Every finding on record at Southside Care Center

Based on observation, interview and document review the facility failed to complete a thorough investigation of alleged abuse, provide documentation of an investigation and take action to prevent further abuse for 1 of 3 residents (R1) reviewed for abuse. This resulted in an Immediate Jeopardy (IJ) when the administrator and the director of nursing (DON) were notified of a possible sexual relationship between cook-A and R1 but failed to complete a thorough investigation prior to cook-A returning to work. The IJ began on 7/10/26, when the facility failed to conduct a thorough investigation when alleged abuse was reported. The administrator and owner were notified of the immediate jeopardy at 4:45 p.m. on 7/16/26. The IJ was removed on 7/22/26, but noncompliance remained at a lower scope and severity level D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1 R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had diagnoses of endocarditis (an infection of the inner lining of heart) anxiety, depression, bipolar disorder, adjustment disorder and was cognitively intact. R1's chart lacked a vulnerability care plan. R1's progress notes lacked documentation of the alleged sexual abuse. R1's chart lacked attempts at communication to investigate alleged abuse. A report submitted to the State Agency (SA) on 7/13/26 at 8:01 a.m., indicated on 7/10/26 two residents informed the director of nursing (DON) that cook-A had a sexual relationship with R1 resulting in R1 becoming upset and then leaving the facility. During an observation on 7/15/26, at 10:45 a.m., cook-A told R2 and R3 told they would be looking for a new place to live if they told the surveyor what occurs at the facility. During an interview on 7/15/26 at 12:03 p.m., R2 stated she shared a room with R1. R2 stated prior to R1 leaving the facility on 7/3/26, R1 was overheard on a phone call with R1's boyfriend. R1 told her boyfriend she was breaking up with him due to having a sexual relationship with cook-A. During an interview on 7/15/26 at 12:04 p.m., R3 stated she also shared a room with R1 and overheard R1 on the phone fighting with her boyfriend because she had a relationship with cook-A. R3 was unsure of the exact date but said it was a few days prior to R1 leaving on 7/3/26. During an interview on 7/15/26 at 12:45 p.m., the administrator stated R1 refused to provide a statement when she did not return his calls on 7/11/26, 7/12/26 and 7/13/26. He stated he interviewed cook-A on 7/14/26 who denied having a relationship with R1. The administrator stated he interviewed two other residents who were severely cognitively impaired and did not interview R1's previous roommates, who reported the allegations. The administrator concluded the allegations were unsubstantiated. The administrator did not suspend cook-A during the investigation as cook-A was not scheduled to work and did not work between 7/10/26 and 7/15/26. During an interview on 7/16/26 at 10:00 a.m., the director of nursing stated on 7/10/26, R2 and R3 reported they overheard R1 fighting with her boyfriend on the phone saying she was breaking up with him because she was in a sexual relationship with cook-A. The DON informed the administrator and the owner via text message on 7/10/26. The DON did not file a police report. She made a report to the SA on 7/13/26. She stated the administrator did not interview R2 and R3 who were the witnesses to the phone call and told the DON she was not allowed to interview cook-A, as she was not his supervisor. The DON stated cook-A was never suspended. A facility internal investigation report, dated 7/15/26, indicated two residents alleged cook-A may have had an inappropriate relationship with a former resident. Cook-A was interviewed and denied all allegations. R1 was discharged from the facility before an interview could be conducted. The facility made attempts to contact R1 on 7/11/26, 7/12/26 and 7/13/26 but R1 was unavailable and could not be interviewed. The investigation findings were noted as unsubstantiated due to insufficient evidence. A report to the SA on 7/17/26 at 6:08 p.m., indicated on 7/15/26 at 10:45 a.m., cook-A was observed by surveyor telling residents not to say anything or they would have to move out. The facility Abuse Prevention policy, dated 5/30/25, directed it is the policy of the facility to establish and enforce a system for prompt reporting of abuse or neglect of any resident of the facilities and have systems in place to prevent abuse. It instructed the facility to attempt to interview staff who worked in the previous 48 hours prior to the incident. Residents should also be interviewed and verified they feel safe living at the facility. If an employee is suspected of abuse, the facility may suspend the employee pending results of the investigation. Police will be notified of physician or sexual abuse. Start internal investigation as indicated by the situation. Person in charge can remove from unit/suspend staff involved, interview staff, obtain written summary of the incident, record review, staff/resident interview, resident assessment, etc. Document all actions taken in a confidential file. If an allegation is not substantiated and not to be reported, actions taken and follow-up will be documented with the complaint/grievance form/file. Review a summary of the cases at the next Quality Assessment Performance Improvement (QAPI) meeting. Initiate any procedural, educational, or personnel actions as indicated to prevent the situation from happening again. The IJ began on 7/10/26 and was removed on 7/22/26 when a thorough investigation into allegations made by R2 and R3 was completed, a report of the allegation was made to law enforcement, facility policies related to thorough investigation into allegations of abuse were reviewed and revised, and staff received education for completing a thorough investigation.

Based on interview, observation and document review the facility failed to maintain a clean and sanitary environment, free of pests. This had the potential to affect residents (R5, R4, R2, R6, R8) as well as all residing at the facility. This resulted in Immediate Jeopardy (IJ) when rodent feces were observed in resident rooms, resident common areas, facility kitchen and facility storage areas. The IJ began on 7/16/26, when the facility failed to take necessary action to control rodents and to make structural repairs which resulted in a rodent infestation. The administrator and owner were notified of the immediate jeopardy on 7/16/26 at 4:45 p.m. The immediate jeopardy was removed on 7/22/26, but noncompliance remained at a lower scope and severity level F, which indicated no actual harm with the potential for more than minimal harm that was not immediate jeopardy. Findings include:R5R5's face sheet dated 7/16/26, identified R5's diagnoses included anxiety disorder and schizoaffective disorder (a chronic mental health condition characterized by a combination of psychotic symptoms). R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 had intact cognition, had other behavior symptoms not directed towards others (such as hitting or scratching self, pacing, and rummaging) that occurred for one to three days, and was independent with transfers. During an observation and interview on 7/16/26 at 9:00 a.m., R5 stated rodents had gotten into a bag of her belongings and had urinated on her important papers. R5 then showed the surveyor a plastic bag with a large hole in the bottom of the bag. The papers were located in the trash can and had yellow stains on them. R5 explained she had placed the plastic bag in the bottom of her closet on the day of her admission and must have left pistachio nuts in the bag. The mice must have gotten into it and peed all over it. R5 further explained, I see mice running in groups of four at time at night, and having mice in my room pisses me off. They should not be in my room.R4R4's face sheet dated 7/17/26, identified R4's diagnoses included depressive disorder, anxiety disorder, post-traumatic stress disorder, and chronic cough.R4's quarterly MDS dated [DATE], identified R4 had intact cognition, had other behavioral symptoms not directed at others four to six days, no rejection of care, and was independent with mobility.During an observation and interview on 7/16/26 at 9:07 a.m., R4 stated the rodents chewed up a quilt she had sitting on a bed in her room. R4 had a quilt over the top of the bed, R4 showed the surveyor the quilt had a hole approximately two centimeters (cm) x two cm with the batting pulled out. Rodent feces were observed on the top of the bed near the hole in the quilt. R4 stated the quilt meant a lot to her and, It pisses me off that the mice wrecked it. R4 further explained she had to put all her snacks in a plastic tub to try and keep the rodents from getting in her food and she had to purchase her own traps to try and catch the rodents. R4 stated, I caught around three mice so far. If the mice get in my food and I happen to eat it, that could make me sick. R2R2's face sheet dated 7/16/26, identified R2's diagnoses included diabetes, borderline personality disorder, and post-traumatic stress disorder.R2's quarterly MDS dated [DATE], identified R2 had intact cognition, had verbal behavioral symptoms towards others that occurred one to three days, had other behavioral symptoms not directed towards others that occurred daily, had rejection of cares daily, and was independent with all transfers. During an observation and interview on 7/16/26 at 10:08 a.m., R2 stated she needed to put her food up to try and keep the rodents from getting it. R2 explained, The mice get in the garbage cans and eat the food I throw in there at times. The facility placed sticky traps and bait stations to try and catch the mice, but I still see the mice running around my room at night. Three bait stations were observed: on the floor in R2's room, in an adjoining room in the closet, in the corner and under an empty bed. R2 further explained, I saw the mice sitting on top of the bait stations. The mice running all over my stuff can make me sick and I could die. R6R6's quarterly MDS dated [DATE], indicated R6's diagnosis included schizophrenia, adjustment disorder, and diabetes. R6's cognition was intact.During an interview on 7/15/26 at 12:37 p.m., R6 stated, Mice had run over me while I'm sleeping.R8 R8's quarterly MDS, dated [DATE], indicated R8's diagnosis included schizophrenia and depression. R8 had moderately impaired cognitionDuring an interview on 7/15/26 at 12:39 p.m., R8 stated, Sometimes I see mice. Last week there was a squirrel in the house.During an observation on 7/15/26 at 10:45 a.m., rodent feces were present in resident rooms, dining room, food storage areas, food preparation areas, close to clean dishes, on the kitchen floor, in the medical supply storage areas and in sanitary linen areas. Large cracks were observed in the concrete foundation of the front porch/patio. Window air conditioning (A/C) units were propped in windows with large gaps on either side were observed throughout the facility, in hallways and resident rooms. Fruit, bakery items, leftover meals, crackers and granola bars were observed in resident rooms. Bait stations, glue traps, and snap traps for rodents were observed in resident rooms, on a resident's dresser, on a resident's bed, in closets, hallways, in the dining room, in food storage areas and the basement.During an interview on 7/15/26 at 12:00 p.m., the administrator stated the director of nursing (DON) found a lot of rodent feces. The administrator told the owners about the rodent feces, and the facility had a monthly contract with an exterminator. The administrator was unaware there was rodent trap on a resident bed. The administrator stated he did not review the pest control reports, and the facility did not have a designated maintenance person on staff.During an interview on 7/15/26 at 1:00 p.m., the facility owner stated they had an ongoing rodent problem. She stated the other owner was at the facility on 7/10/26 and observed traces of rodents and found a deceased rodent. Rodent poison was purchased and placed in the basement.During an interview on 7/15/26 at 1:30 p.m., the exterminator from an outside company stated the recommended structural repairs to the facility have not been made, along with residents maintaining food caches in their rooms. He recommended the facility increase the service contract from quarterly to monthly to better control the rodents, Over a year ago, but the facility declined. The severity of the mice infestation is not new and the owners are aware. He stated he documented his recommendations on the service invoice provided to the facility.During an interview on 7/15/26 at 2:40 p.m., the DON stated she made complaints the week of 6/22/26, regarding unsanitary conditions and rodent problems to the administrator and the owners. The owners instructed her to purchase rodent poison and place it in the residents' rooms, but she did not do that because she did not feel it was safe for the residents. The DON stated she had concerns the residents could get sick and die from the rodents. No education had been provided to the residents or staff to reduce or control mice infestation.During an interview on 7/15/26 at 3:25 p.m., licensed practical nurse (LPN)-A stated rodents have been a problem at the facility. He had not received education regarding reducing or controlling the rodents.During an observation on 7/16/26 at 9:45 a.m., shelves in the cabinet used for activity supplies were covered in rodent feces.During an interview on 7/16/26 at 12:08 p.m., registered nurse (RN)-A stated she had worked the night shift a few days prior and was sitting at the desk in the dining room, A mouse had run across my feet while I was working. I've seen evidence of a large number of mice in the facility. I informed the administration of my observations. RN-A was unable to articulate what the facility was doing to reduce the number of rodents. During an interview on 7/16/26 at 12:30 p.m., RN-B stated rodents were everywhere in the facility, and it had been a problem for years.During an interview on 7/16/26 at 2:30 p.m., the administrator stated he had received complaints about rodents in the facility and shared those complaints with the owners. He stated the rodent feces could make residents sick.During a phone interview on 7/16/26 at 2:50 p.m., medical director (MD) stated he was not aware of the rodent infestation at the facility and with the large amount of evidence being observed it was really bad. MD explained he could see maybe one or two rodents being seen since the facility was an older building. With the large amount of rodent feces near the resident's food, it put the residents at risk for contracting a communicable disease from the rodents. MD stated the risk in the population at the facility was pretty low, but not zero. MD further explained if a resident had a weakened immune system and was admitted to the facility, this could have the potential to cause serious harm or even death by being exposed to the rodent feces or rodent urine. The Centers for Disease Control (CDC), Controlling Wild Rodent Infestations website https://www.cdc.gov/healthy-pets/rodent-control/index.html document, dated 4/8/24, indicated rodents carry many diseases that can spread directly or indirectly to people. During a phone interview on 7/16/26 at 3:52 p.m., infection preventionist (IP) stated, I am aware of a mice infestation in the facility. Having so many mice could put the residents at risk of contracting a communicable disease from the mice. IP was unable to articulate what the facility was doing to eradicate the rodents. During an interview on 7/16/26 at 4:30 p.m., LPN-A stated the residents complained about the rodents all the time.During an interview on 7/17/26 at 10:00 a.m., housekeeper (HSKP)-A stated, I observed evidence of rodent feces in resident rooms when cleaning. The facility tried to use bait to kill the mice, but I am still seeing evidence of the mice. HSKP-A further explained she thought the rodents were coming through all of the cracks in the building and until that was fixed the mice would still come in. HSKP-A stated, The residents living here do not deserve to have to live with mice getting all over their food or belongings. During an observation on 7/17/26 at 10:32 a.m., the surveyor was sitting at a desk in the basement of the facility. A trash can was observed next to the desk with rodent feces on the top of the trash. A mouse was observed running across floor along a wall, the mouse stopped and then proceeded to run back into a room where the food pantry was located. During an interview on 7/17/26 at 12:18 p.m., DON stated, I just watched a mouse run across the dining room floor as the residents were sitting in there for their noon meal. During an observation and interview on 7/17/26 at 12:55 p.m., the DON had a can of spray foam and was filling holes near the kitchen area. The DON stated, A mouse just tried to come out of the hole while I was filling it. I need to go home, because I cannot handle these mice anymore. During an observation on 7/21/26 at 9:45 a.m., rodent feces was observed on storage shelves in the dining room, on the table next to the phone, in the corner of the dining room, on the shelves of food storage areas in the kitchen, next to the seasonings on the kitchen shelves, next to clean pots and pans, under the appliances, and behind the doors. Repairs to the A/C units in the windows were incomplete. Gray fuzz-like material was observed on a rodent trap located on a resident's dresser.During an interview on 7/21/26, at 10:58 a.m., cook-C stated he had seen rodents here and there. A pest control contract, dated 3/14/24, indicated the facility was on a quarterly service plan for pest control.A pest control service invoice dated 6/8/26, indicated on 6/14/24, immediate repairs were recommended for any hole in the siding or foundation larger than two inches and the front patio area was deteriorated. No suggested repairs have been made at this time. Pest control service was provided. The invoice noted heavy rodent activity in the basement. Three mice removed from trap and bait stations.A pest control invoice dated 7/15/26, indicated recommended repairs had not been made and additional structural repair suggestions included door threshold and window frame. A couple of mice were seen during service. Foundation deterioration, window and door framing are in poor condition. Suggested moving to a monthly service and going through residents' rooms private food storage and items to find potential nesting sites.The facility Pest Control policy, dated 5/2008, directed the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Windows are screened at all times. Maintenance services assist, when appropriate and necessary, in providing pest control services.The IJ began 7/16/26 and was removed on 7/22/26 when education was provided to staff regarding proper cleaning methods and instructions to observe for rodent droppings. Education was provided to residents regarding proper storage of personal dry food in plastic bins. A/C unit fittings repaired exterior structural repairs made to control the rodent infestation. An audit of all living, kitchen and storage spaces was conducted. Assessments of all 13 residents were conducted to observe for rodent bites, skin integrity, respiratory symptoms, gastrointestinal symptoms/signs of illness and documented.

Based on observation and document review the facility failed to maintain medical record security and confidentiality when contents of the residents' medical records were stored in resident common area space, where residents could access the information. Findings include:During an observation on 7/15/26 at 1:50 p.m., four discharged residents records were located in the corner of the unlocked furnace room. In addition, an open top box, measuring 12 inches x 12 inches x 12 inches, containing residents' health record information was observed in a shared resident room approximately 6 inches from the door on the floor.During an interview on 7/15/26 at 1:55 p.m., the administrator stated the box contained medical records and personal information for residents who were referred to the facility but never admitted . He was unaware the records were in a shared resident room. He stated they were in there because the facility did not have a shredder or method of proper disposal.During an interview on 7/15/26 at 2:40 p.m., the director of nursing (DON) stated she was concerned about the lack of security for the medical records and made the administrator and facility owners aware of the box of health information located in the shared resident room weeks prior. She stated the facility did not have a shredding service or method to store the records securely.A policy regarding the security and confidentiality of medical records was requested but not received.

Based on observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment when they failed to implement housekeeping and maintenance services to install air conditioning (A/C) units in a manner that would prevent large gaps, failed to repair cracks in the exterior structure, holes in the wall and window coverings and clean the dark gray matter at the base of the walls and bottoms of the doors in the hallway, foyers and kitchen. This had the opportunity to affect all 13 residents.Findings include:During an observation on 7/15/26 at 10:45 a.m., large cracks were observed in the concrete foundation of the front porch/patio. Window A/C units were propped in windows with large gaps on either side observed throughout the facility in hallways and in shared resident rooms: Rooms 101, 203, 205 and in the second floor hallway. The dining room A/C unit had a blanket wrapped around three sides and was hanging down to the dining room floor. Resident rooms appeared cluttered with minimal space for clothing and personal items. Window treatments appeared to be broken. Sheetrock was broken in a shared resident room with a hole measuring approximately four inches x four inches, where R2 and R3 resided. Dark gray matter was built up on the base of the walls and bottoms of doors in the kitchen, hallway, front and back foyer.During an interview on 7/15/26 at 11:25 a.m., R4 stated she had made several requests to the administrator and other staff to have the window A/C unit fitted to her window.During an interview on 7/15/26 at 12:03 p.m., R2 stated the hole in the wall in their shared room had occurred over two weeks prior. She said she had made complaints about the A/C unit in the hall at the top of the stairs being open to the outside, but the facility did not fix it.During an interview on 7/15/26 at 12:00 p.m., the administrator stated the facility did not have designated maintenance staff, the A/C units had been installed in their current status for over a year and he was unaware of the hole in the wall in R2's and R3's room. During an interview on 7/15/26 at 1:00 p.m., the facility owner stated the facility did not have designated maintenance staff but had contractors to contact to complete projects as needed. A policy regarding a safe, clean and home-like environment was requested but not received.A policy regarding building maintenance was requested but not received.

Based on observation, interview and document review, the facility failed to maintain an environment free from fire hazards which had the potential to affect all 13 residents currently residing at the facility. In addition, the facility failed to identify resident risks and implement interventions to reduce risks and monitor a resident (R5) after an incident which included a fall off the facility premises.Findings include:R5's admission Minimum Data Set (MDS) dated [DATE], indicated R5's diagnoses included schizoaffective disorder, psychotic disturbances. R5 was cognitively intact. The MDS indicated R5 had behavioral symptoms and used tobacco, ambulated 10 feet independently and required assistance from staff for showering, putting on footwear, and walking distances over 10 feet. R5 required supervision with stairs. R5 received antipsychotic, antidepressant, antibiotic, diuretic, and hypoglycemic (medications to lower blood sugar) medications. Care area assessments were triggered for cognitive loss/dementia, activities of daily living (ADL) functional/rehabilitation potential, urinary incontinence/catheter, mood state, falls, nutritional status, psychotic drug use, and return to community referral.R5's care plan dated 6/19/26, included nutrition but lacked other areas of care and interventions.R5's progress note dated 7/2/26 at 12:00 a.m., indicated R5 returned to the facility after becoming lost. Around 12:00 a.m., the facility received a phone call from R5. She was disoriented and unable to find her way back. A security guard assisted R5 to make the call and a car service was sent to pick her up. R5 fell while getting into the car and sustained a superficial scrape to the bottom of her foot, denied hitting her head, loss of consciousness, dizziness, or other injuries. Will continue to monitor for any changes in condition.R5's chart lacked an incident report or post-fall observations related to the 7/2/26 incident.During an observation on 7/15/26 at 1:50 p.m., a hospital bed mattress was leaning against the gas furnace and gas water heater in the basement furnace room. There was a large board leaning against the mattress.During an interview and observation on 7/15/26 at 1:50 p.m., the owner stated she did not know who left the mattress leaning against the furnace and water heater. After the surveyor explained the State Fire Marshall was contacted and gave direction to immediately move the mattress, the owner directed the administrator to do so.During an interview on 7/16/26 at 10:20 a.m., the administrator stated his work schedule was 9:00 a.m. to 1:00 p.m. and he worked 16 hours per week which does not allow the opportunity to provide the supervision I need to. The administrator was not aware the mattress was stored in this manner.During an interview on 7/16/26 at 10:57 a.m., the director of nursing (DON) stated on 7/2/26, R5 had an incident where she left the facility independently but was unable to find her way back. She came upon a bus stop security guard who assisted her to call the facility around midnight. The nurse working arranged for a car service to pick R5 up. Upon entering the car, R5 fell to the ground. The DON stated the administrator told her the fall protocol was not necessary since the fall did not occur at the facility. She stated the provider was notified but not R5's emergency contact. She stated R5 did not have a care plan and no new interventions were implemented following the incident.During an interview on 7/22/26 at 10:48 a.m., the administrator stated he was not notified of R5's incident. All falls require nursing to follow the fall protocol which included notifying their emergency contact.During an interview on 7/22/26 at 1:45 p.m., R5 stated she missed the last bus and had to find help to call the facility to find her way back. She fell to the ground as she was getting into the car.The facility Fall Prevention and Fall Management Program, dated 5/30/2018, directed to conduct a fall risk assessment within 24 hours of admission, quarterly, or when a change in health status puts them at increased risk. Any risk should be care planned and treated. Initiate a plan of care within 24 hours of admission based on resident's assessed condition, fall history, needs, behaviors, medications and preferences. Monitor, evaluate and document resident progress and outcomes. When a resident has fallen, the resident will be assessed regarding the nature of the fall and associated consequences, the cause of the fall and the post fall care management needs. Monitor every hour for the first four hours and then every four hours for 24 hours post fall signs of neurological changes. Complete a incident investigation and an incident report including all contributing factors. Redo the fall risk assessment form, review the fall prevention interventions and modify the plan of care in collaboration with the IDT.

Based on observation, interview and document review the facility failed to properly prepare and store food in accordance with safe food handling. This had the potential to affect all 13 residents currently residing at the facility.Findings include:During an interview on 7/15/26 at 10:45 a.m., cook-A stated he was aware of the need to wear a beard net to prevent hair from getting into the food, but the facility refused to purchase them.During an observation on 7/15/26 at 11:50 a.m., cook-A was in the kitchen and not wearing a beard net for beard hair approximately one and one-half inches to two inches long.During an interview on 7/15/26 at 10:46 a.m., the administrator stated cook-A's beard was about one and one-half inches to two inches long and required a beard net while in the kitchen. The administrator stated he was aware that beard nets were important to prevent food getting into residents' food. He previously directed cook-A to order beard nets.During an interview on 7/15/16 at 1:05 p.m., the owner stated she was unsure what the temperature of the refrigerator should be to keep food safe and thought it might be under 38 degrees Fahrenheit (F).During an observation on 7/15/16 at 1:50 p.m., the kitchen floor had 6 loose tiles in the middle of the floor with dark brown matter underneath them. The kitchen refrigerator was at 42 degrees F with the following items stored in the refrigerator: a gallon of milk, ketchup, mustard, barbeque sauce, and mayonnaise that was previously opened but were not labeled with the date. In the top drawer of the kitchen freezer, there was a pink-tinged frozen liquid under frozen chicken. On the counter were opened jars of grape jelly and strawberry jelly with approximately 50% remaining in each jar. Both jars of jelly lacked date opened labels. In the kitchen cabinets, the opened paper sacks of flour and sugar were both folded over and were unsecured, without a date opened on them. Two opened bags of chips were folded over and were not secured in a bowl on top of the refrigerator. Neither bag was labeled with date opened. Rodent feces were observed behind the seasonings in the upper cabinet. A dark, brown matter was under the counters, sink, dishwasher, oven, and refrigerator/freezer. A pile of rodent feces was under the front right leg of the oven. There was a yellow matter stuck to a spatula in the drawer. There were rodent feces in the cabinet next to the clean pots and pans and on the shelf where clean plates and bowls were stored. There were rodent feces on the food prep counter. The was a brown residue on the interior and exterior of the toaster. A hairbrush with a moderate amount of hair in it was observed in the middle kitchen drawer where clean spoons, unused hairnets and unused scrubbing pads were stored. There were piles of rodent feces behind both kitchen doors along with a large amount of gray dark matter.During an interview on 7/15/26 at 1:50 p.m., the administrator stated the kitchen refrigerator was not working correctly and the facility was not using it. The milk was purchased that morning so the residents could have milk on their cereal and should have been stored downstairs in the one refrigerator that was working correctly. The food in the kitchen refrigerator at the time was intended for resident consumption but should have been thrown away and would be thrown away. The administrator stated the residents had not received that food since the refrigerator was not functioning correctly. There was a note on the kitchen refrigerator instructing staff not to use it. The freezer should be cleaned to prevent illness. The jelly was not served for breakfast, and he was unsure why it was left on the counter. The administrator stated the cloths used to clean the kitchen were clean, however they appeared worn and soiled. Items should be dated once opened and closed securely to know when to discard the food items. The administrator was unsure why the items were stored improperly as the cooks had received training. The hairbrush should not have been stored in the kitchen.During an interview on 7/15/26 at 2:40 p.m., the director of nursing (DON) stated she reported concerns of the food storage and unsanitary kitchen to the owner and the administrator two weeks prior. No efforts have been made to correct the improper food storage or to clean. The DON was concerned for the health of the residents.During an interview on 7/16/26 at 12:12 p.m., cook-A stated the kitchen refrigerator hadn't worked in a week. He was aware food was to be labeled when it was opened, so staff knew when to discard it.During an observation on 7/21/26 at 9:45 a.m., rodent feces were near the seasonings in the kitchen cabinet. There was a large pile of rodent feces under the front right leg of the oven and piles of rodent feces behind both kitchen doors.During an observation on 7/21/26 at 10:58 a.m., cook-C was in the kitchen, preparing food, without a hairnet.During an interview on 7/21/26 at 10:58 a.m., cook-C stated he was aware he was supposed to wear a hairnet in the kitchen.During an observation on 7/22/26 at 2:25 p.m., cook-C was in the kitchen without wearing a hairnet.The facility Food Receiving and Storage policy, dated 11/2022, directed food shall be stored in a manner that complies with safe handling practices. Food services, or other designated staff, maintain clean and temperature/humidity appropriate food storage at all times. Dry food storage area must be kept free of insects and rodents and kept clean. Dry foods and goods are stored in a manner that maintains the integrity of the packaging until they are ready to use. All foods in the refrigerator or freezer and covered, labeled and dated. Potentially hazardous foods are stored at or below 41 degrees F, unless otherwise specified by law.The facility Food Storage and Procurement policy, dated 3/30/25, directed if a bag of food is opened but some food remains in the bag, the bag or box must be labeled with and additional label of the date the food was opened. Open packages of food must be closed with tape or label to prevent contamination of the food.

Based on observation, interview, and document review the facility failed to provide oversight and management for the facility when there was a severe rodent infestation, lack of food, and the facility was in disrepair. This had the potential to affect all 13 residents currently residing at the facility as well as all staff and visitors.Findings include:A pest control service invoice, dated 6/8/26, indicated on 6/14/24 immediate repairs recommended for hole in siding or foundation larger than two inches and front patio deteriorated. No suggested repairs have been made at this time. Pest control service was provided. It indicated heavy rodent activity in the basement. Three mice removed from trap and bait stations.A pest control invoice, dated 7/15/26, indicated recommended repairs had not been made and additional structural repair suggestions included door threshold and window frame. A couple of mice were seen during service. Foundation deterioration, window and door framing are in poor condition. Suggested moving to a monthly service and going through residents' rooms private food storage and items to find potential nesting sites.During an observation on 7/15/26 at 10:45 a.m., evidence of rodent feces was present in residents' rooms, the dining room, food storage areas, food preparation areas, near clean dishes, on the kitchen floor, in medical supply storage areas and in sanitary linen areas. Large cracks were observed in the concrete foundation of the front porch/patio. Window air conditioning (A/C) units were propped in windows with large gaps on either side (open to the outdoors) were observed throughout the facility in hallways and residents' rooms. Fruit, bakery items, leftover meals, crackers and granola bars were stored in residents' rooms.During an interview on 7/15/26, at 11:25 a.m., R4 stated she had recently trapped three mice in her room. I purchased my own mouse traps, and the mice had chewed on my quilt.During an interview on 7/15/26 at 12:00 p.m., the administrator stated the director of nursing (DON) found a lot of rodent feces and the facility had a monthly contract with an exterminator. He was unaware there was a rodent trap on a resident's bed. The administrator did not review the pest control reports, and the facility did not have a designated maintenance person on staff. The administrator stated he should have reviewed them but they were sent directly to the owners.During an interview on 7/15/26 at 12:03 p.m., R2 stated the facility lacked healthy food options. When cold cereal with water was provided for breakfast on 7/15/26, R2 opted to eat snacks in her room instead. R2 stated cereal was not on the menu, but the facility rarely followed the menu. The administrator was aware of the rodent problem but did nothing to resolve the concerns.During an interview on 7/15/26 at 12:04 p.m., R3 stated the facility did not follow the menu. When R3 asked for an alternative, cook-A became angry and retaliated by making food that was not palatable such as a stale hot dog bun, covered in wilted lettuce and a large amount of mustard.During an interview on 7/15/26 at 12:37 p.m., R6 stated rodents had run over her while she was sleeping.During an interview on 7/15/26 at 12:39 p.m., R8 stated sometimes she saw rodents and, Last week there was a squirrel in the house.During an interview on 7/15/26 at 1:00 p.m., the facility owner stated they had an ongoing rodent problem. She stated the other owner was at the facility on 7/10/26 and observed traces of rodents and found a deceased mouse. Rodent poison was purchased to place in the basement.During an interview on 7/15/26 at 1:30 p.m., the contracted exterminator stated the recommended structural repairs to the facility have not been made, along with residents maintaining food caches in their rooms. He stated he recommended the facility increase the service contract from quarterly to monthly to better control the rodents over a year ago, but they declined. He stated the severity of the rodent infestation was not new and the owners were aware. He documented his recommendations on the invoices provided to the facility.During an observation on 7/15/26 at 1:50 p.m., four discharged residents' records were located in the corner of the unlocked furnace room. An open top box, measuring 12 inches x 12 inches x 12 inches, containing health information, was observed on the floor in a shared resident room approximately six inches from the door. A plastic covered hospital bed mattress was leaning against the gas furnace and gas water heater in the basement furnace room. There was a large board leaning against the mattress.During an interview on 7/15/26, at 1:55 p.m., the administrator stated the box in the shared resident room contained medical records and personal information for residents who were referred to the facility but never admitted . He stated he was unaware the records were in a shared resident room. He stated they were in there because the facility did not have a shredder or method of proper disposal. He stated the DON informed the owners the facility needed a paper shredder.During an interview on 7/15/26 at 2:40 p.m., the DON stated she made complaints the week of 6/22/26, regarding unsanitary conditions and the rodent problem to the administrator and owners. The DON had concerns the residents could get sick and die from the rodents. The owners directed the DON to purchase mouse poisoning and place it in resident rooms, but she refused as she felt this was unsafe for the residents. The DON stated on the morning of 7/15/26, when she saw cook-A serve cold cereal with water to R7, she immediately asked another staff person to go buy milk. Cold cereal was not on the menu for 7/15/26. The DON made the administrator and facility owners aware of the box of health information located in the shared resident room weeks prior. The facility did not have a shredding service or method to store the records securely. The owners told her they would purchase a shredder and there was no further direction regarding the storage of the box of health information. The facility had not provided education to the staff or the residents to reduce or control the rodent infestation. The DON did not feel the administrator could appropriately supervise the facility as he was in the facility only 16 hours per week.During an interview on 7/15/26 at 3:25 p.m., licensed practical nurse (LPN)-A stated rodents have been a problem at the facility, and they had even trapped some of them. The facility had not provided education regarding reducing or controlling the rodents.During an observation on 7/16/26 at 9:45 a.m., shelves in cabinet used for activity supplies were covered in rodent feces.During an interview on 7/16/26 at 10:20 a.m., the administrator stated his work schedule was 9:00 a.m. to 1:00 p.m. and he worked 16 hours per week which does not allow the opportunity to provide the supervision I need. He shared this concern with the owners. He stated his reduced hours were due to the facility's budget.During an interview on 7/16/26 at 12:12 p.m., cook-A stated the facility often had expired food and did not have the ingredients to make what was on the menu. The refrigerator in the kitchen had not been functioning since 7/10/26. One of the two refrigerators in the basement was in operating condition. The administrator was aware and working on obtaining a replacement refrigerator for the basement and repairing the kitchen refrigerator. Cook-A was not sure how long obtaining the replacement and the repairs would take.During an interview on 7/16/26 at 12:30 p.m., registered nurse (RN)-B stated rodents were everywhere in the facility and it had been a problem for years.During an interview on 7/16/26 at 2:30 p.m., the administrator stated he had received complaints about rodents in the facility and shared those complaints with the owners. He stated the rodents could leave feces and urine which could cause the residents to get sick.During an interview on 7/16/26 at 4:30 p.m., licensed practical nurse (LPN)-A stated he had worked at the facility for seven months and the residents complained about the rodents all the time. He stated he did not do anything in response to this concern.During an observation on 7/21/26 at 9:45 a.m., rodent feces was observed on storage shelves in dining room, on the table next to the phone, in the corner of the dining room, on shelves of food storage areas in the kitchen, next to the seasonings on the kitchen shelves, next to clean pots and pans, under appliances, and behind the kitchen doors. Repairs to the A/C fit in the windows was incomplete. Gray fuzz-like material was observed on a rodent trap located on a resident's dresser.The facility Pest Control policy, dated 5/2008, directed the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Windows are screened at all times. Maintenance services assist, when appropriate and necessary, in providing pest control services.A policy for building maintenance was requested but not received.A policy regarding the security and confidentiality of medical records was requested but not received.

Based on interview and document review the facility failed to establish a system to address, monitor and take actions for a known rodent problem. This had the potential to affect all 13 residents at the facility, staff and visitors.Findings include:The facility's Quality Assessment Performance Improvement (QAPI) committee notes, dated 7/14/26, lacked documentation addressing a plan for the rodent infestation, monitoring the progress of the identified rodent issue or infection concerns related to the rodent infestation. The QAPI notes lacked plans for structural repairs recommended by the pest control service. The document indicated the owner, administrator, director of nursing (DON) and infection preventionist (IP) were present at the meeting.During an observation on 7/15/26, at 10:45 a.m., evidence of rodent feces was present in resident rooms, dining room, food storage, food preparation, clean dishes, kitchen floor, medical supply storage areas and sanitary linen areas. Bait boxes, glue traps, and snap traps for rodents observed in resident rooms, on a resident's dresser, on a resident bed, in closets, hallways, dining room, food storage areas and basement.During an interview on 7/15/26, at 11:25 a.m., R4 stated she had recently trapped three rodents in her room. She stated she had purchased her own rodent traps.During an interview on 7/15/26, at 12:00 p.m., the administrator stated the director of nursing (DON) found a lot of rodent feces and the facility had a monthly contract with an exterminator. He did not review the pest control reports, and the facility did not have a designated maintenance staff person.During an interview on 7/15/26 at 1:00 p.m., the facility owner stated they had an ongoing rodent problem. She stated the other owner was at the facility on 7/10/26 and observed traces of rodents and found a deceased rodent.During an interview on 7/15/26, at 1:30 p.m., the exterminator stated recommended structural repairs to the facility have not been made, along with residents maintaining food caches in their rooms over a year ago. He stated he recommended the facility increase the service contract from quarterly to monthly to better control the rodents, but they declined. He stated the severity of the rodent infestation was not new.During an interview on 7/15/26, at 2:40 p.m., the DON stated she made complaints the week of 6/22/26, regarding unsanitary conditions and the rodent problem to the administrator and owners. The rodent problem was not addressed at the QAPI committee meeting on 7/14/26. The DON stated that was her first time in attendance at a QAPI meeting and she was still learning about the process and purpose of the QAPI program. She stated she had concerns the residents could get sick and die from the rodents. No education had been provided to the residents or staff to reduce or control rodent infestation.During an interview on 7/16/26, at 2:30 p.m., the administrator stated he had received complaints about rodents in the facility and shared those complaints with the owners. He stated the rodents could leave feces and residents could get sick. He stated the rodent infestation was not addressed at the facility's QAPI meeting on 7/14/26.(This is April's interview below:)During an interview on 7/16/26 at 3:52 p.m., the infection preventionist (IP) stated she was aware of the rodent infestation at the facility, however, did not do any audits to determine the location of the rodents or if they had been present in care/food areas. The IP explained that the administrator and/or the director of nursing should have been doing the monitoring. The IP was responsible for tracking resident illnesses and did not monitor the environment for pest infestation. The IP further explained that having rodents in the facility near resident areas and food areas can put the residents at risk of contracting a communicable disease and would fall into infection prevention, however, she had not identified any illness at the facility that would have been caused by rodent infestation. A pest control invoice, dated 7/15/26, indicated recommended repairs had not been made and additional structural repair suggestions included door threshold and window frames. A couple of rodents were seen during service. Foundation deterioration, window and door framing are in poor condition. Suggested moving to a monthly service and going through residents' rooms private food storage and items to find potential nesting sites.The facility Infection Prevention and Control Program (IPCP) and The Role of the Infection Preventionist policy, dated 10/20/25, directed the IPCP will provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The QAPI committee, through the Infection Control Committee, shall oversee the implementation of infection control policies and procedures, and help department directors and managers ensure that they are implemented and followed.The facility Quality Assurance and Performance Improvement (QAPI) Program policy, dated 2/2020, directed the objective of the QAPI program to provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators and establish systems through which to monitor and evaluate corrective actions. The owner/governing board is ultimately responsible for the QAPI program. The administrator is responsible for assuring that the facility's QAPI program complies with federal, state and local regulatory agency requirements.

Based on interview and document review the facility failed to ensure a sanitary environment when the facility was noted to have and failed to respond to a rodent infestation. This had the potential to affect all 13 residents currently residing at the facility as well as staff and visitors.Findings include: A pest control invoice, dated 7/15/26, indicated recommended repairs had not been made and additional structural repair suggestions included door threshold and window frame. A couple of mice were seen during service. Foundation deterioration, window and door framing are in poor condition. Suggested moving to a monthly service and going through residents' rooms private food storage and items to find potential nesting sites. During an observation on 7/15/26 at 10:45 a.m., evidence of rodent feces was present in resident rooms, dining room, food storage, food preparation, clean dishes, kitchen floor, medical supply storage areas and sanitary linen areas. Bait boxes, glue traps, and snap traps for mice observed in resident rooms, on resident dresser, on a resident bed, in closets, hallways, dining room, food storage areas and basement. During an interview on 7/15/26 at 12:00 p.m., the administrator stated the director of nursing (DON) found a lot of rodent feces and the facility had a monthly contract with an exterminator. The administrator was unaware there was rodent trap on a resident bed. He did not review the pest control reports, and the facility did not have a designated maintenance person on staff. During an interview on 7/15/26 at 1:00 p.m., the facility owner stated they had an ongoing rodent problem. She stated the other owner was at the facility on 7/10/26 and observed traces of mice and found a deceased rodent. During an interview on 7/15/26 at 1:30 p.m., the contracted exterminator stated recommended structural repairs to the facility have not been made, along with residents maintaining food caches in their rooms. He stated he recommended the facility increase the service contract from quarterly to monthly to better control the mice, but they declined. He stated the severity of the mice infestation was not new. During an interview on 7/15/26 at 2:40 p.m., the DON stated she made complaints the week of 6/22/26, regarding unsanitary conditions and rodent problem with the administrator and owners. She stated she had concerns the residents could get sick and die from the mice. No education had been provided to the residents or staff to reduce or control mice infestation. During an observation on 7/16/26 at 9:45 a.m., shelves in cabinet used for activity supplies were covered in rodent feces. During an observation on 7/21/26 at 9:45 a.m., rodent feces were observed on storage shelves in dining room, on table next to phone, on the in the corner of the dining room, on shelves of food storage areas in the kitchen, next to the seasonings on the kitchen shelves, next to pots and pans and under the appliances, and behind the doors. Repairs to A/C fit in the windows was incomplete. Gray fuzz-like material was observed on a rodent trap located on a resident's dresser. During an interview on 7/16/26, at 2:30 p.m., the administrator stated he had received complaints about mice in the facility and shared those complaints with the owners. He stated the mice could leave feces and residents could get sick. During an interview on 7/16/26 at 3:52 p.m., infection preventionist (IP) stated she was aware of the rodent infestation at the facility, however, did not do any audits to determine the location of the rodents or if they had been present in care/food areas. IP explained that the administrator and/or the director of nursing should have been doing the monitoring. The IP was responsible for tracking resident illnesses and did not monitor the environment for pest infestation. The IP further explained that having rodents in the facility near resident areas and food areas can put the residents at risk of contracting a communicable disease and would fall into infection prevention, however, she had not identified any illness at the facility that would have been caused by a rodent infestation. The facility Infection Prevention and Control Program (IPCP) and The Role of the Infection Preventionist policy, dated 10/20/25, directed the IPCP will provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The QAPI committee, through the Infection Control Committee, shall oversee the implementation of infection control policies and procedures, and help department directors and managers ensure that they are implemented and followed.

Based on interview and document review the facility failed to offer an interdisciplinary care conference, involve resident in the plan of care, allow the resident to share preferences or ask if they had any concerns with the care provided for 1 of 3 (R5) residents reviewed for the right to participate in care planning.Findings include:R5's admission Minimum Data Set (MDS) dated [DATE], indicated R5's diagnoses included schizoaffective disorder, psychotic disturbances. R5 was cognitively intact. The MDS indicated R5 had behavioral symptoms and used tobacco, ambulated 10 feet independently and required assistance from staff for showering, putting on footwear, and walking distances over 10 feet. R5 required supervision with stairs. R5 received antipsychotic, antidepressant, antibiotic, diuretic, and hypoglycemic (medications to lower blood sugar) medications. Care area assessments were triggered for cognitive loss/dementia, activities of daily living (ADL) functional/rehabilitation potential, urinary incontinence/catheter, mood state, falls, nutritional status, psychotic drug use, and return to community referral.R5's care plan dated 6/19/26, lacked resident preferences. R5's care plan only included nutrition.R5's chart included a care conference note dated 6/29/26, with the director of nursing (DON) and R5 present. It included goals, R5's medical history and orders but lacked addressing R5's preferences, R5's goals for herself, and addressing any concerns.During an interview on 7/16/26 at 10:57 a.m., the DON stated R5 was admitted to the facility over one month prior but had never had a care conference and did not have a care plan. The DON stated care was directed by the physician orders.During an interview on 7/22/26 at 10:48 a.m., the administrator stated care plans were established by the admitting nurse sitting down with the resident and having a conversation with the resident. He stated care conferences were set up on a calendar for the nurses to conduct them within the first 14 days, then quarterly or as needed.During an interview on 7/22/26 at 1:31 p.m., registered nurse (RN)-B stated care is directed by the physician using ordered treatments and the DON was responsible to set up care conferences.During an interview on 7/22/26 at 1:45 p.m., R5 stated the facility had not asked her about her personal, cultural or religious preferences. R5 was not offered a care conference, but a nurse did an assessment. The facility did not to ask her if she had other providers or medical needs. R5 stated she had other providers and needed to schedule medical procedures and establish transportation to the appointments. The facility had not offered her a meeting to discuss concerns or needs. She was not provided with a copy of a care plan.The facility Care Plans, Comprehensive Person-Centered policy, dated 3/2022, directed the resident is informed of his or her right to participate in his or her treatment, and provided advance notice of care planning conferences. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:a. participate in the planning process;b. identify individuals or roles to be included;c. request meetings;d. request revisions to the plan of care;e. participate in establishing the expected goals and outcomes of care;f. participate in determining the type, amount, frequency and duration of care;g. receive the services and/or items included in the plan of care; andh. see the care plan and sign it after significant changes are made.

Based on interview and document review the facility failed to provide 1 of 3 (R5) residents with the Resident [NAME] of Rights (RBoR) orally or in writing upon admission to the facility.Findings include:R5's chart lacked documentation that R5 received a copy of the RBoR.During an interview on 7/16/26 at 10:57 a.m., the director of nursing (DON) stated the administrator was responsible to review the [NAME] of Rights and explain the grievance process to new residents upon admission to the facility.During an interview on 7/22/26 at 10:48 a.m., the administrator stated the admitting nurse was responsible to ensure new residents were informed of the RBoR when they moved into the facility and the DON was responsible to verify all steps of the admission process were complete. The admission process was not in written form. The administrator stated R5's chart lacked evidence she was provided with the RBoR but there was a full listing of the RBoR posted on a facility wall.During an interview on 7/22/26 at 1:55 p.m., R5 stated was not provided with a written copy of the RBoR when she admitted to the facility and did not know if they were posted in the facility. R5 stated the staff did not verbally educate her or review the RBoR with her.The facility Resident Rights and Responsibilities policy, undated, listed resident rights and provided grievance information. The policy lacked direction to provide the resident with the [NAME] of Rights prior to or upon admission.The facility Abuse Prevention policy, dated 5/30/25, directed residents and families are informed on admission how to report concerns, incidents, and grievances. A copy of the Resident [NAME] of Rights is provided and its content is covered upon every admission.

Based on interview and document review the facility failed to notify the resident's representative following an incident involving 1 of 3 residents (R5) reviewed for notification of change.Findings include:R5's admission Minimum Data Set (MDS) dated [DATE], indicated she had diagnoses of schizoaffective disorder, psychotic disturbances and was cognitively intact.R5's chart indicated her friend was her emergency contact.R5's progress note dated 7/2/26 at 12:00 a.m., indicated R5 returned to the facility after becoming lost. Around 12:00 a.m., the facility received a phone call from the resident. She was disoriented and unable to find her way back. A security guard assisted her to make the call, and a car service was sent to pick her up. R5 fell while getting into the car and sustained a superficial scrape to the bottom of her foot.During an interview on 7/16/26 at 10:57 a.m., the director of nursing (DON) stated on 7/2/26, R5 had an incident where she left the facility independently but was unable to find her way back. She came upon a bus stop security guard who assisted her to call the facility around midnight. The nurse working arranged for a car service to pick R5 up. Upon entering the car, R5 fell to the ground. The DON stated the administrator told her the fall protocol was not necessary since the fall did not occur at the facility. R5's provider was notified but not R5's emergency contact.During an interview on 7/22/26 at 10:48 a.m., the administrator stated he was not notified of R5's incident. All falls require nursing to follow the fall protocol which included notifying their emergency contact.During an interview on 7/22/26 at 1:45 p.m., R5 stated she missed the last bus and had to find help to call the facility to find her way back. She fell to the ground as she was getting into the car service. She said her daughter should have been notified.During an interview on 7/22/26 at 3:42 p.m., R5's friend stated she was not informed of R5 having any incidents at the facility but wished she had been notified.The facility Fall Prevention and Fall Management Program, dated 5/30/2018, directed to notify the registered nurse (RN) and the physician when falls occur. The policy lacked direction to notify the resident's representative when accidents occur.

Based on interviews and document review the facility failed to document, track and follow up with grievances filed by residents for 3 of 3 residents (R4, R2 and R3) reviewed for complaints. Findings include:R4R4's face sheet dated 7/17/26, identified R4's diagnoses included depressive disorder, anxiety disorder, post-traumatic stress disorder, and chronic cough.During an interview on 7/15/26 at 11:25 a.m., R4 stated she had complained about rodents chewing on her quilt to the director of nursing (DON) over the past couple weeks but no action had been taken to resolve R4's concern.R2R2's quarterly MDS dated [DATE], indicated R2's diagnoses included post-traumatic stress disorder (PTSD), and anxiety. R2's cognition was intact.During an interview on 7/15/26 at 12:03 p.m., R2 stated she made complaints directly to the administrator over the past few months regarding food portion sizes, being fearful of kitchen staff due to their behavior, and stated nothing gets done.R3R3's quarterly MDS dated [DATE], indicated R3's diagnoses included panic disorder, traumatic brain injury (TBI), anxiety, depression, and PTSD. R3 had moderate cognitive impairment.During an interview on 7/15/26 at 12:04 p.m., R3 stated she told the administrator and the DON she was scared of the two kitchen staff because they slammed things around and made her feel uncomfortable. She stated she complained about the food that was served and the amount of food they were served. R3 stated the administrator did not make any changes or follow up with her regarding her complaints.During an interview on 7/15/26 at 2:40 p.m., the DON stated she made complaints about unsanitary conditions to the administrator and owners during her first week at the facility, the week of 6/15/26. During her second week of employment, she shared her concerns regarding a mouse problem with the administrator and owners. The DON stated she talked to the administrator regarding the kitchen staff playing very loud music with explicit language and them slamming things around in the kitchen, making loud noises and how it bothered the residents. She complained about the amount of food served, not following the menu, expired food being served, and lack of activities at the facility. The administrator and owners of the facility failed to follow-up with her regarding her concerns. She stated the facility didn't have a formal grievance process that she knew of.During an interview on 7/16/26 at 2:30 p.m., the administrator stated the facility only had one complaint in the last year and it was yesterday. He said he had not received any concerns about staff behavior but had received complaints regarding building maintenance issues, including rodents. He also stated some residents had complained there was too much pork on the menu. The administrator stated he was the grievance officer. The grievance forms were kept in the wall pocket near the front door.During an observation on 7/16/26 at 3:30 p.m., there were no grievance forms in the designated location, in the wall pocket near the front door.During an interview on 7/16/26 at 4:30 p.m., licensed practical nurse (LPN)-A stated the facility did not have a formal process to handle complaints. He informed the administrator and DON if there were complaints. The residents complained about the rodents and kitchen staff behavior frequently and LPN-A shared the complaints with the facility administrator many times. During an observation on 7/21/26, at 9:45 a.m., there were no grievance forms in the designated location, in the wall pocket near the front door.During an interview on 7/21/26 at 3:23 p.m., cook-B stated there was not a specific complaint form and complaints should be directed to the administrator.During an observation on 7/22/26 at 1:25 p.m., there were no grievance forms in the designated location, in the wall pocket near the front door.During an interview on 7/22/26 at 1:45 p.m., R5 stated she admitted to the facility on [DATE], and was not informed of the facility's grievance and complaint procedure. She was not informed there were complaint forms.The facility Quality Assessment Performance Improvement (QAPI) committee meeting notes, dated 7/14/26, indicated management discussed resident grievance documentation procedures for recent conduct issues regarding cook-A and the administrator would complete a grievance form. The facility grievance complaint log indicated there was one complaint made on 7/15/26 by R2 when intimidating comments were made by cook-A.The facility policy Resident Rights and Responsibilities policy, undated, directed residents may file grievances verbally or in writing without fear of retaliation. The policy lacked direction to notify residents of right to file grievances through postings in prominent locations and notifying residents individually, right to file a complaint anonymously, reasonable expected time frame for completing review of the complaint, identification of the facility grievance official, contact information for the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIO), the state Survey Agency (SA). The policy lacked direction to take immediate action to prevent further violations while investigating the allegations, immediately report abuse, the process of handling the grievance and following up with the resident, and maintain records of all grievances for at least three years.The facility Abuse Prevention policy, dated 5/30/25, directed residents and families to be informed on admission how to report concerns, incidents, and grievances. A copy of the Resident [NAME] of Rights is provided, and its content is covered upon every admission. Upon hire, all staff are informed to report concerns and/or incidents. This is reviewed in annual in-services as required. After initial investigation a complaint is determined not willful treatment /abuse, this report may be filed on the complaint/grievance form and not reported to the SA. Appropriate follow up will be documented on the form.

Based on observation, interview and document review the facility failed to protect residents' rights to be from verbal abuse, mental abuse and neglect when cook-A verbally threatened R2 and R3, and when the facility lacked administrative supervision of staff performance. Findings include:R2R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had diagnoses of post-traumatic stress disorder (PTSD), anxiety and her cognition was intact.R2's care plan dated 2/16/26, indicated she had diagnoses of borderline personality disorder, depression and diabetes. It directed to encourage resident to express feelings, allow her time to talk and discuss concerns, fears, or issues regarding health or other subjects. It directed a dietary consult should be provided for nutritional regimen.R2's nurse practitioner (NP) note dated 6/29/26, indicated a carbohydrate-conscious diet was recommended.R3R3's quarterly MDS dated [DATE], indicated she had diagnoses of panic disorder, traumatic brain injury (TBI), anxiety, depression, PTSD and had moderate cognitive impairment.R3's care plan dated 10/17/25, directed to discuss concerns, fears, or issues regarding health or other subjects.During an observation on 7/15/26 at 10:45 a.m., cook-A told R2 and R3 they would be, looking for a new place to live, if they told the surveyor what occurs at the facility.During an interview on 7/15/26 at 12:04 p.m., R3 stated she had agoraphobia (anxiety disorder characterized by an intense fear of situations where escape might be difficult or help unavailable, often leading to avoidance of public places or situations that trigger anxiety) and cook-A's threat to not to talk to the surveyor would make her want to stay in her room to avoid him. R3 stated she reported to the administrator when cook-A and cook-B slam things around in the kitchen, it made her feel uncomfortable and unsafe. She told the administrator and director of nursing (DON) but nothing was done.During an interview on 7/15/26 at 12:45 p.m., the administrator stated he was unaware residents felt uneasy with cook-A and cook-B. He stated cook-A cooked lunch and dinner and the administrator left facility by 1:00 p.m. each day, so he did not witness the behavior the residents reported.During an interview on 7/15/26 at 2:40 p.m., the DON stated she also heard cook-A threaten R2 and R3 to not tell the surveyor what occurs in the facility. She told the administrator some residents had complained about cook-A and cook-B's behavior including slamming things around in the kitchen and playing music with explicit language loudly in the kitchen disrupting the peaceful home-like environment. During an interview on 7/16/26, at 10:00 a.m., the DON stated the facility did not initiate abuse education for staff following alleged employee to resident sexual abuse on 7/10/26 or the witnessed verbal threat on 7/15/26.The facility Abuse Prevention policy, dated 5/30/25, directed the facility to have systems in place to prevent abuse. All resident incidents are reviewed to determine whether there is reasonable evidence to suspect abuse and/or neglect of vulnerable adults. Incidents are reviewed by the program director or administrator.

Based on interview and document review the facility failed to immediately report abuse and abuse allegations to the State Agency (SA) within two hours for 3 of 3 (R1,R2,R3) residents reviewed for abuse.R1R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had diagnoses of endocarditis (an infection of the inner lining of heart) anxiety, depression, bipolar disorder, adjustment disorder and was cognitively intact.R1's chart lacked a vulnerability care plan.R1's progress notes lacked documentation of the alleged sexual abuse.R1's chart lacked attempts at communication to investigate alleged abuse.R2R2's quarterly MDS dated [DATE], indicated R2's diagnoses included post-traumatic stress disorder (PTSD), and anxiety. R2's cognition was intact.R3R3's quarterly MDS dated [DATE], indicated R3's diagnoses included panic disorder, traumatic brain injury (TBI), anxiety, depression, and PTSD. R3 had moderate cognitive impairment.A report to the State Agency (SA) on 7/13/26 at 8:01 a.m., indicated on 7/10/26 two residents informed the director of nursing (DON), cook-A had a sexual relationship with R1 resulting in R1 becoming upset and then leaving the facility.During an observation on 7/15/26 at 10:45 a.m., cook-A told R2 and R3 they would be, looking for a new place to live, if they told the surveyor what occurs at the facility.During an interview on 7/15/26, at 12:03 p.m., R2 stated R1 had shared a room with her. R2 stated prior to R1 leaving the facility on 7/3/26, R1 was overheard on a phone call with her boyfriend whom she was breaking up with due to having a sexual relationship with cook-A.During an interview on 7/15/26, at 12:04 p.m., R3 stated she also shared a room with R1 and overheard R1 on the phone fighting with her boyfriend because she [R1] had a relationship with cook-A. R3 was unsure of the exact date but said it was a few days prior to R1 leaving on 7/3/26.During an interview on 7/15/26, at 12:45 p.m., the administrator stated R1 refused to provide a statement when she did not return his calls on 7/11/26, 7/12/26 and 7/13/26. He stated he interviewed cook-A on 7/14/26, who denied having a relationship with R1. The administrator stated he interviewed two other residents who were severely cognitively impaired and did not interview R1's previous roommates, who reported the allegations. The administrator concluded the allegations were unsubstantiated. The administrator stated he was aware abuse must be reported to the SA immediately but thought the DON reported the alleged abuse.During an interview on 7/16/26 at 10:00 a.m., the director of nursing stated on 7/10/26, R2 and R3 reported they overheard R1 fighting with her boyfriend on the phone saying she was breaking up with him because she was in a sexual relationship with cook-A. The DON informed the administrator and the owner via text message on 7/10/26. The DON did not file a police report. She made a report to the SA on 7/13/26. She stated the administrator did not interview R2 and R3 who were the witnesses to the phone call and told the DON she was not allowed to interview cook-A, as she was not his supervisor. The DON stated she was not aware of the requirement to report immediately but thought the administrator was responsible for reporting the alleged abuse.A report to the SA on 7/17/26 at 6:08 p.m., indicated on 7/15/26 at 10:45 a.m., cook-A was observed by surveyor telling residents not to say anything or they would have to move out.The facility Quality Assessment Performance Improvement (QAPI) committee meeting notes, dated 7/14/26, lacked review of report of allegation of sexual relationship between cook-A and R1.The facility Abuse Prevention policy, dated 5/30/25, directed it is the policy of the facility to establish and enforce a system for prompt reporting of abuse or neglect of any resident of the facilities and have systems in place to prevent abuse. We are required to report any allegations regarding abuse, neglect, exploitation or mistreatment, including injuries of unknown source an misappropriation of resident property immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or results in serious bodily injury or suspicion of a crime, or not later than 24 hours if the events that cause the allegations do not involved abuse and do not result in bodily injury, to the administrator and SA. Immediately make an oral report to the staff nurse. The program director, DON and administrator must be notified immediately / as soon as possible of any allegations of mistreatment. Staff may gather some initial information to determine whether an incident potentially meets one or more of the reporting criteria. If so, then report to the SA via on-line reporting. After initial investigation a complaint is determined not willful mistreatment/abuse, this report may be filed on the complaint/grievance form and not reported to the SA. If the event involved allegation of abuse, serious bodily injury or suspicion of a crime it must be reported to the SA and local police within 2 hours. Review summary of cases at the next QAPI committee meeting.

Based on interview and document review the facility failed to document the discharge for 1 of 3 residents (R1) reviewed for discharge process.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated diagnoses of endocarditis (an infection of the inner lining of heart) anxiety, depression, bipolar disorder, adjustment disorder. R1 was cognitively intact.R1's care plan dated 4/27/26, lacked discharge planning.R1's progress notes lacked coordination and communication of discharge with primary physician or receiving provider.R1's chart lacked documentation of R1's discharge or coordination of care with R1's primary physician or receiving provider.During an interview on 7/15/26 at 12:45 p.m., the administrator stated R1 left the faciity on 7/3/26, with her case worker, to move to another facility without providing advanced notice to the facility. He stated the director of nursing (DON) was responsible for documenting discharges.During an interview on 7/15/26 at 2:40 p.m., the DON stated she did not complete a discharge summary or coordinate R1's care with the receiving facility as she was unaware of where R1 went when she discharged . The DON stated R1 was provided with most of her medications upon discharge on [DATE]. The DON notified R1's physician and nurse practitioner (NP) of the discharge on [DATE].The facility Discharging the Resident policy, dated 12/2016, directed if the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed and telephone report is called to the receiving facility. The following information should be recorded in the resident's medical record: The date and time the discharge was made, the name and title of the individual(s) who assisted in the discharge, all assessment data.

Based on interview and document review the facility failed to establish a baseline care plan within 48 hours of admission for 1 of 3 residents (R5) reviewed for baseline care plan. Findings include:R5's face sheet indicated she admitted to the facility on [DATE].R5's admission Minimum Data Set (MDS) dated [DATE], indicated R5's diagnoses included schizoaffective disorder, psychotic disturbances. R5 was cognitively intact. The MDS indicated R5 had behavioral symptoms and used tobacco, ambulated 10 feet independently and required assistance from staff for showering, putting on footwear, and walking distances over 10 feet. R5 required supervision with stairs. R5 received antipsychotic, antidepressant, antibiotic, diuretic, and hypoglycemic (medications to lower blood sugar) medications. Care area assessments were triggered for cognitive loss/dementia, activities of daily living (ADL) functional/rehabilitation potential, urinary incontinence/catheter, mood state, falls, nutritional status, psychotic drug use, and return to community referral.R5's progress note dated 6/16/26, indicated she was admitted and was alert and oriented to self, time, place, and situation.R5's care plan dated 6/19/26, included nutrition but lacked other areas of care and interventions.During an interview on 7/16/26, at 10:57 a.m., the director of nursing (DON) stated R5 was admitted to the facility over one month prior but did not have a care plan because she was not trained how to enter care plans into the resident's chart. She stated she knew all residents should have an initial care plan and care was directed by physician orders.During an interview on 7/22/26 at 10:48 a.m., the administrator stated care plans were established by the admitting nurse sitting down with the resident and having a conversation with the resident. During an interview on 7/22/26 at 1:31 p.m., registered nurse (RN)-B stated care is directed by their ordered treatments and the DON was responsible to establish the resident's care plan.During an interview on 7/22/26 at 1:45 p.m., R5 stated the facility had not asked her about her personal, cultural or religious preferences. She stated she had not been offered a care conference but a nurse completed an assessment. R5 stated she had never met the dietician. R5 stated the facility failed to ask her if she had other providers or medical needs. R5 stated had other providers and needed to schedule medical procedures and establish transportation to the appointments.The facility Care Plans - Baseline policy, dated 3/2022, directed the baseline care plan to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. The baseline care plan includes instructions to provide effective, person-centered care of the resident that meet the professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident. A baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan (no later than 21 days after admission). The resident and/or representative are provided with a written summary of the baseline care plan.

Based on interview and document review the facility failed to develop and implement a care plan for 1 of 3 residents (R5) reviewed for care plans.Findings include:R5's face sheet indicated she admitted to the facility on [DATE].R5's admission Minimum Data Set (MDS) dated [DATE], indicated R5's diagnoses included schizoaffective disorder, psychotic disturbances. R5 was cognitively intact. The MDS indicated R5 had behavioral symptoms and used tobacco, ambulated 10 feet independently and required assistance from staff for showering, putting on footwear, and walking distances over 10 feet. R5 required supervision with stairs. R5 received antipsychotic, antidepressant, antibiotic, diuretic, and hypoglycemic (medications to lower blood sugar) medications. Care area assessments were triggered for cognitive loss/dementia, activities of daily living (ADL) functional/rehabilitation potential, urinary incontinence/catheter, mood state, falls, nutritional status, psychotic drug use, and return to community referral.R5's care plan, dated 6/19/26, included nutrition but lacked other areas of care and interventions.R5's progress notes lacked evidence of care planning.During an interview on 7/16/26 at 10:57 a.m., the director of nursing (DON) stated R5 was admitted to the facility over one month prior but did not have a care plan because she was not trained how to enter care plans into the chart. The DON she knew all residents should have a care plan and care was directed by physician orders.During an interview on 7/22/26 at 9:45 a.m., the dietician stated she interviewed residents to determine their likes and dislikes and reviewed their medical history to establish care plans. She was not included in care conferences and did not collaborate with nursing or any other disciplines. The dietician stated, I have my own notes, but did not share them with the interdisciplinary team (IDT).During an interview on 7/22/26 at 10:48 a.m., the administrator stated care plans were established by the admitting nurse sitting down with the resident and having a conversation with the resident. During an interview on 7/22/26 at 1:31 p.m., registered nurse (RN)-B stated care is directed by their ordered treatments and the DON was responsible to set up care conferences and establish their care plan.During an interview on 7/22/26 at 1:45 p.m., R5 stated the facility had not asked her about her personal, cultural or religious preferences. She stated she had not been offered a care conference, but a nurse did an assessment. R5 stated she had never met the dietician. The facility did not ask R5 if she had other providers or medical needs. R5 stated she had other providers and needed to schedule medical procedures and establish transportation to the appointments.The facility Care Plans - Baseline policy, dated 3/2022, directed a baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan (no later than 21 days after admission). The facility Care Plans, Comprehensive Person-Centered policy, dated 3/2022, directed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.

Based on interviews and document review, the facility failed to maintain a complete, accurate and readily accessible medical record was maintained for 2 of 3 residents (R5, R6) whose records were reviewed for completeness and accuracy. Findings include: R5 R5's face sheet indicated R5 admitted to the facility on [DATE]. R5's admission Minimum Data Set (MDS) dated [DATE], indicated R5's diagnoses included schizoaffective disorder, psychotic disturbances. R5 was cognitively intact. The MDS indicated R5 had behavioral symptoms and used tobacco, ambulated 10 feet independently and required assistance from staff for showering, putting on footwear, and walking distances over 10 feet. R5 required supervision with stairs. R5 received antipsychotic, antidepressant, antibiotic, diuretic, and hypoglycemic (medications to lower blood sugar) medications. Care area assessments were triggered for cognitive loss/dementia, activities of daily living (ADL) functional/rehabilitation potential, urinary incontinence/catheter, mood state, falls, nutritional status, psychotic drug use, and return to community referral. R5's care plan, dated 6/19/26, included nutrition but lacked other areas of care and interventions. R5's progress notes lacked evidence of care planning, care coordination with providers, 7/2/26 fall when away from facility, and response to interventions. R5's chart lacked resident's preferred emergency contact information, as it listed her friend and per R5 it should have been her daughter, contact information for R5's providers physician/nurse practitioner (NP) visit notes, physician/NP orders, assessments following 7/2/26 fall and lab results During an interview on 7/22/26 at 1:45 p.m., R5 stated her daughter should have been notified following an incident on 7/2/26. R6 R6's face sheet dated 7/17/26, identified diagnoses of schizophrenia, bipolar disorder, and diabetes. R6's quarterly MDS dated [DATE], identified R6 was cognitively intact and was independent for all transfers. Review of R6's electronic health record (EHR) from 6/16/26 through 7/16/26 did not include physician visit notes/orders. During an interview on 7/16/26 at 12:41 p.m., the director of nursing (DON) stated R6 had been refusing medication at times and the physician had been notified and gave an order on 7/10/26 to discontinue some medications. DON explained she would need to go onto the outside facility EHR to find the notes as they were not located in the R6's facility chart. DON explained she had been informed by upper management that she did not need to download a copy of the physician notes/orders in any of the resident's EHR records because they could be found in the clinic/hospital EHR. However, not every nurse had access to the clinic/hospital EHR to see the records. The DON further explained that the clinic/hospital records did not belong to the facility and facility nurses only had access to view the records. In the event of an emergency, such as an evacuation, not having the records complete and accurate could cause a delay in care for the residents. During an interview on 7/17/26 at 1:21 p.m., the administrator stated the facility does not have a policy on maintaining a complete and accurate medical record and the physician orders/notes are not placed into the EHR due to being in the outside clinic/hospital records. The facility does not own the records that are in the clinical/hospital record system. The facility can only view the records. Administrator explained by not having all of the physician visit notes/orders in the resident's chart, this had the potential to cause a delay in care in the event the facility had an emergency and needed to transfer the resident to another facility. A policy for complete and accurate medical record was requested but was not received.

Based on observation, interview and document review the facility failed to follow the established menus. This had the potential to affect all 13 residents currently residing at the facility.Findings include:R4 R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4's diagnoses included depression, anxiety, post-traumatic stress disorder (PTSD), and diabetes. R4's cognition was intact.R4's care plan dated 5/4/26, directed staff to provide and serve diet as ordered. Registered dietician (RD) to evaluate and make diet change recommendations as needed and to provide and serve diet as ordered (regular diet). R4's care plan lacked information regarding R4's food preferences.During an interview on 7/15/26 at 11:25 a.m., R4 stated cereal with water was served for breakfast this morning. The facility frequently ran out of food that was on the menu and did not serve what was on the menu. R4 stated the residents did not know what to expect for each meal.R2 R2's quarterly MDS dated [DATE], indicated R2's diagnoses included PTSD, diabetes, and anxiety. R2's cognition was intact.R2's care plan dated 2/16/26, directed staff to encourage the resident to express feelings, allow her time to talk and discuss concerns, fears, or issues regarding health or other subjects. A dietary consult should be provided for nutritional regimen. R2's care plan lacked information regarding R2's dietary preferences.During an interview on 7/15/26 at 12:03 p.m., R2 stated the facility had served cold cereal with water on it for breakfast that morning and no fruit. She stated that is not what was on the menu and the facility frequently did not follow the menu.During an interview on 7/16/26 at 10:15 a.m., R2 shared a photo of supper from 7/15/26, which included a slice of pizza and garden salad.R3 R3's quarterly MDS dated [DATE], indicated R3's diagnoses included panic disorder, traumatic brain injury (TBI), anxiety, depression, and PTSD. R3 had moderate cognitive impairment.R3's care plan dated 10/17/25, directed staff to provide and serve diet as ordered (regular diet), and directed the RD to evaluate and make diet change recommendations as needed. R3's care plan lacked information regarding R3's dietary preferences.During an interview on 7/15/26 at 12:04 p.m., R3 stated pork is frequently served, but you won't see it on the menu. R3 stated, They never serve what's on the menu.R7 R7's quarterly MDS dated [DATE], indicated R7's diagnoses included schizoaffective disorder and psychotic disorder. R7's cognition was intact.R7's care plan dated 1/5/26, directed staff to provide and serve diet as ordered (regular diet), and directed the RD to evaluate and make diet change recommendations as needed. R7's care plan lacked information regarding R7's dietary preferences.During an interview on 7/15/26 at 12:30 p.m., R7 stated he was served cold cereal with water over it for breakfast this morning. He stated it was his only option and it was better than nothing. R7 stated this was the only option because the facility refrigerator was broken and the food on the menu was tossed out.The facility breakfast menu for 7/15/26, directed staff to serve turkey sausages, fruit muffin, and a banana.The facility lunch menu for 7/15/26, directed staff to serve an Italian sub sandwich, whole wheat sub roll, lettuce, tomato, pepper, and apple crisp.The facility dinner menu for 7/15/26, directed staff to serve roast beef, stewed potatoes, carrots and berries.Alternative menu options for lunch and dinner included a peanut butter and jelly sandwich or a deli meat sandwich.During an interview on 7/15/26 at 9:22 a.m., the director of nursing (DON) stated the facility served cold cereal with water for breakfast this morning. She stated the refrigerator was broken and the facility did not have milk or the items on the menu for this morning's breakfast.During an observation on 7/15/26 at 11:45 a.m., residents were served a turkey and cheese sandwich and chips for lunch.During an interview on 7/15/26 at 12:45 p.m., the administrator stated the kitchen refrigerator broke on 7/10/26 so the cook could not prepare breakfast. The one operating refrigerator in the basement was to be used for all cold storage. The milk was left in the kitchen refrigerator and tossed out due to not being cold enough. The administrator did not expect the cook to serve cold cereal with water on it. He expected the cooks to prepare what was on the menu and the cooks were responsible for ordering the food. The administrator stated for the noon meal today, the facility did not have the ingredients to make the food on the menu, so he made turkey sandwiches.During an interview on 7/15/26 at 2:40 p.m., the DON stated she had asked another staff person to go buy milk for breakfast after she saw cook-A serve cold cereal with water on it. The cooks rarely followed the menu. She stated pork was served twice on 7/14/26, without an alternative option for residents who did not eat pork. The DON stated some residents ate peanut butter and jelly sandwiches as an alternate and they had them frequently due to the facility not considering resident preferences.The facility lunch menu for 7/16/26 indicated they were to serve turkey muffins, tabouleh salad, roasted zucchini, and brownie.During an interview on 7/16/26 at 10:20 a.m., the administrator stated he planned to cooked meatloaf because the facility did not have the ingredients to make what was on the menu and he did not know what turkey muffins were.During an observation on 7/16/26 at 11:45 a.m., residents were served meatloaf and mashed potatoes.During an interview on 7/16/26 at 12:12 p.m., cook-A stated the facility was always serving the wrong food and stated the person in charge of ordering the food kept ordering the wrong food. The dietician created the menus but didn't ever talk to the cooks. Cook-A stated the refrigerator in the kitchen and one of the refrigerators in the basement was broken. Both refrigerators had broken within the last week. The administrator and the owners were aware, and he was not aware of the plan to address the non-operating refrigerators. Cook-A stated he was directed to use the only operating refrigerator in the basement until the other two refrigerators were either repaired or replaced.During an interview on 7/16/26 at 2:30 p.m., the administrator stated he was not aware pork was being served frequently and would not expect it to be served twice on the same day. Residents had complained there was too much pork on the menu. The administrator state the dietician was responsible for creating the menus.The facility lunch menu for 7/21/26 indicated they were to serve a ham and Swiss sandwich on whole wheat bread, side salad, and oranges.During an observation on 7/21/26 at 11:45 a.m., residents were served barbeque chicken, boiled potatoes and mixed vegetables.During an interview on 7/22/26 at 9:45 a.m., the dietician stated she met with residents and asked about their preferences. She did not share this information with the facility staff but kept her own notes. She established the menu and expected the cooks to follow that menu as it was based on dietary guidelines and resident needs/preferences. The dietician stated she did not review the menu with the cooks. She was not informed when the facility did not follow the menu, the cooks ordered the food, and she was not aware of the broken refrigerators. The dietician stated the facility should have food on hand if a resident chooses not to eat the main meal on the menu. She would not expect the facility to serve pork twice on the same day.A policy regarding establishing and following menus was requested but not provided.

Based on observation, interview, and document review, the facility failed to ensure resident advance directives were accurately and consistently documented between the physician orders in the resident's electronic health record (EHR) and the Provider Order for Life-Sustaining Treatment (POLST) in the hard chart to ensure the resident's wishes would be followed in the event of a cardiac arrest. This resulted in immediate jeopardy for 2 of 13 residents (R2, R6) whose code statuses were not accurately documented, with an additional resident (R1) discrepancy found in a facility-wide audit.The immediate jeopardy began on [DATE], when interviews with the direct care nurse and director of nursing indicated they would implement incorrect procedures and not started CPR on R2 if found without a pulse and not breathing, and would have started CPR against R6's wishes under those same circumstances. The administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE], at 7:20 p.m. The immediate jeopardy was removed on [DATE]; however, non-compliance remained at an isolated scope with potential for more than minimal harm that is not immediate jeopardy (level D).Findings include: R2 R2's quarterly MDS dated [DATE], indicated the BIMS was completed, and R2 had a score of 15/15, indicating intact cognition. R2's quarterly MDS dated [DATE], indicated R2 was admitted to the facility on [DATE]. The MDS indicated that the BIMS and the staff assessment for mental status were not assessed. R2's care conference form dated [DATE], indicated R2's code status was a full code. R2's POLST dated [DATE], indicated attempt resuscitation/full treatment and was signed by R2 and the provider on [DATE]. R2's EMR order summary had an order dated [DATE] for Do Not Resuscitate (DNR). R2's Provider notes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] include R2's code status as a full code. R2's care conference note dated [DATE], was reviewed and included a section please review POLST. It included a checkmark next to the point, If resident does not have POLST, please make arrangements to complete. The note did not include further information on the advance directive wishes. During an interview on [DATE] at 6:05 p.m., the administrator confirmed this was the most recent care conference note he could find for R2. R2's care plan dated [DATE], was reviewed and did not include a reference to R2's code status. R2's progress notes dated [DATE] to [DATE], were reviewed, and reference to code status was not found. R2's signed physician order report dated [DATE], indicated R2 was a full code. R2's provider note dated [DATE], indicated R2 had a history of diabetes, asthma, chronic anemia (low level of healthy red blood cells to carry oxygen throughout the body), alcohol and opioid use disorder, and obstructive sleep apnea (OSA, repeatedly stop and start breathing during sleep). R2's Profile dated [DATE], indicated R2 was her own responsible party. During an interview on [DATE] at 3:29 p.m., R2 stated that if her heart stopped beating and she stopped breathing, she wanted full resuscitation. During an interview on [DATE] at 3:30 p.m., licensed practical nurse (LPN)-A stated that if R2 was found not breathing and without a pulse, he would check the electronic medical record to see if he needed to start CPR. LPN-A stated the first place he would look at was the profile tab on the EMR, but he did not see the code status for R2 there, so LPN-A stated he would then look at the medical diagnosis, and he did not find code status there. LPN-A stated he would look next at the order summary and stated that R2's code status was DNR/DNI, so he would not start CPR. During an interview on [DATE] at 3:40 p.m., the director of nursing (DON) stated LPN-A would normally be the only nursing staff working at this time and during the evenings, as DON had only come to the facility for the survey. The DON stated if a resident was found with no pulse and was not breathing, she would expect the nurse to first look at the EHR profile and orders and then confirm the order with the POLST to ensure the orders matched. The DON stated that if they did not match, the nurse should follow the POLST. The DON confirmed R2's POLST and EHR order did not match. The DON stated she thought the POLST, which stated R2 was a full code, was correct, but she would double-check with the resident. The DON returned to the interview and stated that R2 wanted CPR, so the POLST was the correct one. The DON stated she thought the order had been entered incorrectly into the EHR, as the facility had recently switched over to using an EHR instead of solely using paper charts. The DON stated that when a new POLST was filled out, the floor nurse working oversaw ensuring the POLST code status matched the one in the EHR. The DON stated code status was very important, so she had reviewed the POLST code status with each resident when she started as DON about four months ago but confirmed she did not have a process in place for ensuring the POLST code status matched the EMR orders/documentation. R6 R6's quarterly MDS dated [DATE], indicated R6 had intact cognition and was independent with most personal cares. In addition, R6 had diagnoses of depression, diabetes, anxiety, and post-traumatic stress disorder. R6's provider notes dated [DATE], [DATE], [DATE], [DATE], [DATE] identified code status, He elects to be DNR and POLST on file at facility and uploaded to MAM [provider portal]. R6's EMR profile, face sheet, care plan, and physician orders reviewed [DATE], failed to identify code status. During interview with LPN-A on [DATE] at 5:10 p.m., LPN-A stated he was a full-time employee. LPN-A stated he would locate resident code status on the EMR profile page and then look for clarifying physician orders. LPN-A looked at R6's EMR and stated, he is not DNR or DNI. LPN-A then pulled up R6's face sheet indicating the form would also have the code status on it. No advance directive mentioned [for R6]. LPN-A stated, I would do CPR on [R6]. If it is not on his face sheet. LPN-A stated importance of following resident code status was to follow their wishes. We must respect their wishes. Cracking ribs and causing more harm is not good. During interview with R6 on [DATE] at 5:21 p.m., R6 stated his wishes for DNR/DNI was communicated to facility when he was admitted . I know people who have had it done [CPR] to them and they are not the same. I don't want to go through that. I want [facility] to let me be. During interview with DON on [DATE] at 5:30 p.m., DON stated it was important for nursing staff to know where the code status was in the computer and paper chart. DON reviewed R6's EMR and verified code status was not on his profile or orders. I expect the staff to perform CPR on him. Then DON looked at R6's paper chart and verified signed POLST dated [DATE], which identified R6 as DNR/DNI. DON stated, [R6] EMR said he was full code but he wasn't. I will have to update that right now. R1 R1's comprehensive Minimum Data Set (MDS) dated [DATE], indicated that the Brief Interview for Mental Status (BIMS) and the staff assessment for mental status were not assessed. R1's quarterly MDS dated [DATE], indicated R1 was admitted to the facility on [DATE]. The MDS indicated that the BIMS and the staff assessment for mental status were not assessed. R1's Advanced Directive Order Form dated [DATE], indicated R1 wanted resuscitation and intubation and was signed by the resident on [DATE] and the provider on [DATE]. R1's care conference note dated [DATE], was reviewed and included a section please review POLST. It included a checkmark next to the point, If resident does not have POLST, please make arrangements to complete. The note did not include further information on the advance directive wishes. During an email communication on [DATE] at [DATE], the DON stated the last care conference note she could find for R1 was on [DATE]. R1's provider notes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] indicated R1's code status was a full code- confirmed with patient today [DATE]. R1's progress notes dated [DATE] to [DATE] were reviewed and did not reference R1's code status wishes. R1's POLST dated [DATE], indicated DNR/allow natural death with selective treatment, which was signed by the resident and then signed by the provider on [DATE]. The POLST indicated it was prepared by the DON but did not include a prepared date. R1's care plan dated [DATE], was reviewed and did not include a reference to R1's code status. R1's face sheet dated [DATE], indicated R1 was her own responsible party. R1's provider note dated [DATE], indicated R1 had a history of cocaine/alcohol abuse, dementia, and multiple sclerosis (MS, a chronic autoimmune disorder causing the breakdown of the protective covering of the nerves). R1's order summary dated [DATE], indicated R1 had two code status orders, one for full code dated [DATE], the other for full code: resuscitate and intubate dated [DATE]. The summary did not include an order for DNR/ allow natural death with selective treatment. During an interview on [DATE] at 9:24 a.m., R1 stated that if her heart stopped beating and she stopped breathing, she wanted staff to let me go and would not want anyone pushing on my chest. During an interview on [DATE] at 9:27 a.m., the DON stated that after the surveyor had asked about R2's code status and she had noticed an error between the EHR and the hard chart, she had begun to audit other residents' code statuses, including R1. The DON stated during this audit on [DATE], she noticed that R1's POLST indicated R1 did not want to be resuscitated, and the order summary was for a full code. The DON stated she believed the electronic medical record had not been updated after a new POLST was filled out, so after checking with R1, she updated the order summary in the EHR to indicate R1 was DNR. The DON stated R1 was alert, oriented, and able to make her own code status decisions. During an interview on [DATE] at 11:04 a.m., the medical director (MD) stated he had been notified by the administrator of the immediate jeopardy. The MD stated he would expect that the POLST matches the order summary in the EHR, so it was clear to staff what the resident's code status wishes were, and it would be concerning if this did not match. During an email communication on [DATE] at 4:34 p.m., the DON stated that although they have had their EHR system in place for a while, the facility had only transitioned to using the EHR on [DATE]th (2026). The Cardiac or Respiratory Arrest policy dated 6/2018, indicated that staff members who witness cardiac or respiratory arrest will identify the individual's resuscitation status, but did not indicate where staff should find this information. The facility's Advanced Directives policy dated 9/2022, indicated the resident had the right to formulate an advanced directive, including the right to accept or refuse medical treatment, and this should be honored according to state law and facility policy. The policy indicated that advanced care planning should occur between individuals and their health care agents to plan for future healthcare decisions when individuals were not able to make their own healthcare decisions. The policy indicated that the advanced directives should be maintained in the same section of the residents' medical record and should be readily retrievable. The director of nursing services or designee should notify the attending physician so that appropriate orders can be documented in the resident's medical record and plan of care. The directive should be placed in a prominent, accessible location in the medical record and discussed during care planning meetings. The policy indicated the Interdisciplinary team (IDT) would review the advance directives annually. The policy indicated that changes or revocations of a directive must be submitted in writing to the administrator. The administrator may require new documents if the changes are extensive. The immediate jeopardy that began on [DATE], was removed on [DATE], when the facility developed and implemented a systematic removal plan. The removal plan was verified through interview and document review as the facility corrected the code status' of R2 and R6, completed a facility-wide audit to ensure there were no other code status discrepancies and corrected any that weren't accurate and/or consistent including R1, reviewed related policies and procedures, and provided education for all staff involved in ensuring advance directives were honored on the CPR and POLST policies/procedures and their respective roles in the process.

Based on interview and document review the facility failed to develop and implement individualized non-pharmacological interventions to manage behaviors for 2 of 2 residents (R1, R3) who had mental health disorders with behaviors. The facility's failures resulted in harm for R1 when she sustained burns from using hot towels to self-soothe to relieve anxiety symptoms and had multiple hospitalization for mental health stabilization. Findings include: R1's face sheet identified R1 was admitted to facility October of 2022 with diagnoses including, borderline personality disorder, generalized anxiety disorder, unspecified mood [affective] disorder, and major depressive disorder, single episode, severe without psychotic features. R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 as cognitively intact with no evidence of acute change in mental status from R1's baseline. R1 did not display behaviors. R1 was independent in mobility and activities of daily living. R1's care plan dated 6/22/23, identified R1 had delirium or an acute confusional episode due to acute disease process [Specify incomplete field] change in condition keep the resident safe from self-harm during episodes of confusion or psychosis. Resident had a history of heating up towels in the microwave and trying to burn herself. Interventions directed staff to identify themselves at each interaction. Face R1 when speaking and make eye contact. Reduce any distractions (turn off TV, radio, close doors etc.). R1 understands consistent, simple, directive sentences. Provide the resident with necessary cues stop and return if agitated. Discuss concerns about delirium with the resident/family/caregiver. Educate the resident/family/caregiver to observe for and report any signs/symptoms of delirium. Engage the resident in simple structured activities that avoid overly demanding tasks. The resident prefers (specify the activities), If resident was not redirectable, send resident 911 to HCMC Hospital for 72 hour hold and 1:1 nursing staffing to prevent self-harm. Resident had a history of trying to burn herself with hot towels from microwave. R1's nurse re-admission record dated 2/21/24, (no time identified) indicated R1 had returned to the facility after a hospitalization that began on 2/16/24 related to mental status changes. The note indicated R1's mental status upon return was cooperative and her anxiety had improved. Medications were adjusted in the hospital. The note indicated on 2/22/24 at 1:30 a.m. R1 up to smoke and to have a snack and beverage. R1 stated she's okand seemed less anxious that night. R1 went back to bed after smoking a cigarette, staff were to continue to monitor. R1 started saying she had anxiety at 3:30 p.m. gave her the medication PRN (as needed) medication to calm her down but she was trying to use the hot towel and scrunching herself up against the wall. At 5:30 p.m. R1 was taken to the hospital by staff. R1's behavior monitoring dated 2/22/24, identified R1 had suicidal ideations let me die, let me die due to excessive anxiety she was having. Behaviors included self-injurious heating towel in the microwave too hot to warm her back x2 occasions in the last 7 days. Crying, tearfulness x4 occurrences in the last 7 days. Nursing interventions/comments: unable to sit or stand still. Had the towel in the microwave extremely hot that could burn her skin. Staff trying to prevent her from using it on her back but she kicked staff away. Impossible to have her under control. Had to be taken to the emergency room . R1's progress note dated 2/22/24 at 5:00 p.m., identified R1 was having a lot of anxiety and crying out for help. All R1's medications were administered, but not helpful. Staff had driven R1 to the hospital and was kept for observation. R1's record did not identify non-pharmacological interventions were offered or attempted to reduce or relieve R1's anxiety. Facility reported incident (FRI) dated 2/26/24, identified on 2/22/24 during an anxiety attack, R1 accidentally self-injured her back trying to sooth herself using a heating pad that was too hot. Staff discovered the heating pad and removed it. R1 was sent to the hospital for an emergency mental health crisis- anxiety attack. R1 had a superficial skin open area on her back measuring 3 centimeters (cm) by 3 cm. R1's care plan was not updated with individualized interventions to prevent R1 from burning herself with hot towels and/or alternatives to offer R1 to use to soothe herself when she became anxious. Emergency Department (ED) discharge summery dated 2/22/24, identified R1 had a hospital visit from 2/22/24 and discharged [DATE] for the principal problem of agitation. Note identified R1 was recently in the hospital and was discharged two days prior when symptoms were similar. Recommendations for outpatient provider identified to address concerns on a follow up visit included: adherence to medications and sleeping well. R1's progress note dated 2/25/24 at 4:30 p.m., R1 was back from hospital. All medication had stayed the same from previous hospitalization . Note indicated R1 was provided with a sleep medication to help her sleep and avoid anxiety episodes during the day. R1's back was charcoal burnt black with two large open areas. Very painful to touch when assisting her to take top off. Writer had applied bacitracin (antibiotic) on gauze to the open areas. Resident strongly advised to stop heating up towels to destroy her back. Resident could have neuropathy so does not feel the excessive heat to the back but was burning her skin. R1's care plan dated 3/2/24, identified R1 was resistive to care due to anxiety attack brought on by episodes of insomnia. During an anxiety attack the resident will ask for help but refuse to go to the hospital. In the past the resident will only agree to go to the hospital if staff drive her in the car. R1 will not go by ambulance through 911. R1 has a history of insomnia resulting in anxiety attack. Staff are to give clear explanation of all care activities prior to and as they occur during each contact. Staff were to give one-to one attention for (individualized minutes and times each day/week field) were left blank. Praise R1 when behavior was appropriate. Provide opportunities for choice during care provision. Resident triggers for resisting care are (Specify incomplete field) were left blank. The resident's behavior was de-escalated by (Specify incomplete field) were left blank. R1's care plan lacked individualized non-pharmacological interventions to manage insomnia to prevent and/or reduce the risk of anxiety attack. The care plan continued to lack individualized non-pharmacological interventions to prevent R1 from burning herself with hot towels and other injurious behaviors to self-soothe. Additionally the care plan did not identify individualized interventions to mange insomnia nor a quanitative/qualitative assessment of R1's sleep patterns in order to develop interventions and/or assessment to determine the effectiveness of sleep medication. During interview on 10/18/24 at 9:37 a.m., R1 reported sleep was a continued factor which affected her anxiety. R1 described a good night sleep of consistent sleep of 8 to 9 hours a night and a poor night sleep would be 3 hours at night or inconsistent sleeping hours or choppy sleep. Poor sleep had been happening approximately one to two times a week while in the facility. R1 reported the first sign of anxiety was pacing and needing to go outside to go for a walk or smoke. R1 reported when the need to repetitively smoke the anxiety was probably starting to get pretty bad. Other coping strategies R1 would utilize in the facility was a hot shower and to try a heated towel from the microwave, R1 would use the hot towel to put on her back to fall asleep. R1 denied it to be an intentional self-injurious, however, reported to be pretty ramped up if using the hot packs. R1 denied ever burning self from a hot pack. R1 had been directed to request PRN medications as needed when needing to shower or use a hot pack. R1 reported she was supposed to ask when needing medications and facility staff do not anticipate R1's anxiety or encourage medication until its uncontrollable. R1 reported when begging or crying for medication it's too late and the medication does not work. R1 reported staff tend to try to talk to her, however when anxiety is too bad its too difficult to be redirected. R1's progress notes, behavior monitoring documentation, and as needed psychotropic medication administrations were reviewed between 3/19/24 through 10/12/24. The record revealed despite R1 continuing to use or attempt to use hot towels and rub her back up against walls no individualized interventions were developed or implemented to manage the behavior other than temporarily removing the microwave, no alternatives were evident including staff consistently offering PRN medications. R1's progress note dated 3/19/24, identified R1 had seen certified nurse practitioner (CNP)-A from clinical psychiatry. R1 had been stable since recent hospitalization when Belsomra (suvorexant) prescribed for bipolar insomnia diagnosis. Disrupted sleep was contributing to anxiety exasperation. Since prescription R1 was sleeping better. No concerns currently. No medication changes were proposed. R1's progress notes from 3/19/24 through 8/22/24 did not address R1's behaviors. R1's progress notes from 8/23/24 at 5:00 p.m., identified R1 had severe anxiety episode. R1 became restless, scratching her back against the wall. Unable to utter sensibility, heating up the towel in the microwave too hot to the back of her skin. Writer was with her most of the time to help calm her down. This time her medication at 5:00 p.m. and the HS (hours of sleep) medication helped, and she was back to normal by 11:00 p.m. R1's progress notes from 8/29/24 from a late note entry dated 8/30/24 identified R1 had severe anxiety at approx. 1:00 p.m. Writer and social worker escorted the resident to United Hospital due to anxiety attack and psychosis. Resident scratching back on doorway trying to self sooth anxiety. Unable to sit still, refusing medication, refusing to eat. 1:1 staffing required, so writer escorted R1 to an inpatient mental health unit. Emergency Department (ED) discharge summery dated 8/29/24, identified R1 had a hospital visit from 8/29/24 and discharged on [DATE]. Reason for admission was due to a concern for mania and chief complaint of anxiety. R1 required hospitalization due to potential safety risk to self or others within the last week., diagnostic clarification, decreased functioning in setting of inadequate outpatient management, need for highly structured inpatient management for stabilization of psychiatric symptoms and for psychiatric medication initiation and stabilization. R1 was stabilized and discharged . R1's progress note dated 9/6/24 at 11:00 a.m. identified R1 had high anxiety this morning and started heating up washcloth and putting on her back. Writer encouraged resident not to do too hot for washcloth to prevent skin burn. There was no indicated other than to encourage her not to use the hot pack to assist with her anxiety. R1's progress note dated 9/6/24 at 3:00 p.m., indicated R1 was a little sad because her dialysis could not be completed and had to go back to the surgical room again on Monday . Noted the presence of anxiety that make her restless. R1 started to heat up towel too hot to warm her back. Scratching her back and legs on the wall and speech not very clear. She asked for PRN medications including Seroquel and calmed her down a bit. At 8:00 p.m. staff had to monitor R1 so she does not warm the towel in the microwave too hot to put on her skin. Given meds at 9:00p.m. R1's progress note dated 9/7/24 at 1:00 p.m., writer had got report from night nurse that R1 used hot towel on her back during night shift. Night nurse took the microwave downstairs. Resident went downstairs and got microwave and started heating up towel too hot. Writer encouraged resident not to do too hot towel. Resident refused and started heating up too hot. Writer removed microwave. R1's progress note dated 9/7/24 4:15p.m., identified R1 took a shower this morning and came out with a towel wrapped around her and writer noticed how badly her back looked. It looked like a lizard skin. Has black (dark) and looked like somebody burned patient all over with cigarette. R1 was starting to wet towels and put them in the microwave for 4 minutes. Writer had to tell her she was endangering herself and burning her back, but patient ignored staff. Writer had to call manager and remove microwave and place it downstairs, hoping it stopped patient from burning her back. R1's progress note dated 9/7/24 at 9:00 p.m., identified resident had been unable to eat all day. Instead, she had been jerking, scratching her back against the wall and unable to sit still. When she sits her preference was to sit on the table and not the chair. Took all medications at 8:00 p.m., but at 9:00 p.m. not the slightest improvement. R1 looked too miserable to be here so writer called and sent resident back to hospital. Emergency Department (ED) discharge summery dated 9/7/24, identified R1 had a hospital visit from 9/7/24 and discharged on [DATE]. The reason for continued admission was due to decompensated mental illness conditions. Stabilization was required prior to transferring R1 back to facility R1's progress notes identified R1 was readmitted to facility from hospital 10/4/24 at 4:00 p.m., and R1 had a follow up outpatient psychology appointment on 10/8/24. R1's PRN medication administration record (MAR) for October 2024 identified the following physician orders: -Order date 10/4/24 Quetiapine (Seroquel) 50 milligram. Take one tablet by mouth every six hours as needed for agitation (not further defined) identified two doses administrated on 10/11/24 at 10:00 p.m. and 10/12/24 at 10:40 a.m. -Order date of 9/5/24 hydroxyzine pamoate 50 mg capsule (Vistaril) 1 cap by mouth every six hours as needed for anxiety (not further defined). Signed on 10/11/24, however time was not noted. R1's progress note dated 10/11/24 identified R1 came out of room reported feeling very anxious and wanted to heat some towels in the microwave. Nurse informed R1 that would not be beneficial and redirected R1 to take a PRN hydroxyzine. R1 agreed and went back to room. While writer was in restroom, R1 used the dining room microwave to heat up wash cloths in a plastic bag. Resident perplexed it helps. Education provided on the dangers of hot towels on skin. Resident reported no its fine. Removed microwave for safety reasons. Besides removing the microwave there was no indication if other interventions were used to address R1 anxiety. R1's document titled behavior sheet dated 10/11/24, identified the following: R1 resists cares does her own plan ignores staff x 2 occurrences in the last seven days. Self-injurious goes out after curfew to smoke x2 occurrences in the last seven days. Delusions x 3 occurrences in the last seven days believes she can take care of herself. Inappropriate smoking behaviors x3 occurrences in the last seven days chain smokes. Nursing interventions/additional comments: Resident believes she can live in her own apartment and take care of herself; staff have to watch her when she is anxious, she will heat towels too hot and burn herself. R1's weekly progress note/care plan review dated 10/11/24, identified R1 rarely requests PRN's during the night shift, she remains intact with bruises and scar tissue, she sleeps well some nights, she goes out after curfew to smoke. R1's progress note dated 10/12/24 at 4:00 a.m., identified writer arrived on shift and immediately R1 went to take shower. It was a long shower. After that asked nurse to warm up towels, nurse replied she was not allowed to do that. R1 continued to ask writer said no again. R1 went to room to sleep. Around 4:00 a.m. R1 tried to teat up towels in kitchen. Writer told her it was not allowed and removed both microwaves due to R1 heating up towels so hot and placing them on her back. R1's back is scarred. R1's progress note dated 10/12/24 at 7:00 a.m., identified R1 was restless all night and was reporting anxiety. R1 received all PRN medication, Resident was undirectable [sic] to any cues. Resident was crying. Writer called 9-1-1 and sent to hospital. Resident was taking hot showers and rubbing against doorways. R1's progress note dated 10/12/24 3:00 p.m., identified resident from when she left until 3:00 p.m. did not sleep. Resident smoked 2-6 cigarettes to keep busy. Resident kept begging staff to get the microwaves out. Resident was crying and rocking back and forth. Called EMS and returned to emergency room . Emergency Department (ED) discharge summery dated 10/12/24, identified R1 had a hospital visit from 10/12/24- Current. R1 was admitted for the chief complaint of anxiety and high blood sugar. R1 arrived by emergency medical services from R1's facility. R1 had reported having an anxiety attack for the last 23 hours and started throwing up and reporting severe abdominal pain. There was no indication in the medical record the the facility had completed a comprehensive assessment to determine triggers, or any specific behaviors pattern or trends that could be addressed by medication management or interventions to reduce or prevent her anxiety that resulted in several hospitalization s. During interview on 10/18/24 at 12:21 p.m., family member (FM)-A reported R1 had a long-standing history of anxiety prior to admitting to the facility. FM-A reported concerns regarding R1's sleep and when FM-A received late-night phone calls to be very worried about R1's anxiety for the next day. If R1's sleep was out of control it would be a trigger for behaviors to get worse. FM-A reported historically R1 had a weighted blanket but was unsure where it had gone. FM-A reported PRN medications were for the facility to provide prior to R1 not sleeping and prior to R1 reporting she needed it. FM-A reported R1 was to receive the PRN's from facility staff based of how R1 was acting or how her behaviors were. During interview on 10/18/24 at 10:15 a.m., licensed practical nurse (LPN)-A reported R1 did fine on her good days, however had times with a lot of anxiety and scratching her back on the walls. LPN-A reported staff were to calm her down by providing R1 with an as needed medication if it was available (Seroquel). LPN-A recalled providing R1 an as needed medication in the month of October as R1 was acting up and having one of her episodes. LPN-A described this behavior as R1 scratching her back on walls, warming up wash cloths and when she starts to beg/cry to know R1 needed her as need medication. LPN-A reported had needed to hide the microwave as R1 was attempting to warm up towels too hot. R1 was independent and able to do so without assistance, but staff do not condone it. LPN-A reported R1 did not display signs of anxiety until R1 was scratching her back. Staff were only able to give her the as needed medication and there is nothing else staff can do. R1 was able to report anxiety and tell staff it's getting worse, but once she's gone, she's gone. LPN-A reported R1 may needed more medication to cope with the anxiety and more psychological help. During interview on 10/22/24 at 10:45 a.m., registered nurse (RN)-B reported R1 was in the facility for medication management and was independent in most of her cares. RN-B reported R1 had anxiety and R1's anxiety presents when she was crying and starts acting like she needs medication. RN-B further described this behavior as crying, taking multiple showers, and warming towels. In most cases R1 would ask for the medication and the PRN medication was for when R1's anxiety was bad. RN-B was unaware of any non-pharmacological options that were successful for R1. RN-B reported when R1's anxiety comes the facility staff cannot control it and was unsure why her medication was not working. RN-B reported staff were unable to provide R1 with PRN medications unless R1 requests it. RN-B would not give PRN medication to prevent anxiety such as going to a dialysis appointment and only provide it if R1 requests it. During interview on 10/18/24 at 2:38 p.m., RN-A recalled being the RN who needed to send R1 to the hospital on the morning of 10/12/24. R1 was noted to be anxious and walking back and forth. When asking about R1's anxiety R1 reported I just can't. R1 was attempting to warm towels with the use of the microwave and education provided for safety. RN-A educated R1 on heating packs that do not get as hot can be sold at Walgreens, however, the facility did not have any alternatives to offer R1. RN-A reported R1 was not allowing RN-A to heat the hot pack for R1, as R1 wanted to heat it longer than 2 minutes. RN-A was attempting to redirect R1 by talking to her. RN-A reported giving all PRN medications available, and R1 wanted to shower when night shift had arrived. RN-A had asked the overnight staff if R1 was able to get any sleep. R1 had not, however, was water seeking and trying to get hot water or to heat towels. LPN-A had removed one of the microwaves. RN-A was worried as R1 had not slept and was rubbing her back on the sides of doorways. RN-A had contacted 911 around 7:00 a.m. RN-A reported only giving a PRN medication if R1 asks for it. During interview with administrator on 10/23/24 at 9:56 a.m., Administrator/director of nursing reported R1 had stress related triggers such as going to multiple medical appointments and inability to sleep. Staff should be giving PRN medication prior to R1 having an episode of crying, using hot packs and the inability to self-regulate/self sooth. Administrator reported the facility could have done a better job offering the PRN medications. Administrator reported R1's sleep could impact her stress tolerance and the facility had been tracking the hours of sleep, however not monitoring the quality of sleep. The facility had a sleep disturbance evaluation tool which could have benefited R1. Additionally, Administrator reported R1's care plan was not individualized and did not have all of R1's triggers nor individualized interventions identified. R1's target behaviors were not being monitored. During interview on 10/22/24 at 3:32 p.m., certified nurse practitioner (CNP)-A reported to be a board-certified nurse practitioner specializing in psychiatry who had worked with R1 for [AGE] years working together on an outpatient bases and consulting as needed while she was inpatient. CNP-A reported seeing R1 about monthly, however due to inpatient hospitalization s outpatient services would be delayed. CNP-A reported seeing R1 in December and then not again until March, May and then June. July got delayed until October due to frequent hospitalization s. During that time CNP-A had contact with impatient psychiatry team. CNP-A reported R1 was on a PRN Seroquel for agitation. R1 should be asking for medications ideally, but the facility should also be offering when they are seeing some key futures of R1's agitation such as pacing or frequently smoking. R1 was described as a very vulnerable adult who may not always present as such due to age and appeared functional. CNP-A reported R1's anxiety presents as very restless and agitated. If R1's behaviors present past that, R1 would either do healthy coping or unhealthy coping such as using hot towels and burn her back. Using hot towels had been a long-standing coping strategy described as an intentional and self-inflicted relief such as cutting/burning/punching self. R1 was known to intentionally attempt this method to self-regulate, not attempting to kill herself. R1's sleep was reported as intermittently terrible and waxes and wanes. R1's sleep was known to affect the way R1 could respond to anxiety or stress. CNP-A reported it was an indicator R1 could be kind of destabilizing and was currently R1's biggest complaints. Non-pharmacological interventions that are successful include some movement with activity, crafting and reported R1 had limited tools and was one of the reasons they were initiating dialectical behavior therapy (DBT) since this recent hospitalization . R3's face sheet printed identified R3 was admitted with diagnoses including, schizoaffective disorder, depressive type, other psychoactive substance use, unspecified with psychoactive substance- induced mood disorder and unspecified mental disorder due to known physiological condition. R3's quarterly change Minimum Data Set (MDS) dated , 7/27/24 identified R3 as cognitively intact with no behaviors. R3 was independent in mobility and activities of daily living. R3's care plan dated, 2/6/2021 identified R3 had alteration in neurological status of paranoid delusions people are out to get her due to schizoaffective disorder. R3 was to be assessed for effects of psychotropic medications, dystnoia, akithesia, akinesia, rigidity, tremors, etc. R3 required cueing reorientation as needed. Staff were to give medication as ordered. Monitor/document for side effects and effectiveness. Staff were to provide main management as needed. See medical doctor (MD) orders. Provide alternative comfort measures as needed. Staff were to give PRN analgesics and monitor effectiveness. Report new onset of pain to MD. R3's medical record lacked individualized behavior interventions for target behaviors. R3's behavior monitoring sheet requested and not received. During an interview on 10/23/24 at 3:33 p.m. DON/administrator stated we have identified target behaviors for our residents but have not gone the extra step to include personalized interventions for target behaviors. During interview on 10/23/24 at 4:13 p.m., DON/administrator reported the facility did not have any policy or procedure related to mental health/behavioral management/psychiatric or mental health care needs.

Based on observation, interview and document review, the facility failed to ensure adequate supervision of 4 of 4 residents ( R3, R4, R7, R13) reviewed during the survey. Findings include: R4's quarterly minimum data set ((MDS) dated [DATE], indicated she was cognitively intact and independent with all activities of daily living. R4's care plan dated 1/23/18, identified [MEDICAL CONDITION] or confusion related to alcohol use/abuse. The care plan further identified behaviors that included bringing alcohol into the facility. A Southside Care Center Fax Transmission dated 11/15/17, indicated R4's physician received the following update: Staff found R4 drinking in her room, vodka. A review of R4's Southside Care Center progress notes identified the following: 1/11/18 - R4 has behaviors of bringing alcohol in from the outside. 2/1/18 - R4 returned to the facility. She was intoxicated and returned with something mixed in a bottle. An untitled facility communication book included the following entries: 2/13/18 - R4 has been drinking 2/13/18 - R4 in and out this shift, then in the bath tub at 1:30 a.m. She has been drinking. 3/7/18 - R4 is drunk. 3/15/18 - R4 requested Tylenol at 3:00 a.m., smell of alcohol on her breath. 3/17/18 - R4 smells of alcohol. R13's quarterly MDS dated [DATE], indicated he was cognitively intact and independent with activities of daily living. R13's care plan dated 3/19/18, identified a potential for limited physical mobility related to hip and arm fractures and behavior problems that included leaving the facility without signing out and a history of [MEDICAL CONDITION] and illicit drug use. The care plan further identified a risk for falls related to balance problems and poor comprehension and directed staff to ensure proper foot wear. R13's care plan did not identify the use of a cane. During an observation on 3/20/18, at 1:25 p.m., R13 was observed ambulating with a cane. He had a splint on his left hand. A review of R7's Southside Care Center progress notes identified the following: 12/3/17 - R13 called the facility to let them know he was in the hospital. Hospital staff stated R13 had been brought in the previous night and had a blood alcohol level of three times the legal limit. R13 required stitches above his left eye. 12/7/18 - X-ray result revealed a fracture of R13's right wrist resulting from a fall while out of facility. 3/9/18 - R13 did not come down for snacks so writer went to his room. He did not look good so blood pressure was checked. R13's blood pressure was 84/45, sent to hospital. R13 returned from the hospital in a cab. He did not bring back a referral, only had a paper with lab work on it. 3/15/18 - R13 went out with another resident Tuesday and got drunk/used alcohol. An Abbott Northwestern Emergency Department lab report dated 3/9/18, indicated R13 had a blood alcohol level of 0.151 R7's admission MDS dated [DATE], indicated intact cognition and independence with all activities of daily living. R7's care plan dated 1/14/18, identified a risk for elopement related to leaving the facility without signing out. A review of R7's Southside Care Center progress notes identified the following: 3/15/18 - R7 went out with R13, kept requesting money from other residents for a cab. At 7:17 p.m. both returned and writer suspected they had used some substances/drugs. R7 then went to another residents room. both residents were screaming at each other, writer stood between them to keep them from physically attacking each other. R3's MDS dated [DATE], indicated she was cognitively intact and independent with all activities of daily living. R3's care plan dated 3/20/18, indicated behaviors that included leaving the facility without signing out. the care plan directed staff to praise improvement in behavior and check room weekly for alcohol and illegal drugs. An untitled facility communication book included the following entries: 2/8/18 - R3 went out at 11:30 p.m., did not tell staff, still not back. 2/9/18 - R3 still not here. 2/10/18 at 10:30 p.m. R3 still out. 2/14/18 - R3 is not in the building when room checks done at 11:00 p.m., did not return on night shift. 3/2/18 - R3 left the facility at 2:00 a.m. in a taxi 3/3/18 - overnight shift R3 still out. An untitled document dated 2/11/18, indicated to R3: I am writing this note to tell you that this is your last leave of absence to leave the facility alone, except medical appointment. R3 will not leave the facility without a friend or family member to sign you out and take your medication. If you attempt to go out alone or without signing out or taking your medications that will be your last day at South Side, you will be discharged immediately. The document was signed by R3 and the director of nursing (DON). A review of R3's Southside Care Center progress notes identified the following: 2/25/18 - Program director, director of nursing (DON) and administrator updated: R3 not at her mothers house and her cell phone goes directly to voice mail. Police contacted to file missing persons report. 2/25/18 - R3 answered call this time, said she was safe and would be back at facility at 5:00 p.m. 2/25/18 - R3 decided not to explain where she was Saturday night, refusing to talk. During an interview on 3/20/18, at 1:41 p.m., LPN-A stated residents were supposed to sign out of the facility and tell staff where they were going. LPN-A stated if the resident did not return, staff called them. He stated if it was suspicious staff were to call the police. In regard to R3 leaving the facility at 2:00 a.m., LPN-A stated, it is not safe for her to leave, not safe at all. LPN-A stated if residents used alcohol the staff confronted them and the physician would be notified. He stated in the past the facility confiscated alcohol bottles. LPN-A stated R13 and R7 went out together and got drunk. He stated if the residents are intoxicated the staff watch them to make sure they don't misbehave. Regarding R13's blood alcohol level on 3/9/18, LPN-A stated he was not aware . LPN-A further stated R13 was a fall risk and stated if he was intoxicated staff helped him up the stairs and told him to say there. LPN-A stated R13 had an alcohol related fall in the past. He stated the residents were told they could not remain in the facility if the behaviors continued but stated, we have to give them time, they don't understand. During an interview on 3/20/18, at 2:30 p.m. the DON stated staff searched R4's room and held her medications if they suspect she had been drinking. The DON stated she had talked to R4 about her drinking and her she shouldn't drink but it didn't work. The DON stated R13 had a history of [REDACTED]. She stated she told R13 he could not go out but he did it anyway's. In regard to R3, the DON stated she had talked to R3's mother and explained after so many days out of the facility R3 could lose her medicaid. The DON stated R3 leaves on the weekend when she know I am not here. During an interview on 3/21/17, at 11:15 a.m. the administrator stated she had been trying to get information from the DON regarding the residents comings and goings. The administrator stated she did not think residents should be allowed to leave the facility at night under any circumstances. She stated the residents were vulnerable and it was too dangerous. The administrator stated she was told there was alcohol consumption occurring and stated she had told the staff it is a form of abuse to allow the residents to consume alcohol and it was not okay. She stated staff felt like the residents would discharge if if they try to stop them. During a subsequent interview on 3/21/17, at 11:35 a.m. LPN-A stated as far as leaving at 2:00 a.m., the best we can do is let them know it isn't safe. He stated the staff face difficult challenges and the only thing they could do is be a little more strict with the residents. He stated they could give a notice but it didn't help. A facility policy titled Southside Care Center Resident Sign- Out dated 7/201 indicated residents who leave the facility are expected to notify staff and utilized the sign out book. A facility policy related to alcohol use was requested but not provided.

Based on observation, interview and document review, the facility failed to protect a resident from physical abuse. This resulted in an immediate jeopardy (IJ) for 1 of 1 resident (R3) who reported an allegation of abuse by a staff person, and other residents. The immediate jeopardy began on 5/23/17, when R3 made an allegation of abuse by a housekeeper and other residents in the facility. The IJ was identified on 5/25/17, and the administrator was notified of the IJ at 2:26 p.m. on 5/25/17. The IJ was removed on 5/26/17, but non-compliance remained at the lower scope and severity level of D. Findings include: R3's quarterly Minimum Data Set ((MDS) dated [DATE], indicated she was cognitively intact and was independent with all activities of daily living. During an interview on 5/23/17, at 1:13 p.m., R3 stated housekeeper (HK)-A had raped her. R3 stated, He's going to kill me. When asked, R3 stated she had not reported the incident to the facility staff. The incident was reported to the director of nursing (DON) on 5/23/17, at 1:24 p.m. by the surveyor. A review of a Southside Care Center Non-Fall Incident Report dated 5/23/17, indicated the following detailed description of the incident: 'Resident (R3) has been taken off the [MEDICATION NAME] due to medication side effects. Resident reported that she was raped. No witness.' The investigation indicated: 'Interviewed the accused person and he denied. Resident refusing to talk or to be interviewed.' There was no evidence of further investigation or interviews with staff or other residents. A review of a 5/23/17 untitled Document (identified as night shift charting), by LPN-A indicated R3 is so delusional I cannot see why anyone believes what she says. As a result of the resident's allegations, additional incident reports were reviewed: A review of a Southside Care Center Fall/Presumed Fall Incident report dated 7/8/16, identified the following: Staff heard residents in room by nursing desk arguing then saw R3 get hit in the face and neck twice by her roommate (R9). The incident report indicated: In this particular incident, this resident (R3) had been loud and agitating to other roommate earlier in the day. A Southside Care Center Non- Fall Incident Report dated 9/8/16, indicated staff was in the dining room passing medications and heard residents in room [ROOM NUMBER] yelling at each other. The report indicated R3's roommate had gone toward R3 and they began to fight. A correlating Southside Care Center progress note dated 9/8/16, indicated at about 7:30 p.m., staff heard yelling coming from R3's room. R9 was swearing at R3 and hitting her. The note indicated the DON had been notified. A Southside Care Center progress note dated 3/12/17, indicated: Incident between R4 and R3. R3 was making rude comments to R4. After R4 told R3 to shut up several times, R4 jumped up and began hitting R3. There was no evidence the facility had investigated the incident any further. A review of an untitled document dated 4/19/17, indicated R9 smacked R3 across the face. There was no indication an investigation had ensued. During a follow up interview with the DON on 5/24/17, at 9:45 a.m., the DON stated the alleged rape incident had not been reported to the State agency. The DON stated she had investigated the incident and stated the administrator would report it. Further, the DON stated the facility had 48 hours to file a report. During an interview on 5/24/17, at 10:17 a.m., the adminstrator stated he was made aware of the allegation the previous day. He stated he asked the DON to interview the people involved and document, and he would come to the facility in the morning and do additional interviews and report as necessary. The administrator stated he did not know if the allegation should be reported to the State agency. He said, it depends on the resident, their history, and whether the allegation can be substantiated. He further stated he was not sure whether the investigation was complete, but verified HK-A continued to work during the investigation. During interview on 5/24/17 at 10:32 a.m., the DON stated the facility had not made a report to the State agency in over a year. She stated if a resident is hitting another resident, We should report that. During interview with the administrator on 5/24/17, at 10:36 a.m., the administrator stated he was not made aware of the incidents involving resident to resident abuse. He stated he was not sure why these had not been reported. During observations on 5/24/17, at 12:52 p.m., R3 was in the dining room. She was observed to repeatedly request medication. Trained medication aide (TMA)-A stated to R3, She's ( the nurse) getting it for you, you speak English. At 12:59 p.m., R3 had not yet received her medication and requested it again. TMA-A asked R3 in a condescending tone, Are you an RN (registered nurse)?, are you an LPN (licensed practical nurse)?, are you a doctor? During an interview on 5/24/17, at 3:02 p.m., the DON stated R3 talks a lot and R4 is always asking her to stop. The DON stated R3 and R4 yell at each other every day. In addition, the DON stated if it happens during the day, staff intervene, but if it happens at night, staff are supposed to report to her or the administrator. The DON stated R3 had been sent to crisis more than once for agitation. She stated usually R3 is loud and other residents react to that. However, the DON stated she had never seen R3 physically abusive to another resident. The DON verified R3 had been sent out of the facility, not the resident who was hitting her, because the other resident is usually the quiet one. HK-A was observed to be working independently again on 5/25/17. At 7:20 a.m. on 5/25/17, HK-A was interviewed and stated he had received training on abuse. He then stated, whatever I see, I don't say anything, I like to keep my nose clean, don't stick my nose where I'm not supposed to. HK-A stated if he saw a staff or another resident physically abusing a resident, he didn't know what he would do. During an interview on 5/25/17, at 9:22 a.m., trained medication aide (TMA)-A stated she had never seen R3 be aggressive with another resident. TMA-A stated she was aware R4 had hit R3 but had never witnessed it. TMA-A stated, During the day they (R3 and R4) are pretty good, on the evening and night shifts they argue and swear at each other 3-4 times per shift. During an observation on 5/25/17, at 9:50 a.m., R3 was heard requesting insulin. The director of nursing (DON) walked over to R3 and yelled at her saying, you go to your room, you are disturbing everyone. During on observation on 5/26/17, at 6:54 a.m., R3 remained in the room she shared with R4. During an interview on 5/26/17, at 8:22 a.m., R3's guardian (G)-A stated someone at the facility had contacted her the previous day about R3. She stated they had discussed R3's behaviors but had not informed them of the rape allegation. G-A stated she did not hear from the facility very often and was not even sure who the current DON was. G-A stated the facility had updated her regarding a medication change several weeks ago, but stated she had not been informed of any issues of resident to resident abuse. G-A stated, I don't feel her (R3) needs are being met at this time. While multiple reports had been made regarding R3 being physically abused by other residents in the facility, there was no evidence the facility had investigated the abuses, nor were these incidents reported to the State agency. Further, while many of the altercations occurred between R3 and her roommate, there was no evidence the facility implemented interventions to keep R3 safe from the physical abuse. R3 and R4 remained in the same room even though the facility had identified multiple verbal and physical altercations between the two. A facility policy titled Southside Care Center Vulnerable Adult Abuse Prevention and Investigation, dated 2/16/15, indicated: At Southside Care Center we are committed to providing a safe, comfortable living environment for all of our residents. To ensure safety, we practice abuse prevention and intervention. The policy directed staff to complete the following procedures after an incident: Administrator of designee will report event to the State agency. Complete an incident report. Update care plan and document in progress notes. Complete Investigation, including but not limited to interview of residents and staff. The immediate jeopardy that began on 5/23/17, was removed on 5/26/17 at 2:23 p.m., when the facility had educated staff related to Abuse Prevention responsibilities/techniques, had implemented measures to provide for R3's safety including: 30 minute checks for increased supervision of R3, scheduled a medical assessment for R3 with her physician, and had modified staff assignments to promote R3's sense of safety and well being. In addition, the facility had initiated reports to the State agency, and had initiated investigations into the abuses R3 allegedly endured.