Every finding on record at Pinnacle Health & Rehab Canton

Based on observations and interviews, the facility failed to ensure the confidentiality of protected health information for 1 of 41 residents during 1 of 3 days of survey (Resident #3).Findings:On 9/24/25 at 3:15 p.m., two surveyors observed an unattended medication cart outside room [ROOM NUMBER] with a fully open computer monitor with Resident #3's electronic Medication Administration Record (eMAR) displayed, visible and easily accessible to residents, visitors or other unauthorized persons. There were no staff observed in the area, and 1 resident was observed in the hall. Approximately 1 minute later the Certified Nursing Assistant/Medication Technician (CNA7) was observed coming from behind the nurses' station and walked up to the medication cart, acknowledged the unsecured medication cart and closed the eMAR stating, I was only over there at the nurses station.During an interview on 9/24/25 at 3:17 p.m., the above was discussed with Director of Nursing.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment for 3 of 3 days of survey (9/22/25, 9/23/25 and 9/24/25) for resident rooms, hallways and the laundry room for 3 of 3 facility tours.Findings:1. On 9/22/25 at 8:00 a.m., a surveyor toured and observed the facility to smell of stale urine and feces throughout the facility.2. On 9/23/25 at 7:55 a.m., a picture was handing on the wall by room [ROOM NUMBER]. The frame was observed to be broken in the bottom left corner and was held together with scotch tape. There was also picture hanging directly across the hall on the wall with the bottom right edge of the frame coming apart. On 9/23/25 at 8:03 a.m. Licensed Practical Nurse (LPN #1) confirmed the finding.3. On 9/23/25 at 9:23 a.m., two surveyors noted a very strong urine order at door of room [ROOM NUMBER]. wet floor sign noted on entrance.4. On 9/24/25 at 8:00 a.m., surveyor again toured and observed the facility to smell of urine and feces throughout the facility. 5. On 9/24/2025 from 8:30 a.m. to 9:05 a.m., a surveyor did an Environmental Tour with the Maintenance Director in which the following findings were discussed and observed:- Resident room [ROOM NUMBER] - Resident #24's motorized wheelchair had an arm rest that had ripped and taped material. Resident #26's wheelchair had rips in both arm rests material. There was clean briefs and clothing on closet floor. The bathroom door trim had chipped/missing paint.- The shower room across from resident room [ROOM NUMBER] had a toilet with a seat that was stained yellowish in color. There were numerous commode buckets, soiled gloves and briefs on the floor. The shower non-skid transition strip was chipped and missing pieces creating an uncleanable surface. - Resident room [ROOM NUMBER]- The inside the toilet bowl was dirty/stained. - Hallway base board heater, outside resident room [ROOM NUMBER], had chipped/missing paint. - The Hallway wall light, across from resident room [ROOM NUMBER], had a broken cover which was dislodged from the lighting unit.- The bathroom across from dining room kitchenette had chipped/missing paint on the doorframe. - The walls in the dining room were marred with black marks and had chipped/missing paint. Laundry:- There were 2 wooden folding tables and 5 wooden laundry carts that had chipped/missing paint and were uncleanable. - The wooden frame, under the small dryer, had chipped missing paint creating an uncleanable surface. - The laundry room floor has chipped/missing paint creating an uncleanable surface. - The wooden drying rack had worn surfaces exposing untreated wood.- The wall exhaust fan was dusty/dirty. On 9/24/25 at 8:15 a.m., in an interview with 2 surveyors present, the laundry aide confirmed the laundry room findings.On 9/24/2025 at 9:05 a.m., in an interview with a surveyor, the Maintenance Director confirmed the findings.

Based on record review and interview, the facility failed to develop/implement goals and interventions for psychotropic use for 3 of 16 care plans reviewed (Resident's #2, #6 and #7).Findings: 1.Resident #3 was admitted on 5/25 and has diagnoses to include major depressive disorder. Review of Resident 's active orders revealed he/she is taking antidepressant medications Remeron and Lexapro, and antianxiety medication Lorazepam. Review of Resident #3's care plan updated 5/13/25 states [Resident #3] uses antidepressant medication r/t Depression. Monitor/document side effects and effectiveness Q-SHIFT. Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. Further review of Resident #3's clinical record lacked evidence he/she was being monitored for side effects from antidepressant medication use. [Resident #3] uses psychotropic medications. [Resident #3] will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Monitor for side effects and effectiveness. Monitor/document/report any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Further review of Resident #3's clinical record lacked evidence he/she was being monitored for side effects from psychotropic medication use. 2. Resident #7 was admitted 6/25 and has diagnoses to include Parkinsons, depression and delusional disorder. Review of Resident's active orders revealed he/she is taking antipsychotic medication Risperdal, and antidepressant medication Duloxetine. Review of care plan initiated 6/24/25 states [Resident #7] uses antidepressant medication. will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Monitor/document side effects and effectiveness Q-SHIFT. Monitor/document/report adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. Further review of Resident #7's clinical record lacked evidence he/she was being monitored for side effects from antidepressant use. [Resident #7] uses anti-anxiety medications. [Resident #7] will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review. Monitor for side effects and effectiveness Q-SHIFT. Monitor [Resident #7] for safety. She is taking ANTI-ANXIETY meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and [NAME] gs. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Further review of Resident #7's clinical record lacked evidence he/she was being monitored for side effects for anti-anxiety medication use. Further review of Resident #7's clinical record revealed he/she is taking antipsychotic medication Risperdal. The facility failed to develop/implement goals and interventions for antipsychotic use. 3. Resident #6 was admitted on 5/24 and has diagnoses to include anxiety disorder, dementia with psychotic disturbance, delusional disorders, and major depressive disorder. Review of Resident 's active orders revealed he/she is taking antipsychotic medication Risperdal and antianxiety medication Buspirone. Review of Resident #6's care plan updated 8/22/25 states [Resident #6] uses anti-anxiety medications. Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. He sometimes will get verbal with roommate. Monitor him for safety. The resident is taking ANTI-ANXIETY meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. Resident #6's clinical record lacked evidence he/she was being monitored for side effects from ANTI-ANXIETY medication use. Review of Resident #6's care plan updated 5/3/24 states [Resident #6] uses psychotropic medications r/t[related to] dementia with psychotic features. Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Further review of Resident #6's clinical record lacked evidence he/she was being monitored for side effects from psychotropic medication use. During an interview in presence of 4 surveyors on 9/23/25 at 12:34 p.m., The Director of Nursing (DON) stated the facility has never monitored anyone for side effects of the above medications.

Based on record review and interviews, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 5 of 16 residents (R) reviewed for care planning (R2, R6, R12, R36, R35).Findings: 1. A review of R35's clinical record revealed an MDS admission Assessment was completed on 8/12/25. Further review of R35's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. On 9/23/25 at 11:32 a.m. during an interview with 2 surveyors, the Social Services Director stated that an IDT meeting was not held following R35's admission Assessment. Findings: 2 Review of Resident #2's clinical record revealed the following: -Annual MDS with completion date 1/22/25. Further review of Resident #2's clinical record revealed the IDT meeting was held on 1/16/25 (6 days prior to completed MDS). Quarterly MDS with completion date 10/23/24. Further review of Resident #2's clinical record revealed the IDT meeting was held on 10/17/24 (7 days prior to completed MDS). 3.Review of Resident #12's clinical record revealed the following: -Quarterly MDS with completion date 1/22/25. Further review of Resident #12's clinical record revealed the IDT meeting was held on 1/16/25 (6 days after the completed MDS). During an interview on 9/23/25 at 10:49 a.m. Licensed Social Worker (SW) stated IDT meetings are scheduled either the week before or the week of the MDS. At this time the above was reviewed and confirmed. 4 Review of Resident #6's clinical record revealed the following: - Quarterly MDS with completion date 11/6/24. Further review of Resident #6's clinical record revealed the IDT meeting was held on 10/31/24 (6 days prior to completed MDS). - Quarterly MDS with completion date 2/5/25. Further review of Resident #6's clinical record revealed the IDT meeting was held on 1/30/25 (6 days prior to completed MDS). 5. Review of Resident #36's clinical record revealed the following: - Quarterly MDS with completion date 6/18/25. Further review of Resident #36's clinical record revealed the IDT meeting was held on 6/12/25 (6 days prior to completed MDS). On 9/24/25 at 1:10 p.m., in an interview with a surveyor, the Licensed Social Worker confirmed that R6's and R36's care plans were not reviewed and completed within 7 days of the IDT meetings.

Based on record review and interviews, the facility failed to monitor and document targeted side effects to support the use of an antipsychotic and antianxiety medication for of 3 residents reviewed for unnecessary medications (Resident's #2, #6 ). Findings: 1.Resident #3 was admitted on [DATE] and has diagnoses to include major depressive disorder. Review of Resident #3's active orders revealed: -Order with start date of 5/14/25 for antidepressant Lexapro Oral tablet 10 mg (Escitalopram) Give 1 tablet by mouth one time a day. -Order with start date of 5/13/25 for antidepressant Remeron Oral Tablet 15 mg (Mirtazapine). Give 1 tablet by mouth at bedtime. -Order with start date of Lorazepam Intensol Oral Concentrate 2 MG/ML (Lorazepam) Give 0.25 ml by mouth every 3 hours as needed for anxiety or restlessness. Review of Resident #3's care plan updated 5/13/25 states: [Resident #3] uses antidepressant medication r/t Depression; Monitor/document side effects and effectiveness Q-SHIFT. [Resident #3] uses psychotropic medications. Monitor for side effects and effectiveness. Further review of Resident #3's entire clinical record lacked evidence he/she was being monitored for side effects of these medications. 2. Resident #7 was admitted with diagnoses to include Parkinson's, depression, and delusional disorders. Review of Resident #7's active medications revealed: -Order with start date of 7/2/25 for antidepressant Duloxetine HCL Capsule Delayed Release Particles 60 mg. Give 1 capsule by mouth two times a day. -Order with start date of 9/17/25 for antipsychotic Risperdal Oral Tablet (Risperidone). Give 0.75 mg by mouth two time a day for delusion, hallucination and mood stabilization. Further review of Resident 7's clinical record lacked evidence that he/she was being monitored for side effects of these medications. Review of Resident #7's care plan imitated 6/27/25 states [Resident #7] uses antidepressant medication. Monitor/document side effects and effectiveness Q-SHIFT. Monitor/document/report PRN adverse reactions: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes . [Resident #7] uses anti-anxiety medications. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report .Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. [Resident #7] has anxiety. Monitor/document for side effects and effectiveness. Review of Resident #7's entire clinical record laced evidence he/she was monitored for side effects of the above medications. During an interview in presence of 4 surveyors. on 9/23/25 at 12:34 DON confirmed the clinical record lacked evidence of monitoring for the side effects of antipsychotic and antianxiety medications. 3. Resident #6 was admitted in 5/24 and has diagnoses to include anxiety disorder, dementia with psychotic disturbance, delusional disorders. Review of Resident 's active orders revealed he/she is taking antipsychotic medication Risperdal and antianxiety medication Buspirone. - Review of Resident #6's active orders revealed: -Order with start date of 5/7/25 for antipsychotic Risperdal Oral Tablet (Risperidone) Give 0.5 mg by mouth two times a day. -Order with start date of 2/16/25 for antianxiety Buspirone HCl Oral Tablet 10 MG (Buspirone HCl) Give 1 tablet by mouth four times a day. - Review of Resident #6's active orders revealed: [Resident #6] uses antipsychotic medications. Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Further review of Resident #6's entire clinical record lacked evidence he/she was being monitored for side effects of these medications. - Review of Resident #6's active orders revealed: [Resident #6] uses anti-anxiety medications. Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Further review of Resident #6's entire clinical record lacked evidence he/she was being monitored for side effects of these medications. On 9/23/25 at 12:35 p.m., in an interview with a surveyor, the Director of Nursing [DON], confirmed the clinical record lacked evidence of monitoring for the side effects of antipsychotic and antianxiety medications.

Based on observations, interviews, and review the facility's Food Storage Policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for fans, a food mixer, and floors. Additionally, the facility failed to ensure foods were properly labeled for 1 of 1 kitchen tour on 1 of 3 days of survey. (9/22/25)Findings:The facility's Food Storage Policy noted: Each item will be dated with a received date, once opened the box will be dated with an open date. Items taken out of the box and opened needs a received date and an open date (as of 9/22/25 all items taken out of a box without labeling of the contents will be labeled with the item name) receive date and open date.On 9/22/25 from 9:00 a.m. to 9:50 a.m., a surveyor conducted a kitchen tour with the Food Service Supervisor in which the following findings were observed: - The dish room had a wall fan that was dusty/dirty, had two ceiling tiles that had fallen partially out of the ceiling grid holding them in place and had a wall air vent that was heavily soiled with dust.- The food mixer had chipped/missing paint on the mix arm and base. Also, there were dried food particles and dried liquid residue on the base. - The dry storage room had ten large bags of cereal that were not labeled. - The walk-in refrigerator floor was extremely rusty. - The walk-in freezer floor was rusty. There were six large bags of breaded patties that were not labeled. On 9/22/25 at 9:50 a.m., in an interview with a surveyor, the Food Service Supervisor confirmed the findings. On 9/22/25 at 2:50 p.m., in an interview, a surveyor discussed the findings with the Food Service Director.

Based on observation, record review, interviews, facility policy, and U.S. Centers for Disease Control and Prevention (CDC) guidance, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection related to the handling of soiled linen for 3 of 3 observations on 2 of 3 days of survey (9/22/25 and 9/24/25) and Enhanced Barrier Precautions (EBP) for 1 of 1 day of survey (9/23/25). Additionally, the facility failed to ensure that a resident being treated for an open and draining wound was maintained on EBP for 1 of 2 sampled residents (R) reviewed for wounds (R35). Findings: The facility's Laundry and Bedding, Soiled policy and procedure dated 04/01/24 noted: Policy: Soiled laundry/bedding(e.g., personal clothing, uniforms, scrub suits, gowns, bedsheets, blankets, towels, etc.) shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. Procedure: 2. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. 3. Place and transport contaminated laundry in bags or containers that are labeled and color-coded in accordance with established policies governing the handling and disposal of contaminated items. 4. Anyone who handles soiled laundry must wear protective gloves and other protective equipment) e.g., gowns if soiling of clothing is likely). 1. On 9/22/25 at 9:45 a.m., a surveyor observed Certified Nursing Assistant (CNA #1) come out of Resident room [ROOM NUMBER] carrying a large armful of unbagged soiled linen against her body and she was not wearing gloves. On 9/22/25 at 9:47 a.m., the CNA #1 confirmed that she should have been wearing gloves, the soiled linen should have been bagged, and she should have not carried it next to her body. On 9/22/25 at 9:58 a.m., in an interview with two surveyors present, the Director of nursing confirmed the finding. 2. On 9/24/25 at 8:00 a.m., a surveyor observed CNA #2 carry an armful of unbagged soiled linen, against her body, to the shower room and put the linen in the soiled linen hamper. She was observed to not be wearing gloves. At this time, the CNA confirmed she carried soiled linen against her body, unbagged and ungloved to the soiled linen hamper. 3. On 9/24/25 at 8:40 a.m., a surveyor observed Registered Nurse (RN #2) carry unbagged soiled linen to the shower room and put it in a soiled linen hamper. RN #2stated that she came from resident room [ROOM NUMBER] and knows the soiled linen should have been bagged. At this time, in an interview with a surveyor, RN #2 confirmed the finding. On 9/24/2025 at 9:45 a.m., in an interview with two surveyors present, the findings were discussed with the Director of Nursing. 4The facilities' Enhanced Barrier Precaution policy and procedure, last reviewed by the facility on 9/9/25 states, Enhanced Barrier Precautions expand the use of Personal Protective Equipment (PPE) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Muli-Drug Resistant Organisms (MDRO) to staff hands and clothing. 4. On 9/23/25 at 10:02 a.m., a surveyor observed CNA#5 remove bed linens from a resident's bed using only gloves in a room with Enhanced Barrier Precautions. On 9/23/25 at 10:17 a surveyor confirmed the finding in an interview with CNA#5. 5. The U.S. Centers for Disease Control and Prevention (CDC), under Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/24 states, Enhanced Barrier Precautions [EBP] are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO [Multi-Drug Resistant Organisms] colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized. Review of facility policy. Categories of Transmission-Based Precautions revised 9/9/25, states, Enhanced Barrier Precautions [EBP] .Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated .for nursing home residents with wounds . Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing . Bathing/showering . Transferring . providing hygiene .changing linens .Changing briefs or assisting with toileting .Wound care . R35 has diagnoses to include cellulitis of right lower limb and rash and nonspecific skin eruption. On 9/22/2025 at 9:28 a.m. and 9/23/25 at 9:20 a.m., observations of R35's room lacked signage for EBP or Personal Protective Equipment [PPE] cart. Throughout the survey, a surveyor observed multiple other rooms on the Long Term Care unit with EBP signs and PPE carts outside resident rooms. R35's care plan, most recently reviewed on 8/22/25 states, .has infection of the rt. [right] lower leg .Administer antibiotic as per MD [medical doctor] orders . Review of R35's August 2025 Medication Administration Record (MAR) indicates R35 received Amoxicillin (an antibiotic) for soft tissue infection from 8/5/25-8/8/25 and 8/8/25-8/11/25 and again received Amoxicillin for cellulitis from 8/19/25 - 8/26/25. Review of R35's active physician orders revealed the following: An order with a start date of 9/9/25 for Refer to wound center for treatment of right lower extremity open areas, weeping An order with a start date of 9/9/25 for cleanse areas on right lower leg with normal saline apply calcium alginate followed by foam dressing change every 3 days and prn [as needed] please soak with normal saline if dressing is adhered. every day shift every 3 day (s) for wound treatment. On 9/24/25 at 8:33 a.m., during an interview with 3 surveyors, the Infection Preventionist (IP) stated residents with surgical wounds or wounds that require care need to be on EBP. At this time, a surveyor discussed the above findings, and the IP stated she knew that R35 had completed his/her antibiotic but was not aware that he/she had a wound being treated and that based on R35's current orders for treatment of an open wound, she would expect R35 to be on EBP. On 9/24/25 at 8:41a.m., during an interview, Registered Nurse (RN) #2 stated R35's wounds are still open but are drying out and that his/her wounds appear worse with the current treatment, so she wants to talk to the provider today before doing R35's wound treatment. At this time, RN #2 stated she wears gloves only for wound care and thinks only residents with infected wounds are placed on EBP. On 9/24/25 at 9:14 a.m., during an interview with 2 surveyors, the above concerns were discussed with the Director of Nursing (DON). At this time, the DON stated only residents with highly draining wounds or wounds with known infectious organisms are placed on EBP and that R35 has a closed dressing for his/her wounds and should not be on EBP.

Based on record review and interview, the facility failed to implement and maintain an effective training program for nursing staff contracted through the AllShifts Application (App) in the areas of dementia care, resident rights, and abuse and neglect training by failing to ensure contracted AllShifts Professionals completed training prior to independently providing services to residents for 4 of 4 contracted staff reviewed during a complaint investigation (Certified Nursing Assistant [CNA] #8, #9, and #10, and Licensed Practical Nurse [LPN] #3).Finding:Review of the AllShifts Terms of Service states, under section 2.1 ALLSHIFTS MARKETPLACE, LLC AS A MARKETPLACE, AllShifts merely makes the Site and Services available to enable Professionals and Facilities to find and transact directly with each other.Users alone are responsible for evaluating and determining the suitability of any shift, Facility, or Professional. and under section 2.2 USERS ARE INDEPENDENT FROM ALLSHIFTS states, .Facilities are solely responsible for and have complete discretion with regard to their use of and activities on AllShifts Marketplace, including.decisions they make with respect to any Professionals with whom they connect for shifts. No actions or decisions of a facility shall in any way affect the relationship of Professionals with AllShifts, which shall remain that of an independent contractor under all circumstances. and under section 3.1 SAFETY AND SUPERVISION BY FACILITIES, states, .It is the sole responsibility of Facilities to monitor and enforce all policies and procedures with Professional, both by including such information in Facilities' User Profiles on the Site and notifying Professionals of such information when they arrive and carry out their responsibilities at Facilities' Facilities.Review of Facility Assessment-Pinnacle Health & Rehab, updated 6/10/25, under Staff training/education and competencies, states, .Upon hire and annually, all employees will attend a comprehensive education program which will include .resident rights, abuse, neglect and exploitation, what constitutes abuse, neglect, exploitation .Each employee must have an orientation check off list completed .A review of the facility's staffing sheets for the dates referenced in the complaint (6/12/24-12/8/24) revealed the following:CNA #8's first shift through AllShifts was 6/17/24, and she worked a total of 16 shifts throughout the above-referenced timeframe. A review of CNA #8's employee file lacked evidence that she received education in the areas of Abuse and Neglect, Resident Rights, and dementia.CNA #9's first shift through AllShifts was 6/12/24, and she worked a total of 25 shifts throughout the above-referenced timeframe. A review of CNA #9's employee file lacked evidence that she received education in the areas of Abuse and Neglect, Resident Rights, and dementia.CNA #10's first shift through AllShifts was 6/18/24, and she worked a total of 11 shifts throughout the above-referenced timeframe. A review of CNA #10's employee file lacked evidence that she received education in the areas of Abuse and Neglect, Resident Rights, and dementia.LPN #3's first shift through AllShifts was 8/8/24, and she worked a total of 10 shifts throughout the above-referenced timeframe. A review of LPN #3's employee file lacked evidence that she received education in the areas of Abuse and Neglect, Resident Rights, and dementia.On 9/24/25 at 12:26 p.m., during an interview, the Director of Nursing (DON) stated that she relies on AllShifts' packet for each contracted Professional that is hired from the App, and that the facility does not provide education to staff contracted through the App. The DON then stated that when a surveyor requested evidence of Abuse and Neglect; Resident Rights; and Dementia training for the above contracted staff yesterday, she contacted AllShifts and requested evidence of the training but has not received it. The DON was unable to provide evidence that the above contracted staff had received the training prior to the end of the survey.

Based on observation, record review and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the annual Long Term Care Recertification Survey, dated 11/19/25, was effective. The Federal citation F583, F584 and F689 were cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 12/30/25.Findings:During the follow-up survey on 12/30/25, it was determined that F583, F584 and F689 would be recited for the same reasons: F583 for failure to ensure the confidentiality of protected health information, F584 for failure to provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment and F689 for failure to ensure that the resident's environment was free of accident hazards. (see F583, F584 and F689)On 12/30/25 at 1:45 p.m., during an interview, the above was discussed with the Director of Nursing.

Based on interviews, record review and facility policy, the facility failed to thoroughly investigate an allegation injury of unknown origin for 1 of 1 facility incident reports reviewed (Resident #12).Findings:Review of Abuse Investigation policy (undated) states All reports of resident abuse, neglect, and.shall be promptly and thoroughly investigated by facility management. The individual conducting the investigation will.Review the completed concern/complaint report; Interview the resident, Interview any witnesses to the incident; Review the resident's medical record to determine events leading up to the incident; interview staff members who have had contact with the resident during the period of the alleged incident; Interview the resident's roommate, family members, and visitors as applicable; Interview other residents to whom the accused employee provides care or services; and review all events leading up to the alleged incident. Witness reports are required to be written with signature and date. On 12/31/24 the Department of Licensing received a facility reported incident stating: On 12/31/24; 12:35 p.m.,. Resident [12], asked to speak with the SW [Social Worker]. [He/she] reported that aide, [Certified Nursing Assistant (CNA)4], pressed [his/her] forehead and pulled [his/her] ear. During an interview on 9/23/25 at 10:49 a.m. Licensed Social Worker (SW) confirmed she was the one that conducted the investigation, but there were no findings. At this time SW was asked to provide complete investigation details. SW stated the whole investigation was in the 5 day follow up. Review of the 5 day follow up dated 12/31/24 states [1/7] Investigation closed. No findings. At this time SW again stated that the entire investigation was on the original incident report, and she had no more information. States she did not interview anyone besides [Resident 12] and [CNA4], and there was no facility education was provided, but she did tell CNA4 not to pull Resident 12's ear anymore. SW confirmed she did not and did not talk to any other residents or staff because she didn't know she needed to.During an interview on 9/24/25 at 11:11 a.m., the above was discussed with Director of Nursing.

Based on record review, interviews, and facility policy, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice by failing to follow their own Accident and Incident and Fall policies when a Certified Nursing Assistant (CNA) failed to notify the charge nurse before moving a resident after a witnessed fall for 1 of 3 residents reviewed for accidents (Resident [R] 26). As a result, the resident's arm got caught in his/her wheelchair, and he/she sustained a right humeral head fracture.Finding:Review of facility 's Accidents and Incidents Policy, revised 9/9/25, states Regardless of how minor an accident or incident may be .it must be reported to the charge nurse as soon as such accident/incident occurs is discovered . The Charge nurse must be immediately informed of accidents or incidents so that medical attention can be provided .Do not move the victim until he/she has been examined for possible injuries .The Charge Nurse shall .Examine all accident/incident victims .Notify the victim's physician of the accident or incident.Review of the facility's Falls Policy, revised 9/9/25, states, All falls need assessment by a licensed nurse prior to moving the resident.On 9/22/25 at 8:41 a.m. during an interview, R26 stated recently, a CNA was pushing him/her in his/her wheelchair when he/she fell forward out of the wheelchair and onto the floor in the hall. R26 then stated his/her right arm and shoulder got broken. A review of R26's clinical record revealed the following progress notes:Nursing progress note, dated 6/24/25, states Resident was sliding from [his/her] wheelchair tonight and when CNA went to pull [him/her] up in chair, [his/her] arm was caught in wheelchair.Nursing progress note, dated 6/24/25, entered 6/25/25, states Late entry: Was told by CNA that Resident was sliding from chair and [he/she] was pulled back up into chair. When [he/she] was pulled up. arm was caught between the wheel and chair. Was not told about [him/her] being on floor at this time.Nursing progress note, dated 6/25/25 states, Seen by . NP [nurse practitioner] for follow up of shoulder pain.Resident is stating [he/she] was 'launched' out of [his/her] wheelchair. Spoke with evening charge nurse, she states she was only told that resident was sliding out of chair and aide pulled [him/her] back, catching [his/her] arm in the chair resulting in the pain.Provider note dated 6/25/25 states, . Patient reported to have been slipping out of [his/her] wheelchair last evening. Reported that [he/she] fell out.complained of right arm pain. has swelling to [his/her] right upper arm with faint bruising and tenderness. states [he/she] cannot extend it because it hurts too much .Due to pain will obtain xray [x-ray] to right shoulder and humerus . Nursing progress note dated 6/25/25 states, Radiology called.verbally reported that resident does have right humeral head fracture. Nursing progress note dated 6/26/25, Follow up investigation of incident- per CNA resident was being wheeled down through hall, aide turned chair to back resident through double doors when resident fell out of chair. She said she sat [him/her] up and then assisted [him/her] back into chair, then went and told nurse about the incident.Per charge nurse, she was not aware an actual fall had occurred, therefore did not notify on call per policy.Review of the facility's incident report dated 6/24/25 states, Resident was sliding out of [his/her] chair and CNA pulled [him/her] back into chair.right arm was caught in between wheel and chair. [He/she] complained to this nurse that [his/her] arm was caught in chair and it was hurting [him/her] at this time. Further review of the incident report and of R26's clinical record lacked evidence that the charge nurse notified the provider of the accident/incident or R26's complaint of arm pain.On 9/22/25 at 2:23p.m., during an interview, the Director of Nursing (DON) stated she is the one who notified the provider the next morning after R26 fell due to increased pain in R26's arm and stated CNA #6 did not tell the charge nurse that R26 had fallen, so the provider was not notified at the time of the accident/incident.On 9/24/25 at 9:16 a.m., during an interview with 2 surveyors, the above concerns, including CNA #6's failure to notify the charge nurse of the fall before moving R26 and the charge nurse's failure to notify the provider of the accident/incident or of R26's complaint of arm pain following the accident/incident, were discussed with the DON. At this time, the DON stated that she would not expect the charge nurse to notify the provider that R26's arm got caught in the wheelchair and that the charge nurse verbally counseled CNA #6 following the incident.

Based on observation and interview, the facility failed to ensure that the resident's environment was free of accident hazards by ensuring a base board heater cover was secure and in place covering sharp metal for 1 of 1 observation on 1 of 3 days of survey. (9/22/25)Finding:On 9/22/25 at 9:53 a.m., a surveyor observed a base board heating unit in the hallway across from resident room [ROOM NUMBER] that had the front cover partially off exposing sharp metal fins.On 9/22/25 at 9:58 a.m., in an interview with two surveyors present, the Director of Nursing confirmed the finding and stated that the facility has residents that ambulate around the facility and move around the facility in wheelchairs.

Based on record review and interview, the facility failed to ensure a residents call bell was within reach for 1 of 1 resident (Resident #1). Findings: Review of Resident #1 progress note dated 5/27/25 at 10:55 a.m. indicated that he/she sustained an unwitnessed fall, he/she was found in front of his/her wheelchair next to his/her bed. Review of the post fall assessment completed 5/27/25 showed the resident did not have his/her call bell within reach at the time of the fall. Review of Resident #1 care plan under the focus states he/she is at risk for falls. Further review shows that under Interventions/Tasks section of the care plan staff should Be sure (his/her) call light is within reach and encourage the resident to use it for assistance as needed On 6/10/25 at 11:00 a.m., the above information was discussed with the Director of Nursing.

Based on observations, interviews, record reviews, and facility policy, the facility failed to update/implement a care plan in the area of falls for 2 of 2 sampled residents (#30 and #80, in the area of Post Traumatic Stress Disorder (PTSD) for 1 of 1 resident (Resident #9), and in the area of mood and behaviors for 1 of 1 residents reviewed for behaviors (Resident #31). Findings: 1. On 7/29/24 at 11:08 a.m., two surveyors observed Resident #30 in a wheelchair with his/her feet on the wheelchair pedals. The call bell was attached to the bed, outside of the resident's reach. The Surveyor asked the resident if he/she could reach the call bell, he/she attempted but could not reach. At this time, Certified Nurse Aide (CNA) #4 confirmed Resident #30 cannot propel independently in his/her wheelchair and would not be able to move the wheelchair to reach the call bell. Review of Resident #30's care plan for falls initiated on 1/5/23 instructs nursing to Be sure [his/her] call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. 2. On 7/29/24 at 11:10 a.m., two surveyors observed Resident #8 lying in bed. The foot of the bed was against the wall next to the call bell, which was coiled up and hanging on the wall, not within reach for the resident. At this time, CNA #4 confirmed Resident #8 requires a hoyer lift for transfers and would not be able to reach his/her call bell. Review of Residents #8's care plan for frequent falls related to impaired mobility, last revised on 6/08/20 instructs nursing to, Be sure [his/her] call light is within reach and encourage [him/her] to use it for assistance as needed. [He/she] needs prompt response to all requests for assistance. [He/she] needs reminding to use the call light when [he/she] needs assist. In addition the care plan for activities of daily living , transfers revised on 6/15/20 instructs nursing to, mechanical lift for transfers and Encourage [him/her] to use bell to call for assistance. On 7/30/24 at 3:44 p.m., the above care plan concerns were discussed with the Director of Nursing. 42531 3. Review of policy Trauma Informed Care undated states .The resident, responsible party, and multidisciplinary team will develop a resident centered care plan the will include triggers that may [case] re-traumatization, as well as [anu] holistic interventions that may keep the resident safe and healthy . Resident #9 was admitted on [DATE] with diagnoses to include paranoid schizophrenia, anxiety disorder, post-traumatic stress disorder (PTSD), bipolar disorder, and major depressive disorder During an interview on 7/31/24 at 9:18 a.m., Licensed Social Worker (LSW) indicated that residents with PTSD should have a care plan that includes their triggers, how they cope, and how facility can help them. During a follow up interview on 7/31/24 at 10:49 a.m., LSW and a surveyor reviewed Resident #9's entire care plan and confirmed Resident #9 was admitted with diagnoses of PTSD and the facility did not update care plan as required for trauma informed care. At this time LSW indicated that when trauma Informed care came out, she made sure all the new people had it in their care plans but didn't go back to the ones that have been here long term. During an interview on 7/31/24 at 11:04 a.m. the above was discussed with DON 4. Resident #31 was admitted to facility on 12/2/22 and has diagnoses to include dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had a Brief Interview for Mental Status (BIMS) of 8 of 15 indicating moderate cognitive impairment. Further review of Resident #31's MDS revealed he/she has physical and verbal behaviors directed towards others. Review of Resident #31's clinical record revealed he/she refuses care often and has verbal and physical behaviors towards staff. Review of Resident #31's care plan most recently updated 7/11/24 lacked evidence of goals and interventions for mood/behaviors. During an interview 7/30/24 12:26 p.m., Certified Nursing Assistant (CNA)#1 indicated Resident #31 refuses care often and refuses to have his/her hair washed at any time and will not always let you shave his/her face and has been both physically and verbally aggressive toward staff. During an interview on 7/31/24 at 10:51 a.m., LSW confirmed Resident #31's refuses care often and has both verbal and physical behaviors. At this time, a surveyor and LSW reviewed Resident #31's entire care plan and confirmed Resident #9's care plan did not include goals and interventions for mood and behaviors/refusal of care.

Based on observations and interviews the facility failed to promote care for a resident in a manner that maintains dignity and respect when staff failed to groom a resident on 3 of 3 survey days (Resident #31). In addition, the facility failed to identify a medication correctly to 1 of 1 resident observed for medication pass (Resident #242). Findings: 1. Resident #31 was admitted on [DATE] and has diagnosis of dementia and is dependent on staff for all of his/her activities of daily living needs. During observations on 7/29/24 at 11:01 a.m., 7/30/24 at 9:39 a.m., and 12:26 p.m., 7/31/24 at 8:21 a.m., Resident #31 was noted to have long facial/chin hair. Review of Resident #31's Task-Personal Hygiene-Support Provided - How resident maintains personal hygiene, including . shaving, revealed Resident #31 received 1-2 person hygiene assistance on 7/26/24 at 11:04 a.m., and 22:05 [10:05 p.m.], on 7/27/24 at 10:14 a.m., and 21:11 [10:11 p.m.], on 7/28/24 at 10:03 a.m., and 17:48 [5:48 p.m.] on 7/29/24 at 10:22 a.m., and 21:52 [10:52 p.m.], on 7/30/24 at 11:04 a.m., and 22:36 [11:36 p.m.] and 7/31/24 at 10:00 a.m. During an interview on 7/30/24 at 12:26 p.m., Certified Nursing Assistant (CNA)#1 indicated residents should be shaved every day and if they refuse, it should be documented, but staff should go back and try again. During an interview on 7/30/24 at 2:48 p.m., CNA#2 indicated all residents should be shaved daily and if they refuse it should be documented in the clinical record, the nurse should be notified, and the resident should be re-approached later or by another staff member. During an observation on 7/31/24 at 9:32 a.m., with Director of Nursing (DON), the DON confirmed Resident #31 had obvious facial/chin hair and stated it should be shaved daily. 50218 2. During observation on 7/30/24 at 9:39 a.m., Registered Nurse (RN) #2 was observed handing Resident #242 a medication cup containing 1 tablet. Resident #242 asked what the medication was, and RN #2 replied it was a TUMS. At this time Resident #242 took the medication. Review of Resident #242's clinical record revealed medication order with start date of 4/26/24 for PreserVision ARDES 2 chewable tablet. Give 1 tablet by mouth one time a day for supplement eye health at 8:00 a.m. During an interview on 7/30/24 at 9:49 a.m., RN #2 confirmed the medication she gave Resident #242 was not TUMS, but a PreserVision ARDES 2 chewable tablet. When asked why she had told Resident #242 it was TUMS, RN #2 stated that the resident was Persnickety about taking medications. During an interview on 7/30/24 at 10:02 a.m., Director of Nursing confirmed with 2 surveyors that failing to accurately answer Resident #242's question was not acceptable practice.

Based on observation, interview, record review and facility policy the facility failed to adequately date and ensure expired medications were removed from the supply available for use in 1 of 2 medication carts observed (nurse medication cart) and failed to ensure biologicals were stored at appropriate temperatures in 2 of 3 refrigerators observed (medication room top and bottom refrigerators). Findings: Facilities Storage of Medications policy and procedure, effective July 2020 states, All medications are maintained within the temperature ranges . refrigerated 36 F to 46 F with a thermometer to allow temperature monitoring .The facility should maintain a temperature log in the storage area to record temperatures at least once a day . The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC guidelines .When the original seal of the manufacturers container or vial is initially broken, that container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened . The nurse will check the expiration date of each medication before administrating it. No expired medication will be administered to a resident. All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. 1. On 7/29/24 at 11:27 a.m., during observation of the nurse medication cart with the Registered Nurse (RN #1), the following was noted by two surveyors: > One Aspart insulin flex pen labeled with an opened date of 6/7/24. Manufactures instructions of, Keep in a refrigerator at 36 to 46 F until first use. After first use store out of the refrigerator below 86 F for up to 28 days. > One Basaglar Kwik Pen (insulin glargine) labeled with an opened dated of 6/01. Manufacture instructions of, Store unused pens in the refrigerator at 36 to 46 F. Do not freeze Basaglar. Do not use if it has been frozen .Throw away the pen you are using after 28 days, even if it still has insulin left in it. > One Lantus SoloStar Pen opened with no date. Manufactures instructions of, Store not in use Lantus refrigerated between 36 to 46 F. Do not freeze Lantus. Discard Lantus if it has frozen. In-use Lantus should be thrown away after 28 days, even if it still has insulin left in it. > Two Lispro Kwiki pens, one opened without a date and one labeled with an open date of 6/5/24. Manufactures instructions of, Insulin lispro should be stored in the refrigerator 36 to 46 F until it is opened, but do not freeze it. Discard unused portion of the pen 28 days after first opening. At this time, RN #1 confirmed the medications were expired and removed them for availability. 2. On 7/30/24 at 9:15 a.m., during observation of the medication room with the Registered Nurse (RN #2) the following was noted by 2 surveyors: >Top dormitory style refrigerator with a freezer compartment had excessive buildup of ice preventing the freezer door from closing. The refrigerator contained a box of Ozempic pens located on the top shelf next to the freezer compartment, several bags containing Trulicity pens on the lower shelf and 5 bottles of Lorazepam concentrated on the door. Ozempic Manufactures instructions; Ozempic should be kept in the refrigerator at a temperature ranging from 36 to 46 F prior to first use. However, Ozempic should not be stored in the freezer or close to the refrigerators cooling element. Trulicity Manufactures instructions; Store in refrigerator of 36 to 46 F .Do not freeze. Lorazepam Manufactures instructions; Store at 36 to 46 F. Review of the top medication refrigerator temperatures documented for the month of July stated 2 of 30 days had the appropriate temperatures between 36 to 46 F, all of the other temps were below the recommended temperature. >Bottom dormitory style refrigerator with a freezer compartment had excessive buildup of ice preventing the freezer door from opening. The refrigerator contained several bags of unused insulin pens stored on the top shelf next to the freezer compartment. The lower shelf had additional insulin pens/vials and a bag with 7 vials of the COVID-19 vaccine. The refrigerator door had an opened and unlabeled multi dose vial of Tuberculin purified protein derivative. COVID-19 manufacturer instructions to store refrigerated between 36 F to 46 F for up to 30 days. Tuberculin purified protein derivative manufacturer instructions to, store at temperature between 36 to 46 F. Do not freeze. and Once entered, vial should be discarded after 30 days. Review of the bottom medication room refrigerator temperatures documented daily for the month of July stated 2 of 30 days had the appropriate temperatures between 36 to 46 F, all of the other temps were below the recommended temperature. On 7/30/24 at 1:43 p.m., the Director of Nursing, RN #2 and the surveyor observed both top and bottom refrigerators, the freezer compartments, the temperatures and the medications being stored confirming the above concerns.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable interior for bathrooms, a ceiling tile, a patient lift, lights, floors and wheelchairs for 1 of 1 facility tour (7/31/24). Findings: A surveyor conducted a facility Environment tour on 7/31/24 from 12:05 p.m. to 12:30 p.m. with the Maintenance Director and the Administrator in which the following findings were observed: > The bathroom, located across from the nurse's station, had a dirty floor around base of the toilet and stained floor tiles. > The hallway ceiling tile, by resident room [ROOM NUMBER], had a large brown stain on it. > The sit-to-stand patient lift, in the hallway by resident room [ROOM NUMBER], had chipped/missing paint on the foot base creating an uncleanable surface. Additionally, there was dirt and food debris in the foot base area. > Resident room [ROOM NUMBER] - There was dust/debris in the bathroom light and the floor was dirty around the base of the toilet. > Resident room [ROOM NUMBER] - The bathroom floor was dirty around the base of the toilet and there was a bedpan sitting on the bathroom floor. Resident #17's wheelchair was dusty and soiled with food debris. > Resident room [ROOM NUMBER] - Resident #30's wheelchair was soiled with food debris and had dried liquid residue on the right side of the chair. > Resident room [ROOM NUMBER] - Resident #7's reclining wheelchair had a footrest with material that was ripped/torn, with ripped black tape on it and in disrepair, creating an uncleanable surface. On 7/31/24 at 12:05 p.m., in an interview, the Maintenance Director and the Administrator confirmed the findings.

Based on record reviews and interview, the facility failed to ensure that 2 of 2 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-Admission Screening & Resident Review Level II (PASRR) evaluation and determination (Resident #10 and Resident #15). Findings: 1. Resident #10 was admitted to the facility on [DATE] with diagnosis of Schizophrenia. Resident #10's clinical record contained a PASRR Level I determination letter dated 6/12/24 that stated further PASRR evaluation was not required due to Resident #10 met the criteria for a short-term convalescence admission. Resident #10 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed after Resident #10's stay changed from short-term to long-term. 2. Resident #15 was admitted to the facility on [DATE] with diagnosis of Schizophrenia and Bipolar Disorder. Resident #15's clinical record contained a PASRR Level I determination letter dated 5/24/24 that stated further PASRR evaluation was not required due to Resident #15 met the criteria for a short-term convalescence admission. Resident #15 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed after Resident #15's stay changed from short-term to long-term. On 7/30/24 at 3:00 p.m., in an interview, the Social Service Director confirmed the finding. On 7/30/24 at 3:30 p.m., in an interview, the surveyor discussed the finding with the Director of Nursing.

Based on record review and interviews, the facility failed to ensure that a care plan was updated to reflect the resident's current needs for range of motion for 1 of 1 residents reviewed for range of motion (ROM) (Resident #4). Finding: Resident #4 was most recently admitted [DATE] with diagnosis of Cerebral Palsy with muscle wasting and atrophy. Observations of Resident #4 on 7/29/24 at 11:56 a.m., and 7/30/24 at 1:15 p.m., revealed he/she has bilateral hand/arm contractures. At this time Resident #4 indicated that he/she did not have a hand brace and did not want one. Review of Resident #4's clinical record revealed order with start date of 12/22/17 states BRACE MAY WEAR PRN as needed for POSITIONING HAND/WRIST FOR NEUTRAL POSITION Further review of Resident #4's clinical record revealed order was discontinued on 9/5/23. Review of Resident #4's entire clinical record revealed that care plan meetings were held on 1/25/2024, 4/18/2024, 7/18/2024, and 10/26/2023. Review of Resident #4's Care Plan most recently updated 7/18/24 states [Resident #4] has cerebral palsy; Use braces and splints as ordered. Has a left elbow splint to be worn except for R.O.M and care and to remove at HS. OT to monitor/document and treat as indicated. Encourage resident/caregivers to use and correctly apply all splints, and braces. Use assistive devices recommended by OT for grooming, and other activities in order to facilitate independence. Further review of Resident #4's care plan lacked evidence that the care plan was updated after the wrist brace was discontinued. During an interview on 7/30/24 at 12:43 p.m., Occupational Therapist (OT) revealed Resident #4 was discharged from OT on 1/5/22 and has not had a left arm brace for at least a year to her knowledge. During an interview on 7/30/24 at 1:17 p.m., Certified Nursing Assistant (CNA)#3 indicated she has been at the facility since 10/23 and has never seen Resident #4 with any kind of brace and has never known him/her to use one. During an interview on 7/30/24 at 1:21 p.m., with Registered Nurse (RN) #4 confirmed Resident #4 Care Plan was incorrect and was not updated after the splints were discontinued. During an interview on 7/30/24 at 1:27 p.m. the Director of Nursing (DON) confirmed the above findings.

Based on interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 2 residents reviewed for baseline care plans. (#190). Findings: Resident #190 was admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD). Review of Resident #190 active orders July 2024 revealed the following: -Order with start date of 7/23/24 for Advair HFA Inhalation Aerosol 115-21 MCG/ACT (Fluticasone-Salmeterol) 2 puff inhale orally two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE. -Order with start date of 7/24/24 for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 6 hours as needed for SOB or Wheezing via nebulizer and 3 ml inhale orally two times a day for copd. -Order with start date of 7/24/24 for Prednisone Oral Tablet 10 MG (Prednisone). Give 3 tablet by mouth one time a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . -Order with start date of 7/23/24 for ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate)2 puff inhale orally every 4 hours as needed for wheezing. Review of Resident #190's care plan initiated 7/23/24 lacked evidence that a baseline care plan was initiated within 48 hours to include goals and interventions for his/her respiratory concerns. On 7/31/24 at 10:53 a.m., during a review of Resident #190's entire clinical record with a surveyor, the Licensed Social Worker confirmed Resident 190's care plan did not include goals and interventions for his/her respiratory diagnoses.

Based on review of the Nursing Facility Reportable Incident Form submitted to the Division of Licensing and Certification on 9/14/20, the facility's internal investigation, and interviews the facility failed to ensure that 1 of 1 resident (Resident #1) was free from physical abuse. Finding: A review of the Nursing Facility Reportable Incident form submitted to the Division of Licensing and Certification on 9/14/20 revealed that on the early morning of 9/14/20 a Licensed Practical Nurse (LPN) entered (Resident # 1's) room, found Resident #1 sitting up on the edge of his/her bed, and was trying to assist Resident #1 to lie back down. Resident #1 became combative, and the LPN lost it and hit (Resident #1) back The Nursing Facility Reportable Incident form states that the LPN hit Resident #1 with a closed fist, Resident #1 had blood on his/her forehead and required treatment to his/her forehead as a result. A review of the facility's internal investigation concluded that on 9/14/2020 at approximately 1:13 a.m. revealed Resident #1 had been hollering in the early morning hours, complaining his/her bed was not working. The LPN made attempts to calm the resident, Resident #1 continued to holler out and the LPN entered the resident's room again, the resident was sitting on the edge of the bed, the LPN attempted to assist Resident #1 to lie back down , Resident #1 became combative, and hit the LPN in the face. The LPN- charge nurse reports that he then hit Resident #1 in the facial/forehead region resulting in a black eye and outer upper eyebrow region bruising, as well as bruising and bleeding to the forehead. 9/22/2020 at 8:45 a.m. in an interview with the Director of Nursing (DON) reported on 9/14/20 she received a phone call from (LPN #1) about 1:14 in the morning. (LPN #1) told me he had hit (Resident #1) in the face. I came in and interviewed him and the other staff that were working that night. I interviewed (Resident #1) and he/she told me that he/she hit (LPN#1) and that (LPN #1) hit him and then (Resident #1) was laughing. (Resident #1) did not appear to be in any distress. (Resident #1) was not grimacing. (Resident #1) denied any pain. (LPN #1) was terminated immediately as of when I relieved (LPN #1) at about 2:30 in the morning. At 3:30 p.m. in an interview with the Director of Nursing (DON), she states the local sheriff department and Adult Protective Services (APS) conducted independent investigations, colored photographs of the resident's injuries were taken immediately after the incident and 3 days later shows physical evidence of injuries to the left eye region and forehead. On 9/22/2020 at 1:00 p.m. an interview and observation of Resident #1 was conducted, he/she stated he/she was struck in the face/forehead with a closed fist by the LPN. Physical evidence of yellowish/bluish discoloration with swelling to the left eye and forehead was visible. Resident #1 states: It doesn't hurt. He hit me here in the head. I hit him. He hit me. 9/23/2020 at 8:05 a.m., in a telephonic interview with the LPN, he confirmed hitting Resident #1 one time with a closed fist in the face/forehead area resulting in injury to Resident #1. I left the room and I called (DON) and told her what happened. He/she had injuries to his/her forehead, I hit him/her once, I hit him/her on the forehead. I opened up some skin tears on his/her forehead and it was bleeding pretty good. I only hit him/her once in the forehead.