Every finding on record at Oaks of West Kettering the

Based on observation, interview and record review, the facility failed to ensure the outside dumpster area was maintained in a sanitary condition. This had the potential to affected all residents in the facility. The facility census was 101.Findings include:Observation on 08/17/26 at 8:00 A.M. of the facility's two outdoor dumpsters, located in the parking lot, revealed multiple trash bags were layered on top of each other in front of the dumpsters. Additionally, there were multiple trash bags on top of the dumpsters.Interview on 08/17/26 at 8:12 A.M. with Dietary Manager (DM) #39 verified the trash that was piled up in front of and on top of the dumpsters. Observation on 08/19/26 at 6:13 A.M. of the facility's two outdoor dumpsters, located in the parking lot, revealed multiple trash bags were layered on top of each other in front of the dumpsters and multiple trash bags were on top of the dumpsters. Review of the facility's disposal of garbage and refuse policy, revised 05/21/26, revealed garbage should not be accumulated or be left outside the dumpster.

Based on observation and staff interview, the facility failed to ensure a functioning dishwasher and three compartment sink to properly clean and sanitize dishware. This affected all residents except for one (#116) resident who received no food by mouth. The facility census was 101.Findings include:Observation of the facility's kitchen on 08/17/26 at 8:12 A.M. revealed there was a sign on the dishwasher that stated the dishwasher was not working. Observation of the facility's three compartment sink on 08/17/26 at 8:12 A.M. revealed Dietary Manager (DM) #39 filled up the facility's three compartment sink and tested the sanitizer solution, receiving a result of zero parts per million (ppm) of sanitizer. DM #39 then obtained another bucket of sanitizer and connected it to the three compartment sink. DM #39 tested the sanitizer solution again and received a result of zero ppm. No sanitizer solution was observed moving through the tubing to the three compartment sink. Further observation of the facility's kitchen revealed Dietary Aide (DA) #51 was washing dishes in the sink on the dirty side of the dish room as the dishwasher and three compartment sink were not in working order. Interview with DM #39 on 08/17/26 at 8:12 A.M. verified the facility's dishwasher had not worked in approximately one week because of an issue with the motor. DM #39 also verified the sanitizer solution in the three compartment sink was zero ppm and was not moving through the tubing from the sanitizer bucket to the sink. Additionally, DM #39 confirmed DA #51 was washing dishes in the sink on the dirty side of the dish room because the facility's dishwasher and three compartment sink were not in working order.

Based on observation, interview and record review, the facility failed to ensure resident Minimum Data Set (MDS) assessments were accurately coded. This affected three (#02, #03 and #06) of 23 residents reviewed for accuracy of MDS assessments. The facility census was 101.Findings include: 1. Review of Resident #06's chart revealed the resident admitted to the facility on [DATE] with diagnoses including other acute osteomyelitis of the left ankle and foot, chronic obstructive pulmonary disease, muscle weakness, unspecified dementia with unspecified severity and without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, cellulitis of the left toe, Type II diabetes mellitus with proliferative diabetic retinopathy with macular edema and congestive heart failure. Review of Resident #06's hospital note dated 05/23/26 revealed Resident #06 had a diabetic foot ulcer with associated recent osteomyelitis of the left foot. Review of Resident #06's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Further review revealed Resident #06 had no diabetic foot ulcers, venous or arterial ulcers or pressure ulcers identified on the MDS assessment. Interview with the Director of Nursing (DON) on 08/19/26 at 2:47 P.M. verified Resident #06 had a diabetic foot ulcer at the time of the 06/02/26 MDS assessment and the MDS was inaccurately coded for wounds. The DON reported Resident #06 went to an outside wound care provider for treatment. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included candidal sepsis, moderate protein calorie malnutrition, Type II diabetes, generalized anxiety disorder, and unspecified mood disorder. Review of the admission assessment dated [DATE] revealed Resident #2 had moderate difficulty hearing and no hearing aids. Review of the MDS assessment dated [DATE] revealed Resident #2 had moderately impaired cognition and adequate hearing with no hearing aids. Review of the care plan dated 11/11/25 revealed Resident #2 had a hearing deficit. Interventions included asking simple yes or no questions, anticipating needs, and monitoring the resident's ability to communicate. During an interview on 08/17/2026 at 3:50 P.M., Resident #2 confirmed she was hard-of-hearing and stated she needed her hearing checked. During an interview on 08/20/2026 at 2:31 P.M., Corporate Registered Nurse (RN) #210 verified Resident #2's admission assessment dated [DATE] showed Resident #2 was assessed to have moderate difficulty hearing and no devices. Corporate RN #210 confirmed the most recent quarterly MDS assessment dated [DATE] was coded incorrectly and did not capture Resident #2's hearing deficits. 3. Review of Resident #3's medical record revealed an admission date of 03/21/25 with diagnoses that included moderate vascular dementia with psychotic disturbances, Type II diabetes, psychotic disorder with delusions, unspecified convulsions, major depressive disorder, and restlessness and agitation. Review of the physician orders revealed an order dated 03/21/25 for a Wanderguard to be placed to Resident #3's left ankle. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3 had severe cognitive impairment and was independent or required minimal staff assistance for personal care. Continued review of the MDS assessment revealed Resident #3 did not display any wandering or exit-seeking behaviors and did not use any wander alarms during the seven-day lookback period. Interview on 08/18/26 at 9:54 A.M. with Licensed Practical Nurse (LPN) #31 confirmed Resident #3 had a Wanderguard alarm on his left ankle. Concurrent observation with LPN #31 confirmed the Wanderguard was in place on Resident #3's left ankle. Interview on 08/20/26 at 12:21 P.M. with the Director of Nursing (DON) confirmed Resident #3 had active orders for, and wore, a Wanderguard alarm. The DON confirmed the quarterly MDS assessment did not accurately identify Resident #3's use of a Wanderguard. Review of the policy titled, Conducting an Accurate Resident Assessment, undated, revealed qualified staff who were knowledgeable about the resident would conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline.

Based on medical record review, staff interviews, and policy review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were accurately and thoroughly completed. This affected three (Residents #4, #11, and #3) of four residents reviewed for PASRR assessments. The facility census was 101. Findings include: 1. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, stage III chronic kidney disease, Type II diabetes, and unspecified seizures. Review of the PASRR assessment completed 04/20/21 revealed Resident #4 had no mental health diagnoses and was not prescribed any psychotropic medications. Review of the care plan dated 05/27/21 revealed Resident #4 was at risk for drug-related complications related to psychotropic medication due to schizoaffective bipolar disorder. Further review of the medical record revealed Resident #4 had no PASRR evaluations completed during her stay at the facility. During an interview on 08/18/26 at 2:57 P.M., Social Services Assistant (SSA) #143 revealed she reviewed PASRRs for accuracy upon admission. SSA #143 confirmed Resident #4's PASRR assessment was inaccurate upon admission and was not revised until discovered during the annual survey process. 2. Review of the medical record for Resident #11 revealed she was admitted to the facility on [DATE] with diagnoses including asthma, morbid obesity, chronic obstructive pulmonary disease, protein-calorie malnutrition, obstructive sleep apnea, Type II diabetes, hypothyroidism, hyperlipidemia, bipolar II disorder, generalized anxiety disorder, insomnia and acute kidney failure. Review of a diagnoses list dated 01/15/25 revealed Resident #11 had a diagnosis of generalized anxiety disorder and bipolar II disorder with an onset date of 01/15/25. Review of Resident #11's PASRR dated 10/29/25 revealed no documentation of any mental health diagnoses or psychotropic medication use. Review of the physician orders for Resident #11 revealed an order for sertraline (antidepressant) 50 milligrams (mg) dated 04/04/26 and trazodone (antidepressant) 50 mg dated 07/30/26. Interview with SSA #143 on 08/18/26 at 2:56 P.M. verified Resident #11's diagnoses of generalized anxiety disorder and bipolar II disorder and the use of psychotropic medications were not listed on the 10/29/25 PASRR. SSA #143 confirmed the facility did not have an updated PASRR for Resident #11 that contained her current diagnoses and medications for mental health diagnoses. 3. Review of Resident #3's medical record revealed an admission date of 03/21/25 with diagnoses that included moderate vascular dementia with psychotic disturbances, Type II diabetes, psychotic disorder with delusions, unspecified convulsions, major depressive disorder, and restlessness and agitation. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #3 had severe cognitive impairment and was independent or required minimal staff assistance for personal care. Review of Resident #3's diagnoses list revealed he was diagnosed with moderate vascular dementia with psychotic disturbance, psychotic disorder with delusions due to known physiological condition, unspecified convulsions, other seizures, and major depressive disorder with an onset date of 03/21/25. Review of Resident #3's PASRR, dated 10/02/24, revealed no documentation of serious mental illness or intellectual or developmental disabilities. Interview on 08/18/26 at 2:56 P.M. with SSA #143 confirmed the facility did not update Resident #3's PASRR with the current diagnoses upon admission to the facility. SSA #143 stated a new PASRR assessment was started on 08/17/26. Review of the policy titled, Resident Assessment – Coordination with PASARR Program, revised 08/01/26, revealed the facility would coordinate the PASRR assessment to ensure that individuals with a mental disorders, intellectual disability, or a related condition received care and services in the most integrated setting appropriate to their needs.

Based on observation, interview and record review, the facility failed to ensure resident care plans were developed to address individual resident needs. This affected three (#03, #08, and #63) of 23 residents reviewed for care planning. The facility census was 101.Findings include: 1. Review of Resident #08's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including gangrene, diabetes mellitus due to underlying condition with foot ulcer, other chronic osteomyelitis of the right ankle and foot, chronic respiratory failure with hypoxia, non-pressure chronic ulcer of other part of the right foot with unspecified severity, end stage renal disease (ESRD) and dependence on renal dialysis. Review of Resident #08's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #08's smoking assessment dated [DATE] revealed the resident was independent with smoking. Review of the current care plan revealed Resident #08 was not care planned for smoking or any non-compliance with the facility's smoking policies and procedures. Observation on 08/17/26 at 11:21 A.M. revealed Resident #08 was smoking outside in the facility's designated smoking area. Concurrent interview with Resident #08 revealed he was only allowed two cigarettes at a time, and he had to sneak additional cigarettes and lighters into the facility. Interview on 08/19/26 at 9:32 A.M. with the Administrator and [NAME] President of Clinical Services (VPCS) #210 verified Resident #08 smoked at the facility and the resident did not have a care plan related to smoking. The Administrator also confirmed Resident #08 was not compliant with the facility's smoking policy and this was also not identified in the resident's care plan. Review of the facility's undated smoking policy revealed cigarettes and lighters would be handled according to the resident's smoking assessment and care plan. 2. Review of Resident #63's medical record revealed Resident #63 admitted to the facility on [DATE] with diagnoses including nondisplaced fracture of the medial malleolus of the left tibia, cellulitis of the left lower limb, stress fracture of the left foot subsequent encounter for a fracture with routine healing, muscle weakness, ESRD, hypotension, Type II diabetes mellitus with ketoacidosis without coma, and atherosclerotic heart disease of native coronary artery with unstable angina pectoris. Review of Resident #63's admission MDS assessment dated [DATE] revealed the resident was cognitively intact. Further review revealed Resident #63 received anticoagulant medication. Review of Resident #63's physician orders revealed an order dated 07/03/26 for apixaban oral tablet five milligrams (mg), give one tablet by mouth two times a day for an anticoagulant. Review of Resident #63's current care plan revealed the resident did not have a care plan for the use of anticoagulant medication or to monitor side effects of anticoagulant medication. Interview with Resident #63 on 08/17/26 at 5:17 P.M. revealed the resident was ordered anticoagulant medication. Interview with [NAME] President of Clinical Services (VPCS) #210 on 08/18/26 at 3:23 P.M. verified Resident #63 did not have a care plan for the use of an anticoagulant medication or to monitor the side effects of anticoagulant medication. 3. Review of Resident #3's medical record revealed an admission date of 03/21/25 with diagnoses that included moderate vascular dementia with psychotic disturbances, Type II diabetes, psychotic disorder with delusions, unspecified convulsions, major depressive disorder, and restlessness and agitation. Review of the physician orders revealed an order dated 03/21/25 for a Wanderguard to be placed to Resident #3's left ankle. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3 had severe cognitive impairment. Review of Resident #3's current care plan revealed no goals or interventions related to the use of a Wanderguard alarm or wandering and exit-seeking behaviors. Interview on 08/18/26 at 9:54 A.M. with Licensed Practical Nurse (LPN) #31 confirmed Resident #3 had a Wanderguard alarm on his left ankle. Concurrent observation of Resident #3, with LPN #31, confirmed the Wanderguard was in place. Interview on 08/20/26 at 12:20 P.M. with the Director of Nursing (DON) confirmed Resident #3's care plan did not include the use of a Wanderguard and associated behaviors and should have. Review of the facility's Comprehensive Care Plans policy, revised 09/01/25, revealed the facility would develop and implement a comprehensive person centered care plan for each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs.

Based on medical record review, observation, staff interviews, and policy review, the facility failed to ensure medications were labeled and stored appropriately. This affected four (Residents #53, #84, #92, and #118) of five residents sampled for medication storage. The facility census was 101.Findings include:1. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included unspecified peripheral vascular disease, congenital glaucoma, corneal transplant status, and chronic obstructive pulmonary disease (COPD). Review of the physician orders revealed Resident #53 had orders for timoptic ophthalmic solution 0.5% (timolol maleate) to instill one drop in the left eye one time a day related to congenital glaucoma.Observation on [DATE] at 1:07 P.M. revealed the East Med Cart contained one box of timolol maleate ophthalmic solution 0.5% for Resident #53. The box contained one open and undated foil package with two single-use ampules. Written directions on the outside of the foil pack indicated the ampules were to be used within one month after the foil pack had been opened.During an interview on [DATE] at 1:16 P.M., Registered Nurse (RN) #175 verified the two ampules of Resident #53's ophthalmic solution were stored in an opened foil package that was undated. RN #175 verified the package stated the ampules were to be used within one month of opening, and she could not determine when the package was opened.2. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE]. Diagnoses included unspecified Alzheimer's disease, Type II diabetes, unspecified schizophrenia, and unspecified seizures.Review of a physician order dated [DATE] revealed Resident #84 had an order for Lantus SoloStar Subcutaneous Solution Pen-Injector 100 units/milliliter (ml) (Insulin Glargine), inject 22 units subcutaneously at bedtime for elevated blood sugar.Observation on [DATE] at 1:07 P.M. revealed the East Med Cart contained one full unopened bottle of Lantus (glargine insulin) stored in the top drawer labeled for Resident #84. Instructions on package stated the product should be stored under refrigeration from 36 to 46 degrees Fahrenheit (F) until first use, and after first use could be stored at room temperature.During an interview on [DATE] at 1:16 P.M., RN #175 verified Resident #84's bottle of Lantus was unopened and was stored at the inappropriate temperature in the medication cart.3. Review of the medical record revealed Resident #92 was admitted to the facility on [DATE]. Diagnoses included COPD, Type II diabetes, and combined heart failure.Review of a physician order dated [DATE] revealed Resident #92 was ordered Humalog Kwikpen Subcutaneous Solution Pen Injector 100 unit per ml (lispro insulin), inject two units subcutaneously before meals and at bedtime.Observation on [DATE] at 12:51 P.M. revealed the [NAME] Med Cart had one opened bottle of Novolog insulin 100 units/ml (lispro insulin) that was labeled Backup usage that was undated.During an interview on [DATE] at 12:52 P.M., Licensed Practical Nurse (LPN) #191 verified the opened bottle of Novolog insulin was undated. LPN #191 stated insulin expired approximately 28 days after the first use and she was unable to determine if the insulin was safe to use as it was undated.During an interview on [DATE] at 3:58 P.M., the Director of Nursing (DON) identified Resident #92 as the only resident on the [NAME] Hall who had active orders for lispro insulin.4. Review of the closed medical record revealed Resident #118 was admitted to the facility on [DATE] and was discharged [DATE]. Diagnoses included emphysema, Type II diabetes, combined heart failure, unspecified anxiety disorder, schizoaffective bipolar type disorder, and post-traumatic stress disorder. Review of a physician order dated [DATE] revealed Resident #118 had an order for ipatropium-albuterol inhalation solution 0.5-2.5 milligrams (mg)/ml, inhale one vial orally via nebulizer every six hours as needed for shortness of breath related to emphysema.Observation on [DATE] at 9:35 A.M. of the East Med Room revealed Resident #118 had an open box with an open foil pack of ipatropium bromide and albuterol sulfate nebulizer solution which contained 19 vials. Neither the box or foil pack was dated. Storage instructions written on the foil pack included to discard unused vials 14 days after opening. During an interview on [DATE] at 9:39 A.M., RN #175 verified Resident #118 had been discharged for months, the opened package was not dated, and the medication should have been either sent back to pharmacy or discarded long ago. Review of the facility policy titled, Medication Storage, dated [DATE], revealed medications were stored according to manufacturer's recommendations at appropriate temperatures and unused, outdated, and defective medications were destroyed according to policy.

Based on observation, interview and record review, the facility failed to ensure food items and kitchen equipment were maintained in a manner to prevent foodborne illness. This affected all residents that resided at the facility except for one (#116) resident that received no food by mouth. The facility census was 101.Findings include:Observation on 08/17/26 at 8:12 A.M. of the facility's kitchen revealed there was a large piece of cardboard on the floor near the dishwasher that was soaked in water. Additional observations of the kitchen revealed a gray debris on the vent on the front of the juice machine, a gray debris on a ceiling air vent that was located above a meal cart near the ice machine and a brown substance on the ceiling of the kitchen. Further observation revealed Dietary Manager (DM) #39 filled up the facility's three compartment sink and tested the sanitizer solution, receiving a result of zero parts per million (ppm) of sanitizer. DM #39 then obtained another bucket of sanitizer and connected it to the three compartment sink. DM #39 tested the sanitizer solution again and received a result of zero ppm. No sanitizer solution was observed moving through the tubing to the three compartment sink. Further observation of the facility's kitchen revealed Dietary Aide (DA) #51 was washing dishes in the sink on the dirty side of the dish room as the dishwasher and three compartment sink were not in working order. Further observation of the walk-in refrigerator revealed a large, undated open bag of grated parmesan cheese; a large, undated open bag of shredded cheddar cheese; an opened and undated bag of ham; a large, undated open bag of shredded mozzarella cheese; a covered container of boiled eggs that were undated; a bag of salad that was open and undated; a covered container of cooked hamburgers that were undated; an opened and undated container of apple sauce; and three undated Styrofoam boxes of salads.Interview with Dietary Manager (DM) #39 on 08/17/26 at 8:12 A.M. verified the above findings. DM #39 stated DA #51 was washing dishes in the sink on the dirty side of the dish room because the facility's dishwasher and three compartment sink were not in working order. Review of the facility's food safety requirements policy revised on 05/22/26 revealed food would be stored, prepared, distributed and served in accordance with professional standards for food safety. The facility should label and date refrigerated food items.

Based on medical record review and staff interview, the facility failed to ensure binding arbitration agreements were not required as a condition of admission. This affected three (#16, #41 and #88) of three residents reviewed for binding arbitration agreements. The facility census was 101.Findings include:1. Review of Resident #16's medical record revealed an admission date of 03/26/26 with diagnoses including vascular dementia, muscle weakness, acute cystitis with hematuria, hyperlipidemia, anxiety disorder, and polyosteoarthritis.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was severely cognitively impaired. Review of the admission agreement, signed on 03/26/26 by Resident #16, revealed the admission agreement stated, any controversy, dispute or disagreement arising out of or in connection with this agreement, breach thereof, or the subject matter thereof including the facility's obligation thereof, shall be settled by binding arbitration. Further review of the admission agreement revealed there was no option for the resident or the resident's responsible party to decline the arbitration agreement section of the admission agreement. Additionally, the admission agreement did not explicitly inform the resident or their representative of their right to not sign the agreement as a condition of admission or as a requirement to continue to receive care at the facility. The admission agreement also did not explicitly state that the resident or their representative had the right to rescind the agreement within 30 days of signing it. 2. Review of Resident #41's medical record revealed an admission date of 11/06/25 with diagnoses including congestive heart failure, Type II diabetes mellitus without complications, unspecified dementia, psychotic disturbance and mood disturbance and end stage renal disease.Review of the quarterly MDS assessment dated [DATE] revealed Resident #41 was cognitively intact. Review of the admission agreement, dated 11/06/25 and signed by Resident #41, revealed the admission agreement stated, any controversy, dispute or disagreement arising out of or in connection with this agreement, breach thereof, or the subject matter thereof including the facility's obligation thereof, shall be settled by binding arbitration. Further review of the admission agreement revealed there was no option for the resident or the resident's responsible party to decline the arbitration agreement section of the admission agreement. Additionally, the admission agreement did not explicitly inform the resident or their representative of their right to not sign the agreement as a condition of admission or as a requirement to continue to receive care at the facility. The admission agreement also did not explicitly state that the resident or their representative had the right to rescind the agreement within 30 days of signing it. 3. Review of Resident #88's medical record revealed an admission date of 01/22/26 with diagnoses including congestive heart failure, acute and chronic respiratory failure with hypoxia, acute kidney failure, hypothyroidism, generalized anxiety disorder and major depressive disorder.Review of the quarterly MDS assessment dated [DATE] revealed Resident #88 was cognitively intact. Review of the admission agreement, dated 01/22/25 and signed by Resident #88, revealed the admission agreement stated, any controversy, dispute or disagreement arising out of or in connection with this agreement, breach thereof, or the subject matter thereof including the facility's obligation thereof, shall be settled by binding arbitration. Further review of the admission agreement revealed there was no option for the resident or the resident's responsible party to decline the arbitration agreement section of the admission agreement. Additionally, the admission agreement did not explicitly inform the resident or their representative of their right to not sign the agreement as a condition of admission or as a requirement to continue to receive care at the facility. The admission agreement also did not explicitly state that the resident or their representative had the right to rescind the agreement within 30 days of signing it. Interview on 08/18/26 at 2:11 P.M. with Marketing Director (MD) #502 verified Resident #16, Resident #41 and Resident #88 had signed admission agreements that included binding arbitration. MD #502 reported all residents were required to sign the admission agreement and residents were not given a choice to refuse the binding arbitration agreement section that was outlined in the admission agreement.

Based on medical record review, observation, staff interview, review of manufacturer instruction guides, and policy review, the facility failed to ensure medication pens were appropriately primed before administration. This affected two (Residents #76 and #84) of four residents sampled for medication administration. The facility census was 101.Findings include:1. Review of the medical revealed Resident #76 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic pancreatitis, Type II diabetes, peripheral vascular disease, generalized anxiety disorder, and acquired absence of the right leg above the knee. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of the current physician orders revealed Resident #76 had an order for Lantus SoloStar Subcutaneous Solution Pen-injector 100 units/milliliter (ml) (Insulin Glargine), inject 15 units subcutaneously every morning and at bedtime related to Type II diabetes without complications.Observation on 08/19/26 at 11:49 A.M. revealed Resident #76 approached the medication cart and asked the nurse if she would check her blood sugar and administer routine insulin. Registered Nurse (RN) #175 checked Resident #76's blood sugar and administered 15 units of Lantus without priming the pen before administration. During an interview on 08/19/26 at 11:54 A.M., RN #175 verified she did not prime the needle before administering insulin to Resident #76. RN #175 stated she had never been instructed to prime the needle after the first use of an insulin pen.Review of Lantus Solostar pen manufacturer's instructions revealed users were required to perform a safety test prior to each use. Steps included applying a pen needle, dialing a test dose of two units, holding the pen with the needle pointing up, lightly tapping the pen to release air bubbles, and pressing the injection button all the way in to see that insulin comes out of the needle. If no insulin was expressed, the steps were repeated up to two more times. If the test was still unsuccessful, a new needle was applied, and the steps were repeated once more. If no insulin appeared at the tip of the needle, users were instructed not to use the pen.2. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE]. Diagnoses included unspecified Alzheimer's disease, Type II diabetes, unspecified schizophrenia, and unspecified seizures.Review of the current physician orders revealed Resident #84 had an order dated 01/04/26 for Ozempic (0.25 or 0.5 milligrams (mg)/dose) Subcutaneous Solution Pen-Injector two mg/three ml (Semaglutide), inject 0.5 mg subcutaneously one time a day every Wednesday for Type II diabetes.Observations on 08/19/26 from 8:41 A.M to 8:50 A.M. revealed RN #175 went to the [NAME] medication room and retrieved a new Ozempic pen for Resident #84 from the refrigerator. RN #175 opened the package at the medication cart and applied the pen needle to the device and carried the insulin pen into Resident #84's room. After washing her hands in the bathroom, RN #175 dialed the pen to 0.5 mg and administered the medication to Resident #84's right upper quadrant without priming the pen prior to administration.During an interview on 08/19/2026 at 8:56 A.M., RN #175 verified she did not prime the pen before administering Ozempic to Resident #84 and stated she followed the directions on the box which did not include priming the pen/needle.Review of Ozempic injection manufacturer's guide (page 12 of 19) revealed Ozempic pens required users to check the medication flow prior to the first-time use of each new pen to ensure proper flow of the medication. Steps included applying a new needle turning the dose selector until the flow check symbol appeared, holding the pen with the needle pointing up, and pressing/holding the dose button until the dose counter showed 0. If no drop appeared at the tip of the needle, these steps could be repeated up to six times. If six tries were unsuccessful, users were instructed to change the pen needle and repeat the steps one time. If no drop appeared, users were instructed to contact the manufacturer and to not use the pen.Review of the facility policy titled, Medication Administration, dated 12/31/25, revealed medications were administered according to manufacturer specifications.

Based on observation, interview and record review, the facility failed to ensure a safe, clean, and homelike environment. This affected one (#21) of six residents reviewed for environment. The facility census was 101.Findings include:Review of Resident #21's chart revealed the resident admitted to the facility on [DATE] with diagnoses including hyperkalemia, anemia, dysphagia, muscle weakness, end stage renal disease, acute respiratory failure with hypoxia and pulmonary fibrosis.Review of Resident #21's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #21 required maximal assistance with toileting, showering, lower body dressing, sitting to standing, chair transfers and toileting and supervision with upper body dressing. Observation of Resident #21's room on 08/17/26 at 10:36 A.M. revealed a leak in her ceiling near the window that left a large black ring on the ceiling tile and black spots on the floorboard along the wall near the door to her room. Concurrent interview with Resident #21 revealed she had a ceiling leak and she was concerned the black spots that occurred as a result of the leak were black mold. Interview with Maintenance #500 on 08/18/26 at 12:07 P.M. confirmed Resident #21 had a ceiling leak in her room. Maintenance #500 stated the roof was leaking into several rooms because there was debris on the roof of the facility. Maintenance #500 verified the black ring on the ceiling tile and along the floorboards. Review of the facility's Safe and Homelike Environment policy, revised on 05/21/26, revealed the facility would provide a safe, clean, comfortable and homelike environment.

Based on interview and record review, the facility failed to ensure resident funds were refunded to the resident or their estate within 30 days of discharging from the facility. This affected one (#117) of one resident reviewed for discharged resident funds accounts. The facility census was 101.Findings include:Review of Resident #117's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, Type II diabetes mellitus with other circulatory complications, major depressive disorder, generalized anxiety disorder and peripheral vascular disease. Resident #117 discharged from the facility on 01/06/26.Review of Resident #117's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired.Review of Resident #117's resident funds account statement from 01/01/26 to 03/31/26 revealed Resident #117 had an ending resident funds account balance of $209.66 on 03/31/26.Review of the facility's resident funds balance sheet dated 08/18/26 revealed Resident #117 had a current resident funds balance of $209.66.Interview with Business Office Manager (BOM) #149 on 08/20/26 at 9:19 A.M. verified Resident #117's resident funds account balance of $209.66 was not refunded to the resident or her estate within 30 days of discharge from the facility on 01/06/26. BOM #149 did not know the reason why Resident #117's funds were not distributed within 30 days after discharge.

Based on medical record review, staff interview, and policy review, the facility failed to ensure advanced directives were accurately documented in the electronic medical record (EMR). This affected one (Resident #2) of five residents sampled for advanced directives. The facility census was 101.Findings include:Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included candidal sepsis, moderate protein calorie malnutrition, Type II diabetes, generalized anxiety disorder, and unspecified mood disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Review of care plan dated 11/03/25 revealed Resident #2 had advanced directives in place for Do Not Resuscitate Comfort Care (DNRCC). Interventions included noting advanced directives on monthly orders and honoring wishes for advanced directives. Review of the medical record revealed Resident #2 had physician orders dated 07/28/26 for DNRCC Arrest.Review of the Do Not Resuscitate (DNR) Order Form signed 10/31/25 revealed Resident #2 had signed for DNRCC protocol to be followed, effective immediately.During an interview on 08/18/26 at 3:21 P.M., Corporate Registered Nurse (RN) #210 verified Resident #2 had signed advanced directives for DNRCC protocol in 2025 which did not match the active order for DNRCC Arrest protocol in the EMR.Review of the facility policy tilted, Residents' Rights Regarding Treatment and Advance Directives, dated 06/01/25, revealed copies of advanced directive were placed in the medical record and communicated to staff responsible for resident care.

Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to provide care and services to treat contractures. This affected one (Resident #109) of one resident sampled for mobility services. The facility census was 101. Findings include:Review of the medical record revealed Resident #109 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, Type II diabetes, severe protein calorie malnutrition, unspecified anxiety disorder, chronic pain syndrome, and calculus of the kidney. Review of the most recent quarterly Minimum Data Assessment (MDS) dated [DATE] revealed Resident #109 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of care plan dated 01/31/20 revealed Resident #109 had impaired range of motion as evidenced by left-sided hemiplegia. Interventions included screening for range of motion (ROM) limitations, performing active and passive ROM exercises, consulting therapy for evaluation as needed, applying splint devices as needed for contracture management, and teaching resident to use assistive devices. Review of the physician orders revealed Resident #109 had no active orders for a splint or brace related to contracture management.Review of the Occupational Therapy (OT) discharge summary for services provided from 05/18/26 to 07/23/26 revealed Resident #109's short-term goals for therapy included increasing the resident's ability to stand supported at commode for one to three minutes with supervision to improve independence; improving the resident's ability to complete toilet transfers with supervision; and wearing a resting hand splint on the left hand up to eight hours with minimal discomfort. Long-term goals included completing staff education regarding orthotic management. Resident #109 was discharged due to hospitalization, and staff education was not completed. Resident #109 was able to tolerate wearing the resting hand splint for four hours prior to hospitalization and discharge from therapy. Observation on 08/17/26 at 4:21 P.M. revealed Resident #109 had contracture to the left hand with fingers closed over the left palm. A hand splint was noted in a laundry basket on the floor in the resident's room. During an interview on 08/17/26 at 4:21 P.M., Resident #109 stated she had a splint that she wore sometimes. She stated she used to be in therapy before she was hospitalized , and they were working on building tolerance with wearing the splint and regaining independence with toileting activities. She had not received therapy services since she returned to the facility from the hospital. Occupational Therapist (OT) #88 said they were supposed to be starting a new orthotic program, but the resident had not heard anything about it since.During an interview on 08/19/26 at 11:23 A.M., Registered Nurse (RN) #175 confirmed Resident #109 had a contracture to the left hand and had no active orders for a resting hand splint to the left hand.During an interview on 08/20/2026 at 1:58 P.M., OT #88 verified Resident #109 had a contracture to her left hand, had a resting hand splint and had no active orders to apply it daily. OT #88 stated Resident #109 required staff to assist with daily stretching exercises prior to applying the splint, which was beyond the scope of nursing to provide. There was no detriment to function and no risk of skin breakdown in the time she had been discharged from services, but OT #88 confirmed the contracture could gradually worsen without intervention. The facility anticipated having a splint program in the future. In the meantime, therapy staff encouraged Resident #109 to bring her splint to the therapy room daily and they assisted to apply it. It was Resident #109's choice to request assistance with splint application. Review of the facility policy titled, Contracture Prevention, Range of Motion (ROM) and Mobility Management Policy, dated 08/01/26, revealed existing contractures were assessed and monitored and provided appropriate interventions to address functional impact and positioning needs to maintain or improve mobility to the highest practicable level consistent with the resident's clinical conditions and preferences.

Based on medical record review, review of pharmacy recommendations, staff interview and review of facility policy, the facility failed to ensure appropriate diagnoses for the use of psychotropic medication and further failed to ensure a resident's gradual dose reduction was thoroughly addressed. This affected two (#09 and #10) of five residents reviewed for unnecessary medications. The facility census was 101.Findings include: 1. Review of Resident #09's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including acute and subacute infective endocarditis, acute respiratory failure with hypoxia, congestive heart failure, chronic obstructive pulmonary disease, anxiety disorder and chronic kidney disease. Review of Resident #09's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Further review revealed Resident #09 received antipsychotic medications. Review of Resident #09's physician order from 05/25/26 to 06/04/26 revealed the resident was ordered risperidone (antipsychotic) 0.25 milligrams (mg), give one tablet by mouth at bedtime for anxiety. Review of the pharmacy recommendation dated 05/31/26 revealed Resident #09 was receiving risperidone oral tablet 0.25 mg, give one tablet by mouth one time a day related to anxiety disorder. The resident was receiving the antipsychotic medication risperidone, but lacked an allowable diagnosis to support its use. Resident #09's physician addressed the pharmacy recommendation on 06/11/26 and wrote that the medication was already discontinued on 06/04/26. Review of Resident #09's physician order from 06/20/26 to 06/22/26 revealed the resident was ordered risperidone 0.5 mg, give 0.25 mg by mouth at bedtime for anxiety related to anxiety disorder. Review of Resident #09's physician order from 06/22/26 to 07/02/26 revealed the resident was ordered risperidone 0.5 mg, give 0.25 mg by mouth at bedtime related to anxiety disorder. Interview with [NAME] President of Clinical Services (VPCS) #210 on 08/19/26 at 10:25 A.M. verified Resident #09 was ordered risperidone 0.25 mg from 05/25/26 to 06/04/26, from 06/20/26 to 06/22/26 and from 06/22/26 to 07/02/26 without an adequate diagnosis as recommended in the pharmacy recommendation. 2. Review of the medical record for Resident #10 revealed an admission date of 02/15/24 with diagnoses that included cerebral atherosclerosis (hardening of the blood vessels in the brain), mild protein-calorie malnutrition, carrier of methicillin resistant Staphylococcus aureus (MRSA), congestive heart failure, and adult failure to thrive. Review of the quarterly MDS assessment completed on 05/29/26 revealed Resident #10 had severe cognitive impairment. Review of the Pharmacist Medication Regimen Review dated 10/30/25 revealed Resident #10 was taking two antidepressant medications, mirtazapine 30 mg at bedtime and Lexapro 10 mg daily. The pharmacist recommended a gradual dose reduction or include a rationale for continuing the current medications if the prescriber disagreed with the dose reduction. Continued review of the recommendation revealed Resident #10's nurse practitioner disagreed with the dose reduction but did not provide a rationale. Interview on 08/20/26 at 12:20 P.M. with the Director of Nursing (DON) confirmed Resident #10's pharmacy recommendation did not include a rationale for the continuation of mirtazapine and Lexapro without attempting a gradual dose reduction. Review of the policy titled Addressing Medication Regimen Review Irregularities, revised 04/10/26, revealed the pharmacist must report any irregularities to the attending physician, the facility's medical director and Director of Nursing (DON). The reports must be acted upon. Additionally, if there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

Based on medical record review, resident interview, staff interviews, and policy review, the facility failed to ensure residents received dental services as recommended. This affected one (Resident #4) of four residents sampled for dental services. The facility census was 101.Findings include:Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, bipolar type, stage III chronic kidney disease, Type II diabetes, and unspecified seizures.Review of the care plan dated 05/27/21 revealed Resident #4 had the potential for complications related to missing teeth and staff assistance for oral care setup. Interventions included assisting with oral hygiene as resident allowed, observing/reporting oral/dental problems, observing for recommendations for dental consult, arranging dental consults as ordered/needed, encouraging resident to keep dental appointments, and including resident/representative in treatment plan.Review of dental visit notes revealed the dentist referred Resident #4 to an oral surgeon for evaluation and treatment on 07/15/25 and 05/04/26.Further review of Resident #4's medical record revealed no evidence the resident had an oral surgeon consultation as recommended on 07/15/25 and 05/04/26.During an interview on 08/17/26 at 2:08 P.M., Resident #4 stated she had a broken tooth that needed to be pulled. Resident #4 denied pain related to the broken tooth. Resident #4 stated the facility dentist told her the tooth was too far back and he could not pull it. Resident #4 stated the facility dentist recommended she see an oral surgeon a few months ago. Resident #4 stated nursing was aware but could not find an oral surgeon who accepted her insurance.During an interview on 08/20/26 at 8:45 A.M., Social Services Assistant (SSA) #143 stated if the facility dentist recommended an oral surgeon, the nursing department would schedule it. SSA #143 confirmed Resident #4 had not had a follow up appointment scheduled with an oral surgeon after recommendations were made on 07/15/25 and 05/04/26.Review of the facility policy titled, Dental Services, undated, revealed the facility provided routine and emergency dental services to meet the resident's needs for oral health.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when providing high contact care activities for residents on Enhanced Barrier Precautions (EBP). This affected one (Resident #2) of four residents sampled for infection control. The facility census was 101.Findings include:Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included candidal sepsis, moderate protein calorie malnutrition, Type II diabetes, generalized anxiety disorder, and unspecified mood disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderately impaired cognition and had an indwelling catheter.Review of the care plan dated 01/02/26 revealed Resident #2 was on EBP related to a wound. Interventions included posting signs on the door to indicate EBP and using gowns and gloves during specific high contact activities including bathing, toileting, wound care, transfers, device care, and changing linens/brief. Observation on 08/17/26 at 3:52 P.M. revealed Certified Nursing Assistant (CNA) #211 entered Resident #2's room and asked permission to provide incontinence care for the resident. Continued observation of incontinence care revealed CNA #211 revealed Resident #2 had an indwelling urinary catheter and CNA #211 did not don a gown while providing care. During an interview on 08/17/26 at 3:57 P.M., CNA #211 verified she provided incontinence care for Resident #2 and did not don a gown. CNA #211 stated she thought the resident's roommate was in precautions and was unaware Resident #2 was in EBP. Review of the facility policy titled, Enhanced Barrier Precautions, dated 07/01/25, revealed the facility implemented EBP for the prevention of transmission of multidrug-resistant organisms, and provided Personal Protective Equipment (PPE) to be to be worn when performing high contact care activities.

Based on personnel file review and staff interview, the facility failed to follow its policy to ensure all staff were screened for a history of abuse, neglect, exploitation or misappropriation of resident property on the Nurse Aide Registry (NAR) prior to hire. This affected five (Director of Nursing [DON], Registered Nurse [RN] #102, Social Services Director [SSD] #132, Business Office Manager [BOM] #147 and Licensed Practical Nurse [LPN] #150) of eight new staff reviewed for NAR checks and had the potential to affect all residents. The facility census was 101.Findings include:1. Review of the DON's personnel file revealed a hire date of 05/12/26. Further review revealed no evidence the DON was checked on the NAR prior to hire. Interview on 08/19/26 at 10:00 A.M. with Human Resources (HR) #72 on 08/19/26 at 10:00 A.M. verified there was no evidence the DON was checked on the NAR registry prior to hire. HR #72 stated she was not aware newly hired staff had to be checked on the NAR. 2. Review of RN #102's personnel file revealed a hire date of 12/22/25. Further review revealed no evidence RN #102 was checked on the NAR prior to hire. Interview on 08/19/26 at 10:00 A.M. with HR #72 verified there was no evidence RN #102 was checked on the NAR prior to hire. HR #72 stated she was not aware newly hired staff had to be checked on the NAR. 3. Review of SSD #132's personnel file revealed a hire date of 08/13/25. Further review revealed no evidence SSD #132 was checked on the NAR prior to hire.Interview on 08/19/26 at 10:00 A.M. with HR #72 verified there was no evidence SSD #132 was checked on the NAR prior to hire. HR #72 stated she was not aware newly hired staff had to be checked on the NAR. 4. Review of BOM #147's personnel file revealed a hire date of 01/06/26. Further review revealed no evidence BOM #147 was checked on the NAR prior to hire. Interview on 08/19/26 at 10:00 A.M. with HR #72 verified there was no evidence BOM #147 was checked on the NAR prior to hire. HR #72 stated she was not aware newly hired staff had to be checked on the NAR. 5. Review of LPN #150's personnel file revealed a hire date of 06/25/25. Further review revealed no evidence LPN #150 was checked on the NAR prior to hire.Interview on 08/19/26 at 10:00 A.M. with HR #72 verified there was no evidence LPN #150 was checked on the NAR prior to hire. HR #72 stated she was not aware newly hired staff had to be checked on the NAR. Review of the facility's abuse, neglect and exploitation policy, dated 03/15/26, revealed potential employees would be screened for a history of abuse, neglect, exploitation or misappropriation of resident property. The facility would maintain documentation of proof that the screening occurred.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) received annual performance evaluations. This affected two (CNA #99 and CNA #140) out of two CNAs reviewed for performance evaluations. The facility census was 101.Findings include:1. Review of CNA #99's personnel file revealed a hire date of 05/29/24. Further review revealed CNA #99 did not have an annual performance evaluation from 05/29/25 to 05/29/26.Interview with Human Resources (HR) #72 on 08/19/26 at 10:00 A.M. verified CNA #99 did not have an annual performance evaluation from 05/29/25 to 05/29/26.2. Review of CNA #140's personnel file revealed a hire date of 08/24/06. Further review revealed CNA #140 did not have an annual performance evaluation from 08/24/24 to 08/19/26.Interview with HR #72 on 08/19/26 at 10:00 A.M. verified CNA #140 did not have an annual performance evaluation from 08/24/24 to 08/19/26.

Based on personnel record review and staff interview, the facility failed to ensure staff were educated on resident rights upon hire. This affected two (Registered Nurse [RN] #102 and the Administrator) of eight new personnel records reviewed and had the potential to affect all residents. The facility census was 101.Findings include:1. Review of RN #102's personnel file revealed a hire date of 12/22/25. Further review revealed no evidence RN #102 received education on resident rights upon hire. Interview on 08/19/26 at 10:00 A.M. with Human Resources (HR) #72 verified there was no evidence RN #102 received education on resident rights. 2. Review of the Administrator's personnel file revealed a hire date of 06/30/25. Further review revealed no evidence the Administrator received education on resident rights upon hire. Interview on 08/19/26 at 10:00 A.M. with HR #72 verified there was no evidence the Administrator received education on resident rights.

Based on interview and personnel record review, the facility failed to ensure Certified Nursing Assistants (CNAs) received at least twelve hours of in-services annually. This affected two (CNA #99 and CNA #140) of two CNAs reviewed for annual in-services. The facility census was 101.Findings include:1. Review of CNA #99's personnel file revealed a hire date of 05/29/24. Further review revealed no documented in-service education from 05/29/25 to 05/29/26.Interview with Human Resources (HR) #72 on 08/19/26 at 10:00 A.M. verified CNA #99 did not have any documented in- service education from 05/29/25 to 05/29/26.2. Review of CNA #140's personnel file revealed a hire date of 08/24/06. Further review revealed no documented in-service education from 08/24/24 to 08/19/26.Interview with HR #72 on 08/19/26 at 10:00 A.M. verified CNA #140 did not have any documented in-service education from 08/24/24 to 08/19/26.Review of the facility's required training, certification and continuing education of nurse aides policy, revised on 02/23/26, revealed the facility would comply with state and federal regulations and requirements as they pertain to training, certification and continuing education of its nurse aides.

Based on record review, observations, staff interviews, facility policy review, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess a resident's skin and failed to timely identify pressure ulcers (injuries to skin and underlying tissue caused by prolonged pressure, friction, or shear, usually over bony areas like the hips, heels, or tailbone) until they had reached an advanced stage. This resulted in Actual Harm for Resident #116 on 12/22/25, when the resident was admitted to the facility without pressure ulcers, was assessed to be at risk for development of pressure ulcers and developed an avoidable unstageable pressure ulcer (a full-thickness wound where damage depth is hidden by slough [a soft, moist, yellow or white devitalized tissue comprised of dead cells, fibrin, and bacteria that forms in the wound bed, acting as a significant barrier to healing by stalling the inflammatory phase] or eschar [a thick, dry, black or brown layer of dead tissue that forms over deep wounds] making an accurate stage assessment impossible and an unstageable pressure area signifies a deep stage III or IV ulcer requiring urgent medical attention) to the left heel. This affected one (Resident #116) of the three residents reviewed for pressure ulcers. The facility census was 107.Findings include:Review of the medical record for Resident #116 revealed an admission date of 11/12/25. Resident #116 was discharged home on [DATE]. Diagnoses included Alzheimer's disease, dementia, toxic liver disease, congestive heart failure (CHF), anxiety disorder, osteoarthritis, chronic kidney disease, and sepsis due to Escherichia coli (E-Coli), Review of the Baseline Care Plan for Resident #116 dated 11/12/25, revealed the resident no had no current skin issues and no history of skin integrity issues.Review of the physician order dated 11/12/25, revealed Resident #116 was ordered to receive weekly skin assessments and to be on a pressure-reduced mattress. Review of the Braden Scale for Predicting Pressure Sore Risk for Resident #116 dated 11/12/25, revealed the resident was at moderate risk for pressure related to skin breakdown. Review of the weekly skin assessment for Resident #116 dated 11/12/25, revealed no identified skin issues related to the left heel. Review of the physician order dated 11/24/25, revealed Resident #116 was ordered to have bilateral heels cleansed and skin prep applied every shift as a preventative measure. Review of the weekly skin assessments for Resident #116 dated 11/25/26, 12/02/26, and 12/06/25 revealed the resident's left heel was identified as being soft and blanchable and preventative measures dated 11/24/25 were to be in place. Review of the bathing documentation for Resident #116 dated 12/08/25,12/09/25, 12/10/25, 12/11/25, 12/12/25, 12/15/25, 12/17/25, 12/19/25, and 12/22/25, completed by Licensed Practical Nurse (LPN) / Wound Nurse #197 revealed the resident had blanchable redness to bilateral heels and no additional skin issues.Review of the weekly skin assessments for Resident #116 dated 12/12/25, revealed no identified skin issues on the left heel. Review of December 2025 Treatment Administration Record (TAR) for Resident #116 dated 12/19/25, 12/20/25, and 12/21/25, revealed the preventative measures (heels cleansed and skin prep applied every shift) were documented as being completed twice daily. Review of the bathing sheet for Resident #116 dated 12/22/25 authored by LPN#197, revealed the resident had no identified wounds or skin integrity issues on the left heel. Review of the nurse's progress note for Resident #116 dated 12/22/25 at 3:56 P.M. recorded as a late entry on 12/23/25 and authored by LPN #197, revealed the resident had an open area on the left heel. The area had slight drainage, and the resident was at risk for skin integrity issues with preventative orders in place. The wound measured 4.5 centimeters (cm) in length by 3 cm in width by 0.1 cm in depth. Review of the weekly skin assessments for Resident #116 dated 12/23/25, authored by LPN #197, revealed an open area to the resident's left heel that measured 4.5 cm in length by 3 cm in width by 0.1 cm in depth.Review of the most recent Skin Breakdown Assessment for Resident #116 dated 12/23/25, revealed the resident had an open area to the left heel that measured 4.5 cm in length by 3 cm in width by 0.1 cm in depth. Review of the most recent Braden Scale for Predicting Pressure Sore Risk for Resident #116 dated 12/23/25, revealed the resident was at high risk for skin breakdown. Review of a facility document titled Wound Evaluation Observation for Resident #116 dated 12/24/25, signed as completed on 01/05/26 by 3:19 P.M. by LPN #197, revealed the resident was identified with a wound to the left heel acquired in-house on 12/22/25. The wound was unstageable, with granulation tissue present, and 90 percent necrotic tissue (dead or devitalized cells that cannot be salvaged, appearing as discolored [black, brown, yellow]), exudate (drainage) was small serosanguinous (mix of pale yellow [serous] fluid and light red [sanguineous/blood] fluid, commonly seen in the first 24-72 hours of healing) with necrotic tissue at 90 percent and granulation tissue at 10 percent (new, vascularized connective tissue that forms on the surface of a healing wound during the proliferative phase, appearing as red, moist). The measurements were 4 cm in length by 4.3 cm in width by 0.2 cm in depth. The treatment consisted of Vashe gauze applied for antimicrobial protection and autolytic debridement and would be evaluated weeklyReview of the physician order dated 12/24/25, revealed Resident #116 was ordered to have heel boots applied as tolerated every shift. Review of Wound Nurse Practitioner (WNP) #550's note for Resident #116 dated 12/24/25 at 3:38 P.M. revealed the resident was assessed with a new in-house acquired unstageable pressure wound on the left heel. The wound measured 4 cm in length by 4.3 cm in width by 0.2 cm in depth with small amount of serosanguinous exudate, 90 percent necrotic tissue and 10 percent granulation. Treatment consisted of Vashe soaked gauze pads for antimicrobial protection and autolytic debridement with a bordered gauze applied daily and as needed. Review of the WNP #550 note for Resident #116 dated 12/31/25, revealed the resident complained of pain in left heel. The resident's wound was still an unstageable pressure wound on the left heel that measured 2 cm in length by 4 cm in width by 0.2 cm in depth with moderate amount of serosanguinous exudate, 30 percent of slough (a soft, moist, yellow or white devitalized tissue comprised of dead cells, fibrin, and bacteria that forms in the wound bed, acting as a significant barrier to healing by stalling the inflammatory phase), 40 percent necrotic tissue and 30 percent granulation. Treatment consisted of Vashe soaked gauze pads for antimicrobial protection and autolytic debridement with a bordered gauze applied daily and as needed. Review of the Interdisciplinary Team (IDT) note for Resident #116 dated 12/28/25 at 3:17 P.M. authored by the Director of Nursing (DON), revealed the team reviewed the pressure ulcer identified on 12/22/26. The floor nurse notified the wound nurse of a new open area to the resident's left heel. The resident had an area to the left heel with slight drainage. New treatment and monitoring orders were put in place. Resident #116's daughter was notified and the facility would continue to monitor signs and symptoms of changes or infection.Review of the physician order dated 12/28/25, revealed Resident #116 was ordered to have the left heel monitored for signs and symptoms of change or infection every shift. Review of the comprehensive plan of care for Resident #116 revised on 12/30/25, revealed the resident had impaired skin integrity related to a pressure ulcer on the left heel and an arterial ulcer to left medial toe secondar to skin breakdown, immobility, and medical comorbidities. Interventions included: supplemental protein, amino acids, vitamins, and minerals as ordered, provide/encourage/assist with application of heel protectors/moon boots to be worn at all times, treat pain as ordered to ensure comfort, consult with a wound nurse, encourage the resident to float heels, encourage/assist resident to turn and reposition every two hours, utilize positioning devices as needed, follow facility protocols and policies related to skin breakdown, monitor/document/report to physician any changes in skin status, pressure relieving mattress/alternating pressure air mattress.Review of the physician visit note for Resident #116 recorded as a late entry on 12/30/25 for a visit dated 12/28/25 and authored by Medical Director (MD) #500, revealed Resident #116 was seen for osteoarthritis. Resident #116 had no new complaints, and the facility reported no new concerns at this time. There was no documentation by MD #500 regarding the new unstageable pressure wound on the resident's left heel identified on 12/22/26.Review of the physician order dated 01/02/26, revealed Resident #116 was ordered to have the left heel monitored for signs and symptoms of infection and notify the physician if any signs of infection. Review of the physician order dated 01/21/26, revealed Resident #116 was ordered to have the left heel wound cleansed, patted dry, a nickel thick layer of Santyl applied, followed by calcium alginate, and a boarder gauze every night shift and as needed.Review of the Minimum Data Set (MDS) assessment, dated 01/30/26, for Resident #116 revealed she had severely impaired cognition. Resident #116 was dependent on staff for all activities of daily living. During an interview on 02/24/26 at 1:19 P.M., LPN #197 stated she was the nurse who identified Resident #116's left heel wound on 12/22/25. LPN #197 stated she discovered the wound during a facility wide skin sweep related to an increase in self-reported incidents (SRI) and increase in wounds. LPN #197 stated the skin sweeps were documented on the Bath and Shower Documentation Sheets. LPN #197 stated she started daily skin sweeps in the Memory Care Unit (MCU). LPN #197 stated Resident #116 did not have any Wound Nurse Practitioner (NP) visits during the weeks of 12/10/25 and 12/17/25 because a previous skin issue in a different location had been resolved. LPN #197 stated she completed a skin sweep on 12/22/25 and identified an unstageable pressure wound on the residents left heel. During an interview on 02/25/26 at 10:37 A.M., WNP #550 verified Resident #116 developed an in-house unstageable pressure ulcer to he left heel identified by the staff on 12/22/25. Review of the facility policy titled, Wound Management and Documentation dated 12/2024, revealed the facility would complete accurate documentation of treatments and focused wound assessments, including response to treatment, change in condition, and changes in treatment. Focused wound assessments were to be documented weekly, and as needed if the resident or wound condition deteriorates.Review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, dated 2014, pages 70-71, at (https://npiap.com/general/custom.asp?page=2014Guidelines), revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Unstageable pressure ulcer is defined as a depth unknown full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined.

Based on record review, review of emergency room (ER) records, staff interview, review of the facility's investigation and policy review, the facility failed to ensure a resident was safely turned in bed during incontinence care resulting in the resident falling out of bed. This resulted in Actual Harm when Certified Nursing Assistant (CNA) #355 was providing incontinence care to Resident #116 and the resident rolled out of the bed onto the floor. Resident #116 was sent to hospital and was diagnosed with a head injury which required staples. This affected one (Resident #116) of the three residents reviewed falls. The facility census was 107.Findings included: Review of the medical record review for Resident #116 revealed an admission date of 11/12/25 and discharged home on [DATE]. Diagnoses included toxic liver disease, congestive heart failure, constipation, anemia, anxiety disorder, Alzheimer's disease, osteoarthritis, chronic kidney disease, sepsis due to Escherichia coli, and dementia.Review of comprehensive plan of care for Resident #116 dated 11/16/25, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to confusion/dementia and the level of assistance from staff varied throughout the day. The resident had behaviors related to being resistive to care resulting in injury. Interventions included: monitor and anticipate the resident's care needs, scoop mattress, and assess the resident for fall risks. There was no plan of care implemented for the resident being at risk for falls and no interventions implemented until after the fall occurred on 11/24/25. Review of the Interdisciplinary Team (IDT) note dated 11/21/25 at 5:00 A.M. and recorded as a late entry on 12/01/25 at 4:44 P.M. and authored by the Director of Nursing (DON), revealed CNA #355 provided care for Resident #116 and once completed, CNA #355 turned to reach for the bed remote to lower the bed when Resident #116 shifted in the bed resulting in the resident rolling off the bed. Registered Nurse (RN) #134 was alerted and upon the nurse's entry into the resident's room, Resident #116 was lying on the floor with a laceration on the left forehead. The new intervention was a two-person assistance with bed mobility and transfers to reduce the risk of further falls and injury.Review of witness statement by CNA #355 dated 11/21/25 (three days prior to the incident), revealed CNA #355 provided incontinence care to Resident #116 and when finished, CNA #355 turned to get the remote for the bed so the bed could be lowered and Resident #116 rolled out of bed. CNA #355 got RN #134 to assess the resident.Review of the nurse's progress note for Resident #116 dated 11/24/25 at 5:42 A.M. and authored by RN #134, revealed the nurse was called into the resident's room by CNA #355 related to injuries the resident sustained after falling out of the bed. Resident #116 had a laceration to the top of the head, with a significant amount of blood. Direct pressure was applied to the site until emergency medical services (EMS) arrived. CNA # 355 reported Resident #116 decided to roll towards the floor from the bed during personal care. CNA #355 indicated the bed was up high and the bed rails were down. The new interventions included adding bedrails to the bed and two-person assistance required for care. Review of the ER records for Resident #116 dated 11/24/25 at 6:34 A.M., revealed the resident was admitted to the ER for a closed head injury, scalp laceration, and cervical strain. The head wound was 3.2 centimeters (cm) in length and four staples were placed. Resident #116 was discharged from the hospital on [DATE] at 10:44 A.M.Review of the Incident Report dated 11/24/25 at 5:00 A.M., and authored by RN #134, revealed the nurse was called to Resident #116's room due to a fall with injuries to the resident's head. Resident #116 had a laceration to her head with a significant amount of blood and vital signs were taken. Direct pressure was applied to the site until EMS arrived. The new intervention was to add side rails and a two-person assist for all personal care. The physician and family members were notified of the fall. Review of the physician progress notes for Resident #116 dated 11/30/25 at 3:00 A.M. and recorded as a late on 12/01/25 at 1:00 P.M., revealed Resident #116 was assessed by Medical Doctor (MD) #500 and the primary reason for visit was listed as osteoarthritis. Resident #116 was listed as having no new complaints and the facility had no concerns. There was no documentation related to the witnessed fall on 11/24/25. Review of a Fall Risk Assessment for Resident #116 dated 12/02/25, revealed the resident was at high risk for fallsReview of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #116 had severely impaired cognition. Resident #116 was dependent on staff for all activities of daily living. During an interview on 02/24/26 at 4:30 P.M., the Administrator stated CNA #355's write-up on 11/25/25 was directly related to the incident involving Resident #116's fall on 11/24/25. The Administrator verified CNA #355 was terminated related to Resident #116 rolling out of bed during his care on 11/24/25. The Administrator verified CNA #355 diverted his attention away from Resident #116 and the resident rolled out of bed causing the injuries to the resident's head. During an interview on 02/24/25 at 4:45 P.M., RN #134 stated she was responsible for caring for Resident #116 on 11/24/25 around 5:42 A.M. when the resident rolled out of bed during care by CNA #355 and sustained a head injury. RN #134 stated CNA #355 called her into the resident's room after the resident had a fall with injury. RN #134 stated CNA #355 reported that he provided personal care to Resident #116 and turned to grab something and Resident #116 rolled off the bed. RN#134 stated there was a lot of blood, and she had to hold a washcloth to Resident #116's head to try and control the bleeding. RN #134 stated she incorrectly documented that there were no bedrails in place when the resident fell but later realized the bed rails were down because CNA #355 had the bed in the highest position during care. RN #134 stated she recommended the intervention for Resident #116 to be a two-person assist with care and transfers.Review of the employee file for CNA #355 on 02/25/26 at 1:00 P.M., revealed he was hired on 05/07/25. CNA#355's employee file had a write up for 11/25/25 related to poor work performance. CNA #355 was terminated on 12/11/25 related to poor work performance. During an interview on 02/25/26 at 3:26 P.M., the DON stated the facility does not review falls as an IDT. The DON stated the nurse on duty would complete the risk assessment investigation and should put an immediate intervention in place. The DON stated she would review the interventions after the nurse put something in place. The DON stated she is the only one from the IDT that reviewed falls after an incident. The DON stated she has been in the DON role for four weeks; however, prior to the role of DON she was the Assisted Director of Nursing (ADON) at the time of the incident on 11/24/25. The DON stated the IDT meets once monthly and would review falls. The DON stated the facility has not completed any IDT meetings since she took over the DON role. Review of facility policy titled, Fall Prevention Program, dated 06/17/25, revealed each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Upon admission, the nurse would complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk, and provide interventions as directed by the IDT review, including but not limited to assisted devices, medication review, low bed, alternate all system access, scheduled ambulation or toileting assistance, family/resident education, and therapy services referral.

Based on medical record review, staff interviews, observation, review of maintenance logs, and review of facility policy, the facility failed to ensure a resident was free from accidents/hazards. This resulted in Actual Harm when Resident #66 utilized the first-floor restroom on 12/15/24 and while washing his hands, the floating handwashing sink fell on him resulting in a laceration to the left knee that required 17 sutures, the use of antibiotics for infection prevention and continued wound care. This affected one (#66) of three residents reviewed for accidents. The facility census was 101. Findings included: Review of the medical record for Resident #66, revealed an admitted [DATE]. Diagnoses included toxic encephalopathy, schizophrenia, chronic viral Hepatitis-C, visual hallucinations, auditory hallucinations, alcohol abuse, drug induced akathisia, muscle weakness and dysphagia. Review of the admission Minimum Data Set (MDS) assessment for Resident #66 dated 11/18/24, revealed Resident #66 had moderate cognitive impairment and the resident required moderate assistance with transfers and sitting to standing. Review of an incident report titled Skin Tear dated 12/15/24 at 11:23 A.M. and authored by Licensed Practical Nurse (LPN) #233 revealed a Certified Nursing Assistant (CNA) reported Resident #66 was bleeding. There was blood noted in the elevator when Resident #66 returned from smoking. A large laceration that was approximately three inches long by one inch wide was noted on the resident's left shin below the knee and a small cut was noted under the resident's right eye. Resident #66 stated when he went to smoke, he used the bathroom downstairs and the sink broke and cut him. The area was cleansed, and steri- strips, an abdominal (ABD) pad along with kerlix were applied. Resident #66's vital signs were obtained, and the resident's physician was notified. Review of an alert note for Resident #66 dated 12/15/24 at 1:18 P.M., and authored by LPN #272, revealed Resident #66's family was in the facility and observed an open area to the resident's left lower extremity. The family called nine-one-one (911) and Resident #66 was transported to the hospital. The physician was made aware. Review of a physician order for Resident #66 dated 12/15/24, revealed the resident was ordered to have the left shin cleansed with normal saline, patted dry, ABD applied, covered with kerlix every day and monitor the steri-strips for placement. The order was discontinued 12/29/24. Review of the hospital record for Resident #66 dated 12/15/24, revealed Resident #66 was going to the bathroom at his skilled nursing facility when the ceramic sink fell from the wall hitting his knee and causing a laceration. Resident #66's family reported a provider at the facility applied steri-strips and stated the resident did not need to go to the hospital, and he did not require any sutures. Resident #66's family stated they noticed Resident #66's leg was continuing to bleed and the family insisted the resident come to the emergency department for evaluation. Resident #66 was positive for joint pain and had a five-centimeter (cm) laceration noted to the left knee and there was active bleeding noted. The laceration was closed with 17 sutures, Bacitracin applied and then gauze and Coban applied. Resident #66 was discharged from the hospital on 12/15/24 and to follow-up with his primary care provider and have the sutures removed in 12-14 days. Review of the hospital After Visit Summary (AVS) for Resident #66 dated 12/15/24, revealed Resident #66 was seen for an extremity laceration. The resident was diagnosed with a laceration of the lower left extremity which required sutures, and the sutures were to be removed in 12 to 14 days. Review of a MDS note for Resident #66 dated 12/16/24 at 9:47 A.M., revealed Resident #66's care plan was updated related to a skin tear. Care plan goals and interventions were in place at that time. Review of a care plan for Resident #66 dated 12/16/24, revealed Resident #66 had impaired skin integrity related to a skin tear to the left knee and bruising to the right eye. Interventions included apply treatments as ordered, educate the resident, family and caregivers of causative factors and measures to prevent skin injury, include the resident and responsible party in the treatment plan, update the treatment plan as indicated by change in condition or treatment, measure area every week, and observe the wound for signs and symptoms of infection. Review of a hardware store receipt dated 12/16/24 revealed items including a white wall mount sink, drywall repair panels, a drain, and bath faucet were purchased. Review of a health status note for Resident #66 dated 12/29/24 at 6:53 P.M., and authored by LPN #150, revealed the hospital discharge orders from 12/15/24, indicated the resident's sutures were to be removed in 12-14 days and today was day 14. An order was not located in the paper chart or in the electronic medical record (EMR). Resident #66's physician was contacted and verified Resident #66's sutures were to be removed. This nurse found a small dehiscence (opening of a wound), serous sanguineous fluid leaking and there was a lot of heat and swelling to the area. Resident #66's physician gave an order to start Resident #66 on doxycycline (antibiotic) 100 milligrams (mgs) twice a day for ten days and to leave the wound open to air. Review of a health status note for Resident #66 dated 12/29/24 at 6:58 P.M., and authored by LPN #150, revealed LPN #150 and another nurse on the unit attempted to remove the sutures from the left lower extremity. It was noted the wound edge was thought to be closed and well approximated (wound edges close together) except for a small 1 cm by 1 cm opening that began to open up during the suture removal process. Resident #66 stated the process was becoming painful and was afraid the wound would open more, and the resident requested LPN #150 and the other nurse to stop and wait to be seen by the physician in the morning. The nurse reached out to the physician. Review of a physician order for Resident #66 dated 12/29/24, revealed an order for the sutures to be removed from his left lower extremity or knee. The order was discontinued 12/30/24. Review of a health status note for Resident #66 dated 12/30/24 at 3:32 P.M., revealed Nurse Practitioner (NP) #151 provided new orders including cleanse the wound area with normal saline, pat dry, apply bordered gauze daily and as needed. Resident #66 and the resident's sister were notified. Review of a wound care note for Resident #66 dated 12/30/24 and authored by NP #151, revealed the resident was seen for an initial evaluation and management of the wound to the left lower extremity. Resident #66 was alert with cognitive impairment and resided in the memory care unit. Resident #66 denied pain. The staff attempted to apply a dry dressing for a small amount of bleeding to protect the wound but Resident #66 refused multiple times. The nurse reported that the sutures were removed, and Resident #66 was placed on doxycycline on 12/30/24. The wound was listed as in-house acquired, traumatic in etiology and it had full thickness. The wound was 1 cm in length by 4 cm in width and 0.1 cm in depth. Resident #66 was to have a bordered foam dressing three times a week and as needed. Review of a physician order for Resident #66 dated 12/31/24, revealed an order to have the left knee cleansed with normal saline, patted dry, and covered with bordered gauze daily and as needed. The order was discontinued 01/15/25. Review of a physician order for Resident #66 dated 12/31/24, revealed an order for doxycycline 100 mg give one tablet by mouth two times a day for infection prevention for ten days until finished. The order was discontinued 01/10/25. Review of a wound care physician note for Resident #66 dated 01/06/25 and authored by NP #151, revealed the resident was seen for a wound follow up on his left lower extremity. The wound was listed as improved. The wound was 1.5 cm in length by 3.5 cm in width by 0.1 cm in depth. Resident #66 was to have a bordered foam dressing three times a week and as needed. Review of a health status note for Resident #66 dated 01/09/25 at 5:29 P.M., revealed the resident was to continue antibiotics for his wound. Resident #66 was afebrile (without fever) and removed his bandage three times that shift. Resident #66 was educated on keeping the wound clean and dry and the resident taped on a piece of gauze and told the nurse to leave it alone. Review of a physician order for Resident #66 dated 01/13/25, revealed an order to cleanse the area to the left knee wound, apply collagen to the wound bed, lightly pack the wound with Vashe (a wound Solution intended for cleansing, irrigating, moistening, debridement and removal of foreign material) soaked moistened gauze, and covered with a bordered gauze every day and as needed. Review of a wound care physician note for Resident #66 dated 01/13/25 and authored by NP #151 revealed the resident was seen for a wound follow up on his left lower extremity. The wound was listed as improved. The wound was 1.2 cm in length by 2.5 cm in width by 0.3 cm in depth. Resident #66 was to have a collagen sheet applied to the wound bed, lightly pack the wound with Vashe soaked gauze and cover with a bordered gauze every day. Observations of the facility on 01/16/25 from 7:32 A.M. to 2:00 P.M. revealed no concerns related to accidents/hazards. There was a public restroom located on the first floor that had a floating porcelain sink affixed to the wall. The sink was noted to be sitting on a bracket that was affixed to the wall with a strip of caulking on the top of sink. Interview with Resident #66 on 01/16/25 at 8:10 A.M., revealed he independently walked into and used the first-floor bathroom around the end of December 2024. Resident #66 stated he went to wash his hands, and the handwashing sink fell on him and cut open his left knee. Resident #66 reported that his left knee was bleeding, and he was sent out to the hospital to get stitches. Resident #66 stated he was not aware of his family being notified of the injury but stated they were at the hospital with him. Resident #66 reported that he had a current dressing on his left knee, but his stitches had been taken out. Resident #66 stated his pain was not too bad. Observation of Resident #66 at the time revealed the resident was lying in bed, appeared clean, and the resident was observed to have a bordered dressing on his left knee that was not labeled or dated. Interview with the Administrator on 01/16/25 at 10:19 A.M., revealed the staff took Resident #66 to smoke on 12/15/24 and the staff noticed Resident #66 was bleeding when they got on the elevator to go back up to the resident's unit on the second floor. The Administrator stated Resident #66 reported the sink cut him. Resident #66's physician was notified, and the physician gave an order for a dressing to the wound, but the resident's family was not satisfied and wanted him sent out to the hospital. The Administrator stated Resident #66 was sent to the hospital, and he obtained sutures to his left knee. The Administrator reported the bathroom sink was found lying on the floor when staff looked in the bathroom and the bathroom was locked so other residents could not enter it. Interview with the Director of Nursing (DON) on 01/16/25 at 12:54 P.M., revealed she received a phone call on 12/15/24 from the nurse notifying her the first-floor bathroom handwashing sink fell on Resident #66 cutting his left knee. The DON stated the physician was notified, and the physician ordered staff to cleanse the area with normal saline, pat dry, apply an ABD pad and apply kerlix. The DON stated Resident #66's family was not notified because Resident #66 was his own responsible party, but his family came to the facility later that day and requested that he go out to the hospital. The DON stated that Resident #66 returned to the facility from the hospital with stitches. Attempted interview with LPN #233 on 01/16/25 at 12:56 P.M. was unsuccessful. A message was left to return the call, and no return call was received. Interview with Maintenance Director #800 on 01/16/25 at 12:58 P.M., revealed Maintenance Director #800 was notified on 12/15/24 the sink in the first-floor bathroom fell off the wall and cracked. Maintenance Director #800 reported the sink was on the floor in several pieces and the pipes were still attached to the sink but were not leaking. Maintenance Director #800 stated he replaced the sink with a new floating sink, replaced the dry wall, replaced the drains and applied new caulking. Maintenance Director #800 reported the sink that fell on Resident #66 was a floating sink and floating sinks will tilt if someone puts too much weight on the sink. Maintenance Director #800 stated any floating sink could possibly fall off the wall because floating sinks sit on an anchor with caulking but are not directly bolted to the wall. Observation of wound care for Resident #66's left knee wound on 01/17/25 at 9:34 A.M., revealed LPN #236 washed her hands, donned a gown and gloves. LPN #236 removed an undated bordered dressing from Resident #66's left knee. LPN #236 doffed her gloves, washed her hands and donned a new pair of gloves. LPN #236 cleansed the area with Vashe wound solution, applied collagen to the wound bed, packed the wound with Vashe moist gauze and covered the wound with a bordered gauze. LPN #236 then labeled the dressing with the date and her initials. Interview with Activities Aide (AA) #801 on 01/17/25 at 1:02 P.M., revealed she took Resident #66 to smoke outside on the first floor of the facility on 12/15/24. AA #801 stated Resident #66 finished smoking, and he went to the bathroom on the first floor by himself. AA #801 reported Resident #66 came out of the bathroom and she was not aware that anything occurred in the bathroom because she did not hear anything as she was watching the bathroom door from a distance. AA #801 stated Resident #66 was wearing dark pajama pants, and she initially did not see any blood. AA #801 reported they went back upstairs from smoking, and she saw a few red drops in the elevator, but she thought it was juice. AA #801 stated Resident #66 stated he was going to talk to the nurse, and she went on about her day but later found out that the sink fell on Resident #66 in the downstairs bathroom and cut his left knee. Review of the facility's investigating and reporting accidents and incidents policy dated December 2009 revealed all accidents and incidents involving residents, employees, visitors, and vendors occurring in the facility shall be investigated and reported to the administrator. This deficiency represents non-compliance investigated under Complaint Number OH00161103.

Based on observation, interview, record review, review of a police report, review of facility document, and policy review, the facility failed to protect the resident's right to be free from sexual abuse by a visitor for one (Resident #137) of three resident's reviewed for abuse. This resulted in Actual Harm on 04/09/24 when Resident #48's significant other, Family Member (FM) #16, touched Resident #137's breasts and private area and exposed his genitalia to the resident on a patio in the facility courtyard where residents smoked. FM #16 admitted to the police that he committed the actions against the resident, despite Resident #137 telling him, No. The failure resulted in Resident #137 being tearful and so traumatized by this event, that it felt like she was raped. Findings included: Medical record review revealed the facility admitted Resident #137 on 07/01/22. According to the Admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stroke), schizoaffective disorder bipolar type, tobacco use, depression, generalized anxiety disorder, hemiplegia (paralysis or weakness) affecting the left nondominant side, need for assistance with personal care, and unsteadiness on feet. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/24, revealed Resident #137 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS revealed the resident required supervision or touching assistance (the helper provided verbal cues and/or touching/steadying and/or contact guard assistance as the resident completed the activity) with walking and with upper body dressing. The MDS also indicated the resident had limited range of motion of the upper and lower extremities on one side and utilized a walker. According to the MDS, Resident #137 had no physical, verbal, or other behavioral symptoms. The MDS indicated the resident smoked during the assessment period. Resident #137's Care Plan included a focus area initiated on 04/03/24 that indicated the resident was at risk for injury related to smoking. The Care Plan revealed the resident smoked tobacco-cigarette products and did not need supervision when smoking. A police report dated 04/09/24 revealed at approximately 1:03 P.M. on 04/09/24, a police officer was dispatched to the facility in response to a Morals/Sex Offenses complaint that occurred from 10:30 A.M. to 11:00 A.M. on 04/09/24. The report revealed upon arrival, the Administrator notified the police officer that Resident #137 had reported that FM #16 inappropriately touched the resident. The report revealed the Administrator had security camera footage from the courtyard of the incident involving Resident #137 and FM #16; however, the video did not have an audio recording aspect. According to the report, the camera footage revealed FM #16 was sitting across from Resident #137 at a table located in the outdoor smoking area (courtyard) of the facility. The report revealed FM #16 was seen standing up and walking toward Resident #137 and positioned himself to stand behind Resident #137 as the resident sat in a chair. The report revealed camera footage showed FM #16 placed his hands and arms across Resident #137's shoulder and FM #16's hands were in motion around Resident #137's breasts for approximately 30 seconds as the resident sat there motionless. According to the police report, FM #16 was then observed moving over to the left side of Resident #137 where FM #16 reached into his own pants. The report revealed FM #16 was observed manipulating something in front of his pants with his left hand. According to the report, Resident #137 briefly looked down at FM #16's private area, slightly leaning away from FM #16, and then looked at FM #16's face. The police report revealed FM #16 placed his right hand on Resident #137's shoulder and slightly pulled the resident toward him. The report revealed FM #16 then zipped up his pants and looked around before placing his right hand and arm inside Resident #137's shirt and began to rub the resident's breast and private area for approximately 25 seconds. According to the police report, once again, Resident #137 sat there motionless and stared forward at the table in front of her. The report revealed FM #16 continued to rub Resident #137's back and hair as the resident stared forward at the table in front of them. The report revealed that it should be noted that a male was seen in the video outside near both parties during a portion of the incident; however, staff advised that the male suffers from mental disabilities and would not be able to give a statement of what occurred. According to the police report dated 04/09/24, Resident #137 stated she was outside smoking when FM #16 began to touch her bare breasts underneath her shirt with bare hands. The report revealed Resident #137 stated FM #16 then proceeded to rub Resident #137's private area through her pants. The report revealed Resident #137 stated she told FM #16, No, multiple times while the actions were occurring. Per the report, Resident #137 stated FM #16 revealed his genital area and stated, I want you to do me a favor, walk to the bathroom and I'll follow you so you can give me a [oral sex]. The report revealed after Resident #137 said no, FM #16 walked away. According to the report, Resident #137 stated she was so traumatized by this event, that it felt like [the resident] was raped. The report revealed that Resident #137 stated she had been at the facility for physical therapy since 03/26/24 and had seen FM #16 outside in the smoking area. The report revealed Resident #137 stated she had several conversations with FM #16 and never felt threatened in any way. The report revealed Resident #137 stated FM #16 usually smelled like alcohol but seemed highly intoxicated that day. The report revealed when the officer asked Resident #137 to complete a written statement, the resident hesitated and agreed that the verbal testimony recorded on the officer's body worn camera would suffice so she did not have to go through the trauma of rearticulating the story again. The report revealed Resident #137 advised the officer that she wanted to pursue charges against FM #16. According to the police report dated 04/09/24, the officer left the facility and later arrested FM #16. The report revealed FM #16 stated to the officer that he was at the facility and confirmed standing behind Resident #137 and touching her bare breasts. FM #16 also confirmed hearing the resident say no multiple times but continued to touch the resident's private area through her pants. According to the report, FM #16 stated that Resident #137 still did not approve of FM #16's actions so he stood by the resident's side and showed his genitalia to Resident #137. Observations on 07/08/24 through 07/11/24, revealed a sign posted at the nurse's station of the memory care unit (MCU) that indicated FM #16 is NOT allowed on the premises of the facility. If he/she is in the building you will need to call the police. If you have any questions, please let me know. During an interview on 07/10/24 at 12:05 P.M., the Assistant Director of Nursing (ADON) stated Resident #48 was a long-term resident and FM #16 previously visited them daily. The ADON stated the allegation was reported to the Director of Nursing (DON) and the Administrator and they watched the security footage and called the police who then arrested FM #16. The ADON stated FM #16 was found guilty in a court of law for being sexually inappropriate with Resident #137 due to exposing themselves and groping the resident on the patio. The ADON stated FM #16 was out of jail on probation at the current time but was no longer allowed on the premises. During an interview on 07/10/24 at 12:35 P.M., Resident #32 and Resident #73 stated they were not on the patio when the incident occurred between FM #16 and Resident #137. Per Resident #32 and Resident #73, Resident #137 told them that FM #16 exposed themselves, put their arms down the resident's shirt, and requested they go to the bathroom together. An interview with the DON on 07/10/24 at 3:44 P.M. revealed on 04/09/24, the previous activity director told her that Resident #32 and Resident #73 notified her that FM #16 had inappropriately touched Resident #137 on the smoking patio. The DON stated she watched the video camera footage which showed FM #16 behind Resident #137 with his hands down the resident's shirt and FM #16 exposed himself to the resident. Per the DON, she immediately talked to Resident #137 who confirmed the action was not warranted and wanted to involve the police. The DON stated the facility filed a police report and FM #16 was arrested that day and was then court ordered to not be allowed on the premises moving forward. During an interview on 07/29/24 at 11:23 A.M., the DON stated prior to the incident, FM #16 was a frequent visitor of Resident #48 and visited daily from 8:00 A.M. until approximately 1:00 P.M. to 2:00 P.M. The DON stated that prior to the incident, FM #16 would occasionally go out and smoke and there had never been any issues. According to the DON, FM #16 was arrested the day of the incident and after FM #16 was initially released from jail, they allowed FM #16 supervised visits in the common area with Resident #48. The DON stated the visits were shorter than before, lasted for a week or two, and FM #16 was not allowed to go out and smoke with the residents. The DON stated FM #16 visited around lunch time to feed Resident #48. She stated FM #16 came to the main entrance, checked in with the receptionist, and someone called for staff to bring Resident #48 downstairs to the common area. The DON stated when FM #16 left, the receptionist had staff come down to get Resident #48. The DON stated no one sat with FM #16, but the receptionist and Human Resources/Business Director were in their offices with the door open. During an interview on 07/29/24 at 11:27 A.M., the Administrator stated the immediate actions taken were for FM #16 to be trespassed from the facility. The Administrator stated the police later found and arrested FM #16. The Administrator stated a few weeks after the incident, FM #16 was arrested for another incident and after FM #16 went to court, FM #16 was not allowed to be in the facility at all. During an interview on 07/29/24 at 1:03 P.M., the Receptionist stated that initially after the incident when FM #16 wanted to come to the facility, the visits had to be supervised. The Receptionist stated that when FM #16 came for the supervised visits, she called, and staff brought Resident #48 to visit FM #16 in the common area. The Receptionist stated that after FM #16 had a court date, FM #16 was not allowed in the facility at all. During an interview on 07/29/24 at 1:12 P.M., the Human Resource (HR) Manager stated she was not aware of any other incidents with FM #16. The HR Manager stated she observed FM #16 during supervised visits and only recalled FM #16 coming in about three times. The HR Manager stated presently FM #16 was not allowed back into the facility and she thought FM #16 served jail time. During an interview on 07/29/24 at 1:24 P.M., Licensed Practical Nurse (LPN) #18 stated initially after the incident, FM #16 had supervised visits with Resident #48 in the common area. LPN #18 stated FM #16 only visited a few times. LPN #18 stated that after the incident, signage was also placed at the nurses' station indicating FM #16 was not allowed at the facility. LPN #18 stated FM #16 had not been back to the facility to visit. During an interview on 07/29/24 at 1:37 P.M., Resident #137 stated they were outside smoking alone when FM #16 came out to smoke. Resident #137 stated FM #16 placed their hands down their shirt, and they asked FM #16 to stop. Resident #137 stated they told the DON, and the police were immediately called. Resident #137 stated, as a result of the incident, FM #16 received five years of probation, had to do anger management, and was listed as a sexual offender. Resident #137 stated she felt safe after FM #16 was arrested. According to Resident #137, on one occasion after the incident, they saw FM #16 downstairs at the facility with Resident #48. Resident #137 stated it bothered her that FM #16 was there, but once she let staff know, Resident #137 did not see FM #16 anymore. During an interview on 07/29/24 at 1:43 P.M., Resident #75 stated they observed FM #16 putting their hands over the shoulder and breasts of Resident #137 and Resident #137 was laughing. Resident #75 stated they left afterwards. Resident #75 stated they had never seen FM #16 doing anything to anyone else. During an interview on 07/29/24 at 4:25 P.M., the Social Services Director (SSD) stated she was called in when the Administrator reported the incident to the police. The SSD stated she sat with Resident #137 when the police officer interviewed the resident. The SSD stated Resident #137 was tearful when talking with the officer. The SSD stated she met with Resident #137 for about three days after the incident and she also referred Resident #137 for psychiatric services, but the resident discharged not long after the incident. The SSD stated Resident #137 started having problems with a few of the other residents about the incident, but Resident #137 continued to go outside and smoke. During an interview on 07/30/24 at 4:02 P.M., the Administrator stated her expectation was for the facility to be free from abuse and the residents were protected and safe. A facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 2016, indicated, the facility will not tolerate Abuse, Neglect, Exploitation of its residents or the Misappropriation of Resident Property. This deficiency represents non-compliance investigated under Complaint Number OH00154929.

Based on medical record review, review of facility investigations, review of hospital documentation, observations, staff interviews, and policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being cognitively impaired and at risk for elopements did not elope from the facility. This resulted in Actual Harm when Resident #04 eloped from the secured memory care unit on 01/23/24 without staff knowledge, and was found outside the facility by a generator. Resident #04 sustained injuries from a fall that occurred during the elopement which required hospital evaluation and treatment for the placement of a suture to a lip laceration and for treatment of a right thigh contusion. This affected one (#04) of three residents reviewed for elopement risk. The census was 84. Findings include: Review of Resident #04's medical record revealed an admitted d 01/10/24. Diagnoses included anxiety disorder, major depressive disorder, iron deficiency anemia, and mental disorder. Resident #04 was admitted for a respite stay. Resident #04 resided in the secured memory care unit on the second floor of the facility. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. Resident #04 was assessed as wandering daily. Review of an Elopement Evaluation dated 01/10/24 revealed Resident #04 was at risk for elopement. Resident #04 scored eight out of a possible nine. Scores above one were at risk for elopement. Review of a Secured Unit Evaluation dated 01/10/24 revealed Resident #04 was approved for admission to the secure unit. Resident #04 was evaluated as habitually wandering and would be able to wander out of the facility and not find their way back. Review of a care plan initiated on 01/10/24 revealed Resident #04 was at risk for wandering and elopement and at for risk for falls and fall related injury. Review of Resident #04's physician orders dated 01/12/24 revealed the resident may reside on secured care unit related to decreased cognitive awareness and safety. Review of progress notes revealed on 01/10/24 Resident #04 was moved from a first-floor room to the secure memory care due to wandering concerns. While on the memory care unit, Resident #04 was documented as wandering, exit seeking, and resisting care. On 01/23/24 Resident #04 was documented as being treated after a fall. Resident #04's upper lip was bleeding, and she had a swollen right knee. Resident #04 was sent to the emergency room (ER) per her daughter's request. Further review of the progress notes and medical record revealed there was no documentation of Resident #04's elopement on 01/23/24. Review of the facility's investigation revealed Resident #04 was last seen by staff in the secured memory care unit on 01/23/24 at 7:30 A.M. At 7:40 A.M., memory care staff Licensed Practical Nurse (LPN) #140, State tested Nursing Assistant (STNA) #130, and STNA #160 were not able to locate Resident #04 so they began searching the secured memory care unit. No exit alarms had sounded. Resident #04 was found outside the back of the facility by Activity Aide (AA) #120 that was entering the building. Resident #04 was standing by the facility trying to exit from inside the chain link fence that surrounded the generator. Resident #04's hair braids got stuck in a metal loop and AA #120 helped free them. AA #120 called for assistance to dietary staff. Dietary Director (DD) #150 met LPN #140 and STNA #130 who were looking for Resident #04 exiting the elevator. Resident #04 was treated for a bleeding lip and right knee injury. Resident #04's daughter and physician were informed. Review of Hospital emergency room (ER) documentation dated 01/23/24 revealed Resident #04 was assessed for post-fall injuries. Resident #04's upper lip had a small laceration of less than five millimeters (mm) that was repaired with one suture. Resident #04 complained of right leg pain. X-rays to the right leg were negative for any acute injury. Resident #04 was diagnosed with right thigh contusion. A magnetic resonance imaging (MRI) scan of Resident #04's head was negative for any acute injury. Resident #04 was admitted to the ER at 12:00 P.M. and discharged at 2:24 P.M. During an interview on 01/31/24 at 10:25 A.M. the Director of Nursing (DON) confirmed Resident #04 eloped from the memory care unit and was found outside the back of the facility on 01/23/24 by AA #120 who was coming into work. No exit alarms had been activated. The DON stated the facility conducted an investigation into the elopement but was unsure how Resident #04 had eloped from the secured memory care unit located on the second floor and exited the facility. Exit alarms were checked by maintenance and were found to all be working correctly. No video surveillance was available. Resident #04's Wanderguard (alarm device to prevent elopement) was checked and was functioning. Observations of Resident #04 in the secured memory care unit on 01/31/24 at 10:55 A.M., 3:01 P.M. and 3:50 P.M. revealed she was confused and unable to be interviewed. A Wanderguard was in place to Resident #04's left ankle. During an interview on 01/31/24 at 11:30 A.M. with AA #120 she stated that she found Resident #04 outside the back of the facility on 01/23/24 when walking from the parking lot. Resident #04 was first seen inside of a chain link fence barrier around the facility's generator. Once AA #120 recognized Resident #04 she opened an entrance door located by the generator and called for dietary staff to help. Dietary Director (DD) #150 responded and went for help. AA #120 walked with Resident #04 and tried to convince her to go back into the facility. Human Resource (HR) #200 and LPN #140 responded and were able to get Resident #04 back into the facility. Resident #04's lip was bleeding, and her pants were ripped. During an interview on 01/31/24 at 12:30 P.M., STNA #130 stated that she was passing out breakfast trays on 01/23/24. STNA #130 stated Resident #04 was standing near the food tray cart. STNA #130 went down the hall to deliver another resident's breakfast tray and when she came back to get another tray, LPN #140 asked if she had seen Resident #04. STNA #130 along with LPN #140 and STNA #160 started searching the secured memory care unit for Resident #04. STNA #130 stated Resident #04 was not found in the unit, so STNA #130 and LPN #140 went downstairs to see if therapy staff had come and took her out of the unit. While exiting the elevator, STNA #130 stated DD #150 informed them Resident #04 was found outside back of the facility. STNA #130 went with LPN #140 to get Resident #04 back into the facility. Resident #04's lips were bleeding, and she had a tear on her black jeans. STNA #130 stated no exit alarms had been activated. During a phone interview on 01/31/24 at 2:20 P.M., LPN #140 stated that on 01/23/24 at approximately 7:30 A.M. she observed Resident #04 sitting in the common area talking to another resident. LPN #140 stated on 01/23/24 at approximately 7:40 A.M. Resident #04 was unable to be found and all resident rooms and bathrooms were searched on the secured memory care unit. LPN #140 stated when Resident #04 was unable to found on the secured care unit, LPN #140 and STNA #130 went downstairs on the elevator to see if therapy staff had taken her and not informed them. LPN #140 stated no exit alarms in the memory care unit had been activated. While exiting the elevator, DD #150 approached and informed LPN #140 that Resident #04 was outside the facility with AA #120. LPN #140 stated Resident #04's lip was bleeding, and her jeans were ripped. LPN #140 treated Resident #04's lip and knee. LPN #140 called Resident #04's daughter and her physician. Resident #04 reported to LPN #140 that she fell downstairs chasing a boy. During an interview on 01/31/24 at 2:20 P.M., the Administrator and DON both confirmed Resident #04 had eloped from the secured memory care unit and was found behind the facility on 01/23/24. The Administrator and DON stated the facility conducted an investigation, but it was unable to be determined how Resident #04 eloped from the unit. The Administrator and DON stated there was no video surveillance of the elopement. The Administrator and DON confirmed Resident #04 was treated at the hospital for injuries she sustained from a fall during the elopement. Review of an undated facility policy titled The Oaks of [NAME] regarding Missing Residents revealed staff shall investigate all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or DON. This deficiency represents non-compliance investigated under Complaint Number OH00150572.

Based on medical record review, resident interview, staff interview, review of hospital records, review of staff statements, review of hospice notes, review of an Emergency Medical Services (EMS) run report, observations, and policy review, the facility failed to provide adequate behavioral health services for one Resident (#78) who voiced suicidal ideations. This resulted in Immediate Jeopardy and the potential for serious life-threatening injury, harm, impairment, and/or death, when Resident #78 told Hospice Nurse #150 maybe someday they'll come in and find me hanging, was left unsupervised on 10/17/22 from 2:43 P.M until 3:28 P.M. and was subsequently found unresponsive with a call light cord wrapped around his neck. This affected one (#78) of three residents (#09, #25, and #78) identified by the facility as receiving behavioral health services. The facility census was 85. On 11/29/22 at 5:15 P.M., the Administrator, Director of Nursing (DON) #163, and [NAME] President (VP) of Clinical Compliance and Reimbursement #160 were notified Immediate Jeopardy began on 10/17/22 at 2:08 P.M., when Resident #78 told Hospice Nurse #150 maybe someday they'll come in and find me hanging. Hospice Nurse #150 asked if Resident #78 would like Hospice Nurse #150 to call Resident #78's mother to explain the situation, and Resident #78 stated he would leave a note. After the visit with Hospice Nurse #150 on 10/17/22, Resident #78 was left unsupervised from 2:43 P.M. until 3:28 P.M. On 10/17/22 at 3:28 P.M., Resident #78 was found in his room in his bed, which was in a high position, with a cord wrapped around his neck. Resident #78 was unresponsive at that time, the cord was removed, a sternal rub was completed, and Narcan (medication used to reverse the life-threatening effects of a known or suspected opiate overdose) was administered. Resident #78 became responsive and was subsequently sent to the hospital on 10/17/22 at 3:44 P.M. and was admitted to the inpatient psychiatric unit. The Immediate Jeopardy was removed on 11/30/22, when the facility implemented the following corrective actions: On 10/17/22, former DON #51, Assistant Director of Nursing (ADON) #49, and Wound Nurse Licensed Practical Nurse (LPN) #25 assessed all in house residents which included all hospice residents for feelings of self-harm, hopelessness, or suicidal ideation. This was completed on 10/17/22. Additionally, all in house residents had a current Patient Health Questionnaire-9 (PHQ-9) [a questionnaire which aids in screening, diagnosing, monitoring, and measuring the severity of depression] reviewed by former DON #51, ADON #49, and Wound Nurse LPN #25. This was completed on 10/17/22. There were no significant findings on all above assessments. On 10/17/22, Corporate Nursing Team [NAME] President (VP) of Clinical Compliance and Reimbursement #160 and Registered Nurse (RN) Corporate Nurse #161, former DON #51, ADON #49, and Wound Nurse LPN #25, reviewed the medical records of all in house residents to identify any like residents. There were no significant findings. On 10/17/22, a root cause analysis was started by former DON #51, ADON #49, Wound Nurse LPN #25, and VP of Clinical Compliance and Reimbursement #160. The findings were that Resident #78 had a long history of alcohol abuse. It was alleged that Resident #78 was consuming alcohol while on hospice services. Hospice Nurse #150 came in and spoke with Resident #78. Resident #78 made a statement that maybe one day they would find him dead. Upon assessment of all records, it was determined that Resident #78's suicide attempt was due to changes in service and feeling of loss of control due to inability to stop consuming alcohol. This was completed on 10/18/22. On 10/17/22, VP of Clinical Compliance and Reimbursement #160 implemented a formal suicide prevention policy. On 10/17/22, the Administrator, Director of Rehabilitation/Occupational Therapist (OT) #99, former DON #51, ADON #49, Dietary Director #19, and Housekeeping Director #28, immediately started all staff education on the Suicide Prevention Policy. The facility was using agency staff. Former DON #51 provided the staffing agency with copies of the Suicide Prevention Policy on 10/17/22 and 10/18/22 for education with agency staff prior to working in the facility. All education was completed on 10/18/22. Central Supply Director #02 sent a follow up email to the staffing agency on 11/29/22 regarding the Suicide Policy. All new employees are educated by the DON/designee on suicide prevention during new hire orientation prior to providing resident care. On 10/18/22, an ad hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held by Medical Director/Primary Care Physician (PCP) #155, Administrator #03, DON #51, ADON #49, and VP of Clinical Compliance and Reimbursement #160. The plan of correction was reviewed and agreed upon. On 11/09/22, an all-staff meeting was held, and suicide prevention was reviewed with all staff. The education was provided by ADON #49 Audits were completed four to five times weekly with review of all in house residents progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents are reviewed for potential discharges and change in levels of care by RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160. All in house residents are reviewed as part of the audits. All audits will be brought to the QAPI team for review for three months and then as needed. From 10/17/22 through 10/23/22, RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160 reviewed all resident progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents were reviewed for potential discharges and change in levels of care. There were no concerns identified. From 10/24/22 through 10/30/22, RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160 reviewed all resident progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents were reviewed for potential discharges and change in levels of care. There were no concerns identified. Resident #78 returned to the facility from the hospital on 10/28/22. Facility Admissions Director #04 and the Administrator remained in contact with the hospital throughout Resident #78's entire hospital stay. The Administrator required that Resident #78 be cleared from psychiatric services prior to returning to the facility. Resident #78 was discharged from the hospital as stable and at no harm/risk to himself. According to progress notes from the hospital, the hospital felt Resident #78's suicide attempt was more behavioral than an actual suicide attempt. Medical Director/Primary Care Physician (PCP) #155 was made aware of Resident #78's return to the facility by nursing staff. Psych 360 (a psychiatric ancillary service) saw Resident #78 on 11/04/22 and 11/18/22. Former DON #51 followed up with Resident #78 upon his readmission to the facility on [DATE] with no issues identified. Upon Resident #78's return to the facility, staff were made aware by former DON #51 that Resident #78 would require increased supervision. Facility nursing staff completed increased supervision until 11/04/22 when Psych 360 evaluated Resident #78, and Resident #78 was determined to be stable. Upon readmission on 10/28/22, Resident #78 was offered hospice services by Social Service Director #100, but Resident #78 declined and requested therapy services. Facility accommodations were made to provide therapy services for Resident #78. From 10/31/22 through 11/06/22, RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160 reviewed all resident progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents were reviewed for potential discharges and change in levels of care. There were no concerns identified. From 11/07/22 through 11/13/22, RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160 reviewed all resident progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents were reviewed for potential discharges and change in levels of care. There were no concerns identified. From 11/14/22 through 11/20/22, RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160 reviewed all resident progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents were reviewed for potential discharges and change in levels of care. There were no concerns identified. From 11/21/22 through 11/27/22, RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160 reviewed all resident progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents were reviewed for potential discharges and change in levels of care. There were no concerns identified. On 11/30/22, the Administrator, RN Corporate Nurse #161, VP of Clinical Compliance and Reimbursement #160, and Maintenance Director #44, reviewed the call light system and determined Resident #78 would have a cordless call light system that would remain integrated into the facility call light system. Maintenance Director #44 and VP of Clinical Compliance and Reimbursement #160 removed Resident #78's long call light cord from Resident #78's room and replaced the call light with a wireless call light system. Resident #78 was also provided a wireless remote system which would allow Resident #78 to use a sound activated system which alarms at the nurse's station. All staff were immediately educated on the new call light system by the Administrator, RN Corporate Nurse #161, and VP of Clinical Compliance and Reimbursement #160. All oncoming staff are made aware of any residents who have been identified as being at risk for suicidal ideations via staff-to-staff report. During report, staff are made aware of the risk and appropriate interventions needed to keep the resident safe. Interviews on 11/29/22 with LPN #15, Maintenance Director #44, STNA trainee #65, and STNA #92, revealed they had been in-serviced and were aware of suicide prevention interventions. Observation on 11/30/22 at 4:25 P.M. with the VP of Clinical Compliance and Reimbursement #160 revealed Resident #78's call light cord had been cut, which left only a fragment to pull if needed out of the wall to signal a call. Resident #78 was also provided a cordless remote which when pushed, sounded at the nurses' station. The observation revealed the call light was functional. All other call light cords in the room were removed. Resident #78 was the only resident residing in the room. The call light cord in the bathroom was cut which left only enough length to pull and activate the call light. Although the Immediate Jeopardy was removed on 11/30/22, the facility remains out of compliance at Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring for effectiveness and on-going compliance. Findings include: Review of the medical record for Resident #78 revealed he was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Resident #78's diagnoses included, but were not limited to, major depressive disorder, alcohol abuse, paraplegia, opioid use, and alcoholic cirrhosis of the liver with ascites. Review of Resident #78's care plan, dated 06/24/22, revealed Resident #78 had a behavior problem related to the Hospice Nurse confirming Resident #78 had been drinking alcohol in his room and noted a smell of alcohol from Resident #78's room. On 08/11/22, the care plan was updated to indicate there was a potential that Resident #78 was drinking alcohol in his room. Review of Resident #78's quarterly Minimum Data Set (MDS) assessment, dated 08/26/22, revealed Resident #78 was cognitively intact. Resident #78 required limited assistance of one staff for bed mobility and dressing. Resident #78 required supervision of one staff for transfers and locomotion. Resident #78 did not walk. Resident #78 reported feeling down, depressed, or hopeless 12 to 14 days during the two-week look back period. He also reported feeling tired or having little energy for seven to 11 days during the look back period. He denied having thoughts that he would be better off dead or having thoughts of hurting himself in some way. The assessment further revealed Resident #78 received antipsychotic, antianxiety, antidepressant, and opioid medication. Review of Resident #78's care plan, initiated on 10/18/22, revealed the care plan addressed Resident #78's behavior of threats to harm himself as he attempted to inflict self-harm on 10/17/22 when he was found with a call light cord around his neck. Interventions included sending Resident #78 to the hospital on 10/17/22 for evaluation and admission to the psychiatric unit. Other interventions included assessing pattern, intensity, and duration of the problem behavior; attempting to determine if the behavior was associated with events; assessing for recent medication changes or changes in environment as possible causes; considering pain, discomfort, hunger, boredom, and personal needs that Resident #78 was unable to communicate as possible causes of behavior. Additional interventions included anticipate and meet needs to attempt to control behavior problems; providing calm reassurance, redirection or distractions and assessing effectiveness; providing positive reinforcement for appropriate behavior; confront gently and respectfully when behavior is inappropriate and set limits; share effective interventions with other staff members; maintain routine and stress free environment; keep noise to a minimum; encourage activities and socialization; update the physician as needed regarding changes in behavior status; include Resident #78 in care; explain care before giving and segment tasks to promote Resident #78's involvement and control over care; use two care givers as indicated to provide safe care and to shorten the amount of time needed to provide care; include Resident #78 and/or resident representative in treatment plan and update regarding change in status/treatment plan. Review of Resident #78's progress note, dated 10/17/22 at 2:06 A.M., revealed Resident #78 came out of his room and went down the elevator. The note indicated a strong odor of alcohol followed Resident #78. The nurse (LPN #10) went into Resident #78's room and searched for the presence of alcohol. A water bottle was stashed in his bedside commode and was wrapped in a grocery bag. LPN #10 opened it, and there was a strong smell of vodka. LPN #10 then asked a State tested Nursing Assistant (STNA) to smell the water bottle as a witness. The STNA confirmed the odor smelled like vodka. The water bottle was returned. LPN #10 then called the hospice provider to report the findings. LPN #10 was told a note would be left for the case manager to reach out to the facility during day shift. Review of Resident #78's progress note, dated 10/17/22 at 6:38 A.M., revealed staff reported to Primary Care Physician (PCP) #155 that Resident #78 reeked of alcohol and vodka was found in Resident #78's bedside commode. PCP #155 advised staff to discontinue all medications and all medications were discontinued. Review of Resident #78's progress note, dated 10/17/22 at 9:54 A.M., revealed LPN #15 went to check on Resident #78. The note indicated when Resident #78 turned around and saw LPN #15, he burst into tears. LPN #15 stated that she was not there to pass judgement, that she was just checking on Resident #78. Resident #78 stated that he did not do it all the time. The nurse reminded Resident #78 of his safety (concern) because of the medication that he took. Resident #78 was reminded of prior times when it was suspected he was drinking, and when talked to, Resident #78 did not admit or deny the drinking. It was explained that Resident #78 just succeeded on the first step which was admitting it. Resident #78 again admitted his drinking. Resident #78 was told that the hospice nurse would be there that day to talk with him and they would go from there. Resident #78 was informed that if he needed to talk to let LPN #15 to let her know and she would listen. Review of Resident #78's Hospice visit note, dated 10/17/22, revealed Resident #78 was seen at 2:00 P.M. The note indicated Resident #78 was alert and oriented times four. Resident #78's affect was depressed and flat. The note indicated Resident #78 reported he hurt all over. The visit summary indicated Resident #78 was in his room, seated in his wheelchair with his back to the door when Hospice Nurse #150 arrived. It was noted Resident #78 turned around and faced Hospice Nurse #150 and was crying, stating he had screwed up, and stating it was him and his wife's anniversary, which was why he used alcohol the night before and not to beat him up over his alcohol use. Hospice Nurse #150 explained that he was not judging him but did need to let him know that he did violate his signed agreement from last month at the in-patient unit. Resident #78 stated that he understood and realized that they would need to discharge him. Resident #78 asked if his medications could be tapered and Hospice Nurse #150 explained that decision was up to the facility and PCP #155, but he would ask the nurse to ask PCP #155. Resident #78 made the comment that maybe someday they'll come in and find me hanging, and then spoke about how they took my bedside commode and started laughing. The note indicated Hospice Nurse #150 told Resident #78 that if he was having any issues, that the facility would send him to the hospital to be helped if that was appropriate. Resident #78 continued to talk about how he screamed from the rooftops for help, but no one would ever help him. Hospice Nurse #150 asked Resident #78 if he wanted Hospice Nurse #150 to call his mom to explain any details regarding the current situation and Resident #78 said he would leave her a note. Resident #78 told Hospice Nurse #150 he was sorry for wasting his time and cut the assessment short. Hospice Nurse #150 left the room to inform the floor nurse (LPN #15) of Resident #78's comments about hanging, as well as about leaving a note for his mom. Hospice Nurse #150 then indicated that he found former DON #51 and informed her of Resident #78's comments, and she stated that she expected that they were going to put him on a suicide watch. The note indicated Hospice Nurse #150 called and spoke with ADON #49 who was out of the facility at that time. Review of Resident #78's progress note, dated 10/17/22 at 4:00 P.M., revealed Hospice Nurse #150 came into the facility to speak with Resident #78 and explained that hospice would be discontinuing hospice services due to Resident #78 not following the hospice care plan. Upon exiting Resident #78's room, the nurse (Hospice Nurse #150) notified LPN #15 that Resident #78 was upset and made comments that maybe someday they would find him hanged. This was reported to the (former) DON #51. Staff were assigned for supervision of Resident #78 until a psychiatric evaluation could be obtained. When staff entered Resident #78's room, he was found in the room with a cord wrapped around his neck. It was noted that Resident #78 had an order for Do Not Resuscitate Comfort Care (DNRCC). The progress note indicated a sternal rub was provided, Emergency Medical Technicians (EMT) were called, and Narcan was administered. Resident #78's response increased as interventions were provided. After Narcan was administered, vital signs were obtained, and Resident #78's pulse was 109 and his oxygen saturation rate was 88 percent (%). Resident #78's vitals stabilized. The EMT arrived and Resident #78 was sent to the hospital. The PCP and family were made aware. The facility followed up with the hospital. Resident #78 was admitted to the inpatient psychiatric unit and was stable at that time. Review of the statement, dated 10/17/22, provided by Hospice Nurse #150, revealed he met with Resident #78 on 10/17/22 at 2:00 P.M. to discuss with him the issue of his drinking the night before. Hospice Nurse #150 stated he entered the room and Resident #78 had his back to him, sitting in his wheelchair. Hospice Nurse #150 sat down and waited a minute until he turned to face him. The statement indicated Resident #78 told him he didn't need to beat him up about his drinking, to which he explained that he was not there to judge. Resident #78 spoke most of the time and stated he screwed up. Resident #78 made a comment that maybe someday they'll find me hanged, but then continued to talk about his issues with alcohol. Hospice Nurse #150 asked him if he wanted him to talk to his mother about the situation, and Resident #78 said no, I can leave her a note. Resident #78 also asked if he would be able to have his medication tapered down, and he explained that was a decision for PCP #155. Resident #78 thanked him, and Hospice Nurse #150 left the room to inform LPN #15 of Resident #78's comments. Hospice #150 told LPN #15 he was going to find DON #51 and ADON #49 to inform them, as well, of Resident #78's comments. Hospice Nurse #150 found DON #51 downstairs and informed her of Resident #78's comments, and texted ADON #49 to call him at 2:46 P.M., to which she promptly called back, as she was out of the building. Review of the statement provided by Maintenance Director #44, dated 10/17/22, revealed he walked into Resident #78's room around 2:00 P.M. and Resident #78 was crying while listening/talking to the hospice representative. Maintenance Director #44 indicated he immediately stepped out and shut the door. Maintenance Director #44 indicated Resident #78 looked very upset. Review of the statement provided by LPN #15, dated 10/17/22, revealed Hospice Nurse #150 approached her at approximately 4:30 P.M. to let her know that he had informed Resident #78 that he was going to be removed from hospice as of the next day. Hospice Nurse #150 stated that the resident (Resident #78) made statements that he should just go ahead and kill himself. At that moment she informed Hospice Nurse #150 that what he had just informed her had to be told to DON #51. LPN #15 indicated she walked with Hospice Nurse #150 to find DON #51. LPN #15 then attended to one of her residents. LPN #15 stated Wound Nurse LPN #25 came to her at approximately 3:15 P.M. to let her know that they were putting Resident #78 on suicide watch. Wound Nurse LPN #25 and former DON #51 had a conversation with the person who was going to be sitting with Resident #78. Wound Nurse LPN #25, STNA #30, and LPN #15 went into Resident #78's room approximately 3:30 P.M. LPN #15 heard Wound Nurse LPN #25 state oh my God as she was entering the room. When she walked behind the curtain, she saw Wound Nurse LPN #25 taking the call light cord from around Resident #78's neck. Resident #78 was high up and was not dangling. Resident #78 was not responding so Wound Nurse LPN #25 did a sternal rub. LPN #15 ran out of the room to call a code, then realized Resident #78 was a DNRCC and told the staff to get help for Resident #78's room. She went back into the room as Wound Nurse LPN #25 was performing another sternal rub and Resident #78 seemed to be gasping for air. Resident #78 started acting as if he was going to throw up. The vitals machine was attached, but the only vital LPN #15 remembered was a pulse of 109. LPN #15 began to talk to Resident #78 as he was looking at her when the squad arrived. Review of the statement from Wound Nurse LPN #25, dated 10/17/22, revealed at approximately 3:00 P.M., DON #51 notified her they needed to place Resident #78 on suicide watch for making statements of concern. Wound Nurse LPN #25 grabbed her laptop and paperwork from her office and headed upstairs to DON #51's office. Once on the unit, the Hospitality Aide (STNA #30) was asked to sit with Resident #78, the paperwork was printed and explained to STNA #30, and they entered Resident #78's room at 3:30 P.M. Wound Nurse #25 observed Resident #78 lying in bed with a call light cord tied around his neck. The cord was immediately removed, Wound Nurse #25 yelled for assistance, 911 was called, and a crash cart was obtained. Resident #78 was assessed for pulse and breathing. Resident #78 was found to have a very shallow, faint pulse with minimal breathing. Bilateral pupils were assessed, fixed, and dilated. A sternal rub was given with no response and oxygen was placed on Resident #78. DON #51 arrived in the room and Narcan was administered into Resident #78's left nostril by DON #51. Resident #78 reacted to the administration. Resident #78 was placed on his right side for rescue positioning and vital signs were obtained. EMT arrived on the scene and took over care of Resident #78. The local police department also arrived. Resident #78 left via stretcher and all details were given to the officer. Wound Nurse #25 indicated she returned to DON #51's office and placed a call to Resident #78's power of attorney (his mother), and she was notified at 3:56 P.M. of Resident #78's transport to the hospital. Review of a statement from Agency STNA #164, dated 10/17/22, revealed around 3:30 P.M. someone called a code, and she went into the room and his (Resident #78's) eyes were black and he was gasping for air. Nurses started a sternal rub, gave him Narcan, and he improved. Nine-one-one (911) was called as soon as they called a code. Review of the EMS run report, dated 10/17/22, revealed a call was received on 10/17/22 at 3:32 P.M. and EMS was dispatched. EMS arrived at the facility at 3:39 P.M. The run report indicated the primary symptom was suicidal ideations and the provider's primary impression was a suicide attempt. The report revealed EMS was dispatched for an attempt (suicide). The report revealed the patient (Resident #78) was found with the nurse call button cord wrapped around his neck by nursing home staff. The nursing home staff took it off his neck and called 911. Nursing home staff gave the patient Narcan prior to their arrival. The report indicated the patient (Resident #78) was told that day that he would no longer be under hospice care for cirrhosis of the liver due to his continued alcohol consumption. The patient (Resident #78) was noted as being alert but not speaking to crews once on the scene. The patient (Resident #78) was flailing around on his bed and did smell of alcohol. Resident #78 was transferred to the hospital and arrived at 3:51 P.M. Review of the Emergency Department to inpatient hand off report, dated 10/17/22, revealed the chief complaint was the patient (Resident #78) presenting as suicidal with alcohol intoxication. The report noted the patient (Resident #78) came from the nursing facility after trying to commit suicide with a call light cord after being told he would no longer be in Hospice care because he was intoxicated. The final diagnoses included acute alcoholic intoxication, hyperammonemia, intentional self-harm by strangulation, and suicidal ideations. Testing results included no acute intracranial process seen from the Computed Tomography (CT) scan of the head. His CT scan of the cervical spine showed no acute fracture or subluxation. The portable x-ray of his chest showed mild subsegmental atelectasis at the right lung base, and mild vascular congestion and interstitial edema were questioned. Review of the hospital Discharge Planning Brief Note, dated 10/28/22, revealed the psychiatric nursing supervisor received a call from the Administrator at the facility. The Administrator requested that it was documented that he (Resident #78) was okay to discharge from a psychiatric standpoint and that it was ok that he has increased supervision (it was noted they generally round on patients every two hours but state they will be rounding more frequently on Resident #78 due to the recent events). The requests were deemed okay from the hospital's standpoint. Review of Resident #78's progress note, dated 10/28/22, revealed Resident #78 returned to the facility. Resident #78 was returned to the same room he was in prior to the hospitalization . Review of Resident #78's significant change MDS assessment, dated 11/04/22, revealed Resident #78 was cognitively intact. Resident #78 required supervision with no setup help for bed mobility, transfer, and locomotion on the unit. Resident #78 did not walk. Resident #78 was independent with no set up help for locomotion off the unit. The assessment revealed Resident #78 felt down, depressed, or hopeless 12 to 14 days during the two-week look back period. Resident #78 indicated he had thoughts that he would be better off dead, or of hurting himself in some way two to six days during the look-back period. The assessment further revealed Resident #78 received antipsychotic, antianxiety, antidepressant, and opioid medication. Interview with Resident #78 in his room on 11/22/22 at approximately 3:50 P.M., revealed Resident #78 had been drinking Vodka and juice and Hospice Nurse #150 told him he was being taken off Hospice care. Resident #78 indicated he had experienced depression before however he had never tried to harm himself. Resident #78 stated when Hospice Nurse #150 came to see him on 10/17/22, Hospice Nurse #150 told him that he wouldn't be getting any more pain medication and that he was being taken off Hospice care. Resident #78 indicated he was seeing a Hospice counselor every Monday prior to being at the facility; however, he did not see a counselor very often while at the facility. Resident #78 revealed after speaking with Hospice Nurse #150 on 10/17/22, it felt like a couple of hours had gone by prior to staff coming back in his room. Resident #78 indicated he had planned for his suicide attempt to work and had time to get stuff together. Resident #78 stated he thought he would be successful before anyone came back to check on him. During the interview, Resident #78 was observed to be lying in bed with the call light cord hanging on the wall next to his bed. Interview with the Administrator on 11/22/22 at 3:03 P.M., revealed she was not sure why Hospice Nurse #150 walked out of Resident #78's room and indicated maybe Hospice Nurse #150 did not take it seriously. The Administrator indicated after the staff knew what Resident #78 stated to Hospice Nurse #150, they were in the process of initiating one-on-one supervision prior to finding Resident #78 with the call light cord around his neck. The Administrator stated Resident #78 had not had a history of suicidal ideation and had never voiced it to her knowledge. The Administrator indicated Resident #78 returned from the hospital on therapy and continued to be off hospice care. Interview with Hospice Nurse #150 on 11/23/22 at 12:24 P.M., revealed he came to the facility in the afternoon around 2:00 P.M. after Resident #78 had been identified as drinking alcohol in the facility. Hospice Nurse #150 stated Resident #78 was on a step three plan which was a written contract indicating Resident #78 would not drink alcohol again while on prescribed narcotic medication. Hospice Nurse #150 revealed after the first time Resident #78 was found to be drinking alcohol in September, the facility physician moved away from prescribing narcotics for Resident #78 and Hospice took over prescribing Resident #78's narcotics. At that time since Resident #78 had been off the narcotics, Hospice arranged for Resident #78 to go to the inpatient unit for 10 days to prevent seizures from narcotic withdrawal. Resident #78 was discharged from the inpatient unit and had a signed contract that he would not use alcohol again. The day before, Resident #78 had been discovered to be drinking and was showing signs of intoxication and was running into walls, was having difficulty getting to the first floor, and had [TRUNCATED]