Every finding on record at Pine Grove Healthcare & Wellness Centre, LP

Based on interview and record review, the facility failed to ensure competencies and skills sets to provide nursing and related services were completed for five (5) of 5 sampled nursing staff in accordance with the facility assessment and policy and procedures (P&P). This deficient practice has the potential to result in an increased risk for improper care provided to the residents which could negatively affect the residents' overall wellbeing.Findings:During a concurrent review and interview on 3/18/2026 at 2PM with the Director of Staff Development (DSD), Certified Nurse Assistant 1's (CNA 1) employee records were reviewed. The DSD stated CNA 1 was hired on 2/13/2025. The DSD stated the facility form titled Facility Support Assistant Onboarding Activities and Skills Observation Checklist is used to evaluate the competency of CNAs' skills upon hire. The DSD stated the skills competency log includes, but is not limited to, evaluating CNAs on activities of daily living, vital signs, feeding techniques, and residents' rights. The DSD verified that CNA 1's Facility Support Assistant Onboarding Activities and Skills Observation Checklist, dated 2/13/2025, was not conducted correctly. The DSD stated she signed off on the checklist without observing CNA 1's skills. The DSD stated she only verbally discussed the skills with CNA 1 on 2/13/2025 and signed off the checklist. The DSD stated CNA 1's skills should have been observed and validated to ensure CNA1 was competent in providing care to the residents. During a concurrent record review and interview on 3/18/2026 at 2:10 PM with the DSD, Restorative Nurse Assistant 1's (RNA 1) employee records were reviewed. The DSD stated RNA 1 was hired on 12/3/2025 as a CNA and transitioned to RNA on 2/18/2026. The DSD stated RNA 1's 16-hour clinical orientation, which was also used to evaluate competency, was incomplete, as all skills were signed off on 2/18/2026 without documentation of the method of skills validation. During a concurrent record review and interview on 3/18/2026 at 2:15 PM with the DSD, Licensed Vocational Nurse 1's (LVN 1) employee records were reviewed. The DSD stated LVN 1 was hired on 1/15/2025. The DSD stated LVN 1 did not have documented evidence of a completed skills competency evaluation upon hire and annually thereafter. The DSD stated it is important to evaluate licensed nurses' skills competency before releasing them from orientation to determine whether additional training is needed and to ensure residents' safety. The DSD stated the facility's form titled, Licensed Nurse Onboarding Activities Checklist, is used to evaluate the competency of licensed nurses upon hire and annually. The DSD stated the skills competency log includes, but is not limited to, evaluating licensed nurses on medication documentation and dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care. During a concurrent record review and interview on 3/18/2026 at 2:17 PM with the DSD, LVN 2's employee records were reviewed. The DSD stated LVN 2 was hired on 1/24/2026. The DSD stated LVN 2 did not have documented evidence of a completed skills competency evaluation upon hire. The DSD stated all employees should complete and be deemed competent in the skills required of them upon hire and annually to ensure licensed nurses are capable of providing necessary care to residents. During a concurrent record review and interview on 3/18/2026 at 2:20 PM with the DSD, Registered Nurse 1's (RN 1) employee records were reviewed. The DSD stated RN 1 was hired on 7/29/2025. The DSD stated RN 1 did not have documented evidence of a completed skills competency evaluation upon hire. The DSD stated the Assistant Director of Nursing (ADON) is responsible for conducting skills competency evaluations for registered nurses upon hire and annually. During a concurrent record review and interview on 3/19/2026 at 12:23 PM with the ADON, the licensed nurses' employee records were reviewed. The ADON stated the competency skills evaluations were not and should have been completed for LVN 1, LVN 2, and RN 1. The ADON stated it was important to complete the skills competency upon hire and annually thereafter in accordance with the policy to ensure staff knew how to perform their assigned tasks for resident safety. The ADON stated that nursing practices are continually changing; therefore, annual skills evaluations are important to ensure that nurses remain updated in their skills and knowledge. During a review of the Facility Assessment, updated 1/1/2026, the Facility Assessment indicated that the assignments and tasks of each staff member are based on the needs of the facility and the residents. All assignments and tasks are also based on community standards. For more details regarding the individual tasks and assignments of each staff member, refer to their job descriptions, which are available upon request. During a review of the facility's P&P titled, Staff Competency Validation, revised on 3/28/2024, the P&P indicated that competency validation is completed to evaluate individual performance, evaluate group performance, meet regulatory standards, address problematic issues, and enhance performance reviews. Competency validation is a determination based on an individual's satisfactory performance of each specific element of their job description and the specific requirements of the area in which they are employed. The P&P also indicated that staff are required to complete competency validation based on their job description and assigned duties.

Based on observation, interview and record review, the facility failed to ensure garbage was properly disposed of in accordance with the facility's policy and procedure titled, Waste Management. This deficient practice had the potential to attract pests and rodents and may cause disease and other health issues to residents, staff, and the community.Findings: During a concurrent observation and interview on 3/16/2026 at 8:01 AM with the Dietary Supervisor (DS), in the facility's parking lot, two lidless/uncovered trash bins with wheels were filled with bags of trash placed next to three dumpsters. DS stated the two trash bins were filled with nursing trash and were not covered and the two trash bins should be covered. During a concurrent interview and record review on 3/19/2026 at 9:35 AM with Assistant Director of Nursing (ADON), the facility's Waste Management policy and procedure (P&P) dated 4/21/2022 was reviewed. The P&P indicated dispose of all regulated or potentially regulated waste, close and dispose regulated waste according to state and federal regulations and dispose bag into large, covered waste bin. ADON stated all trash should be transferred from the trash bins with wheels should have a cover and transfer the content into the dumpsters. ADON stated the trash bin was not supposed to be left outside uncovered exposing the garbage inside the trash bin. ADON stated this is an infection control issue since the trash was improperly disposed. ADON also stated stray animals and/ or rodents could get access to the trash and could cause a mess.

Based on interview and record review, the facility failed to ensure vital (objective, measurable indicators of the body's most essential physiological functions, used to evaluate physical health, monitor illness, which includes blood pressure) were documented accurately for two (2) of three (3) sampled residents (Residents 5 and 82) reviewed for dialysis. This failure resulted in the facility not documenting blood pressure readings were taken in the correct arm for Residents 5 and 82 which can lead to potential harm and/ or injury to the residents. Findings: 1. During a review of Resident 5's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of end stage renal disease (ESRD, irreversible kidney failure), and dependence on renal dialysis (hemodialysis; a life-sustaining medical treatment that filters waste products, toxins and excess fluids from the blood when the kidneys have failed). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment too), dated 3/10/2026, the MDS indicated Resident 5 has independent (decisions consistent) cognitive (person's ability to think, learn, remember, use judgement, and make decisions) skills for daily decision making. The MDS indicated Resident 5 was independent (Resident completes the activity by themselves with no assistance from a helper) with oral and toileting hygiene, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 5 required setup or clean-up assistance (helper sets up or cleans up, resident completes activity) with eating. The MDS indicated Resident 5 required supervision or touching assistance (helper provides verbal cues) with shower. In addition, the MDS indicated Resident 5 acquired arteriovenous fistula (AV fistula; a surgically created connection between an artery [high-pressure blood vessel] and a vein [low-pressure blood vessel], usually in the arm designed for hemodialysis). During a review of Resident 5's Order Summary Report dated 3/18/2026, Resident 5's Order Summary Report indicated an order initiated on 1/20/2025 for no blood pressure checks to AV fistula location (left upper arm) as appropriate. During a review of Resident 5's Care Plan, initiated on 6/24/2022 and revised on 3/15/2026, indicated Resident 5 needed hemodialysis related to ESRD. The care plan indicated intervention to not draw blood or take blood pressure in the arm with graft (AV fistula) (left arm). During an interview and record review on 3/19/2026 at 8:36 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 5's blood pressure (BP) vital sign documentation dated March 2026 was reviewed. Resident 5's BP vital sign documentation indicated Resident 5's blood pressure was taken on the left arm (extremity with AV fistula) on 3/1/2026, 3/2/2026, 3/3/2026, 3/4/2026, 3/5/2026, 3/6/2026, 3/7/2026, 3/9/2026, 3/11/2026, 3/13/2026, 3/14/2026, 3/15/2026, 3/16/2026, 3/17/2026 and 3/18/2026. LVN 1 admitted he is one of the licensed nurses who documented wrong site of where the blood pressure was taken. LVN 1 stated Resident 5's blood pressure was taken on right upper arm, and never in her (Resident 5) left upper arm because of the dialysis access. LVN 1 stated he mistakenly clicked the wrong site when documenting Resident 5's blood pressure in the resident's vital signs. LVN 1 stated it is not the facility's practice to document blood pressure that was taken from the arm with dialysis access, because it is wrong. LVN 1 added it is very important to maintain accurate documentation with resident's vital signs because it is used as part of the assessment process to ensure residents are stable and to ensure appropriate care is being provided. During a concurrent interview and record review on 3/19/2026 at 9:11 AM with MDS Coordinator (MDSC), Resident 5's blood pressure (BP), vital sign documentation dated March 2026 were reviewed. Resident 5's BP vital sign documentation indicated Resident 5's blood pressure was taken on the left arm (extremity with AV fistula) on 3/1/2026, 3/2/2026, 3/3/2026, 3/4/2026, 3/5/2026, 3/6/2026, 3/7/2026, 3/9/2026, 3/11/2026, 3/13/2026, 3/14/2026, 3/15/2026, 3/16/2026, 3/17/2026 and 3/18/2026. MDSC stated Resident 5 had an AV fistula in her (Resident 5) left upper extremity and the documented BP readings that were taken on Resident 5's left arm were documented incorrectly. MDSC stated wrong documentation can lead to wrong treatment which might cause harm to any residents. 2. During a review of Resident 82's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of essential (primary) hypertension (HTN; high blood pressure that develops gradually over time without direct, known medical cause) and dependence on renal dialysis. During a review of Resident 82's History and Physical Examination (H&P), dated 3/12/2026, the H&P indicated the resident had the capacity to understand and make her own decisions and had ESRD and on hemodialysis every Tuesday, Thursday and Saturday with a right upper extremity AV fistula for dialysis access. During a review of Resident 82's Order Summary Report dated March 2026, Resident 82's Order Summary Report indicated an order initiated on 3/11/2026 for no blood pressure checks to AV fistula location (right arm) as appropriate.During a review of Resident 82's Care Plan dated 3/12/2026, Resident 82's Care Plan indicated Resident 82 needed hemodialysis related to renal failure and indicated an intervention to not draw blood or take blood pressure in the arm with graft (AV fistula). During a concurrent interview and record review on 3/18/2026 at 10:58 AM with Assistant Director of Nursing (ADON), Resident 83's BP vital sign documentation dated March 2026 were reviewed. Resident 83's BP vital sign documentation indicated Resident 83's blood pressure was taken on the right arm (extremity with AV fistula) on 3/12/2026, 3/14/2026, 3/15/2026 and 3/16/2026. ADON stated Resident 83 had an AV fistula in her right upper extremity and the documented BP readings on 3/12/2026, 3/14/2026, 3/15/2026 and 3/16/2026 were documented incorrectly because the BO was taken from the resident's left arm. ADON stated the correct laterality (preference for using one side of the body over the other) should have been documented for those BP readings because whatever is on the resident's chart reflects what was done and it is important to ensure charting is accurate. During a review of the facility's policy and procedure (P&P) titled, Completion & Correction, revised 1/1/2012, the P&P indicated its purpose is to ensure that medical records are complete and accurate, and entries will be complete, legible, descriptive and accurate.

Based on interview and record review, the facility did not implement water testing samples (to collect and deliver for analysis a sample of water representative of the bulk of water being examined) to initially validate the facility's water management program control measures (actions that can be taken to reduce the potential of exposure to a hazard) to ensure the facility's water was free of waterborne (carried or transmitted by water and especially by drinking water) pathogens (any organism that can cause disease) such as legionella (a bacterium which cases legionnaires' disease [a severe form of pneumonia - lung inflammation usually caused by infection]). This failure resulted in the facility having no initial baseline validation for their water management program and had the potential to place the residents in the facility at risk for developing severe respiratory infection (pneumonia).Findings: During a concurrent interview and record review on 3/17/2026 at 12:10 PM with Property Manager (PM) and Maintenance Supervisor (MS) the Centers for Disease Control (CDC) toolkit titled, Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, dated 6/24/2021 and the ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Addendum to ASHRAE Standard [PHONE NUMBER] (defines types of buildings and devices that need a water management program) titled, Legionellosis: Risk Management for Building Water Systems, dated 6/23/2018 were reviewed. The CDC toolkit indicated, Your program team should establish procedures to confirm, both initially and on an ongoing basis that the water management program effectively controls the hazardous conditions throughout the building water systems. This step is called 'validation.' The ASHRAE Standard 188-201 indicated the Program Team shall establish procedures to confirm both initially and on an ongoing basis, that the Program is being implemented as designed. PM stated he understood the concept of validation of the water management program and further stated they have had no testing done for their water management program and have no initial validation for their controls. During an interview on 3/18/2026 at 7:38 AM with the Administrator (ADM), ADM stated there was no initial validation test done for the controls for their water management program. During an interview on 3/18/2026 at 1:57 PM with ADM, ADM stated the importance of initially validating the controls of their water management program is so they can ensure the program is working.During a review of the facility's policy and procedure (P&P) titled, Water Management, dated 12/22/2025, the P&P indicated, The facility will develop and utilize water management strategies, using the Core Elements of a Water Management Plan (WMP), to reduce the risk of growth and spread of Legionella and other opportunistic water-borne pathogens in facility water systems, and indicated its purpose, To minimize exposure to legionella and other water-borne pathogens to our residents, family members, staff and visitors. The P&P further indicated: Control Measures and Corrective ActionsFollowing national, state and local guidelines, the team will identify needed control measures based on the risk assessment performed, and how to monitor them.Verification and ValidationThe team will ensure the program is running as designed and effective. During a review of the Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey and Certification Group letter titled, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) revised 7/6/2018, indicated, Surveyors will review policies and procedures and reports documenting water management implementation results to verify that facilities:Implement a water management program that considers the ASHRAE industry standard and the Centers for Disease Control (CDC) toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections and environmental testing for pathogens.Specify testing protocols and acceptable ranges for control measures and document the result of testing and corrective actions taken when control limits are not maintained. During a review of the CDC toolkit titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/24/2021 was reviewed. The CDC toolkit indicated, Now that you have a water management program, you need to be sure that it is effective. Your program team should establish procedures to confirm, both initially and on an ongoing basis, that the water management program effectively controls the hazardous conditions throughout the building water systems. This step is called 'validation.' Environmental testing for Legionella is useful to validate the effectiveness of control measures. The program team should determine if environmental testing for Legionella should be performed and, if so, how test results will be used to validate the program. Factors that might make testing for Legionella more important include: Being a healthcare facility that provides inpatient services to people who are at increased risk for Legionnaires' disease. IP stated they had only had testing done initially in 2018 and did not do any water testing afterwards. IP further stated the importance of validating controls on an ongoing basis is to prevent legionella from happening in the facility. A review of ASHRAE Addendum to ASHRAE Standard [PHONE NUMBER] (defines types of buildings and devices that need a water management program) titled, Legionellosis: Risk Management for Building Water Systems, dated 6/23/2018, indicated the Program Team shall establish procedures to confirm, both initially and on an ongoing basis, that the Program is being implemented as designed. The resulting process is verification. The Program Team shall establish procedures to confirm, both initially and on an ongoing basis, that the Program, when implemented as designed, controls the hazardous conditions throughout the building water systems. The resulting process is validation. The Program Team shall determine whether testing for Legionella shall be performed and if so, how test results will be used to validate the Program. If the Program Team determines that testing is to be performed, the testing approach, including sampling frequency, number of samples, locations, sampling methods, and test methods, shall be specified and documented. The Program Team shall consider include the following as part of the determination of whether to test for Legionella:b. A healthcare facility provides in-patient services to at-risk or immuno-compromised population.

Based on interview and record review, the facility failed to provide documented evidence or written notice of why a room change was required and failed to accommodate the request to be roomed together as a married couple from 5/5/2025 to 7/21/2025 for two (2) of 19 sampled residents (Residents 43 and 44) when they did not in accordance with the facility's policy and procedure titled Resident Rights. This failure resulted in violation of Residents 43 and 44 right to be notified of the reason why they needed to change rooms and had the potential to result in Residents 43 and 44 feeling sad, lonely and abandoned.1. During a review of Resident 43's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of paraplegia (the loss of movement and sensation in the lower half of the body, including both legs) and generalized (widespread) muscle weakness (decreased ability to use your muscles, making daily activities feel like they require extra effort). Resident 43's admission Record also indicated Resident Representative 1 (RP 1) was Resident 43's responsible party. During a review of Resident 43'S Minimum Data Set (MDS - a resident assessment tool), dated 2/24/2026, the MDS indicated the resident had moderate impairment with cognitive (ability to think, remember, and reason) skills for daily decision making. The MDS also indicated Resident 43 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with rolling left and right in bed, upper and lower body dressing (the ability to dress and undress above and below the waist), putting on/taking off footwear, personal hygiene and eating.2. During a review of Resident 44's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of unilateral (one side) primary osteoarthritis (weak and brittle bones due to lack of calcium and Vitamin D) of the right knee and generalized muscle weakness. During a review of Resident 44'S MDS, dated [DATE], the MDS indicated the resident was moderately impaired with cognitive skills for daily decision making. The MDS also indicated Resident 44 needed substantial/maximal assistance (helper does more than half the effort) with chair/bed-to-chair transfers and going from sitting to standing. In addition, the MDS indicated Resident 44 needed partial/moderate assistance (helper does less than half the effort) with walking 10 feet, going from lying down to sitting on the side of the bed and with putting on/taking off footwear and needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with upper and lower body dressing and eating. During an interview on 3/16/2026 at 2:49 PM with Responsible Party 1 (RP 1), RP 1 stated Residents 43 and 44 are married to one another and there have been times over the past year where the facility had separated Resident 43 and 44's room to accommodate other residents being admitted to the facility. RP 1 also stated she was not agreeable to the room change and had always expressed to the facility wanting Residents 43 and 44 to stay together since Resident 43 is bedridden and unable to call for help. RP 1 further stated, Resident 43 normally asks Resident 44 to notify facility staff when she (Resident 43) needs assistance since the resident cannot do it herself. During an interview on 3/17/2026 at 1:51 PM with RP 1, RP 1 stated there was a time in 2025 where Residents 43 and 44 were assigned separate rooms for 2 months. RP 1 also stated that she had mentioned to facility staff that she would prefer Residents 43 and 44 not be separated since Resident 43 is unable to call for help from facility staff without the help of Resident 44 (Resident 43's husband). During an interview on 3/18/2026 at 7:45 AM with Resident 44, Resident 44 stated when the facility had previously separated him and his wife, Resident 43, he was not notified prior to the new arrangement or the reason why he needs to be in a separate room with Resident 43.During an interview on 3/18/2026 at 11:13 AM with Assistant Director of Nursing (ADON), ADON stated there were times Residents 43 and 44 needed to be placed in a separate room and moved to different rooms to accommodate for the admission of a new resident who was under isolation (the physical separation of sick people with a contagious disease from those who are not sick). ADON stated prior to a room change, a room change notification needed to have been done with the resident(s) and/or their responsible party. ADON also stated it would be the Social Services Director (SSD) who would be in charge of contacting the resident's responsible party regarding the room change needed. During an interview on 3/18/2026 at 11:27 AM with ADON, ADON stated for every single room change, there needs to be a room change notification documentation done as well as a room change follow-up visit. During a concurrent interview and record review on 3/18/2026 at 11:30 AM with ADON, Residents 43's Electronic Medical Record (EMR; a digital, computer-based version of a patient's paper chart, containing their medical history, diagnosis and treatment plans) dated 8/27/2024 to 3/18/2026 and Resident 44's EMR dated 9/1/2024 to 3/18/2026 were reviewed. Residents 43 and 44's EMR indicated Residents 43 and 44, who were initially in the same room, were separated and moved to different rooms on 5/5/2025 and remained separated until 7/21/2025. Resident 43 and 44's EMR also indicated no room change notification documentation or progress note was found for 5/5/2025. ADON verified that Residents 43 and 44 were initially in the same room together and were separated and moved to different rooms on 5/5/2025 and remained separated until 7/21/2025. ADON also stated there was no room change notification to the residents or RP 1 nor progress note documented for both Residents 43 and 44 for their room change on 5/5/2025. During an interview on 3/18/2026 at 11:32 AM with ADON, ADON stated a documented room change notification is to let the resident's family and/or responsible party as well as the resident(s) know about the room change because the facility is their home and it is their right to receive written notice regarding the room change. ADON stated it is also important to notify the resident or resident's representative to help with the transition of the room change so that family and visitors know which room they will be going to and also stated if the resident(s) and/or responsible party is not agreeable to the change, the facility cannot force the room change upon the resident. ADON further stated if the facility has the rooms available, it is better for Residents 43 and 44 to stay together. During an interview on 3/18/2026 at 11:45 AM with SSD, SSD stated for any room change the resident and/or responsible party need to be notified and they (resident/ resident representative) have a right to refuse. SSD stated she was aware of RP 1's request that Residents 43 and 44 stay together. SSD stated for every room change there needs to be a room change notification documented, however, on 5/5/2026 SSD was busy and was not able to document a room change notification for Residents 43 and 44. SSD also stated there should have been a documented room change notification done for both residents to ensure their responsible party was notified and also to show it was explained why the room change was needed as well as giving the responsible party a chance to express their concerns and/or their refusal. SSD further stated a follow up room change visit and documentation should have been done to assess the residents' transition to their new rooms and stated there was no follow-up done after 5/5/2026 for both Resident 43 and 44. During a concurrent interview and record review on 3/18/2026 at 1:55 PM with the Administrator (ADM), the Facility Census dated 5/4/2025 and 5/5/2025 were reviewed. The Facility Census on 5/4/2025 indicated Residents 43 and 44 were both in room [ROOM NUMBER] and on 5/5/2025 Residents 43 and 44 were separated and moved to other rooms to accommodate a new resident being admitted with an isolation. ADM also stated the facility underwent room renovations starting on 5/6/2025. During an interview on 3/19/2026 at 11:56 AM with RP 1, RP 1 stated she was not provided with any written notice of the reason why a room change was necessary for Residents 43 and 44 on 5/5/2025. During a concurrent interview and record review on 3/19/2026 at 12:24 PM with ADM, the Facility Census dated 5/4/2025, 5/5/2025, 5/6/2025, 5/20/2025 and 5/27/2025 were reviewed. The Facility Census on 5/4/2025 indicated Residents 43 and 44 were both in room [ROOM NUMBER] and on 5/5/2025 Resident 43 and 44 were separated and moved to other rooms to accommodate a new resident being admitted with an isolation. The facility census on 5/27/2025 indicated an empty room available for Residents 43 and 44 to be moved back into the same room. ADM stated on 5/27/2025, they should have accommodated Residents 43 and 44 to be moved back into the same room and should not have had to wait until July 2025 to place both residents back into the same room. ADM also stated RP 1's request for Residents 43 and 44 to be together should have been accommodated especially for their (Resident 43 and 44) emotional support and also because Resident 44 watches over Resident 43 and calls for assistance for her. ADM further stated a written notice of the room change should have been provided to RP 1 to validate that they were educated on the reason why the room change was needed and to give RP 1 a chance to agree or disagree. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 1/1/2012, the P&P indicated its purpose is to promote and protect the rights of all residents at the facility which includes a resident's right to share a room with a spouse, it that is mutually agreeable (and feasible). During a review of the facility's P&P titled, Resident Rights - Quality of Life, revised March 2017, the P&P indicated the facility staff keeps the resident informed and oriented to his/her environment and procedures are explained to the residents before they are preformed and the resident is told in advance if he/she is to be taken out of his/her usual or familiar surroundings. During a review of the facility's P&P titled, Room or Roommate Change, revised March 2018, the P&P indicated:When making a change in room or roommate assignment, the resident's needs and preferences are considered and will be accommodated to the extent practical.Prior to changing a room or roommate assignment, the resident, the resident's representative (if available), and the resident's new roommate will be provided with timely advance notice of such a change.The notice of a change in room or roommate assignment must be given in writing, and will include the reason(s) for such change.The facility will use SS-12-Form A-Notification of Room Change or SS-12-Form B Notification of Roommate Change to notify the resident, or the resident's representative of the room or roommate change.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 34) reviewed for restraint (restricting freedom of movement) was free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body) by failing to conduct an assessment for the use of wheelchair and bed alarm (monitoring devices used in healthcare settings to detect when a person attempts to rise, triggering an alert for caregivers). This deficient practice had the potential to negatively affect Resident 34's physical and psychological wellbeing and quality of life.Findings: During a review of Resident 34's admission Record, the admission Record indicated an original admission to the facility on 3/9/2022, and readmission on [DATE]. Resident 34's diagnoses included difficulty in waking, dementia (a brain disorder that results in memory loss, poor judgment, and confusion), and history of falling. During a review of Resident 34's Minimum Data Set (MDS, a resident assessment too), dated 2/25/2026, the MDS indicated Resident 34 had severely impaired cognitive (person's ability to think, learn, remember, use judgement, and make decisions) skills for daily decision making. The MDS indicated Resident 34 required partial/moderate assistance (helper does less than half the effort) with eating and oral hygiene. The MDS indicated Resident 34 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, upper and lower body dressing. During a review of Resident 34's Order Summary Report, dated 3/18/2026, timed 2:26 PM, indicated the following orders:May have bed pad alarm to alert staff when resident is getting out of bed without assistance. Every shift for safety precaution and history of fall Monitor bed pad alarm function and placement, Y= proper function and placement, N= not proper function or placement. Ordered on 3/15/2026.May have wheelchair alarm to alert staff when resident is getting out of the wheelchair without assistance. Every shift for safety precaution while up on wheelchair, monitor wheelchair alarm function and placement, Y= proper function and placement, N= not proper function or placement. Ordered on 3/15/2026. During an observation on 3/16/2026 at 1:47 PM, in the front lobby, Resident 34 was observed sitting in a wheelchair. Resident 34 was observed with a wheelchair alarm. During a concurrent review of Resident 34's restraint assessments and active orders and interview on 3/19/2026 at 10:15 AM with Registered Nurse 2 (RN 2), RN 2 stated Resident 34 has been using bed and wheelchair alarm for a while now and was discontinued when Resident 34 had a change of condition and was transferred out of the facility on 2/12/2026. RN 2 stated that Resident 34 was readmitted back to the facility on 2/18/2026. RN 2 stated that an order of bed and wheelchair alarm to alert staff when Resident 34 is getting up without assistance was obtained by the Director of Nursing on 3/15/2026. RN 2 stated that prior to use of bed and wheelchair alarm, the interdisciplinary team (IDT, a collaborative group of health professionals who work together to create a unified, person-centered care plan) should conduct restraint-physical evaluation for its use because it can be a form of restraint. RN 2 stated that the following are included in evaluation:Reason for restraintRestraint reduction strategies and alternatives attempted.Effectiveness of restraint.Recommendations from IDT.IDT membersCommunicationRN 2 stated Resident 34 did not and should have had an assessment for the use of bed and wheelchair alarm. RN 2 stated there was no documented evidence that the restraint-physical evaluation from 3/15/2026 to 3/19/2026 was conducted for Resident 34. RN 2 stated she had seen Resident 34 with wheelchair alarm. During a concurrent review of Resident 34's restraint assessments and active orders and interview on 3/19/2026 at 1:33 PM with Assistant Director of Nursing (ADON), ADON stated Resident 34 did not have a restraint-physical evaluation prior to the use of bed and wheelchair alarm, which was ordered on 3/15/2025. ADON stated a restraint assessment should have been conducted before using the bed and wheelchair alarm to ensure that Resident 34 needed it, and it was not a form of restraint for the resident's safety. ADON stated that she had seen Resident 34 with a wheelchair while sitting in wheelchair. During a review of facility's Policy and Procedure (P&P) titled, Restraints, revised in 1/25/2024, the P&P indicated restraints require a physician order and are used as a last resort to be used only when deemed necessary by the IDT, and in accordance with the resident's assessment.

Based on interview and record review, the facility failed to ensure an accurate assessment of the Minimum Data Set (MDS, a resident assessment tool) for one of two sampled residents (Resident 9) to reflect the antipsychotic (drug that works by altering brain chemistry to help reduce psychotic symptoms like hallucinations [an experience which a person sees, hears, feels, or smells something that does not exist], delusions [fixed false beliefs], and disordered thinking) medication taken and Antipsychotic Medication Review (a structured, interprofessional evaluation of a resident's antipsychotic drug therapy to assess effectiveness, monitor side effects, and determine the need for continued use, dose reduction, or withdrawal). This deficient practice had the potential for the facility not to develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental psychosocial needs) to monitor antipsychotic medication use and delivery of necessary care and services. Findings: During a review of Resident 9's admission Record, the admission record indicated Resident 9 was admitted to the facility on [DATE], with the diagnoses including but not limited to schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel), and emphysema (a long-term lung condition that causes shortness of breath). During a record review of Resident 9's Order Summary Report, dated 4/10/2025, the physician order indicated Quetiapine Fumarate (antipsychotic medication used to treat schizophrenia) oral tablet 25 milligrams (mg, unit of measurement) - Give two tablets by mouth at bedtime for schizophrenia manifested by auditory hallucinations (hearing voice telling to harm herself). During a record review of Resident 9's Minimum Data Set, dated [DATE], the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was moderately impaired. The MDS indicated Resident 9 was taking an antipsychotic medication. The MDS also indicated Resident 9 did not receive antipsychotics (it prompted to skip over when the last gradual dose reduction [GDR, a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued] was attempted and if the physician documented GDR as clinically contraindicated). During a record review of Resident 9's Care Plan, revised 2/13/2026, the Care Plan indicated Resident 9 used psychotropic medications (Quetiapine) related to behavior management, schizophrenia. The care plan also indicated the staff interventions were to consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly, discuss with physician family re-ongoing need for use of medication, and review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. During a concurrent interview and record review on 3/19/2026 at 10:48 AM with the Minimum Data Set Coordinator (MDSC), Resident 9's MDS dated [DATE], MDSC stated Resident 9 was taking an antipsychotic medication. MDSC stated the Antipsychotic Medication Review was conducted for review when a resident took antipsychotic medication. MDSC stated Resident 9's MDS indicated Resident 9 currently did not receive any antipsychotic medication. MDSC stated the MDS was not accurate, and the answer should have been documented as yes antipsychotic were received on a routine basis only. MDSC stated the Antipsychotic Medication Review was done to review if there was a gradual dose reduction done within the past year or past six months or if there was any contraindication from the physician. MDSC stated if GDR was attempted for Resident 9, it should have been documented in Resident 9's MDS dated [DATE]. MDSC stated GDR for Resident 9 was done on 4/10/2025 and it should have been documented in the resident's MDS because this would allow the facility to be able to track any contraindication by the physician or if there was any dosage that could be adjusted. During a review of the facility's policy and procedure (P&P) titled, Resident Assessment Instrument (RAI) Process, revised 10/4/2016, the P&P indicated to provide resident assessments that accurately depict the identify resident-specific issues and objective as required, while meeting state and federal guidelines and data submission requirements.

Based on observation, interview and record review, the facility failed to provide one (1) of three (3) sampled residents (Resident 1) meal trays that were appetizing and palatable (agreeable to one's sense of taste). This failure had the potential to result in dissatisfaction, decreased food intake and placed Resident 1 at risk for unplanned weight loss.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of type two (2) diabetes mellitus (DM2; a disorder characterized by difficulty in blood sugar control and poor wound healing) with ketoacidosis (a life-threatening, emergency complication of DM occurring when the body lacks enough insulin [a hormone that acts as a key, unlocking cells to allow sugar {glucose} from food to enter and provide energy] to use glucose for energy) without coma (a state of deep, prolonged unconsciousness where a person is alive but unable to wake up, more, or respond to their surroundings, sounds or pain) and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). During a review of Resident 1'S Minimum Data Set (MDS - a resident assessment tool), dated 2/25/2026, the MDS indicated the resident was cognitively intact (ability to think, remember, and reason) with cognitive skills for daily decision making. The MDS also indicated Resident 1 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with chair/bed-to-chair transfers, going from sitting to standing and with putting on/taking off footwear. It indicated, Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with upper and lower body dressing (the ability to dress and undress above and below the waist) and also needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with personal hygiene and eating.During a review of Resident 1's Order Summary Report dated March 2026, Resident 1's Order Summary Report indicated an order initiated on 3/3/2026 for consistent carbohydrate (CCHO; a diabetes management plan that involves eating plan that involves eating roughly the same amount of carbohydrates at the same times each day) standard portion diet with regular texture and thin consistency. During an interview on 3/16/2026 at 10:15 AM with Resident 1, Resident 1 stated the food he receives from the facility is bad and has no flavor and does not like to eat the food.During a food test tray (a quality assurance audit where a meal tray is selected, tracked, and evaluated for accuracy, temperature, safety, and palatability) on 3/18/2026 at 12:33 PM the tray itself did not look appetizing with the spinach on the plate being bland with no flavor. During the same food test tray on 3/18/2026 at 12:33 PM with Dietary Supervisor (DS), DS tasted the spinach and stated it was bland and it needed more flavor. DS stated she does not like food without any flavor and stated because residents who are older in age have a diminished ability to taste and the medications some of the residents take can also affect their ability to taste. DS also stated it is important that the food has good flavor or else the residents might not eat the food. DS further stated good flavor is the only way to ensure residents eat well because if not, there is a risk for the residents to lose weight. During a review of the facility's policy and procedure (P&P) titled, Dietary Department - General, revised 6/1/2014, the P&P indicated the primary objectives of the dietary department include preparation and provision of nutritionally adequate, attractive, well-balanced meals that are consistent with physician orders and maintenance of standards for quality of food.

Based on interview and record review, the facility failed to follow its hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) agreement to coordinate care for one out of two sampled residents (Resident 42) reviewed for hospice by failing to develop an effective communication process for Resident 42's plan of care, hospice visitation, and physician's orders. This deficient practice had the potential for Resident 42 not to receive the hospice care and services necessary to promote comfort and quality of life.Findings:During a review of Resident 42's admission Record, the admission Record indicated an admission to the facility on [DATE]. Resident 42's diagnoses included aortic aneurysm (a dangerous, balloon-like bulge or weak spot in the wall of the aorta [the body's main artery that carries blood from the heart to the rest of the body], heart disease (any condition that affects the heart's structure or function, preventing it from working properly) and encounter for palliative care (specialized medical care focused on providing relief from the symptoms, pain, and stress of a serious illness to improve quality of life for both the patient and their family). During a review of Resident 42's Minimum Data Set (MDS, a resident assessment too), dated 12/31/2025, the MDS indicated Resident 42 had modified independence (some difficulty in new situations only) cognitive (person's ability to think, learn, remember, use judgement, and make decisions) skills for daily decision making. The MDS indicated Resident 42 required setup or clean-up assistance (helper sets up or cleans up) with eating. The MDS indicated Resident 42 required partial/moderate assistance (helper does less than half the effort) with oral hygiene. The MDS indicated Resident 42 required substantial/maximal assistance (helper does more than half the effort) with upper body dressing and personal hygiene. The MDS indicated Resident 42 was dependent (helper does all the effort) with toileting hygiene, lower body dressing, and putting on/taking off footwear. During a review of Resident 42's Plan of Care (POC) Summary, dated 3/19/2026, the summary indicated a physician's order, dated 1/202/26 to recertify patient to Hospice 1 for care from 1/20/2206 to 3/20/2026, with primary diagnosis of end stage heart failure (the final, most severe stage of heart failure where the heart is too weak to pump blood effectively, and standard treatments no longer work, it is marked by persistent, severe symptoms like severe breathlessness even while resting, and extreme fatigue) for symptom management and comfort focused care. Ordered on 1/20/2026. During a review of a Resident 42's Care Plan (CP), focusing on Resident 42's terminal prognosis related to abdominal aortic aneurysm (AAA, dangerous, often silent, bulge or swelling in the aorta [the main blood vessel supplying blood to the body-as it passes through the abdomen]), initiated 11/27/2024, and revised 3/15/2026, the CP indicated intervention included was to work cooperatively with hospice team to ensure the residents' spiritual, emotional, intellectual, physical and social needs are met. During an interview on 3/19/2026 at 9:19 AM with Registered Nurse 2 (RN 2), RN 2 stated Resident 42's care plans were developed based on active physician's order in electronic medical record. RN 2 stated that Resident 42 has a hospice binder located in Nursing Station 2. RN 2 stated that the facility practice was to transcribe (the accurate, manual copying of prescribed order details from a primary source onto a resident's medical records) all hospice orders to the facility's electronic medical records. RN 2 stated conflicting orders from the hospice binder and Resident 42's electronic medical records can cause confusion and potentially inaccurate, incomplete and unsafe hospice plan of care for Resident 42. RN 2 stated that Resident 42's hospice diagnosis of end stage heart failure was not in the care plan. RN 2 also added that the following hospice staff frequency of visits was not and should have been in the care plan.Master of Social Work (MSW, staff who provides essential psychosocial support, counseling, and resources to patients with terminal illnesses and their families) visit every recert to evaluate and identify psychosocial and emotional needs of patient and family. May send one extra visit per month as needed and per patient/family request for symptom management. Ordered on 4/5/2025.Spiritual Counselor (SC, a Chaplain) visit once every recert for spiritual needs of patient and family. May send one extra visit per month per patient/family request for symptom management. Ordered on 4/4/2025.All personnel to visit patient face to face unless requested by patient/family. May do telephone visit via phone, or other technology options. Ordered on 4/1/2025.Hospice Aide (HA, a certified professional providing essential personal care, companionship, and comfort to patients) to visit patient two times a week for assistance with personal care needs. Ordered on 4/1/2025.RN visits every 14 days thereafter for ongoing comprehensive assessment and supervisory visits. Recertification assessment per schedule for skilled assessment and intervention. Ordered on 4/1/2025.Skilled Nurse visits once a week, and two as needed a week to promote comfort and symptom management and for change of condition. Ordered on 4/1/2025. During a concurrent record review of Resident 42's CP and interview on 3/19/2026 at 9:25 AM with MDS assistant, the MDS assistant stated that Resident 42's hospice frequency of visits was not and should have been in the care plan. MDS assistant stated that it was important to reflect hospice frequency of visits on the care plan for the entire care team to know the specific care for Resident 42 who is on hospice care. During a concurrent record review and interview on 3/19/2026 at 9:35 AM with the Director of Nursing (DON), Hospice 1's contract agreement, dated 8/20/2025 and Resident 42's hospice binder was reviewed. The DON stated Resident 42's electronic medical records were inconsistent with the records that are in Resident 42's hospice binder. The DON stated that facility did not develop Resident 42's hospice care plan. The DON stated this can lead to inconsistency of care that may cause harm to Resident 42. The DON stated the Hospice 1 Agreement indicated Both the plan of care and the nursing care plan developed by the agency will be part of the patient's record in the facility. Both of these will be developed in collaboration with the agency and the facility staff. The facility staff will notify the agency if there are any changes in the plan of care or the nursing care plan and make copies available to the agency personnel. The DON stated that the hospice care plan developed for Resident 42 was incomplete and does not and should have included all the orders that are indicated in Resident 42's POC summary filed in the hospice binder. During a review of the Contract Agreement between Hospice 1 and facility, dated 8/20/2025, the Contract Agreement indicated responsibilities of the agency and the provider in the admission, assessment, care planning, coordinating, supervising and evaluating the care and services provided, interdisciplinary group care conferences, development review revision, and review of the plan of care. The contract agreement also indicated the hospice plan of care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. The hospice plan of care reflects the participation of the hospice, the facility, and the patient and family to the extent possible. Any changes in the hospice plan of care must be discussed with the patient or representative, and facility, and must be approved by the hospice before implementation. During a review of facility's Policy and Procedure (P&P) titled, Hospice Care of Residents, revised on 1/1/2012, the P&P indicated the hospice and facility will collaborate on a care plan for the resident. It also indicated all documentation concerning hospice services will be maintained in resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure the call light for one (1) of 1 sampled resident (Resident 83) reviewed for environment was within reach.This failure had the potential to put Resident 83 at risk for experiencing a delay in receiving assistance from facility staff which could lead to a fall or accident and unmet needs.Findings:During a review of Resident 83's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of unspecified sequelae of cerebral infarction (the lasting physical, cognitive [ability to think, remember and reason] or emotional impairments that remain after a stroke [blocked blood flow to the brain])and generalized (widespread) muscle weakness (decreased ability to use your muscles, making daily activities feel like they require extra effort). During a review of Resident 83's History and Physical Examination (H&P), dated 3/13/2026, the H&P indicated the resident had mild cognitive impairment and only able to make decisions for her basic needs. During a review of Resident 83's admission assessment dated , 3/11/2026, Resident 83's admission Assessment indicated resident 83's cognitive (mental action or process of acquiring knowledge and understanding) level as having moderate impairment (memory loss). The admission Assessment also indicated Resident 83 had no impairment with her upper extremity range of motion but had impairment on one side for her lower extremity range of motion. Resident 83 was also assessed to be bedfast (being confined to bed due to serious illness, injury or old age) all or most of the time. During a review of Resident 83's Care Plan, dated 3/13/2026, Resident 83's Care Plan indicated Resident 83 was noncompliant evidenced by attempts to get out of bed without assistance. The care plan also indicated Resident 83 did not consistently use the call light and had increased risk for falls with injury. Staff intervention included was to ensure the call light is within reach at all times.During a review of Resident 83's Care Plan, dated 3/18/2026, Resident 83's Care Plan indicated call light would be secured by wrapping it around the grab bar to maintain accessibility. The Care Plan also indicated a goal of Resident 83 maintaining safe access to the call light. During an observation on 3/16/2026 at 10:25 AM in Resident 83's room, Resident 83 was observed lying down in bed with her call light observed hanging off the right side of her bed on the floor on top of the fall mat (a cushioned floor pad designed to help prevent injury should a person fall). During a concurrent observation and interview on 3/16/2026 at 10:29 AM with Assistant Director of Nursing (ADON) in Resident 83's room, Resident 83 was observed turned onto her left side on the bed with both her legs attempting to come off the side of the bed and touching the floor and her call light was observed hanging of the right side of her bed on the floor on top of the fall mat. ADON stated Resident 83's call light was on the floor and out of her reach. During an interview on 3/18/2026 at 11:06 AM with ADON, ADON stated the purpose of a call light is so the resident can ask for assistance and if it is not within reach, there is a risk for a delay in staff providing assistance to the resident. During a review of the facility's policy and procedure (P&P) titled, Communication - Call System, revised 8/24/2024, the P&P indicated, The call alert device will be placed within the resident's reach.

Based on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq.ft. - unit of measurement) per resident in multiple resident bedrooms for 13 of 35 residents' rooms (Rooms 5, 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22, and 23) in the facility. This deficient practice had the potential to affect the ability to provide care, safety, and a home-like environment for the residents.Findings: During a tour of the facility on 3/16/2026 at 10 :00 AM, 13 of 35 residents' rooms did not meet the minimum 80 sq. ft. per resident in multiple resident bedrooms. These are Rooms 5, 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22, and 23. During a concurrent observation and interview on 3/16/2026 at 1:35 PM in room [ROOM NUMBER], one resident (Resident 3) was observed sitting on the edge of her bed, about to get up and ambulate with a walker. Resident 3 stated that the space in the room was adequate and that she has a walker, which allows her to move around without difficulty. Resident 3 also stated that staff have enough space to move around while providing care.During a concurrent review of the facility's client accommodation analysis and interview with the Administrator (ADM) on 3/18/2026 at 7:50 PM, the ADM stated the facility has 35 resident rooms. The ADM stated 13 of these rooms do not meet the requirement of 80 square feet per resident in multiple - resident bedrooms. The ADM stated that she will continue to request a room waiver because not meeting the required square footage does not affect the health and safety of the residents. The ADM also stated that there is enough space for staff to provide care for the residents. During a review of the facility's room waiver letter, dated 3/16/2026, the room waiver indicated the following:Room Sq. Ft. Bedsroom [ROOM NUMBER] - 226.9 sq. ft. - 3 bedsroom [ROOM NUMBER] - 222.24 sq. ft. - 3 bedsroom [ROOM NUMBER] - 226.9 sq. ft. - 3 bedsroom [ROOM NUMBER] 222.24 sq. ft. - 3 bedsroom [ROOM NUMBER] - 226.9 sq. ft. - 3 bedsroom [ROOM NUMBER] - 222.24 sq. ft. - 3 bedsroom [ROOM NUMBER] - 221.9 sq. ft. - 3 bedsroom [ROOM NUMBER] - 221.9 sq. ft. - 3 bedsroom [ROOM NUMBER] - 221.9 sq. ft. - 3 bedsroom [ROOM NUMBER] - 221.9 sq. ft. - 3 bedsroom [ROOM NUMBER] - 221.9 sq. ft. - 3 bedsroom [ROOM NUMBER]- 216.26 sq. ft. - 3 bedsroom [ROOM NUMBER] - 216.26 sq. ft. -3 bedsThe minimum square footage for a 3-bedroom is 240 sq. ft. During a review of the facility's room waiver letter, dated 3/16/2026, the facility's room waiver indicated a request for re-authorization of waivers for the following 13 resident 3-bed rooms floor areas ranging 216.26 to 226.9 square feet per room. These rooms are in accordance with the needs of residents, do not have an adverse effect on the residents' health and safety, nor impede the ability of any resident to attain his or her highest practicable well-being. During the survey from 3/16/2026 to 3/19/2026, rooms 5, 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22, and 23 were observed with adequate ventilation and lighting. The residents in the rooms have bathroom and toilet facilities. The residents have privacy curtains around their beds, which assured privacy. There was adequate space for getting in and out of wheelchairs and residents were afforded sufficient freedom of movement in the rooms. The residents did not complain regarding the space in their room. There was enough space for the staff to provide care and enough storage for residents' belongings. Residents that were wheelchair bound were able to move in the room without difficulty. The Department would recommend the room waiver for Rooms 5, 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22, and 23.

Based on interview and record review, the facility failed to prevent sexual abuse (non-consensual sexual contact of any type with a resident) for one of two sampled residents (Resident 1) on 2/11/2026 in the facility's hallway. On 2/11/2026, Visitor (Visitor 1) witnessed Resident 2's hand was inside Resident 1's pants. This failure can result in Resident 1 and 2 experiencing emotional trauma (response to deeply distressing or disturbing events) or psychological trauma (damage to the mind that occurs as a result of a severely distressing event).Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included dementia (progressive brain disorder that slowly destroys memory and thinking skills), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), and hypertension (high blood pressure). The admission Record indicated Resident 1 was not self- responsible and the party responsible is Resident 1's Representative 1 (RR1). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/21/2025, the MDS indicated Resident 1's cognitive skills (processes of thinking and reasoning) for daily decision making were severely impaired. The MDS indicated Resident 1 requires partial moderate assistance (the helper does less than half the effort) for sit to stand (the ability to a standing position from sitting), walk 10 feet (ft.-unit of measurement) once standing the ability to walk at least 10 ft, in a room, corridor or similar space once standing. The MDS also indicated Resident 1 required partial moderate assistance to wheel 50 ft. with two turns using a wheelchair. During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, tool used by health care professionals when communicating about critical changes in a resident's status), dated 2/11/2026 at 3PM, the SBAR indicated Resident 1 was at risk for emotional distress related to alleged inappropriate touching. The SBAR also indicated the charge nurse received a report from a witness (Visitor 1) that Resident 1 was being touched inappropriately by Resident 2 while sitting in their wheelchair in the hallway. During a review of Resident 1's Change in Condition Evaluation dated 2/11/2026 at 2:41 PM, the change in condition evaluation indicated Resident 1 was at risk for emotional distress related to alleged inappropriate touching. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE]. Resident 2's diagnoses included muscle weakness, gait mobility, dysphagia (difficulty swallowing). The admission Record indicated Resident 2 was not self- responsible and the party responsible is Resident Representative 2 (RR2). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 2 requires partial moderate assistance on sit to stand, walk 10 ft once standing. During a review of Resident 2's SBAR dated 2/11/2026 at 3PM, the SBAR indicated there was an allegation of inappropriate sexual behavior towards Resident 1 as manifested by inappropriate touching. During a review of Resident 2's Change in Condition Evaluation dated 2/11/2026 at 2:57 PM, the Change in Condition Evaluation indicated Resident 2 was being monitored for inappropriate behavior manifested by touching of Resident 1. During an interview on 2/12/2026 at 10:50 AM, with Visitor 1, Visitor 1 stated, on 2/11/2026 (unable to recall time), after leaving Room A and walking down the hallway going to the nurse's station, Visitor 1noticed 2 wheel chairs side by side, there was Resident 1 in the wheelchair closest to the wall and Resident 2 next to Resident 1 in the other wheelchair. Visitor 1 also stated, she noticed the male (Resident 2) had his hand down the front inside of the female (Resident 1) pants and was moving his hand. During an interview on 2/12/2026 at 11:28 AM with License Vocational Nurse (LVN 1), LVN 1 stated, on 2/11/2026 at around 3PM, Visitor 1 went to the nursing station 2 and reported to LVN 1 that Resident 2's hand was inside Resident 1's pants. During a concurrent interview on 2/12/2026 at 3:42 PM with the Director of Nursing (DON) and the Administrator (ADM), the ADM stated they (ADM and DON) reviewed the video footage from the surveillance camera at the hallway near nursing station 2 which was recorded on 2/11/2026 at approximately between 2:45 PM to 3 PM. ADM stated the video showed Resident 1 and 2 sitting side by side while they were in their wheelchair along the hallway. ADM also stated the video footage also showed Resident 2 attempting to place his hand under and in front of Resident 1's pants. ADM also stated they were not able to prevent Resident 2's sexual inappropriate touching. ADM further stated residents should not be touched on their private parts by staff or other residents especially if without consent. During an interview on 2/13/2026 at 12 PM, with House Keeping (HK1), HK 1 stated on 2/11/2026 around 3 PM, Visitor 1 told him (HK1) something about Resident 2 was touching Resident 1 while pointing towards Resident 1 and 2. HK 1 stated he did not fully understand what Visitor 1 was saying regarding the two residents, so he did not report it to the nurse or other staff. During a concurrent observation and interview on 2/13/2026 at 1:43 PM, with the DON and ADM, the video footage dated 2/11/2026 was reviewed. ADM stated, at 2:21:38 PM, the video showed Visitor 1 exiting Room A while Residents 1 and 2 were sitting in their wheelchair beside each other (Resident 1 closer to the wall). ADM stated, at 2:21:46 PM, Resident 1 swayed Resident 2's hand away. The ADM stated that at 2:21:56 PM, Visitor 1 was speaking with HK1. The ADM also stated Resident 2's hand exact location was not visible in the video footage. During a concurrent interview on 2/13/2026 at 4:56 PM with the DON and ADM, ADM stated everyone is a mandated reporter and staff are required to report even if it is an alleged abuse so the facility can investigate properly. ADM also stated the facility was not able to prevent Resident 2 from touching Resident 1 inappropriately. ADM further stated Residents 1 and 2 did not have consent to touch, especially in the private area or for any sexual interaction with another resident in the facility. ADM also stated that if sexual inappropriate touching was not consensual, it was considered sexual abuse. During a record review of the facility's policy and procedures (P&P) titled, Abuse and Neglect (fail to care properly) dated 2022, it indicated the facility does not condone any form of resident abuse. The P&P also indicated the purpose of the policy was to address the health, safety, welfare, dignity and respect of residents.

Based on interviews and record review, the facility failed to provide adequate intervention such as bed alarm (a safety device, often for the elderly or those with dementia, that alerts caregivers when a person tries to get out of bed), to monitor/document sleeping pattern and inform the resident's physician of any insomnia (trouble falling asleep or staying asleep) or anxiety (natural feeling of worry, fear, or unease, often a physical and emotional reaction) for one (1) of two (2) sampled residents (Resident 1) who was assessed as at risk for fall. This deficient practice resulted in Resident 1 sustaining a fall in the resident's room on 12/31/2025 around 5:30 AM. Resident 1 was found on the floor on the right side of the bed and was assessed to have a small abrasion (a superficial skin injury, also known as a scrape) measuring 2 centimeters (cm, unit of measurement) on the left forehead.Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), hypertension (HTN-high blood pressure), and legal blindness (severe vision loss). During a review of Resident 1's Fall Risk Evaluation, dated 11/12/2025, the Fall Risk Evaluation indicated Resident 1 was at risk for fall. The Fall Risk Evaluation indicated the following:Level of consciousness / mental status = Intermittent confusion (experiencing temporary, recurring periods where you can't think clearly)Ambulation / elimination status = Bed bound / Incontinent (involuntary leakage of urine or stool).Vision status = Poor During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/12/2025, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 has impairment on both upper extremities, and one side impairment on lower extremity. Resident 1 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with rolling left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed. The MDS indicated Resident 11 has no history of falls. During a review of Resident 1's Care Plan (CP), revised on 11/18/2025, it indicated Resident 1 has coronary artery disease (fatty buildup narrows or blocks the arteries) related to hypercholesterolemia (having abnormally high levels of fats in your blood) and HTN. The CP intervention indicated to monitor/document sleeping pattern and inform the resident's physician of any insomnia or anxiety. Give sedatives (a drug or substance that calms you down) as ordered. During a review of Resident 1's CP, revised on 11/18/2025, it indicated Resident 1 is at risk for falls. The CP indicated the following interventions: If a resident is a fall risk, initiate fall risk precautions.May put bed to the lowest position every shift for safety and history of fall related to restlessness. During a review of Resident 1's CP initiated on 4/1/2025, and revised on 11/18/2025, it indicated Resident 1 is at risk for falls related to confusion, gait/balance problems, poor communication/comprehension, unaware of safety needs, and restlessness while in bed. The CP indicated interventions included the following:Anticipate and meet the resident's needs.Follow facility fall protocol.May put bed to the lowest position every shift for safety and history of fall related to restlessness. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR -a communication tool used by healthcare workers when there is a change of condition among the residents) summary for providers, dated 12/31/2025 at 2:11 AM, entered by Registered Nurse 1 (RN 1), it indicated Resident 1 was observed to be restless and grimacing (a facial expression in which your mouth and face are twisted in a way that shows disgust, disapproval, or pain). During a review of Resident 1's Transfer to Hospital Summary dated 12/31/2025, timed 6:08 AM, entered by RN 1, it indicated Resident 1 was found lying on the floor between the nightstand and the bed with the resident's face down. During a review of Resident 1's Change of Condition (COC) evaluation, dated 12/31/2025, timed 7:27 AM, entered by Licensed Vocational Nurse 1 (LVN 1), the COC evaluation indicated Resident 1 had a fall. The COC evaluation indicated Resident 1 with new COC of restlessness and constant moving in bed around 2 AM. The COC evaluation indicated at 5:30 AM, Resident 1 was found on the floor on the right side of the bed. The COC evaluation also indicated Resident 1 obtained a small abrasion measuring 2 cm on the left forehead. During a review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals) Progress notes, dated 1/2/2026, timed at 12:51 PM, it indicated Resident 1 had a fall on 12/31/2025. The IDT Progress notes indicated prior to the incident, Resident 1 was observed making moaning noises and exhibiting constant movement in bed despite repositioning and distraction attempts for comfort. The IDT Progress notes indicated that Resident 1 had been restless throughout the night, with constant body movement. The IDT Progress notes indicated a root cause for Resident 1's fall was most likely due to severe cognitive impairment, restlessness, and significant physical limitations. The IDT progress notes also indicated on the night of the fall, Resident 1 exhibited agitation, restlessness, and constant movement During an interview on 1/6/2026 at 12:20 PM with RN 1, RN 1 stated she was assigned to Resident 1 on 12/31/2026 when Resident 1 had a fall. RN 1 stated on that night, Resident 1 was restless, screaming, and constantly moving in bed. RN 1 stated at around 5:30 AM, CNA 1 called her to Resident 1's room where they observed Resident 1 on the floor, face down, on the right side of the bed, between the bed and the nightstand. During an interview on 1/6/2026 at 2:17 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 is able to move while in bed, Resident 1 does not use the call light, and is unable to verbalize needs. LVN 1 stated Resident 1 did not have a bed alarm and should have an order of bed alarm to alert staff when Resident 1 is no longer in a safe position to prevent the resident from falling from the bed. LVN 1 stated bed alarm is usually placed in the middle of the bed, and it will alarm when it detects weight change when resident lifts off the bed. During an interview on 1/6/2026 at 4:05 PM with CNA 2, CNA 2 stated he is familiar with Resident 1. CNA 2 stated Resident 1 is usually restless and does not sleep in the evening like other residents. CNA 2 stated Resident 1 usually move around while in bed. During a concurrent interview on 1/7/2026 at 8:10 AM with RN 1, and record review of Resident 1's medical records dated from 11/18/2025 to 1/7/2026 were reviewed RN 1 stated that on 12/31/2025, Resident 1 has no sedative order. RN 1 stated Resident 1 is usually awake, with moaning and screaming behavior at night. RN 1 stated that Resident 1 has care plan for CAD revised on 11/18/2025 with intervention to monitor/document the resident's sleeping pattern, to inform physician of any insomnia or anxiety, and to give sedatives as ordered. RN 1 stated there was no documented evidence that Resident 1's sleep pattern has been monitored. RN 1 stated there is no sedatives order, and the CP was not resident centered. RN 1 stated if Resident 1's sleep pattern/anxiety has been monitored and documented, Resident 1's Physician could have ordered a medication to relieve Resident 1's anxiety, and inability to sleep which will help prevent Resident 1 to move around in bed and could have prevented the fall. RN 1 also added Resident 1 could have benefited from a bed alarm to alert staff that resident is no longer in a safe spot so the staff can intervene right away and prevent Resident 1 from falling. During a concurrent interview on 1/7/2026 at 8:30 AM with LVN 2 and record review of medical records, LVN 2 stated monitoring and documenting sleep pattern should have been ordered if it was in Resident 1's care plan to reflect in the medication administration record, where in licensed nurses would be documenting residents' hours of sleep. LVN 2 stated a bed alarm could have prevented Resident 1's fall if it was added in the plan of care and provided to the resident. During a telephone interview on 1/8/2026 at 9:20 AM with CNA 1, CNA 1 stated that on 12/31/2025, around 1 AM, Resident 1 has been more restless than usual. CNA 1 stated that Resident 1 squirms (twist the body from side to side, especially as a result of nervousness or discomfort) in bed and being repositioned frequently. During an interview on 2/8/2026 at 10:53 AM with Assistant Director of Nursing (ADON), ADON stated Resident 1's sleeping pattern was not monitored, and there was no documented evidence of Resident 1's sleep pattern. ADON stated since it is part of Resident 1's CP, it should have been ordered to reflect in Resident 1's MAR. During an interview on 12/8/2026 at 12:39 PM with ADON, she stated Resident 1 could have benefited the use of bed alarm to alert staff when the pressure was off, it will make the staff know that the resident is no longer in a good position in bed. ADON stated that when a resident does not get enough sleep at night place the resident to be restless that is why Resident 1 does a lot of moving around the bed. During a concurrent interview and record review on 2/8/2025 at 4 PM with the Director of Nursing (DON), Resident 1's medical records dated from 3/25/2025 to 12/31/2025 were reviewed. The DON stated Resident 1 has been at risk of falling because of cognitive problems, blindness and contractures. The DON stated Resident 1 had a fall on 3/25/2025 and a care plan was initiated on 4/1/2025 that Resident 1 is risk for falls related to confusion, balance problems, poor communication/comprehension, unaware of safety needs and restlessness while in bed. The DON verified that the CP did not indicate an intervention to address Resident 1's restlessness while in bed and the intervention to follow facility fall protocol was general and not resident- specific. The DON stated, Resident 1 had a CP for CAD that was revised on 11/18/2025 with intervention to monitor and document sleep pattern, and the DON verified the intervention was not implemented or was not done. During a review of facility's P&P titled, Person-Centered care Planning, revised on 4/24/2025, it indicated interventions are actions, treatments, procedures, or activities designed to meet an objective. It also indicated Person-centered care plan means making an effort to understand what is important to each resident with regard to daily routines and preferred activities and having an understanding of the resident's life before coming to reside in nursing facility. During a review of facility's Policy and Procedure (P&P) titled, Fall Management program, revised in 8/28/2025, the policy indicated the facility will implement an interdisciplinary fall prevention program that includes risk screening, individualized care planning, and targeted interventions. During a review of facility's P&P titled, Fall Management program, revised in 8/28/2025, the P&P indicated licensed nurse will develop a care plan according to the identified risk factors.

Based on interview and record review, the facility failed to ensure an antibiotic time- out (ATO-a structured process where healthcare providers review and assess the need for ongoing antibiotic therapy) was completed within 48 to 72 hours for two (2) of three (3) sample residents (Residents 1 and 3), sampled for antibiotic use, as indicated in the facility's policy. These failures had the potential to result in Residents 1 and 3 to receive unnecessary antibiotic therapy with the risk of creating antibiotic resistance (bacteria develop and resist the effects of the antibiotics used to kill them).Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure), urinary tract infection (UTI- an infection in any part of the urinary system) and enterocolitis (inflammation [the body's response to an illness, injury or something that doesn't belong in the body] of both the small intestine [enteritis] and large intestine [colitis]) due to clostridium difficile (C.diff- a highly contagious bacteria that causes severe diarrhea). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated, 8/28/2028, the MDS indicated Resident 1 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with eating, oral and personal hygiene and dependent (helper does all effort needed to complete activity) with toileting hygiene, shower/bathing and dressing. The MDS also indicated Resident 3 was receiving an antibiotic in the facility. During a review of Resident 1's Order Summary Report, dated 8/27/2025, the Order Summary Report indicated metronidazole (medication used to treat bacterial infections in different areas of the body) oral tablet 500 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), give one (1) tablet by mouth four (4) times a day for C. diff infection for 10 days, last dose 9/6/2025 5:00 PM. During a review of Resident 1's MARs dated 8/1/2025 through 8/31/2025 and 9/1/2025 through 9/30/2025, the MARs indicated Resident 1 was administered metronidazole 500 mg 1 tablet every day from 8/27/2025 through 9/6/2025 for C. diff infection. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included heart failure (a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs), bacteremia (bacteria in the blood) and end stage renal disease (ESRD - irreversible kidney failure). During a review of Resident 3's Order Summary Report, dated 7/25/2025, the Order Summary Report indicated ciprofloxacin (used to treat infections caused by bacteria) hydrochloride (HCl- a commonly used salt) oral tablet 500 mg, give 1 tablet by mouth every 24 hours for bacteremia, until 8/14/2025 at 5 PM status post (s/p- after) transurethral resection of the prostate (TURP- a surgical procedure used to treat an enlarged prostate gland) of prostatic abscesses. During a review of Resident 3's MDS, dated 8/1/2025, the MDS indicated Resident 3 with moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 3 required substantial/maximal assistance with eating, oral and personal hygiene, showering/bathing and dependent with toileting hygiene. The MDS also indicated Resident 3 was receiving an antibiotic in the facility. During a review of Resident 3's MARs dated 7/1/2025 through 7/31/2025 and 8/1/2025 through 8/31/2025, the MARs indicated Resident 3 was administered ciprofloxacin HCl 500 mg 1 tablet every day from 7/25/2025 through 8/12/2025 for bacteremia. During an interview on 9/15/2025 at 10:46 AM with the Infection Preventionist (IP), the IP stated the facility policy, an ATO should be done within 48 to 72 hours of starting the antibiotic. The IP states an ATO includes reviewing culture (a test to identify whether you have a bacterial infection) results, lab results and reporting to the physician and documenting if the antibiotic is continued or discontinued. During a concurrent interview and record review on 9/15/2025 at 1:37 PM with the IP, the facility's Infection Surveillance Monthly Report, dated 8/2025, indicated:a. Resident 1 had a clostridium difficile infection and treatment of metronidazole oral tablet 500 mg, ordered on 8/28/2025.b. Resident 3 with a bacteremia infection and treatment of ciprofloxacin 500 mg, ordered on 7/25/2025.The IP stated per facility protocol, Resident 1 would need an ATO done for metronidazole by 8/30/2025 and Resident 3 would need an ATO done for the ciprofloxacin by 7/28/2025. During the same concurrent interview and record review on 9/15/2025 at 1:37 PM with the IP, Resident 1 and Resident 3's electronic medical charts were reviewed. The medical charts for Residents 1 and 3 failed to indicate an ATO was completed for Resident 1's metronidazole by 8/30/2025 and an ATO for Resident 3's ciprofloxacin by 7/28/2025. The IP stated Resident 1 and Resident 3's ATOs should have been completed within the 48 to 72-hour window but were not done. The IP stated an ATO is time taken for licensed nurses to stop and check the residents for any adverse effects (an undesired harmful effect resulting from a medication or other intervention) from the antibiotics, justify continued use of the antibiotics and help prevent antibiotic resistance in the residents. The IP also stated ATO's need to be done because [most] residents are elderly and/or over the age of 65 and are vulnerable to becoming resistant to antibiotics because of frequent antibiotic prescriptions. During an interview on 9/15/2025 at 2:14 PM with the Registered Nurse Supervisor (RNS), the RNS stated ATO's are done 3 days after the initiation of antibiotics and any licensed nurse can complete the ATO. The RNS also stated that ATOs are important to assess if the resident needs the antibiotic and prevent antibiotic resistance due to unnecessary use. RNS stated if residents become resistant to antibiotics, it will limit the available antibiotics that can be used to treat their infections. During an interview on 9/15/2025 at 2:55 PM with the Director of Nursing (DON), the DON stated Resident 1 did not have an ATO completed within the 48 to 72 hours after starting metronidazole in the facility and it should have been done. The DON also stated Resident 3 did not have an ATO completed within the 48 to 72 hours after starting ciprofloxacin in the facility and it should have been done. The DON stated it is important to ensure the ATOs are completed to prevent resistance from inappropriate antibiotic use, causing multidrug-resistant organisms (MDROs- bacteria or other microorganisms that have become resistant to multiple types of antibiotics) in the residents. During a review the facility's policy and procedure (P&P) titled Antibiotic Time - Out (ATO) Policy, revised 9/14/2017, the P&P indicated the need for antibiotics will be reassessed when clinical and laboratory data become available at which time an ATO will be considered and discussed with the physician. The P&P also indicated an ATO is meant to prompt the physician to revisit the need for the antibiotic 48 to 72 hours after starting the antibiotic and the facility licensed nurse (IP, DON or charge nurse) will contact the prescribing physician 48 to 72 hours after initiation of an antibiotic. During a review of the facility's P&P titled Antibiotic Stewardship, revised 5/20/2021, the P&P indicated the purpose of the policy was to optimize the use of antibiotics by improving prescribing practices and reduce inappropriate antibiotic use. The P&P indicated antibiotic time-outs (ATO) is a review process for all antibiotics prescribed in the facility, and will be utilized when appropriate and prompts clinicians to reassess the ongoing need for an antibiotic after culture results are available. The P&P also indicated the facility will provide education on antibiotic stewardship to prescribing medical providers, nursing staff, other staff (as appropriate) and the IP will review antibiotic use protocols, antibiotic use and share the information with licensed nursing staff as needed.

Based on observation, interview, and record review, the facility failed to maintain residents' room temperature level between 71 to 81-degree Fahrenheit ( F-a unit of temperature measurement on the Fahrenheit scale, where water freezes at 32 degrees Fahrenheit and boils at 212 degrees Fahrenheit) for three (3) of eleven (11) sampled residents (Resident 126, Resident 63, and Resident 36). This deficient practice resulted in the resident's increased level of discomfort and had the potential to negatively impact the resident's quality of life. Findings: 1. During a review of the admission record, the admission record indicated Resident 126 was initially admitted to the facility on [DATE], with diagnoses that included but not limited to nondisplaced fracture (a broken bone where the pieces of the bone remain aligned) of greater trochanter (a bony projection on the upper part) of right femur (thing bone), subsequent encounter for closed fracture with routine healing (encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase), protein-calorie malnutrition (a condition that occurs when someone does not get enough protein and calories in their diet. It can range from mild weight loss to severe wasting), muscle weakness, and history of falling. During a review of Resident 126's Minimum Data Set (MDS - resident assessment tool), dated 11/20/2024, the MDS indicated Resident 126 does not have impaired cognitive skills for daily decision making. Resident 126 needed partial to moderate assistance (helper does less than half the effort) from the staff for the activities of daily living such as toileting hygiene and upper body dressing and required substantial/maximal assistance (helper does more than half the effort) for shower, lower body dressing, and personal hygiene. During a review or Resident 126's Care Plan indicated Resident 126 is at risk for insomnia related to difficulty sleeping at night. Interventions indicated to monitor for factors that may contribute to poor sleep pattern. During an observation and interview with Resident 126 on 2/4/2025 at 9:04 AM, Resident 126's was inside an isolation room (a room that separates residents with infections or conditions that make them susceptible to infection from others) with the door closed. Resident 126 was observed to be sitting up in bed and was noticeably sweating and attempting to fan herself with her hands. Resident 126's hair was wet and sticking to her face and neck and her gown was noticeably wet from her torso (central part of the body that includes the chest, abdomen, back, and pelvis) area. Resident 126 stated, The temperature inside the room was terrible this morning. It was like a sauna (a special heated room in which people sit or lie down in order to get hot and sweat). It was really hot. Then I heard the thermostat (a device that automatically regulates temperature, or that activates a device when the temperature reaches a certain point) outside click off and it cooled off a bit. During a concurrent interview with Resident 126 on 2/4/25 at 9:14 AM, Resident 126 stated, You think it's hot now, you should have seen how hot it was earlier this morning. I had sweat all over myself and my door was closed. I didn't get any fresh air. Usually, I am not able to sleep well, and with how hot the room was, I could not go to sleep at all last night, it was too hot. During an observation and interview with Maintenance Staff on 2/4/2025 at 9:22 AM, Maintenance Staff confirmed Resident 126's room was hot by measuring the temperature at 92 degrees Fahrenheit. Maintenance Staff stated that resident's rooms should be kept anywhere from 72 degrees Fahrenheit to 73 degrees Fahrenheit to keep them comfortable. Maintenance Staff stated, I will have to go and change the thermostat and put it to 73 to74 degrees. During an observation of Maintenance Staff and Resident 126 on 2/4/2025 at 9:24 AM, Maintenance Staff asked Resident 126 if the room was too hot for her. Resident 126 once again stated the room was really hot and to please keep the room cooler since it was very uncomfortable, and her door was kept closed. 2. During a review of the admission record, the admission record indicated Resident 63 was initially admitted to the facility on [DATE], with diagnoses that included but not limited to acute kidney failure (a short-term condition where the kidneys can't filter waste from the blood), protein-calorie malnutrition, muscle weakness, difficulty in walking, history of falling, heart failure (a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs). During a review of Resident 63's MDS, dated [DATE], the MDS indicated Resident 63 does not have impaired cognitive skills for daily decision making, and needed substantial/maximal assistance (helper does more than half the effort) from the staff for the activities of daily living such as showers, upper and lower body dressing. During an observation and interview with Resident 63 on 2/4/2025 at 9:29 AM, Resident 63 was inside an isolation room with the door closed. Resident 63 was observed to be sitting up in bed. Resident 63 stated he was very uncomfortable inside the room because the room was too hot. 3. During a review of the admission record, the admission record indicated Resident 36 was initially admitted to the facility on [DATE] and re admitted on [DATE], with diagnoses that included but not limited to polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain), type 2 diabetes mellitus with diabetic polyneuropathy (a chronic condition where the body has trouble using sugar [glucose] from food properly and as a complication of the diabetes, there is nerve damage affecting multiple nerves throughout the body), end stage renal disease (irreversible kidney failure), anemia (a condition where the body does not have enough healthy red blood cells), dysphagia, oropharyngeal phase (a swallowing difficulty that occurs in the mouth and throat when food or liquid moves from the mouth to the throat). During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36 does not have impaired cognitive skills for daily decision making. Resident 36 needed partial to moderate assistance (helper does less than half the effort) from the staff for the activities of daily living such as eating and oral hygiene and substantial/maximal assistance (helper does more than half the effort) for dressing, toilet and personal hygiene. During an observation and interview with Resident 36 on 2/4/20205 at 9:32 AM, Resident 36 was sitting up in bed. Observed Resident 36's bed next to window. Observed window to be opened about one third of the way. Resident 36 stated he was upset because the room was really uncomfortable and very hot. Resident 36 stated, It's really hot in here. I have told multiple staff and it's still very hot. I told the Maintenance Supervisor over a week ago. I also told the Certified Nurse Assistant, the Nurse Supervisor and anyone that will come in here. They always say they will check but it's still very hot all the time and on top of that, they want to keep the door closed. Even if I have the window open, it's hot all the time. And I'm not talking just a little hot, it's so hot that I feel like I have fever During a concurrent observation and interview with Maintenance Staff on 2/4/2025 at 9:46 AM, Maintenance Staff tested the temperature inside Resident 63 and Resident 36's room. Maintenance Staff stated he had already regulated the thermostat and the temperature inside Residents room was now 78 degrees. During an interview with Infection Control Nurse (IP) on 2/4/2025 at 9:49 AM, IP stated Maintenance Supervisor had not arrived at the facility yet but that he is the one responsible for the temperatures in the facility and even if the doors are closed, he can monitor the temperatures from his phone. IP stated, If the residents have a grievance (complaint or protest), we text him and he can lower the temperature automatically. During a concurrent observation and interview with IP on 2/4/2025 at 9:50 AM, observed IP walk inside Resident 63 and Resident 36's room and asked the residents if it was too hot inside the room. Both residents stated it was. Resident 36 also stated, You guys ask all the time and just leave but nothing gets done. It's still too hot and on top of that you want to keep the door closed. IP explained to both residents that they were in isolation and they had to maintain the door closed. Resident 36 responded to IP that he had been asking multiple staff many times to fix the temperature and it's still very hot. During an interview with Maintenance Supervisor on 2/4/2025 at 10:18 AM, Maintenance Supervisor stated he had checked the temperature for Resident 63 and Resident 36's room and it indicated it was at 75 degrees. Maintenance Supervisor stated, I can control the thermostat from my cell phone when it's over 81 degrees the app (an application, especially as downloaded by a user to a mobile device) will notify me. Maintenance Supervisor stated rooms 1 to 4 were considered one unit (single thing, a standard measurement, or a part of a larger whole) and he was not notified by the app that any of the rooms were at 92 degrees. During a concurrent interview with Maintenance Supervisor on 2/4/2025 at 10:21 AM, Maintenance Supervisor stated that the temperature inside the residents' rooms should not be set at 92 degrees. The range for inside the residents' room should be 71 to 81 degrees because that is within the range for the resident's comfort. Maintenance Supervisor also stated that the way to measure the temperature inside a resident's room is to use a temperature gun that is called Raytek. Maintenance Supervisor also confirmed that he did receive a call 2/3/2025 at 5:02 PM when he was at home from Resident 63 who was complaining that the room was very hot. During a review of the facilities Policy and Procedure (P&P) titled, Resident Rooms and Environment, revised 1/1/2012, the P&P indicated its purpose to provide residents with a safe, clean, comfortable and homelike environment. The Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. Procedure: 1. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: F. Comfortable temperatures During a review of the Housekeeper/Janitor Job Description, the description indicated Principal Responsibilities: Perform tasks to ensure a safe, comfortable and sanitary environment for all residents, staff and visitors according to established policies and procedures. During a review of the facilities P&P titled, Maintenance Service, revised 1/01/2012, the P&P indicated its purpose to protect the health and safety of residents, visitors, and Facility staff. The Maintenance Department maintains all areas of the building, grounds, and equipment. Procedure: II. Functions of the Maintenance Department may include, but are not limited to: D. Maintaining the heat/cooling system, in good working order. During a review of the facilities P&P titled, Resident Rights-Accommodation of Needs, revised 1/1/2012, the P&P indicated its purpose to ensure that the Facility provides an environment and services that meet residents' individual needs.

Based on observation, interview, and record review, the facility failed to ensure the food service area was maintained in a clean and sanitary manner and proper food handling was provided in accordance with the facility's policy and procedure(P&P) by failing to: 1.Ensure one can opener was sanitized and was not rusted (a reddish-brown substance that forms on the surface of iron and steel as a result of reacting with air and water) according to the facility's P&P titled, Can Opener Use and Cleaning. 2.Ensure [NAME] non- stick spray oil was properly covered with a lid. 3. Ensure cheese stored in the refrigerator was labeled with an open date or use by date (a calendar date that indicates when a product is best quality) and in a sealed container. These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization . Findings: During an observation on [DATE] at 7:44 AM in the facility kitchen, one can opener was observed rusted. During an observation on [DATE] at 7:45 AM in the facility kitchen, [NAME] non -stick spray oil was observed without a lid. During an observation on [DATE] at 7:52 AM in the facility kitchen, cheese was observed in the refrigerator that did not have a lid and did not indicate an open or use by date. During a concurrent observation and interview on [DATE] at 8:48 AM with the dietary consultant (DC), DC stated the can opener was rusted. DC also stated there was a possibility for cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) since the can opener was rusted. During a concurrent observation and interview on [DATE] at 8:49 AM with the DC, DC stated [NAME] non- stick spray oil did not have a lid. During a concurrent observation and interview on [DATE] at 8:50 AM with the DC, DC stated the cheese in the refrigerator was open and not properly sealed. The DC stated the cheese was unlabeled and did not have an open and use by date. DC also stated all containers should be sealed properly and labelled with an open and use by date. DC stated all containers should be sealed properly to prevent cross contamination, since dust and tiny insects could get into the food. During an interview on [DATE] at 9:12 AM with dietary aid (DA), DA stated all containers must be covered and dated to prevent contamination from insects and/or tiny dust from being mixed into the food. During a concurrent interview and record review on [DATE] at 11:23 AM with the Director of Nursing (DON), the facility's P&P titled, Food Storage and Handling, dated 2022, was reviewed. The DON stated the P&P indicated that frozen cheese storage guidelines indicated to label and date all food items. The P&P indicated for foods in the dry storage area, that open products were placed in a storage container with tight fitting lids and to label and date all food items. The DON stated that the [NAME] nonstick oil spray should be covered, and the cheese container located in the refrigerator should be sealed properly, and should have a label indicating dates, to prevent food contamination, and identify if foods are expired. The DON stated labeling and dating foods were important to prevent sickness. During a concurrent interview and record review on [DATE] at 11:24 AM with the DON, the facility's P&P titled, Can Opener Use and Cleaning revised [DATE], was reviewed. The DON stated the P&P indicated the purpose was to establish guidelines for the use and cleaning of a can opener. The dietary staff will use the opener according to the manufacturer's guidelines. The P&P indicated the can opener would be sanitized between uses. The DON stated the can opener must be sanitized between uses.

Based on observation, interview, and record review, the facility failed to ensure three (3) of 3 dumpsters (a movable waste container designed to be brought and taken away) were closed and not overflowing, in accordance with the facility's Waste Management.Policy and Procedure. This deficient practice had a potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) and may cause disease and other health issues to residents, staff, and the community. Findings: During a concurrent observation and interview on 2/5/2025 at 6:40 AM with the Dietary Supervisor (DC), in the facility's parking lot, 3 dumpsters were observed. The dumpsters were overflowing with personal protective equipment (PPE- is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) and kitchen trash. During a concurrent observation and interview on 2/6/2025 at 8:50 AM with DC, DC stated one dumpster in the facility's parking lot was observed. DC stated the dumpster was overflowing with used PPE and kitchen trash. DC stated dumpsters were not supposed to be overflowing, since it could attract insects, rats and could cause sickness, and was an infection control concern. During a concurrent interview with the Administrator (ADM) and record review of facility's Policies and Procedures (P&P) on 2/7/2025 at 1:11 PM titled, Waste Management, revised 4/21/2022, the ADM stated P&P's purpose was to reduce the risk of contamination from regulated waste and maintain appropriate handling and disposable of all waste. P&P also indicated to close the lid on biohazard containers (disease producing agents that can be transmitted to individuals through various routes of exposure [modes of transmission]. Exposure to these hazards may result in acute or chronic health conditions). P&P also indicated food waste will be placed in covered garbage and trash can. The ADM stated the facility was not compliant with the P&P, and that trashcans were supposed to be closed all the time for infection control. The ADM stated when dumpsters were left opened, and garbage was overflowing with kitchen waste, it may cause unpleasant odor and could attract insects.

Based on interview and record review, the facility failed to observe infection control measures as indicated on the facility policy when facility failed to establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease (LD, a serious and often deadly form of lung infection [pneumonia, lung inflammation usually caused by infection], acquired by breathing in water droplets caused by the bacteria, legionella [the bacteria that causes LD]). This failure had the potential to place the residents at risk for developing severe respiratory infection (pneumonia). Findings: During an interview on 2/6/2025 at 10:26 AM with Maintenance Supervisor (MS), MS stated that the way the facility control legionella at the facility is through their control measures and that to his knowledge, the facility does not do any sort of testing for legionella. During an interview on 2/6/2025 at 10:56 AM with MS, MS stated that they do not test for legionella. MS stated that they did not have an initial test and they do not do any sort of ongoing testing to confirm or validate that their control measures are working and stated it is because they are not required to test and, in his experience, they have not had any resident that was diagnosed with pneumonia caused by legionella. During an interview on 2/6/2025 at 12:37 PM with Infection Preventionist (IP), IP stated that she does not think they test for legionella or other waterborne pathogens but stated that she had suggested testing because that will be a validation if the facility's control measures are working or not. During a review of the facility's policy and procedure (P&P) titled Water Management revised 5/25/2025, the P&P indicated, The facility with develop and utilize water management strategies, using the Core Elements of a Water Management Plan (WMP), to reduce the risk of growth and spread of Legionella and other opportunistic water-borne pathogens in facility water systems, with its purpose, To minimize exposure to Legionella and other water-borne pathogens to our residents, family members, staff and visitors. The P&P also indicated under Control Measures and Corrective Actions: Following national, state and local guidelines, the team will identify needed control measures based on risk assessment performed, and how to monitor them and under Verification and validation: The team will ensure the program is running as designed and is effective. During a review of the Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey and Certification Group letter titled, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD), dated 6/2/2017, the letter indicated a review of the facility's policies and procedures and reports documenting water management implementation results to verify that facilities: A. Implement a water management program that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE, global organization that develops standards and guidelines for HVAC[heating, ventilation, and air conditioning] systems, indoor air quality, and energy efficiency) industry standard and the Centers for Disease Control (CDC) toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections and environmental testing for pathogens. B. Specify testing protocols and acceptable ranges for control measures and document the result of testing and corrective actions taken when control limits are not maintained. During a review of the CDC's toolkit titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/24/2021, indicated, Now that you have a water management program, you need to be sure that it is effective. Your program team should establish procedures to confirm, both initially and on an ongoing basis that the water management program effectively controls the hazardous conditions throughout the building water systems. This step is called 'validation.' Environmental testing for Legionella is useful to validate the effectiveness of control measures. The program team should determine if environmental testing for Legionella should be performed and, if so, how test results will be used to validate the program. Factors that might make testing for Legionella more important include: Being a healthcare facility that provides inpatient services to people who are at increased risk for Legionnaires' disease. During a review of ASHRAE Addendum to ASHRAE Standard [PHONE NUMBER] (defines types of buildings and devices that need a water management program) titled, Legionellosis: Risk Management for Building Water Systems, dated 6/23/2018, indicated the Program Team shall establish procedures to confirm, both initially and on an ongoing basis, that the Program is being implemented as designed. The resulting process is verification. The Program Team shall establish procedures to confirm, both initially and on an ongoing basis, that the Program, when implemented as designed, controls the hazardous conditions throughout the building water systems. The resulting process is validation. The Program Team shall determine whether testing for Legionella shall be performed and if so, how test results will be used to validate the Program. If the Program Team determines that testing is to be performed, the testing approach, including sampling frequency, number of samples, locations, sampling methods, and test methods, shall be specified and documented. The Program Team shall consider include the following as part of the determination of whether to test for Legionella: b. A health care facility provides in-patient services to at-risk or immunocompromised population.

Based on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home like environment for two (2) of 11 sampled residents (Residents 15 and 23) by failing to: 1. Ensure the bedside control (used to adjust the bed height, head of bed and/ or foot of the bed) wires for Residents 15 and 23 were not exposed (occur when the insulation around electrical cords and cables is frayed or damaged, revealing the wires within). 2. Facility failed to ensure the trash cans were not overflowing for Rooms A, B and C. These deficient practices caused an unsanitary and had a potential for residents to be placed at risk for serious illness and/ or injury. Findings: 1.During a review of Resident 23's Admission Record, the Admission Record indicated Resident 23 was initially admitted to the facility on [DATE] with diagnosis which included muscle weakness, anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), history of falling. During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 12/2/2024, the MDS indicated Resident 23 cognitive skills (processes of thinking and reasoning) for daily decision making was severely impaired (never/rarely made decisions) During observation on 2/4/2025 at 11:07 AM at Resident 23's room, Resident 23's bed control wires were exposed. During a concurrent observation and interview on 2/7/2025 at 12:05 PM with the Director of Nursing (DON), the DON stated Resident 23's bed control wire was exposed green, yellow, blue and red wire were showing. During a review of Resident 15's Admission Record, the Admission Record indicated Resident 15 was initially admitted to the facility on [DATE] with diagnosis which included lack of coordination, history of falling and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). During a review of Resident 15's MDS dated [DATE], the MDS indicated Resident 15 cognitive skills for daily decision making was moderately impaired. During observation on 2/4/2025 at 2:30 PM at Resident 15's room, Resident 15's bed control were exposed. During a concurrent observation and interview on 2/7/2025 at 12PM with the DON, the DON stated Resident 15's bed control wires were exposed and the yellow, brown, red and orange wires were showing. 2.a During observation on 2/4/2025 at 11:06 AM at Room A with the certified nursing assistant 4 (CNA 4), CNA 4 stated the trash can was open and filled with plastic and used Personal protective equipment (PPE, is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). During a concurrent interview and record review of the facility's Policy and Procedures (P&P) on 2/7/2025 at 1:23 PM with the Administrator (ADM), P&P titled Room and Environment date revised 1/1/2012. ADM stated P&P indicated Purpose to provide resident with a safe clean, comfortable and home like environment. ADM also stated all trashcans were supposed to be closed all the time. ADM also stated exposed bed control wires was not safe for residents, can cause fire, shocks and accident. 48395 2.b During a concurrent observation and interview on 2/5/2025 at 2:56 PM with Infection Preventionist (IP) in Room B, Room B's trash can was observed to be overflowing with trash and discarded PPE. IP stated trash cans should not be overflowing and need to be sealed or covered for bacteria to not come out of the trash can. During a concurrent observation and interview on 2/6/2025 at 11:15 AM with Licensed Vocational Nurse 2 (LVN 2) in Room C, Room C's trash can was observed to be overflowing with trash and discarded PPE. LVN 2 stated when the trash is overflowing, there is no more room for anyone else to discard their trash and it should not be like that due to infection control. 2.c During an observation on 2/5/2025 at 11:40 AM in Room C, Room C's trash can was observed to be overflowing with trash and PPE. During an interview on 2/7/2025 at 1:49 PM with the DON, the DON stated trash should not be overflowing from the trash cans in residents' rooms due to being an infection control issue. During a review of the facility's P&P titled, Waste Management, revised 4/21/2022, the P&P indicated, Dispose of non-regulated waste in appropriate, non-combustible waste containers, and When waste bags are 3/4 full, close bag and remove from area. Dispose bag into large, covered waste bin or cart in soiled utility room. During a review of the facility's P&P titled, Infection Control - Policies & Procedures, revised 1/1/2012, the P&P indicated, The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission(spread) of diseases and infections. The P&P further indicated an objective including, Maintain a safe, sanitary and comfortable environment for personnel, residents, visitors, and the general public.

Based on observation and interview and record review, the facility failed to provide reasonable accommodations for Resident 36's needs and preferences with a wheelchair that was comfortable for his size, was not damaged, ripped, dusty and old. This failure had the potential for Resident 36 to be placed at risk for negative impact of his psychosocial wellbeing, result in delayed provision of services and/or risk for injury. Findings: During a review of the admission record, the admission record indicated Resident 36 was initially admitted to the facility on [DATE] and re admitted on [DATE], with diagnoses that included but not limited to polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain), type 2 diabetes mellitus with diabetic polyneuropathy (a chronic condition where the body has trouble using sugar [glucose] from food properly and as a complication of the diabetes, there is nerve damage affecting multiple nerves throughout the body), end stage renal disease (irreversible kidney failure), anemia (a condition where the body does not have enough healthy red blood cells), dysphagia, oropharyngeal phase (a swallowing difficulty that occurs in the mouth and throat when food or liquid moves from the mouth to the throat). During a review of Resident 36's Minimum Data Set (MDS - resident assessment tool), dated 11/20/2024, the MDS indicated Resident 36 does not have impaired cognitive skills for daily decision making. Resident 36 needed partial to moderate assistance (helper does less than half the effort) from the staff for the activities of daily living such as eating and oral hygiene and substantial/maximal assistance (helper does more than half the effort) for dressing, toilet and personal hygiene. During an observation and interview with Resident 36 on 2/4/2025 at 9:32 AM, Resident 36 was resting in bed and stated, I can't walk. I get physical therapy (PT) because we need to work on my legs. Apparently, I had a deep vein thrombosis (DVT-is a medical condition where a blood clot forms in a deep vein, usually in the legs) but my doctor cleared me. I keep reminding the staff that for activities, they offer me to stretch my legs but they don't have a wheelchair my size to take me outside like I requested multiple times so I can get some sun and fresh air. It's been over a month that I've had to stay in bed. I would prefer to go outside. To be honest, it makes me feel sad and I'm starting to get depressed. During an interview with the Director of Nursing (DON) on 2/04/25 at 9:57 AM, RN stated that when the equipment in the facility is damaged or needs maintenance, the staff usually call Maintenance Supervisor to fix it. RN stated the equipment in the facility needed to be in good condition at all times for the safety of all the residents. RN also stated it would be unacceptable for a resident to use damaged equipment since it could place the resident at risk of harm. During a concurrent interview with Resident 36 on 2/4/2025 at 11:16 AM, Resident 36 stated he had been asking staff to take him outside, but they told him the facility does not have a wheelchair big enough for him, so he stays in bed all the time. Per Resident 36, the Occupational Therapy Staff (OT) did attempt to transfer him to a wheelchair, but the wheelchair was too snug (something is too tight or fits too closely). Resident 36 stated he felt upset because it has been over a month when the facility staff told him they were working on getting a larger wheelchair so he can go outside, and the facility still has not received it. During an interview with Certified Nursing Assistant 5 (CNA 5) on 2/5/2025 at 9:37 AM, CNA5 stated she had cared for Resident 36 often and had not seen a wheelchair large enough for Resident 36 inside or outside the room. Per CNA5, Resident 36 would remain in bed and was not transferred to a wheelchair to go to the patio. During an interview with Social Service Director (SSD) on 2/5/2025 at 9:45 AM, SSD stated that Resident 36 did mention about needing a wheelchair his size but that she would have to confirm with the doctors' orders and make sure the wheelchair would be part of the Durable Medical Equipment (DMEs) to process through Home Health (medical services provided in a patient's home rather than in a hospital or other healthcare facility) upon Resident 36's discharge. During a follow up observation and interview with SSD on 2/5/2025 at 9:58 AM, SSD stated Resident 36 did have a wheelchair inside his room for his own personal use. Upon further inspection of Resident 36's room, SSD confirmed there was no such wheelchair inside the room. SSD then stated the wheelchair was stored away inside the storage room. Upon further inspection there was no large size wheelchair inside storage room. SSD then proceeded to state that the wheelchair was outside in the patio area. Upon further inspection of the patio area, SSD showed a wheelchair that was ripped, old, and dusty and stated that was the wheelchair that was provided for Resident 36's use. SSD did at that time confirm the wheelchair should be in better condition without any rips or dirt on it in order for Resident 36 to use. During an interview and record review with OT on 2/5/2025 at 10:15 AM, OT stated, In terms of his level on how much he can assist, he is max assist times 2 to sit at edge of bed. He used a Hoyer Lyft (a mechanical device that helps caregivers move people with limited mobility) at home. We have attempted to transfer him from bed to chair but he said the wheelchair was too snug for him. We were increasing sitting tolerance but the wheelchair we found was too snug we wanted to look for another wheelchair wider for his comfort but was not sure if they did. During a concurrent interview with the DON on 2/7/2025 at 4:08 PM, the DON stated Resident 36 should have a proper size wheelchair to accommodate his needs. The DON also stated, It is not acceptable for a resident to use a wheelchair that is damaged such as being ripped, old or dirty. If a resident was to use a damaged wheelchair it could cause potential danger like an accident and if it was dirty, it could harbor bacteria. During a review of the Housekeeper/Janitor Job Description, the description indicated Principal Responsibilities: Perform tasks to ensure a safe, comfortable and sanitary environment for all residents, staff and visitors according to established policies and procedures. During a review of the facility's Policy and Procedure (P&P) titled, Maintenance Service, revised 1/1/2012, the P&P indicated its purpose to protect the health and safety of residents, visitors, and Facility staff. The Maintenance Department maintains all areas of the building, grounds, and equipment. Procedure: II. Functions of the Maintenance Department may include, but are not limited to: D. Maintaining the heat/cooling system, in good working order. During a review of the facility's P&P titled, Resident Rights-Accommodation of Needs, revised 1/1/2012 indicated its purpose to ensure that the Facility provides an environment and services that meet residents' individual needs. Procedure: IV. In order to accommodate residents' needs and preferences, the Facility may make adaptations to the physical environment, including the residents'' bedroom and bathroom as well as the common areas in the Facility. Examples of such adaptations may include: D. Providing a variety of types (for example, chairs with and without arms) sizes, (height and depth), and firmness of furniture in rooms and common areas so that the residents with varying degrees of strength and mobility can independently arise to standing position. V. In order to accommodate residents' individual needs and preferences, Facility Staff attitude and behavior are directed towards assisting the resident's in maintaining independence, dignity and well-being to the extent possible according to residents' wishes. During a review of the facility's titled, Infection Control-Policies & Procedures, revised 1/1/2012 indicated its purpose to provide infection control policies and procedures required for a safe and sanitary environment. I. The Facility's infection control policies and procedures apply equally to all Facility Staff, consultants, contractors, residents, visitors, volunteer works, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. II. Objectives: A. Prevent, detect, investigate, and control infections in the Facility B. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. D. Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard precautions. F. Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment.

Based on observation, interview, and record review, the facility failed to supervise one of three sampled residents (Resident 1) to prevent resident while in his wheelchair, from rolling out from the transportation van onto the pavement causing the wheelchair ' s footrest to retract and pushing against resident ' s legs while the resident was being transported from the facility to the doctor ' s office. This deficient practice resulted to Resident 1 ' s accident on 12/8/2022, sustaining a right tibial (along the length of the bone, below the knee and above the ankle) fracture (a complete or partial bone break). Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted on [DATE] with diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), contracture (a fixed tightening of muscle, tendons, ligaments, or skin. It prevents normal movement of the associated body part) of right and left hip, muscle weakness and other lack of coordination. A review of Resident 1 ' s history and physical, dated 11/16/2022, indicated, the resident did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/20/2022 indicated Resident 1 was totally dependent (needs full staff performance) with transferring from bed to wheelchair or wheelchair to bed and needs extensive assistance (resident involved in activity but staff provides maneuvering of limbs) to move around when in wheelchair. On 12/13/2022 at 11:09 AM, during an interview with Administrator (ADMIN), he stated Resident 1 was scheduled for a doctor ' s appointment on 12/08/2022 at 2:15 pm. The resident was accompanied to his doctor ' s appointment by Transport Company Driver (TC 1) and Restorative Nurse Assistant (RNA). The ADMIN stated during his investigation of the incident, when Resident 1 was unbuckled from his wheelchair and released from the vehicle ' s wheelchair locks, the resident ' s wheelchair rolled out of the vehicle, causing injury to Resident 1 ' s legs. On 12/13/2022 at 12:08 PM, during an observation and interview with Resident 1, the resident was observed lying in bed (with head of bed slightly elevated) wearing a leg immobilizer (removable devices that maintain stability of the knee. Knee immobilizers are typically used for injuries that benefit from immobilization but can tolerate brief periods without immobilization and thus do not require casting) and splint (supportive device that protects a broken bone or injury) on resident ' s right leg and purplish discoloration (bruise) on resident left knee and lower shin. Resident 1 stated, he had a fall when he went to his doctor ' s appointment on 12/08/2022. Resident 1 stated, while TC 1 was unbuckling his seatbelt (from the vehicle) and releasing the wheelchair strap (used to secure the wheelchair in place) from the van, the resident ' s wheelchair rolled out from the van. Resident 1 stated he stuck both legs out to brace his fall and hurt his legs. Resident 1 stated, the other staff (RNA) was outside the van when it happened and was not able to catch him to prevent him from falling. On 12/22/2022 at 12:44 PM, during an interview with RNA, he stated he was the staff member who accompanied Resident 1 to the doctor ' s office on 12/08/2022. RNA stated on the day of the incident (Resident 1 rolled out the van), TC 1 was releasing the resident ' s wheelchair from the vehicle, and after releasing the wheelchair from the strap Resident 1 rolled out from the van RNA was waiting outside of the transport vehicle for the resident. On 12/22/2022 at 2:15 PM, during a telephone interview, TC 1 staff stated when transporting residents from the facility to their doctor ' s appointment, it involves safely picking up the resident and taking them to their destination. TC 1 staff stated on 12/8/2022 (afternoon) he was unbuckling Resident 1 ' s wheelchair from the van, Resident 1 fell out of his wheelchair and hurt his legs when he fell on to the ground. TC 1 staff stated he cannot remember if the resident ' s wheelchair was on rake and when he unlatched the wheelchair lock (strap from the vehicle to secure the wheelchair in place) from inside the transport vehicle and unbuckled the resident from his safety belt (from the vehicle); the wheelchair began to roll, and he did not have a good grip on the wheelchair and the escort staff (RNA) was not inside to assist him with the resident. On 12/22/2022 at 2: 45 PM, during an interview with the Director of Nursing (DON), she stated per when residents are transferred to their doctor ' s appointment and require additional assistance or monitoring to ensure safety due to their physical limitations, such as with Resident 1 who has dementia and muscle weakness, a staff from the facility must go with the resident. The DON stated if the facility staff goes with the resident they must always remain beside the resident and should help assist the driver (TC 1) to transport the resident to the doctor ' s appointment, including making sure resident is safe while in the vehicle. On 12/29/2022 at 1:25 PM, during an interview with the Assistant Administrator (AAdmin), stated there was no specific policy to address safety and monitoring of residents during transportation to outside services and appointments. The AAdmin stated, there should be a written policy to address this because residents in the facility regularly visit outside services such as doctor ' s appointments and to ensure their safety during that process, and that facility staff are responsible for the resident ' s safety while in the vehicle and transfer to the resident ' s appointment. A review of Resident 1 ' s Interdisciplinary Team (IDT, comprised of a primary care physician, nurse, social worker, dietician, personal care attendant and other professionals discusses the resident ' s condition and coordinate a person- centered care plan) progress notes dated 12/09/2022 1:25 PM, indicated on 12/8/2022 when the resident went to his doctor ' s appointment, TC 1 released Resident 1 ' s the seat belt (not specified), and resident ' s wheelchair wheeled down, TC 1 and staff (RNA) tried to stop the wheelchair, but it rolled out from the car and the footrest made contact to the concrete which cause the footrest to retract, pushing against resident ' s legs. Resident 1 was assessed, and the physician ordered for the resident to be transferred to hospital. A review of report titled Radiology Report from the facility ' s contracted radiology services Radiology Clinic 1, dated 12/08/22 indicated the resident had a right tibial fracture. A review of Resident 1 ' Physician ' s order dated 12/09/2022 indicated to transfer the resident to the hospital due to acute fracture. A review of Resident 1 ' s Radiology Report from General Acute Care Hospital 1 (GACH 1), dated 12/09/22 indicated computed tomography (CT, medical imaging technique used to obtain detailed internal images of the body) of both legs was done and indicated the resident had an acute nondisplaced (broken bones but the pieces did not move far enough) right tibial medial malleolus (bony projection with a shape likened to a hammer head) fracture. A review of Resident 1 ' s Emergency Department History and Physical from GACH date 12/08/22, indicated resident was placed in right knee immobilizer and right posterior (back part of the body) leg splint. A review of the facility policy titled Resident Safety dated 4/15/2021, indicated that the purpose to provide a safe and hazard free environment. To ensure safety of a resident, any facility staff member who identifies an unsafe situation, practice or environment risk factor should immediately notify their supervisor or charge nurse.

Based on observation, interview, and record review, the facility failed to provide the necessary care and treatment to one of 15 sampled residents (Resident 1) by failing to: 1. Assess and monitor Resident 1's skin condition and rashes. 2. Notify the physician timely of the change in Resident 1's skin condition when his rashes worsened and spread to his abdomen, trunk, bilateral arms and legs and sustained skin tears and scabs (a dry, rough protective crust that forms over a cut or wound during healing) caused by intense itching and scratching. 3. Implement the physician's orders [REDACTED]. These failures resulted in Resident 1 suffering and experiencing discomfort and skin injuries from intense itching and scratching. Findings: A review of Resident 1's admission record (Face Sheet) indicated Resident 1 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's admission assessment, dated October 23, 2017, indicated resident had rashes with petechiae (a small red or purple spot caused by bleeding into the skin) on the chest and back upon admission. A review of the admission orders [REDACTED]. Another physician's orders [REDACTED]. A review of the Resident 1's Care Plan for Skin Rash dated October 23, 2017, indicated Resident 1 had rashes to chest and back. The care plan goal indicated Resident 1's rash will clear or reassess, and Resident 1's itching will be relieved. The listed nursing interventions included to check Resident 1's skin to determine affected areas, provide medication and treatment as ordered and assess for effectiveness and side effects, trim/file nails, and bathe three times a week. During an initial tour observation of the facility with Registered Nurse (RN) 3 on October 27, 2017, at 7:02 p.m., Resident 1 was observed sitting up in bed scratching both arms, abdominal area and chest and rubbing back vigorously against the mattress. Resident 1 complained of severe itching. As Resident 1 leaned forward, stains of blood were observed on the pillowcase and bed sheet behind the resident's back. Resident 1's back was red and bleeding and had red pinpoint raised rashes and excoriated (abrading or wearing off the skin) rashes. Resident 1's chest, abdominal area, flanks, upper arms and legs were also observed with scattered red pinpoint raised rashes. In a concurrent interview, Resident 1 stated the staff would apply lotion which would help for a little bit, but there was nothing else they could do about it. RN 3 then stated that she would check with the medication nurse if Resident 1 had something for the itching. During an observation on October 28, 2017, at 7:50 a.m., Resident 1 was observed in bed eating breakfast and constantly scratching his upper arms and trunk area and rubbing his back against the mattress. Resident 1's bilateral upper extremities were observed with red pinpoint rashes and scattered scabs. During a concurrent interview, Resident 1 complained of intense itching and stated that he has had the rashes for a few weeks and was getting lotion and [MEDICATION NAME] for it, but was not really helping. Resident 1 stated that he had not seen a dermatologist and asked Surveyor if he could see one right away because the itching was so uncomfortable. During an observation on October 28, 2017, at 9:45 a.m., Resident 1 was observed lying in bed. Resident 1 stated that he feels a little better after taking a shower, but he was still itching and scratching. Resident 1 stated that he feels very uncomfortable and sore from scratching too much. During an interview on October 28, 2017, at 9:55 a.m., Treatment Nurse (TN) 1 stated that Resident 1 was readmitted from the acute care hospital and the rashes to the chest and back started in the hospital. TN 1 stated that Resident 1 gets [MEDICATION NAME] for the itching PRN. When asked if she knew about Resident 1's skin bleeding from intense itching and scratching, TN 1 stated no and that no one reported it to her. According to TN 1, Resident 1 had not been seen by a dermatologist. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1 on October 28, 2017, at 10:54 a.m., Resident 1's Medication Record for October 2017 indicated the [MEDICATION NAME] was not administered PRN for itching since it was ordered by Resident 1's physician on October 23, 2017. LVN 1 stated that she did not know about Resident 1's rashes until yesterday. LVN 1 further stated that she was informed that Resident 1 complained of itching yesterday, but she was busy with another resident and could not give the [MEDICATION NAME] to Resident 1 at that time. During a concurrent interview and treatment observation on October 28, 2017, at 11 a.m., Resident 1's skin was observed with generalized red pinpoint rashes, excoriated rashes, and scattered scabs all over resident's back, chest, abdomen, flank, and bilateral upper and lower extremities. TN 1 stated that Resident 1's rashes spread and looked worse today. TN 1 stated that she would notify Resident 1's physician and request for a dermatology consult. During an interview on October 28, 2017, at 3:20 p.m., Certified Nursing Assistant (CNA) 1 stated that she noticed Resident 1's skin with scattered red rashes on the stomach, sides, back, chest, and arms and told the charge nurse about it on Thursday (October 26, 2017). CNA 1 stated that Resident 1 had been itching and scratching and the charge nurse already knew about it. According to CNA 1, she would apply lotion to Resident 1's body. During an interview on October 28, 2017, at 4:58 p.m., the Director of Nursing (DON) stated that skin condition should be monitored while providing care and any changes in the skin should be reported to the licensed nurse and the licensed nurse should notify the physician promptly of the changes. However, the DON reviewed the clinical record and was unable to find documented evidence that Resident 1's skin condition was assessed and monitored and that Resident 1's physician was notified regarding the rashes spreading to other parts of the body and the skin bleeding from intense itching and scratching. Additionally, the DON was unable to find documented evidence that Resident 1's intense itching and scratching was addressed. After reviewing Resident 1's Medication Records, the DON stated that the [MEDICATION NAME] was only administered once on October 28, 2017 at 10:55 a.m. During an observation on October 28, 2017, at 5:20 p.m., the DON checked on Resident 1 with Surveyor 1 and Surveyor 2. Resident 1 was observed scratching his trunk and arms and rubbing his back against the mattress. The pillow on Resident 1's head was observed with spots of blood from the excoriated rashes. Resident 1 complained that he was itching too much and stated Please do something. During an observation on October 29, 2017, at 6:30 a.m., Resident 1 was observed in bed awake, scratching his arms and abdomen and rubbing his back against the mattress. Resident 1 stated This is terrible. I'm so sore from all the itching and scratching. Resident 1 stated that he was given [MEDICATION NAME] and it helped a little. The facility's policy and procedure dated January 1, 2012, titled Skin and Wound Management indicated facility staff will take appropriate measures to prevent and reduce the likelihood that residents will develop pressure ulcers and other skin conditions. All nursing staff is responsible for the prompt reporting of any skin related conditions to the licensed nurse. The licensed nurse will notify the attending physician promptly at the first occurrence of a pressure ulcer or other skin related problems. The facility's policy and procedure dated January 1, 2012, titled Change of Condition Notification indicated the facility will promptly inform the resident, consult with the resident's attending physician, and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in their condition caused by, but not limited to: an accident, a significant change in resident's physical, mental or psychosocial status; and/or a significant change in treatment. Change of Condition related to attending physician notification is defined as when the attending physician must be notified when any sudden or marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require medical assessment, coordination and consultation with the attending physician and a change in the treatment plan.