Every finding on record at Pine Trail Nursing and Rehab Center

Based on observation, interview and record review, the facility failed to ensure the call light system was in working condition for 7 of 7 sampled residents with voiced concerns, Resident #12, Resident #19, Resident #20 Resident #22, Resident #42, Resident #52 and Resident #53. The findings included: Review of the policy dated 09/01/24, and titled, Policies and Procedures Subject: Call Light Policy, documented, in part: The purpose of this policy is ensuring residents' requests and needs are responded to. Procedure: 1. Call light should be within reach of the resident. 2. Answer the resident's call as soon as possible. 3. Be courteous in answering the resident's call light. 4. Some residents may not be able to use their call light. Check on these residents frequently. 5. Report malfunctioning call lights to Maintenance, ED, and/ or DON promptly. 6. Offer stationary bells and/or round frequently on residents if the call light system is malfunctioning. 1. Record review revealed Resident #53 was admitted on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #53 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the current care plan dated 04/25/26 documented .Focus: .has an ADL self-care performance deficit r/t [related to] Fatigue, Impaired balance .Goal: The resident will improve current level of function through the review date . Interventions: .EATING: Set-up assistance with meals. Encourage the resident to use bell to call for assistance. During an interview on 05/11/26 at 10:46 AM when asked about his care, Resident #53 stated when he called the CNAs (Certified Nursing Assistants) and Nurses on the call bell it didn't work. Resident #53 stated he yells out for help and no one comes; he demonstrated to the surveyor how loud he yelled; no staff member was observed to come into the room. The call bell was pressed by the resident and there was no call light observed to be activated outside of the resident's door. On 05/11/26 at 10:55 AM, the surveyor walked to the nurses' station to see if Resident #53's call bell had activated. When asked where the call bells sound is activated, the ADON (Assistant Director of Nursing) stated the call bells did not work and the residents had hand bells given to them and they receive 15-minute checks in place of it. When asked how long the call bells have not been working, the ADON stated she would have to ask management. On 05/11/26 at approximately 11:00 AM, Resident #53 was asked if he noticed that the staff have been coming in more frequently to check on him since the call bell has been not working. Resident #53 stated they did not check on him. On 05/12/26 at 12:14 PM during a dining observation, Resident #53 was observed for lunch in his room. Resident #53 was sitting in his wheelchair besides his bed with his meal on top of his side table. He stated he was unable to use his right hand to feed himself. Resident #53 was observed trying to eat with his left hand and unable to cut his food. He stated he needed assistance, but when he called for someone, they did not come. When asked about his hand bell, Resident #53 stated he could not reach it and pointed at it. Resident #53's hand bell was observed to be placed at the opposite lower corner of his bed as the resident was sitting in his wheelchair. On 05/14/26 at 9:25 AM, during a follow up interview, Resident #53 was asked how his day was going, and he stated the call bell was now working again. When asked to test his call bell, Resident #53 pressed his call light, but no lights were observed to come on outside his room door. On 05/14/26 at 9:36 AM, the surveyor went to the nurses' station to verify the call bells, when asked if the call bells were now fixed, the ADON stated the call bells were still not working and restated the residents have hand bells to use. The ADON was again asked how long the call bells had not been working, the ADON stated she would have to ask her administrator. Resident #53 was then informed the call bells were not functioning still, Resident #53 was observed to be visibly upset and stated, there is nothing I hate more than liars, they told me it was working now. On 05/14/26 at 9:39 AM when asked how long the call bells had been not working the DON (Director Of Nursing) stated for at least 5 months since she had been there. When asked if maintenance was aware of it, she stated yes and that they were also in touch with corporate to try to fix it. When asked what interventions they had in place for the call bells, the DON stated the staff were doing 15-minute checks and provided the residents with hand bells. When asked how they are keeping track of checks, the DON stated with documentation on a form and they had a binder for it. When asked to provide proof of the documentation, the DON went to find the CNA in charge of doing the 15-minute checks. During an interview on 05/14/26 at 9:57 AM, Staff H, CNA, stated she had been working for 7-8 months at the facility. When asked how long the call bells had not been working she stated for about 1 -3 months. When asked when the checks started, Staff H stated they had done the checks prior to the call lights not working and that they had always been documented on paper. Staff H showed the surveyor an example of a check sheet for the floor. When asked when her shift starts, she stated at 7 AM she starts her shift and checked on what the residents needed. She stated she was not assigned to do direct care, did not have an assignment, and she only performed resident checks. During an interview on 05/14/26 at 10:23 AM when asked how long he had been working at the facility, the Maintenance Director stated he had been there since August of 2025. When asked how long the call bells had not been working, he stated since mid-September to mid-October 2025 (7-8 months.) When asked if there was a plan to fix them, he stated, yes, they had an invoice from December 2025 to fix it. When asked why it had taken so long to try to fix it, the Maintenance Director stated he had already called a couple of vendors and one was located [out of State], so they had to fly to fix. On 05/14/26 at approximately 10:30 AM, the NHA (Nursing Home Administrator) joined the conversation. She added that a temporary call bell system could have been installed, and the company had told her it was available for her when she called. The NHA stated in the meantime the residents had frequent checks and hand bells instead. The NHA was made aware of Resident #53's concerns of the hand bells and checks not working. The Maintenance Director stated corporate was working to approve it due to wanting many different quotes. He stated another [company] was coming next week on Thursday. The NHA and the maintenance director got on different phone calls, and both stated the temporary system would be delivered today. They were asked if the phone calls were able to be made today and got approved so quickly for a temporary call bell system why wasn't this done sooner. The NHA stated I don't know I have only been here for 5 weeks. The Maintenance Director was asked for proof of all invoice attempts and any attempts made to attempt to resolve the call bell issue On 05/14/2026 at 11:05 AM, the Maintenance Director stated the [company] who provided the December 2025 quote which was the 1st attempt was not picking up but he had a January 2026 quote which was their 2nd attempt. He stated corporate was currently still reviewing the quotes and working numbers to get it approved. The Maintenance Director was then asked to provide of corporates active reviews of the call bell situation. On 05/14/2026 at 11:37AM, the Maintenance Director told the surveyor that this situation was budget related and that was why it had taken so long. He stated he was asked to get 3 more quotes and stated this building does not make a lot of money and everything is budget related but said he would get it fixed. The Maintenance Director stated residents had hand bells and log checks in the meantime. He was made aware the interventions were not effective per resident's complaints and agreed with the findings. The Maintenance Director did not provide the surveyor any additional quotes. Review of a document titled, Ad Hoc Quality Assurance & Performance Improvement Meeting, revealed the call light system had been identified as broken in each hallway since 03/01/25 (at least over a year and 2 months). 2. During an observation on 05/11/26 at 10:48 AM, when pushed, the electronic call bell would light up in the room of Resident #12 but did not illuminate or sound any ringing sound in the hallway or at the nurses' station. 3. Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses to include muscle weakness, altered mental status, and gait abnormality. Review of the current re-admission MDS assessment dated [DATE] documented the resident had a BIMS score of 4, on a 0 to 15 scale, indicating the resident had severe cognitive impairment. This same MDS documented the resident had impaired range of motion to one side of his upper extremities and to both lower extremities. This MDS documented Resident #42 was dependent on staff for all Activities of Daily Living (ADLs). Review of the Fall Risk Assessment completed upon re-admission and dated 04/28/26 documented a score of 12, indicating the resident was at risk for falls. On 05/13/26 at 9:11 AM, upon entering the resident's room, Resident #42 was lying in a low bed with the head of the bed elevated about 45 degrees. The resident was leaning out of the bed toward his right side with his head resting on the over the bed table. The resident had a splint on his left arm and his right arm lying on the bed was at least foot below the table so that the portable hand bell sitting on the table was out of reach. When asked if he was OK, Resident #42 stated, I'm starving . I need food. When asked if he could use the call bell to get help the resident stated he couldn't. The electronic call bell was out of reach lying over the bedside dresser. The surveyor pressed the electronic call bell at which time the light on the panel in the room was illuminated but the light at the door did not illuminate nor was a sound heard. The surveyor summoned help from the direct care nurse who came into the room. The Assistant Director of Nursing (ADON) also arrived to the room. The resident was unable to assist with the bed mobility as the nurse had to physically lift/move him back into the center of the bed. When asked what was happening with the call bell system as it was not working, the ADON stated, He is supposed to use the bell on the table. When asked how he was to use the hand bell on the table when it was higher than his shoulders and out of reach, the ADON had no answer but said, We were about to get him up anyway. 4. Record review revealed Resident #19 was admitted to the facility on [DATE]. Review of the current Quarterly MDS dated [DATE] documented the resident had a BIMS score of 11, on a 0 to 15 scale, indicating moderate cognitive impairment. As of the 12/03/25 MDS assessment the resident had moved into her current room. During an interview on 05/11/26 at 11:29 AM, Resident #19 stated she was cold. When asked how she would get ahold of someone for assistance, the resident stated, The call bell, but it has been broken. The resident was unsure as to how long it had been broken. An observation of the electronic call bell switch on the wall revealed a lack of a string which would enable the resident to use it for assistance. Photographic Evidence Obtained. A small hand bell was noted on the over-the-bed table. When asked about the small hand bell use, Resident #19 stated, They just brought that in today. On 05/11/26 at 2:37 PM, Resident #19 was heard yelling out for help. Staff responded to the resident's yelling and assisted her up to the wheelchair. The resident's relative was visiting and an interview was completed. When asked if the resident could use the call bell, the relative stated, I think so . if she had one. She just has to yell out. When asked how long the resident had been without the call bell, the relative stated since she had been in that room. 5. Record review revealed Resident #20 was admitted to the facility on [DATE] with medical diagnoses which included, Unsteadiness on Feet and Generalized Weakness. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 15, on a 0-15 scale, indicating the resident was cognitively intact. The MDS also documented the resident was on Hospice Care and required supervision for dressing and personal hygiene. During an interview with Resident #20 on 05/11/26 at 10:13 AM, the resident was asked how she called for assistance. The resident replied that she yelled for help because the staff did not respond when she used the electronic call light. Resident #22 demonstrated pressing the electronic call light three times. There was no sound or light observed in the hallway with each attempt. A hand bell was observed on tray table beside the bed. 6. Record review revealed Resident #52 was admitted to the facility on [DATE]. Medical diagnoses included Cerebral Infarction (Stroke), Unsteadiness on Feet and Generalized Muscle Weakness. Review of the current MDS dated [DATE] documented a BIMS score of 14, indicating the resident was cognitively intact. The resident required moderate assistance with toileting and dressing. During an observation on 05/11/26 at 10:37 AM, Resident #52 was observed in bed. The resident's electronic call light was not connected. The electronic outlet was on the wall, and there was no cord attached. Resident was asked how he called for help. He stated if he needed help, he would ask his roommate to call as his roommate's call light worked. No hand bell was observed for Resident #52's use. 7. During an initial interview on 05/11/26 at 11:49 AM, Resident #22 stated the bandage that was on his pressure sore had come off last night. Resident #22 was asked if he told someone that his bandage had come off and he stated nobody came in to check on him. Resident #22 was then asked how he gets help when he needed it and he stated, yell, I guess. He was asked if he had an electronic call bell and he showed the surveyor the wall where there was a call bell plug in the wall, but no cord was attached to the plug. The resident stated it has been like that for the whole time he has been at the facility. Photographic Evidence Obtained. An interview was conducted with Staff H, Certified Nursing Assistant (CNA), who has worked in the facility for 8 months. Staff H was asked if the electronic call bells work and she stated that Resident #22 did everything himself up until the fall he had and did not need to use the call bell. Staff H stated that if a call bell is not working then we check on residents every 15-30 minutes and that she was told from the maintenance department that the electronic call bells are not working. During an observation on 05/12/26 at 9:12 AM, Resident #22 stated that he still does not have a working electronic call bell and that that they did bring him a hand bell to ring when he needs help.

Based on interview and record review, the facility failed to act promptly and resolve grievances for 3 of 3 sampled residents, Resident #55, #21, and #58 who expressed concerns over the temperature of food in 4 of the 6 monthly meeting minutes reviewed. There were grievances initiated based on the concerns for 3 of the 6 months reviewed. The findings included:Review of the record revealed Resident #21 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15 on a 0-15 scale, indicating intact cognition.Review of the record revealed that Resident #55 was admitted to the facility on [DATE]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #55 had a BIMS score of 15 on a 0-15 scale, indicating intact cognitionReview of the record revealed that Resident #58 was admitted to the facility on [DATE]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #58 had a BIMS score of 15 on a 0-15 scale, indicating intact cognition.An interview was conducted on 05/12/26 with the Social Services Director (SSD) who agreed to assist with setting up a Resident Council meeting to include the Resident #21, Resident #55, and Resident #58 who attend the meetings regularly.Review of the minutes from the Resident Council Meetings for the time frame of 11/2025-04/2026 revealed the following complaints were made related to the temperature of food;11/25: Staff working on 3PM-11PM shift are not passing meal trays in a timely manner.12/25: No food concerns noted.01/26: Resident complained that in the morning the eggs are cold and staff are not reading the meal tickets.02/26: Residents expressed that by the time they receive their breakfast, the eggs are cold.03/26: Not getting food in a timely manner because staff working on 3PM-11PM shift are not passing meal trays because they just stand around.04/26: No Food concerns noted.Review of the Grievances that were generated from the Resident Council Meetings related to the temperature of the food included:11/24/25: Residents complaining about tray passing on 3PM-11PM shift. Findings area not filled in. Resolution-education and in services given to staff about passing trays during mealtime. In service sign in sheet signed by 9 CNA's01/19/26: Resident complained that in the morning the eggs are cold and staff are not reading the meal tickets. Findings: Dietary staff and nursing staff will be educated on the importance of making sure food is coming out at the correct temperature. Resolution-In services will be done with dietary and nursing. In service form not provided to surveyor.02/20/26: Residents did complain of getting cold eggs but there was not a Grievance generated to address the complaint of residents getting cold eggs.03/19/26: Residents complained that they get their food cold during the 3PM-11PM shift because Certified Nursing Assistants (CNA) are talking and not passing the trays. Findings-CNAs were speaking while actively passing trays. Resolution-continued education on efficient tray passing. In service conducted but no date on sign in sheet with 12 staff members signatures including the SSD, The Assistant Director of Nursing (ADON).A Resident Council Meeting was conducted with the surveyor on 05/12/26 at 3:00 PM with Resident #21, Resident #55, and Resident #58. The residents were asked if they feel that the food issues that have been brought up during recent Resident Council Meetings have been resolved or if they are ongoing. They all stated that they feel the food issue is ongoing and all three residents voiced concerns with the temperature of the food stating that the hot food is cold and the cold food is not very cold when the meal trays are delivered to the dining room and/or the residents' room. Resident #55 and #58 stated that they observed the food tray cart sitting in the hallway and nobody passes a tray for 30 minutes. Resident #58 stated that he was told by staff that the facility was not allowed to have hot boxes/insulated carts and that he did understand why since that may help to keep the hot food hot. Resident #55 who typically eats meals in the independent dining room was asked if there are typically 6 staff members passing trays in the dining room which was observed by surveyors this week and she stated, No.An interview was conducted on 05/13/26 at 2:35 PM with the SSD and she was asked about the grievances that she submitted following the monthly Resident Council Meetings and if she felt like residents were concerned about the same issues each month. The SSD stated that different residents complain about cold food and it may be dietary sending cold food or the trays are not passed to residents in a timely manner. There were the same residents complaining about cold food but then after holding the Resident Council Meeting directly after the monthly party more residents stayed for the meeting and there were new complaints about staff not passing the trays in a timely manner. The SSD was asked if she feels the cold food issue has been resolved and she stated that the dietary manager has requested to get warming pods/plate heaters but since we do not have them yet, the cold food issue is ongoing. The SSD was asked about having staff pass the meal trays in a timely manner and she stated that grievance goes to nursing but that she goes back and sees if it is done.An interview was conducted on 05/11/26 at 8:45 AM with the Dietary Manager (DM) who has been working at the facility for 4 months. The DM was asked if the facility has plate warmers or insulated food carts. She stated they do not have either of them. The DM provided a copy of emails that were sent to the facilities management dated 02/23/26 that stated there were two quotes for the plate warmers.

Based on policy review, observation, interview, and record review, the facility failed to provide Restorative services as recommended by Occupational Therapy for 1 of 2 sampled residents reviewed for Activities of Daily Living, Resident #17.The findings included:Review of the facility's policy titled, Restorative Nursing Program, revised on 08/2023 documented, in part, 1. Obtain physician order for Restorative Nursing Programs. 2. A Restorative Care Plan to be developed by the Restorative Nurse/ designee. 3. Restorative Nurse / designee to document in the medical record the initiation of a restorative program. 4. Restorative Nurse Aide/Certified Nursing Assistant (RNA/CNA) will document resident's participation and actual number of minutes participating in the restorative intervention.Record review revealed Resident #17 was admitted to the facility on [DATE]. The medical diagnoses included: Hemiplegia (difficulty moving or controlling one side), Hemiparesis (weakness on one side of the body) following a Cerebral Infarction (stroke) affecting the Right Dominant Side, Congestive Heart Failure and Generalized Muscle Weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 00, on a 0-15 scale, indicating the resident was severely cognitively impaired. The MDS also documented Resident #17 had impairment to one side of both upper and lower extremities, which required assistance from the staff for eating and dependence on the staff for dressing, personal hygiene, toileting and bathing.Review of the quarterly Occupational Therapy (OT) Discharge summary dated [DATE] to 03/10/26 recommended Restorative range of motion (ROM) and transfer program for Resident #17 for bilateral upper extremities strengthening and functional transfers with rolling walker or wheelchair.Review of the current care plan dated 03/02/26 lacked documentation for Restorative services for Resident #17.Review of the physician orders dated from 03/10/26 to 04/27/26 lacked documentation of the initiation and/or the discontinuation of Restorative services.During an observation on 05/11/26 at 10:10 AM, 05/11/26 at 12:40 PM and on 05/12/26 at 10:00 AM, Resident #17 was observed in bed, and communicated with slow and soft speech.During an interview and side-by-side record review, the Director of Rehabilitation Services, who is an Occupational Therapist, on 05/13/26 at 12:32 PM, was asked about the process for residents who were recommended for Restorative Services. He stated the department worked within 72 hours to screen, evaluate and get the residents started on PT(Physical Therapy)/OT services. Once they have come off PT/OT services, every resident is placed on Restorative services. The Director of Rehabilitation Services further explained that a list of the residents is provided to the Restorative Nursing Aide /Certified Nursing Assistant (RNA/CNA) with the order of exercises for each resident. The RNA/CNA documented on a task list when the exercises were completed. He stated Resident #17 was recommended for Restorative services on 03/10/26 and placed on the RNA/CNA list on 03/16/26. These services later ended as the resident either improved or had reached his maximum potential. The Director of Rehabilitation Services, after reviewing the orders, confirmed there was no order placed to initiate or to discontinue Restorative services. During an interview and side-by-side review of the records on 05/13/26 at 1:56 PM, Staff E, Restorative Aide, stated she would get the list of residents from the Director of Rehabilitation services which detailed the activities for each resident. Once a task was completed, she documented on the task list. Staff E reviewed the record and confirmed there was no documentation of the tasks for Resident #17.During an interview on 05/13/26 at 2:18 PM, the Director of Nursing (DON) stated when an order is placed for Restorative services, it would be reflected on the task list and the care plan. The DON, after reviewing the record, confirmed there was no documentation of the initiation and discontinuation of Restorative services for the resident.

Based on record review, observation and interview, the facility failed to ensure medications were administered as per physician order during medication administration for 1 of 25 medication administration opportunities, Resident #15. The findings included:Record review revealed Resident #15 was admitted on [DATE].Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating intact cognition.Review of the active orders revealed the following medications were due at 9:00 AM:Aspirin 81 mg tablets- 1 tabletFamotidine tablet 20 mg- 1 tabletColace Capsule 100 mg - 2 capsulesFerrous Sulfate 325 mg - 1 tabletMetoprolol Succinate 25 mg - 1 tabletMultivitamin Oral Tablet- 1 tabletOlanzapine 10 mg - 1 tabletValproic Acid capsule 250 mg -2 capsulesA medication administration observation was conducted for Resident #15 on 05/12/26 at 9:22 AM with Staff B, Licensed Practical Nurse (LPN). Staff B was observed preparing the resident's morning medications. Staff A stated this was the full medications for the resident and had not given any prior medications. Staff B was asked if she had completed preparing all her medications in which she stated she was. A reconciliation count was made where Staff B was asked to count the total amount of pills she had in her medication cup, and stated her total number of pills were 9. The surveyor's count was 10 per the medication card's doses. Staff B was asked to review the physician orders, upon her review Staff B stated there should be 10 pills and then recounted her pills in the medication cup and counted 9. Staff B began to check the medication packages against each medication she had prepared and stated she forgot to prepare Metoprolol and then put it in the medication cup. Staff B acknowledged the importance of checking the physician orders prior to medication administration.

Based on observation, interview, and record review, the facility failed to provide wound care and dressing changes as needed for 1 of 1 sampled resident reviewed for Pressure Ulcers, Resident #22.The findings included: Review of the record revealed Resident #22 was admitted to the facility on [DATE]. The medical diagnoses included: Osteomyelitis of Vertebra, Sacral and Sacrococcygeal region (Infection of the spine, the bottom of the spine located between the buttocks), Stage 4 Pressure Ulcer of Sacral Region (full thickness tissue loss exposing bone, muscle or tendon), Muscle Weakness and Chronic Pain Syndrome. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13, on a 0-15 scale, indicating the resident was cognitively intact. The MDS also documented the resident had 1 Stage 4 Pressure Ulcer that was present on admission. Resident #22 had frequent bowel and bladder incontinence. The resident required maximum assistance from the staff for toileting and bathing; moderate assistance from the staff for dressing.Review of the current care plan dated 04/27/26 documented Resident #22 had a sacral wound with Osteomyelitis. The goal was to show signs and symptoms of healing with interventions for Enhanced barrier precautions and treatment to the sacrum as per orders. The resident's course of antibiotic was completed on 05/06/26.Review of the physician's orders dated 04/27/26 instructed to cleanse sacral wound with normal saline, pat dry, apply silver alginate, cover with silicone superabsorbent dressings every night shift for wound care, and as needed for soiled and/or dislodged dressing.During an observation on 05/11/26 at 11:49 AM, Resident #22 was observed in bed. The resident stated that the dressing to his sacrum had fallen off overnight. He discarded the dressing in the garbage but was unable to report it because he had not seen anyone.During an observation on 05/11/26 at 3:24 PM, the resident was again observed in bed. The resident restated that the dressing to the wound fell off last night and had not been replaced since. The resident revealed an approximate 4.0 centimeters (cm) x 4.0 cm exposed wound to the sacrum. There was no dressing in place. During an interview and side by side review of the records on 05/11/2026 at 3:36PM, Staff C Registered Nurse (RN), stated she was aware that the resident had a dressing which was to be changed each night shift. Staff C stated she had neither assessed the dressing, nor had she been informed that the dressing had been dislodged up to that time. She went into the resident's room; the resident showed her his exposed wound and reported to her that it had been that way overnight. Staff C reviewed the orders and confirmed that the resident's wound care dressing should have been changed when dislodged. During an interview with Staff D, Certified Nursing Assistant (CNA) on 05/12/26 at 2:41PM, he was asked to explain his usual duties to his assigned residents. Staff D explained he assisted the residents with their activities of daily living such as toileting and incontinent care. He stated he assisted Resident #22 with incontinent care on 05/11/26 between 1:30 PM to 2:00 PM. Staff D stated the resident's dressing was soiled with blood and was dislodged during care which he reported to the Assistant Director of Nursing (ADON).During an interview with the ADON on 05/13/26 at 10:44 AM, she was asked what the policy was to report any change or unusual finding for a resident. The ADON stated the staff would report immediately to the resident's nurse, the unit manager or any available nurse. The nurse would then assess and report any critical finding to a practitioner. When asked if any finding was reported to her for Resident #22, she stated Staff D reported to her at approximately 1:30 PM or 1:45 PM that the resident's dressing had fallen off. The ADON stated she told Staff C, then they changed the resident's dressing. She was asked at what time the wound care and dressing change were done, she stated at approximately 2:00 PM. The ADON was made aware that at 3:24 PM and at 3:36 PM, the resident's wound had no dressing in place. Also, Staff C stated she was not aware the resident's wound was exposed. The ADON then stated that she did not remember the time the wound care and dressing change were done.

Based on observation, interview, policy review and record review, the facility failed to provide care and services to prevent accidents for 3 of 4 sampled residents, as evidenced by failure to keep the environment free from hazards for Resident #50, failure to thoroughly investigate or make changes after two identical falls (and near fall) for Resident #42, and failure to ensure quarterly assessment, education, and smoking safety for Resident #28. The findings included:1. Review of the policy titled, Policies and Procedures Falls, with an effective date of 09/01/23 and a revision date of 02/11/26, documented in part, Policy: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) and minimize the potential for a resulting injury. B. Fall Mitigation Strategies: 1. Develop resident centered interventions based on resident risk factors. 2.Update the resident's care plan with interventions. Record review revealed Resident #50 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15 on a 0-15 scale, indicating intact cognition. Review of the care plan initiated on 10/21/25 and revised on 05/12/26 revealed Resident #50 was at risk for falls related to gait/balance problems, decreased mobility, on opioid, psychotropic medications and sleep supplement use, vitamin deficiency, and on 05/09/26 status post fall - tripped over the base of table, sustained displaced fracture of the right humerus bone. Review of the interventions on the care plan did not address maintaining a clear path in the bedroom to reduce further fall risk. An initial interview was conducted on 05/11/26 at 11:54 AM with Resident #50 who was wearing a sling on his right arm and stated that he fallen in his room on 05/09/26, late at night, while walking back from the bathroom and that he caught his foot under the frame of the bedside table and fell on his right shoulder. Resident #50 stated he got himself back into bed and in the morning his shoulder was really hurting and had notified staff. Resident #50 stated he was sent to the hospital and had an X-ray and had a shoulder fracture. On 05/11/26 at 12:22 PM, Resident #50 was observed walking independently down the hallway with his left hand on a rolling walker and his right arm in a sling. An observation and interview were conducted with Resident #50 and his roommate on 05/12/26 at 9:14 AM. It was observed that there were tubing/air hoses from Resident #50's roommate's air mattress located on the floor in front of the foot of the bed, blocking the path to Resident #50's bed. Resident #50 stated that he almost tripped over the tubing last night while walking to the bathroom. Resident #50 stated his roommate has his feet close to or on the footboard of the bed and the brackets that hold the motor unit onto the foot of the bed get dislodged by his roommate's leg movements and the motor unit often falls on the ground blocking his path to the bathroom. Photographic Evidence Obtained. On 05/12/26 at 9:23 AM, Staff F, Certified Nursing Assistant (CNA), knocked on the door and requested to come into the room to do room rounds. Once he entered the room, the surveyor asked him if he noticed something that would be considered a fall risk and he noticed the tubing blocking the path in front of the bed of Resident #50's roommate. The CNA reached under the foot of the bed and found the motor unit of the air mattress on the floor and picked it up and placed it back on the foot of the bed. Resident #50 advised the CNA that he almost tripped on the tubing last night and the CNA asked Resident #50, you mean it was like this last night. Resident #50 responded yes. Resident #50 stated his roommate's feet hit it and it would probably fall off the bed's footboard again. The CNA agreed to have the Maintenance Director look at it. 2. Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses to include muscle weakness, altered mental status, and gait abnormality. Review of the current re-admission MDS assessment dated [DATE] documented the resident had a BIMS score of 4, on a 0 to 15 scale, indicating the resident had severe cognitive impairment. This same MDS documented the resident had impaired range of motion to one side of his upper extremities and to both lower extremities. This MDS documented Resident #42 was dependent on staff for all Activities of Daily Living (ADLs). Review of the Fall Risk Assessment completed upon re-admission and dated 04/28/26 documented a score of 12, indicating the resident was at risk for falls. Review of the progress notes revealed Resident #42 had two falls on 05/09/26. At 10:12 AM, the resident was found face on the floor while his lower body remained on the bed., and the resident had some blood coming out of his nose. A second note documented that at about 10:15 PM, the resident's roommate alerted staff that Resident #42 was on the floor. The resident was lying on the floor on the left side of the bed in the prone position with his right foot still on the bed. He sustained a raised area above his right eye. Review of the current care plan initiated on 08/29/24 and updated on 05/11/26 indicated the resident had had seven falls in 2025 with no injuries, that included a fall on 02/15/26 resulting in a nose fracture, and two falls on 05/09/26. The only new intervention as of 05/09/26 was to complete 72-hour monitoring. Review of the investigations for the two falls revealed the root cause analysis was documented as the resident was post hospitalization and started on therapy to regain strength. One of the falls documented the resident was attempting to get up unassisted and an addition to the root cause. Neither documented a true root cause analysis to attempt to determine the reason and/or what led up to the falls. The investigation lacked any new interventions to prevent further falls and or injuries. On 05/13/26 at 9:11 AM, upon entering the resident's room, Resident #42 was lying in a low bed with the head of the bed elevated about 45 degrees. The resident was leaning out of the bed toward his right side with his head resting on the over the bed table. The surveyor summoned help from the direct care nurse, who straightened the resident up in the bed by physically moving his torso to the center of the bed. During an interview on 05/14/26 at approximately 12:30 PM, when asked to describe Resident #42 and the two recent falls, the Director of Nursing (DON) explained the resident came back from the hospital recently, was pretty much just lying there, and they thought he was a Hospice candidate. The DON stated the resident then started therapy, gained strength, and wanted to get out of bed. During this interview and a side-by-side review of the resident care plans, when asked what changes were made after the resident's two recent falls, the DON was unable to verbalize any except for the 72-hour monitoring. When asked if the interdisciplinary team discusses the falls to determine what changes could be initiated, the DON stated, 'they do get together after the falls, but this one happened on the weekend and maybe .'. The DON did not finish her sentence. 3. Record review revealed Resident #28 was admitted to the facility on [DATE]. Review of the Quarterly MDS assessment dated [DATE] documented Resident #28 had a BIMS score of 15, on a 0 to 15 scale, indicating intasct cognition. Review of the current care plan initiated on 01/11/26 documented the resident exhibits tobacco use related to nicotine dependence. Interventions included to review the smoking policy with the resident quarterly and as needed and report evidence of non-compliance with smoking policies, permit smoking only in designated smoking area, provide direct staff supervision during smoking times, allow smoking only during posted smoking times, prohibit resident from keeping smoking materials in room or possession, and to secure smoking materials with nursing staff with family to bring items to staff for storage. The facility's smoking times were designated as 9:00 AM to 9:30 AM, 11:30 AM to 11:45 AM, 1:30 PM to 2:00 PM, 4:15 PM to 4:45 PM, and 6:30 PM to 7:00 PM. Further review of the record revealed the only Smoking Safety Evaluation for Resident #28 was completed on 12/15/25. During an interview on 05/11/26 at 2:11 PM when asked about her ability to smoke at the facility, Resident #28 stated staff are often not available at the designated smoking times, so she tries to keep one or two cigarettes with her. On 05/12/26 at 10:46 AM, a non-smoking time, Resident #28 walked out to the gazebo, a designated smoking area. The surveyor joined her at 10:50 AM and she was just finishing a cigarette. Resident #28 grabbed the top of the outdoor cigarette receptacle, at which the top became ajar from the bottom. When the resident threw the cigarette into the top part, the cigarette went down the long neck and fell out onto the cement pad, missing the bottom of the container. During an interview on 05/14/26 at 1:10 PM, when asked about the frequency of resident Smoking evaluations, the Social Services Director (SSD) explained she and nursing completed them together upon admission or when the resident first requests to smoke, and again if there are any changes with the resident. When advised the care plan and policy both document quarterly evaluations and education to the residents, the SSD stated, Oh, I don't do them quarterly. When told of the observation of Resident #28 smoking outside of designated smoking times and the concern with the cigarette receptacle, the SSD and Assistant Director of Nursing (ADON) who was present at the time, agreed with the findings. During a second observation on 05/14/26 at 1:37 PM, the same outdoor cigarette receptacle was noted ajar, off the base again. Photographic Evidence Obtained.

Based on observation, record review, and interview, the facility failed to ensure appropriate care and services for oxygen use for 1 of 1 sampled resident as evidenced by the lack of oxygen orders for Resident #42 who was observed using oxygen, and lack of oxygen saturation levels to ensure appropriate need and discontinuation of the oxygen.The findings included:Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses to include Heart Failure and Respiratory Failure. Review of the admission Minimum Data Set (MDS) assessment for the resident's re-admission to the facility on [DATE], documented Resident #42 had a Brief Interview for Mental Status (BIMS) score of 4, on a 0 to 15 scale, indicating the resident had severe cognitive impairment. This same MDS lacked any oxygen use. Review of current care plans lacked any mention of oxygen.Review of the current and discontinued physician orders lacked any physician's order for oxygen use but had an order to change the oxygen tubing and humidifier every Wednesday and assess for shortness of breath when flat every shift.Review of the oxygen saturation levels revealed the following:a) On 04/28/26 at 4:51 PM, the oxygen saturation level was 98% on room air.b) On 04/28/26 at 4:56 PM, the oxygen saturation level was 98% on oxygen.c) On 04/28/26 at 7:42 PM, the oxygen saturation level was 97% on room air.d) On 04/29/26 at 7:01 AM, the oxygen saturation level was 96% on room air.e) On 04/30/26 at 7:07 P,M the oxygen saturation level was 97% on room air.f) On 05/03/26 at 7:02 PM, the oxygen saturation level was 98% on oxygen.g) On 05/07/26 at 7:20 AM, the oxygen saturation level was 98% on room air.h) On 05/07/26 at 7:03 PM, the oxygen saturation level was 94% on oxygen.i) On 05/08/26 at 6:57 AM, the oxygen saturation level was 92% on room air.j) On 05/10/26 at 6:00 AM, the oxygen saturation level was 96% on room air.k) On 05/11/26 at 7:52 PM, the oxygen saturation level was 99% on oxygen.A nurse's progress note dated 04/28/26 at 6:34 PM documented the resident's oxygen saturation was 98% on 2 liters of continuous oxygen as ordered.Physicians' follow up progress notes dated 05/01/26 at 9:15 AM and 05/04/26 at 9:17 AM documented the resident's oxygen saturation was 95% and 97% on room air, respectively.A physician progress note dated 05/12/26 at 8:41 AM documented the resident's oxygen saturation was 98% on room air and to use oxygen as needed to maintain a level of greater than 92%.An observation on 05/11/26 at 10:30 AM revealed Resident #42 in bed with the oxygen running at 2 liters/minute via nasal cannula. The resident's breathing was somewhat labored while trying to talk.On 05/12/26 at 12:36 PM, Resident #42 was back in bed after having spent the morning up in a recliner without oxygen use. The oxygen concentrator was at his bedside with the tubing wrapped around his arm and the nasal canula on the floor. The concentrator was not turned on at this time. Photographic Evidence Obtained.On 05/13/2026 at 9:11 AM, the oxygen concentrator had been removed from the room.During a side-by-side record review and interview on 05/14/26 at 12:19 PM, when asked what should be documented if a resident was using oxygen, the Assistant Director of Nursing (ADON) stated the order for the use of oxygen and tubing changes, and oxygen saturation levels. When asked specifically about Resident #42, the ADON stated he had been on continuous oxygen earlier this week and she had entered the order. Review of the record revealed the order was entered on 05/12/26. Review of the oxygen saturation levels and progress notes revealed the resident had been on oxygen since readmission on [DATE] yet there was not order. The sporadic oxygen saturation levels revealed a lack of routine monitoring and the lack of rationale for discontinuation of the oxygen. The ADON agreed with the findings and also stated the admission nurse should have entered the oxygen orders for Resident #42.

Based on observation, interview, and record review, the facility failed to ensure pain management for 1 of 2 sampled residents, as evidenced by the failure to follow hospital discharge orders for use of ice for acute pain for Resident #50. The findings included:Review of the record revealed that Resident #50 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15 on a 0-15 scale, indicating intact cognition. Review of the facilities Resident Matrix dated 05/13/26 revealed that Resident #50 had a Fall with Injury.Review of the progress notes and Physician orders revealed that the fall happened on 05/09/26 and Resident #50 was transferred to the hospital for further evaluation and management. Further review of the progress notes revealed that a progress note dated 05/10/26 at 12:49 PM documented that Resident #50 returned with an adjustable sling in place on the right upper extremity, new medication orders, and ice therapy was ordered as needed (PRN)for pain/swelling management. Further review of the record revealed that the radiology report indicated Resident #50 had a mildly displaced fracture of the humeral neck with no dislocation identified and moderate degenerative changes and osteopenia are also noted per radiology findings.An initial interview was conducted on 05/11/26 at 11:54 AM with Resident #50 who was wearing a sling on his right arm and stated that he fell in his room on 05/09/26 , late at night while walking back from the bathroom and that he caught his foot under the frame of the bedside table and fell on his right shoulder. Another observation was made on 05/11/26 at 12:22 PM of Resident #50 walking down the hallway pushing a rolling walker with his left hand and his right arm was in a sling and was overheard telling a Certified Nursing Assistant (CNA) that he wanted to get pain medication as his shoulder was really hurting.An interview was conducted on 05/12/26 at 9:07 AM and Resident #50 stated that the pain medication he is getting does not work. Another observation was made at 9:21AM to see if Resident #50 ate his breakfast and he stated that he had not eaten it. Resident #50 went on to say that ever since the fall he has been in pain and has lost his appetite. Resident #50 was asked if he told the nurses that he was in pain and he stated, yes, I tell them when they come in the room or when I go to the nurse's station. Resident #50 was asked if the nurses have been giving him ice for his shoulder or if he had asked for an ice pack and he stated, I did not know that I could get ice and that is why I never asked for it.On 05/13/26 at 12:30 PM, Resident #50 stated he was unable to sleep last night since his shoulder pain was so bad and that when he asked the nurse for pain medication he was told that the pain medication was discontinued and they were going to contact the Physician and also let the Physician know that the current pain medication was not working.An interview was conducted on 05/14/26 at 9:26 AM with Staff G, Licensed Practical Nurse (LPN) who was assigned to Resident #50 and was asked if she has any residents on her assignment that have orders for ice and she stated she did not. Staff G was then asked if Resident #50 had a Physicians order for ice as needed to his right shoulder and she checked his records and stated that he did not have an order for ice. Staff G was asked if Resident #50 had requested pain medication and she stated that he complained of a pain level of 6/10 and was given his medication this morning.An interview was conducted with the Assistant Director of Nursing (ADON) on 05/14/26 at 10:51AM and she was asked why there would have been a nursing progress note dated 05/10/26 that included, ice therapy was ordered as needed (PRN)for pain/swelling management for Resident #50 but was never written on the orders, was not on the Medication Administration Record (MAR), and ice was never given to Resident #50. The ADON was unsure and went to find out and came back at 12:46 PM and stated that there was hospital discharge paperwork that included a homecare section that had documented to apply an ice pack to the injured area for 20 minutes every 1-2 hours the first day, continue with ice packs 3 to 4 times a day for the next 2 to 3 days and then use the ice as needed to relieve pain and swelling. The ADON stated that the nurse on duty should have added the ice order to the system but did not and that she agreed with the findings.

Based on record review and interview, the facility failed to ensure clarification or physician response to pharmacy recommendations for 1 of 5 sampled residents, as evidenced by the failure to respond to the need for a medication dose for Resident #12.The findings included:Record review revealed Resident #12 was admitted to the facility on [DATE]. Review of the current physician orders included the ointment Voltaren pain gel 1%. This order documented to apply topically two times a day for pain. The order lacked how much of the gel to apply. This medication typically had a measuring device that indicated the grams to apply, with a usual dose being one to two inches of ointment.Review of the pharmacy recommendation for January 2026 documented Resident #12 was ordered Diclofenac Gel (Voltaren) to his right knee twice daily for pain. The recommendation further listed the recommended dosages. The prescriber's comment area simply documented OK with the providers signature and date of 02/10/26. There was no subsequent pharmacy recommendation for the VoltarenDuring an interview 05/13/26 at 1:17 PM when asked about the January 2026 recommendation related to the Diclofenac, the Consultant Pharmacist explained the recommendation was made prior to her arrival at the facility and agreed there was no documented dose in response to the recommendation or in the current order.On 05/13/26 at 1:28 PM, when asked how she would know how much Diclofenac to apply to the knee of Resident #12, Staff A, Registered Nurse (RN), stated she could not tell by the order but would take a small medication cup and put the ointment in the cup to apply. The RN further explained the amount would depend upon the area of pain, but she would use like two pea size dots.

Based on interview, observation and record review, the facility failed to serve food at a safe and appetizing temperature for 8 of 8 voiced complaints for Residents #55, #39, #50, #21, #10, #46, #54, and #53.The findings included:During a Resident Council meeting that was conducted on 05/12/26 at 3:00 PM, Residents #55, #21, and #58 revealed unresolved concerns over the temperature of food during 4 of the last 6 Resident Council monthly meetings. Please refer to citation #F565 for further information. 1. Record review revealed Resident #55 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15 on a 0-15 scale, indicating intact cognition. An initial interview was conducted on 05/12/26 at 8:33 AM and Resident #55 was asked if her food is served warm and she stated, no, it is cold and I eat in the dining room. An observation was conducted on 05/12/26 at 11:55 AM in the independent dining room where Resident #55 was eating with a friend and stated the temperature of the food is okay today, but it is never like this, the food is usually cold. Resident #55 was asked if there are usually 6 staff members in the dining room delivering the meals and she state, no. Resident #55 added that she attends the Resident Council meetings and that they have brought up the cold food issue during several of the recent meetings. 2. Record review revealed Resident #39 was admitted to the facility on [DATE]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #39 had a BIMS score of 15 on a 0-15 scale, indicating intact cognition. An initial interview was conducted with Resident #39 on 05/11/26 at 12:49 PM and she stated that she sits in the dining room with Resident #55 for lunch and dinner and the food is usually cold by the time we get it. An observation was conducted on 05/12/26 at 11:55 AM while Resident #39 was in the dining room eating lunch and she was asked if her food is warm and she stated that the food is warm today but added that it is not usually warm, it is usually cold. 3. Record review revealed Resident #50 was admitted to the facility on [DATE]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #50 had a BIMS score of 15 on a 0-15 scale, indicating intact cognition. During an initial interview on 05/11/26 at 12:07 PM, Resident #50 was asked where he eats his meals and he stated in his room. The resident was asked if his meals are hot when they arrive to his room and he stated, No. He stated they are scheduled to deliver lunch at 12:00 PM and sometimes they bring it as late as 1:00 PM and it is ice cold and I refuse to eat it and tell them to take it away. An observation was conducted on 05/13/26 at 11:30 in the kitchen while the Dietary Manager (DM) was taking temperatures of the food while on the steam table prior to initiating the tray line. The temperatures were as follows all in degrees Fahrenheit (F): Broccoli - 152F, Stuffing 170F, Turkey Breast 145F. All other items on the menu were 165 degrees or above. Observation of the Tray line was conducted on 05/13/26 at 11:40 AM. The plates were covered and then placed on a tray and the tray placed on a open air metal cart that once full, was covered with a plastic bag for transfer to the units. The surveyor requested a test tray that was also loaded onto the cart last. The cart was full by 11:50 AM and arrived at the dining room at 11:53 AM. The first tray was delivered at 11:54, and the last tray (Test Tray) was retrieved at 12:08 PM after the last resident was served his tray at 12:06. Temperature of test tray items at 12:08 PM (18 minutes after it left the kitchen) were: Turkey 116F, Stuffing 122F, and Broccoli 97F. Photographic Evidence Obtained. 4.On 05/11/26 at 10:12 AM, Resident #10 was interviewed and stated he has been at the facility for a year. When asked about the food, Resident #10 stated the food was cold and not warm enough. 5.On 05/11/26 at 10:18 AM, Resident #46, admission date of 04/23/24, was interviewed about food and stated the food was cold all the time and eats it anyways but would want it hot. On 05/12/26 at 12:10 PM, Resident #46 told the surveyor her relative brought her Burger King and restated she does not lie about the food here. 6.On 05/11/26 at 10:35 AM, Resident #54 stated his biggest problem was that the food came cold all the time and said he wanted hot food. Resident #54 stated he was okay with what they want to serve but he wanted it served hot. When asked how long it has been cold for, he stated it had always been like that since he had been there. Resident #54 stated he had timed it and stated the carts sit out in the hallway on arrival to the dining room. Resident #54 stated that only one time he had received warm eggs and the rest of the times they were cold. On 05/11/26 at 12:00 PM, a dining observation was conducted on the independent dining room, the menu for lunch was Egg salad plate, three bean salad, sugar cookie bar, crackers for salad. Resident # 54 was observed for dining and stated he received what was on the menu for lunch but had Bud's Chicken been brought to him to have a warm meal. On 05/12/26 at 11:49 AM, the lunch cart arrived at the independent dining. Observation revealed 6 staff members passing trays to residents. The menu of the day was Pork cutlet, brown gravy, herbed rice, seasoned zucchini, apple cobbler. On 05/12/26 at 11:57 AM, Resident #54 was served his lunch meal and interviewed. When asked how his meal was, Resident #54 stated as he put his hand over his plate, I can feel the heat coming out of the food today, but its normally not like this, the food is usually cold. He stated he thinks it is because the kitchen is far. When Resident #54 tasted the food, he stated that the food was warm, but he would like it hot. 7. On 05/11/26 at 10:40 AM, Resident #21 who had been at the facility since 03/18/26, stated the food is always cold because the kitchen does not have any heat lamps or heat boxes. Resident #21 stated he was used to prison food, so this was still better. 8.On 05/11/26 at 10:46 AM, Resident #53 who was admitted on [DATE], stated that the food is always cold but eats it still to survive. On 05/11/26 at 12:33 AM, during a dining observation Resident #53 was observed in his room as he was being served his meal tray by a CNA (Certified Nursing Assistant.) Resident #53 looked down at the tray and asked the CNA what is that and that he did not want to eat it. Resident #53 was upset over his lunch meal and stated he never gets a choice to eat what he wants. On 05/12/26 at 12:14 PM, during a dining observation Resident #53 was observed in his room upon arrival of his lunch tray. Resident #53 was asked how the temperature of his food was and he stated the food was cold. On 05/14/26 at 09:25 AM, Resident #53 was asked about his meals yesterday, he stated they were cold, It is always going to be the same, no changes will be made.

Based on record review and interview the facility failed to ensure the comprehensive care plans for 2 of 22 sampled residents were developed by the interdisciplinary team (IDT), including the resident and resident representative, as evidenced by the failure to ensure care plan meetings for Resident #9 and Resident #42.The findings included:1. Record review revealed Resident #9 was admitted to the facility on [DATE]. Review of the current Annual Minimum Data Set (MDS) assessment had an Assessment Reference Date (ARD) of 03/31/26. The record lacked any evidence of an IDT care plan meeting.During an interview on 05/14/26 at 2:58 PM, when asked the process for ensuring IDT participation in the care planning process with a care planning meeting for each resident, the Social Services Director (SSD) stated the MDS Coordinator provides a list of needed care plan meeting as she is doing the assessments. The SSD stated they have a Care Plan Meeting form that is filled out and signed for each meeting, that she maintains in a binder. The SSD was asked to locate and provide the care plan meeting for the most recent assessment of 03/31/26 and was unable to do so. 2. Record review revealed Resident #42 was admitted to the facility on [DATE]. Review of the recent Significant Change MDS assessment had an ARD of 02/28/26.During the continued interview on 05/14/26 at 2:58 PM, the SSD was asked to locate and provide evidence of the IDT care plan meeting for the significant change assessment, and the SSD was unable to do so.

Based on a review of the admission packet, record reviews, and interviews, the facility failed to refund to the resident or resident representative all refunds due to the resident within 30 days from the resident's date of death / discharge from the facility, for 3 of 3 sampled residents, Resident #1, Resident #2, and Resident #3. The findings included: The facility's admission packet stated that the facility will refund any overpayment within 30 days. 1. Record review revealed Resident #1 expired on [DATE] and had a refund amount of greater than $1040.00 owed to the resident. During an interview with Resident #1's daughter on [DATE], at 12:00 PM, the daughter said that the family received the check last Thursday ([DATE]) for the amount of money owed to her. That was approximately 3 months and 8 days after the resident's expired from the facility. Review of documents provided by the Business Office Manager (BOM), showed a refund to the Resident / Payer, Resident #1, which was processed on [DATE], in the amount $30.00. There was an additional refund to the Resident / Payer Resident #1 processed on [DATE] in the amount $1057.15. Photographic Evidence Obtained. 2. Record review revealed Resident #2 was discharged on [DATE]. Documentation provided by the BOM showed a refund processed on [DATE] in the amount $23,857.87. This was approximately 3 months and 19 days after the resident's discharge from the facility. Photographic Evidence Obtained. 3. Record review revealed Resident #3 expired on [DATE]. Documentation provided by the BOM showed a refund processed on [DATE] for the amount $664.63. This was approximately 3 months and 19 days after the resident's discharge from the facility. Photographic Evidence Obtained. An interview was conducted with the BOM on [DATE] at 12:50 PM, who was asked to describe the refund process. She explained that when a patient is discharged (or expired), the facility has 30 days to refund any money that was due to the resident or to their family. She said she provided a package for each resident to the corporate office who in turn processes their refunds. The BOM stated on [DATE] at approximately 2:50 PM, that the requested reports of the refunds were just sent to the facility by the corporate office. The surveyor and the BOM reviewed the refund dates for Residents #1, #2, and #3. On [DATE] at 3:00 PM, the BOM was asked why she thought the residents or family representatives waited so long (more than 3 months), to receive their refunds. The BOM stated she thought she had sent the packages (refund requests) to the corporate office on time. She stated that maybe the corporation sent the check, and it came back. She added that she previously didn't have access to the report that showed the dates that the checks were issued. The BOM agreed with the findings.

Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistive devices to prevent accidents and injuries, and ensure a safe environment, failed to ensure a complete investigation and follow up were completed for 1 of 2 sampled residents reviewed for falls, Resident #32. The findings included: Record review revealed Resident #32 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Unspecified Intracapsular Fracture of left femur, Hypertension, and Major Depression. The significant change Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Review of a fall investigation and nursing progress note dated 09/23/24 at 6:00 AM revealed the resident was found on the floor next to his bed. The resident was observed laying on his left side. He was unable to give a description of what happened and was showing signs and symptoms of pain to the left hip. He was transferred into bed. The Physician and family were notified and the Physician ordered an x-ray to the left hip. The X-ray results noted an acute left acetabular fracture and the Advanced Registered Nurse Practitioner (ARNP) was notified and gave an order to send the resident to the emergency room for evaluation. An interview was conducted on 12/18/24 at 10:45 AM with the Director of Nurses (DON) during the side-by-side review of the unwitnessed fall investigation. The DON was asked what the resident was doing prior to the fall, what he was wearing, when was the last time he received care, were fall mats by the bed at the time of the incident, what was the position of the bed, and were there witness statements. The DON then produced two witness statements: A statement from the nurse who was present and the CNA (certified nursing assistant) who found him. The fall investigation did not include that the resident was found to have a fracture or any follow up in-services done with the staff or any care plan updates. The DON stated upon review of the fall during the Interdisciplinary team (IDT) meeting, it was decided that the fall did not result in a fracture and the fracture was a spontaneous event (a pathological fracture). There were no in-services done. The surveyor asked for documentation of this meeting and the DON stated they have no documentation. When asked how they determined that the fracture did not result from the fall, she stated they based it on the hospital records. The surveyor asked who else was present at this meeting and she stated it was the Administrator, Social worker, Minimum Data Set (MDS) person and Rehab Director. An interview was conducted with Staff F, Rehab Director, on 12/18/24 at 11:16 AM. He stated it was determined it was a pathological fracture due to the hospital notes and he would find where he read that on the hospital record and provide it to the surveyor. On 12/18/24 at 12:55 PM, he returned and stated he could not find any notes from the hospital that stated it was a pathological fracture. Review of the care plans for Resident #32 revealed a care plan for at risk for injury related to falls related to recent fall, history of falls, history / recent fall with fracture, impaired mobility, poor balance, poor safety awareness, doesn't recognize limitations, antidepressant medications, anticoagulant / antiplatelet use, respiratory status increases risk. The care included the following updates: 06/25/24, status post (s/p) fall no injury 06/28/24, s/p fall no injury 09/23/24, s/p fall 09/30/24, readmit with left femur fracture This care plan was initiated on 06/26/24 and revised on 12/17/24. Interventions included: 09/23/24, Resident transferred to hospital date initiated 09/23/24. 09/23/24, x-ray to left hip date initiated 09/23/24. Remind/encourage Mr . to call for assistance when needed date initiated 06/28/24. Call bell in reach date initiated 06/26/24. 06/25/24, therapy referral / evaluation / treatment as indicated date initiated and revised 06/26/24. 06/28/24, remind / encourage to call for assistance as needed date initiated 06/28/24 and revised 08/22/24. Assist as needed with transfer / ambulation date initiated 06/26/24. Transfer/gait belt for transfers and/or ambulation date initiated 06/26/24. Ensure proper foot wear worn date initiated 06/26/24. (3/4, 1/2, 1/4) Side rails to promote independence in bed mobility date initiated 06/26/24. Bed in low position date initiated 06/26/24. Bed/chair alarm as ordered date initiated 06/26/24. Observe for a report changes in mobility and/or range of motion date initiated 06/26/24. Remind / encourage use of glasses date initiated 06/26/24. R/O [rule out] falls with bruising of unknown origin or new complaint of pain date initiated 06/26/24. Room change as indicated date initiated 06/26/24. Use mechanical lift for transfers date initiated 06/26/24. Floor mats to both side/s of bed when in bed date initiated 06/26/24 and revised 08/22/24. Review of the fall investigation revealed no indication as to whether or not floor mats were in place. There were no new interventions on the care plan post fall with fracture on 09/23/24. An interview was conducted with the Administrator on 12/18/24 at 12:03 PM who stated she would not report this event because it was a fall and because it wasn't determined to be unknown (pathological) as they figured out how it happened, and she would not do an immediate or 5 day report. On 12/18/24 at 3:35 PM, an observation of the resident's room revealed no floor mats were in the resident's room. An interview conducted with Staff E, Certified Nursing Assistant, CNA, who worked in the facility for 8 years, revealed she did not recall ever seeing floor mats by his bed or in his room. On 12/19/24 at 9:00 AM, observation was made of the resident in bed with no floor mats beside the bed.

Based on observations, interviews, and record review, the facility failed to ensure adequate hot water temperatures for 3 of 31 residents' rooms (Rooms 4, 27 and 28) and 1 of 2 shower rooms reviewed for comfortable temperature levels; failed to ensure 4 of 4 hallways had firmly secured handrails to the walls; failed to ensure the emergency call system cord were long enough and accessible for 5 of 31 resident's bathrooms (Rooms 16, 20, 21, 24, and 27); failed to provide covers for florescent light fixtures located above residents' beds for 60 of 61 beds reviewed for safe, comfortable, homelike environment; and failed to secure residents' personal property and medical records. The findings included: 1. During tour of the facility conducted on 12/16/24 at 10:34 AM of room [ROOM NUMBER] and 28, it was observed that after running the hot water in the bathroom for 2 minutes, it was not hot to the touch. An interview was conducted on 12/16/24 at 10:38 AM with both residents residing in room [ROOM NUMBER] who stated the hot water does run out at times, especially later in the day when the water is just warm. Both residents stated that this has been an issue for about 4 weeks and the staff is aware, but nothing is being done. An interview was conducted on 12/17/24 at 3:58 PM with the resident residing in room [ROOM NUMBER] who stated there's no hot water in the shower room or in his bathroom. He stated he would like weekly showers but the water is too cold, never gets hot, and he does not want a shower. An interview was conducted on 12/17/24 at 1:20 PM with the Maintenance Supervisor, who stated he started working at the facility in September 2024. He stated that he was not aware of any issues with the hot water. At this time, a tour of the rooms was conducted to test the temperature of the water in residents' rooms. The Maintenance Supervisor had his own non-digital thermometer, which he stated he uses to randomly check the water temperatures monthly. The Maintenance Supervisor ran the hot water for 2 minutes in room [ROOM NUMBER]'s bathroom sink, and then placed the thermometer under the running water for 30 seconds, which read 90 degrees Fahrenheit (F). This process was repeated for room [ROOM NUMBER], which the hot water temperature read below 90 F, and again was done for room [ROOM NUMBER] in which the hot water temperature was 92 F. The Maintenance Supervisor stated that he has checked the water temperatures this month and the temperatures were not this low. An interview was conducted on 12/17/24 at 2:00 PM with Staff R, Certified Nursing Assistant (CNA), who stated she has been working at the facility for 4 months. She stated sometimes she must let the hot water run for a while (she was unable to state how long) but if the resident states the water is too cold, she just runs the hot water and will wait until it is warmer. Review of the water temperatures for the month of December (dated 12/09/24) revealed water temperatures were checked in 8 rooms and the shower rooms with the temperatures ranging between 109F and 111F. An interview was conducted on 12/17/24 at 2:44 PM with the Maintenance Supervisor and the Environmental Director. The Maintenance Director stated she has part-time and full-time maintenance staff and there is a maintenance binder located at the nurses' station which is checked throughout the day by the maintenance staff. Any staff member can enter a maintenance request, and her staff is to sign off only when the work has been completed or resolved. Review of the maintenance binder (log) located at the nurses' station revealed the following: On 11/11/24, a nurse reported family complained about no hot water in the building and it was signed by maintenance staff as in progress. On 11/12/24, a staff member reported no hot water and it was signed by maintenance staff as parts are on order for repair. On 11/21/24, a CNA reported there is still no hot water pipe runs for 15 minutes still nothing cold as ice and it was signed by maintenance staff as in progress. On 11/23/24, a CNA reported shower room head need fixing, still no hot water and maintenance staff signed as in progress. On 11/27/24, a staff member reported no hot water in the shower room and maintenance staff signed as in progress. An interview was conducted on 12/17/24 at 4:35 PM with the Maintenance Supervisor who stated that on 11/12/24, there was water boiler issue throughout the building (prior he had stated there were no hot water issues), and they tried to figure out the issue themselves, but were not able to and a third-party vendor was called (company name provided). In the meantime, the nursing staff were instructed to run the hot water longer. Review of the [Company]'s invoice dated 12/02/24 revealed the cause for not having hot water in the building for the month of November was due to the high limit was set incorrectly causing heater to turn off before meeting temperatures. An interview was conducted on 12/18/24 at 8:30 AM with the Maintenance Supervisor and the Environmental Director. The Maintenance Supervisor stated that he regulated the boiler yesterday (12/17/24) and the boiler temperature was at 120F. He stated he tested the water temperatures this morning and they are still reading at around 90F. The Environmental Director stated that there's no invoice for ordered parts (from 11/12/24 maintenance log) because the third-party vendor came in on 12/02/24 and stated no need for parts, just the boiler settings were off. She noted a plumber had been called as of Tuesday 12/17/24 to look at the boiler. An interview was conducted on 12/18/24 at 3:07 PM with Staff H, CNA, who stated she has worked at the facility for 7 years. Staff H stated she often feels rushed when providing care to the residents. She noted it takes about 10 minutes to get the water warm enough for the residents and she does not open the cold water. Staff H was observed during catheter care, and she acknowledged that she left the water running for most of the procedure to ensure the water was warm enough. A hot water temperature test was conducted on 12/20/24 at 10:20 AM of rooms 4, 27,28,12 and shower room (across the nurses' station) with the Maintenance Supervisor and Environmental Director. The hot water temperatures ranged from 84F to 95F. The Environmental Director acknowledged that the boiler supplies hot water for both buildings (the nursing home and another residence building that's attached), and this can be why the water temperatures vary throughout the day. In addition, the Maintenance Supervisor stated the plumbing company came in on 12/19/24 and provided options to get the hot water to the residents that are farthest from the boiler room (rooms [ROOM NUMBERS] hot water temperature read 84F to 90F). 2. Review of the record revealed Resident #43 was admitted to the facility 04/02/24 with the primary diagnosis of Cerebral Infarction (a disruption of blood flow to the brain), and oher diagnoses to include Altered Mental Status, Ahasia (a language disorder that affects how you communicate) and Depression. Review of the care plan dated 04/15/24 documented, Resident #43 has impaired cognition as evidence by cerebral vascular accident, stroke . etc. The goal stated The resident will make appropriate decisions daily related to personal preferences and/or through next review. The intervention documents, Encourage decision making related to personal preference and care with each encounter. An interview was conducted on 12/16/24 at 2:19 PM with Resident #43's representative who voiced that there was not any hot water available when she tried to bathe the resident. She stated the resident did not want to get cleaned because the water was too cold and he preferred hot water. 3. On 12/16/24 from 9:30 AM to 12:00 PM during initial tour of the facility, the handrails next to room [ROOM NUMBER], #10, #14, #18, and #26, were worn and loosely affixed to wall. 4. On 12/16/24 at 8:40 AM, an observation was made in conference room (not labeled as such) with boxes of medical records stored on floor, broken chairs, and various items of clothing, some in bags, some not in bags. Photographic Evidence Obtained. 5. On 12/16/24 at 9:10 AM, an observation was made of the Central Supply Room door being open with Staff P, Medical Record / Central Supply Clerk inside. There were several boxes of supplies stored directly on the floor, some items were on wooden platform type pallets. Photographic Evidence Obtained. Two 2 of the 6 ceiling light fixtures with fluorescent bulbs were not functioning. 6. On 12/17/24 at 8:46 AM, an observation was made of 2 fire doors that lead to hallway with rooms 9-15, propped open and 2 fire doors that lead to hallway with room [ROOM NUMBER]-8 propped open. Photographic Evidence Obtained. 7. An environmental tour was conducted on 12/20/24 at 10:40 AM with the Environmental Director, the Maintenance Supervisor and the Regional Maintenance Director present. The following side-by-side observations were completed with the Environmental Director, the Maintenance Supervisor and the Regional Maintenance Director who acknowledged the identified issues as follows: a. Fluorescent light fixtures behind head of bed was not covered in 60 of the 61 beds (only bed with properly covered fluorescent light fixture was in room [ROOM NUMBER]-A). b. Short emergency cords in 5 of 31 resident bathrooms (rooms #16, #20, #21, #24 and #27). c. Call lights located on the floor and not accessible to residents in rooms (1B, and 9B). d. Handrails throughout facility worn and not securely fixed to walls. e. The room next to the social worker office had multiple boxes with medical records (with resident information) stored on floor, broken furniture, used resident clothing and personal items some in bags, some in ripped bags, some just loose and broken and non-functioning fluorescent ceiling lights. Photographic Evidence Obtained. An interview was conducted on 12/16/24 at 9:13 AM with Staff P, Medical Record / Central Supply Clerk, who stated she has worked at the facility for 15 plus years with the old company and 1 year with the new company. When asked about the Central Supply Room, she said it has always been this way. An interview was conducted 12/17/24 at 12:40 PM with the Regional Director of Maintenance who stated the double fire doors should never be propped open, and he told staff that when he walked in today.

Based on observations, record review and interview, the facility failed to follow the regular diet menus, affecting 53 of 55 residents receiving a regular diet. The findings included: Review of the facility's menu, titled, Pine Trail Menu F/W 24/25 Week at a Glance for Regular/Regular Week 1, listed Monday (Day 2) lunch as open face hot turkey sandwich, poultry gravy, garlic mashed potatoes, California blend vegetables, pineapple tidbits, bread for open-face sandwich, coffee/tea, and condiments; and listed Wednesday (Day 3) lunch as beef cubed steak with onion gravy, scalloped potatoes, buttered carrots, chocolate chip cookie, dinner roll, margarine, coffee/tea and condiments. Review of the facility menu, titled, 7 Day Hot Weather/Cold Food Menu Week 1, listed Day 2 lunch as egg salad sandwich, marinated beet and onion salad, fruit mix, sandwich bread, coffee/tea, and condiments; and listed Day 4 lunch as tuna salad sandwich, three bean salad, chilled pears, sandwich bread, coffee/tea and condiments. On 12/16/24 (Monday) at 11:20 AM, the facility served sliced turkey on bread with cooked carrots, and pineapple tidbits. On 12/18/24 (Wednesday) at 11:35 AM, the facility served pasta (hot) with meat and tomato sauce containing sausage (hot) with cooked sliced carrots and peas with sliced peaches. An interview was conducted on 12/16/24 at 11:30 AM with the Certified Dietary Manager who was asked why they are not following the Pine Trail Menu F/W 24/25 Week at a Glance for Regular/Regular Week 1. She stated, because they have no working oven, so the company that makes up their menus supplied them with a 7 Day Hot Weather/Cold Food Menu Week 1 that they have been using since before Thanksgiving (11/28/24), but she would substitute the cold vegetable with a hot vegetable so that the residents will get at least one thing hot with each meal. When asked to clarify if it is the same weekly menu each week since before Thanksgiving, she said yes. When asked why they did not serve the egg salad sandwich today, she stated they did not have enough leftover eggs from the previous day's breakfast to make the egg salad, so she substituted the protein with the sliced turkey. When asked how many ounces of sliced turkey is provided for each resident, she said it was 2-ounces. When asked for a scale to measure the sliced turkey on a plate, she stated they do not have a scale, and they just estimate the portion of the turkey. An interview was conducted on 12/18/24 at 11:38 AM with the Certified Dietary Manager who was asked why they were not following the '7 Day Hot Weather/Cold Food Menu Week 1' today for Wednesday (Day 4). She stated, because they had to throw refrigerated and frozen food away yesterday due to the refrigerator and freezer not working properly, she improvised with making a pasta and meat and tomato sauce (hot). When asked what menu she followed, she said she did not follow a menu but was sure she could locate one to provide to surveyor. When asked what meat was used in the meat and tomato sauce, she stated it was sausage. When asked what the residents were served for breakfast, she stated sausage, then added we had to use it up before it went bad. An interview was conducted on 12/20/24 at 1:50 PM with the Certified Dietary Manager (CDM) who was asked what was being provided for lunch today. She stated a 2-ounce slice of ham, a 1-ounce slice of cheese 2 slices of bread and mashed potatoes and vegetable. When asked how, if the ham was presliced, she said they sliced it, when asked how they knew each slice of ham is 2-ounces and whether they weigh the ham, she said, 'no, they just estimate it'. When asked f they have a scale, she said, 'no, they still do not have a scale in the kitchen to weigh food'. When asked how long they have not had a scale, she said she noticed that when she arrived in May 2024. When asked if she had communicated a need for and lack of a scale to anyone, she said to her boss, Staff N, owner.

Based on observations and interview, the facility failed to ensure food was stored and served in sanitary manner with potential to affect 53 of 55 residents. The findings included: During the initial kitchen tour conducted on 12/16/24 at 9:10 AM with the Certified Dietary Manager (CDM), the following was observed: a. Small refrigerator with open cheese in zip lock type plastic bag was not closed. b. Baking potatoes in a cardboard box under prep counter across from 2 compartment sink was wet and upon closer observation the potatoes in the bottom of the box were wet. c. Divided plates were stored right side up on shelf under prep table. Photographic Evidence Obtained. d. Two (2) red buckets with water and rag in each bucket. e. Unlabeled white granular substance in clear container with lid in beverage serving area. Photographic Evidence Obtained. f. Bottom shelf of beverage serving area covered with tin foil, pulled back to reveal rusty surface. g. Ice machine with missing panels on both sides, exposing corroded material and rust. h. Ice scoop in blue plastic holder on wall with large hole in bottom of the plastic container. i. Push cart with containers for hot beverages and condiments with rust on the cart near the wheels. j. In the walk in refrigerator were several open items with no date including jar of jelly, large container of mustard, large container of picante sauce, large container of pickles, 2 large containers of salad dressing, large container of soy sauce, large container of Worcestershire sauce. Also was an open container of sour cream with an expiration date of 12/02/24. k. The walk in refrigerator floor had cracks and was rusty around the parameter edges at base of walls. l. In the walk in freezer (0 degrees Fahrenheit) were several items opened and exposed to the air with no date including the following: half box of sausage patties, half box of sausage links, half box of pizza shells, box of green beans and box of kernel corn with freezer burn, box of pancakes and box of French toast soft to touch, boxes of turkey breast partially defrosted. There was condensation dripping from the ceiling onto the closed boxes of food. m. In the dry goods pantry, there were several open items with no date including the following, bag of macaroni, bag of yellow cake mix, bag flour inside a black plastic bag open, bag of mashed potatoes, clear plastic bin of oatmeal covered with ill-fitting broken plastic lid, second clear plastic bin with oatmeal covered with baking sheet, 3 bags of gelatin, 7 bags of bread, open container of dry mustard powder with no lid, 14 spices with no date, gravy mix. n. In the Caper Room (not marked as such), there were several supplies of paper and plastic items including napkins not sealed or covered with an umbrella next to the napkins. o. Restroom in kitchen with slicer covered with plastic bag and on a push cart. p. Thirty-six (36) florescent light fixtures in the kitchen over food preparation area, food cooking areas and dishwashing areas with cracks in the plastic covers and missing pieces of plastic. q. Two (2) white cutting boards with stains and several baking sheets and pots with dark matter stuck on inside surface that would come in contact with food. During an observation conducted on 12/20/24 at 1:45 PM in the kitchen, Staff M, Dietary Aide, was working on the tray line with no beard net over his beard, just a procedure mask under his chin. An interview was conducted on 12/16/24 at 9:10 AM with the Certified Dietary Manager (CDM) who stated she has worked at the facility since 05/28/24. She stated the maintenance personnel informed her the ice machine works better without the side panels. She was asked about the ovens and stated they (Administration) are aware of the ovens being broken and they are in process of getting them repaired. When asked about checking the red buckets for strength of sanitization, she said they contain no sanitation chemicals, just soap and water. When asked how they sanitize the food prep surfaces, she said they do not sanitize the food prep surfaces, they just clean them with soap and water. She added, they (Administration) knows about this.

Based on observation, interviews and record review, the Administrator failed to ensure the facility was administered in a manner that enabled use of its resources effectively and efficiently which affected all 55 residents in the facility at the time of the survey. The findings included: 1. An interview was conducted with the Administrator / Risk Manager on 12/20/24 at 12:30 PM. The Administrator was apprised of the concerns of the survey team relating to Administration, as follows: a) Four Licensed Practical Nurses administering (IV) intravenous medications without IV certification. Refer to F694 for details. b) Discussed the resident who had an unwitnessed fall with fracture and who was not able to verbalize how it happened. There was no immediate or 5 day report done and the fall investigation did not determine how the fall occurred or what interventions were in/or not in place at the time of the fall. Refer to F689 for details. c) The Administrator was not aware the facility had a pest control issue and had not had a pest technician visit since 12/02/24 when the facility's exterior was treated. The next treatment was supposed to be interior but it had not been done yet. Refert o F925 for details. 41837 2. During the initial kitchen tour conducted on 12/16/24 at 9:10 AM with Staff Certified Dietary Manager (CDM) the following was observed: There were 2 broken ovens with signs labeled broken. Refer to F908 for details.

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficient practices for F803, Menus Meet Resident Nds/Prep in Adv/Followed; F812, Food Procurement, Store/Prepare/Serve Sanitary; and F925, Maintains Effective Pest Control Program. These repeated deficient practices have the potential to affect all 55 residents residing in the facility at the time of this survey. The findings included: Review of the facility's survey history revealed the facility was cited F803 - Food and Nutrition Services related to menus, F812 - Food and Nutrition Services related to kitchen sanitation issues, and F925 - Physical Environment related pest control, during the Recertification and Relicensure survey with an exit date of 09/28/23. Review of the QAPI program with the Administraor revealed the lack of an effective corrective action plan for the above defeciencies. During an interview with the facility's Administrator on 12/20/24 at 12:30 PM, the Administrator was apprised that these 3 deficiencies would be cited on this current survey. This was acknowledged by the Administrator.

Based on observations and interview, the facility failed to ensure kitchen equipment was maintained in safe operating conditions for 2 of 2 ovens, 1 of 1 freezer and 1 of 1 walk-in refrigerator. The findings included: During the kitchen tour conducted on 12/16/24 at 9:10 AM, an observation was made of 2 broken ovens, labeled with signs saying 'broken'. An interview was conducted on 12/17/24 at 1:20 PM with the Administrator and the Certified Dietary Manager (CDM) who stated there are 2 ovens in the kitchen and both are broken. When the CDM was asked if there is any equipment in the kitchen including the refrigerator and freezer, that has issues, the CDM stated that she felt there might be some issues with the walk-in freezer and the walk-in refrigerator since the initial tour of the kitchen with surveyor on 12/16/24. The administrator stated she had only discovered today that the walk-in freezer and walk-in refrigerator was not keeping food at appropriate temperatures and had contacted a vendor to come on 12/17/24 to repair the freezer, but they were unable to repair walk-in refrigerator. An interview was conducted on 12/20/24 at 1:50 PM with the CDM who was asked if they have a scale or weighing foods. She said, 'no they still do not have a scale in the kitchen to weigh food.' When asked how long they have not had the scale, she said she noticed that when she arrived in May 2024. When asked if she had communicated a need for and lack of a scale to anyone, she said to her boss Staff N, owner. An interview was conducted on 12/19/24 at 11:00 AM with the Administrator, who said she was unaware of kitchen not having a scale or of any issue with the refrigerator or freezer until this survey. The Administrator stated she received emails from Regional Director Of Maintenance (RDOM) and Chief Executive Officer (CEO) about the oven but was never provided any documentation from the vendor of invoices that the oven was ordered or the expected delivery.

Based on observation, interview, and review of exterminator service inspection reports, the facility failed to maintain an effective pest control program, as evidenced by observed insects in all stages of life in 1 of 4 hallways ([NAME]), documentation of inconsistent extermination during the past five months, and voiced resident confirmation during interviews. The findings included: During a resident observation on 12/16/24 at 10:36 AM, roach activity was seen in Resident #7's room. Multiple dead roaches and a roach egg were noted behind the resident's bed. Upon further observation, 2 live roaches were seen crawling underneath the resident's bed and wheelchair. Photographic Evidence Obtained. During an interview on 12/16/24 at 11:07 AM, when asked if she had seen any insects in her room, Resident #22 voiced she had seen roaches in her room. She stated, I don't like them. During an interview on 12/16/24 at 11:14 AM, when asked if they had ever seen any bugs in their room, Resident #49 stated he had seen roaches on his side of the room but not as many as his roommate who was by the window. During an interview on 12/16/24 at 11:29AM, Resident #44, who is Resident #49's roommate, stated he has seen roaches everywhere, especially by his window. He voiced that he tried to kill them himself because there were so many. When asked if staff are aware of this issue, he stated that they were aware and they told the resident the pest control company was taking care of the matter but stated he still saw them afterwards. Resident #44 voiced, My family doesn't want to come and visit me because they are afraid to take the roaches home with them. During an interview on 12/16/24 at 02:19 PM, Resident's #43's representative stated she had seen roaches when providing care to the resident. During a follow-up observation on 12/17/24 at 9:10 AM, Resident #7's room still had dead roaches and a roach egg on the floor located behind the resident's bed. During a medication administration observation on 12/19/24 at 8:58 AM, a live roach was observed crawling out from underneath a resident's bed. During an interview on 12/19/24 at 1:09 PM, when asked if the facility had a pest control issue, the Nursing Home Administrator (NHA) stated that there was nothing she was aware of. The NHA was informed of the live crawling insects observed and the voiced confirmations made by multiple resident's and family members. The NHA was asked to locate and provide evidence of pest service for the past couple of months. Review of the service inspection reports by the exterminator revealed the following: On 08/01/24 and 09/01/24, a monthly service was provided by [Company Name} Exterminations where the exterminator was targeting rodents, flies and fire ants. In October of 2024, no exterminator service was provided to the facility On 11/25/24, a biweekly service by [another Company Name] Solutions documented, While doing the initial inspection I was able to walk through and treat the entire facility. Critical areas such as the kitchen was baited and treated in the cracks and crevices. The soiled rooms, common areas, break rooms, and dining rooms. I only treated near the window and bathrooms in the patient's rooms. No obvious signs of insect activity was found today. On 12/02/24, a biweekly service by [Company Name] Solutions documented, The entire exterior of the building was treated for ants and other general household pests. There was lots of ant mounds all over the lawn and exterior of the building. I will continue to follow up on the treatment. Next treatment will be interior. When asked why the service changed from [Name provided] Exterminations to [Name provided] Solutions, the NHA stated that the company was too expensive and they needed a cheaper rate. The month of October with no pest control service to the facility was used to find the cheaper pest control company. When asked to provide evidence of the most recent service for the week of 12/16/24, the NHA stated the exterminator had an emergency and was not able to come out to the facility and is scheduled to service them next week. When asked if she thought the cheaper pest control company was effective she stated, No, not if there are still roaches in the facility.