by the State Agency on 4/29/26 revealed: Resident (R803) reported to The Director of Nursing (DON)) that his golden chain with a cross and two rings were missing. (R803) stated that while he was playing (Name of card game) with the Activities Director (Staff E), she took his chain off of his neck, and stated that she had to use the bathroom, and would be right back. When she came back, (R803) stated that he requested for his chain but (Staff E) claimed that she did not have it. (R803) insisted that (Staff E) give him back his jewelry, but she maintained that she did not have it. The (Nursing Home) Administrator (NHA) received a call from The Director of Nursing (DON) reporting the incident. The administrator (NHA) initiated the investigation as it relates to this matter.Review of the report Investigation summary revealed: Resident (R803) admitted to the facility on [DATE] and lives with the following diagnosis: other seizures.cerebral infarction (stroke)., adjustment disorder with anxiety.It was reported to the administrator that (R803) was missing some jewelry and money and that the activity supervisor (Staff E) had the items. After inquiring with the activities supervisor (Staff E), she stated that the previous administrator had kept the items in the safe. Upon returning to work, the administrator opened the safe and saw two envelopes with Mr. Hernandez's jewelry and money. The resident was informed that his items were in the safe and he was satisfied. On 4/29/2026, the resident asked for his jewelry and it was presented to him. He, however, informed the administrator that he needed the chain not the rings. When asked about the chain, which was not part of the jewelry in the envelope, the resident stated that on the day it was reported while he was playing (Name of card game) with the activity supervisor (Staff E), she had removed his chain and since then he had not seen it. There was more jewelry than just the rings and that was inconsistent with what the activities supervisor (Staff E) had stated days before. This writer contacted the activity supervisor (Staff E) for an interview regarding the chain. Activity supervisor (Staff E) when queried if she was playing (Name of card game) on 4/24/2026 (date of incident) with (R803), she declined (sic) and stated that she had not worked closely with the resident and that the resident actually did not play (Name of card game) on that day. When asked if she had (R803's) chain, she denied and stated that all she knew was what was held by the previous administrator. The activity supervisor (Staff E) was suspended pending investigation. The administrator continued the investigation and retrieved footage from the video recording around the area that the resident (R803) alleged the incident occurred. Upon review, it was evident that (R803) played (Name of card game) with the activity director (Staff E). Also, the employee (Staff E) was seen taking (R803's) necklace and was not seen returning it. Facility concludes that the activity director (Staff E) took (R803's) chain and was the last one in possession of the necklace. Although (Staff E') vehemently denies possession of the necklace, this matter has been referred to the.(Name) County Sheriff's Office. The facility is determining the value of the missing necklace to replace it for (R803). He (R803) was informed and was satisfied about replacement. The report further revealed, When (date and time) did the problem occur? 04/24/2026 1:58 PM. (date of incident). Are law enforcement agencies involved? Yes. Police agency/precinct contacted: (Name) Sheriff's Office. Date contacted: 04/29/2026. (Date reported to State Agency). Time contacted: 12:15 PM. Were There Any Witnesses? No. Were Other Agencies Notified? No. The report confirmed the incident occurred on 4/24/2026 and was not reported to the State Agency until 4/29/2026, five days later. On 5/04/26 at 12:38 p.m., Certified Nurse Aide (CNA) D was asked about the incident between R803 and Staff E on 4/24/26. CNA D confirmed the incident occurred on 4/24/26, when R803 came to the nurse's station on Friday, 4/24/26, and said, My necklace, my necklace.It's gone. CNA D said R803 spoke very clearly, despite English being their second language. CNA D described R803 always wore the gold chain, and it had his wife's ring on it, with a cross as well, and said always wore them. R803 reportedly explained to CNA D that Staff E took off his necklace and pointed to his ring on (his hand) and said, I just didn't get back the necklace and cross. CNA D reported they saw R803 did not have their gold necklace on. CNA D said they understood misappropriation was a form of abuse and reported the incident to the Director of Nursing (DON), who was at the nurse's station when R803 reported their necklace was taken on 4/24/26. CNA D said they found R803 understandable. Review of the Electronic Medical Record (EMR) showed R803 scored 15/15 on the Brief Interview for Mental Status (BIMS) assessment, dated 2/11/26, which showed they were cognitively intact. On 5/04/26 at 3:40 p.m., R803 agreed to an interview with this Surveyor via use of phone interpreter services provided by the facility Director of Nursing (DON), who was present during the interview. R803 was asked what happened on Friday, April 24th (2026). R803 said he was playing (Name) cards with my friend (in English). R803 described, .She (Staff E) took the chain off of me and (the) little Christ (religious) medal and she (Staff E) put in on the table and came back; I didn't saw (see) it anymore. She (Staff E) took the chain and she went to the bathroom. R803 was asked if they knew her name, and R803 responded, (Staff E), and said, .Only me and her were there. R803 also reported Staff E kept coming in their room. Then R803 became emotional, appeared upset, and began crying. It did not appear they could answer more questions, so they were not interviewed further about the incident. R803 was asked if they felt safe at the facility and said he was Ok, in English. On 5/04/26 at 4:55 p.m., video footage of the incident was reviewed with the Nursing Home Administrator (NHA) and the Human Resources representative, Staff F. It was noted there was no audio of the footage. It was observed on 4/24/26, with a video timestamp, beginning at 1:55 p.m., R803 was dressed and seated in their manual upright wheelchair in the dining room lounge, with Staff E seated on an orange couch on their right side, with a table in front of both them. Staff E leaned over and reached for R803's necklace and then walked behind R803 and unfastened it. Staff F sat back down on the orange couch and appeared to place the necklace on the table where they were playing cards and continued playing cards with R803. Then Staff E picked the necklace up and left shortly afterwards and walked out of the camera view in the area. On 5/04/26 at 8:15 a.m., the NHA acknowledged R803 spoke to Licensed Practical Nurse (LPN) G when the incident occurred (on 4/24/26) and confirmed the DON was in the facility. The NHA said they spoke to Staff E on the phone and they denied the incident occurred at that time and said R803's jewelry was stored in the facility safe. The NHA said when they returned to work on 4/27/26 they found four rings in the facility safe and (cash amount) and said they were satisfied with that. The NHA reported LPN G and CNA D had done a room search when the incident occurred and had not found the necklace or cross pendant after R803 reported their necklace was missing. The NHA confirmed that the incident was not reported to the police or State Agency until 4/29/26, when they watched the video footage of the incident on 4/29/26, and R803 reported to them that on 4/29/26 they were missing a necklace with a cross on it. The NHA confirmed they terminated Staff E after they watched the video and had concerns about Staff E taking R803's necklace, from their observations from the video, and some inconsistencies during their interviews about the incident with Staff E. The NHA explained they immediately reported the incident to the police and State Agency on 4/29/26 when they confirmed the incident had occurred from video footage received on 4/29/26 and said there were no witnesses to the incident. The NHA said R803's description of the incident on 4/24/26 had stayed consistent from their reporting. On 5/05/2026 at 9:35 a.m., LPN G said they recalled the incident between R803 and Staff E on 4/24/26 when they were working. LPN G said they saw the necklace earlier that day around R803's neck, midway through the day, and R803 said he couldn't find his gold necklace, around 3:30 p.m . LPN G described R803 wore the necklace regularly around his neck with his wife's wedding rings and reported R803 said to LPN G, The lady who I played (Name of card game) took if off. and said R803 was upset and crying. LPN G explained they and the nursing staff searched R803's room and could not find his necklace and said they reported his concerns to all the necessary parties (management) at that time, including the Unit Manager, LPN H, who was there at the nurse's station when the incident occurred. LPN G said there were no witnesses reported. LPN G said R803 was a reliable reporter as he was always alert and fully oriented and had no psych or behavioral issues nor had any accusations prior. On 5/05/26 at 11:38 a.m., Unit Manager, LPN H, reported they were at the nurse's station on 4/24/26 with the DON, LPN G, and CNA D when the incident occurred. LPN H described R803 came up to them and said, My necklace is missing.She took my necklace off for my ring and I did not get it back. LPN H said they asked R803 who and he said, (Staff E) from activities, and explained, I asked her to take my necklace off to put my ring on (it) and it is missing; I did not get it back. R803 said this happened when they were playing cards with Staff E, and kept saying, I thought she was my friend. LPN H said they texted Staff E at 3:04 p.m. and showed Surveyor a text message from their cell phone and said they asked Staff E what happened. LPN H reported Staff E said they never played cards with R803 and LPN H said to Staff E they saw them playing cards with R803, and Staff E never responded back after. LPN H said they found this concerning since they had directly witnessed Staff E playing cards with R803 that afternoon. LPN H said they and CNA D searched for the necklace including in R803's room, tray table, and dresser and never found the necklace. LPN H said R803's description stayed consistent. LPN H said Staff E was in the facility the following Monday (4/27/26) working and again denied the incident occurred as described by R803. When asked if this was a concern to them, LPN H said it was a form of abuse and said the DON was aware and they understood the NHA was made aware on 4/24/26, per a phone call made to the NHA after the incident. On 5/05/26 at 12:45 p.m., the DON was asked about R803 reporting their necklace was missing. The DON confirmed they were working on 4/24/26 when the incident occurred. The DON said they were at the nurse's station with LPN H, LPN G, and CNA D when R803 came up to them in their wheelchair and told them (Staff E) took his necklace off while they were playing (name of card game) and said, Where's my necklace? The DON further described R803 pointed at their own cross they were wearing, and they said to R803, What happened?. The DON reported R803 described they were playing (Name of card game) with (Staff E, which they mispronounced) and said (Staff E) took my necklace off, and said in Spanish, Mi amiga, mi amiga (my friend, my friend).She was my friend. The DON said they and staff searched in the facility, and in the area where R803 and Staff E played cards, and in R803's room, and never found the necklace. The DON said R803 reported the incident to them on 4/24/26 in the 3:00 (p.m.) hour. The DON confirmed they called the NHA after R803 reported the incident to them and told the NHA R803 reported Staff E had taken off their necklace when they were playing (Name card game) and said the incident would be considered misappropriation. When asked about R803's cognition, The DON said R803's BIMS score was 15 (of 15), and they were alert and oriented times four (to person, place, time, and situation). The DON said they reported the incident to the NHA on 4/24/26, after R803 alleged Staff E had taken their necklace off of them and it was missing. Review of LPN G witness statement, dated 4/29/26 at 3:14 p.m., received from the NHA on 5/05/26, revealed R803 reported to them on 4/24/26 their necklace was missing, and said the resident (R803) notified staff the necklace could not be located. Their statement described a thorough search was conducted by them, LPN H, and CNA D, and R803's necklace was not found. The statement further revealed R803 stated, The one he plays (Name of card game) with took it off him. Review of the policy, Compliance with Reporting Allegations of Abuse, Neglect, Exploitation, implemented 11/01/2022, revealed, It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property are reported immediately ot the Administrator (NHA) of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes.

This citation relates to Intake 2731788. Based on interview and record review, the facility failed to ensure appropriate documentation for skin and wound treatment for one Resident (R802) of two residents reviewed for skin and wounds. Findings include: A complaint received by the State Agency on 2/02/26 revealed: Complainant states the resident (R802) has developed deep bedsores on her buttocks that staff have to pack. The complainant states he hasn't seen the sores, but his wife said they were deep. The complainant states on an unknown date, an unknown female nurse applied menthol to the resident's buttocks which made her cry in pain. Complainant states the resident is left in a urine-soaked brief for up to 8 hours before being changed. Review of R802's census revealed they were admitted to the facility on [DATE] and were discharged [DATE].Review of R802's profile revealed they were their own responsible party. Review of R802's Minimum Data Set (MDS) assessment revealed they were admitted with diagnoses including lung disease, pneumonia, heart failure, and morbid obesity. The assessment revealed they were dependent for toileting, bed mobility, and transfers. The Brief Interview of Mental Status (BIMS) assessment showed they were cognitively intact. Review of the skin assessment showed R802 was admitted with no pressure ulcers and Moisture Associated Skin Damage (MASD - a condition where prolonged exposure to moisture leads to inflammation and erosion of the skin, often red or raw in appearance). Review of R802's Electronic Medical Record (EMR) showed they were sent to the emergency room on 2/13/26 for a urinary tract infection. The EMR including census confirmed R802 was not admitted to the hospital at that time or during their stay. Review of R802's physical orders revealed two orders for wound care after discharge as follows: Clean sacrum with NS (normal saline). Pat dry, apply zinc oxide ointment (a topical skin protectant), apply ABD (dressing), Every Monday, Wednesday, Friday. Date started 2/02/26 at 7:00 a.m. and discontinued 2/17/26. Left gluteal (buttocks area); cleanse with ns (normal saline) or wound cleanser; dry and apply triad (wound paste used for a variety of wound types) bid (twice daily) and prn (as needed). Dated 2/01/26 to 2/18/26. It was noted neither order included a wound description, or reason for the treatment. Review of R802's Treatment Administration Record (TAR), dated February 2026, revealed sacral wound treatments were missed (blank entries) on 2/04, 2/06, and 2/16. Review of R802's TAR, dated February 2026, revealed R802's buttocks wound treatments were missed (blank entries) on 2/01 (p.m.), 2/04 (a.m. and p.m.), 2/06 (a.m.), 2/08 (a.m.), 2/14 (a.m.), 2/15 (p.m.), and 2/18 (a.m.). Review of the EMR including R802's progress notes showed no documented reasons for the omissions, and no descriptions of the wounds or clear reasons for treatments. Review of R802's physician Discharge summary, dated [DATE] at 22:19 (10:19 p.m.), revealed no notation or mention of any skin concerns, wound descriptions, reasons for skin treatments, or any documentation of skin related issues. Review of R802's physician medicine and rehabilitation progress notes, dated 2/17/26, and 2/12/26, showed no skin concerns, or documentation of reasons for skin or wound treatments.Review of R802's advanced (nursing) skilled evaluations, dated 2/16/26, 2/15/26, 2/13/26, 2/12/26, 2/11/26, and 2/08/26, all revealed, .Skin: No skin issues identified. This was despite wound care treatments being in place on these dates. Review of R802's advanced skill evaluation, dated 2/09/26 at 14:50 (2:50 p.m.), revealed, .Skin note: Barrier cream applied to buttocks. This was a notation that showed no diagnoses and had no notation regarding the sacral treatment or wound. Review of R802's advanced skill evaluation, dated 2/07/26, revealed, .No skin issues identified. Skin note: Barrier cream applied. There was no notation regarding the sacral treatment. Review of R802's nurse noted, dated 2/09/26 at 13:38 (2:38 p.m.), revealed, .She has an open area to left gluteal which is receiving treatment. This was the first notation found regarding a skin concern, and showed an open area, which was not clearly described. Review of R802's transfer form to the hospital, dated 2/13/26, revealed, Pain Location: Site: Groin: Red and Moist. Left buttock: Open area. Right buttock: Open area.Skin/Wound Care: Pressure Ulcers/ Injuries (stage, location, appearance, treatments): Open areas of concern. Other wounds / bruises: (blank). Review of R802's hospital hand off form to facility, dated 1/21/26, revealed, Friction and shear (R buttock) and non-stageable (left buttock). Triad (wound paste) over wound base and foam. This appeared to show R802 was admitted with open areas, which may have been pressure ulcers or open wounds. There was no other description found. Review of R802's assessments with the Director of Nursing (DON) confirmed there were no wound assessments, descriptions, or skin assessments found. Review of R802's February TAR was reviewed with the DON, and the missing wound treatments, with blank entries. On 5/05/26 at approximately 1:15 p.m, the DON reported they understood the concern, and their expectation would be the skin and wound assessments as well as wound description would be found in the EMR, per standards of wound care practice. The DON had no explanation for the missing wound treatments, after they reviewed R802's progress notes with Surveyor. The DON concurred there was no explanation for the missing TAR entries, with no explanation found in R802's progress notes and understood the concern. Review of R802's Care Plan with the DON showed R802 had an abrasion. There was no mention of MASD, open areas, pressure ulcers, or other skin concerns. On 5/05/26 at 3:06 p.m., the DON returned and reported the facility had switched EMR's and they found one wound description document for R802's left gluteal wound, which showed an abrasion. The DON said the documents may have been missing between EMR's but provided no additional documents which described R802's sacral wound by exit. So, it remained unclear why R802 had a sacral wound treatment, and if it was an open area. The ICD 9 code on the document showed an abrasion to their left lower leg per the DON. The DON reported it remained unclear why the Triad wound treatment cream was being used, although they reported it was a wound treatment or a barrier cream. The DON clarified their documentation expectations for wounds would be weekly measurements, wound descriptions, skin assessments, and wound staging (for severity) if there was a pressure injury. The DON said they understood the concern related to incomplete skin and wound documentation. The DON concurred there was no way to tell if R802's wound treatments were provided on the dates of wound treatment log omissions for February 2026 and said they understood the concern. Review of a wound care provider document provided by the DON, dated 1/30/26, was an untitled document by a wound care provider. The documents revealed R802 was referred by R802's primary care provider. The assessment revealed R802 had a skin concern on their left glut (buttocks) with no drainage, 7 days old. The wound showed an abrasion on R802's left lower leg (not MASD). Showed not resolved, ICD: S80.812D. Reported on 1/23/26, with an area of .8 (centimeters). [NAME]. Size 0.9 x 0.8 x 0.1. Area square centimeters: 0.72 (centimeters) with healing tissues and no infection. This was called wound 1. This showed the wound was likely acquired after R802's admission on [DATE], as the wound was documented initially on 1/23/26. Review of a second wound care provider note, dated 2/13/26, revealed R802's wound 1 was resolved 2/13/26 on their left glute and area was 0 with healed tissue. The treatment Triad remained in place per provider orders, and the document showed abrasion handwritten on the bottom. On 5/05/26 at 4:20 p.m., the complainant reported in a phone interview that R802 had an open sized wound on her bottom, and alleged they weren't treating it the way was supposed to be done when sometimes they (nursing staff) did the treatments and sometimes they did not, as people were calling off work. R802 said they had a picture of one of the wounds and said the nurse's were discussing packing the wound. The complainant reported they had filed at least one grievance during R802's stay. Review of a photo received from the complainant showed two smaller adjacent open areas on the back of the left thigh, flat in appearance, with pink granulation tissue primarily seen in the wound bed. No photo was received of a sacral wound. Concerns were shared with the Nursing Home Administrator (NHA), who asked surveyor to speak with the former NHA/DON prior to exit related to no nursing wound care assessments, descriptions, skin assessments, and limited documentation found in the EMR, and the missing February (2026) TAR entries. The NHA reported they had no additional documentation to provide. The NHA denied having any concern forms for R802. On 5/05/26 at approximately 5:55 p.m., the former NHA/DON reported R802 had MASD, and not an abrasion, despite the Care Plan and the wound care description note of an abrasion, which was shared. The former DON reported Zinc Oxide did not always have menthol, and acknowledged they were aware it had irritated R802, and said they had discontinued the treatment and changed it out for Triad paste. Surveyor shared the Zinc Oxide order remained on the TAR for one of the two wounds, near R802's discharge, on 2/17/26. The former DON had no explanation. The former DON denied R802 had any pressure ulcers and said their wound may have been from friction and shear and the rest of the treatments were prophylactic. The former DON said there may have been concerns when they switched EMR's related to the missing wound care documents. The DON said R802's gluteal wound was MASD and their sacral treatment was prophylactic only (preventative, with no wound). The omissions on the R802's February TAR were reviewed with the former DON and they had no explanation. The former DON reported they understood the concerns with the missing skin assessments and said they would have benefitted from a wound care coordinator at that time. The former NHA/ DON denied having any concern forms for R802. The NHA /facility was given an opportunity to provide any additional documents prior to exit and none were provided. Surveyor conveyed concerns remained related to missing nursing and physician wound documentation, no skin assessments, no clear wound descriptions (other than wound care provider notes not in EMR), and the missing February (2026) TAR entries. No additional comment was provided or documents by exit. Review of the policy, Wound Treatment Management, dated 1/1/2022, revealed, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.Policy Explanation and Compliance Guidelines:1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.3. Dressing changes may be provided outside the frequency parameters in certain situations:a. Feces has seeped underneath the dressing.b. The dressing has dislodged.c. The dressing is soiled otherwise or is wet.4. Dressings will be applied in accordance with manufacturer recommendations.5. Treatment decisions will be based on:a. Etiology of the wound:i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial,venous, diabetic, moisture or incontinence related skin damage.ii. Surgical.iii. Incidental (i.e. skin tear, medical adhesive related skin injury).iv. Atypical (i.e. dermatological or cancerous lesion, pyoderma, calciphylaxis).b. Characteristics of the wound:i. Pressure injury stage (or level of tissue destruction if not a pressure injury).ii. Size - including shape, depth, and presence of tunneling and/or undermining.iii. Volume and characteristics of exudate.iv. Presence of pain.v. Presence of infection or need to address bacterial bioburden.vi. Condition of the tissue in the wound bed.vii. Condition of peri-wound skin.c. Location of the wound.d. Goals and preferences of the resident/representative.6. Guidelines for dressing selection may be utilized in obtaining physician orders (see attached).a. The guidelines are to be used to assist in treatment decision making.b. Due to unique needs and situations of individuals, the guidelines may not be appropriate foruse in all circumstances.c. The facility will follow specific physician orders for providing wound care.7. Treatments will be documented on the Treatment Administration Record.8. The effectiveness of treatments will be monitored through ongoing assessment of the wound.Considerations for needed modifications include:a. Lack of progression towards healing.b. Changes in the characteristics of the wound (see above).c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance withhis/her rights. Reference: European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance.

Based on observations, interviews, record review the facility failed to ensure medication and treatment supplies were secured to prevent unauthorized access, as evidence by an unlocked treatment cart accessible in-patient care area. Findings include:On 1/26/26 at 8:44 AM, the facility medication treatment cart was observed unlocked and unsecured across from the nurse's station. On 1/26/26 at 9:18 AM, the medication treatment cart was observed unlocked. Nurse E was interviewed and asked should the treatment cart be locked, Nurse E reported yes and proceeded to lock the cart. On 1/26/26 at 1:32 PM, the facility's medication treatment cart was observed unlocked and unsecured across from the nurse's station. On 1/27/26 at 8:21 AM, the facility's medication treatment cart was observed unlocked and unsecured across from the nurse's station. On 1/27/26 at 12:03 PM, the director of nursing (DON), was interviewed and asked should treatment carts be locked when unattended the DON reported the carts should be locked. There was no additional information provided at the exit of survey.

Based on observation, interview, and record review, the facility failed to maintain an ongoing resident-centered activities program to provide meaningful activities per resident preferences to support their physical, emotional, cognitive, and psychosocial well-being for five residents (R6, R9, R10, R15 and R30) of five residents reviewed for activities. Findings include:Review of the resident census upon survey entry was 21 residents, confirmed by the Nursing Home Administrator (NHA) / Director of Nursing (DON), who assumed both roles upon hire, on/ near 1/09/26. On 1/26/26 at approximately 10:05 a.m., the NHA/DON described upon entry that the facility was a sub-acute short-stay rehabilitation unit (facility). It was clarified there were only two long-term care residents at the facility, R2 and R3, who would mainly require activities. When asked about resident council, the NHA/DON explained they had no resident council president, as there were no resident council meetings in the facility. This Surveyor asked to speak with the Activity Director for clarification on the resident council process. The NHA/DON reported they had no Activity Director or any activity staff. The NHA/DON clarified the Certified Nursing Aides (CNAs) were completing activities with the residents. Review of the provider description revealed the facility was a 29 bed SNF/NF facility, which meant all the beds (including the resident census of 21 residents) were subject to the regulatory guidance requirements for the provision of an Activity Director, who would be expected to oversee an active ongoing activities program. R6 On 1/26/26 at approximately 11:55 a.m., the unit was observed for an activity calendar, with none observed. The nursing staff confirmed there was no activity calendar, and there had not been for at least a few months. On 1/26/26 at 11:58 a.m., R6 was observed in their room, seated upright in their wheelchair, with a pack of crayons on their bedside table. R6's room had no activities present, such as puzzle books, coloring pages, crafts, magazines or evidence of any activities. There was no activity calendar observed in R6's room. On 1/26/26 at 12:00 p.m., R6 said their daughter brought them the crayons. R6 said they would like some activities such as word searches, puzzle books, and coloring pages, and wished they had activities to attend such as BINGO, parties, etc. R6 stated their only activity was therapy and staff were not doing any activities with them. R6 believed there should be activities available, and said their daughter was going to bring them coloring pages. R6 reported this concerned them. R6 shared they would be at the facility longer than expected, until they saw a neurologist regarding their difficulty standing and walking, so having activities was important to them. Review of the Electronic Medical Record (EMR) revealed R6 was admitted to the facility on [DATE]. On 1/26/26 at 4:36 p.m., CNA I was asked if they had been asked by facility management to provide activities to residents by facility management. CNA I reported they were a newer hire this month and said they had not been educated in their orientation or after to provide activities to facility residents. Surveyor asked if there was any charting for their residents to complete activities. CNA I confirmed there was no charting for complete activities with the residents. CNA I shared they had not seen activities being provided to facility residents when asked however said they had played cards with one resident who had asked them. R15 Review of R15's Minimum Data Set (MDS) assessment, dated 1/15/26, showed they were admitted to the facility on [DATE]. The assessment showed R15 had cognitive impairment. Review of R15's profile revealed they had diagnoses including metabolic encephalopathy (brain dysfunction from metabolic causes), dementia, heart disease, kidney disease, a fall with a fractured clavicle, and a history of hip replacements. Review of R15's Care Plan, accessed 1/27/26 at 5:29 p.m., revealed no activity problems, goals or interventions. The care plan revealed R15 required significant assistance for toileting, bed mobility, transfers, and further revealed R15 became agitated with care and had care refusals at times. On 1/26/26 at 1:28 p.m., R15 was observed in the hallway across from the nurse's station, seated in their high back wheelchair, staring ahead. R15 was asked how they were doing and said they wanted to talk to their wife. Nursing staff were made aware. There were no activities on the unit or nearby. On 1/26/26 at approximately 4:45 p.m., R15 was observed seated across from the nurse's station on the unit in their recline high back wheelchair, with an empty tray table and water on their side. R15 was asked how they were doing. R15 said they wished they could go fishing and wanted to be with their family. R15 was asked if they would participate in activities if available, smiled, and said they liked to fish. R15 said, I like to keep busy, and said they wished they had something to do. There were no activities on the unit or nearby. On 1/27/26 at 9:27 a.m., R15 was observed seated upright in their high back wheelchair again in the hallway across from the nurse's station, with a tray table other with only a Styrofoam cup next to the them. There were no activities on the unit or nearby. There was no activity calendar on the unit which nursing staff confirmed. On 1/27/26 at 9:28 a.m., R15 was asked how they were doing. R15 said they were doing fine, but said they liked to move around. When asked what they would like to do, R15 said they liked music activities and magazines for fishing and travel since they liked to travel. R15 was asked about their vision (to see magazines) and said it was very good. R15 also said they liked to go to church and play games and cards also. R15 clarified their hobbies in life had been tennis, bowling, fishing, and said they enjoyed going out. R15 said, It is boring (here). On 1/27/26 at approximately 9:30 a.m., CNA J was observed to approach R15, and asked if they were ok, R15 said they were fine, and CNA J left. No activities were provided. On 1/27/26 at 10:09 a.m., R15 was observed seated in their wheelchair outside their room, across from the nurse's station, with no activities or staff completing activities with them. LPN D was at the nurse's station during the observation. On 1/27/26 at approximately 10:11 a.m., Licensed Practical Nurse (LPN) D was asked about activities being done with residents at the facility. LPN D said since most residents were there on a short-term stay, they did not think it was a priority. LPN D said R2 and R3 were the only long-term care residents at the facility. LPN D was asked if they had any concerns with residents not receiving activities. LPN D said they sometimes gave residents coloring sheets, newspapers, or magazines however said there were no activity staff providing them. LPN D was asked if any of the CNAs were completing activities with the facility residents. LPN D responded, No. LPN D was asked if residents should have been receiving activities. LPN D stated, Yes, in the afternoon, things slow down after lunch and after lunch would be a good time to have activities. Yes, that would be beneficial to give them something to do. And it might prevent falls and prevent them from being restless. Arts and crafts, BINGO.Mostly residents are just watching TV (television). Review of the EMR showed R15's EMR showed R15 had three falls since their admission, on 1/10/26, 1/23/26, and 1/25/26. On 1/27/26 at 10:42 a.m., R15 was observed seated in their wheelchair across from the nurse's station, appearing drowsy, with the tray table with water on their right side, with no magazines or activities observed. There were no activities observed on the unit or nearby. On 1/27/26 at 11:09 a.m., R15's Family Member, FM S, was asked during a phone interview if they believed R15 could participate in an activities program if there was one at the facility. FM S responded, Yes. As long as they could work with his dementia. FM S clarified R15 was being discharged home soon and said they would provide R15 with activities at home. On 1/27/26 at 11:55 a.m., and 12:00 p.m., R15 was observed seated outside their room across from the nurse's station in their wheelchair, awake, with their tray table with water only, not participating in activities. There were no activities observed on the unit or nearby. On 1/27/26 at approximately 12:02 p.m., R15 was asked how they were doing. R15 said they had nothing to do. On 1/27/26 at 2:57 p.m., R15 was observed in their bed, awake, with no activities in their room including puzzle books, color pages, or magazines. Their room was empty and bare, and there was no activity calendar in their room. On 1/27/26 at 4:51 p.m., R15 was observed in their wheelchair seated outside their room at the nurse's station, with no activities on their empty tray table. There were no activities on the unit or nearby. On 1/28/26 at 1:24 p.m. R15 was observed in their wheelchair outside their room, across from the nurse's station. Their empty tray table was in front of them. There were no activities on the unit. There were four nursing staff at nurse's station. Review of the EMR showed a nursing progress note, dated 1/26/26 at 4:19 p.m., which revealed, (R15) has become agitated since wife left facility. (Physician T) recommended Seroquel 25 mg (an anti-psychotic medication) for agitation or anxiety. R9 On 1/26/26 at 11:49 a.m., R9 said when they were in their wheelchair, There is nothing to do . and stated this bothered them. R9 was asked if they would participate in activities if available; R9 said they would. When asked what they would like to do, R9 said they wanted more to do, and did not explain further when asked. On 1/27/26 at 10:25 a.m., LPN H was asked about R9 and their ability to participate in activities. LPN H said R9 had a disability and had just a little cognitive impairment. LPN H said they made sure R9's TV was on for them. LPN H said when R9 was sitting in the wheelchair in the hallway, they would want to get back in bed to watch TV. On 1/27/26 at 10:30 a.m., LPN H was asked if there were any activities being provided by facility staff, including CNAs. LPN H said the aides were not providing activities to the residents. LPN H stated, .I believe that they (the facility) should be having like a devotional or news printed out and even crossword puzzles.They (residents) do not do any coloring pages. LPN H said nursing staff tried to keep the residents entertained by talking with them. LPN H clarified, They (the residents) are sitting there bored and their TV (television) on. I don't think anyone wants to sit there and just watch TV . LPN H said physical therapy got the residents moving but otherwise there were no activities going on in the facility. On 1/27/26 at 4:52 p.m., R9 was observed in their wheelchair, seated across from the nurse's station. R9 was observed rocking back and forth at the hips; no activities were observed around them. R9 was asked how they were doing and said they had nothing to do. There were no activities around them or going on in the facility. On 1/28/26 at 1:24 p.m. R9 was observed seated next to R15 in their wheelchair outside their room, across from the nurse's station. Their empty tray table was in front of them. There were no activities on the unit or nearby. There were four nursing staff at nurse's station. Review of R9's MDS assessment, dated 12/29/25, revealed R9 scored as cognitively intact, with no behaviors, symptoms of depression, psychosis, or rejection of care. R9 was able to feed themselves and required maximal assistance with bed mobility and transfers. Review of R9's profile revealed R9 was admitted to the facility on [DATE], with diagnoses including sepsis (severe systemic infection), pulmonary embolism (lung blood clot), and schizophrenia (a mental disorder which may have psychotic features). The profile showed R9 had a guardian. Review of R9's Care Plan, accessed 1/28/26 at 8:44 a.m., revealed R9's discharge plan was to return to the community upon discharge. Review of R9's progress notes showed they were at the facility for short-term rehabilitation and had lived in supported housing in the community prior to being at the facility. R10 On 1/27/26 at 9:37 a.m., R10 was observed lying in their hospital bed. On 1/27/26 at 9:39 a.m., R10 was asked if they would participate in activities if offered. R10 said they would participate in select activities when able, including attending a music event, bowling, BINGO, or playing cards if it was offered. R10 said they were working through back pain and were at the facility for therapy. R10 was alert and oriented to themselves, situation, and place. On 1/27/26 at 2:55 p.m., R10 was in their room, seated in a chair. R10 was asked how they were doing and responded, I am bored. Review of R10's face sheet revealed R10 was admitted to the facility on [DATE] with diagnoses including compression fractures of vertebra (back bones), sepsis, and metabolic encephalopathy. Review of R10's Care Plan , accessed on 1/28/26 at 12:20 p.m., revealed R10 required one-person assistance with toileting and transfers and planned to return to the community with the support of family members. The behavioral Care Plan showed R10 had behaviors of agitation and restlessness at times. Review of R6, R9, R10, and R15's Electronic Medical Records (EMR) revealed no activity assessment, activity logging, activity participation, or activity care planning including activity goals, interests, preferences, and abilities. Observations throughout the survey yielded no activity calendars on the resident unit, in common areas, the dining room, residents' rooms, which nursing staff confirmed. Observation throughout the survey yielded no group or individualized activities. On 1/27/26 at 11:42 a.m., NHA B said they had no documentation of their checking in with residents when they were the NHA at the facility prior to the current NHA. NHA B explained they were not aware of a binder. NHA B said they provided activity packets including word searches and trivia from a cart during the weeks when they were at the facility but had no documentation of these interactions. NHA B concurred there were no activities formally since August 2025, when the former Activity Director vacated their position. NHA B conveyed R5 had newly become a long-term care resident. On 1/28/26 at approximately 2:10 p.m., the current NHA, with NHA B present, reported they understood the concerns related to no current Activity Director since August 2025. Review of R6, R9, R10, and R15's Electronic Medical Records (EMR) revealed no activity assessment, activity logging, activity participation, or activity care planning including activity goals, interests, preferences, and abilities. Observations throughout the survey yielded no activity calendars on the resident unit, in common areas, the dining room, residents' rooms, which nursing staff confirmed. Observations throughout the survey yielded no group or individualized activities. Review of the Policy, Activities, revised 2/24/24, It is the policy of this facility to provide on ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both impendence and interaction within the community. Activities refer to any endeavor, other than routine ADLs, in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence. Policy Explanation and Compliance Guidelines: 1. Each resident's interest and needs will be assessed on a routine basis. The assessment shall include but is not limited to: a. RAI (Resident Assessment Instrument) Process: MDS/CAA (Care Area Assessment)/Care Plan. b. Activity assessment to include resident's interest, preferences and needed adaptation. c. Social History. d. Discharge information, when applicable. 2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. b. Create opportunities for each resident to have a meaningful life. c. Promote or enhance physical activity. d. Promote or enhance cognition. e. Promote or enhance emotional health. f. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success, and independence. g. Reflect resident's interests and age. h. Reflect cultural and religious interests of the residents. h. Reflect cultural and religious interests of the residents. i. Reflect choices of the residents. 3. ADL=related activities, such as manicures/pedicures, hair styling, and makeovers, may be considered part of the activities program. 4. Activities may be conducted in different ways: a. One-to-One Program. b. Person-Appropriate – activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for. 5. Scheduled activities are posted in the resident's room, where appropriate, and in a prominent place in the facility. 6. Residents are encouraged, but not mandated, to participate in scheduled activities. 7. Space and equipment necessary are provided to ensure the resident's care plan is followed. 8. Activities will include individual, small and large group activities as well as: a. Indoor and Outdoor Activities. b. Activities away from the facility. c. Religious Programs. d. Exercise Programs. e. Community Activities. f. Social Activities. g. In-Room Activities. h. Individualized Activities. i. Educational Programs. 9. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. These include, but are not limited to, considerations for: a. Residents who exhibit unusual amounts of energy or walking without purpose. b. Residents who engage in behaviors not conductive with a therapeutic home like environment. c. Residents who exhibit behaviors that require a less stimulating environment to discontinue. d. Residents who go through others' belongings. e. Residents who have withdrawn from previous activity interest/customary routines, isolates self in room/bed most of the day. f. Residents who excessively seek attention from staff and /or peers. g. Residents who lack awareness of personal safety. h. Residents who have delusional and hallucinatory behavior that is stressful to themselves. 10. All staff will assist residents to and from activities when necessary. 11. All dietary needs and restrictions will be accommodated on an individual basis when applicable. 12. Activities can occur at any time and are not limited to formal activities provided by the activities staff and can include other facility staff members, volunteers, visitors, residents, and family members. 13. The facility will consider accommodations in schedules, supplies, and timing in order to optimize a resident's ability to participate in an activity of choice. 14. The facility will provide one or more rooms designed for resident dining and activities. These rooms will be: a. Well lighted. b. Well ventilated. c. Adequately furnished. d. Have sufficient space to accommodate all activities. 15. The physician, in coordination with the comprehensive assessment, approves activity programs. Review of the Job Description, Activities Director, Copyright 2023, Compliance Store, provided by the NHA, revealed, Department: Activities. Reports to: Nursing Home Administrator. Reporting to this position: Assistant Activities Coordinator, Activity Assistants, Volunteer Coordinators, Beauty Shop Operators. Classification: Department Manager. Position Purpose: Plans, organizes, supervises, and directs all administrative and operational activities of the Activities Department.The activities director is responsible for directing the development, implementation, supervision, and ongoing evaluation of the activities program, designed to meet the social, psychosocial and therapeutic needs of the resident. This includes the completion and/or directing the completion of the activities component of the comprehensive assessment and contributing to and/or directing /delegating the contrition to the comprehensive care goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident in compliance with Federal and State regulations. Directing the activities program includes scheduling of activities, both individual and groups, implementing and or delegating the implementation of recreational, educational, cultural and arts and crafts programs, monitoring the response, reviewing and evaluating the response to the programs to determine if the activities meet the assessed needs of the resident, and making revisions as necessary. The Director ensures that scheduled program activities are carried out seven days per week. The Director will ensure each resident is offered at least one cognitive activity, two recreational activities, and three ADL (activities of daily living) activities daily. Activities are to be tailored to the residents unique requirements and skills. At least one individual activity is planned for residents who are unable or unwilling to participate in group activities daily. Oversees the transportation of residents to social activities programs inside and outside the facility.The Activity Director is responsible for overseeing the establishment of a Resident Council and responsible for its smooth operation and documentation.Prepares a monthly calendar of activities written in large print and posted in a prominent location that is visible to residents and visitors.Assess residents needs and develops resident activities goals for the written Care Plan. Encourages resident participation in activities and documents outcomes. Reviews goals and progress notes. Properly documents MDS reports and progress notes. Obtains necessary equipment and supplies and provides for their accessibility through organized storage.Participates the Administrator in developing a budget. Contributes to facility efforts to maintain and /or improve quality of care through participation in the following: Attends Care Plan meetings, serves as a member of the QAPI committee (Quality Assurance and Performance Improvement), serves as a member of the behavioral management committed, attends department head meetings, attends mandatory in-services, successfully completes the facility required training, and the Activity Director Licensure continuing education requirements. R30 On 1/26/26 at 8:44 AM, R30 was observed lying in bed. R30 appeared to be sleepy and was asked if he had a good night's sleep. R30 explained he usually talked on the phone at night and then would sleep until late morning. R30 was asked if this was his routine from his life before being admitted . R30 explained there was nothing else to do, he just stayed in bed all the time, did not go anywhere else. R30 was asked if he would go to activities that the facility organized. R30 explained he would, he liked to meet new people. Review of the clinical record revealed R30 was admitted into the facility on 1/21/26 with diagnoses that included: fracture of T7-T8 thoracic vertebra, paraplegia and generalized anxiety disorder. According to an admission nursing assessment dated [DATE], R30 was alert and orientated to person, place and time [A&O x 3]. On 1/27/26 at 10:25 AM, the Regional Social Worker [SW] 'L' was interviewed and asked about R30 staying in bed, alone in his room all the time. SW 'L' explained she encouraged all the residents to get up, be around people and do things. When asked what things were there for residents to do, SW 'L' explained they could watch the big television in the common area or talk. On 1/27/26 at 3:09 PM, CNA 'J' was asked what activities were available for the residents. CNA 'J' explained sometimes the residents would congregate at the nurse station and laugh and have fun, or they could go to the dining room and play cards if there was someone to play with.

Based on interview and record review, the facility failed to ensure there was a qualified activity professional who directed and oversaw an ongoing activity program to ensure meaningful activities were provided consistently per resident preferences for four Residents (R6, R9, R10, and R15) of four residents reviewed. Findings include: Review of the resident census upon survey entry was 21 residents, confirmed by the Nursing Home Administrator (NHA) / Director of Nursing (DON), who assumed both roles upon date of hire, on/near 1/09/26. On 1/26/26 at approximately 10:05 a.m., the NHA/DON described upon entry that the facility was a sub-acute short-stay rehabilitation unit (facility). It was clarified there were only two long-term care residents at the facility, who would mainly require activities. When asked about resident council, the NHA/DON explained they had no resident council president, as there were no resident council meetings in the facility. This Surveyor asked to speak with the Activity Director for clarification on the resident council process. The NHA/DON reported they had no activity director or any activity staff. The NHA/DON clarified the Certified Nursing Aides (CNAs) were completing activities with the residents. Review of the provider description revealed the facility was a 29 bed facility, which meant all the beds (including the resident census of 21 residents) were subject to the regulatory guidance requirements for the provision of an Activity Director, who would be expected to oversee an active ongoing activities program. R6 On 1/26/26 at 11:58 a.m., R6 indicated they wished there were facility activities, such as BINGO, parties, word searches, coloring pages, and arts and crafts. R6 was alert and oriented to themselves, their situation, surroundings, and time. On 1/26/26 at 3:55 p.m., the Human Resources Manager, Staff R, was asked how long the facility was without an Activity Director and if any other staff had assumed the role or any activity job responsibilities. Staff R reported they had worked in their role as the Human Resources Manager for about two and a half years. Staff R stated, There is nobody in the position right now. There is a candidate we are looking at . Staff R was asked if there were any staff in the activity department currently providing activities to residents, such as an activity aide, therapy staff, or anyone working towards certification. Staff R responded, No.I have no knowledge of anyone else assuming that role. Staff R said they were recruiting to find an Activity Director however they had no open posted position for an activity aide or other activity staff. Staff R clarified the Resident Council meetings were part of the Activity Director's role when asked. Staff R stated the former Activity Director had been in their position from 1/04/22 until 8/04/25. Staff R confirmed there had been no Activity Director, activity staff, or activity aide since 8/04/25, as they solely had an Activity Director position posted. On 1/26/26 at approximately 4:05 p.m., Staff R was asked if there were any Certified Nurse Aides (CNAs) who had been acting in the role as activity aides. Staff R said they had no knowledge of anyone in the facility fulfilling this role. Staff R stated, It (an activity aide position) should always come through me. If there was a CNA (acting as an activity aide), we (human resources) would have given them (assigned) both roles (i.e. CNA and activity aide). So, there was no CNA in the (activity aide) role either. On 1/26/26 at 4:36 p.m., CNA I was asked if they had been asked by facility management to provide activities to residents by facility management. CNA I reported they were a newer hire this month and said they had not been educated in their orientation or after to provide activities to facility residents. Surveyor asked if there was any charting for their residents to complete activities. CNA I confirmed there was no charting for complete activities with the residents. CNA I shared they had not seen activities being provided to facility residents when asked however said they had played cards with one resident who had asked them. R15 On 1/26/26 at approximately 4:47 p.m., R15 was asked how they were doing. R15 was seated there across from the nurse's station with an empty tray table. R15 said they wished they could go fishing and be with their family. R15 was asked if they would participate in activities if available, smiled, and said, I like to keep busy. R15 explained they wished they had something to do. Nursing staff were on the unit when R15 shared this and no activities were provided. R15 was interviewable and was oriented to themselves and their surroundings. On 1/27/26 at 9:28 a.m., R15 was asked how they were doing, while again seated across from the nurse's station with an empty tray table. R15 said they liked to participate in tennis, bowling, and fishing, and enjoyed going out before coming to the facility. When asked what kinds of activities they would do, R15 said they liked music activities and magazines for fishing and travel since they liked to travel. R15 also said they liked to go to church sometimes and played games and cards also. R15 said, It is boring (here). No activities were provided or nearby. R9 On 1/26/26 at 11:49 a.m., R9 said, There is nothing to do . R9 said this bothered them. R9 was asked what they would like to do, R9 said they wanted more to do but was not specific. R9 was oriented to themselves and their surroundings. On 1/27/26 at 10:25 a.m., LPN H was asked about R9 and their ability to participate in activities. LPN H said R9 had a disability and had just a little cognitive impairment. LPN H said they made sure R9's TV was on for them. LPN H said when R9 was sitting in the wheelchair in the hallway, they would want to get back in bed to watch TV. On 1/27/26 at 10:30 a.m., LPN H was asked if there were any activities being provided by facility staff, including CNAs. LPN H said the aides were not providing activities to the residents. LPN H stated, .I believe that they (the facility) should be having like a devotional or news printed out and even crossword puzzles.They (residents) do not do any coloring pages. LPN H said nursing staff tried to keep the residents entertained by talking to them. LPN H clarified, They (the residents) are sitting there bored and their TV (television) on. I don't think anyone wants to sit there and just watch TV LPN H said physical therapy got the residents moving but otherwise there were no activities going on in the facility. On 01/27/2026 at 4:52 p.m., R9 was observed in their wheelchair, seated across from the nurse's station. R9 was observed rocking back and forth at the hips, with no activities were observed around them. R9 was asked how they were doing and said they had nothing to do. R10 On 1/27/26 at 2:55 p.m., R10 was in their room, seated in a chair. R10 was asked how they were doing and responded, I am bored. On 1/27/26 at 9:39 a.m., R10 was asked if they would participate in activities if offered. R10 said they would participate in select activities when able, including attending a music event, bowing, BINGO, or playing cards if it was offered. R10 said they were working through back pain and they were at the facility for therapy. R10 was alert and oriented to themselves, situation, and place. Review of R6, R9, R10, and R15's Electronic Medical Records (EMR) revealed no activity assessment, activity logging, activity participation, or activity care planning including activity goals, interests, preferences, and abilities. Observations throughout the survey yielded no activity calendars on the resident unit, in common areas, the dining room, residents' rooms, which nursing staff confirmed. Observation throughout the survey yielded no group or individualized activities, and no activity mediums were observed at these residents' bedsides. On 1/27/26 at 11:42 a.m., NHA B said they had no documentation of them checking in with residents when they were the NHA at the facility prior to the current NHA. NHA B explained they were not aware of a binder. NHA B said they provided activity packets including word searches and trivia from a cart during the weeks when they were at the facility but had no documentation of these interactions. NHA B concurred there were no activities formally since August 2025, when the former Activity Director vacated their position. NHA B conveyed R5 had newly become a long-term care resident. 0n 1/27/26 at 1:05 p.m., the Resident Council task questions were reviewed with R6, as they agreed to be interviewed and were alert and fully oriented. R6 said they wanted to attend the resident council meetings if they were offered, since they were staying longer at the facility for an upcoming neurology appointment related to their mobility challenges. R6 said the facility should have more social activities there, per their earlier interview. On 1/28/26 at approximately 2:10 p.m., the current NHA, with NHA B present, reported they understood the concerns related to no current Activity Director since August 2025. Review of the Job Description, Activities Director, Copyright 2023, Compliance Store, received from the NHA, revealed, Department: Activities. Reports to: Nursing Home Administrator. Reporting to this position: Assistant Activities Coordinator, Activity Assistants, Volunteer Coordinators, Beauty Shop Operators. Classification: Department Manager. Position Purpose: Plans, organizes, supervises, and directs all administrative and operational activities of the Activities Department.The Activities Director is responsible for directing the development, implementation, supervision, and ongoing evaluation of the activities program, designed to meet the social, psychosocial and therapeutic needs of the resident. This includes the completion and/or directing the completion of the activities component of the comprehensive assessment and contributing to and/or directing /delegating the contribution to the compressive care goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident in compliance with Federal and State regulations. Directing the activities program included scheduling of activities, both individual and groups, implementing and or delegating the implementation of recreational, educational, cultural and arts and crafts programs, monitoring the response, reviewing and evaluating the response to the programs to determine if the activities meet the assessed needs of the resident, and making revisions as necessary. The Director ensures that scheduled program activities are carried out seven days per week. The Director will ensure each resident is offered at least one cognitive activity, two recreational activities, and three ADL (activities of daily living) activities daily. Activities are to be tailored to the residents unique requirements and skills. At least one individual activity is planned for residents who are unable or unwilling to participate in group activities daily. Oversees the transportation of residents to social activities programs inside and outside the facility.The Activity Director is responsible for overseeing the establishment of a Resident Council and responsible for its smooth operation and documentation.Prepares a monthly calendar of activities written in large print and posted in a prominent location that is visible to residents and visitors.Assess residents needs and develops resident activities goals for the written Care Plan. Encourages resident participation in activities and documents outcomes. Reviews goals and progress notes. Properly documents MDS (Minimum Data Set - Standardized Nursing Assessment) reports and progress notes. Obtains necessary equipment and supplies and provides for their accessibility through organized storage.Participates with the Administrator in developing a budget. Contributes to facility efforts to maintain and /or improve quality of care through participation in the following: Attends Care Plan meetings, serves as a member of the QAPI committee (Quality Assurance and Performance Improvement), serves as a member of the behavioral management committee, attends department head meetings, attends mandatory in-services, successfully completes the facility required training, and the Activity Director Licensure continuing education requirements.

Based on observation, interview and record review, the facility failed to ensure an appropriate Geri-chair [reclining chair with wheels] for two (R3 and R30) of two residents reviewed for accommodation of needs. Findings include:R3On 1/26/26 at 9:01 AM, R3 was observed lying in bed. R3 was asked if she was able to get out of bed. R3 explained she wanted to get out of the bed, but she had not been up in a long time. R3 was asked if she used a wheelchair. R3 explained they would bring in a reclining chair and put her in that, but it had been a long time since she had seen it. No wheelchair or geri-chair were observed in R3's room.On 1/26/26 at 12:52 PM, R3 was observed sitting in a tan colored geri-chair in her room. R3 explained with a smile that it was the first time she had been up in a long time and she was happy. Review of the clinical record revealed R3 was admitted into the facility o 7/31/25 with diagnoses that included: metabolic encephalopathy, muscle weakness and need for assistance with personal care. According to the Minimum Data Set [MDS] assessment dated [DATE], R3 had moderately impaired cognition.R30On 1/27/26 at 12:40 PM, R30 was observed lying in bed eating lunch. A narrow, blue geri-chair was observed in R30's room, on the opposite side of the room. The chair was observed to have tape on both arm rests, and a rip in the fabric on the right arm rest. R30 was asked if he ever sat up to eat. R30 explained he had sat in a wheelchair, but he kept sliding out, so they had put him in a geri-chair. R30 was asked if he used the blue chair on the other side of the room. R30 explained the one he had been in was tan. R30 was asked how often he got out of bed. R30 explained he thought he would get up later that day, he would like to get out of his room and meet people.Review of the clinical record revealed R30 was admitted into the facility on 1/21/26 with diagnoses that included: fracture of T7-T8 thoracic vertebra, paraplegia and generalized anxiety disorder. According to an admission nursing assessment dated [DATE], R30 was alert and orientated to person, place and time [A&O x 3].On 1/28/26 at 8:41 AM, R30 was observed lying in his bed. R30 was asked if he had gotten up the previous day. R30 explained he was told someone else was using the geri-chair, so he did not get up. But he had already asked to get up that day.On 1/28/26 at 9:15 AM, Certified Occupational Therapy Assistant [COTA] 'P' was interviewed and asked how many geri-chairs were at the facility. COTA 'P' explained there were two geri-chairs, but one of them was very small.On 1/28/26 at 11:00 AM, R30 was observed sitting in the tan geri-chair in his room. Occupational Therapist [OT] 'O', who was also present in R30 room, was asked if R30 could have used the blue geri-chair in the room. OT 'O' explained the blue geri-chair was too small for R30. When asked how wide the blue geri-chair was, OT 'O' explained it was 16 wide. OT 'O' was asked how wide the tan geri-chair was. OT 'O' explained it was 20 wide.On 1/28/26 at 11:04 AM, Certified Nursing Assistant [CNA] 'I' was interviewed and asked how many residents at the facility used geri-chairs. CNA 'I' explained they currently had three residents that sat in the geri-chair. CNA 'I' was asked if either of the other two residents would fit into the blue geri-chair. CNA 'I' explained the blue geri-chair was too small for all of their residents, they all needed the tan geri-chair.On 1/28/26 at 11:05 AM, CNA 'K' was interviewed and asked what happened when two residents wanted to get up to a geri-chair at the same time. CNA 'K' explained only one resident could get up at a time.On 1/28/26 at 12:10 PM, the Administrator, who also served as the DON, was interviewed and asked why only one resident at a time was able to get out of bed and into a geri-chair. The Administrator/DON explained she had not been informed that there were additional residents that were requesting to use a geri-chair. The Administrator/DON was asked about the small blue geri-chair with the tape and rips. The Administrator/DON explained that geri-chair should be removed and additional geri-chairs should be obtained.A facility policy on accommodation of needs was requested, none was received prior to the end of the survey.

Based on interview and record review, the facility failed to complete the Minimum Data Assessment (MDS) discharge assessment for one Resident (R7) of one resident reviewed for resident assessments. Findings include:Review of the recertification survey documentation software in the triggered task, Resident Assessment, revealed R7 was admitted to the facility on [DATE], and their MDS record was over [AGE] years old (had not been completed).Review of R7's resident census in the Electronic Medical Record (EMR) revealed R7 was admitted to the facility on [DATE] on a Skilled Level of Care and was discharged on 9/16/25.Review of R7's nursing Discharge summary, dated [DATE], closed on 9/18/25 by the MDS nurse, Registered Nurse (RN) C , revealed R7 was discharged from the facility on 9/16/25 with an AMA (Against Medical Advice) status, and had been admitted on [DATE] for therapy.Review of R7's MDS assessment page on 1/28/26 at 1:21 p.m., with RN C , revealed there was no MDS discharge assessment.On 1/28/26 at 1:23 p.m., RN C was asked about R7's MDS assessment and any missing assessment per the task trigger. RN C stated the discharge MDS assessment was missed and should have been completed on or near the time of R7's AMA discharge on [DATE]. RN C was asked what occurred and indicated they accidentally missed the discharge assessment, and it was not intentional.On 1/28/26 at approximately 1:45 p.m., R7's missing discharge MDS assessment was reviewed with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), who was serving in dual roles. The former NHA, NHA C , was also present for the interview, as they were the administrator when the omission occurred and were serving as a survey consultant. Surveyor explained this concern was triggered by the Resident Assessment task for the recertification survey. The NHA/DON explained they were not aware of this occurrence and had no comment at that time. No additional comment or feedback was received from their team by survey exit, or at the exit conference.Review of the policy, MDS 3.0 Completion, revised 2/23/24, revealed, Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan.Policy Explanation and Compliance Guidelines: According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI [Resident Assessment Instrument - A standardized, mandatory process required by CMS (Centers for Medicare and Medicaid Services) that evaluates residents' strengths, needs and preferences to develop comprehensive individualized care plans] specified by the State.f. Discharge Assessment - Completed using the discharge date as the ARD (Assessment Reference Date - Typically marking the last day of a resident's care or services). Must be completed within 14 days of the discharge date /ARD.

Based on observation, interview, and record review, the facility failed to provide an accurate, consistent description and assessment of a wound for one Resident (R15) of one resident reviewed for skin management/ wound care, per best practice standards. Findings include:On 1/26/26 at 1:28 p.m., R15 was observed seated in a high-back wheelchair outside their room. A thin gel wheelchair cushion was underneath them in their wheelchair.On 1/26/26 at 1:29 p.m., R15's bed was observed. There was a standard mattress on their bed.Review of R15's Minimum Data Set (MDS) assessment, dated 1/15/26, showed they were admitted to the facility on [DATE] with diagnoses including dementia, arteriosclerotic heart disease, and kidney disease. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 4/15, which showed R15 had cognitive impairment. The assessment revealed that R15 was incontinent of bowel and bladder. Review of R15's Care Plan (CP), accessed 1/27/26, revealed, Problem: I have a pressure ulcer: due to multiple underlying medical conditions, wounds may not heal and formation of more wounds may be unavoidable: (R15) has a Stage 2 (pressure ulcer) to left inner gluteal fold (horizontal skin crease below the buttocks); w/c (wheelchair) bound, immobility, episodes of incontinence. (R15) will refuse to lay back down during the day to elevate feet and relieve pressure to his buttocks. Category. Start date: 1/27/26. Last reviewed: 1/21/26.Review of R15's nursing progress note, by Licensed Practical Nurse (LPN) F, dated 1/21/26 at 4:50 a.m., revealed, Skin assessment completed. Writer notes an open area to left buttock (intergluteal fold). Area cleansed and treatment implemented for Calmoseptine (wound protective menthol barrier cream) applied and dry dressing BID (twice daily) and after each incontinent episode. Wound care consultation order placed.Review of R15's nursing progress noted, dated 1/27/26 at 9:59 a.m., by RN C, revealed, Observed a stage 2 to left inner buttock during toileting, has tx (treatment) order in place for Calmoseptine (ointment) and dressing; dressing needs to be discontinued as it does not adhere in this area between the buttocks; surrounding skin is macerated at this time, no measurable depth. Wound base is 100% granulation issues; incontinence and mobility; is on a w/c (wheelchair) cushion, poc (plan of care) updated; will be seen by wound care this Friday (1/30/26).Review of R15's nursing progress note, dated 1/28/26 at 5:37 a.m., by LPN F, revealed, A quarter size bed sore observed during skin assessments, writer cleansed it with NS (Normal Saline - wound care rinse) and covered with 4 x 4 Silicon foam (wound care) dressing and resident well tolerated, denies pain during the assessment. Continue to monitor. It was noted all the wound descriptions were completed by different nurses, and there were no wound measurements after the 1/21/26 progress note.Review of R15's skin assessment, dated 1/21/26, showed a new wound but had no measurements.Review of R15's skin assessment, dated 1/24/26, showed no wound description.Review of R15's skin assessment, dated 1/26/26, showed no wound description.Review of R15's nursing assessments revealed no wound description other than the initial wound description in the 1/21/26 documentation.Review of R15's EMR (electronic medical record) on 1/27/26 showed no wound consult by the wound care team, no clear description of R15's wound after 1/21/26, and no wound measurements.On 1/27/26 at approximately10:00 a.m., LPN D was asked about R15's wound to their buttocks. LPN D , reviewed the EMR and described the wound care team rounds with residents with wounds/new wounds every Friday. LPN C could not explain why R15 had not been seen by the wound care team on 1/23/26, and said they would be seen on 1/30/26, eight days later after the inception/discovery of R15's wound to their buttocks.On 1/28/26 at 10:12 a.m., the MDS nurse, Registered Nurse, RN C, was asked about R15's wound, per their progress note and CP entry on 1/28/26, as they documented the wound as a Stage 2 pressure ulcer. RN C reported they overheard nursing staff talking about R15 having a pressure ulcer on 1/27/26 and said they had observed the wound and stated the wound was a Stage 2 pressure ulcer on R15's buttocks. RN C clarified the typical process was nursing staff would have made them aware of a new wound/pressure ulcer. RN C confirmed R15 should have been seen by the outside wound care staff on 1/23/26, who provided the wound descriptions and measurement, and they were not sure why this was missed. RN C clarified there was no wound care nurse per se in the facility, and wound care observations, measurements and descriptions were provided by the wound care team who made rounds every Friday. RN C stated they put a note up at the nurse's station to remind staff R15 needed to be seen on 1/30/26, when the wound care staff next rounded in the building. RN C was asked if their expectation would have been there would be wound measurements for a documented pressure ulcer, so 1/30/26's measurements could have been compared to 1/21/26's measurements, per best standards of wound care practice. RN C said they needed to review the skin and wound policy. Review of R15's Electronic Medical Record (EMR) with RN C revealed on 1/28/26 LPN F had classified the wound as the size of a quarter in their progress note. When asked if an LPN F could stage or measure a wound, RN C clarified an LPN could not stage a wound, however, they could have completed measurements or sent for an RN in the building including themselves to have measured R15's wound. RN C concurred there were no wound measurements in the EMR for R15.On 1/28/26 at approximately 10:20 a.m., RN C reported the wound description, and measurements should have been documented in the EMR. RN C acknowledged they should have completed this documentation in the wound management section of the chart when they described R15's wound which they called a Stage 2 pressure ulcer on 1/27/26, when they had observed the wound. RN C reported they measured R15's wound however had forgotten to place the measurements in R15's chart. RN C was asked if the wound being described as quarter size was acceptable per standards of best practice for wound care. RN C said they would need to review the wound care policy. RN C agreed best practices for wound care indicated any new pressure ulcer and or skin wound should be measured at the wound inception. RN C reported they understood the concern without an initial measurement the wound care team wound not be able to tell if the wound progressed when they were scheduled to round the facility's' residents' wounds on 1/30/26.Review of the facility's skin and wound care policies with RN C on 1/28/26 at 10:23 a.m., received from the Nursing Home Administrator (NHA) and Director of Nursing (DON), who assumed both roles, revealed the policies referenced the size of the wound(s) should be noted, with no further description.Review of R15's physician orders on 1/28/26 with RN C revealed orders for Calmoseptine (ointment) wound care treatment to R15's buttocks wound remained in place.Review of R15's EMR with RN C revealed their Braden assessment score was 16, which per RN C showed they were at risk for pressure ulcers/skin concerns. RN C reported R15's Stage 2 pressure ulcer was unavoidable, which they documented in R15's Care Plan.On 1/28/26 at 10:56 a.m., the former NHA, NHA B was asked who oversaw wound care currently and when they were the NHA. NHA B reported the DON oversaw wound care oversight.On 1/28/26 at 11:12 a.m., Observation of R15's wound care by Surveyor RN, with LPN E and CNA K, revealed an area on the left gluteal fold that appeared to be Moisture Associated Skin Damage (MASD), approximately 1 1/4 inch by 3/4 inch. The Calmoseptine cream applied covered the entire area completely. On 1/28/26 at 1:05 p.m., LPN E was asked about R15's wound description during their wound care treatment on this date, when observed by RN Surveyor. LPN E reported R15's wound appeared to be more so a skin tear from what my eyes saw, but I don't stage (stage the wounds).It was there in the gluteal fold.We don't measure it. Our wound care lady (wound care provider staff) does this on Fridays. It was noted the RN Surveyor described the appearance during the wound observation as MASD (MASD - non- pressure related). Both LPN E and the RN surveyor concurred the wound did not appear to be a pressure ulcer, showing marked documentation inconsistencies since R15's wound to their left buttocks gluteal fold was first described by nursing staff on 1/21/26, and described on 1/28/26 by LPN F, in their nursing progress note. On 1/28/26 at approximately 1:45 p.m., the NHA/DON was asked about R15's and the documentation inconsistencies and documentation omissions by nursing facility staff, no wound measurements, as well as R15 not being seen by the wound care provider team on 1/23/26, per best practice standards for wound care. The NHA/DON reported they had observed R15's wound on this date (1/28/26), and clarified the wound was MASD, not a pressure ulcer. The NHA/DON reported the wound care treatment was appropriate (Calmoseptine) and remained in place. The NHA/DON confirmed they would have their wound care provider observe R15's buttocks wound on 1/30/26. The NHA/DON reported they understood the concerns related to wound care best practices, per facility policy, and would move forward with staff education.Review of the facility policy, Wound Treatment Management, DateImplemented: 11/1/2022.Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.Policy Explanation and Compliance Guidelines:1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.b. Characteristics of the wound:i. Pressure injury stage (or level of tissue destruction if not a pressure injury).ii. Size - including shape, depth, and presence of tunneling and/or undermining.iii. Volume and characteristics of exudate.iv. Presence of pain.v. Presence of infection or need to address bacterial bioburden.vi. Condition of the tissue in the wound bed.vii. Condition of peri-wound skin.c. Location of the wound.d. Goals and preferences of the resident/representative.6. Guidelines for dressing selection may be utilized in obtaining physician orders (see attached).a. The guidelines are to be used to assist in treatment decision making.b. Due to unique needs and situations of individuals, the guidelines may not be appropriate foruse in all circumstances.c. The facility will follow specific physician orders for providing wound. 7. Treatments will be documented on the Treatment Administration Record.8. The effectiveness of treatments will be monitored through ongoing assessment of the wound.Considerations for needed modifications include:a. Lack of progression towards healing.b. Changes in the characteristics of the wound (see above).c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance withhis/her rights.

Based on observation, interview and record review the facility failed to ensure wound care was implemented per physician orders, as evidence by missed and incomplete wound care treatments for one(R2) of three residents reviewed for wound care. Placing the resident at risk for infection, delayed wound healing and further skin break down. Findings include: On 1/26/26 at 9:30 AM, R2 was observed lying in the bed with a green wedge placed under their left side. R2, was then interviewed about their stay at the facility but the conversation was not coherent due the resident having a Brief interview for mental status(BIMs) score of 7 which indicated severe cognitive impairment. A review of the record revealed that, R2 was admitted to the facility on [DATE] with the admitting diagnosis of metabolic encephalopathy, Pressure Ulcer of the sacral region, unstageable and muscle weakness. A further review of the record revealed that on 1/16/26, R2 was seen by wound care, the consult report stated, Resident has two new wounds on her mid lower back that is a UTD (unable to determine) and a new right heel stage two. Both heels were hyper granulating, sliver nitrate used to knock it down. See orders for details and please off load. Wound was consulted and wound care was ordered in part . Left lower back un staged pressure 3 times a week and as needed Normal saline or wound cleanser Calcium alginate with Medi honey border foam The record revealed that, on 1/28/26 the wound care orders that had been provided by the wound care provider on 1/16/26 was not carried out in the medical record. On 1/28/26 at 10:27 AM, the Director of Nursing (DON) was interviewed, and they were asked who over sees the wounds at the facility and who is responsible for completing and transcribing treatments. The DON reported that there was an outside company that oversees the care and physician oversite for the wounds at the facility. The DON reported that floor nurses was responsible to round with the provider and if there were any new orders or changes made to existing orders the floor nurses are to carry the orders out. The DON, was asked about R2's wounds and how often were they seen. The DON reported, that R2 was seen monthly and it was up to the facility to ensure treatments and skin checks were completed accurately. The DON was then asked about the wound care consult on 1/16/26 and where could the orders be found and the documentation of the implementation of the Silver Nittrate order. The DON was also asked, how are they monitored the status of R2 wounds if there is not any documentation for two new skin areas that deteriorated. The DON, reported that, they will be overseeing the coordination of care for wounds moving forward. There was no additional information provided by exit.

Based on observation, interview, and record review, the facility failed to ensure one Resident (R15) of one resident reviewed for accidents/falls had their fall interventions implemented after two falls out of bed. Findings include:On 1/26/26 at 1:28 p.m., R15 was observed seated in a high-back wheelchair outside their room. R15 was seated on a thin gel wheelchair cushion in their wheelchair.Review of R15's Minimum Data Set (MDS) assessment, dated 1/15/26, showed they were admitted to the facility on [DATE]. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 4/15, which showed R15 had cognitive impairment. Review of R15's profile revealed they had diagnoses including metabolic encephalopathy (brain dysfunction from metabolic causes), dementia, heart disease, kidney disease, a fall with a fractured clavicle, and a history of bilateral (both) hip replacements.Review of R15's Fall Care Plan, accessed 1/27/26, dated 1/10/26, revealed, Problem: I am at risk for falling r/t (related to): Mobility limits, Cognitive limits, hx (history of) falls, impulsive attempts to self transfer; has dx (diagnosis) of dementia and will not remember to use a call light for assistance .Review of R15's Fall Care Plan Interventions, dated 1/27/26, showed interventions including ensuring their bed was in the lowest position and their call light being in reach at all times.On 1/27/26 at 2:55 p.m., R15 was observed in their hospital bed. R15 had the covers over them. R15's bed was mid-height (transfer height). It was not in the low position.On 1/27/26 at 9:29 a.m., R15 was observed in their hospital bed sleeping. R15's bed was observed at mid-height, and their soft touch pad call light was on their nightstand, out of their reach. Their bed was a regular flat mattress, with a bare floor. It was noted R15's bed was the same height as their roommates bed, who self transferred, when viewed from the foot of their beds.On 1/27/26 at approximately 9:32 a.m., Licensed Practical Nurse (LPN) H and Certified Nurse Aide (CNA I) were asked to observe R15 in their bed with Surveyor present. LPN H and CNA I observed R15 and confirmed R15's bed was at mid-height, and their call light was out of reach, on their nightstand.On 1/28/26 at approximately 9:35 a.m., LPN H was asked about the observation. LPN H confirmed R15 was at risk for falls and understood the concern.On 1/28/26 at 9:40 a.m., CNA I was asked about R15's bed being at mid-height and their call light being out of reach, per their fall Care Planned interventions. CNA I reported they were assisting with the residents on the unit, and had removed R15's call light when they were picking up their tray and cleaning their tray table and forgot to put R15's call light back in their reach. CNA I also stated they were not aware R15's bed was supposed to be at the lowest height. CNA I said on this date (1/28/26) there was no one present to give them shift report at shift change. CNA I explained they were made aware R15 had fallen a few days ago, and said they should have lowered their bed. CNA I was asked if they had reviewed R15's Care Plan interventions. CNA I said they were a newer employee and they had not been given access to any residents' Care Plans, including R15's. CNA I reported they had worked as a CNA elsewhere prior to this facility, and they knew they needed to have access to residents' Care Plans.On 1/28/26 at approximately 10:30 a.m., R15 was observed sleeping in their bed with their bed was lowered and call light in reach. R15's bed was observed a few inches lower than their roommates bed, when viewed from the foot of bed.Review of R15's nursing progress notes revealed R15 had three falls since their admission on [DATE], as follows:1/10/26. Fall out of chair. Non injury.1/23/26. Fall out of bed. No injury.1/25/26. Fall out of bed. Skin tear left elbow.Review of R15's Fall event reports related to their three falls revealed their Care Plan was updated with new interventions on 1/10/26, however was not marked as reviewed or updated on 1/23/26 and 1/25/26.Further review of R15's Fall Care Plan revealed there were no new fall interventions after their falls, until the Care Plan was updated on 1/27/26, two days after their second fall out of bed.On 01/28/2026 at 11:49 a.m., the Nursing Home Administrator (NHA)/ Director of Nursing (DON) (who assumed both roles this month) was asked about R15's Fall Care Plan interventions not being followed per their Care Plan or reviewed shortly after their falls out of bed. The NHA was also made aware of CNA I reporting they did not have Care Plan access. The NHA/DON reviewed R15's Care Plan and indicated they understood the training and implementation/review concerns and planned to follow up.Review of the policy, Incidents and Accidents, dated 11/01/22, revealed, It is the policy of this facility for staff to utilize Incident Reports to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.Policy Explanation: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences.Review of the policy, Comprehensive Care Plans, revised 2/26/25, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care.8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on observation, interview and record review, the facility failed to obtain physician orders for care and monitoring of a peripherally inserted central catheter [PICC] for one (R19) of one resident reviewed for PICC lines. Findings include:On 1/26/26 at 8:56 AM, R19 was observed walking from his bathroom to his bed. An intravenous [IV] pole with an IV bag and tubing was observed next to the bed. R19 was asked if he was receiving IV medication while at the facility. R19 explained he was receiving antibiotics through is PICC line. R19 was asked how often the facility changed the dressing on his PICC line. R19 explained he was not sure if they had changed the dressing. Observation of the PICC line dressing on R19's right upper arm revealed a dressing held on with tape at the top and bottom and faintly dated either 1/12/26 or 1/22/26.Review of the clinical record revealed R19 was admitted into the facility on 1/9/26 and readmitted [DATE] with diagnoses that included: osteomyelitis of vertebra, heart disease and osteoporosis. According to the Minimum Data Set [MDS] assessment dated [DATE], R19 was cognitively intact.Review of physician orders for R19 revealed no order found for dressing changes and no order found for monitoring of PICC line site for signs and symptoms of infection.On 1/27/26 at 11:45 AM, the Administrator, who also served and the Director of Nursing [DON] was interviewed and asked how often a PICC line dressing should be changed. The Admin/DON explained the dressing should be changed every week or if soiled. The Admin/DON was asked about R19's PICC line dated either 1/12/26 or 1/22/26. The Admin/DON explained R19 had gone to the hospital to have the PICC line replaced on 1/22/26 and was not due for a dressing change yet. The Admin/DON was asked about the lack of physician orders for dressing change and monitoring of the site. The Admin/DON looked at the current and discontinued orders for R19 and did not find any physician orders regarding the PICC line. The Admin/DON was asked how the staff would know when to change the dressing, or where they would document that it was done. The Admin/DON had no answer.Review of a facility policy titled PICC/Midline/CVAD Dressing Change dated 11/1/22 read in part, .It is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing, weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify typre of dressing and frequency of changes.

Based on observations, interview and record review, the facility failed to provide administration of the Influenza vaccine for one (R6) of five residents reviewed for immunizations. Findings include:Review of the clinical record revealed R6 was admitted into the facility on [DATE] with diagnoses that included: stroke, heart failure and diabetes.Review of R6's Preventive Health Care tab revealed on 12/23/25 documentation of R6 having received Pneumococcal, RSV [respiratory syncytial virus] and COVID-19 vaccines previous to admission to the facility. There was no documentation of the Influenza vaccine.On 1/27/26 at 3:21 PM, the Administrator, who was also serving as the Director of Nursing [DON] and Infection Preventionist, was asked to provide documentation of R6's consent or declination form for the Influenza vaccine.Review of a Resident - Vaccine Consent form, signed by R6 and dated 12/23/25 revealed a check mark in the Accept circle for the FLU Vaccine.On 1/27/26 at 4:05 PM, R6 was observed sitting in a wheelchair in her room. R6 was asked if she had received the Influenza vaccine while at the facility. R6 explained she had signed up for it, but had not received it yet.Review of a facility policy titled, Influenza Vaccination dated 11/1/22 read in part, .Influenza vaccinations will be routinely offered annually from October 1st through March 31st. Individuals receiving the influenza vaccine, or their legal representative, will e required to sign a consent form prior to the administration of the vaccine. The completed, signed, and dated record will be filed in the individual's medical record.

Based on observation, interview, and record review, the facility failed to maintain a pest free environment. This deficient practice had the potential to affect all residents in the facility. Findings include: On 10/29/24 at 9:00 AM, during a tour of the kitchen serving area with Dietary Manager G, there was standing water and cobwebs observed in the corner under the steam table. Several gnats were observed near the standing water and flying about the kitchen area. When queried, Dietary Manager G stated the water was from filling the wells of the steam table. No explanation was provided for the gnats observed in the kitchen area. On 10/29/24 at 9:20 AM, several gnats were observed flying about in the hallway near the resident rooms. According to the 2017 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4. (D) Eliminating harborage conditions.

Based on interview and record review, the facility failed to notify, in writing, the reason for a discharge out of the facility to a representative of the State Long term Care Ombudsman for two Residents (R15 and R17) of two residents reviewed for discharge. Findings include: Resident #15 (R15) Review of the Minimum Data Set (MDS) assessment, dated 7/31/24, revealed R15 was admitted to the facility on [DATE] and discharged from the facility on 7/31/24. Review of facility report of discharges for month of July 2024 did not reveal R15 on the discharge report sent to the Ombudsman. Resident #17 (R17) Review of the MDS assessment, dated 9/2/24, revealed R17 was admitted to the facility on [DATE] and discharged from the facility on 9/2/24. Review of facility report of discharges for the month of September 2024 did not reveal R17 on the discharge report sent to the Ombudsman. During an interview on 10/30/24 at approximately 12:55 p.m., Social Worker C stated, R17 is not on the list for the ombudsman and should be. Review of facility policy titled Transfer and discharge date implemented 11/1/22, read in part . The facility will provide transfer/discharge notice to the resident/representative and Ombudsman as indicated .the Social Services Director, or designee will provide copies of notices . of transfer to the Ombudsman .such as in a list of residents on a monthly basis. During an interview on 10/30/24 at approximately 3:20 p.m., the Nursing Home Administrator (NHA) stated, I know a list of discharges is supposed to be sent to the Ombudsman . It is something we missed.

Based on interview and record review, the facility failed to provide written notification of the bed hold policy to resident or their representative prior to hospital transfer for one Resident (R17) of two residents reviewed for hospitalization , resulting in the potential of resident and/or resident representative being uninformed of the bed hold policy. Findings include: Resident #17 (R17) Review of the Minimum Data Set (MDS) assessment, dated 9/2/24, revealed R17 was admitted to the facility on [DATE] and discharged from the facility to the hospital on 9/2/24. During an interview on 10/30/24 Social Worker C stated, I don't know that I have a bed hold policy that was given to the resident or resident representative .it was not given to them, and I don't know what to tell you it just wasn't done .it was not given to R17 upon discharge. Review of facility policy titled Bed Hold Notice Upon Transfer last reviewed/revised 3/13/24, read in part . At the time of transfer for hospitalization .the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy . the facility will keep a signed and dated copy of the bed hold notice information given to the resident and/or resident representative in the residents file. During an interview on 10/30/24 at approximately 3:20 p.m., the Nursing Home Administrator (NHA) stated, I know a bed hold policy is supposed to be given upon discharge . It is something we missed.

Based on interview and record review, the facility failed to complete a discharge summary for one Resident (R17) of two residents reviewed for discharge from the facility. This deficient practice resulted in the potential for compromised continuity of care. Findings include: Resident #17 (R17) Review of the MDS (minimum data set) assessment, dated 9/2/24, revealed R17 was admitted to the facility on [DATE] and discharged from the facility on 9/2/24. A Review of R17's Electronic Medical Record (EMR) revealed no discharge summary or recapitulation of stay was present in the record. Review of facility policy titled Discharge Summary date implemented 11/1/22, read in part . It is the policy of this facility to ensure that a discharge summary is provided upon a residents discharge .the discharge summary provides necessary information to continuing care providers pertaining to the residents course of treatment while the resident was in the facility and the residents plan of care after discharge .It must include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another. During an interview on 10/30/24 at 1:30 p.m., RN/MDS (Registered Nurse/Minimum Data Set) A stated, I do the discharge summaries for the residents .I did not do a discharge summary for R17 .it was not done. During an interview on 10/30/24 at approximately 3:20 p.m., the Nursing Home Administrator (NHA) stated, I know we are supposed to do a discharge summary . It is something we missed.

Based on interview and record review, the facility failed to ensure that residents received assistance with showering for one Resident #13 (R13) of one resident reviewed for ADL (activities of daily living) care, resulting in the potential for embarrassment, frustration, and unmet care needs. Findings include: Resident #13 (R13) Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: diabetes mellitus, hypertension, and arthritis. R13 scored a 13 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition. Further review of MDS assessment revealed the resident needed substantial/maximal assistance for showers/bathing. During an interview on 10/29/24 at 10:51 a.m., R13 stated, I have only had one shower since being here .I got a shower last month and I look forward to getting a shower this month. Review of the Electronic Medical Record (EMR) revealed that R13 had one shower since admission to the facility. Review of facility shower schedule dated 8/14/24 revealed that R13 should be offered showers on Wednesday and Saturday. During an interview on 10/30/24 at 9:45 a.m., RN/MDS (Registered Nurse/minimum Data Set) A stated, I am unable to find the charting in the EMR for the showers . Review of facility policy titled Resident Showers date implemented 11/1/22, read in part . It is the policy of this facility to assist residents with bathing to maintain proper hygiene .residents will be provided showers as per request or as per facility schedule. Review of facility policy titled Activities of Daily Living (ADLs) date implemented 11/1/22, read in part . Care and services will be provided for the following activities of daily living: bathing .

Based on interview and record review, the facility failed to ensure weekly weights were completed for one Resident #4 (R4) of one resident reviewed for nutritional needs. This deficient practice resulted in the potential for missed weight fluctuations. Findings include: Resident #4 (R4) Review of R4's Minimum Data Set (MDS) assessment, dated 10/7/24 revealed admission to the facility on [DATE], with active diagnoses that included: diabetes mellitus, malnutrition, anxiety disorder, and depression. R4 scored a 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. During an interview on 10/29/24 at 1:03 p.m., R4 stated I don't get enough food or snacks. I have lost weight since being here . I have been weighing myself by the Activity room and have lost several pounds . I have told the staff, but they did not believe me and told me you have not lost weight. Review of R4's Electronic Medical Record (EMR) revealed a Doctors order for weekly weights, R4 had an admission weight, and no subsequent weights had been completed. During an interview on 10/30/24 at approximately 9:20 a.m., RN/MDS (Registered Nurse/Minimum Data Set) A stated, R4 had an admission weight but there were no other weights completed since then. Review of facility policy titled, Weight Monitoring last reviewed/revised 3/27/24, read in part . A weight monitoring schedule will be developed upon admission for all residents .newly admitted residents- monitor weight weekly for four weeks .

Based on observation, interview and record review, the facility failed to ensure ongoing assessment and monitoring for weight loss for three (R6, R8, and R12) of four residents reviewed for nutrition, resulting in significant and/or severe weight loss and the potential for further clinical compromise. Findings include: According to the facility's policy titled, Nutrition (Impaired)/Unplanned Weight Loss dated 2/24/22, .The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month - 5% weight loss is significant; greater than 5% is severe .3 months - 7.5% weight loss is significant; greater than 7.5% is severe .6 months - 10% weight loss is significant; greater than 10% is severe .The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes .The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition .Evaluating the resident's response to interventions should be based on defined criteria for improvement/worsening of nutritional status; for example, stabilization of weight .food/fluid intake .Recognizing the emergence of new risk factors; for example, pressure ulcers . Resident #6: On 2/22/22 at 9:53 AM, R6 was observed lying in bed, facing the door. The resident's body frame was noted to be very thin. Upon approach, resident was very confused. Review of the clinical record revealed R6 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R6 had severe cognitive impairment, weighed 115, had no unplanned weight loss/gain, and received a mechanically altered diet. On 2/22/22 at 2:30 PM, review of the available weights documented for R6 revealed an admission weight on 11/11/21 was 114.6 pounds (lbs). The most recent weight documented on 1/5/22 read 105.6 lbs (a loss of 9 lbs/7.85% in less than three months). Review of the most recent nutritional assessment dated [DATE] by Certified Dietary Manager (CDM 'A') read, .Nutritional Status Underweight. (R6) po intake is fair at this time. His current diet is regular, thin liquid. He also requires an mech soft chopped texture. He receives a mighty shake tid (three times a day) with all meals. He did receive a diet upgrade. His bmi (body mass index) is 15.59. His cbw (current body weight) is 105.60/1/4/22. He does have an ulcer .He stain <sic> a 5.5% weight loss in 30 day on 1/4/22, no weights for x90 or x180 days. Will continue to montior <sic>. Review of the nutritional assessment dated [DATE] by Registered Dietician (RD 'B') read, .Nutritional status underweight; significant weight loss x 30 days and admission weight; weight down 6# (pounds) x 30 days and 9# since admission. Weight loss was unplanned, unavoidable, likely r/t (related to) variable intakes, 50% of meals, had PNA (pneumonia), pressure ulcer healing .R hip pressure ulcer stage 2- will recommend MVT (multivitamin) and prostat TID (nutritional supplement three times a day) .Intervention: Place on weekly weights x 2 weeks . There were no additional weights obtained or documented since 1/5/22. On 2/23/22 at 9:50 AM, an interview was conducted with the Vice President of Operations (Staff 'H') who was assisting administration during this survey. When asked about what the facility's process was for monitoring weights, Staff 'H' reported it would be done weekly for four weeks and a re-weight would occur if the weight obtained was more than or less than five pounds from the previous weight. On 2/24/22 at 9:11 AM, CDM 'A' was asked to obtain a weight for R6. At that time, CDM 'A' reported they had obtained a weight yesterday (following concerns with lack of resident weights identified during survey) but that had not been put into the electronic clinical record yet. CDM 'A' was asked to observe a current weight with R6 and indicated they would be able to do that now. R6's current weight was 110.2 lbs. On 2/24/22 at 9:25 AM, an interview and record review were conducted with CDM 'A'. When asked about the facility's process for monitoring resident's nutritional status and weights, CDM 'A' reported they were the primary person and there was also a corporate dietician that assisted. When asked to review R6's weight variance reports, CDM 'A' confirmed the last documented weight was 105.6 on 1/5/22. The CDM also confirmed the weight on 12/16 was also 105.6 lbs and the weight previous to this was 111.8 lbs. CDM 'A' confirmed there was no re-weight done following the weight loss beyond five lbs on 12/16. CDM 'A' reported the nurse should've notified them of the weight variance to obtain a re-weight and address interventions at that time. The next weight following the weight on 12/16/21 was not obtained until 1/4/22 (which was 105.2). A re-weight was done on 1/5/22 which documented 105.6. When asked about what interventions were implemented following the significant weight loss identified on 1/5/22 and a new pressure ulcer identified on 1/3/22, CDM 'A' reported they had sent an email to RD 'B' and the Director of Nursing (DON) on 1/5/22. CDM 'A' could not explain why they had not been notified of R6's weight loss identified by nursing on 12/16/21. When asked what was done following the notification to RD 'B' on 1/5/22, CDM 'A' reported they had an email response (which was offered to be viewed by CDM 'A') from RD 'B' on 1/28/22 which included multiple recommendations. When asked the delayed response, CDM 'A' was unable to offer an explanation and further reported the goal for the RD is to come in once a month to see the residents but that didn't work out as they worked mostly remotely and covered 10 buildings. CDM 'A' reported the recommendation from RD 'B' on 1/28/22 included weekly weights for two weeks. When asked about their assessment on 2/15/22 and if they had identified a lack of follow up with RD 'B's recommendation for weekly weights was not completed, CDM 'A' was unable to offer any further explanation. CDM 'A' was asked how it was determined R6's weight loss was unavoidable and CDM 'A' reported when the resident came in he was only eating about 25% and then had weight loss. When asked if they had determined if there was any difficulty eating/chewing, or food dislikes or any other contributing factors or clinical rationale from the physician to be able to identify wt loss was unavoidable, CDM 'A' responded, I see what you mean. CDM 'A' further reported their process for monitoring residents' weights was to do weekly for four weeks, then monthly if stable. When asked who monitored the resident's food/fluid intake and where that would be documented, CDM 'A' reported that was not documented and that they kept track of that information since they did all the meal tray set up and they were able to see what was eaten when the trays came back. When asked how nursing staff became aware which residents needed to be weighed, CDM 'A' reported they used to give nursing staff a sheet of which residents needed to be weighed but that they had not done that in a while. When asked what was the reason that had not been done, CDM 'A' did not offer any further explanation. At that time, CDM 'A' was asked to review R6's weights and acknowledged they had not identified the weight loss from 12/16/21 until R6's weight was obtained on 1/4/22. CDM 'A' further reported R6 should have been on weekly weights. When asked who was responsible for ensuring weights were done or following up if they were not, CDM 'A' reported that was the nursing staff's responsibility. On 2/24/22 at 9:50 AM, an interview and record review were completed with RD 'B'. When asked about their position with the facility, RD 'B' reported they covered 10 facilities (mostly) remotely and became full-time in October 2021. When asked about their process for monitoring resident's nutritional status, weights, etc., they reported they oversee the CDM and for at-risk residents such as those on tube feeding, [CONDITION(S)] or had pressure ulcers. When asked about the delayed response to CDM 'A's email notification of R6's significant weight loss on 1/5/22, RD 'B' reported, Honestly I was stuck at another building. Had talked in meantime and put plan together. When asked who was responsible to ensure weights were being obtained and monitored, RD 'B' reported typically the CDM lets nursing know, I communicate with CDM and monitor weights at the beginning of the month, the CDM talks to DON and the DON, CDM and Administrator follow up. When asked if they participated in the at-risk meetings, RD 'B' reported the CDM was the designated person from dietary for those meetings. When asked if they participated in any quality assurance meetings to identify concerns with nutritional processes, RD 'B' reported the CDM was involved in those meetings as well. When asked if they had recommendations, how did those get implemented, RD 'B' reported they would send an email to the CDM and DON of items recommended and the DON would put an order in for the recommendations as the CDM did not have access to order entry. On 2/24/22 at 10:48 AM, an interview was conducted with the DON. When asked about who was responsible for making sure the weights were obtained as needed, or if they were not, who was overseeing this process, the DON reported the CDM was to give a list to nursing staff and the nurses assigned CNAs to obtain and that information was given back to the CDM. When asked if they were aware of any concerns that weights were not being done as recommended or per facility policy, the DON reported I have not been notified. When asked if they had participated in any of the at-risk meetings, the DON reported, The DON further reported that they had not been at these meetings since they had been pulled to work at another facility and that out of the past six weeks, they had been gone about four weeks. R8 On 2/22/22 at 3:58 PM, a review of R8's clinical record was conducted and revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's most recently completed MDS assessment dated [DATE] indicated they had moderately impaired cognition, did not exhibit any hallucinations, delusions, behaviors, or rejection of care, was non ambulatory and required extensive assistance from one staff member for activities of daily living. A review of R8's documented weights in the electronic medical record revealed the following documented weights: 12/8/22 147 lbs, 1/4/22 138.6 lbs and 1/5/22 139.6 lbs. It was noted no weight had been documented for February 2022. A review of R8's progress notes was conducted and revealed the following: A progress note from Certified Dietary Manager (CDM) 'A' dated 1/10/22 that read, Significant Loss Nutritional Status .(R8) has an <sic> 5% weight loss for x30 days .Expect weightloss <sic> continue because of poor intake . A progress note from CDM 'A' dated 1/25/22 that read, (R8) po (oral) intake continues to be <25% of all meals. Weightloss <sic> may be unavoidable due to poor intake. Will speak with the idt (interdisciplinary team) about a <sic> approach. A progress note from Registered Dietician (RD) ' B' dated 1/28/22 that read, Weight Loss .significant weight loss x30days; <sic> weight down 8# (lbs) x30 days <sic. Weight loss was unplanned, unavoidable, likely r/t (related to) variable intakes .Intervention: Place on weekly weights x 2 weeks, Will add Med pass 2.0 (dietary supplement) 1x/day, (once per day) Notify MD .of weight loss . A progress note from the Administrator dated 1/31/22 that read, At Risk: (R8) was discussed by IDT .Weight loss noted, RD made aware . A progress note from the Administrator dated 1/31/22 that read, At Risk: (R8) was discussed by IDT members .Glucerna (dietary shake supplement) ordered due to poor intake . On 2/22/22 at 4:22 PM, a review of R8's orders was conducted and did not reveal any active, completed, or cancelled orders for weekly weights, or Med Pass 2.0 supplement referenced in RD 'B's note on 1/28/22, or the Glucerna Shake supplement referenced in the Administrator's note on 1/31/22. On 2/23/22 at 11:30 AM, an interview was conducted with R8's assigned nurse, Registered Nurse (RN) 'F'. They were asked if the nursing staff administered Med Pass 2.0 supplements and said they did. They explained there would be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/23/22 at 2:05 PM, CDM 'A' was observed to obtain a weight for R8. R8's weight was 137.8 pounds, showing an additional loss of 1.8 pounds since their last documented weight on 1/5/22 where they had previously been identified as having a significant weight loss over a thirty day period. On 2/24/22 at 9:46 AM, an interview was conducted with RD 'B' regarding R8's significant weight loss. RD 'B' was asked about their recommendation for weekly weights referenced in their note on 1/28/22 and said CDM 'A' was responsible for making sure the weekly weights were done. RD 'B' was asked if they followed up to ensure CDM 'A' obtained the weights and said they were currently overseeing ten different buildings and they checked them monthly. RD 'B' was then asked about the order for Med Pass 2.0 and after reviewing the clinical record confirmed they had put the order in but somehow it had also been discontinued the same day, also by them. RD 'B' said they must have made a mistake when they put the order in. RD 'B' was then asked about the use of food acceptance records and said CDM 'A' monitored that. They were asked where CDM 'A' documented food acceptance and said they did not have a place for it to be documented. RD 'B' was asked if they sat in on the IDT meetings and said they did not, CDM 'B' went to the IDT meetings. RD 'A' said they remotely charted on residents, made recommendations, and e-mailed them to the CDM 'A' and the Director of Nursing, but they did not follow-up to check on their recommendations. Resident #12 A review of the medical record revealed that R12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed R12 was to be weighed upon admission, weekly time four and then monthly if weights were stable. Review of the medical record only revealed weights for 12/16/21 (Admission weight of 151.2 lbs), 1/4/22 (137.4 lbs), and 1/5/22 (137 lbs). On 2/23/22 surveyor requested a current weight for R12, it was 135.8 lbs. Review of a Nutritional Assessment Progress Note dated 1/11/22, written by Certified Dietary Manager (CDM A) revealed, Significant Loss .(R12) has sustained a 9.4% in 20 days weight loss. No weights for 90 or 180 days .He is required 1:1 feeding .cbw (current body weight) is 137. During an interview on 2/23/22 at 11:30 a.m. when asked if R12 has lost any weight recently and when did the weight loss occur CDM A stated that (R12) triggered for severe weight loss last month. We liberalized his diet, asked for weekly weights and he is on the nutritional supplement. I request for weekly weights from nursing if I don't get them then I don't. During an interview on 02/24/22 at 9:45 a.m. when asked when they were notified of R12's weight loss, RD B replied, I am not sure. No weekly weights were completed. When asked who is involved in evaluating and addressing any underlying causes of nutritional risks or impairment, RD B replied, If I am notified of an impairment I reach out to the CDM and get their assessment and observations of the residents, intakes, and preferences. I review the chart and try to figure out what's going on. When asked if R12 lost any weight recently RD B replied, Yes. When asked when the weight loss occurred, RD B stated, I am not sure there was no weekly weights done. If there was I would have gotten it the next week.

This citation pertains to intakes #MI 635 and #MI 441. This citation has two deficient practice statements. Deficient Practice Statement #1: Based on interview and record review, the facility failed to reassess, monitor, treat in a timely and appropriate manner a resident with low blood pressure level, for one (R#122) of two residents reviewed for change of condition, resulting in the resident becoming non-responsive, a transfer to the hospital emergency department, ICU (Intensive Care Unit) admission, and placed on a ventilator. Findings Include: A complaint was filed with the State Agency (SA) on 1/28/20 that alleged the facility failed to assess and monitor the resident for respiratory distress resulting in ICU admission. The complaint further read, On 1/28/20 the facility was going to discharge the resident, but the daughter said the resident was not well enough to be discharged . The resident had a mental status change and was having difficulty breathing the daughter told the staff to call 911. The resident was admitted to local hospital (Name Redacted) 'Y' and sent to the ICU on a ventilator. Review of the clinical record revealed R#122 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the 14-Day Minimum Data Set (MDS) assessment dated [DATE] revealed R#122 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicting severely impaired cognition and required extensive assistance with one-person physical assist for most ADL care. R#122's care plan revealed the following: Focus: (R#122) is at risk for cardiac distress R/T (related to) DX (Diagnosis) of HTN,[MEDICAL CONDITIONS] . Support/Task: Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate ([MEDICAL CONDITION] and effectiveness . Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, [MEDICAL CONDITION] activity, difficulty breathing (Dyspnea). Vital signs as ordered. Progress Note dated 1/28/2020 at 08:35 (8:35 am) . Skilled Evaluation . Vitals: Temperature: T 98.4 - 1/28/2020 08:35 Route: Oral Blood Pressure: BP 98/56 (Normal is 120/less than 80), - 1/28/2020 08:36 Position: Other Pulse: P 72 - 1/28/2020 08:36 Pulse Type: Regular . Respiration: R 18 - 1/28/2020 08:36 O2 sats: O2 94 % - 1/28/2020 08:36 Method: Room Air Blood Glucose: (Blank) Weight: W 63.0 lb. - 1/16/2020 19:06 Scale Indicators of pain: None. Progress note dated 1/28/2020 at 09:39 (9:39 am) Orders - Administration Note Text: flush peg tube 100 cc (cubic centimeter) water every shift to maintain patency every shift Refused x 3. There were no progress notes or documentation of R#122's condition after 9:39 a.m. until 5:06 p.m. (approximately 8 hours) before R#122 was found unresponsive by the nurse. The facility failed to identify R#122's declining change of condition before the family identified it first. Progress note dated 1/28/2020 at 17:06 (5:06 pm), Note Text: Daughter was here to pick up the resident and the CNA (Certified Nursing Assistant) went into the room to assist the resident to put on her coat. Daughter was agitated r/t (related to) discharge. Per CNA the daughter was on the phone upset about being discharge. Resident was alert and verbal. Writer and the nurse from the other hall were notified by the daughter that the resident was now breathing like crap. Nurse from the other hall went into the room. Writer also went into the room and observed the resident unresponsive . BP (Blood Pressure) was 88/43 with the machine. Unable to obtain a manual BP. Pulse Ox (Oximeter) registered between 67%-74% on room air. Heart Rate was 48. Respirations were 28 with rhonchi (rattling lung sounds) noted. Accu check (glucose monitoring use for diabetes) was 141. Breathing treatment was given. D.O.N. (Director of Nursing), writer and nurse from the other side were at the bedside. NRB (non-rebreather mask) applied. 911 called. ER (emergency room ) and doctor notified. Review of the local hospital (Named Redacted) 'Y' medical records revealed the following: Date of Admit: 01/28/2020 18:24 (6:24 p.m.) thru Date of Service: 02/10/2020 (13 days) Reason for hospitalization : Dyspnea Last Set of Vitals: BP: 93/52 - 2/10/20, Pulse: 93 - 2/4/20, . O2 Sat: 59.0% (100%) (Ventilator) - 2/8/20, Heart Rate: 65 - 2/10/20 Hospital Course: .(Identity Redacted) (R#122) who presents to local hospital (Name Redacted) 'Y' ED from facility (Name Redacted) for [MEDICAL CONDITION] (absence of enough oxygen in the tissues to sustain bodily functions) and increased work of breathing. Patient was found to be saturating in the low 60s which did not improve with non-rebreather breathing treatments <sic> Per nursing report, there was concern patient aspirating earlier during the day . In the ER patient was placed on [MEDICAL CONDITION] with slight improvement. She was also found to be hypotensive with systolic 80s . Her mentation continued to decline and there was concern for inability to protect her airway; subsequently patient was intubated . She was .transferred to the ICU for further management . admitting [DIAGNOSES REDACTED].[MEDICAL CONDITION] Disorder .Esophagitis and gastritis . Essential Hypertension, [MEDICAL CONDITION] . On 9/28/20 at 1:50 p.m., an interview was conducted with the DON regarding R#122's low blood pressure. The DON was asked what was the facility's protocol when a resident is not at their baseline regarding vitals? The DON stated, She (R#122) ran low. She was really little. The nurse would not have taken vitals because that was her (R#122) norm. I think it was her sugar that dropped. The doctor was here. I think he saw her .She was going to be discharged . There was no documentation in the clinical record that R#122 was seen by the physician after their decreased blood pressure level. Blood Pressure Vitals from 1/11/20 (readmission) to 1/28/20 (discharge) revealed the following: 1/28/2020 16:03 88 / 43 mmHg Other (Manual) 1/28/2020 08:36 98 / 56 mmHg Other (Manual) 1/27/2020 12:40 105 / 70 mmHg (Manual) 1/27/2020 03:30 133 / 82 mmHg Sitting r/arm (Manual) 1/26/2020 16:02 121 / 53 mmHg (Manual) 1/26/2020 03:30 118 / 73 mmHg Lying l/arm (Manual) 1/25/2020 12:13 105 / 73 mmHg (Manual) 1/24/2020 14:13 106 / 55 mmHg (Manual) 1/18/2020 13:46 101 / 60 mmHg Sitting r/arm (Manual) 1/14/2020 08:01 133 / 70 mmHg (Manual) 1/13/2020 11:35 105 / 67 mmHg (Manual) 1/12/2020 10:44 153 / 98 mmHg (Manual) 1/12/2020 02:19 120 / 87 mmHg Lying l/arm (Manual) 1/11/2020 13:06 112 / 59 mmHg (Manual) 1/11/2020 03:47 127 / 73 mmHg Lying l/arm (Manual) When queried if former Nurse 'Z' should have reassessed (within 8 hours), documented, and/or reported (R#122's) abnormal vitals on 1/28/20) to the Unit Manager/Charge Nurse, DON or called the physician, the DON stated, They (Nurse 'Z') should have reassessed (R#122) if (their) blood pressure was low. A review of the facility's policy titled Change in a Resident's Condition or Status - Protocols and Standards revised 9/28/20 read in part as follows: Policy Statement: Facility (Name Redacted) will promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care .Policy Interpretation and Implementation: 1. The Nurse Supervisor/Charge nurse will notify the resident's Attending Physician or On-Call Physician when there has been .d. A significant change in the resident's physical/emotional/mental condition .f. Refusal of treatment or medications (i.e., two (2) or more consecutive times); g. a need to transfer the resident to a hospital/treatment center .2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when .b. There is a significant change in the resident's physical, mental, or psychosocial status .6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . Deficient Practice Statement #2: Based on observation, interview and record review, the facility failed to ensure that ted ([MEDICAL CONDITION] disease) hose (elastic stockings that compress the veins in the lower limbs) were consistently applied per physician's order for one (R#17) and provide skin/wound treatments per physician orders for one (R#121) resident of two resident reviewed for physician orders, resulting in continuous swelling and the potential for blood clots to form for R#17 and the potential for delayed surgical healing, worsening of skin conditions and infection for R#121. Finding Include: R#17 Review of the clinical record revealed R#17 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE] R#17 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition and was independent with no assistance from staff for activities of daily living. On 9/22/20 at 9:47 a.m., R#17 was observed in bed. Their legs, ankles and feet were [MEDICAL CONDITION]. When asked questions about their care at the facility, R#17 stated, My legs are swelling like crazy. I wish the swelling would go down in my legs. They were wrapping them. I don't know why they stopped. I told the nurse, she said, 'She don't know why they stopped wrapping them. A physician's order started 7/16/20 revealed the following: TED hose to be applied every morning and dc'd (discontinued) every evening Once A Day 06:00 AM On 9/22/20 at 3:30 p.m., during the Confidential Group meeting, R#17 was not wearing Ted Hose as prescribed by the physician, but instead, R#17 was wearing non-skid socks on their swollen feet. On 9/23/20 at 12:10 p.m., Resident was observed in bed with [MEDICAL CONDITION] (swollen with excessive accumulation of fluid) legs. When asked if they were supposed to have Ted Hose on their legs, R#17 stated, Yes. R#17 was observed without Ted Hose. When asked the last time they wore Ted Hose on their legs, R#17 stated, I don't know. On 9/23/20 at 3:30 p.m., during an interview, when asked how it was determined when to apply R#17's Ted Hose, Certified Nursing Assistant (CNA) 'I' stated, If it's in their care, I just make sure they are on. The nurses will let us know. On 9/23/20 at 3:35 p.m., Registered Nurse (RN) 'F', was asked who was responsible for the application of R#17's Ted Hose. RN 'F' stated, It's on the MAR and the nurses just have to make sure the CNAs apply them. Whether delegate or just do it themselves. On 9/23/20 at 3:45 p.m., an observation of R#17's legs was made along with CNA 'O'. R#17 was not wearing Ted Hose. R#17 was queried as to why they were not wearing Ted Hose. R#17 stated, I don't know. On 9/23/20 at 3:50 p.m., RN, 'F' was queried why R#17 was not wearing Ted Hose. RN 'F' explained the midnight shift was supposed to put them on. When asked if the midnight shift did not apply R#17's Ted Hose, who was supposed to put them on? At that time, RN 'F' was asked when they went into R#17's room to administer medication, if they checked to see if R#17 was wearing their Ted Hose, RN stated, No . On 9/23/20 at 4:00 p.m., an interview was conducted with the DON regarding the application of R#17's Ted Hose. The DON stated, They (nurses and CNAs) should put them on. It was on the Medication Administration Record (MAR) and not the Treatment Administration Record (TAR) for the CNAs to see it . Review of the MAR for September 2020 did not reveal an order for [REDACTED].#17's Ted Hose. On 9/24/20 at 2:55 p.m., R#17 was in bed with bilateral ace bandage wraps. R#17 stated, They wrapped them since they don't have the stockings. Review of the facility's policy titled Applying anti-Emboli Stockings (Ted Hose) revised 8/5/2020 read in part as follows: Purpose .to improve venous return to the heart, to improve arterial circulation to the feet, to minimize [MEDICAL CONDITION] to the legs and feet, and to prevent complications associated with [MEDICAL CONDITION] and [MEDICAL CONDITION] embolism. Preparation: 1. Verify that there is a physician's order for anti-emboli stockings .2. Review the resident's care plan to assess for any special needs .General Guidelines: 1. If possible, anti-emboli stockings should be applied in the morning, prior to the resident getting out of bed. 2. Remove the stockings every eight (8) hours and inspect the skin. Leave the stockings off for 30 minutes and then reapply, as ordered .Assessment: 1. Assess the lower extremities for: a. Posterior tibial and dorsalis pedis pules .b. Skin color, temperature and condition, skin irritation, and open areas; c. Presence of [MEDICAL CONDITION] .d. Pain or tenderness in the calf .Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that anti-emboli stockings were applied. 2. The stocking size and length .5. The schedule of removal and reapplication. 6. If the resident refused the treatment, the reason(s) why and the intervention taken. 7. The name and title of the individual(s) who performed the procedure. Reporting: 1. Notify the supervisor if the resident refuses the procedure . R#121 On 9/22/20 at 11:30 AM, R#121 was observed lying in bed with an [DEVICE] with pins to the right lower extremity. The resident reported he was recently involved in a car accident and recently admitted to the facility. When asked about the facility's provision of wound care, R#121 reported no one had completed any wound care since admission on 9/17/20 and was unsure how often that should be done. A review of the clinical record revealed R#121 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. There was no completed minimum data set (MDS) assessment completed for review at this time. A review of R#121's admission hospital records documented, .Pt presented to (name of local hospital) on 8/29/2020 s/p (status [REDACTED]. pt was front passenger, front end collision - resulting in air bag deployed .Imaging showed right tibial plateau fracture with associated proximal fibula fracture . A review of R#121's physician orders for wound care since admission included: On 9/18/20, PIN CARE every other day, cleanse around pin, wrap xerofprm <sic> gauze around each pin site and cover with 4x4 drain sponge, then wrap with [MEDICATION NAME] and wrap entire ex-fix with 6 inch ACE wrap .Once A Day Every Other Day. A review of R#121's documentation on the Medication/Treatment Administration Records (MAR/TAR) since admission revealed R#121 the following: A comment documented by Nurse BB on 9/18/20 at 10:45 AM read, Not Administered: Other .done yesterday at hospital. due to be changed tomorrow. The entry sections on the MAR/TAR for 9/19 and 9/21 were left blank (incomplete). There was no further documentation including a progress note that the treatment had been completed, or that the physician had been notified of the missed treatments and/or provided alternate wound care instructions. On 9/22/20 at 1:02 PM, an interview with the assigned nurse (Nurse BB) was conducted. When queried about R#121's pin care, Nurse BB reported, He has pin care every other day. Nurse BB was asked to review the treatment record to see when the pin care was last documented as completed and upon review documentation an electronic notification on the screen read, Last Administered 9/18/20 at 9:00 AM (however documentation on 9/18 reflected wound care was not done on 9/18 since it was done at the hospital on 9/17). When asked why pin care had not been provided since admission, Nurse BB reported she was not sure but would follow up. On 9/23/20 at 9:23 AM, an interview and record review was completed with the Director of Nursing (DON). Upon review of R#121's wound care documentation, the DON confirmed the blank entries and when asked what the facility's process was for missed or delayed treatments, the DON reported, Most treatments I put on day shift. If nurses wanted to pass on to another shift they can. They can change and put in a one-time order. The DON was unable to explain why no one else had identified the concern regarding missed treatments. According to documentation, the last time R#121 had received pin care was at the hospital (5 days earlier). A review of the facility's Wound Care policy dated Reviewed 9/22/20 documented, in part: .The following information should be recorded in the resident's medical record .The type of wound care given .The date and time the wound care was given .The name and title of the individual performing the wound care .If the resident refused the treatment and the reason(s) why .Report other information in accordance with facility policy and professional standards of practice .

This citation pertains to intake #MI 441. Based on observation, interview and record review, the facility failed to ensure ongoing assessment, monitoring, and implementation of nutritional interventions upon identified changes in status for one (R2) of five residents reviewed for nutrition/food, resulting in a severe weight loss (-6.7% in six days) likely due to lack of timely monitoring, reassessment, and implementation of planned interventions, and the increased likelihood for further decline in overall health status. Findings include: A review of the facility's menus for the week which included all therapeutic diets revealed: the lunch meal to be provided on Tuesday 9/22/20 was: tuna casserole, vegetable blend, dinner roll, margarine, orange sherbert, 2% milk, coffee, and hot tea; the breakfast meal to be provided on Wednesday 9/23 was: orange juice, oatmeal, sausage pattie, muffin, margarine, jelly, 2% milk, coffee, and hot tea. (res had only oatmeal, sugar packets and orange juice (thickened). A review of the clinical record revealed R2 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R2 had moderately impaired cognition, required supervision with set up for eating, received a mechanically altered diet, had a weight of 155 with no weight changes (either increase or decrease). Review of the previous MDS assessment dated [DATE] documented R2 had a weight of 166 pounds. A review of the interdisciplinary progress notes revealed: On 9/3/20 at 3:56 PM, an entry by Nurse E read, Pt (patient) observed having difficulty while eating. OT (Occupational Therapy) notified. On 9/4/20 at 2:04 PM, an entry by Nurse V read, Pt observed having difficulty while eating. OT notified. A review of the therapy documentation provided by the facility revealed R2 had been seen by occupational therapy four times during the 9/7/20 - 9/17/20 progress period. Therapy documentation completed by OT Staff W read, in part: .pt (patient) scored 10/30 normalized for education level, this score indicated markedly impaired cognition and new learning capability. For this reason, pt would not benefit from further skilled training to increase .independence. Pt will continue to require a substantial amount of supervision and cuing for functional activities due to pathology of medical dx (diagnosis) .Treatment results communicated to Interdisciplinary Team .Discharge Recommendations: Divided plate with dycem, up in chair during all meals to promote self feeding independence and allow pt to live in least restrictive environment .Pt issued divided plate and (namebrand of a non-slip material) for feeding assistance, AE (Adaptive Equipment) given to dietary manager to implement during mealtimes . A review of R2's current physician orders [REDACTED].>Ordered 5/30/20, Diet: Regular diet, puree texture, nectar thickened liquids. Ordered 9/11/20, Pt (patient) to be up in cardiac chair and supervised during mealtimes. With Meals 08:00 AM, 12:00 PM, 06:30 PM. Ordered 9/11/20, Pt to use divided plate placed on (namebrand of a non-slip material) during mealtimes. With Meals 08:00 AM, 12:00 PM, 06:30 PM. On 9/22/20 at approximately 1:00 PM, R2 was observed seated in a gerichair recliner with an overbed tray table in front of the resident. R2 was very thin and had long fingernails with dark debris underneath the nail tips. R2 repeatedly attempted to scoop up orange liquid that had spilled all over the food tray with a spoon and fingers. There were two small food bowls, one had green colored pureed food (vegetable blend) and one had tan colored pureed food (tuna casserole). The only other food on the meal tray was an empty container of ice cream (orange colored which had melted over the entire meal tray). There was no divided plate or non-slip material utilized. Further review of the meal ticket on the meal tray documented R2 was to receive pureed foods with large portions and nectar-thick coffee (although the double portions were not specified in the physician orders). R2 was asked about the lunch meal and although was very slow to respond, stated I'm hungry. Throughout this meal observation, there were no staff observed supervising the resident during the meal. On 9/23/20 at 8:45 AM, Nurse F was observed to enter R2's room (resident was already observed eating the breakfast meal), obtain a blood pressure reading and immediately exited the room. On 9/23/20 at 8:47 AM, R2 was observed seated in a gerichair recliner with an overbed tray table in front of the resident. R2's breakfast meal consisted of two containers of oatmeal, three unopened sugar packets and thickened orange juice. R2 attempted to scoop oatmeal from the small container which slid around the meal tray. There was no divided plate, non-slip material, nor was there any protein item (such as the sausage) provided on the meal tray. On 9/23/20 at 8:49 AM, Certified Nursing Assistant (CNA B) was queried about R2's breakfast meal and what food was usually provided. CNA B confirmed there was only oatmeal, sugar packets and orange juice on the meal tray and reported, It's oatmeal, usually give yogurt and applesauce. When asked about whether R2 used a divided plate with non-slip material, CNA B denied being aware of the resident's need for either item. When asked how information was provided to staff of resident's specific care needs, CNA B reported there was a care guide in the (name of current electronic medical record/EMR) system. At that time, CNA B was asked to access R2's care guide via the EMR and upon review confirmed there was an order for [REDACTED]. CNA B proceeded to follow up with the Dietary & Housekeeping Manager (Staff J). On 9/23/20 at 8:57 AM, Staff J was observed walking into R2's room while holding a divided plate still encased in a plastic covering. When asked about the divided plate, Staff J reported, The problem is we (facility) don't do the dishes. This (pointed to divided plate in plastic) was on my desk. Problem is we don't wash our own dishes (resident dishware sent to another facility for cleaning) then it's brought back later. So at the end of the day, this was not available. When asked about the resident's lack of protein or nutritional shakes provided with the breakfast meal, Staff J reported There is sausage. When asked if there was more than one divided plate available to ensure R2 did not go without at all meals, Staff J offered no further response. When asked if residents on pureed diet would receive sausage in pureed form, Staff J reported, (R2) should've received even if pureed. I can get him some. On 9/23/20 at 9:10 AM, Staff J was observed to provide R2 a divided plate which had the small food bowls of oatmeal and applesauce placed directly on top of the divided sections of the plate (food was not directly placed into the divided plate). Continued observation of the breakfast meal revealed Staff J did not ask the resident if they wanted any additional food and did not provide any additional food such as the sausage mentioned earlier, or a nutritional shake. On 9/23/20 at approximately 10:30 AM, an interview was conducted with RD C. When queried about R2's weight and nutritional status and whether there were any reported concerns for R2's such as decreased oral intake, difficulty eating, or ability to feed self, RD C denied being aware of any recent concerns or changes. RD C was requested to obtain and observe a current weight. On 9/23/20 at approximately 10:50 AM, an observation of R2's weight revealed a current weight (taken while R2 stood on the scale) as 133.4 pounds. The last documented weight for R2 was on 9/17/20 as 143 pounds (a severe weight loss of 6.71% in six days; facility policy noted 5% in one month was considered severe). On 9/23/20 at 11:04 AM, RD C was requested to provide any additional documentation regarding R2's weights, assessments and care plans as the facility had previously used another EMR system prior to June 2020. RD C was asked about the 10 pound weight loss in just under one week and did not offer any further response or explanation. On 9/23/20 at 11:25 AM, RD C confirmed the last documented nutritional assessment was completed on 7/23/20. When asked about the observation of the orange liquid observed at the lunch meal on 9/22/20, RD C reported, That (orange sherbert) does not come in nectar thick consistency and (R2) should not have received the orange sherbert, but should've had a nutritional supplement. When asked to clarify what kind of supplement, RD C stated, It's usually a mighty shake that's thickened. When asked about the discrepancy between the meal ticket which documented double portions, and what was observed provided to R2, RD C stated, That is not double portions. A review of R2's nutritional documentation provided by RD C included: A nutrition care plan which had been initiated 6/10/20, with no further revisions/interventions implemented. This care plan documented, in part: Problem Start Date: 06/10/2020 .Resident has potential alteration in nutritional status R/T (related to) PMH (past medical history) of: DYSPHAGIA; [MEDICAL CONDITION]; IS ON MECHANICALLY ALTERED DIET of Puree with nectar thick liquids. New baseline weight is 140#. Res is able to stand. An Activities of Daily Living (ADL) care plan initiated 6/10/20 included interventions that read, Approach Start Date: 09/22/2020, divided plate with meals and Approach Start Date: 09/22/2020 dycem to w/c (wheelchair); up for meals. R2's nutrition assessments (most recently completed by RD C on 7/23/20 at 3:50 PM) documented, Res presents with change in weighing method from wheelchair to standing resulting in a significant weight change of 10.7%, will reweigh again and weigh weekly x 4 weeks to ensure that new baseline weight is accurate. There have been no reports of declining appetite and resident is alert and can hold conversation, can tell you what he likes and he can feed himself with set up. Res is provided a puree diet with NTL's (nectar thick liquids) which has been tolerated well for some time. Res current weight is 140# which resident remembered and he was able to recall that he stood and explained that people didn't know he can stand. As a precaution, will add a supplement at lunch and follow weight again x 1 week. There was no further nutritional assessment by RD C since this assessment, or following identified changes as reported by nursing on 9/3 and 9/4. R2's weights provided by RD C included: 6/7/20=155 pounds (lbs); 7/23/20=140 lbs; 7/30/20=140 lbs; 8/6/20=140.1 lbs; 9/17/20=143. The weights were not completed weekly x 4 as indicated in the nutrition assessment on 7/23/20 (no weight from 8/7/20 - 9/16/20). There were no weights provided prior to 6/7/20 as requested since R2's admission. On 9/23/20 at 12:22 PM, RD C was asked about the lack of revised interventions since 6/10/20 and nutritional assessment following the 7/23/20 assessment, RD C provided no response. When asked if there was any physician involvement or notification regarding any unintended weight loss, difficulty eating, or nutritional concerns for R2, RD C stated, No. I'm only here one time a week. We do (review) at risk weekly meetings, the DON (Director of Nursing) will identify and notify the physician. At that time, RD C was requested to provide any physician documentation for follow up for R2's nutritional needs and reported he would follow up. On 9/24/20 at 11:00 AM RD C provided additional documentation which included a restorative care program following R2's recent discharge from Occupational Therapy with an effective date of 9/11/2020 which read, Goals for Restorative Program: 1) Preserve pt's (patient's) ability to self-feed safely and effectively to decrease risk of malnutrition. Approach/Recommendations for implementation for above goals: 1) Pt to be up in geri-chair and supervised during meal times 2) pt's food to be served on divided plate placed on (namebrand of non-slip material) Precautions or Comments to this program: puree diet, nectar-thick liquids. This form was only signed by the therapist on 9/11/20 and the section of the form for the restorative nurse/aide was left blank. On 9/24/20 at 11:24 AM, the DON was asked about the facility's restorative care program and reported, We all do it (restorative). When asked if the facility had a restorative program, the DON reported, We just put the order in we don't actually have a restorative program. When asked about the recommendation for increased supervision with meals and informed of the lack of supervision with meals throughout the survey, the DON offered no response. On 9/24/20 at 11:51 AM, Therapy Manager D was asked about the facility's process following resident's completion of therapy and recommendations for nursing and reported, When done with therapy, nurses put in order to follow whatever recommendation was identified. Not aware of an actual restorative program here. A review of the documentation provided by the facility included the following policies: A Nutritional Assessment policy dated Reviewed 9/23/2020 documented, in part: .The Dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident .and as indicated by a change in condition that places the resident at risk for impaired nutrition . A Nutrition (Impaired)/Unplanned Weight Loss policy dated Reviewed 9/23/2020 documented, in part: .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month - 5% weight loss is significant; greater than 5% is severe .The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include .Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals .

This citation pertains to Intake #MI 489 Based on interview and record review the facility failed to initiate Cardiopulmonary Resuscitation (CPR) and promptly call 911 for one (#14) of one Resident reviewed for CPR who had a documented full code status resulting in an Immediate Jeopardy (IJ) when the Resident was found unresponsive with no pulse or respirations. This had the likelihood to cause serious injury, harm and/or death. Findings include: The IJ started on [DATE]. The IJ was identified on [DATE] at 4:52 PM. The immediacy was removed on [DATE] based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with actual harm that is not an immediate jeopardy. On [DATE] a review of a Facility Reported Incident (FRI) reported to the State Agency included an allegation that R#14 was found unresponsive and CPR was not started by Licensed Practical Nurse (LPN) 'E', and that LPN 'E' did not call 911 per facility policy. According to the FRI, under 'Investigatory Information' the following was documented: Reason for Investigation: CPR not started. How did it occur? CNA (Certified Nursing Assistant) 'D' observed resident unresponsive and call for nurse immediately. Nurse arrived in resident's room and assessed resident immediately. Actions taken during investigation to protect resident and like-residents: Nurse suspended pending investigation. On [DATE] Nurse was terminated from (Name of Facility). Investigatory conclusion statement: Substantiated CPR was not started. Per nurse's assessment / interview 'resident was already gone.' On [DATE] a record review was conducted. During the review, it was discovered R#14 was originally admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS) assessment with an assessment reference date of [DATE], R#14 had a staff assessment of Moderately Impaired cognition. The MDS assessment also indicated R#14 was totally dependent on staff for all activities of daily living. According to an order dated [DATE], R#14 was a Full Code. A further record review revealed a progress note written by LPN 'E' on [DATE] that read, Resident received at 7pm in bed this writer observed resident at appx 7:45pm resting without s/s (signs or symptoms) of discomfort or distress. At appx 9:40pm while passing medications this writer was called by cna (CNA 'D') to resident room, upon entering the room resident was observed with my (sic) wide open pupils dilated. Skin was warm to touch, writer called resident names (sic) twice then shook him and he did not respond, writer was unable to obtain a pulse and there was no respirations observed. Director of Nurses was phone (sic) at 10:10pm with no answer, no message was left by writer, writer then phoned administrator and informed her that resident had expired, she stated to call the doctor and the family . Review of an interview statement given by LPN 'E' dated [DATE] as part of the facility's investigation, the following was documented, Employee stated she observed resident from the doorway approximate 7:50pm. At approximately 9:40pm she was passing medication and the CNA (CNA 'D')said Nurse, I need you in here. The nurse went in resident's room (R#14) called his name, shook him and looking at him, his mouth was open and pupils dilated. At 10:10pm she called (Director of Nursing), DON. She didn't leave a voicemail. The employee called NHA (Administrator) . Employee stated she called the doctor and checked the code status after 10pm and before NHA was notified. Employee stated she didn't start CPR because she knew he was gone . Review of an interview statement given by CNA 'D' dated [DATE] as part of the facility's investigation, the following was documented, Upon entering the room employee observed he (R#14) did not appear to be breathing. She called out to him and rubbed his arm. His skin color was off. He looked pale. Employee checked his carotid and radial pulse which was absent. She called the nurse (LPN 'E'). The nurse arrived to the room right away. The nurse checked the resident and said she had to call and talk to someone . On [DATE] at 2:18 PM a phone call was made to LPN 'E' and a message was left. LPN 'E' did not return the call prior to the end of the survey. On [DATE] at 2:22 PM a phone call was made to CNA 'D' and a message was left. CNA 'D' did not return the call prior to the end of the survey. On [DATE] at 2:30 PM a phone interview with CNA 'C' was conducted. During that interview CNA 'C' was asked about R#14. CNA 'C' replied that she had worked on [DATE] from 7:00 AM to 7:30 PM and been assigned R#14's room. CNA 'C' stated, I did not notice anything different with (R#14) during the day. On [DATE] at 2:39 PM an interview with LPN 'A' was conducted. During that interview LPN 'A' revealed she had worked on [DATE] from 7:00 AM to 7:30 PM. LPN 'A' was queried about R#14. LPN 'A' replied, There was nothing out of the ordinary with him, I was very shocked when I heard (about R#14's death). LPN 'A' was asked when was the last time she had observed R#14, LPN 'A' replied, it was after dinner, about 5:30 - 6:00 PM. On [DATE] at 3:04 PM an interview with the Administrator for the facility was conducted. During that interview the Administrator was queried about the FRI involving R#14. The Administrator stated, (LPN 'E') had only been here two weeks, she had gone through all the training, I had done a lot myself. She had her Basic Life Saving (BLS) card and knew how to do CPR. The Administrator was asked what should have been done per facility policy. The Administrator replied, (LPN 'E') should have called 911 and started CPR. The Administrator was asked how a nurse would know if a resident was full code or not, the Administrator replied, When you pull up a resident in the computer, it is listed on the banner at the top of the page. Per the Administrator all the residents in the facility were full code at the time of the incident. On [DATE] a review of a copy of a BLS card for LPN 'E' documented the employee was certified on [DATE]. The card indicated it was valid for two years. A review of the facility's policy titled, Emergency Procedure-Cardiopulmonary Resuscitation revised [DATE] read, 8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 9. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR . The facility submitted the following acceptable plan including supporting documentation to remove the immediacy on [DATE]: IJ Plan of Removal for CPR Not Performed * Administrator notified of Immediate Jeopardy for CPR not performed on [DATE] * Resident no longer resides in the facility. The Nurse was suspended immediately and terminated at the end of the investigation for failure to follow facility policy and procedure. * A code status audit was immediately completed for all current residents. All residents have an order for [REDACTED].>* An advance directive audit was completed weekly with no concerns noted. * Policy on CPR and death of a resident was reviewed and deemed appropriate. * All Nurses & CNA's were educated on emergency actions to be taken in the event a resident is observed without vital signs or a significant change in condition. * Recognizing resident deterioration * Assessment and activation (Starting CPR, calling 911) * Calling Physician, if no return call back. Call Medical Director * Calling Code Blue via Hospital system * CPR continuing until 911 arrives * Ventilation * Notifying emergency contact for resident * Facility policy for CPR & Death of a resident * Mock code was preformed with all staff responding appropriately. * CPR policy and education were added to the Facility Orientation packet.

This citation pertains to MI 544 Based on observation, interview and record review, the Facility failed to prevent staff to resident abuse for one resident (#701) out of three reviewed for abuse, from a total sample of three, following resident #701's refusal to loan money to a Facility staff member who forcibly bent the resident's index finger backwards, resulting in a fracture to the right index finger, pain, reduction in the Resident's ability to self ambulate in a wheelchair, hospital treatment and mental anguish. Findings include: On 5/15/18 the Facility reported to the State Agency that Resident #701 alleged being physically abused. On 5/30/18 at approximately 9:00 AM, Resident #701 was observed sitting in a wheelchair in the dining room watching television. The Resident was wearing a split on her right hand with gauze wrapped around the entire hand and extending past the wrist. The Resident was queried as to what happened to her hand. Resident #701 stated, A woman, who looked Mexican, came into my room and asked to borrow $20, when I told her No, she bent my hand all the way back and broke my finger. (Resident #701 demonstrated how her hand was pushed back and pointed to her right index finger.) Resident #701 reported that another woman with long hair witnessed the incident. Resident #701 was queried as to whether the women who hurt her finger worked at the Facility, Resident #701 stated, Yes, but she doesn't anymore. Resident #701 reported that she told people what happened on that day and reported that she was in pain to other staff members. When queried as to what happened following the incident, Resident #701 stated, It (right finger/hand) was hurting me and then next day I got an X-ray and then I went to the hospital and they put on this cast. It still hurts. I have to go back to the doctor. On 5/30/18 at approximately 09:50 AM a review of the Resident's clinical record documented that Resident #701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Resident's Minimum Data Set ((MDS) dated [DATE] documented that the Resident had a Brief Interview of Mental Status (BIMS) score of 12/15 (moderately impaired). and require limited to extensive one person assist for all ADL's (activity of daily living.) On 5/30/18 at approximately 10:00 AM, the Facility's investigation documentation was reviewed and documented, in part, the following: 5-day investigation summary Investigation reason: Resident (name redacted) #701 (room # redacted) allegation of physical abuse .Incident Summary: On 5/15/18 at 8:30 am DON (director of nursing) notified administrator that resident #701 (name redacted) had alleged abuse by a CNA (certified nursing assistant). Administrator and DON interviewed resident who stated on 5/14/18, 2 (two)CNA's came into her room. One CNA asked to borrow $20, Resident wouldn't lend her the money so the CNA bent her (R) finger/hand all the way back. The other CNA was at the end of the bed watching . Investigation commenced immediately .Staff interviewed (staff names are redacted) .CNA C, CNA D, CNAE, Nurse F, CNA G, CNA H, Housekeeper I, CNA J, Nurse K, CNA L, CNA M, Nurse N New order received for STAT X-ray of (R) right hand/fingers. X-ray result showed a non-displaced [MEDICAL CONDITION] base of the proximal (middle) of the right index finger with adjacent soft tissue swelling. Resident sent to ER for further evaluation. Returned with soft cast and orders to follow-up .Sheriff arrived on 5/16/18 .Detective (name redacted) arrived on 5/17/18 and returned on 5/18/17 . Investigation conclusion statement(emphasis added): The investigation was able to substantiate 1 CNA E ( name redacted) physically abused resident per resident identification and 1 CNA D (name redacted) witnessed the incident. Resident Investigation Interview: Resident's Name (redacted) #701: Date of situation: 5/14/18 .Resident interviewed by Administrator and DON at 5/15/18 at 8:30 am upon receiving report of resident allegation that a CNA bent her finger back on 5/14/18. Resident asked what happened to her (R) hand. Resident stated: Yesterday before lunch I woke up and I was out for a while. 2 CNA's came to change me. 1 CNA had long hair, maybe she was Mexican. The other CNA was white. She stood back laughing while the other CNA asked to borrow $20. I told her I didn't have it She grabbed my hand and bent my finger all the way back. Resident asked how she knew they were CNA's resident stated because of the color of their uniforms. It was burgundy. Also because they take care of me and they clean the room Resident stated she would recognize the staff member if she saw her again .On 5/16/18 Resident and Administrator viewed camera surveillance together. Resident identified both CNA's involved in incident. Resident identified (name redacted) CNA E as the CNA that physically hurt her and CNA D (name redacted) as the CNA who stood by and watched (name redacted) CNA E hurt resident. (name redacted) Resident #701 states she is 100% sure of identification of these CNA's. Continued review of Resident 701's Hospital Record and medical records was conducted on 5/30/18 at approximately 10:45 AM and documented, in part, the following: Hospital Emergency: admitted /time: 5/15/2018 (16:09) Chief Complaint: upper extremity pain Pain Assessment: Score 8/10. Imaging Department (name redacted): Findings: There is a non-displaced fracture at the ulnar base of the proximal phalanx of the index finger with adjacent soft tissue swelling. Name Redacted (Psychology follow-up re allegations of patient of staff physical assault) Date: (MONTH) 16, (YEAR) Asked to see the patient who alleged that a female staff assaulted her, causing injury to the right arm which is bandaged .Conclusion: patient appeared consistent in the story of being assaulted by a female staff member after the patient was unable to loan her $20. She also seemed confident in her identification of both women involved. Anxiety was WNL (within normal limits .Assessment & Plan: Adjustment disorder with anxiety: Plan Crisis evaluation. On 5/30/18 at approximately 3:00 PM an interview and record review was conducted with the Administrator regarding the incident involving Resident #701. The Administrator was queried as to her investigation conclusion statement that read: The investigation was able to substantiate that CNA (E) physically abused resident per resident identification and another, CNA (D), witnessed the incident per resident investigation. The Administrator confirmed her investigation conclusion. The Administrator reported that the on 5/15/18 the DON reported to her that CNA D had informed her that morning that contingent CNAM had told her that Resident #701's reported to her that her finger was bent back and it hurt. The Administrator stated, When I received the information I started to immediately investigate. I interviewed Resident #701 early that morning and Resident #701 reported that two women were in her room and one bent her finger back and another watched. Later I watched a video with Resident #701 that was recorded on 5/14/18 of staff entering in and out of Resident #701's room. Resident #701 was able to identify CNA E as the person who bent her finger back and CNA D as the one that watched. Resident #701 was sent to the emergency room Hospital and treated for [REDACTED]. She still is receiving care for the injury. On 5/30/18 at 4:00 PM a review of the Facility Policy titled, Resident Abuse/Neglect (Policy revised 10/4/2017) was conducted and documented, in part, the following: Policy Statement: The facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately .1.Abuse is defined as willful infliction of injury .Willful as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .RESPONSIBILITY 1. The Administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures .RECOGNIZING ABUSE 1. the following are some examples of actual abuse .that should be promptly reported .f. signs of/ Actual Physical Abuse: welts or bruises .3. fractures, dislocations or sprains of questionable origin . ABUSE PREVENTION PROGRAM .3. the protection of residents during abuse investigations .REPORTING OBSERVED OR SUSPECTED ABUSE .12. when an incident of resident abuse is suspected or alleged, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred .13. upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record .the person performing the examination must document the examination findings on approved forms and obtain a written, signed and dated statement from the person reporting the incident .

This citation refers to Intake # MI 935. Based on observation, interview and record review, the facility failed to ensure interventions were in place to prevent elopement for one (#801) of five residents reviewed for elopement, from a total sample of five. This resulted in an Immediate Jeopardy when an independently ambulatory resident with severely impaired cognition and recent exit seeking behaviors, exited the facility using the elevator, took a bus approximately 20 miles to another city, had a police encounter at a family home, and did not return to the facility until the following day. This deficient practice had the potential for serious injury, harm, and/or death and immediate correction is necessary. The Immediate Jeopardy was identified on 6/8/17 at 8:30 AM. The Administrator was notified of the Immediate Jeopardy on 6/8/17 at 9:28 A.M. A plan to remove the immediacy was requested. The immediacy was removed on 6/8/17 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: An incident report to the State Agency by the facility on 5/22/17 documented that Resident #801 was missing from the facility. On 6/7/17 at 12:10 P.M., during a tour of the facility, the double doors near the therapy room and beauty shop that entered into the unit where the residents resided was observed to make a chiming noise at the nurses' station when opened. The double doors that enter into the other side of the unit from the lobby (near the freight elevator) had a sign posted that read, Please Do Not Use This Door. Alarm is On. The front desk in the lobby was observed not to have any staff member present and the elevators and double doors used to exit the facility were accessible without any code or alert. On 6/7/17 at 1:00 P.M., the facility's investigation was reviewed for Resident #801 and it revealed the following: A investigation summary signed by the former Administrator (E) that documented, Approximately 9:10 A.M. it was noted that Resident #801 was not in his room nor was he in the dining room; staff searched the (facility name) area which included rooms, bathrooms, visitors bathrooms, shower room and the adjoining hallway . It was documented that staff continued to search the facility, the adjoining building, the hospital across the street, the city blocks, parking lots, and parking garage. At 9:50 A.M., the police were called. At 10:15 A.M., security was called. 10:18 A.M. (Administrator E) called facility to see if Resident #801 came back as he was at the group home (approximately 3 miles from the facility) where Resident #801 used to reside with the police. Administrator E reviewed security cameras with the police at 10:28 A.M. and Resident #801 was seen leaving the building on camera at 8:22 A.M. The summary further documented, On 5/23/17 at approximately 5:30 A.M., Resident #801 was returned to (the facility) by (another city approximately 20 miles away) police. Upon this writer calling the police they stated that they had an earlier run in with Resident #801 at his home that he grew up in and Resident #801 gave them a false name at around 10:30 P.M. which they then released him. At around 4:30 A.M., Resident #801 arrived at (local) police department and asked for a ride and was returned to (the facility). Resident #801 was interviewed by Administrator E at 6:00 A.M. and he stated, that he met a friend .at (a local donut shop) and he bought him donuts, smoked a cigarette then (friend's name) gave him two dollars for the bus. Resident #801 stated that he then went to (a location approximately 20 miles away) where he grew up and wanted to go home . On 6/7/17 at 1:30 P.M., Resident #801's clinical record was reviewed and revealed the following: Resident #801 was admitted into the facility on [DATE], readmitted on [DATE], and discharged on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #801 had severely impaired cognition (indicated by a Brief Interview for Mental Status - BIMS score of 7 - a score of 0-7 indicates severe cognitive impairment). The MDS assessment documented that Resident #801 was independent and did not require any physical assistance from staff for ambulation. A Letter of Guardianship that indicated Resident #801 was a legally incapacitated individual. A Nurse's Note dated 5/17/17 1 PM late entry written by Nurse H documented, Writer observed res (resident) walking toward elevator. Writer asked how res was doing. Res responded with, 'It's nice out and I want to go get some air.' Writer instructed res he needed to be accompanied by a staff member in order to go outside .Will cont(inue) to monitor. An Admission Nursing assessment dated [DATE] documented in the elopement assessment that Resident #801 was ambulatory. It did not document that he had cognitive impairment (it was documented on the MDS that Resident #801 had severe cognitive impairment). The elopement assessment noted, If Yes checked for 1, 2, & 3, resident is an elopement risk. If 4 or more checked Yes, implement a prevention plan of care for wandering/elopement risk. A Resident Elopement assessment dated [DATE] (after Resident #801 eloped from the facility) documented, .History of Elopement (within the past 6 months), No History (Resident #801 eloped from the facility on 5/22/17) . The assessment noted that a total score of 10 or higher is at risk. Resident #801's score was 8 which indicated he was not at risk (one or more episodes of elopement within the past 6 months indicated the resident was at risk for elopement). On 6/7/17 at 1:40 P.M., the Director of Nursing (DON) was interviewed regarding any interventions that were in place to prevent residents leaving the facility unattended. The DON stated, The doors have alarms now. They always had a chiming noise, but not a loud alarm. Everyone gets an elopement assessment when they are admitted , but I took it a step further and do a second, more thorough assessment to make sure. On 6/7/17 at 2:00 P.M., Certified Nursing Assistant (CNA) G was interviewed regarding Resident #801 and the elopement on 5/22/17. CNA G reported that she was assigned to Resident #801 on 5/22/17. When queried about any interaction with Resident #801 on that day, CNA G reported that she came in a little late that day and Resident #801 was in the dining room for breakfast, asked for a shower, and CNA G told him that she would provide a shower after breakfast was finished. CNA G reported that it was approximately 8:25 A.M. and that was the last time Resident #801 was seen by CNA G. When queried about whether or not Resident #801 ever expressed a desire to leave the facility, CNA G stated, Not really, but activities recently took him outside and then he wanted to go out all the time. He would ask a lot. He even refused a shower once because he wanted to go outside. That was unlike him. CNA G reported that Resident #801 could walk independently. When queried about the doors that separated the lobby from the unit on 5/22/17, CNA G stated, Those doors were open during the day. On 6/7/17 at 2:35 P.M., Nurse I was interviewed regarding Resident #801 on 5/22/17. Nurse I reported that Nurse F was assigned to Resident #801 on that day. Nurse I recalled observing Resident #801 in the dining room during breakfast around 7:45 A.M. or 8:00 A.M. Nurse I reported that around 9:30 A.M., she was notified that Resident #801 could not be found and a search was started. When queried about the door that separated the resident area from the lobby and if they made any noise when entered or exited, Nurse I stated, They chimed, but we kept them open. We didn't have any elopement risks. Nurse I was asked about Resident #801 and if he was an elopement risk. Nurse I stated, (Resident #801) never gave the thought that he wanted to go anywhere. He liked it here. He went out with activities and then he would ask to go outside a lot. We would just tell him he had to wait for Activities Aide A. He always followed the rules. Nurse I further stated, He would ask to go out every 2-3 days and that was different, not typical for him, but we would just redirect him. On 6/7/17 at 2:43 P.M., Activities Aide A was interviewed. Activities Aide A was asked about Resident #801 and if he participated in any activities at the facility. Activities Aide A stated, Sometimes he did. When asked if Resident #801 was ever taken outside, Activities Aide A stated, I took him out twice. He just wanted fresh air and to smoke. He didn't make any attempts to leave or anything. Activities Aide A was asked if Resident #801 ever tried to leave the facility. Activities Aide A stated, I think he was trying to get on the elevator once, but was stopped by staff. On 6/7/17 at 2:47 P.M., Nurse F was interviewed via the telephone regarding any interaction with Resident #801 on 5/22/17. Nurse F stated, (Resident #801) was in the dining room for breakfast. I gave him medications. He was talking about a shower. The CNA said he could have a shower after breakfast was done, then I left the dining room. Nurse F reported that Resident #801 was still in the dining room at the time she left. Nurse F was asked how she became aware that Resident #801 was missing on 5/22/17. Nurse F stated, Another nurse was doing rounds and said he (Resident #801) was not in his room and if I knew where he was. We checked the shower room and he wasn't there or in the dining room. Everyone started looking for him and we notified Administrator E. When queried about the last time Resident #801 was seen, Nurse F stated, I saw him last at around 8:15 A.M. Nurse F reported that the other nurse (identified as Nurse D) first noticed that Resident #801 was missing around 9:00 (A.M.). Nurse F reported that Resident #801 was independently ambulatory. Nurse F was asked if the doors that separated the resident area from the lobby alerted staff when someone entered or exited. Nurse F stated, It would chime when the door was opened, but we kept the doors open during the day shift. On 6/7/17 at 2:52 P.M., camera footage from inside the facility was reviewed with the current Administrator (K). The following was observed: At 7:54 A.M., Resident #801 was seated at a table with another resident in the dining room. A nurse (identified as Nurse F) was standing at the medication cart facing away from the dining room. At 8:04 A.M., Nurse F approached Resident #801 and gave medications and returned to the medication cart with her back to the dining room. At 8:05 A.M., Resident #801 stood up and walked behind Nurse F and sat down in the sitting area near the dining room. At 8:10 A.M., Resident #801 walked to the nurse's station and stopped. There were no staff members at the nurse's station. Resident #801 proceeded to walk down the hallway past the nurse's station and turned right and exited out the double doors that led to the lobby of the facility at 8:11 A.M. Resident #801 re-entered the unit from the lobby through the same doors, walked to his room, and exited his room at 8:13 A.M. Resident #801 put on a white coat and exited the unit to the lobby through the double magnetic doors that were observed to be open. At 8:14 A.M., Resident #801 walked past the front desk and entered the second elevator on the right. There were no staff members present at the desk or in the lobby of the facility. On 6/7/17 at 3:33 P.M., Nurse H was interviewed regarding any interaction with Resident #801. Nurse H identified herself as the wound care nurse and had worked at the facility for less than one month and stated, I had him a few times when I worked the floor. When queried about the nurse's note from 5/17/17, Nurse H stated, I was coming around by the beauty shop and looked up and he (Resident #801) was in the lobby going toward the elevator. The social worker (who no longer worked at the facility) was in the office so I asked if he could be out there and she said, 'He's ok.' I went up to him and asked him what he was doing and he said he was just walking around and that it was nice out and wanted to get fresh air. He never stepped on the elevator, he was just going toward it. Nurse H was asked if she notified anyone of Resident #801 approaching the elevator and expressing the desire to go outside. Nurse H stated, Well, I mentioned it to social work and MDS when I walked by. The Administrator's office is also right there so I think they knew he was out there. I thought I did what I needed to do at that point. On 6/7/17 at 3:53 P.M., the building security manager C was interviewed. Security Manager C explained that they are not contracted with the facility. Security Manager C was asked to review the camera footage for the downstairs area of the building. Security Manager C reviewed the camera history and reported that they no longer had the footage from 5/22/17. On 6/7/17 at 4:15 P.M., the DON was interviewed. The DON was asked to explain the facility's process for determining if a resident was an elopement risk. The DON stated, An assessment is completed at admission and the assessment tells you what to do. He (Resident #801) was not an elopement risk. When queried about what staff should do if a resident made exit seeking statements or gestures, the DON stated, The first sign of a risk is if they say they are going home now, especially when they are ambulatory, that would start a risk and an elopement risk assessment would be completed, a picture would be placed in the elopement book and at the nurse's station. The DON was asked if any interventions were put in place after Resident #801 was observed by Nurse H on 5/17/17 approaching the elevator and expressed the desire to go outside. The DON stated, No. Nothing was put in place after that. I still don't believe he was a risk of getting away. He was just wandering in the lobby like the others. I heard that activities took him outside and maybe that started a pattern of him wanting to go outside. When queried about the doors that separate the lobby from the resident area and if there was any way staff would know when a resident left the unit (at the time of the elopement on 5/22/17), the DON reported that the doors stayed open at that time. The DON reported that there was not always staff located at the front desk in the lobby. On 6/8/17 at 8:10 A.M., Administrator K (who was not the Administrator at the time Resident #801 eloped from the facility) was interviewed about the facility's policies and procedures for preventing elopement of residents from the facility. Administrator K stated, On admission an elopement assessment is completed. The DON does another one to ensure accuracy. Cognitively intact residents can sign out at the desk. A person is supposed to start on Monday at the front desk. They will make sure residents sign out. We don't have any residents who are at risk at this point. When queried about how Resident #801 eloped from the facility if he was not at risk, Administrator K stated, Prior to the elopement, it was my understanding that he was not at risk. When queried about what should have been done when he was observed approaching the elevator on 5/17/17 and expressed the desire to go outdoors and when multiple staff members noticed that Resident #801 made frequent statements about wanting to go outside and identified it as unusual behavior for Resident #801 (as mentioned by CNA G and Nurse I), Administrator K stated, Another assessment would have been appropriate at that point. On 6/8/17 at 8:20 A.M., Administrator E was interviewed. Administrator E reported that he was the administrator of the facility until 6/2/17. When queried about Resident #801's prior history of frequently asking to go outside and the observation of Resident #801 approaching the elevator on 5/17/17, Administrator E stated, I didn't find that out until the investigation. It was one time and he was redirected. When asked if anything was put into place to prevent Resident #801 leaving the building, Administrator E reported he did not know. Administrator E reported that the doors that separated the lobby and the resident area were left open prior to 5/22/17 because We didn't have an issue with elopement. On 6/8/17 at 11:57 A.M., the elopement assessment completed by the DON on 5/23/17 was reviewed with the DON. When asked why Resident #801 was scored as having no history of elopement, the DON stated, I didn't consider it to be a history because he wasn't exit seeking. When queried about how he was not exit seeking when he actually eloped from the building on 5/22/17, the DON stated, Ok. It should have been coded as a history. On 6/8/17 at 1:00 P.M., the facility's Emergency Preparedness Manual was reviewed and revealed a policy titled, Missing Resident dated 2/2015 (confirmed by Administrator K as being a current policy), documented, .It is the responsibility of all personnel to report any resident attempting to leave premises .to the charge nurse as soon as practical . The facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 6/8/17: Element 1 Upon returning to the building the resident was assessed for injuries. There were no injuries noted. Vial signs were within normal limits, and the resident showed no signs of a catastrophic event. All door alarms were checked for proper functioning. An alarm was placed on the lobby exit door. His room was changed closer to the nursing station. His elopement assessment was updated as well as his care plans being revised and updated. The Guardian was notified and the plan is to have the resident discharge (back) to the group home on 5/24/17. The Re-education on elopement and prevention of elopement was immediately initiated for staff. Element 2 An Elopement re-assessment of the facility residents was conducted to identify others that may be potentially affected by this practice. There were no other residents identified at this time. All Elopement risk scores were below 9 which is identified not at risk. All new admissions will be assessed for elopement upon admission, quarterly, annually, prn and when exit seeking behaviors occur. Also all new admission residents/family-guardians will be informed of the LOA policy. Element 3 All residents that are cognitively impaired and that independently ambulate or propel wheelchairs without assistance have the potential to be effected by this incident if the staff are not properly educated on the Elopement Policy. The re-education of the facility staff was immediately initiated on 5/22/17. All new hires will receive elopement education during orientation and annually for all. On 5/22/17 a QA meeting was held to review the elopement policy and procedure at this time new interventions were put in place 1) alarm on lobby exit door. 2) Resident room change. 3) Daily audits to be conducted x 1 week them weekly thereafter. Follow up audit findings monthly and prn in QA meeting. The Social Worker/designee will conduct monthly elopement drills. Element 4 The Administrator or DON will monitor the process and provide 1:1 education with repeat offenses and follow the disciplinary action process. Random door alarm drills will be conducted by the Administrator or designee weekly. All results will be reviewed in the QA meetings for further recommendation. Date of completed of plan of correction 6/8/17.

This pertains to intake #MI 699. Based on observation, interview, and record review, the facility failed to provide adequate supervision and consistently implement fall safety interventions for one (#701) of three sampled residents reviewed for accidents from a total of three, resulting in falls, pain, a laceration, and emergency hospital treatment for [REDACTED]. On 10/19/15 at 10 AM, resident #701 was observed in bed with her husband at the bedside and her daughter visiting by Internet video conference. The resident had a splint on the left wrist, bilateral fall safety floor mats, and two fall safety alarms. One of the alarms was clipped to the resident's gown with a cord leading to the alarm control box to detect an unassisted transfer attempts and sound when tension was placed on the cord. The other alarm involved a sensor pad located underneath the resident to detect body movement and sound to alert staff of an attempt to self-transfer. The resident's daughter said, My mother has had several falls. One time I came in and found her on the floor sitting in stool and crying. Nobody (staff) was around. On 10/19/15 at 1:30 PM, resident #701's clinical record, Incident/Accident (I/A) Reports, and fall investigations, were reviewed with the Director of Nursing (DON). Resident #701 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was also receiving Hospice services. Minimum data sets dated 8/28/15 and 10/9/15 noted that the resident had severe cognitive impairment, was non-ambulatory, and required extensive assistance for transfers and bed mobility. The following was revealed regarding incidents involving resident #701: 1. I/A Report dated 8/30/15-The resident was found on the floor next to the bed with a laceration to the right elbow area; The resident was confused and was walking back from bathroom and slipped on cover (linen). The I/A Report noted however, the fall was unwitnessed and the resident was unable to explain what happened. Interventions to prevent future falls: an alarm was placed on the resident (clip alarm) and frequent visual checks. A fall risk care plan for resident #701 dated 8/31/15 noted: Resident is at risk for future fall/injury related to frequent attempts to transfer without assistance. There was no documented indication why an alarm was not placed until 8/30/15 in lieu of the history of self-transfers. The DON was unable to respond, when asked. 2. I/A Report dated 9/7/15 and nurses notes-Staff heard another resident yelling for help, went into resident #701's room and found the resident on the floor by the bed; There was no indication that an alarm sounded to alert staff; no noted injury; The resident was confused; The intervention: The resident was told to use the call light and not to get up without assistance. When asked, the DON did not respond why the alarm was not mentioned and how this confused resident would have been able to use the call light. Per nurses notes dated 9/9/15, the resident was observed ambulating by the bed with increased confusion and saying that she wanted to go to the bathroom. 3. I/A Report and Nurse Practitioner (NP) progress note dated 9/17/15-The resident was found on the floor by the bed; The NP noted that the daughter told her that she came in to (find) her mother on the floor, crying and in her own feces.; There was no indication an alarm sounded; Intervention: fall safety mat placed by the bed. The DON did not respond why the alarm was not mentioned and the fact that the daughter had to notify staff of the fall. 4. I/A Report dated 9/30/15-The resident was observed lying on the left side on the opposite side of room; The resident was confused and complained of right hip pain; There was no indication that an alarm sounded; Intervention: Resident to have alarm on at all times. The fall investigation noted: Please place alarms at all time when in room or unattended Resident confused with no bed alarm/wheelchair alarm. A diagram in the investigation indicated that the resident fell from the wheelchair, however, the fall was noted as unwitnessed. A right hip X-ray dated 10/1/15, performed due to complaint of pain, was negative for fracture. 5. I/A Report dated 10/4/15-The resident was observed lying on her stomach on the floor in the hallway to the left of the nursing station and sustained a swollen left wrist. The DON said, I can explain. She was sitting in a geri-chair by the desk. She reached up (to the shoulder area), unhooked the alarm, scooted up to the edge of the chair, got up and fell . (Nurse 'A') was there when she fell . When asked, the DON said that the resident was seated by the desk for supervision. The DON was asked how the resident had time to go through all the steps she mentioned, without staff intervening to prevent the fall, if the resident was being supervised and the fall was witnessed. The DON said that nurse 'A' was on the phone and that the fall and the resident's actions before the fall, were not witnessed. The DON did not respond when asked how she concluded that the resident had unhooked the alarm versus staff leaving it disconnected. Further review of the fall investigation revealed the following note: Alarm being used at the time of the fall? Yes. If yes, was it working correctly? No, someone had turned it off. The investigation indicated that the alarm was connected to the resident, but the control was turned off preventing it from alarming. On 10/4/15, resident #701 was transported to the hospital for an X-ray of the left wrist. The X-ray noted: Acute traumatic distal radius fracture. The fracture was noted as impacted, meaning one broken end of the wrist bone was driven into the other broken end. On 10/19/15 at 2:15 PM, nurse 'A' was interviewed by phone regarding the incident on 10/4/15. She said, (Resident #701) got up out of the geri-chair and fell on the floor. When asked for further details, nurse 'A' said, I heard a noise and looked over and she was on the floor. When asked how she knew the resident got up from the chair versus falling forward out of the chair, nurse 'A' said, I didn't see it. I was on the phone talking to management (the Administrator). There is a video of it. At 2:30 PM, the DON repeated that there was a video of the incident and when asked, stated that all other information had been provided regarding resident #701's incidents. At 3 PM, the Administrator was asked if nurse 'A' was talking to her by phone at the time of the incident on 10/4/15 and if there was a video. The Administrator said yes to both, but that the video was no longer available. She did not respond why resident #701 was not adequately supervised and safety devices were not consistently implemented for fall safety. There was no additional information provided by the end of the survey regarding incidents or pre/post fall interventions involving resident #701. ( )