Every finding on record at River Heights Healthcare Center

Based on interview, record review, and facility policy review, the facility failed to ensure residents were free from verbal abuse when a registered nurse used profane, intimidating, and demeaning language toward two (2) of 10 residents reviewed for abuse. Resident #1 and Resident #4.Based on corrective actions taken by the facility on 6/3/26, the State Agency determined the deficiency to be Past Non-Compliance, and the facility was in compliance on 6/4/26 prior to survey entrance on 6/15/26. Findings included:Record review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat the resident's symptoms .Resident #1Record review of facility investigation regarding an allegation of the verbal abuse of Resident #1 revealed on 5/31/2026 at 11:11 PM, Registered Nurse (RN) #1 notified the Administrator (ADM) that RN #2 used profanity toward the resident during medication pass on the 7am-3pm shift. On 6/1/2026 RN #3 stated that Resident #1 asked RN #2 Can I have my medicine, over and over, and she witnessed RN #2 state, Get the f*** away from me. During interview RN #2 denied cursing at the resident. Further interviews revealed that Certified Nursing Assistant (CNA) #1 also heard RN #2 cursing at Resident #1. Based on the investigation the facility corroborated the verbal abuse towards Resident #1.Record review of Statement of Witness-Confidential dated 6/1/26, signed by CNA #1 revealed he witnessed RN #2 tell Resident#1 to Get the f*** away from her cart.Record review of Statement of Witness-Confidential dated 6/2/26, signed by RN #3 revealed that she witnessed RN #2 tell Resident #1 to Get the f*** away from me. Record review of admission Record revealed that the facility admitted Resident #1 on 10/6/2023 with diagnoses including Unspecified Convulsions and Restlessness and Agitation.Record review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 3/23/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 03 indicating that the resident was severely cognitively impaired.Resident #4 Record review of facility investigation of an allegation of the verbal abuse of Resident #4 revealed on 6/2/2026 at 3:45 PM, during Resident Council meeting, Resident #2 and Resident #3 reported to ADM that they witnessed RN #2 curse at Resident #4 on 5/31/2026 when he asked about his medicine. Resident #3 reported that Resident #4 asked the nurse where the rest of his medicine was and the white nurse stated, N**** this is your medicine. His ugly a** need to leave me alone. Resident #4 stated that he asked the nurse what the medicine was she was giving him, and she told him that she didn't have time to explain and she walked on down the hall; and she said, If you want them come down the hall your d*** self. Resident #2 stated, I was there, I was standing right in front of the nurse's station, and it was that white nurse. We were at the nurse's station, and he asked what pill he was taking. And the nurse said, I don't got no d*** time to explain no medicine to a resident. Based on the investigation the facility corroborated verbal abuse towards Resident #4.Interview with the Administrator on 6/15/26 at 3:00 PM, she verified that based on the facility's investigation they corroborated verbal abuse of Resident #1 and Resident #4 by RN #2. Interview with the Director of Nursing on 6/16/26 at 8:00 AM, she stated that RN #3 did not tell her that RN #2 had cursed at the resident. She only told her that she was rude. She stated she did not find out that RN #2 cursed the resident until the next day when the ADM talked to her about the situation.Interview with Resident #4 on 6/16/26 at 9:00 AM, he verified that RN #2 cursed at him during medication administration on 5/31/26 During the day stating that she Did not have d*** time to explain medication to a resident and walked away stating If you want them come down the hall your d*** self.Interview with Resident #3 on 6/16/26 at 9:05 AM, she verified that she was present and heard RN #2 curse at Resident #4 but did not specify what she heard the nurse say. Interview with Resident #2 on 6/16/26 at 9:07 AM, he stated that he was present on 5/31/26 when RN #2 cursed at Resident #4. He stated the only curse word she used was d***. He verified that the nurse said she Did not have d*** time to explain medication to a resident if you want them come down the hall your damn self, and she walked away.Record reviews and follow-up interview with Administrator on 6/16/26 at 9:25 AM, revealed that the facility thoroughly investigation the allegations. An abuse in-service was initiated, and staff were not allowed to work until in-service was attended. The facility reported the abuse to all necessary entities. Facility initiated audits to identify and prevent abuse. Both residents were assessed and monitored for trauma, with no negative outcomes and their care plans were updated. The ADM confirmed that the incident and investigation results were presented to the Quality Assurance Committee on 6/3/26 during which the facility policy was reviewed with no revisions made. State Agency validated this was completed on 6/3/26 and the facility was in compliance on 6/4/26 prior to State Agency entrance on 6/15/26.Record review of admission Record revealed that the facility admitted Resident #2 on 1/23/26 with a diagnosis of Displaced Transverse Fracture of Shaft of Right Tibia.Record review of the MDS with an ARD of 4/28/26 revealed Resident #2 had a BIMS score of 15 indicating that the resident was cognitively intact. Record review of admission Record revealed that the facility admitted Resident #3 on 11/11/24 with a diagnosis of Sickle-Cell Disease. Record review of the MDS with an ARD of 5/25/26 revealed Resident #3 had a BIMS score of 15 indicating that the resident was cognitively intact. Record review of admission Record revealed that the facility admitted Resident #4 on 6/23/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record review of the MDS with an ARD of 2/16/26 revealed Resident #4 had a BIMS score of 15 indicating that the resident was cognitively intact.

Based on observations, interviews, record review and facility policy review the facility failed to implement physician orders related to colostomy care and suprapubic catheter care for one (1) of (1) care observations. Resident #9Findings Include:A record review of the facility's policy Compliance Risks--Resident Quality of Care and Quality of Life revised January 2025, revealed Compliance with the Medicare and Medicaid Requirements of Participation for resident quality of care and resident quality of life is consistent with the goals of the overall compliance and ethics program .On 5/5/26 at 2:00 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated Resident #9 performs his own catheter care.On 5/5/26 at 3:27 PM, during an interview and observation with Resident #9 stated he performs his own catheter care and colostomy care. He stated the 11-7 nurse brings his colostomy bag to his room around 3:00-4:00 AM daily. He stated he applies three pairs of gloves and removes one pair after each step of care, uses a wet soap towel for catheter care, and wipes from the insertion site downward. He stated a nurse had never observed him performing the care. A clean colostomy bag was observed on the bedside table.On 5/6/26 at 12:20 PM, during an observation a clean colostomy bag was observed on the table by Resident #9's bed.During an interview on 5/7/26 at 11:23 AM, the Director of Nursing (DON) confirmed she was aware that Resident #9 performs his own colostomy and suprapubic catheter care. She stated the resident is at risk for infection and that there is no physician order or assessment in place for the resident to perform his own care. She stated she is aware that nurses have been signing off on the ETAR as if the care was completed by order. She stated they did not follow physician orders.During an interview on 5/7/26 at 11:45 AM, Registered Nurse (RN) #3 confirmed she is aware that Resident #9 performs his own colostomy and suprapubic catheter care and that she has been signing the ETAR. She stated she cuts the wafer and provides supplies, and the resident does the care.A record review of the admission Record revealed the facility admitted Resident #9 on 3/5/24 with diagnoses including Urinary Tract Infection, Uninhibited Neuropathic Bladder Not Elsewhere Classified, Colostomy complications unspecified, and Other Retention of Urine.A record review of Resident #9's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/4/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact.A record review of the Order Summary Report revealed an order dated 8/1/24, Clean suprapubic catheter with soap and water per Certified Nursing Assistant (CNA) every shift and an order dated 9/13/24 Clean the stoma with soap and water, pat dry, wipe skin around stoma with skin prep, and apply wafer with bag as needed.A record review of Resident #9's Electronic Treatment Administration Record (ETAR) for April and May 2026 revealed numerous signatures by nurses that the colostomy and suprapubic catheter care were being completed by nurses. RN #3 signed it on 5/7/26.

Based on interview, record review and facility policy review, the facility failed to ensure residents were treated with respect and dignity from a staff member for six (6) of eleven (11) residents who attended the Resident Council meeting on 5/5/26. Residents #2, #20, #19, #29, #18, #47.Findings include:A review of the facility policy, Resident Rights, revised October 2025, revealed, Policy Statement .Employees shall treat all residents with kindness, respect, and dignity .A record review of the grievance logs for 2026 revealed no documented concerns related to staff conduct or resident dignity.A record review of the Resident Council meeting minutes for 2026 revealed no documented concerns related to staff conduct or resident dignity.During a Resident Council meeting on 5/5/26 at 2:00 PM, (11) residents were present, all with a Brief Interview for Mental Status (BIMS) score of (15), indicating the residents were cognitively intact. All (11) residents identified Licensed Practical Nurse (LPN) #1 as often being rude during medication administration and general interactions. They specifically stated she is rude, pushy, and snappy, and speaks to them as though they are children. Many indicated they had not previously reported this concern because they feel staff members side with one another. The State Agency asked the Resident Council President and [NAME] President why the concern had not been reported to the Administrator. They stated they believed the Administrator would take the nurse's side and that reporting would do no good.Resident #2 On 5/5/26 at 3:11 PM, during an interview with Resident #2, he indicated that he does not like interacting with LPN #1, as she is rude when administering his medications and often talks to him as if he were a child. He says it is not going to do any good complaining to the staff because they will not do anything.A record review of the admission record revealed the facility admitted Resident #2 on 10/14/24 with diagnoses including Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Hypokalemia.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/12/26 revealed a Brief Interview Mental Score (BIMS) of (15), indicating the resident is cognitively intact.Resident #20 On 5/6/26 at 2:53 PM, during a follow-up interview with Resident #20, he reported that when LPN #1 brings his medications, often before dinner, he requests to take them after eating instead, as they upset his stomach. He asserts that the nurse consistently refuses this request, responding in a confrontational manner, stating, You have to take it now, and I'm not leaving your room until you do! Resident #20 emphasizes that her tone is disrespectful and condescending, making him feel treated like a child. He mentioned that he brought this issue to the Administrator's attention months ago, who promised to investigate it. However, he noted that the nurse's behavior remains unchanged.A record review of the admission record reveals the facility admitted Resident #20 on 7/1/24 with diagnoses including Abdominal Distension (Gaseous).A record review of the MDS with an ARD of 3/30/26 revealed a BIMS score of 15 indicating the resident is cognitively intact.Resident #19 On 5/6/26 at 3:07 PM, during a conversation with Resident #19, the Resident Council President shared his feelings about LPN #1's tone towards him. He described her communication style as condescending when she gives him his medications, which he interpreted as rudeness. He states her behavior has left him feeling hopeless and disrespected. He said that he hasn't felt comfortable discussing these concerns with the Administrator or the Social Worker, as he has seen in the past that the staff tends to support one another in ways that may overlook the feelings and experiences of the residents.A record review of the admission Record reveals the facility admitted Resident #19 on 5/7/13 with diagnoses including Unspecified Lack of Coordination.A record review of the MDS with an ARD of 4/16/26 revealed a BIMS score of 15, indicating the resident is cognitively intact.Resident #29 On 5/7/ 2026, at 8:06 AM, during an interview with Resident #29, she stated that whenever she tries to speak with LPN #1, the nurse often responds rudely. This harsh treatment leaves her feeling vulnerable and rejected, making her feel unable to change the way she is treated. She longs for kindness because the nurse's rudeness hurts her feelings, and she does not appreciate it.A record review of the admission Record revealed the facility admitted Resident #29 on 11/11/24 with diagnoses including Osteomyelitis of the Vertebra, Sacral, and Sacrococcygeal Region.A record review of the MDS with an ARD of 2/16/26 revealed a BIMS score of 15, indicating the Resident is cognitively intact.Resident #18 On 5/7/26 at 8:12 AM, during an interview with Resident #18, he expressed frustration and sadness about his interactions with LPN #1. He recounts how, when he has questions about his medications, she often snaps at him. He expresses that she frequently comes into his room in a bad mood. It makes him feel angry and helpless, as he feels there's little, he can do to change the situation. He just endures it, which adds to his sense of isolation and sorrow.A record review of the admission Record revealed the facility admitted Resident #18 on 1/25/21 with diagnoses including Orthostatic Hypotension.A record review of the MDS with an ARD of 2/15/26 revealed a BIMS score of 15 indicating the resident is cognitively intact.Resident #47 On 5/7/ 2026, at 8:30 AM, in an interview with Resident #47, who holds the position of [NAME] President of the Resident Council. During our discussion, she shared that multiple residents have voiced concerns about the way LPN #1 talks to them. She has witnessed this behavior in front of staff, which has led residents to believe that reporting her actions would be ineffective, as they feel no meaningful action will be taken to address the issue.A record review of the admission Record revealed the facility admitted Resident #47 on 2/2/19 with diagnoses including Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting the right dominant side.A record review of the MDS with an ARD of 3/29/26 revealed a BIMS score of 15 the resident is cognitively intact.During an interview on 5/6/26 at 3:41 PM, LPN #1 stated she ensures she treats residents with dignity and does not raise her voice. She stated some residents with behavioral concerns accuse her of yelling when she does not. She stated she is not aware of any resident or staff complaints that she has mistreated residents and denied any such complaints had been made. When discussing how she responds to Residents who refuse to take medications at the time indicated, LPN #1 mentioned that one resident comes to mind, Resident # 20. She indicates that he has a medication that he takes at 5 PM and other at 8 PM. She revealed that for this Resident, due to the importance of the medication, she does not allow him to take it later and that she stays in his room ensuring that he takes it before he leaves. She adds she only an hour after the scheduled medications before it is determined late, so she likes to make sure she stays within those parameters when giving medications to the Residents. However, with Resident #20 she could consider giving him his medications at the 8 PM medication pass time.During an interview on 5/7/26 at 10:15 AM, the Director of Nursing (DON) stated that when a resident reports that a nurse is rude or speaking to them in a demeaning manner, the social worker files a grievance, an investigation is initiated, and witness statements are obtained from both the nurse and the residents. She stated there is no minimum number of residents required to report a nurse before an investigation is begun, and that a nurse would not be allowed to remain in the building during such an investigation. She stated that (6) residents reporting a nurse as rude and speaking down to them is a very serious situation, and that this type of behavior is a violation of residents' dignity and respect.During an interview on 5/7/26 at 10:52 AM, the Administrator stated she had received prior reports regarding LPN #1 and had completed some corrective counseling but stated no residents had reported concerns about LPN #1's rudeness to her. She stated that when a resident reports a nurse is rude, her process is to interview the residents involved, in-service staff on abuse and neglect, and implement corrective counseling depending on the level of the allegation. She stated this type of behavior is a violation of residents' dignity, respect, and resident rights, and could cause mental anguish.

Based on interview, record review, and facility policy review, the facility failed to promote and facilitate resident self-determination by restricting residents' right to freely congregate in the activity room during evening hours for three (3) of eleven (11) residents who attended the Resident Council meeting on 5/5/26. Residents #2, #20 and #40.Findings include:A review of the facility policy, Resident Rights, revised October 2025, revealed, Policy Statement .Employees shall treat all residents with kindness, respect, and dignity .Policy Interpretation and Implementation. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to .exercise their rights as a resident of this facility .f.be supported by the facility in exercising their rights.A record review of the grievance logs for 2026 revealed no concerns documented related to restrictions on resident congregation.A record review of the Resident Council meeting minutes for 2026 revealed no documented concerns related to restrictions on resident congregation.During a Resident Council meeting on 5/5/26 at 2:00 PM, (11) residents were present, all with Brief Interview for Mental Status (BIMS) scores of 15, indicating each was cognitively intact.The residents expressed that they are not permitted to congregate in the activity room, which is also the dining area, to play cards, dominoes, or simply socialize after administrative staff leave the building during evening hours. They stated they would like to use the activity room around 8:00 PM to play dominoes, cards or to simply socialize but that the nurse on duty refuses to allow them in the area, stating there must be a staff member present to monitor them and that no staff are currently assigned to do so. They stated they had brought this concern to the Activity Director, who repeated that they must be monitored. They expressed that this is upsetting because they are adults, this is their home, and their ability to freely gather should not be restricted.Resident #2 On 5/5/26 at 3:14 PM, during an interview with Resident #2 in the Resident Council meeting, he indicated that he does not like interacting with Licensed Practical Nurse (LPN) #1, as she is rude and talks to him and the other Residents as if they were children when trying to sit in the dining area to play dominoes or socialize during the late evening. He said this upsets him because this place is his home, he is an adult and feels it is his right to be there anytime he wants.A record review of the admission record revealed the facility admitted Resident #2 on 10/14/24 with diagnoses including Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Hypokalemia.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/12/26 revealed a Brief Interview for Mental Score (BIMS) score of (15), indicating the resident is cognitively intact.Resident #20 On 5/5/26, at 3:17 PM, during the Resident Council meeting, Resident #20 expressed his desire for the option to stay in the activity area to socialize with other residents in the evening. He stated that currently, staff require them to leave because they need supervision, and since no staff members are available to sit with them, they are unable to remain in the space. He feels this is unfair and believes it violates his rights as a resident of the facility.A record review of the admission record revealed the facility admitted Resident #20 on 7/1/24 with diagnoses including Abdominal Distension (Gaseous).A record review of the MDS with an ARD of 3/30/26 revealed a BIMS score of 15 indicating the resident is cognitively intact.Resident # 40 During the Resident Council meeting on 5/5/26 at approximately 3:28 PM, Resident #40 explained that he likes to play dominoes in the evening with some of the other Residents around 8:00 PM or later. The nurse on duty will say he and the other Residents are not allowed in there this late because no one is in there to sit with them. He states that this irritates him because he does not understand why he is not allowed in there, since this is where they usually do their activities during the day. He adds that he is an adult and would like the freedom to gather with other Residents in this area at any time of day.On 5/6/26 around 4:00 PM, the State Agency (SA) noticed Resident #40 looking pretty frustrated as he wheeled himself into his room with a box of dominoes in his lap. He shared that LPN #1 had just told him to leave the activity area with the dominoes and head back to his room. Resident #40 was clearly annoyed, saying he was tired of talking to him like he was a kid and telling him what to do. He pointed out that it just wasn't right for her to treat him that way.A record review of the admission record revealed the facility admitted Resident #40 on 9/29/22 with diagnoses including Muscle Weakness (Generalized).A record review of the MDS with an ARD of 2/9/26 revealed a BIMS score of 15 indicating the resident is cognitively intact.During an interview on 5/6/26 at 10:15 AM, the Activities Director stated residents had told her they wanted to gather in the dining and activity room area. She stated she brought this to the Administrator, who responded that residents are not allowed in that area when staff is not present. She explained that residents expressed that they feel they are being treated as children and that it is their right to freely congregate adding, the Administrator has been consistent with this decision. She further stated residents are permitted to congregate in the day room area near the front of the building, but that it contains only one table and becomes crowded quickly depending on how many residents come up front.During an interview on 5/6/26 at 3:41 PM, LPN #1 stated she works evening shifts from time to time and acknowledged that residents are not allowed in the dining area in the evening around 8:00 PM to play dominoes or engage in other social activities. She stated the facility does not have available staff to sit with them in that area to ensure safety but acknowledged it is the residents' right to be able to congregate with or without a staff monitor present.During an interview on 5/7/26 at 10:29 AM, the Administrator stated there is currently no staff member assigned to monitor residents in the activity area during evening hours, and they are not permitted to congregate in the activity room unsupervised due to past allegations between the residents. She added that residents should be allowed to go anywhere in the building as a matter of resident rights.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two (2) of (16) sampled residents reviewed (Resident #7 and Resident #9).Findings include:A record review of the facility's Care Plans, Comprehensive Person-Centered with a revision date of March 2022 revealed, A comprehensive person-centered care plan that includes measurable, objective and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident.Resident #7A record review of Resident #7's Care Plan Report revealed an intervention to maintain Enhanced Barrier Precautions (EBP) including washing hands, wearing a gown, wearing gloves, and other precautions when performing close contact care in the resident's room.During an observation on 5/6/26 at 9:20 AM, Licensed Practical Nurse (LPN) #1 was observed administering medication via Percutaneous Endoscopic Gastrostomy (peg) tube to Resident #7. Enhanced Barrier Precaution signage was posted on the door. LPN #1 did not put on a gown prior to administering medication via peg tube.During an interview on 5/6/26 at 9:54 AM, LPN #1 confirmed she did not wear a gown while administering medication via peg tube. She stated she forgot to put it on. She stated the purpose of the gown is to protect the nurse and resident from body secretions that may come from the abdomen, and that she placed the resident at risk for infection by not wearing a gown. She stated she did not follow the care plan.During an interview on 5/7/26 at 10:51 AM, Registered Nurse (RN) #1 stated the care plan provides a road map for resident care and that all staff are expected to be knowledgeable about and follow the individualized care plan. She stated all peg tube residents are care planned for EBP and that a sign is posted on the door.During an interview on 5/7/26 at 11:16 AM, the Director of Nursing (DON) stated LPN #1 should have worn a gown prior to care because the resident has a peg tube. She stated the peg tube is an opening into the resident's body and that the resident was placed at risk for possible infection. She stated her expectation is that staff wear a gown for all EBP residents and that LPN #1 did not follow the care plan.A record review of the admission Record revealed the facility admitted Resident #7 on 6/23/11 with diagnoses including Dysphagia Oropharyngeal Phase.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/2/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact.Resident #9A record review of Resident #9's Care Plan Report revealed a care plan with interventions that included .Clean stoma with soap and water, pat dry, wipe skin around the stoma with skin prep, and apply wafer with bag as needed. Clean suprapubic catheter with soap and water each shift.The position assigned was listed to Licensed Practical Nurse (LPN) and Registered Nurse (RN).During an interview on 5/5/26 at 2:00 PM, LPN #1 stated Resident #9 performs his own catheter care.During an interview and observation on 5/5/26 at 3:27 PM, Resident #9 stated he performs his own catheter care and colostomy care. He stated the 11-7 nurse brings his colostomy bag to his room around 3:00-4:00 AM daily. He stated he applies three pairs of gloves and removes one pair after each step of care, uses a wet soap towel for catheter care, and wipes from the insertion site downward. He stated a nurse had never observed him performing the care. A clean colostomy bag was observed on the bedside table.During an observation on 5/6/26 at 12:20 PM, a clean colostomy bag was observed on the table by Resident #9's bed.During an interview on 5/7/26 at 11:23 AM, the DON confirmed she was aware that Resident #9 performs his own colostomy and suprapubic catheter care. She stated the resident is at risk for infection and that there is no physician order or assessment in place for the resident to perform his own care. She stated she is aware that nurses have been signing the ETAR as if the care was completed per order. She stated staff did not follow physician orders.During an interview on 5/7/26 at 11:45 AM, RN #3 confirmed she is aware that Resident #9 performs his own colostomy and suprapubic catheter care and that she has been signing the ETAR. She stated she cuts the wafer and provides supplies, and the resident performs the care.A record review of the Order Summary Report revealed an order dated 8/1/24 Clean suprapubic catheter with soap and water per Certified Nursing Assistant (CNA) every shift and an order dated 9/13/24 Clean the stoma with soap and water, pat dry, wipe skin around stoma with skin prep, and apply wafer with bag as needed.A record review of the admission Record revealed the facility admitted Resident #9 on 3/5/24 with diagnoses including Urinary Tract Infection, Uninhibited Neuropathic Bladder Not Elsewhere Classified, Colostomy Complications Unspecified, and Other Retention of Urine.A record review of Resident #9's MDS with an ARD of 3/4/26 revealed a BIMS score of 15, indicating the resident is cognitively intact.A record review of Resident #9's Electronic Treatment Administration Record (ETAR) for April and May 2026 revealed the colostomy and suprapubic catheter care was signed off as completed by numerous nurses. RN #3 signed the ETAR on 5/7/26.

Based on interview, record review, and facility policy review the facility failed to ensure that complete and accurate direct care staffing information was electronically submitted to the Centers for Medicare & Medicaid Services (CMS) through the Payroll-Based Journal (PBJ) system within the required timeframe for one (1) of four (4) quarters reviewed, FY (Fiscal Year) Quarter 1 2026 (October 1-December 31).Findings Include:A review of the facility policy Reporting Direct Care Staffing Information (Payroll-Based Journal) with a revision date of August 2022 revealed, Direct care staffing information is reported electronically to CMS through the Payroll-Based Journal system. Policy Interpretation and Implementation 1. Complete and accurate direct care staffing information is reported electronically through the PBJ system in a uniform format specified by CMS .10. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows: Quarter 1 Submission Deadline - February 14th.During an interview on 05/04/2026 at 11:33 AM, the Administrator revealed that the person in charge of submitting Payroll-Based Journal (PBJ) data for the facility is the Chief Operating Officer (COO). She stated that she knew he had submitted the data and was therefore unsure why it did not appear as submitted and stated she was unaware that the submission had not been accepted.During an interview with the COO on 5/5/26 at 12:57 PM, he revealed that PBJ data is due to be reported to CMS within 45 days after the end of each quarter and is considered late on any date after that deadline. He noted that he was out of town during the week of the Quarter 1 PBJ submission for fiscal year 2026. He stated that he submitted it on Friday (Day 44) of that week and then did not recheck the submission on Saturday (Day 45) because he had never previously experienced any issues. He stated that upon returning to the office on Monday, he received fatal warnings from CMS regarding the submission. He then emailed CMS but was instructed that they were unable to assist him due to the volume of facilities they oversee. He acknowledged that this is the second facility under his oversight to experience this issue, noting that he submits PBJ data for all four facilities under his management simultaneously. He stated that he already has a plan of correction prepared.During a follow-up interview on 5/6/26 at 12:10 PM, the Administrator presented an email on her computer from the COO in which he explained that he was out of town during the week of the PBJ submission, that he submitted on Day 45, and that he subsequently received fatal warnings from CMS following that submission.During an interview with the Director of Nursing (DON) on 05/07/2026 at 8:43 AM, she revealed that the COO collects PBJ staffing data via emails from herself and Registered Nurse (RN) #1, which contains staffing numbers for each day. She stated the COO stores that data and utilizes it to submit the facility's PBJ report to CMS.During a follow-up interview with the Administrator on 5/7/26 at 12:45 PM, she noted that the importance of timely PBJ data submission is to ensure that facilities maintain adequate staffing numbers as required.

Based on observation, interview, record review, and facility policy review the facility failed to ensure staff adhered to Enhanced Barrier Precaution (EBP) protocols during high-contact resident care activities for one (1) of (1) residents reviewed. (Resident #7)Findings include:A record review of the facility's Enhanced Barrier Precautions with a revision date of 12/2024 revealed Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug-resistant organisms (MDRO's) to residents .7. a. Gowns and gloves are applied prior to performing the high contact resident care activity (as opposed to before entering the room) .During an observation on 5/6/26 at 9:20 AM, Licensed Practical Nurse (LPN) #1 was observed administering medication via Percutaneous Endoscopic Gastrostomy (PEG) tube to Resident #7. EBP signage was posted on the door. LPN #1 entered the room but did not don (put on) a gown prior to administering medication via PEG tube, as required by the facility's EBP policy and the posted door signage.During an interview on 5/6/26 at 9:54 AM, LPN #1 confirmed she did not wear a gown while administering medication via PEG tube to Resident #7. She stated she forgot to put it on. She further stated that the purpose of the gown is to protect both the nurse and the resident from body secretions that may come from the abdomen and acknowledged that she placed the resident at risk for infection by not wearing a gown. During an interview on 5/7/26 at 10:21 AM, LPN #2/Infection Prevention Nurse stated that LPN #1 should have worn a gown and that not wearing one placed the resident at high risk of infection. She stated her expectation is that staff wear a gown when performing direct care for residents on EBP to prevent the spread of infection.

Based on interview, record review and facility policy review, the facility failed to ensure pain management was provided consistent with professional standards of practice for one (1) of (1) sampled residents reviewed for pain management. (Resident #1).Findings include: A policy review of the Pain Management and Assessment policy no date, reveals, Purpose . The purposes of this procedure are to help the staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying causes of pain .General guidelines. 1. Pain management is a multidisciplinary process that includes the following .monitoring for the effectiveness of interventions; and modifying approaches as necessary .During an interview on 5/4/26 at 1:00 PM, Resident #1 stated he has been experiencing consistent pain at a level of 6 for the last couple of years and that his current pain medication regimen is not strong enough. He stated he has reported this to his medication nurse and to the Nurse Practitioner (NP), who told him it will get better eventually, but it has not. He stated he walks around the building daily after lunch for exercise but fears this will eventually have to stop due to the increasing pain in his legs, feet, and back.During an interview on 5/4/26 at 1:09 PM, Licensed Practical Nurse (LPN) #1 who serves as the Minimum Data Set (MDS), acknowledged that Resident #1 walks around the building daily after lunch as part of his exercise routine.During an interview on 5/5/26 at 3:50 PM, Registered Nurse (RN) #2 stated standard nursing procedure is to notify the NP when a resident reports that their pain regimen is not working. She stated that once the NP is notified, it is up to the NP to adjust medications. She stated pain affects all aspects of a resident's daily life, including participation in day-to-day activities and eating habits, and that it is important to address any resident report of ineffective pain medication.During an interview on 5/6/26 at 11:20 AM, LPN #2 stated she has worked at the facility for the past two years with Resident #1 and that he has consistently reported his current pain medications are not enough, consistently indicating a pain level of 6, which she documents as required. She stated she reported this to the NP a couple of months ago, and the NP indicated there was nothing she could do. She stated she informed the resident of this response.During an interview on 5/7/26 at 9:24 AM, the NP stated her normal process when any resident reports frequent pain on more than two occasions is to evaluate them and order x-rays. She stated that if conservative medications are not working, she would change the medication regimen or refer the resident to Pain Management, particularly if the resident reports pain is affecting their daily activities. With regard to Resident #1, she stated she had evaluated him a few months ago because his nurse reported his complaints of pain, but she did not see a reason to adjust his medications at that time. Upon the State Agency's review of the Weight and Vitals summary reflecting consistent nursing documentation of Resident #1 reporting a pain level of 6 or higher from March 2026 through May 2026, the NP stated she drives three hours to the facility one time per week and is only in the building for two hours, does not get to see all residents, and that she missed the frequency of this resident's documented pain. She acknowledged it was her fault and stated she would reevaluate him while at the facility that day.During an interview on 5/7/26 at 2:32 PM, the Director of Nursing (DON) stated that following her discussion with the State Agency that day, the NP reported she had interviewed Resident #1 and that during that discussion he did not express concerns about his current pain medication regimen, stating only that he was constipated. The DON stated the NP did not adjust the pain regimen but provided medication for constipation. Following this interview, the State Agency interviewed Resident #1 with the DON and the Administrator present. Resident #1 restated he is currently experiencing pain in his legs, back, and feet and needs staff to do something to help him, confirming the concerns he expressed during the initial interview on 5/4/26.A record review of the admission Record revealed the facility admitted Resident #1 on 3/4/20 with diagnoses including Pain in Right Lower Leg, Pain in Left Lower Leg, Pain in Right Leg, Muscle Spasm of Back, Pain in Right Foot, Chronic Pain Syndrome, and Other Chronic Pain.A record review of Resident #1's Order Summary Report revealed the following active pain-related medication orders: Acetaminophen Extra Strength Oral Tablet 500 milligrams (mg), give 2 tablets by mouth every 6 hours as needed for pain; Tizanidine HCl Oral Capsule 2 mg, give 2 mg by mouth two times a day related to Muscle Spasm of Back; Hydroxychloroquine Sulfate Oral Tablet 200 mg, give 1 tablet by mouth two times a day related to Other Chronic Pain; and Acetaminophen-Codeine Tablet 300-30 mg, give 1 tablet by mouth two times a day related to Pain in Leg, Unspecified.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact.A record review of the Weight and Vitals summary from March 2026 through May 2026 revealed consistent nursing documentation of Resident #1 reporting a pain level of 6 or higher.

Based on interview, facility policy review, and record review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to sustain corrective action to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to ensure infection control standards were adhered to related to proper use of Enhanced Barrier Precautions (EBP) during care in June 2025 and was again cited for the same deficient practice on the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of eight (8) deficiencies cited. F880. Findings included:Record review of the facility policy Quality Assurance and Performance Improvement Program revealed Policy Statement: The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents .Record review of the Centers for Medicare and Medicaid Services (CMS) Form 2567 (Statement of Deficiencies) dated 6/5/2025 revealed that the facility was cited in June 2025 for citation F880 - Failure to Ensure Infection Control Practices, specifically related to a Certified Nursing Assistant (CNA) performing catheter care without wearing appropriate Enhanced Barrier Precautions (EBP) personal protective equipment (gown). The current survey identified the same practice concern, demonstrating that the facility's QAPI interventions were insufficient to sustain long-term compliance and prevent a repeat deficiency.An interview with on 05/07/2026 at 1:40 PM, the Administrator revealed that the facility's QAPI committee meets monthly, although the regulatory requirement is at minimum quarterly. Committee members include department heads: the Administrator, Director of Nursing (DON), Activity Coordinator, Head CNA, Maintenance Supervisor, Medical Director, Social Worker, Dietary, Assistant Director of Nursing (ADON), Treatment Nurse, and Business Manager. The Administrator stated that new areas of focus are identified and discussed in QAPI meetings, followed by implementation of an evaluation plan via monthly or weekly audits. She further confirmed that the facility first discussed the results of the June 2025 annual survey during the July 2025 QAPI meeting. At that time, it was identified that the facility had received a citation for Infection Control (F880) related to a CNA performing catheter care without wearing appropriate EBP personal protective equipment. She confirmed that during the current survey cycle, the same concern was again identified. As part of the Plan of Correction from the 2025 survey, the facility initiated weekly audits of CNA staff compliance with EBP protocol for a period of 12 weeks. Once administration deemed staff compliant, monitoring was discontinued. The Administrator acknowledged that staff may have become complacent following the cessation of monitoring and subsequently failed to maintain appropriate EBP practices. She stated that to prevent recurrence, the facility may implement an extended monitoring period beyond the previously established 12-week timeframe. She noted that in addition to CNA education and monitoring, infection control audits are conducted monthly as agreed upon during QAPI, with the next audit scheduled for May 14, 2026. The Administrator explained that the purpose of QAPI is to discuss clinical performance each month, identify areas of concern, implement plans to resolve issues, address grievances, ensure compliance, maintain quality of care, and follow facility policy.

Based on interview, record review and facility policy review, the facility failed to ensure the Facility Assessment was updated to include a comprehensive evaluation of the resident population and the necessary resources, including staffing levels and competencies, required to meet resident needs under both routine and emergency conditions for three (3) of three (3) survey days. Findings include: Review of the facility policy titled Facility Assessment with a revision date of December 2024 revealed Policy Statement: A facility assessment is conducted annually to determine and update the capacity to meet the needs of and competently care for residents during day-to-day operations (including nights and weekends) and emergencies. Facility Assessment .4. The facility assessment is used to inform staffing decisions.A. The facility assessment is used to ensure there is enough staff with appropriate competencies and skill sets to meet the needs of the residents identified through the review of resident assessments and plans of care.(2) Staffing needs are considered for each shift, including day, evening, and night shifts, and adjusted as necessary based on changes in the resident population. A review of the Facility Assessment document revealed that under Section II (Staffing, Training, Services & Personnel) and Section III (Physical Environment, Technology, & Equipment), the Sufficiency Analysis Categories were marked only as Evaluated. The assessment lacked documentation of specific staffing levels required for each shift (day, evening, and night) and did not address the specific skills and competencies necessary for staff to provide care for the facility's current resident population. During an interview on June 5, 2025, at 12:05 PM, the Administrator revealed that she completes the facility Assessment using the (proper name)Program. She revealed that she has always answered those questions and marked either 'evaluated' or 'sufficient' for staff. She confirmed that she has always only documented in the facility assessment that the staffing was sufficient, but did not actually calculate or address the staffing and skills needed for specific shifts, including night shifts, weekends, and emergencies.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to provides an environment that is free from accident hazards as evidenced by failure to implement interventions to reduce fall hazards for one (1) of 40 residents sampled, Resident #15. Findings include: Review of the facility policy titled, Safety and Supervision of Residents with a revision date of July 2017 revealed under, Policy Statement .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities .Resident Risk and Environment Hazards .c. Falls. During observations on 6/03/25 at 10:18 AM and again at 2:00 PM, revealed Resident #15 lying in bed with a fall mat folded up and leaning against the wall and without a wedge placed between his thighs. During an observation and interview on 6/4/25 at 11:03 AM, with Certified Nursing Assistant (CNA) #1, she confirmed that the fall mat was folded up and propped against the wall. She revealed that the fall mat was supposed to be laid out on the floor in case he fell. She further confirmed that should he fall out of bed without the fall mat in place, he could potentially break a bone or get seriously hurt. She confirmed he did not have a wedge between his thighs, nor did he even have a wedge in his room. During an observation and interview on 6/4/25 at 11:06 AM, with Licensed Practical Nurse (LPN) #1, she confirmed the fall mat was propped against the wall but should be on the floor beside his bed. She verbalized that the mat was there to help prevent injury should the resident fall out of bed. Additionally, she stated that he could break a bone if he fell out of bed without the mat in place. She confirmed that Resident #15 did not have a wedge between his thighs. She also could not find one in his room as well. During an interview on 6/4/25 at 11:10 AM, with the Director of Nursing (DON), she confirmed the fall mat should have been in place on the floor beside his bed and he should have the wedge cushion in place. She confirmed that the mat was put in place to help prevent a serious injury should he fall out of bed. Record review of the admission Record that Resident #15 was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and unspecified convulsions. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/17/25, under Section C for Resident #15, revealed, .resident is rarely/never understood .

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide the necessary foot care to maintain skin integrity and prevent complications for one (1) of three (3) residents reviewed that needed assistance with foot care. Resident #7 Findings Include: Review of the facility policy titled Foot Care with a revision date of 10/2022 revealed under, Policy Statement: Resident receive appropriate care and treatment in order to maintain mobility and foot health. Also revealed under, Policy Interpretation and Implementation: 1. Residents are provided with foot care and treatment in accordance with professional standards of practice. 2. Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions. On 6/03/25 at 10:28 AM, during an observation and interview with Resident #7 she stated, Are you here to trim my toenails? She revealed her toenails needed cutting and the podiatrist was here weeks ago, but she was told she was not on the list to be seen. The resident reported she was having left heel pain and explained she had told the nurse. An observation of the left heel revealed a circular area with excessively thick dry and peeling skin, with dark redness surrounding the area. There was a small open area inside the patch of dryness that measured approximately 0.8 centimeters (cm) x 0.5 centimeters (cm) and was V-shaped in appearance with no intact skin and dark purple outer edges. The resident stated she had been applying lotion to it every day, but the staff were not doing a treatment. She stated the area was painful to touch. Several calluses were observed on both feet and her toenails on both feet were excessively thick and long extending approximately eight (8) millimeters (mm) past the tips of the toes. Record review of Resident #7's Progress Notes revealed there was no documentation regarding a skin concern. Record review of Resident #7's June 2025 Treatment Administration Record (TAR) there were no orders to provide care to the left heel. Record review of Resident #7's Skin Check dated 6/03/25, 5/27/25, 5/20/25, and 5/13/25 revealed No skin issues was documented. An interview with the Wound Care Nurse on 6/04/25 at 10:21 AM revealed she worked weekends and helped some during the week with wound care. She explained Resident #7 did not have skin concerns other than some dry skin at times. The Wound Nurse stated, She's complaining all the time that her feet felt like they were bursting. Following an observation of Resident #7's left heel with the Wound Nurse, she stated she was unaware of the wound. She described the area as dry, thick cracking skin with redness around the edges. The resident confirmed the area was tender to touch. The Wound Nurse provided measurements of the entire circumference of the wound that measured 9.5 centimeters (cm) x 3.5 centimeters (cm). She confirmed the resident had excessively long thick toenails that needed to be cut. She revealed this could cause skin concerns or injury to the resident. The Wound Nurse acknowledged the residents' foot concerns should have been discovered during routine weekly skin checks and stated early identification could prevent foot complications. An observation and interview with the Assistant Director of Nursing (ADON) on 6/04/25 at 10:46 AM revealed the medication nurses were responsible for doing the weekly body audits. She revealed she was not aware of any skin concerns the resident had. After assessing Resident 7's left heel, she confirmed this should have been detected during the body audit done yesterday and a treatment initiated. An interview with Licensed Practical Nurse (LPN) #2 on 6/04/25 at 2:10 PM revealed she conducted the skin audit on Resident #7 yesterday. She confirmed she did not document accurately to reflect the resident skin condition. LPN #2 stated she had been applying lotion to the area, but she did not have any documentation to prove she had been doing it. She explained the podiatrist was here last month and she thought he saw her and stated, Maybe he didn't document it. Record review of Resident #7's Foot Care Progress Note dated 2/24/25 revealed the resident was seen for toenail care with recommendations of Daily moisturizer twice daily and 60 day follow up for corns and callus. An interview with the Director of Nursing (DON) on 6/05/25 at 8:15 AM confirmed Resident #7 had excessively long thick toenails. She revealed the resident was at risk for infection and ingrown toenails or injury. She confirmed the resident was last seen by the podiatrist in February 2025. Record review of admission Record revealed the facility admitted Resident #7 on 5/08/20 with medical diagnoses that included [NAME] and Callosities, Unspecified Intellectual Disabilities and Paranoid Schizophrenia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #7 was cognitively intact.

Resident #49 An observation on 6/3/25 at 7:30 AM revealed Resident #49's breakfast tray sitting on her bedside table, not opened or set up. The resident was in bed with her head covered with a blanket. Continued observation revealed that staff finally came in to assist the resident with breakfast at 8:00 AM. An interview with CNA #1 on 6/3/25 at 8:00 AM verified that Resident #49 has to be assisted with meals. She revealed that staff know they are not supposed to leave trays in the rooms of residents that need assistance, if they cannot feed them at that time. She stated that if a resident needs to be fed you are supposed to sit down and feed the resident when you bring the tray into the room. She stated that the tray should have been left on the cart until she was available to assist the resident. She verified that the food could get cold and that residents may not want to eat it. An interview with CNA #2 on 6/3/25 at 8:03 AM confirmed that when a meal tray is placed in the room you are to assist the resident at that time and not leave the tray sitting in the room. An interview with LPN #1 on 6/3/25 at 8:05 AM confirmed that if a resident requires assistance with meals they are to be assisted when the tray is taken into the room and Resident #49 should have been assisted with breakfast when the tray was delivered. An interview with the Administrator on 6/4/25 at 11:00 AM stated that she expected the staff to assist residents with their meals when they bring their tray to their rooms. Record review of the admission Record revealed the facility admitted Resident #49 on 12/26/23 with a diagnoses including DiffuseTraumatic Brain Injury. Record review of the MDS with an ARD of 12/19/24 for Resident #49 revealed a BIMS score of 11, indicating the resident is moderately cognitively impaired. Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene (Resident #1 and #17) and failure to provide timely assistance with meals (Resident #49) for three (3) of 57 residents in the facility. Findings include: Review of facility policy titled, Activities of Daily Living (ADL) Supporting with revision date March 2018, revealed, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Resident #1 During observations and interviews on 6/3/25 at 8:22 AM and again at 1:54 PM, Resident #1 had a buildup of a thick brown/yellow substance on his teeth. This buildup was observed on both the upper and lower teeth. The resident stated he would like to have his teeth cleaned and it had been a while since anyone had offered. He verified he would not decline if they offered. During an observation and interview on 6/4/25 at 12:20 PM with Certified Nursing Assistant (CNA) #2, she confirmed the resident's teeth had buildup and should have been brushed. She revealed that not receiving daily oral care could lead to gum disease and/or cavities. During an observation and interview with the Director of Nursing (DON) on 6/4/25 at 12:26 PM, she confirmed that Resident #1 was in need of oral care and that the CNAs were responsible for providing that daily. She further revealed that lack of oral care could lead to dental caries. Record review of the admission Record revealed that Resident #1 was admitted to the facility on [DATE], with medical diagnoses that included Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other lack of coordination, need for assistance with personal care, contracture of muscle right hand, contracture of muscle left hand, and muscle weakness (generalized). Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/25 revealed, under Section C, a Brief Interview for Mental Status (BIMS) score of 11, indicating that the resident had moderate cognitive impairment. Resident #17 An observation on 6/3/25 at 7:37 AM revealed Resident #17's fingernails on both hands had a brown substance under each nail bed, was jagged and long extending approximately three-fourths (3/4) of an inch long past the tips of fingers; facial hair was visible on the resident's cheeks, chin and upper lip that was approximately one-half (1/2) inch long. During an observation and interview on 6/4/25 at 12:14 PM with CNA #2, she confirmed Resident #17 had 1/2 facial hair to his face and upper lip and that his fingernails were very long and dirty as well. She verbalized that he should be clean shaven, and his fingernails should also be trimmed. She confirmed that having long fingernails and long facial hair could be a source for bacteria to grow. Additionally, he could cause a skin tear with his long nails. During an observation and interview on 6/4/25 at 12:20 PM with Licensed Practical Nurse (LPN) #2, she confirmed that Resident #17, scratches and digs, with his fingernails, however they should be kept trimmed and clean. She also confirmed that his facial hair was several days old and should have been shaved off. She verbalized that he could scratch himself with his long nails and cause infection. During an interview with the DON on 6/4/25 at 12:26 PM, she confirmed that fingernails should be trimmed and cleaned as needed and that Resident #17 should have already been shaved. She confirmed he could cause a skin tear and/or infection with long, jagged nails. Record review of the admission Record revealed Resident #17 was admitted to the facility on [DATE], with medical diagnoses that included Epilepsy and Vascular Dementia. Record review of the quarterly MDS with an ARD of 4/18/25 indicated, under Section C, a BIMS score of 7, which indicated the resident had moderate cognitive impairment. Section GG revealed Resident #17 was dependent on staff for personal hygiene.

Resident #49 Record review of Resident #49's care plans revealed an alteration in ADL's related to general weakness , impaired mobility dated 12/26/23 with an intervention of Total Assist times one (1) staff with eating. On 6/3/25 at 7:30 AM an observation revealed Resident #49's breakfast tray was sitting on her bedside table. The resident was lying in bed with her head covered and continued observation revealed that no staff entered the room to assist the resident or set tray up until 8:00 AM. On 6/3/25 at 8:00 AM during interview with CNA #1 she verified that Resident #49 had to be assisted by staff during meals. Interview with Licensed Practical Nurse (LPN) #1 on 6/3/25 at 8:05 AM she confirmed that Resident #49 should have been assisted with breakfast when the tray was delivered. An interview with the Care Plan Nurse at 8:53 AM on 6/5/25 she verified that the care plan should have been followed but wasn't. Record review of the admission Record revealed the facility admitted Resident #49 on 12/20/23 with a diagnosis of Diffuse Traumatic Brain Injury Record review of the MDS with an ARD of 12/19/24 for Resident #49 revealed a BIMS score of 11, indicating the resident is moderately cognitively impaired. Resident #7 Record review of Resident #7's Activities of Daily Living (ADL) Care Plan revealed under, Focus: Alteration in ADL's and additionally revealed under, Interventions: May provide fingernail and toenail care as needed. On 6/03/25 at 10:28 AM, an observation and interview with Resident #7 revealed her toenails needed cutting. An observation revealed the residents toenails on both feet were excessively thick and long extending approximately 8 millimeters (mm) past the tips of the toes. An observation and interview with the Wound Care Nurse on 6/04/25 at 10:21 AM confirmed Resident #7's toenails needed care. An interview with the MDS Nurse on 6/05/24 at 8:50 AM revealed the purpose of the care plan was to have an individual resident centered care plan to meet the resident needs. She explained it was a road map for resident care. The MDS Nurse acknowledged the care pan was not followed for Resident #7's nail care. Record review of admission Record revealed the facility admitted Resident #7 on 5/08/20 with medical diagnoses that included [NAME] and Callosities, Unspecified Intellectual Disabilities and Paranoid Schizophrenia. Record review of the MDS with an ARD of 2/11/25 revealed under section C, a BIMS summary score of 15, which indicated Resident #7 was cognitively intact. Resident #44 Record review of Resident #44's Care Plan Report revealed under, Focus: Risk for psychosocial complications R/T (related to) diagnosis of PTSD (Post-Traumatic Stress Disorder. Also revealed under, Interventions: Assess for anxiety and triggers contributing to PTSD. During an interview with Resident #44 on 6/04/25 at 1:42 PM, he revealed he was a United States [NAME] in the military for 5 years and was a sniper during wartime. He stated that he does suffer from post-traumatic stress disorder and has nightmares on and off. The resident explained that when a helicopter passes over the facility, it bothers him (triggers). The resident additionally revealed he was run over by an automobile before coming to the facility and had numerous broken bones and head trauma that required surgery. Record review of Resident #44's Trauma Informed Care Assessment-Post Traumatic Stress Disorder (PTSD) dated 5/19/25 revealed under, PTSD Screen: Sometimes things happen that are unusually or especially frightening, horrible, or traumatic. For example: *a serious accident or fire* a physical or sexual assault or abuse* an earthquake or flood* a war* seeing someone killed or seriously injured* having a loved one die through homicide or suicide . 1. Have you ever experienced this kind of event? No was documented. An interview with Social Services #1 on 6/04/25 at 1:50 PM confirmed Resident #44's trauma assessment was completed inaccurately, and as a result, the facility failed to identify his symptoms (nightmares) and potential triggers. An interview with MDS Nurse on 6/05/25 at 8:50 AM confirmed Resident #44's trauma informed care assessment was inaccurate; therefore, the care plan was not followed to identify resident triggers contributing to his diagnosis of PTSD. Record review of the admission Record revealed the facility admitted Resident #44 on 11/30/23 with medical diagnoses that included Encounter for Surgical Aftercare Following Surgery on the Nervous System and Post-Traumatic Stress Disorder. Record review of the MDS with an ARD of 2/12/25 revealed, under section C, a BIMS summary score of 15, which indicated Resident #44 was cognitively intact. Based on observation, staff and resident interview, record review and facility policy review, the facility failed to implement care plans: 1) related to Activities of Daily Living (ADL) assistance (Resident #1, #7, and #17); 2)trauma informed care (Resident #44), 3)prevention of accidents/positioning (Resident #15); and 4) assistance with feeding (Resident #49). This was for six (6) of 22 resident's care plans reviewed. Findings Include Review of the facility policy titled, Care Plan, Comprehensive Person-Centered with a revision date of March 2022 revealed under the Policy Statement .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #1 Record review of Resident #1's Activities of Daily Living (ADL) care plan, with no date, revealed, .oral hygiene assist daily and as needed . On 6/3/25 at 8:22 AM and again at 1:54 PM, observations and interviews with Resident #1 revealed he had visible thick, brownish-yellow discoloration and buildup on the upper and lower front teeth. Resident #1 revealed that it had been a while since anyone had brushed his teeth for him. He stated he would not refuse mouth care if someone offered it. He mentioned that sometimes staff performed mouth care, but not often. Review of Resident #1's ADL care plan on 6/4/25 at 12:37 PM with the Care Plan nurse revealed the ADL care plan was fully developed and included oral care on the Kardex for the aide's instruction. She confirmed that the care plan was not implemented by the staff. She further stated that the care plans were individualized for each resident and provided treatment and goals tailored to each resident. Record review of the admission Record that Resident #1 was admitted to the facility on [DATE], with medical diagnoses that included Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other lack of coordination, need for assistance with personal care, contracture of muscle right hand, contracture of muscle left hand, and muscle weakness (generalized). Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/25 revealed, under Section C, a Brief Interview for Mental Status (BIMS) score of 11, indicating that the resident had moderate cognitive impairment. Resident #15 Record review of Resident #15's care plan, Fall Risk related to history of falls, impaired mobility, date initiated 7/10/2018 revealed, .floor mat to floor at bedside to prevent injury from falls .apply wedge between thighs . On 6/03/25 at 10:18 AM and again at 2:00 PM, during observations revealed Resident #15 lying in bed without wedge cushion placed between thighs, and a fall mat was folded up and leaning against the wall. Review of Resident #15's Fall care plan with Care Plan Nurse on 6/04/25 at 12:45 PM confirmed the fall care plan was fully developed and included the placement of the fall mat at the bedside and the wedge between the resident's thighs. She acknowledged that the care plan had not been implemented by the staff. Additionally, she confirmed that the care plans were individualized for each resident and provided specific treatment and goals tailored to each resident's needs. Record review of the admission Record that Resident #15 was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and unspecified convulsions. Resident #17 Record review of Resident #17's ADL care plan, with no date, revealed, .staff to provide ADL care every (Q) day as appropriate . During an observation on 6/3/25 at 7:37 AM it was revealed Resident #17's bilateral fingernails were approximately three-fourths (3/4) of an inch long and jagged, extending past the tips of fingers; a brown substance was noted under each nail. Additionally, facial hair was approximately one-half (1/2) inch long and was observed on the cheeks, chin, and above the resident's lip. Review of Resident #17's ADL care plan with Care Plan Nurse on 6/4/25 at 12:41 PM confirmed that the ADL care plan was fully developed and included oral care on the Kardex for the aide's instruction. She acknowledged that the care plan had not been implemented by the staff. Furthermore, she confirmed that the care plans were individualized for each resident, providing specific treatment and goals tailored to each resident's needs. Record review of the admission Record revealed Resident #17 was admitted to the facility on [DATE], with medical diagnoses that included Epilepsy and Vascular Dementia. Record review of the quarterly MDS with an ARD of 4/18/25 indicated, under Section C, a BIMS score of 7, which indicated the resident had moderate cognitive impairment. Section GG revealed Resident #17 was dependent on staff with personal hygiene.

Based on staff interviews, record reviews and facility policy review, the facility failed to timely submit the quarterly Minimum Data Set (MDS) assessment for one (1) of 22 resident MDS assessments reviewed for timely submissions: Resident #17. Findings include: Record review of the facility policy titled MDS Completion and Submission Timeframes, with revision date July 2017, revealed the following policy statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . Record review of Resident #17's Quarterly MDS assessment with Assessment Reference Date (ARD) of 10/21/2024 revealed, Section Z0500 .B. Date Registered Nurse (RN) Assessment Coordinator signed assessment as complete: 11/14/2024 . Record review of Resident #17's Quarterly MDS assessment with of ARD 4/18/2025 revealed, Section Z0500 .B. Date Registered Nurse (RN) Assessment Coordinator signed assessment as complete: 6/4/2025 . During an interview on 6/4/25 at 1:18 PM with the MDS Nurse, she confirmed quarterly MDS assessments for Resident #17 with ARD dates 10/21/2024 and 4/18/2025 were both submitted after the 14-day timeframe. She explained that in October 2024, she missed a significant amount of work due to a family illness, and in April 2025, she was out for surgery. She further stated that no one filled in for her during her absence, resulting in delays in submitting assessments. During an interview on 6/5/25 at 1:47 PM with the Director of Nursing (DON), she confirmed her expectation that MDS assessments to be submitted timely. Record review of the admission Record revealed Resident #17 was admitted to the facility on [DATE], with medical diagnoses that included Epilepsy and Vascular Dementia. Record review of the quarterly MDS with an ARD of 4/18/25 indicated, under Section C, a Brief Interview for Mental Statue (BIMS) score of 7, which indicated the resident had moderate cognitive impairment.

Based on facility investigation review, record review and staff interview, the facility failed to protect the residents' right to be free from sexual abuse by other residents for one (1) of six (6) residents reviewed for abuse. Resident #49. Findings included: Record review of the facility policy, titled Abuse Prevention Program, revealed Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Resident #49 Record review of the facility investigation titled Report of Investigation dated 2/24/25, regarding an allegation of sexual abuse involving Resident #52 and Resident #49 revealed that on 2/20/2025 at approximately 5:10 AM Certified Nurse Assistant (CNA) witnessed Resident #52 with his hand underneath Resident #49's blouse rubbing her breasts in the day room. The residents were separated, and Resident #52 was placed on one-on-one monitoring. Resident #49 was assessed and found to have no injuries. Record review of Fact Finding Witness Interview-Confidential, dated 2/20/25 revealed that during interview with Social Services Resident #52 denied rubbing Resident #49's breasts, stating that she was trying to stand up and her breast fell out and he was trying to cover it. Record review of Fact Finding Witness Interview-Confidential, dated 2/20/25 revealed that during interview with Social Services Resident #49 indicated that she was touched by Resident #52. In an attempted interview with Resident #49 on 6/3/25 at 8:18 AM she did not respond. In an attempted interview with Resident #52 on 6/3/25 at 8:21 AM, he stated get the hell out. Interview with the DON on 6/3/25 at 11:00 AM, she confirmed that the facility investigation confirmed that Resident #52 was witnessed by a staff member rubbing Resident 49's breast and agreed that this action constituted abuse. Telephone interview with CNA #3 on 6/3/24 at 4:54 PM she stated on 2/20/25 around 5:10 AM she was making rounds and went to the day room area and saw Resident #52 with his right hand through the sleeve of Resident 49's shirt rubbing her breasts. She stated that she separated the residents and notified the nurse. She stated that Resident #52 has a history of inappropriately touching staff but has not touched a resident before. Record review of the admission Record revealed the facility admitted Resident #49 on 12/26/23 with a diagnosis of Diffuse Traumatic Brain Injury and Cognitive Communication Deficit. Record review of the MDS with and ARD of 12/19/24 for Resident #49 revealed a BIMS score of 11, indicating the resident is moderately cognitively impaired. Record review of the admission Record revealed the facility admitted Resident #52 on 7/26/24 with diagnoses including Traumatic Hemorrhage of Cerebrum. Record review of the MDS with an ARD of 1/23/25 for Resident #52 revealed a BIMS score of 11, indicating the resident is moderately cognitively impaired.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to provide a safe, homelike environment as evidenced by an unsanitary bathroom for one (1) of the thirty resident shared bathrooms observed. room [ROOM NUMBER], and room [ROOM NUMBER] Findings include: Review of the facility policy titled Safe environment, undated, revealed, The facility must provide- (1) A safe, clean, comfortable, and homelike environment (2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . Review of the facility policy titled Bathrooms, undated, revealed that Bathrooms shall be maintained in a clean and sanitary manner and shall be cleaned on a daily basis. Record review of Grand Rounds for room [ROOM NUMBER] dated 5/27/25, 5/28/25, 5/29/25, 6/2/25, and 6/3/25 revealed that, under Free from urine odors, and bathroom cleaned it was documented No (N). An observation on 6/3/25 at 2:40 PM revealed a strong urine odor in the shared bathroom of Rooms #133 and #135. A thick black substance was around the base of the toilet. An observation on 6/4/25 at 8:55 AM, and again at 1:25 PM, revealed a strong urine odor in the shared bathroom of Rooms #133 and #135. The thick black substance remained around the base of the toilet. During an observation and interview on 6/04/25 at 3:55 PM, Registered Nurse (RN) #1 revealed that the bathroom shared by room [ROOM NUMBER] and room [ROOM NUMBER] has been a work in progress for quite some time. He revealed that four men share that bathroom, and maintenance has changed out the toilet several times. He confirmed the room had a strong urine smell, and there was a black substance around the base. An observation and interview on 6/04/25 at 4:17 PM with the Maintenance Assistant revealed that he wasn't aware of the significant amount of black corrosion around the base of the toilet and stated, That's on us. I'll let my maintenance director know. He confirmed the bathroom had a strong urine smell. During an interview on 6/04/25 at 4:30 PM, the Housekeeping Director revealed he was aware of the strong urine smell in the resident's bathroom. He revealed that four males share it, and we are cleaning that room more frequently because the men are missing the toilet; it is just a constant battle. During an interview on 06/04/25 at 4:52 PM, the Maintenance Director revealed the department heads make rounds to each resident's rooms and bathrooms each morning and report anything that may be in disrepair or need cleaning during the stand-up meeting. He revealed that he was not aware of the black corrosion around the base of the toilet until his Maintenance Assistant took him into the bathroom a few minutes ago to show him. He confirmed that the toilet had black corrosion around its base, and the strong urine smell was because the tile needed to be replaced. During an interview and observation on 6/04/25 at 5:06 PM, the Administrator revealed that department heads conduct Grand Rounds each morning in each resident room, which includes their bathroom, and discuss any issues found during the stand-up meeting. She confirmed that there was a strong urine odor in the bathroom that rooms #133 and #135 shared. She acknowledged there was a black corrosion around the base of the toilet and stated, We will replace the tile, but until then, a little bleach and Pine-Sol would do a lot of good. During an interview on 6/04/25 at 5:13 PM, Medical Records revealed she is responsible for the morning Grand Round for the shared bathroom of rooms #133 and #135. She revealed that Every day, I go in there. Honestly, it has a strong odor of urine, and the bathroom is dirty. I always put it down on the sheet and notify housekeeping in the hallway, and I also address it during our morning stand-up meeting. She revealed this has been a constant issue.

Based on staff interviews, record review, and facility policy review, the facility failed to notify a resident representative of the risk and benefits for the initiation of a new psychotropic medication for one (1) of two (2) residents reviewed for psychotropic medication use. Resident #31 Findings Include: Review of the facility policy titled Psychotropic Medication Use with a revision date of 2/2025 revealed under, Informed consent or refusal: 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: . b. the indications and rationale for the recommendation; c. the potential risk and benefits (including possible side effects, adverse consequences, and the black box warning); and d. the resident's/representative's right to accept or decline the treatment. Record review of Resident #31's Psych Progress Note dated 11/8/24 revealed, Facility request visit due to recent combative behavior. Staff report that a resident is displaying combative behaviors . Resident is often noted to be reaching for things or pulling at blankets and fidgety often. However, staff reported that the resident has now become combative with staff. Behaviors have been monitored for approximately 1 week and seem to be worsening. Additionally reveled under, Recommendations: Initiate Rexulti 0.5 mg (milligram) q (every) pm (evening) for a diagnosis of Alzheimer's disease. Record review of Resident #31's Progress Notes dated 11/08/24 revealed, Psych (psychiatric) NP (nurse practitioner) gave recommendation for Rexulti. The proper name of RR (resident representative) called to make her aware of the new order. Explained med (medication) is for Alzheimer's and also treats agitation. The proper name of RR said she believed the agitation was related to her not being able to visit lately. There was no documentation that the representative was informed of the risk and benefits of the antipsychotic medication Rexulti, nor that alternative treatments were discussed or that informed consent was obtained. During an interview on 6/4/25 at 2:24 PM, the Director of Nursing (DON) confirmed that staff contacted the resident representative of Resident #31 to inform her of the new medication. However, the representative was not informed of alternative treatment options, potential risks and benefits, or provided the opportunity to consent or refuse treatment. The DON acknowledged the representative should have received this information to make an informed decision. Record review of the admission Record revealed the facility admitted Resident #31 on 10/15/21 with diagnoses that included Dysphagia following Cerebral Infarction and Alzheimer's Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score was not conducted because Resident #31 was rarely/never understood.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to provide dignity to a resident, as evidenced by leaving an indwelling urinary catheter bag and tubing uncovered for one (1) of three (3) residents with a catheter reviewed. Resident #55 Findings include: A review of the facility policy, Dignity with a revision date of February 2021, revealed .12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: . a. helping the resident to keep urinary catheter bags covered . An observation on 06/03/25 at 7:49 AM, and again at 9:08 AM, revealed Resident #55 lying in his bed in his room. A urinary catheter bag containing 200 milliliters of yellow urine was hanging on his bed and visible from the hall, with no privacy bag in place. During an interview on 6/04/25 at 10:05 AM with Certified Nurse Aide (CNA) #4 and CNA #6, CNA #4 revealed that all urinary catheters are supposed to be kept inside a privacy bag, so the resident's urine is not visible to anyone else; it's a dignity issue. CNA #6 (lead CNA) revealed that the catheter is always supposed to be kept inside the privacy bag and confirmed that the urinary catheter bag was uncovered the previous morning, stating, We are doing much better today, looking at that. In an interview on 6/4/2025 at 2:42 PM, the Director of Nurses (DON) revealed that it is our expectation that if a resident has a urinary catheter, it should be placed inside a privacy bag so that the urinary contents are not visible to anyone else. She revealed that if it were not inside a privacy bag, then it would be a dignity issue. Record review of Resident #55's admission Record revealed the facility admitted the resident on 4/15/2025 with medical diagnoses that included Multiple Sclerosis, and Neuromuscular dysfunction of the Bladder. Record review of Resident #55's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/21/25 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated that the resident had moderate cognitive impairment.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure an accurate trauma-informed care assessment was completed for one (1) of two (2) residents reviewed for Post-Traumatic Stress Disorder (PTSD). Resident #44 Findings Include: Review of the facility policy titled Trauma Informed Care and Culturally Competent Care with a revision date of 8/2022 revealed under, Purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Also revealed under, Resident Assessment: 1. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers . An interview with Resident #44 on 6/04/25 at 1:42 PM revealed he was a United States [NAME] in the military for five (5) years and was a sniper during wartime. He stated that he does suffer from PTSD and has nightmares on and off. He explained that when a helicopter passes over the facility, it bothers him (triggers). The resident additionally revealed he was run over by an automobile before coming to the facility and had numerous broken bones and head trauma that required surgery. Record review of Resident #44's Trauma Informed Care Assessment-Post Traumatic Stress Disorder (PTSD) dated 5/19/25 revealed under, PTSD Screen: Sometimes things happen that are unusually or especially frightening, horrible, or traumatic. For example: *a serious accident or fire* a physical or sexual assault or abuse* an earthquake or flood* a war* seeing someone killed or seriously injured* having a loved one die through homicide or suicide . 1. Have you ever experienced this kind of event? No was documented. An interview with Social Services #1 on 6/04/25 at 1:50 PM revealed that all she knew regarding Resident #44's background she obtained from a family member, who mentioned that he was homeless and was hit by a car. SS #1 stated she was not aware that he was a [NAME] and in a war. She confirmed being in a war and being hit by an automobile were both traumatic events. She stated, He has never had an episode to make us think he had post-traumatic stress disorder. She acknowledged the trauma assessment was completed inaccurately, and as a result, the facility failed to identify his symptoms (nightmares) and potential triggers. An interview with Licensed Practical Nurse (LPN) #2 on 6/04/25 at 1:56 PM revealed she was assigned to Resident #44 but was unaware he had PTSD. She stated he had not reported any triggers to her. An interview with the Director of Nursing (DON) on 6/04/25 at 2:01 PM confirmed her expectations were for Resident #44 to have an accurate trauma-informed assessment completed so that staff could identify the resident triggers to prevent any potential re-trauma. Record review of the admission Record revealed the facility admitted Resident #44 on 11/30/23 with medical diagnoses that included Encounter for Surgical Aftercare Following Surgery on the Nervous System and Post-Traumatic Stress Disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #44 was cognitively intact.

Based on observation, resident and staff interview, record review and facility policy review the facility failed to prevent an accident that resulted in an injury, as evidenced by a staff member using a lift the physician had not ordered for one (1) of four (4) residents reviewed that required a lift. Resident #1 Findings Include Review of the facility policy titled, Modified Lifting Policy with no revision dated revealed .Policy Interpretation and Implementation .3. Staff will follow the documented lifting protocol deemed appropriate for each resident. This information is documented in the resident's chart and on the Resident Care Sheet. This information should be referred to prior to lifting/transferring or assisting each resident . An interview and observation on 4/17/24 at 9:10 AM, revealed Resident #1 lying in bed with a total lift sling underneath her. She revealed they now use a lift that lifts her up out of the bed and sits her in her wheelchair. She stated she hurt her shoulder a few weeks ago, but they were using a different kind of lift then. She stated that she was holding herself up for too long on that lift and that's what hurt her shoulder. She admits she feels better now and likes this lift better. Record review of the facility's Report of Investigation for Resident #1's incident revealed that on 3/21/24 the resident was left in a sit to stand lift too long without assistance, which resulted in an injury of a dislocated right shoulder. The report indicated Certified Nursing Assistant (CNA) #5, an agency CNA, provided care to resident by herself. Record review of Resident #1's Radiology Interpretation: x-ray report dated 3/25/24 revealed .Significant Findings: Right Shoulder X-Ray .Findings: There is anterior shoulder dislocation . Record review of the witness statement dated 3/26/24 from CNA #5 revealed she had put Resident #1 in the bed on Wednesday or Thursday around 6:30 PM and the resident stated that the lift was hurting and then complained the next day with her shoulder hurting so she told the nurse. Record review of Resident #1's Departmental Notes dated 3/26/24 at 3:58 AM, revealed the resident returned to the facility from the ER (emergency room ) and report from the ER nurse revealed that the resident had a dislocated shoulder, was given local anesthesia and shoulder put back in place. Record review of Resident #1's Physicians Orders revealed an order dated 3/9/23 Transfer using full body mechanical lift with 2 persons assist. An interview and observation on 4/17/24 at 9:35 AM, revealed CNA #1 and CNA #2 used a total lift to get Resident #1 out of bed and into her wheelchair. Both CNAs revealed that the resident used to be a sit to stand lift but that the resident got to where she could not bear weight, so they changed her to a total lift. CNA #1 stated that the lift change was not long ago. CNA #2 stated that when residents are admitted that therapy decides what type of lift the resident needs and then the nurses tell the CNA's. Both CNAs stated that they were not aware of any care guide that they can look at that tells them what kind of lift to use for the resident. CNA #2 stated that they just know if the residents are weight bearing or not and that helps us to know what kind of lift they need. CNA #1 stated they also have colored dots on their room number that indicate what kind of lift they need. This observation revealed that Resident #1 did not have a colored dot by her room number. An interview on 4/17/24 at 10:15 AM, with Registered Nurse (RN) #1 stated that the residents should have a care plan for lift transfers and that it should confirm rather they are a total or a stand-up lift. She confirmed that the dots that are on the resident's door indicates whether they are independent (green), sit to stand (yellow) or full body lift (red). RN #1 revealed that it lets the nurse aides know which lift to use and that they should use two people with both lift transfers. An interview on 4/17/24 at 10:30 AM, with CNA #3 stated that Resident #1 was not always able to hold her weight up on the Sit to Stand lift so they recently changed her to a Total Lift. An interview on 4/17/24 at 10:50 AM, with CNA #4 confirmed that the colored dots on the resident's room doors let the CNA's know what type of lift to use on the resident. She confirmed that Resident #1 did not have a colored dot on her door. She stated if she did not have a dot then she would just have to ask the nurse what kind of lift to use. She confirmed she was not aware of any care guide that indicated what type of lift the residents use. An interview on 4/27/24 at 11:00 AM, with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that it was discovered during the investigation of Resident #1's right shoulder dislocation that CNA #5 used a sit to stand lift on the resident by herself. The DON stated that an X-ray revealed the resident's right shoulder was dislocated. The ADON revealed that they immediately started an investigation that began with interviewing Resident #1. She stated that the resident told her that she had to hold herself up too long on that lift and that was when her shoulder started hurting. The DON stated that CNA #5 admitted that she used the Sit to Stand lift without any other staff help. The ADON revealed that they changed Resident #1 from a sit to stand lift to a total lift after this incident because the resident drops her weight by bending her knees and couldn't always hold herself up. They both revealed that the CNA's have a care guide at the nurse's station that tells them what kind of lift to use, but the residents also have colored dots on their room numbers that indicate what kind also. An interview on 4/17/24 at 11:20 AM, with the Administrator stated that he knew that CNA #5 had used a Sit to Stand lift without any help and she was not supposed to do that, so she is on my no hire list. An interview and record review on 4/17/24 at 11: 40 AM with the DON confirmed that Resident #1 had an order for a Total Lift to be used since 3/9/2023. The DON stated, so she (CNA) #5 did not even use the correct lift. She stated that she thought the resident had an order for a Sit to Stand but confirmed that she did not. She stated that the use of the wrong lift was against their policy and not following physicians' orders, which could have led to the residents dislocated shoulder. She stated that they put the colored dots in place to indicate the type of lift a little while back but admits that the staff need to be educated on the use of their care guide. An interview and record review on 4/17/24 at 11:50 AM, with CNA #1 revealed she had never seen the care guide form before that indicated a number system that told what type of lift the resident supposed to use. She stated she did not know that Resident #1 was supposed to have been using a total lift because they had always used a sit to stand with her until this incident happened. An interview on 4/17/24 at 12:00 PM, with the Administrator revealed he was not aware that CNA #5 had used the wrong lift and stated that staff must not be looking at the resident's care guides like they are supposed too. Record review of Resident #1's Daily Care Guide revealed the resident needed Total Dependence for transfer. Record review of Resident #1's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia following Cerebral Infarction affecting left nondominant side.

Based on resident and staff interview, record review and facility policy review the facility failed follow the person centered care plan to use a full body lift as indicated, causing a dislocated shoulder for Resident #1. This was for one (1) of four (4) resident care plans reviewed. Findings Include Record review of the facility policy titled, Care Plans, Comprehensive, Person Centered with no revision dated revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident . Record review of Resident #1's Care Plan revealed a care plan dated 3/8/23 Alteration in ADLS (Activities of Daily Living) r/t (related to) generalized weakness, difficulty walking, impaired mobility secondary to Hx (history) CVA (Cerebral vascular accident) with left sided Hemiplegia, extensive assist x (times) 2 staff with bed mobility and transfer .Interventions .Transfer using full body mechanical lift with 2 persons assist . During an interview on 4/17/24 at 9:10 AM, revealed Resident #1 stated she hurt her shoulder a few weeks ago, but they were using a different kind of lift then. She revealed that she was holding herself up for too long on that lift and that's what hurt her shoulder. During an interview on 4/17/24 at 9:35 AM revealed CNA #1 and CNA #2 both reported Resident #1 used to be a sit to stand lift but that the resident got to where she could not bear weight, so they changed her to a total lift. During an interview on 4/17/24 at 10:50 AM, with CNA #4 confirmed she did not have access to the resident's care plans. She stated that the care plans should let them know what care the resident needed. During an interview on 4/17/24 at 11:00 AM, with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that it was discovered during the investigation of Resident #1's right shoulder dislocation that CNA #5 used a sit to stand lift on the resident by herself. The ADON revealed that they changed Resident #1 from a sit to stand lift to a total lift after this incident because the resident drops her weight by bending her knees and couldn't always hold herself up. During an interview and record review on 4/17/24 at 11:40 AM, the DON confirmed Resident #1 had a Physician's order for a Total Lift to be used since 3/9/2023 and a care plan for the use of a Total Lift with a start date of 3/8/23. She stated that care plans are used to direct the care needed for the residents. During an interview on 4/17/24 at 11:42 AM, with Licensed Practical Nurse (LPN) #1 stated that care plans are important to help guide the care that the resident is supposed to receive. During an interview on 4/17/24 at 11:45 AM, with the Director of Clinical Services confirmed that the care plan is put into place to guide the staff on what type of care the resident needs. During an interview on 4/17/24 at 12:00 PM, the Administrator stated staff must not be looking at the resident's care plans like they are supposed too. Record review of Resident #1's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia following Cerebral Infarction affecting left nondominant side. Record review of the facility's Report of Investigation for Resident #1's incident revealed that on 3/21/24 the resident was left in a sit to stand lift too long without assistance, which resulted in an injury of a dislocated right shoulder. The report indicated Certified Nursing Assistant (CNA) #5 provided care to resident by herself. Record review of Resident #1's Radiology Interpretation: x-ray report dated 3/25/24 revealed .Significant Findings: Right Shoulder X-Ray .Findings:There is anterior shoulder dislocation .

Based on observation, record review and staff interview, the facility failed to provide services as directed by care plans for positioning and restraint release for one (1) of six (6) residents observed. (Resident #2) Findings include: Cross Refer to F-314 for failure of the facility to provide services to promote healing of pressure ulcers and prevent further pressure ulcer development for one (1) of six (6) residents observed. (Resident #2) Review of the facility's policy entitled "Care Plans-Comprehensive", no dated, revealed, "3. Each resident's comprehensive care plans has been designed to (a) incorporate identified problem areas; (b) incorporate risk factors associated with identified problems; (d) reflect treatment goals and objective in measurable outcomes; (e) identify the professional services that are responsible for each element of care; (f) aid in preventing or reducing declines in the resident's status. 5. Care plans are revised as changes in the resident's condition dictate." Review of the facility's policy entitled "Abuse Prohibition", not dated, revealed: "(Section III D 1) Care plans will be routinely revised/ updated to assure the prevention of abuse, neglect, and/or misappropriation of resident property". Record review on 6/21/13 revealed that Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set, with an Assessment Reference Date of 6/7/13, revealed a Brief Interview for Mental Status, which indicated resident was not able to complete the interview for cognition determination. Observation on 6/22/13 from 6:00 a.m. through 10:30 a.m. revealed Resident #2 remained seated in a wheelchair with a restraint in place. Resident #2 was not released from the soft belt restraint, repositioned or offered any fluids except for during breakfast from 6:00 a.m. to 10:30 a.m. during an uninterrupted observation by the surveyor. Review of Resident #2 care plans dated 5/10/13 revealed the following approaches for the resident's care: "Incontinent care every 2 hours and prn (as needed). Turn & reposition every 2 hours & prn. High back wheelchair with soft waist restraint. Reposition resident every 2 hours. Assist to change position every 30 minutes to 2 hours. Check q (every) 30 minutes and release q (every) 2 hours x 10 minutes for positioning, toileting and exercise." Interview on 6/22/13 at 11:15 a.m. with RN #1 revealed, "We let him down, he fell between the cracks. I have RN's on the floor to supervise and make sure what should be done is being done."

Based on observation, record review and staff interview the facility failed to prevent neglect of dependent residents for one (1) of six (6) residents observed, Resident #2, as evidenced by, failure to provide release from restraint, reposition resident, offer supplemental oral fluids, and failure to follow/develop care plans. CI MS # Findings include: Cross Refer to F-314 for the facility's failure to provide services to promote healing of pressure ulcers and prevent further pressure ulcer development for one (1) of six (6) residents observed (Resident #2). Review of the facility's policy entitled "Abuse Prohibition", not dated, revealed: "(Section III D) Residents with needs and behaviors which might lead to conflict or neglect, such as, those that require heavy nursing care and/or are totally dependent on staff will be routinely assessed for needs and changes in condition." Review of the facility's policy entitled "Abuse Education Guide", not dated, revealed: "Indicators of neglect - pressure sores/untreated sores" During an uninterrupted observation on 6/22/13 revealed Resident #2 remained in a wheelchair and was not released from the soft waist restraint, repositioned, or offered additional fluids from 6:00 a.m. through 10:30 a.m. During this uninterrupted observation, a Certified Nurse Aide (CNA) entered Resident #2's room to wheel the resident to the dining room for breakfast and a CNA later obtained a blood pressure reading but neither CNA released or repositioned Resident #2. Interview on 6/21/13 at 2:00 p.m. revealed the Wound Center's Registered Nurse stated, "He (Resident #2) was soaked, I understand he could have urinated on himself before he got here. I think he is being neglected; they are not turning or drying him. He is more lethargic since he started coming here on 4/30/13. His right heel has decreased in size, left heel increased in size since initial assessment on 6/4/13, his left lateral leg increased from 3 cm(centimeters) to 12 cm in 2 weeks and the scrotum was new on 6/18/13. I think the scrotum is from being wet because the open areas were along the folds". Interview on 6/22/13 at 10:35 a.m. with Certified Nurse Aide (CNA) #14 and CNA #7, revealed both stated, "No" when asked if Resident #2 was able to use call light. Both CNAs stated, "No" when asked if resident was able to let staff know if he needed to be cleaned up or needed something. CNA #7 and CNA #14 stated resident at times would talk and ask for water but mostly was unable to make needs known. Interview with the Director of Nursing on 6/22/13 at 11:15 a.m. revealed, "I call (Physician) on yesterday 6/20 about a doppler for his legs but I have not heard". Record Review revealed no orders for a Doppler Study. Interview on 7/18/13 at 9:50 a.m. revealed Resident #2's Primary Physician stated, "In the first place, he needed good nursing care. The nurses said they were doing the wound care, turning and drying but this was not evident from what we saw at the wound center. All (ulcers) have actually increased. All of his ulcers could have been preventive with good nursing care; but, I don't know where to find good nursing care anymore. He does have some co-morbidities like Diabetes, Hypertension. He is unable to turn himself, and total care of the nurses is needed. He is confused, knows his name, eats well, and they have to feed him at times. I'm sure he has [MEDICAL CONDITIONS] but with good nursing care this could have been prevented". Record review on 6/21/13 revealed that Resident #2 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score at 99, which indicated Resident #2 was not able to complete the interview to determine resident's cognitive status. Record review on 6/21/13 revealed that Resident #2 was readmitted to the facility from the local Long Term Acute Care (LTAC) on 5/24/13 with debrided decubitus to left heel measuring 2.0 x 1.0 cm (centimeters), right heel measuring 2.0 x 1.0 cm and decubitus to coccyx measuring 6.5 x 1.0 cm. Review of the "Completed Care Tasks (CNA care documentation sheet)", revealed there was no documentation of AM (morning) care, bed mobility, and ADL (activity of daily living) care from 2:41 a.m. until 11:09 a.m. on 6/22/13. Review of Resident #2 care plans, dated 5/10/13, revealed, "Incontinent care every 2 hours and prn (as needed).Turn & reposition every 2 hours & prn. Reposition resident every 2 hours. Assist to change position every 30 minutes to 2 hours. Check q (every) 30 minutes and release q (every) 2 hours x 10 minutes for positioning, toileting and exercise." Record review revealed resident developed a pressure ulcer on the left outer leg on 6/3/13 with a measurement of 3.5 x 1.8 x 0.1 cm. This pressure ulcer on the left outer leg continued to worsen to a stage II which measured 23.0 x 6.5 cm on 6/24/13. Resident #2 was admitted to the hospital on [DATE] where the resident's left leg was amputated above the knee on 7/9/13.

Based on observation, record review and staff interview the facility failed to release restraints and reposition as ordered and care planned for one (1) of six (6) residents record reviewed. (Resident #2) Findings include: An uninterrupted observation on 6/22/13 revealed Resident #2 remained in a wheelchair with a soft waist restraint in place and was not released from restraint, repositioned, or offered supplemental fluids from 6:00 a.m. until 10:30 a.m. Record review on 6/21/13 and 7/17/13 revealed that Resident #2 was admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2 was readmitted to the facility on [DATE] with status [REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 99, which indicated that Resident #2 was not able to complete the interview. Interview with Registered Nurse (RN) #3 on 6/22/13 at 11:15 a.m. concerning Resident #2's lack of release from restraint revealed, "We let him down, he fell between the cracks". Interview on 7/17/13 at 10:00 a.m. with Registered Nurse #3 about the need for restraints for Resident #2, revealed "We tried the chair alarm but he still could get up and fall or hit a resident so the lap restraint was the least restrictive for safety to him, staff and other residents. We had a bed alarm but he kept trying to get up, we couldn't tie him to the bed so we put a floor mat beside his bed to minimize chances of injury". Interview on 7/17/13 at 11:25 a.m. with Certified Nurse Aide (CNA) #1 regarding concerns with releasing restraints revealed, CNA#1 stated, "I work 6a-2p. I would not know of changes until about 7 (a.m.) when report is given. I don't open the (computer documentation program) until I chart the care." CNA #1 stated if nobody updated the (computer), she would not know about restraints until report time. Interview on 7/17/13 at 3:00 p.m. Certified Nurse Aide (CNA) #12 stated, "The (computer) only has "Did you reposition q 2 hours yes/no" , there is no place to mark time. No, I don't look at the chart only what's on the (computer)." Review of "Completed Care Tasks (CNA care documentation)", dated 6/22/13, revealed AM (morning) care, bed mobility and ADL self performance was done at 2:41 a.m. There was no further documentation of care by the CNA until 6/22/13 at 11:09 a.m. Record review of physician orders, dated 4/22/13, revealed an order for [REDACTED]." Review of Resident #2's care plans dated 5/10/13 revealed approaches which included: High back wheelchair with soft waist restraint. Reposition resident every 2 hours. Assist to change position every 30 minutes to 2 hours. Check q (every) 30 minutes and release q (every) 2 hours x 10 minutes for positioning, toileting and exercise. Review of the facility policy "Use of Restraints" dated 2/17/11 revealed, "12. c. A resident placed in restraints will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the medical record. 12. d. The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during two (2) hours in which restraints are employed. 12. e. Restrained residents must be repositioned at least every two (2) hours on all shifts".

Based on observation, record review and staff interview the facility failed to provide services to promote healing of pressure ulcers and prevent further pressure ulcer development for one (1) of six (6) residents observed. (Resident #2) Findings include: Record review of the facility wound treatment records dated from 6/3/13 to 6/24/13 revealed measurements showing the development of a decubitus and a progressive increase in decubitus size which resulted in the amputation of Resident #2's left leg above the knee: Left heel decubitus increased from 2.0 x 1.0 centimeter (cm) to 5.5 x 5.0 cm with slough. Left lateral ankle decubitus increased from 0.8 x 0.9 cm to 1.2 x 1.0 cm. A new decubitus was noted on 6/3/13 on the left lateral lower leg. The left lateral leg decubitus increased from 3.5 x 1.8 x 0.1 cm on 6/3/13 to 23.0 x 6.5 cm on 6/24/13 with heavy drainage, and had merged with left ankle decubitus. According to documentation from the wound care center, another new decubitus on Resident #2's scrotum was noted on 6/18/13. The facility failed to document the decubitus to the scrotum until 6/21/13. Uninterrupted observation of Resident #2 on 6/22/12 from 6:00 a.m. to 10:30 a.m. revealed Resident #2 was not repositioned during the entire observation. Observation on 6/22/13 at 10:35 a.m. revealed Certified Nurse Aides were observed in Resident #2's room to place him in bed. Resident #2's bilateral feet were swollen. Dressings were intact with drainage visible to right ankle and left lower leg. A strong foul odor was noted to the dressings on the resident's legs. Record review 6/21/13 revealed that Resident #2 was admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2 was not able to complete the Brief Interview for Mental Status (BIMS) according to the 6/7/13 Minimum Data Set. Interview on 6/21/13 at 2:00 p.m. with wound center's Registered Nurse revealed Resident #2's left heel increased in size since initial assessment on 6/4/13, his left lateral leg increased from 3 cm to 12 cm in 2 weeks and the scrotum was new on 6/18/13. Interview on 6/22/13 at 11:15 a.m. with Registered Nurse #3 confirmed the Stage II to Resident #2's left lower leg was acquired in the facility. Interview on 7/18/13 at 9:50 a.m. with the Primary Physician revealed, "All (ulcers) have actually increased. All of his ulcers could have been preventive with good nursing care. He does have some co-morbidly like Diabetes, Hypertension. I'm sure he has [MEDICAL CONDITION] but with good nursing care this could have been prevented." Interview on 7/18/13 at 3:00 p.m. with Registered Nurse #3 regarding concerns with wound to scrotum documented at the (Local Wound Center) on 6/18/13 revealed, "The order for the scrotum was over looked, I triple checked, but I have not found anything before 6/21/13." Review of Resident #2 care plans dated 5/10/13 revealed "Incontinent care every 2 hours and prn (as needed). Turn & reposition every 2 hours & prn". Review of the facility's policy entitled "Pressure Area Protocol", not dated, revealed, "It is the policy of this facility to help prevent pressure areas and/or help in the healing of pressure areas present".