Every finding on record at Southern Oaks Therapy and Living Center

Based on observation, interview, and record review, the facility failed to ensure that the bed rails, mattress, and bed frame were compatible for 2 of 6 residents (Resident #2 and Resident #3) reviewed for physical environment. -The facility failed to provide Resident #2 and Resident #3 with a mattress that was functional, comfortable, and appropriate to their needs. This failure could place residents at risk of not having appropriate furniture to accommodate special needs, which could affect their health, comfort, and safety.Findings included:1. Record review of Resident #2's Quarterly MDS Assessment, dated 06/16/26, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident's BIMS score was 15, which indicated her cognition was intact. The MDS Assessment under Section GG-Functional Abilities reflected Resident #1 was totally dependent on staff for most self-care ADLs and mobility. The MDS Assessment under Section I-Active Diagnoses reflected Resident #1's active diagnoses included: cerebrovascular diseases (disorder that affects blood flow to brain), body mass index of 50.0-59.9, adult (severe obesity weight category), and lack of coordination. The MDS Assessment under Section K-Nutritional Status reflected Resident #2 was 5 feet tall and weighed 298 lbs. Record review of Resident 2's care plan, dated 06/30/26, reflected the resident had limited physical mobility and was at risk for falls r/t obesity and lack of coordination. Interventions included: providing supportive care and assistance with mobility as needed, providing appropriate level physical assistance with ADLs as needed, and a therapy referral. Further review of this document reflected there was no focus or interventions r/t bed mobility, safety, or comfort. Record review of Resident #2's physician orders, dated 07/08/26, reflected in part the following:-Pressure-reducing mattress to bed for pressure injury prevention; Start date: 06/30/26Further review of this document did not reflect an active order for a bariatric mattress or bedrails. In an observation and interview on 07/08/26 at 11:30 a.m., Resident #2 was observed lying in bed. Resident #2 was a bariatric resident. Resident #2 stated she felt unsafe in her bed and had asked multiple times for bedrails, but they were never provided. Resident #2 stated she had not had any falls or other accidents, but she still felt unsafe and uncomfortable. Observation of the bed revealed it was a bariatric bedframe with a mattress that was too large and did not fit properly. The mattress extended approximately 4-6 inches beyond the frame of the bed. Resident #1 stated she was unaware that the mattress was too big for the frame, but that could be why she felt a need for bedrails to keep her from rolling off the side of the bed. Further observation revealed the bed was in the lowest position for a fall intervention and there were no other hazards in the room. 2. Record review of Resident #3's Quarterly MDS Assessment, dated 06/22/26, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident's BIMS score was 15, which indicated cognition was intact. The MDS Assessment under Section GG-Functional Abilities reflected Resident #1 required maximal assistance with most self-care ADLs and supervision assistance for mobility with use of a motorized wheelchair. The MDS Assessment under Section I-Active Diagnoses reflected Resident #1's active diagnoses included: heart failure, respiratory failure, morbid obesity, and muscle wasting and atrophy (loss of muscle tissue). The MDS Assessment under Section K-Nutritional Status reflected Resident #2 was 5 feet 11 inches tall and weighed 355 lbs. Record review of Resident #3's care plan, dated 05/06/26, reflected the resident was at risk for planned or expected weight gain r/t edema (swelling caused by excessive fluid). Interventions included: notifying the MD of increased shortness of breath, escalating edema, increased anxiety, inability to lie flat, and change in alertness. Further review of this document reflected there was no focus or interventions r/t bed mobility, safety, or comfort. Record review of Resident #3's physician orders, dated 07/08/26, reflected there was no active order for any type of therapeutic mattress. In an observation and interview on 07/08/26 at 11:48 a.m., Resident #3 was observed sitting in her motorized wheelchair in the room. Resident #3 stated her motorized wheelchair was functional and comfortable; however, she was uncomfortable in her bed. Resident #3 stated the bed was large enough, but the mattress was old and lumpy, which caused increased pain in her back. Resident #3 stated this also disturbed her sleep because she had to constantly toss and turn to find a comfortable spot. Resident #3 stated she had not had any falls or other accidents. Resident #3 stated the mattress was worn down due to her size and she reported this to Administrator, but nothing was done. Observation of Resident #3's bed revealed it was a bariatric bedframe with a properly fitted mattress; however, the mattress was lumpy with an uneven structure. In an interview on 07/08/26 at 12:58 p.m., RN A stated she worked on the 500 hall with Resident #2 and Resident #3. RN A stated both residents were considered bariatric and required a bariatric bed and at least 2-person assist with care. RN A stated she was not aware of any issues with the residents' beds and there were no reported changes in condition. In an interview on 07/08/26 at 2:36 p.m., the DON stated all residents in the facility were considered a fall risk; however, Resident #2 was not a high fall risk. The DON stated Resident #2's bed was kept in the lowest position to prevent any risk of falls with harm. The DON stated she was not aware that Resident #2 had concerns about her safety in bed, and there were no reported issues with her condition. The DON stated she was also unaware of any issues with Resident #3's mattress. The DON stated she made Resident #3's bed because she liked her sheets tucked tightly, but the resident never complained to her about the mattress being lumpy or uncomfortable. The DON stated there were also no reported changes in Resident #3's condition. In an interview on 07/08/26 at 3:35 p.m., the NP stated he was not aware that Resident #2 wanted bedrails on her bed to feel safer, but he was open to assessing her for them. The NP stated he was also unaware that Resident #2 and Resident #3 had issues with their bariatric mattresses. The NP stated concerns for changes in condition and safety would be on his radar if the mattresses were inappropriate due to both residents being bariatric nut none had been reported. The NP stated any changes in condition would be specific and possibly different for each resident; however, increased pain and discomfort could be a risk based on the residents' comorbidities. In an interview on 07/08/26 at 4:00 p.m. with the DON and Administrator, the Administrator stated the facility had gotten rid of all rental beds about two weeks ago and this included Resident #2's bed. The Administrator stated Resident #2 received another bariatric bed, but he was unaware that the mattress did not fit properly. He stated the former maintenance director assembled the bed, but failed to inform him that the mattress was too large. The Administrator stated the facility used 42-inch mattresses for the bariatric beds, but somehow Resident #2 had a 48-inch mattress. The Administrator stated he did not know where the 48-inch mattress came from. The Administrator provided the state surveyor with an order form as proof that a new mattress had just been ordered for Resident #2. He also stated the facility had assist rails delivered for Resident #2's bed; however, they were still in the box because they did not fit her bedframe. Regarding Resident #3, The Administrator stated she only reported needing a new mattress after she found that another resident received one. The Administrator stated he checked Resident #3's mattress and did not find any issues. The Administrator stated the facility's management system informed them when it was time to check the beds; however, there was no policy on how often the mattresses had to be changed and it was done as needed. The Administrator stated Resident #3 had the same mattress for years and just recently started complaining. The Administrator stated it was his expectation for all residents to have functional furniture to maintain their safety and well-being. The DON stated being bariatric could place residents at risk for many things, but she refused to provide clinical insight regarding potential risks associated with having an inappropriate bed. Review of the facility's policy titled Safe, Comfortable, Homelike Environment revised 1/2022, reflected in part the following: Policy: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongingsto the extent possible.Procedure1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs andpreferences.2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect apersonalized, homelike setting. These characteristics include:.Personalized furniture and room arrangements;.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 3 residents (Resident #1) reviewed for resident rights. -The facility failed to accommodate Resident #1's needs by not ensuring that his call light was within reach for him to call for assistance when needed. -The facility failed to accommodate Resident #1's needs by not providing a functional and properly fitted wheelchair to maintain the resident's independence. These failures could place residents at risk of a decline in their dignity and well-being.Findings included:Record review of Resident #1's Quarterly MDS Assessment, dated 06/01/26, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. The resident's BIMS score was 4, which indicated severe cognitive impairment. The MDS Assessment under Section GG-Functional Abilities reflected Resident #1 used a manual wheelchair and was totally dependent on staff for most self-care ADLs and mobility. The MDS Assessment under Section I-Active Diagnoses, reflected Resident #1's active diagnoses included: cerebrovascular diseases (disorder that affects blood flow to brain), body mass index of 23.0-23.9, adult (within healthy weight category), seizure disorder (brain disorder that causes involuntary movement), traumatic brain injury (brain injury caused by outside trauma), hemiplegia and hemiparesis (weakness and paralysis that affects one side of the body), and depression (mood disorder). The MDS Assessment under Section K-Nutritional Status reflected Resident #1 was 5 feet 11 inches tall and weighed 166 lbs. Record review of Resident 1's care plan, dated 05/29/26, reflected the resident had an ADL self-care performance deficit r/t physical limitation secondary to Parkinson's Disease, hemiplegia, history of CVA (stroke), and traumatic brain injury. Interventions included: conversing with resident while providing care, explaining all procedures and tasks before starting, praising all efforts at self-care, promoting dignity by ensuring privacy, providing the appropriate level of physical assistance with ADLs, encouraging resident to discuss feelings about self-care deficits, encouraging resident to participate to the fullest extent possible with each interaction, encouraging use of call light for assistance, monitoring, documenting and reporting to MD any potential for improvement and declines in function, and completing skin assessments. Further review of this document reflected Resident #1 had potential for nutritional problems r/t decrease in appetite, protein calorie malnutrition, diabetes mellitus and hyperlipidemia, with a current weight of 166.2 lbs. and a weight 30 days back of 191.9 lbs. Interventions included: a diet as ordered by the MD, honoring resident's rights to make personal dietary choices with education as needed, house supplements as needed, providing meals in dining rooms if resident agrees, monitoring, documenting, and reporting s/sx of malnutrition to MD, obtaining and monitoring labs as ordered, dietician to evaluate and make diet changes, and weekly weights for four weeks. Record review of Resident #1's therapy evaluation, dated 9/10/25, reflected in part the following: Power Chair Eligibility Assessment:Subjective: Pt is [AGE] year-old male with primary diagnosis of encephalopathy and history of brain injury more than 10 years ago. Pt with history of owning power chair, however, denied and removed from facility due to behavioral concerns. Preliminary evaluation completed this date to see if Pt is appropriate for power wheelchair. Pt educated regarding purpose of preliminary evaluation and evaluation videotaped with verbal permission from patient.VII. Assessment Conclusions: Pt presents to skilled preliminary power chair evaluation with noted decreased head control, poor trunk control, decreased motor control of L side of body, decreased functional strength in RUE, decreased bilateral coordination, decreased gross and fine motor coordination, and decreased activity tolerance. In addition, Pt with moderate cognitive impairment with decreased orientation and memory recall. Through observation, Pt with multiple behaviors which impact judgement and impulse control. Due to these observations, Pt is no appropriate for power w/c due to being a safety hazard to self and others with poor judgement, poor safety awareness, poor impulse control, poor insight intodeficits, limited motor control, and impaired executive functioning. In addition, Pt currently in custom manual w/c with [brand] cushion that provides appropriate supports meeting all seating and positioning needs. In an observation and interview on 07/08/26 at 10:00 a.m., Resident #1 was observed lying flat in bed with limited ROM of left arm and fingers. Resident #1 had to ask for assistance with zipping his bag. Resident #1 became upset and stated, They do me bad in here! He proceeded to state that he stayed in bed most of the time because he was uncomfortable sitting in his wheelchair. Resident #1 stated the wheelchair was too wide and he was unable to propel himself due to the weakness in his arms. Resident #1 stated staff would push him to one spot and leave him, and the Administrator would not allow his friends to help him, so he was unable to move around like he wanted to. Resident #1 stated he asked for a motorized wheelchair and the facility kept lying to him about getting one. The manual wheelchair was observed in Resident #1's room and was wider and more heavy-duty than an average sized wheelchair. Resident #1 asked for a drink, and when told to use his call light, the resident stated he did not know where it was. The state surveyor searched and found Resident #1's call light clipped to the back of the bed, out of Resident #1's reach. RN A was called into the room, and she observed Resident #1's call light clipped behind his bed. In an interview on 07/08/26 at 10:15 a.m., RN A stated the expectation was for call lights to be always clipped within reach so the residents could call for assistance as needed. RN A stated she did not know why Resident #1's call light was clipped behind his bed and out of reach. She stated she would speak with the aides on her hall to ensure that they understood where the call lights should be placed. In further interview on 07/08/26 at 12:53 p.m., RN A stated she worked at the facility since October 2025 and worked on the 500 hall with Resident #1. She stated Resident #1 required a 2-person assist with care due to behaviors and mobility issues, which was also why it was important for his call light to remain within reach. RN A stated staff were expected to check for call light placement during rounds and anytime they entered resident rooms. RN A stated Resident #1 was transferred out of bed per his request; however, he chooses to remain in bed often. In an interview on 07/08/26 at 1:16 p.m., the DOR stated he worked at the facility since May 2025. He stated Resident #1 was receiving rehab services when he started, and was discharged on 06/22/26, after he exhausted all his Medicare Part A benefits. The DOR stated Resident #1 had a customized manual wheelchair that he refused to use because it was too big for the resident since he had lost weight. The DOR stated Resident #1 requested a motorized wheelchair that he felt might benefit the resident, but he had to be re-evaluated for it. The DOR stated Resident #1 was on the list to be evaluated, but it was taking a while because he was working through the list alone. The DOR stated Resident #1 also needed to be switched to Medicare Part B to get back in therapy. The DOR stated he could help Resident #1 get a smaller manual wheelchair, in the meantime if he wanted. In an interview on 07/08/26 at 1:54 p.m., CNA B stated she worked at the facility for 8 years. She stated she worked on 500 hall with Resident #1; however, she was not the only staff who went into his room. CNA B stated she was unaware that Resident #1's call light was clipped to the back of his bed. She stated she checked the placement of call lights during her rounds and ensured that they were within reach of the residents. In an interview on 07/08/26 at 2:21 p.m., CNA C stated he worked at the facility for 2 years. He stated he worked on 500 hall with Resident #1 and described the resident as non-compliant with care and would refuse to get out of bed. CNA C stated when Resident #1 would ask to be transferred out of bed, he would yell to get right back in bed. CNA C stated Resident #1 never told him that the wheelchair was uncomfortable. CNA C stated Resident #1 just had a behavior of yelling and being aggressive towards staff. In an interview on 07/08/26 at 2:32 p.m., the DON stated the expectation was for staff to ensure that call lights were always placed within reach of the residents. The DON stated call light placement was checked during rounds, at least every 2 hours. The DON stated not keeping the call light within reach could place residents at risk of not getting help when needed. The DON stated Resident #1 never reported any concerns about his manual wheelchair to her, and he remained in bed by choice. The DON stated Resident #1 was usually non-compliant with ADLs and did not like to participate in any activities. In an interview on 07/08/26 at 3:28 p.m., the NP stated he visited with Resident #1 yesterday, and there were no reported issues. The NP stated he was not aware that Resident #1's manual wheelchair was not suitable or that it prevented him from wanting to get out of bed. The NP stated it was previously reported that Resident #1 often refused therapy and other activities, but he never attributed it to the wheelchair. The NP stated if the wheelchair was uncomfortable, it would make sense why Resident #1 stayed in bed. The NP stated he would look into this issue during next visit. In an interview on 07/08/26 at 3:51 p.m., the Administrator stated Resident #1 was evaluated for a motorized wheelchair in September 2025 and did not qualify due to physical condition and behaviors. The Administrator stated Resident #1 had a motorized wheelchair previously, and he was a danger to himself and other residents. The Administrator stated the facility recently received new wheelchairs and Resident #1 received one. The Administrator stated he was unaware that the manual wheelchair in Resident 1's room was not suitable for him. The Administrator stated it was possible that the wheelchairs got mixed up when staff were cleaning them because the resident's wheelchair should not be too wide. He stated the resident recently went into the community with family in his wheelchair with no reported issues. The Administrator stated Resident #1 could not propel himself in the manual wheelchair, but it was mostly due to him not wanting to put in the effort. The Administrator stated although Resident #1 did not qualify for the motorized wheelchair in September 2025, it was his right to be re-evaluated if he requested it. The Administrator stated Resident #1 needed Medicare Part B to start therapy again; however, he would follow up with the DOR. Review of the facility's policy titled Resident Rights and Responsibilities, notice of revised February 2025, reflected in part the following: Policy: It is the policy of this facility to inform the resident both orally and in writing of his/her rights as a resident, as well as, the rules and regulations governing the resident's conduct and responsibilities during his/her stay in the facility.Further review of this document reflected it did not address call lights. The facility's policies on resident rights (call lights) and quality of care (assistive devices) were requested from the Administrator on 07/08/26 at 2:50 PM and an accessible copy was not provided prior to exit.

Based observation, interview, and record review the facility failed to notify the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status or need to alter treatment for 1 resident (Resident #1) of 6 residents reviewed for resident rights. The facility failed to notify Resident #1's delegated representative of a change in treatment on 05/13/26 when the physician ordered an antipsychotic medication, Risperidone 1 mg, to be administered twice daily. This failure could place residents at risk of not being able to exercise their rights regarding care, which could lead to harm or decreased quality of life.Findings included: Record review of Resident #1's Quarterly MDS Assessment, dated 03/30/26, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident's BIMS score was 15, which indicated cognition was intact. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required moderate assistance with most self-care ADLs. The MDS Assessment under Section I-Active Diagnoses, reflected Resident #1's active diagnoses included: bipolar disorder (mental condition that causes extreme mood swings) and schizophrenia (severe mental illness that causes delusions and disorganized thinking). Record review of Resident 1's care plan, dated 05/04/26, did not reflect the resident's need for a representative's involvement in decision making. Record review of a consent for treatment form provided by the DON, dated 05/14/26, reflected Resident #1 signed for consent to be administered risperidone for treatment of schizophrenia/psychosis. Further review reflected the document was not signed by Resident #1's POA/RP. Record review of Resident #1's progress notes, dated 05/15/26 at 7:55 p.m. by PA, reflected the following: History includes:1.On 5/11/26, [Resident #1] exhibited verbal and physical aggression. Nursing staff contacted 911, and responding officers recommended a transfer to [psych hospital] for further evaluation. [Resident #1] was subsequently transported via EMS. [Resident #1] returned to the facility on 5/13/26. While medical records from the hospital visit are currently limited, please note that the following medications were initiated upon her return: amlodipine, cetirizine, risperidone, and proctofoam HC foam. Additionally, guaifenesin, topical hydrocortisone, hydroxyzine, and ondansetron were added on a PRN basis. On 5/14, [Resident #1] also began a lactobacillus probiotic regimen.Subjective: [Resident #1] was observed seated on her rollator walker in the dining room listening to music. [Resident #1] stated that she is doing 'fine' today. When asked regarding her recent hospitalization, [Resident #1] indicated that she was unsure of the reason for her stay. [Resident #1] reports that her chronic pain remains stable. [Resident #1] denied experiencing chest pain, fever, chills, or shortness of breath. Per medical record review, she has not had a bowel movement today. [Resident #1's] plan and progress was discussed with nursing staff and therapy. Record review of Resident #1's progress notes, dated 05/16/26 at 7:36 p.m. by RN A, reflected the following: [Resident #1's POA/RP] has some concerns about [Resident #1] having a reaction to medication and requested to place psych risperidone on hold until she was able to speak to Psych Dr. On call [NP]. was notified and NP request and ordered for education to be provided to [Resident #1's POA/RP] about safety and if [Resident #1] was to have a behavior it could result in resident being transferred out to psych. [Resident #1's POA/RP] stated she understands and medication was placed on hold for 8 days. will continue to monitor for any acute changes. [sic] Record review of Resident #1's active physician orders, dated 06/04/26, reflected in part the following: - risperidone oral tablet 1 mg-give 1 tablet by mouth two times a day for bipolar disorder. Start Date: 05/13/26 Record review of Resident #1's EHR on 06/04/26, reflected the resident had a delegated medical POA and resident representative. Further review of this document did not reflect that a judge deemed Resident #1 incompetent. Record review of Resident #1's MAR, dated 05/2026, reflected the resident's risperidone oral tablet 1 mg was started on 05/13/26 at 9:00 p.m. and held on the following dates and times: -05/16/26 at 9:00 p.m.-05/17/26 at 9:00 a.m. and 9:00 p.m.-05/18/26 at 9:00 a.m. and 9:00 p.m.-05/19/26 at 9:00 a.m. and 9:00 p.m.-05/20/26 at 9:00 a.m. and 9:00 p.m.-05/21/26 at 9:00 a.m. and 9:00 p.m.-05/22/26 at 9:00 a.m. and 9:00 p.m.-05/23/26 at 9:00 a.m. and 9:00 p.m.-05/24/26 at 9:00 a.m. Further review of the document reflected Resident #1's risperidone oral tablet 1 mg was resumed on the following date:-05/24/26 at 9:00 p.m. In an interview on 06/04/26/26 at 9:35 a.m., Resident #1's POA/RP revealed the facility transported Resident #1 to a local psychiatric hospital without notifying her first after the resident had a behavioral crisis. The POA/RP stated Resident #1 was given risperidone which caused her to drool and have slurred speech that. The POA/RP stated the symptoms continued after Resident #1 returned to the facility so she told the nurse to stop the medication until she could find a different doctor because she did not trust the facility's MD. The POA/RP stated it was reported to her that Resident #1 was taken off the medication. She stated she was not aware that it was resumed on 05/24/26 because she had not found a different doctor or spoken with the facility's psych doctor. The POA/RP stated the facility usually notified her regarding Resident #1's care but they failed to inform her that the risperidone was being administered again. The POA/RP stated she never signed a consent form for Resident #1 to start the medication, and she was upset that the resident was taking it without her knowledge. In an observation and interview on 06/04/26/26 at 10:15 a.m., Resident #1 stated she felt okay and denied having any bad symptoms from the medications she took. Resident #1 was not drooling, and her speech did not sound slurred. Resident #1 recalled going to the local hospital but did not know why she went or what medications she was given. Resident #1 also could not recall what new medication she was taking at the facility. Resident #1 stated her family helped her make decisions regarding her care. In an interview on 06/04/26/26 at 2:58 p.m., the MD stated he ordered risperidone 1 mg bid for Resident #1 on 05/13/26 after discharge recommendation from the local psychiatric hospital. The MD stated Resident #1 had a positive response to the medication as she was calmer and able to communicate clearly when he visited her. The MD stated a signed consent form was required before risperidone could be administered and it was the facility's responsibility to ensure that it was completed. The MD stated the former interim DON was very good and he trusted that she had gotten it signed by the appropriate party. In an interview on 06/04/26/26 at 3:16 p.m., the DON stated she has worked at the facility for one week. She stated risperidone was a medication that was required to have a signed consent by the resident or the family if they were listed as representative before it was administered. The DON stated if the resident was able to sign the consent form themselves the family would still be notified with permission from the resident. The DON stated she did not work at the facility when Resident #1 was ordered the risperidone and did not know who was responsible for getting the consent form signed at that time. The DON stated it was important for appropriate consent to be given for psychoactive medications due to the class of medication and black box warnings (serious, life-threatening, or permanently disabling adverse effects) that could come from taking it. In an interview on 06/04/26/26 at 5:06 p.m., the Administrator initially stated Resident #1's family was only listed as the resident's POA for care; however, Resident #1 had a BIMS of 15 and had the capacity to make her own decisions. After checking the chart, the Administrator stated Resident #1's family was also listed as the resident representative. He stated the facility notified the resident representative regarding a resident's care, but they did not have to consent to medical treatment if the resident could do so. Review of the facility's policy titled Psychoactive Medications revised May 2025, reflected in part the following: POLICY:It is the policy of this facility to maintain every resident's right to be free from use of psychoactive medication. Other alternative measures to manage target behavior will be tried prior to the use of psychoactive medications. PROCEDURES: The use of psychoactive medication must first be explained to the resident, family member, or legal representative. A consent is to be obtained either from the resident or responsible party if resident unable to give. A verbal consent may be obtained if no responsible person is available. The person obtaining the consent is to sign the consent once obtained. The facility must explain, in the context of the individual resident's condition and circumstances, the potential risks and benefits of all options under consideration including using a restraint, not using a restraint, and alternatives to restraint use. Explain the potential negative outcomes of psychoactive medication, show symptoms of withdrawal, depression, or reduced social contact.

Based on interviews and record reviews, the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents (Resident #1) reviewed for medication errors. The facility failed to administer Resident #1's thyroid medication since she was admitted on [DATE]. This failure could place residents at risk of their medical conditions worsening from lack of treatment. Findings included:Record review of Resident #1's admission MDS, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting the left side of her body and her ability to speak, diabetes, kidney failure, and hypothyroidism (thyroid not producing enough hormones, slowing their metabolism). Her BIMS score was 15, indicating she was cognitively intact. Her Functional Abilities assessment indicated she required assistance with her ADLs. Her Medication assessment reflected that she used insulin daily, and no drug issues were found during review of her medication regimen.Record review of Resident #1's care plan, dated 04/24/26, reflected her need for dialysis but did not reflect her hypothyroidism. Hypothyroidism was listed in her diagnoses on the care plan. Record review of Resident #1's discharge record from her previous nursing home, dated 03/06/26, listed hypothyroidism as one of her diagnoses. The physician's History and Physical reflected she was on Levothyroxine 112 mcg daily for thyroid disorder. Her discharge instructions listed Hypothyroidism, continue levothyroxine, monitor for acute needs, labs per primary care provider. Her medication administration record listed Levothyroxine 112 mcg 1 tablet in the morning for low thyroid. Her physician discharge notes listed hypothyroidism as one of her diagnoses, her medications included levothyroxine 112 mcg in the morning.Record review of Resident #1's CAA worksheet, uploaded to her EHR from the facility's previous EHR program, reflected a date range from 11/01/25 to 05/01/26. Thyroid problem was listed under Other diseases and conditions that can affect appetite of nutritional needs. Under Analysis of Findings, thyroid disease is listed Under Medical Problems that can affect cognition, thyroid disorder is listed. Her care plan, dated 03/24/26, reflected she had hypothyroidism with interventions of give thyroid replacement therapy as ordered, obtain and monitor lab work as ordered. Record review of Resident #1's Admit Assessment for her current facility, dated 03/19/26, did not mention the resident's hypothyroidism. Record review or Resident #1's current medication administration record did not list levothyroxine as one of her medications. In an interview on 05/21/26 at 9:20 AM, the Administrator stated the facility did not have a DON currently and the ADON was not working on this date. In a phone interview on 05/21/26 at 12:35 PM, Resident #1's family member stated when the resident was admitted to the hospital (unrelated to her hypothyroidism), they were asked if the resident had been taking her thyroid medication because her lab work was very elevated, as if she had not been taking it. The family member stated he asked Resident #1 if the facility had been giving her thyroid medication, and she stated she had not had it. In an interview on 05/21/26 at 12:42 PM, the NP stated he was unaware of Resident #1 having hypothyroidism. He stated she exhibited no symptoms of hypothyroidism that would have clued him in. He stated his medical group had assumed care on 05/01/26 when the facility had a change in ownership, and there was no indication of hypothyroidism in her EHR, or that she had been taking levothyroxine. He stated the attending physician must not have reviewed all her records since hypothyroidism was listed as one of her diagnoses. The NP stated he had no explanation of how Resident #1 was not on her thyroid medication. He stated going without her medication could cause several problems, but the resident had not exhibited any symptoms of low thyroid. Phone interview attempt on 05/21/26 at 1:00 PM with Resident #1's physician was unsuccessful, message left. In an interview on 05/21/26 at 1:20 PM, LVN-A stated he was unaware Resident #1 was supposed to be on thyroid medications. He was unaware the resident had hypothyroidism. He stated neither the resident nor the resident's family had mentioned it to him. He stated he did not review the residents' history from the previous facility. LVN-A stated the ADON usually reviews new admissions to ensure all orders were in place. In an interview on 05/21/26 at 1:50 PM, Hospital RN C stated Resident #1's TSH (Thyroid Stimulating Hormone) level was very high. RN C stated he had to administer twice the normal dose of levothyroxine as normal to the resident. He was unable to share what her level was. In an interview on 05/21/26 at 3:30 PM, MA C stated she did not recall ever administering levothyroxine to Resident #1. She stated she did not recall seeing that order at any time . Phone interview attempt on 05/21/25 at 3:45 PM with Resident #1's physician was unsuccessful. Message left. Record review of the facility's Medication Administration policy, dated July 2020, reflected: It is the policy of this facility that medications shall be administered as prescribed by the attending physician

Based on observation, interview and record review, the facility failed to ensure, based on a resident's comprehensive assessment, residents maintained acceptable parameters of nutritional status for 1 of 5 residents (Resident #1) reviewed for nutrition.The facility failed to monitor Resident #1's weight and meal intake which resulted in the resident's weight loss not being identified. This failure placed residents at risk for loss of weight and inadequate nutrition. Findings included:Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included bipolar disorder, psychotic disorder, antisocial personality disorder, and homelessness. Resident #1 had a BIMS of 15 which indicated her cognition was intact. The MDS reflected the resident was independent with eating and her height was recorded as 59 inches and weight was 151 pounds. Record review of Resident #1's care plan revised on 11/04/25 reflected the resident had a nutritional problem or potential nutritional problem. Interventions included to serve diet as ordered and the RN to evaluate and make diet change recommendations. Record review of Resident #1's May 2026 physician's orders reflected the resident was on monthly weights. Record review of Resident #1's weight from October 2025 to May 2026 reflected the following:admission - October - 148.4 poundsNovember - 147.4 poundsDecember - 150.4 poundsJanuary - 149.63 poundsFebruary - 150.2 poundsMarch - 151.3 poundsApril - 151.4 poundsSurveyor Witnessed weight - 05/06/26 at 3:28 PM - 127.4 poundsRecord review of an invoice dated 05/05/26 reflected the facility's scale had been calibrated on that date, and it was in good working order. Record review of Resident #1's meal intake percentages from 04/11/26 to 05/07/26 reflected the following:76% to 100% eaten - 24 meals51% to 75% eaten - 8 meals26% to 50% eaten - 3 mealsResident Refused - 6 mealsObservation and interview on 05/06/26 at 12:00 PM with Resident #1 revealed she was in the dining room sitting at the dining table with another resident. Resident #1 was listening to the music on the television and she was dancing. The resident said she did not feel like she had lost any weight because all of her clothes still fit. The resident was given her meal tray which she pushed aside and did not eat and said she was not that hungry. Interview on 05/06/26 at 1:50 PM with Resident #1's family revealed they noticed about a 50lb weight loss since the resident was admitted to the facility. The resident's family said she could just tell she had lost weight.Interview on 05/06/26 at 3:02 PM with the ADON revealed Resident #1 ate what she wanted for the most part and the ADON said she had not noticed any weight loss issues since the resident had been at the facility. Interview on 05/06/26 at 3:44 PM with CNA A revealed Resident #1 was independent with eating and would eat what she wanted off the meal tray. CNA A said if the resident did not like what was served, she would eat a grilled cheese sandwich in her room, and it was very rare that she ate in the dining room. CNA A further stated he did not notice any weight loss in the resident. CNA A said if Resident #1 was served in the dining room, the resident would try to give her meal tray to her tablemates so a tray with a grilled cheese would be delivered to her room for her to eat when she was ready. Observation on 05/06/26 at 5:30 AM revealed Resident #1 was given a meal tray for dinner, and she did not eat it and gave it to her tablemate. Resident #1 then asked for a grilled cheese sandwich which she put in a napkin and stored it in the seat of her rolling walker. Interview on 05/06/26 at 5:39 PM with RN B revealed Resident #1 ate sporadically and if staff pushed her to eat, she would become upset. RN B said at times the staff left her tray in her room and Resident #1 would state she would eat it later. RN B further stated she did not directly work with Resident #1 but she had noticed the resident might have lost some weight in the last 2 months but could not tell how much. Observation on 05/07/26 at 12:15 PM of Resident #1 revealed she was in the dining room during lunch sitting with her tablemate. The resident was given a grilled cheese sandwich, and she told the staff to take it to her room and she would eat it later because she was not hungry at the time. Interview on 05/07/26 at 1:30 PM with MA A revealed she helped monitor in the dining room during lunch and said there were times Resident #1 ate and other times when she did not. MA A said there were also times when Resident #1 would try and give her food to her tablemate and she would be reminded not to do that and then Resident #1 would become upset and not eat at all. MA A further stated on the days Resident #1 would not eat her meal she would later ask to have something else made for her like a grilled cheese sandwich. MA A further stated she had not noticed any weight loss on the resident. Interview on 05/07/26 at 1:38 PM with RN D revealed Resident #1 had some days when she ate and other days when she just drank coffee. RN D said Resident #1 was independent with her ADLs and chose when and what she ate. RN D further stated she had not noticed any weight loss in the resident. Interview on 05/07/26 at 1:56 PM with the Dietitian revealed Resident #1's weights were being monitored monthly, and no one had told her the resident was not eating or had any weight loss. The Dietitian said she spoke with Resident #1 today, (05/07/26) and the resident told her she was trying to exercise and keep her belly down. The Dietitian stated Resident #1 told the Dietitian she liked grilled cheese sandwiches and at times she liked to save them for later. The Dietitian said based on Resident #1's current height and weight (59 inches and 126 pounds) she was within her BMI and based on her assessment the resident did not appear to have any physical symptoms of weight loss such as temporal or muscle wasting. The Dietitian further stated if she knew the resident was losing weight, she would have recommended 3 shakes a day as her first intervention between her meals. The Dietitian said it was important for the resident's weight to be monitored accurately to know how many calories they were taking in and ensure the residents were getting adequate nutrition. Interview on 05/07/26 at 2:27 PM with the Dietary Manager revealed Resident #1 was independent and normally ate grilled cheese for lunch and dinner either in her room or the dining room. The Dietary Manager said Resident #1 was very vocal and usually told the staff what she wanted to eat. The Dietary Manager further stated she was not aware of the resident not eating and also did not notice any weight loss in the resident. Interview on 05/07/26 at 2:35 PM with the ADON revealed the resident ate in her room most times and would order grilled cheese sandwiches. The ADON said she was not aware of or noticed any weight loss in Resident #1. Interview on 05/08/26 at 10:52 AM with Resident #1's family revealed they visited the resident the evening prior (05/07/26) and said as they were putting clothes up in the resident's drawer and they noted there were 2 uneaten grilled cheese sandwiches in a drawer that they threw away and they reminded the resident not to do that because she could attract bugs. Record review of the facility's policy titled Vital Signs, Weight and Height revised on 08/2021 reflected the following: .3. The resident's weight shall be taken monthly in accordance with the Weighing Schedule and recorded in the health record no later than the 10th day of each month. A licensed nurse is to review all weight taken on the same day so that follow-up to reweight a questionable weight can be done promptly or within significant changes.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #1 and #2) reviewed for infection control practices.1. CNA B and CNA C failed to perform hand hygiene before contact, between care, and change of gloves while providing incontinence care to Resident #1 and Resident #2.2. CNA B and CNA C failed to put on PPE while providing incontinence care to Resident#1, who was on enhanced barrier precautions due to having a feeding tube.These failures could place residents at risk of exposure to infectious agents and could lead to the development of infection. Findings included:1. Record review of Resident #1's Comprehensive MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with a readmission of 07/16/24. Resident #1 was cognitively intact with a BIMS score of 15. He had diagnoses which included hypertension (abnormally high arterial blood pressure) and aphasia (a disorder that results from damage (usually from a stroke or traumatic brain injury) to areas of the brain that are responsible for language). He also had a feeding tube.Record review of Resident #1's care plan, dated 01/27/26, reflected: Focus: [Resident #1] Has functional bladder incontinence rule out Confusion, Disease Process, Impaired Mobility. Goal: [Resident #1] will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Check and change Resident#1 every 2-4 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes.Resident#1's care plan dated 01/27/26 reflected: Focus: [Resident#1] on enhanced barrier precaution due to gastronomy tube and wound. Goal: [Resident#1] will remain in Enhanced barrier precautions without complications thru next review. Interventions: Proper signage to be clearly indicated, PPE, including gowns and gloves available outside room, alcohol-based hand rub available at rooms, proper trash can inside residents' room and near exit for discarding PPE prior to exit of the room. Proper use of PPE to be observed, use of gown and gloves during high contact resident care activities that provide opportunities for transfer of multi-drug-resistant organism. 2. Record review of Resident #2's Quarterly MDS Assessment, dated 02/26/26, reflected the resident was a [AGE] year-old female, who admitted on [DATE]. Resident#2 was cognitively intact with a BIMS score of 15, and her diagnoses included contractures of the right and the left knee (the permanent, abnormal shortening or tightening of muscles, tendons, skin, or tissues, which causes joint stiffness and restricts movement).Record review of Resident #2's care plan, dated 04/16/26, reflected: Focus: [Resident #2] has bladder incontinence rule out decreased mobility and weakness. Goal: [Resident #2] will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Check the residents during rounds and as required for incontinence. Wash, rinse and dry perineum [the area between the anus and vulva]. Change clothing as needed after incontinence episodes.Observation on 04/21/26 at 12:28 PM revealed CNA B and CNA C went to Resident #1's room to provide the resident incontinence care. CNA B first knocked on the resident's door and then entered the room. Without washing her hands, CNA B put on gloves and put her supplies together. CNA C also entered the room to help, and she also put on gloves without washing her hands. Observation revealed Resident #1 had a gastronomy tube and had an enhanced barrier precaution sign outside the door and PPE was outside the room. CNA B and CNA C did not put on a gown upon entering the room. CNA B proceeded to use wet wipes to cleanse Resident #1's abdominal folds and perineal area (the anatomical region located between the thighs). Her technique was one wipe, one swipe. She wiped down the peri area from inner area towards the outer area. Resident #1 then was turned on his right side, and CNA B wiped the resident's buttocks and thighs from inner area towards the outer area. Resident #1 was wet and had bowel movement. CNA B then removed the soiled brief and discarded it. Without performing hand hygiene or changing her gloves, CNA B took a clean brief and put the clean brief on Resident #1. They then positioned the resident in bed with the call light in reach. They removed their gloves, took the trash, and left the resident's room without washing hands. CNA B took the trash to the soiled closet and without washing her hands she went to Resident #2 room.Observation on 04/21/26 at 12:39 PM revealed CNA B and CNA C went to Resident #2's room to provide the resident incontinence care. CNA B first knocked on the resident's door and then entered the room. She explained the procedure and went to wash her hands and before she could wash her hands, she left the room and went back to Resident#1's room. She came back with another bag of trash she put on the soiled closet and came back to Resident#2 room. Without washing her hands, she put on gloves and put her supplies together. CNA C also put on gloves without washing her hands. CNA B used wet wipes to cleanse Resident #2's abdominal folds and perineal area (the anatomical region located between the thighs). Her technique was one wipe, one swipe. She wiped down the peri area from inner area towards the outer area. Resident #2 then was turned on her right side, and CNA B wiped the resident's buttocks and thighs from inner area towards the outer area. Resident #2 was heavily wet with urine, and CNA B removed the soiled brief and discarded it. Without performing hand hygiene or changing her gloves, CNA B took a clean brief and put the clean brief on Resident #2. CNA B and CNA C then positioned the resident in bed with the call light in reach. Lastly, they removed their gloves, took the trash, and left the resident's room without washing their hands.Interview with CNA C on 04/21/26 at 12:47 PM revealed she knew she was supposed to perform hand hygiene before contact with Residents #1 and #2, between the care, and with each removal of gloves. She also stated they were supposed to wear gowns with Resident #1 who was on enhanced barrier due to gastronomy tube, but she forgot. She stated failure to perform hand hygiene before contact, between care, and after removal of gloves and wearing PPE could lead to contamination and spread of infection. She stated she had done training on hand washing and PPE, but she could not remember when.Interview with CNA B on 04/21/26 at 1:50 PM revealed she was supposed to perform hand hygiene before contact and after care and with each change of gloves, but she did not know she was supposed to change gloves between care since she came from another state and things were different. She stated she was also supposed to wear PPE with Resident#1, who was on enhanced barrier. CNA B confirmed there was an enhanced barrier sign on the door to the room, and PPE was located by the door due to the resident having a feeding tube. CNA B stated she forgot. She revealed she did not change her gloves or wash her hands between the residents. She also revealed she did not change her gloves or wash her hands while moving from handling soiled briefs and then clean briefs. She stated she did not have reason for not doing it. She stated that failure to perform hand hygiene during incontinence care, between residents and wearing of PPE on resident with enhanced barrier signs could lead to cross contamination and infection. She stated she usually forget to wear PPE because she was always in a hurry to get care done. She stated she had not received in-service training on hand washing and infection control in the facility because she was newly hired.Interview with ADON on 04/21/26 at 3:15 PM revealed her expectation was for staff to perform hand hygiene before contact with residents, between care, and when they changed their gloves. The ADON stated she also expected staff to wear PPE before entering resident rooms with signs of enhanced barrier by the door. She stated failure to perform hand hygiene before contact, between care, and change of gloves while soiled could lead to cross contamination and spread of infection. She stated failure to wear PPE before contact with residents on enhanced barrier could also lead to cross contamination. She stated CNA B had been in the facility for three weeks, and she had not received training on infection control. She stated the facility had offered training on hand washing and wearing PPE, and she was not sure whether the two staff were in attendance. Record review of the facility's current Hand Hygiene policy, dated 03/01/22, reflected the following: This facility considers hand hygiene the primary means to prevent the spread of infections.1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.3. Hand-hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) should be readily accessible and convenient for staff use to encourage compliance with hand-hygiene policies 7. Use an alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents.j. After contact with blood or bodily fluids; A Resident contact .m. After removing gloves.n. Before and after entering isolation precaution settings. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment.9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.Record review of the facility's current Infection Prevention and Control Program policy, dated 1/1/ 24, reflected the following: c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #1, #2, #3, and #4) of fifteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1, #2, #3, and #4's rooms was in a position that was accessible to the residents on 02/015/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Resident #1 Record review of Resident #1's Face Sheet, dated 02/15/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included contracture (tightening or shortening of the muscles), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body).Record review of Resident #1's Quarterly MDS Assessment (tool used to assess health status), dated 01/01/2026, reflected the resident had a moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS (tool used to assess cognitive status) of 09. The Quarterly MDS Assessment indicated the resident was dependent on staff for eating, hygiene, dressing, bed mobility, and transfer.Record review of Resident #1's Comprehensive Care Plan, dated 01/22/2026, reflected the resident had alteration in musculoskeletal (having to do with muscles, bones, joint, ligaments, and tendons of the body) status r/t contracture and intervention included to be sure call light was within reach. During an observation and interview on 02/15/2026 at 9:29 AM, revealed Resident #1 was observed in her bed, awake. Resident #1's call light was observed lying on the floor. The resident stated she used the call light if she needed to call the staff. She said she did not have the call light and could not find it. She said it was not the first time that she could not find her call light. Resident #2 Record review of Resident #2's Face Sheet, dated 02/15/2026, reflected a [AGE] year-old female admitted on [DATE]. Diagnoses included epilepsy (brain disorder caused by abnormal electrical signals in the brain), muscle wasting, lack of coordination, and unsteadiness of the feet.Record review of Resident #2's Quarterly MDS Assessment, dated 12/21/2025, reflected the resident had severe impairment (resident required significant assistance and support in daily life) cognitively with a BIMS score of 00. The Quarterly MDS Assessment indicated the resident needed assistance for transfer, bed mobility, toileting hygiene, shower, dressing, and personal hygiene.Record review of Resident #2's Comprehensive Care Plan, dated 12/30/2025, reflected the resident had alteration in musculoskeletal status r/t contractures and interventions included to be sure call light was within reach. The care plan reflected the resident was at risk for falls.During an observation and interview on 02/15/2026 at 9:31 AM, Resident #2 was observed in her bed, awake. Her call light was observed coiled on the lowest bed frame and was not within reach. When asked where her call light was, the resident did not reply.During an observation and interview on 02/15/2026 at 9:35 AM, LVN A stated call lights should always be within reach of the residents in case the residents needed to call the staff for assistance. She said without the call lights, the residents might be upset or might fall if they tried to do things by themselves. LVN A was observed going inside Residents' #1 and #2's room. LVN A was observed picking up Resident #'s call light off the floor, she then placed the call light where Resident #1 could reach it. LVN A then went to Resident #2's side of the room removed Resident #2's call light from the frame of the bed and placed the call light within Resident #2 reach. She said staff should make sure that the residents' call lights were within resident before living the room.Resident #3 Record review of Resident #3's Face Sheet, dated 02/15/2026, reflected a [AGE] year-old male admitted on [DATE]. Diagnoses included difficulty in walking, epilepsy, repeated falls, and fracture (broken bone).Record review of Resident #2's Quarterly MDS Assessment, dated 12/10/2025, reflected resident had a severe impairment in cognition with a BIMS score of 04. The Quarterly MDS Assessment indicated the resident needed assistance for transfer, bed mobility, toileting, hygiene, shower, and dressing.Record review of Resident #3's Comprehensive Care Plan, dated 01/13/2025, reflected resident had an actual fall on 10/30/2025 and interventions included to be sure call light was within reach. During an observation and interview on 02/15/2026 at 9:34 AM, Resident #3 was observed in his bed, awake. Resident #3 's call light was observed on the floor. The resident stated his call light had been on the floor since morning, and staff had not placed it back to his bed.During an observation and interview on 02/15/2026 at 9:40 AM, CNA C stated she did not notice that Resident #3's call lights was on the floor when she brought the resident's breakfast. She said she should have made sure the call light was within the resident's reach when she left the resident's room. She said the residents used call lights to call the nurse if they needed something. CNA C picked up the call light and placed it within reach of the resident. She said she would also check the call lights of the residents assigned to her if they were within reach of the residents.Resident #4 Record review of Resident #4's Face Sheet, dated 02/15/2026, reflected a [AGE] year-old female admitted on [DATE]. Diagnoses included obesity (excessive accumulation of body fats) and polyneuropathy (damage of multiple nerves).Record review of Resident #4's Quarterly MDS Assessment, dated 12/12/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident needed assistance for dressing, transfer, bed mobility, hygiene, and shower.Record review of Resident #4's Comprehensive Care Plan, dated 01/11/2026, reflected the resident was at risk for fall and interventions included be sure call light was within reach. During an observation and interview on 02/15/2026 at 9:44 AM, Resident #4 was observed in her bed, awake. The resident's call light was observed hanging on the repositioning bar. The resident said the staff would always hang her call light on the repositioning bar, but it was difficult for her to turn just to get the call light. She said she hoped the staff would put it somewhere that would be easier for her to reach it.During an observation and interview on 02/15/2026 at 9:55 AM, CNA D stated call lights were important for the residents because the residents used the call lights to call the staff if they needed something. She went inside Resident #4's room and saw the call light dangling from the bed and that was not within reach of the resident. CNA D took the call light from the railings and asked the resident where she wanted the call light. The resident said to clip it to her side.During an interview on 02/15/2026 at 10:28 AM, LVN B stated she did not notice that Resident #4's call light was not within the reach of the resident. She said if the call lights were not with the residents, then there was no way the residents would be able to make their needs known. She said the residents would use their call lights to call the staff if they needed to be changed, needed a pain pills, or even to refill their pitcher. During an interview on 02/15/2026 at 11:58 AM, the ADON stated call lights were important for the residents because the residents used them to call the staff when they needed something or needed assistance. She said all the staff were responsible in making sure the call lights were with the residents. She said residents might fall trying to get the call light or trying to go to the bathroom by themselves. She said the call lights were for all the residents, whether dependent or independent. She said the expectation for the staff was to make sure the call lights of the residents were with the residents at all times. She said she would start an in-service regarding the call lights.In an interview on 02/03/2026 at 12:48 PM, the Administrator stated staff should make sure the call lights were within reach of residents in case they needed help. He said sometimes residents would knock the call lights down when they move so the staff should make sure the call lights were secured that even when the residents moved, they would not fall. He said the call lights were for both the dependent and independent residents. He said independent residents might be having a distress and would not be able to call the staff because their call lights were not with them. She said the call lights should be monitored throughout the day by the CNAs and the nurses. He said the ADON already started an in-service for call lights. Record review of the facility's policy, Call Lights: Accessibility and Timely Response revised 01/01/2024 reflected Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance . Policy Explanation and Compliance Guidelines . 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Residents #1) of ten residents reviewed for medication storage. The facility failed to ensure that Resident #1's barrier cream was stored properly and not left on the resident's side table visible and accessible to the resident and other residents on 02/15/2026.These failures could place the residents at risk of misuse of medications and possible adverse reactions.Findings included: Record review of Resident #1's Face Sheet, dated 02/15/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included dementia (a condition characterized by loss of memory and ability to reason), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body).Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected the resident had a BIMS of 09 which indicated her cognition was moderately impaired. The Quarterly MDS Assessment indicated the resident was incontinent for bladder and bowel.Record review of Resident #1's Comprehensive Care Plan, dated 01/22/2026, reflected the resident was incontinence and goals included the resident would be free from skin breakdown. During an observation and interview on 02/15/2026 at 9:32 AM, Resident #1 was observed in her bed, awake. A tube of barrier cream was observed on top of the resident's side table and was accessible to the resident and others. The resident stated the staff would use the cream when they clean and changed. She said, sometimes, some staff would put it on her side table.During an observation and interview on 02/03/2026 at 10:38 AM, LVN A stated she did not know who left the barrier cream in Resident #1's room. She said the tube should be inside the cart or where the resident could not reach it. She said the residents might use them more than the recommended and could result in skin redness or dryness. She said confused residents might consume cream as well that could result to upset stomach and nausea. LVN A was observed removing the medication and she said she would put it inside the treatment cart. During an interview on 02/15/2026 at 11:58 AM, the ADON stated medications should not be stored inside the residents' rooms because residents might use the medication inappropriately and could result in adverse reactions. She said the tube of wound dressing cream should have been inside the nurse's cart and not within reach of any resident. She said the expectation was for the staff to always scan the rooms of the residents to see if there were medications inside the rooms of the residents. She said she would start an in-service about not leaving any form of medication inside the residents' rooms.In an interview on 02/03/2026 at 12:48 PM, the Administrator stated the expectation was for the staff to be mindful to look around the residents' rooms for any medication for resident's safety. He said residents could consume or use medications inappropriately left at bedside that could result to harm. He said the ADON already started an in-service about medication storage.Record review of the facility's policy, Medication Labeling and Storage 2001 MED-PASS, Inc., no revision date, reflected Policy Statement: The facility stores all medications and biologicals in locked compartments.

Based on observation, interview, and record review the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 3 residents (Resident #1) reviewed for discharge. The facility failed to ensure that Resident #1's responsible party was notified of the resident's discharge, following (or at the time of) the issuance of a NOMNC notifying the resident of the end of his Medicare-covered services, before Resident #1, who did not fully understand the contents, signed the notice. This failure could place residents at risk of not having access to available advocacy services, discharge options, and appeal processes, which could result in an unsafe discharge.Findings included: Record review of Resident #1's face sheet, dated 02/06/26, reflected a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included: malignant neoplasm of prostate (prostate cancer) and cognitive communication deficit (difficulty in communication related to cognitive impairments-such as memory and attention). Record review of Resident 1's admission MDS assessment, dated 01/15/26, reflected the resident's BIMS score was 14, which indicated intact cognitive. The MDS Assessment under Section B-Hearing, Speech, and Vision, reflected Resident #1 was usually understood and usually understood others, and had adequate vision. Section GG-Functional Abilities reflected Resident #1 required supervision or touch assistance with most ADLs. Record review of Resident 1's care plan, dated 01/09/26, did not address the resident's need for a representative's involvement in decision making. Record review of Resident #1's EHR on 02/06/26, reflected the facility had a family member listed as the resident's RP. Record review of Resident #1's admission agreement documents, dated 01/14/26, reflected that the documents were signed for Resident #1 by his designated RP. Record review of Resident #1's NOMNC notice, dated 02/02/26, reflected the Administrator notified Resident #1 of the notice on 02/03/26 at 12:44 PM, and the last covered day would be on 02/05/26. The notice reflected that if Resident #1 disagreed with the notice he could appeal the decision. Record review of Resident #1's progress notes, dated 02/03/26 at 12:46 PM by the Administrator, reflected the following: admin, in the presence of the receptionist presented [Resident #1] with a copy of the NOMNC. Last cover day is 2.25.2026 with discharge date as 2.6.2026. [Resident #1] was asked about home health and discharge location. Admin will speak to rehab manager on DME needed. Record review of Resident #1's progress notes, dated 02/04/26 at 3:48 PM by the Administrator, reflected the following: [Resident #1] called his [family/RP] who came to my office while on the phone with the police. [Resident #1] called his [family/RP] and informed her that I threatened to put him out. That never happened. [Resident #1] kept on saying that we were evicting him to which I replied, no sir, you were admitted on a short-term stay, the insurance issued a NOMNC which you signed and didn't appeal, there has been no application for Medicaid submitted and thus you are expected to discharge home on Friday. I had HR manager and Dietary manager with me as witnesses to the conversation. [Family/RP] stated that we cannot put [Resident #1] out, that we must give him 30 days. [Family/RP] was informed that his LCD is tomorrow and that we were able to verify that he has not submitted a Medicaid application for long term stay. [Family/RP] provided my description to the police and then walked away when I informed her that [Resident #1] is expected to discharge on Friday. [Family/RP] replied, No sir, and walked away. Police arrived at the facility. [Family/RP] proceeded to point admin out to th [sic] police. Officers listened to explanation of discharge process. [Family/RP] responded that [Resident #1] was under the influence and not able to make informed decisions. Administrtaor [sic] informed [family/RP] that [Resident #1] is his own responsible party and thus we must speak directly to him. Officers responded that [NAME] [sic] is a civil matter and asked about [Resident #1's] admission and his plans for discharge upon admission. [Family/RP] insisted that officers lay eyes on [Resident #1] which they did. [Resident #1] was awake, alert and oriented when visited earlier. In an interview on 02/05/26 at 2:45 PM, Resident #1's family/RP stated Resident #1 was initially admitted to the facility for rehabilitation and she was told that he could transition to LTC. The family/RP stated she spoke with the BOM about documents needed for LTC, and she was still working on gathering Resident #1's social security card and identification card. The family/RP stated she handled all of Resident #1's business with the facility and signed all documents because the resident was not coherent enough due to being heavily medicated and unable to read well; however, when it came to Resident #1's discharge notice, she was not notified or provided with the document to sign. She stated the facility provided Resident #1 the document to sign without her being present. The family/RP stated Resident #1 called and told her that he had to sign some papers and was being kicked out of the facility. The family/RP stated she went to the facility and was told that she needed to take Resident #1 home with her. The family/RP stated the Administrator was short-tempered and did not explain the discharge process or offer any assistance. The family/RP stated she was still under the impression that Resident #1 could do LTC at the facility. She stated the facility's BOM was previously helping her with the LTC process, but she had not seen her at the facility for several days. In an interview on 02/06/26 at 9:27 AM, the Administrator stated Resident #1 admitted to the facility in January under an HMO policy (a type of health insurance plan that typically requires members to use a specific network of doctors, hospitals, and other healthcare providers), and the facility had to report updates on the resident's condition every 6-7 days until Resident #1 received a NOMNC on 02/02/26. The Administrator stated the discharge plan from the beginning was for Resident #1 to discharge home with family; however, it was never specified which family member. The Administrator stated he called Resident #1 into his office with the receptionist as a witness and explained the NOMNC and appeal process to the resident. The Administrator stated Resident #1's family, who was listed as the resident's RP in the EHR, was not present. The Administrator stated Resident #1 was his own RP and was able to comprehend what was being explained to him regarding the NOMNC when he signed it. He stated he was not sure why Resident #1 was not listed as his own RP in the EHR or why he did not sign his own admission documents. The Administrator stated he knew that Resident #1 understood the NOMNC process because he called and told his family that he was being discharged . The Administrator stated Resident #1's family came to the facility, and he explained the NOMNC process to her, but she tried to bully her way through any conversations about the discharge. The Administrator stated since Resident #1 did not appeal the NOMNC, his last cover date was on 02/05/26, and he needed to either discharge home or switch to private pay because there was no Medicaid application pending. The Administrator stated corporate had already issued Resident #1 a letter notifying him that he was now considered private pay, and Resident #1 tossed the letter aside and stated he did not want it. The Administrator stated Resident #1's family/RP had discussed LTC at the facility; however, she never initiated an application for LTC Medicaid and did not provide the facility with the required documents for them to assist her with the process. In an observation and interview on 02/06/26 at 12:30 PM, Resident #1 was observed lying in his bed dressed and well-groomed but appeared to be thin and fragile. Resident #1 stated he was ill from cancer and worried about where he was going to live since he had to leave the facility. Resident #1 was trying to see the battery percentage on his cell phone, and he was squinting his eyes and having a hard time, so he asked the surveyor to look for him. Resident #1 stated he was partially blind in one eye from a cataract and was not comfortable reading, so he allowed his family to take care of his business, including at the facility. Resident #1 stated the facility allowed his family/RP to sign all his paperwork for him; however, one day he was on his way to the dining area when the Administrator stopped him and called him into his office. Resident #1 stated the Administrator told him that he had to sign some paperwork. Resident #1 stated he did not understand what he was signing and just signed it because the Administrator told him he had to. Resident #1 stated he called his family/RP after signing the paperwork and she told him that he messed up and signed discharge papers. In an interview on 02/06/26 at 1:33 PM, the Receptionist stated she was present when the Administrator provided Resident #1 with his NOMNC notice. She recalled hearing the Administrator explain the notice to Resident #1 before he signed it, but she could not state exactly what was explained, or if Resident #1 understood it. The Receptionist stated she was also present when Resident #1's admission agreement was signed. The Receptionist stated getting admission agreements signed was not part of her normal work duties, but she was helping the facility out. The Receptionist stated she was the one who explained the services and agreement to Resident #1's family/RP and had her sign where the former BOM had highlighted. The Receptionist stated the former BOM told her to have Resident #1's family to sign the admission agreement on his behalf because the resident probably would not understand what he was signing. In an interview on 02/06/26 at 3:21 PM, CNA A revealed he worked at the facility for about a year. He stated he worked with Resident #1 and the resident was independent with a lot of his ADLs, but staff would assist him when needed. CNA A stated the only thing he would see Resident #1 reading was his bible. CNA A stated Resident #1 did not wear eyeglasses normally but anytime he was reading his bible he would have them on. CNA A stated he did not know if Resident #1 was partially blind in one eye, he just knew that he needed his eyeglasses when he was reading. Record review of the facility's Transfer and Discharge (including AMA) policy, revised 01/01/25, reflected in part the following:Policy:It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances.Definitions:. Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected.Policy Explanation and Compliance Guidelines:1. The facility will evaluate and determine the level of care needed for the resident prior to admission toensure the facility's ability to meet the resident's needs.2. Once admitted , the resident has the right to remain at the facility unless their transfer or dischargemeets one of the following specified exemptions:a. The transfer or discharge is necessary for the resident's welfare and the resident's needscannot be met in the facility.b. The transfer or discharge is appropriate because the resident's health has improved sufficientlyso that the resident no longer needs the services provided by the facility.c. The safety of individuals in the facility is endangered due to the clinical or behavioral status ofthe resident.d. The health of individuals in the facility would otherwise be endangered.e. The resident has failed, after reasonable and appropriate notice, to pay or have paid underMedicare or Medicaid for his or her stay at the facility. Nonpayment applies if the resident doesnot submit the necessary paperwork for third party payment or after the third party, includingMedicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay.f. The facility ceases to operate.4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. Review of the Centers for Medicare and Medicaid Services (CMS) website, https://www.cms.gov/medicare/appeals-and-grievances/mmcag/downloads/nomncinstructions.pdf reflected in part the following: Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10095.The notice must be validly delivered. Valid delivery means that the enrollee must be able to understand the purpose and contents of the notice in order to sign for receipt of it. The enrollee must be able to understand that he or she may appeal the termination decision. If the enrollee is not able to comprehend the contents of the notice, it must be delivered to and signed by a representative .

Based on observation, interview, and record review, the facility failed to provide service for incontinent care for 1 of 5 residents (Resident #2) reviewed for incontinent care, in that: The facility failed to provide incontinent care to Resident #2, which resulted in Resident #2 being left unchanged for approximately 7 hours.This failure could result in skin sores, infection and could affect resident's dignity. Findings included:Record review of Resident #2's face sheet, dated 1/14/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included brain bleed, back pain and type 2 diabetes.Record review of Resident #2's MDS assessment, dated 10/14/2025, revealed her BIMS score was 15, which indicated the resident was cognitively intact.Record review of Resident #2's progress note, dated 1/13/2026 at 11:30 PM, revealed the resident returned to facility via ambulance service.Record review of Resident #2's care plan, dated 1/14/2026, revealed she was on antibiotic therapy for urinary tract infections. The Care plan also revealed she had bladder incontinence and one of the interventions listed was to check as required for incontinence.In an interview on 1/14/2026 at 11:11 AM, Resident #2 stated she got back from the hospital at midnight and she was provided incontinent care around 4 or 5 AM this morning. She said she had not been changed yet and it's causing her distress because she was sitting in wet brief She stated she was not usually at the facility in the mornings because she saw therapy every morning at another location. She was at the facility this morning because she just got discharged from the hospital. She stated she would push the call light to ask to be changed after the interview with state surveyor.In an observation and interview on 1/14/2026 at 12:50 PM, Resident #2 was still left unchanged. She stated it had been more than 7 hours since Resident #2 was last changed. She stated she pushed the call light about an hour ago and a nurse answered the call, and stated she would get an aide to help, but Resident #2 stated nobody had been back to change her since then. She stated she could not recall the nurse's name. She stated the nurse was usually sitting by the nurse station. In an interview on 1/14/2026 at 1:00 PM, CNA B stated she was assigned to Resident #2 today. She stated she had not checked in with Resident #2 yet. She stated she believed the resident just got back from the hospital about 2 hours ago. She stated she came in at 6AM this morning and she had not yet made rounds to see Resident #2 because she was busy. She stated she checked in with residents every 2 to 3 hours to ensure they were safe and their needs were met. She stated the risk of not changing residents every 2 hours included skin breakdown and infections.In an interview with RN D on 1/14/2026 at 2:05 PM, she stated she made rounds every morning and as needed. She was assigned to Resident #2 today. She stated CNAs were expected to make rounds every 2 to 3 hours. She stated residents should be changed every 2 hours or if they were wet or soiled. She stated the risks of leaving residents wet or soiled, more than 2 hours included infections, pressure sores and skin breakdown. She stated she answered Resident #2's call light after breakfast around 9AM, but Resident #2 stated she was good. She was unsure who answered Resident #2's call light earlier. She stated all nurses could provide incontinent care, especially when CNAs were busy.In an interview with the DON on 1/14/2026 at 1:44 PM, the DON stated CNA B was assigned to Resident #2 today, she stated CNA B should have made rounds and if she did she should know the resident was in the facility. She expected her staff to check in with residents every 2 hours and provide incontinent care every 2 hours to avoid skin breakdown and infection. She stated residents should never be left wet for more than 4 hours. She stated it would be neglect. She also stated nurses could also provided incontinent care if CNAs were busy. She provided in-services on incontinent care monthly. Record review of the facility's Abuse & Neglect policy & procedure, dated 8-10-2022, revealed neglect is defined as when a reasonable person would conclude that a deprivation of the omitted goods and services would cause, among other things, emotional distress.

Based on interview and record review the facility failed to ensure residents had the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service for 6 of 6 confidential residents reviewed for weekend mail delivery.The facility failed to ensure residents promptly received their mail on the weekend.This failure could place residents at risk of not receiving mail in a timely manner and could result in a decline in residents' psychosocial well-being and quality of life.During a confidential resident group interview 6 of 6 residents stated that they never receive mail on Saturday.In an interview on 09/09/2025 at 10:15 AM with the AD, she said the BOM brings her the mail during the week to distribute to the resident, she said she brings it to the resident's rooms, if they are not in their rooms she leaves it on their bedside table. She stated that she comes in on Saturday to make sure Saturday activities are being completed, but she doesn't deliver the mail. In an interview on 09/09/2025 at 10:33 AM with the BOM, she stated that during the week when she receives the mail, she divides the facility mail (bill, invoices, and checks) and resident mail, she then gives it to the AD. She said if mail is delivered on Saturday, the mailman puts it in the facility mailbox at the front door. There is a code on the mailbox to get into it and she is the only one with the code. If there is mail delivered on Saturday, she'll get it on Monday and have the AD deliver it to the residents on Monday. Record review of the facility's, Mail policy revised January 2011 reflected: 4. Mail will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries).

Based on interviews and record reviews, the facility failed to notify the resident and resident's representative(s) in writing of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 3 (Resident #1, Resident #2, and Resident #3) of 6 residents reviewed for discharge planning. - The facility failed to notify the resident/ residents representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understand. - The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #1, #2, and #3.This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. Findings Include:Record review of Resident #1 revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of acute congestive heart failure, emphysema, osteoarthritis, morbid (severe) obesity, type 2 diabetes, chronic obstructive pulmonary disease, and chronic respiratory failure. Her MDS dated [DATE] reflected a BIMS score of a 15 which indicated normal thinking and memory, meaning the individual's cognition is intact.Record review of Resident #1's progress note dated 09/01/2025 revealed the resident was sent to the ER, the resident's family member was notified. There was no evidence of a discharge notice sent to the resident, the resident's representative or to the LTC Ombudsman. Record review of Resident #2 revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of congestive heart failure, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, depression, asthma, morbid severe obesity with alveolar hypoventilation (excess body weight puts pressure on the diaphragm and lungs, reducing their ability to expand and take in oxygen), and kidney failure. Her MDS dated [DATE] reflected a BIMS score of a 14 which indicated the resident was cognitively intact and suggesting no or very minimal cognitive impairment. Record review of Resident #2's progress note dated 05/08/2025 at 10:48 am revealed the resident was sent to the ER. The note reflected, resident has critical hemoglobin level of 6.7. NP notified, order received to send resident out to ER. DON notified, unable to reach RP, left a message to call facility. There was no evidence of a discharge notice sent to the resident, the resident's representative or to the LTC Ombudsman. Record review of Resident #2's progress note dated 05/22/2025 at 5:00 pm, revealed, Resident request to be transferred to ER. transfer to ER per Family and Resident request. There was no evidence of a discharge notice sent to the resident, the resident's representative or to the LTC Ombudsman.Record review of Resident #3 revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of end stage renal disease, epilepsy, atrial fibrillation, toxic liver disease with fibrosis and cirrhosis of liver, congestive heart failure, and urinary tract infection. His MDS dated [DATE] reflected a BIMS score of a 15 which indicated the resident was cognitively intact and suggesting no or very minimal cognitive impairment. Record review of Resident #3's progress notes dated 08/23/2025 at 2:31 pm revealed, (NP) instructed that the resident be sent to the ER for further evaluation. The resident's RP was called but could not be reached. A VM was left with the facility's callback number. There was no evidence of a discharge notice sent to the resident, the resident's representative or to the LTC Ombudsman.In an interview with the LMSW on 09/10/2025 at 11:45 am, when asked what notifications if any are given to the resident or the RP when a resident discharged to the hospital, she stated that the nurse who sent the resident to the hospital will call the family to let them know the resident was sent to the hospital. She added that the facility doesn't send written documentation to the family, resident, or local ombudsman.In an interview with the DON on 09/10/2025 at 1:38 pm when asked what notifications if any were given to the resident or the RP when a resident discharged to the hospital, she said, the nurse on duty would call the RP. When asked if anything in writing was provided to the resident or residents RP the DON stated no.A record review of the facilities Transfer and Discharge policy dated 01/01/2025 revealed: Policy Explanation and Compliance Guidelines:4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided:a. The specific reason and basis for transfer or discharge.b. The effective date of transfer or discharge.c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .d. An explanation of the right to appeal the transfer or discharge to the State.e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests.f. Information on how to obtain an appeal form.g Information on obtaining assistance in completing and submitting the appeal hearing request.h. The name, web address, and phone number of the representative of the Office of the State Long-Term Care Ombudsman.i. For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, web address and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations.5. Generally, the notice must be provided at least 30 days prior to a facility-initiated transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is effected because: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; b. The resident's health improves sufficiently to allow a more immediate transfer or discharge; c. An immediate transfer or discharge is required by the resident's urgent medical needs; or d. A resident has not resided in the facility for 30 days. 6. In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC ombudsman as soon as practicable before the transfer or discharge.7. The facility will maintain evidence that the notice was sent to the Ombudsman.12. Emergency Transfers/Discharges - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).a. Obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis.b. Contact an ambulance service and provider hospital, or facility of resident's choice, when possible, for transportation and admission arrangements.c. For a transfer to another provider, ensure necessary information listed in #9 of this policy is provided along with, or as part of, the facility's transfer form. d. The original copies of the transfer form and Advance Directive accompany the resident. Copies are retained in the medical record.e. Provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form and manner that the resident can understand.f. Document assessment findings and other relevant information regarding the transfer in the medical record.g. Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated.h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices.

Based on record reviews and interviews, the facility failed to ensure four out of six Residents the right to receive written notice, including the reason for the change, before the resident's room in the facility is changed.The facility did not provide evidence that four out of six Residents was given a written notice of a room change before the resident was moved.This failure could place all residents at risk for being displaced without notice and/or reason and decrease quality of life being in a new environment.Record review of Resident #1 revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of acute congestive heart failure, emphysema, osteoarthritis, morbid (severe) obesity, type 2 diabetes, chronic obstructive pulmonary disease, and chronic respiratory failure. Her MDS dated [DATE] reflected a BIMS score of a 15 which indicated normal thinking and memory, meaning the individual's cognition was intact.Record review of Resident #1 census report dated September 8, 2025, revealed the resident was moved to another room on 06/04/2025.Record review of Resident #1 progress notes with an effective date range of 05/20/2025 to 09/10/2025, indicated no written notification to the resident or representative about why a room change was done. Record review of Resident #1 progress note dated 05/28/2025 social services noted, This writer along with Social Services spoke with the resident about her concerns regarding the room change. It was reiterated to the resident that she will have a roommate due to room consilidations and that she was properly notified beforehand that a room change was going to occur. It was explained to the resident that she must declutter some of the items in her room to ensure proper space for her roommate. The resident was unreceptive to this conversations. Unable to interview Resident #1 as she was discharged to the hospital.Record review of Resident #2 revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of congestive heart failure, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, depression, asthma, morbid severe obesity with alveolar hypoventilation (excess body weight puts pressure on the diaphragm and lungs, reducing their ability to expand and take in oxygen), and kidney failure. Her MDS dated [DATE] reflected a BIMS score of a 14 which indicated the resident was cognitively intact and suggesting no or very minimal cognitive impairment. Record review of Resident #2's census report dated September 8, 2025, revealed the resident was moved to another room on 06/04/2025. In an interview on 9/8/2025 at 10:44 am with Resident #2, when asked if she's ever changed rooms, she said she has changed rooms but was never given a written notice.Record review of Resident #2's progress notes with a date Range of 06/01/2025 to 06/10/2025 indicate no documentation or written notification to the resident or representative about why a room change was done. Record review of Resident #3 revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of end stage renal disease, epilepsy, atrial fibrillation, toxic liver disease with fibrosis and cirrhosis of liver, congestive heart failure, and urinary tract infection. His MDS dated [DATE] reflected a BIMS score of a 15 which indicated the resident was cognitively intact and suggesting no or very minimal cognitive impairment. Record review of Resident #3's census report dated September 9, 2025, revealed the resident was moved to another room on 06/04/2025.Unable to interview Resident #3 as he was discharged to the hospital.Record review of Resident #3's progress notes with a date range of 06/03/2025 to 09/10/2025 indicated no documentation or written notification to the resident or the RP about why a room change was done. Record review of Resident #4 revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of transient visual loss, major depressive disorder, diverticular disease of intestine (a condition where small, bulging pouches form in the wall of the large intestine), cardiac arrest, anoxic brain damage (a condition where the brain is deprived of oxygen for a prolonged period, leading to brain cell death and damage), dysphagia, and end stage renal disease. Record review of Resident #4's MDS dated [DATE] reflected a BIMS score of a 12 which indicated the individual was likely experiencing difficulties with some aspects of cognitive function.Record review of Resident #4's census report dated 09/10/2025, revealed resident was moved to another room on 06/12/2025.In an interview with Resident #4 on 9/8/2025 at 11:01 am when asked if he's ever changed rooms, he said he has changed rooms but was only told that he was moving. When asked if he was given a written notice or told why, he said no.Record review of Resident #4's progress notes from 06/11/2025 to 09/10/2025 indicated no documentation or written notification to the resident or representative about why a room change was done. During an interview on 09/08/2025 at 2:45 PM with the LMSW, when asked what the procedures were when residents moved to a different rooms she said if residents needed to move rooms, the facility would try to find matching compatible roommates, and if the resident didn't like who they chose for their roommate, the resident had a right to refuse to move, and the facility would look for another roommate. She said, they told the residents verbally that they were going to move rooms. When asked if they provided written notices when residents moved to different rooms, she said, The building is so small we only provide a verbal notice.Record Review of the facility's Change of Room or Roommate policy dated 01/01/2023 revealed: 4. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible. 5. The notice of a change in room or roommate will be provided in writing, in a language and manner the resident and representative understands and will include the reason(s) why the move or change is required.7. The Social Service designee or Licensed Nurse should inform the resident's sponsor/family in advance of a change in the resident's room or roommate.

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (CNA A) of two staff observed for infection control. CNA A failed to change their soiled gloves and wash hands during incontinent care to Resident #1. This failure could place residents at risk for spread of infection through cross-contamination. Findings included: Observation of incontinence care on 05/19/2025 at 11:24 a.m. revealed CNA A used hand gel in the hallway and donned (placed on gloves & gown) clean gloves and gown. CNA A entered the room, Resident #1 was lying on his back. CNA A unfastened the resident's brief tabs and wiped the pubic area with a disposable wipe, discarding the wipe in the trash bag. CNA A wiped the genitals, discarding the wipe in the trash bag. CNA A wiped the shaft of the penis and discarding the wipe in the trash bag, and then cleaned the head of the penis and discarding the wipe in the trash bag. CNA A positioned Resident #1 on his right side with the help of another staff member. CNA A wiped the rectal area that was soiled with bowel movement and discarded the wipe, using another wipe CNA A completed cleaning the rectal area of bowel movement, discarding the wipe. CNA A wiped the right buttocks, which was soiled with urine, discarding the wipe. Repositioning Resident #1with her soiled gloves to his left side, CNA A cleaned the left buttocks, which was soiled with urine, discarding the wipe. CNA A assisted, with her soiled gloves, the other staff member to reposition Resident #1 on his back. CNA A pulled the clean brief up underneath him with the soiled gloves and fastened the brief, removing the soiled brief placing it in the trash. CNA A then pulled the clean sheet up on the resident. CNA A removed her dirty gloves did not wash her hands or use hand sanitizer, placed on new gloves, and continued to assist the other staff member to straighten Resident #1 clothing and his linens and blanket on the bed. CNA A removed her gloves and gown in the room and then washed her hands. In an interview on 05/20/2025 at 1:00 p.m., CNA A said she was to perform hand hygiene before and after the procedure and between changes of gloves. The glove changes should occur at the beginning and at the end of the incontinent care. She said she did not do it this time because she was nervous and talking. She stated the risk would be spread of infection. In an interview on 05/20/2025 at 2:45 p.m., the DON stated the expectation was to perform hand hygiene and glove changes before and after any care, and any time after removing dirty gloves. If hands are visibly soiled clean with soap and water, otherwise can use hand sanitizer. The DON stated the risk is not performing hand hygiene, would be cross contamination. The DON stated she would be doing proficiency skills testing again starting next week. Review of in-services reflected an in-service performed by the DON on 04/15/2025 covering hand hygiene and incontinent care. CNA A was reflected as to have attended the in-service. Review of the facility's policy Handwashing/Hand Hygiene revised July 2012, revealed, Policy Statement The facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. B. before and after direct contact with residents .i. after contact with resident's intact skin, j after contact with bodily fluids .m. after removing gloves, n. before and after entering isolation precaution settings, . 9. The use of gloves does not replace hand washing/hand hygiene. Review of the facility' policy Infection Control Guidelines for all Nursing Procedures dated July 2012 reflected purpose: To provide guidelines for general infection control while caring for residents. General Guidelines 3. Employees must wash their hands .a. before and after direct contact with resident .d. after removing gloves .,

Based on interview and record review, the facility failed to ensure residents who needed colostomy care were provided such care, consistent with professional standards of practice for 1 of 5 (Resident #1) residents reviewed for ostomies (surgical opening from an area inside the body to the outside). 1. The facility failed to follow their Colostomy-Ileostomy policy as the nursing staff did not document each time colostomy/ileostomy care was provided for Resident #1. 2. The facility failed to ensure Resident #1's physician's order for changing of his ostomy bag (every 3 days), order for cleansing the area (every shift), or the order for emptying the bag (every shift) was reactivated on 04/01/25 when Resident #1 readmitted to the facility from the hospital. These findings placed resident at risk of complications related to a colostomy. Findings Included: Record review of Resident #1's Face Sheet dated 04/22/2025 indicated the [AGE] year-old male was admitted to the facility on [DATE] with diagnoses which included Colostomy Status (a surgical procedure where the end of the colon is brought out through an opening in the abdominal wall, allowing waste to be collected in a bag), Hepatic Encephalopathy (a brain disorder caused by the buildup of toxins in the blood due to liver failure or damage), Congestive Heart Failure (a chronic condition in which the heart does not pump blood as well as it should), and End-Stage Renal Disease (a severe condition where the kidneys have permanently lost their ability to function, requiring dialysis or a kidney transplant to maintain life). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15. Under Section H (Bladder and Bowel) revealed Resident #1 had an Ostomy. Resident #1 was continent of bowel and occasionally incontinent of urine. Resident #1's active diagnosis included heart failure, end-stage renal disease, cerebrovascular accident, cirrhosis of liver, etc. Resident #1 had no behaviors and no rejection of care. Record review of Resident #1's Care Plan, dated 04/23/25 indicated Resident #1 had an alteration in gastro-intestinal status r/t Colostomy. Under goals listed [Resident #1] would remain free from discomfort, complications or s/sx related to gastro-intestinal alterations through review date. Under interventions listed avoid activities that involve bending, lifting. Record review of Resident #1's Nurses Notes dated 03/29/25 at 12:36 PM the nurse documented, RSDT (Resident) with S/S of AMS, V/S 142/91 Resp increased to 22, HR (heart rate) at 47, RSDT with purse Lip breathing, Info given to NP [Name], Notified her of the RSDT being 2 hours into Dialysis, N/O (new order) received to send the RSDT to Hospital ER for Eval/Tx., Info applied to PCC and given to dialysis nursing. Record review of Resident #1's eMar (Medication Administration Record) Note dated 3/30/25 at 1:43 PM the nurse documented, Remains at the hospital. Record review of Resident #1's Nurses Notes dated 04/01/25 at 1:38 PM the nurse documented, Resident readmitted to the facility under the care of [Doctor]. Resident arrived via a stretcher accompanied by 2 EMS personnel and was transferred to the bed. Resident has a Hx of Alcoholic Cirrhosis of liver, A-fib, CHF, Hepatic Encephalopathy and HTN (Hypertension). Skin assessment was completed with the following issues noted: Permacath to the R-chest with intact dressing and Colostomy bag to the LLQ (left lower quadrant). Resident does not have open areas or redness observed. Respiration is even and unlabored with symmetrical rise and fall of chest, skin warm and dry. NP was notified and medication review was completed with her and agreed to continue with the discharge orders Record review of Resident #1's TAR (Treatment Administration Record) dated April 2025 revealed Resident #1's Ostomy care was discontinued on 04/01/2025. Further review of Resident #1's TAR revealed due to the Ostomy care being discontinued, there were no entries marked as Ostomy care being provided from 04/01/2025 until 04/23/2025. Record review of Resident #1's Order Summary printed on 04/22/2025 did not reveal any Orders related to Ostomy care. Record review of Resident #1's Order Summary printed on 04/23/2025 revealed the below Orders had been reactivated on 04/23/2025: OSTOMY: Change ostomy bag every 3 days every evening shift every 3 day(s) for Ostomy care Order Date: 04/23/2025 Start Date: 04/24/2025 OSTOMY: Clean area around the stoma with soap and water, pat dry, apply skin prep/stoma adhesive. Every 3 days. Every shift for ostomy care. Order Date: 04/23/2025 Start Date: 04/23/2025 OSTOMY: Empty bag q-shift every shift for Ostomy Care Order Date: 04/23/2025 Start Date: 04/23/2025 In an interview on 04/23/25 at 10:20 AM, LVN D stated she followed the Colostomy/Ileostomy Care Policy. LVN D stated they obtained a doctor's order for the necessary care to be provided. LVN D stated she was orientated to the facility's rules and policies by the ADON. LVN D stated the Orders were in PCC under Ostomy Care. LVN D stated they checked the bag, and if the bag needed to be flushed or cleansed, they addressed it. LVN D stated as a nurse, they should document what was addressed with the Resident. LVN D stated they should not leave the stoma exposed because feces may be everywhere. In an interview on 04/23/25 at 11:25 AM, the DON stated Resident #1 was sent out to the hospital on Saturday (3/29/25) and readmitted to the facility on Tuesday (4/1/25). The DON stated Resident #1's Ostomy treatment Orders should had been reactivated when he readmitted to the facility on [DATE]. The DON stated each time staff provided care to a Resident with an Ostomy, they should document the care provided. The DON stated if there were any concerns, staff should notify the NP. The DON stated if something were not documented, one could not confirm if the Nurse provided care or changed the Colostomy bag. The DON stated even though Nurses provided a verbal shift change report, if they were not documenting, her recommendation would be that every Nurse must document because documentation was part of the Resident's care. The DON stated if Nurses were not documenting in PCC when they changed the Colostomy bag or provided care, one would not know the status. In an interview on 04/23/25 at 12:00 PM, the ADON stated Nurses should document each time they changed and inspected the Colostomy bag. The ADON stated when a Resident returned from the hospital, they followed the Orders sent back from the hospital and informed the doctor and NP. The ADON stated the doctor would say resume previous Orders or he would make revisions. The ADON stated with Orders not being restarted, they needed to in-service staff on Orders being re-instated when a resident readmitted to the facility. The ADON stated moving forward, she would educate the nurses on making sure prior Orders were reinstated. In an interview on 04/23/25 at 12:25 PM, LVN B stated once it was reported to her that a resident needed their colostomy bag changed, she changed it. Resident #1 stated any time she was informed Resident #1 needed a colostomy bag, she changed it. LVN B stated Resident #1 had never been left without a colostomy bag especially when receiving Lactulose 3 times a day. LVN B stated sometimes she documented and sometimes she did not. LVN B stated it was a failure on her part for not adhering to policy. LVN B stated without proper documentation, someone coming on after her would not know the status of the resident if there had been any concerns. In an interview on 04/23/25 at 03:30 PM, the ADM stated nurses made sure the Colostomy bag was emptied and assessed the resident to ensure there was no irritation. The ADM stated moving forward, everything for a resident should be documented and there was no way around it. The ADM stated upon a resident's return to the facility, orders must be reinstated or modified. Record review of the facility's policy Colostomy/Ileostomy Care dated 5/11/2012, revealed, Purpose: The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the colostomy/ileostomy care was provided. 2. The name and title of the individual(s) who provided the colostomy/ileostomy care. 3. Any breaks in resident's skin, signs of infection (purulent discharge, pain, redness, swelling, temperature), or excoriation of skin. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. Record review of the facility's policy Charting and Documentation dated 3/1/2022, revealed, All services provided to the resident .shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record: . c. Treatments or services performed .

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 of 5 (Resident #1) residents reviewed for resident rights. 1. The facility failed to ensure on 04/17/25, during the overnight shift, that Resident #1's room was without soiled linen placed on the floor and a brown smeared substance was on the wall directly above the soiled linen. 2. The facility failed to ensure on 04/17/25, during the overnight shift, that Resident #1's floor next to his bed was without dried up brown substances and yellow liquid stains. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept and clean environment. Findings included: Record review of Resident #1's Face Sheet dated 04/22/2025 indicated the [AGE] year-old male was admitted to the facility on [DATE] with diagnoses which included Colostomy Status (a surgical procedure where the end of the colon is brought out through an opening in the abdominal wall, allowing waste to be collected in a bag), Hepatic Encephalopathy (a brain disorder caused by the buildup of toxins in the blood due to liver failure or damage), Congestive Heart Failure (a chronic condition in which the heart does not pump blood as well as it should), and End-Stage Renal Disease (a severe condition where the kidneys have permanently lost their ability to function, requiring dialysis or a kidney transplant to maintain life). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15. Under Section H (Bladder and Bowel) revealed Resident #1 had an Ostomy (a surgically created opening on the abdominal wall that allows waste products (stool or urine) to exit the body). Resident #1 was continent of bowel and occasionally incontinent of urine. Resident #1's active diagnoses included heart failure (unable to pump enough blood to meet the body's need), end-stage renal disease, cerebrovascular accident (blood flow to the brain is disrupted), cirrhosis of liver (late-stage scarring of the liver, where healthy tissue is replaced with scar tissue), etc. Record review of Resident #1's Care Plan, dated 04/23/25, indicated the resident had a behavior problem related to he removed his ostomy bag multiple times and said, I didn't remove it. Resident #1 removed his ostomy multiple times and said, I hate those bags. The goal was to have no evidence of behavior problems by the next target date of 05/15/2025. Some of the interventions included, administer medications as ordered, monitor/document for side effects and effectiveness; anticipate and meet the resident's needs, assist resident to develop more appropriate methods of coping and interacting; monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved, and situations, document behavior and potential causes, etc. Record review of Resident #1's Behavior Notes dated 03/23/25 at 7:53 PM the nurse documented, Note Text: NSG applied x3 separate times that the Nursing applied colostomy bags and gave colostomy care, RSDT (Resident) CONT (continue) to remove colostomy bags after care, RSDT denies that he's removing his colostomy bags, NSG attempts to redirect the RSDT with no success. Record review of Resident #1's Behavior Notes dated 04/20/25 at 8:04 PM the nurse documented, NSG applied x3 separate times that the Nursing applied colostomy bags and gave colostomy care, RSDT CONT to remove colostomy bags after care, RSDT denies that he's removing his colostomy bags, NSG attempts to redirect the RSDT with no success, NSG CONT to attempt to reeducate the RSDT on the Pros/Cons of leaving on the colostomy bags/Colostomy care as ordered, RSDT stated that he hates the bags, NSG verbalized understanding but no success on the RSDT leaving colostomy bags on, no change in status. Record review of the photo provided by an anonymous employee showed soiled linen placed on the floor against the wall and directly above the soiled linen was a brown smeared substance on 4/17/25. Record review of the video recording provided by anonymous employee showed dried up brown substances and yellow liquid stains on the floor next to Resident #1's bed on 4/17/25. In an observation and interview on 04/22/25 at 11:20 AM, Resident #1 was observed in his room sitting in his wheelchair eating and watching television. Resident #1's room was clean and organized. Surveyor observed Resident #1's wall and the floor on both sides of his bed as reflected in the photo to be clean without any stains. Resident #1's room did not have any foul odors. Resident #1 stated staff changed his colostomy bag with no issues, and he was unsure if his colostomy bag had ever broken. Resident #1 denied that he had ever attempted to remove his colostomy bag. In an interview on 04/22/25 at 2:00 PM CNA B stated Resident #1's mental status changed based on the days he had dialysis. CNA B stated she had never observed Resident #1's colostomy bag to burst. CNA B stated Resident #1 tended to take his colostomy bag apart on his own. CNA B stated she never asked Resident #1 about it, she just cleaned him up and informed the nurse. CNA B stated she had never had a nurse not go in to change his colostomy bag. CNA B stated they were supposed to place soiled linen in a plastic bag, take it to the soiled linen room, rinse the linen and then place it in the soiled linen barrel for the laundry staff to take to the laundry room. CNA B stated protocol must be followed to prevent contamination. In an interview on 04/22/25 at 2:25 PM CNA C stated she provided Resident #1 his showers and his colostomy bag had never busted. CNA C stated once Resident #1's shower was completed, the nurse changed his colostomy bag. CNA C stated all soiled linen must be placed in a plastic bag prior to transporting it through the facility. CNA C stated if there was any type of bodily fluids, they must rinse the items in the soiled linen closet prior to placing the items in the soiled linen barrel. CNA C stated soiled linen should not be left on the floor of a resident's room to prevent contamination. In an interview on 04/22/25 at 2:50 PM LVN C stated Resident #1's room was kept clean due to him receiving in-room dialysis. LVN C stated Resident #1's colostomy bag was to be changed every three days or as needed. LVN C stated she was trained by the ADON and LVN A. LVN C stated she also observed them work the floor. LVN C stated if linen had bodily fluids, it should be bagged up, rinsed, and placed in the appropriate barrel to be taken to the laundry. LVN C stated if the linen was badly soiled, it should be disposed. LVN C stated soiled linen should never be left out to avoid contamination. In an interview on 04/22/25 at 3:15 PM the ADON stated Resident #1 had instances where he attempted to remove his colostomy bag. The ADON stated they talked with Resident #1 and re-educated him and he denied doing it and would laugh. The ADON stated the content of the colostomy bag would drip on the floor, but she had never witnessed it all over the place. The ADON stated any soiled linen should not be placed on the floor. The ADON stated linen with bodily substances should be placed in a bag, taken to be rinsed in the soiled utility room and then placed inside of the soiled linen barrel for laundry to pick up. The ADON stated if a staff member entered any Resident's room and observed soiled linen on the floor, it could had been rectified with the CNA and the Nurse. The ADON stated not adhering to policy could create a potential contamination. In an interview on 04/22/25 at 3:40 PM the DON stated Resident #1 was impulsive and he was care-planned for removing his colostomy bag. The DON stated Resident #1 was provided a bed pan and he was educated on the importance of not removing his colostomy bag. The DON stated if the linen had bodily substances or blood on it, the linen would be rinsed out before sending it to the laundry. The DON stated staff should not leave soiled linen in a resident's room on the floor. In an interview on 4/23/25 at 09:20 AM HK A stated staff placed soiled linen in a plastic bag, rinsed it and then place it into the soiled linen barrel. HK A stated laundry staff transported the soiled linen barrel to the laundry room. HK A stated she did not handle soiled linen in a Resident's room. HK A stated after staff changed the linen, housekeeping would disinfect the mattresses only. In an interview on 4/23/25 at 9:45 AM LA A stated staff were supposed to bag heavily soiled linen, rinse it to the best of their ability in the soiled linen closet and then place it in the soiled linen barrel for her to transport and wash. LA A stated she had to wash Resident #1's red blanket (in the video) on Tuesday (4/15/25), Thursday (4/17/25) and again yesterday (4/22/25). LA A stated staff should not be placing soiled linen on a resident's floor to prevent contamination. In an interview on 4/23/25 at 10:20 AM LVN D stated all soiled linen should be placed inside of a plastic bag and transported to the soiled linen closet to be rinsed. LVN D stated staff should never leave soiled linen on the resident's floor. LVN D stated they had a soiled utility room where they rinsed the soiled linen and placed it in the soiled linen barrel for laundry to pick up. In an interview on 4/23/25 at 10:42 AM, an anonymous employee stated the room in the photo was Resident #1's room. The anonymous employee stated a nurse told her Resident #1 needed to be changed right before she took the photos on 4/17/25 at 2:11 AM. The anonymous employee stated she worked the 10PM to 6AM shift. The anonymous employee stated she assumed someone placed the sheets in the corner on the prior shift (2PM to 10PM). The anonymous employee stated she was unsure who removed the linen or cleaned the stain off the wall. The anonymous employee stated she did not show or tell anyone present at the facility about the soiled linen. The anonymous employee stated she texted the photos to the on-call phone number. The anonymous employee stated LVN A had the on-call phone and when she spoke to LVN A, LVN A provided her the phone number for the DON. The anonymous employee stated she called the DON, but she did not answer. The anonymous employee stated she only sent the photos to the on-call number. In a re-interview on 4/23/25 at 11:25 AM the DON stated no one had sent her any photos nor video. The DON stated she had not been made aware until the information was with her yesterday (4/22/25). The DON stated she had no clue who placed the items there, or who removed the items and cleaned the wall. In an interview on 4/23/25 at 12:25 PM, LVN B stated no one informed her of soiled linen being observed on Resident #1's floor. LVN B stated soiled linen should be placed in a bag, taken to the soiled linen closet, and rinsed out. LVN B stated bodily substances and vomit should be rinsed, placed in a yellow bag, and placed in the barrel for laundry. LVN B stated she usually did everything herself. LVN B stated she had never arrived to work and saw soiled linen with feces laid out on the floor. LVN B stated not handling soiled linen properly could lead to contamination. In an interview on 4/23/25 at 3:30 PM, the ADM stated he had only worked at the facility for two days. The ADM stated prior to his arrival, he had not been made aware of an issue regarding any photos or video prior to him starting on Monday (4/21/25). The ADM stated there was no knowledge of who placed or removed the sheets, or who cleaned the wall. The ADM stated if an allegation was made of Abuse or Neglect, the Abuse and Neglect Coordinator should be notified and an investigation would be initiated. The ADM stated he attempted to get a statement from the staff member that made the allegation, but she had not answered nor returned his call. The ADM stated if it involved a staff member, they followed the disciplinary process of suspending the staff member. The ADM stated once the investigation was completed, if it was substantiated, the staff member would be terminated. The ADM stated if it was unsubstantiated, the staff member would be allowed to return, coached, and issued a warning. The ADM stated all Resident Rights were to be honored. The ADM stated every resident deserved a clean environment. Record review of the facility's policy Laundry and Bedding, Soiled dated 3-1-2022, revealed . Handling 1. All used laundry is handled as potentially contaminated until it is properly bagged and labeled for appropriate processing. a. Soiled laundry and bedding (e.g., personal clothing, uniforms, scrub suits, gowns, bed sheets, blankets, pillows, towels, etc.) contaminated with blood or other potentially infectious materials is handled as little as possible and with a minimum of agitation. b. Laundry that is contaminated with blood or body substances is placed in leak-proof bags or containers. c. Contaminated laundry is placed in a bag or container at the location where it is used and not sorted or rinsed at the location of use Record review of Residents' Rights Nursing Facilities issued by Health and Human Services and dated April 2019, revealed under Dignity and respect: You have the right to: Live in safe, decent, and clean conditions.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for five (Halls 100, 200, 300, 400, 500 nurse's station, kitchen conference room break room, and the main dining room), of five halls reviewed for pest control program. The facility had live flies and gnats in areas of the facility including the nurse's station, Halls 100, 200, 300, 400, 500, conference room, break room, and the main dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings included: An observation on 08/06/24 at 8:00 a.m. revealed two live flies were in the conference room, one on the wall by the television and one on the window seal. An observation on 08/06/24 at 8:25 a.m. revealed two live house flies in the dining room that crawled on the left-over eggs. The food had been left in the dining room after breakfast had been served. Several gnats were observed around the glass of left over juice on the table. A fly was also observed crawling on the back of the medication cart in the dining room. An observation on 08/06/24 at 8:43 a.m. revealed three gnats and two flies flying around the conference room. An interview on 08/06/24 at 8:26 a.m. with MA D revealed the flies and gnats were bad. The MA stated she thought the files and gnats came in the front and the back doors. The MA stated she had told the housekeeping staff that there were so many flies and gnats, but they did not know what to do. She stated there was nowhere to report the sightings, no book, and she had not seen a pest control person at the facility to tell. MA D stated she did not know what else to do, she was not sure who to tell. An observation on 08/06/24 at 8:15 a.m. 3-4 live houseflies were observed in the kitchen. They were flying throughout the kitchen, around the food preparation areas and the sink area An observation on 08/07/24 at 8:20 a.m. on Hall 400, of Resident #154 with MA D revealed while giving medication to the resident a fly was flying around the resident's head. The MA was swatting at the fly. The resident would not comment about the fly. MA D stated, I told you yesterday the flies were everywhere. An observation on 08/06/24 at 8:30 a.m. on Hall 200 revealed two gnats in the sink of the supply room. An observation on 08/06/24 at 8:39 a.m. revealed a live fly on the wall of Hall 300 near the fire doors. An observation on 08/06/2024 at 9:45 a.m. on Hall 100 revealed three flies flying down the hallway. An observation on 08/06/24 at 10:45 a.m. there was a fly crawling across the top of the nurse's station. An observation on 08/06/2024 at 12:00 p.m. revealed during the lunch, meal service there were 3 to five flies that were flying about the dining area as the residents were served their meals. An observation on 08/06/24 at 1:25 PM revealed 3-4 two liveflies were in the kitchen landing on food preparation surfaces. An observation on 08/08/2024 at 11:45 AM 2-3 live flies were observed in the food preparation areas during food holding temperature observations. The Flies were observed flying all over the food holding areas. An Interview on 08/06/24 at 1:25 PM with Dietary Manager revealed the facility did everything they can to keep the flies out but they are still in the kitchen. The Dietary Manager stated the facility had traps and pest control coming out but the flies are still in the kitchen. In a confidential group meeting on 08/07/2024 with 5 residents revealed the flies and gnats were still a problem. The residents stated the flies and gnats have not gotten any better in the last six months but had gotten worse. The new Administrator said the flies and gnats were going to be taken of. Observation and interview on 08/08/24 at 11:00 a.m. with LVN A at the nurse's station revealed there were no pest control log of communication in the computer system. The flies had been bad since I started working here in April, they were everywhere, there were two gnats around my treatment cart this morning I had to just keep swatting at them. The nurses just swat at the flies and the gnats, they were so annoying. LVN A stated she had asked about having a fly swatter at the nurses stion, but I was told I could not have one . LVN A stated the flies could cause carrying disease to residents. Interview on 08/08/24 at 11:04 a.m. with RN B revealed he had only worked at the facility for ten days. RN B stated he had seen flies and gnats everywhere. He swatted the flies or gnats and moved on. He had not reported the fly and gnat situation to anyone and he did not know who to report to . RN B stated flies were dirty, carried diseases. In an interview on 08/07/24 at 10:00 a.m. with Administrator revealed she was aware of the fly and gnat problem. The Administrator stated she called the pest control company today (08/07/24). The Administrator stated she had informed the pest control company she wanted a visit today (08/07/24). The Administrator stated she wanted the visit to include the placement of fly lights placed by the doors and other places in the hallway. The Administrator stated apparently there was nothing done before she came to work here (at the facility) this past Monday. The Administrator stated there was not a pest control book available to the staff to report and no system available to report either. The Administrator stated the assistant maintenance man did not know anything about the pest control company and the new company was looking for a Maintenance person. The Aministrator stated the flies and gnat problem could cause disease to spread. Record review of the facility's policy revised July 2013, and titled Pest control reflected Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program for insects and rodents 47855

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for five (Halls 100, 200, 300, 400, 500 nurse's station, kitchen conference room break room, and the main dining room), of five halls reviewed for pest control program. The facility had live flies and gnats in areas of the facility including the nurse's station, Halls 100, 200, 300, 400, 500, conference room, break room, and the main dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings included: An observation on 08/06/24 at 8:00 a.m. revealed two live flies were in the conference room, one on the wall by the television and one on the window seal. An observation on 08/06/24 at 8:25 a.m. revealed two live house flies in the dining room that crawled on the left-over eggs. The food had been left in the dining room after breakfast had been served. Several gnats were observed around the glass of left over juice on the table. A fly was also observed crawling on the back of the medication cart in the dining room. An observation on 08/06/24 at 8:43 a.m. revealed three gnats and two flies flying around the conference room. An interview on 08/06/24 at 8:26 a.m. with MA D revealed the flies and gnats were bad. The MA stated she thought the files and gnats came in the front and the back doors. The MA stated she had told the housekeeping staff that there were so many flies and gnats, but they did not know what to do. She stated there was nowhere to report the sightings, no book, and she had not seen a pest control person at the facility to tell. MA D stated she did not know what else to do, she was not sure who to tell. An observation on 08/06/24 at 8:15 a.m. 3-4 live houseflies were observed in the kitchen. They were flying throughout the kitchen, around the food preparation areas and the sink area An observation on 08/07/24 at 8:20 a.m. on Hall 400, of Resident #154 with MA D revealed while giving medication to the resident a fly was flying around the resident's head. The MA was swatting at the fly. The resident would not comment about the fly. MA D stated, I told you yesterday the flies were everywhere. An observation on 08/06/24 at 8:30 a.m. on Hall 200 revealed two gnats in the sink of the supply room. An observation on 08/06/24 at 8:39 a.m. revealed a live fly on the wall of Hall 300 near the fire doors. An observation on 08/06/2024 at 9:45 a.m. on Hall 100 revealed three flies flying down the hallway. An observation on 08/06/24 at 10:45 a.m. there was a fly crawling across the top of the nurse's station. An observation on 08/06/2024 at 12:00 p.m. revealed during the lunch, meal service there were 3 to five flies that were flying about the dining area as the residents were served their meals. An observation on 08/06/24 at 1:25 PM revealed 3-4 two liveflies were in the kitchen landing on food preparation surfaces. An observation on 08/08/2024 at 11:45 AM 2-3 live flies were observed in the food preparation areas during food holding temperature observations. The Flies were observed flying all over the food holding areas. An Interview on 08/06/24 at 1:25 PM with Dietary Manager revealed the facility did everything they can to keep the flies out but they are still in the kitchen. The Dietary Manager stated the facility had traps and pest control coming out but the flies are still in the kitchen. In a confidential group meeting on 08/07/2024 with 5 residents revealed the flies and gnats were still a problem. The residents stated the flies and gnats have not gotten any better in the last six months but had gotten worse. The new Administrator said the flies and gnats were going to be taken of. Observation and interview on 08/08/24 at 11:00 a.m. with LVN A at the nurse's station revealed there were no pest control log of communication in the computer system. The flies had been bad since I started working here in April, they were everywhere, there were two gnats around my treatment cart this morning I had to just keep swatting at them. The nurses just swat at the flies and the gnats, they were so annoying. LVN A stated she had asked about having a fly swatter at the nurses stion, but I was told I could not have one . LVN A stated the flies could cause carrying disease to residents. Interview on 08/08/24 at 11:04 a.m. with RN B revealed he had only worked at the facility for ten days. RN B stated he had seen flies and gnats everywhere. He swatted the flies or gnats and moved on. He had not reported the fly and gnat situation to anyone and he did not know who to report to . RN B stated flies were dirty, carried diseases. In an interview on 08/07/24 at 10:00 a.m. with Administrator revealed she was aware of the fly and gnat problem. The Administrator stated she called the pest control company today (08/07/24). The Administrator stated she had informed the pest control company she wanted a visit today (08/07/24). The Administrator stated she wanted the visit to include the placement of fly lights placed by the doors and other places in the hallway. The Administrator stated apparently there was nothing done before she came to work here (at the facility) this past Monday. The Administrator stated there was not a pest control book available to the staff to report and no system available to report either. The Administrator stated the assistant maintenance man did not know anything about the pest control company and the new company was looking for a Maintenance person. The Aministrator stated the flies and gnat problem could cause disease to spread. Record review of the facility's policy revised July 2013, and titled Pest control reflected Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program for insects and rodents

Based on observations, interviews, and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for eight (Residents #2, #4, #5, #8, #11, #54, #55, and #158) of twelve residents reviewed for essential equipment and one of one clean utility room reviewed for hazards. The facility failed to ensure treatment supplies in the clean utility room on Hall 200 was secured or attended by authorized staff when unlocked. The facility failed to properly maintain wheelchairs for Residents #2, #4, #5, #8, #11, #54, #55, and #158. These failures could place residents at risk for equipment that was in unsafe operating condition, which could cause injury and/or resident access to harmful supplies leading to a risk for injury. Findings included: 1. An observation on 08/06/24 at 9:00 a.m. revealed the clean utility room door on Hall 200 was left unlocked and the door was left open. There was a sign on the door stating, keep door closed and locked at all times when not in use. An observation of the supplies of the clean utility room on Hall 200 at 9:05 a.m. revealed the following supplies: suction equipment, nutritional gastronomy tube formulas (for using with residents who have feeding tubes), tubing for Foley's (tubing to allow urine to come out of body), Syringes (shots) with needles, twelve boxes of syringes 3cc and Tuberculin syringes, eight boxes of needles, a variety of catheters (latex tubing), Prostate ( medication for protein supplement), and Arginade (medications supplement for protein). An observation on 08/06/24 at 9:30 a.m. revealed the clean utility room door on Hall 200 was left unlocked and the door was left open. An observation and interview on 08/06/24 at 9:41 a.m. revealed the clean utility room door on Hall 200 was left unlocked and the door was left open. There was an unidentified staff member in the room removing a cleaning solution that had been left on the counter of the room. The unidentified staff member stated that the door should be closed and always locked, when not in use. They were not sure who had keys to the room. They stated that they had seen the cleaning solution in there earlier and thought they should get it, because it really did not belong in there. An observation on 08/06/24 at 10:30 a.m. revealed the clean utility room door on Hall 200 was left unlocked and the door was left open. An observation on 08/06/24 at 11:16 a.m. revealed the clean utility room door on Hall 200 was left unlocked and the door was left open. There was an unidentified resident getting paper towels and looking for Kleenex in the cabinets out of the clean utility room. In an interview on 08/06/24 at 11:17 a.m. with the ADON revealed the clean equipment room on Hall 200 should be locked at all times, when not in use. The ADON stated the nurses have a key. The ADON could not explain why the supply room had been unlocked all morning. The ADON stated if any resident got supplies form this room they could be harmed. The ADON agreed that the items that were listed above observation were the items always kept in the room. In an interview on 08/07/24 at 4:00 p.m. with the DON revealed the supply room on Hall 200 should always been locked when not in use. If the residents were allowed to get into the supply room, it could cause danger and possible injury to the resident. 2. Review of Resident #2's quarterly MDS assessment, dated 6/20/2024, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (confusion and forgetfulness), generalized weakness, and anxiety (nervousness). Resident #2 had a BIMs score of 07 indicating she was moderately cognitively impaired. Review of the Resident #2's plan of care dated 06/22/2024 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 08/06/2024 at 7:45 a.m. revealed Resident #2 was sitting in her wheelchair in the front of the facility and had no skin problems. The wheelchair's left armrest cracked with exposed foam. Review of Resident #4's annual MDS assessment, dated 07/13/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of paranoid schizophrenia (mental illness) and muscles weakness. Resident #4 had a BIMs score of 10 reflecting she was mildly cognitively impaired and able to make decisions for herself. Review of the Resident #4's plan of care dated 07/23/2024 with updates reflected goals and approaches to include wheelchair mobility for locomotion. An observation on 08/06/2024 at 12:05 p.m. revealed Resident #4 was sitting in her wheelchair in the dining room and had no skin problems. The wheelchair's right armrests were missing, and the left armrest was turned upside down and taped onto the wheelchair. An attempt to interview Resident #4 on 08/06/2024 at 12:05 a.m. revealed she was not interested in talking about her wheelchair. Review of Resident #5's annual MDS assessment, dated 07/24/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of paranoid schizoaffective (mental illness), muscle weakness (muscle deterioration), traumatic brain injury (brain injury), and diabetes (increase in your sugar level). Further review of the MDS reflected the resident was severely cognitively impaired and unable to make decisions for themselves. Review of the Resident #5's plan of care dated 07/27/24 with updates reflected goals and approaches to include wheelchair mobility. Observation on 08/06/24 at 12:20 p.m., revealed Resident #5 was sitting in her wheelchair in the dining room and the wheelchair's left and right armrests were cracked with exposed foam. There were no skin tears on the resident arms. The wheels of the wheelchair had dried food substance on both wheels and on wheel rims. Review of Resident #8's quarterly MDS assessment, dated 07/17/2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of cardio-obstructive pulmonary disease (breathing problems), cancer, and muscle weakness. Resident #8 had a BIMs score of 15 reflecting he was cognitively alert, oriented, and able to make decisions for himself. Review of the Resident #8's updated plan of care dated 07/20/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 08/06/2024 at 12:07 p.m. revealed Resident #8 in his wheelchair sitting at the table in the dining room. Resident #8 stated that his arm rests were broken. The wheelchair's right and left armrests were cracked with exposed foam. The left armrest had tape around both ends of the armrest and was sidewise on the wheelchair. Resident #8 stated he had told the nurses that his wheelchair arms were broken, but nothing had been done. He stated that it was about three weeks ago that he thought that he told the staff, but he could not recall which staff member he told. Review of Resident #11's quarterly MDS assessment, dated 07/25/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), cardiovascular accident (stroke), seizures (brain disorder), and unsteady on feet (instability). Resident #11 had a BIMs score of 9 reflecting she was moderately cognitively impaired and able to make decisions for herself. Review of the Resident #11's plan of care dated 07/27/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 08/06/2024 at 12:10 p.m. revealed Resident #11 sitting in her wheelchair, in the dining room Resident #11 revealed the wheelchair's left and right armrests were cracked with exposed foam. Resident #11 was asked about her wheelchair, and she stated, It was needing some work, and the wheelchair had been provided to her by the facility. There were no skin tears on the resident's arms. Review of Resident #54's quarterly MDS assessment, dated 06/27/24, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of congestive obstructive disorder (respiratory ability to breath), congestive heart disease (heart disease), and right below knee amputation. Further review of the MDS reflected the resident was severely cognitively impaired and unable to make decisions for themselves. Review of the Resident #54's plan of care dated 06/30/24 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 08/06/24 at 12:30 p.m., revealed Resident #54 was sitting in her wheelchair, in the dining room and had no skin problems. The wheelchair's right armrest was cracked with foam exposed. There were dried food substances on the back of the wheelchair. Record review of Resident # 55's quarterly MDS assessment, dated 06/21/24, revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included dementia, delirium due to known physiological condition, generalized idiopathic epilepsy, repeated falls, and history of traumatic brain injury. The cognitive section C100 of the MDS indicated Resident #55 had severe cognitive impairment. She had symptoms of inattention, disorganized thinking, altered level of consciousness, and wandering. She had an unsteady gait and required a wheelchair for mobility. Record review of Resident #55's Care Plan dated 06/26/24, revealed with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 08/06/24 at 12:32 p.m., revealed Resident #55 was sitting in her wheelchair, in the dining room and had no skin problems. The wheelchair's right armrest was cracked with foam exposed. There were dried food substances on the back of the wheelchair. Review of Resident #158's quarterly MDS assessment, dated 05/22/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of hemi-left dominant side (cannot use that side), convulsions (seizures), abnormalities of gait and mobility (unable to mobilize safety), and depression (mental illness). Further review of the MDS reflected the resident was alert and oriented and able to make decisions for themselves. Review of the Resident #158's updated plan of care dated 05/24/24 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 08/06/24 at 10:32 a.m., revealed Resident #158 was in her wheelchair in the hallway, and the wheelchair's right and left armrests were missing. The back of the wheelchair was frayed and had an open cracked back. There were no skin tears on the resident's arms. There were dried food particles in the cracked area of the back of the wheelchair. Resident #158 stated the back of the wheelchair did not bother her, but she would like to have some armrests on this wheelchair. She stated she did not want another wheelchair this one was big enough for her. In an interview on 08/06/2024 at 12:45 p.m. with RN B revealed that if one of the residents had a broken wheelchair, he would tell the DON. The RN stated he had only been working at the facility for ten days. The RN stated he did not think they had a maintenance person at the facility. In an interview on 08/07/2024 at 11:00 a.m. with LVN A revealed the nurse had no idea how to order or who to tell about new parts for a broken wheelchair. LVN A stated she had worked there since April, and no one had asked about wheelchairs or told her anything about a maintenance log. LVN A stated, she was unaware if there was a maintenance person. In an interview on 08/07/2024 at 9:00 a.m. with the Assistant maintenance person revealed he knew nothing about repair on any wheelchairs. The Assistant Maintenance person stated, the new Administrator that started working on the past Monday, had spoken to him about parts. The Assistant maintenance person stated, the Administrator told him there were going to be parts ordered and then the wheelchairs could be repaired. The Assistant maintenance person stated before the new Administrator came, no one had mentioned anything to him about broken wheelchairs or ordering parts. The Assistant maintenance person stated the Administrator had only been there two days, and there was no maintenance supervisor. The Assistant maintenance person stated if there were rough edges on the wheelchair, it could hurt the resident's skin. In an interview on 08/07/2024 at 10:00 a.m. with Administrator who had only been there two days, stated that was one thing she looked at on yesterday (08/06/2024) was wheelchairs. The Administrator stated there was a receipt provided of the equipment that had been ordered to repair wheelchairs. The Administrator stated wheelchairs and repair were a big concern for her, and she wanted them fixed with a program put in place, so all staff understood how to report the need for wheelchair repair. In an interview with the DON on 08/07/2024 at 11:00 a.m. revealed she was not aware of any wheelchairs that would require repairing. Review of the Maintenance logs for the past three months reflected there was no entries concerning repair of wheelchairs. Review of receipt of the wheelchair parts dated 08/07/2024 reflected fifteen different parts, including arm rests and backs ordered by the new administrator. A review of the facility's policy and procedure equipment-General Use for All Residents revision dated July 2012 reflected Policy Statement Our facility shall provide routine equipment for the general us of resident population. 1. Wheelchairs, Are maintained by our facility for the general use of all residents

Based on observations, interviews, and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for eight (Residents #2, #4, #5, #8, #11, #54, #55, and #158) of twelve residents reviewed for essential equipment and one of one clean utility room reviewed for hazards. The facility failed to ensure treatment supplies in the clean utility room on Hall 200 was secured or attended by authorized staff when unlocked. The facility failed to properly maintain wheelchairs for Residents #2, #4, #5, #8, #11, #54, #55, and #158. These failures could place residents at risk for equipment that was in unsafe operating condition, which could cause injury and/or resident access to harmful supplies leading to a risk for injury. Findings included: 1. An observation on 08/06/24 at 9:00 a.m. revealed the clean utility room door on Hall 200 was left unlocked and the door was left open. There was a sign on the door stating, keep door closed and locked at all times when not in use. An observation of the supplies of the clean utility room on Hall 200 at 9:05 a.m. revealed the following supplies: suction equipment, nutritional gastronomy tube formulas (for using with residents who have feeding tubes), tubing for Foley's (tubing to allow urine to come out of body), Syringes (shots) with needles, twelve boxes of syringes 3cc and Tuberculin syringes, eight boxes of needles, a variety of catheters (latex tubing), Prostate ( medication for protein supplement), and Arginade (medications supplement for protein). An observation on 08/06/24 at 9:30 a.m. revealed the clean utility room door on Hall 200 was left unlocked and the door was left open. An observation and interview on 08/06/24 at 9:41 a.m. revealed the clean utility room door on Hall 200 was left unlocked and the door was left open. There was an unidentified staff member in the room removing a cleaning solution that had been left on the counter of the room. The unidentified staff member stated that the door should be closed and always locked, when not in use. They were not sure who had keys to the room. They stated that they had seen the cleaning solution in there earlier and thought they should get it, because it really did not belong in there. An observation on 08/06/24 at 10:30 a.m. revealed the clean utility room door on Hall 200 was left unlocked and the door was left open. An observation on 08/06/24 at 11:16 a.m. revealed the clean utility room door on Hall 200 was left unlocked and the door was left open. There was an unidentified resident getting paper towels and looking for Kleenex in the cabinets out of the clean utility room. In an interview on 08/06/24 at 11:17 a.m. with the ADON revealed the clean equipment room on Hall 200 should be locked at all times, when not in use. The ADON stated the nurses have a key. The ADON could not explain why the supply room had been unlocked all morning. The ADON stated if any resident got supplies form this room they could be harmed. The ADON agreed that the items that were listed above observation were the items always kept in the room. In an interview on 08/07/24 at 4:00 p.m. with the DON revealed the supply room on Hall 200 should always been locked when not in use. If the residents were allowed to get into the supply room, it could cause danger and possible injury to the resident. 2. Review of Resident #2's quarterly MDS assessment, dated 6/20/2024, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (confusion and forgetfulness), generalized weakness, and anxiety (nervousness). Resident #2 had a BIMs score of 07 indicating she was moderately cognitively impaired. Review of the Resident #2's plan of care dated 06/22/2024 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 08/06/2024 at 7:45 a.m. revealed Resident #2 was sitting in her wheelchair in the front of the facility and had no skin problems. The wheelchair's left armrest cracked with exposed foam. Review of Resident #4's annual MDS assessment, dated 07/13/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of paranoid schizophrenia (mental illness) and muscles weakness. Resident #4 had a BIMs score of 10 reflecting she was mildly cognitively impaired and able to make decisions for herself. Review of the Resident #4's plan of care dated 07/23/2024 with updates reflected goals and approaches to include wheelchair mobility for locomotion. An observation on 08/06/2024 at 12:05 p.m. revealed Resident #4 was sitting in her wheelchair in the dining room and had no skin problems. The wheelchair's right armrests were missing, and the left armrest was turned upside down and taped onto the wheelchair. An attempt to interview Resident #4 on 08/06/2024 at 12:05 a.m. revealed she was not interested in talking about her wheelchair. Review of Resident #5's annual MDS assessment, dated 07/24/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of paranoid schizoaffective (mental illness), muscle weakness (muscle deterioration), traumatic brain injury (brain injury), and diabetes (increase in your sugar level). Further review of the MDS reflected the resident was severely cognitively impaired and unable to make decisions for themselves. Review of the Resident #5's plan of care dated 07/27/24 with updates reflected goals and approaches to include wheelchair mobility. Observation on 08/06/24 at 12:20 p.m., revealed Resident #5 was sitting in her wheelchair in the dining room and the wheelchair's left and right armrests were cracked with exposed foam. There were no skin tears on the resident arms. The wheels of the wheelchair had dried food substance on both wheels and on wheel rims. Review of Resident #8's quarterly MDS assessment, dated 07/17/2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of cardio-obstructive pulmonary disease (breathing problems), cancer, and muscle weakness. Resident #8 had a BIMs score of 15 reflecting he was cognitively alert, oriented, and able to make decisions for himself. Review of the Resident #8's updated plan of care dated 07/20/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 08/06/2024 at 12:07 p.m. revealed Resident #8 in his wheelchair sitting at the table in the dining room. Resident #8 stated that his arm rests were broken. The wheelchair's right and left armrests were cracked with exposed foam. The left armrest had tape around both ends of the armrest and was sidewise on the wheelchair. Resident #8 stated he had told the nurses that his wheelchair arms were broken, but nothing had been done. He stated that it was about three weeks ago that he thought that he told the staff, but he could not recall which staff member he told. Review of Resident #11's quarterly MDS assessment, dated 07/25/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), cardiovascular accident (stroke), seizures (brain disorder), and unsteady on feet (instability). Resident #11 had a BIMs score of 9 reflecting she was moderately cognitively impaired and able to make decisions for herself. Review of the Resident #11's plan of care dated 07/27/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 08/06/2024 at 12:10 p.m. revealed Resident #11 sitting in her wheelchair, in the dining room Resident #11 revealed the wheelchair's left and right armrests were cracked with exposed foam. Resident #11 was asked about her wheelchair, and she stated, It was needing some work, and the wheelchair had been provided to her by the facility. There were no skin tears on the resident's arms. Review of Resident #54's quarterly MDS assessment, dated 06/27/24, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of congestive obstructive disorder (respiratory ability to breath), congestive heart disease (heart disease), and right below knee amputation. Further review of the MDS reflected the resident was severely cognitively impaired and unable to make decisions for themselves. Review of the Resident #54's plan of care dated 06/30/24 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 08/06/24 at 12:30 p.m., revealed Resident #54 was sitting in her wheelchair, in the dining room and had no skin problems. The wheelchair's right armrest was cracked with foam exposed. There were dried food substances on the back of the wheelchair. Record review of Resident # 55's quarterly MDS assessment, dated 06/21/24, revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included dementia, delirium due to known physiological condition, generalized idiopathic epilepsy, repeated falls, and history of traumatic brain injury. The cognitive section C100 of the MDS indicated Resident #55 had severe cognitive impairment. She had symptoms of inattention, disorganized thinking, altered level of consciousness, and wandering. She had an unsteady gait and required a wheelchair for mobility. Record review of Resident #55's Care Plan dated 06/26/24, revealed with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 08/06/24 at 12:32 p.m., revealed Resident #55 was sitting in her wheelchair, in the dining room and had no skin problems. The wheelchair's right armrest was cracked with foam exposed. There were dried food substances on the back of the wheelchair. Review of Resident #158's quarterly MDS assessment, dated 05/22/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of hemi-left dominant side (cannot use that side), convulsions (seizures), abnormalities of gait and mobility (unable to mobilize safety), and depression (mental illness). Further review of the MDS reflected the resident was alert and oriented and able to make decisions for themselves. Review of the Resident #158's updated plan of care dated 05/24/24 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 08/06/24 at 10:32 a.m., revealed Resident #158 was in her wheelchair in the hallway, and the wheelchair's right and left armrests were missing. The back of the wheelchair was frayed and had an open cracked back. There were no skin tears on the resident's arms. There were dried food particles in the cracked area of the back of the wheelchair. Resident #158 stated the back of the wheelchair did not bother her, but she would like to have some armrests on this wheelchair. She stated she did not want another wheelchair this one was big enough for her. In an interview on 08/06/2024 at 12:45 p.m. with RN B revealed that if one of the residents had a broken wheelchair, he would tell the DON. The RN stated he had only been working at the facility for ten days. The RN stated he did not think they had a maintenance person at the facility. In an interview on 08/07/2024 at 11:00 a.m. with LVN A revealed the nurse had no idea how to order or who to tell about new parts for a broken wheelchair. LVN A stated she had worked there since April, and no one had asked about wheelchairs or told her anything about a maintenance log. LVN A stated, she was unaware if there was a maintenance person. In an interview on 08/07/2024 at 9:00 a.m. with the Assistant maintenance person revealed he knew nothing about repair on any wheelchairs. The Assistant Maintenance person stated, the new Administrator that started working on the past Monday, had spoken to him about parts. The Assistant maintenance person stated, the Administrator told him there were going to be parts ordered and then the wheelchairs could be repaired. The Assistant maintenance person stated before the new Administrator came, no one had mentioned anything to him about broken wheelchairs or ordering parts. The Assistant maintenance person stated the Administrator had only been there two days, and there was no maintenance supervisor. The Assistant maintenance person stated if there were rough edges on the wheelchair, it could hurt the resident's skin. In an interview on 08/07/2024 at 10:00 a.m. with Administrator who had only been there two days, stated that was one thing she looked at on yesterday (08/06/2024) was wheelchairs. The Administrator stated there was a receipt provided of the equipment that had been ordered to repair wheelchairs. The Administrator stated wheelchairs and repair were a big concern for her, and she wanted them fixed with a program put in place, so all staff understood how to report the need for wheelchair repair. In an interview with the DON on 08/07/2024 at 11:00 a.m. revealed she was not aware of any wheelchairs that would require repairing. Review of the Maintenance logs for the past three months reflected there was no entries concerning repair of wheelchairs. Review of receipt of the wheelchair parts dated 08/07/2024 reflected fifteen different parts, including arm rests and backs ordered by the new administrator. A review of the facility's policy and procedure equipment-General Use for All Residents revision dated July 2012 reflected Policy Statement Our facility shall provide routine equipment for the general us of resident population. 1. Wheelchairs, Are maintained by our facility for the general use of all residents