Every finding on record at Senior Care Center - St Marys

Based on observations, staff interviews, and review of the facility's policies titled, Foodborne Illnesses, and Food Ordering, Receiving, and Storage, the facility failed to ensure food for residents was stored, prepared, and served in a sanitary manner in the kitchen. Specifically, the facility failed to label and date food in the freezer, the refrigerator/walk-in cooler, and the dry storage pantry, with a received by date, open date, expiration, and/or use-by date, failed to discard food by the expiration or use-by date, and failed to ensure meat was thawed properly and in a sanitary manner. This deficient practice could have affected 62 of 65 residents receiving an oral diet.Findings included:Review of the Facility's policy titled, Foodborne Illnesses, with revised date October 18, 2017, documented. Procedure: 2. Foods will be used before the expiration date, use by date, best by date, and sell by date, as indicated on the food item. Foods not used prior to the expiration date, us by date, best by date, or sell by date must be discarded. 7. Meats will be thawed and cooked to appropriate internal temperature to prevent foodborne illnesses. Thaw meats under refrigeration at or below 41 degrees Fahrenheit in a drip proof container or submerged in a solid bottom pan under cold running water.Review of the facility's policy titled, Food Ordering, Receiving, and Storage with revised date October 23, 2025, documented, . Storage and Rotation Guidelines: Date all stock items with delivery date.During a tour and observation of the dietary department on 05/06/2026, starting at 12:15 PM, five staff members were working: Dietary Manager JJ, Dietary Aide EE, Dietary [NAME] FF, Dietary [NAME] GG, and Dietary Aide HH. During the tour, observations, and interview with dietary staff, revealed expired food, food with no label/dates, no label/dating system, and meat improperly thawed as follows: Observation in the two compartment sinkOne large roll of ground beef was submerged in water on the left side of the two compartment sink, with a peel and stick label with Ground Meat and a prep date of 4/24/26. No other date or label was on the item.One large roll of ground beef was submerged in water on the left side of the two compartment sink, with a peel and stick/sticker label with Ground Meat and a prep date of 4/17/26. No other date or label was on the item.Observation inside the double door freezer in the dietary departmentA bag of French Toast had a prep date of 5/1/26 on the sticker label. No other dates were on the item.A bag of Breaded Zucchini slices was out of date, with a prep date of 1 2 and a use by date of 2 2 on the label. No other dates were on the item.A bag of Okra was out of date, with a use by date of 4/3/26 on the label.A bag of Mixed Vegetables was out of date, with a prep date of 4 20 26 and a use by date of 4 23 26 on the label.A bag of Field Peas with Snaps had a prep date of 3'/6/26. No other date was on the item.A bag of Vegetable Blend had a prep date of 3/27/2026. No other dates were on the item.Two bags of Breaded Squash had no labels or dates on themA bag of (broccoli/cauliflower) Vegetable Blend had a prep date of 3/27/26. No other dates were on the item.A bag of Garlic Bread had no label or date on it.A box containing individual bags of frozen, mashed Sweet Potatoes had no labels or dates on the bags or the box.Observation on a spice rack revealed: A large container of opened Light Chili Powder was out of date, with an expiration date of 4/11/2026.A large container of opened Granulated Onion had no label or date on it.A large container of opened Lemon Pepper Seasoning had no label or date on it.A large container of opened [Brand name] Chicken Seasoning had 1 31 op, 7 31 ex {sic}. No other dates were on the item.A large container of [Brand name] Seasoning Salt was open and had no label or date on it.An opened container of Instant Food Thickener had 3 20 written on the container. No other dates or label were on the item.A large box of Granulated Chicken Bouillon had been opened and was out of date, with 6/20/25 written on the container. No other date or label was on the item.A large container of opened Oregano Leaves was dated 9/9/24, written in Sharpie/marker, and had a sticker label with op 1 11 26, Exp 7 11 26.Two opened containers of [Brand name] Chicken Flavored Base had no label or dates on either item.An opened box of Raisins was dated 6/20/25. No other dates were on the item.Observation of the pantry revealed:A zip lock bag of loose Pinto Beans had the labels Pinto Beans and was dated 5 22 25.An open bag of Northern Beans was inside a zip lock bag. No label or dates were on the item or the bag.A large, open bag of Sugar Frosted Flakes cereal was held closed with a binder clip. No label or dates were on the item.A large, unopened bag of generic-brand [NAME] Krispies cereal dated 10/24.A large, open bag of Raisin Bran cereal had a sticker label dated 10/24.A large, open bag of Froot Loops cereal was dated 10/24 and was held closed with a binder clip. Seven large bags of Croutons were dated 10/24.Eleven boxes of [Named brand] starch dated 8/22.Four bags of Instant Gravy Mix were dated 4/13/26.Four bags of Turkey Gravy were dated 4/13/26.Several bags of Chicken flavored Gravy Mix had two dates, 3/ 21 and 5/2/26.A large, open bag of dry spaghetti noodles was rolled up with plastic wrap around it but was not sealed completely closed. Three opened packages and two unopened packages of Taco Seasoning had no labels or dates on them. One opened bag was held closed with a binder clip, and one with a rubber band.A large tub of Peanut Butter was opened on 5/6/26. No use by or expiration date was on the item.Two large dry-ingredient bins, one labeled Sugar and one labeled Flour, contained white substances. No dates or other labels were on the bins.One large dry-ingredient bin containing a white substance had no label or date. Interview with Dietary [NAME] FF revealed it was a thickener. Dietary [NAME] FF stated he did not know when the thickener was received, opened, or put inside the bin. Dietary [NAME] FF then obtained a label and placed it on the bin with prep date 5/6/26 and use by date 7/6/26.A gallon container of BBQ Sauce was dated 4/13/26. A gallon container of Tartar Sauce was dated 1/21. A gallon container of Creamy Italian Dressing was dated 1/21. A gallon container of Creamy Italian Dressing was dated 3 21 26, prep date of 3 13, and use by date 5 13.A large container of Worcestershire Sauce was dated 2/13. No label or other date was on the item.A gallon container of Soy Sauce was dated 3 21 26.A large container of Lime Gelatin had a date of 3 21 26.A large plastic tub of individual packages containing two Saltine crackers had no label or date on the container or the individual crackers. Dietary [NAME] FF confirmed the foods in the Pantry were not labeled or dated with received, open, and/or expiration dates.Observation inside the walk in cooler/refrigerator, outside, and behind the dietary department revealed: A large, open bag of whipped topping had the tip still in the piping bag, with no label or dates on the item.Two large containers of Cottage Cheese were on the top shelf, and one box with two 5 lb containers of Cottage Cheese was inside the box. No label or date was on the box or the individual containers.A gallon container of Balsamic Vinaigrette had a use by date of [DATE]. A gallon container of [Name brand] Balsamic Vinaigrette had no label or date. The printed date on the container was 26 [DATE].Two gallons of Milk were dated 4/24/26, and one gallon of Milk was dated 5/4/26.Two large/gallon unopened bags of Shredded Hash Browns had no labels or dates on them.Ten to twelve unopened bags of hamburger buns had no labels or dates.Several packages (at least 20) that appeared to be bologna had no labels or dates.Two large-gallon bags of shredded cabbage for slaw had no labels or dates.One large/gallon bag of lettuce, some of which was brownish, had no label or date on the item.One large gallon tub of Cherry filling had no label or date on it.One large, square, white tub of Hard Cooked Eggs contained eggs in a blue bag submerged in a liquid. The blue bag was inside the tub, and there was liquid around its outside. There was also an unusual, bad smell. The item was dated D/C 3/21. No other date or year was listed.The tour of the kitchen also revealed two large, round rolls of ground meat in the two-compartment sink, now in a large pan of water. An interview with a dietary cook revealed that the meat should be thawed under running water, but they did not know that it should not be left submerged. Dietary cook FF and DM confirmed the expired food items, confirmed foods in the Pantry were not properly labeled and dated with received, open, and/or expiration dates, were not able to provide the date when the items were delivered, and confirmed meat was thawing submerged in water in the sink and now submerged in a large pan.Interview on 05/08/2026 at 3:02 PM with Dietary Manager (DM) JJ confirmed expired and past-use-dated food, no proper labeling/dating system, and improper thawing of meat.

Based on resident and staff interviews, record review, and review of the facility's policy titled Abuse Prevention and Reporting, the facility failed to ensure three of 15 residents (R) (R1, R2, and R3) were protected from verbal and/or physical abuse by staff. This deficient practice had the potential to affect the quality of life for all residents reviewed.Findings included:Review of the facility's policy titled Abuse Prevention and Reporting, revised June 20, 2025, documented Definitions: Abuse: Any intentional or grossly negligent act or series of acts or intentional or grossly negligent omission to act which causes injury to a resident, including but not limited to, assault or battery, failure to provide treatment or care, or sexual harassment of the resident. Verbal Abuse: Any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents regardless of age, ability to comprehend, or disability. Policy: This assisted living center will not tolerate abuse, neglect or exploitation of its residents by anyone. Such incidents will be reported to all appropriate authorities, agencies and registries and a written copy as such reports maintained in a central file and the resident's file.1. R1 was a [AGE] year-old (y/o) female who was admitted with a primary admission diagnosis of cerebral infarction. Other diagnoses included, but were not limited to, Alzheimer's disease, generalized muscle weakness, history of falling, overactive bladder, irritable bowel syndrome with constipation, shortness of breath, diaper dermatitis, vitamin B12 deficiency anemia, and malignant neoplasm of the cranial nerve.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R1 reported Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) score 08, indicating moderate cognitive impairment. Indicators for mood or behaviors in sections D (Mood) and Section E (Behaviors) identified during the assessment period. GG-R1 required a wheelchair for mobility, had lower extremity impairment on one side, and required supervision/touch assistance for eating, oral hygiene, dressing, footwear, personal hygiene, rolling in bed, lying to sitting, sit to lying, moderate assist for toilet transfer & tub/shower, and dependent for toileting, partial/moderate assistance for toilet, bed-to-chair, tub/shower transfer, walking 10 feet, wheeling 50 feet with two turns. H-R1 was frequently incontinent of bladder, and occasionally incontinent of bowels. No training program. M-Risk of developing pressure ulcers/injuries.Review of the care plan, last reviewed/revised on 04/09/2026, revealed R1 had a risk for skin breakdown related to (r/t) bladder and bowel (B/B) incontinence, need for ADL (Activities of Daily Living) assistance, impaired mobility, risk for impaired mobility/ weakness, risk for falls r/t impaired mobility and weakness associated with CVA (cerebrovascular accident/stroke), is an ADL decline r/t CVA, reduced mobility, and impaired vision.Review of wound history revealed R1 had a rash in the perineal area that was not there on admission, and it was first identified on 01/13/2026. The color is pink, localized, warm, circular, and itchy. Orders for butt cream back to 09/23/2025 for diaper dermatitis, and po meds and prescription ointments started in January 2026.An interview on 05/05/2026 at 1:45 PM with R1 revealed she had a bowel problem, and when she needed help, she pushed the button. R1 revealed that Certified Nursing Assistant (CNA) UU spoke to her in a mean manner, mistreated her, and would not help or change when needed. CNA UU yelled and told me to get up and go by myself. CNA UU did not want to change her wet pants. R1 stated CNA UU had no business talking to her that way.An interview on 05/05/2026 at 2:40 PM with Registered Nurse (RN) LL revealed she usually worked on A hall and confirmed several residents reported abuse by CNA UU. RN LL revealed CNA UU was terminated in the last few weeks because of the mistreatment/abuse/neglect reported by several residents. A phone interview on 05/05/2026 at 1:55 PM with the family of R1 confirmed that the CNA UU yelled at R1, refused to change or provide care for R1, or help her to the bathroom.2. R2 was a 50-y/o female admitted with primary/admission diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Other diagnoses included, but were not limited to, cerebral infarction, insomnia, constipation, chronic candidiasis, muscle weakness, diarrhea, and major depressive disorder.Review of the Quarterly MDS assessment dated [DATE] reported Section C-BIMS score 13, indicating little to no cognitive impairment. GG-Impairment on one side, upper and lower extremities, required partial/moderate assistance for rolling side to side in bed. Maximum/ substantial assistance for sit-to-lying or lying-to-sitting, transferring from bed to chair, and toilet & tub/shower transfer. Dependent for toileting hygiene, bathing, dressing, footwear, and personal hygiene. H-R2 was always incontinent with bladder and bowels, and not on a toileting training program. M-Risk of developing pressure ulcer/injury.Review of the care plan, last reviewed/revised 04/13/2026, revealed R2 required training and skill practice in bed mobility-start date 11/10/2025, had CVA(Cerebrovascular Accident) with left hemiparesis, left foot drop and left hand contracture and needs extensive to total help in ADLs-start date 09/02/2024, risk for pressure ulcers related to impaired mobility, risk for contracture r/t CVA w/left hemiparesis-apply palm guard left hand, risk for skin breakdown r/t bladder and bowel (B/B) incontinence, need for ADL assistance, impaired mobility.Interview on 05/05/2026 at 2:10 PM with R2 confirmed the abuse by a staff. R2 revealed it was a CNA named [CNA UU], on the night shift. R2 stated CNA UU took off her gown and snatched it, yanked it, and pulled her left shoulder, and then wiped her private (labia) hard, and where she wiped me, it hurt badly. R2 stated that she told CNA UU, and she didn't care; she didn't slow down or stop; she kept on. R2 reported it to my night nurse. R2 confirmed that the police spoke with her. R2 was not sure whether CNA UU was still employed at the facility and hoped she was not, and stated that CNA UU had not returned to provide care for her.3. R3 was a 75 y/o female admitted with primary/admission diagnosis of Alzheimer's disease. Other diagnoses included but not limited to orthopedic aftercare, hypothyroidism, glaucoma, major depressive disorder, muscle weakness (generalized), insomnia, protein-calorie malnutrition, osteoarthritis, pain, acute embolism and thrombosis of deep veins of left lower extremity, localized swelling, mass and lump left lower limb, adult failure to thrive, diarrhea, severe protein-calorie malnutrition, cutaneous abscess of buttock, local infection of the skin and subcutaneous tissue, anxiety disorder, depression.Review of Physician orders included pain evaluation every shift, Treatments: Non-Rx: Clean area to coccyx with normal saline (NS) and pat dry, apply hydrocolloid as needed, start date 04/22/2026, Treatments Non-Rx: Clean area to coccyx with normal saline(NS) and pat dry, apply dry Optiview dressing once a day every three days, start date 04/24/2026, weekly skin assessment.Review of the Quarterly MDS assessment dated [DATE] for R3 reported Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) score 12, indicating little to mild cognitive impairment. D-Felt down/depressed/hopeless 7-11 days and poor appetite 12-14 days of the seven-day look-back period. E-No behaviors exhibited. GG-R3 had impairment on both sides in upper & lower extremities, no device for mobility (R3 rarely got out of bed). R3 required substantial/maximum assistance for bathing self, dressing, footwear, rolling left to right in bed, and was dependent for toileting, personal hygiene, sit to lying (ability to move from bed), lying to sitting on side of bed, chair/bed-to-chair transfer, toilet and shower transfer, and walking was not attempted due to medical reasons. H- Always incontinent of B&B and no toileting program. M-R3 had a risk for pressure ulcer/injury.Review of the care plan, last reviewed/revised on 04/21/2026, revealed R3 had a risk for ADL functional status/rehabilitation potential. Has a decline related to neuralgia and Alzheimer's disease with a start date of 09/03/2024. Risk for falls r/t impaired mobility and cognition, start date 09/03/2024. Interventions: Place the call light within reach, keep the environment safe. Impaired skin integrity: small open area on her coccyx, start date 04/21/2026. Interventions dated 04/21/2026 included wound care as ordered, turn and reposition, and observe for /report s/s of infection. Risk for skin breakdown r/t impaired mobility and bowel and bladder incontinence. Interventions: Keep skin as clean and dry as possible, minimize skin exposure to moisture, start date 3/6/25, verbal education given to the resident on changing positions and getting out of bed to prevent skin breakdown-12/17/25, encourage changing positions and getting out of bed-12/18/2025. Mobility: has impaired mobility r/t weakness and impaired cognition, start date 09/03/2024.An interview on 05/05/2026 at 1:55 PM, R3 confirmed being treated roughly by [Named CNA UU]. She revealed she had a hip replacement and a blood clot in her leg, and CNA UU was pulling her leg hard, and she would not stop when she told her it hurt. She revealed that R1 family member had called the police, and that the officer had spoken with several residents in B hall, including R3 and her roommate, R9.An interview on 05/05/2026 at 1:55 PM with R9 revealed her roommate, R3, needed her catheter emptied so it would drain properly and not back up. R9 revealed that she reminded CNA UU the night before to please empty it the next morning before leaving, so it would drain properly. CNA UU did not empty her catheter drainage bag. R9 confirmed that the police officer came in and spoke with her and R3 about CNA UU, and they told the police officer how rough she was with R3. R3 and R9 revealed the facility was short-staffed, or they just won't do their job. Often, it takes a long time for staff to answer call lights, especially on the night shift.Review of a Police report dated 04/11/2026 for Abuse, Neglect or Exploitation of a disabled or elderly person confirmed that the police investigated an incident at the facility and talked to the nurse, Director of Health Services (DHS), a family member, and three residents. The Officer documented that he was dispatched to the facility regarding neglect.Review of Police Report case number 2026-00011423, with date of occurrence 04/11/2026, revealed that the local police were called and dispatched to the nursing home. They made a report that included the Police officer talking with a family member, residents, two hall nurses, and the Director of Nursing (DON) related to the offense of abuse, neglect, or exploitation of disabled or elderly persons by a staff member. The DON revealed to the Police officer that CNA UU would be placed on administrative suspension. She also said that prior to my involvement, CNA UU had been removed from the wing where the reporting residents were. When the Police officer gave the description and name of the CNA UU to the DON, she nodded to indicate she knew who he was talking about.Review of Facility Reported Incident (FRI) 202604212 dated 04/10/2026 for abuse. Details of the incident were documented on 04/10/2026 at approximately 2:52 PM. The facility was notified that a resident reported to her granddaughter that a CNA had handled her roughly during care. The granddaughter contacted local law enforcement, who responded to the facility to investigate the allegation. Education on abuse and neglect was initiated by the DHS. R1 stated that the CNA entered her room using a loud-voiced tone and spoke to her in an inappropriate manner. Documentation revealed that the CNA was immediately suspended, and the family and physician were notified. Further review of facility documentation also revealed that after investigation of the incident, which included interviewing staff and residents, the CNA who was involved in the allegation was terminated, but not reported to the licensure boardA review of a Notification-Allegation of Abuse and Neglect to the Ombudsman by the Director of Health Services (DHS) documented that the facility became aware that a resident had reported to her that a family member had handled her roughly while providing care. The granddaughter contacted law enforcement, and an officer responded. Measures have been implemented to ensure the resident's safety, and the CNA involved has been removed from the resident's care duties pending the outcome of the investigation.Review of the documentation revealed that, in the Status of Employee dated 04/21/2026, the CNA remained suspended during the investigation. Upon completion of the investigation, the facility attempted to contact CNA UU to schedule a meeting, review the findings, and complete the required re-education prior to the CNA's return to work. After multiple attempts without response, the facility determined the CAN UU had abandoned her position (job abandonment) in accordance with facility policy.A review of the Investigation Summary dated 05/16/2026 revealed that, during the investigation, other residents in the same unit were interviewed. Four residents expressed concerns about CNA UU's manner of providing care, describing CNA UU as rough and/or rushed; however, none reported any specific incidents of injury, neglect, or harm. No resident provided sufficient detail to establish that abuse as defined by regulation occurred. CNA UU reported she provided care in accordance with training and facility policy. Based on information obtained, abuse was unsubstantiated as there is no evidence to support that abuse or neglect occurred.Review of the documents revealed that during interviews with residents, law enforcement noted that the CNA UU was rude, yelled, and failed to provide requested care. The officer interviewed other residents who reported similar concerns involving the same CNA UU as being rude and speaking in a yelling/angry tone.Review of witness statements revealed that CNA SS documented, Residents c/o (complained of) CNA talking and shouting at them. The complaint was reported to the supervisor from 3:00 PM to 11:00 PM. The CNA was (CNA UU), and the residents' c/o (complaining) were R2 and R3.An interview on 05/07/2026 at 2:05 PM with the Administrator confirmed the abuse allegation of CNA UU by R1, revealed that it was investigated and reported, and she was terminated. The incident with R1 was reported to her by staff after R1 called her family, who overheard the CNA on the phone with R1. The Administrator provided the state report of the incident for review and confirmed that CNA UU immediately left the facility and was suspended pending investigation. R1 had no history of reporting false allegations against staff. The Police were called and interviewed by R1's family member, and afterward interviewed other cognitively impaired residents who resided in A-hall, where CNA UU was assigned. It was reported that there had been other incidents of CNA UU speaking inappropriately to residents, neglecting residents by refusing to provide needed care, or physically being rough with residents during care. The Administrator also revealed all staff had been in-service on abuse and reporting abuse. The Administrator revealed she did not have an incident report on any other residents, but others were identified through the investigation.An interview on 05/13/2026 at 2:55 PM with the DHS OO revealed that she participated in the investigation into R1 abuse. The facility called her and the Administrator, and she came to the facility that day, one to two hours after they called. CNA UU was not at the facility when she arrived. The plan was to suspend her pending an investigation. CNA UU was scheduled to work that night, but DHS OO spoke with her and told her she could not work. She wanted to know what the problem was and why she could not work. DHS OO spoke with CNA UU, who denied any wrongdoing. DHS OO spoke with all residents CNA UU had cared for; she was only in A hall, so she focused on that hall. Residents complained about the way CNA UU spoke to them and how she responded when they asked or spoke to her. It was just verbal; they were complaining about it. CNA UU left and never came back. The DHS OO revealed she tried to call her, but CNA UU did not answer any of her calls. DHS OO revealed the incident was not reported on CNA UU's license. It was reported to law enforcement and the Ombudsman. DHS NN revealed the incident was unsubstantiated. It was only CNA UU being loud, talking to the roommate; she is mean and rude and told R1 to get up and go to the bathroom on her own, but there was no physical contact, no abuse. The Police came, spoke with several other residents, and were still at the facility when DHS arrived. The other residents reported the same thing. The CNA was mean talking but she never responded. It was all verbal. When asked, DHS OO stated she did not feel that being mean, talking, and being loud was verbal abuse. DHS OO felt like it was her tone of voice.

Based on observations, resident and staff interviews, record reviews, and review of the facility's policies titled Restorative Nursing Program and Therapy Evaluations, the facility failed to ensure that restorative nursing services were consistently provided following the completion of therapy for four of eleven residents (R ) (R12, R13, R14, and R15) reviewed for restorative nursing services. Specifically, the facility failed to provide required restorative interventions, including transfer assistance for R12; ambulation/walking programs for R13 and R14; and Range of Motion (ROM) exercises for the upper or lower body for R12, R13, and R14. This deficient practice has the potential to diminish residents' quality of life.Findings included:Review of the facility's policy titled Therapy Evaluations, revised May 13, 2020, documented the following procedures: 5. The evaluation will include recommendations for treatment and follow up as clinically indicated. 12. Therapy will foster an interdisciplinary approach to care by educating departments on safe transfer techniques, environmental adaptations, and patient/resident specific restorative nursing programs as indicated.Review of the facility's policy titled, Restorative Nursing Program, revised November 4, 2021, documented Policy Statement: It is the policy of this healthcare center to provide restorative nursing which actively focuses on achieving and maintaining optimal physical, mental, and psychological functioning and wellbeing of the patient/resident. Restorative Nursing Program is under the supervision of a Registered Nurse (RN) or Licensed Practical Nurse (LPN) and restorative nursing services are provided by Restorative Nursing Assistants (RNAs) and other qualified staff. Definitions: Restorative nursing program refers to interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. Passive Range of Motion (PROM)-movements in order to maintain flexibility and useful motion in the joints of the body. Active Range of Motion (AROM)-exercised performed by the resident, with cueing, supervision, or physical assistance by the staff. Documentation: 1. Restorative nursing care will be documented in the EHR (Electronic Health Record) or paper form. 2. The nurse will evaluate the patient's progress. Document in resident's care plan.1. R12 was an [AGE] year-old (y/o) admitted to facility 10/28/2025 with primary/admission diagnosis of chronic obstructive pulmonary disease. Other diagnoses included, but were not limited to, Vitamin B12 deficiency anemia, muscle weakness, difficulty in walking, muscle spasm of the calf, hypothyroidism, osteoporosis, and constipation.Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R12 reported Section C-Cognitive Patterns BIMS (Brief Interview for Mental Status) score of 15, which indicated little to no cognitive impairment. I-Active diagnoses: Debility, cardiorespiratory conditions. Section O-Special Treatments and Therapies revealed that the resident did not receive any therapies and received restorative nursing services for transfer and active and passive range of motion on one day during the seven-day look-back period.Review of the care plan, last reviewed/revised date 03/13/2026, revealed that R12 had a problem with ADLs (Activities of Daily Living) functional status/rehabilitation potential and required training and skill practice in transfers and active range of motion for the bilateral upper and lower extremities six days per week. Interventions: Follow treatment guidelines of PT (Physical Therapy) . RNP (Restorative Nursing Program) once a day for transfer and AROM (Active Range of Motion).Review of PT Discharge Summary dated 12/04/2025 for R12 under Discharge Recommendations and Status documented Discharge Recommendations: Restorative Range of Motion Program and Restorative Transfer Program. The prognosis to maintain CLOF was good with consistent staff follow-through. There was no documentation of restorative nursing services for review. An interview on 05/13/2026 at 12:22 PM with R13 revealed that the only exercises she received were those Certified Nursing Assistant (CNA) QQ gave her, and they might be once a week or not at all. R13 stated she asked CNA QQ if she could do her exercises while working on the floor and was told she couldn't do both. R13 revealed that the frequency of exercise depended on whether CNA QQ was working on the floor. The problem is they don't have enough help. R13 was concerned and stated that she would not improve by exercising only once a week. R13 continued to reveal staffing issues and said residents are at their mercy. R13 2. Review of the medical record revealed R13 was a 66 y/o who was admitted with a primary/admission diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Other diagnoses included, but were not limited to, respiratory syncytial virus as of 03/21/2026, acute bronchitis due to respiratory syncytial virus, muscle weakness, hypothyroidism, difficulty in walking, and peripheral vascular disease.Review of Quarterly MDS assessment dated [DATE] for R13 reported Section C-Cognitive Patterns BIMS score 14, which indicated little to no cognitive impairment. I-Active diagnoses: Stroke. Section O-Special Treatments and Therapies revealed the resident did not receive restorative nursing services during the seven-day look-back period. Section O-reported R13 received OT and no RNP in the past seven-day look-back period. Review of the care plan, last reviewed/revised date 04/21/2026, revealed that R13 had a problem with ADLs' functional status/rehabilitation potential and required training and skill practice in walking and active range of motion for the bilateral lower extremities (BLEs) six days per week. Interventions: Follow treatment guidelines of PT. RNP once a day ambulation and AROM.Review of Physical Therapy PT Discharge Summary dated 12/30/2025 for R13 under Discharge Recommendations and Status documented, Discharge Recommendations: RNP for Restorative Ambulation Program, Restorative Range of Motion Program. The prognosis to maintain CLOF was excellent with consistent staff follow-through. There was no documentation of restorative nursing services for review.Interview on 05/13/2026 at 2:25 PM with R13 revealed that CNA QQ did exercises at the same time as her roommate, focusing on her legs, ankles, and arms. She did not get therapy every day, only about once or maybe twice a week. 3. Review of the medical record revealed R14 was an 86 y/o who was admitted with a primary/admission diagnosis of dementia. Other diagnoses included, but were not limited to, hypothyroidism, type 2 diabetes mellitus, osteoarthritis, weakness, constipation, age-related osteoporosis, and disorders of bone density and structure.Review of Quarterly MDS assessment dated [DATE] for R14 reported Section C-Cognitive Patterns BIMS score 12, which indicated moderate cognitive impairment. I-Active diagnoses: Non-traumatic brain dysfunction. Section O-Special Treatments and Therapies revealed R14 received restorative nursing services for AROM and walking one day during the seven-day look-back period.Review of the care plan, last reviewed/revised date 03/24/2026, revealed that R14 had a problem with ADLs' functional status/rehabilitation potential and required training and skill practice in walking and active range of motion to BLEs (Bilateral Lower Extremities), six days per week. Interventions: Follow treatment guidelines of PT. RNP once a day ambulation/walking and AROM.Review of Physical Therapy PT Discharge Summary dated 11/12/2025 for R14 under Discharge Recommendations and Status documented, Discharge Recommendations: RNP for Restorative Ambulation Program, Restorative Range of Motion Program. The prognosis to maintain CLOF was good with consistent staff follow-through. There was no documentation of restorative nursing services for review.Interview on 05/13/2026 at 12:20 PM with R14 revealed that CNA QQ performs leg exercises. She does not come every day. She does it one to two times a week. R14 revealed she did not have restorative today, and there is only one girl for a lot of people. 4. Review of the medical record revealed R15 was admitted with a primary/admission diagnosis of nondisplaced fracture of the second cervical vertebra dated 09/04/2025. Other diagnoses included, but not limited to, disease of the upper respiratory tract-03/04/2026, muscle weakness (generalized), chronic obstructive pulmonary disease with acute exacerbation, presence of right artificial knee joint, idiopathic gout, spinal stenosis lumbar region with neurogenic claudication, wedge compression fracture of third thoracic vertebra, wedge compression fracture of first lumbar vertebra, fracture of left acetabulum.Review of Annual MDS assessment dated [DATE] for R15 reported Section C-Cognitive Patterns BIMS score 15, which indicated little to no cognitive impairment. I-Active diagnoses: Medically Complex conditions. Section O-Special Treatments and Therapies revealed R15 did not receive restorative nursing services during the seven-day look-back period.Review of the care plan, last reviewed/revised date 04/21/2026, revealed R13 had a problem with ADLs' functional status/rehabilitation potential and required training and skill practice in walking, and active range of motion to BLEs six days per week. Interventions: Follow treatment guidelines of PT. RNP once a day walking and AROM.Review of Physical Therapy PT Discharge Summary dated 10/31/2025 for R15 under Discharge Recommendations and Status documented, Discharge Recommendations: RNP for Restorative Ambulation Program, Restorative Range of Motion Program. The prognosis to maintain CLOF was Other prognosis: Factors impacting prognosis-consistency/follow-through with recommendations. There was no documentation of restorative nursing services for review.A review of the staffing schedule dated 04/11/2026, for the 7:00 AM to 7:00 PM shift showed that CNA UU was marked out, and a name was written in. DON OO confirmed that the name listed for the other CNA on B hall was not a CNA; it was LPN KK, who worked as a CNA. DON OO revealed that the other nurse covered LPN KK's rooms.An interview on 05/12/2026, from 12-12:25 PM with R15 revealed that she had fallen a while back and had been hospitalized for two days. She got therapy way back, and CNA QQ worked with her about a month ago, but she was not getting therapy now. CNA QQ was the restorative aide but has not had restorative care in three to four weeks. R15 confirmed that no one does range of motion, walking, transfer, or exercises with her.During the survey, no observations of R12, R13, R14, or R15 receiving restorative services for walking, transfers, or ROM exercises were made from 05/05/2026 to 05/13/2026.Interview on 05/13/2026 at 2:04 PM with Occupational Therapist (OT) staff. OT PP revealed that both Physical Therapy (PT) and OT can recommend a restorative nursing program (RNP) after completion of therapy. The therapy discharge evaluation documents whether RNP is recommended, but it is very basic; the primary communication to the nurse includes all the details in the electronic medical record (EMR). It will be an order or a teaching record. OT PP revealed there should be an RNP care plan for residents on restorative care. OT PP revealed that if she discharged a resident with a recommendation for RNP, she would expect it to be five days a week, Monday through Friday, because that is what therapy did, and she felt the resident needed to maintain and/or prevent decline. She confirmed CNA QQ was the staff member who did restorative but was not certain whether restorative was done every day. OT PP saw CNA QQ in the facility, but did not know in what role, whether she provided restorative care or floor CNA. OT PP confirmed that R12, R13, R14, R15, and R16 were recommended for Restorative and should be on it.Interview on 05/13/2026 at 2:17 PM with CNA QQ revealed that she had been a restorative aide for 2 years. She started as a CNA on the floor in February 2024 and became a Restorative CNA in June 2024. She does not do restorative nursing on the days she is pulled to work as a CNA on the floor because she cannot do both. She revealed that she worked Monday-Friday and that there was no restorative care on weekends. The interview revealed that, over five days, she may be on the floor two to three days each week. She revealed they were usually short-staffed, and the first people they pull to go to the floor are the restorative staff. Last week, she was on the floor Monday, Tuesday, and Wednesday, and did restorative Thurs and Friday. Interview on 05/13/2026 at 10:40 AM with Director of Health Services (DHS) NN who was from a sister facility and was at this facility assisting the Administrator and interim DHS OO during the complaint investigation revealed the facility did not have a restorative nursing program (RNP) but had a functional Restorative CNA who did range of motion and walking, to keep residents where they are and try to prevent a decline.Interview on 05/13/2026 at 2:55 AM with DHS OO revealed the facility did not have an RNP but had someone who does restorative exercises. She revealed that as soon as the resident finished therapy, an assessment would be done. If the resident needs functional restorative they put them on restorative, but it is not consistent because if the restorative CNA is needed on the floor, she does not do restorative. If we don't need her on the floor, she does restorative exercises. DHS OO revealed she did not know how long it had been since they last had a restorative program, and that restorative exercises are done occasionally. DHS OO revealed that CNA QQ is the restorative aide and is scheduled for restorative care as much as possible, but if they have callouts, she is pulled. DHS OO expectation was to have restorative daily and not have to pull the restorative aide to work on the floor.

Based on resident and staff interviews, record review, and review of the facility's policy titled Occurrences, the facility failed to provide protective oversight and supervision to prevent elopement and ensure resident safety. This deficient practice resulted in one of four sampled residents (R) (R1 and R10) exiting the facility and remaining unaccounted for by staff for over one hour, and in R10 experiencing a fall with major injury in the shower, resulting in a subarachnoid hemorrhage. Findings included:A review of the facility's policy titled, Occurrences, with a revised date of January 11, 2024, revealed under Policy Statement: .To prevent occurrences, each patient/resident will be observed and assessed for risks. Definitions: Occurrence hazards are physical features in the healthcare center environment which may pose a risk to a patient/resident's safety, including but not limited to: Any event, accident, or incident, on or off healthcare center property which results in an injury or has the potential for injury. Elopement from healthcare center property regardless of whether there was an injury associated with the elopement. 1. Review of R4's clinical record revealed R4 was an [AGE] year-old male admitted with primary/admission diagnoses of multiple fractures of ribs, left side, fracture of first thoracic vertebra, fracture of scapula, left shoulder, subsequent encounter for fracture with routine healing. Additional diagnoses included, but were not limited to, muscle weakness, need for assistance with personal care, dementia with behavioral disturbance, pain, stroke, and non-Alzheimer's Dementia.Review of Physician orders include, but are not limited to, behavior monitoring; Wander Guard to left ankle; check functioning and placement every shift; start date 03/11/2026.Review of the admission five-Day Minimum Data Set (MDS) assessment dated [DATE] reported Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) score of 02 indicating severe cognitive impairment, Section E (Behaviors) wandering behavior occurred one to three days, wandering placed the resident at significant risk of getting (outside the facility), and the wandering behavior is worse compared to prior assessment. Section GG (Functional Abilities and Goals) R4 was coded as independent for self-care, indoor mobility, and functional cognition. No impairment in upper or lower extremities, and no device used for mobility, and Section P documented that a wander/elopement alarm was used less than daily.Review of the care plan included Behavioral symptoms: Presence of Behavioral Symptoms-wanders unsafely, start date 03/05/2026. Interventions included assessing the appropriateness of the Wander guard start date (03/09/2026) and moving the resident closer to the nurses' station start date (03/11/2026).A review of the room census revealed that R4 was in room A/14-b from 03/05/2026 to 03/11/2026. Room A-14 was the last room on the right at the end of Hall A, next to the door that exited the facility.The review of the assessment for elopement, titled Elopement Risk Observation Form, dated 03/07/2026, was completed after R4 eloped from the facility on 03/07/2026 and revealed a 0-4 Low Risk. 5-10 Moderate Risk. 11 or Greater - High Risk: Interventions for high risk included but are not limited to: 3-day monitoring and Wander guard Program. R4's elopement risk score was 17.0, indicating high risk. Review of progress notes documented, 03/07/2026 5:22 PM: Resident is an [AGE] year-old male, who is alert/confused and wears a wander guard for being in unfamiliar surroundings. On 03-07-2026, the resident escaped from [Named] facility and walked to his previous residence, where he contacted his family to inform them about his location. The family member contacted the police department, and the resident was brought back to the facility unharmed and assessed by the nurse for injuries that may have occurred while he was away from the facility.Review of Facility Incident Report(FRI) dated 03/07/2026 documented, Elopement resident [R4] 03/07/2026 at 4:45 PM, Resident reported to have left the facility without signing out. Whereabouts are unknown. Elopement education was provided to all staff. All doors were checked to ensure they were locked. Resident count was completed to ensure all residents were accounted for. A copy of a Police Officer's card was with the report, Case number 2026-7627, Officer [Name].Review of form titled, SBAR (Situation, Background, Assessment, Recommendation) Communication Form (undated) documented, Post elopement started on 03/07/2026, the new environment made the condition or symptoms worse.Review of Event Note dated 03/07/2026 documented, Wander guard to left ankle #A02253145. The resident is an [AGE] year-old male who is alert/confused and wears a wander guard due to unfamiliarity with the nursing environment. On 03/07/2026, the resident escaped from [Named] facility and walked to his previous residence, where he contacted his family to inform them about this location. The family contacted the police department, and the resident was brought back to the facility unharmed and assessed by the nurse for injuries that may have occurred while he was away from the facility.A review of the two-week staffing grid for the date of the elopement, March 7, 2026, revealed that the PPD (per patient day) ratio of staff to residents was 1.87, as confirmed by the DHS (Director of Health Services).A review of the staff assignment for 03/07/2026 revealed that two nurses and two Certified Nursing Assistants (CNAs) initialed the assignment sheet to confirm their presence. For the night shift (7:00 PM to 7:00 AM), the two-week staffing had 12 RN (Registered Nurse) hours. The initial nurse scheduled was marked out, and the DHS was assigned for 7:00 PM to 5:00 AM, although on the two-week grid, it showed 12 RN hours.2. R10 was a [AGE] year-old male with most recent readmit on 03/24/2026. Diagnosis: acute bronchiolitis due to respiratory syncytial virus (RSV)-Primary/admission diagnosis (dx) as of 03/24/2026. Additional diagnoses included, but were not limited to, chronic obstructive pulmonary disease, malignant neoplasm of unspecified part of bronchus or lung, chronic kidney disease, stage 4, difficulty in walking, muscle weakness (generalized), and nontraumatic subarachnoid hemorrhage-admit dx on 02/12/2026.Review of the MDS assessment dated [DATE] reported a BIMS score of 14, indicating little to no cognitive impairment. GG-documented impairment on both sides in lower extremities, and used a wheelchair for mobility, independent for sit to stand (the ability to transfer to and from a bed to a chair or wheelchair), and supervision for toileting, dressing, footwear, toilet chair/bed transfer, and walking 10 feet.Review of the care plan included Falls: R1 had a risk for falls related to unsteady gait.Review of the witness statement documented that CNA stated that, while starting to shower, R10 turned his head to close the door, and when he turned back, R10 began to fall backward and hit his head on the shower room wall.Review of Progress Note dated 02/09/2026 11:48 AM documented, Resident ambulated with the assistance of two to the shower room and was seated in the shower chair. The resident pushed himself back in the chair, causing it to flip backward and hit his head on the back of the ceramic wall. EMS (Emergency Medical Services) was contacted, and the resident was transported to the hospital for further evaluation. Daughter and physician both notified via phone call.Review of SBAR Communication Form dated 02/09/2026 documented date admitted was 02/06/2026, and reason for transfer was a fall. It was signed by LPN TT.Review of Fall Event' dated 02/11/2026 documented a fall in the shower room. The resident was sitting in a shower chair waiting to be showered. The resident exhibited a complaint of pain related to the fall, rated five on the pain scale, 0-10. The location of the injury was the occipital part of the head.Review of Associated FRI 202601687 dated 2/18/2026. R1 had a witnessed fall with major injury in the shower room when a staff person was about to give the resident a shower. The resident was sitting on a shower bench, the staff member turned to provide privacy, and R1 attempted to move to his wheelchair. The wheelchair rolled. R1 was wet, started slipping, fell, and hit his head. The resident was sent to the hospital for evaluation and diagnosed with a subarachnoid hemorrhage. Interview with R1, interview with staff, review of clinical records, and review of facility documentation. Education for staff was given, and an associated FRI #202601687 was submitted to the State Survey Agency. The final investigation for incident, FRI 202601687, dated 02/18/2026, documented, Resident was assisted to the shower room by the CNA. While the CNA turned to shut the door, the patient was sitting on a shower bench. CNA states that when he turned back around, he noticed the patient leaning backward, falling, and hitting his head. Patient was assessed by staff and DHS; no bleeding or lumps noted. Per protocol, the patient was sent to the hospital. When they called to check on the resident, they were informed of the subarachnoid hemorrhage and were transferred to [Named] hospital in [Named] city for further evaluation. On 02/12/2026, the patient returned to the facility. The resident was interviewed, and he revealed that he was attempting to sit when he fell backward. Neglect was not substantiated.An interview on 05/05/2026 at 12:35 PM with R10 revealed he liked it at the facility, that it was alright, as good as can be expected, and that when he needed help, he hit the call light. R10 revealed that it sometimes takes 30-40 minutes, sometimes an hour or longer, for staff to come when he uses the call light, if at all. R10 revealed his urinal had sat on his over-the-bed table for over half an hour. He would need to use it and wait so long that, by the time they came, he no longer needed it because he had wet himself and the bed, and they had to change the bed sheets. He revealed yesterday, the day before our interview, that he was constipated and finally had to go. He called for help, and it took so long that he got up unassisted, used his wheelchair, and was on the toilet by the time they finally came. Staff told him not to do that anymore because he could slip and fall. He revealed that if he had not, they would have to change a dirty bed.An interview on 05/05/2026 at 2:40 PM with RN LL confirmed R4 eloped from the facility and walked all the way to his house, down by the waterfront, approximately two miles. R4 was gone long enough for the neighbor to call the nursing home to report it. The facility did not know until they got a call. RN LL revealed that two other residents, R5 and R6, also left through the front door and went to the parking Lot. RN LL confirmed education in-service on elopement and the wander guard after the incident. Review of the staff assignment with RN LL; she confirmed they had initialed their names to confirm they were present.An interview on 05/05/026 at 3:11 PM with Housekeeping (HK) Aide MM revealed she was aware of one elopement about four weekends ago. R4 lived close to the facility, and the neighbor saw him and brought him back.An interview on 05/05/2026 at 3:21 PM with Licensed Practical Nurse (LPN) KK confirmed there was an elopement several weeks ago, the weekend after the prior Director of Health Services (DHS) quit. R4 got out and walked to his home. LPN KK revealed that there have also been times when R5 and R6 went out the front door and reached the parking lot. They followed a visitor or someone out. There is now an alarm on the front door. She confirmed they did in-services, but not in person. They posted a paper, and the staff was supposed to read and sign it. She revealed that staff are instructed to keep a close eye on R5 and R6. They both have a Wander guard, but the alarm is only on the front door. Review of the staff assignment with LPN KK; she confirmed that the initials by their name confirmed they worked.An interview on 05/05/2026 at 4:25 PM with CNA BB revealed that she had heard about a resident who eloped from the building. It was a weekend, and she was off, but she heard staff talking about it. It was a male (R4). The family member brought him back from his house. She revealed that she did not know which door he had gotten out of and said there was an alarm on the front door. All other doors require a badge swipe to open. There are exit doors on A, B, C, and D hall, and in the Activity room at the end of D hall.An interview on 05/05/2026 at 5:00 PM with the Administrator confirmed that R4 exited the facility through the door at the end of A hall, which did not close properly. R4 left the property and walked to his nearby home. He was seen by a neighbor who called his family. The family called the police, and he returned. R4 was in the room at the end of A hall, next to the door. He had not been here long, and he wanted to go home. The Administrator confirmed R4's elopement but denied that any other residents had left the property.An interview on 05/13/2026 at 9:00 AM with the Maintenance Director revealed a resident elopement through the door at the end of A hall. He revealed that the door frame appeared to have several coats of paint and a thick buildup that may have prevented the door from being locked. He revealed he worked on the door, ground down the paint, checked the lock, and it has worked properly ever since. He revealed he checks all doors twice a day and checks the Wander guard alarm on the front door to make sure the door locks when you go out. He confirmed that there have been no problems with the doors since R4 eloped.A follow-up interview on 05/13/2026 at 10:30 AM with R10 revealed that when he fell in the shower, a staff member was present but had stepped away from him. There were two stalls, and R10 was sitting on the shower chair/stool in one stall. The staff turned to check on the person in the other stall. R10 got up to get to his wheelchair. He tried to get into his wheelchair on his own, and it was not locked. He revealed that the wheelchair started rolling, he was wet, and he started sliding. He also revealed that the wait time for staff answering the call light can sometimes be one, two, or three hours, if it gets answered at all.An interview on 05/13/2026 at 2:55 PM with the DHS confirmed R4's elopement. She revealed she could not tell me the exact time he left, but it was documented. It was early in the morning. It happened on the 7 AM to 7 PM shift. They notified the Administrator first, then notified the DHS, and started the investigation. R4 was brought back unharmed. She revealed they did education with all staff. The interview further confirmed that R10 had a fall in the shower, that staff were present, and that he was sent out for evaluation and treatment. He returned to the facility; he sustained a subarachnoid hemorrhage. The DHS revealed they have staffing issues at times, but that was not why R10 fell. Her expectation was that staff would always stay close to residents in the shower and closely monitor all residents, especially those who wander.

Based on resident and staff interviews, record review, review of facility documents titled, PBJ (payroll-based journal) Staffing Data Report, and review of the policy titled, State Minimum Staffing for Healthcare Centers, The facility failed to ensure adequate nursing staff to meet residents' needs in a timely manner. This failure delayed the provision of care, increased the risk of elopement and falls resulting in major injury, and could have decreased the quality of life of 61 residents residing in the facility. Findings included:Review of the facility's policy titled, State Minimum Staffing for Healthcare Centers, last reviewed November 2, 2025, documented Policy Statement: The facility will maintain the minimum staffing hours in accordance with federal law and the respective state's rules and regulations. Staff shall be sufficient to meet the healthcare needs of each patient/resident as identified in the patient/resident's plan of care.Review of the Facility Assessment for the period May 12, 2026 - May 11, 2027, with last activity on May 12, 2026, revealed that the number of licensed beds was 78, and the current census was 67. Overall staffing was documented as sufficient, for contractures-sufficient, for Rehabilitative Services (for those receiving therapy), documented In Progress, and Recreational Therapy documented In Progress.The Facility assessment dated [DATE] documented a request for the prior Facility Assessment, which revealed that neither documented the average daily census in the facility, nor the average hourly staffing needs per day for licensed nurses providing direct care, nor the hours for nurse aides. Review of the PBJ Staffing Data Report FY (fiscal year) Quarter 1 2026 (October 1- December 31) revealed, based on the data submitted, the facility triggered excessively low weekend staffing.Review of Grievances/Complaint Log Form for the past seven months, from 09/02/2025 to present, revealed the following complaints reported:On 02/04/2026-Spouse reports a delay in care caused the resident distress and worry about the adequacy of the resident's medical management. A Foley catheter was inserted for a full bladder but not done in a timely manner; the spouse reports it took over 20 hours to receive medical attention. Spouse requested that care be provided more promptly to avoid prolonged discomfort and potential complications.On 03/06/2026-More than one incident of not being helped with toileting, sat in wet clothes and bedding for four hours after calling for help (03/02/2026), and on 03/06/2026, the resident called for help at 11:30 AM, and at 3:00 PM, still nobody came to help her. Family visits ended up helping the residents.On 03/13/2026-Complaint of Certified Nursing Assistant (CNA) ignoring residents when they asked for something, bad behavior, ignoring and not providing care when requested, not putting a dependent resident to bed until 11 PM, even when asked several times earlier.On 10/09/2025-Not getting showers and staff being rough with residents during transfer.Review of Resident Council minutes for the past eight months revealed the following:On 10/07/2025, residents complained that the response time to call lights is unacceptable; the wait time is long when residents call the CNA; they are not getting showers on scheduled days; and residents are left alone in the shower.On 11/11/2025, CNAs walked past the lights without checking.On 12/09/2025-Response time is long when a resident calls for help. Three residents have not showered in three days. The board in the room is not updated daily (with date, nurse, and CNA name). No restorative care is provided after being discharged from therapy. Housekeeping is changing residents due to understaffing.On 01/13/2026-Understaffed on the weekends, no one checks on residents at night, call lights are not being answered, and staff scolds residents for needing to be changed.On 02/10/2026-Need more CNAs and nurses on weekends, phones not being answered at the front desk, call lights are still not answered in a timely manner, all staff can answer call lights when available but don't, nurses need to assist with getting residents up, changing, and putting to bed, one resident reported witnessing a CNA push items off a resident's desk, eating residents food, and placing items out of residents reach.On 04/07/2026-Response time is 45 mins before anyone answers. One resident said she never gets a response on the intercom. When [NAME] is not here, no one answers phone calls. (R9) reported that one nurse was rude when called to use the restroom and scolded her. One resident reported she did not have a shower, and no one was in the dining room when serving trays.Review of the two-week staffing grid for the date of the elopement, March 7, 2026, revealed the ppd (per patient day) ratio for staff to residents was 1.87, confirmed by the DHS (Director of Health Services).Review of the two-week staffing grid for March 1 to March 14, 2026, revealed a 1.87 ppd (per patient day) staff-to-resident ratio on March 7; 1.77 ppd on March 8, 2026; 2.0 ppd on March 10, 2026; 2.05 ppd on March 11, 2026; and 2.06 ppd on March 12, 2026.Review of the staff assignment for Saturday, 03/07/2026, revealed that two nurses and two Certified Nursing Assistants (CNAs) had initialed the assignment sheet to confirm their presence. For the night (7p-7a shift), the two-week staffing had 12 RN (Registered Nurse) hours. The original nurse scheduled was marked out, and the DHS was assigned for 7 PM to 5 AM, although on the two-week grid, it showed 12 RN hours.Interviews with every cognitive resident during the seven-day survey period reported insufficient staffing and untimely, unacceptable call-light responses. Many residents reported they were not getting restorative care after completion of therapy because the restorative aide had to work as a floor CNA two to four days a week, and she cannot do both. One resident was very concerned that she would decline due to not receiving restorative exercises/training. Four residents reported verbal, physical abuse, and/or neglect by CNA UU. Some residents had diaper dermatitis, developed wounds, and were not receiving restorative nursing services after completion of therapy. One resident eloped and went two miles from the facility for several hours, and the staff was not aware until someone called to notify the facility. One resident fell in the shower and sustained a major head injury.An interview on 05/05/2026 at 1:45 PM, R1 revealed they needed more help. She revealed she had a bowel problem, and when she needed help, she pushed the button. R1 confirmed CNA UU talked mean to her, mistreated her, and refused to help or change her or assist her with going to the bathroom. R1 confirmed verbal abuse and neglect.An interview on 05/05/2026 at 1:55 PM with R9 revealed her roommate, R3, needed her catheter emptied so it would drain properly and not back up. R9 revealed that she reminded CNA UU the night before to please empty it the next morning before leaving, so it would drain properly. CNA UU did not empty her catheter drainage bag. R9 confirmed that the police officer came in and spoke with her and R3 about CNA UU, and they told the police officer how rough she was with R3. R3 and R9 revealed the facility was short-staffed, or they just won't do their job. Often, it takes a long time for staff to answer call lights, especially on the night shift.An Interview on 05/05/2026 at 2:28 PM with a Dietary Aide EE revealed that she started in March 2026, and her training consisted of shadowing someone who no longer works here, observing, and being told things. She revealed she felt they needed at least two more staff because if someone was off, they would be short. She revealed she was one of the staff members who worked several 16-hour days due to being short-staffed. They had four kitchen staff in total. They would rotate with only one cook and one aide for the whole day. The next day, the other two would work: one cook and one aide. She revealed they did 16-hour days every other day for a month.An Interview on 05/05/2026 at 2:40 PM with RN LL confirmed R4 eloped on March 7 and confirmed they were short-staffed. Review of the two-week staffing grid revealed a 1.87 ppd (per patient day) staff-to-resident ratio on March 7, 2026.An Interview on 05/05/2026 at 2:52 PM with the Dietary Aide HH revealed that the facility had been running a skeleton crew, sometimes with only two CNAs for the whole building. She used to be in the laundry department but transferred to the kitchen. She revealed that there were supposed to be two cooks, one staff member to handle tickets, one to handle mechanical diets and related tasks, and one to wash dishes. She revealed that she had little training, having started in the kitchen.An interview on 05/07/2026 at 2:05 PM with the Administrator confirmed the PBJ data for Q1 (October 1 to December 31, 2025), showing low weekend staffing.An interview on 05/13/2026 at 10:40 AM with RN LL, and review at that time of the nurse staffing assignment dated April 11, 2026, that showed CNA AA was a C/O (call-out) and the name unknown was written in her place to cover B hall. RN LL confirmed that there were only two nurses and two CNAs in the facility that day.An interview on 05/13/2026 at 10:45 AM with LPN (KK)/Charge nurse, and review at that time of the nurse staffing assignment dated April 11, 2026 that showed CNA AA was a C/O (call-out) and a name written in her place to cover B hall, LPN KK confirmed that it was her, she had to do her nursing duties plus CNA duties because there was only two CNA's in the building. Another person came in to help out but did not do hardly anything.

Based on observations, staff interviews, record review, and review of the facility policy titled, Accident Reporting and Investigation Program, the facility failed to ensure hot water temperatures were in the acceptable range (110 degrees F (Fahrenheit) or less) in the bathroom sink for 13 of 38 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). The deficient practice had potential for residents to receive a scalding injury due to the water temperature.Findings include:Review of the facility policy titled, Accident Reporting and Investigation Program revised November 2009 revealed under Definitions: An accident is any occurrence that interrupts or interferes with the orderly progress of a job or task, usually occurring suddenly and unexpectedly, and results in harm to people. an accident may also be an injury caused to a patient/resident due to defective equipment.Observation and temperature check on 9/30/2025 during initial screening of residents revealed concerns with the hot water temperature in the bathroom sink of resident rooms on B hall. Initial check of the hot water by finger/hand test revealed the water was so hot this surveyor could not hold her hand under the water for more than a very few seconds. After the hand test the surveyors hand remained bright pink for a long time. A check of the hot water temperature with this surveyor's thermometer revealed the following: 114 degrees F in adjoining bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] on B hall at 11:30 am.112 degrees F in adjoining bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] on B hall at 11:40 am.116 degrees F in adjoining bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] on B hall at 11:50 am. Rooms with elevated water temperature concerns were identified on B-hall during walking rounds starting on 9/30/2025 at 2:00 pm with the Maintenance Director. The following water temperatures were observed using the facility's calibrated thermometer:120.0 degrees F in adjoining bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] on B hall at 2:04 pm. 115.0 degrees F in adjoining bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] on B hall at 2:07 pm.118.4 degrees F in adjoining bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] on B hall at 2:11 pm.120.3 degrees F in adjoining bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] on B hall at 2:15 pm. 118.0 degrees F in adjoining bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] on B hall at 2:19 pm.119.3 degrees F in adjoining bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] on B hall at 2:24 pm.118.4 degrees F in private bathroom in room [ROOM NUMBER] on B hall at 2:27 pm.Observation and interview on 9/30/2025 at 2:29 pm with the Maintenance Director revealed the facility had four hot water heaters/boilers. A tour and observation of the hot water/boiler for B hall, in a room behind and to the side of the nurses station by the front entrance revealed the thermometer was set at 117 degrees F, it has been at this setting since he started October 2024 and he had not adjusted the temperature thermostat and there were no issues with the heater/boiler. He stated he did not know why the water on hall B was higher than the setting on the heater/boiler. He revealed prior to today, the highest water temp he had ever got in a resident room sink was 120 degrees F and he did not know what the temperature should be set at.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to ensure one of 29 sampled residents (R) (R57) did not have unauthorized, unsecured medications at bedside. This deficient practice had the potential to allow unauthorized access to medications to other residents and visitors in the facility.Findings include:A review of the facility policy titled Self-Administration of Medications by Patients/Residents dated 1/6/2025 stated under Policy Statement: Each patient/resident who desires to self-administer medication is permitted to do so if the health care center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients /residents of the healthcare center. Medication self- administration also applies to family members who wish to administer medication. Under Procedures: .3. If the Licensed nurse determines the patient /resident or family member to be capable of self -administration of medications, the attending physician must write an order to that effect that includes the specific medications based off of the Self Administration Medication Observation.A review of electronic medical record (EMR) for R57 revealed the following diagnoses, but not limited to, vascular dementia, paroxysmal atrial fibrillation, hypertension, and chronic obstructive pulmonary disease.A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R57 presented with a Brief Interview Mental Status (BIMS) score of 15, indicating little to no cognitive impairment.An observation on 9/30/2025 at 10:01 am of R57's room revealed four pills (medications) in a medication cup sitting on the resident bedside table. R57 reported that a nurse had given her the pills to take later. R57 reported that the nurse had authorized her to self-administer medications daily.A review of the EMR for R57 revealed an omission of a completed assessment to determine whether or not the resident was capable of self-administration of medications.A review of R57 's care plan revealed no focus area for self-administration of medications.Record review of R57's September 2025 Physician Order Form (POF) and Medication Administration Record (MAR) revealed an order for gabapentin capsule 100 mg (milligram) three times a day and an order for sevelamer carbonate tablet, 800 milligram three times a day with meals.During an interview at the time of observation of resident R57's room on 9/30/2025 at 4:01 pm with Licensed Practical Nurse (LPN) CC and the Director of Health Service (DHS), both staff confirmed the medications left in the resident room. LPN CC and the DHS reported that R57 was not capable of self-administering medications without supervision. LPN CC reported being unaware of medications in the resident room. The DHS described the medications as most likely being pain pills. She reported that the identity of the pills will be followed up. The DHS removed the medications from the room.During a later interview on 10/1/2025 at 1:20 pm with the Administrator and the DHS, the Administrator confirmed that this was a deficient practice and in-services were provided to her nurses. The DHS reported that she was able to identify the medications (pills) at the bedside in the medication cup as medications from the medication carts that were prescribed to the resident per her physician order. She stated that one pill was identified as gabapentin 100mg and three of the pills were sevelamer carbonate 800 mg, the same as the pill on the POF. The DHS reported that all scheduled medications should be administered by the nurse and the nurses ensuring all medications were swallowed by the resident prior to leaving the room. Any refused medications by a resident needed to be compensated for and disposed of properly. The Administrator categorized the deficient practice of unsupervised medications as being a risk to resident safety for residents who wander and residents who may have allergies.

Based on observation, staff interview, and review of the facility policy titled, Food and Supply Storage, the facility failed to ensure all pans and dishes were allowed to be air dried before stacked and failed to ensure all food in the freezer was sealed closed. These failures had the potential to affect 63 of 65 residents who consumed an oral diet. Findings include: Review of the facility's policy titled, Food and Supply Storage, dated 1/2024 revealed, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Frozen storage: Wrap food tightly to prevent cross contamination. Use food grade plastic bags for food storage. During an observation on 3/11/2024 at 9:58 AM, the following observations in the kitchen were made with and verified by the Supervisor Food/Nutrition (SFN): 1. The freezer contained one bag of chicken and one bag of hamburgers that were not closed shut. 2. There were 12 plastic plate covers being used for lunch that were not allowed to air dry. 3. There were 20 plastic cups that were being used that were wet on the inside and not allowed to air dry. 4. An exhaust fan in the clean dish area was covered in thick, gray dust. During an interview with the Administrator on 3/14/2024 at 1:15 PM revealed My expectation for the kitchen is that they all work together to have the kitchen organized and give the residents good tasting food. We want to do the best job possible. We want to give our staff what they need to do the best job possible.

Based on staff interview, facility document review, and review of the facility policy titled, Quality Assurance/Performance Improvement, the facility staff failed to maintain an effective Quality Assurance/Performance Improvement (QAPI) program regarding the facility's Performance Improvement Plan (PIP) for Certified Nursing Assistants (CNAs) documentation. This had the potential to affect all residents of the facility. Findings include: Review of the facility policy titled, Quality Assurance/Performance Improvement (undated) revealed, .The facility will implement the Plan-do-Study-Act (PDSA) cycles as its QAPI methodology for testing actions and implementing and evaluating change. The facility will conduct and include Root Cause Analysis in their PDSA methodology. PIPs are evaluated to address gaps/and or effectiveness in systems and processes. Corrective actions may be taken when evaluating effectiveness. Changes identified in PIP action steps may require the development of additional measures for monitoring (audits/checklists), in effort to evaluate PIP effectiveness in achieving desired goals . Review of the facility's PIP dated 4/05/2023 provided by the facility revealed a problem of incomplete and inconsistent CNA Activity of Daily Living (ADL) documentation which was found on 3/23/2023. The PIP consisted of the problem statement, goal, baseline data, root causes, barriers, and established completion date as ongoing. There was no further information provided to the survey team. During the QAPI tasks, the survey team members, the Director of Nursing (DON) and the Administrator were all in attendance which met on 3/14/2024 at 5:45 PM. The Administrator stated, We found this to be a problem of the CNAs not completing their charting in the computer before they left their shift which made the next CNA not able to chart at all unless they finished the charting of the CNA on the previous shift. So, we immediately began having the CNAs document on paper to alleviate the issue we were having. The DON stated, This was something that we did not want to continue, and we did not know of the extent of this problem until we began a PIP on the incomplete CNA documentation. The survey team asked the Administrator and DON if there was any additional information or documentation to support the findings of the audits completed, if there were any barriers found that were unexpected, and when the goal was met and if not the explanation of why it was not met. The Administrator and DON stated they would go and look and bring back any additional information they had to the survey team. At 6:15 PM on 3/14/2024, the administrator returned to the survey team and stated, I know we did each of the steps of this PIP, but we cannot find any more documentation to give to you at this time.

Based on staff interviews, document review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy titled, Antibiotic Ordering, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional Antibiotic Stewardship Program that followed the McGeer Criteria for antibiotics. This had the potential to affect all 65 resident of the facility, specifically being prescribed antibiotics that were potentially unnecessary. Findings include: Review of the facility policy titled, Antibiotic Ordering dated 9/01/2023 revealed . 10. The Infection Control Preventionist (lCP) will monitor resident antibiotic use to determine appropriateness.11. The ICP will utilize evidence-based, standard definitions for identifying infections as the criteria in determining antibiotic appropriateness.12. The ICP will review antibiotic surveillance findings during the monthly lnfection Prevention and Control Team (IPCT) meetings. The IPCT will develop antibiotic stewardship action plans, if indicated. 13. The ICP will consult with the Medical Director in the review of antibiotic use and appropriateness. ln the event that unnecessary antibiotics have been ordered, the Medical Director will consult and provide antibiotic stewardship education with the Attending Physicians and/or Nurse Practitioners . Review of a CDC document undated titled, The Core Elements of Antibiotic Stewardship for Nursing Homes indicated .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority.Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use'. CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use.Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Below are examples of antibiotic use and outcome measures.Process measures: Tracking how and why antibiotics are prescribed.Antibiotic use measures.Tracking how often and how many antibiotics are prescribed.Antibiotic outcome measures.Tracking the adverse outcomes. Review of documents provided by the facility titled, The Revised McGeer Criteria for Surveillance Checklist (a set of criteria if a resident had an infection or not and if an antibiotic might be indicated to treat) had documentation for the months of January 2023 through December 2023, and January and February 2024 which revealed there were infections being treated by the prescriber by ordering antibiotics that did not meet McGeer's criteria for the specific infection to be treated. Review of the Infection Control Book provided by the facility had compiled data that identified the percentage of infections that did not meet McGeer's criteria but was treated as follows: January 2023 - 36% February 2023 - 31% March 2023 - 29% April 2023 - 59% May 2023 - 33% June 2023 - 50% July 2023 - 36% August 2023 - 64% September 2023 - 30% October 2023 - 33% November 2023 contained no data. December 2023 contained no data. January 2024 - 66% February 2024 - 38% During phone interviews on 3/14/2024 between 12:15 PM and 12:45 PM with each of the prescribing physicians (Medical Doctor (MD) 1, MD 2, and MD 3) all three confirmed they had ordered antibiotics for residents before the results or cultures were received back from the laboratory. The Medical Director during this phone interview stated he remembered the infections were discussed in the Quality Assurance Performance Improvement (QAPI) committee meeting but did not recall how in depth the discussion was or if the percentage of infections treated did not meet the criteria were discussed. During an interview on 3/14/2024 at 2:45 PM, the Director of Nursing (DON) stated, I am acting as the infection control nurse until we find one. We had a contract nurse for this, but she just left at the beginning of the month. I didn't know these numbers were broken down like this. During an interview with the Administrator on 3/14/2024 at 5:30 PM, the Administrator stated, I did not know this data existed before this meeting. If I had known, we would have provided this information to the physicians to make them more aware of their ordering of the appropriate antibiotics and when not to order the antibiotics.

Based on observations, record review, staff interviews, and review of facility policy titled, Resident Call Lights, the facility failed to ensure one of 30 Residents (R) 22 had their call light in reach during multiple observations. This had the potential for the resident to have unmet care needs. Findings include: Review of the facilities' undated policy titled, Resident Call Lights revealed the purpose was to respond to resident's needs. Further review of the policy revealed resident call lights will be kept within the resident's reach when the resident is in the room. Review of R22's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R22 was admitted to the facility with a diagnosis of cardiac pacemaker. Review of R22's admission Minimum Data Set (MDS) assessment located in the EMR under the MDS tab with an Admission Reference Data (ARD) of 2/22/2024 revealed R22 had impaired vision and a Brief Interview of Mental Status (BIMS) of seven out of 15 which indicated severely impaired cognition. Reveal of the MDS further revealed R22 needed assistance with Activities of Daily Living (ADLs). Review of R22's admission comprehensive Care Plan dated 2/22/2024 located in the EMR under the Care Plan tab revealed a problem was listed for Visual impairment related to decreased visual acuity. During an observation of R22 on 3/11/2024 at 10:57 AM revealed he was lying in bed in his room on his right side and the call light was to the left of the bed hanging downward to the back of the small bed rail toward the floor past the mattress. During an observation and interview of R22 on 3/11/2024 at 2:18 PM revealed he was in his room and sitting up in a Geri chair and the call light remained on the left side of the bed hanging down the side. A family member of R22 was visiting and said the resident was blind. During an observation on 3/11/2024 at 4:05 PM revealed R22 was in his bed in his room and the call light was hanging down the left side of the bed, not within R22's reach. Observation further revealed when R22 was asked if he could reach his call light, he replied he did not know where it was and took his hands and felt around the bed and could not find the call light. During an observation of R22 on 3/11/2024 at 4:24 PM revealed he was in bed in his room and the call light remained hanging down to the left side of the bed and was not in his reach. During an interview on 3/11/2024 at 4:25 PM with Certified Nursing Assistant (CNA)1 revealed R22 was blind in the left eye and could barely see out of the right eye. CNA1 further revealed she attached the call light to his shirt and would put his hand on it to let him know where the call light was. CNA1 revealed a resident could panic if their call light was not in reach and may try to get up without assistance. CNA1 revealed she had been in with R22 today and thought she attached his call light to his shirt. Interview further revealed after going into R22 room that his call light was not attached to him but was dangling down the side of the bed and was not in his reach. CNA1 revealed the call light should be in his reach and when she asked R22 if he could reach it, he replied no and did not know where it was. During an observation and interview on 3/12/2024 at 9:59 AM revealed R22 was lying in bed on his back and the call light was draped over the bed to the back of R22 dangling down, not attached to him, and not in his reach. Licensed Practical Nurse (LPN)1 who was also in the room confirmed R22 could not reach his call light. LPN1 placed it closer to him and he was able to turn it on. LPN1 further revealed the call light should be attached to his gown. During an interview with the Director of Nursing (DON) on 3/13/2024 at 9:06 AM confirmed call lights should be placed close to the resident and the clip should be attached to the sheets or something that the resident could reach. During an interview on 3/14/2024 at 10:42 AM the Administrator revealed call lights should absolutely be within the residents reach and not dangling down the side of the bed.

Based on observation, record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that two residents (Resident (R) 47 and R14) out of 30 sampled residents had an accurate Minimum Data Set (MDS) assessment. Findings include: Review of the RAI Manual, dated 10/01/2023, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Inter-Disciplinary Team] completing the assessment . 1.Review of R47's electronic medical record (EMR) undated, Admission Record, located under the Profile tab, indicated R47 was admitted to the facility with diagnoses that included: stroke affecting the right side, and aphasia (loss of ability to speak). Review of R47's annual MDS located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 1/18/2024 indicated the assessment inaccurately indicated R47 took an anticoagulant (blood thinner). Aspirin (antiplatelet/anti-inflammatory) was coded as an anticoagulant. 2.Review of R14's EMR undated, Admission Record, located under the Profile tab, indicated R14 was admitted to the facility with diagnoses that included: peripheral vascular disease (PVD), congestive heart failure (CHF) and Type I diabetes. Review of R14's quarterly MDS located in the EMR under the MDS tab with an ARD of 2/13/2024 indicated the assessment inaccurately indicated R14 took an anticoagulant. Aspirin was coded as an anticoagulant. During an interview with the Minimum Data Set Coordinator (MDSC) on 3/12/2024 at 12:30 PM confirmed The assessments were wrong. The facility had an agency MDS nurse at the time and she coded aspirin as an anticoagulant. Interview with the Administrator on 3/14/2024 at 1:20 PM revealed The MDS nurse will be cognizant of what is classified as an anticoagulant and if there are any questions, they will consult with the physician, pharmacist, or the Director of Nursing (DON).

Based on observations, record review, staff interviews, and review of Rehab Department Procedures, the facility failed to ensure an order for a resident's palm protector was followed for one of two residents (Resident (R) 47) reviewed for range of motion (ROM). The deficient practice had the potential to inhibit optimal independence for R47 by not applying splints as ordered for contractures. Findings include: Review of a document provided by the facility titled, Rehab Department Procedures (undated), revealed Original orders are placed in a folder in Medical Records office to be signed by the physician. After originals are signed, they are placed in patient's medical hard chart. Review of R47's electronic medical record (EMR) Admission Record located under the Profile tab, indicated R47 was admitted to the facility with diagnoses that included stroke affecting the right side and aphasia (difficulty in speaking). Review of R47's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 1/18/2024 indicated R47 had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which is indicative of moderate cognitive impairment. Review of R47's Occupational Order dated 1/31/2023 located in the EMR under the Orders tab revealed an order for a right palm protector to be worn as tolerated and removed for hand hygiene/skin check on a daily basis. Review of R47's EMR revealed no evidence the palm protector was put on the resident. During an observation on 3/13/2024 at 11:17 AM revealed that R47 was in the activity room without her right-hand palm protector. Her right hand was folded in and could be pried open, however would not stay open. The palm protector was observed in R47's room on the bedside table. During an observation and interview with R47 on 3/14/2024 at 9:00 AM revealed that R47 did not have her palm protector on. When R47 was asked if she would like to wear her hand splint she stated Yes. During an interview on 3/14/2024 at 9:31 AM with the Director of Nursing (DON) confirmed R47 wore the palm protector on and off. The DON confirmed the order dated 1/31/2023 showed the order was for therapy and not treatment, and that was why the nurses did not know to put the splint on. During an interview on 3/14/2024 at 9:53 AM with the Rehabilitative Occupational Therapist (OT) revealed they put another order in for R47's right hand palm protector (today). The OT revealed the order was put in back in January 2023 and did not know what happened to it. During an interview on 3/14/2024 at 12:09 AM with the Administrator revealed Until we change to a new EMR system, we need daily communication with OT and all orders are to be brought to nursing management. This was a system failure between nursing and therapy.

Based on record review, staff interview, and review of the facility policy titled, Pain & Assessment Control, the facility staff failed to perform a pain assessment prior to administering a narcotic as needed (PRN) pain medication and failed to assess the effectiveness after the medication was administered for one of ten Residents (R) 2. The deficient practice had the potential to prevent the accurate determination of the effectiveness of the pain medication regimen. Findings include: Review of the facility policy Pain & Assessment Control dated 09/22/22 revealed, . The patient's pain is treated promptly accordingly to physician's orders. The patient is reassessed to determine pain relief. a. The patient is evaluated at appropriate intervals after he/she is medicated using the appropriate pain scale. b. All patients receiving medications for pain control are reassessed . Review of R2's undated Face Sheet provided by the facility revealed R2 was admitted to the facility with a diagnosis of acute pain. Review of R2's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/07/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 indicating the resident was cognitively intact. Review of R2's Physician's Orders located under the Orders tab in the electronic medical record (EMR) revealed an order dated 3/08/2024 for Norco 5-325 milligrams (mg) take one table by mouth every six hours PRN. Review of R2's Medication Administration Record (MAR) for March 2024 revealed Norco was given on 3/08/2024 at 5:41 AM, and at 6:49 PM, on 3/09/2024 at 2:01 AM, at 8:15 AM, and 10:19 PM, on 3/10/2024 at 2:55 PM, at 10:49 PM, on 3/11/2024 at 9:50 AM, and at 10:42 PM, on 3/12/2024 at 10:28 PM, on 3/13/2024 at 4:28 AM, and 11:55 AM. Further review of R2's MAR for March 2024 revealed pain assessments once a shift and recorded but no further documentation of pain assessments before and after pain medication being administrated to R2. Review of R2's Progress Notes located under the Notes tab revealed no documentation of pain assessments before and after pain medication administrated to R2 for the dates and times Norco was given to the resident for pain. During an interview on 3/11/2024 at 10:53 AM R2 revealed the pain medication she was given did help her with her pain. During an interview with the Director of Nursing (DON) on 3/14/2024 at 2:00 PM, the DON stated, The nurses did pain assessments twice a day but confirmed they failed to do them before the pain medication was given and then after it was given to check to see if it was effective.

Based on record review, staff interview, review of the Dialysis Agreement, and review of the facility policy titled, Dialysis, the facility failed to have collaboration of care between the facility and the dialysis center for one of three (Residents (R) 45) receiving dialysis treatments. This had the potential for R45 to have unmet care needs. Findings include: Review of the facility policy titled, Dialysis dated 7/10/2023 revealed, . The facility and the dialysis clinic will coordinate and communicate resident needs pertinent to dialysis care and services . Review of the dialysis agreement between the facility and the dialysis center dated 6/05/2007 revealed, . Center shall provide to Facility (sic) information on aspects of the management of the resident's care . Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated (sic) Residents (sic) at the time of the transfer to the Center. This information, shall include, but is not limited to, where appropriate, the following: . (d) Appropriate medical records, including history of the Designated (sic) Resident's (sic) illness, including laboratory, and x-ray findings; (e) Treatment presently being provided to the Designated (sic) Resident (sic), including medications and any changes in a patient's condition (physical or mental), change of medication, diet (sic) or fluid intake . Review of R45's undated Face Sheet provided by the facility revealed R45 was readmitted to the facility with the diagnosis of stage four chronic kidney disease requiring dependence of renal dialysis. Review of R45's Physician Orders under the Orders tab located in the EMR revealed an order for hemodialysis on Mondays, Wednesdays, and Fridays. Review of R45's electronic medical record (EMR) and the hard chart revealed no documentation of communication notes between the facility and the dialysis center on the days R45 received dialysis. During an interview with the Director of Nursing (DON) on 3/13/2024 at 3:05 PM confirmed there was no communication between the facility and the dialysis center for R45.

Based on record review and staff interviews, the facility failed to ensure a psychotropic medication was discontinued when ordered by the physician for one of five residents (Resident (R) 55) reviewed for unnecessary medications. The resident continued to receive the medication for two months after it was discontinued. Findings include: The policy for pharmacy recommendations was requested but not provided by the time of the exit of the survey. Review of R55's Face Sheet in the electronic medical record (EMR) under the Face Sheet tab revealed R55 was admitted to the facility with diagnoses that included Alzheimer's disease, hypertension, non-traumatic brain dysfunction and anxiety. Review of R55's admission Minimum Data Set (MDS) located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 10/03/2023 revealed a Brief Interview of Mental Status (BIMS) was not done due to impaired cognition. Review of the high-risk drug class of the MDS revealed antipsychotics were used on a routine basis. Review of R55's undated Consultant Pharmacist Recommendations in the hard copy chart under the Physician tab the pharmacist recommended an appropriate diagnosis for the use Seroquel (antipsychotic) since the diagnosis of anxiety was not appropriate. Review of the response from the physician revealed the physician discontinued Seroquel on 12/22/2023. Review of R55's Medication Administration Record (MAR) located in the EMR under eMAR tab revealed Seroquel 25 milligram (mg) give 1/2 tab (12.5 mg) twice a day (bid) had been administered from 12/01/2023 to 02/20/2024, even though it was discontinued on 12/22/2023. During an interview on 3/13/2024 at 1:15 PM the Director of Nursing (DON) confirmed there was a pharmacy review done in 12/2023 to discontinue Seroquel and she did not see where the Seroquel was discontinued until 2/20/2024. The DON confirmed the medication was not discontinued timely because after the physician signed the recommendation it was being put in the medical records slot to be filed in the record and the nurses were not reviewing the orders. During an interview on 3/13/2024 at 4:15 PM the Administrator revealed the pharmacy recommendations and reviews had been reviewed by the physicians but the replies from the physician had been put into the medical records box and filed without the nurses reviewing them. The Administrator further revealed they had identified there was a problem with pharmacy recommendations not being acted upon. During a telephone interview on 3/14/2024 at 12:56 PM with Medical Director (MD)1 revealed he was made aware in February 2024 that some of his physician orders for pharmacy reviews were not being acted upon.

Based on observation, record review, staff interviews, review of Lippincott procedures, and review of facility policy titled, Medication Administration-General, the facility failed to ensure there was less than a five percent (%) medication error rate. Two errors were observed out of 27 opportunities for one Resident (R)6 out of the six residents observed during medication administration resulting in a mediation error rate of 7%. Findings include: Review of the facility policy tilted, Medication Administration-General policy with a revised date of 12/01/2019, revealed the purpose of the policy was to provide resident medication efficacy and safety by following established principles of medication administration. Procedural Guidelines Medication Administration that medications will be administered per the [NAME] Manual of Nursing Practice. Review of the Lippincott procedures - Enteral tube drug instillation, long-term care manual, with a revised date of December 11, 2023, provided by the facility revealed don't mlx different medications intended for administration together through the enteral tube because of the risks of physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug response. Review of R6's Physician Orders located in the electronic medical record (EMR) under the Order tab revealed an order for Simethicone 80 milligram (mg) (for relief of gas) via g-tube three times a day (tid) and Dicyclomine Hydrochloride 20 mg (relieves stomach cramping) via g-tube tid. During an observation of the medication administration on 3/12/2024 at 2:15 PM for R6 revealed Registered Nurse (RN)2 crushed Dicyclomine Hydrochloride 20 mg one tab and Simethicone 80 mg one tab into one pill cup and mixed water with it. The RN then administered the two crushed medications together and flushed the g-tube after the medications. During an interview with RN2 on 3/12/2024 at 2:30 PM, the RN revealed that medications can be crushed together and administered by g-tube unless a black box warning was noted. RN2 revealed she had worked in the hospital previously and it was okay to crush the pills together, but she was still learning long term care procedures. RN2 revealed the facility did go over policy and procedures on orientation. During an interview with the Director of Nursing (DON) on 3/13/2024 at 8:46 AM revealed the protocol for g-tube medication administration was to crush each medication individually, add water, and administer separately from other medications. The DON revealed it was not the best practice to crush medications together that were to be given by g-tube. During an interview with the Administrator on 3/14/2024 at 10:48 AM she revealed g-tube medications should not be crushed together.

Based on observation, record review, and staff interviews, the facility failed to maintain infection control during incontinence care during a dressing change for one of five (Residents (R)8) observed for incontinence care. Findings include: Review of R8's undated Face Sheet provided by the facility revealed R8 was readmitted to the facility with the diagnosis of stage three pressure ulcer. During an observation of wound care on 4/14/2024 at 11:23 AM with Registered Nurse (RN)1 revealed as RN1 removed the old dressing to the sacral area and R8 began to have a bowel movement. Certified Nursing Assistant (CNA)2 began to perform incontinence care with a disposable wipe. CNA2 proceeded to wipe from the anal area up towards the sacral pressure ulcer to remove the bowel movement. During an interview, on 3/14/2024 at 1:40 PM with the Director of Nursing (DON) revealed The CNA should never wipe bowel movement up in the direction of a resident's wound as it could potentially contaminate the wound. During an interview with CNA2 on 3/14/2024 at 1:51 PM the CNA was asked when she performed incontinence care to R8 should the resident have been cleaned with a wipe from the anal area up in the direction of the wound, CNA2 stated, I really don't know.

Based on observation, interviews, record review, and review of facility policy titled Infection Prevention and Control Program Overview the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. The facility census was 53. Findings include: Review of facility's undated policy titled Infection Prevention and Control Program Overview 5. The facility will ensure the following elements are incorporated within the IPCP management activities. Elements may include, but are not limited to: IPCP Coordination, Communication, and Oversight Written Policies and Procedures Surveillance and Data Analysis Antibiotic Stewardship Community Acquired and Healthcare Associated Infections Outbreak Control Vaccinations and Screening Employee Health and Safety 6. The facility will designate a licensed nurse, who meets the infection control training requirements, to be the facility's Infection Control Preventionist (ICP). The ICP's role and responsibilities will include: Coordinating and overseeing the facility's IPCP Leading the facility's Infection Prevention and Control Team (IPCT) Reporting IPCP management activities to the facility's Quality Assurance /Performance Improvement (QAPI) Team, at least quarterly. 9. The facility's ICPT responsibilities will include, but not be limited to: Assisting in the development of IPCP policies Establishing and maintaining an active and effective IPCP Monitoring the implementation of the facility's IPCP Collecting, reviewing, and analyzing infection control surveillance data (monthly and annually with the IPCP Risk Assessment) Determining and implementing action plans as a result of the infection control surveillance data and approved by the QAPI Team Evaluating the effectiveness of infection control action plans Review of the Infection Control Book from 6/2021 to 6/2022 revealed the facility did not collect surveillance data for six months (January 2022 through June 2022). During interview with Director of Nursing (DON) / Infection Control Preventionist (ICP) on 6/30/22 at 1:24 p.m., revealed the facility's ICP left the position in December 2021. DON stated the ICP role was handed down to her by the administrator because she has the ICP certification. DON stated the administrator gave her that task after the ICP left but that was not her primary responsibility, and it was not her primary focus. DON stated she have not been able to complete the task or do anything with it as far as tracking or surveillance because of her other responsibilities to include daily overseeing of the Nurses and CNAs, reporting to NHSN, monthly update of the matrix, and reporting to NRChealth.com formerly called my interview. Further interview with the DON about the infection rates for the last six months, she stated she does not know what the rates were because she has not been documenting them. DON re-stated that she assumed the responsibility of Infection Control in January 2022, and that infection control was not her primary focus. Interview with the Administrator on 6/30/22 at 2:28 p.m. revealed the DON is the Infection Preventionist, and she is responsible for the Infection Control Program. Administrator stated infections are extremely important, she stated she expects it to be tracked. She stated she would expect for the DON to assign the task to the Assistant Director of Nursing (ADON) or another licensed nurse if she was not able to complete it.

Based on staff interviews, and review of facility documents, the facility failed to establish an Antibiotic Stewardship Program that included antibiotic use protocols and a monitoring system to track and trend antibiotic use. The facility census was 53 residents. Findings include: Interview with Infection Control Preventionist (ICP)/ Director of Nursing (DON) on 6/30/22 at 1:24 p.m. revealed she has completed the CDC Nursing Home Infection Preventionist Training Course. DON stated the facility uses the McGeers Criteria to determine if there was an infection and if it was community or facility acquired. She stated she have not used this criterion because she has not been monitoring. Continued interview with the DON revealed there has not been anyone tracking the antibiotics since the last IP left in December 2021. DON stated the IP role was handed down to her after the previous ICP stopped working at the facility. However, she has not been able to do anything with it as far as tracking the antibiotics and maintaining the Antibiotic Stewardship program. She stated she has other duties and responsibilities and has not been able to address Antibiotic Stewardship. DON stated antibiotics are discussed in care plan meetings, and pharmacy sends a daily and monthly list of antibiotics. DON stated care plans are updated with any new antibiotic. DON stated she and the Administrator are the only two who are certified with the ICP certificate. DON stated Infection Control was not her primary focus. She stated her other jobs were her primary focus which includes reporting NHSN monthly, update matrix and staffing report to NRChealth.com formerly called my interview, oversee daily nursing and CNAs. She stated the ADON oversees wound care and falls program, serve as a resource to the nurses when they are on the floor. She stated she get pulled to the med cart to work sometimes but not too often. She further stated the Interview with the Administrator on 6/30/22 at 2:28 p.m. revealed she is aware that there has not been any tracking and trending of antibiotic use since December 2021. She stated the Antibiotic Stewardship is familiar to her. Administrator stated she would look for the Antibiotic Stewardship book. Administrator reported that she would not know of trends with infections if it were not tracked and documented. Administrator stated infections are extremely important, and she expected them to be tracked. Administrator expressed that she would expect for the DON to assign to the ADON or another licensed nurse if she is not able to complete the task. Administrator was unable to provide any documentation of an Antibiotic Stewardship Program Administrator confirmed there was no tracking and trending of antibiotic use in the facility.

Based on staff interview and record review, the facility failed to ensure that the correct transfer method was utilized, as careplanned, for one resident (#1) from a total sample of 35 residents. This failure resulted in actual harm for R#1, who sustained a fracture to the right leg on 7/10/16. Findings include: Resident (R) #1 had a care plan problem, since 10/26/15, for having a deficit in Activities of Daily Living (ADL's) due to a [DIAGNOSES REDACTED]. There was also a care plan problem, since 10/26/15, for being at risk for fractures due to a [DIAGNOSES REDACTED]. However, on 7/10/16 Certified Nursing Assistants (CNA's) GG and HH failed to utilize a mechanical lift, as careplanned, when transferring R#1 from the bed to a geriatric chair. As a result, the resident sustained [REDACTED]. During interviews on 5/3/17 at 1:55 p.m. with CNA HH and on 5/4/17 at 8:32 a.m. with CNA GG, they confirmed that a mechanical lift was not used to transfer the resident from the bed to the chair on 7/10/16. Cross refer to F323

Based on observation, staff interview and record review, the facility failed to ensure that the correct transfer method was utilized, as careplanned, for one resident (#1), and failed to ensure an oxygen concentrator was connected to an appropriate power source for one resident (#25) from a total sample of 35 residents. This failure resulted in actual harm for resident #1, who sustained a fracture to the right leg on 7/10/16. Findings include: 1. Resident (R) #1 had [DIAGNOSES REDACTED]. There was a care plan problem, since 10/26/15, that the resident had a deficit in Activities of Daily Living (ADL's) due to the [DIAGNOSES REDACTED]. There was also a care plan problem, since 10/26/15, that the resident was at risk for fractures due to the [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessments revealed that the resident was dependent for transfers, with two or more staff persons. However, on 7/10/16 Certified Nursing Assistants (CNA's) GG and HH failed to utilize a mechanical lift, as careplanned, when transferring R#1 from the bed to a geriatric chair. As a result, the resident sustained [REDACTED]. Licensed Practical Nurse (LPN) JJ documented in a nurse's note on 7/10/16 at 7:28 a.m. that the CNA reported, that while transferring R#1 from the bed to a geriatric chair, the resident's right leg was caught between the bed and chair. The nurse's note further documented that the resident was assessed and had pain to the right leg when range of motion was performed. The physician was notified and the resident was sent to the emergency room for evaluation. The emergency care center records documented the resident sustained [REDACTED]. The resident returned to the facility on the same day, 7/10/16, with the leg wrapped and physician's orders [REDACTED]. A review of the clinical record revealed the resident received nonsurgical treatment for [REDACTED]. During an interview on 5/3/17 at 1:55 p.m. with CNA HH, she stated that she was aware a mechanical lift should have been used to transfer R#1. However, she thought CNA GG and herself could handle it due to their size. During an interview on 5/4/17 at 8:32 a.m., CNA GG stated he was aware that they were suppose to use a mechanical lift but just was not thinking, because the resident had been a two person assist for transfers in the past before they started using the mechanical lift for her. Both CNA's received further training regarding transferring residents appropriately. 2. On 5/2/17 at 9:07 a.m. and 11:47 a.m., resident (R) #25's oxygen concentrator was observed to be plugged into a power strip on the floor between and behind the A- and B- beds, and the power strip was not secured to the wall in any manner. On 5/3/17 at 8:43 a.m., this power strip was noted to have R#63's phone charger plugged into it, and R#25's oxygen concentrator and a weather station plugged into it. During interview with R #63 at this time, she stated that she did not think the power strip belonged to her or R #25, and that this was the only outlet available for use other than one in the corner of the room by the B-bed. On 5/3/17 at 2:24 p.m., the Facilities/Maintenance supervisor stated that he knew that power strips should be mounted on the the wall, and should be used more for household- type items like fans, and needed to be UL (Underwriters Laboratories) approved. He further stated that they inspected anything electrical that a resident or family brought into the facility on admission, and also relied on the staff to let him know if something needed to be looked at. He verified R#25 and R#63's unmounted power strip at this time, that R#25's oxygen concentrator was plugged into it, and that he was not aware of it.