Every finding on record at Sagebrook Nursing and Rehabilitation

Based on interviews, and record review, the facility failed to ensure that residents who require dialysis receive such service, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 8 (Resident #2) residents reviewed for dialysis care. The facility failed to document Resident #2's post dialysis assessment in the medical record for 04/27/26, 06/23/26, 06/27/26, 07/02/26, 07/07/26, and 07/08/26. This failure could place residents at risk for untreated medical issues and diminished quality of care. Findings included: Record review of Resident #2's face sheet dated 07/15/26 reflected a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included Klebsiella Pneumonia (type of bacteria causing pneumonia or inflammation of air sacs in the lungs) as the cause of diseases classified elsewhere, chronic kidney disease stage 5, renal osteodystrophy (bone disease that occurs in people with chronic kidney disease), acquired absence of kidney, and dependence on renal dialysis. Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 15 indicating cognition intact. Section H for bladder and bowel reflected Resident #2 had an ostomy (including urostomy, ileostomy, and colostomy). Section O for special treatments reflected resident was on dialysis treatments. Record review of Resident #2's care plan last revised 04/27/26 reflected a focus on the resident has an ostomy ileostomy with interventions change ostomy appliance as needed and report illness, inflammation or draining at ostomy site. There was no care plan focus on Resident #2's dialysis treatment, goals, or interventions. There was no interventions included for the assessments of the ostomy appliance prior to dialysis treatments to prevent the rejection of the dialysis center. There was no care plan focus for special dietary needs as it pertained to Resident #2's renal diet order. Record review of Resident #2's orders reflected an order with a start date of 06/18/26 renal diet regular texture, regular consistency, LCS Record review of Resident #2's orders reflected an order with a start date of 06/18/26 dialysis days T-TH-Sat Record review of Resident #2's orders reflected an order with a start date of 06/18/26 dialysis days -tue-thurs-sat @ 1220 to 0620 [dialysis address 1] Record review of Resident #2's orders reflected an order with a start date of 06/18/26 dialysis [dialysis address 2] M-W-F 0630 chair time Record review of Resident #2's orders reflected an order with a start date of 06/18/26 dialysis- monitor av shunt/fistula to (LUE) for thrill & bruit Q shift notify MD/NP for any unusual/ unexpected findings Record review of Resident #2's orders reflected an order with a start date of 06/18/26 dialysis- no blood pressure or venipuncture on extremity with dialysis access site extremity: LUE Record review of Resident #2's orders reflected an order with a start date of 06/18/26 ileostomy care Q shift and PRN Record review of Resident #2's orders reflected an order with a start date of 06/18/26 ileostomy wafer and bag-change q3 days and PRN Record review of Resident #2's progress note reflected a nursing note dated 07/08/26 pt had accident with colostomy in dialysis yesterday and was not able to complete her dialysis tx. Dialysis rescheduled for today. Pt picked up by [family] for tx at dialysis today. Record review of Resident #2's facility dialysis communication form dated 04/27/26 which contained information on assessment before the resident went to dialysis completed by facility staff, assessment and vitals at dialysis completed by dialysis staff, and assessment after returning to the facility to be completed by facility staff. The assessment and vitals section to be completed by nursing home staff upon resident return and placed in the clinical record was left blank. This included vitals, changes in temperature, edema checks (fluid retention), access type and assessment, shunt/thrill and bruit presence, perma cath check, and a section to document other problems or concerns noted on assessment. Record review of Resident #2's facility dialysis communication form dated 06/23/26 which contained information on assessment before the resident went to dialysis completed by facility staff, assessment and vitals at dialysis completed by dialysis staff, and assessment after returning to the facility to be completed by facility staff. The assessment and vitals section to be completed by nursing home staff upon resident return and placed in the clinical record was left blank. This included vitals, changes in temperature, edema checks (fluid retention), access type and assessment, shunt/thrill and bruit presence, perma cath check, and a section to document other problems or concerns noted on assessment. Record review of Resident #2's facility dialysis communication form dated 06/27/26 which contained information on assessment before the resident went to dialysis completed by facility staff, assessment and vitals at dialysis completed by dialysis staff, and assessment after returning to the facility to be completed by facility staff. The assessment and vitals section to be completed by nursing home staff upon resident return and placed in the clinical record was left blank. This included vitals, changes in temperature, edema checks (fluid retention), access type and assessment, shunt/thrill and bruit presence, perma cath check, and a section to document other problems or concerns noted on assessment. Record review of Resident #2's facility dialysis communication form dated 07/02/26 which contained information on assessment before the resident went to dialysis completed by facility staff, assessment and vitals at dialysis completed by dialysis staff, and assessment after returning to the facility to be completed by facility staff. The assessment and vitals section to be completed by nursing home staff upon resident return and placed in the clinical record was left blank. This included vitals, changes in temperature, edema checks (fluid retention), access type and assessment, shunt/thrill and bruit presence, perma cath check, and a section to document other problems or concerns noted on assessment. Record review of Resident #2's facility dialysis communication form dated 07/07/26 which contained information on assessment before the resident went to dialysis completed by facility staff, assessment and vitals at dialysis completed by dialysis staff, and assessment after returning to the facility to be completed by facility staff. The assessment and vitals section to be completed by nursing home staff upon resident return and placed in the clinical record was left blank. This included vitals, changes in temperature, edema checks (fluid retention), access type and assessment, shunt/thrill and bruit presence, perma cath check, and a section to document other problems or concerns noted on assessment. Record review of Resident #2's facility dialysis communication form dated 07/08/26 which contained information on assessment before the resident went to dialysis completed by facility staff, assessment and vitals at dialysis completed by dialysis staff, and assessment after returning to the facility to be completed by facility staff. The assessment and vitals section to be completed by nursing home staff upon resident return and placed in the clinical record was left blank. This included vitals, changes in temperature, edema checks (fluid retention), access type and assessment, shunt/thrill and bruit presence, perma cath check, and a section to document other problems or concerns noted on assessment. During an interview on 07/16/26 at 12:13 PM with LVN A, she stated that for resident on dialysis there was a binder which contains communication forms and they were used to assess the site for dialysis and make sure everything was in place before the residents are sent off to treatment. LVN A stated the form also has sections for vitals because they had to check vitals before the resident leaves for dialysis and then once again when they return and document everything. LVN A stated if assessments were not being completed the resident could have a hypertension crisis which is why it was important to ensure everything was stable upon their return from treatment. She stated fluid overload could also be a negative outcome which can be a medical emergency. LVN A stated she did not believe she was completing the last section of the dialysis communication forms which included the assessment for Resident #2's return to the facility vitals. LVN A stated if she took vitals it was only documented in the POC system but may not have made it to the dialysis communication forms. She stated Resident #2 has not had any negative outcomes from any missed vitals. During an interview on 07/16/26 at 01:48 PM with the DON, she stated that it was her expectation that in addition to documenting a residents vitals in the POC system, that nursing staff were responsible for completing the dialysis communication forms which included the final return assessment with vitals and to ensure that was uploaded back into the system. The DON stated that if vitals were missed or not done timely something could be missed after the resident returns from dialysis treatment and could have low blood pressure, bleeding, a temperature, could have fluid retention, or a delayed reaction that could be missed. During an interview on 07/16/26 at 02:42 PM with the ADM, he stated it was the expectation that assessments were completed and documented appropriately. He stated that if they don't have vitals done, or documentation nobody would know if the appropriate steps were taken to resolve a residents condition or concerns. Record review of the policy for charting and documentation last revised July 2017 reflected: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation of procedures and treatments will include care-specific details, including:a. The date and time the procedure/treatment was provided;b. The name and title of the individual(s) who provided the care;c. The assessment data and/or any unusual findings obtained during the procedure/treatment;d. How the resident tolerated the procedure/treatment;e. Whether the resident refused the procedure/treatment;f. Notification of family, physician or other staff, if indicated; andg. The signature and title of the individual documenting. The policy for Quality of Care was requested from the ADM 07/16/26 at 09:07 AM, per the ADM the facility did not have a Quality of Care policy.

Based on observations, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 25.93 % based on 7 errors out of 27 opportunities, which involved three residents (Resident #76, Resident#101 and Resident#39) of five reviewed for medication administration.The facility failed to ensure that the analgesic (Medications for relieving pain), anticonvulsant ( a drug primarily used to prevent or treat seizures and convulsions) and anti-parkinsonism medications of Resident #101, Resident #39 and Resident#76 were administered within the liberalized scheduled time (6:00am to 10:00am), before 8:00am for medications that were scheduled at 7:00am and before 9:00am that was scheduled at 8:00am, on 07/14/26 as well as the period between 07/01/26 and 07/16/26, as per facility policy and as scheduled by the physician.These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications risking seizure activities, managing pain and aggravated symptoms of Parkinson's disease. The findings included:Resident #76:Record review of Resident #76's face sheet dated 07/16/26 reflected Resident #76 was admitted on [DATE]. She was a [AGE] year-old female diagnosed with epilepsy(seizure) , polyneuropathy(a type of nerve damage affects multiple peripheral nerves) , chronic pain syndrome, contracture(permanent tightening of muscles, tendons, skin, or other tissues) and tremor (shaking of body). Record review of Resident #76's admission MDS dated [DATE] reflected a BIMS score of 15 indicating her cognition was intact. Further review revealed she was taking anticonvulsant and opioid( a class of medications for reducing the intensity of pain) for chronic pain syndrome, polyneuropathy and seizure disorder.Record review of Resident #76's care plan dated 06/13/26 reflected Resident #76 used opioids and anticonvulsants medications r/t Pain Management and Seizures treatment. The relevant intervention was administering the medications as ordered by physician and monitoring for side effects and effectiveness.Record review of Resident #76's physician's order reflected the following: Clonazepam Oral Tablet 0.5 MG (Clonazepam): Give 1 tablet by mouth two times a day related to anxiety disorder, unspecified- -Start Date- 06/29/2026.It was scheduled to be administrated between 6am to 10am and 6pm to 10pm. Gabapentin Capsule 400 MG: Give 1 capsule by mouth two times a day for Nerve Pain.-Start Date-06/26/2026 .It was scheduled to be administrated at 8am and 4pm. Keppra Tablet 500 MG (Levetiracetam): Give 1 tablet by mouth two times a day for Seizure D/O. -Start Date-05/21/2026 .It was scheduled to be administrated between 6am to 10am and 6pm to 10pm. Primidone Tablet 50 MG Give 2 tablet by mouth two times a day for Seizure d/o Give 2 tabs to equal 100 mg.-Start Date-05/21/2026. It was scheduled to be administrated between 6am to 10am and 6pm to 10pm. Buspirone HCl Oral Tablet 10 MG (Buspirone HCl): Give 1 tablet by mouth three times a day for anxiety. -Start Date-06/11/2026It was scheduled to be administrated at 7:00am and 1:00pm and 7:00pm.During an observation on 07/15/26 at 10:45am, MA F was administering Resident#76's all morning medications, including the above-named medications. Resident #76 accepted the morning medications without complication and stated she was waiting for the medication.During a record review of Resident #76's MAR for July 26 it was revealed that she had 6 medications that were scheduled to be administered between 6:00am and 10:00am and two medications at 9:00am , one medication at 7:00am and one medication at 8:00am. Further review of the July 26 MAR revealed that Resident#76's morning medications on 07/14/26, 07/13/26, 07/12/26, 07/10/26, 07/04/26 and 07/02/26 were administered after 10:45am. Resident #101:Record review of Resident #101's face sheet dated 07/16/26 reflected Resident #101 was admitted on [DATE]. He was a [AGE] year-old male diagnosed with type 2 diabetes, epilepsy, hypertensive heart disease, dementia, chronic kidney disease and shortness of breath.Record review of Resident #101's admission MDS dated [DATE] reflected a BIMS score of 11 indicating her cognition was moderately impaired. Further review revealed that he was taking Anticonvulsant and Opioid for seizure Disorder and chronic pain syndrome.Record review of Resident #101's care plan dated 06/22/26 reflected that The resident was potential for pain r/t disease process. The relevant intervention was anticipating resident's need for pain relief and responding immediately to any and notifying the physician if interventions were unsuccessful or if the complaint had a significant change from resident's experience of pain.Record review of Resident #101's physician's order reflected the following: Keppra Tablet 500 MG (levetiracetam) : Give 1 tablet by mouth two times a day for Seizure d/o. -Start Date-06/16/2026It was scheduled to be administrated between 6am to 10am and 6pm to 10pm. Acetaminophen Oral Tablet 325 MG (Acetaminophen): Give 2 tablet by mouth three times a day for pain Do not exceed 3 gm in 24 hours from all sources.-Start Date-06/23/2026It was scheduled to be administrated in the morning, midday and bed time. Lyrica Oral Capsule 50 MG (Pregabalin): Give 1 capsule by mouth threetimes a day for chronic pain -Start Date-06/18/2026.It was scheduled to be administrated in the morning, midday and bedtime. During an observation on 07/15/26 at 11:15 am, MA F was administering Resident#101's all morning medications, including the above-named medications. Resident #101 accepted the morning medications without complication.During a record review of Resident #76's MAR for July 26 it was revealed that he had 11 medications that were scheduled to be administered between 6:00am and 10:00 am and 2 medications at 900:am and one medication at 7:00 am. Further review of the July 26 MAR revealed that Resident#101's morning medications on 07/14/26, 07/13/26, 07/12/26, 07/11/26, 07/10/26,07/09/26 and 07/08/26 were administered between 11:00 am and 12:45pm. Resident#39:Record review of Resident #39's face sheet dated 07/16/26 reflected Resident #39 was admitted on [DATE]. He was a [AGE] year-old male diagnosed with dementia, chronic obstructive pulmonary disease, Parkinson's disease (a progressive nervous system disorder that affects movement), neurocognitive disorder with Lewy bodies (a progressive brain disease caused by abnormal protein deposits called Lewy bodies) and chronic pain syndrome.Record review of Resident #39's quarterly MDS dated [DATE] reflected a BIMS score of 12 indicating her cognition was moderately impaired. Further review revealed he was taking medications for Parkinson's diseases and chronic pain syndrome.Record review of Resident #39's care plan dated 04/20/26 reflected the resident had Parkinson's Disease, neuropathy and seizure d/o. The relevant intervention was administering medications as ordered by the physician and monitoring side effects and effectiveness.Record review of Resident #39's physician's order reflected the following: Amantadine HCl Oral Tablet 100:MG (Amantadine HCl): Give 1 tablet by mouth one time a day for Parkinson's Disease. --Start Date- 04/07/2026It was scheduled to be administrated between 6am to 10am. Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate): Give 1 tablet by mouth two times a day for Pain.-Start Date-04/06/2026It was scheduled to be administrated between 6am to 10am and 6pm to 10pm. Gabapentin Oral Capsule 300 MG (Gabapentin): Give 1 capsule by mouth three times a day for Neuropathy. -Start Date-04/06/2026It was scheduled to be administrated in the morning, midday and bedtime. During a record review of Resident #39's MAR for July 26 it was revealed that he had 4 medications that were scheduled to be administered between 6:00am and 10:00am. Further review of the July 26 MAR revealed that Resident#39's morning medications on 07/14/26, 07/09/26, ,07/07/26 and 07/06/26 were administered after 10:30am.During an interview on 07/14/26 at 12:15 PM, MA F stated that she worked at the facility from 7:00 AM to 7:00 PM as one of the two MAs on the day shift. She stated that medications should be administered within one hour before or after the scheduled time. She further stated that if there was a specific time frame indicated, medications should be given within that period. MA F said that, given there were only two MAs responsible for approximately 90 residents, the medication administration task was very challenging, often resulting in her being late for the last residents in the hallways. She stated she was assigned to Hall 300 and Hall 200, starting with Hall 200. She said , by the time she reached the end of Hall 300, she would be late. She added that this situation occurs most days. MA F stated that administering medications within the scheduled times was important to ensure residents receive the full therapeutic benefit of the medications.During an interview on 07/14/26 at 2:30 PM, MA E stated that he had worked at the facility as an MA for about 15 years. He explained that meeting the scheduled times for medication administration was not always possible due to the number of residents to be attended to by the morning MAs. He said that, previously, there were more MAs available, which made it easier to administer medications on time. He said, however, there are only two MAs responsible for all the residents at the facility. MA E stated that the main challenge in meeting the schedule occurs mainly with morning medications. He reported that he had previously raised this concern with management, but no changes have been implemented so far. MA E stated that delays in medication administration did occur, but not all are due to time constraints. He added, sometimes, residents themselves request the MAs to visit them later for medication administration.During an interview on 07/16/26 at 11:30 AM, the NP stated that administering medications in a timely manner was important; however, the impact of delays varies depending on the medication. She explained that medications taken once daily or twice daily were generally acceptable even if there were minor delays. She said , however, medications such as anti-Parkinsonian drugs, analgesics, and anticonvulsants were time-sensitive and must be given at their scheduled times. She added that these medications were scheduled within a liberal time window, but it was crucial to provide them within the designated timeframe and avoid exceeding the threshold time. She stated if there was a delay in Resident #76, Resident#101 and Resident#39 's analgesic, anticonvulsant or anti-parkinsonism medications in a regular pattern was a big concern and should be addressed with immediate effect. She stated she visited them at the facility regularly and had not noticed any harm had occurred so far.In an interview on 07/16/26 at 3:30 PM, the DON stated that the facility follows a liberal medication administration schedule. She explained that some medications are scheduled at specific times, while others are more flexible. The DON stated that medications with a liberal schedule were to be administered within a designated time window, but those scheduled for a particular time could be given one hour before or after the scheduled time. She said that the expectation was for MAs and nurses to adhere to the facility's policies. The DON noted that delayed medication administration could negatively impact residents, depending on the medications they are taking. She said that most delays in medication administration did not pose significant concerns, but certain medications must be administered at prescribed times to ensure effectiveness. She stated she believed , with proper time management two MAs and LVNs could accomplish the task of medication administration in a timely manner.During an interview on 07/16/26 at 2:38pm the ADM stated the facility ensured the staff were following facility policies by making rounds and training programs . Any issues identified would be discussed in QAPI. He stated that the management related to the medications was delegated to the DON and she would be the right person to answer relevant questions.Record review of undated facility policy Medication Administration reflected: Facility staff should take all measures required by Facility Policy, Applicable Law, and the State Operations Manual when administering medications. Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. During medication administration, the facility staff should observe the 6 Rights, ensure that the resident is properly positioned, administer medications at the appropriate medication administration time, document scheduled medication administration per facility policy, observe resident privacy rights per applicable law, observe manufacturer medication administration guidelines, and confirm resident consumption of the medication. Medications arc administered within 60 minutes before or after the scheduled time, except for orders to administer with meals which must be administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. This facility follows person centered care for liberalized medication pass. Daily meds medication pass is 6am to 10am.HS medication pass times are 6pm to 10pm.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (Resident #42, Resident #61, Resident #78, Resident #81, and Resident #89) of 9 residents reviewed for infection control.1. LVN C failed to use appropriate infection control techniques while providing gastrostomy tube site care for Resident#89, by repeatedly wiping the gastrostomy stoma (opening) back and forth with the same moistened gauze during an observation of care on 07/15/2026 at 9:25 a.m.2. MA E and MA F failed to sanitize the blood pressure monitors on 07/14/26 while obtaining blood pressure on Resident #78, Resident # 81, Resident #61 and Resident #42.These failures increased the risk of spreading infections among residents. Findings included:Record review of Resident #42's face sheet dated 07/16/26 reflected Resident #42 was initially admitted on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female diagnosed with dementia, acute respiratory failure(lungs cannot get enough oxygen) , chronic obstructive pulmonary disease (difficulty to breath) , pain and hypertension.Record review of Resident #42's quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating her cognition was intact. Further review revealed he was diagnosed with hypertension.Record review of Resident #42's care plan dated 3/20/24 reflected that The resident had hypertension. The relevant intervention was administering anti-hypertensive medications as ordered and monitoring for side effects such as orthostatic hypotension and increased heart rate (Tachycardia).Record review of Resident #42's physician's order reflected the following: Amlodipine Besylate Tablet 2.5 MG: Give 1 tablet by mouth one time a day for hypertension. Hold for SBP less than 110.-Start Date-11/12/2025.Record review of Resident #61's face sheet dated 07/16/26 reflected Resident #61 was admitted on [DATE]. He was a [AGE] year-old male diagnosed with parkinsonism (condition with tremors, slowed movement, and muscle stiffness), heart failure, hypotension, chronic obstructive pulmonary disease (Difficulty in breathing), retention of urine and insomnia(lack of sleep) due to medical condition.Record review of Resident #61's quarterly MDS dated [DATE] reflected a BIMS score of 14 indicating his cognition was intact. Further review revealed he was diagnosed with orthostatic hypotension (Low blood pressure when standing up).Record review of Resident #61's care plan dated 10/21/24 reflected that he had hypotension and the relevant intervention was administering medications as ordered.Record review of Resident #61's physician's order reflected the following: Droxidopa Oral Capsule 100 MG (Droxidopa): Give 2 capsule by mouth one timea day for Neurogenic orthostatic hypotension. Hold for SBP >120.-Start Date-08/10/2025.Record review of Resident #78's face sheet dated 07/16/26 reflected Resident #78 was admitted on [DATE]. She was a [AGE] year-old female diagnosed with dementia, hypertension, muscle weakness and obesity.Record review of Resident #78's quarterly MDS dated [DATE] reflected a BIMS score of 10 indicating her cognition was moderately impaired. Further review revealed she was diagnosed with hypertension.Record review of Resident #78's care plan dated 09/15/23 reflected that she had hypertension and the relevant intervention was administering medications as ordered and monitoring for side effects such as orthostatic hypotension and effectiveness.Record review of Resident #78's physician's order reflected the following: Losartan Potassium Oral Tablet 25 MG (Losartan Potassium): Give 1 tablet by mouth one time a day for Hypertension. Hold for SBP < 110.-Start Date-08/23/2023Record review of Resident #81's face sheet dated 07/16/26 reflected Resident #81 was admitted on [DATE]. She was [AGE] year-old female diagnosed with dementia, muscle weakness, hypertension, tachycardia (fast resting heart rate of more than 100 beats per minute), hypertensive heart disease and cerebrovascular disease(stroke).Record review of Resident #81's quarterly MDS dated [DATE] reflected a BIMS score of 03 indicating her cognition was severely impaired. Further review revealed she was diagnosed with hypertension.Record review of Resident #81's care plan dated 04/06/23 reflected that she had cardiac disease r/t hypertension. Relevant intervention was administering medication as per physician orders.Record review of Resident #81's physician's order reflected the following: Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate): Give 25 mg by mouth one time a day for hypertension, tachycardia. Hold for heart rate < 55. Hold for SBP < 110. -Start Date-04/28/2023.Record review of Resident #89's admission MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified dementia, protein-calorie malnutrition(low protein and carb level) and , dysphagia (difficulty to swallow) , and gastrostomy(surgical opening made through the abdominal wall into the stomach to place a feeding tube) status. The assessment reflected a BIMS score of 7, indicating severe cognitive impairment. Resident #89 required extensive assistance with dressing, grooming, and personal hygiene and was totally dependent for eating, receiving 51% or more of his nutritional intake through a gastrostomy tube.Record review of the active physician's orders reflected an order dated 07/10/2026 for gastrostomy tube site care to cleanse the site with normal saline, pat dry, and apply split gauze every evening.Record review of Resident #89's comprehensive care plan reflected the resident required tube feeding related to dysphagia. Interventions included providing gastrostomy tube site care as ordered and monitoring for signs and symptoms of infection.In an observation on 07/14/26 at 9:45 a.m., MA E did not sanitize the upper arm blood pressure monitor before using them on Resident #78, between Resident #78 and Resident #81, and after Resident #81. MA E measured Resident #78's blood pressure with the upper arm blood pressure monitor without prior sanitization. He picked up a cuff band (A fabric wrap with a Velcro fastener that goes around the upper arm) from a collection of cuff bands of various sizes in the basket of the blood pressure monitor stand, and after trying it on Resident #78, he changed it to a larger size. After completing the task, he returned the cuff band into the basket without sanitizing it. He then administered medications to Resident #78. After the completion of medication administration to Resident #78 he moved on to Resident #81 and took her blood pressure using the same cuff band, without sanitizing it and stored among other cuffs in the basket without sanitization.In an interview and observation on 07/14/26 at 10:35 a.m., MA E stated that he had been employed at the facility for approximately fifteen years and had received in-service training on infection control on many occasions; however, none of these trainings in the recent past specifically addressed the sanitization of medical equipment. He explained that on this day, he had already administered medications to more than 15 residents, which involved taking their blood pressure. He stated that he did not sanitize the blood pressure monitor at any point during the day. MA E then looked for a sanitizing wipe in various drawers of the medication cart but could not find one. He stated that following his mistake, he recognized the importance of sanitizing blood pressure cuffs between residents, as it helps to reduce the risk of transmitting infectious diseases through contamination.During an observation on 07/14/26 at 10:50 a.m., MA F did not sanitize the wrist blood pressure monitor before using it on Resident #61, between Resident #61 and Resident #42, and after Resident #42. She measured Resident #61's blood pressure with the cuff without prior sanitization. After administering medications, she moved to Resident #42 and took his blood pressure using the same monitor. After completing this, she returned the monitor to the medication cart without sanitizing it.During an interview on 07/14/26 at 11:20 a.m., MA E stated that the monitor was owned by her and that she usually sanitizes it thoroughly after her duties and before taking it home. She said that she had not sanitized the monitor at any point during that day. MA F stated that she had been employed at the facility for approximately two years and could not recall receiving any in-service training specifically on sanitizing medical equipment. She stated that she understood the importance of sanitizing blood pressure cuffs between residents and stated that going forward, she would make a point to sanitize them after every use to help to prevent the spread of contagious diseases through contaminated blood pressure cuffs.In an observation on 07/15/2026 at 9:25 a.m., LVN C performed gastrostomy tube site care on Resident#89. LVN C wiped around the gastrostomy stoma, then repeatedly wiped back and forth across the stoma site multiple times using the same moistened 4 x 4 gauze pad rather than using a clean portion of the gauze or replacing it as needed to avoid contaminating the insertion site.In an interview on 07/15/2026 at 9:47 a.m., LVN C stated the gastrostomy site should be cleansed from the inner portion of the stoma outward. He acknowledged he should not have wiped the stoma multiple times with the same 4 x 4 gauze. He stated he had received in-service education regarding gastrostomy tube care and infection control practices but was unsure whether he had completed a visual competency for gastrostomy tube site care. LVN C stated repeatedly wiping the stoma with the same gauze could place the resident at risk for infection.In an interview on 07/16/2026 at 1:30 p.m., the Director of Nursing (DON) stated nurses were expected to follow facility policy and accepted infection control practices when providing gastrostomy tube site care. The DON stated the nurse should not have wiped repeatedly around the gastrostomy stoma using the same moistened 4 x 4 gauze. She stated annual nursing skills competency validations were completed by the DON and Assistant Director of Nursing (ADON) to ensure nurses were competent in performing gastrostomy tube care. The DON stated improper cleansing technique could result in skin breakdown, infection of the stoma, and pain.In a follow-up interview on 07/16/26 at 3:30 p.m., the DON stated that her expectation was for all staff to sanitize medical equipment, including blood pressure cuffs, between residents. She reported that she observed deficiencies in infection control practices during routine rounds in the facility by her and the ADON. She explained that when deficiencies were identified, staff members were retrained and re-educated accordingly. The DON stated that the facility conducted in-service training on standard precautions at least once a month, which included sanitization practices and the sanitization of medical equipment. She added that she would include additional topics specific to the sanitization of medical equipment in future in-service sessions.Record review of facility policy titled Ostomy Care reflected Cleanse the peristomal skin gently with warm water using gauze pads or washcloth, dry completely. Skin is not scrubbed.Requested wound care policy/procedure 7/15/26 at 12:34p.m. via email to the ADMRequested wound care policy/procedure 7/16/26 at 11:20a.m. via email to the ADMRequested wound care policy/procedure 7/16/26 at 1:30p.m. verbally in interview with DONNo wound care policy/procedure provided by facility. Review of the in-service records from 01/04/26 to 07/15/26 revealed there were no in-services on cleaning medical equipment.Record review of facility's policy Cleaning and Disinfection of Resident-Care Items and Equipment revised in September 2022 reflected: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).

Based on observation, interviews, and record review, the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 (Resident #25) of 5 residents reviewed for respect and dignity. The facility failed to ensure CNA A did not enter Resident #35's room, to answer their call light, without knocking and/or announcing themself prior to entry. This failure could place residents at risk of an invasion of their privacy.Findings included:Record review of Resident #35's quarterly MDS assessment dated [DATE], reflected a [AGE] year-old-female admitted to the facility on [DATE]. Her diagnoses included: stroke (a medical emergency that occurs when blood flow to the brain is blocked or a blood vessel in the brain bursts, causing brain cells to die), high blood pressure (when the pressure in your blood vessels is too high), neurogenic bladder (a condition in which nerve damage or dysfunction disrupts communication between the brain, spinal cord, and bladder, leading to impaired bladder control), hemiplegia (complete paralysis) or hemiparesis (partial weakness), depression (common and serious mood disorder), and chronic pain. Resident #35 had a BIMS score of 12, indicating moderately impaired cognition.Record review of Resident #35's comprehensive care plan dated 05/01/2026 reflected Resident #35 had an ADL self-care performance deficit r/t hx of CVA with interventions of requiring substantial assist by 1 staff to turn and reposition in bed. She had contractures of the left and right legs and left arm. She required 2 staff assistance for transfers. In an observation on 07/14/2026 at 11:17 AM, CNA A walked into Resident #35's open room, without knocking on the door/wall or announcing herself to answer Resident #35's call light and change Resident #35's brief.In an interview on 07/14/2026 at 11:37 AM, Resident #35 stated that her and her roommate typically kept their door open, but staff would knock on it and speak before entering. She stated that she was not startled during this occasion due to the surveyor already being in the room, but if someone just walked into her room without saying anything she would wonder what they were doing and feel a sense of apprehension. In an interview on 07/14/2026 at 1:54 PM, CNA J stated that she had been working for the facility for 2 years. She stated she was answering Resident #35's call light, and that typically she was supposed to knock or announce herself before entry. She stated she should do that to provide privacy and let residents know they were there to help and not harm the residents. She stated they received in-servicing on knocking on doors and announcing themselves before entering a residents room, a while ago. In an interview on 07/16/2026 at 1:48 PM, the DON stated that the facility's policy regarding knocking before entering a resident's room was to always knock, introduce oneself, ask respectfully what a resident needed, and meet their needs. She stated that staff were educated on privacy and dignity through in-servicing often which included verbalizing that this was the residents home and the staff work for the residents. She stated this could negatively impact a resident by embarrassing the resident and invading their privacy. In an interview on 07/16/2026 at 1:48 PM, the ADM stated that the facility policy was to always knock before entering a resident's room and to announce oneself before entering. He stated he had not recently received any grievances on this subject, but they had done in-services on it based on complaints. He stated that staff are educated on privacy/dignity through in-services. He stated that he monitors compliance r/t resident dignity and privacy during rounding, if he saw staff not doing the proper procedures he would correct them immediately. He stated that negative impacts to residents would be a lack of privacy. Review of the facility's policy titled 'Resident Rights' dated February 2021 revealed:Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:privacy and confidentiality;

Based on observation, interviews and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 5 residents (Resident #17) reviewed for resident rights.The facility failed on 07/14/2026 at 10:36 AM and 12:29 PM to ensure that Resident #17 had clean bed linens, and the room was free from odors.These failures could place residents at risk for the potential to compromise the resident's dignity, comfort, skin integrity, and quality of life.Findings included:Record review of Resident #17's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses that included vascular dementia (a type of dementia caused by reduced or blocked blood flow to the brain), hyperlipidemia (abnormally high levels of lipids in the blood), anxiety disorder (excessive, persistent fear or worry that interferes with daily life), and chronic pain. The assessment reflected a BIMS score of 6, indicating severe cognitive impairment. Resident #17 required substantial to maximal assistance with dressing, grooming, and toileting hygiene and was always incontinent of urine. The Assessment reflected no rejection of care or behavioral symptoms.Record review of Resident #17's comprehensive care plan dated 04/18/2026 reflected the residents had bladder incontinence related to impaired mobility and physical limitations. Interventions included the use of disposable briefs, changing the briefs as needed, and cleansing the perineal area with each episode of incontinence.During an observation and interview on 07/14/2026 at 10:36 a.m., Resident #17 was observed lying in a soiled bed with a strong odor of urine. Yellow-brown urine rings were present on both the top and bottom bed sheets. Resident #17 denied that his bed was wet and stated he could not remember the last time staff had checked on him. He stated he was fine and had no concerns related to his care.During a second observation on 07/14/2026 at 12:29 p.m., Resident #17's bed remained covered with urine-soiled sheets, and a strong urine odor continued to be present in the room. Resident #17 was not in the room at that time.In an interview on 07/14/2026 at 12:35 p.m., CNA D stated Resident #17 had refused to be changed that morning but she had assisted him with a shower and getting up for the day. She stated she knew soiled linens were supposed to be removed from the room and placed in the laundry hamper located outside the room but she had forgotten to remove the urine-soiled sheets. She stated she was responsible for removing soiled linens from the room. CNA D stated leaving soiled linens in the room was not homelike and placed residents at risk for infection and skin irritation.In an interview on 07/14/2026 at 12:45 p.m., LVN C stated residents were checked every two hours and as needed by either nurses or nurse aides. He stated it was not a normal practice for staff to leave urine-soiled linens on a resident's bed and that CNAs were responsible for ensuring soiled linens were removed and placed in the laundry. He stated the potential negative outcomes included skin irritation, infection, decreased morale due to the foul odor, and an environment that was not homelike.In an interview on 07/16/2026 at 1:30 p.m., The DON stated residents should be monitored frequently and that residents remaining on wet sheets should not happen ever. The DON stated administrative staff conducted daily morning rounds to ensure resident rooms were clean and tidy and that CNAs were responsible for changing soiled linens. The DON stated Resident #17 required frequent monitoring and toileting and that failure to promptly change wet linens could result in skin breakdown, infection, and impaired dignity.In an interview on 07/16/2026 at 2:20 p.m., The ADM stated CNAs and nursing staff were expected to monitor residents at least every two hours and change residents immediately when found soiled. If a resident refused care, staff were expected to continue attempting different approaches or involve another caregiver. The ADM stated supervisory staff also conducted morning rounds to identify concerns about the units. The ADM stated prolonged exposure to urine-soiled linens could lead to skin breakdown, decreased quality of life, and loss of dignity.Record review of facility policy titled Homelike Environment dated 2001 reflected Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The community team members and management maximize, to the extent possible, the characteristics of the community that reflect a personalized, homelike setting. These characteristics include clean, sanitary, and orderly environment; clean bed and bath linens that are in good condition; and pleasant, neutral scents.

Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days for 1 of 5 resident (Resident #17) reviewed for PRN psychotropic medications, in that:The facility failed to ensure Resident #17 did not have an PRN order for Ativan 0.5 mg after 14 days without a stop date or re-evaluation by the physician to evaluation if the medication was still needed.This failure could place residents at risk for receiving unnecessary psychotropic medications and could result in residents experiencing adverse drug reactions. Findings included:Record review of Resident #17's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses that included vascular dementia (a type of dementia caused by reduced or blocked blood flow to the brain), hyperlipidemia (abnormally high levels of lipids in the blood), anxiety disorder (excessive, persistent fear or worry that interferes with daily life), and chronic pain. The assessment reflected a BIMS score of 6, indicating severe cognitive impairment. Resident #17 required substantial to maximal assistance with dressing, grooming, and toileting hygiene and was always incontinent of urine. The Assessment reflected the resident exhibited no rejection of care or behavioral symptoms. Record review of Resident #17's comprehensive care plan dated 04/18/2026 reflected The resident uses anti-anxiety medications related to anxiety disorder interventions included: Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision.Record review of Physicians Orders summary dated 7/14/26 reflected an order for Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet orally every 12 hours as needed for agitation initiated on 6/12/26. There was no stop date on the order. Record review of Physicians' Letter pharmacy review on file dated 6/16/26 included the following recommendation CMS requires evaluation of psychotropic ordered PRN greater than 14 days. Please review continued use of below PRN Ativan order and for possible dose reduction. Please indicate a short-term duration of therapy. In an interview on 07/16/2026 at 1:30p.m., the DON stated the ADONs were responsible for reviewing new orders every morning to ensure diagnosis and stop dates were in place for psychotropic medications. She stated she was not sure why the order was not reviewed and corrected at the time it was received. She stated the order must have been missed. She stated all psychotropic PRN medications should be reviewed every 14 days and as needed. She stated potential negative effects for not reviewing psychotropic medication orders to ensure stop dates were in place included oversedation, the residents may receive medication that was unnecessary and not needed. In an interview on 07/16/2026 at 2:20p.m., the ADM stated PRN psychotropic medications should be reviewed every 14 days. He stated he had no idea why the nurses did not review the order and correct it when it was received. He stated negative effects could be over medication and unnecessary medications. Record review of facility policy titled Psychotropic Medication Use dated 2001 reflected Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #2) reviewed for care plans. The facility failed to ensure Resident #2's comprehensive care plan addressed her dialysis needs and interventions were in place to ensure the ileostomy(surgical opening of the intestine to allow stool to pass without going through the colon or anus) bag was intact and secure before dialysis to prevent from being returned without treatment. This failure could place residents at risk of not having their individual medical and nursing needs being met.Findings included: Record review of Resident #2's face sheet dated 07/15/26 reflected a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included Klebsiella Pneumonia (type of bacteria causing pneumonia or inflammation of air sacs in the lungs) as the cause of diseases classified elsewhere, chronic kidney disease stage 5 (kidney failure needing dialysis or transplant to survive), renal osteodystrophy (bone disease that occurs in people with chronic kidney disease), acquired absence of kidney, and dependence on renal dialysis. Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 15 indicating cognition intact. Section H for bladder and bowel reflected Resident #2 had an ostomy (including urostomy, ileostomy, and colostomy). Section O for special treatments reflected resident was on dialysis treatments. Record review of Resident #2's care plan last revised 04/27/26 reflected a focus on the resident has an ostomy ileostomy with interventions change ostomy appliance as needed and report illness, inflammation or draining at ostomy site. There was no care plan focus on Resident #2's dialysis treatment, goals, or interventions. There was no interventions included for the assessments of the ostomy appliance prior to dialysis treatments to prevent the rejection of the dialysis center. There was no care plan focus for special dietary needs as it pertained to Resident #2's renal diet order. Record review of Resident #2's orders reflected an order with a start date of 06/18/26 renal diet regular texture, regular consistency, LCS Record review of Resident #2's orders reflected an order with a start date of 06/18/26 dialysis days -tue-thurs-sat @ 1220 to 0620 [dialysis address 1] Record review of Resident #2's orders reflected an order with a start date of 06/18/26 dialysis [dialysis address 2] M-W-F 0630 chair time Record review of Resident #2's orders reflected an order with a start date of 06/18/26 dialysis- monitor av shunt/fistula to (LUE) for thrill & bruit Q shift notify MD/NP for any unusual/ unexpected findings Record review of Resident #2's orders reflected an order with a start date of 06/18/26 dialysis- no blood pressure or venipuncture on extremity with dialysis access site extremity: LUE Record review of Resident #2's orders reflected an order with a start date of 06/18/26 ileostomy care Q shift and PRN Record review of Resident #2's orders reflected an order with a start date of 06/18/26 ileostomy wafer and bag-change q 3 days and PRN Record review of Resident #2's progress note reflected a nursing note dated 07/08/26 pt had accident with colostomy in dialysis yesterday and was not able to complete her dialysis tx. Dialysis rescheduled for today. Pt picked up by [family] for tx at dialysis today. During an interview on 07/15/26 at 10:01 AM, Resident #2 stated she gets regular dialysis and the facility helped with transportation to and from appointments. She stated she was concern that she would sometimes have issues with her ostomy bag not being intact and when she would [NAME] the dialysis center, she would not be able get dialysis because the dialysis center will turn her away since they do not care for the ostomy bags. She said this would result in missed treatment days if she was turned away. She stated she would get the treatment rescheduled and had not had any negative outcomes due to missing a day of treatment. During an interview on 07/16/26 at 12:13 PM, LVN A stated the purpose of the care plan was to have somewhere to go that covered the residents goals and overall situation. She stated the care plan included residents needs such as social, medication, health situation. LVN A stated the care plan was to be updated frequently in order to reflect the current care needs of the resident. She stated if a resident had an ostomy or was on dialysis she would expect to see that in the care plan. LVN A stated residents on dialysis are at risk for infection and have a system that is more compromised. She stated if ostomy bags were not taken care of that could also increased the risk of infection and hospitalization. LVN A stated if residents go to dialysis and they do not have their ostomy bag intact they will be sent back from dialysis with their treatment interrupted. She stated failing to get the treatment would then result in increased blood pressure and other health risks. She stated that Resident #2 had been returned as a result of ostomy bags not being intact but she would be rescheduled to make up the missed visit. During an interview on 07/16/26 at 01:48 PM, the DON stated the purpose of the care plan was to paint a picture of the residents needs and promote good care of the resident. She stated it was her expectation that it reflected current behaviors, certain medications, goals and interventions and things that have been successful. She stated it should be up to date and reflect a residents current status. The DON stated that if a resident was on dialysis and had an ostomy bag that she would expect that information to be reflected on the care plan with goals and interventions. The DON stated the purpose of having dialysis on the care plan was to ensure residents were being assessed appropriately and to ensure needs were met. She stated the same for an ostomy, if there are issues they are sent back as it pertained to dialysis. She stated if these items were not care planned it would not be painting an accurate picture of their care. During an interview on 07/16/26 at 02:42 PM, the ADM stated it was his expectation that care plans showed the overall plan for care and any special needs. He stated it should be comprehensive and updated as needed, every 3 months, or on admission or readmission. The ADM stated if a resident had dialysis or ostomy those were areas that should be on the care plan. He stated a potential negative outcome of not having those care areas on the plan of care would be if someone new was working with the resident they would not see everything that is required for their care, new staff would not know to do those things. Record review of the facility policy Care Plans, Comprehensive Person-Centered last revised December 2016 reflected: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan will:a. Include measurable objectives and timeframes;b. Describe the services that are to be furnished to attain or maintain the resident's highest practicablephysical, mental, and psychosocial well-being;c. Describe services that would otherwise be provided for the above, but are not provided due to theresident exercising his or her rights, including the right to refuse treatment;d. Describe any specialized services to be provided as a result of PASARR recommendations;e. Include the resident's stated goals upon admission and desired outcomes;f. Include the resident's stated preference and potential for future discharge, including his or her desireto return to the community and any referrals made to local agencies or other entities to support such adesire;g. Incorporate identified problem areas;h. Incorporate risk factors associated with identified problems;i. Build on the resident's strengths;j. Reflect the resident's expressed wishes regarding care and treatment goals;k. Reflect treatment goals, timetables and objectives in measurable outcomes;l. Identify the professional services that are responsible for each element of care;m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels;n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; [NAME]. Reflect currently recognized standards of practice for problem areas and conditions.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 (Resident #100) of 5 residents reviewed for bathing. The facility failed to provide Resident #100 with a shower within her first few days of admission, and gave her a bed bath on 07/14/2026 despite Resident #100 preferring, and asking for a shower. This failure could place residents at risk of skin breakdown, infection, and/or mental dissatisfaction related to their self-worth.Findings included: Record review of Resident #100's baseline care plan initiated 07/10/2026 reflected a [AGE] year-old-female who admitted to the facility on [DATE] from another NF. She was admitted for LTC with no discharge anticipated. Resident #100 was alert to person, place, and time and her short- and long-term memory were intact. Her ADL's revealed that she required extensive assistance with transfers and bed mobility. Her intervention for bathing/showering revealed she required extensive assistance by 1 staff with shower. Record review of Resident #100's shower task (bath/shower performed?) question in the POC revealed a check mark under 'Not Applicable' for 7/11/26, 7/12/26, 7/13/26. Review of Resident #100's ADL-bathing task (bathing: self-performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower) question in the POC revealed a check mark under 'Not Applicable' for 7/10/26, 7/11/26, 7/12/26, 7/13/26. In an observation and interview on 07/14/2026 at 10:48 AM with Resident #100, she stated that she was admitted on [DATE] from a long stay in the hospital. She stated that she had not been showered since she was admitted to this facility, and she wanted a shower bad because she was not used to having to wear briefs. Her hair appeared greasy and a bit disheveled, but no foul odors were observed at this time. In a follow-up interview on 07/16/2026 at 9:22 AM with Resident #100 she stated that the staff gave her a bed bath on Tuesday (7/14/2026), she stated that CNA I went into her room and told her she was giving her a bed bath, she did not offer her to go shower. When Resident #100 asked to go to the shower, she was told no. She stated they have not established her shower days yet. She stated that she was discharged from a previous NF to the hospital for 3 weeks, and then to this facility. She stated she felt filthy until she was 'semi-cleaned' on Tuesday. In an interview on 07/16/2026 at 9:53 AM LVN H stated that he had been working at this facility for 5 years. He stated that he was not working on Resident #100's admission day, but he did normally work on Fridays. He stated that they try to give a new admission a shower as long as it was a reasonable time of day, if not on that day, then on Saturday. However, they typically do not shower on Sundays. He stated that typically they try to wait on a PT assessment, but that did not mean that they would not do a bed bath for the residents. He stated sometimes an assessment would come with the resident that showed the staff their transfer status. He stated that Resident #100 would be a M/W/F based on her room # and bed, but if she wanted that changed they could adjust. He stated that sitting there dirty could introduce germs and bacteria and/or insects, it could also mentally impact someone by their sense of self-worth and feeling down about themselves. In an interview on 07/16/2026 at 9:55 AM with CNA G, she stated that she has been working there about 4 months and was working the day after Resident #100's admission. She stated that Resident #100 did not ask for a shower on that day (2nd day of admission). She stated that the expected timeframe to give a new admission a shower was on the day they admitted if they admitted in the morning or early afternoon, but if they admitted later in the day, the bath/shower should be given the next day. She stated that the 'b bed' in resident rooms were scheduled to receive showers in the morning, but at the time Resident #100 admitted , her shower time would have been in the afternoon (a-bed). She stated that if she did not know the new admissions transfer status, she would use observations of the resident, ask the nurse, but she would normally conduct a bed bath, and/or use the mechanical lift and transport the resident to the shower, if that was what they requested. She stated that CNAs were responsible for giving showers. She stated a negative outcome of residents not receiving a shower after being admitted for 4 days could be skin issues such as dry skin, rashes, being stinky, and could make the resident depressed and feel yucky. In an interview on 07/16/2026 at 10:09 AM with the ADON, she stated she had been ADON for about a year. She stated that if a resident was admitted from the hospital the facility tried to get the resident in the shower the day they admitted . She stated if they were coming from another nursing facility they would fall into the posted shower rotation. She stated that it would not be acceptable for a resident to receive a bed bath until Tuesday after a Friday afternoon admission, because showers occur on Saturdays and Mondays. She stated that CNA's were responsible for showering/bathing. She stated that the nurse should be able to tell the CNA the residents' capability. She stated that the CNA could have asked the nurse on duty what the resident's transfer status was. She stated that physically not receiving a shower could harbor bacteria, cause infection, and emotionally the resident could feel nasty. In an interview on 07/16/2026 at 10:14 AM with CNA I, stated that she has been working at the facility for about 3 months. She stated that she recalled giving Resident #100 a bed bath in her room on Tuesday. She stated that there was a nurse working that day and she asked them what Resident #100's transfer status was, she also asked therapy, and neither were able to give her an answer because the resident had not been fully assessed yet. She stated she also asked the resident what her transfer status was, and the resident told her that she could barely move her hips due to a recent fall/hospitalization at a previous facility. CNA I stated that since therapy had not assessed Resident #1, she wanted to prevent an accident. She stated that after the bath the resident verbalized satisfaction. She stated that she asked the resident if she could assist in the upper extremity portion of bed bathing and she said she was still learning how to do that. she stated the day she bathed the resident was her first interaction with the resident. She stated that the resident expresses pain r/t her hips. In an interview on 07/16/2026 at 1:20 PM with the DON, stated that the expectation for a resident to receive a shower or bath within a certain timeframe after admission was that the admitting staff should offer it, but if the resident was coming from another facility, they would resume a similar shower schedule as the previous facility. If the resident was admitted from a hospital or home, they would encourage the resident to get one the day of admission and then roll them into a schedule. She stated it was not written in a policy but was facility procedure. She stated that determination upon admission of a resident's bathing preference was on a shower list by room number, 'a bed' being in morning and 'b bed' in afternoon or something similar, but the resident could be changed to anything they requested, and they would meet the resident's needs. She stated that staff should know when a new admit was due for their first shower/bath through the computer tasks or they would get it in report from the outgoing staff. She stated that Resident #100 was admitted late on a Friday night, and she was not sure why she did not receive the bed bath until the following Tuesday. She stated they were working on education to the CNA''s about meeting needs as best as possible. She stated that if a CNA did not know the residents transfer status, the documentation could be viewed on the d/c summary of the residents admission paperwork from the previous facility, but ultimately if the resident preferred a shower, the staff could have worked as a 2 person assist to shower the resident. She stated that a resident could be physically and emotionally negatively affected by feelings of depression from feeling unclean, feeling self-conscious, and skin breakdown. In an interview on 07/16/2026 at 1:30 PM with the ADM, he stated that as far as he knew, the expectation for a new admission to receive a bath/shower was to be put on the next shower rotation day. He was not sure if the expectation was in policy or if it was a facility procedure. He stated he was not sure how the resident's bathing preference was determined upon admission. He stated that the person responsible for communicating resident shower/bath preferences to the CNA's would be whoever did the admission assessment and it was put in the care plan. He stated that staff knew when a new admission was due for their first shower/bath because it should be put in the rotation/system that the resident was due for one. He was not sure why Resident #100 did not receive a shower/bath within the aforementioned expectations after admission. He stated that by not receiving a shower/bath within a reasonable time, a resident's physical and emotional health and happiness could be negatively affected. Review of the facility's policy dated March 2018 and titled, 'Activities of Daily Living (ADLs), Supporting' revealed:Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:a. Hygiene (bathing, dressing, grooming, and oral care);

Based on observation, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 2 (400 hall cart) medication carts reviewed for pharmacy services. RN B failed to ensure the 400-hall medication cart was locked and medications were secured and not accessible to other staff, residents, or visitors when not in use on 07/14/26. This failure could place residents at risk of having access to unauthorized medications and lead to an increased risk for drug diversion and possible harm.Findings included: During an observation on 07/14/26 at 02:15 PM in the 400 hall a medication cart was observed unlocked. At 02:18 PM RN B was observed coming out of a residents room wearing PPE (gown and gloves) and retrieving wound care supplies from the bottom drawer of the unlocked med cart. After gathering the wound care items RN B was observed returning to the residents room on the 400 hall and closing the door without locking the medication cart. The medication cart remained unlocked, unattended, and out of view of the staff, in the middle of the hall, until 02:32 PM when RN B returned from the residents room and surveyor brought it to her attention. Between 02:15 PM and 02:32 PM there were 2 residents wandering the hall, 2 CNAs, 1 LVN and 1 visitor observed that walked by the unlocked unattended cart. During an observation and interview on 07/14/26 at 02:32 PM, RN B stated it was the facility policy and expectation that if staff are walking away from the medication cart it needed to be locked and secured. She stated she forgot to lock the cart and was not thinking about it. She stated a potential negative outcome of leaving the medication cart unlocked was that residents could take out medication that did not belong to them and they would not know what the medication was for and the side effects. She stated she has worked at the facility for 4 months now and during this time she has been trained on the expectation to secure the medication cart but it was not on her mind. An observation was made of the drawers that were unlocked and accessible and included but not limited to insulin, antidepressant medication, Parkinson's medication (Carbidopa Levodopa), breathing treatments, wound care supplies, needles, and lancets. During an interview on 07/16/26 at 12:13 PM, LVN A stated she assists with medication passes and has been trained on medication security. She stated it was the facility expectation that staff were to never walk away from a medication cart and to leave it open. She stated they need to be locked and safe and nobody else can have access to it. She stated a negative outcome of leaving it unlocked was; there were many residents in the facility that are known wanderers and could take the medication which could put them at risk for negative effects and could also place their nurse license at risk. She stated important medications could go missing. She stated, it would not be good for the nurse or the residents in the building. During an interview on 07/16/26 at 01:48 PM, the DON stated it was her expectation that if nursing staff were away from the medication cart they were locking it and keeping information private. She stated a negative outcome of leaving it unlocked and unattended was patients could open it, take medications and something could happen if they take medication that is not theirs, or hurt themselves with treatment supplies. During an interview on 07/16/26 at 02:42 PM, the ADM stated it was his expectation that medication carts remained locked when not in use or when nursing staff step away from it. He stated a negative outcome of leaving it unlocked, anyone could take the medications, residents included. Record review of the undated facility policy Medication Administration reflected: During the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications and all outward sides must be inaccessible to residents or others passing by.

Based on observation, interview, and record review the facility failed to have the results of the most recent survey of the facility posted in a place readily available to residents, family members, and legal representatives for 1 of 1 survey results books.The facility failed to ensure there was a survey binder posted in a place readily available to everyone which contained the results of the most recent health recertification survey or all surveys, certifications, and complaint/ incident investigations during the 3 preceding years and any plan of correction in effect with respect to the facility.This failure placed residents at risk of not having all the information necessary to make decisions about living at the facility. Findings included:During an observation and interview on 07/14/26 at 02:04 PM, the AD stated she did not know where the survey binder was located. The AD and surveyors walked around inside of the facility and attempted to find the binder and were unsuccessful in locating the survey binder containing the 2567's from previous visits. The AD stated she would need to ask the ADM where it was located. During an observation on 07/14/26 at 02:11 PM, the ADM was observed walking around attempting to locate the survey binder and could not find it. The ADM was observed asking nursing staff at the central nurse's station if they had seen the survey binder to which they responded no. During an observation on 07/14/26 at 03:01 PM, a black binder with the title survey results found by the ADM was observed sitting at the central nurse's station. A review of the survey binder reflected that the most recent 2567 from a health visit was dated 05/14/25. Additionally, it included 2567 visits 03/28/24, 11/21/24, 01/26/23, and 08/23/23. The binder did not include the 2567 for the visits from 07/02/25, 07/17/25, 08/06/25, 03/12/26, 05/07/26, or most recently 07/02/26. During a confidential interview with confidential residents, 13 of 13 residents stated they did not know where the survey binder was located or that they had the information available to them. During an interview on 07/16/26 at 12:13 PM, LVN A stated the purpose of the survey binder was that residents, their families, or any visitors knew what was going on in the facility or how well they are doing. She stated she believed the survey binder was supposed to be located somewhere in the front and was supposed to be made available to everyone. She stated that if the survey binder was not available nobody would have access to the information, they needed to make decisions if they considered placing a resident here. She stated she had not recently seen the binder or knew where it was located. During an interview on 07/16/26 at 01:48 PM, the DON stated that the survey binder tracks complaints and past surveys and the purpose of the survey binder was to ensure that information was accessible to everyone. She stated it was the expectation that the binder was placed in a central location and accessible for everyone to see. She stated she believed it migrated due to the renovations the facility was doing but that it should have been placed somewhere accessible where visitors or residents still had access to information like the central nurses station. She stated a negative outcome of not having the binder or information available was visitors would not have an accurate visual of survey or complaints if they are touring or finding a place for their loved one.During an interview on 07/16/26 at 02:42 PM, the ADM stated he located the survey binder in an office near the front lobby. He stated the purpose of the survey binder was to ensure visitors and residents had access to see survey results. He stated the information should have been easily accessible. The ADM stated it was typically stationed at the front, but when they began renovating things were moved to different places. He stated a negative outcome of not making the previous survey results available to the public was they would be in the dark about things that have happened and could affect their choice if they wanted to remain or move in and be cared for here. Record review of the facility policy Resident Rights last revised February 2021 reflected: Residents should be treated with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to - examine survey results.

Based on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 (07/15/2026 and 07/16/2026) of 3 days reviewed for nurse staffing posting.The facility failed to have nurse staffing information prominently posted in a manner that was accessible to residents and visitors on 07/15/2026 and 07/16/2026.This failure could place residents, families, or visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings included:In an observation on 07/15/2026 at 2:56 PM of the right-side wall behind the second set of entry doors to the facility revealed a paper with the facility's name, date, census, and total number and actual hours worked per shift for licensed staff responsible for resident care dated 07/15/2026. However, it was approximately 5 feet up the wall, and behind a potted indoor tree. The form was not at eye level of someone in a wheelchair, or viewable from behind the tree. The surveyor had to maneuver around the tree to read what was written. In an observation on 07/16/2026 at 9:15am of the right-side wall behind the second set of entry doors to the facility revealed a paper with the facility's name, date, census, and total number and actual hours worked per shift for licensed staff responsible for resident care dated 07/16/2026. However, it was approximately 5 feet up the wall, and behind a potted indoor tree. The form was not at eye level of someone in a wheelchair, or viewable from behind the tree. The surveyor had to maneuver around the tree to read what was written. In an interview on 07/16/2026 at 9:17 AM with the ADM, a policy request was made that covered nurse staffing postings. He stated that they did not have a policy on this topic, but that they could move the tree out of the way and move the posting down the wall.In an interview on 07/16/2026 at 1:30 PM with the DON she stated that she had been helping with the nurse staffing posting requirement, and the ADON's handle it as well. She stated that the nurse staffing posting should be located on the wall behind the second set of doors, but ever since the remodeling the tree had been put in that area also. She stated they had some residents that grab things and keep them, so they try to keep postings out of reach and off accessible tables or desks. She stated the postings might not be readily accessible to someone in a wheelchair. She stated that residents or visitors would have to ask someone about the staff posting if they could not read it. In an interview on 07/16/2026 at 1:30 PM with the ADM, he stated that any of the nurse managers were responsible for compliance with the nurse staff posting requirement. He stated that the location of the staff posting had always been located that high on the hall, but the tree in front of it used to be in the front lobby and was moved during their renovations. He stated that he thought a resident in a wheelchair could read the sign from the height it was posted. He stated that the process used to ensure compliance with staff posting in the absence of a written policy was that he checked it every day when he arrived, but on weekends, the RN weekend supervisor checked it, and any nurse manager could ensure it was updated. He stated that the expectation was for it to be updated daily and visible to residents, staff, and visitors. The facility did not have a policy regarding posting the nursing staffing information.

Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident#1) reviewed for respiratory care.The facility failed to ensure the humidifier water bottle and oxygen cannula connected to the oxygen concentrator of Resident#1 were changed every Sunday as ordered by the physician.This failure could place residents at risk for respiratory infections through contamination. Findings included:Record review of Resident #1's face sheet dated 07/06/26 reflected Resident #1 was initially admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with acute respiratory failure with hypoxia (low oxygen level in blood), hypertensive (high blood pressure) heart disease, obesity due to excess calories, adult failure to thrive (unexplained weight loss, decreased appetite, physical inactivity, and cognitive or mental decline ) and difficulty in walking.Record review of Resident #1's initial MDS dated [DATE] reflected a BIMS score of 13 indicating her cognition was intact. Further review revealed she was on oxygen therapy for respiratory issues.Record review of Resident #1's care plan dated 04/23/25 reflected that she had oxygen therapy related to ineffective gas exchange (reduced transfer of oxygen and carbon dioxide in lungs) . The relevant interventions were:Provide continuous O2 @ 3L via nasal canula.Titrate oxygen to maintain SPO2 of greater than 92%. every shift . Change O2 tubing/water every week on Sunday and PRN every night shifts every Sunday.Record review of Resident #1's physician's order reflected : Change O2 tubing/water every week on Sunday and PRN every night shifts every Sunday.-Start Date-08/10/2025.Record review of Resident #1's June and July 2026 MARs revealed that the oxygen tubing and humidifier bottle were documented as changed on 06/28/26 by RN B and on 07/05/26 by LVN C.During an observation on 07/06/26 at 10:20 a.m., Resident #1 was observed to reside in Hall 200 and was on continuous oxygen therapy. Observation of the humidifier bottle revealed that the bottle had no water in it. The date written on the oxygen cannula was 06/21/26.During an interview on 07/06/26 at 10:25 a.m., Resident #1 stated she had difficulty breathing and needed oxygen throughout the day, but she took it off when sleeping at night. She stated that staff were normally diligent about changing the water bottle and oxygen cannula every week; however, last Sunday an agency nurse was present, and she did not change them. Resident #1 stated she could not remember if they had been changed in the previous week.During an interview on 07/06/26 at 11:10 a.m., LVN A stated that Resident #1 approached her and mentioned that she discovered that the oxygen tube and water bottle had not been changed for the last 15 days. LVN A said she changed them immediately as she found that they had not been changed since 06/21/26. LVN A stated that the tubes and humidifying bottle were supposed to be changed every Sunday but had not been changed since 06/21/26 by the nurses. LVN A stated that if the tubes were not changed periodically, there was a risk of respiratory infection. She added that the humidifier bottle was supposed to be changed when empty to prevent nasal dryness and bleeding however the absence of water in the humidifier bottle was not a significant issue for Resident #1, given the low concentration of oxygen that she had. LVN A said that, regardless, it was the nurses' duty to follow physician orders or recommend changes to the physician if they think it was necessary.During a telephone interview on 07/06/26 at 1:35 p.m., RN B stated that she served as the night shift nurse for Hall 200 on 06/28/26. She said that it was her responsibility as the Sunday night shift nurse to change the humidifier bottles and oxygen tubes for residents in that hall. RN B identified Resident #1 as being on continuous oxygen therapy provided by an oxygen concentrator. She said that she had entered Resident #1's room to change these components on 06/28/26 in the night but did not do so because Resident #1 was sleeping and she did not want to disturb her. RN B stated that later, due to being occupied with other nursing tasks, she forgot to complete this task that night. She said that regular changing of these components was necessary to minimize the risk of respiratory infections and stated that failing to do so compromised infection control protocols. RN B said that it was the duty of every nurse to adhere to physician's orders by administering medications, therapies, and treatments as prescribed.On 07/06/26 at 1:45pm, voice message was left on agency nurse LVN C's phone requesting a call back. There was no return phone call received as of 6:00pm on 07/06/26.During an interview on 07/06/26 at 1:50 p.m., the ADON stated that she was the supervisor for the staff on that day, as the DON was on leave. She said that humidifier bottles, tubing, and oxygen nasal cannulas should be removed and replaced with new ones as ordered by the physician. The ADON said that this practice was intended to minimize the risk of respiratory infections caused by contaminated equipment. The ADON said it was the responsibility of the nurse on the Sunday night shift to ensure that this task was completed routinely. She stated that nurses on other shifts had a duty to verify that the Sunday night nurse had completed this task and to make replacements as soon as they noticed it had not been done. The ADON noted that nurses are supposed to document a task in the medical record only after it has been completed. She explained that false documentation could negatively impact the residents' plan of care and, consequently, the quality of care provided. The ADON stated that the facility would conduct a one to one in-service with RN B and might consider discontinuing the services of agency nurse LVN C.Record review of the in-services since March 2026 revealed there were no in services on safe handling of respiratory equipment.Review of the facility policy Oxygen Administration revised in October 2010 reflected : PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administration .8. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through.

Based on observation, interview, and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that are complete, accurately documented, readily accessible; and systematically organized for 1 of 5 residents (Resident#1) reviewed for respiratory care.The facility failed to ensure RN B and LVN C did not document the changing of water bottle and oxygen cannula connected to the oxygen concentrator of Resident#1 as completed on 06/28/26 and 07/05/26 on the MAR, when it was not completed on those days.This failure placed residents at risk for not receiving scheduled medications and treatments. contamination.Findings included:Record review of Resident #1's face sheet dated 07/06/26 reflected Resident #1 was initially admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with acute respiratory failure with hypoxia, hypertensive (high blood pressure) heart disease, obesity due to excess calories, adult failure to thrive (unexplained weight loss, decreased appetite, physical inactivity, and cognitive or mental decline ) and difficulty in walking.Record review of Resident #1's initial MDS dated [DATE] reflected a BIMS score of 13 indicating her cognition was intact. Further review revealed she was on oxygen therapy for respiratory issues.Record review of Resident #1's care plan dated 04/23/25 reflected that she had oxygen therapy related to ineffective gas exchange (reduced transfer of oxygen and carbon dioxide). The relevant interventions were:Provide continuous O2 @ 3L via nasal canula.Titrate oxygen to maintain SPO2 of greater than 92%. every shift . Change O2 tubing/water every week on Sunday and PRN every night shifts every Sunday.Record review of Resident #1's physician's order reflected : Change O2 tubing/water every week on Sunday and PRN every night shifts every Sunday. -Start Date-08/10/2025.Record review of the June 2026 MAR of Resident #1 revealed RN B documented that the Oxygen tubing & humidifier bottle were changed on 06/28/26.Record review of the July 2026 MAR of Resident #1 revealed LVN C documented that the Oxygen tubing & humidifier bottle were changed on 07/05/26.During an observation on 07/06/26 at 10:20 a.m., Resident #1 was observed to reside in Hall 200 and was on continuous oxygen therapy. Observation of the humidifier bottle revealed that the bottle had no water in it. The date written on the oxygen cannula was 06/21/26.During an interview on 07/06/26 at 10:25 a.m., Resident #1 stated she had difficulty breathing and needed oxygen throughout the day, but she took it off when sleeping at night. She stated that staff were normally diligent about changing the water bottle and oxygen cannula every week; however, last Sunday an agency nurse was present, and she did not change them. Resident #1 stated she could not remember if they had been changed in the previous week.During an interview on 07/06/26 at 11:10 a.m., LVN A stated that Resident #1 approached her and mentioned that she discovered that the oxygen tube and water bottle had not been changed for the last 15 days. LVN A said she changed them immediately as she found that they had not been changed since 06/21/26. LVN A stated that the tubes and humidifying bottle were supposed to be changed every Sunday but had not been changed since 06/21/26 by the nurses. LVN A stated that if the tubes were not changed periodically, there was a risk of respiratory infection. She added that the humidifier bottle was supposed to be changed when empty to prevent nasal dryness and bleeding however the absence of water in the humidifier bottle was not a significant issue for Resident #1, given the low concentration of oxygen that she had. LVN A said that, regardless, it was the nurses' duty to follow physician orders or recommend changes to the physician if they think it was necessary. She stated part of her responsibilities included administering medication and treatments, and she would only document in the MAR after administering each medication or treatment, not beforehand.During a telephone interview on 07/06/26 at 1:35 p.m., RN B stated that she served as the night shift nurse for Hall 200 on 06/28/26. She said that it was her responsibility as the Sunday night shift nurse to change the humidifier bottles and oxygen tubes for residents in that hall. RN B identified Resident #1 as being on continuous oxygen therapy provided by an oxygen concentrator. She said that she had entered Resident #1's room to change these components on 06/28/26 in the night but did not do so because Resident #1 was sleeping and she did not want to disturb her. RN B stated that later, due to being occupied with other nursing tasks, she forgot to complete this task that night. She said that regular changing of these components was necessary to minimize the risk of respiratory infections and stated that failing to do so compromised infection control protocols. RN B said that it was the duty of every nurse to adhere to physician's orders by administering medications, therapies, and treatments as prescribed. RN B also stated she was aware that nurses were supposed to sign the MAR only after completing the task. She said on 06/28/26 she marked the task as completed in the MAR in advance, before actually performing it, which she said was not compliant with professional standards. RN B stated she would not repeat this mistake in the future.On 07/06/26 at 1:45pm, voice message was left on agency nurse LVN C's phone requesting a call back. There was no return phone call received as of 6:00pm on 07/06/26.During an interview on 07/06/26 at 1:50 p.m., the ADON stated that she was the supervisor for the staff on that day, as the DON was on leave. She said that humidifier bottles, tubing, and oxygen nasal cannulas should be removed and replaced with new ones as ordered by the physician. The ADON said that this practice was intended to minimize the risk of respiratory infections caused by contaminated equipment. The ADON said it was the responsibility of the nurse on the Sunday night shift to ensure that this task was completed routinely. She stated that nurses on other shifts had a duty to verify that the Sunday night nurse had completed this task and to make replacements as soon as they noticed it had not been done. The ADON noted that nurses are supposed to document a task in the medical record only after it has been completed. She explained that false documentation could negatively impact the residents' plan of care and, consequently, the quality of care provided. The ADON stated that the facility would conduct a one to one in-service with RN B and might consider discontinuing the services of agency nurse LVN C.Record review of the facility policy Charting and Documentation revised in July 2017 reflected : Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Documentation of procedures and treatments will include care-specific details, including:a. The date and time the procedure/treatment was provided .

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #71, Resident #191, and Resident #194) reviewed for rights. The facility failed to ensure PTA and RN A knocked on Resident #71, Resident #191, and Resident #194's doors when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #71's Face Sheet dated 05/14/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #71's diagnoses included kidney failure, muscle wasting, muscle weakness, difficulty walking, cognitive communication deficit (problems with communication), need for assistance with personal care, respiratory failure, type 2 diabetes mellitus without complications (high blood sugar), morbid obesity, hyperthyroidism (excessive production of thyroid hormones), diarrhea, insomnia (difficulty sleeping), and anxiety (feeling of uneasiness or worry). Record review of Resident #71's admission MDS assessment dated [DATE] revealed Resident #71 had a BIMS score of 14 indicating intact cognitive response. Review of Resident #191's Face Sheet dated 05/14/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #191's diagnoses included end stage renal disease (kidney failure), and discitis lumbar region (a rare and serious medical condition that involves inflammation and infection of the intervertebral disc in the spine). Record review of Resident #191's admission MDS assessment dated [DATE] revealed Resident #191 had a BIMS score of 14 indicating intact cognitive response. Review of Resident #194's Face Sheet dated 05/14/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #194's diagnoses included cerebral infraction (long term effects of a stroke). Record review of Resident #194's admission MDS assessment dated [DATE] revealed Resident #194 had a BIMS score of 03 indicating severe cognitive impairment. Observation while talking to Resident #71 on 05/12/2025 at 10:34 a.m., revealed that PTA and RN A both walked into Resident #71's room without knocking before entering. Observation of 100 hall on 05/12/2025 at 11:13 a.m., revealed that RN A walked into Resident 191's room without knocking before entering. Observation of 100 hall on 05/13/2025 at 08:36 a.m., revealed that RN A walked into Resident 194's room without knocking before entering. During an interview with Resident #71 on 05/12/2025 at 10:35 a.m., revealed that staff do not always knock before entering her room. She said that it did not bother her if staff were coming in and out. She said she did not get upset but would like for staff to knock. During an interview with Resident #194's POA on 05/13/2025 at 1:00 p.m., revealed that he visited Resident #194 daily and stayed for up to 8 hours. He said that staff do not always knock. He said it was mainly the nurses that did not knock. He said that it was not necessary for staff to knock. He said staff were not going to walk into anything going on in the room, so it did not bother him if staff knocked or not. During an interview with Resident #191 on 05/13/2025 at 2:26 p.m., revealed staff do not knock. She said that she would like for staff to knock before entering her room because she said there was no telling what position she could be in. She said that it would irritate her sometimes when staff did not knock, and she would tell them to please knock before coming into her room. During an interview with the PTA on 05/13/2025 at 3:34 p.m., revealed he had been trained on resident rights. He said the policy for knocking on the resident's door was knock, ask if can come in, and tell the resident who you are. He said any staff going into the resident's room should knock before they enter. He said there was not a time that staff do not need to knock. He said if staff did not knock then the resident may feel like their privacy was not being respected. He said everyone was responsible for monitoring to ensure staff were knocking. He said staff monitor by visually watching each other. He said he did not know why he did not knock on Resident # 71's door before entering. He said normally he was going back and forth getting things, but he should be knocking all the time. During an interview with RN A on 05/14/2025 at 8:44 a.m., revealed she had been trained on resident rights. She said the policy for knocking on the residents' doors was knock, wait for them to answer before entering. She also said for residents who could not answer your knock to wait a bit, then go in. She said that staff should always knock on the resident's door. She said that everyone should knock before entering. She said the resident may feel like staff are invading one of their rights by entering and not knocking. She said there was not a reason that staff did not need to knock. She said that the charge nurse was responsible for monitoring to ensure staff knocked. She said that knocking was monitored through observations. She said she did not recall walking into Resident #191, Resident #71, and Resident #194's room without knocking. During an interview with the DON on 05/14/2025 at 8:52 a.m., revealed that she and staff had been trained on resident rights. She said the policy for knocking on the door was always knock before entering. She said the resident would tell staff if it was okay to come into the room. She also said if the resident was nonverbal staff were to still knock tell them who they were and what the staff member was going to do. She said that staff should always knock on the resident's door prior to entering the room. She said everyone should knock before entering the resident's room. She said the resident may feel like they were not respected by staff, or the staff may make the resident feel like they were not seen as a person. She said that there was no reason why staff did not need to knock on the door before entering. She said that all management were responsible for monitoring to ensure that staff are knocking before entering. She said that management monitored through spot checks, and rounds. She said that if management seen staff not knocking, they address it right away. She said she did not know why staff were not knocking on the residents' doors. During an interview with the ADM on 05/14/2025 at 9:02 a.m. he stated he and staff had been trained on resident rights. He said that the policy was that staff were to knock before entering the resident's room. He said all staff were to always knock before going into the resident's room. He said if staff did not knock before entering the room the resident may feel like their privacy was not being respected. He said the only time staff did not have to knock on the door before entering was in the event of an emergency. He said knocking was monitored by everyone. He said everyone holds each other accountable and that knocking was monitored by doing rounds. He said that he did not know why staff did not knock before entering. Record review of Resident Rights Nursing Facilities Policy dated 04/2019 revealed right to be treated with dignity, courtesy, consideration and respect. A person living in a nursing home had the right to privacy.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 8 of 10 residents (Resident #10, Resident #32, Resident #35, Resident #76, Resident #52, Resident #22, Resident #15 and Resident #193) reviewed for infection control. 1. CNA A did not conduct hand hygiene between each resident when passing lunch trays on the 400 Hall to Residents #10, #35, #76, #52, #22, and #15. 2. During peri-care, CNA B did not sanitize her hands or change gloves when going from the front to the back for Resident #10. 3. RN A did not wear a gown for Enhanced Barrier Precautions when administering medications to Resident #193, who had an enteral feeding tube. 4. RN B did not conduct hand hygiene with glove changes when providing Foley catheter care and wound care to Resident #32. These failures could place residents at risk of transmission of disease and infection. Findings included: Record review of Resident #10's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included Alzheimer's disease, muscle weakness, dysphagia (difficulty swallowing), difficulty in walking, diabetes mellitus type 2, and hypertension (high blood pressure). Record review of Resident #10's Quarterly MDS dated [DATE] reflected Resident #10 had a BIMS Score of 08, which indicated moderate cognitive impairment. Record review of Resident #10's Care Plan, last revised on 02/07/25, reflected a focus on ADL care, and more specifically meal set-up and reminders to eat. Record review of Resident #193's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #193 had diagnoses which included Down's syndrome, gastrostomy status, dysphagia (difficulty swallowing), and muscle weakness. Record review of Resident #193's Quarterly MDS dated [DATE] reflected he had a BIMS Score of 08, which indicated moderate cognitive impairment. Record review of Resident #193's Care Plan, last revised on 05/07/25, reflected he had Enhanced Barrier Precautions related to a PEG tube. Interventions included Enhanced Barrier Precautions will be maintained and resident will not develop an opportunistic infection through review date. Staff to follow Enhanced Barrier Precautions when providing close contact resident care. Record review of Resident #32's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #32 had diagnoses which included acute cystitis with hematuria (a urinary tract infection with microscopic blood in the urine), muscular weakness, neuromuscular dysfunction of the bladder, pressure ulcer of buttock, and need for personal assistance. Record review of Resident #32's Quarterly MDS dated [DATE] reflected he had a BIMS Score of 08, which indicated moderate cognitive impairment. Resident #32 had a Foley catheter, and he required the assistance of two staff members to provide his activities of daily living . Observation on 05/12/25 at 12:08 PM revealed CNA A was not conducting hand hygiene between each resident when passing lunch trays to resident rooms. CNA A was observed coming out of a room, no hand hygiene conducted, and she picked up a lunch tray and brought it to Resident #35. She went to pick up a tray and brought it to Resident #10. No hand hygiene conducted. CNA A then picked up a tray and brought it to Resident #15. No hand hygiene was observed. On 05/12/25 at 12:19 PM a second cart was brought onto the hall, and CNA A brought a tray to Resident #76. She then returned to the cart and picked up a tray and took it to Resident #52. No hand hygiene was observed. She then picked up a tray and brought it to Resident #22, and no hand hygiene was observed. Interview on 05/12/25 at 12:35 PM with CNA A revealed she had forgotten to use hand sanitizer between each resident when passing lunch trays. CNA A further stated she had been trained on hand hygiene and infection control, and an adverse outcome could be passing an infection to another resident. Observation on 05/14/25 at 09:06 AM revealed CNA B did not change gloves or conduct hand hygiene when going from the front to the back when conducting peri-care for Resident #10. Observation on 5/14/25 at 09:18 AM revealed RN A did not put on a gown during medication administration for Resident #193. His medications were administered via enteral feeding tube, which required any staff providing direct care to wear a gown for Enhanced Barrier Precautions. Interview on 5/14/25 at 09:36 AM with RN A revealed she had forgotten to put on a gown due to feeling nervous. RN A stated the importance of putting on a gown for Enhanced Barrier Precautions was to prevent the spread of infections throughout the facility. RN A further stated she had received training on Enhanced Barrier Precautions and Infection Control. Observation on 05/14/25 at 11:06 AM revealed RN B did not conduct hand hygiene with each glove change when providing Foley catheter care and wound care to Resident #32. During an interview on 04/14/25 at 03:47 PM with DON revealed her expectation of hand hygiene while providing peri-care to residents was handwashing/hand hygiene and glove change should be conducted when going from dirty to clean. The DON stated Enhanced Barrier Precautions should be followed for any resident identified, and when staff are providing resident care. DON further stated an adverse outcome of staff not following proper hand hygiene with glove change and not following Enhance Barrier Precautions puts the resident at risk of an infection. During an interview on 04/14/25 at 04:15 PM with ADM revealed his expectation for infection control protocol while providing resident care was for staff to conduct handwashing before and after to prevent spread of infection. ADM further stated the potential adverse outcome of staff not following infection control protocol during resident care would be placing residents at risk of infections. A record review of the facility's policy titled Infection Control dated October 2017 reflected, To maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public and To prevent, detect, investigate, and control infections in the facility.

Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to report within 2 hours to the SA after Resident #1 alleged sexual abuse to her Hospice caretaker on 12/13/24, who subsequently notified the facility on 12/16/24. The facility did not report Resident #1's allegation to the SA until 12/18/24. This failure could place residents at risk of sexual abuse and receiving substandard quality of care. Findings include: Review of Resident #1's admission record, dated 12/19/24, reflected she was an [AGE] year old female who was readmitted to the facility on [DATE] and had diagnoses including unspecified Alzheimer's disease, generalized muscle weakness, dementia, delusional disorders, unspecified depression, and unspecified anxiety disorder. Review of Resident #1's quarterly MDS assessment, dated 11/22/24, reflected she had a BIMS of 3, which indicated she had severe cognitive impairment. Resident #1's functional abilities section was blank. Resident #1 always had urinary and bowel incontinence. Review of Resident #1's care plan, dated 11/13/24, reflected Resident #1 had an ADL self-care performance deficit and required one CNA to extensively assist with toileting. Resident #1 also had impaired cognitive function and used psychotropic medications. There was special instructions on Resident #1's care plan that indicated, Female caregiver only. During an interview on 12/19/24 at 10:05 a.m., the ADM stated Resident #1 reported a sexual abuse allegation to her Hospice caretaker on 12/13/24. The ADM explained the Hospice caretaker didn't report Resident #1's sexual abuse allegation until 12/16/24. The ADM explained the Hospice caretaker reported Resident #1's sexual abuse allegation to the Hospice Agency on 12/16/24, who reported Resident #1's sexual abuse allegation to the facility on [DATE]. The ADM stated the Hospice Agency reported Resident #1 told her Hospice caretaker that she was raped 3 times. The ADM said, Our (him and the DON's) initial reaction was that we felt [Resident #1's] allegation wasn't reportable, but after further reflection, we felt it was reportable. The ADM stated he knew to report abuse allegations within 2 hours to the SA. The ADM stated he knew anyone at the facility could report an abuse allegation to the SA, but he and the DON were responsible for reporting abuse allegations to the SA within 2 hours. The ADM stated he knew it was important to report abuse allegations within 2 hours to the SA and said, To make sure everything else could be accurately portrayed and to make sure the residents were safe. During an interview on 12/19/24 at 10:06 a.m., the DON stated she interviewed the facility staff and residents on 12/16/24 and found no one was aware of Resident #1's sexual abuse allegation. The DON stated her and the ADM's initial reaction was that they felt Resident #1's allegation wasn't reportable, but after further reflected, they felt it was reportable. The DON stated she knew to report abuse allegations within 2 hours to the SA. The DON stated she knew her and the ADM were responsible for reporting abuse allegations to the SA within 2 hours. The DON stated she knew it was important to report abuse allegations within 2 hours to the SA and said, To make sure the residents were safe. During an interview on 12/19/24 at 11:00 a.m., Resident #1 said, I was raped 3 times. 2-3 months ago, I can't remember what happened. I knew who did it. A man had done it. I don't remember when it happened. The man grabbed me here (Resident #1 pointed at her left and right arm) and threw me down and acted like he knew me. There was a woman involved. The female was violent against me because this part (Resident #1 pointed at both her arms again). She was very frightening, hurt my toes, and acted like she was going to kill me. I don't remember what time of day it happened. It happened 3 different times. I don't remember if they work at the same place. I've seen the man and woman recently. It has been very long since I've seen the woman and man. I don't exactly remember when I last saw the man and woman. Resident #1's statement continued to change several times during the interview. At some point in the interview, Resident #1 had no additional information to provide. Attempts to contact Resident #1's Hospice caretaker were made on 12/19/24 at 2:52 p.m. and at 3:59 p.m. A voicemail and call back number was left on both attempts. Resident #1's Hospice caretaker didn't return the calls before exit. During an interview on 12/19/24 at 2:54 p.m., CNA A stated Resident #1 never reported a sexual abuse allegation to her. CNA A stated she was most recently in-serviced on abuse and reporting online 1-2 weeks ago. CNA A stated she knew the ADM was the abuse and neglect coordinator. CNA A stated she knew to immediately report abuse allegations. During an interview on 12/19/24 at 3:19 p.m., CNA B stated Resident #1 never reported a sexual abuse allegation to her. CNA B stated she was trained and most recently in-serviced on abuse and reporting on 12/18/24 and learned to report right away to the charge nurse if she saw or heard any abuse. CNA B stated she didn't know who the abuse and neglect coordinator was. CNA B stated she knew it was important to immediately report abuse allegations and said, So they could be investigated right away and residents may forget if reporting was prolonged. During an interview on 12/19/24 at 3:39 p.m., LVN C stated Resident #1 never reported a sexual abuse allegation to her. LVN C stated she was most recently in-serviced on abuse and reporting on 12/18/24 and learned the ADM was the abuse and neglect coordinator and to immediately report abuse allegations. LVN C stated she would immediately report abuse allegations. LVN C stated she knew it was important to immediately report abuse allegations and said, So they (the facility) could contact the authorities and to make sure the resident was safe. During an interview on 12/19/24 at 4:00 p.m., CNA D stated he didn't work with Resident #1 because female caregivers were required to work with her. CNA D stated he was most recently in-serviced on abuse and reporting in November or December 2024. CNA D stated he knew to report abuse allegations to the abuse and neglect coordinator. CNA D stated he didn't know who the abuse and neglect coordinator was. CNA D stated he knew to immediately report abuse allegations. CNA D stated he knew it was important to report abuse allegations and said, So the resident won't get violated and so the abuse doesn't lead to something else. During an interview on 12/19/24 at 4:14 p.m., CNA E stated Resident #1 never reported a sexual abuse allegation to her. CNA E stated she was most recently in-serviced on abuse and reporting alleged violations on 12/16/24. CNA E stated she would report abuse immediately to the charge nurse, LVN, RN, ADON, DON, and ADM. CNA E stated she knew the ADM was also the abuse coordinator. CNA E stated she knew it was important to report immediately abuse allegations and said, It's very important because no one deserves to be hit, whatever abuse is, needs to be dealt with, investigated, and needed to be looked into. Review of the facility's in-services from December 2024 reflected staff were trained on abuse and neglect reporting by the ADM and DON on 12/16/24. Staff were taught to report suspected abuse or neglect immediately to the appropriate person and the abuse/neglect coordinator was the ADM. Before 12/16/24, staff were in-serviced on the Abuse, Neglect, and Exploitation policy by the DON on 10/03/24. Staff were taught that the abuse coordinator was the ADM. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, reflected the following, Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: . 9. Investigate and report any allegations within timeframes required by federal requirements. Review of the facility's Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility Must Report to the Health and Human Services Commission Provider Letter, issued 08/29/24, reflected the following, A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Abuse . Abuse (with or without serious bodily injury) is to be reported immediately, but not later than two hours after the incident occurs or is suspected . HHSC rules define abuse as: The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code S21.08 (indecent exposure) or Penal Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault . CMS defines abuse as: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of the facility's Abuse and Neglect Clinical Protocol, revised March 2018, reflected the following: Definitions: 1. Abuse is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . 3. Sexual abuse is defined at S483.5 as non-consensual sexual contact of any type with a resident.

Based on observations, interviews, and record reviews, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #2) of 5 residents reviewed for unwitnessed falls. The facility failed to adjust Resident #2's wheelchair brakes so they locked in place. On 12/19/24, Resident #2 went to the bathroom unsupervised and fell due to wheelchair brakes not properly locking, subsequently leading to soreness and pain. This failure could place residents at risk of falls, bruises, skin tears, fractures, and hospitalization s. Findings include: Review of Resident #2's admission record, dated 12/19/24, reflected he was a [AGE] year old male who was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, mild cognitive impairment of uncertain or unknown etiology, pain in right hip, generalized muscle weakness, difficulty in walking, unsteadiness on feet, unspecified lack of coordination, fracture of superior rim of right pubis (hip bone), age related osteoporosis, other chronic pain, and repeated falls. Review of Resident #2's quarterly MDS assessment, dated 09/21/24, reflected he had a BIMS of 9, which indicated he had moderate cognitive impairment. Resident #2 had no falls since admission. Resident #2 required supervision or touching assistance with toileting hygiene and partial/moderate assistance with toilet transfers. Resident #2 was occasionally urinary and bowel incontinent. Resident #2 also used a wheelchair as his normally used mobility device. Review of Resident #2's care plan, dated 09/23/24, reflected he had an ADL self-care performance deficit and required limited assistance by one CNA for toileting and to move between surfaces. Resident #2 was also at moderate risk for falls and staff were required to anticipate and meet his needs, be sure his call light was within reach, encourage him to use his call light for assistance as needed, required prompt response to all requests for assistance, ensure he was wearing appropriate footwear when ambulating and mobilizing in wheelchair, was evaluated and treated as ordered or as needed, and required a safe environment with even floors from spills and/or clutter, adequate glare-free light, a working and reachable call light, the bed in low position while in bed, side rails as ordered, handrails on walls and personal items within reach. Review of Resident #2's care plan, dated 12/19/24 at 2:34 p.m., reflected staff revised to include they were to supply a grabber for him and review information on past falls and attempt to determine cause of falls. Review of Resident #2's plan of care, dated 12/19/24 at 2:41 p.m., reflected Resident #2 required supervision and set-up only assistance with toilet use on 12/19/24 at 5:09 a.m. There were no other entries until 12/19/24 at 1:03 p.m. in which Resident #2 required one person extensive, physical assistance with toilet use. Review of Resident #2's progress notes, as of 12/19/24 at 2:24 p.m., reflected the following: *11/23/24 reflected he was on the floor in the bathroom and told staff that he hit his face on the floor when he fell . *10/15/24 reflected he was on the floor in his room, on his buttocks, legs flexed and back to his wheelchair and told staff that he was looking for his phone, then reached for his chair to sit but it was unlocked and he fell . *10/05/24 in which he was found on his knees next to his bed and told staff that he was trying to reach his soda bottle on the floor and slid down. During an observation of Resident #2's hallway on 12/19/24 at 11:20 a.m., there was no staff in the hallway. Resident #2 was yelling, Help me! Help me please! The call light was not on outside Resident #2's room. During an observation of Resident #2's hallway from 12/19/24 11:21 a.m. through 11:29 a.m., there was no staff in the hallway. Resident #2 continued to yell, Help me! Help me please! The call light was not on outside Resident #2's room. During an observation of Resident #2's hallway and interview on 12/19/24 at 11:30 a.m., the surveyor notified CNA F, who walked out the dining area and into the front of Resident #2's hallway, about hearing Resident 2 yelling for help. CNA F and the surveyor walked from the front to back of Resident #2's hallway. The surveyor identified Resident #2's room, whose door was closed. The surveyor and CNA F heard Resident #2 yell inside his closed bathroom, Help me! CNA F opened Resident #2's bathroom door. RN G ran from the front of Resident #2's hallway to Resident #2's room. CNA F, the surveyor, and RN G observed Resident #2's knees on the bathroom floor, his upper body leaning on his wheelchair seat, and his right arm in between the gap of his wheelchair backrest and seat. Resident #2 yelled, I've been calling for help for 30 minutes! I've been waiting for a long time! RN G asked Resident #2 how he fell . Resident #2 yelled, Don't lecture me about falling down and not getting up! I don't want to talk about it! I fell , been face down, and screaming for help for a long time! RN G proceeded to ask Resident #2 if he hit his head. Resident #2 yelled, Enough! RN G asked Resident #2 again if he hit his head during her assessment and Resident #2 denied hitting his head. RN G completed her assessment and determined Resident #2 had no physical injuries. RN G and CNA F helped Resident #2 back into his wheelchair. CNA F left Resident #2's room. RN G asked Resident #2 if he was in any pain. Resident #2 said, Yeah a little bit. I'm sore in this arm (Resident #2 pointed at his left arm). This was the arm I leaned on the wheelchair with. RN G left Resident #2's room to get his pain medication. Resident #2 said, I got up, started using the wheelchair, got up from the wheelchair, it started rolling, and I fell . I've been laying here a long time. I don't call unless it was an emergency. I fell out my wheelchair and couldn't move. I screamed and screamed and screamed. I had a knee on the ground. I was on the ground for a long time. After a while, I thought staff would be here. I think there's several problems at this facility, but one of them is people calling for help because they aren't aware of what they're saying and people like me who call for help and staff don't go and don't answer. Staff do it regularly. It's daily. We don't get any help. To tell you the truth, I was in the position for a while, I made a move and slid down to my knees. My wheelchair brakes were out. I mentioned it to staff that they've gone out a couple times. This happened a hand full of times. The second time I made it to the wheelchair. I'm sorry, it's hard to answer questions, I'm just flustered. I fell into the wheelchair seat with my legs on the ground. RN G returned with Resident #2's pain medication, took Resident #2's blood pressure and pulse, gave him pain medication, and assessed his knees and found no injuries except redness. The DON visited Resident #2's room and asked Resident #2 what happened. The surveyor explained to the DON what occurred. The DON left Resident #2's room. Review of the facility's incident log, dated 12/19/24 at 11:07 a.m., reflected Resident #2's unwitnessed fall was not listed. Review of Resident #2's orders, as of 12/19/24 at 1:54 p.m., reflected no new orders for 12/19/24. The most recent order listed was from 12/09/24. Review of Resident #2's MAR/TAR, as of 12/19/24 at 1:55 p.m., reflected no pain levels documented for 12/19/24. Review of Resident #2's pain level summary, as of 12/19/24 at 1:55 p.m., reflected no pain levels documented for 12/19/24. Review of Resident #2's neurological check list, effective on 12/19/24 at 12:24 p.m., reflected his most recent pulse and blood pressure levels were checked on 12/19/24 at 11:10 a.m. and at normal ranges and his most recent temperature and respiration levels were checked on 11/24/24 at 1:10 a.m The remainder of the neurological check list was blank. Review of the facility's work order report, from 10/01/24 through 12/19/24, reflected a high priority order to adjust the right side of Resident #2's wheelchair break was initiated on 12/19/24 at 12:43 p.m. Before 12/19/24, there was a resolved order related to wheelchair brakes for another resident that was initiated on 11/05/24 at 10:27 a.m. During an observation and interview on 12/19/24 at 12:00 p.m., Resident #2 demonstrated to the surveyor and the MS, who visited Resident #2's room, locking his left wheelchair brake, which locked into place when he motioned his wheelchair forwards and backwards. Resident #2 demonstrated to the surveyor and the MS his right wheelchair brake, which dragged when he motioned his wheelchair forward and backwards and said, It doesn't hold like it should. There were two times of it slipping under me. I had the wheelchair for about a year. I was admitted to the facility over a year ago. I went to the bathroom on my own, but I'm thinking I might need staff to start helping me because of this. The first time it happened I was right in front of the room door. This time, I wasn't near the call light. I couldn't reach it. I don't know exactly how long I was on the floor, but I was on the floor for a long time. The MS said, I've adjusted his (Resident #2's) wheelchair a couple times. The MS told Resident #2, I would like to adjust your wheelchair, but I know it's lunchtime, so I'll adjust it after lunch. The MS left Resident #2's room. During an interview on 12/19/24 at 12:15 p.m., the MS said, I don't know if there was a work order submitted, but I know I tightened it (wheelchair wheels) a couple of times. During an interview on 12/19/24 at 12:49 p.m., the MS stated he worked at the facility for 7 years and 4 months. The MS stated he was responsible for tightening residents' wheelchair locks. The MS said, Once brought to my attention, sometimes I can correct it on the spot. If it is a critical area, it depended on the state of the brakes and condition of the wheelchair if it needed to be adjusted. When asked when Resident #2 most recently informed him about experiencing issues with his wheelchair wheels not locking, the MS said, It's been awhile since he last brought it up. I did it one time. I have adjusted it before. With enough force he could move it. It (Wheelchair locks) clicked in place pretty well. Found one work order (from Resident #2) about a year old and put one in today. When asked when he inspected, repaired and/or replaced wheelchair locks, the MS said, That's constant. Will go good for a while, and then will have one (work order) show up where brakes failed. The brakes with enough force can move and require adjustments. I had a monthly task of checking. Best course was to check with the CNAs and ask if they're noticing any issues with residents transferring into wheelchairs. Nurses and CNAs will tell me. I will do a wheelchair wash every 2-3 times a year. I put a whole assembly line to wash and maintenance wheelchairs. I can't tell you if I kept the documentation, but I don't remember if I kept any while we (him and the staff) washed them. There's no work order record system that's kept, but I do a lot of that stuff. There's a monthly task that is 100% check on every single unit and there's random checks done every month so we can identify any issues specific to wheelchairs. Just functionality of all wheelchairs. That's performed monthly. I don't put it into a specific task. I just do the adjustment and cleared the task as complete. CNAs can also input work orders. The MS stated he knew it was important to inspect and maintain wheelchairs and said, It's the safety part and one could roll out from under them (residents). They can get hurt on the next transfer. Anything reported on the wheelchairs are immediately reported. As soon as they (nursing staff) report it, they have residents put in bed, and I adjust wheelchairs accordingly. I put antiroll back kits on them and put them in a prior months' notice. My job is to make sure people are kept safe and secure. Wheelchairs are important. That's why I wanted[Resident #2's] wheelchair, but he was going to lunch and so I'm going to follow up with him later. During an observation and interview on 12/19/24 from 1:11 p.m. through 1:30 p.m., Resident #2 was still using the same wheelchair. When asked if the MS adjusted his wheelchair, Resident #2 said, No. When asked if staff offered to put him in a different wheelchair for the time being, Resident #2 said, No. During an interview on 12/19/24 at 1:2 p.m., RN G stated she was assigned to work Resident #2's hall on 12/19/24 from 6:00 a.m. through 2:00 p.m. RN G stated she was trained on falls. RN G stated she could not recall when she was most recently in-serviced on falls by the facility. RN G stated she defined an unwitnessed fall as a patient on the floor and said, [Resident #2], clearly gravity took him, but he didn't hit his head and nobody saw it. When asked what she was required to do when a resident had an unwitnessed fall, RN G said, I would initiate neuros right then and there, get vitals, and tell them (residents) to call if they understand. I tell him (Resident #2) all the time and he doesn't listen. We are also supposed to ensure his safety and we remind him. He should call, but he doesn't call. He should have 1 assist with minimal intervention, but sometimes he's a max assist. Sometimes he can help you and sometimes he can't. When asked what happened during Resident #2's fall, RN G stated she was walking down the hallway coming from the dining area to give another resident a sandwich, she didn't hear Resident #2 screaming for help, she observed the surveyor and CNA F at Resident #2's room, rushed into Resident #2's bathroom with CNA F, observed Resident #2's arm in back of his wheelchair, his knees on the bathroom floor, his hips leaning on the wheelchair seat, her and CNA F guided Resident #2 down on his knees, gave Resident #2 time to breathe, and while holding wheelchair, guided Resident 2 back to his wheelchair. RN G stated Resident #2 said, I don't need a lecture, when she asked what happened and if he's in any pain. RN G stated she didn't want to move Resident #2 if he was in pain, but Resident #2 was able to move what she asked and her and CNA F were able to move him. RN G stated she was required to check residents' vitals and pain and if they can move all extremities whenever there was a witnessed or unwitnessed fall and said, He (Resident #2) didn't hit his head, so I didn't think to check pupils but I was ready to. If he hit his head, it would've been part of his neuro checks. I didn't want to wait to take his vitals, but I didn't want to do it right then and there, so I waited 10-15 minutes to check his blood pressure and so he could calm down and verbalize what happened. RN G stated Resident #2 told her that he was just getting off the toilet, didn't ask for help, tried to get back into his wheelchair, reached for the wheelchair and said, The darn brakes, I believe he put weight on the wheelchair and fell in, thankfully he fell into the wheelchair and not all the way back. RN G stated Resident #2 never mentioned to her about his wheelchair wheels not locking and said, He (Resident #2) probably mentioned it to maintenance man himself because he was cognitive of who played what role and would've told someone like [The MS or the ADM]. RN G stated Resident #2 told her that he was in pain in his shoulders and neck, gave him Tylenol 500mg and notified the DON, NP and ADM. When asked if she notified Resident #2's family, RN G said, I don't think he has any family, maybe a friend. I was behind on other stuff, but didn't have time to notify the family, but would be someone I would notify. RN G stated she mentioned that Resident #2 was experiencing issues with his wheelchair to the DON and that the wheelchair wheels needed to be fixed. RN G stated staff offered to push Resident #2's wheelchair to the dining room. RN G stated the MS fixed Resident #1's wheelchair wheel brakes after the surveyor left Resident #2's room on 12/19/24 around 1:40 p.m. RN G stated she knew it was important to follow fall protocol and conduct neuro checks and said, So the resident didn't suffer any injuries, not suffer a brain bleed, and had no injuries anywhere that could be exacerbated if not followed. So yeah to prevent any further injury or harm. And if they have a brain bleed, cannot do neuros because they could be dead. When asked when CNAs check on residents, RN G said, CNAs round on residents as soon as they get to the facility and every two hours. Nurses of course also round on residents. Administration always around on residents and are readily available and I do see a lot of them in the halls. RN G stated she didn't have any other residents report concerns about their wheelchair wheels not locking into place. RN G stated she assumed the MS was responsible for checking on residents' wheelchairs. RN G stated if a resident reported wheelchair issues, she would notify the DON, MS and Housekeeping Supervisor and tell the DON to follow-up with the issue. RN G stated she didn't have access to work order system at the facility, would write down maintenance issues and informed other staff. An attempt to contact CNA F was made on 12/19/24 at 2:36 p.m. A voicemail and call back number was left. CNA F did not return the call. During an interview on 12/19/24 at 4:34 p.m., the DON stated she in-serviced and hosted an all staff meeting that covered fall protocol, who to report falls to, and what to do when falls occur to reiterate importance. The DON stated she most recently in-serviced staff on falls in November 2024 and taught staff about the types of falls, checking for ROM and vitals, CNA reporting to nurse, notifying her of falls, nurses starting neuros, notifying the doctor, family, ADON, her and the NP, and checking for blood thinners. The DON stated nurses were expected to conduct neuros for 72 hours regardless of if the resident hit their head or not. The DON stated she knew it was important to initiate neuros and said, Because they (residents) can have a change in condition and that way you have a timeline when the change in condition occurred and can address it as needed. The DON said the frequency for neurological checks were, 15 minutes first hour, 30 minutes second hour, once an hour, and then every shift until 72 hours was up. The DON stated if there were any changes in condition, staff would notify her even if it was minor. The DON stated she knew it was important to follow fall protocol and said, Because if the resident had an injury, the injury could be reaggravated, it could cause a change in condition, addressing it in a timely fashion so further injury doesn't occur. The DON stated Resident #2 did not call for help and she believed he was more independent than he was. The DON stated staff were supposed to check on Resident #2 every two hours. The DON stated she recently placed Resident #2 on physical therapy services for mobility and were in process of getting a wheelchair more appropriate for him. The DON stated Resident #2 never reported any concerns about his wheelchair having any issues. The DON stated the MS looked at Resident #2's wheelchair before. The DON stated if there were any maintenance issues, she expected staff to put in an order in the facility's work order system or notify her and ADM to notify the MS. The DON stated she knew it was important to notify wheelchair issues and said, So it wouldn't put him at risk for injury again and so he could have more independent mobility. The DON stated the MS was responsible for inspecting and maintaining wheelchairs. The DON stated she did not know how often the MS was required to maintain and fix wheelchairs. The DON stated she expected staff to notify her, the ADM and MS whenever a resident reported a wheelchair issue. The DON stated she expected staff to assess a resident, conduct vitals and neuros, continue the fall process per fall policy, monitor continuously and document if a resident had an unwitnessed fall. The DON stated she defined an unwitnessed fall as If didn't see it, it was unwitnessed. During an interview on 12/19/24 at 5:33 p.m., the RNC said, There's a difference between witnessed and unwitnessed, which was when conducting neuro checks. Unwitnessed fall is going to be neuro checks no matter what. If you can verify the resident didn't hit their head or not, would still do neuro checks. During an interview on 12/19/24 at 5:58 p.m., the ADM stated he could not recall when he most recently in-serviced staff on falls. The ADM stated staff complete annual educations on falls. The ADM stated he defined an unwitnessed fall as no one saw the fall. The ADM stated he expected staff to quickly as they can go and assist if a resident had an unwitnessed fall. The ADM stated if the resident changed planes, he considered it to be an unwitnessed fall. The ADM stated he expected staff to immediately provide care if a resident was found on the ground, knees on the ground, and leaning on the wheelchairs. The ADM stated he expected any staff to check on residents as needed, whenever residents' press the call light, and roughly every two hours. The ADM stated he knew it was important to follow fall protocol and said, To make sure anything isn't serious and no underlying issues occurred that staff didn't know about. The ADM stated he expected his CNAs and nurses to render aide as quickly as they can if there was an unwitnessed fall. The ADM stated he expected staff to report to the nurse or let the MS know how to handle it or have staff enter work orders directly if residents reported wheelchair issues. The ADM said, Generally speaking, therapy and maintenance staff were responsible for adjusting wheelchairs and swapping out wheelchairs. Adding or fixing would be maintenance. The ADM stated he knew it was important to notify the MS of wheelchair malfunction and said, So they can be fixed as quickly as possible and so they don't quickly malfunction. The ADM stated he never been notified of any issues about Resident #2's wheelchair. The ADM stated Resident #2 told an unknown staff member this or last week about his wheelchair. The ADM stated he expected neuro checks to be completed as soon as staff can after the unwitnessed fall incident. The ADM stated he didn't know what level of assistance Resident #2 required to go to the restroom, but believed Resident #2 might be a 1-person assist. Review of the facility's in-services, from 09/01/24 through 12/19/24, reflected staff were trained on falls and fall risk managing policy on unknown date. Staff were also in-serviced on fall precautions by the DON and ADM on 09/04/24 and were taught to ensure all interventions in place. Staff were also in-serviced on neuro checks by the DON and ADM on 09/03/24 and taught it was the nurses responsibility to initiate neuro checks immediately when a patient has an unwitnessed fall and or a witnessed fall with hitting their head and if a neuro check is abnormal to call on-call NP not leave a message in PCC in communications or in NP box. Review of the facility's Logbook Documentation Mobility Aids: Conduct wheelchair inspection, from 09/01/24 through 12/19/24, reflected the MS inspected, repaired, and replaced wheelchairs on 11/05/24, 10/07/24, and 09/11/24. There was no documentation for December 2024. The MS was required to completed the following steps, Inspect wheelchairs for damaged or missing components 1. After lock out or repair work order Is issued, Inspect and or repair (Just a note lock out of a manual wheelchair is not needed) o Check wheelchairs for the following: o Brakes . o Wheels 2. Repair or replace as necessary o Check wheelchair for proper operation 1. Tighten all adjustment points o Items identified as poor condition should be removed from service. Review of the facility's neurological evaluation flow sheet, undated, reflected staff were required to conduct neurological checks according to the following suggested frequency: Complete checks: every 15 minutes x 1 hour, every 30 minutes x 2 hours, every 1 hour x 2 hours, every shift x 72 hours. Staff were also required to date, time, initial, use Glasgow Coma scale to complete assessment, and check and document left and right reactions, arms, legs, blood pressure, pulse, respiration, temperature, and sign for each frequency. Review of the facility's Care Path for Falls, 2014-2021, reflected the following, Fall: Unintentional change in position coming to rest on the ground or onto the next lower surface. Take Vital Signs: Temperature, Blood Pressure, Pulse, Respirations, Oxygen Saturation . Manage in Facility: Document fall per facility policy, monitor vitals for 24-72 hours, monitor neuro checks for 24-72 hours, check for pain level, check for new bruising or other evidence of injury, review of orders for medications associated with increased fall risk . Review of the facility's Accidents and Incidents Investigating and Reporting policy, revised July 2020, reflected the following, Policy Statement: Accidents or incidents involving residents, employees, visitor , vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation: 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included in the Risk Management report: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; I. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. Review of the facility's Falls and Fall Risk Managing policy, revised April 2022, reflected the following, Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation: Definition: According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force ( e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred . Fall Risk Factors: Environmental factors that contribute to the risk of falls include: .e. Improperly fitted or maintained wheelchairs . 2. Resident conditions that may contribute to the risk of falls include: .c. delirium and other cognitive impairment; d. pain; e. lower extremity weakness; . i. functional impairments; . k. incontinence . 3. Medical factors that contribute to the risk of falls include: .d. neurological disorders; and e. balance and gait disorders; Resident-Centered Approaches to Managing Falls and Fall Risk: .6. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 7. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . Review of the facility's Neurological Assessment policy, undated, reflected the following, Purpose: The purpose of this procedure is to provide guidelines for conducting a neurological assessment (neuro checks) on residents with known or suspected head trauma or acute changes in mental or motor function that may be indicative of a neurological event . Steps in the Procedure: 1. Conduct neurological checks as frequently as ordered . 13. Frequency of neurological checks will be (Total of 72hrs): Every 15 minutes x 4 . The remainder of the policy was blank.

Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials for 1 (Resident #1) of 4 residents reviewed for incidents. The facility staff failed to inform the ADM of Resident #1's allegation of neglect from 10/19/24 until 10/22/24, subsequently making the ADM's report late to the SA. This failure could place residents at risk of neglect and receiving substandard quality of care. Findings include: Review of Resident #1's admission record, dated 11/21/24, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, major depressive disorder, age-related osteoporosis (a disease that causes bones to become weak and more likely to break), and other specified disorders of bone density and structure. Review of Resident #1's quarterly MDS assessment, dated 10/14/24, reflected she had a BIMS score of 12, which indicated she had moderate cognitive impairment. Resident #1's functional abilities section was blank. Resident #1 frequently had urinary incontinence and always had bowel incontinence. Review of Resident #1's care plan, dated 10/22/24, reflected Resident #1 had an ADL self-care performance deficit and required two CNAs to turn and reposition her in bed. Review of Resident #1's progress notes reflected a note made by LVN A on 10/19/24 at 1:26 PM, Resident was found to have bruising to right thumb down to wrist. NOC shift nurse reported to day shift and was found to be a light blue color. Resident not able to push call light button, but able to move around. Resident stated it happened during a transfer and that its been sore since. Family and weekend supervisor notified. Review of Resident #1's self-report, dated 10/22/24, reflected Resident #1 made a neglect allegation at an unknown date. Resident #1 alleged the neglect incident happened on 10/16/24 at 1:00pm in her room. The facility reported Resident #1's neglect allegation to the SA on 10/22/24 at 1:10pm. There were no alleged perpetrators and witnesses. Resident #1 alleged a CNA hurt her arm and thumb during repositioning for care on either 10/16/24 or 10/18/24. Resident #1 was assessed head to toe on 10/19/24 at 1:25 PM by LVN A. LVN A found bruising to Resident #1's right thumb down to her wrist. The facility initiated safe surveys and skin checks for all residents on Resident #1's hall and found there were no other signs of abuse/neglect. The facility also initiated education on abuse/neglect and proper methods of repositioning during care. Resident #1 was unable to remember when the incident occurred and give a description of the CNA that performed the care. Resident #1 was consistent that the CNA was providing service and used her arm to reposition her. Resident #1 stated she didn't feel pain during the care and noticed her thumb was sore and some slight bruising. Resident #1 kept repeating the incident happened either on 10/16/24 or 10/18/24. Resident #1's bruising looked consistent with someone locking hands in a helping manner around Resident #1's lower wrist and thumb area. Resident #1 repeated during all her interviews that the incident happened while a CNA was providing care and didn't feel that the action was done intentionally. The facility interviewed all staff that were assigned to Resident #1's room on the alleged days except for an Agency CNA that would not return calls and had not been to the facility since. All other interviewed staff stated they didn't use Resident #1's hand to reposition Resident #1, but used a draw sheet. The investigation findings were unconfirmed. During an interview on 11/21/24 at 8:56 AM, the DON stated Resident #1 didn't immediately report her alleged neglect incident. The DON stated she didn't know when Resident #1 initially reported her alleged neglect incident. During an interview on 11/21/24 at 9:30 AM, CNA B stated he was in-serviced on abuse and neglect. CNA B stated he knew the ADM was the abuse and neglect coordinator. CNA B stated he would immediately report abuse and neglect. During an interview on 11/21/24 at 9:43 AM, CNA C stated she worked at the facility for [AGE] years. CNA C stated she was given orientation training on abuse and neglect. CNA C stated she knew the ADM was the abuse and neglect coordinator. CNA C stated she would immediately report abuse or neglect. An attempt to interview Resident #1 was made on 11/21/24 at 9:48 AM. Resident #1 was sleeping in her room. During an interview on 11/21/24 at 9:50 AM, LVN A stated he worked at the facility for 3.5 years. LVN A stated he was given orientation training on abuse. LVN A stated he knew to notify the ADM, who was the abuse and neglect coordinator, on abuse and neglect. LVN A stated he would immediately report abuse or neglect. LVN A stated he was not working when Resident #1 alleged neglect. During an interview on 11/21/24 at 9:54 AM, the ADON stated she knew the ADM was the abuse and neglect coordinator. The ADON stated she would immediately report abuse and neglect. The ADON stated she was not working when Resident #1 alleged neglect. An attempt to interview Resident #1 was made on 11/21/24 at 10:00 AM. Resident #1 was sleeping in her room. During an interview on 11/21/24 at 10:52 AM, LVN A stated he reported what he wrote in his progress note on 10/19/24 to the weekend supervisor. LVN A stated he couldn't recall who the WS was. LVN A stated he knew it was important to immediately report abuse or neglect to ensure it didn't happen to anyone else. LVN A stated he didn't report directly to the DON and ADM because it wasn't something that he saw, Resident #1 didn't have right mindset with her memory, and he just reported it to the weekend supervisor. During an interview on 11/21/24 at 10:56 AM, the ADM stated he couldn't recall when and who reported Resident #1's alleged neglect incident. The ADM stated on 10/21/24, during a morning meeting, it was brought up about Resident #1's alleged neglect incident. The ADM stated he considered Resident #1's alleged incident as neglect and followed the neglect reporting procedures outlined in the provider letter for reporting neglect to the SA. The ADM stated he went by the within 24 hour timeframe for reporting neglect. The ADM stated all staff were responsible for immediately reporting abuse and neglect to him so he could report to the SA. During an interview on 11/21/24 at 11:22 AM, the DON stated she was notified on 10/21/24 during morning meeting about Resident #1's alleged neglect incident. The DON stated she initiated the neglect reporting protocol because it wasn't suspected abuse and because Resident #1 didn't state that the incident was abuse. The DON stated neglect was reported to the SA within 24 hours. The DON stated neglect was reported to the SA within two hours if staff suspected abuse. The DON stated she knew it was important to report abuse and neglect to the SA because staff can remove the alleged staff member from the resident, ensure resident safety, ensure other residents were not harmed, and initiate an investigation. The DON stated residents could be harmed if staff were not reporting within the required timeframes. The DON stated as soon as she's notified of allegations or suspicions of abuse and neglect, she would report right away. The DON stated she did not know why the WS and LVN A, who wrote the progress notes on 10/19/24, didn't report Resident #1's alleged neglect incident to her and the ADM. The DON stated she believed the WS didn't immediately report because the WS didn't think Resident #1 was in immediate danger. An attempt to contact the WS was made on 11/21/24 at 11:32 AM. A voicemail and call back number were left. The WS didn't return the call before exit. Review of the facility's incident log, from 10/01/24 through 11/21/24, reflected Resident #1's bruise incident was on 10/19/24 at 1:20 PM. Review of the facility's in-services, from 10/01/24 through 11/21/24, reflected staff were trained on the abuse and neglect policy and procedure on 10/03/24. Staff were trained on reporting immediately to the ADM of any allegations and suspicions of abuse and neglect. Review of the SA's provider letter for reporting neglect to the SA, issued 08/29/24, reflected: A facility must report to the SA the following types of incidents, in accordance with applicable state and federal requirements: Neglect Do Report: An incident that does not result in serious bodily injury but that involves any of the following: Neglect: Immediately, but not later than 24 hours after the incident occurs or is suspected.

Based on observation, interview, and record review, the facility failed to ensure the resident has a right to a safe, clean, comfortable and homelike environment for 2 of 4 (Resident #1 and Resident #2) residents reviewed for environmental concerns. The facility failed to ensure that the Resident #1 and Resident #2's bedding, and Resident #1's air mattress were clean and free of dirt and dried food. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. The findings included: Record review of Resident #1's Admission Record dated 10/09/2024 revealed the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #1's medical diagnoses included Alzheimer's disease (brain disorder that gets worse over time), dementia (memory, thinking, difficulty), muscle weakness, lack of coordination, weakness, morbid obesity, type 2 diabetes mellitus without complications (high blood sugar), protein-calorie malnutrition, kidney disease, sepsis (a life threatening complication of an infection), cholecystitis (inflammation of the gallbladder), bacteremia (infection in the blood stream), malaise (feeling of general discomfort), major depressive disorder, COVID 19, dysphagia (difficulty swallowing), abnormal weight loss, chronic pain, and cognitive communication deficit (problems with communication). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed that Resident #1 had a BIMS score of 01 indicating the resident had severe cognitive impairment. Record review of Resident #2's Admission Record dated 10/09/2024 revealed the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #2's medical diagnoses included type 2 diabetes mellitus with unspecified complications (high blood sugar), cerebral infarction (long term effects of a stroke), end stage renal disease (end stage of kidney disease), hyperlipidemia (high cholesterol), hypertension (high blood pressure), and depression. Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed that Resident #2 had a BIMS score of 00 indicating the resident had severe cognitive impairment. Observation of Resident #1's room on 10/09/2024 at 8:02am revealed that the resident was asleep in her bed. The resident's comforter and a sheet were on the floor and there were visible food crumbs, white and brown substance smeared on areas of the mattress and a large area that appeared to be wet or dark stained on the air mattress. Observation of Resident #1's room on 10/09/2024 at 10:12am revealed that the resident's comforter and sheet were still on the floor. The comforter had a dried orange substance on it that appeared to be food. Observation of Resident #1's room on 10/09/2024 at 11:05am revealed that housekeeping was cleaning Resident#1's room. Observation after housekeeping on 10/09/2024 at 11:05am revealed housekeeping cleaned Resident #1's room and that the comforter (the resident's personal comforter) that was on the floor was made on the bed and the air mattress was not cleaned. Lifted the covers and flat sheet and the air mattress still had brown smeared substance and white smeared substance on it. There was also still crumbs of what appeared to be food on the air mattress. An interview with Resident #1 on 10/09/2024 at 11:06am was unsuccessful; Resident #1 would not talk to surveyor. An interview with Resident #1's POA on 10/09/2024 at 9:09am and 10:19am were unsuccessful and call was not returned. An interview with Resident #2's POA on 10/09/2024 at 11:24am revealed that she had an incident about a week before where Resident #2 had dried feces on her bed and her floor. She stated the staff had the let the cleaning solution soak on the floor and come back and clean it up because it had dried. Observation of Resident #2's room on 10/09/2024 at 11:38am revealed that her bed was made and in the middle of her bed was dried brown in color substance that was a little bigger than a quarter. Observation of Resident #2's room on 10/09/2024 at 12:50pm revealed that CNA A was sitting in a chair in Resident #2's room. Resident #2 was observed laying in the bed with the dried food still on the comforter sleeping. An interview with CNA A on 10/09/2024 at 12:50pm revealed that she was watching Resident #2 because she was getting into things and was all over the floor. She also said that the bedding is changed when it gets dirty. She said that the nurses and CNAs were responsible for changing the resident bedding. She said it was not good hygiene to have dirty bedding on a resident's bed. She also said that she did not notice the dried food on the resident's bed. An Interview with the DON on 10/09/2024 at 1:00pm revealed that staff had been trained in resident rights. She stated that the nursing staff were responsible for picking up the resident's rooms. She also said that the nurses and CNAs were responsible for ensuring the resident's bedding was clean. She said that anytime they were soiled the staff were expected to change them. She also said that housekeeping was responsible for wiping down the air mattress when they cleaned the residents' rooms. She said it was a hygiene issue. She stated she did not know why Resident #1 and Resident #2's bedding had dried food on them. An interview with the ADM on 10/09/2024 at 1:38pm revealed that staff were trained on resident rights. He said they did not have a housekeeping policy, but his expectation was if any staff saw the mattress was dirty then it should be cleaned. He said he was not aware that the resident's bedding was dirty. He also said he did not know why the bedding and mattress was not cleaned. An interview with CNA B on 10/09/2024 at 2:34pm revealed she had been trained on resident rights. She stated the CNAs were responsible for changing the resident's bedding and wiping down the air mattresses. She said that the air mattress was to be wiped down when the resident was gotten up and then it was to be air dried. She also said that when the resident's bedding was soiled, or dirty staff were supposed to send it to laundry to be cleaned. She said a resident would never have a blanket or sheet that was dirty. She said the resident may feel nasty or dirty if their bedding is dirty. She said by having dirty bedding the resident could get an infection. She did not know why Resident #1 or Resident #2 had dirty bedding and Resident #1's air mattress was dirty. An interview with CNA C on 10/09/2024 at 2:41pm revealed that she had been trained on resident rights. She stated the CNAs were responsible for picking up and keeping the resident's belongings in place. She said the resident's bedding and air mattress were cleaned the day the resident gets his or her shower. She also said that if the resident's bedding were dirty or the resident spilled something on it then staff would send it to the laundry to be cleaned. She said that by the resident's bedding not being cleaned the resident could get depressed, upset or feel uncomfortable. She stated she did not know why Resident #1 and Resident #2's bedding was dirty. An interview with LVN D on 10/09/2024 at 3:04pm revealed she had been trained on resident rights. She stated that the nursing staff were responsible for ensuring resident's belongings and bedding were clean. She said that was part of the residents' ADLs. She stated the air mattresses were cleaned daily because they did not have sheets on them. She also said that if the air mattress needed cleaning more often staff were to clean them more often. She said that the resident should always have clean bedding, and it should be put in a plastic bag and sent to laundry if it was soiled or dirty. She stated that residents should not be using dirty or soiled blankets or sheets. She said if the resident was bed bound then staff were to change the bedding and clean the resident up. She said residents would not be happy if they had dirty bedding. She said the resident could get ants in their room if they had dirty bedding. She said she did not know why Resident #1 and Resident #2 had dirty bedding. Record review of Homelike Environment Policy revised on February 2021 revealed residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The community team members and management maximize to the extent possible the characteristics of the community that reflect a personalized homelike setting. These characteristics include clean, sanitary and orderly environment, clean bed and bath linens that are in good condition.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure a care plan was developed to address Resident #1's psychiatric behaviors such as wandering, insomnia, aggitation, and anxiety. This failure could place residents at risk of not having their individualized needs met, a delay in services, and not receiving adequate care. Findings included: Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, type II diabetes , stroke, and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS assessment, dated 04/17/24, reflected a BIMS of 11, which indicated a moderate cognitive impairment. Section D (Mood) reflected he often felt lonely or isolated from those around him. Section E (Behavior) reflected he had no hallucinations, delusions, or physical/verbal behavioral symptoms directed towards others. Record review of Resident #1's quarterly care plan, revised 05/09/24, reflected he used antidepressant medication related to depression and anti-anxiety medications related to anxiety disorder with interventions of administering medications as ordered by the physician. There was no mention of psychiatric behaviors. Record review of Resident #1's physician order, dated 01/15/24, reflected Depakote Oral Tablet Delayed Release 125 MG - Give two tablets by mouth three times a day for behavioral disturbance. Record review of Resident #1's physician order, dated 03/18/24, reflected Zoloft Oral Tablet - Give 100 mg by mouth one time a day for anxiety/depression. Record review of Resident #1's physician order, dated 05/14/24, reflected Buspirone HCl Tablet 5 MG - Give two tablets by mouth three times a day for anxiety. Record review of Resident #1's psychiatric assessment, dated 05/27/24, reflected the following: [Resident #1] is being seen today for the management of psychotropic medications and side effects, and to monitor the effect of medication and for dosage adjustment. [Resident #1]'s psychotropic medication is beneficial in this case to control their psychiatric symptoms and to manage [Resident #1]'s condition and to prevent relapse or hospitalization . Review of Resident #1's progress notes, dated 01/04/24 at 1:10 AM, relected the following: [Resident #1] awake, in hallway, looking at clock on wall, and then back to his room. Review of Resident #1's progress notes, dated 01/06/24 at 12:43 AM, reflected the following: [Resident #1] disoriente to time, even asking staff for time, ambulatin to various clocks on wall to look at time, and then going to bed. Review of Resident #1's progress notes, dated 01/15/24 at 12:10 AM, reflected the following: [Resident #1] has been up and about, constantly coming to nurse, asking for a job, being difficult to redirect. He propels in dining room, drinking from pitchers lying about, and then back to his room. Review of Resident #1's progress notes, dated 01/15/24 at 8:06 PM, reflected the following: [Resident #1] walked out the front door of the building, following the lab tech out . Review of Resident #1's progress notes, dated 01/15/24 at 9:50 PM, reflected the following: DON was notified following [Resident #1]'s exit-seeking and leaving through the front door. During an interview on 06/06/24 at 11:43 AM, Resident #1's FM A stated she was aware he was on a few psychotropic medications. She stated the facility did inform her. She stated since being put on the psychiatric medications he was more calm, less anxious, and he slept through the night. During an interview on 06/06/24 at 12:32 PM, the ADM stated the MDSC was normally responsible for care plans but any nurse could update them. He stated he would expect Resident #1's behaviors to be documented in his care plan. He stated care plans were important to be able to provide necessary care and not providing the best care possible could be a negative outcome if the residents' care plans were not complete and comprehensive. During an interview on 06/06/24 at 12:39 PM, the MDSC stated she was responsible for initial and quarterly care plans and when there was a change in a resident's condition. She stated things such as pain, ADLs, wounds, and falls should be care planned. She stated Resident #1's behaviors, such as his constant wandering, agitation, and confusion, should have been care planned . Record review of the facility's Comprehensive Person-Centered Care Plan Policy, revised December 2016, reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.