Every finding on record at Saint Luke Lutheran Home

Based on record review and interview, the facility failed to ensure an effective administration staff. This finding had the potential to affect all residents residing in the facility. The facility census was 121.Findings include:1. Observation and subsequent interviews on 01/08/26 revealed Certified Nursing Assistant (CNA) #624 kicked Resident #117's bed and hit the resident with a closed fist. Further reviews revealed CNA #624's Nursing Orientation Checklist dated 12/05/25 did not have evidence of the entire second page of care including resident property sheet process, falls management program, gait belt, safe transfers, safety, sit-to-sand, mechanical lift, using your maxi move, call system basics, sensor alarms, resident alarms, shift to shift walking rounds, morning care, management of difficult behaviors, avoiding bruising and skin tears in the elderly, dementia bathing, restraints, mood and behavior patterns. The form was noted dated or signed by the employee or staff member completing the orientation.Interview on 03/09/26 at 11:02 A.M. with Human Resources (HR) #995 confirmed the above findings.2. Review of Resident #6's medical record and subsequent observation on 03/02/26 revealed the resident reported an allegation of neglect to the nursing staff who did not report to the administrative staff and no investigation was initiated for neglect.Interview on 03/03/2026 5:02 PM with the Administrator verified he was not informed of Resident #6's allegation of neglect.3. Review of Residents #10 and #47's medical records and subsequent observations revealed the staff did not report other staff taking Resident #10's pictures during care and staff did not report Resident #47's bruising to the right arm.Interview on 03/02/26 at 3:42 P.M. with the Administrator and Director of Nursing (DON) confirmed staff had not reported that other staff were taking Resident #10's pictures during care.Interview on 03/04/26 at 11:41 A.M. with the DON confirmed Resident #47's bruising to the right arm was not adequately assessed and monitored.4. Interview on 03/09/26 at 2:35 p.m. with the Administrator and the DON confirmed they took over a failing building and were in the process of replacing staff. The Administrator confirmed that new management took over and were trying to address these issues. Further interview on 03/09/26 at 2:50 p.m. with the Administrator confirmed he took over the building 08/04/25.5. Telephone interview on 03/09/26 at 3:46 P.M. with the Medical Director confirmed he was not aware of the identified concerns and would work with the facility administration to correct the issues for an effective administration.This deficiency represents non-compliance investigated under Complaints 2790371 and 2741949.

Based on observation, interview, and facility policy, the facility failed to maintain a sanitary kitchen This had the potential to affect all residents receiving meals from the kitchen. The facility indicated three (Residents #1, #63 and #136) do not receive meals from the kitchen as they receive nothing by mouth. The facility also failed to ensure resident room and unit refrigerators were monitored and maintained in a safe manner. This affected five (Residents #25, #85, #100, #101, and #110) and had the potential to affect 25 (Residents #6, #16, #22, #25, #26, #30, #34, #37, #38, #41, #43, #58, #74, #75, #82, #85, #97, #100, #101, #102, #104, #109, #110, #118, and #123) residents the facility indicated had room refrigerators. The facility census was 121.Findings include:Initial kitchen tour was completed on 03/02/26 at 8:30 A.M. with Dietary Director #845 and Dietary Supervisor #958. Observation on 03/02/26 at 8:39 A.M. of the stand mixer revealed dried food particles on the front and top of the mixer. Dietary Supervisor #958 confirmed the mixer should have been cleaned following use.Observation on 03/02/26 at 8:52 A.M. with Dietary Director #845 of the walk-in refrigerator revealed two gallons of whole milk with use by date of 02/27/26, one open, undated 32 oz container of almond milk, seven (5#) containers of sour cream with a use by date of 02/27/26, one (25#) open and partially used container of hard-boiled eggs with a received date of 01/02/26 and no open date. Interview with Dietary Director #845 at the time of the observation confirmed he was unsure how long the almond milk had been opened but thought it was about a week. Dietary Director #845 also confirmed the two gallons of whole milk with a use by date of 02/27/26, the containers of sour cream with a use by date of 02/27/26, and the opened and partially used container of hard-boiled eggs with a received date of 01/02/26 and no open date.Observation on 03/02/26 at 9:14 A.M. with Dietary Director #845 revealed the drawer below the stand-up mixer revealed the drawer had a dried spill in the bottom of the drawer with a paper over it that was stuck to it. Dried loose particles were also visible on the bottom of the drawer. Mixer parts were stored on top of the paper. One drawer on the prep table across from the mixer also had dried stains and dried food particles in the bottom. Observation on 03/02/26 at 9:16 A.M with Dietary Director #845 revealed two of the four totes sitting on top of the counter which contained kitchen utensils and scoops were visibly dirty in the bottom with dried food particles loose on the bottom. Dietary Director #845 confirmed the totes were supposed to be cleaned weekly and should not have had crumbs in the bottom and are supposed to have a cover over them when not in use. Observation on 03/02/26 at 9:20 A.M. with Dietary Supervisor #958 revealed the high temperature dish washer was working but had a visible leak. Observation at the time revealed the dish machine running with water leaking out the side and was draining down the wall behind the dish machine near electrical outlets onto the floor. A large puddle of water was observed on the floor which was approximately an inch deep and staff working the dish machine appeared to have wet shoes standing in front of the dish machine. Unnamed dish machine worker stated it was a pain to stand in the water while trying to keep the dishes moving. Interview at the time of the observation with Dietary Supervisor #958 confirmed the dish machine had been leaking for about three weeks.Review of the meal temperature logs for the month of February 2026 revealed not all pre-meals temperatures were completed as required. Breakfast temperatures were not completed for 02/02/26, 02/19/26, and 02/20/26. Lunch temperatures were not completed for 02/02/26 and dinner temperatures were not completed for 02/02/26, 02/03/26, 02/06/26, 02/09/26, 02/11/26, 02/12/26, 02/14/26, 02/15/26, 02/16/26, 02/17/26, 02/19/26, and 02/20/26. Interview on 03/02/26 at 9:27 A.M. with Dietary Supervisor #958 confirmed the meal temperature logs are supposed to be completed prior to each meal and recorded on the temperature log. Interview on 03/04/26 at 10:47 A.M. with the Administrator revealed that due to repairs on the dish machine needing to be completed, the facility would be using disposable plates for the lunch service.Observation on 03/04/26 at 11:34 A.M. with [NAME] #988 of the meal tray line revealed the following temperatures for the food on the steam table: bean soup was 170 degrees Fahrenheit (F); pureed bean soup, 170 degrees F; chicken, 152 degrees F; mechanical soft chicken, 171 degrees F; pureed chicken, 170 degrees F; mashed potatoes,160 degrees F; pureed bread, 160 degrees F; gravy, 160 degrees F; chicken tenders, 150 degrees F; green beans, 148 degrees F; Tator tots, 168 degrees F; and grilled cheese, 146 degrees F.Observation on 03/04/26 at 11:40 A.M. revealed 11 kitchen delivery carts for tray service were loaded with food items and requested beverages such as coffee, tea, milk, and fruit juices. The food delivery carts contained no source of heat or refrigeration. Observation on 03/04/26 from 11:47 A.M. until 1:38 P.M. with [NAME] #988 and [NAME] #708 revealed:At 11:47 A.M. meal tray line service began with Styrofoam cups and plates covered with a dome lid. Soup was placed in a paper bowl and covered with a lid. Metal eating utensils were used. At 12:02 P.M. the [NAME] #988 used a gloved hand to pick up bread and move it onto the plate. At 12:12 P.M. [NAME] #988 using his gloved hand to pick up bread and place on resident plate.At 12:47 P.M. [NAME] #988 stating he was running low on chicken and needed the next pan of chicken. [NAME] #708 brought an additional pan of chicken, which had a temperature of 183 degrees F. [NAME] #988 removed the pan of remaining chicken from the steam table which contained seven pieces of chicken and set it on the table behind the serving station. [NAME] #988 left the serving line and [NAME] #708 continued with tray line service.At 1:03 P.M. Physical Therapist #998 entered the kitchen and was standing next to the serving line requesting items. Interview with Physical Therapist #998 at the time of the observation confirmed she was not wearing a hair net and was inside the kitchen near the serving line. At 1:21 P.M. [NAME] #708 stated she was running low on chicken and needed more chicken. [NAME] #708 stated there was a pan behind her with a few pieces of chicken but had not been on a heat source. Dietary Director #845, who was on the other side of the kitchen instructed [NAME] #708 to bring the chicken over to have it warmed back up to temperature. Dietary Director #845 took the pan of leftover chicken with six pieces and put it in the warmer.At 1:36 P.M. [NAME] #708 brought the re-warmed chicken to the line. The chicken was held but not needed prior to the end of the tray line service. Tray line ended at 1:38 P.M.Interview on 03/04/26 at 1:40 P.M. with [NAME] #988 confirmed he had touched multiple surfaces and handles prior to picking up bread from a container and placing it on individual plates. [NAME] #988 stated he should have been using tongs.The test tray was sampled at 1:46 P.M. with Dietary Director #845 following the last resident tray being served. The following temperatures on the test tray were observed: the bean soup was 141.6 degrees F; the yogurt was 73 degrees F; milk was 61.3 degrees F; mashed potatoes, 132.4 degrees F; mechanical chicken, 101.3 degrees F; and pureed bread, 119.3 degrees F. Taste test of the items with Dietary Director #845 revealed the mechanical chicken did not taste warm enough for his preference, the pureed bread was bland and not warm enough, the bean soup was warm enough but tasted bland and the Dietary Director #845 stated the soup needed more seasoning. Dietary Director #845 confirmed the cold items were not held at appropriate temperature to maintain a safe meal service. The Dietary Director #845 stated if he were a resident he would have wanted the items to be warmer as the hot foods were not at a personal preferable temperature and he would also want more seasoning. Dietary Director #845 also confirmed he was not aware the leftover chicken had been without a heat source for approximately an hour when [NAME] #708 stated she was running low on chicken.Observation on 03/05/26 at 11:33 A.M. with Dietitian #925 of resident room refrigerators and unit refrigerator revealed the following concerns:1. Resident #100 and #101's shared room refrigerator revealed no evidence of temperature monitoring and no thermometer in the refrigerator. The freezer door was iced over and was unable to be opened.2. Resident #25's room refrigerator revealed no evidence of temperature monitoring or thermometer. The contents revealed one container of four-ounce yogurt with a use by date of 02/08/26, three containers of 5.3-ounce Greek yogurt with a use by date of 02/28/26, two containers of eight-ounce magic cups (nutritional supplement) in the freezer that were undated and partially eaten with visible freezer burn, two additional containers of magic cups. Interview at the time of the observation with Resident #25 confirmed the freezer had thawed for an undisclosed amount of time and the items had re-frozen but she was unsure how long ago it had been.3. Resident #85's room refrigerator contained one 16-ounce open, undated package of smoked ham with use by date of 02/18/26. Observation on 03/05/26 at 12:05 P.M. of the Southern Hills unit refrigerator revealed four undated ham and cheese sandwiches that appeared to be hard and dried. The freezer had an eight-ounce water bottle that was one quarter full and contained a green unidentified substance that appeared to be very discolored. Interview at the time of the observation with Registered Dietitian #925 confirmed all of the above findings. RD #925 stated she just took over the room refrigerators on 02/18/26 and stated she had ordered thermometers for the room refrigerators but had not had a chance to put them in. She stated with her other responsibilities, she had not had the time to monitor the refrigerators nor confirm whether the list of room refrigerators was accurate. RD #925 stated she was in the process of trying to update the facility policy for outside food monitoring procedure and confirmed there was no current temperature monitoring process and did not have evidence of previous temperature monitoring for resident room refrigerators prior to her start about six weeks ago.Review of the 2001 facility policy called Foods Brought by Family/Visitors revealed food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared foods. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. The nursing staff will discard perishable foods on or before the use by date. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates.)Review of the 2017 facility policy called; Food Safety and Sanitation revealed all local, state and federal standards and regulations will be followed in order to assure a safe and sanitary department of food and nutrition services. The food and nutrition services department will follow regulations as outlined by other official health agencies and organization with jurisdiction over the facility. Hair restraints are required and they should cover all hair on the head. Under #4 Food Storage part a stated Stored food is handled to prevent contamination and growth of pathogenic organisms. All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered and dated when stored. When the food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the date. Perishable food with expiration dates is used prior to the use by date on the package.

Based on record review, and staff interview the facility failed to ensure annual evaluations was completed. This had the potential to affect all 121 residents. The facility census was 121. Findings include: Review of personal file for Certified Nursing Assistant (CNA) #718 revealed the facility had not completed an annual evaluation for CNA #718 since 04/21/21.Interview on 03/09/26 at 9:48 A.M. Human Resources Manager #995 verified the facility has not completed an annual evaluation on CNA #718 since 04/21/21.

Based on observation, staff interview, family interview, and review of facility policy, the facility failed to ensure a clean and sanitary environment and failed to ensure patient care equipment was maintained in good repair. This finding affected six (Residents #4, #34, #69, #87, #134 and #137) of eleven resident rooms reviewed for environmental concerns. The facility census is 121.Findings include:Observations on 03/05/26 from 11:54 A.M. to 12:19 P.M. with Maintenance Director (MD) #827 of resident rooms revealed:Resident #4's bed remote had wires coming out of the remote and the facility had placed tape around the cord from about halfway up the cord to the remote itself. The cord was attached to the bed.Resident #34's curtain rod was bent and the rod with the curtains attached was hanging down at an angle above the residents bed.Resident #69's carpet had multiple stains and deep drywall scratches with missing paint.Review of Resident #87's wheelchair revealed dried brown debris was on the footrest clips on both the right and left side. The daughter who was seated in the room at the time of the observation indicated the debris was probably dried stool.Resident #134's wall behind the recliner had deep drywall scratches and grooves in the wall with missing paint.Resident #137's carpet had multiple stains.Interview on 03/05/26 at 12:20 P.M. with MD #827 confirmed the above findings.Review of the Homelike Environment policy revised 02/2021 revealed residents were provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.This deficiency represents non-compliance investigated under Complaint Number 2741949.

Based on observation, record review, interview, and policy review, the facility failed to ensure staff provided assistance with activities of daily living (ADL's) including toileting, showering and shaving for Residents #1, #4, #13, and #57. This affected five (#1, #4, #13, and #57) of 14 residents reviewed for ADL's. The facility census was 121.Findings include:1.Review of the medical record for Resident #1 revealed an admission date of 04/20/23 with diagnoses chronic respiratory failure, diabetes mellitus and repeated falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. He was able to understand staff and staff understood him. He had no behaviors noted on the assessment. He was dependent on staff for ADLs. Review of the shower schedule, undated, revealed Resident #1's showers were scheduled on Sunday and Thursday afternoons. Review of the shower sheets and electronic medical record from 01/01/26 through 03/01/26 for Resident #1 revealed the did not have showers on 01/11/26, 01/15/26, 01/29/26, 02/01/26, 02/08/26, 02/12/26 and 02/19/26. Interview on 03/02/26 at 12:33 P.M. with Resident #1 revealed he had not been receiving his showers on Sunday and Thursday as scheduled. The resident stated most of the time, he received only one shower per week. Resident #1 stated he would like to have showers at least twice per week. Interview on 03/05/26 at 9:58 A.M. with the Director of Nursing (DON) verified she had provided all of the shower documentation for Resident #1. 2. Review of the medical record for Resident #4 revealed an admission date of 05/31/24 with diagnoses chronic kidney disease, hypertension, hemiplegia affecting left non-dominant side and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed Resident #4 had intact cognition, had no behaviors or rejection of care. Resident #4 required substantial to maximum assistance from staff for showers and bathing herself. Review of the shower schedule, undated, revealed Resident #4's showers were scheduled on Mondays and Thursdays on dayshift. Review of the shower sheets and electronic medical record from 01/01/26 through 03/01/26 for Resident #4 revealed the resident did not have showers on 01/01/26, 01/06/26, 01/08/26, 01/10/26, 01/19/26, 01/25/26, 02/05/26, 02/16/26, 02/19/26, 02/23/26 and 02/26/26. Interview on 03/03/26 at 8:30 A.M. with Resident #4 revealed she was not getting her showers as scheduled per her preference. Interview on 03/05/26 at 9:58 A.M. with the DON verified she had provided all of the shower documentation for Resident #4. 3. Review of the medical record for Resident #57 revealed an admission date of 05/08/24 with diagnoses of depression, chronic pain and anemia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #57 had intact cognition, had no behaviors or rejection of care. Resident #57 needed substantial to maximum assistance from staff for showers. Resident #57 was occasionally incontinent of urine. Review of the shower schedule, undated, revealed Resident #57's showers were scheduled on Mondays and Thursdays on dayshift. Review of the shower sheets and electronic medical record from 01/01/26 through 03/01/26 for Resident #57 revealed the resident did not have showers on 01/16/26, 01/19/26, 01/23/26, 01/26/26 and 02/25/26. Interview on 03/02/26 at 12:43 P.M. with Resident #57 revealed she was not getting showers like she should. She stated she had to argue with staff to ensure she gets some showers. Interview on 03/05/26 at 9:58 A.M. with the DON verified she had provided all of the shower documentation for Resident #57. 4. Review of the medical record for Resident #13 revealed an admission date of 07/26/2024. Diagnoses included Alzheimer's disease, senile degeneration of the brain, depression, adult failure to thrive, history of falling, and unspecified dementia. Review of Resident #13 significant change MDS assessment dated [DATE] revealed the resident had a moderate cognitive impairment. Observations of Resident #13 on 03/02/2026 at 12:53 P.M. and 03/03/2026 at 4:01 P.M. revealed the female resident had a significant amount of grey/white chin hair approximately one inch long. Interview on 03/03/2026 at 4:01 P.M. with Licensed Practical Nurse (LPN) #961 verified resident is unable to complete her own shaving and she would have someone shave her. Interview on 03/04/2026 at 9:05 A.M. Resident #13 stated she prefers to have her chin hair shaved. She asked if someone could shave her at this time. Observation at this time revealed the chin hair was still present. Interview on 03/04/2026 at 9:08 A.M. LPN #986 verified Resident #13 chin hair had not been shaved and reported she would find someone to assist her. Review of Resident #13's progress notes revealed no refusals in March 2026 for shaving related to personal care or assistance with activities of daily living. Review of Resident #13's behavioral tracking for March 2026 revealed no concerns related to refusals of care. Review of Resident #13's care plan dated 9/8/2025 revealed the resident had a self-care deficit and impaired mobility due to a diagnosis of dementia, senile degeneration of brain, muscle weakness and history of fracture. The goals stated the resident will be clean and well-groomed with needs met through the next review. Interventions included dependent assistance with upper body dressing, personal hygiene, and showers and bathing. Review of the facility policy called; Activities of Daily Living (ADL), Supporting, dated April 2025 revealed residents are provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently are to receive the services necessary to maintain good nutrition, grooming and person and oral hygiene. Appropriate care and services are provided for resident 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 hygiene (bathing, dressing, grooming and oral care), mobility (transfer and ambulation, including walking), elimination (toileting), dining (eating, including meals and snacks), and communications (including speech, language and other functional communication systems). The care, treatment, and services are provided to ensure their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate diminishing ADLs are unavoidable. This deficiency represents non-compliance investigated under Master Complaint Number 2799697 and Complaint Number 2741949.

Based on observation, interview and review of maintenance logs and repair invoices, the facility failed to ensure kitchen equipment repairs were completed timely. This had the potential to affect all residents receiving meals from the kitchen. The facility indicated three (Residents #1, #63 and #136) receiving nothing by mouth. The facility census was 121. Findings include:1. Observation on 03/02/26 at 9:20 A.M. during the kitchen initial tour with Dietary Supervisor #958 revealed the high temperature dish washer was working but had a visible leak. Observation at the time revealed the dish machine running with water leaking out the side and was draining down the wall behind the dish machine near electrical outlets onto the floor. A large puddle of water was observed on the floor which was approximately an inch deep and staff working the dish machine appeared to have wet shoes standing in front of the dish machine. Unnamed dish machine worker stated it was a pain to stand in the water while trying to keep the dishes moving. Interview at the time of the observation with Dietary Supervisor #958 confirmed the dish machine had been leaking for about three weeks.Review of maintenance work order #600 dated 02/16/26 timed at 11:37 A.M. with a priority level of critical revealed there was noted water leaking and running out from under the dishwasher in dietary. The status of the work order was changed to completed on 02/16/26 at 11:37 A.M.Review of maintenance work order #610 dated 02/17/26 timed at 9:15 A.M. with a priority level of critical revealed maintenance checked the leak yesterday but the problem still exists and getting worse. The status of the work order was changed to completed on 02/17/26 at 2:17 P.M.Interview on 03/03/26 at 9:56 A.M. with Maintenance Director #827 confirmed the dish machine concern was reported on 02/13/26 but he was not working and did not work again until 02/16/26. Maintenance Director #827 attempted to fix the dish machine on 02/16/26, but another concern was reported on 02/17/26 which stated the leak was getting worse. Maintenance Director #827 stated he had not had a chance to schedule the repair since the survey team was here. Maintenance Director #827 confirmed he was calling a repair service then to get a service scheduled.Interview on 03/04/26 at 1:56 P.M. with Dietary Director #845 confirmed the dish machine was reported on 02/16/26 by another staff member and stated he was told maintenance came to look at it on 02/17/26 but was not fixed until 03/04/26.Phone interview on 03/10/26 at 12:28 P.M. with Plumbing Contractor #634 confirmed they were not contacted regarding repairs to the dish machine prior to 03/03/26. While at the facility, piping was replaced with copper pipes and also installed new isolation valves. Repairs have been made in the past and have failed causing the leaks.2. Observation on 03/04/26 at 9:35 A.M. with Dietary Supervisor #958 of pureed food preparation revealed when Dietary Supervisor #958 placed the ham and bean soup in the robot coupe (commercial food processor), the food processor was missing the center part of the cover which sealed the cover but also provided a handle to turn and scrape the sides of the machine while running. Observation at the time revealed Dietary Supervisor #958 attempt to cover the hole in the top cover with aluminum foil. Upon turning on the food processor, the soup sprayed out from underneath the aluminum foil and sprayed out onto the surrounding countertop and onto dishes on the rack behind it. Dietary Supervisor #958 confirmed the missing piece made it much more difficult and time consuming to puree items to obtain smooth consistency due to not being able to use the center piece to scrape the sides while the machine was running. Dietary Supervisor #958 confirmed the part had been missing for at least several weeks and was unsure if the parts had been ordered.Review of the phone text dated 02/04/26 from Dietary Manager #845 revealed a text exchange to Corporate Dietary #629 revealed information for the necessary parts were sent and requested to be ordered for the Robot Coupe.Review of the email dated 02/26/26 dated 02/26/26 from Corporate Dietary #629 timed at 8:00 A.M. revealed he was still working on the quote and hoped to order it that day.Review of the email dated 02/27/26 from Corporate Dietary #629 revealed the parts for the Robot Coupe were ordered.Interview on 03/05/26 at 10:33 A.M. with Dietary Manager #845 confirmed the Robot Coupe part had been ordered on 02/27/26 and was supposed to be delivered but had not been received. Review of the undated facility policy titled Community Equipment Policy Statement revealed all foodservice equipment will be clean, sanitary, and in proper working order. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. This deficiency represents non-compliance investigated under Complaint Number 2799697.

Based on observation, interview and review of the facility policy the facility failed to ensure palatable meals for residents receiving meals from the kitchen. This affected two (#14 and #134) and had to the potential to affect all residents who received meals from the kitchen. The facility identified three residents (#1, #63 and #136) who received nothing by mouth. The facility census was 121.Findings include:1. Review of the medical record for Resident #14 revealed an admission date of 02/05/26. Diagnoses included unspecified fracture of the lower end of the right radius, anxiety disorder, morbid obesity and need for assistance with personal care.Review of the physician order dated 02/05/26 for Resident #14 revealed a diet order for a regular diet with thin liquids.Review of the 02/10/26 Medicare five-day Minimum Data Set (MDS) assessment for Resident #14 revealed a Brief interview of Mental Status (BIMS) of 13 which indicated intact cognition. Resident #14 was noted to be dependent upon staff for eating and all activities of daily living (ADLs.)Interview on 03/02/26 at 12:45 P.M. with Resident #14 revealed food is not always hot by the time staff are able to assist her with her meals.2. Review of the medical record for Resident #134 revealed an admission date of 02/25/26. Diagnoses included displaced transverse fracture of right and left patella, osteoporosis with current fracture, congestive heart failure and chronic kidney disease.Review of the 02/25/26 admission assessment for Resident #134 revealed she was cognitively intact and was independent for eating meals.Review of the physician orders dated 03/03/26 for Resident #134 revealed a regular diet with thin liquids.Interview on 03/02/26 at 1:08 P.M. with Resident #134 revealed meals are frequently cold and do not taste good.Interview on 03/04/26 at 10:47 A.M. with the Administrator revealed due to repairs to the dish machine being completed, the facility would be using disposable plates for the lunch service.Observation on 03/04/26 at 11:34 A.M. with [NAME] #988 of the meal tray line revealed the following temperatures for the food on the steam table: bean soup was 170 degrees Fahrenheit (F); pureed bean soup, 170 degrees F; chicken, 152 degrees F; mechanical soft chicken, 171 degrees F; pureed chicken, 170 degrees F; mashed potatoes,160 degrees F; pureed bread, 160 degrees F; gravy, 160 degrees F; chicken tenders, 150 degrees F; green beans, 148 degrees F; Tator tots, 168 degrees F; and grilled cheese, 146 degrees F.Observation on 03/04/26 at 11:40 A.M. revealed 11 kitchen delivery carts for tray service were loaded with food items and requested beverages such as coffee, tea, milk, and fruit juices. The food delivery carts contained no source of heat or refrigeration. Observation on 03/04/26 at 11:47 A.M. with [NAME] #988 revealed meal tray line service began with Styrofoam cups and plates covered with a dome lid. Soup was placed in a paper bowl and covered with a lid. Metal eating utensils were used. Observation on 03/04/26 at 1:38 P.M. revealed the last meal cart was prepared and a test tray was requested. The test tray was sampled at 1:46 P.M. with Dietary Director #845 following the last resident tray being served. The following temperatures on the test tray were observed: the bean soup was 141.6 degrees F; the yogurt was 73 degrees F; milk was 61.3 degrees F; mashed potatoes, 132.4 degrees F; mechanical chicken, 101.3 degrees F; and pureed bread, 119.3 degrees F. Taste test of the items with Dietary Director #845 revealed the mechanical chicken did not taste warm enough for his preference, the pureed bread was bland and not warm enough, the bean soup was warm enough but tasted bland and the Dietary Director #845 stated the soup needed more seasoning. Dietary Director #845 confirmed the cold items were not held at appropriate temperature to maintain a safe meal service. The Dietary Director #845 stated if he were a resident he would have wanted the items to be warmer as the hot foods were not at a personal preferable temperature and he would also want more seasoning.Review of the facility policy called Community Dining and Meal Service Policy last reviewed on 12/01/25 revealed the dining experience will be person centered with the purpose of enhancing each individual patient's/resident's quality of life and will be supportive of each individual's needs during dining. Individuals will be provided with nourishing, palatable, attractive meals and will support each individual's daily nutritional and special dietary needs.This deficiency represents non-compliance investigated under Master Complaint Number 2799697.

Based on medical record review, interview and policy review the facility did not honor dietary preferences for three (Residents #8, #14, and #45) residents and did not tell or offer the family of Resident #8, who was cognitively impaired, the option to complete weekly menus. This had the potential to affect all resident receiving meals from the facility. The facility indicated three residents (Residents #1, #63 and #136) who received nothing by mouth. The facility census was 121. Findings Include:1.Review of the medical record for Resident #8 revealed an admission date of 09/08/23. Diagnoses included but were not limited to Alzheimer's disease, displaced comminuted fracture of shaft of left humerus with routine healing, and age-related physical debility. Review of the 08/25/25 physician order revealed and order for a regular mechanical soft diet with thin liquids with ice cream at lunch and dinner. Review of the 10/22/25 dietary note revealed the mini nutrition assessment was completed and noted no significant weight changes in the past three months. No noted evidence of dietary modifications or family involvement for preferences to increase intake. Resident #8 was noted to have a body mass index (BMI) of 18 with an average intake of 65% over the past 14 days and 42 meals reviewed. Review of the 02/13/26 quarterly Minimum Data Set (MDS) 3.0 for Resident #8 revealed a Brief Interview of Mental Status (BIMS) of 0 which indicated severe cognitive impairment. Resident #8 was noted to require moderate assistance for eating and receive a mechanically altered diet. Review of the 02/13/26 nutrition assessment for Resident #8 revealed no noted resident preference updates or evidence of family involvement with the assessment. BMI was noted to 18.1 and no significant weight changes were noted. Review of the care plan for Resident #8 revealed it was last reviewed on 02/22/26. No noted changes in nutrition care plan since 10/22/25. Interview on 03/02/26 at 3:37 P.M. with Resident #8's son revealed due to her cognitive impairment, she is not able to remember to request alternative food items and stated family has not been asked to update preferences or told they could fill out weekly menus. Interview on 03/05/26 at 1:40 P.M. with Registered Dietitian (RD) #925 revealed she updates resident preferences upon admission and at least quarterly. RD #925 stated every resident/family should be offered the chance to do weekly menus. RD #925 stated she was unable to provide evidence that Resident #8's family had been offered the chance to complete menus or update dietary preferences since she has only worked at the facility for about six weeks. 2. Review of the medical record for Resident #14 revealed and admission date of 02/05/26. Diagnoses included but were not limited to unspecified fracture of the lower end of the right radius, anxiety disorder, morbid obesity, and need for assistance with personal care. Review of the physician order dated 02/05/26 for Resident #14 revealed an order for a regular diet with thin liquids. Review of the 02/10/26 dietary Nutrition Assessment for Resident #14 revealed a regular diet and set up assistance required for meals. No comments were listed in the comments section under diet orders. Review of the 02/10/26 Medicare five-day Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) of 13 which indicated intact cognition. Resident #14 was noted to be dependent for all activities of daily living (ADLs). Review of Resident #14's care plan revealed potential risk for altered nutritional status related to fracture, reflex sympathetic dystrophy. Resident #14 was noted to have some meal refusals. Interventions listed included but were not limited to provide, serve diet as ordered. RD to evaluate and make diet change recommendations as needed. Interview on 03/02/26 at 12:45 P.M. with Resident #14 revealed the first day she told staff she did not like, and they stated they would let the kitchen know, but she continues to receive chicken. She stated she receives daily menus but has not consistently had staff offer to assist her to fill them out. Review of the facility diet ticket for Resident #14 dated 03/05/26 revealed a regular diet with no specified preferences listed. Interview on 03/05/26 at 1:40 P.M. with RD #925 confirmed Resident #14's dietary ticket did not list a dislike of chicken, was unable to provide evidence of resident preferences being documented and also confirmed staff are supposed to assist with filling out the daily menus. RD #925 stated daily menus go down on the breakfast care for the following but was unsure whether staff are consistently passing them out or if staff are consistently assisting resident who require assistance filling out the menus. 3. Review of Resident #45's medical record revealed the facility admission date was 06/28/22 with a diagnosis of unspecified dementia and a regular diet order with regular texture, and thin liquids. Review of Resident #45's care plan, dated 06/27/22, for the potential of alteration in nutrition revealed the risk for the overall decline in activities of daily living (ADL) due to advanced age and decline in cognition with an intervention to review food likes, dislikes, and meal preferences as needed. Observation on 03/04/26 at 8:00 A.M. of Resident #45's breakfast tray revealed water, juice, hard-boiled egg, oatmeal, hash brown, and a cake like pastry that contained yellow pieces of possibly fruit. The tray meal ticket revealed the choice of cereal, hard-boiled egg, blueberry muffin, hash brown, milk, coffee, and juice. During the observation, Resident #45 appeared upset. Resident #45 indicated all that was requested was frosted flakes, coffee, and milk. Interview on 03/04/26 at 8:06 A.M. with Certified Nursing Assistant (CNA) #860 confirmed Resident #45's tray was incorrect. CNA #860 indicated dietary messed up residents' orders all the time. Observation on 03/04/26 at 8:14 A.M. with CNA #860 brought Resident #45 frosted flakes, milk, and coffee. Observation on 03/04/2026 at 8:24 A.M. revealed Resident #45 was finishing the frosted flakes and coffee. During the observation Resident #45 appeared happy and indicated not understanding why meals were always wrong. Interview on 03/05/26 at 8:42 A.M. with Resident #45 indicated breakfast was terrible and did not get what was ordered. Interview on 03/05/26 at 10:46 A.M. with Dietician #925 revealed being aware of the concern Resident #45 had about not receiving the food that was ordered. Dietician #925 indicated the dietary staff was having a hard time knowing what each resident wanted. In April 2026, the dietary department will be changing to a meal tracker system to organize the kitchen to better serve the residents and ensure residents are getting what they ordered. Review of therapeutic diets policy, revision date 10/17, revealed diets will be determined in accordance with the resident's informed choices, preferences, treatment goals, and wishes. Review of the 2001 facility policy called; Therapeutic Diets revealed diet will be determined in accordance with the resident's informed choices, preferences, treatment goal and wishes. The dietitian, nursing staff and attending physician will regularly review the need for, and resident acceptance of prescribed therapeutic diets. This deficiency represents non-compliance investigated under Master Complaint Number 2799697.

Based on record review, interview, review of facility Self-Reported Incidents (SRIs) and policy review the facility failed to complete an investigation for Resident #47 and also failed to complete a thorough investigation for Resident #117 as required. This affected two (#47 and #117) of three residents reviewed for abuse. The facility census was 121. Findings include:1.Review of the medical record for Resident #117 revealed an admission date of 12/29/25. Diagnoses included but were not limited to neurocognitive disorder with Lewy Bodies, generalized anxiety disorder, chronic pain syndrome and Alzheimer's dementia. Review of the physician's orders revealed an order dated 12/30/25 for Resident #117 for hospice services. Review of the 01/02/26 admission Minimum Data Set (MDS) 3.0 for Resident #117 revealed a Brief Interview of Mental Status (BIMs) of four which indicated severe cognitive impairment. Resident #117 was noted to require maximum staff assistance with toileting. Review of the facility Self-Reported Incident (SRI) dated 01/09/26 opened at 10:58 A.M. for Resident #117 revealed the report indicated an allegation was reported by the resident's family. Resident #117 was indicated to not have provided meaningful information due to dementia. No negative effects were observed at the time of the observation of Resident #117. The narrative of the incident dated 01/08/26 timed at 10:30 P.M. revealed on 01/08/26 a family member called police to report they witnessed the in-room camera alleged a staff member (Certified Nursing Assistant (CNA) #624) kicking a resident's bed. Police and family arrived at the facility at approximately 10:30 P.M. on 01/08/26. Alleged staff member was removed and suspended pending investigation. Resident #117 was assessed for injuries and distress. Review of the investigation did not reveal any written staff statements other than from CNA #624. The facility census for 01/09/26 was included and indicated an audit with check marks on all of the interviewable residents with a statement at the bottom stating that all residents report feeling safe, had no signs or symptoms of distress, and there were no needs at this time. No evidence was provided as to what responses each interviewed resident had provided. There was no documentation regarding how the non interviewable residents were assessed. Review of the 01/09/26 employee counseling form for CNA #624 revealed on 01/08/26 a work performance and department policy violation with a description of failure to follow proper resident care procedures/improper brief change. CNA #624 was noted as terminated on 01/09/26 via telephone by the Director of Nursing (DON) and Administrator. Interview on 03/05/26 at 11:19 A.M. with the Administrator and DON confirmed the Administrator did not feel the incident was an intentional aggressive action against the resident and stated he thought CNA #624's behavior was bizarre but did not feel it was classified as neglect. The Administrator also confirmed kicking the bed was not an appropriate provision of care. The DON confirmed she was unable to provide written evidence of staff interviews other than CNA #624 or individual resident responses other than a check mark on the census form following the reported allegation on 01/08/26. Phone interview on 03/09/26 at 8:45 A.M. with Resident #117's granddaughter stated she viewed the video the evening of 01/08/26 and called the police while she was enroute to the facility about abuse towards Resident #117. Phone interview on 03/09/26 at 9:30 A.M. with Registered Nurse Coordinator #981 confirmed she was working when Licensed Practical Nurse (LPN) #712 came to her with Police Officer #626 to view the videos and was not asked to write a witness statement. Phone interview on 03/09/26 at 10:38 A.M. with CNA #628 confirmed she was working the night of 01/08/26 and was not asked to write a witness statement. Phone interview on 03/09/26 at 3:45 P.M. with the Medical Director confirmed he did not recall being notified of an allegation of abuse for Resident #117. Review of the 2016 facility policy called; Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed it is the facility's policy to investigation all alleged violation involving abuse, neglect, exploitation, mistreatment of a resident or misappropriation of Resident property, including all injuries of unknown source, in accordance with this policy. On page five, under section F, number two indicated to interview the resident, the accused, and all witnesses. Witnesses generally include anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident (including other residents, family member), and employees who worked closely with the accused employee(s), and/or alleged victim of the day of the incident. If there are no direct witness, then the interviews may be expanded. For example, to cover all employees on the unit, or, as appropriate, the shift. Under number three in section F stated evidence of the investigation should be documented. 2. Review of the medical record for Resident #47 revealed an admission date of 01/06/10 with diagnoses of adult failure to thrive, paranoid schizophrenia (chronic mental health condition characterized by intense, irrational, and persistent hallucinations or delusions, often focusing on persecution or conspiracy) and dementia. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #47 had severely impaired cognition. Review of the Nurse Practitioner (NP) progress note dated 02/12/26 revealed Resident #47's skin was intact with no bruising to the extremities. Review of the physician's orders for Resident #47 for March 2026 revealed she was not on an anticoagulant or antiplatelet which could lead to her bruising more easily. Review of nursing progress notes from 02/03/26 through 03/04/26 for Resident #47 revealed there was no indication she had a bruise to her right forearm or assessments or an investigation had been completed. Observation on 03/02/26 at 11:06 A.M. of Resident #47 revealed a circular bruise that was purplish red in color approximately the size of a half dollar to her right forearm. Resident #47 was unable to answer questions correctly and was not able to state how she obtained the bruise on her right forearm. Observation on 03/04/26 at 8:28 A.M. of Resident #47 revealed a circular bruise that was purplish red in color, which appeared to be diminishing. Director of Resident Services #892 was present and verified the bruise on Resident #47's right forearm. Interview on 03/04/26 at 9:57 A.M. with Regional Direct of Clinical Services #610 verified facility staff had not documented Resident #47 had a bruise to her right forearm and no assessment was completed. Interview on 03/04/26 at 10:05 A.M. with the DON verified the facility had not performed an investigation related to Resident #47's bruise to her right forearm as staff had not brought it to her attention. Interview on 03/04/26 at 1:10 P.M. with LPN #604 revealed she had worked on 03/04/26 during the dayshift. She stated she had noticed the bruise to Resident #47's right forearm but believed it was an old area as the nurse aides had not reported new skin issues, so she marked no new skins issues on Resident #47's shower sheet. LPN #604 stated she had not reported the bruise to anyone nor filled out any statements. Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 2016, revealed the facility staff did not follow their policy. The policy stated staff would investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property including injuries of unknown source. The facility staff should immediately report all such allegations to the Administrator and to the State Agency in accordance with the procedures in the policy. Injury of unknown source is defined as the source of the injury that was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, location of the injury or the number of injuries observed at one particular time or the incidence of injuries over time. Staff should be able to identify events such as suspicious bruising and trends that may constitute abuse. Under the response section of the policy, it stated staff should report all incidents/allegations immediately to the Administrator or designee. Once the Administrator was notified, an investigation of the allegation violation would be conducted and documented. This deficiency represents non-compliance investigated under Complaint Number 2741949 and Complaint Number 2741907.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure monthly pharmacy recommendations were completed timely and further failed to ensure the physician order for pharmacy recommendations were followed. This affected two (#4 and #6) of five residents reviewed for unnecessary medications. The facility census was 121. Findings include:1. Review of the medical record for Resident #4 revealed an admission date of 05/31/24 with diagnoses including chronic kidney disease, depression and anxiety. Review of the pharmacy recommendation dated 03/20/25 revealed the pharmacist reviewed Resident #4's medication and inquired if a gradual dose reduction of either Fluoxetine 20 milligrams (mg) (antidepressant) or Hydroxyzine 10 mg (antihistamine with sedative properties used to treat anxiety and itching) would be appropriate at that time. The physician had responded on 06/09/25, stating to discontinue the Hydroxyzine. Review of the physician orders revealed no order to discontinue the Hydroxyzine. Review of the medication administration records for March 2025, April 2025, May2025, June 2025 and July 2025 for Resident #4 revealed the resident was administered Hydroxyzine 10 mg three times a day until she discharged to the hospital on [DATE]. Review of the nursing progress notes from 03/20/25 through 07/28/25 for Resident #4 revealed no indication nursing had followed the physician's order of discontinuing the Hydroxyzine on 06/09/25 as the physician had ordered. Interview on 03/05/26 at 9:58 A.M. with the Director of Nursing (DON) verified the pharmacy recommendation dated 03/20/25 was not provided to the physician timely and the physician order to discontinue the Hydroxyzine had not followed. The DON verified Resident #4 received the Hydroxyzine until she was discharged to the hospital on [DATE]. 2. Review of the medical record for Resident #6 revealed an admission date of 11/28/2025. Diagnosis included ischemic cardiomyopathy, acute respiratory failure with hypoxia, chronic atrial fibrillation, chronic obstructive pulmonary disease (COPD) with acute exacerbation, diabetes mellitus, anxiety disorder, and depression. Review of Resident #6's Pharmacy recommendation dated 01/23/26 revealed Resident #6 is an [AGE] year-old male with a history of depression, anxiety, and insomnia with targeted medications including Buspirone 10 mg twice a day, Lorazepam 1 mg at night, Lorazepam 0.5 mg daily as needed anxiety, and Trazodone 100 mg daily as needed insomnia. The recommendation asked if it would be appropriate for a gradual dose reduction at this time? Continued review revealed the recommendation revealed the recommendation was not reviewed or addressed by the physician until 03/02/26 when the physician decided to maintain the current order. Interview on 03/05/2026 at 9:28 A.M. the DON revealed the previous Assistant DON was monitoring pharmacy recommendations for the facility, and the January 2026 recommendations were given late to the physician to review. The DON stated her expectation is for the pharmacy reviews to be addressed within the month of the recommendation or when the physician is in the facility next after the recommendation is received. Review of the facility policy titled, Administering Medications, dated April 2019, revealed medications were to be administered in accordance with the prescriber's orders. Review of the facility policy titled, Psychotropic Medication Use, dated February 2025, revealed residents on psychotropic medications would receive gradual dose reductions to determine whether the continued use of the medication was benefiting the resident, to find an optimal dose, or in an effort to discontinue the medication.

Based on observation, record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were administered as ordered. This affected three (#1, #4 and #47) of seven residents reviewed for medications administration. The facility census was 121.Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 04/20/23 with diagnoses including chronic respiratory failure, diabetes mellitus, chronic kidney disease and depression.Review of the current physician's orders revealed Resident #1 had orders dated 01/31/26 for Albuterol Sulfate Inhalation 2.5 milligrams (mg) per 3 milliliters (mL), inhale orally three times a day for shortness of breath, Clonidine 0.1 mg every eight hours for hypertension, Gabapentin 400 mg three times a day for pain, and Hydralazine 100 mg three times a day for hypertension. Review of the Medication Administration Record (MAR) for February 2026 for Resident #1 revealed Albuterol Sulfate was not administered on 02/05/26, 02/08/26 and 02/22/26 at 6:00 A.M. and on 02/22/26 at 2:00 P.M. Clonidine was not administered on 02/05/26, 02/08/26 and 02/22/26 at 6:00 A.M. and on 02/22/26 at 2:00 P.M. Gabapentin 400 mg was not administered on 02/05/26, 02/08/26 and 02/22/26 at 6:00 A.M. and on 02/22/26 at 2:00 P.M., and Resident #1's Hydralazine 100 mg was not administered on 02/05/26, 02/08/26 and 02/22/26 at 6:00 A.M. and on 02/22/26 at 2:00 P.M.Review of the nursing progress notes from 02/05/26 through 03/01/26 for Resident #1 revealed there was no indication as to why the Albuterol Sulfate, Clonidine, Gabapentin and Hydralazine were not administered as ordered on 02/05/26, 02/08/26, and 02/22/26 and there was no documentation of the physician updated on the medications not being administered.Interview on 03/02/26 at 12:33 P.M. with Resident #1 revealed at times medications are not administered as ordered. Interview on 03/04/26 at 11:41 A.M. with the Director of Nursing (DON) verified Resident #1's medications were not administered as ordered on 02/05/26, 02/08/26, and 02/22/26. The DON had no explanation as to why medications were not administered as ordered on those dates and further verified there was no documentation in Resident #1's medical record to indicate why the medications were not administered and further verified there was no documentation of the physician being notified of the medications not being administered.2. Review of the medical record for Resident #4 revealed an admission date of 05/31/24 with diagnoses including chronic kidney disease, depression, anxiety and diabetes mellitus.Review of the current physician's orders for Resident #4 revealed the resident had orders for Gabapentin 300 mg three times a day for pain dated 08/03/25, Lipitor 40 mg at bedtime for hyperlipidemia dated 08/03/25, Pantoprazole Sodium 40 mg in the morning for gastroesophageal reflux disease dated 08/04/26, and cranberry 450 mg twice a day for prophylaxis for urinary tract infections dated 08/06/25.Review of the MAR for January and February 2026 for Resident #4 revealed nursing staff had placed a code nine on the MAR, which meant other, for her Gabapentin 300 mg on 01/10/26 at 9:45 A.M., Lipitor 50 mg at bedtime; Pantoprazole Sodium 40 mg on 01/18/26 at 10:04 A.M.; and cranberry 450 mg on 02/24/26 at 10:48 A.M.Review of the nursing progress notes from 01/10/26 through 03/03/26 for Resident #4 revealed Gabapentin 300 mg was not administered on 01/10/26 at 9:45 A.M. due to being on order. On 01/12/26 Resident #4's Lipitor 50 mg was not administered at bedtime due to being on order. On 01/18/26 at 10:04 A.M. the nursing progress note stated Pantoprazole Sodium 40 mg was not administered in the morning due to being on order. On 02/24/26 at 10:48 A.M. Resident #4's cranberry 450 mg was unavailable on the cart to be administered. There was no documentation in the medical record that the physician was updated that the medications were not administered.Interview on 03/03/26 at 8:30 A.M. with Resident #4 revealed she did not receive her medications like she should from nursing staff.Interview on 03/04/26 at 11:41 A.M. with the DON verified Resident #4's Gabapentin on 01/10/26 at 9:45 A.M., Lipitor on 01/12/26, Pantoprazole Sodium on 01/18/26, and cranberry on 02/24/26 at 10:48 A.M. was not administered and the physician was not notified.3. Review of the medical record for Resident #47 revealed an admission date of 02/23/13 with diagnoses including paranoid schizophrenia (chronic mental health condition characterized by intense, irrational, and persistent hallucinations or delusions, often focusing on persecution or conspiracy), adult failure to thrive, depression, pain and dementia. Review of the current physician's orders for Resident #47 revealed orders for Aricept 10 mg in the afternoon for Alzheimer's Disease dated 06/15/22, and an order for Sodium Chloride tablet 1 gram three times a day for low sodium dated 05/09/25.Review of the MAR for February and March 2026 for Resident #47 revealed nursing staff had placed a code nine on the MAR, which meant other, for the Sodium Chloride 1 gram on 02/25/26 at 4:59 P.M., on 02/25/26 at 8:00 P.M., on 02/26/26 at 8:20 A.M., on 03/01/26 at 3:55 P.M., on 03/01/26 at 5:24 P.M., on 03/03/26 at 10:54 A.M. as well as her Aricept 10 mg on 03/01/26 at 3:52 P.M. Review of the nursing progress notes from 02/03/26 through 03/03/26 for Resident #47 revealed Sodium Chloride 1 gram was not available and on order on 02/25/26 at 4:59 P.M., on 02/25/26 at 8:00 P.M., on 02/26/26 at 8:20 A.M., on 03/01/26 at 3:55 P.M., 03/01/26 at 5:24 P.M. and on 03/03/26 at 10:54 A.M. On 03/01/26 at 3:52 P.M. Resident #47's Aricept 10 mg was on order and not able to be administered. Further review of the nursing progress notes revealed there was no documentation that the physician was updated on the medications not being administered.Interview on 03/04/26 at 11:41 A.M. with the DON verified Resident #47 did not receive Sodium Chloride 1 gram on 02/25/26 at 4:59 P.M., on 02/25/26 at 8:00 P.M., on 02/26/26 at 8:20 A.M., on 03/01/26 at 3:55 P.M., on 03/01/26 at 5:24 P.M., on 03/03/26 at 10:54 A.M., and Aricept 10 mg on 03/01/26 at 3:52 P.M. as ordered. The DON had no explanation as to why they were not administered and further verified the physician was not notified of the medications not being administered.Review of the facility policy titled, Administering Medications, dated April 2019, revealed medications were to be administered in a safe and timely manner in accordance with the prescriber orders including any required time frames. This deficiency represents non-compliance investigated under Complaint Number 2791849.

Based on observation, record review, resident interview, staff interview, and the facility policy review the facility failed to ensure Resident #01's percutaneous endoscopic gastrostomy (PEG) tube dressing was in place. This affected one of one residents reviewed for PEG tube care. The facility census was 121. Findings include:Review of Resident #01's medical record revealed a facility admission date of 01/31/26 with a diagnosis of pneumonitis due to inhalation of food and vomit.Review of Resident #01's Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #01 had a feeding tube.Review of Resident #01's physician orders revealed an order for PEG tube site care to cleanse around the PEG tube site with normal saline daily and apply a split dry dressing every night shift.Review of Resident #01's enteral nutrition care plan, dated 02/18/26, revealed no PEG tube dressing care listed as an intervention in the care plan.Review of Resident #01's treatment administration record revealed the PEG tube dressing was not signed off on 02/02/26, 02/04/26, 02/19/26, and 02/23/26.Observation on 03/05/2026 at 11:50 A.M. of Resident #01's medication administration with Agency Licensed Practical Nurse (LPN) #620 revealed Resident #01 did not have a dressing in place to the PEG tube site.Immediately following the observation, Agency LPN #620 confirmed there was no dressing to the PEG tube site. Agency LPN #620 indicated being unsure why there was no dressing in place and stated, I thought that was weird too and continued down the hall to nurses' station. Observation on 03/09/26 at 8:10 A.M. revealed Resident #01 was lying in bed, and no dressing was noted to the PEG tube site. There was no redness noted but dry, scabbed skin around PEG tube site. During the observation, interview with resident indicated there was a dressing on the site the prior day but it was taken off due to his shower and not replaced. Certified Nursing Assistant #965 confirmed no dressing to PEG tube site and was unsure why. Review of the facility's enteral nutrition policy, dated 11/18, revealed the provider will consider the need for supplemental orders, including: instructions for enteral nutrition preparation. Staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as skin breakdown around insertion site.

Based on record review, observation and interview, the facility failed to ensure Resident #10's foley catheter output was monitored as ordered. This affected one (Resident #10) of three reviewed for catheters. The facility census was 121. Findings include:Review of the medical record for Resident #10 revealed an admission date of 01/30/26 with diagnoses including heart failure, diabetes mellitus and muscle weakness.Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was dependent for toileting, showers and transfers. Resident #10 was occasionally incontinent of bowel and had an indwelling catheter.Review of the care plan dated 02/10/26 for Resident #10 revealed he had an indwelling catheter. Interventions included for staff to record input and output.Review of the physician's orders for Resident #10 revealed he had an order for staff to record foley output every shift (day, evening and night shift) dated 02/03/26 and discontinued 02/26/26. His physician's orders also revealed foley catheter was removed for a voiding trial on 02/18/26.Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for February 2026 for Resident #10 revealed foley output was not monitored on 02/03/26, 02/04/26, 02/05/26, 02/07/26, 02/09/26, 02/10/26, 02/13/26 and 02/16/26 on night shift; 02/04/26, 02/15/26, 02/16/26 and 02/17/26 on dayshift; and on afternoons on 02/08/26.Interview on 03/04/26 at 9:57 A.M. with Director of Clinical Services #610 verified Resident #10's foley output was not completed each shift as ordered on the dates listed above.Review of the facility policy titled, Catheter Care, Urinary, August 2022, revealed staff should observe the resident's urine level for noticeable increases or decreases as well as follow the facility procedure for measuring and documenting input and output.

Based on observation, interview, and record review the facility failed to ensure Resident #117 received a thorough fall investigation and failed to ensure fall interventions were in place for Resident #8. This affected two (#117 and #8) of four residents reviewed for falls. The facility census was 121. Findings include:1.Review of the medical record for Resident #117 revealed the resident was admitted on [DATE] with diagnoses including Lewy Bodies Dementia, chronic pain syndrome and Alzheimer's disease. Review of Resident #117's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #117's care plan dated 01/01/26 revealed a risk for falls characterized by history of falls/injury and multiple risk factors. Interventions included analyzing previous resident falls to determine whether pattern/trend can be addressed, call light accessible, and if a fall occurs, assess factors leading to fall and notify the doctor and family of occurrences. Review of Resident #117's Fall Risk assessment dated [DATE] revealed the resident was high risk for falls. Review of Resident #117's video surveillance dated 03/05/26 at 2:08 A.M. revealed the resident was dressed in shorts and shirt. She was sitting on her floor in front of the door and had appeared to have fallen. Two staff members are observed responding. Further review revealed Resident #117's fall dated 03/05/26 at 2:08 A.M. was not documented in the resident's medical record. Interview on 03/05/26 at 1:06 P.M. with Resident #117's family members confirmed they were not notified of the fall on 03/05/26 at 2:08 A.M. Interview on 03/09/2026 at 9:05 A.M. the Director of Nursing (DON) stated she spoke with Licensed Practical Nurse (LPN) #973 who worked on 03/05/26. LPN #973 reported to her that they were already doing neurological checks from a fall that happened earlier that day and this is why she did not document the fall. The DON stated she provided education, went back and made notifications, and started a fall investigation for the late report. 2. Review of Resident #8's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease, essential hypertension and generalized anxiety disorder. Review of Resident #8's physician orders revealed an order dated 12/10/24 to encourage the resident to wear non-slip socks while in bed as tolerated. Review of Resident #8's fall care plan dated 12/10/24 and revised 08/22/25 revealed an intervention dated for non-slip socks to be worn while in bed as the resident allows. Review of Resident #8's Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of Resident #8's medical records revealed the resident had sustained falls on 01/20/26, 02/01/26/ 02/14/26 and 02/26/26. Review of Resident #8's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment. Attempted interview on 03/09/26 at 9:12 A.M. with Resident #8 and the resident was not interviewable. Observation at 9:13 A.M. at the time of the interview revealed the resident was lying in bed and her bilateral feet were uncovered. Non-slip gripper socks were not observed on her feet, and the gripper socks were not on the bed or on the floor near the bed. Interview on 03/09/26 at 9:17 A.M. with Certified Nursing Assistant (CNA) #992 confirmed Resident #8 was to have bilateral gripper socks on while in bed and the gripper socks were not observed on or near the resident to prevent the resident from further falls. Review of the facility policy, Falls and Fall Risk, Managing dated March 2018 under the section titled Monitoring Subsequent Falls and Fall Risk revealed staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of failing. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has been resolved. If the resident continues to fall, staff will re-evaluate the situation and decide whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. This deficiency represents non-compliance investigated under Complaint Numbers 2741907 and 2799697.

Based on observation, record review, staff interview, and policy review, the facility failed to implement pressure ulcer prevention interventions and treatments. This affected one (#10) of three residents reviewed for pressure ulcers. The facility census was 121. Findings include:Review of the medical record for Resident #10 revealed an admission date of 01/30/26 with diagnoses including heart failure, diabetes mellitus and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was dependent for toileting, showers and transfers. Resident #10 was occasionally incontinent of bowel. He had no skin impairment noted on this assessment. Review of the care plan dated 02/10/26 for Resident #10 revealed he was at risk for skin breakdown related to incontinence of bowel, having an indwelling device, impaired mobility, weakness and age-related changes. Interventions included to notify the physician of skin problems and treatments would be initiated per orders. Review of the nursing progress note dated 03/02/26 at 10:41 P.M. for Resident #10 revealed an aide had discovered a pressure wound to his coccyx. The nurse was updated and performed an assessment. The coccyx wound measured 0.5 centimeters by 0.2 centimeters with scant bleeding. The wound was cleaned with normal saline and Vitamin A and D ointment was applied followed by powder and a dry foam dressing was placed. Resident #10's son was updated. Review of the physician orders for 03/02/26 through 03/04/26 at 2:00 P.M. revealed there were no treatment orders to Resident #10's coccyx pressure ulcer. Observation of wound care on 03/04/26 at 2:01 P.M. with Registered Nurse (RN) #727 to Resident #10 revealed he did not have a treatment to his coccyx. RN #727 verified there was no treatment to his coccyx for his pressure ulcer. Upon further interview with RN #727 she verified there were no physician's orders for wound care or treatment to Resident #10's pressure ulcer from when the wound was first observed on 03/02/26 until observation on 03/04/26. Review of the facility policy titled, Prevention of Pressure Injuries, dated April 2020, revealed the facility would evaluate, report and document potential changes in the skin. Staff were to review the interventions and strategies for effectiveness. This deficiency represents non-compliance investigated under Master Complaint Number 2799697.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure adequate monitoring, assessments, and wound treatments were completed as ordered. This affected one (#31) of one resident reviewed for wounds. The facility census was 121. Findings include: Review of Resident #31's medical record revealed the resident was admitted on [DATE] and expired in the facility on [DATE]. Diagnoses included Alzheimer's disease, and peripheral vascular disease. Resident #31 was discharged to the hospital on [DATE] and returned to the facility on [DATE] status post (s/p) right great toe amputation on [DATE]. Review of Resident #31's Discharge Return Anticipated MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #31's admission Assessment form (readmission) dated [DATE] revealed the resident was unable to understand and had surgical incisions of the right hip and right great toes. Review of Resident #31's history and physical dated [DATE] revealed the resident was readmitted to the facility on [DATE]. The resident was sent to the emergency room (ER) on [DATE] with a worsening wound on the right foot with progressive swelling and redness. The resident was found to have sepsis and osteomyelitis and underwent an amputation of the right great toe with metatarsal resection and sesamoid complex of the right foot, with irrigation and debridement (I&D) of the right medial heel on [DATE]. The resident underwent a primary closure of the right heel and application of a wound vac on [DATE]. Infectious Disease recommended six weeks of Doxycycline and Augmentin. The resident underwent an angiogram and angioplasty in the right leg by a vascular surgeon on [DATE]. Review of Resident #31's physician orders revealed an order dated [DATE] for Doxycycline oral tablet 100 milligrams (mg), one tablet by mouth two times a day for a wound infection for sixty-six administrations due at 6:00 A.M. and 6:00 P.M. Review of Resident #31's medication administration record (MAR) from [DATE] to [DATE] revealed no evidence the Doxycycline antibiotic was administered on [DATE] at 6:00 A.M., [DATE] at 6:00 A.M., [DATE] at 6:00 A.M., [DATE] at 6:00 A.M., [DATE] at 6:00 P.M., [DATE] at 6:00 A.M., and [DATE] at 6:00 A.M. Review of Resident #31's wound assessment dated [DATE] revealed the resident had a right second toe diabetic ulcer first acquired [DATE] which measured 2.9 centimeters (cm) length by 1.2 cm width with undetermined depth and the wound bed was necrotic with dried eschar, a right plantar foot diabetic wound first acquired [DATE] measuring 1.2 cm length by 2.0 cm width by 1.1 cm depth, a right fourth lateral toe web diabetic ulcer first acquired [DATE] which measured 1.0 cm length by 0.5 cm width by 0.1 cm depth. The form listed the wound bed as granulation tissue. Resident #31 also had and a right four toe tip diabetic ulcer first acquired [DATE] which measured 1.0 cm length by 1.6 cm width by undetermined depth with eschar to the wound bed, a right toe amputation which measured 6.2 cm length by 2.2 cm width by undetermined depth with granulation tissue listed on the wound bed, a left plantar foot diabetic ulcer first acquired [DATE] which measured 2.0 cm length by 1.5 cm width by undetermined depth. The wound assessment indicated the right 5th toe healed as of [DATE]. Review of Resident #31's physician orders revealed an order dated [DATE] to cleanse the right great toe amputation site with normal saline (NS), pat dry, apply calcium alginate to the wound bed, cover with an abdominal dressing daily and as needed until resolved. Orders dated [DATE] to cleanse the right second, fourth, and fifth toes by flossing a 4x4 gauze with NS between the toes; dry thoroughly, weave mesalt (sodium chloride impregnated wound dressing designed to cleanse heavily exuding, infected and sloughy wounds) rope between the toes, cover with an abdominal dressing and kerlix daily and as needed until resolved and an order to cleanse the right plantar foot with NS, pat dry, apply an abdominal dressing and kerlix over the incision site daily and as needed until resolved. Both orders were discontinued on [DATE] and new physician orders were written which included the right second through fifth toes to be cleansed by flossing with a 4X4 gauze with NS between the toes, dry thoroughly, apply betadine to the wound beds and cover with an abdominal dressing and kerlix daily and as needed until resolved, an order to cleanse the right plantar foot incision with NS, pat dry, apply oil emulsion followed by calcium alginate cut to size. Cover with an abdominal dressing and kerlix daily and as needed until resolved, an order to cleanse the right fourth lateral toe with NS soaked 4x4 gauze flossed between the toes, apply betadine-soaked gauze to the wound bed, cover with an abdominal pad and kerlix daily and as needed until resolved. Another order written [DATE] included to cleanse the right great toe amputation with NS, pat dry, apply oil emulsion followed by calcium alginate cut to size, cover with an abdominal dressing and kerlix daily and as needed until resolved. The right plantar foot order was updated on [DATE] and read to cleanse with NS, pat dry, apply mesalt rope packing too the wound bed and tunneling at 3:00 o'clock using a cotton tip applicator and cover with an abdominal pad and kerlix daily and as needed until resolved. Further review of physician orders revealed a new order dated order dated [DATE] to cleanse the left medial plantar foot with normal saline, pat dry and cover with a dry dressing every shift until healed. The order was discontinued on [DATE] and a new order was written to cleanse with NS, pat dry, apply betadine to the wound bed daily and every night shift starting [DATE]. Other orders dated [DATE] included to cleanse the right second to fifth toes by flossing 4x4 gauze with NS between toes, dry thoroughly, apply betadine to the wound beds, cover with an abdominal dressing and kerlix until healed, and to cleanse the right plantar foot with NS, pat dry, apply mesalt rope packing to the wound bed and tunneling at 3:00 o'clock using cotton tip applicator and cover with abdominal pad and kerlix daily and as needed until resolved. Orders dated [DATE] were for the right fourth lateral toe to cleanse with NS soaked 4x4 gauze flossed between the toes, apply betadine-soaked gauze to the wound bed, cover with an abdominal dressing and kerlix daily and as needed until resolved and for the right great toe amputation to be cleansed with NS, pat dry, apply oil emulsion followed by calcium alginate cut to size, cover with an abdominal dressing and kerlix daily and as needed until resolved. Review of Resident #31's treatment administration records (TARS) from [DATE] to [DATE] revealed no evidence wound care was completed for the right second to fifth toes on [DATE], [DATE], [DATE] and [DATE], for the right plantar foot incision on [DATE], [DATE], [DATE], and [DATE], no evidence wound care was completed for the right fourth lateral toe on [DATE], [DATE], and [DATE], no evidence wound care was completed for the right great toe amputation on [DATE], [DATE], [DATE], and [DATE], and no evidence wound care was completed to the left medial foot on [DATE]. Telephone interview on [DATE] at 12:13 P.M. with RN Wound Nurse (WN) #727 revealed Resident #31's diabetic foot ulcers started out as a closed callus. RN WN #727 confirmed two days later the wound became necrotic and the resident was sent to the hospital for osteomyelitis. She stated the toenails were thicker but not unmanageable. RN WN #727 also confirmed she was unaware Resident #31 was not administered multiple doses of the resident's antibiotics and doxycycline antibiotics were in the pyxis medication system which staff were able to access. RN WN #727 also confirmed Resident #727's medical record did not have evidence of wound care for multiple wounds on the right and left feet. Telephone interview on [DATE] at 12:43 P.M. with Wound Nurse Practitioner (NP) #632 revealed Resident #31 had multiple incisions and gangrenous toes. Wound NP #632 indicated the resident would self-propel and hit his feet against things while on the secured Memory Care unit and the resident also had poor nutrition. Wound NP #632 denied concern with Resident #31's wound care. Review of the Wound Care policy revised 10/2010 revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. This deficiency represents non-compliance investigated under Master Complaint Number 2799697.

Based on observation, record review, staff interview, and review of facility policy, the facility failed to ensure Resident #10 had privacy during care. This affected one (#10) of two residents observed for care. The facility census was 121. Findings include: Review of the medical record for Resident #10 revealed an admission date of 01/30/26 with diagnoses including heart failure, diabetes mellitus and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was dependent for toileting, showers and transfers. Resident #10 was occasionally incontinent of bowel. Review of the care plan dated 02/10/26 for Resident #10 revealed he had self-care deficits which required staff assistance with activities of daily living related to functional decline, impaired mobility, weakness, end stage disease and age related changes. Staff were to ensure resident was clean and well groomed daily. Observation on 03/04/26 at 9:39 A.M. of Resident #10's room revealed his door was open. After knocking on the open door, this surveyor walked into the room and noted privacy curtain was open. Upon entering Resident #10's side of the room, Certified Nursing Assistant (CNA) #882 was noted to be providing incontinence care to Resident #10 without ensuring the resident had privacy. Interview on 03/04/26 at 9:46 A.M. with CNA #882 verified she had not provided privacy to Resident #10 by pulling the resident's privacy curtain or shutting his door. Review of the facility policy titled Activities of Daily Living, Supporting, dated April 2025 revealed residents were provided with care, treatment, and services as appropriate to maintain or improve their ability of care for activities of daily living.

Based on observation, record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure resident rooms were clean, sanitary and that residents had clean linens. This affected two (#85 and #110) out of three residents observed for a homelike environment. The facility census was 121.Findings include:1. Review of the medical record for Resident #85 revealed an admission date of 11/23/22 with diagnoses including chronic kidney disease, diabetes mellitus, heart failure and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 had intact cognition. He had no behaviors and was dependent on staff for hygiene and transfers. Observation and interview on 03/05/26 at 12:38 P.M. with Resident #85 revealed he was in bed. There were dirty bed linens draped over his wheelchair, dirty incontinence care wipes on the floor beside his bed, a bed pad on the corner of his tray table with creams and medications and his recliner had a white powdery substance on the back and seat portion. Resident #85 stated they were from the midnight shift staff who did not take the dirty items out of his room. Psychotherapist #618 was present in the room and verified she had been there for at least 30 minutes and no staff had entered the room. Certified Nursing Assistant (CNA) #619 entered the room and verified the dirty wipes, soiled linens on his wheelchair and tray table was covered with incontinence care items. She stated the soiled linens were not in his room when she provided care earlier in the day. CNA #619 then proceeded to clean resident's room, however, after removing items from his tray table, did not clean or disinfect his tray table. CNA #619 left the room and came back at 12:55 P.M. with Resident #85's lunch tray and placed it on his tray table without ensuring his tray table was clean. She verified she had not properly cleaned his tray table prior to placing his lunch meal on it. Additional interview on 03/05/26 at 1:00 P.M. with Resident #85 revealed staff did not clean his room before leaving to ensure soiled items were removed. He stated the facility utilized agency staff and they did not know how to do their job. Review of the facility policy, Homelike Environment, dated February 2021, revealed facility staff and management should maximize to the extent possible characteristics of the facility that reflects a personalized homelike setting including clean, sanitary and orderly environment, clean bed and bath linens. 2. Review of Resident #110's medical record revealed the resident was admitted on [DATE] and re-admitted on [DATE] with diagnoses including psychotic disorder with delusions, hemiplegia and quadriplegia. Review of Resident #110's quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Observation on 03/03/26 at 9:50 A.M. revealed Resident #110 had four pillows behind her head, and no pillow cases were observed on the pillows. Interview on 03/03/26 at 9:52 A.M. with Resident #110 confirmed she did not have pillow cases on her pillows, and she did not know why she did not have pillow cases, but she wanted some for her pillows. Interview on 03/03/26 at 9:58 A.M. with CNA #613 confirmed Resident #110 did not have pillow cases for the four pillows underneath of the resident's head and the midnight shift must have forgotten them. Interview on 03/03/26 at 3:51 P.M. with Registered Nurse (RN) #918 confirmed Resident #110 did not have pillow cases on her pillows and CNAs refused to provide care. Observation on 03/04/26 at 10:32 A.M. with Resident #110 revealed the resident had four pillows under her head. Two of the pillows had pillow cases and the other two plastic pillows did not have pillow cases. A subsequent interview with Resident #110 at the time of the observation revealed the staff ran out of pillow cases. Interviews on 03/04/26 at 10:40 A.M. with CNAs #855 and #949 revealed the supply closet did not have enough pillow cases on the floor to place on Resident #110's pillows. Observation on 03/04/26 at 10:42 A.M. with CNA #949 of the second-floor linen supply closet revealed three pillow cases were on the second shelf. Observation on 03/04/26 at 10:45 A.M. with Laundry Aide #714 revealed a laundry cart with approximately seven or eight pillowcases that were folded and placed on the laundry cart. A subsequent interview with Laundry Aide #714 at the time of the observation revealed the facility had an appropriate number of linens including pillow cases and a linen cart was sent to the floor twice a day. Review of the Homelike Environment policy dated 02/2021 revealed the facility staff and management maximizes to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean bed and bath linens that were in good condition. This deficiency represents non-compliance investigated under Complaint Number 2741949.

Based on record review, interviews, review of in-room videos, review of the facility self-reported incident, and review of facility policy, the facility failed to ensure Resident #117 was free from physical abuse. This affected one (#117) of four residents reviewed for abuse. The facility census was 121.Findings include:Review of the medical record for Resident #117 revealed and admission date of 12/29/25. Diagnoses included but were not limited to neurocognitive disorder with Lewy Bodies dementia, generalized anxiety disorder and Alzheimer's disease with late onset. Resident #117 was also noted to receive hospice services.Review of Resident #117's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and required maximum assistance for toileting hygiene. Review of Resident #117's care plan last reviewed on 01/14/26 revealed Resident #117 was receiving hospice services, was noted to have self-care deficits and required staff assistance with activities of daily living (ADLs) related to functional decline and impaired mobility. Resident #117 noted to required substantial/maximum assistance with toileting hygiene. Review of the nursing progress note for Resident #117 dated 01/08/26 timed at 10:52 P.M. revealed a skin sweep was completed with no areas of noted concern. No signs or symptoms of pain or distress were noted. Resident #117 was noted to be resting in bed. No evidence was noted of the family providing an in-room video or reporting an allegation of abuse.Review of Resident #117's video surveillance (20260206_101250), not timed but dated 01/08/26 revealed at the three second mark, Certified Nursing Assistant (CNA) #624 entered the room and kicked the right side of the Resident #117's mattress twice with her right foot. Resident #117's legs lifted up from the mattress and then down with each kick. CNA #624 proceeded to remove the resident's covers without speaking to her. Resident #117 stated You don't like me. CNA #624 stated Yes, I do. CNA #624 when responding to the resident proceeded to walk back towards the bathroom door. Resident #117 again stated, No, you don't like me. CNA #624 did not respond to Resident #117. Review of Resident #117's video surveillance (20260206_101253), not timed but dated 01/08/26 revealed at the 15 second mark, CNA #624 entered the room and approached Resident #117's bed, pulled back the covers and tapped Resident #117's left leg with a gloved fist. CNA #624 did not appear to speak to the resident. Resident #117's hands appeared to be up as if in confusion and CNA #624 was observed to leave the room without speaking to the resident. As CNA #624 left the room, Resident #117 continued to appear confused.Review of Resident #117's video surveillance (20260206_101242), not timed but dated 01/08/26 revealed CNA #624 provided incontinence care to the resident. At the seven second mark, Resident #117 was heard telling CNA #624 Thank you. There was no response from CNA #624. At the 15 second mark, Resident #117 was heard stating, I like you a lot. There was no response from CNA #624. At the 45 second mark, Resident #117 was heard again saying, Thank you. CNA #624 did not respond. At the one minute 23 second mark, Resident #117 was heard stating, You're so good at what you do, again there was no response from CNA #624. At the one minute 40 second mark, CNA #624 told Resident #117 to stand up and at one minute 45 seconds mark, Resident #117 moving toward the edge of the bed stated, You want me to stand up? CNA #624 was walking toward the bathroom. At one minute 48 seconds mark, CNA #624 told Resident #117 to Hold on, hold on in a loud and aggressive tone. At the two-minute mark, Resident #117 attempted to get out of bed and put her leg on the seat of the wheelchair and CNA #624 said, No, sit down and then ordered her in a loud aggressive manner to Sit back.Review of police report dated 01/08/26 for incident #2026-00000242 for Resident #117 timed at 10:06 P.M. revealed Resident #117's family reported abuse. Police Officer (PO) #626 reported he was dispatched to the facility on [DATE] at 10:02 P.M. PO #626 stated he spoke with Resident #117's family member via phone who reported they saw from a security camera in the room, a CNA identified as CNA #624 appear to strike Resident #117 on the leg with her hand. A second video was also viewed which showed CNA #624 come back into the room and appears to either kick Resident #117 in the leg twice or kick the mattress she was sleeping on twice. The kick appeared to be more forceful than the hand strike. After viewing the video, PO #626 went into the facility and spoke with Registered Nurse (RN) #712. RN #712 watched the video and then told CNA #624 she needed to go home, and her actions would be investigated. PO #626 spoke to CNA# 624 who reported she did not strike the resident. She reported that Resident #117 had soiled herself twice that day, once right after she had just gotten changed into a new diaper. CNA #624 reported that she never lost her temper or patience with Resident #117, and she told her she Loved her. CNA #624 did not recall any actions she may have taken that could be misconstrued as striking Resident #117. PO #626 then met with Resident #117 and her family and informed them it would be investigated in accordance with the facility policy. PO #626 informed the family that the report would be turned over to the Prosecutor. Resident #117 was noted to be in good spirits and was unable to recall anything happening to her legs. Review of the facility's neglect Self-Reported Investigation (SRI) with tracking number #269600 dated 01/09/26 opened at 10:58 A.M. revealed on 01/08/26 a family member called police to report what they saw during review of an in-room camera (surveillance video). The family alleged that a staff member was observed kicking a resident's bed. Police and family arrived at the facility at approximately 10:30 P.M. on 01/08/26. The alleged staff member was removed from care immediately and suspended pending an investigation. Resident #117 was assessed. Upon reviewing the camera footage, the CNA #624 was observed contacting the resident's bed frame with her foot in a non-aggressive manner. CNA #624 proceeded to provide incontinence and dressing care in a [NAME] manner. During the care, CNA #624 was noted to touch the resident on her leg, appearing to cue Resident #117 during care. Upon interview with CNA #624, she indicated that she was attempting to scratch an itch on her foot by scratching her foot on the bed frame. CNA #624 stated that she was diabetic and experienced tingling in her feet when her blood sugar dropped, and she explained that she was wearing gloves and did not want to touch her foot due to infection control. Camera footage verified that she was wearing gloves. The facility conclusion/disposition was indicated as unsubstantiated as evidence indicates abuse, neglect or misappropriation did not occur. The investigation was completed by the Director of Nursing.Review of CNA #624's witness statement dated 01/09/26 revealed on 01/08/26 she was caring for Resident #117. CNA #624 stated she came in to check on Resident #117 when her foot itched and since she was wearing gloves, she used the bed frame to scratch her itchy foot. CNA #624 stated she was not trying to kick the resident but did not want to contaminate her gloves, so she had to use the bed to scratch her foot. CNA #624 also stated she tapped on the resident twice to let her know that she was about to provide personal care and to let the resident know it was time to get up for incontinence care. Incontinence care was provided and CNA #624 assisted to the common area.Review of the 01/09/26 skin assessment for Resident #117 revealed a skin tear to the left pinky toe.Review of the 01/09/26 nursing progress note for Resident #117 timed at 11:11 A.M. authored LPN #897 revealed the daughter and power-of-attorney (POA) were notified of the scratch to the right foot pinky toe and treatment order was in place for the resident. The treatment order was discontinued on 01/12/26 at 3:42 P.M. as the right foot pinky toe scratch was healed.Review of the 01/15/26 skin assessment for Resident #117 revealed the skin tear was resolved.Review of the hospice notes from 01/02/26 to 01/16/26 for Resident #117 did not reveal any notification of an allegation of abuse or assessment by the hospice nurse.Review of the hospice care plan for Resident #117 did not reveal any changes made following the allegations of abuse.Interview on 03/04/26 at 7:15 A.M. with CNA #740 revealed she was working the night of the incident on the Memory Care unit with Resident #117 but did not see the incident and was not asked to write a witness statement. Interview on 03/04/26 at 10:40 A.M. was attempted with Resident #117 revealed resident was pleasantly confused but unable to provide information related to the incident due to severe cognitive impairment. Interview on 03/05/26 at 11:19 A.M. with the Administrator and Director of Nursing (DON) stated the police came to the facility on the evening of 01/08/26 and they sent CNA #624 home. The facility suspended CNA #624 and ensured the safety of Resident #117. The Administrator stated he did not feel the incident was an intentional aggressive action against Resident #117 but did think the behavior was bizarre and classified it as neglect. The Administrator confirmed he did not feel using the bed to kick or scratch was not a dignified action when providing care for a resident.Phone interview on 03/05/26 at 2:29 P.M. with Licensed Practical Nurse (LPN) #712 revealed she did not hear or observe any concerns until the police showed up and she viewed the videos provided by Resident #117's family. LPN #712 stated following viewing the video, she confirmed she did not feel CNA #624's care was appropriate. LPN #712 stated she felt the kick to the bed was unnecessary and thought it appeared as if she was kicking the bed and did not accidentally fall into the bed. LPN #712 was not asked to write a witness statement.Interview on 03/09/26 at 8:48 A.M. with Resident #117's granddaughter indicated the family put a camera in the resident's room the day of the incident. The granddaughter stated she left the facility and when she got home she checked the video surveillance before going to bed and upon seeing the videos, she contacted the police and drove back to the facility. She stated they found Resident #117 at the nursing station sitting in a wheelchair across from CNA #624. The resident did not recall the incident.Phone interview on 03/09/26 at 9:30 A.M. with Registered Nurse (RN) Coordinator #981 revealed while she was working, LPN #712 came up to her with Police Officer #626. Police Officer #626 told her what had happened and showed the video surveillance. The first video showed CNA #624 aggressively slapping the resident's leg and the second video showed the CNA #624 kicking the bed. RN Coordinator #981 revealed it did not appear as an accidental action and appeared purposeful.Telephone interview on 03/09/26 at 10:37 A.M. with CNA #624 revealed she started working in the facility about one month prior to the incident. She stated she received orientation but was unsure who had signed off her orientation forms and confirmed she worked on multiple units. CNA #624 indicated on 01/08/26 during the night shift, Resident #117 had a bowel movement, and she went in to change her. She stated she had an itchy foot and kicked the bed rail. She later came in to change her, put on a brief and then pulled up the brief. CNA #624 indicated when she provided Resident #117's care, she just told her what she needed to do and did not interact with her and could not recall if she spoke to the resident. She stated she did not want to contaminate her hands with gloves, so she scratched her foot by kicking the bed. CNA #624 denied hitting Resident #117 and stated she tapped her on the leg to get her attention.Interview on 03/09/26 at 11:02 A.M. with Human Resources Manager #995 confirmed CNA #624's orientation forms were not signed off as completed by the nurse as required.Interview on 03/09/26 at 11:56 A.M. with Licensed Social Worker (LSW) #745 revealed Resident #117 was not provided psych services following the incident and stated hospices services would provide psych services.Telephone interview on 03/09/26 at 12:00 P.M. with Hospice RN #625 revealed hospice was not notified by the family of the incident of abuse. Hospice RN #625 confirmed the resident was not provided psych services.Telephone interview on 03/09/26 at 3:45 P.M. with the Medical Director indicated he did not recall being notified of Resident #117's allegation of abuse.Telephone interview on 03/10/26 at 10:35 A.M. with Police Receptionist #627 confirmed the incident involving Resident #117 on 01/08/26 was turned over to the prosecutor but no criminal charges were being pursued.Review of the 2016 facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, revealed it is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident or misappropriation of resident property. Facility staff should immediately report all such allegations to the Administrator in accordance with the procedures in this policy. In cases where a crime is suspected, staff should also report the same to local law enforcement in accordance with facility's crime reporting policy. This deficiency represents non-compliance investigated under Complaint Number 2741949.

Based on observation, record review, resident interview, staff interview, and policy review, the facility failed to implement their abuse policy when Resident #6's allegation of abuse and staff concerns regarding the neglect of care for Resident #10 were not reported to the Administrator. Additionally the facility failed to ensure Resident #47's injury of unknown origin were reported to the State Agency. This affected three (#6, #47 and #10) of four residents reviewed for abuse. The facility census was 121. Findings include: 1.Review of the medical record for Resident #6 revealed an admission date of 11/28/2025. Diagnoses included ischemic cardiomyopathy, acute respiratory failure with hypoxia, chronic atrial fibrillation, chronic obstructive pulmonary disease with acute exacerbation, diabetes mellitus, anxiety disorder, and depression. Review of Resident #6's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact. Review of Resident #6's March 2026 physicians orders revealed and order for continuous oxygen at three liters via nasal cannula every shift. Observation on 03/03/2026 at 9:21 A.M. revealed Resident #6 was resting in bed with oxygen in place per a nasal cannula at four liters. Further observation of Resident #6's room revealed a motorized wheelchair with white box attached to the back of the wheelchair. The white box is labeled for a place to insert battery to power the resident's portable oxygen machine. Interview on 03/03/2026 at 9:21 A.M. Resident #6 reported two nights prior that he had become short of air after falling asleep in his motorized wheelchair. Resident #6 reported his oxygen battery had ran out of charge and he used his motorized wheelchair to go to the hall. He called out to Certified Nursing Assistant (CNA) #718 in a panic asking for her to change the battery. CNA #718 stated to him, you do not need to be rude. She changed the oxygen battery but did not turn the power on. He reported he asked CNA #718 to turn the machine on and she stated, do it yourself and walked away. He panicked again and used his motorized wheelchair to go to a different hall where two other CNAs were working and turned it on for him. Resident #6 stated he felt like CNA #718 was trying to kill him and it was an act of abuse. Additionally, the resident reported he was so upset he called 911 after the incident. Resident #6 stated he reported the incident the morning of 03/02/26 to the Unit Manager Licensed Practical Nurse (LPN) #889 and was told the incident would be investigated. Review of the facility Self-Reported Incidents (SRI) for March 2026 revealed the facility had not reported this alleged allegation to the State Agency. Review of Resident #6's nursing progress notes for 03/01/26 revealed no evidence of a respiratory assessment or a progress note regarding the alleged incident. Interview on 03/03/2026 at 1:10 P.M. with Unit Manager LPN #889 verified that Resident #6 reported to her a CNA over the weekend refused to change the battery on his oxygen concentrator. Unit Manager LPN #889 reported she was aware the resident called 911 after the incident and that he stated he felt like the CNA's actions were attempted murder. Unit Manager LPN #889 stated she did not report the incident to the Administrator but believed that Registered Nurse Coordinator #981 spoke with the CNA involved and was aware of the situation. Phone Interview on 03/03/2026 at 1:27 P.M. with CNA #702 revealed she was working 3:00 P.M. until 10:00 P.M. on 03/01/26 when Resident #6 came a crossed the building to her side requesting help. CNA #702 reported Resident #6 was anxious and upset and stated that the CNAs on the other side of the building refused to provide care and were rude to him. CNA #702 reported that the resident needed someone to turn his oxygen machine on and put him to bed and that he did not feel safe asking the other CNAs. CNA #702 reported she and CNA #865 assisted Resident #6, and that CNA #865 turned on the resident's oxygen machine. CNA #702 then stated she went over to the two CNAs (CNA #718 and Agency CNA #622) and asked what was going on. The CNAs reported they were not going to take care of him because he was being rude and they, do not care what he has to say. CNA #702 stated she then went to Agency LPN #623 and reported the incident. Phone interview on 03/03/2026 at 2:58 P.M. with Registered Nurse Coordinator #981 revealed she was unaware of the incident and had not spoken with CNA #718 or Unit Manager LPN #889 regarding Resident #6. Interview on 03/03/2026 at 5:02 P.M. with the Administrator and Director of Nursing (DON) revealed they were not aware of the allegations reported by Resident #6. The DON stated it is the facility policy for staff to report all allegations of abuse right away. She verified this was not done. Interview on 03/03/2026 at 5:07 P.M. CNA #865 reported that on 03/01/26 Resident #6 came to him upset alleging that the CNAs on the other side of the building were not taking care of him and would not turn his oxygen on. CNA #865 verified he turned the oxygen on for Resident #6. CNA #865 stated CNA #702, who was also present went to speak with the CNAs working on the other side of the building and when she came back she reported to him that the CNAs told her that they did not care. Phone interview on 03/04/26 at 1:39 P.M. LPN #977 revealed she was working on hall 200 but on the opposite side of where Resident #6's room was on 03/01/26. LPN #977 stated CNA #718 and Agency CNA #622 were assigned to Resident #6's care and they had reported Resident #6 was being mean to them and they were going to ask another CNA put him to bed for them. LPN #977 stated the two CNAs told her that Resident #6 stated he was going to call the police on them and that she heard him yell at them at one point, but she did not inquire why because she was busy with her medication pass. Phone interview on 03/09/26 at 12:23 P.M. CNA #718 reported last weekend while she was obtaining clean towels from the utility closet Resident #6 came to her frantically stating he needed his battery changed. She told him, calm down you do not need to yell. CNA #718 stated she changed the battery and handed him the old one to charge and went on about her business as she was heading back down the hall to change another resident. CNA #718 stated the nurse later told her that she forgot to turn the oxygen machine after she changed the battery and Resident #6 was upset as a result. CNA #718 stated the nurse said she tried to reassure Resident #6 that it was not intentional, but the resident did not believe her. CNA #718 verified the nurse had switched the assignment and had someone else to put Resident #6 to bed. Review of the undated policy, Abuse, Neglect, Exploration, and Misappropriation of Resident Property revealed the facility will not tolerate Abuse, Neglect, Exploitation of its residents or the Misappropriation of Resident Property. It is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property, including Injuries of Unknown Source, in accordance with this policy. Facility staff should immediately report all such allegations to the Administrator and to the State Agency In accordance with the procedures in this policy. 2. Review of the medical record for Resident #47 revealed an admission date of 01/06/10 with diagnoses of adult failure to thrive, paranoid schizophrenia (chronic mental health condition characterized by intense, irrational, and persistent hallucinations or delusions, often focusing on persecution or conspiracy) and dementia. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #47 had severely impaired cognition. Review of the Nurse Practitioner (NP) progress note dated 02/12/26 revealed Resident #47's skin was intact with no bruising to the extremities. Review of the physician's orders for Resident #47 for March 2026 revealed she was not on an anticoagulant or antiplatelet which could lead to her bruising more easily. Review of nursing progress notes from 02/03/26 through 03/04/26 for Resident #47 revealed there was no indication she had a bruise to her right forearm or assessments or an investigation had been completed. Observation on 03/02/26 at 11:06 A.M. of Resident #47 revealed a circular bruise that was purplish red in color approximately the size of a half dollar to her right forearm. Resident #47 was unable to answer questions correctly and was not able to state how she obtained the bruise on her right forearm. Observation on 03/04/26 at 8:28 A.M. of Resident #47 revealed a circular bruise that was purplish red in color. The bruise appeared to be diminishing as it was smaller and lighter in color. Director of Resident Services #892 was present and verified the bruise on Resident #47's right forearm. Interview on 03/04/26 at 9:57 A.M. with Regional Direct of Clinical Services #610 verified facility staff had not documented Resident #47 had a bruise to her right forearm and no assessment had been completed. Interview on 03/04/26 at 1:10 P.M. with Licensed Practical Nurse (LPN) #604 revealed she had noticed the bruise to Resident #47's right forearm but believed it was an old area as the nurse aides had not reported new skin issues, so she marked no new skins issues on Resident #47's shower sheet. LPN #604 stated she had not reported the bruise to anyone nor filled out any statements regarding the bruising. 3. Review of the medical record for Resident #10 revealed an admission date of 01/30/26 with diagnoses including heart failure, hypertension, chronic kidney disease and diabetes mellitus. He was admitted to the facility with services for hospice. Review of the comprehensive MDS assessment dated [DATE] for Resident #10 revealed he had severely impaired cognition, dependent on staff for toileting, and occasionally incontinent of bowel. Review of the care plan dated 02/10/26 for Resident #10 revealed the resident had self-care deficit and required staff assistance with activities of daily related to functional decline, impaired mobility, weakness, end stage disease and age-related changes. The goal was the resident would be clean and well groomed. Interventions included for staff to treat resident respectfully during care. Review of undated pictures submitted via a complaint to the State Agency on 02/27/26, revealed an unidentified male, though named as Resident #10, covered in dried brown feces. The unidentified male was observed to be naked. Interview on 03/02/26 at 3:42 P.M. with the Administrator and DON revealed they were unaware of pictures taken by staff of Resident #10 during care. The DON stated she had heard that an aide CNA #603 had taken pictures showing a resident soiled but when she spoke to CNA #603, she denied taking pictures. Interview on 03/02/26 at 3:53 P.M. with CNA #916 verified another aide (CNA #603) had spoken to him about taking pictures of Resident #10 to send to the State Agency. CNA #916 stated he had not seen the pictures and verified he had not updated his supervisor or the DON as he was standing at the nurse's station and thought the nursing staff had heard the conversation and was aware of the pictures being taken. Interview on 03/03/26 at 6:49 P.M. with LPN #729 revealed she had heard rumors that an aide took pictures and was sending them to the state related to lack of care for the residents. LPN #729 stated she was unsure which resident was involved and verified she had not updated the DON related to possible pictures being taken of residents. Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 2016, revealed the facility staff did not follow their policy. The policy stated staff would investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property including injuries of unknown source. The facility staff should immediately report all such allegations to the Administrator and to the State Agency in accordance with the procedures in the policy. Injury of unknown source is defined as the source of the injury that was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, location of the injury or the number of injuries observed at one particular time or the incidence of injuries over time. Staff should be able to identify events such as suspicious bruising and trends that may constitute abuse. Neglect is defined as the failure of the facility, its employers or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. Staff should be able to identify events such as trends that may constitute abuse. Under the response section of the policy, it stated staff should report all incidents/allegations immediately to the Administrator or designee. This deficiency represents non-compliance investigated under Complaint Numbers 2791099 and 2741949.

Based on observation of facility recorded video footage with sound, observation of police officer body camera footage, medical record review, facility incident review, review of a self-reported incident, interview, dementia training curriculum review, facility assessment review and policy review the facility failed to ensure Resident #145, who was cognitively impaired and had a diagnosis of dementia, was provided adequate, necessary kind, appropriate and dignified dementia care to meet his total care needs. This resulted in immediate jeopardy and the potential for serious harm and injury on 07/06/25 at 5:46 A.M. when the resident began to wander throughout the facility secured dementia unit. Certified Nursing Assistant (CNA) #800 and CNA #568 were observed on video to yell at the resident to get out of other resident rooms, to go back to his room, the facility was not his home and to stop hitting staff or they would call the police, and he would go to jail. The lack of planned and appropriate intervention, lack of appropriately trained staff to care for the residents (including Resident #145), on the specialty unit, and lack of staff supervision resulted in police being called to the facility to assist with the resident. The CNAs falsely reported to the police resident behaviors, and the resident was unnecessarily transferred to the hospital emergency room and returned to the facility the same day. The facility consultant psychiatrist then implemented the use of Depakote (an anti-seizure medication that can be used as a psychotropic medication), to the resident's treatment plan to manage the resident's behaviors. This affected one resident (Resident #145) of three residents reviewed. The facility census was 141.On 07/16/25 at 1:45 P.M., the Administrator, Director of Nursing (DON) and Assistant Director of Nursing were notified Immediate Jeopardy began on 07/06/25 at 5:46 A.M. when Resident #145 began to wander on the facility secured dementia unit. CNA #800 and CNA #568 were observed on video to yell at the resident to get out of other resident rooms, to go back to his room, the facility was not his home and to stop hitting staff or they would call the police, and he would go to jail. The police were contacted to assist in the care of Resident #145 and the resident was unnecessarily transferred to the hospital after CNA #585 and CNA #800 falsely reported resident behaviors to the police department and facility nursing staff. Facility Administration failed to complete a thorough investigation of the incident, failed to review the facility recorded security camera video footage with sound from the secured dementia unit common area, failed to ensure staff responded appropriately to a population in their facility requiring specialized training and permitted CNA #585 and #800 to return to work on 07/06/25 to provide care to the residents on the secured dementia unit, including Resident #145.The Immediate Jeopardy was removed on 07/18/25 when the facility implemented the following corrections: On 07/16/25 (no time provided) Certified Nursing Assistant (CNA) #568 and #800 were suspended and a full internal investigation was initiated. CNA #800 was placed on the do not return list and CNA #568 will remain on suspension pending the outcome of the investigation. On 7/16/25 (no time provided) Pharmacist #300 completed a medication regimen review for Resident #145 and no changes were recommended. On 07/16/25 at 4:00 P.M. Social Services #400 contacted Resident #145's wife to discuss the facility's plan to involve the resident's family in future behavioral interventions such as notifying the resident's spouse anytime, day or night, of behaviors and/or incidents. The resident's wife plans to spend some nights with the resident and the staff will ask the resident's spouse to assist and/or be present during any behaviors. On 07/16/25 Social Services #502 implemented the facility Notification Protocol for Resident #145 which required staff to immediately notify Resident #145's wife of significant behaviors or interventions. If immediate notification was unable to be made, the resident's wife/family would be notified within 12 hours. The spouse's input would be incorporated into the resident's care plan to reduce reliance on restrictive interventions. Beginning 07/16/25 and continuing until all 105 nursing staff (18 Registered Nurses, 22 licensed practical nurses and 65 CNA) are educated prior to their next scheduled shift on the secured unit, in-person by the DON or designee related to preventing and responding to catastrophic reactions, trauma-informed dementia care, use of calm, kind, respectful tone: zero tolerance for threats or intimidation, communication and behavioral de-escalation during high stress situations via training materials and using sign in sheets. Information packets will be available for agency staff to review and sign prior to working on the secured unit. Beginning 07/16/25 incident review by the charge nurse and DON is required before calling external authorities. The medical director or on-call physician's input is also required unless there is an immediate life-threatening emergency. De-escalation and resident specific interventions must be exhausted first. This will be included in the all-staff education provided by the DON/designee. On 07/17/25 Psychiatry Services re-evaluated the resident and reviewed appropriateness of medications. At the request of the resident's spouse, Depakote was discontinued. On 07/17/25 (no time provided) the resident's care plan was updated to provide the staff with behavioral triggers, calming interventions and redirection methods. An escalation protocol was also added for potential catastrophic reactions and non-pharmacologic interventions will be exhausted prior to any medication intervention. Beginning 07/17/25 and concluding 07/18/25, Social Worker #400 audited the other 34 residents on the secured unit to ensure they were not affected by the deficient practice. No concerns were identified. Any new or concerning resident behaviors will be discussed in the morning clinical meetings. On 07/17/25 the Assistant Director of Nursing posted the facility Code [NAME] Protocol on the dementia unit. This informed the staff of overhead paging capability from any facility phone to request assistance on the secured unit. A written escalation plan was also placed on the secured unit to clarify when Code [NAME] should be used and how. Administrative staff (the DON and/or Administrator) will be notified of any behavioral code or help request on the secured unit after the Code [NAME] incident is resolved. On 07/18/25 (no time provided) the Administrator and DON conducted a video review of the incident, confirming inappropriate staff behavior and identifying failure points in staff training, communication protocols and response procedures. On 07/18/25 (no time provided) the Administrator, DON and Social Services #400 conducted a root cause analysis that highlighted an inappropriate tone and approach by staff, failure to follow non-threatening dementia care practices, the facility protocol was not followed to notify the Administrator/designee and poor communication between nursing staff, medical providers and family. On 07/18/25 (no time provided) a self-reported incident was submitted to the state survey agency. On 07/21/25 (no time provided) the Administrator contacted the North [NAME] Police Department and made them aware of the new information received regarding 07/06/25. An officer at the police department would follow-up with the CNAs and amend the report to reflect what he found. On 07/21/25 new expectations were established to ensure contracted and primary care physicians received complete and accurate information regarding behavioral changes, medication responses, incidents or staff interventions using the eInteract Change in Condition Evaluation. Communication measures will be monitored through the weekly audits completed by the DON/designee for two months and findings will be shared with Quality Assurance Performance Improvement. Beginning 07/21/25 the Administrator or designee will observe, three times a week for 60 days, the secured/dementia unit to ensure all staff interventions reflecting the new dementia training Weekly review of the video footage in the secured unit common area totaling one hour of footage on random shifts for 60 days completed by the DON or Administrator. Weekly audit of all incident reports to confirm accurate behavior documentation, appropriate communication with family and physicians, interventions align with the resident's care plan for 60 days Social Worker #400 will observe/interview all dementia unit residents weekly to assess psychosocial well-being and monitor for staff misconduct or resident fear for 60 days. All findings will be reviewed in the QAPI Committee with any follow-up actions documented.Although the Immediate Jeopardy was removed on 07/18/25 the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimum harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.Findings include:Review of the medical record revealed Resident #145 was admitted on [DATE] with diagnoses that included ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive. A care plan dated 06/25/25 revealed Resident #145 had inappropriate behavior and was resistive to care. Interventions to allow flexibility in the activities of daily living routine to accommodate mood, elicit family input for best approaches to Resident #145, and leave and return in five to ten minutes if Resident #145 refuses care. A nurse note dated 06/25/25 at 10:41 P.M. revealed Resident #145 arrived at the facility at 7:56 P.M. Resident #145 appeared to be in a good mood and was happy to be closer to home. Review of Certified Nursing Assistant (CNA) documentation from 06/26/25 through 07/06/25 revealed on 07/01/25 and 07/04/25 there was documentation of Resident #145 wandering. There were no other behaviors documented. A dietary note dated 06/26/25 at 11:05 A.M. revealed Resident #145 was hospitalized for paranoid behavior from 06/17/25 to 06/25/25. Resident #145 was 73 inches (six feet) tall and weighed 211 pounds on 06/20/25. Resident #145 was ordered Seroquel (antipsychotic) prior to hospitalization. Resident #145 was started on Remeron (antidepressant) at the hospital. Resident #145 had been refusing medication at home, would not eat the food his wife prepared at home, was refusing medications at home, and was wandering and leaving the home. It was noted that Resident #145 had advancing dementia.Review of the physician orders revealed olanzapine 2.5 milligrams (mg) daily as needed for anxiety.Review of the medication administration record (MAR) dated 06/28/25 at 11:30 P.M. revealed Resident #145 received olanzapine (antipsychotic) 2.5 milligrams as needed for anxiety. A nurse's progress note dated 06/29/25 at 2:39 A.M. revealed Resident #145 was walking up and down the halls. Resident #145 had a skin tear to his left elbow that measured one centimeter (cm) long and 3 cm wide. Resident #145 was unable to describe what happened. Resident #145 had been observed leaning on the walls and bumping on the side boards (handrails) along the hallways. The physician and nursing coordinator were notified and Resident #145's family would be notified in the morning. A nurse progress note dated 06/29/25 at 4:42 A.M. revealed Resident #145 had been up most of the night pacing halls and trying to go into other resident rooms. Resident #145 was very difficult to redirect and as needed medication was administered. A medication administration note dated 06/29/25 at 7:43 A.M. revealed olanzapine 2.5 mg was ineffective. There was no documentation following the ineffective medication.A nurse progress note dated 06/29/25 at 2:51 P.M. revealed Resident #145's wife would like to be notified anytime day or night and stated she did not mind being awakened for incidents or information of importance. A nurse progress note dated 07/01/25 at 3:49 P.M. revealed Resident #145 was seen by the physician and a new order was received for Resident #145 to have a psychiatric consult. Review of facility recorded video footage (with sound) of the hall and common area outside Resident #145's room revealed on 07/06/25 at 5:46 A.M. Resident #145 walked out into the hallway wearing only a disposable incontinence brief. Resident #145 had a slow gait and was looking down at the floor. Resident #145 stopped and rubbed his face and looked around. At 5:47 A.M. Resident #145 walked down the hall and entered the next room on the left (Resident #67). CNA #568 can be seen entering the bottom left hand corner of the video and stated, Honey, that is a woman's room, and you cannot go in there. CNA #568 entered the room and told Resident #145 that his room was over there and pointed in the direction of the resident's room. CNA #800 informed the resident he must come out of that room as she stood in the doorway with her arms crossed at her chest. At 5:48 and nine seconds A.M. Resident #145 exited Resident #67's room and walked slowly back towards his room. At 5:48 and 15 seconds CNA #800 stated your room is right there and that is where you need to go. At 5:48 and 20 seconds Resident #145 stated something about court. At 5:48 and 22 seconds CNA #586 stated we will meet you there, but I suggest if we go to court, you put some clothes on which are in your room. At 5:48 and 33 seconds, Resident #145 turned away from his room and started toward Resident #51's room which was located directly across the hall from Resident #145's room. At 5:48 and 34 seconds CNA #586 raised her voice and told Resident #145 do not go into a patient's room. At 5:48 and 35 seconds CNA #586 again stated in an even louder voice Do not go in a patient's room. At 5:48 and 40 seconds CNA #586 and CNA #800 entered Resident #51's room with Resident #145. CNA #800 stated in a firm voice, you cannot go in here that is a woman's room. At 5:48 and 43 seconds CNA #800 yelled stop and CNA #586 yelled don't touch her. At 5:48 and 45 seconds, CNA #586 exited the room and said that's it, I'm calling the cops. At 5:48 and 47 seconds, CNA #800 also exited the room. At 5:48 and 56 seconds, CNA #586 reentered the room and said, I will not let you near my patients. You will get out. At 5:49 AM CNA #586 said in a loud voice, yes, you will and then repeated yes you will in a louder voice. At 5:49 AM and seven seconds, CNA #586 yelled out, He's beating the (expletive) out of me. CNA #800 yelled, I'm coming. At 5:49 and 15 seconds CNA #800 entered the room and CNA #586 stated, he threw me on the floor. At 5:49 and 21 seconds yelling in loud voices from CNA #586 and CNA #800 included: you can get out, OUT, You are on a memory care unit, Get out, You need to go now, out. At 5:49 and 30 seconds can see Resident #145 slowly approach the doorway from Resident #51's room to the hallway. CNA #568 and CNA #800 can be heard telling Resident #145 it was not his house, and he was at a nursing facility. At 5:50 and 24 seconds, CNA #568 called 911. A CNA can be heard stating Resident #145 was a new resident, was combative, and staff had been injured, and Resident #145 was threatening other residents. CNA #568 stated there was not proper staffing and there was not a nurse on the unit. CNA #568 stated a police officer was needed if the facility was not going to staff properly. At 5:51 and 40 seconds AM CNA #800 walked out of the room and was on the phone standing in the hallway. CNA #568 was still in Resident #51's room and on the phone with 911. CNA #568 stated she did not need a medic yet but may if Resident #145 did not stop. CNA #800 spoke up and said Resident #145 had tossed both CNA's and was extremely combative. At 5:51 and 49 seconds, Resident #145 stepped out of view back into Resident #51's room. Both CNA's told Resident #145 to leave the room. CNA #568 stated she needed the police soon. At 5:52 and two seconds CNA #568 yelled ouch and in a firm voice stated you need to move. At 5:52 and 19 seconds CNA #568 stated there was no one at the front door to let the police in. CNA #800 stated (to Resident #145) you need to get out of this room. This is a woman's room, NOW! At 5:53 and 15 seconds CNA #568 was heard saying do not go near my patient in a loud voice and then again in a louder voice. At 5:53 at 23 seconds, CNA #800 stated let's go and CNA #586 stated Protect your license, protect your license. At 5:54 at 19 seconds, Resident #145 can be observed again standing at the doorway to Resident #51's room. At 5:55 and four seconds, Resident #145 stepped slowly back into Resident #51's room. A CNA can be heard saying Do not come any closer in a loud voice and then stating it again in a louder voice. At 5:55 and 14 seconds, a crash sound was heard and CNA #568 stated we wanted you to sit down the whole time.blow the place up too. At 5:57 and eight seconds, CNA #586 said You will go to jail if you touch anyone down here. CNA #586 exited the room. At 5:57 and 13 seconds CNA #800 left the room. At 5:57 and 18 seconds CNA #800 made a phone call and asked for a nurse to come to the unit. At 5:58 A.M. CNA #586 and #800 reentered the room. At 6:00 and ten seconds CNA #586 and CNA #800 left Resident #51's room while Resident #145 was still in Resident #51's room. At 6:00 and 44 seconds police arrive at the unit. CNA #586 told the police she did not know why Resident #145 was here. The CNA's told the police they gave all the grace in the world to Resident #145 and gently asked him to return to his room. Resident #145 tossed CNA #568 like a ragdoll. At 6:04 and 12 seconds CNA #586 told the police that they needed Resident #145 to understand (the CNA was unable to finish her sentence) but the police officer interrupted CNA #586 and stated they could not make Resident #145 understand. At 6:40 Emergency Medical Services (EMS) arrived and at 6:50 A.M. Resident #145 was sitting calmly on the transport cot and EMT's wheeled Resident #145 down the hall. The resident was transported to the hospital.A police report/incident #25-008748 dated 07/06/25 revealed an incident occurred around 5:50 A.M. The police responded to a call for a report of a combative patient. Employees reported a male patient became combative towards them when he (Resident #145) wandered into other patients' rooms. CNA #568 and CNA #800 stated Resident #145 was a new patient and wandered into other resident's rooms. The CNA's stated it was a memory care unit, and residents were not allowed in other resident rooms. Resident #145 started to argue with CNA #568 and CNA #800. Resident #145 pushed CNA #800 and knocked her down. When CNA #568 tried to intervene, Resident #145 threw CNA #568 to the ground. Upon arrival of the police, Resident #145 was sitting in a chair in another resident's room. Resident #145 appeared confused and was not aware he was in a care facility. Resident #145 kept saying it was his house. The police attempted to get Resident #145 to return to his room, but Resident #145 refused. The facility director advised Resident #145 needed to be transported to the emergency room for an evaluation. EMS responded and Resident #145 was transported without incident. A nurse progress note authored by RN #578 dated 07/06/25 at 10:34 A.M. revealed at 6:15 A.M. Registered Nurse (RN) #578 received phone call from CNA #800. CNA #800 stated she needed a nurse NOW. Resident #145 had beaten up a couple of staff and was trying to get to another resident. RN #578 immediately rushed to the memory care unit. CNA #568 and CNA #800 had called the police, and the police arrived shortly after this nurse arrived. CNA #568 and CNA #800 reported Resident #145 woke up and was trying to go into multiple resident rooms. CNA #568 and CNA #800 stated they were gently trying to encourage Resident #145 not to go into another resident's room when Resident #145 suddenly struck CNA #800 in the chest and knocked CNA #568 to the floor. When RN #578 arrived, Resident #145 was sitting at the foot of the bed in a chair against the wall in Resident #51's room with no clothes on. The police officers tried to get Resident #145 to leave Resident #51's room and return to his own room. Resident #145 would not move and would not speak to the police. The police stated another plan was needed as they would not be able to do anything with Resident #145 at the police station. RN #578 called RN #704, who was the acting Director of Nursing (DON) at the time. RN #704 told RN #578 to call 911 and have Resident #145 taken to the emergency department so Resident #145 could be pink slipped (taken to the hospital for a mental evaluation) to a psychiatric facility. Emergency medical services (EMS) were called, and Resident #145 was placed on a stretcher without incident. Resident #145's wife was notified of the incident and Resident #145 being transferred to the hospital on [DATE] at 6:50 A.M. A statement by CNA #568 revealed CNA #568 and CNA #800 had been alone on the memory care unit since approximately 12:15 A.M. when the nurse left and went home. LPN #712 was notified around 12:30 A.M. that there were only two CNAs on the memory care unit and the nurse had left. LPN #712 stated there was no one available so they would be alone. CNA #568 did not have access to locked areas, residents did not get medications passed, and to call LPN #712 if there was an emergency. LPN #712 was called at the first verbal altercation to let LPN #712 know that CNA #568 and CNA #800 did not feel safe and Resident #145 would not cooperate or redirect and was threatening CNA #568 and CNA #800. This was around 5:00 A.M. and LPN #712 advised that one of the CNA's sit on the couch at the end of the hall to make sure Resident #145 (unable to read what was written) room. Before CNA #568 could get off the phone, Resident #145 entered Resident 67 room. The door to Resident #67's room was closed, and Resident #145 knew it was not his room. Despite Resident #145 being verbally abusive and threatening, CNA #568 and CNA #700 agreed Resident #145 was alert and oriented to person, place, and time. CNA #568 and CNA #800 went down the hall to Resident #67's room and reminded Resident #145 that his room was next door. Resident #145 stated he was going anywhere the (expletive) he wanted and then entered Resident #51's room. CNA #568 and CNA #800 calmly followed Resident #145 in Resident #51's room and attempted to redirect Resident #145 and asked Resident #145 not to approach Resident #51. Resident #145 purposefully did exactly what staff asked him not to do. CNA #568 offered to watch television in common area, a snack, and anything to redirect Resident #145. Resident #145 laughed maniacally and said he could do anything he wanted. Resident #145 then grabbed CNA #800, and the main assaults began. After CNA #800 was pushed very hard, CNA #568 stepped between Resident #145 and Resident #51 and attempted to calm and redirect Resident #145. Resident #145 seemed like he wanted to physically fight and continued to threatened CNA #568 and CNA #800. Resident #145 took another step towards CNA #568 and Resident #145's feet were almost touching CNA #568's. CNA #568 took a step back and Resident #145 grabbed CNA #568's forearm and flung her to the side. Resident #145 then used his other hand/arm to punch CNA #568 in the face. CNA #568 flew on the floor and her ankle turned under CNA #568's weight and CNA #568 hit something with the left side of her face. CNA #568 wrote that she had multiple places that were badly bruised and neck and shoulder felt jarred. At some point, Resident #145 stomped on CNA #568's left foot after CNA #568 stood up. Because LPN #712 had been called when Resident #145 got out of bed and was verbally abusive in his own room during rounds and bed checks, CNA #568 knew Resident #145 was combative and threatened CNA #568 and CNA #800, and there was no way out of the room, and CNA #568 had been hit in the head and face, so CNA #568 called 911. As soon as Resident #145 heard CNA #568 call 911 he sat in a chair in Resident #51's room. Because of Resident #145's size and sitting down forcefully, Resident #145 shoved an oxygen tank standing between the chair and piece of furniture. The oxygen tank wobbled but the wheels kept the tank from falling over. CNA #568 explained calmly that the oxygen tank could not be touched due to safety concerns. Resident #145 stated he could do whatever he wanted. Resident #145 was purposefully blocking the doorway and CNA #568 and #800 were unable to get out of Resident #51's room until Resident #145 sat down. Resident #145 was observed by CNA #568 and CNA #800 to be seeking satisfaction from conflict. Resident #145 did everything CNA #568 and CNA #800 asked him not to do. An example: you can be in the hall, common areas or your room but please do not startle other residents by entering rooms that are not yours. Resident #145 immediately would enter a room he knew was not his to see what CNA #568 and CNA #800 would do about it. CNA #568 and CNA #800 quietly agreed not to tell Resident #145 not to do anything so to engage or escalate him. CNA #568 did not feel safe around Resident #145. It then occurred to CNA #568 that the police could not enter the building as the door was locked and required a staff member to answer the phone to unlock the door, but because of being so short staffed there was no one answering the phones. CNA #800 called the phone number the police would need to call to enter the building and verified no one answered the phone. An undated statement by CNA #800 revealed the nurse on the memory care unit had left around 12:15 A.M. or 12:30 A.M. LPN #712 was told the nurse on the memory care unit went home and left the keys with CNA #568 and CNA #800. LPN #712 was called again around 5:00 A.M. and told Resident #145 was awake and verbally abusive and threatening CNA #568 and CNA #800. LPN #712 advised that one CNA watch Resident #145, but CNA #568 and CNA #800 were not comfortable with doing that. But Resident #145 had already entered Resident #67's room. CNA #800 and CNA #568 calmly told Resident #145 to please leave Resident #67's room. Resident #145 stated he would do what he wanted. Resident #145 knew it was not his room. Even though Resident #145 was being verbally abusive, CNA #800 and CNA #568 agreed Resident #145 was alert and oriented to person, place, and time. CNA #800 and CNA #568 told Resident #145 where his room was, which he already knew. Resident #145 finally left Resident #67's room. CNA #800 and CNA #568 tried to redirect Resident #145 back to his room. Resident #145 started to verbally abuse CNA #568 and CNA #800 and then went towards Resident #51's room. Resident #145 then entered Resident #51's room. CNA #800 and CNA #568 calmly followed Resident #145 into Resident #51's room and tried to redirect Resident #145. Resident #145 was asked not to approach Resident #51, but Resident #145 purposefully continued to approach Resident #51. Resident #145 was offered a snack, to watch television in the common area, and anything to redirect him. Resident #145 laughed maniacally and said he could do what he wanted. CNA #800 was standing between Resident #145 and where Resident #51 was lying in bed. Resident #145 then grabbed CNA #800's right arm and the assault began. Resident #145 swung CNA #800 across the room. After that, CNA #800 calmly told Resident #145 to please not put his hands on her. Resident #145 kept trying to get to Resident #51 and CNA #800 tried to block Resident #145 before he got to Resident #51. Resident #145 got very angry and hit CNA #800 on the chest with both of his hands so hard CNA #800 went flying to the ground and hit her neck and back. CNA #568 got between CNA #800 and Resident #145 and told Resident #145 not to touch CNA #800. Resident #145 grabbed CNA #568's arm and used his other arm to punch CNA #568 in the face. After that, Resident #145 grabbed CNA #568's arm and threw her to the ground. CNA #568's face slammed into the ground and CNA #568's left foot buckled under her and her arm hit the edge of the bed. After CNA #568's got up, both CNA's stood their ground to get Resident #145 to go to his room. Resident #145 would not move. CNA #800 and CNA #568 had no way to escape and were trapped because Resident #145 purposefully blocked the doorway. CNA #800 stated they were going to get help and Resident #145 stood in the doorway so CNA #568 and CNA #800 could not get out of the room. The CNA's tried to get out for a while and then CNA #568 called 911 and CNA #800 tried to call a nurse working on another unit. CNA #800 called the facility three times and finally got a nurse and CNA #800 yelled who she was, where she was, and needed help because a resident had beat up the CNA's and the CNA's could not get out of the room. The nurse hung up after CNA #568 was on the phone with 911. Resident #145 heard CNA #568 talking to the police so he flung himself into a chair which, because of Resident #145 ‘s size, the chair and oxygen tank wobbled. CNA #568 and CNA #800 told Resident #145 please do not touch the oxygen tank. Resident #145 stated he would do what the (expletive) what he wanted. The police could not get into the facility because there was not a staff member available to let them in. Panic and fear set in, but CNA #568 and CNA #800 stayed calm. CNA #800 and CNA #568 both observed Resident #145 to be seeking satisfaction from conflict and did literally everything he was asked not to do. Example: you can be in the hall or common areas but please do not enter other resident's rooms. Resident #145 immediately entered rooms that he knew were not his. He challenged CNA #568 and CNA #800. CNA #568 and CNA #800 agreed not to tell Resident #145 to do anything. CNA #800 wrote she did not feel safe around Resident #145. Review of hospital notes dated 07/06/25 revealed a [AGE] year-old male was brought to emergency department (ED) from a nursing home by ambulance for aggression. Resident #145 was alert to person only with a history of dementia. Resident #145's behavior was appropriate, and speech was appropriate for rate and volume. Resident #145 was mildly anxious and confused. Resident #145 would sometimes wander. A licensed professional counselor assessed Resident #145 face-to-face. Resident #145 was cooperative in the ED. Resident #145 thought he was in a video game, and someone was trying to take his identity. Resident #145 stated there was a fight downtown I think but denied being in the fights. The ED nurse and nursing home staff member stated Resident #145 got in another resident's face. The aides attempted to redirect Resident #145 and Resident #145 slammed the aid on the floor and threw another staff member against the nurse's station. The RN at the nursing home stated Resident #145's wife had requested Seroquel (antipsychotic) and olanzapine (antipsychotic) be discontinued on 06/01/25. Since the discontinuation of the medication Resident #145 had been more difficult to redirect. Resident #145's wife stated Resident #145 did not have a history of aggression with her. The nursing home staff reported Resident #145's wife had endorsed aggression as the reason for needing nursing care and stated she was no longer able to manage Resident #145 at home. Resident #145's wife expressed concern that Resident #145 had been looking for her and that was why he was wandering into rooms. A RN stated Resident #145 would become more confused and harder to redirect when family left. The mental status exam at the hospital revealed Resident #145 was alert to person only, was cooperative, and mildly anxious and confused. Resident #145 allegedly hit a nurse at the nursing facility and was at moderate risk to non-lethal harm to others. Resident #145 did not meet the criteria for inpatient psychiatric admission. It was recommended that Resident #145 follow up with outpatient providers [NAME][TRUNCATE

Based on observation, record review, policy review, and interviews, the facility failed to implement a comprehensive and resident centered plan to prevent and/or treat the development of pressure ulcers. Actual harm occurred beginning on 06/08/25 when Resident #95, who was at high risk for pressure ulcer development and dependent on staff for activities of daily living, developed an avoidable Stage II pressure ulcer (partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose [fat] is not visible, and deeper tissues are not visible. Granulation tissue, slough and eschar are not present) to the left buttock. The wound was not comprehensively assessed, wound treatments were not consistently provided and appropriate staff were not notified of the development of the pressure ulcer. The pressure ulcer subsequently declined and on 07/17/25 was assessed to be a Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be visible) pressure ulcer to the left buttock. Resident #95 also developed an additional facility acquired Stage III pressure ulcer to her left buttock as a result of the lack of adequate, comprehensive and individualized interventions and monitoring. This affected one resident (#95) of three residents reviewed for pressure ulcers. Findings include:Review of the medical record revealed Resident #95 was admitted on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, and psychosis.A plan of care revised 01/12/23 revealed Resident #95 had a self-care deficit and impaired mobility due to dementia. Interventions included a super soaker brief due to diuretic use and transfer with a mechanical lift. A plan of care revised 11/22/23 revealed Resident #95 required assistance with toileting and was incontinent. Interventions included to encourage Resident #95 to perform toileting and hygiene every two hours while awake and assist as necessary and check for wetness on rounds during the night. A plan of care revised 11/22/23 revealed Resident #95 had the potential for skin breakdown due to Resident #95 requiring assistance with mobility needs and incontinence. Interventions included weekly skin checks performed by a licensed nurse, barrier cream after each incontinence care and as needed, turn and reposition Resident #95 every two hours and as needed as the resident will allow, a pressure reduction cushion to wheelchair, and the physician, unit manager, nursing staff, and family would be notified of skin problems and a treatment would be initiated as ordered. On 03/01/25 Resident #95 weighed 109 pounds. On 04/02/25 Resident #95 weighed 108 pounds. On 05/02/25 Resident #95 weighed 108 pounds.The quarterly Minimum Data Set (MDS)dated 05/13/25 revealed Resident #95 had a memory problem and was dependent on staff for toileting, rolling left to right, and from sitting to lying. The MDS also revealed Resident #95 was always incontinent of bowel and bladder. The MDS revealed Resident #95 had no skin concerns. The quarterly Braden Scale for Determination Pressure Sore risk dated 05/23/25 revealed Resident #95 was at high risk. Resident #95 scored a 10 with a score below 12 identified as high risk. Resident #95 had very limited ability to respond meaningful to pressure related discomfort, had constant moisture, was chair fast, was completely immobile, and required moderate to maximum (staff) assistance in moving. A weekly skin check marked on the treatment administration record (TAR) dated 06/02/25 revealed Resident #95 had no evidence of skin impairment.On 06/04/25 Resident #95 weighed 103 pounds.A nursing progress note dated 06/08/25 at 7:23 P.M. by an agency nurse revealed Resident #95 had an open area to the left buttocks that measured 0.5 centimeters (cm) long, 0.5 cm wide, and less than 0.1 cm deep. A new order was received for Resident #95's left buttock to be cleansed with normal saline and a foam dressing applied every day at bedtime and as needed.A weekly skin check marked on the treatment administration record (TAR) dated 06/09/25 revealed Resident #95 had no evidence of skin impairment.A dietary note by Registered Dietician (RD) #732 dated 06/09/25 at 9:34 P.M. revealed Resident #95's current weight was 103 pounds. Resident #95 had a significant weight loss of 16 pounds in the last six months. The weight loss was not planned by the doctor but likely expected per the progress note (the resident had been receiving hospice services since 11/09/23). The current nutrition plan was to be continued, and Resident #95 would be monitored and followed up on. Review of the TAR revealed no evidence the treatment to the left buttock area was completed as ordered on 06/11/25, 06/24/25, or 06/26/25. A weekly skin check marked on the TAR dated 06/16/25 revealed Resident #95 had no documented evidence of skin impairment.A weekly skin check marked on the TAR dated 06/23/25 revealed Resident #95 had no documented evidence of skin impairment.A hospice interdisciplinary team visit note dated 06/24/25 at 12:00 P.M. revealed Resident #95 had a Stage II to the left buttock. The primary care nurse (none named) was notified by hospice RN #901. The hospice note did not provide a description or measurement of the pressure ulcer, and there was no information about wound care or Resident #95's care plan being updated. Review of meal intakes from 06/24/25 to 07/21/25 revealed Resident #95 refused meals twice, ate 0-25 precent (%) ten times, 26-50 % 23 times, 51-75% 16 times, and 76-100% seven times. An order dated 06/29/25 revealed Resident #95's left buttock was to be cleansed with normal saline and patted dry. A foam dressing was to be applied night shift/early morning, prior to getting Resident #95 out of bed and as needed until healed. A weekly skin check marked on the TAR dated 06/30/25 revealed Resident #95 had no documented evidence of skin impairment.The TAR revealed the treatment was not completed as ordered on 07/05/25.A weekly skin check marked on the TAR dated 07/07/25 revealed Resident #95 had no documented evidence of skin impairment.An interview on 07/09/25 at 9:55 A.M. with Licensed Practical Nurse (LPN) #648 revealed the agency nurse on the memory care unit had left sometime during her shift on 07/06/25. LPN #648 revealed treatments were not completed by the agency nurse who left. LPN #648 also revealed as a result of the staffing on the unit there were multiple residents who were soiled, and incontinence care had to be provided by oncoming staff the morning of 07/06/25. An interview on 07/09/25 at 10:09 A.M. with Certified Nursing Assistant (CNA) #637 revealed multiple residents (including Resident #95) were soiled upon day shift arrival the morning of 07/06/25. CNA #637 stated the nurse on the memory care unit had left during her shift and there were only two Certified Nursing Assistant (CNA) staff left on the memory care unit.A hospice interdisciplinary team visit note dated 07/09/25 at 12:45 P.M. revealed no information related to a continued plan of care or updated wound care orders for Resident #95.An interview on 07/09/25 at 2:17 P.M. with the Director of Nursing (DON) revealed weekly skin assessments were to be completed on bathing sheets and marked on the TAR as completed. The DON verified the weekly skin assessments on the TAR for Resident #95 did not show a place to document if the resident's skin was intact, red, or open. The DON stated the TAR should list those options for the nurses to use when completing a weekly skin assessment. An interview on 07/09/25 at 3:19 P.M. with the facility wound nurse, LPN #544, verified Resident #95 developed a Stage II pressure ulcer. LPN #544 verified however, there was not a wound grid completed as of 07/09/25. LPN #544 also verified there was no description or measurements of the wound. LPN #544 verified a hospice nurse made a notation on the hospice notes that Resident #95 had a Stage II pressure ulcer to the left buttock. LPN #544 verified she was not notified of the wound until the surveyor asked to see the wound (on this date). During the interview, LPN #544 also verified treatments were not completed every shift as ordered in June and July 2025 as noted above.An observation on 07/10/25 at 10:07 A.M. revealed a note was hanging in Resident #95's room. The note was dated 07/01/25 and revealed the nurse was to be notified if the bandage to the (resident's) left buttock was not in place. The resident was not observed to have any type of air mattress in place a the time of the observation. Continued observation at 10:09 A.M. with LPN #544 revealed a bandage (dressing) was not in place to Resident #95's left buttock. LPN #544 verified the dressing was not in place and stated staff must have removed it because it was wet. LPN #544 verified there was a sign in the room stating the nurse should be notified if the bandage was removed. LPN #544 measured the wound and stated the wound measured 1.5 cm long and 1.1 cm wide. Slough (a yellowish or white substance in the wound bed that delays healing and increases infection risk) was noted to the wound. LPN #544 stated the wound was now probably a Stage III pressure ulcer. The LPN revealed although she felt the area was probably a Stage III at this time she wanted to verify this with the wound certified nurse practitioner. A Skin and Wound assessment dated [DATE] completed by LPN #544 documented Resident #95 had new in-house acquired Stage II pressure ulcer to the left buttock that measured 1.5 cm long, 1.1 cm wide, and 0.1 cm deep. A new order was put in place for calcium alginate for autolytic debridement and hospice was made aware of the new order. A physician order dated 07/10/25 revealed Resident #95's left buttock was to be cleansed with normal saline and patted dry. Calcium alginate (to absorb excess wound fluid, preventing maceration and promoting a healing environment) was to be applied to the wound bed and covered with a bordered dressing every night prior to getting Resident #95 out of bed. Review of the TAR revealed the treatment was not completed on 07/13/25.A weekly skin check marked on the TAR dated 07/14/25 inaccurately reflected Resident #95 had no documented evidence of skin impairment.A Skin and Wound assessment dated [DATE] revealed Resident #95 had an in-house Stage III pressure ulcer to left buttock discovered on 07/10/25. The pressure ulcer measured 1.3 cm long, 1.1 cm wide, and 0.1 cm deep. The wound bed had 90% slough and 10% granulation tissue with a moderate amount of serosanguinous drainage noted. The area was cleansed with normal saline and calcium alginate was to be applied to the wound bed to promote autolytic debridement and then covered with bordered dressing. It was noted that the wound had deteriorated. The assessment note included Resident #95 was to be turned every two hours as the resident allowed.A Skin and Wound assessment dated [DATE] revealed Resident #95 had a new in-house acquired Stage III pressure ulcer to the left buttock that measured 0.6 cm long, and 1.5 cm wide and 0.1 cm deep. The wound bed had granulation and slough with full thickness lost. The wound bed had 90% slough and 10% granulation tissue with a moderate amount of serosanguinous drainage. The area was cleansed with normal saline and calcium alginate was applied to wound bed to promote autolytic debridement, and then covered with a bordered dressing. Resident #95 was on hospice and hospice was notified of the new wound. The wound was likely due to poor intake and overall decline. Resident #95 was to be turned every two hours as the resident allowed. An interview on 07/17/25 at 4:08 P.M. with LPN #544 verified an additional new pressure ulcer was found on 07/17/25 to Resident #95's left buttock. LPN #544 stated the new wound was found under the bandage that was already in place for the existing pressure ulcer Resident #95 had to the left buttock. There was no evidence new pressure relieving interventions had been implemented (including the possible use of an air mattress) despite the development of the resident's pressure ulcer on 06/09/25. In addition, review of the resident's medical record and TAR revealed no documented evidence the resident was being turned and repositioned at least every two hours as care planned. A nursing progress note dated 07/17/25 at 5:06 P.M. authored by LPN #544 revealed a new pressure area was noted to Resident #95's left proximal buttock measuring 0.6 cm long and 1.5 cm wide. The on-call hospice nurse was notified. The note indicated an air mattress with bolsters for offloading was ordered and would be delivered on 07/18/25. A physician order dated 07/18/25 revealed the proximal/distal left buttock was to be cleansed with normal saline and patted dry. Calcium alginate was to be applied to the wound bed and covered with a bordered dressing every day.A dietary note dated 07/18/25 at 4:07 P.M. authored by RD #732 revealed the wound nurse reported Resident #95 had a Stage III pressure wound to left distal buttock and a new Stage III pressure wound to the left proximal buttock. A new recommendation was made for four-ounce 2.0 calorie supplement twice a day. An interview on 07/22/25 at 10:13 A.M. with Registered Nurse (RN) #540 revealed she had been unaware of the presence of a (Stage II) pressure ulcer for Resident #95 on 06/24/25. The RN verified the ulcer should have been assessed, had a treatment order initiated and notification to LPN #544 (the facility wound nurse) of the open area. An interview on 07/23/25 at 8:50 A.M. with Hospice RN #901 revealed the facility wound nurse would be the person to monitor Resident #95's pressure ulcer. Hospice RN #901 stated the hospice aide notified her of the open area to Resident #95' left buttock and the facility floor nurse was notified (in June 2025). Hospice RN #901 stated she also completed a visit note and put it in the hospice binder located at the nurse's station.An interview on 07/23/25 at 9:15 A.M. with RD #732 revealed LPN #544 would notify her of all pressure ulcers. RD #732 stated LPN #544 was not aware of Resident #95's pressure ulcer until 07/10/25. LPN #544 had sent RD #732 an email, but the facility dietician services had been suspended on 07/01/25 due to facility non-payment to the company RD #732 worked for. RD #732 stated services were suspended until 07/18/25. RD #732 verified she was aware Resident #95 had two Stage III pressure ulcers. RD #732 had since ordered a supplement for Resident #95 twice a day (to promote wound healing). An interview on 07/23/25 at 10:43 A.M. with Chief Operating Officer(COO)/RD #730 revealed there had been problems with the facility paying for RD services. The COO/RD revealed services were held for one day in January 2025 and again in June/July 2025. COO/RD #730 verified services were suspended from 06/30/25 until 07/18/25. The facility had to pay the balance owed plus pre-pay until 08/01/25 to resume services. The facility was also required to pre-pay again by 08/01/25 to cover services until 08/20/25 when they reportedly would be hiring a company to provide dietician services. An additional interview on 07/23/25 at 11:25 A.M. with LPN #544 verified an agency nurse documented on 06/08/25 Resident #95 had an open area. The agency nurse did not complete a skin grid which LPN #544 would have made her aware of the skin impairment. LPN #544 verified hospice staff made a note on 06/24/25 that Resident #95 had a Stage II pressure ulcer to the left buttock. LPN #544 stated this information was not communicated to her by the floor staff or hospice nurse. LPN #544 verified she was aware a registered dietician was not available in July 2025. LPN #544 verified Resident #95's Stage II pressure had since deteriorated to a Stage III pressure ulcer and the resident developed an additional Stage III pressure ulcer to the buttocks area. LPN #544 verified an air mattress was not implemented until after 07/17/25. An interview with Physician #727 on 07/28/25 at 11:44 A.M. revealed the physician was aware the RD had to meet with the facility administrator in order to get paid. However, the physician was not aware the facility was without an RD from 07/01/25 through 07/17/25. Physician #727 stated it would be the expectation that all new wounds would be assessed by the facility wound nurse. During the interview, Physician #727 could not state if the timely implementation of nutritional supplements, adequate monitoring, and an air mattress would have prevented Resident #95's wound from declining but stated the interventions could have been beneficial. Review of the assessment/documentation for skin wounds policy dated 06/2020 revealed when it was determined a resident had an alteration in skin integrity the wound was to be assessed and measured and observations were to be recorded. The Wound Grid, Braden Scale, and Comprehensive Pain Assessment were to be initiated. The resident's physician, family, and dietary department were to be notified of the new wound areas. A treatment order for the wound was to be initiated and implemented following the facility's wound care algorithm or following specific orders received from the resident's attending physician. Following the initial documentation, the wound/skin condition was to be reassessed, and the observation was to be documented on the wound grid every seven days to provide information in order that care may be rendered to promote healing.Review of the wound treatment management policy revised 04/01/20 revealed in the absence of treatment orders, the licensed nurse would notify the physician to obtain treatment orders. This may be done by the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse. Review of the pressure injury prevention guidelines policy revised 04/01/20 revealed prevention devices would be utilized in accordance with manufacturer recommendations (such as cushions and mattresses). The effectiveness of interventions would be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include the development of a new pressure injury, lack of progression towards healing or changes in wound characteristics. This deficiency demonstrated non-compliance investigated under Complaint Number OH001297238 (OH00167453).

Based on observation, review of the medical record, and interview, the facility failed to timely identify areas of new skin impairment for Resident #39. This affected one resident (Resident #39) of one reviewed for pressure ulcers. Actual harm occurred on 01/03/23 when Resident #39, who was cognitively impaired, at high risk for pressure ulcer development, and dependent on staff for bed mobility, was found to have a deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration) with a necrotic area to the left heel. Findings include: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, congestive heart failure, hypertension, pain, hypothyroidism, benign neoplasm of the meninges, and venous insufficiency and diabetes. Review of the Admission assessment dated [DATE] revealed Resident #39 was admitted with two Stage II pressure ulcers; one to the left buttock which measured 0.5 centimeters (cm) in length by 0.5 cm in width by 0.1 cm in depth and one to the right buttock which measured 2.0 cm in length by 1.0 cm in width by 0.1 cm in depth. Further review of the admission assessment dated [DATE] revealed no documentation of a left heel pressure injury. Review of the Braden scale (assessment for predicting pressure sore risk) dated 12/19/22 revealed Resident #39 had a moderate risk of developing pressure injuries. Review of the physician's orders dated 12/19/22 revealed Resident #39 had orders for Skin Prep (protective barrier film) to bilateral heels every day on midnight shift for two weeks, weekly skin checks every Monday, turn and reposition every two hours and as needed, and float heels when in bed. Review of the Admission Minimum Data Set assessment dated [DATE] revealed Resident #39 had severely impaired cognition and required extensive assistance with bed mobility. Resident #39 was at risk for developing pressure injuries and was admitted with two Stage II pressure ulcers. Review of the Braden scale dated 12/26/22 revealed Resident #39 had a high risk of developing pressure injuries. Review of the December 2022 Treatment administration record (TAR) revealed Resident #39 received Skin Prep to bilateral heels every midnight shift from 12/19/22 through 01/02/23 then it was discontinued on 01/02/23. Resident #39 she had a weekly skin check done on 12/26/22. Review of the January 2023 TAR revealed Resident #39 had a weekly skin check done on 01/02/23. Review of the Wound Nursing assessment dated [DATE] revealed Resident #39 developed an in facility suspected deep tissue injury to the left heel measuring 2.5 cm in length by 4.7 cm in width by and undetermined depth. The wound bed was necrotic/eschar (dead tissue) and the surrounding tissue was pink in color. Further review of physician's orders revealed Resident #39 had orders for Skin Prep, pad and protect with abdominal dressings and Kerlix to the left heel suspected deep tissue injury every day until resolved dated 01/04/23, and for an air mattress to the bed dated 01/05/23 . On 01/25/23 at 10:00 A.M. an interview with Registered Nurse (RN) #18 revealed Resident #39 was residing in the Assisted Living when she had a stroke and was sent out to the hospital. RN #18 indicated Resident #39 came to the nursing facility for rehabilitation. When Resident #39 was admitted her left heel was mushy. They started Skin Prep to both heels for two weeks but unfortunately she still developed a hard necrotic area. RN #18 stated they put an air mattress on the bed after the necrotic area was found. RN #18 stated Resident #39 was having poor meal intakes and her protein and albumin levels were low. Observation of wound care on 01/25/23 at 10:10 A.M. with RN #18 revealed Resident #39 had a hard, black necrotic area covering 100 percent of the deep tissue injury on the left heel. On 01/25/23 at 4:24 P.M. an interview with RN #18 revealed she had been incorrect when she stated Resident #39 had been admitted with mushy heels. RN #18 stated Resident #39 did not have any pressure injuries to her heels when she was admitted . RN #18 verified the first documentation of the left heel wound was as a necrotic area. RN #18 was not able to explain why Resident #39's left heel had developed into a hard necrotic/eschar area without being noticed by the nursing staff when Skin Prep was being applied to the heels daily. Review of the laboratory results dated [DATE] revealed Resident #39 had a protein level of 6.9 (normal 6.0 to 8.3) and a albumin level of 3.7 (normal 3.5 to 5.5).

Based on interview and record review, the facility failed to treat Resident #100's complaints of pain. Actual harm occurred when Resident #100's complaints of pain were not addressed and it was discovered later she had an acute displacement of the distal femur fracture. This affected one of three residents (#63, #100 and #110) reviewed for fractures. The facility census was 106. Findings include: Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set 3.0 (MDS) resident assessment dated [DATE] indicated she had severe cognitive impairment. Resident #100 was identified to have verbal behavioral symptoms directed toward others and wandering on one to three days of the assessment period. No physical behaviors were identified. Resident #100 required the extensive assistance of two plus staff for transfers, and the extensive assistance of one staff for all other activities of daily living. She utilized a wheelchair for mobility. Resident #100 was always incontinent of bladder and frequently incontinent of bowel. The assessment indicated Resident #100 had no pain. Review of the pain assessment dated [DATE] indicated Resident #100 had no pain. Review of the plan of care identified Resident #100 having resistance to treatment and care at times. The plan lacked the identification of her specific behaviors when resisting care. The plan of care lacked any mention of non-verbal indicators that might have been associated with pain. A pain plan of care was developed related to normal aging process on 09/02/20 after the identification of the femur fracture. Review of the physician orders [REDACTED]. Review of the nurses note dated 08/24/20 at 9:04 A.M. revealed the resident grimaced and shouted in pain and the pain level was noted as a seven out of 10 with 10 being the most severe. There was no mention in the nurses note that pain medication was administered. Nurses notes dated 08/31/20 at 3:08 A.M. revealed Resident #100 was non complaint with care, yelling and kicking her legs. Her leg remained warm to touch and an over the counter pain reliever was given for pain. The note did not indicate the type of pain or location or whether the pain medication provided relief. Review of the Medication Administration Record [REDACTED]. The pain assessment indicated she had pain at a level of eight out of 10 on 08/29/20 and she was not provided any pain medication. She was given pain medication on 08/30/20 for a pain level of three out of 10. There was no evidence the resident received pain medications for pain rated at a level of 10 on 08/24/20 or on 08/31/20 as indicated in the nurses' notes. There was no indication of follow up pain assessments being done after pain medication was administered to determine effectiveness for relief of pain. Review of the behavior documentation on the August 2020 MAR indicated [REDACTED]. On 08/28/20 and 08/30/20 on the second shift the resident was agitated, kicked, slapped and was afraid. There was no indication in the plan of care that Resident #100's behaviors could be associated with pain or to assess for pain when the behaviors were being displayed. Nurses notes dated 08/31/20 at 6:50 A.M. revealed a request was made to the physician for an X-ray regarding right knee swelling, complaints of pain and resident guarding of the area. On 08/31/20 at 10:06 A.M. the X-ray results showed an acute displacement of the distal femur fracture and she was sent to the hospital for treatment. Resident #100 returned to the facility on [DATE] at 7:00 P.M. with an immobilizer to her right leg. Interview with State tested Nurse Aide (STNA) #213 on 10/06/20 at 2:37 P.M. revealed when she saw Resident #100 on Thursday 08/27/20 she noticed bruises on both of her arms and when propelling her in her wheelchair to the dining room she guarded her leg and said her right leg hurt. STNA #213 indicated anytime you would get near her leg she would yell and you couldn't touch it at all. STNA #213 reported this to the nurse on duty who said the resident had a [MEDICAL CONDITION] infection and that was what the pain was from. STNA #213 said the pain appeared severe. STNA #213 worked with Resident #100 from 08/27/20 to 08/31/20 for the regular aide who was on vacation. The resident reacted the same at each encounter. A sit to stand lift plus another STNA were used to transfer her and she complained of pain all along. STNA #213 said she reported it to each nurse who worked that weekend and all said it was due to [MEDICAL CONDITION]. On Sunday 08/30/20 the resident refused to get out of bed and continued to complain of pain. On Monday 08/31/20 STNA #213 then reported Resident #100's consistent severe pain to the nurse supervisor and made a request that she have an X-ray. She was not aware if the nurses provided pain medication to the resident only that she reported the pain to the nurses at each instance. Interview with Licensed Practical Nurse (LPN) #216 on 10/07/20 at 7:20 A.M. reported she worked midnight shift on Resident #100's unit part time. She indicated Resident #100 typically could be the sweetest but then she could be aggressive, and sometimes hit and kick. She instructed the STNAs to leave her alone for a bit and return later. She did not notice anything until 08/31/20 when there was a change in the resident. Resident #100 was screaming and yelling and the STNA notified her. LPN #216 reported the right knee was really swollen and the resident was guarding it. LPN #216 called to get an X-ray which showed a fractured femur. Interview with the Director of Nursing on 10/07/20 at 7:45 A.M. verified a lack of evidence pain assessments were completed when Resident #100 displayed obvious signs of pain, and verified the lack of evidence she was provided medication and assessed for effectiveness for relief of pain and was later found to have a fractured femur.

Based on observation, interview and record review, the facility failed to properly transfer one resident (Resident #12) in a wheelchair by placing footrests on the chair. Actual Harm occurred when Resident #12 placed her foot down while being transported resulting in a periprosthetic fracture around the internal right knee. This affected one resident (#12) of one resident reviewed for accidents/injury of unknown origin. The facility census was 155. Findings include: Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/07/19 the resident was diagnosed with [REDACTED]. Review of Resident #12's Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident required extensive assistance of two people for bed mobility, transfer, dressing, toilet use and personal hygiene. Review of Resident #12's comprehensive plan of care indicated a self-care deficit with the need for assistance of two persons for transfers. The care plan was updated on 08/08/19 to reflect an acute comminuted [MEDICAL CONDITION] femur at the superior edge of the knee prosthesis. Interventions included to give pain and anti-[MEDICAL CONDITION] medications as ordered, handle gently when moving or positioning, and maintain proper body alignment. Review of a Self Reported Incident (SRI) dated 08/07/19 at 2:15 P.M. revealed Resident #12 was sitting in wheelchair at the nurses' station. Resident #12 usually self-propelled her wheelchair. The resident asked the State tested Nurse Aide (STNA) #201 to help her to the bathroom. STNA #201 pushed the resident toward the main bathroom, which was about 10 feet away. Before they reached bathroom, the resident dropped her right foot to the floor and yelled out in pain. The nurse who was nearby at the medication cart observed this. He approached the resident and asked her what was wrong. The resident stated her leg was broken. The nurse along with another STNA attempted to take the resident to restroom together, and the resident had difficulty standing. The resident's physician was notified and ordered an X-ray. The results of the X-ray revealed a [MEDICAL CONDITION] leg at the artificial knee site. Resident #12 was sent to hospital to be treated. Staff were educated to encourage residents who self-propelled wheel chairs to do so or to allow staff to put leg rests on their wheel chair when asked to be transported. Review of a witness statement completed by Unit Manager Registered Nurse (RN) #300 revealed on 08/07/19 upon arrival on the unit at 3:00 P.M. the current nurse Licensed Practical Nurse (LPN) #200 informed him that Resident #12 had hyper-flexed her right knee. RN #300 could hear Resident #12 yelling for help in her room and the STNA went to check her. LPN #200 obtained an order and an X-ray was taken. RN #300 gave Resident #12 pain medication. Certified Nurse Practitioner (CNP) #300 was notified of the X-ray results and ordered to send Resident #12 to the ER. Review of LPN #200's witness statement revealed Resident #12 was sitting in front of the bathroom asking for toileting assistance. STNA #201 pushed Resident #12 forward in the wheel chair and the resident screamed. Resident #12 was seated properly in the wheel chair. The resident said the STNA hurt her knee on purpose. STNA #201 said the resident put her foot down while she was pushing the wheel chair and they hadn't even moved a couple of inches. Another STNA came to assist Resident #12 to the bathroom. Resident #12 screamed again when trying to stand. Resident #12 said, I broke my knee. Resident #12 stayed in the wheelchair. The resident's physician and family were notified. STNA #210 assisted Resident #12 to her room. The oncoming nurse RN #300 medicated the resident for pain and called for an X-ray. Review of Resident #12's nurses notes dated 08/07/18 at 2:53 P.M. revealed the resident's right knee was hyper-flexed while being propelled in her wheelchair by staff. The resident said, I broke my knee, and complained of pain at a level of 10 (on a scale of 0-10 with 10 being the worst pain). The physician and family were notified. At 6:05 P.M. X-ray results were received which indicated an acute comminuted [MEDICAL CONDITION] femur at the superior edge of the right knee prosthesis. The physician and Power of Attorney (POA) were notified. Observation of Resident #12 on 08/19/19 at 10:20 [NAME]M. and 12:30 P.M. revealed the resident did not respond to her name. Resident #12 had been turned from her left side to her back. Her right leg was straight and supported with pillows. The head of the bed was slightly elevated. Interview with the Director of Nursing (DON) on 08/19/19 at 4:20 P.M. verified the above findings. This deficiency is an incidental finding to Complaint Number OH 159.

Based on observation, interview, policy review and record review, the facility failed to adjust treatment to Resident #17's pressure ulcer when the wound was not responding to treatment. This resulted in harm when the in house acquired Stage 1 (intact skin with a localized area of non-blanchable redness) pressure ulcer declined to a Stage III (full-thickness skin loss, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed.) pressure ulcer. This affected one of two residents reviewed for pressure ulcers. Findings include: Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual comprehensive assessment dated [DATE] indicated Resident #17 was rarely/never understood, displayed no behaviors, had total dependence on two plus staff for activities of daily living, was incontinent of bowel and bladder and had no pressure ulcers. The comprehensive assessment dated [DATE] indicated Resident #17 developed one Stage III pressure ulcer. Review of the skin risk assessments revealed the resident was at high risk for the development of pressure ulcers since 02/17/18. Review of the plan of care identified Resident #17 was at risk for skin breakdown. Interventions included 10/02/14 floating the heels; 12/11/18 Prevalon boots (suspends and cushions the foot to minimize irritation and pressure points) bilateral heels, to be worn at all times, and 12/18/18 keeping weight off affected area/limb at all times - elevate legs with two to three pillows, heels to be completely suspended off surfaces at all times . Review of the wound nurse assessment dated [DATE] revealed Resident #17 developed a pressure ulcer on the right heel measuring 2.1 centimeters (cm) by 3.2 cm, Stage I in house acquired. The area was treated with pad and protect every three days. Review of the physician's orders [REDACTED]. Review of the wound nurse assessment dated [DATE] revealed the right heel declined to a Stage II ( Partial thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) measuring 2.2 cm by 3.2 cm by 0.1 cm deep. The blister was open with macerated edges and a shallow red base. There was no documentation the physician was notified of the worsening pressure ulcer and no new treatment orders were obtained. Review of the wound nurse assessment dated [DATE] revealed the area measured 3 cm by 3 cm with no depth. There were no descriptors documented. The nurse noted Skin Prep (a liquid film forming dressing that upon application to intact skin forms a protective film to reduce friction) to bilateral heels twice daily done only to left heel due right heel being open. Review of the wound nurse assessment dated [DATE] revealed the right heel measuring 3 cm by 2.2 cm by unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). The facility consulted wound care specialists. Review of the physician's orders [REDACTED]. Review of a physcian order dated 11/09/18 indicated to cleanse the right heel with a bleach solution, apply Santyl (enzymatic [MEDICATION NAME] ointment), Calcium Alginate (a highly absorptive dressing composed of calcium sodium alginate that creates a [MEDICATION NAME] protective gel when in contact with exudate and helps maintain a moist wound environment), pad and protect with ABD and Kerlix (stretch gauze) and change daily and as needed until healed. Review of the wound grid dated 12/06/18 revealed the right heel wound measured 2.5 cm by 1.8 cm and was unstageable. On 01/09/19 a [DIAGNOSES REDACTED]. Review of the wound nurse assessment dated [DATE] revealed the right heel measured 0.9 cm by 1.3 cm by 0.3 cm deep, Stage III. Interview with Registered Nurses (RNs) #68 and #930 on 01/15/19 at 4:06 P.M. verified the pressure ulcer was acquired in house. The facility padded and protected the right heel until the wound specialist became involved. They confirmed they should have obtained a new treatment order when the pressure ulcer declined to a Stage II. On 01/16/19 at 9:24 A.M. RN's #68 and #903 were observed to complete a dressing change to Resident #17's right heel. A [DEVICE] to the right heel was removed. RN #903 described the pressure ulcer as measuring 1.8 cm by 0.5 cm by 0.3 cm deep with serosanguinous (pink watery drainage). Review of the assessment/documentation policy for skin wounds dated (MONTH) 2013 indicated following the initial documentation, the wound/skin condition was to be reassessed and the observation was to be documented on the appropriate wound grid weekly to provide information in order that care could be rendered to promote healing and to assess the effectiveness of care and provide effective alternate interventions as necessary. In the event the implemented treatment had not been effective in promoting healing of the area in a two-week time period, the resident's attending physician was to be contacted for an alternative treatment or a referral to the wound nurse practitioner. Review of the wound treatment algorithm revised 01/24/17 indicated the following. Stage I (red area, not open or blanchable). Heels: use skin prep and float heels. Stage II (partial thickness loss without slough). Cleanse area with normal saline, pat dry, skin prep to periwound, hydrogel to wound bed and cover with bordered foam dressing. Change every other day and as needed.