Every finding on record at Robison Jewish Health Center

Based on interview and record review it was determined the facility failed to ensure a resident was treated with dignity and respect for 1 of 5 sampled residents (#4) reviewed for dignity and respect. This placed residents for diminished quality of life. Findings include: Resident 4 admitted to the facility in 7/2026 with diagnoses including fracture to the right arm and left wrist. A 7/2/26 Care plan indicated Resident 4 had an ADL deficient due to fractures and required moderate to maximum assistance from 1 female staff member, if present and available, with showering twice weekly. The facility's Incident Report dated 7/17/26, indicated Staff 9 (CNA) told Resident 4 to clean her/his crotch then rinsed and re-cleaned the area roughly with a washcloth. Resident 4 stated she/he felt uncomfortable and stated she/he has refused showers from any staff after the incident. An 8/8/26 education document for Staff 9 indicated Staff 9 received education on how to refer to a resident's private areas, including the vagina, penis, or peri area, as crotch was professionally inappropriate. In an interview on 8/19/26 at 3:35 PM Resident 4 stated during shower care, Staff 9 directed the resident to wash my crotch, then proceeded to shove the resident into a chair and rinse the resident's peri area. Resident 4 stated Staff 9 subsequently attempted to re-clean the resident's peri area with a washcloth in a rough manner. Resident 4 stated she/he told Staff 9 to stop, and Staff 9 stopped cleaning the resident. Resident 4 stated they had fractures involving both arms, which made it difficult to perform personal hygiene independently. Resident 4 stated they felt humiliated and treated in an undignified manner as a result of the interaction. Resident 4 stated she/he was uncomfortable receiving shower care from facility staff and subsequently refused further showers until discharged home the following week. In an interview on 8/19/26 at 4:10 PM, Staff 8 (CNA) stated Resident 4 reported Staff 9 was rude and demanding during shower care. Staff 8 stated Resident 4 said she/he did not want to receive any more showers from staff in general after the incident. Staff 8 told Staff 10 (LPN) and then wrote an incident report on the event. In an interview on 8/20/26 at 11:07 AM, Staff 9 confirmed he referred to Resident 4's peri area as 'crotch' when providing the resident with her/his shower. Staff 9 stated he observed Resident 4 had arm braces on but did not check with the nurse regarding Resident 4's care needs. Staff 9 denied shoving Resident 4 into a chair after directing Resident 4 to wash her/his peri area. Staff 9 stated he was later educated on the use of appropriate language by staff when referring to residents' peri areas. Staff 9 stated Resident 4 had not complained to him about feeling humiliated at any time during shower care. In an interview on 8/20/26 at 1:29 PM, Staff 10 stated Staff 8 reported Resident 4 complained Staff 9 threw a rag at her/him during shower care and told the resident to wash herself/himself. Resident 4 complained Staff 9 was rough with his care toward Resident 4 and Resident 4 didn't want to be showered after that incident. In an interview on 8/21/26 at 1:22 PM, Staff 2 (DNS) stated Staff 9 was educated on the use of the word crotch and that it was inappropriate language. Staff 2 stated after Staff 9 was given education he still was not conscientious about resident care or the needs of residents. Staff 2 stated facility staff are not supposed to use inappropriate language toward residents. Staff 2 stated Staff 9 was terminated on 8/14/26 for failure to meet professional CNA performance standards.

Based on interviews and record review it was determined the facility failed to ensure a Stage 2 pressure ulcer was identified, assessed, treated and monitored upon admission to the facility for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. As a result, Resident 1 experienced significant damage to her/his penis, which was unrepairable and resulted in the resident no longer being able to urinate from her/his penis. Findings include:Resident 1 admitted to the facility on 8/2025 with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, a foley catheter, and a Stage 2 pressure ulcer located on the resident's penis.Per CMS, a Stage 2 Pressure Ulcer is defined as a partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present.Resident 1's admission paperwork from her/his previous facility, which included an admission and Discharge Summary, and an Order Summary dated 8/26/25 indicated the resident had a Stage 2 pressure ulcer located on her/his left lateral meatus (penis). In addition, the resident's Order Summary indicated to apply triple antibiotic ointment every shift with catheter care until resolved. If worsening, consult RCM. Review of Resident 1's clinical record found no documented evidence the facility identified, assessed, treated and monitored the resident's Stage 2 pressure ulcer located on her/his left lateral meatus of the penis. Resident 1's admission Nursing Database Skin assessment dated [DATE] identified no pressure ulcer to the resident's left lateral meatus of the penis. Resident 1's Urinary Incontinence/Indwelling catheter CAA dated 8/29/25 indicated the resident had a catheter in place and was followed by a urologist. There was no documentation of the resident's pressure ulcer located on her/his penis.Resident 1's Care Plan dated 8/29/25 identified she/he had skin impairment to her/his bilateral lower extremities. The resident's care plan did not address her/his Stage 2 pressure ulcer to left lateral meatus of the penis.Resident 1's admission Physician Orders dated 8/30/25 had no orders to address and treat the residents Stage 2 pressure ulcer of the left lateral meatus of the penis.Resident 1's MDS admission assessment dated [DATE] indicated the resident was cognitively intact and the resident had no pressure ulcer/skin injury, no skin tears, however, the resident was at risk of developing pressure ulcers/injuries. Resident 1's 9/2025 and 10/2025 TAR did not identify any Stage 2 pressure ulcer to the resident's penis. Resident 1's progress notes dated 8/29/25 through 10/12/25 revealed no documentation of a penile pressure ulcer, wound, injury, or related treatment.Resident 1's hospital records dated 10/12/25 to 10/20/25 revealed the following: -10/12/25 Emergency Department Visit Summary indicated the Foley catheter had eroded through the penile scrotal junction as well as erosion in the meatus. -10/12/25 Hospital Urology Note indicated Resident 1's penile urethra had eroded from the urethral meatus to the penile junction, attributed to prolonged urethral catheter placement. It was uncertain whether the catheter had ever been replaced while the resident was at the facility. A follow-up appointment with the urology clinic was planned to assess the urethral condition and discuss alternative catheterization options in light of the urethral erosion. -10/13/25 Attending Inpatient Note indicated that upon arrival to the emergency department, Resident 1 was found to have urethral erosion extending through the entirety of the penile shaft. -10/19/25 Attending Inpatient Note indicated Resident 1 was evaluated for bladder outlet obstruction associated with a chronic Foley catheter, which resulted in traumatic hypospadias (a condition caused by urethral injury, often related to prolonged catheterization, leading to abnormal urethral positioning and functional complications). The note further documented that the resident's penis was splayed the entire length of the shaft, and that the resident will never be able to urinate normally again. The attending physician noted that surgical options for penile reconstruction are extremely limited. A urology clinic follow-up was planned to evaluate and develop a plan for suprapubic catheter placement. (A thin, flexible tube used to drain urine from the bladder, which is inserted through a small incision in the lower abdomen, just below the navel, bypassing the urethra). On 10/29/25 at 1:53 PM, Staff 16 (CNA) stated once, while providing perineal care to Resident 1, bleeding was observed below the penis and scrotal area. The bleeding was promptly reported to the nurse. On 10/30/25 at 10:13 AM, Witness 1 (Complainant) stated Resident 1's hospital physician requested a complaint be filed with the state due to concerns regarding the condition of the resident's penis upon arrival to the emergency department on 10/12/25.On 10/30/25 at 10:50 AM, Staff 8 (LPN) stated the first time he worked with Resident 1, a CNA alerted him to a concern regarding the resident's penis. Upon assessment, Staff 8 observed what he described as a big tear along the penis, located below the urethral opening. He noted that the tear did not appear to be a fresh wound. On 10/31/25 at 1:30 PM, Witness 2 (Hospital Physician) stated Resident 1's Foley catheter was exiting from the base of Resident 1's penis and that significant pressure from the catheter likely caused erosion of the penile tissue. When asked whether the penile injury could have occurred during transport to the emergency department on 10/11/25 or while in the emergency department, Witness 2 stated such an injury could not have resulted from events occurring only on that night. Due to loss of sensation in the area, the resident was not experiencing pain associated with the erosion. Witness 2 indicated the erosion could be considered a pressure ulcer, as the Foley catheter exerted continuous pressure on the urethra. Witness 2 further stated Resident 1 reported having informed facility staff of the penile issue and had requested to see a urologist. On 10/31/25 at 3:57 PM, Staff 6 (RN) stated he had provided catheter care for Resident 1. Staff 6 reported observing oozing from the resident's penis on at least one occasion. He further stated that the resident's penis had a split, which he believed could occur naturally. When the surveyor asked Staff 6 to clarify his statement regarding a naturally occurring split in the penis, he reiterated that sometimes it just happens naturally to a penis.On 11/3/25 at 12:34 PM, Witness 4 (DNS from Discharging Facility) stated Resident 1 was discharged with a Stage 2 pressure ulcer caused by the catheter. The ulcer was first documented on 7/21/25, measuring approximately 1 cm x 1 cm, located on the left lateral meatus of the penis. The resident reported no pain associated with the wound. The resident was educated on alternating the catheter tubing anchor between legs and leaving more slack in the tubing to reduce tension on the urethral opening. Witness 4 indicated the resident's last skin check prior to discharge on [DATE], performed by her on 8/27/25, revealed the pressure ulcer was healing but not fully healed. At that time, the wound measured 0.8 cm x 0.8 cm, superficial in depth, showed improvement, and had no drainage.On 11/3/25 at 1:05 PM, Staff 18 (CNA) stated while providing perineal care for Resident 1, she observed what appeared to be a sore or cut on the penis. Staff 18 stated she notified the nurse on duty but could not recall who was working that shift. She also reported mentioning the injury to several other nurses. According to Staff 18, any staff providing catheter or perineal care would notice the wound if they examined the area closely. She described the wound as a rip, noting that discharge was visible each time the brief was changed. She recalled the wound being on the left side of the penis and stated it resembled a split like a hot dog bun, causing the resident pain during cleaning.On 11/4/25 at 2:55 PM, Staff 2 (DNS) and Staff 3 (Resident Care Manager) stated they were not aware of Resident 1's Stage 2 pressure ulcer.On 11/4/25 at 3:10 PM, Staff 4 (Resident Care Manager) stated during his initial visit with Resident 1, the resident expressed experiencing discomfort in the penis area, describing it as a sensation of something pulling. Staff 4 stated based on the way the resident communicated her/his concern, Staff 4 interpreted the discomfort was not current but had occurred previously. Staff 4 stated on 9/4/25 he looked at the resident's penis and noticed a split, maybe around an inch long, which was reported to the facility provider. On 11/4/25 at 4:04 PM, Staff 1 (Administrator) and Staff 19 (Regional Director of Quality Assurance) were informed of findings for Resident 1 who was admitted with a Stage 2 pressure ulcer located on the left lateral meatus of the penis which was not identified, assessed, or care planned upon her/his admission to the facility.

Based on interview and record record it was determined the facility failed to monitor for legionella in 1 of 1 facility reviewed for infection control. This placed residents at risk for infection from exposure to water borne pathogens. Findings include:The facility's Infection Prevention and Control Program policy and procedure dated 10/1/25 indicated:- A water management program has been established as part of the overall infection prevention and control program, - Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems, and- The Maintenance Director serves as the leader of the water management program. On 9/19/25 11:02 AM Staff 15 (Maintenance Technician) and Staff 39 (Maintenance Technician) stated that had not been trained on water borne pathogens and had not been instructed to monitor for legionella's presence in the facilities water system. On 9/19/25 at 11:13 AM Staff 40 (Maintenance Director) stated she was unaware of areas at risk for development of legionella in the facility and confirmed no monitoring had been performed to ensure legionella or any other water borne pathogens were not present in the facility.On 9/19/25 at 2:34 PM Staff 4 (LPN-Resident Care Manager/Infection Preventionist) stated an understanding legionella could develop in areas of standing water and stated she had not been involved in the identification of areas at risk for legionella or monitoring for legionella.

Based on interview and record review it was determined the facility failed to ensure a system was in place to receive, track and resolve resident and/or resident representative grievances for 1 of 1 sampled facility reviewed for Resident Council. This placed residents at risk for unreported and unresolved grievances. Findings include:The facility's Grievance policy revised in April 2017 stated the following:- Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designed to hear grievances (e.g., the State Ombudsman).- The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. - The Administrator has delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer who is the Social Services Coordinator.- Upon Receiving a grievance and complaint report, the Grievance Officer will begin an investigation into the allegations.- The Grievance Officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. - The results of all grievances filed, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. 1. Review of the facility's 2025 Grievance binder revealed the following:- No grievance records for 6/2025, 7/2025 and 8/2025. - Four incomplete grievance records dated in 4/2025, 5/2025 and one undated.The Resident Council meeting on 9/17/25 at 2:00 PM revealed the following: - Residents were unclear how to file a grievance or the process for grievance resolution by the facility.- Resident 72 stated she/he filed a grievance two months ago without follow-up by the facility. On 9/18/25 at 9:07 AM Staff 29 (CNA) stated they did not receive instruction on grievances. Staff 29 stated they knew there was a box next to the elevator, but they had not been trained or informed on the process of residents filing a grievance. On 9/18/25 at 11:14 AM Staff 12 (CNA) stated they thought the grievance forms were kept at the front desk and if a resident expressed a concern, they would refer them to Staff 2 (DNS). Staff 12 stated boxes were located by the elevators and thought the grievance forms were for employees. Staff 12 stated family members who complained knew who to report concerns to. On 9/18/25 at 2:49 PM staff 31 (CNA) stated they did not fully understand grievance forms and assumed from the name they should offer the form if a resident had a repeated complaint. Staff 31 stated they had not received training on grievances and did not think it was part of a CNA's job. On 9/16/25 at 2:50 PM Staff 7 (Social Services) stated there was not a consistent way grievances were received. Staff 7 did not think residents and/or resident representatives knew how to turn in grievances. Staff 7 stated the system was broken down and there was currently no protocol for processing grievances or a tracking system in place for knowing which grievances had been addressed and resolved. On 9/17/25 at 4:30 PM Staff 1 (Administrator) acknowledged there was no clear system in place for tracking residents' grievances or knowing with certainty which concerns had been addressed or resolved 2. Resident 89 was admitted to the facility in 8/2025 with diagnoses including diffuse large B-cell lymphoma (a fast-growing blood cancer that affects the body's immune system) and type 2 diabetes. Resident 89's 8/18/25 admission MDS revealed she/he had moderate cognitive impairment and required supervision or touching assistance to transfer from a seated position to standing. Resident 89's care plan initiated 8/14/25 indicated staff were to anticipate and meet her/his needs to reduce her/his risk of falls. On 9/16/25 at 9:47 AM Resident 89 stated she/he was out of the facility for an appointment shortly after she/he was admitted to the facility. Resident 89 stated the transportation company contracted through the facility took 20 hours to pick her/him up and bring her/him back to the facility. Resident 89 stated the transportation piece was terrible and she/he waited on a bench in a hallway at the hospital for the driver to pick her/him up. On 9/16/25 at 10:06 AM Resident 89 stated she spoke with Staff 21 (RN) about the delayed transportation issue. Resident 89 stated Staff 21 listened to her/him and said he was going to get the grievance paperwork but never came back. On 9/18/25 at 10:46 AM Resident 89 stated she/he expected Staff 21 to come back but he didn't and that was not the right thing to do. Resident 89 stated she/he wanted to submit a grievance so the transportation delay didn't happen to anyone else. On 9/18/25 at 11:13 AM Staff 21 acknowledged he did not provide a grievance form to Resident 89. He stated he took complaints very seriously and he talked to residents to understand what the problem was and usually tried to see if something could be done in the interim. Staff 21 stated he also referred residents to Staff 7 (Social Services), Staff 2 (DNS) or one of the Care Managers. Staff 21 stated he never provided the grievance form to a resident and did not know where to find the form. On 9/18/25 at 11:14 AM Staff 12 (CNA) stated they thought the grievance forms were kept at the front desk and if a resident expressed a concern, they would refer them to the Staff 2. Staff 12 stated boxes were located by the elevators and thought they were for employees. Staff 12 stated family members who complained knew who to report concerns to. On 9/18/25 at 11:21 AM Staff 14 (Lead CNA) stated there were no grievance forms located on the skilled halls but grievance forms were located on the long-term care halls. On 9/22/2025 at 12:25 PM Staff 1 (Administrator) stated she expected residents to have access to grievance forms whenever they wanted and staff were to assist them in completing a grievance if they were unable to complete it independently. Staff 1 stated a functioning grievance procedure was necessary to know when things were not working so they could be corrected before the issue became a system problem.

Based on observation, interview and record review it was determined the facility failed to ensure physician orders were followed, and failed to identify, assess, and treat a change in a resident's skin condition for 3 of 9 sampled residents (#s 19, 84 and 87) reviewed for unnecessary medications and skin conditions. This placed residents at risk for adverse medication effects and untreated and worsening skin impairments. Findings include: 1.The facility's Medication Administration policy revised 10/1/24 stated the following:- Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Resident 84 was admitted to the facility in 8/2025 with diagnoses including Multiple Myeloma (a cancer of white blood cells). Resident 84's 8/11/25 admission MDS indicated the resident had moderate cognitive impairment. Resident 84's 8/2025 and 9/2025 MAR indicated the resident was to receive:- Venetoclax (a cancer medication) 100 mg, four tablets at 9:00 AM and 11:00 AM daily. Do not crush; swallow one whole at a time with applesauce. A time stamped Medication Administration Audit Report from 8/8/25 through 9/17/25 indicated the following:- Twenty-seven times Resident 84's Venetoclax was administered more than 60 minutes late. On 9/15/25 at 2:24 PM Witness 4 (Family Member) expressed concerns the resident was not receiving her/his cancer medication on time. On 9/17/25 at 10:01 AM Resident 84 stated she/he had not received her/his 9:00 AM dose of Venetoclax. On 9/17/25 at 10:17 AM Staff 30 (CMA) was observed administering Resident 84's 9:00 AM dose of Venetoclax. Staff 30 acknowledged administration was late and stated the resident required up to a half hour to take the medication and they did not have time to wait. Staff 30 stated they were told to administer Resident 84's Venetoclax at the end of medication pass due to the extended administration time needed. On 9/22/25 at 4:42 PM Staff 27 (LPN) stated facility policy allowed medications to be given within one hour before and after the scheduled time. Staff 27 stated Resident 84 took a long time to swallow her/his Venetoclax and sometimes refused the medication. Staff 27 stated she was aware during medication pass, the CMAs would attempt to administer Resident 84's medication first, but if she/he refused they moved on to other residents and returned later to reapproach her/him. On 9/22/25 at 8:46 AM Staff 2 (DNS) stated staff had reported they were unable to consistently administer Resident 84's Venetoclax on time due to the resident's difficulty swallowing and it could take up to an hour for the resident to finish. Staff 2 stated the facility was unable to commit to Resident 84 getting her/his Venetoclax “on the dot” due to the needs of other residents. Staff 2 was made aware of the number of late administrations for Resident 84's medication and acknowledged the medications were not given timely. 2. Resident 19 admitted to the facility in 8/2025 with diagnoses including epilepsy (seizure disorder) and right-side hemiplegia (paralysis). An 8/7/25 provider order for Lacosamide 100mg (an antiseizure medication) was instructed to be administered twice a day at 8:00 AM and 8:00 PM. Multiple progress notes from the morning of 8/8/25 indicated a script for Lacosamide was not sent with Resident 19 upon admission, the 8/7/25 8:00 PM administration was missed, the provider was contacted about the missed administration, and the provider wrote a new script for the medication. A progress note from 8/8/25 at 2:48 PM indicated the Lacosamide had arrived from the pharmacy. The note indicated the provider was contacted and gave permission for a late administration of the medication and instructed facility staff to administer the next dosages according to the set schedule. A review of the 8/2025 MAR indicated Resident 19 did not receive Lacosamide on 8/7/25, and received the 8/8/25 8:00 AM administration of Lacosamide late. No other administrations of Lacosamide were missed. A review of the 8/2025 Medication Admin Audit Report revealed the following: - On 8/8/25 Lacosamide was given at 2:28 PM. - On 8/9/25 Lacosamide was given at 10:42 AM. - On 8/9/25 Lacosamide was given at 10:05 PM. - On 8/10/25 Lacosamide was given at 9:34 AM. - On 8/11/25 Lacosamide was given at 9:11 AM. - On 8/14/25 Lacosamide was given at 11:14 AM. - On 8/17/25 Lacosamide was given at 9:55 AM. - On 8/22/25 Lacosamide was given at 9:14 PM. - On 8/25/25 Lacosamide was given at 9:06 PM. - On 8/26/25 Lacosamide was given at 9:35 PM. - On 8/27/25 Lacosamide was given at 9:14 AM. On 9/19/25 at 12:34 PM, Witness 5 stated Resident 19 had missed multiple doses of her/his Lacosamide, and received multiple doses of Lacosamide later than the provider instructed administration times during 8/2025. On 9/22/25 at 4:26 PM, Staff 39 (CMA) stated she administered medications on all halls of the facility. She stated antiseizure medications were to be given at specific times to avoid poor outcomes for the residents. On 9/22/25 at 4:35 PM, Staff 40 (RN) stated she administered medications at the facility while Resident 19 was a resident, but did not remember her/him. She stated antiseizure medications were to be administered within one hour prior or one hour after the provider instructed time. On 9/22/25 at 11:05 AM, Staff 3 (RNCM) stated she remembered Resident 19 and the situation regarding the medication script not being sent upon admission. She stated the expectation for new admissions was to ensure all needed scripts were sent to the pharmacy, and all medications were administered according to provider instructions. On 9/22/25 at 1:03 PM, Staff 2 (DNS) acknowledged Resident 19's antiseizure medication was not given as the provider instructed. She stated the expectation for administering antiseizure medications was for them to be prioritized and administered within an hour before or an hour after the provider scheduled time. 3. Resident 87 was admitted to the facility in 6/2025 with diagnoses including Parkinsonism unspecified (a group of symptoms that are similar to Parkinson's disease but do not have a definitive underlying cause). Resident 87's 6/28/25 admission Record indicated the resident had no known allergies. Resident 87's 7/4/25 admission MDS revealed the resident was cognitively intact. On 9/15/25 at 1:34 AM, Resident 87 was observed in her/his room in bed. Resident 87 stated she/he experienced constant itching on her/his back, shoulders and neck since she/he admitted to the facility. Resident 87 stated she/he scratched so much she/he frequently made her/himself bleed. Resident 87 stated she/he thought she/he was allergic to the material of the bedding, and she/he informed all of the CNAs but nothing had been done to relieve her/his itchiness. On 9/16/25 at 2:57 PM, Resident 87 was observed in her/his room in bed. Resident 87 did not wear a shirt and her/his robe was partially draped over her/his upper body. A bright red ring and scratch marks were observed around the resident's neck that spanned from shoulder to shoulder and was approximately six inches in width. A small spot of blood was observed in the center of her/his chest. Resident 87 stated she/he had been scratching and thought she/he was experiencing an allergic reaction. On 9/17/2025 at 2:04 PM, Witness 4 (Family Member) stated Resident 87 started to itch as soon as she/he moved into the 400 Hall. Witness 4 stated she reported the resident's itchiness to various staff but nothing had been done. On 9/17/25 at 3:26 PM, Staff 29 (CNA) stated Resident 87 complained about being itchy and allergic to the bedding for at least two months, and she observed the resident to itch daily. Staff 29 stated she did not report the resident's itchiness or possible allergy to a nurse but did report the resident's concerns to Staff 38 (Housekeeping/Laundry Supervisor). Staff 29 further stated she did not think anything had been done to alleviate the resident's itchiness. On 9/18/25 at 2:49 PM, Staff 31 (CNA) stated when he worked with Resident 87 last week the resident talked a lot about being itchy and allergic to the bedding. Staff 31 stated he did not report these concerns to anyone as the resident stated she/he had already reported the concerns to upper management. On 9/19/25 at 6:44 AM, Staff 37 (CNA) stated Resident 87 had been scratchy for the past few months, the resident stated she/he thought it was an allergic reaction to the bedding and all the nurses were aware of her/his itchiness and possible allergy. Staff 37 stated some nurses put lotion on the resident when she/he was observed to itch but was unaware of any additional interventions tried to improve the resident's comfort. On 9/19/25 at 9:16 AM, Staff 18 (LPN) stated Resident 87 experienced itchiness on her/his back, and when she observed the resident to itch, she applied lotion. Staff 18 stated she had not informed the resident's resident care manager or physician of her/his itchiness. On 9/19/25 at 10:17 AM, Staff 38 stated she was questioned about the material of the facility's sheets a few weeks ago but was not informed about any concerns related to Resident 87. On 9/19/25 at 10:48 AM, Staff 1 (Administrator) stated Resident 87's physician should have been notified of her/his itchiness as soon as it was observed.

Based on observation, interview and record review it was determined the facility failed to ensure medications and biologicals were secured and only accessible to authorized persons for 1 of 4 Halls and 1 of 4 Households observed. This placed residents at risk for receiving unprescribed medications and drug diversion. Findings include: The facility's 10/2024 Medication Storage Policy revealed the following:-All drugs and biologicals will be stored in locked compartments, such as medication carts, cabinets, drawers, refrigerators and medication rooms.-Only authorized personnel will have access to the keys to locked compartments.-During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 1. Resident 31 was admitted to the facility in 8/2025 with diagnoses including Parkinsonism unspecified (a group of symptoms that are similar to Parkinson's disease but do not have a definitive underlying cause). Resident 31's 9/2025 Physician Orders directed the resident to receive carbidopa-levodopa (a medication used to increase dopamine levels in the brain) five times daily for Parkinson's disease and levothyroxine (a medication used to treat low thyroid activity) once daily for hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormones). On 917/25 at 5:59 AM, a small plastic cup was observed to sit on top of the medication cart in the 300 Household. The cup contained what appeared to be crushed medications mixed with a pudding-like substance. Staff 33 (Agency CNA) stated the nurse responsible for the medication cart was unavailable as he was in another Household on a different floor of the building. On 9/17/25 at 6:32 AM, Staff 34 (LPN) returned to the 300 Household. Staff 34 stated the plastic cup that sat on top of the medication cart contained Resident 31's carbidopa-levodopa and levothyroxine. Staff 34 stated he inadvertently left the cup that contained resident medications on top of the cart and the medications should have been locked in the cart while unattended. On 9/19/2025 at 2:02 PM, Staff 2 (DNS) stated all medications should be secured in the medication cart when unattended. 2. On 9/17/25 from 5:09 AM to 5:32 AM, an unlocked and unattended treatment cart was observed at the end of the 700 Hall. CNA staff were in the area and the contents of the cart were accessible. On 9/17/25 at 5:32 AM, Staff 32 (RN) acknowledged the treatment cart was unlocked and unattended. Staff 32 reviewed the contents of the cart with the State Surveyor and confirmed the cart contained insulin and medicated creams. Staff 32 stated he typically left the treatment cart unlocked when agency staff worked because the facility did not have enough keys. On 9/17/25 at 5:53 AM, an unlocked and unattended treatment cart was observed in the 300 Household. The State Surveyor observed the cart contained insulin and medicated creams. Staff 33 (Agency CNA) stated the nurse responsible for this treatment cart was unavailable as he was in another Household on a different floor of the building. On 9/17/25 at 6:32 AM, Staff 34 (LPN) returned to the 300 Household. Staff 34 stated he inadvertently left the treatment cart unlocked and stated it should have been locked while unattended. On 9/19/2025 2:02 PM, Staff 2 (DNS) stated the treatment carts should have been locked while unattended. 3. On 9/16/25 at 10:48 AM, the medication cart in the 900 Household was observed to be unlocked. On 9/16/25 at 10:49 AM, a staff member obtained some wires from the medication cart and walked away. On 9/16/25 at 10:53 AM, a staff member used the alcohol-based hand rub on top of the unlocked medication cart. On 9/15/25 at 10:55 AM, Staff 24 (RN) acknowledged the unlocked medication cart. She opened the medication cart to reveal resident prescribed medications. Staff 24 stated she should've locked the medication cart before walking away from the medication cart. On 9/22/25 at 2:21 PM, Staff 2 (DNS) stated she expected all staff members to ensure medication carts were securely locked before leaving them unattended.

Based on observation, interview and record review it was determined the facility failed to provide occupational and physical therapy services as ordered for 3 of 4 sampled residents (#s 11, 22 and 89) reviewed for rehabilitation services. This placed residents at risk for a decline in functional abilities and diminished quality of life. Findings include: The facility's Specialized Rehabilitative Services policy dated 10/2024 included the following: - The facility shall provide or obtain services from an outside resource for specialized rehabilitative services. These services will assist them in attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psycho-social well-being. - Specialized rehabilitative services include but are not limited to physical therapy and occupational therapy. - Specialized rehabilitative services will be provided under the written order of a physician by qualified personnel. - Specialized rehabilitative services are considered a facility service and included within the scope of facility services. 1. Resident 11 was admitted to facility on 9/5/25 with diagnoses including chronic venous hypertension with ulcers of the bilateral lower extremities (a condition where high pressure in the leg veins prevent proper blood return, leading to swelling, skin changes, and open sores). A review of Resident 11's clinical record revealed there were physician's orders on 9/5/25 for physical therapy. A review of Resident 11's physical therapy notes revealed she/he was evaluated on 9/6/25 to receive physical therapy four to five times per week. There was no evidence found to indicate Resident 11 received physical therapy. On 9/18/25 at 11:21 AM, Staff 6 (Physical Therapist) confirmed Resident 11 was evaluated on 9/6/25 to receive physical therapy four to five times per week but did not receive the services as ordered. On 9/22/25 9:46 AM, Staff 5 (Physical Therapist Assistant – Director of Rehabilitation) stated although Resident 11 refused one session of physical therapy, she/her did not receive subsequent services as ordered. On 9/22/25 at 12:19 PM, Staff 1 (Administrator) stated she expected Resident 11 to be provided rehabilitation services per physician orders. 2. Resident 22 admitted to facility in 4/2025 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting dominant right side (stroke affecting right side). On 9/17/25 at 1:39 PM, Witness 2 (Family Member) stated Resident 22 had a physician's order for physical therapy, which the facility failed to provide. A review of Resident 22's clinical record revealed there were physician's orders on 8/28/25 for physical therapy. A review of Resident 22's physical therapy notes revealed she/he was evaluated on 8/28/25 to receive physical therapy two times per week and she/he received services on 9/11/25. On 9/18/25 at 11:21 AM, Staff 6 (Physical Therapist) confirmed Resident 22 was evaluated on 8/28/25 to receive physical therapy two times per week and she/he had received services for one day on 9/11/25. Staff 6 stated Resident 22 had not been on his list of residents to see and was unsure as to why Resident 22 did not receive physical therapy as ordered. On 9/22/25 at 9:46 AM, Staff 5 (Physical Therapy Assistant – Director of Rehabilitation) confirmed Resident 22 only received one session of physical therapy on 9/11/25 and was unsure as to why she/he had not been receiving services as ordered. On 9/22/25 at 12:19 PM, Staff 1 (Administrator) stated she expected Resident 22 to be provided rehabilitation services per physician orders. 3. Resident 89 was admitted to the facility in 8/2025 with diagnoses including diffuse large B-cell lymphoma (a fast-growing blood cancer that affects the body's immune system) and type 2 diabetes. Resident 89's 8/18/25 admission MDS revealed she/he had moderate cognitive impairment and required supervision or touching assistance to transfer from a seated position to standing and to walk. Resident 89's care plan related to falls and ambulation was initiated on 8/14/25 and indicated she/he used a walker, staff were to anticipate and meet her/his needs to reduce her/his risk of falls and staff were to encourage her/him to participate in activities that promoted exercise and physical activity for strengthening and improved mobility. A review of Resident 89's 9/4/25 signed physician orders revealed she/he was to be evaluated and treated by Physical Therapy (PT) and Occupational Therapy (OT). Resident 89's 9/5/25 PT evaluation indicated she/he was to receive PT three to five times each week between 9/5/25 and 10/4/25 to address her/his physical impairments and instruct her/him in the use of compensatory strategies to decrease her/his risk of falls and further decline in independence. Resident 89's 9/5/25 OT evaluation indicated she/he was to receive OT three to five times each week between 9/5/25 and 11/4/25 to address her/his physical impairments and provide instruction in adaptive strategies to decrease her/his reliance on caregivers. Resident 89's therapy schedule for the week of 9/7/25 through 9/13/25 revealed the following:-Received two PT sessions-Received two OT sessions Resident 89's therapy schedule for the week of 9/14/25 through 9/20/25 revealed the following: -Received two PT sessions-Received two OT sessions On 9/16/25 at 9:40 AM Resident 89 stated she/he was frustrated because she/he admitted to the facility to improve her/his strength and then discharge home but did not receive the number of therapy sessions she/he was supposed to receive. Resident 89 stated PT and OT told her/him there was a gym in the facility but she/he did not see it. Resident 89 also stated PT and OT told her/him she had an appointment for therapy but it never happened. On 9/18/25 at 12:14 PM Staff 6 (Physical Therapy) stated residents were evaluated via telehealth and then received treatment in the facility by therapy staff. Staff 6 stated Resident 89 was supposed to receive three to five PT and OT sessions per week and there were no records of her/him refusing sessions. Staff 6 also stated the facility did not have enough staff to provide Resident 89 with the number of therapy sessions indicated on her/his PT and OT evaluations. Staff 6 stated residents' therapy sessions were scheduled by Staff 5 (Physical Therapy Assistant - Director of Rehabilitation) who worked offsite at a different building. On 9/22/25 at 9:45 AM Staff 5 stated she was in charge of scheduling therapy sessions for all residents at the facility. Staff 5 stated Resident 89 did not receive the number of PT and OT sessions indicated on her/his evaluations because the facility did not have enough therapy staff to cover the number of sessions residents were supposed to receive based on their evaluations. On 9/22/25 at 12:21 PM Staff 1 (Administrator) stated the facility census receiving therapy was so large the facility did not have enough therapy staff to cover the number of therapy sessions required. Staff 1 stated she expected residents to receive the number of therapy sessions indicated on their evaluation.

Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for 1 of 2 sampled residents (#49) reviewed for position and mobility. This placed residents at risk for worsening contractures (a permanent tightening of the muscle, tendons and skin causing the joint to shorten and stiffen) and conditions. Findings include:Resident 49 was admitted to the facility in 3/2022 with diagnoses including hemiplegia (a condition that causes paralysis or severe weakness on one side of the body). Resident 49's 7/2/25 Quarterly MDS revealed the resident was severely cognitively impaired and experienced upper extremity impairment on one side of her/his body.Resident 49's 7/23/25 Care Plan indicated the resident experienced contractures in her/his third, fourth and fifth fingers on her/his left hand and she/he was to work with RA to decrease the worsening of her/his contractures. Resident 49's 9/1/25 Physician Orders directed the following:-Staff were to place a contracture pillow (a specialized medical cushion designed to prevent or manage muscle and joint contractures) in her/his hand during the day and remove the pillow at night. -Staff were to roll a washcloth and place under the fingers on the resident's left hand during the day and remove the washcloth at night. No evidence was found in Resident 49's clinical record to indicate her/his contractures were comprehensively assessed, ongoing monitoring was provided or RA exercises were completed to prevent further declines. Random observations of Resident 49 from 9/15/25 to 9/18/25 between 7:42 AM to 4:33 PM revealed the resident to be in her/his wheelchair in the facility's common areas or in her/his room in bed. Resident 49 was not observed to have a contracture pillow or rolled washcloth placed in her/his left hand.On 9/15/25 at 12:00 PM Resident 49 was observed in the common area in the 400 Household and sat in her/his wheelchair. The third, fourth and fifth fingers on the resident's left hand were observed to firmly press in against the palm of the resident's hand. Resident 49 attempted but was unable to move any of these three fingers when verbally cued by the State Surveyor. Resident 49 stated the fingers on her/his left hand were frozen and she/he sometimes used a rolled washcloth in her/his left hand. Resident 49 was unable to articulate additional details about her/his contracture or interventions in place. On 9/17/25 at 2:57 PM, Staff 27 (LPN) stated nurses were responsible to place a rolled washcloth in Resident 49's contracted hand. Staff 27 stated she had never utilized a contracture pillow for Resident 49 as she was not sure what a contracture pillow was. On 9/17/25 at 3:19 PM, Staff 29 (CNA) stated CNAs were responsible to place a rolled washcloth in Resident 49's contracted hand in the morning and remove the washcloth at night. Staff 29 stated Resident 49 did not refuse the washcloths when they were offered. Staff 29 stated Resident 49 was offered a rolled washcloth maybe a couple of times a week and it was frequently overlooked. Staff 29 further stated therapy staff provided RA to residents and Resident 49 did not receive any RA services. On 9/18/25 at 12:25 PM, Staff 11 (CMA) stated she used to provide RA to residents but no longer did so because the facility needed her to pass medications instead. Staff 11 stated the last time she provided RA to Resident 49 was approximately three months ago.On 9/18/25 at 1:04 PM, Staff 6 (PT) stated the facility had one person designated to provide RA to residents and that person was currently on leave.On 9/18/25 at 1:43 PM, Staff 35 (CNA) stated Resident 49 never refused care. Staff 35 stated he washed the resident's left hand but had no additional responsibilities related to the resident's contracted fingers. Staff 35 stated he had never seen Resident 49 with a rolled washcloth or contracture pillow in her/his left hand. Staff 35 stated CNAs did not provide RA to residents as it was the responsibility of the designated RA. Staff 35 further stated he was unsure if the facility currently had an RA. On 9/18/25 at 2:07 PM, Staff 36 (CNA) stated Resident 49 never refused care or the placement of the rolled washcloth. Staff 36 stated the resident never removed the washcloth once it was placed. Staff 36 stated agency staff would sometimes forget to place the rolled washcloth in the resident's contracted hand. Staff 36 further stated Resident 49 did not receive RA. On 9/18/25 at 3:15 PM, Staff 42 (Agency LPN) stated she did not know anything about Resident 49's contractures and was unaware of any nursing responsibilities related to the resident's contractures. On 9/19/25 at 6:44 AM, Staff 38 (CNA) stated the rolled washcloth Resident 49 was supposed to use was never in place when she started her shift in the afternoons. On 9/19/25 at 2:07 PM, Staff 2 (DNS) and Staff 4 (LPN Resident Care Manager) were present for an interview. Staff 2 stated she expected Resident 49 to utilize a rolled washcloth or contracture pillow daily as ordered. Staff 4 stated neither ongoing monitoring of Resident 49's left-hand contractures nor RA was being provided to the resident and should have been.

Based on observation, interview and record review it was determined the facility failed to maintain a homelike environment with comfortable sound levels and exercise reasonable care for the protection of resident's property from loss for 2 of 3 sampled residents (#s 5 and 87) reviewed for environment. This placed residents at risk for lack of a homelike environment, lost sleep and lost personal property. Findings include:1. The facility's 10/2024 Resident Personal Belongings Policy revealed the following: -The facility will exercise reasonable care for the protection of the resident's property from loss or theft. -All resident possessions, regardless of their apparent value to others, will be treated with respect. Resident 87 was admitted to the facility in 6/2025 with diagnoses including Parkinsonism unspecified (a group of symptoms that are similar to Parkinson's disease but do not have a definitive underlying cause). Resident 87's 7/4/25 admission MDS revealed the resident was cognitively intact. On 9/15/25 at 1:48 PM, Resident 87 was observed in her/his room in bed. Resident 87 stated she/he reported a number of missing personal items, which included dress shirts and dress pants, in 6/2025. Resident 87 stated she/he reported her/his missing items to multiple nursing staff at the facility. On 9/17/25 at 2:04 PM, Witness 4 (Family Member) stated Resident 87 was missing personal items, including dress shirts and dress pants, since 6/2025. Witness 4 stated staff at the facility were informed of the resident's missing clothing items and nothing had been done. On 9/18/25 at 9:07 AM, Staff 29 (CNA) stated she had not received any education or training on what to do when residents' personal property went missing. Staff 29 stated she looked in a resident's room and in the laundry room when a clothing item was reported as missing, and if she could not find the item, no further action was taken. Staff 29 further stated Resident 87 reported missing multiple shirts approximately a month ago and was unsure if the resident's missing items were ever found. On 9/18/25 at 1:33 PM, Staff 35 (CNA) stated he was aware Resident 87 was missing shirts and pants. Staff 35 stated he did not report the missing items to anyone as the staff who worked night shift were responsible for managing resident clothing. On 9/19/25 at 10:17 AM, Staff 38 (Housekeeping/Laundry Supervisor) stated the facility experienced constant staff turnover and the facility utilized lots of agency staff so resident personal belongings were frequently mixed up and items often did not go back to the correct resident. Staff 38 stated she was unaware of any missing personal items for Resident 87. On 9/19/25 at 10:37 AM, Staff 7 (Social Services Director) stated Resident 87 reported various missing personal items since the day she/he admitted to the facility but had difficulty articulating exactly what was missing. Staff 7 stated Staff 1 (Administrator) was the resident's contact person at the facility and spoke with the resident daily about her/his concerns. On 9/19/2025 at 10:48 AM, Staff 1 (Administrator) stated staff should report missing resident personal items, including clothing, to a supervisory staff, such as Staff 7 or Administrator, and the items should be returned or replaced within seven days. Staff 1 stated she was unaware of any missing personal items for Resident 87. Staff 1 further stated staff should have reported Resident 87's missing items and replaced them within seven days of receiving the report. 2. Resident 5 was admitted to the facility in 5/2025 with diagnoses including gram-negative sepsis (an infection in the bloodstream that triggers an excessive immune response) and anxiety disorder. Resident 5's admission MDS dated [DATE] revealed she/he had moderate cognitive impairment. It was very important for Resident 5 to choose her/his own bedtime. Resident 75 was admitted to the facility in 3/2025 with a diagnosis of encephalopathy (a general dysfunction of the brain that affects cognitive function, consciousness and behavior). Resident 75's 3/11/25 admission MDS revealed she/he had moderate cognitive impairment and adequate hearing. Resident 75's care plan initiated for activities on 6/15/25 indicated she/he preferred to watch television and movies independently. On 9/15/25 at 11:38 AM Resident 75's television was audible in Resident 5's room with her/his door closed. Resident 5 stated her/his neighbor, Resident 75, watched television 24/7 and her/his television was mounted on the wall behind Resident 5's headboard. Resident 5 stated Resident 75 used headphones the facility provided to her/him for two weeks but then stopped using them. Resident 5 said, I don't look forward to going to bed but eventually passed out from exhaustion of waiting and said she/he now only slept about three hours per night because of the noise. On 9/16/25 at 10:05 AM Resident 75 was observed in her/his room watching television with the volume playing loudly. Resident 75 stated a CNA asked if she/he would lower the volume but stated she/he did not want to turn down the volume. On 9/18/25 at 1:08 PM in Resident 5's room, Resident 75's television was audible through the wall at the head of Resident 5's bed and in the bathroom. Resident 5 stated the television volume level was typical for Resident 75. Resident 5 stated she/he spoke to CNAs about the issue and Resident 75 lowered the volume for a few minutes at night but then raised it again. Resident 5 stated she/he asked Resident 75 to lower the volume because it was too loud. Resident 5 spoke with Staff 1 (Administrator) about the noise and was told, We can move you downstairs. Resident 5 stated, she/he did not want to move because this was her home and it was quiet before Resident 75 arrived. On 9/18/25 at 2:45 PM Witness 3 (Private Caregiver) stated Resident 75's television was audible in Resident 5's room especially when it was quiet at night time. Witness 3 stated she and Resident 5 reported the noise to CNAs but Resident 75 continued to play the television loudly. Witness 3 stated Resident 5 was very grouchy in the mornings because she did not sleep well due to the noise and sometimes Resident 5 stated she/he can't take it anymore. On 9/18/25 at 2:54 PM Staff 22 (CNA / CMA) stated Resident 5 complained to her twice about a month ago because of the television noise. On 9/18/25 at 2:59 PM Staff 23 (CNA) stated Resident 5 complained to him about Resident 75's television volume multiple times and Resident 75 turned the volume back up whenever he or other CNAs lowered it for her/him. Staff 23 stated he told an agency nurse about the issue but he did not remember their name. Staff 23 stated Resident 5 reported her/his concerns to the nurse most of the time. On 9/18/25 at 9:14 PM Resident 75's door was open, her/his television was on and the program was clearly audible in the hallway adjacent to Resident 5's room. On 9/18/25 at 9:24 PM Staff 23 exited Resident 75's room and left the door open. Resident 75's overhead light was on and she/he was seated in her/his recliner watching television. The television audio was loud and clearly audible in the hallway between Resident 75 and Resident 5's rooms. On 9/18/25 at 9:27 PM Staff 20 (CNA) stated Resident 5 called almost every night and was upset because she/he could not sleep due to the Resident 75's television volume being too loud. Staff 20 stated sometimes Resident 75 let staff lower the volume but she/he raised it once staff left her/his room. Staff 20 also stated Resident 75 occasionally declined lowering the television volume when her/his television was audible from outside her/his room. Staff 20 stated Resident 5 was happy when Resident 75 used headphones for about two weeks because the noise level was better and she/he slept better. Staff 20 stated Resident 75 stopped using the headphones and her/his television was loud again. On 9/18/25 at 9:52 PM Resident 5 was observed sitting in her/his wheelchair in her/his room. Resident 75's television was clearly audible in Resident 5's bedroom and in her/his bathroom with the doors to both residents' rooms closed. Resident 5 stated the volume of Resident 75's television was typical for that time of night and she/he planned to get into bed and wait until she/he passed out from exhaustion rather than falling asleep peacefully the way she/he preferred. On 9/22/25 at 12:14 PM Staff 1 (Administrator) stated she spoke with Resident 5 about the issue with Resident 75's television volume. Staff 1 stated she provided headphones to Resident 75 but she/he no longer wanted to wear them. Staff 1 stated she did not realize the extent of the noise problem at night and she expected quiet hours to be enforced so that all residents can get the sleep they needed.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for experiencing adverse side effects of medication. Findings include: The facility's 10/2024 Use of Psychotropic Medication(s) Policy revealed PRN orders for psychotropic medications, excluding antipsychotics (a class of drugs used to treat mental health conditions such as schizophrenia and bipolar disorder), shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. Resident 8 was readmitted to the facility in 6/2025 with diagnoses including hip fracture. Resident 8's 6/3/25 Physician Orders directed the resident to receive lorazepam (a medication used to relieve symptoms of anxiety) every four hours PRN for agitation and anxiety. A review of Resident 8's MARs revealed the resident received nine PRN doses of lorazepam in 6/2025, two in 7/2025, three in 8/2025 and one in 9/2025. No documentation was found in Resident 8's clinical record to indicate a physician rationale for extending the resident's PRN lorazepam beyond 14 days was provided. On 9/22/25 at 9:57 AM, Staff 2 (DNS), Staff 3 (RNCM) and Staff 4 (LPN Resident Care Manager) were present for an interview. Staff 4 stated a physician was required to re-evaluate PRN psychotropic medication orders at the end of the 14 days in order to determine medication appropriateness for the resident. Staff 2, Staff 3 and Staff 4 acknowledged Resident 8's order for PRN lorazepam was not re-evaluated by a physician at the end of 14 days and should have been.

Based on interview and record review it was determined the facility failed to ensure the state Long Term Care Ombudsman's office was notified of facility transfers or discharges for 2 of 2 sampled residents (#s 93, and 95) reviewed for hospitalization and discharge. This placed residents at risk for lack of advocacy. Findings include: 1. Resident 93 admitted to the facility in 7/2025 with diagnoses including aftercare following surgery and lower left leg cellulitis (bacterial infection of the skin).An 8/2/25 progress note indicated Resident 93 was transferred to the hospital for nausea and vomiting.A 9/22/25 review of Resident 93's medical chart did not reveal any notification to the LTCO's (Long Term Care Ombudsman) office regarding her/his transfer to the hospital.On 9/22/25 at 12:52 PM, Staff 2 (DNS) stated she was unaware who oversaw the notification to the LTCO's office for resident transfers.On 9/22/25 at 2:07 PM, Staff 1 (Administrator) stated she was unaware notifying the LTCO was a requirement for resident transfers.2. Resident 95 admitted to the facility in 6/2025 with diagnoses including Alzheimer's Disease and metabolic encephalopathy (change in brain function due to chemical imbalance).A 7/9/25 progress note indicated Resident 95 was transferred to the hospital due to wound complications.A 9/22/25 review of Resident 95's medical chart indicated she/he discharged from the facility after going to the hospital, and did not reveal any notification to the LTCO's (Long Term Care Ombudsman) office regarding her/his transfer to the hospital or discharge from the facility.On 09/22/25 at 12:52 PM, Staff 2 (DNS) stated she was unaware who oversaw the notification to the LTCO's office for resident transfers and discharges.On 9/22/25 at 2:07 PM, Staff 1 (Administrator) stated she was unaware notifying the LTCO was a requirement for resident transfers and discharges.

Based on observation, interview, and record review, it was determined that the facility failed to ensure residents received treatment and care according to professional standards of practice related to neurological checks after a fall for 2 of 3 sampled residents (#s 5 and 6) reviewed for falls. This placed residents at risk for unmet care needs. Findings include: The Facility's 2025 Resident Fall Procedure Guidance revealed residents who experienced falls in the facility were to be placed on neurological checks (neuro checks) for 72 hours to monitor any changes of condition or altered cognitive status. Each neuro check was to be documented in the Neuro Check Binder at the nurse's station until the 72-hour mark had been reached.1. Resident 5 was admitted to the facility in 8/2025, with diagnoses including joint replacement surgery.Resident 5's 8/23/25 Care Plan revealed the resident had self-care performance deficits with activities of daily living due to her/his joint replacement surgery. Resident 5's 8/23/25 Fall Risk Evaluation rated Resident 5 as a high fall risk.An Incident Note dated 8/23/25 at 6:00 PM, revealed Resident 5 experienced an unwitnessed fall to the floor when attempting to self-transfer to the restroom. Staff 9 (LPN) was noted to have assessed and administered pain medication to Resident 5 after she/he reported back pain from the fall.A Progress Note dated 8/24/25 at 1:17 PM, revealed Resident 5 began experiencing excruciating pain from the mid back to the left hip. Staff 10 documented in the resident's clinical progress note that Staff 9 failed to complete neuro check assessments and monitor Resident 5 after her/his fall in the facility.On 9/12/25 at 12:13 PM, a review of Resident 5's clinical record found no documented evidence that neuro check assessments were completed after the resident fell on 8/23/25. 2. Resident 6 was admitted to the facility in 7/2025, with diagnoses including right femur fracture and dementia.Resident 6's 8/2025 Care Plan revealed the resident had limited mobility and a self-care performance deficit due to a right femur fracture and dementia.Resident 6's 8/2/25 Fall Risk Evaluation rated Resident 6 as a high fall risk.A Progress Note dated 8/14/25 at 12:19 PM, revealed Staff 12 (LPN) identified a bruise on Resident 6's left hand when being assisted with toileting. Staff 12 stated a documented fall occurred earlier that morning at 3:33 AM. Staff 12 indicated Resident 6 complained of significant pain in the left hip area and was placed on neuro checks after the fall.On 9/12/25 at 12:13 PM, a review of Resident 6's clinical record found no documented evidence that neuro check assessments were completed. On 9/9/25, this surveyor attempted to interview Staff 9 and Staff 12 but was unable to reach them.On 9/8/25 at 2:54 PM, Staff 7 (LPN) stated all residents who experienced a fall in the facility were to be placed on neuro checks to confirm any changes in their condition. Staff 7 indicated staff weren't always able to meet this requirement due to time being spent caring for other residents. On 9/9/25 at 11:58 AM, Staff 4 (Medical Records) confirmed no neuro check documentation was completed for Resident 5 and Resident 6.On 9/10/25 at 10:14 AM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed Staff 9 and Staff 12 did not follow Resident 5 and Resident 6's post-fall procedures related to neuro checks.

Based on interview and record review it was determined, the facility failed to provide assistance with bathing for 1 of 3 sampled residents (#4) reviewed for bathing. This placed residents at risk of unmet care needs. Findings include:Resident 4 was admitted to the facility in 5/2025, with a diagnosis including stroke. Resident 4 was unable to be observed or interviewed as she/he no longer resided in the facility.Resident 4's 5/19/25 care plan indicated Resident 4 required maximum assistance with a Hoyer (a mechanical device used to transfer residents with limited mobility) and was dependent on one staff for showering twice weekly and as necessary.A review of Resident 4's 6/2025, 7/2025, and 8/2025 Task Charting revealed on 6/6/25, 6/20/25, 6/26/25, 8/8/25, and 8/15/25, bathing was documented as NA.(not applicable) by Staff 24 (CNA), Staff 25 (CNA), and Staff 26 (CNA). There was no evidence that a make-up shower was provided.On 9/8/25 at 4:17 PM, Staff 25 stated she charted NA for bathing on 8/8/25 for Resident 4 because she wasn't able to find someone to help get Resident 4 up using the Hoyer and bathing was not provided.On 9/4/25 at 12:35 PM, Witness 1 (Family Member) stated Resident 4 was not provided assistance with showers twice weekly.On 9/8/25 at 4:33 PM, Staff 26 stated on 8/15/25 she charted NA because bathing was not completed for Resident 4 due to a lack of assistance from other staff.On 9/9/25 at 9:09 AM, Staff 24 stated that he charted NA on 6/6/25, 6/20/25, and 6/26/25 for bathing because he was unable to complete Resident 4's bathing due to a lack of staff and Hoyer lifts not being available.On 9//9/25 at 1:05 PM, Staff 3 (RNCM) stated she was not surprised Resident 4 was not bathed or showered on the above dates because the facility had difficulties with staffing.On 9/10/24 at 10:14 AM, the findings were reviewed with Staff 1 (Administrator) and Staff 2 (DNS) who stated residents should be bathed in accordance with their care plans and as needed.

Based on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 2 sampled residents (#1) reviewed for dignity and respect. This placed residents at risk for decreased quality of life. Findings include: Resident 1 admitted to the facility in 10/2021, with diagnosis including acute cerebrovascular insufficiency (a condition where blood flow is reduced in the brain causing damage). Resident 1's 1/24/23 Care Plan revealed the resident with a communication and ADL self-care performance deficit related to cognitive impairment and left sided weakness. Facility interventions included adequately timed and non-rushed guided care, ensuring a safe environment through eye contact and continuous face to face verbal communication and cues when providing peri-care. A video recorded incident report dated 1/5/25 revealed the following: Resident 1 was observed through an observational security camera receiving cares from Staff 4 (CNA). Staff 4 was viewed while providing peri-care grabbing Resident 1's groin without cues or prompting causing Resident 1 to respond verbally in a painful manner. The facility's investigation dated 1/9/25 concluded Resident 1 showed no adverse behaviors, physical or psycho-social injuries as a result of the incident. On 2/4/25 at 11:12 AM, Resident 1 was observed in her/his room, clean, no markings or bruises were noted on her/his body. Resident 1 did not appear frightful during interaction no odors related to poor incontinence care were observed. On 2/4/25 at 12:39 PM, review of the video was confirmed to have occurred on 1/2/25 at 5:43 AM. Staff 1 (Administrator) and Staff 4 (CNA) confirmed Staff 4 was the CNA identified in video. Staff 4 during the video was viewed stating to Resident 1 to stop touching her/his genitals in a frustrated manner. Staff 4 was viewed grabbing Resident 1's genitals without cueing or directing which prompted Resident 1 to yell oww. Observation of video could not confirm abuse or neglect had occurred. On 2/4/25 at 12:48 PM, Staff 4 denied allegations that she provided inappropriate care to Resident 1. Staff 4 stated Resident 1 yelled to many times and becomes handsy during care. Staff 4 then confirmed this was her in the video and confirmed care was not performed according to Resident 1's care plan and denied allegations of abuse. On 2/4/25 at 12:50 PM, Staff 1 during observation of the video confirmed that Staff 4 made contact with Resident 1's genitals and provided care that was not performed in a dignified manner in accordance with Resident 1's care plan.

Based on interview and record review it was determined the facility failed to implement interventions to prevent a fall for 1 of 3 sampled residents (# 20) reviewed for accidents. This failure resulted in Resident 20 having a fall with serious injury including a head hematoma (a pool of blood under the skin), a gluteal hematoma, multiple rib fractures and skin avulsions (skin tears) which required emergency medical services and treatment at the hospital. Findings include: Resident 20 was admitted to the facility 12/2020 with diagnoses including dementia and anxiety. Resident 20's 12/10/23 Annual MDS indicated Resident 20 was noted to have wandering behavior and was exit seeking. A 4/17/24 Behavior and Psychotropic Meeting Note indicated Resident 20 exhibited wandering behaviors. Resident 20's 6/11/24 Quarterly MDS revealed she/he had severe cognitive impairment. A 6/18/24 Care Plan indicated Resident 20 had a pattern of wandering. A 7/9/24 Facility Incident Report revealed Resident 20 had an unwitnessed exit from her/his unit and was found at the bottom of the stairs where she/he had fallen with her/his walker. Facility door alarms were found not to be armed when Resident 20 exited the side door from her/his unit resulting in a fall with injuries. A 7/9/24 Incident Note reported Resident 20 experienced an abrasion to her/his right arm, lump on the forehead, lump on top of the head, and a lump on the right side of her/his head as a result of the fall. The resident also had a small bruise to the left side of her/his eye and was holding her/his side. A 7/12/24 Hospital Record revealed Resident 20 was admitted to the hospital from 7/9/24 through 7/12/24 due to injuries sustained from her/his fall at the facility on 7/9/24. Resident 20 was treated for displaced left rib fractures, hematomas to the frontal scalp and gluteal posterior and an avulsion to her/his right forearm. On 7/31/24 at 8:27 AM Staff 19 (CNA) stated Resident 20 would push on doors in an attempt to open them and would try to follow people out of doors. Staff 19 also stated if the door alarms had been armed, they would have sounded for the resident's protection. On 7/31/24 at 8:38 AM Staff 9 (CNA) stated Resident 20 was exit seeking and would try to follow people out of doors. Staff 9 also stated there were no exit seeking/wandering interventions in place prior to the resident's fall and she/he had started wandering more often a few weeks before she/he fell . On 8/1/24 at 11:55 AM Staff 4 (RNCM) stated the door alarm was not armed at the time of Resident 20's unwitnessed fall on 7/9/24. Staff 4 stated an unknown staff member exited the door and did not reset the alarm which resulted in an unwitnessed fall with multiple injuries. Staff 4 acknowledged Resident 20 had increased wandering prior to the fall but no new interventions or care plan updates had been implemented. On 8/1/24 at 12:12 PM Staff 2 (DNS) confirmed Resident 20 experienced a fall with injuries as a result of fall interventions not being implemented.

Based on observations, interviews and record review it was determined the facility failed to implement infection control practices for 18 of 18 residents (#s 2, 4, 5, 8, 9, 10, 11, 14, 18, 21, 25, 26, 27, 29, 31, 33, 34 and 36) and 1 of 4 staff (# 15) reviewed for infection control. This placed residents at risk for infection. Findings include: 1. The Center for Disease Control and Prevention (CDC) website section titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) specified enhanced barrier precautions (EBP) include the use of gowns and gloves during high contact resident care activities when a resident has a wound or an indwelling medical device such as an urinary catheter. Examples of high contact resident care activities requiring gown and glove use for EBPs include: - Dressing - Bathing/showering - Transferring - Providing hygiene - Changing linens - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator - Wound care: any skin opening requiring a dressing Review of medical records revealed four residents (#s 2, 11, 25 and 29) had a urinary catheter and were to be placed on enhanced barrier precautions. Review of medical records revealed 14 residents (#s 4, 5, 8, 9, 10, 14, 18, 21, 26, 27, 31, 33, 34 and 36) received wound care and were to be placed on enhanced barrier precautions. Observations of all units of the facility on 7/30/24 and 7/31/24 revealed enhanced barrier precautions were not implemented for any of the residents listed above when high contact resident care activities were being provided. On 7/31/24 nursing staff were interviewed in each section of the facility. All staff stated gloves were worn when providing care which involved direct resident contact but gowns were not worn when providing care with any residents in the facility. On 7/31/24 at 3:54 PM Staff 2 (DNS) stated she was the facility's Infection Preventionist. Staff 2 stated infection control techniques were only used with residents with an active infection and enhanced barrier precautions could be used based on their discretion when a resident does not have an active infection. On 8/1/24 10:13 AM Staff 2 (DNS) confirmed enhanced barrier precautions including use of gloves and gowns should have been in place for residents who received wound care or had a catheter. 50926 2. The facility Administering Medication policy (revised 2019) specified Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. The facility procedure guidelines Administering Oral Medications (revised October 2010) included 26 steps. Three steps in the procedure were related to infection control practices: -1. Wash your hands. - 9 e. for tablets or capsules from a bottle. Pour the desired number into the bottle cap and transfer to the medication cup. Do not touch the medication with your hands. -23. Perform hand antisepsis. During medication administration on 7/31/24 at 8:45 AM. Staff 15 (LPN) used her fingers to retrieve a pill out of the med cup and placed it in a resident's mouth. Staff 15 did not perform hand hygiene. She then returned to cart, prepared another resident's medications, and administered them without performing hand hygiene. Staff 15 on 7/31/24 at 9:15 AM stated she was expected to perform hand hygiene before and after administering medication and should not touch medications with bare hands. Staff 15 confirmed she touched the medication with her bare hand and did not complete hand hygiene before and after medication administration. Staff 2 (DNS) on 8/2/24 at 11:21 AM confirmed her expectation that hand hygiene should be completed before and after each medication administration and the medications should not be touched with bare hands.

Based on observation, interview and record review it was determined the facility failed ensure the ice machine was cleaned adequately to maintain sanitary conditions in 1 of 1 kitchen reviewed for sanitary kitchen services. This placed residents at risk of foodborne illness. Findings include: On 7/29/24 at 9:49 AM the facility's ice machine located adjacent to the dry storage area and non-meat side of the kitchen was observed to have a powdery gray/green substance accumulated in the grooves of the panel directly above supply of ice. Condensation dripped across the panel's grooves and onto the supply of ice. Staff 29 (Executive Chef/Director of Dining Services) acknowledged the presence of the powdery substance and stated, It should not be like that and should be cleaned. A review of the Ice Machine Cleaning Log posted adjacent to the ice machine revealed staff cleaned the machine on a monthly basis. The task of cleaning the ice machine was not indicated in the kitchen's weekly Deep Cleaning Schedule or Daily Cleaning Schedule. On 8/2/24 at 11:48 AM Staff 29 stated she expected the ice machine to be cleaned to prevent ice provided to residents from being contaminated.

Based on interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: The facility's revised 4/2007 Staffing Policy indicated the facility provided adequate staffing to meet the needed care and services of the residents. On 7/29/24 the facility had a census of 39 residents in four houses (each house was a self-contained unit). On 8/2/24, Staff 2 (DNS) provided a list of residents who: -Required two-person mechanical lift transfers: 13; -Required one or two-person extensive or total assistance for bathing: 24; -Required one or two-person extensive or total assistance for toileting: 29; -Required one or two-person extensive or total assistance for dressing: 30; -Required two person assistance at all times for all care: 2; -Had behavioral healthcare needs which required monitoring: 7; -Were at risk for elopement: 2; -Were considered high fall risks: 2 and -Were bariatric residents (having a body mass index greater than 40): 4. On 7/29/24 at 10:33 AM Resident 8 reported the facility did not have enough staff and she/he had to wait a while in her/his bathroom for assistance, at times. On 7/31/24 at 8:55 AM Staff 23 (CNA) stated each of the four houses typically had two CNAs assigned on day and evening shift. Staff 23 stated staffing was an issue because there were times on day shift when both CNAs were in a room providing care and no other staff were in the house so residents were left unattended. Staff 23 stated approximately 50% of the time there were enough staff to manage the residents. On 7/31/24 at 9:44 AM Staff 24 (CNA) stated the facility was at least one CNA short, at times, which made it hard for staff to provide two person assistance with transfers and to provide all of the care the residents required. Staff 24 stated the residents ended up waiting longer for call lights to be answered. On 7/31/24 at 2:10 PM Staff 18 (Staffing Coordinator) stated she used the State mandatory minimum staffing ratio to determine CNA staffing. Staff 18 stated the facility had three residents who were approved to receive the State bariatric rate but was unaware the facility was required to staff an additional CNA per shift. Staff 18 stated staffing was challenging since COVID-19 and especially since the facility stopped utilizing agency staff. Staff 18 stated any staffing over the State mandatory minimum staffing requirements were determined by Staff 1 (Administrator) and Staff 2 (DNS). On 8/1/24 at 8:46 AM Staff 22 (CNA) stated the facility had many residents who required two person assistance with transfers and care, and the 400 house had residents with the highest acuity needs. Staff 22 reported there were three residents in the facility that required close monitoring and frequent checks. Staff 22 stated on night shift, there were not enough CNAs and nursing staff to provide the level of care and supervision necessary to monitor the residents and keep them safe so residents wandered into other resident's rooms and there were increased falls, especially in the 400 house. Staff 22 stated many times there were no other staff available to assist with two person transfers or care so she had to provide care by herself. Staff 22 stated she reported her concerns to Staff 2 (DNS) and Staff 18 (Staffing Coordinator) but nothing changed. On 8/1/24 at 9:57 AM Staff 28 (LPN) stated the facility needed more CNA and nursing staff, especially on the night shift. Staff 28 stated there were not enough staff available to supervise all of the residents who were at high risk for falling and elopement or to take care of the residents' needs. Staff 28 stated there were many heavy care residents, especially in the 400 house, and many residents who required two person assistance with transfers and care. In addition, there were two residents who required frequent checks and constant monitoring for safety. Staff 28 stated she assisted CNAs when she could but often was too busy so CNAs had to provide two person assistance with transfers and care with only one staff. Staff 28 stated there were nights when it was impossible to provide the level of care and supervision that was needed. On 8/1/24 at 10:52 AM Staff 20 (CNA) stated the facility was in the process of being sold so many staff in housekeeping and activities were let go which resulted in the CNA staff having to pick up extra tasks such as spot cleaning carpets and transporting residents to and from activities. Staff 20 stated CNAs were responsible for several other non-resident care tasks which included doing residents' laundry, taking out the garbage, getting groceries and stocking the individual house kitchens. Staff 20 stated in order to get all of the required tasks completed and provide care for the residents, she had to skip breaks. On 8/1/24 at 11:04 AM Staff 19 (CNA) stated sometimes the facility was short staffed. Staff 19 stated evening shift was especially challenging because there were many residents who required two person assistance with transfers or care and residents had to wait a long time to get back to bed or to get their showers because another staff member was not always available. On 8/1/24 at 11:10 AM Staff 13 (CNA) stated night shift was very challenging because there was only one CNA assigned to each house and the facility had many residents who required frequent checks and had to be closely monitored. Staff 13 stated it was challenging to ensure another staff member was available to cover the house while she was in a room providing care. On 8/1/24 at 11:24 AM Staff 21 (CNA) stated on evening and night shift, there were often no other staff to cover the houses when CNAs were providing two person assistance with care, and that left the houses unattended. Staff 21 stated, at times, a nurse was available to assist but not always, so CNA staff had no other choice except to leave the residents unattended. Staff 21 stated staff were concerned because there was a resident in the 400 house who required close supervision because she/he was fast and did a lot of wandering and staff were not always able to provide the level of supervision the resident needed. Staff 21 stated she would try to reach a nurse to help cover the house but the nurse can't be every where at once. Staff 21 stated staff were often unable to get all of the required tasks and care done because they were too busy chasing around the resident that required frequent checks and close monitoring. Staff 21 stated staffing issues were ongoing since the last survey. On 8/1/24 at 11:37 AM Resident 7 stated the facility did not have enough staff in the 400 house, especially on night shift. Resident 7 stated she/he often waited between 30 and 90 minutes for her/his brief to be changed. Resident 7 stated the lack of staff resulted in residents not being properly supervised and on 8/1/24 in the early morning, a resident, who required 15 minute checks, wandered into her/his room naked. Resident 7 stated people are falling because it took too long for staff to respond to call lights so residents got up and fell . Resident 7 stated, because of the staffing issues, she/he did not feel the 400 house was safe during the night shift. On 8/1/24 at 11:09 PM Staff 26 (CNA) stated staffing on evening shift was challenging because it was difficult to get help when residents required two person assistance with transfers or care. In addition, Staff 26 stated when she worked the night shift, at times, she was the only person available to provide care to the residents who needed two person assistance because there were no other staff available. Staff 26 reported the biggest issue with staffing on night shift was having no help. On 8/1/24 at 11:25 PM Staff 27 (CNA) stated there was a resident in the 400 house who is up all night and has trouble sleeping and required 15 minutes checks. Staff 27 stated when both CNAs were with a resident, the resident who wandered had to be left unattended which was unsafe. On 8/2/24 at 10:41 AM Staff 2 (DNS) stated she assisted with staffing and staffing was determined based on the State mandatory minimum CNA ratios. Staff 2 reported the facility had three State approved bariatric residents but she was unaware of the bariatric staffing requirements. Staff 2 reported she had been informed that staff were not always readily available in a house when two person assistance with transfers or care was required, so staff had to attempt to locate a staff member from a different house. Also, staff reported that sometimes they had to wait a long time for help to arrive and sometimes a staff member said they would come to help, but then never showed up. Staff 2 stated she expected the facility to be staffed so the residents got the care they needed in a timely manner.

Based on observation and interview it was determined the facility failed to ensure drugs and biologicals were secured and not expired for 3 of 4 medication carts and 1 of 1 medication room reviewed for medication storage. This placed residents at risk for adverse medication effects. Findings include: The facility Storage of Medication policy statement dated April 2007, stated The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 1. On 8/1/24 at 11:06 PM the treatment cart on the [NAME] Hall was observed to be unlocked and unattended by staff. On 8/1/24 at 11:31 PM Staff 16 (RN) confirmed she left the treatment cart unlocked and unattented. 50926 2. On 7/31/24 at 8:13 AM Staff 10 (LPN) discovered expired Lantus (an injectable insulin for treatment of Diabetes) in a medication cart. On 7/31/24 at 8:13 AM with Staff 10 confirmed the Lantus insulin had expired on 7/24/24 and should not be in the medication cart. In the medication storage room on 07/31/24 at 08:20 AM with Staff 10 (LPN) noted the emergency refrigerator was unlocked. Staff 10 (LPN) on 07/31/24 at 08:20 AM confirmed the emergency medication refrigerator should have been locked. On 7/31/24 at 11:29 AM Staff 17 (CMA) reviewed a medication cart on the 400 hall. Staff 17 observed a bottle of fish oil (a supplement) with an expiration date of 6/2024 and confirmed the supplement was expired and did not belong on the cart. On 7/31/24 at 12:13 PM an observation in the medication storage room with Staff 4 (RNCM) the medication refrigerator contained four boxes Fluzone High Dose Quadrivalent prefilled syringes and one box Seqirus Influenza vaccine an Adjuvanted Fluad Quadrivalent prefilled syringes (two types of influenza vaccines) that expired in 6/2024 . On 7/31/24 at 12:13 PM Staff 4 confirmed the prefilled syringes had expired 6/2024 and should not be in the refrigerator. On the 200 hall on 8/1/24 at 10:56 PM revealed two medication carts were left unlocked and unattended. Staff 16 (RN) on 8/1/24 at 11:17 PM, confirmed the two medication carts on the 200 hall were left unlocked and unattended. Staff 2 (DNS) on 8/2/24 at 11:25 AM stated her expectation was the carts and refrigerators would not contain expired medications and would be locked when unattended.

Based on observations, interviews and record review it was determined the facility failed to develop and implement person centered care plans for 2 of 8 residents (#s 3 and 8) reviewed for falls and medications. This placed residents at risk for falls and adverse medication effects. Findings include: 1. Resident 3 was admitted to the facility in 5/2021 with diagnoses including congestive heart failure. A 5/26/24 Fall Risk Evaluation determined Resident 3 to be at a moderate risk for falls. A 6/14/24 Care Plan identified Resident 3 at a moderate risk for falls with interventions including placing her/his bed in a low position to decrease the risk of injuries from falls. On 7/31/24 at 10:03 AM Resident 3 was observed asleep in bed with the bed at a normal height. On 7/31/24 at 10:09 AM Staff 30 (CNA) stated Resident 3 was not at risk for falls and was not aware of interventions in place regarding bed positioning to reduce the risk for falls. On 7/31/24 at 11:30 AM Staff 4 (RNCM) stated Resident 3's care plan including having her/his bed in a low position. Staff 4 observed Resident 3's bed position and stated her/his bed was not in a low position. Staff 4 confirmed Resident 3's fall prevention techniques included in her/his care plan were not being implemented which placed Resident 3 at an increased risk for falls. 50926 2. Resident 8 was admitted to the facility in 7/2023 with diagnoses including other pulmonary embolism with acute cor pulmonale (a blood clot in the lung that causes the heart to work hard to pump blood in and out of the lungs). Review of Resident 8's Order Summary Report included Apixaban 5 mg (an anticoagulant and high-risk medication used for the treatment of blood clots in the lungs) started 7/12/23. Resident 8's care plan did not include monitoring of high-risk medication. Staff 2 (DNS) on 8/2/24 at 11:13 AM confirmed the expectation for high-risk medications, such as an anticoagulant, to be on the care plan. She confirmed Resident 8's care plan did not include high-risk medication.

Based on observation, interview and record review it was determined the facility failed to safely transfer a resident with the use of a mechanical device for 1 of 1 sampled resident (#301) reviewed for accidents. This failure resulted in Resident 301 falling during a transfer and was hospitalized with a subdural hematoma (a pool of blood between the brain and its outermost covering). Findings include: Resident 301 was admitted to the facility in 11/2022 with diagnoses including atrial fibrillation. Resident 301's 11/7/22 Care Plan indicated the following: -The resident required assistance from two staff via a mechanical lift as necessary; and -The resident was on anticoagulant therapy (medicine to prevent blood clots). A 1/14/23 Progress Note revealed the resident slipped out of the sling connected to the mechanical lift and her/his head hit the floor. The resident sustained a bump to the back of her/his head as a result of the fall and was sent to the hospital. A review of the Resident 301's clinical record indicated she/he was hospitalized from 1/14/23 to 1/16/23 with a subdural hematoma. A 1/14/23 Post Fall Assessment revealed the following: -Two CNAs were helping the resident transfer with a mechanical lift to the bedside commode prior to the fall; -Staff 18 (Agency CNA) assisted the resident into the sling; -Staff 19 (Former CNA) was assisting with the mechanical lift and transfer; and -The sling for the mechanical lift was not placed correctly, contributing to the resident sliding out of the sling. On 4/20/23 at 8:58 AM Witness 5 (Family Member) stated Resident 301 was hospitalized for two nights as a result of the fall out of the mechanical lift. Witness 5 stated the resident suffered and was in a great deal of pain as a result of this fall. On 4/20/23 at 10:21 AM Staff 19 (Former CNA) stated she went to grab the resident's commode while Staff 18 hooked the sling containing the resident up to the mechanical lift. Staff 18 stated she operated the lift and the resident slid out because Staff 18 failed to cross the straps of the sling under the resident's legs which was standard practice. Staff 18 stated when the resident fell , the first part of the resident's body to hit the ground was her/his head. On 4/20/23 at 11:47 AM Staff 20 (Former RNCM) stated she was the manager on duty at the time of the incident. Staff 20 stated she entered the resident's room shortly after the fall and found the resident on the ground yelling get me up, my neck hurts. Staff 20 stated the resident was immediately sent to the hospital. Staff 20 stated she was unable to interview Staff 18 as she was unable to locate her after the fall. Staff 20 stated she interviewed Staff 19 who indicated the straps of the sling were not crossed under the resident's legs during the transfer. Staff 20 stated the correct placement of the sling was to have the straps crossed underneath the resident's legs.

1. Based on interview and record review it was determined the facility failed to follow care plan interventions for 1 of 4 sampled residents (#4) who were reviewed for accidents. As a result of not following the care plan, Resident 4 suffered an acute nondisplaced fracture of the left femur. Findings include: Resident 4 was admitted to the facility in 2/2016 with [DIAGNOSES REDACTED]. The resident passed away on 11/28/16. The resident's current care plan and Resident Care Guide identified safety and fall interventions to include visual checks, non-skid socks and to keep room tidy and free of tripping hazards. The resident's 11/2016 TAR documented non-skid socks when in bed (ordered on [DATE]). The resident's 9/15/16 Quarterly Nursing Summary identified the resident was at risk for falls and the resident had one or more falls in the previous month. On 11/19/16 at 8:14 am, the resident's Clinical Note documented the resident had a fall at 7:00 am and the nurse found the resident on the floor lying on her/his left side. The physician was notified and an x-ray was ordered. Resident 4's x-ray results dated 11/19/16 noted the findings as there is an acute nondisplaced fracture of the proximal left femur. The resident's Fall Investigation dated 11/19/16 identified the resident attempted to get out of bed and fell . The final investigation review completed by Staff 1 (DNS) concluded Resident 4 was not wearing non-skid socks and the resident's care plan was not followed. The caregiver was counseled and all regular socks were removed and replaced with non-skid socks. In an interview on 11/30/16 at 4:08 pm, Staff 7 (CNA) stated she was working the night of the resident's fall but was not assigned to the resident. Staff 7 stated she did recall the resident's fall and stated there were only two of us and it was hard to watch all the residents. Staff 7 stated the aide assigned to Resident 4 the morning of the resident's fall no longer worked at the facility, but the nurse told her the resident's fall was because the resident was not wearing non-skid socks. In an interview on 12/1/16 at 7:23 am, Staff 6 (LPN) stated she worked on the day of the resident's fall. Staff 6 stated she recalled the resident's call light going off at about 6:55 am and paged the aide. Staff stated she went back to chart and had a page for Code Green and responded to the resident's room. Staff 6 stated she observed the resident lying on the floor on her/his left side, the resident had her/his pajamas on and was not wearing non-skid socks. Staff 6 stated all residents were to have non-skid socks on when residents are put to bed, and confirmed the aide told her she forgot to put the resident's non-skid socks on. In an interview on 12/2/16 at 8:40 am, Staff 1 (DNS) acknowledged the findings and confirmed the aide no longer worked at the facility. 2. Based on observation, interview and record review it was determined the facility failed to ensure a resident's environment remained free of accident hazards for 1 of 4 sampled resident (#45) reviewed for accidents. This placed residents at risk for accidents. Findings include: Resident 45 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. The in-room Resident Care Guide dated 10/25/16 indicated use of bilateral side rails. On 11/29/16 at 9:00 am, the resident was observed lying in bed on her/his back with her/his eyes close. Several small scratches and bruises were observed on the resident's arms. On 11/29/16 at 9:50 am, the resident was observed lying in bed. Bilateral half side rails were observed on the resident's bed. An gap of approximately five inches was observed between the mattress and the side rail on the right side of the bed. The resident's right arm was resting near the edge of the mattress. On 11/29/16 at 9:55 am, Staff 2 (CNA) stated the resident moved a lot in bed, especially during care. On 11/30/16 at 10:45 am, the resident was observed lying in bed with her/his eyes closed. A bandage was observed on the resident's left arm just above the wrist and a bruise on her/his left hand. On the resident's right arm was a bruise just above the elbow, a bruise just below the wrist and multiple scratches approximately one inch in length. On 11/30/16 at 10:45 am, the resident was observed lying in bed slowly moving her/his arms up and down. On 11/30/16 at 12:57 pm, the resident was observed lying in bed. A pillow was placed to fill the gap between the mattress and side rail. On 12/01/16 at 8:29 am, the resident was observed lying in bed. On the right side of the bed, a gap of approximately five inches was observed between the mattress and the side rail. On 12/01/16 at 8:30 am, Staff 3 (CNA) stated she had not seen the resident get her/his arm stuck between the mattress and side rail at any time. Staff 3 acknowledged the space was large enough for the resident to get her/his arm stuck. On 12/01/16 at 8:37 am, Staff 11 (Assistant DNS) was shown the gap between the mattress and the side rail. Staff 11 stated she planned to use pillows to fill the space. On 12/01/16 at 9:39 am, the resident was observed lying in bed. A pillow was observed to fill the gap between the mattress and the side rail. On 12/01/16 12:28 pm Staff 19 (RNCM) stated the resident moved around a lot and hit things and that may have caused the bruising and skin tear. Staff 19 stated she discussed the side rails with other staff to consider whether the risk of injury was greater to the resident than the benefit. Staff 19 stated she felt they might be more of a risk because of the potential for bruising if the resident hit them or became entrapped because of the gap.

Based on interview and record review it was determined the facility failed to follow care planned fall interventions for 1 of 3 sampled residents (#1) reviewed for falls. Resident 1 sustained a laceration that required sutures and staples. Findings include: Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The 8/21/15 Cognitive Loss and Falls CAAs noted the resident had short term and long term memory loss and was alert and oriented to self but not always to place or time. The resident had impaired balance, fatigued easily and attempted self transfers. The Care Plan Report included a 5/28/16 fall intervention directing staff to toilet the resident immediately after each meal. Staff were not to leave the resident unattended in the wheelchair prior to toileting. The 6/10/16 at 2:41 am Clinical Note disclosed on 6/9/16 at 7:45 pm, staff heard the resident calling out and found the resident on the floor. Resident 1 was on her/his knees, with her/his head on the walker. The resident had a cut on the right side of her/his head, which bled and a skin tear on the left forearm. The bleeding did not stop and the resident was sent to the Emergency Department at around 8:00 pm. The correlating facility investigation noted the resident was in the wheelchair at the time of the fall and determined the care plan was followed. However, the 6/17/16 Nursing Facility Incident Self-Report Form documented staff were aware of the care plan to toilet the resident after dinner, which was not done. The 6/9/16 Emergency Department noted the resident had a 10 cm scalp laceration extending from the right forehead towards the right temporal area. The wound was repaired with staples and sutures. The 6/10/16 at 9:24 am Clinical Note indicated Resident 1 returned from the hospital. The resident's laceration was treated with three sutures and nine staples. In interviews on 8/16/16 at 2:51 pm and 8/18/16 at 1:24 pm Staff 1 (DNS) stated Resident 1 was to be toileted upon return from dinner and when the resident attempted self transfers it was for toileting. On 6/9/16 the resident was not toileted, got up and fell . The staff assigned to Resident 1 at the time of the fall included Staff 7 (RN), an agency CNA and Staff 9 (CNA) who was not normally assigned to the resident and was not available for interview at the time of the survey. In interview on 8/19/16 at 9:44 am Staff 7 (RN) stated Resident 1 was to be toileted before and after meals and when the resident attempted to get up on her/his own it was normally related to toileting. Staff 7 stated she did not know if the resident was toileted after dinner on 6/9/16.