Every finding on record at Rosewood at Tybee Island of Journey LLC, The

Based on resident and staff interviews and record review, the facility failed to ensure a vermin-free environment related to an active raccoon infestation within the facility's attic ceilings, main dining room, and walls. This failure placed 82 of 82 residents at substantial and immediate risk for physical injury (scratches/bites) and exposure to infectious vectors and diseases, including rabies.On 6/6/2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Executive Director (ED) and Director of Nursing Services (DNS) were informed of the Immediate Jeopardy (IJ) on 6/6/2026 at 6:17 pm. The noncompliance related to the IJ was identified as having existed on 5/18/2026.An Acceptable Removal Plan was not received at the time of exit on 6/7/2026. Therefore, the IJ status was ongoing.Findings included:1. A review of the electronic medical record (EMR) revealed that R24 was admitted to the facility on [DATE], with diagnoses including, but not limited to, disorders of muscle, depressive episode, anxiety disorder, insomnia, major depressive disorder, and muscle weakness.A review of R24's Nurse Progress Note dated 5/28/2026 at 6:55 pm revealed an encounter adjustment disorder with mixed anxiety and depressed mood related to stressors (financial, functional, environmental).2. A review of the EMR revealed that R31 was admitted to the facility on [DATE] with diagnoses including but not limited to muscle weakness, difficulty in walking, and cognitive communication deficit.A review of R31's Nurse Progress Note dated 5/26/2026 at 7:41 pm revealed in encounter Remeron 30 milligrams (mg) at bedtime for insomnia. The recommended nonpharmacological interventions were to maintain a quiet and stress-free environment.During an observation on 6/5/2026 at 10:32 am, there was a hole in the ceiling of R24's room. She indicated that the hole was caused by a raccoon falling through the previously wet ceiling tile and that the incident occurred on Tuesday, 6/2/2026. R24 expressed her concerns about sleeping at night, fearing that another object might fall through. Additionally, R24 presented a photograph showing the raccoon positioned between the wall and the nightstand, with the document dated Tuesday at 6:15 pm.During an interview and observation conducted on 6/5/2026 at 10:44 am, R29 stated that she experiences fear at night due to the sound of something heavy moving in the ceiling. She is concerned that it may collapse through the stained ceiling tiles above her bed.During an interview conducted on 6/5/2026 at 4:20 pm, the Director NN reported that a raccoon had entered through the ceiling. However, she clarified that the raccoon did not fall onto the residents. This incident occurred on 6/4/2026 at 10:43 am. She further confirmed that the raccoon fell onto the floor. The facility has since ordered tiles and traps throughout the premises, and three raccoons were captured and relocated to wildlife. She mentioned that there are several more raccoons in the ceiling, and their presence can be heard. In total, three raccoons were captured from Monday to Thursday. One of the raccoons was discovered in the hallway near the kitchen by a nurse.During an interview on 6/6/2026 at 9:43 am, R24 stated that her primary concern was the prolonged duration taken to repair the hole in the ceiling.During an interview on 6/6/2026 at 9:50 am, the Business Office Director stated that staff were moving about in a state of fear because a raccoon had fallen from the ceiling in the residents' room. She stated that upon entering the room, she noticed the hole, closed the resident's door, took two pillowcases, and used them to capture the raccoon, placing it in a trap until wildlife rescue could retrieve it. She mentioned that the raccoon had fled to the corner of the room and was hiding between the nightstand and the wall.During an interview on 6/6/2026 at 1:33 pm, R31 stated that no one inquired whether she wished to be moved from the room; they primarily communicated with her roommate.During an interview on 6/6/2026 at 1:33 pm, R24 stated that on 6/2/2026, a raccoon had fallen from the ceiling into the room adjacent to her bed. R24 mentioned that the staff tried to remove her from the room but were unable to get the bed through the doorway. R24 stated that she and R31 remained in the room with the ceiling still exposed. Additionally, R24 stated that she feared that other objects, such as a snake, a mother raccoon, or any other item, might fall through.During an interview on 6/6/2026 at 3:06 pm, the DNS stated that she observed the incident in the dining room late in the evening. A staff member captured the raccoon in a cage and subsequently removed it from the premises. This was the only instance she was aware of before 6/1/2026, and she expressed uncertainty regarding any previous occurrences. She mentioned that the ED was informed, as she had contacted him. The DNS also communicated with the Registered Nurse (RN) OO and the Certified Nursing Assistant (CNA) BB to relocate residents. The DNS recounted that while she was walking, the raccoon fell. She reported that she informed the ED, who then contacted corporate, leading to a call to pest control. She instructed the staff to keep the residents' room door closed and advised them to reach out to the appropriate personnel. The DNS indicated that she only assessed the resident's room where the raccoon was found but did not conduct interviews with other residents; however, she did speak with one resident outside at that time. She stated that she directed the staff RN OO and CNA BB to relocate the resident to another room, but later discovered that they had not done so. She reiterated that both residents were supposed to be moved. However, CNA BB explained to her that they could not move the bed because it would not fit through the door, and the bedrails could not be lowered. The DNS expressed concern for the other residents, noting that they could have moved her, but there was no available bed for R24 to transfer into. The DNS admitted she did not have an explanation for why the roommate was not relocated. She felt that if R24 was being left behind, there was no point in moving the other resident, R31, because the raccoon fell on the R24 side of the room. The DNS shared that she visits the resident's room daily and has concerns regarding the exposed hole. She discussed this issue with the ED, who ordered tiles to address the situation. The DNS confirmed that the residents were still at risk; however, she did not consider them at risk because she was unsure if there were other issues present. The DNS acknowledged the risk posed by the open hole and the potential dangers it presented. She does not require staff to document frequent checks or to inform the Social Worker to follow up with the residents.During an interview on 6/6/2026 at 3:28 pm, CNA CC stated that she heard about a raccoon falling from the ceiling in a resident's room. She mentioned that she had observed them outside in traps located in the designated smoking area. CNA CC stated that she had seen traps positioned near the dumpsters. She confirmed she has noticed the raccoons outside by the dumpsters since last year.During an interview on 6/6/2026 at 3:31 pm, the ED stated that on 5/19/2026 (error), the prior Maintenance Assistant PP had indicated they heard noises coming from the ceiling. (It was later confirmed by the administrator that the date of 5/19/2026 was an error, and the actual date of the sighting was 5/18/2026.) The ED stated that upon investigation, Maintenance Assistant PP climbed a ladder and discovered a raccoon in the [NAME] Wing. He mentioned that the DNS and the entire staff were informed about the raccoon sighting during a staff meeting on the same day. He noted that between (5/18/2026) and 6/1/2026, no additional raccoons were captured. On (5/18/2026), only one raccoon was caught in a trap, and the second raccoon was captured on 6/1/2026 after it fell through the ceiling. He stated that discussions were held with the staff regarding the issue, but they had not been addressed in the Quality Assurance and Performance Improvement (QAPI) meetings. He mentioned that they had set out one trap approximately three weeks ago and added three more traps this past Friday, 6/5/2026. The ED reported that they have successfully captured four raccoons and a cat. He acknowledged that this has been an ongoing issue on the island. He mentioned that there is a Performance Improvement Plan (PIP) concerning the raccoon situation, but there has been no meeting regarding it. They offered to relocate R24, and although she initially agreed, she later decided to return. He confirmed the hole was repaired either on 6/5/2026 or 6/6/2026. He expressed uncertainty regarding his ability to implement temporary coverings for the ceiling on the same day as the incident until the order was received. He revealed the pest control company visits the facility on a daily basis to inspect the traps, and their contract is on an as-needed basis. He confirmed the presence of two raccoons in the courtyard and two in the dumpster, indicating the locations of the traps; no traps were set within the building or attic due to their excessive weight, which prevents them from being placed on the ceiling structure. He pointed out that the raccoon issue had been present before his arrival and that the facility was aware of it. He explained the facility is set to receive a new roof, but he believes that this will not address the raccoon problem. He attributed the presence of raccoons and cats to the condition of the dumpsters, which the ED verified as having broken lids. He clarified that the bulky furniture next to the dumpster was from the previous company that leased equipment and was replaced by the new ownership. The company recently came to retrieve their equipment. He speculated that the items had been outside since 2/1/2026. He mentioned that he had not personally observed the issue but had heard staff discussing it, especially concerning the ceiling scratching that occurred on (5/18/2026). He stressed that this situation presents infection control and health risks, including those associated with rabies, as well as bites and scratches that could affect the residents, among other concerns. He noted that the infant raccoons that had been captured do not have rabies and that the mother approached the buildings to give birth to them. He indicated that they are performing patchwork today due to the presence of water spots on the tiles. He confirmed that the Maintenance Director would be responsible for ensuring that the facility is free of any open and exposed external holes.During an interview on 6/6/2026 at 3:47 pm, CNA BB stated that he worked on 6/2/2026. On 6/1/2026 or 6/2/2026, a baby raccoon fell in the middle of the hallway. He stated the ED was in the hall, and they blocked the hallways. The ED and a nurse proceed to put a raccoon in the cage. He stated he was working when a raccoon fell in the resident's room. He was instructed to do frequent rounds; he attempted to move the resident, but the pin to the bedrail was stuck. He stated he was unsure if the hole from the ceiling was fixed after that day. He did say the resident was okay with being back in the room as long as they fixed the hole. He informed Licensed Practical Nurse (LPN) GG that at the time he couldn't get the bed out and he passed that responsibility to the nurse. He said the room was for a new admit and was going to hold her until they arrived. He said the nurse spoke with social services, and she went to speak with the residents. CNA BB stated the residents voiced that they felt unsafe cause there was a raccoon in the building.During an interview on 6/6/2026 at 4:13 pm, CNA GG stated that two raccoons had fallen from the ceiling-one in the hallway and the other in a resident's room. CNA GG confirmed that she helped remove the raccoon that had fallen in the hallway; she used a broom to sweep it out into the patio area and into a cage. CNA GG highlighted that this raccoon was aggressive, hissing, and very resistant.During an interview on 6/6/2026 at 5:01 pm, CNA HH revealed that she had heard scratching noises a week prior while she was charting at the nurse station from the ceiling. However, this week she heard R24 shout that a raccoon had fallen into her room. CNA HH explained she believed the raccoon managed to enter through the ceiling, as the rain had caused a water stain to appear on it.During an interview on 6/6/2026 at 5:20 pm, CNA EE stated that she hears noises and movements that resemble running during the night. She confirmed observations of a raccoon at night, particularly in the parking lot and near the entrance door. She has not reported any sounds, except for last weekend in East Wing room [ROOM NUMBER], where a visitor, the brother of R2, was present during the daytime. The R2 brother voiced a complaint at the nurse's station, indicating that it sounded like an animal in the building. CNA EE disclosed that the report was written two weeks ago, noting that R2 requires total care. She confirmed that she has not received any in-service training regarding what to do if she encounters wildlife in the building.

Based on observations, resident and staff interviews, record review, and review of the Administrator and Director of Nursing Job Description, the facility administrations failed to manage the facility in a manner that protects residents' health and safety by failing to identify, remediate, and eliminate a known active raccoon infestation within the facility's attic ceilings, main dining room, and walls. Specifically, administration had documented knowledge of wildlife infestation since 5/19/2026, when staff observed a live raccoon in the ceiling, but failed to implement effective eradication measures or secure the building. This administrative failure placed 82 residents at substantial and immediate risk for physical injury (scratches/bites) and exposure to infectious vectors and diseases, including rabies, resulting in a determination of an ongoing immediate jeopardy.On 6/6/2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Executive Director (ED) and Director of Nursing Services (DNS) were informed of the Immediate Jeopardy (IJ) on 6/6/2026 at 6:17 pm. The noncompliance related to the IJ was identified as having existed on 5/18/2026.An Acceptable Removal Plan was not received at the time of exit on 6/7/2026. Therefore, the IJ status was ongoing.Findings included:During an observation on 6/5/2026 at 10:32 am, R24 was observed in her room lying in her bed. During an observation of the room, the ceiling tile was observed to have a hole, and pinkish colored insulation was observed bulging through the hole. During an interview with the resident at this time, she stated that the hole was caused by a raccoon falling through the wet ceiling tile. She stated that this incident occurred on Tuesday, 6/2/2026, and pulled up a photo on her cellular phone of a raccoon crouching in the corner between the wall and the nightstand (photo dated and timestamped as Tuesday, 6/2/2026 at 6:15 pm). She stated that she was concerned because they had not fixed the hole, and she feared that something else might fall through the ceiling while she was sleeping.During an observation on 6/5/2026 at 11:02 am, the hallway between the main lobby and the entrance door to the main dining area revealed an opening in the ceiling, with only one ceiling tile positioned to cover the area of two tiles. These ceiling tiles exposed pink-brownish colors of insulation. There were several soiled/saturated brownish colored ceiling tiles surrounding the area, near the main dining area and the east wing.During an interview on 6/6/2026 at 3:06 pm, the Director of Nursing Services (DNS) revealed that she witnessed an incident near the dining room when a raccoon fell from the ceiling. She stated that Registered Nurse (RN) OO and the Certified Medical Assistant (CMA) BB relocate residents. The DNS recounted that while she was walking, the raccoon fell. She reported that she informed the ED. The DNS indicated that she only assessed the resident's room where the raccoon was found but did not conduct interviews with other residents; however, she did speak with one resident outside at that time. She directed RN OO and CMA BB to relocate the resident to another room, but later discovered that they could not move the bed because it would not fit through the door, and the bedrails could not be lowered. The DNS expressed that R3 could have moved her, but there was no available bed for R24 to transfer into. She felt that if R24 was left behind, there was no point in moving the other resident, R31, because the raccoon fell on R24's side of the room. The DNS shared that she visits the resident's room daily and has concerns regarding the exposed hole. The DNS acknowledged the risk posed by the open hole and the potential dangers it presented.During an interview with the ED on 6/6/2026 at 3:31 pm, he revealed that on 5/19/2026, the previous Maintenance Assistant (MA) PP reported the resident hearing noises from the ceiling. Upon further investigation, he ascended a ladder and found a raccoon in the [NAME] Wing. He noted that the DNS and the entire staff were informed about the raccoon sighting during a staff meeting on that same day. On 5/19/2026, only one raccoon was captured in a trap, while a second raccoon was caught on 6/1/2026, after it fell through the ceiling in the East Wing. He mentioned that they had set one trap approximately three weeks prior and added three additional traps on Friday, 6/5/2026. The ED reported that they have successfully captured four raccoons and a cat. He confirmed that the holes were repaired either on 6/5/2026 or 6/6/2026. He verified the presence of two raccoons in the courtyard and two in the dumpster, indicating the locations of the traps; no traps were placed within the building or attic due to the excessive weight of the traps, which prevents them from being positioned on the ceiling structure. He pointed out that the raccoon issue existed before his arrival and that the facility was aware of it. He emphasized that this situation poses infection control and health risks, including those related to rabies, as well as bites and scratches that could impact the residents, among other concerns. He noted that the infant raccoons that had been captured do not have rabies and that the mother approached the buildings to give birth to them. He indicated that they are conducting patchwork today due to the presence of water spots on the tiles. He confirmed that the Maintenance Director would be responsible for ensuring that the facility is free of any open and exposed external holes. He stated that discussions were held with the staff regarding the issue, but it had not been addressed in the past, and it had not been addressed in the Quality Assurance and Performance Improvement (QAPI) meetings.(Note: The date of 5/19/2026 was later clarified by the ED as an error. The actual date of the first sighting of the raccoons was 5/18/2026, when the MA PP had looked in the attic and sighted a live raccoon.)A review of the Pest Control Report dated 5/18/2026 revealed the contractor noted: service was for raccoon removal. Signature of Owner, Resident or Custodian of the property dated 5/19/2026. An interview was attempted on 6/6/2026 with the Pest Control Technician; however, he declined to answer any questions.A review of the facility's Job Description for the job title of ED. The description included that the ED is responsible for assuring that the center operates in full compliance with Federal and State regulations, which will result in high levels of performance in each of the center's Strategic Focus Areas. The ED is responsible for planning and is accountable for all activities and departments of the Center, subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The ED administers, directs, and coordinates all activities of the Center to ensure that the highest degree of quality of care is consistently provided to residents. Positions reporting to the ED include the DNS.A review of the facility's Job Description for the job title of DNS. The description included that the DNS is responsible for driving, supporting, and modeling a service-oriented culture focused on top-of-license practice, interprofessional collaboration, employee engagement, quality, patient safety, service excellence, fiscal responsibility, and the overall patient/resident experience.A review of the Pest Control Report documented a pest control contract dated 5/18/2026 with service for noted: raccoon and special instructions noted: raccoon removal.

Based on observations, staff interviews, review of the facility documents, and review of the facility's policies titled Food Safety Requirements and Ice Machines and Portable Ice Carts, the facility failed to properly discard expired food items and properly store, label, and date them. Additionally, the facility failed to prevent wet nesting and maintain the ice machine in a sanitary condition. These deficiencies posed a potential risk to 79 out of 82 residents who received an oral diet from the kitchen, increasing their vulnerability to foodborne illnesses. Findings included:A review of the facility's policy titled Food Safety Requirements dated February 2025 documented that food would be stored, prepared, distributed and served in accordance with professional standards for food service safety. Policy Explanation and Compliance Guidelines 1. Food safety practices shall be followed throughout the facility's entire food handling process. b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from the growth of microorganisms. A review of the facility's policy titled Ice Machines and Portable Ice Carts, implemented on 11/15/2024, documented that the ice machines/carts can be prone to microbial contamination due to improper handling or storage of ice, poor cleaning or maintenance of equipment, or through ice handling equipment. Proper cleaning, maintenance, and infection control in relation to ice machines are important to decrease the risk of illness to residents, staff, and visitors. Compliance Guidelines 1. Ice machines will be cleaned at a frequency specified by the manufacturer or, if manufacturer specifications are absent, at a frequency necessary to preclude accumulation of soil or mold. 2. The facility will determine the frequency at which the ice machine (interior, exterior, parts, etc.) will be cleaned/ sanitized (i.e., daily, monthly, quarterly, annually, etc.) with documentation to support the cleaning procedures.A review of the Department of Public Health inspection dated 4/30/2026 at 2:30 pm revealed in the Observations and Corrective Actions section 4-2B, observed mold-like build-up on the baffles of the ice machine in the front dining service area.During the kitchen initial tour on 6/5/2026 at 7:44 am, revealed in the dry storage area that one white oversized container with rice, inside rice presented one scoop, on top of a box adjacent to the white containers were four unbagged scoops, three 111 ounces (oz.) beans dented cans located on the active stock shelf. Five packages of 16 oz. enriched macaroni lasagna, with an expiration date of 4/22/2026, and one box containing 10 lbs. of lasagna, with an expiration date of 4/9/2025. Several open, unlabeled, and undated items were observed: two 10-pound (lbs.) bags of penne pasta, one 10 lbs. elbow noodles, one 5 lbs. egg noodles, and one10 lbs. spaghetti noodles. Confirmed with Dietary Manager (DM).Inside the kitchen, there was one stand-alone reach-in freezer and one double-door reach-in refrigerator positioned side by side, near the stove and steam table. The reach-in freezer was observed and revealed 20 bags of 20-count breadsticks, two repackaged bags of chicken, one 10 lbs. chicken in a blue bag, and one package of repackaged clear-wrapped chicken breast strips, as confirmed by the DM, along with one 12-count pretzels neither labeled nor dated. The reach-in refrigerator contained one 4-quart (qt.) container of boiled eggs that were neither labeled nor dated, one 12 oz. jar of grape jelly, and one square piece of cake on a paper plate that also lacked a label and date.The walk-in freezer revealed four pork chops in a clear repackaged bag that were unlabeled and undated, along with one 5 lb bag of cookie dough. Confirmed by the DM. The ice machine inspection was conducted by the DM, who donned a glove and utilized a white paper napkin to assess the condition of the ice machine. The DM placed the white paper napkin on the inner fold and swiped it across, revealing a brow-like residue. The DM confirmed that the ice machine required cleaning and acknowledged the presence of the brown-like residue on the napkin.During an interview on 6/5/2026 at 9:25 am, the Registered Dietitian (RD) confirmed his awareness of all the issues identified during the initial kitchen tour, as well as some additional concerns. The RD explained that the staff has progressed from not labeling and dating to now having some items that are labeled and dated. He emphasized the importance of celebrating small victories. The RD acknowledged that while the kitchen has its challenges and is a hot mess, it is a work in progress.On 6/6/2026 at 11:25 AM, the Regional Nurse Consultant confirmed that there was no ice machine cleaning log.During an observation and interview on 6/7/2026 at 12:26 pm, during the preparation of the lunch meal trays, it was noted that [NAME] II retrieved a stack of plates from the plate warming station to start assembling the residents' trays. After preparing plates and completing one with the lunch meal, it was confirmed that the plates were for use and displayed excessive water along with the served plated meals. The RD confirmed the observation, removed the affected plates from the line, and started using white disposable plates. [NAME] II explained that they usually plug in the plate warmer, and it dries the plates, but they forgot today.During an interview on 6/7/2026 at 12:31 pm, the Dietary Aide (DA) JJ disclosed that she was tasked with plugging in the plate warmer. However, she forgot to do so. She confirmed that all the plates were wet, which posed a risk of infection.During an interview on 6/7/2026 at 12:34 pm, the RD confirmed the wet-prepped plates and stacked wet plates. He revealed that neither he nor the DM conducted an in-service training with the team regarding wet nesting and is aware that the wet plates should not be stacked as it may lead to bacteria growth and cross-contamination.

Based on observations, staff interviews, and a review of the facility policy titled Laundry, the facility failed to maintain infection control practices realted to: (1) resident personal care items not stored properly to prevent cross-contamination; (2) maintaining one of two shower rooms (West Hall) in a sanitary condition; and (3) ensuring that the resident laundry was free of exposure of environment hazardous material and contamination. The deficient practice had the potential to expose residents to infections due to cross-contamination.Findings included:2. During an observation of the [NAME] Wing Shower Room on 6/5/2026 through 6/7/2026, a soiled washcloth covered with dark substances was sitting on a rack, and a dirty razor was on the bathroom floor. During an observation walk-through tour of the laundry room on 6/7/2026, the Consulting Housekeeping Staff confirmed the sanitation conditions of the shower room. 3. During an initial tour of the facility laundry room on 6/5/2026 at 11:01 am with the Housekeeping Laundry Aide (HK/LA) KK and LL. The following infection control concerns were identified regarding the sanitation of resident clothes in the laundry area: The facility laundry room exterior/interior entrance door (which connects the outside of the building to the inside of the building) did not have a secure, tight fit due to large gaps of wood missing on the side frame, top frame, and bottom frame of the door, allowing accessibility to dust, insects, and rodents. Staff were observed using dirty bed coverings covered with dark brown stains filled with greyish substances and dark stains, which were identified by staff as layers of dirt and dust to prevent the door from opening. Interview and observation with HK/LA KK revealed that since the last survey, the door was identified, and maintenance was supposed to add aluminum frames to the door, but no one followed up on the repairs. She reported that any insects or rodents can enter the door. The laundry staff tries to sweep and monitor for dust and fecal materials from rodents as much as possible. This is hard to do at times. The blanket is used to hold the door closed, but does not cover all the cracks at the top, sides, and bottoms. The laundry room flooring was observed to be dirty, soiled wet bed linen covering, and towels used for water leakage on the floor throughout the laundry room, one blanket was placed in front of the washer, and other areas near clean and dirty clothes bins. An interview was conducted with HK/LA KK. She reported that due to water puddles coming from the floor structures and washers, the blankets and towels were being used to dry up the water. A large commercial fan sitting on the floor, blowing directly towards the resident's clothes area, revealed the blades of the fan and frame of the fan coated with thick dark greyish substances with dark black speckled substances. An interview was conducted with HK/LA KK, and she described the substances as dust and dirt. The wall-mounted washer chemical dispenser revealed that the pumps were not attached. During an interview at this time, HK/LA KK reported that the dispenser pumps had been detached from the wall mount for almost a year and a half. She was instructed to use a measuring cup to pour the detergent into the washer from the large gallon containers. She was not sure of the correct measuring device for how much chemical to use. It was based on her estimation and not the manufacturer's guidance. She reported that the previous Administrator had instructed her to just use the measuring cup. During a tour of the facility laundry room with the Administrator on 6/5/2026 at 11:38 am, the Administrator reported being unaware of the laundry room door and the sanitation condition of the laundry room, including the commercial washer chemical dispenser needing repairs. The Administrator verified that the laundry room door was unable to be secured due to large opening gaps at the top of the door, the side of the door, and the bottom of door was an infection control concern due to residents' clothes being accessible to rodents and dust. He reported that the plan is to have the chemical pump looked at, repaired, the fan cleaned, to cover the gaps in the door, and to possibly order a new door in the future. During an observational tour of the facility laundry room on 6/7/2026 at 10:12 am, Administrator B (an administrator from a sister facility) confirmed that all identified needed repairs and the sanitation of the facility laundry room continued to exist (door with large gaps, chemical wall-mounted pump system, dirty fan, and wet blankets and towels remaining on the floor). A review of the facility policy titled Laundry dated 2/1/2024 stated the facility launders linens and clothing in accordance with current CDC guidelines to prevent transmission of pathogens. If using fans in laundry processing areas, prevent cross-contamination of clean linens from air blowing from soiled processing areas (i.e., the ventilation should not flow from soiled processing areas to clean laundry areas). 1. A basic infection control policy was requested but was not received. During observations on 6/5/2026 at 10:07 am, 6/6/2026 at 8:02 am, and 6/7/2026 at 11:40 am of the bathroom in room [ROOM NUMBER], a brown smeared substance was observed on the bathroom floor in front of the toilet. The observation also included a shelf above the toilet with two urinals resting inside a bedpan and two additional urinals and one bedpan resting on the shelf. Neither the bedpans nor the urinals were labeled or bagged. During an interview on 6/7/2026 at 11:42 am, the Director of Nursing Services (DNS) confirmed through observation that the urinals and bedpans resting on the shelf above the toilet needed to be bagged and labeled to eliminate the spread of infection. The DNS confirmed the brown smeared substance located in front of the toilet in the bathroom of room [ROOM NUMBER] needed to be removed/cleaned immediately.

Based on observations, staff interviews, and a review of the facility policy titled Soiled Linen and Trash Containers, the facility failed to ensure outdoor garbage was secured in safe working conditions and that the refuse area was maintained in a sanitary manner, creating the potential for harboring pests, insects, and rodents. Census 82. Findings included:A review of the facility policy titled Soiled Linen and Trash Containers, reviewed dated 2/16/2024, revealed under Policy Explanation and Compliance Guidelines: 7. Loose trash and linen shall be appropriately bagged before placing into the large storage bins. During the initial observation and interview of the dumpster area on 6/5/2026 at 8:28 am, with the Dietary Manager (DM), revealed two blue dumpsters were open. Upon facing the dumpsters, it was observed that the dumpster positioned on the left had its left door open, while the right dumpster had a broken lid on the left side and exposed trash. Further observation revealed the area was surrounded by discarded bulk furniture and a black wheelbarrow containing trash. The DM confirmed that the dumpsters were open and should be secured, ensuring that no trash was present on the ground or in the surrounding area. The DM also mentioned that the discarded bulk furniture had been present since she began her tenure, approximately two to three months ago. During an observation on 6/6/2026 at 8:23 am, facing the two blue dumpsters, the left dumpster door was open on the left side, whereas the right dumpster had a damaged lid on the left side, which revealed trash placed on top of the broken lid. Additional observations showed that the vicinity was cluttered with abandoned bulk furniture.During an interview on 6/6/2026 at 12:07 pm, the Executive Director (ED) confirmed that the presence of dumpsters is a contributing factor to the issue of raccoons and cats. The ED mentioned that he had observed that the top of the dumpsters was missing/broken. ED explained that the previous company leased equipment to the facility, and it was replaced by new ownership, and the leased bulk furniture was placed outside near the dumpster awaiting pickup. ED expressed that he believes that those items have been outside since 2/1/2026.During an interview on 6/6/2026 at 3:47 pm, Certified Medical Assistant (CMA) BB revealed that raccoons are seen going into the open dumpsters all the time, as recently as 6/2/2026.

Based on observations, staff interview, record view, and a review of the facility policy titled Safe Water Temperature, the facility failed to maintain safe water temperatures in eight of 43 Residents' Rooms (RM) (RM 204, RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], and RM [ROOM NUMBER]) and one of two common-use shower rooms. Findings included: A review of the facility policy titled Safe Water Temperatures, revised on 2/16/2024, revealed that it is the policy of this facility to maintain appropriate water temperatures in resident care areas. Staff will be educated on safe water temperatures upon employment and on a regular basis. Thermometers will be available as needed for use by all staff. Staff will report abnormal findings, such as complaints of water is too cold or hot, burns or redness, or any problems with water temperature (ex. water is painful to touch or causes redness), to the supervisor and/or maintenance staff. Water temperatures will be set to a temperature of no more than 120 F (Fahrenheit) or the state's allowable maximum water temperature. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. Documentation of testing will be maintained for three years and kept in the maintenance office. During observations on 6/5/2026 from 9:01 am to 9:33 am, the residents' rooms in the [NAME] Wing were observed. When checking the water temperature in the sinks, the water was uncomfortably hot to the hand and could not be run over the bare skin for more than ten seconds. This was observed in resident rooms 204, 206, 123, 208, 210, 209, 211, 211, and 212, and the [NAME] Wing Shower Room (shower sprinkler head and sink) was uncomfortably hot to the touch and could not be run over bare skin for more than 10 seconds.During an environmental tour of the facility with the Housekeeping Floor Technician beginning on 6/5/2026 at 10:01 am and ending at 10:25 am, water temperatures were taken using a digital water thermometer with the water running from the faucets (of the room sinks (photographic evidence). During an observation of the water temperature taken in the resident rooms located on the [NAME] Wing and the [NAME] Wing shower room between 10:00 am and 10:32 am on 6/5/2026, the following: At 10:01 am, the water in room [ROOM NUMBER] (sink) was 122.5 degrees F.At 10:04 am, the water in room [ROOM NUMBER] (sink) was 122.3 degrees F.At 10:10 am, the water in room [ROOM NUMBER] (sink) was 123.2 degrees F.At 10:11 am, the water in room [ROOM NUMBER] (sink) was 122.0 degrees F.At 10:13 am, the water in room [ROOM NUMBER] (sink) was 121.2 degrees F.At 10:14 am, the water in room [ROOM NUMBER] (sink) was 120.0 degrees F.At 10:16 am, the water in room [ROOM NUMBER] (sink) was 121.8 degrees F.At 10:22 am, the water in room [ROOM NUMBER] (sink) was 120.2 degrees F. At 10:25 am, the water in the [NAME] Wing shower room was observed:The sink was observed at 121.2 degrees F, and the shower was observed at 123 degrees F. The following vulnerable residents were identified as being at potential risk of hot water burns associated with the rooms identified for hot water temperatures: A review of the electronic medical record (EMR) for R10 revealed a diagnosis of dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R10 had a Brief Interview Mental Status (BIMS) score of 10, indicating severe cognitive impairment, and that R10 was ambulatory with a walker. A review of the EMR for R28 revealed a diagnosis of Alzheimer's Disease. The quarterly MDS assessment dated [DATE] revealed that R28 had a BIMS score of six, indicating moderate cognitive impairment, and that R28 was ambulatory. A review of the EMR for R30 revealed a diagnosis of schizoaffective disorder and bipolar disorder. The quarterly MDS assessment dated [DATE] for R30 revealed that R30 had a BIMS score of six, indicating moderate cognitive impairment, and that R30 was non-ambulatory but able to self-propel in a wheelchair. A review of the EMR for R69 revealed a diagnosis of cognitive impairment. The quarterly MDS assessment dated [DATE] revealed that R69 had a BIMS score of six, indicating moderate cognitive impairment, and was ambulatory. During the process of taking the water temperatures, an interview was conducted with the Housekeeper Floor Technician on 6/5/2026 at 10:44 am. The Housekeeper Floor Technician reported that the facility no longer had an active Maintenance Worker or a Maintenance Department. He reported that the Executive Director (ED) had instructed him to perform the water temperatures of the identified rooms for hot water with the surveyor team. He reported being aware of regulations related to water temperature based on his former job as a Maintenance Director at another facility. He reported that the safe temperature (parameter ranges) should be maintained no higher than 110 degrees F and no higher than 120 degrees F to prevent burns or injuries. However, he reported that he was not responsible for taking the hot water temperature, and his job duties were as a Housekeeper Floor Technician. He reported that his knowledge of water temperature was from his previous job as a Maintenance Director at another facility. He could not say why the temperatures were varying like they were from room to room, but since the temperatures were above 120 degrees F, he planned to check the gauges on the boiler and would attempt to lower the temperature by using the mixer. Once the adjustment was made, he planned on waiting for 15-30 minutes before rechecking the temperatures in the residents' rooms. During an interview on 6/5/2026 at 10:55 am, the ED confirmed the situation with the hot water temperatures. He reported being unaware of the elevated hot water temperatures at the sink in the resident's room. The maintenance director and the maintenance assistant were no longer employed by the facility. Reported that at this time, the facility did not have any maintenance workers and was working to fix the problem. Staff would be notified and advised not to use the hot water in the resident sink and to ask for staff assistance if there was a need for hot water. The administrator reported not being aware of any incidents wherein a resident, staff, or visitor had been burned or scalded by the hot water in the building. During an interview on 6/7/2026 at 12:12 pm, the ED on 6/5/2026 at 12:12 pm reported that they were unable to access the water temperature logs due to being unable to obtain access to the electronic maintenance system and locate the maintenance director's log book. The maintenance director was last employed on 4/28/2026. The ED reported that he had been employed with the facility for only four weeks and had no record of whether hot water temperatures were being taken by other facility staff for the resident's rooms and showers.

Based on record review and interviews, the facility failed to address pharmacy recommendations for a gradual dose reduction (GDR) for one of five residents (R) (81). Findings included:A review of R81's electronic medical record (EMR) revealed that she had diagnoses including, but not limited to, major depressive disorder, recurrent anxiety disorder, chronic obstructive pulmonary disease with (acute) exacerbation, and chronic obstructive pulmonary disease. A review of R81's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R81 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates cognitively intact, and was receiving an antianxiety, anticoagulant, opioid, and antidepressant drug all seven days of the assessment period. A review of R81's March 2026 Physician's Orders revealed an order for Buspirone hydrochloride (HCl) Oral Tablet 5 milligrams (MG). Give one tablet by mouth two times a day for anxiety. A review of R81's April 2026 Physician's Orders revealed an order for Buspirone HCl Oral Tablet 5 MG. Give one tablet by mouth two times a day for anxiety. A review of R81's May 2026 Physician's Orders revealed an order for Buspirone HCl Oral Tablet 5 MG. Give one tablet by mouth two times a day for anxiety. A review of R81's June 2026 Physician's Orders revealed an order for Buspirone HCl Oral Tablet 5 MG. Give one tablet by mouth two times a day for anxiety. A review of the last attempted Gradual Dose Reduction (GDR) for R81 was dated 3/22/2026, noting that the current order is Trazodone 50 MG every night at bedtime (QHS) and Buspirone 5 mg twice a day (BID). A review of the Consultant Pharmacist Consultation Report for R81's dated 3/22/2026 revealed the following:Comment: R81 has received trazodone 50 mg QHS and Buspirone 5 mg BID, which are in the timeline for review for a dose reduction.Recommendation: Please attempt a gradual dose reduction (GDR) to Buspirone 5 mg daily and then discontinue if appropriate. Physician's response: I accept the recommendation(s) above with the following modification (s): trazodone 25 MG by mouth (PO) QHS for two weeks, then stop. Signed and dated by the Medical Director on 4/2/2026. A review of R81's March, April, May, and June 2026 Medication Administration Record (MAR) revealed an order for Buspirone 5 mg BID with a check mark by each date and time indicating the medication was administered. Review of R81's March, April, May, and June 2026 MAR revealed R81 received Buspirone 5 mg BID.During an interview on 6/7/2026 at 2:01 pm, the Director of Nursing Services (DNS) stated that she was not there in March 2026 and that she was not aware of the pharmacy recommendation on 3/22/2026. The DNS stated that she was responsible for monitoring and following up with the GDRs.

Based on staff interviews, record review, and review of the facility policy titled Comprehensive Care Plans, the facility failed to revise the care plan for two of 32 sampled residents (R58 and R49) related to the residents' advance directive. This failure placed residents at risk of not having their end-of-life wishes honored.Findings included: A review of the facility's policy titled Comprehensive Care Plan with a revision dated of [DATE] documented under the Policy stated it is the policy of the develop and implement a comprehensive person-center care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychological needs and all are identified in the resident's comprehensive assessment and meet professional standards of quality. (5) the comprehensive care plan will be received and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 1. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R58 presented with a Brief Interview for Mental Status (BIMS) score of 14, indicating little to no cognitive impairment. A review of the care plan revealed that the top banner on the document titled special instructions was documented as (Do Not Resuscitate) DNR. However, R58 care plan documented resident has physician's orders that include a status of full code with interventions to ensure full code order on chart and ensure staff is aware of code status through designated systems. During an interview on [DATE] at 10:25 am with the MDS Coordinator, confirmed R58 electronic medical record (EMR) was inaccurate. She stated R58's Physicians' Orders for Life-Sustaining Treatment (POLST) is a full code. However, the profile banner on the EMR and the care plan banner state R58 is a DNR. The MDS Coordinator continued to state that it is the responsibility of any staff member to update the care plan at any time. 2. A review revealed R49 was admitted to the facility on [DATE] with diagnoses included, but not limited to, heart failure, chronic obstructive pulmonary disease, and acute and chronic respiratory failure with hypoxia or hypercapnia. A review of the quarterly MDS assessment dated [DATE] revealed R49 had a BIMS score of nine, which indicated moderate cognitive impairment. A review of the medical record revealed an active Physician Order dated [DATE] for a full code and a POLST for a DNR order dated [DATE]. A review of the care plan for R59 revised [DATE] revealed a focus on Advance Directive Full Code with interventions including, but not limited to, In the event of a code call 911 and begin CPR, date initiated [DATE]; honor code status wishes, date initiated [DATE]; in the event of cardiac arrest, initiate CPR, date initiated [DATE]; keep family informed of change in condition, date initiated [DATE]; and review code status quarterly and PRN (as needed) date initiated [DATE]. During an interview on [DATE] at 10:24 am, the MDS Coordinator confirmed R49's current active physician order for a full code order, a POLST for DNR dated [DATE], and a care plan for a full code. The MDS Coordinator confirmed the care plan should have been updated once the code status changed. She revealed that the code status change was not communicated to her and therefore the care plan was not revised to reflect the resident's life code status of DNR. During an interview on [DATE] at 10:50 am, the Director of Nursing Services (DNS) verified and confirmed that R49 had a current active physician order indicating Full Code status, a POLST dated [DATE] indicating DNR, and a care plan reflecting Full Code status. The DNS stated that the MDS Coordinator is responsible for updating and revising resident care plans. The DNS further explained that resident status changes are discussed during clinical meetings, stand-down meetings, and risk management meetings. According to the DNS, care plans are updated and revised in real time during these meetings as changes are identified and discussed. The DNS confirmed the physician order should match the life code status listed in the care plan and stated she would fix all documentation to match the R49's preference of DNR.

Based on staff interviews, record reviews, and the facility policy titled Resident Assessment-Coordination with PASARR Program, the facility failed to ensure submission to the state-designated authority for a Preadmission Screening and Resident Review (PASARR) Level II for two of two residents (R) (R4 and R29) reviewed for PASARR. This deficient practice increased the potential to place R4 and R29 at risk of not receiving services and/or care according to their needs.Findings included:A review of the facility's policy titled Resident Assessment-Coordination with PASARR Program, dated 12/24/2023, documented that PASARR Level I initial pre-screening is completed prior to admission. A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A record of the pre-screening shall be maintained in the resident's medical record. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days, the facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD (mental disorder), ID (intellectual disability), or a related condition to the appropriate state-designated authority for a Level II PASARR evaluation and determination. The Level II resident must be completed within 40 calendar days of admission. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 1. A review of the electronic medical record (EMR) revealed that R4 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, anxiety disorder, bipolar disorder, schizophrenia, and depression. A review of the annual Minimum Data Set (MDS) assessment for R4, dated 4/30/2026, documented that R4 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition and presented with active diagnoses of anxiety disorder, depression, and schizophrenia. A review of the PASARR Level I Assessment for R4, dated 4/18/2024, revealed that the diagnoses of schizophrenia, bipolar disorder, and anxiety disorder were not marked. A review of the clinical record for R4 revealed no submissions for a PASARR Level II after admission. During an interview conducted on 6/7/2026 at 10:11 am, the admission Coordinator stated she is responsible for completing PASARR Level II screenings for residents. She reported that the resident's diagnosis was major depression and indicated that this diagnosis does not qualify for PASARR Level II services. The surveyor asked the admission Coordinator to review the resident's diagnoses after observing a diagnosis of schizophrenia documented at admission. Upon reviewing the resident's EMR, the admission Coordinator confirmed the resident had a documented schizophrenia diagnosis at admission and that schizophrenia is a qualifying diagnosis for PASARR Level II services. She stated she would complete the PASARR Level II assessment immediately. 2. A review of R29's EMR revealed that she was admitted to the facility on [DATE] with diagnoses including, but not limited to, cognitive communication deficit, Schizophrenia Disorder, bipolar disorder, and hypertension. A review of the quarterly MDS assessment dated [DATE] revealed that R29 presented with a BIMS score of 12, moderate cognitive impairment. A review of the Care Plans for R29 revealed a care plan dated 4/24/2026. Focus: the resident has a psychosocial well-being problem r/t having little interest or pleasure in doing things. Interventions: Initiate referrals as needed or increase social relationships. During a record review of the undated PASARR Level II list of residents provided by the facility, revealed R29 was not listed. A record Review of PASARR Level I dated 9/6/2024 revealed approval with the physician's signature. PASARR Level II dated 6/7/2026 revealed pending. During an interview on 6/5/2026 at 10:44 am, R29 expressed that she feels isolated. R29 mentioned, I feel like I am going to go crazy, no one talks to me. During an interview on 6/6/2026 at 9:45 am, an interview was conducted with the Social Service Director (SSD). During this meeting, the PASARR binder was reviewed, and it was confirmed that the SSD does not possess the PASARR Level II for R29. It was also confirmed that she has the PASARR Level I documentation available upon admission, and it is possible that the admission Coordinator may have the required information. During an interview on 6/6/2026, at 10:03 am, with the admission Coordinator indicated that she has never submitted a PASARR Level II for the diagnosis associated with R29. The admission Coordinator reviewed R29's diagnosis and confirmed that she was admitted to the facility in 2024 and has never displayed behaviors that would suggest a need for a submission. A follow-up interview with the admission Coordinator at 1:32 pm revealed that while there was a previous Social Worker, the new social worker is unfamiliar with the process of submitting PASSAR applications; with her previous experience, she is now responsible for completing the PASSAR's. The admission Coordinator confirmed that she was never informed by the psychiatric staff or nursing staff that R29 required a PASSAR Level II. She acknowledged that she overlooked this submission. AC emphasized that if you look at R29, there is no need for a PASSAR Level II, as there are no exhibited behaviors.

Based on interviews, record review, and a review of facility policy titled Discharge Planning Process, the facility failed to ensure residents were not inappropriately transferred or discharged against the resident's/residents' representative's wishes for one resident of 82 sampled residents (R)(R85). Findings included:A review of the facility's policy titled Discharge Planning Process, dated 3/20/2025, revealed that an active individualized discharge care plan will address, at a minimum: Discharge destination, with assurances that the destination meets the resident's health/safety needs and preferences. The facility will update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. A review of 85's electronic medical record (EMR) revealed R85 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic kidney disease, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, type 2 diabetes mellitus without complications, mood disturbance, and anxiety. R85 census indicated that R85 was discharged on 5/1/2026. A review of the R85's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R85 had a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicates severe cognitive impairment, and R85 required substantial/ maximal assistance with toilet, supervision, or touching assistance for bathing. He required a manual wheelchair for mobility. A review of R85's progress notes dated 5/1/2026 revealed an order for Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams (MG); give one tablet by mouth every six hours as needed for pain 5-10. There was no documentation of a transfer/discharge summary in the electronic health record.There was no documentation that the transfer/discharge is documented in the R85's medical record and that appropriate information is communicated to the receiving health care institution or provider. There was no documentation for the basis for the transfer/discharge. There was no documentation of the R85's status at the time of discharge. There was no documentation that the physician or ombudsman was notified of the transfer/discharge. During an interview on 6/7/2026 at 11:05 am, the Director of Nursing Services (DNS) revealed that R85 was at another facility (a sister facility). She stated that she started in April 2026, and before she was hired, she was told that he was trying to go out the door. She stated that he has a skin assessment at the sister facility. During an interview on 6/7/2026 at 2:10 pm, the DNS further revealed that there are no progress notes of R85's transfer. She stated that the charge nurse was responsible for the documentation and that it wasn't documented because the nurses felt like he was going across the street, so they did not document that he went across the street. The DNS stated that she felt like, since it was one building, they did not need to document the transfer/discharge. The DNS stated that she was not sure if the ombudsman was notified of the discharge/transfer. She stated that she did not notify the ombudsman of the transfer, but she would find out and get back to the surveyor if someone else notified the ombudsman.

Based on observations, resident staff interviews, and record review, the facility failed to maintain a clean and comfortable homelike environment for two of 27 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) related to dirty Packaged Terminal Air Conditioner (PTAC) filters, debris build-up on the floor, unidentified clothing items on the floor, a unknown bagged item stored in the residents room, and a light bulb base hanging from the ceiling bathroom. Findings included: During an observation on 6/5/2026 at 8:42 am, the PTAC Unit in room [ROOM NUMBER] revealed that the PTAC Unit filter contained thick, grayish-colored fuzzy debris. During an observation on 6/5/2026 at 9:17 am and 6/6/2026 at 7:46 am in room [ROOM NUMBER] revealed the PTAC filter obtained a gray thick fuzzy debris, a thick gray substance underneath the PTAC unit with a business card embedded in the debris, a square black item wrapped in a black garbage bag placed next to the bedroom sink, unidentified clear bag containing clothing items, and the light bulb base was hang by wires from the ceiling bathroom. A review of R58's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating little to no cognitive impairment.During an interview on 6/5/2026 at 9:17 am, R58 revealed the black square items placed next to the sink belonged to a resident that was previously occupied the room. He continued to state it had been there for a while, and not sure why it was still in his room. Further, R58 stated the unidentified item placed next to his headboard was not his clothing items, and it has been on his floor for a few days now. Continued with the interview with R58, who revealed he uses his restroom and stated he noticed the hanging light bulb and stated it has been like that for a while. R58 stated that he was not satisfied with the conditions of his room, and he stated that his room is not cleaned on a routine basis. During a walk-through observation and interview on 6/7/2026 at 1:59 pm, the Executive Director (ED)confirmed that the PTAC filters in rooms [ROOM NUMBERS] contained thick gray fuzzy debris on the filters. Continued with the walk-through observation and interview with the ED confirmed room [ROOM NUMBER] had thick gray debris underneath the PTAC unit, room [ROOM NUMBER] light bulb base was hanging from the ceiling, unidentified clothing items in an unclear and unlabeled bag were on the floor next to R58 bedside, and an unknown item covered in a black garbage bag should not be there or needs to be fixed. Lastly, the ED continued to state that his expectations are for daily rounds to be conducted to identify these areas of concern and be addressed by the appropriate department.

Based on resident and staff interviews, record review, and review of the facility's policy titled Advance Directives, the facility failed to provide two of three residents (R) (R49 and R58) written information with options regarding their right to accept or refuse medical or surgical treatment and failed to ensure a physician's order matching the resident's documented wishes was established and maintained in the medical record. This failure denied the residents the opportunity to have choices and preferences with their health care decisions and to formulate an Advance Directive, and placed the residents at risk for receiving or not receiving unwanted cardiopulmonary resuscitation in a medical emergency.Findings included: A review of the undated policy titled Advance Directives, under the Policy Interpretation and Implementation, it was documented that Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions about medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. 9. The Director of Nursing Services (DNS) or designee will notify the Attending Physician of advance directives so that the appropriate orders can be documented in the resident's medical record and plan of care. Further, it was documented in the section Documentation/Obtaining Copy of Advance Directive that, should the resident indicate that he or she issued an advance directive about his or her care and treatment, documentation must be recorded in the medical record of such directive and a copy of such directive must be included in the resident's medical record. 1. A review of R49's admission Packet revealed it did not contain language that pertained to the facility's provision of written information about the resident/representative's right to accept or refuse medical or surgical treatment. A review of the electronic medical record (EMR) revealed R49 was admitted to the facility on [DATE] with diagnoses not limited to heart failure, unspecified, chronic obstructive pulmonary disease, unspecified, and acute and chronic respiratory failure, unspecified, whether with hypoxia or hypercapnia. A review of the quarterly Minimums Data Set (MDS) assessment dated [DATE] revealed R49 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. Further review of the medical record revealed, under the Orders tab, an active Physician Order dated 1/30/2026 for a full code. Record review revealed a Physician Orders for Life Sustaining Treatment (POLST) for a Do Not Resuscitate (DNR) dated 5/12/2026. A review of the care plan for R49 revised 2/25/2026 revealed a focus of Advance Directive Full Code with interventions including, but not limited to, In the event of a code call 911 and begin CPR (Cardiopulmonary resuscitation), Date Initiated: 2/13/2026; Honor code status wishes, Date Initiated: 2/13/2026; In the event of cardiac arrest, initiate CPR, Date Initiated: 2/13/2026; Keep family informed of change in condition, Date Initiated: 2/13/2026; and Review code status quarterly and PRN (as needed). Date Initiated: 2/13/2026. During an interview on 6/6/2026 at 8:00 am, R49 confirmed she wanted to be a DNR. She stated she was her own representative. She stated she did not remember receiving anything or signing anything in regard to an advance directive check that let her know her rights to formulate an advance directive or to accept or deny medical/surgical treatment. During an interview on 6/7/2026 at 10:03 am, the facility's admission Coordinator confirmed no evidence was found to support that the resident had been provided with written information related to their right to accept or refuse medical or surgical treatment on or after admission to the facility. During an interview on 6/7/2026 at 10:50 am, the DNS confirmed the resident had an active physician order for a full code. She verified that the resident had a POLST signed for a DNR on 5/12/2026. She revealed that the existing order for a full code should have been discontinued on 5/12/2026 and a new order for a DNR should have been entered under the orders tab. 2. A review of the EMR for R58 revealed he was admitted to the facility on [DATE] with a diagnosis including, but not limited to, type two diabetes mellitus without complications, acute bronchitis (inflammation of the bronchial tubes that carry air to the lungs), and dysphagia oropharyngeal phase (difficulty transferring food from the mouth to the esophagus). A review of R58's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, indicating little to no cognitive impairment. A review of the physicians' orders for R58 revealed there was no order for a code status. A review of the care plan revealed that the top banner on the document titled special instructions was documented as DNR. However, R58 care plan documented resident has physician's orders that include a status of full code with interventions to ensure full code order on chart and ensure staff is aware of code status through designated systems. A review of the EMR banner titled Special Instructions for R58 revealed code status as DNR. A review of the EMR under the contact tab revealed R58 was documented as his own responsible party. A review of the POLST for R58 revealed he is documented as attempting CPR with R58's signature dated 2/21/2025. A review of the admission Records in the advance directive section for R58 was documented as DNR. A review of the admission Agreement revealed that there is no documentation acknowledging DNR code status. A review of the DNR Book for the [NAME] Wing revealed R58 name is on the DNR list. A review of the code status list revealed R58 is documented as a full code. During an interview on 6/6/2026 at 8:12 am, R58 revealed he signed himself as a full code during his admissions process. He confirmed that the POLST form provided by the facility staff was incorrect and was not the document he signed. During an interview on 6/7/2026 at 9:45 am with the AD, the Social Worker is responsible for the code status during the resident admission process. The AD confirmed that on 2/21/2025, R58 was documented as full-code status. During an interview on 6/7/2026 at 10:25 am, the MDS Coordinator confirmed R58 EMR is documented as a DNR, and he is a full code; there is no physician's order for a code status, and there is a mix-up with documentation with the POLST because the DNR is for R58's family member who is next door at the sister facility. During an interview on 6/7/2026 at 10:51 am, the DON confirmed in R58's EMR system that he is coded as a DNR. The DON further stated on the banner in the EMR under the special instructions acts as the physician's order. Further, the DON confirmed the code status is inaccurate throughout R58's EMR. [Cross-Reference F657]

Based on record review, staff interviews, and review of the facility's policies titled Abuse Neglect and Exploitation and Proper Use of Bed Rails, the facility failed to protect one Resident (R) (R3) from neglect by not providing adequate supervision and oversight to ensure the resident was free from the risk of entrapment related to the use of side rails. Specifically, the assigned Certified Nursing Assistant (CNA) FF failed to provide required monitoring and assistance with Activities of Daily Living (ADL) care for R3 on [DATE] between 12:46 am to 4:30 am. As a result, R3 was found unresponsive with agonal breathing and entrapped in the siderails for an unknown amount of time. R3 required emergency resuscitation by Emergency Medical Services (EMS) enroute to the hospital and had to be intubated (a procedure to insert a tube into the airway to maintain breathing). R3 later expired at the hospital on [DATE]. The facility's failure to protect the resident from neglect caused or was likely to cause serious injury, harm, impairment, or death to the resident. Immediate Jeopardy was identified on [DATE] at 8:16 am and was determined to have existed on [DATE] at appropriately 5:00 am. The facility's Administrator was notified that an acceptable IJ removal plan was received on [DATE] at 9:38 am. The surveyor validated the full implementation of the facility's removal plan, and the Administrator was notified on [DATE] that the Immediacy had been removed on [DATE].Findings include:Review of the facility's policy titled Abuse Neglect and Exploitation dated [DATE] under Policy section revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Neglect is defined as failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will develop and implement written policies and procedures that: prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; Establish policies and procedures to investigate any such allegations; and include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and establish coordination with the QAPI program.Review of the facility's policy titled Proper Use of Bed Rails dated [DATE] under Policy section revealed, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Entrapment is defined as an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail. The facility will assess to determine if the bed rails meets the definition of a restraint. A bed rail is considered to be a restraint if the bed rail keeps a resident from voluntarily getting out of bed in a safe manner due to his/her physical or cognitive inability to lower the bed rail independently. If it is determined to be a restraint, the facility will follow their procedures related to physical restraints.Review of medical records revealed, R3 was admitted to the facility on [DATE] with diagnoses that included but not limited to, acute and subacute infective endocarditis, end stage renal disease, unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, bacteremia, and other cervical disc degeneration, unspecified cervical region.Review of the Medicare 5 (five)-day Minimum Data Set (MDS) for R3 dated [DATE] for Section C (Cognitive Pattern) revealed, a Brief Interview of Mental Status (BIMS) score of eight which indicated moderate cognitive impairment; Section GG (Functional Abilities and Goals) revealed, the resident was dependent on staff for all ADLs and Section P (Restraints and Alarms) revealed, bed rails were not used.Review of R3's admission assessment dated [DATE] for Risks vs. Benefits revealed, side rails was placed to assist with movement within the bed (moving up and down for positioning).Review of the facility's records revealed there was no evidence that the safe rail spacing and regular inspection of side rails/bed had been completed.Record review revealed nursing staff observed the resident at 12:46 am and provided R3 with a sponge bath. There was no other evidence that the resident was monitored and provided with ADL care assistance on [DATE] between 12:46 am to 4:30 am.Review of the Progress Notes for R3 dated [DATE] revealed, Registered Nurse (RN) EE documented, 515a CNA staff reported Res had fallen out of bed and needs assist getting him back to bed. Only the lower body was distended out of bed. Staff x3 was able to safely transfer him back in bed. No verbal interaction noted from Res. No eye contact VS/103/69 97% RA 97.7 92. Notified MD, Admin, DON and family. Called 911 to transfer to ER for eval and treat.Review of the Hospital emergency room (ER) notes dated [DATE] revealed that R3 was brought in by EMS for altered mental status and respiratory failure. Further review of the notes revealed, brought in by EMS per reports, recent extended hospitalization, unknown diagnosis, unknown medication, found at some point altered, decreased responsiveness, found to have agonal respirations with Glasgow Coma Scale (GCS) of three on EMS arrival, bagging. Patient is wearing a Do not Resuscitate (DNR) wrist band but uncertain of his code status. No further available information. No real records sent. Patient was in a dirty Cervical (C)-collar at his facility.Review of the death certificate revealed R3 expired on [DATE]. The cause of death listed was pulseless electrical activity, metabolic acidosis, end stage renal disease, and sepsis due to unspecified organism.During an interview with RN EE on [DATE] at 4:14 pm, she stated that on [DATE], around 5:00 am, CNA FF came to her and told her that she needed help with R3. RN EE stated that when she went into his room, she saw his lower part of his body hanging off the bed, but the top part of his body was still on the bed. RN EE stated that his elbow (she motioned her right elbow) was wedged into the 1/2 side rail. RN EE stated that because his elbow was wedged into the side rail, it took three staff members to position him and get him back in the bed. RN EE stated that R3 was quadriplegic, and she asked CNA FF how he got into that position. RN EE stated that CNA FF stated that she did not know because that was her first time seeing him since she came to work at 11:00 pm. RN EE further stated that R3 was not as alert as when she put him in bed. She stated that he went to bed talking and making sense. RN EE stated she performed sternum rubs on him, but he did not respond, she stated that his eyes were open, but he was not focusing. RN EE stated that she sent him to the hospital because he was not responding. R3 did not return to the facility and expired on [DATE].Interview with CNA FF on [DATE] at 3:15 pm revealed that she reported to both nurses to come help her get R3 off the floor. She stated she came in at 11:00 pm and R3 was still up and his bed was to the floor. CNA FF stated she saw R3 again between 4:30 am to 5:00 am. She stated that she placed the call light in his hands and he would usually press the call light if he wanted something but he did not press his call light all night. CNA FF stated when she went in his room between 4:40 am to 5:00 am she pulled the curtain back and saw R3 on his knees and his hand was tangled up into the bed rail. CNA FF stated that R3 could not walk but he could use his hands. CNA FF asked the surveyor if she could demonstrate how R3 was positioned. CNA FF got on her knees and stated that R3 was all the way out of the bed on his knees with his left hand tangled up in the side rail. She stated that once they got him back on the bed they told her to check his vitals. CNA FF stated that R3 was not talking but moaning.Interview with the Maintenance Director on [DATE] at 8:44 am revealed that he checked the bedrails last year, but he did not have proof. He stated that the old company took everything with them.A copy of the safe rail spacing and regular inspection of side rails/bed was requested but was not received.

Based on resident and staff interviews, record review, and review of facility documents, the facility failed to provide sufficient licensed nursing staff to meet the needs of residents (R) residing on one of two wings, the [NAME] Wing. Specifically, the facility did not have licensed nurse coverage for the [NAME] Wing after 6:00 PM during the 3:00 PM to 11:00 PM shift on December 25, 2025. This deficient practice had the potential to place residents residing on the [NAME] Wing at increased risk of unmet care needs.Findings include:Review of the facility provided document titled [facility name] Daily Staffing, dated December 25, 2025, revealed that the schedule documented no licensed nursing staff listed for the [NAME] Wing for the 3:00 PM to 11:00 PM shift.A review of the facility-provided Grievance/Complaint Report dated 12/26/2026 revealed that DON CCC filed a report stating some residents, who resided on the [NAME] Wing, reported not receiving medication doses at 9:00 PM on 12/25/2025. The report also listed that the Medical Director was notified, and no further orders or interventions were needed at this time.A review of the quarterly Minimum Data Set (MDS) assessment for R6, with an assessment reference date (ARD) of 12/25/2025, revealed that section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 14 (indicating little to no cognitive impairment).A review of the quarterly MDS assessment for R2, with an ARD of 12/26/2025, revealed that section C (Cognitive Patterns) documented a BIMS of 15 (indicating little to no cognitive impairment).A review of the quarterly MDS assessment for R1, with an ARD of 12/17/2025, revealed that section C (Cognitive Patterns) documented a BIMS of 15 (indicating little to no cognitive impairment).In an interview on 01/20/2026 at 1:49 PM, LPN NN stated that she was the Unit Manager for the East Wing. LPN NN stated that she worked on 12/25/2025 on the medication cart for the 7:00 AM to 3:00 PM shift because they had no nurse; she was the only nurse on the East Wing, and she worked until 7:00 PM on 12/25/2025. LPN NN stated that LPN AA and another nurse worked on the [NAME] Wing on the day shift on 12/25/2025. LPN NN stated that the two nurses on the [NAME] Wing left around 6:00 PM. LPN NN stated that LPN AA called her to come and get her facility keys. She stated she informed LPN AA that she was unable to take the keys, as she was working the East Wing. She stated that the two nurses on the [NAME] Wing counted the medication cart with each other, left the keys on the unit at the nurse's station, and left the facility. LPN NN stated that the residents told her the next day that a nurse came in at about 2:00 AM and they did not receive their medications or insulin.In an interview on 1/21/2026 at 9:56 AM, Certified Nursing Assistant (CNA) QQ revealed that she has been in the scheduler position since August 2025. She stated that the facilities used agencies for nursing staffing and that there had been many call-outs with both agencies and with in-house staff. She confirmed that no licensed nurses were assigned to the [NAME] Wing on 12/25/2025 for the 3:00 PM to 11:00 PM shift, and she was unable to fill the assignments with nurses. She further stated that the DON CCC was notified and did not come in to work the shift.In an interview on 01/21/2026 at 10:52 AM, Administrator JJ stated he was unaware that there was no nurse in the [NAME] Wing after 6:00 PM on 12/25/2026.In an interview on 01/21/2026 at 11:02 AM, Regional Nurse Consultant RN BBB confirmed there was no nurse on the [NAME] Wing on 12/25/2025 after 6:00 PM. In an interview on 01/21/2026 at 3:35 PM, LPN AA stated that she worked for a staffing agency, and she worked the 7:00 AM to 3:00 PM shift on 12/25/2025 on the [NAME] Wing. She stated that no one showed up to relieve her at 3:00 PM, and she called the Staffing Scheduler, DON CCC, and Administrator JJ to inform them that a nurse did not show up to relieve her at shift change. She stated that the DON stated there was nothing she could do. LPN AA stated she stayed until almost 6:00 PM, and she and Registered Nurse (RN) BB locked the medication cart keys in the medication storage room and left the facility.In an interview on 01/22/2026 at 2:28 M, LPN AAA stated that she worked the morning of 12/26/2025, but she did not remember who she relieved. She stated that sometimes the nurses arrive late, and she has to count the cart with a nurse from another hall. LPN AAA stated that she remembers residents complaining about not receiving their medication because there was no nurse available to give it. In an interview on 01/27/2026 at 11:31 AM, RN BB stated that she started her shift at 11:00 PM on 12/24/2025. She stated that her shift was supposed to end at 3:00 PM, but no one came in to relieve her. RN BB stated that she informed the DON, CCC, and Administrator JJ that she had no relief. She stated that Administrator JJ told her that he would try to find some relief. She stated that she stayed until almost 6:00 PM, counted the medication cart with LPN AA, put her keys in the locked medication room, and left the facility.In an interview on 01/20/2026 at 12:27 PM, R6 stated that on Christmas Day last year, there was no nurse after 3:00 PM to give them their medicine. He stated that there were two nurses during the day, but they left at 6:00 PM.In an interview on 01/21/2026 at 11:29 AM, R2 stated that there was no nurse on the [NAME] Wing on the evening shift on Christmas Day. She stated that there had been a couple of days when no nurse was available, usually around the holidays.In an interview on 01/21/2026 at 11:40 AM, R1 stated that he went out with his family on Christmas Day, and when he returned to the facility around 7:00 PM, there was no nurse working on the [NAME] Wing. He stated that he is a diabetic, and he did not receive any medicine until the next day.

Based on staff interviews and record review, the facility failed to provide sufficient qualified licensed nursing staff to achieve the highest practicable level of well-being for all residents. Specifically, the facility did not have a licensed nurse (Registered Nurse RN or Licensed Practical Nurse LPN) on duty for at least 30 minutes on [DATE] between 7:00 pm through 7:30 pm. The census was 83 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Regional Director of Clinical Operations, and Director of Operations were informed of the Immediate Jeopardy (IJ) on [DATE], at 3:48 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE], and included additional staffing agency support, daily staffing schedules, shift rounding, emergency staffing plan, education on emergency procedures, state minimum daily PPD requirements, and maintaining a licensed nurse every shift. The survey team validated the implementation of the removal plan, and the Immediate Jeopardy was removed on [DATE]. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of an L, no actual harm, with potential for more than minimal harm widespread. Findings include:A review of the facility document titled Punches Report dated [DATE] to [DATE] revealed that there was no RN or LPN on duty at the facility on [DATE] except for LPN LLL. In an interview with LPN LLL, she revealed that she worked remotely on the morning of [DATE] and clocked out at 5:00 pm the same day, filling out a manual clock form. She stated that she did not work on [DATE] from 7:00 pm to 7:00 am. On [DATE] at 2:06 am, LPN AA documented that Code Blue was called by the receptionist at 8:00 pm. Once on the scene, he observed R6 in the chair, unresponsive. His skin was cold, and he did not have a pulse. LPN AA documented that he then asked the receptionist to call 911 while he initiated CPR [Cardiopulmonary Resuscitation] with nursing staff (Certified Medication Assistant (CMA) and Certified Nursing Assistant (CNA)). He documented that they performed CPR until the Emergency Medical Services (EMS) arrived. R6 was still unresponsive with no pulse upon the EMS arrival. The resident was pronounced dead by EMS at 8:30 pm. Interview with Business Office Manager (BOM) PP on [DATE] at 12:27 pm revealed the BOM stated that there was hardly ever a nurse in the facility on the night shift. She stated that sometimes there were only CMAs in the building. The BOM stated that LPN QQQ left the faciity on [DATE] at 7:00 pm, knowing that there was not a nurse in the facility, and LPN QQQ left the East wing knowing that there was not a nurse or CMA to relieve her. She stated that LPN QQQ gave the keys to one of the CMAs on the [NAME] wing, left, and went home. The BOM further revealed that she called the administrator 17 times on the night that R6 expired, and the Administrator did not respond to her phone calls or texts.Interview with LPN LLL on [DATE] at 3:56 pm revealed that she worked on [DATE] during the day shift and clocked out around 5:00 pm the same day. She stated that when she comes in and helps them, she uses a missed punch form, and that Human Resources (HR) keys her time in the system. She stated that the HR person entered the information incorrectly. LPN LLL stated that she did not work the 7:00 pm to 7:00 am shift on [DATE]. Further interview with LPN LLL revealed that she was not physically in the facility on [DATE], and she worked remotely and did a missed punch form. LPN LLL stated that she normally works the [NAME] wing on Saturday and Sunday, 7:00 pm to 7:00 am. She stated that when she works, there are always two Licensed nurses on the [NAME] wing and one nurse on the East wing. Interview with LPN ZZ on [DATE] at 11:33 am revealed that she was working on [DATE]. She stated that she left at 4:45 pm, and she was relieved by CMA YY. She stated that CMA RRR was working on the top hall of the [NAME] wing.Interview with LPN AA on [DATE] at 11:22 am revealed that he was initially scheduled to work across the street at the sister facility, but ended up at the current facility due to no nurses being in the building. He stated that he took report at the sister facility and came to the current facility around 7:30 pm. LPN AA reported that upon arrival at the facility at 7:30 pm, no nurse was present in the facility. He stated that there were two Certified Medication Assistants (CMAs) on the [NAME] wing. He stated that he got the keys to the medication cart from one of the CMAs from the [NAME] wing. Interview with LPN QQQ on [DATE] at 12:15 pm revealed that on [DATE], she was working on the East wing on the 7:00 am to 7:00 pm shift. She stated that she left the facility at 7:00 pm and gave the keys to the medication cart and the keys to the narcotics to a CMA on the [NAME] wing. She stated that the Director of Nursing (DON) PPP told her she could leave if she gave the keys to someone. LPN QQQ stated that DON PPP was not in the building at the time.Interview with RN JJJ on [DATE] at 12:46 pm revealed that she was working on the medication cart during the day on [DATE] at the sister facility, and did not know that there was no nurse on the East wing at the current facility. RN JJJ stated that she instructed LPN AA to go to the East wing to see if they needed him; if not, he was to return to the sister facility. RN JJJ stated that a CNA from the current facility called her and told her that they need her. When she came to the scene, EMS and cops were there, and R6 was lying on the ground with a white sheet over him. RN JJJ stated that she attempted to call the Administrator but did not get an answer and sent a text message.

On July 15, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Regional Director of Clinical Operations, and Director of Operations were informed of the Immediate Jeopardy (IJ) on July 15, 2025, at 3:48 pm. The noncompliance related to the IJ was identified to have existed on June 13, 2025.An acceptable Immediate Jeopardy Plan of Removal was provided on July 18, 2025, and included interviews and skin assessments, education on abuse policy, threatening or violent behavior in the workplace, policy review, no weapons signage, night receptionist and weekend managers' new addition. The survey team validated the implementation of the removal plan, and the Immediate Jeopardy was removed on July 24, 2025. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of an L, no actual harm, with potential for more than minimal harm widespread.Based on observations, interviews, record reviews, and review of the facility policies titled, Abuse, Neglect, and Exploitation, Work Place Violence, and Active Shooter, the facility failed to ensure residents were free from staff to resident abuse by not preventing two Certified Nursing Assistants (CNAs), BB and CC, from bringing a firearm into the workplace on the East Wing and threatening other employees in a resident-occupied environment for Resident (R) (R1, R2, R3, R4, and R5) on 7/1/2025. This failure placed all residents at serious risk of physical injury or death, as well as significant psychosocial trauma. Findings include:Review of the facility policy titled, Abuse Prevention dated 3/25/2025 stated, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibited and prevent abuse, neglect, exploitation, and misappropriation of funds. Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, pain or mental anguish, which can include staff to resident abuse, etc. VI.Protection of resident (F) providing emotional support and counseling to residents during the investigations and as needed.Review of the facility policy titled, Workplace Violent Prevention Program dated 7/1/2025 stated, It is the policy of this facility to promote a safe, respectful, and productive environment in which to deliver quality healthcare and administrative services. Violence in the workplace will not be permitted or tolerated. The facility will develop a workplace violence prevention program to identify and prevent episodes of workplace violence. Workplace violence is defined as any threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the worksite.Review of the facility policy titled, Active Shooter/Violent Incidents dated 9/16/2024 stated Our facility is committed to maintaining a safe environment, including a safety from violence and threats of violence. Intent of Policy: to minimize the potential to residents, employees, visitors, and property resulting from individuals brandishing firearms or other weapons or claiming to possess a firearm/weapon with the expressed intention of causing harms, expressed threats, bomb threaten, threatening individuals while under a restraining order, or hostage situation. All staff will receive training upon hire and annually to increase awareness of potential threat or violent incidents including, but not limited to, acts of terrorism, active shooters, bomb threats/explosives, assaults, hostage situations.Record review of the police incident report dated 7/1/2025 at 11:05 pm documented law enforcement was dispatched to the facility regarding 2 (two) employees with firearms in the east wing, threatening another employee, CNA DD. A continued review of the document revealed that the Administrator wanted all suspects formally trespassed from the property.Record review of the document titled Criminal Trespass Warning/Ban Form dated 7/1/2025 stated Employees advised CNA CC, and another female employee got into a verbal altercation where they announced they had firearms with them. Administrator advised that she wanted both subjects banned.1. Record review of the Electronic Medical Record (EMR) for R1 revealed diagnoses, including but not limited to Alzheimer's disease, unspecified psychosis not due to substances or known physiological conditions. The Quarterly Minimum Data Set (MDS) dated [DATE], Section C (Cognitive Patterns) assessed a Brief Interview Mental Status Score (BIMS) of eight, which indicates moderate cognitive impairment. Section GG (Functional Abilities) assessed dependent for care for all Activities of Daily Living Skills, nonambulatory, and no limitations for Range of Motion (ROM) regarding upper/lower extremities.On 7/1/2025, R1 was sitting in a geriatric chair in front of the nurses' station on the East Wing during the incident and was unable to remove himself, nor did staff remove R1when the incident occurred.Record review of the document titled Social Services Quarterly Evaluation dated 7/17/2025 for R1stated he was an established client receiving psychiatric counseling services. The document further revealed that on 7/1/2025, R1 witnessed staff with a firearm.2. Record review of the EMR for R2 revealed diagnoses, including but not limited to bipolar disorder, generalized anxiety disorder, and PTSD. The Quarterly MDS dated [DATE], Section C assessed a BIMS score of 15, which indicates little to no cognitive impairments.Record review revealed that R2 ‘s room was located directly in front of the nurse station on the East Wing. During an interview on 7/10/2025 at 11:01 am, R2 reported being awakened by staff arguing. She described the argument as being very loud with the use of profanity. She reported standing in the doorway and later returning to her bed. R2 revealed that when the police arrived at the hall, she learned about the firearms. She stated that it made her feel very uncomfortable because she has a history of substance abuse, drugs, domestic violence, and dealing with people with firearms. R2 stated that the next day, the Administrator confirmed in a meeting that the CNAs had brought firearms into the facility. R2 reported being afraid for her safety and others' safety. She stated, Just witnessing the number of police officers in the hallway which was uncomfortable for her.Record review of the facility document titled, Social Services Quarterly Evaluation for R2 dated 7/17/2025 revealed that on 7/1/2025, R2 witnessed staff with a firearm.3. Record review of the EMR for R3 revealed diagnoses, including but not limited to bipolar disorder, anxiety disorder, schizophrenia, and depression. The Quarterly MDS dated [DATE] assessed Section C, a BIMS score of 15, which indicates little to no cognitive impairments.During an interview on 7/10/2025 at 1:08 pm, R3 reported witnessing staff arguments. R3 reported ambulating in the hall at the time of altercations with another resident, R4. He described the nursing assistants' arguments as being very loud, the use of profanity, and disturbing. R3 reported being afraid for others' safety after learning about firearms being in the building. He reported being in the lobby when the police officers arrived on site.Record review of the facility document titled, Social Services Quarterly Evaluation for R3 dated 7/17/2025, revealed the resident was already an established client receiving psychiatric counseling services. The document also stated that on 7/1/2025, R3 witnessed staff with a firearm. The form stated that R3 stated he did feel he was in danger and felt safe being in the facility. 4. Record review of the EMR for R4 revealed the following diagnoses, including but not limited to Alzheimer ‘s disease, generalized anxiety disorder, and major depressive disorder. The Quarterly MDS dated [DATE] assessed a BIMS score of eight, which indicates moderate cognitive impairments.During the interview on 7/10/2025 at 1:12 pm, R4 was unable to recall the specifics of the events involving a firearm. R4 could recall being informed that people had firearms in the building from other people, and that her account of the event was cloudy. R4 stated she was afraid of firearms coming in and responded with the statement uggh.Record review facility document titled, Social Services Quarterly Evaluation dated 7/17/2025 stated that on 7/1/2025, R4 witnessed staff with a firearm.5. Record review of the EMR for R5 revealed the following diagnoses, including but not limited to paranoia, schizophrenia. The Quarterly MDS dated [DATE] Section C assessed a BIMS score of 15, which indicates little to no cognitive impairments.During an interview on 7/9/2025 at 4:20 pm, R5 reported that he was sitting in the front lobby of the building when police officers arrived. He stated there were firearms in the building brought in by CNAs. R5 further revealed being worried about CNAs returning to the building and being concerned about a shootout. R5 revealed he would not be able to run because he was in a motorized wheelchair and one hand was contracted.Record review of the facility document for R5 titled, Social Services Quarterly Evaluation dated 7/17/2025 stated that on 7/1/2025, R5 witnessed staff with a firearm. Interview on 7/8/2025 at 1:16 pm with CNA DD confirmed getting into a verbal altercation with CNA BB in the East Wing Hall of the facility. She reported that several residents were present at the time of the arguments. She revealed that R1 was sitting in a geriatric chair in front of the desk. R3 and R4 were observed walking in the hall. She reported that she removed herself from the nurse station prior to CNA BB and CNA CC displaying their firearm to CNA EE. CNA DD reported that she was not aware of contacting 911 immediately. She confirmed she did not receive any active shooter or workplace violence training until after the incident occurred.Interview on 7/8/2025 at 2:31 pm with CNA EE confirmed being in the East Wing hall during the time of the altercation between CNA DD and CNA BB. She reported that R1 was sitting in a geriatric chair in front of the nurse station, and R2 (room [ROOM NUMBER]) was standing in the doorway of her room, which is directly across from the nurse station. She reported that CNA BB was using profanity and speaking in a loud, angry voice tone. She reported witnessing CNA BB leaving the hall and later returning to the nurse station with a purse. She reported that CNA BB removed a firearm from her purse and waved the firearm in the air at the nurse station. She stated that R1 was still in front of the nurse station in a geriatric chair and witnessed the firearm. She stated that CNA BB placed the firearm back into her purse and began pacing the hall using profanity and continuing to speak in a loud, angry voice tone with the purse in her hand. CNA EE reported that several residents' room doors were open in the hall. CNA EE reported observing CNA CC sitting at the nurse station and opening her bookbag, revealing a firearm. She further revealed that she contacted the Administrator to inform her of the incident and did not contact 911. CNA EE stated that the Administrator contacted 911. CNA EE reported that she was not aware she needed to contact 911 immediately. CNA EE confirmed that she did not receive any active shooter or workplace violence training until after the incident occurred on 7/1/2025.Interview with the Administrator on 7/8/2025 at 3:31 pm revealed that the two CNAs(CNA BB and CNA CC) involved in the incident were agency staff and that 7/1/2025 was their first shift. The Administrator stated she was not familiar with the CNAs (CNA BB and CNA CC) work ethics or background checks, and the hiring agency is responsible for the completion of references or background checks. The Administrator reported being informed of firearms present in the facility by CNA EE, and that her actions to contact 911 and file a no trespass ban were solely based on CNA EE‘s statement. She reported being unaware of any residents being present to witness a firearm or being in the lobby or smoke porch until made aware by the survey team. She reported that she did not follow up with the staff to inquire if any residents were up during the incident. The Administrator revealed that the day after the incident, she placed a sign up No Firearms Prohibited in the front entrance of the facility to ensure all staff and visitors are aware not to bring firearms in the building. The Administrator further stated that she serves as the Human Resources (HR) personnel and is solely responsible for the training and hiring of new staff in her building. She reported that all newly hired facility staff are oriented to the facility handbook during their orientation, and the handbook discusses prohibiting firearms. The Administrator further revealed that agency staff do not receive training or a copy of the facility handbook.Interview with the Director of Nursing (DON) on 7/9/2025 at 3:00 pm revealed that she was made aware of an active shooter incident at 4:00 am on 7/2/2025 by another staff member. She reported having staff only complete assessments for cognitive residents, not all residents in East Hall. The DON stated that she did not interview or follow up with any of the CNAs to determine if any residents witnessed the events or were awake in the East Hall, as this information was not made known to her. She reported that she received information from the Administrator that no residents were up or awake. She was only informed of rumors of staff threatening to have a firearm. The DON stated that if she had been made aware of or heard anything indicating a loud argument, residents witnessing a firearm, or a resident feeling uncomfortable or felt threatened, her interventions and response as the DON would have been different. She reported that interventions would have included ensuring that residents received follow-up psychiatric services immediately. She would have focused more on the residents who witnessed the firearm, R1, to ensure no negative or adverse effects. The DON reported that her expectations for the staff to ensure resident safety in the case of a workplace violence/ active shooter incident are for staff to remove the resident and close the room door immediately in the hall, and call 911, then call the Administrator and herself. If a staff member feels threatened, they should call the charge nurse. Staff should not have waited to call 911. Interview on 7/9/2025 at 4:37 pm with Receptionist HH reported observing CNA BB exiting the lobby and building, walking towards her car in the parking lot at least twice or more during the shift. She observed CNA BB exiting the lobby and later returning to the facility with food (pizza). Additionally, she observed CNA BB going to the parking lot again, almost close to 11:00 pm. She recalled seeing the CNA BB with a purse in her hand. She reported that R5 and some other unidentified residents were present in the lobby area and the smoke area (located off the lobby) throughout the incident, including the time of the active shooter incident. She also stated that the residents were present in the lobby when the officers entered the building. Receptionist HH reported that she was not aware of contacting 911 immediately. She confirmed she did not receive any Active Shooter or Workplace Violence Training until after the incident occurred.Interview on 7/9/2025 at 11:57 am, Licensed Practical Nurse (LPN) AA reported being unaware of CNA BB and CNA CC's behavior of threatening staff until after the incident had occurred. He recalled earlier during the shift, prior to taking his break, witnessing CNA BB and CNA CC speaking about their disagreement with their resident assignment, and making complaints of not having enough staff to work the floor. He confirmed that several residents were in the smoke area during the time the incident occurred. LPN AA confirmed that when CNA EE approached him to inform him of both CNA BB and CNA CC having firearms. He stated that CNA EE appeared upset and spoke to him in French so as not to alarm the residents. He reported that CNA EE stated she would call the Administrator. He reported that he approached CNA BB and CNA CC and asked them to leave the facility. He observed both CNAs (CNA BB and CNA CC) leaving the building, going to their cars. CNA CC had a bookbag, and CNA BB had a purse. LPN AA confirmed that he did not receive Active Shooter or Workplace Violence Training until after the incident occurred.Interview with CNA BB on 7/10/2025 at 11:15 am, CNA BB reported exiting the building and going to the parking lot on several occasions during her shift. She confirmed having a firearm in her possession in her vehicle on the premises. She confirmed having a verbal altercation with CNA DD about assignments. She confirmed making a statement. CNA BB confirmed not receiving any training from the facility on workplace violence and active shooters. Interview on 7/10/2025 at 12:13 pm CNA CC reported having a bookbag at the nurse station. She confirmed having a firearm in her possession in her vehicle but denied bringing a firearm into the facility. CNA CC confirmed not receiving any training from the facility on workplace violence and active shooters. CNA confirmed that R1 was sitting at the nurse station during the verbal altercation between CNA BB and CNA DD. She confirmed witnessing R3 and R4 walking the hall at the time of the verbal altercation.Interview on 7/9/2025 at 3:44 pm with the Social Service Director (SSD) reported being instructed in the morning meeting on 7/2/2025 by the Administrator that, due to two certified nursing assistants bringing firearms into the building to follow up with interviewing cognitive residents in the East Hall for any concerns or trauma. The Administrator wanted her to just ask basic general questions and nothing pertaining to the incident. The interview consisted of just general questions: Do you feel safe? She reported that she had not had a conversation about what happened that night. She avoided asking the East Hall residents if they had heard disturbances from the night before. She reported that none of the residents voiced any concerns about the active shooter incident or firearms. She was not made aware of residents being present in the lobby or on the smoke area patio (off the lobby) during the active shooter incident. She reported that if she was made aware of other residents, her interview would have included those residents. She confirmed that no referrals for follow-up psychiatric services were made for the residents.An undetermined number of residents were present in the lobby and the smoke area when CNA BB entered the facility (passing both areas) with a concealed firearm on 7/1/2025, confirmed by Receptionist HH.A psychiatric referral was processed on 7/17/2025 for R1, R2, R3, R4, and R5.

On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Regional Director of Clinical Operations, and Director of Operations were informed of the Immediate Jeopardy (IJ) on [DATE], at 3:48 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE], and included review of policies and procedures for emergency staffing, review of job descriptions, education on additional staffing agency support, daily staffing schedules, shift rounding, emergency staffing plan, education on how to respond to active shooter events and emergency preparedness, and an ad hoc QAPI meeting. The survey team validated the implementation of the removal plan, and the Immediate Jeopardy was removed on [DATE]. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of an L, no actual harm, with potential for more than minimal harm widespread. Based on staff interviews, record review, and a review of the facility's policy titled Quality Assurance-Performance Improvement Management (QAPI) Change Process- Work Instruction, the facility failed to identify concerns and effectively implement Quality Assurance Process Improvement (QAPI) plans related ensure all staff received active shooter/workplace violence training to ensure residents (including R1, R2, R3, R4, and R5) were free from abuse from an active shooter/workplace violence incident. In addition, the facility to ensure availability of sufficient licensed nurse staffing was present and available in the building to respond to medical emergencies for a code blue for R6, who was later pronounced deceased by Emergency Medical Services (EMS). The census was 83.Findings Include: The QAPI policy titled Quality Assurance Performance Improvement Management dated [DATE] stated It is the policy of this facility to develop, implement, and maintain an effective comprehensive data driven program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. Adverse Event is an untoward, undesirable and unsafe unanticipated event that causes death or serious injury, or the risk thereof. 2. Governing and Leadership: (iv) Ensure the program is adequately resourced, including ensuring staff time, equipment, and technique training as needed (vii) Setting clear expectations around safety, quality rights, choices, and respect.1. Record review of the police report and the no trespass ban form, both documents dated [DATE], revealed that two Certified Nursing Assistants (CNAs), CNA BB and CNA CC brought firearms into the building threatening coworkers in the proximity of residents (R5 and an undetermined number of residents were present in the lobby and the smoke area). CNA BB removed the weapon from her purse, waved the weapon in the air, and proceeded to walk down the hallway, making threatening comments with the firearm concealed in her purse. CNA CC was sitting at the East wing nurse station, opening her bookbag, which revealed her firearm, with a resident (R1) at the nurses' station and residents (R2 and R3) present on the East wing.2. Record review revealed on [DATE] between the hours of 7:00 pm through 7:30 pm, R6 was observed by staff to be nonresponsive, sitting on the facility patio. Continued record review revealed that there were no licensed nurses (Licensed Practical Nurse (LPN) or Registered Nurse (RN)) available in the building (7:00 pm through 7:30 pm) to respond to medical emergencies. A blue code was not called until 8:00 pm, and the resident was pronounced deceased by Emergency Medical Services (EMS) at 8:30 pm outside on the patio at the facility.The Administrator was unable to provide evidence that the facility had or was currently addressing workplace violence and active shooter incidents, nor was there a systematic review of the issue to develop an action plan meeting the residents' needs, prior to the incident on [DATE]. Record review revealed that the facility did not post a No Weapons or Firearms poster on the exterior entrance doors until [DATE].R1, R2, R3, R4, and R5 did not receive psychological evaluations until [DATE].Interview on [DATE] at 12:03 pm with the Administrator revealed that the QAPI committee tracks and trends based on identified problems. When asked if the Quality Assurance (QA) program had identified a concern or developed an action plan regarding the firearm incident or staff training, she reported no. She stated that she was unsure of why the facility did not provide training to all employees, including contract workers, regarding workplace violence. She confirmed that training on workplace violence and the prohibition on firearms will be provided this week for all employees. The Administrator revealed that the staffing of licensed nurses was not a part of her QA meetings, because staffing of licensed nurses was not a concern. The QA team never placed emphasis on licensed nurses' coverage, only on CNA coverage.Interview on [DATE] at 1:26 pm with the Regional Director of Operations (RDOP) revealed that the facility has recommendations for agency staff training requirements prior to hire. However, they are required and are unsure why training is not followed up to ensure these requirements are met. The RDOP stated they recommend that the facility put agency staff through the facility orientation; however, that is just a recommendation.Cross-reference F600, F725, and F835

Based on staff interviews, record review, and a review of the Administrator and Director of Nursing (DON) Job Description, the Administration failed to provide oversight related to workplace violence, failed to provide sufficient qualified licensed nursing staff to achieve the highest practicable level of well-being for all residents, and failed to protect residents from alleged emotional and potential physical abuse during an active shooter incident. The census was 83.On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Regional Nurse Consultant, and Operations Consultant were informed of the Immediate Jeopardy (IJ) on [DATE], at 3:48 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE] and included education on emergency plan, workplace violence and an active shooter situation, policy review, job description review, additional education related to managing daily operations, coordinate and oversee department heads, providing education and compliance training, ensure licensure staff have appropriate education, competency checks are maintained. The survey team validated the implementation of the removal plan, and the Immediate Jeopardy was removed on [DATE]. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of an L, no actual harm, with potential for more than minimal harm widespread. Findings include:The facility had a Job Description for the job title of Administrator. The description documented the purpose of this position is leads, guides, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards, and established facility policies and procedures to provide appropriate care and services to residents. Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. Establishes an ongoing system to monitor these key indicators such as the Quality Assurance and Performance Improvement process throughout the facility. Promotes and encourages an environment of trust among all employees related to the overarching goal of resident safety and abuse prevention. The facility had a Job Description for the job title of Director of Nursing. The description included that the Director of Nursing position purpose is to planning, organizing, developing, and directing the overall operation of the Nursing Service Department in accordance with local, state, and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents. Interprets and communicates policies and procedures to nursing staff, and monitors staff practices and implementation. Oversees nursing schedules to ensure resident needs, regulatory and budget standards are met. Ensures delivery of compassionate quality care and nursing supervision as evidenced by adequate staff coverage on the units, general cleanliness, and maintaining optimal resident functions. Monitors for allegations of potential abuse or neglect, or misappropriation of resident property and participates in the investigative process. Facility Administration, specifically the Administrator and DON, failed to protect residents and effectively oversee areas of the facility that were included in their job descriptions. 1. The facility's Administration failed to implement and enforce policies and procedures that ensure the safety and security of residents when two staff members, Certified Nursing Assistant (CNA) BB and CNA CC, accessed the facility on [DATE] with concealed firearms and engaged in threatening behavior in the presence of residents. Additionally, the facility failed to ensure that a licensed nurse (Registered Nurse (RN) or Licensed Practical Nurse (LPN)) was present in the building on [DATE] from 7:00 pm to 7:30 pm and available to respond to medical emergencies. Cross-reference to F600, F725.2. The Administration failed to protect residents from alleged emotional and potential physical abuse during an active shooter incident. Cross-reference to F600.3. The Administration failed to provide sufficient qualified licensed nursing staff to achieve the highest practicable level of well-being for all residents. The facility did not have a licensed nurse on duty for at least 30 minutes on [DATE] between 7:00 pm to 7:30 pm. Cross-reference to F725. 4. The Administration failed to utilize Quality Assurance Performance Improvement (QAPI) for adverse events related to workplace violence and staffing. Cross- reference to F600, F725, F867 On [DATE] at 2:06 am, LPN AA documented that Code Blue was called by the receptionist at 8:00 pm. Once on the scene, he observed R6 in the chair, unresponsive. His skin was cold, and he did not have a pulse. LPN AA documented that he then asked the receptionist to call 911 while he initiated CPR [Cardiopulmonary Resuscitation] with nursing staff (Certified Medication Assistant (CMA) and CNA). He documented that they performed CPR until the Emergency Medical Services (EMS) arrived. R6 was still unresponsive with no pulse upon the EMS arrival. The resident was pronounced dead by EMS at 8:30 pm. Interview with LPN AA on [DATE] at 11:22 am revealed that he was initially scheduled to work across the street at the sister facility, but ended up at the current facility due to no nurses being in the building. He stated that he took report at the sister facility and came to the current facility around 7:30 pm. LPN AA reported that upon arrival at the facility at 7:30 pm, no nurse was present in the facility. He stated that there were two CMAs on the [NAME] wing. He stated that he got the keys to the medication cart from one of the CMAs from the [NAME] wing. Interview on [DATE] at 2:31 pm with CNA EE confirmed being in the East wing hall during the time of the altercation between CNA DD and CNA BB. She reported that R1 was sitting in a geriatric chair in front of the nurse station, and R2 (room [ROOM NUMBER]) was standing in the doorway of her room, which is directly across from the nurse station. She reported that CNA BB was using profanity and speaking in a loud, angry voice. She reported witnessing CNA BB leaving the hall and later returning to the nurse station with a purse. She reported that CNA BB removed a firearm from her purse and waved the firearm in the air at the nurse station. She stated that R1 was still in front of the nurse station in a geriatric chair and witnessed the firearm. She stated that CNA BB placed the firearm back into her purse and began pacing the hall using profanity and continuing to speak in a loud, angry voice tone with the purse in her hand. CNA EE reported that several residents' room doors were open in the hall. CNA EE reported observing CNA CC sitting at the nurse station and opening her bookbag, revealing a firearm. She further revealed that she contacted the Administrator to inform her of the incident and did not contact 911. CNA EE stated that the Administrator contacted 911. CNA EE reported that she was not aware she needed to contact 911 immediately. Interview on [DATE] at 3:31 pm with the Administrator revealed that the two Certified Nursing Assistants (CNAs) had never worked in her building until [DATE]. The Administrator confirmed that both CNAs were contract agency staff. She was not familiar with the two agency CNAs (CNA BB and CNA CC), work ethics, or background checks. The Administrator revealed that she serves as the Human Resources (HR) personnel and is solely responsible for the training and hiring of new staff in her building. The Administrator stated that contract and/or agency staff do not receive training/orientation on the facility handbook, nor are they provided a copy of the facility handbook (the handbook contains information for prohibiting firearms in the facility). The Administrator revealed that the day after the incident, she placed a sign up No Firearms Prohibited in the front entrance of the facility to ensure all staff and visitors are aware not to bring firearms in the building.Interview with the Director of Nursing (DON) on [DATE] at 3:00 pm revealed that she was made aware of an active shooter incident at 4:00 am on [DATE] by another staff member. She reported that staff only completed assessments for cognitive residents, not all residents in East Hall. The DON stated that she did not interview or follow up with any of the CNAs to determine if any residents witnessed the events or were awake in the East hall, as this information was not made known to her. She reported that she received information from the Administrator that no residents were up or awake. She was only informed of rumors of staff threatening to use a firearm. The DON stated that if she had been made aware of or heard anything indicating a loud argument, residents witnessing a firearm, or a resident feeling uncomfortable or threatened, her interventions and response as the DON would have been different.Interview on [DATE] at 12:03 pm with the Administrator revealed that the committee tracks and trends concerns based on identified problems. When asked if the Quality Assurance (QA) program had identified a concern or developed an action plan regarding the firearm incident or staff training, she reported no. She stated that she was unsure of why the facility did not provide training to all employees, including contract workers, regarding workplace violence. She confirmed that training on workplace violence and the prohibition on firearms will be provided this week for all employees. The Administrator revealed that the staffing of licensed nurses was not a part of her Quality Assurance (QA) meetings, because staffing was not a concern. The QA team never placed emphasis on licensed nurses' coverage, only on CNA coverage. An undetermined number of residents were present in the lobby and the smoke area when CNA BB entered the facility (passing both areas) with a concealed firearm on [DATE], confirmed by Receptionist HH.A psychiatric referral was processed on [DATE] for R1, R2, R3, R4, and R5.

Based on staff interviews, record review, and review of facility documents, the facility failed to ensure that Certified Medication Aides (CMAs) completed a skills competency check-off before being allowed to administer medications. In addition, the facility failed to ensure CMAs did not administer narcotic medications to one of 18 sampled residents (R) (R12). This deficient practice had the potential to place the 83 residents residing in the facility at risk of receiving medication from incompetent staff. Findings include: Review of the facility-provided undated document titled Medication Technician/Aide revealed the Position Purpose section stated, Assists licensed nursing staff by administering daily medications as ordered by the physician in accordance with established nursing standards, facility policies, and procedures and state requirements.1. The facility was unable to provide current annual competencies that were signed and dated for six of the seven Certified Medication Aides (CMAs) (CMA JJ, CMA GGG, CMA KKK, CMA RRR, CMA UUU, CMA YY) actively working at the facility. 2. Review of the facility-provided document titled Medication Administration Clinical Skills Checklist, dated 2/14/2025, for CMA EE revealed the section titled 12. Administered medications using appropriate technique for dosage form/route & administered accurate amount: C. Liquid Morphine (a narcotic medication used to treat pain) stated Not certified to give. The document was initiated by a Registered Nurse and signed by CMA EE. Review of the Medication Administration Record (MAR) for R12, dated 6/1/2025 through 6/30/2025, revealed that the schedule 5-325 milligram (MG) hydrocodone-acetaminophen (a narcotic medication used to treat pain) was initialed as given by CMA YY on 6/4/2025 at 9:00 am and 3:03 pm. Review of the Staff Administration Legend: June 2025, located on the MAR, revealed the medication was administered by CMA YY. In an interview on 6/24/2025 at 9:05 am, CMA GGG stated that she works on the floor as a Certified Nursing Assistant (CNA) most of the time, and she fills in on the medication cart on the 7:00 pm to 7:00 am shift. She stated that she had signed off on the narcotics sheets and administered narcotics to residents. CMA GGG further stated that she had a skills check-off at the facility's sister facility, but she could not remember who completed the check-off or when it was completed. In an interview on 7/9/2025 at 1:48 pm, the Regional Consultant Nurse (RNC) OOO stated that CMAs completed a quarterly check-off with a Registered Nurse (RN) or a Pharmacist. She further stated that the CMAs were not checked off on or allowed to administer narcotics, and she was unaware that the CMAs were administering narcotics to residents. In an interview on 6/24/2025 at 2:19 pm, the Interim Director of Nursing (DON) PPP stated that she was not aware that the CMAs were giving narcotics or controlled substances. She stated that they have started education on what they can and cannot do. She stated that going forward, the CMAs will not have access to the narcotic keys. In an interview on 6/25/2025 at 12:32 pm, Registered Nurse (RN) FFF stated that she had worked alongside a CMA; she had one cart, and the CMA had the other cart. RN FFF stated that she pulls the narcotics from the box and gives them to the CMA to administer them. She stated that she trusts CMA YY because she is really thorough.In an interview on 6/25/2025 at 2:20 pm, the Operations Consultant (OC) NNN revealed he was not aware that CMAs were administering narcotics. In an interview on 6/26/2025 at 3:38 pm, the Medical Director (MD) stated that he was not aware that CMAs were administering narcotics. He stated he was sure that the CMAs were not allowed to administer narcotics. In an interview on 6/26/2025 at 4:10 pm, Nurse Practitioner (NP) VVV stated that she was not aware that the CMAs were administering narcotics or controlled substances. She stated that CMAs should not be administering narcotics or controlled substances. In an interview on 7/8/2025 at 12:40 pm, CMA EE stated that she had relieved a CMA and counted the narcotics with a CMA. In an interview on 7/7/2025 at 4:42 pm, the Interim DON TTT stated that CMAs should not be administering narcotics. She stated that she was not aware that the CMAs were administering narcotics.

Based on observations, staff interviews, record reviews, and review of the facility policy titled Laundry, the facility failed to maintain the laundry area in a sanitary manner to ensure residents' clothes were free from contamination. This deficient practice had the potential to place all residents residing in the facility at increased risk for infection related to cross-contamination. Findings include:Review of the facility policy titled Laundry, revised 6/11/2025, revealed the Policy section stated, The facility launders linens and clothing in accordance with current CDC [Center for Disease Control and Prevention] guidelines to prevent transmission of pathogens. The Policy Explanation and Compliance Guidelines section included, .2. The facility's laundry area will provide hand washing facilities and products as well as PPE [personal protective equipment]. 4. Soiled laundry shall be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons. a. Linens shall be bagged separately from resident's clothing at the point of use. b. Sorting of laundry shall occur after washing. 6. If using fans in laundry processing area, prevent cross-contamination of clean linens from air blowing from soiled processing areas, (i.e., the ventilation should not flow from soiled processing area to clean laundry areas). Observation of the facility's laundry room on 7/22/2024 at 12:33 pm revealed a thick dark greyish substance coating the ceiling and pipes in the laundry room. Further observations revealed: Two racks of clean clothes hanging on hangars, uncovered, coated with dark grey substance. Uncovered blankets on shelves, coated with a dark grey and dark speckled substances. Two piles of uncovered clean clothes stacked on a container, coated with dark grey and dark speckled substances. Uncovered sheets and pillowcases on shelves, and coated with dark grey and dark speckled substances. Two bins of uncovered clean clothes, coated with dark grey and dark speckled substances. One large floor-standing industrial fan frame and blades covered with thick dark grey substances, blowing directly on clean clothes. A window covered with thick grey substance and broken glass, exposing dust and dark black substances. Observation of the PPE revealed one apron, which was coated with dust and debris, and no other PPE. Observation revealed no separate designated hazardous container in the laundry room. The can, which the staff reported as a biohazardous container, was being used as a trash can with trash and debris. In an interview on 7/22/2025 at 12:18 pm, the Housekeeping Manager described the thick grey substances as dust and dark speckled substances as dirt or debris. He stated that all resident clothes and linens should be covered after washing to prevent cross-contamination, and the laundry room should have aprons and goggles for the laundry staff to use. He further stated that the laundry area should have a separate, designated biohazard container. During an observation of the laundry room on 7/22/2025 at 1:36 pm, the Administrator and Operation Consultant NNN confirmed that a heavy layer of greyish color substance and debris was coating the ceiling and the ceiling pipes. Both staff members described the substances as dust, dirt, and debris. The Administrator reported that the dust particles built up on the ceiling, dust on the ceiling pipes, and sanitation of the laundry room were identified earlier this year. The problem was addressed a while back to have a staff to blow the dust off the ceiling and ceiling pipes monthly. She was not aware that the pipes and the ceiling were not being maintained by the staff who was assigned to the task. The Administrator confirmed the uncovered, clean clothing, blankets, and linen, the missing biohazard container, the fan covered with thick, dark grey substances, and broken window glass. Laundry room cleaning logs were requested and not provided. In an interview on 7/22/2024 at 1:40 pm, Laundry Aide (LA) NN reported she had worked in the laundry department for at least one year and had never witnessed staff cleaning the ceiling or pipes. She reported being unaware that residents' clothes and linen should be covered. LA NN reported that no one used the PPE apron and stated there was only one apron and no other PPE in the laundry room. She reported that biohazardous materials were usually placed in the washer first or just kept in a bin with all other laundry items.In an interview on 7/30/2025 at 2:22 pm, the Director of Nursing (DON)/Infection Preventionist (IP) stated her expectation was for all residents' laundry and linen to be maintained in a sanitary manner to prevent cross-contamination. She reported she was unaware of the condition of the laundry room.