Every finding on record at Stella Maris, Inc.

Based on observations, record review, and staff interviews, it was determined that the facility failed to: (1) ensure oxygen tubing and related oxygen delivery equipment were consistently dated and labeled in accordance with professional standards of practice; and (2) ensure a physician's order was available for oxygen administration for a resident receiving oxygen therapy. This deficient practice was evident for 5 (Residents #29, #87, #287, #3, and #6) of 5 residents reviewed for oxygen therapy during the facility's recertification survey. The findings include: Oxygen tubing is the flexible plastic line that safely delivers supplemental oxygen from a source like a portable tank, liquid oxygen system, or stationary concentrator directly to the user. It connects directly to a nasal cannula or face mask and comes in various lengths for daily use. A nasal cannula is a lightweight, flexible plastic device used to deliver supplemental oxygen to people who have difficulty breathing. It features two small prongs that rest directly inside your nostrils, connected to tubing that loops over the ears and rests comfortably under the chin. A humidifier is a device that adds water vapor to the air to increase indoor humidity. It is commonly used to combat dry air caused by winter heating or air conditioning, which can help relieve dry skin, chapped lips, and irritated nasal passages. 1) On 07/21/2026 at 9:30 AM, during the initial tour of the facility, the surveyor observed Resident #29 receiving oxygen via nasal cannula. Observation of the oxygen equipment revealed that the oxygen tubing was not labeled or dated. On 07/21/2026 at 9:32 AM, the 3P Unit Manager was interviewed. She stated that it was the facility's expectation that all oxygen tubing be changed according to physician orders and labeled with the date it was changed. The surveyor informed the Unit Manager that Resident #29's oxygen tubing was not labeled or dated. The Unit Manager acknowledged the observation. On 07/21/2026 at 9:43 AM, during continued tour of the facility, the surveyor observe Resident #87 receiving oxygen therapy via nasal cannula. The humidifier and nasal cannula were observed without a date or label. On 07/21/2026 at 10:42 AM, the surveyor requested a dual observation with Ground [NAME] Unit Manager and she confirmed that the oxygen tubing and humidifier were not dated or labeled. When asked regarding the facility's expectation for dating and labeling oxygen equipment, she stated that the equipment was expected to be changed weekly and dated/labeled after the change. On 07/21/2026 at 11:26 AM, during continued tour of the facility, Resident #287 was observed receiving oxygen therapy via nasal canula. The oxygen tubing/nasal canula was observed without a date or label. On 07/21/2026 at 11:30 AM, Resident #3 was observed receiving oxygen therapy via nasal canula. The oxygen tubing/nasal canula was observed without a date or label. On 07/21/2026 at 11:37 AM, during an interview with the Unit Manager for [NAME] 1, when asked when the oxygen tubing/nasal cannula for Residents #287 and #3 was last changed, the Unit Manager stated that she did not know and would follow up. During a dual observation, the Unit Manager confirmed that the oxygen tubing/nasal cannula for both residents was not labeled. When asked regarding the facility's expectation for oxygen equipment labeling, the Unit Manager stated that oxygen tubing should be dated and labeled after each change. On 07/23/2026 at 8:42 AM, the surveyor reviewed the facility policy titled Oxygen Therapy. Under the Procedure section, item #8 stated, Oxygen tubing, mask, and/or cannula are changed weekly and when soiled. Label and date all tubing. On 07/24/2026 at 9:15 AM, during an interview with the Director of Nursing (DON), when asked regarding the facility's expectation for dating and labeling oxygen equipment, the DON stated that the standard practice was for oxygen tubing and humidifiers to be changed weekly and dated/labeled after each change. When informed of the findings, the DON acknowledged the concern. 2) On 7/22/2026 at 8:37 AM, an observation of Resident #6 was conducted. The resident was observed to be on oxygen therapy delivered via nasal canula. The resident stated that the oxygen therapy was started in the hospital and continued after being admitted to the facility. On 7/24/2026 at 8:28 AM, a review of Resident #6's orders was conducted. The resident had a parameter order for the Oxygen therapy to Start to Wean Oxygen as tolerated to maintain SPO2 of 92% started 7/15/2026. There were no orders specifying the specific liters of oxygen to be administered, the route of administration, or the frequency of the administration. On 7/24/2026 at 12:15 PM, an interview with the Director of Nursing (DON) was conducted. When asked if a resident receiving oxygen should have an order in the chart to specify the administration of oxygen, the DON stated that there should be an order for oxygen in the resident's chart. The DON confirmed that Resident #6 did not have an oxygen administration and stated that they would address this after surveyor intervention. On 7/27/2026 at 1:30 PM, a review of Resident #6 orders was conducted. An order for Oxygen to be given continuously at 2 liters per minute for hypoxia via nasal cannula every shift was started on 7/24/2026 at 7:00 PM.

Based on record review and staff interview, it was determined that the facility failed to develop and implement a hospice care plan for a resident admitted to hospice services. This deficient practice was evident for 1 (Resident #17) of 1 resident reviewed for hospice services during the facility's recertification survey. The findings include:A care plan is a written, individualized document that identifies a resident's assessed needs, goals, preferences, and the specific interventions and services required to meet those needs. It serves as a communication tool for the interdisciplinary team to ensure consistent, coordinated, and person-centered care. On 07/22/2026 at 11:37 AM, review of Resident #17's electronic medical record revealed the resident was admitted to hospice services on 07/09/2026. However, a hospice care plan was not identified in the electronic health record.On 07/22/2026 at 11:52 AM, review of Resident #17's paper medical record located on the nursing unit also failed to identify a hospice plan of care.On 07/22/2026 at 12:11 PM, during an interview, the Unit Manager for 1 [NAME] stated that Resident #17 had been admitted to hospice on 07/09/2026. When asked who was responsible for overseeing care plans, she stated that the interdisciplinary team shared responsibility. When asked who was responsible for updating the nursing portion of the care plan, she stated that responsibility was hers. When asked whether Resident #17 had a hospice care plan, she reviewed the resident's electronic health record and stated that no hospice care plan had been initiated. When asked whether Resident #17 should have had a hospice care plan in place, she stated yes and explained that The social Worker assigned to Ground [NAME] and 1 [NAME] units (Staff #9) should have initiated the hospice care plan and that she should have notified Staff #9 to ensure the care plan was developed.On 07/22/2026 at 12:28 PM, during an interview, Staff #9 (the Social Worker assigned to the Ground [NAME] and 1 [NAME] units) stated that either the Social Worker or Unit Manager could initiate the hospice care plan; however, it was her responsibility to verify completion. Staff #9 confirmed that Resident #17 had been admitted to hospice services on 07/09/2026 and stated that a hospice care plan should have been initiated. When asked when the hospice care plan should have been developed, Staff #9 stated that it was typically initiated upon notification of hospice admission. When asked whether she had been notified of Resident #17's hospice admission, Staff #9 stated that she was aware of the admission but was unsure why the hospice care plan had not been initiated.On 07/22/2026 at 12:49 PM, the concern was discussed with the Director of Nursing (DON) and the Administrator. Both acknowledged the findings.On 07/22/2026 at 1:47 PM, following surveyor intervention, Staff #9 initiated a hospice care plan for Resident #17 and provided a copy of the completed hospice care plan to the surveyor.

Based on interviews and review of records, it was determined that the facility failed to administer and document medications as prescribed. This was evident for 2 (Resident #173 and #200) out of 3 residents who were reviewed for medication administration during the recertification survey.The findings include: 1). On 07/21/2026 at 10:17 AM, an interview with Resident #173 was conducted. The resident reported that their medications were administered late. The resident was unable to recall any dates or timeframes. On 07/22/2026 at 12:13 PM, a review of the medication administration audit for the last 7 days (July 13th to July 21st) was conducted. The review revealed the following:-Eliquis Oral Tablet 5 MG (Apixaban) and Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) were ordered to be given at 7 AM. Both medications were given late 6 out of 7 days. -Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) Give 1 tablet by mouth one time a day for hypertension ordered for 9am was administered late 7 out 7 days.On 07/21/2026 at 9:45 AM, an interview with Resident #200 was conducted. They reported that their medications were administered late. They reported this happened several days about 2 weeks ago. 2). On 07/22/2026 at 1:51 PM, a review of Resident #200's medical record was conducted. The review revealed that the resident had the following active medication orders: -Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for Atrial Fibrillation. -Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth in the morning for Congestive heart failure. -Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for Atrial Fibrillation. A review of the July 1st to July 7th 2026, medication administration audit was conducted. The review revealed the following: On 7/2/2026 Apixaban Oral Tablet 5 MG ordered for 8 AM, Furosemide Oral Tablet 40 MG ordered for 9 AM and Metoprolol Tartrate Oral Tablet 25 MG ordered for 9 AM were given at 12:05 PM and documented at 12:07 PM. On 7/3/2026 Apixaban Oral Tablet 5 MG ordered for 8 AM, Furosemide Oral Tablet 40 MG ordered for 9 AM and Metoprolol Tartrate Oral Tablet 25 MG ordered for 9 AM were administered at 2:47 PM and documented at 2:48 PM. On 07/22/2026 at 1:16 PM, an interview with the Unit Manager was conducted. She reported that facility staff are expected to administer medications an hour before or after the ordered time and document the drug administration in real time. The surveyor reviewed the medication administration record audit with the unit manager who confirmed that the medications were administered late. On 07/24/2026 at 9:14 AM, a follow up interview with the Director of Nursing (DON) was conducted. She clarified that the facility had a liberal medication pass timeframe. Therefore, medications ordered for 7am could be administered until 11am. However, if a medication was ordered outside the liberal time frames, 7 am or 11am for morning shifts, then the medication were to be given an hour before or an hour after the ordered time. The medication administration audits for Resident #173 and #200 were reviewed with the DON who verbalized understanding of the concerns.

Based on record review, policy review, and staff interviews, it was determined that the facility failed to: (1) consistently maintain the required separate written reports of medication regimen review irregularities, and (2) ensure documentation was available to demonstrate that pharmacist-identified medication regimen review irregularities had been reviewed by the physician and that the physician had responded to those irregularities. This deficient practice was evident for 2 (Residents #2 and #5) of 5 residents reviewed for Medication Regimen Review during the facility's recertification survey. The findings include: 1) On 07/23/2026 at 11:27 AM, a review of the consulting pharmacist's Monthly Medication Regimen Review (MRR) tracking for Resident #2 identified pharmacist reviews completed monthly. The tracking indicated irregularities were identified on 08/28/2025, 12/26/2025, 03/26/2026 and 05/18/2026. Copies of the reports documenting those irregularities were requested for review. On 07/23/2026 at 11:32 AM, review of the electronic medical record for Resident #2 identified a pharmacy review progress note dated 05/18/2026 stating, Pharmacy order reviewed. See report for any noted irregularities and/or recommendations. The progress note also documented an order was obtained for continuation of PRN lorazepam beyond 14 days due to the resident's limited life expectancy. Review of a pharmacy review progress note dated 08/28/2025 stated, Pharmacy order reviewed. See report for any noted irregularities and/or recommendations, and documented a recommendation to request a psychiatric consultation to assess progress and gradual dose reduction (GDR). On 07/24/2026 at 9:09 AM, the facility was unable to provide the separate written consultant pharmacist reports for the medication regimen reviews dated 05/18/2026 and 08/28/2025 that identified the irregularities referenced in the pharmacist's progress notes. Therefore, the specific irregularities and recommendations documented by the consultant pharmacist could not be verified. On 07/24/2026 at 1:24 PM, during an interview, the consultant pharmacist stated he completed monthly medication regimen reviews and documented identified irregularities in the electronic health record. He stated he did not always prepare a written report for the attending physician and sometimes contacted the physician directly by telephone, obtained orders, and documented the outcome in the electronic health record. On 07/24/2026 at 1:26 PM, a review of the facility policy titled Medication Regimen Review indicated the consultant pharmacist was to prepare a written report of all identified irregularities and recommendations for the Director of Nursing and Medical Director. The policy further stated that written reports, as applicable, were to be provided to the attending physician or prescriber for review and response, and that physician responses or other actions could be documented either on the written report or within the electronic health record. On 07/27/2026 at 1:56 PM, the Director of Nursing was asked to provide the separate written reports submitted to the attending physician identifying the resident's name, relevant medication, and identified irregularity, as well as documentation that the attending physician reviewed the identified irregularities and documented any action taken or rationale for not accepting the recommendation. The Director of Nursing stated the facility did not have a separate written report and presented the consultant pharmacist's progress notes instead. Review of the progress notes did not identify the specific medication irregularities or recommendations referenced by the consultant pharmacist and did not demonstrate physician documentation acknowledging review of the reported irregularities or documenting any action taken or rationale for not implementing recommendations. 2) On 07/27/2026 at 10:21 AM, the surveyor reviewed Monthly Medication Regimen Reviews for Resident #5 from February 2026 through July 2026 and it identified medication irregularities in February and March. The pharmacist recommendations and documentation of physician review and response were requested. On 07/27/2026 at 11:40 AM, the Director of Nursing (DON) provided the pharmacy recommendation related to the March medication irregularity and provided the pharmacist progress note related to the February identified irregularity. The DON stated that she was unable to provide documentation of the physician's response related to the February 2026 medication irregularity. Review of the pharmacist progress note dated 02/22/2026 revealed the pharmacist documented, Will request review for continued need and benefit from nystatin treatment and ketoconazole shampoo. When asked regarding the physician's decision related to the recommendation, the DON stated that she would look for the documentation. On 07/27/2026 at 1:28 PM, during an interview with the Medical Director, when asked about the process for pharmacy reviews and communication with physicians, he stated that there was a process in place to acknowledge that a recommendation had been made and that it was the physician's responsibility to agree or disagree with the recommendation. When informed of the inconsistency between pharmacist recommendations and available physician documentation of responses, the Medical Director acknowledged the concern and stated that there should be a process to ensure pharmacy recommendations and physician responses were completed and documented. He stated that he would investigate reasons for the inconsistencies and provide education to the physicians. On 07/27/2026 at 3:46 PM, the DON stated that she could not locate the physician's response for the February medication irregularity. The DON was informed that the inability to provide documentation of physician review and response was a concern.

Based on interviews and medical record review, it was determined that the facility failed to ensure residents received routine dental services. This was evident for 1 (Resident #80) of 1 resident reviewed for dental services during the annual survey. The findings include: On 07/21/2026 at 1:05 PM, during an interview, Resident #80 stated that they had not seen a dentist since being admitted to the facility.On 07/22/2026 at 12:12 PM, a review of the medical record revealed that Resident #80 was admitted to the facility in August 2024. The record showed the resident was scheduled for a dental appointment in November 2024, but refused the visit. Further review of the medical record revealed no subsequent dental appointments had been scheduled or completed following the refusal.On 07/23/2026 at 9:04 AM, the Assistant Director of Nursing (ADON) was interviewed. She confirmed Resident #80 was scheduled for a dental appointment in November 2024 but refused the visit. She stated that after the refusal, the resident was not placed back on the dental provider's schedule and had not been offered another routine dental appointment. The ADON confirmed the resident had not been seen by a dentist since admission. She stated that, following survey intervention, the facility would schedule the resident for a dental appointment.On 07/23/2026 at 10:36 AM, the Director of Nursing (DON) was interviewed. When asked whether Resident #80 had been offered or seen by a dentist during 2025 or 2026 prior to survey intervention, she stated, No. After the resident refused in 2024, it was never offered again. She further stated that the facility was working with the dental provider to ensure residents are routinely seen or offered dental services.

Based on record review and staff interviews, it was determined that the facility failed to: (1) maintain accurate and complete documentation related to residents' advance directives; and (2) ensure the accuracy of residents' medical records. This deficient practice was evident for 2 (Residents #245 and #319) of 2 residents reviewed for advance directives during the facility's recertification survey. The findings include: A MOLST, or Medical Orders for Life-Sustaining Treatment, is a portable medical form that translates a seriously ill person's choices about CPR, intubation, and other care into real medical orders. An HCA/POA (Health Care Agent / Power of Attorney) is a legal document and designated person that allows a trusted individual to make medical choices for someone if they become unable to speak or decide for themselves. 1) On [DATE] at 8:50 AM, a review of Resident #245's electronic health records was completed. The resident had 2 separate active MOLST forms were identified to have 2 different code statuses. The MOLST form from [DATE] was marked as Full Code and the form from [DATE] was marked as No Cardiopulmonary Resuscitation (CPR) and do not intubate. On [DATE] at 12:20 PM, a review of Resident #245's paper chart was conducted. The 2 MOLST forms with different code statuses were in the chart in a red translucent folder. On [DATE] at 12:47 PM, an interview with Staff #23 was conducted. When asked where nursing staff can locate the MOLST form, Staff #23 stated in the electronic health record or in the paper chart. When asked which MOLST form the nursing staff use if there are multiple in the chart, Staff #23 stated the most recently completed form. On [DATE] at 8:40 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that their expectation is that the old MOLST form is voided and crossed out by the provider creating the new MOLST. The Old MOLST form is then placed in the back of the chart and the form is updated in the electronic health record to reflect that it has been voided. The Surveyor made DON aware of Resident #245 having multiple MOLST forms with different code statuses in both the paper chart and the electronic health record. The DON confirmed that Resident #245's old MOLST form should have been crossed out by the provider at the time the new MOLST was created. 2) On [DATE] at 8:51 AM, review of Resident #319's progress notes identified a social work note dated [DATE] documenting that the resident's active MOLST inaccurately indicated the resident had a health care agent/power of attorney. The note stated, SWK informed physician via email today that the resident's MOLST notes that resident has an HCA POA, but that the resident does not have one due to resident and son not completing the advanced directive paperwork. On [DATE] at 9:07 AM, review of the resident's active MOLST, completed in 2023, revealed the signature section identified the decision maker as either the patient or the patient's health care agent named in an advance directive. The MOLST also contained the statement in the Other Orders section, Based on conversation with patient's son (HCDM) . On [DATE] at 11:08 AM, Social Worker #14 was interviewed. She stated that part of her responsibilities included reviewing completed MOLST forms for accuracy and notifying physicians when corrections are needed. She stated that Resident #319 was capable of making their own medical decisions and did not have any completed advance directives. She acknowledged the MOLST incorrectly reflected that the resident had a health care decision maker and stated that a new MOLST should have been completed once the error was identified. During a follow-up interview on [DATE] at 11:37 AM, Social Worker #14 stated that she had reviewed the MOLST with the resident during care plan meetings and that the resident agreed with the treatment preferences documented on the form. However, she again confirmed the resident did not have an advance directive or designated health care decision maker and acknowledged the active MOLST was not completed correctly because it stated the orders were based on a conversation with the resident's son. Social Worker #14 confirmed the inaccurate MOLST should have been replaced with a corrected form after the error was identified.

Based on observation, review of Complaint #3092378, and staff interviews, it was determined that the facility failed to maintain effective pest control measures to prevent and control rodent activity within the facility. This deficient practice was evident on 1 (Ground [NAME]) of 9 units observed during the facility's recertification survey. The findings include:On 07/27/2026 at 9:45 AM, while on the Ground [NAME] Unit of the facility, the surveyor observed a mouse emerge from room SMK089 and enter a closed storage room through a gap beneath the door. The surveyor immediately notified Licensed Practical Nurse (LPN #24) and the Unit Manager, who were present with the surveyor at the time of the observation. Both LPN #24 and the Unit Manager turned toward the area, observed the mouse, and confirmed the surveyor's observation.On 07/27/2026 at 12:44 PM, the surveyor reviewed Complaint #3092378, which alleged the presence of rodents within the facility.On 07/27/2026 at 12:48 PM, during an interview, the Unit Manager, stated that the adjacent room where the mouse entered was used to store transport wheelchairs, floor mats, heel floatation boots, and Geri chairs. When asked about possible contributing factors related to the rodent sighting, she stated that one of the residents in the room kept sugar and food crumbs in the room and that Housekeeping usually took time to clean the room. When asked what actions were taken when a rodent was observed, she stated that nursing staff notified Environmental Services, who then contacted the pest control company. The Unit manager informed the surveyor that Environmental Services had been notified of the mouse sighting after the observation was made.On 07/27/2026 at 1:09 PM, during an interview, the Environmental Services (EVS) Supervisor (Staff #25) stated that a rodent had been sighted on the second floor on 07/22/2026. Staff #25 further stated that she had also been informed of the mouse sighting on 07/27/2026 and had not yet printed the email notification. When asked whether the facility had received complaints regarding rodents, Staff #25 stated that they received such complaints frequently.On 07/27/2026 at 1:17 PM, the Director of Environmental Services joined the interview and stated that the pest control contractor had already responded after receiving a work order regarding the mouse sighting. He further stated that an opening used as the rodent's point of entry had been identified and that the Maintenance Department was addressing the issue.On 07/27/2026 at 1:18 PM, the concern was discussed with the Nursing Home Administrator (NHA), who stated that she had been notified of the rodent sighting.

Based on observation and interview, it was determined that the facility failed to ensure dignity was maintained for Resident #55 and Resident #84. This was evident for 2 residents out of 9 residents reviewed for activities of daily living during the facility's annual survey.The findings include: 1) On 07/15/2025 at 3:30 PM, during the surveyor's follow-up observation rounds of the 1st Floor [NAME] Unit, while also accompanied by the Unit Manager #22, Resident #55 was observed from the hallway through the completely ajar door, and no privacy curtain in use. Resident #55 was seated in a wheelchair next to the bedside, while Wound Nurse #21 was performing wound care to the resident's left lower extremity. On 07/15/2026 at 3:31 PM, the surveyor conducted an interview of Unit Manager #22, who confirmed the same observation of the Wound Nurse #21 performing wound care to Resident #55's left lower extremity with no privacy curtain and door open, with Resident #55 able to be seen from the hallway during dressing changes. Unit Manager #22 stated this is not the expectation of wound care for the residents, and it would be reported to the Director of Nursing #2. On 07/23/25 at approximately 3:00 PM, the surveyor shared the concern of maintaining privacy for dignity for the resident during the exit conference with the facility's Administrator, Director of Nursing, and Executive Director. 2) On 7/15/25 at 9:54 AM, during the surveyor's tour of the Ground [NAME] Unit, Resident #84 was observed by the surveyor from the hallway to be lying in bed asleep with their Hoyer lift sling wrapped under and surrounding them with no staff present. Resident #84's breakfast meal was observed sitting on their bedside table, uncovered, and appeared to be uneaten. At this time, the surveyor proceeded to find unit staff to share the concern. On 7/15/25 at 9:55 AM, the surveyor requested that Unit Manager #17 perform a dual observation of the concern with them. Unit Manager #17 observed Resident #84 with the surveyor and acknowledged understanding of the surveyor's concerns and confirmed with the surveyor that they expected that it was not acceptable for the sling to be left on the resident when in bed, and additionally confirmed the resident required staff feeding assistance to eat. On 7/15/25 at 9:58 AM, Geriatric Nursing Assistant (GNA) #18 was observed pushing a rolling bedside table down the hallway, collecting dirty breakfast dishes. At this time, Unit Manager #17 informed GNA #18 of the surveyor's concern. Unit Manager #17 stated to the surveyor that GNA #18 had gone to find help from another staff member because the resident required the transfer assistance of two staff. However, the surveyor noted that GNA #18 was observed collecting dirty dishes and had not returned to the room with any additional staff. On 7/15/25 at 9:59 AM, the surveyor conducted an interview of GNA #18, who stated the following to the surveyor: I was going to look for someone to help. When the surveyor inquired as to what staff member they had asked to assist them, they responded: I'm gonna get somebody, I'm going to get another GNA. On 7/17/25 at 12:44 PM, the surveyor shared the concern with the facility's Director of Nursing. On 7/23/25 at approximately 3:00 PM, the surveyor shared the concern during the exit conference with the facility's Administrator, Director of Nursing, and Executive Director.

Based on medical record review, staff interviews, and the facility's investigation, it was determined that the facility failed to ensure Resident #199 was free from verbal abuse by staff. This deficient practice was evident for 1 of 5 residents reviewed for abuse during the recertification survey. The facility implemented corrective measures following this incident, therefore, this deficiency will be cited as past noncompliance. The date of correction was 6/7/25.Findings include:The facility-reported incident was reviewed on 7/21/25 at 10:00 a.m. The investigation revealed that on 4/15/25, at approximately 11:10 p.m., Resident #199 reported that GNA Staff #25 called the resident fat and questioned the resident about not being able to hold urine and stool. Medical record review revealed that the resident was incontinent.During interviews, Witness GNA (Geriatric Nursing Assistant)#27 stated GNA Staff #25 was angry and repeatedly called Resident #199 names related to the resident's incontinence, expressing frustration over the need to use the sit-to-stand lift instead of performing a stand/pivot transfer.The facility's investigation substantiated the allegation of verbal abuse. GNA Staff #25 was immediately suspended, terminated from employment, and reported to the Board of Nursing. Additionally, the facility notified the police, Ombudsman, attending physician, and the resident's emergency contact.During an interview with the Director of Nursing on 7/21/25 at 12:00 p.m., she confirmed that the verbal abuse had been witnessed by another staff member, was substantiated, and resulted in termination and mandatory reporting of the GNA.Although the deficient practice resulted in Resident #199 experiencing verbal abuse, the facility took immediate corrective action at the time of the incident. The staff member was removed from duty, terminated, and reported to the appropriate agencies. All required notifications were completed. The facility's corrective measures were implemented and completed prior to the start of the current survey; therefore, this deficiency is cited as Past Non-Compliance.

Based on record reviews and interviews, it was determined that the facility failed to report an allegation of abuse and an injury of unknown origin to the Office of Health Care Quality (OHCQ) within the specified timeframe. This was evident for 2 residents (Resident #177 and Resident #161) out of 10 residents investigated for Facility Reported Incidents during this facility's annual survey.The findings include: 1) On 07/18/25 at 8:32 AM, during the facility's reported incident record review, it revealed the facility reported to OHCQ on 07/02/25 at 4:55 PM that GNA #23 stated they observed GNA #23 hit Resident #177 at approximately 9:00 AM. On 07/23/25 at 9:03 AM, the surveyor conducted an interview with Director of Nursing #2 regarding the delay in reporting alleged physical abuse to OHCQ; stated they are aware there was a delay in the time of reporting to OHCQ. On 7/23/25 at approximately 3:00 PM, the surveyor shared the concern of delayed reporting to OHCQ during the exit conference with the facility's Administrator, Director of Nursing, and Executive Director. 2) Review of Resident #161's medical record review and other pertinent documentation on 07/18/2025 at 10:00 AM revealed a doctor progress note dated 06/05/2025 that the resident had persistent left knee pain with difficulty bending the joint. An X-ray was negative for acute findings, and an MRI (Magnetic Resonance Imaging) was ordered for further evaluation on 06/18/2025. Further review revealed the MRI of the left knee without contrast was performed on 06/18/2025, and results revealed a nondisplaced vertical/oblique fracture through the anterolateral distal femur. A doctor's progress note dated 07/03/2025 states the resident did not have any fall; the mechanism of injury suggests a pathological fracture, and a DEXA scan would be obtained to evaluate for Osteoporosis. During an interview on 07/21/2025 at 09:37 AM, the Director of Nursing stated that the facility did not know how or why Resident #161 sustained a left leg nondisplaced vertical/oblique fracture through the anterolateral distal femur, but a DEXA scan had been scheduled and had not been done as of 07/21/2025 on Resident#161. During an interview on 07/21/2025 at 10:45 AM, the Administrator and Director of Nursing stated to the surveyor that there was no report made to the Office of Health Care Quality regarding Resident #161's fracture/injury of unknown origin.

Number of residents sampled: Number of residents cited: Based on medical record review and staff interview it was determined the facility staff failed to notify the resident/resident representative (RP) in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#90) of 5 residents reviewed for hospitalization during a recertification. The findings include: During the investigation of Complaint 339997 on 7/17/25 at 10am revealed Resident #90 was recently hospitalized . On 7/17/25 at 10:15 am a review of nurses' progress notes and change in condition documentation dated 6/18/25 at 01:05 am revealed Resident #90 was sent to the ER (emergency room) via 911 on 6/18/25.However, there was no documentation/evidence that the resident and/or RP were notified in writing about the reason for transfer to the hospital. On 7/17/25 at 11:15 AM an interview was conducted with the Nursing Home Administrator regarding written notification of reason for transfer to the hospital, she stated that the reason for transfer was documented in the change in condition form included in the transfer packet sent with the resident to the hospital. She stated that the resident was notified verbally of the reason for the transfer to the hospital. During a follow-up interview with the Nursing Home Administrator (NHA) on 7/18/25 at 3:47 PM, the Surveyor was informed that the facility was unable to provide documentation to verify that Resident #90 and /or their RP received in writing the reason of the transfer to the hospital on 6/18/25.

Based on review of medical records and interviews, it was determined that the facility failed to ensure that a resident who required a Hoyer lift for transfer was transferred correctly. This was evident for 1 (Resident #161) out of 8 residents reviewed during the survey.The findings include the following:During an interview on 07/16/2025 at 4:00 PM Resident #161 alleged that staff assisted him/her into the wheelchair and because of the transfer sustained a left lower extremity fracture.Review of Resident #161's medical record on 07/18/2025 at 9:55 AM revealed a care plan with a focus area that was initiated on 12/31/2024 stating that resident had an ADL self-care performance deficit related to right above the knee amputation and muscle weakness with an approach that resident requires Mechanical Lift (Hoyer) with 2 staff assistance for transfers.Review of Resident #161's medical record and other pertinent documentation on 07/18/2025 at 10:00 AM revealed that on 05/09/2025 prior to going to dialysis, Staff #7 and #8 assisted and transferred the resident using stand/pivot to a wheelchair and did not use a Hoyer lift. While performing this transfer the resident stated ouch and that staff #8 had stepped on his/her foot but was ok.Per facility progress note dated 05/09/2025 at 18:36 PM, resident returned to facility from dialysis in stable condition and denied pain. Per facility progress note dated 05/10/2025 at 09:25 AM resident complained of left leg/foot pain, the doctor was notified and new orders for stat x-ray to left leg and foot were given and as well resident was medicated for pain. Radiology Results Report dated 05/10/2025 revealed no evidence of fracture. During an interview on 07/18/2025 at 2:27 PM the Director of Nursing stated and confirmed that on 05/09/2025 staff #7 and #8 failed to transfer Resident #161 with a Hoyer lift. During review of facility investigation staff statements on 07/21/2025 at 10:05 AM revealed that Staff #7 and #8 were aware that Resident #161 required a 2 person Hoyer lift and had participated in the stand, turn pivot transfer of Resident #161 on 05/09/2025 prior to going to dialysis.

Based on medical record reviews and interviews, it was determined that the facility failed to ensure that resident medical records were accurate. This was evident for 2 (Resident #310 and #84) out of 6 residents reviewed during the facility's recertification survey.The findings include: 1. On 07/18/25 at 10:56 AM, review of resident records revealed that Resident #310's care plan referred to Resident #310 as [incorrect resident name]. On 07/18/25 at 12:38 PM, the Director of Nursing staff #2 was interviewed. During the interview, Staff #2 was made aware that Resident #310's care plan referred to Resident #310 with the incorrect resident name. Staff #2 stated that the facility will correct Resident #310's care plan. 2. During an interview on 7/15/25 at 9:58AM Unit Manager #17 stated to the surveyor that GNA #18 had went to find help from another staff member because the resident required the transfer assistance of two staff. On 7/17/25 at 11:45AM the surveyor reviewed the medical record of Resident #84 which revealed the following care plan intervention in place dated as initiated on 5/19/25 by Licensed Practical Nurse (LPN) #19: TRANSFER: The resident requires Mechanical Lift/Hoyer transfer by 1-2 staff assistance for transfers. Review of the facility's safe transfers policy by the surveyor on 7/17/25 at 12:00PM revealed the following documented information: PROCEDURE: Mechanical Lifts: .All mechanical lift activities require two-person trained staff during the transfer process, .Hoyer Lifts: Two-person transfer is required for all Hoyer Lift transfers from the initiation of the lift pad to the end product of the lifting process. Review on 7/17/25 at 12:03PM of the facility's nursing education department clinical orientation packet for geriatric nursing assistants was provided by the facility's Director of Nursing (DON) in response to an inquiry made by the surveyor as to training provided to Geriatric Nursing staff upon hire with regard to the use of Hoyer Lifts revealed a document titled: Mechanical Lift practice session which included the following information regarding use of the mechanical lift: Two person use ALWAYS. On 7/17/25 at 12:44PM the surveyor conducted an interview of the facility's DON and inquired to them as to why the care plan intervention for Resident #84 stated 1-2 assistance for transfers when they required a mechanical lift, to which they replied: It should say 2 person assist. At this time the surveyor shared their concern with the DON who acknowledged and confirmed understanding of the concern. On 7/18/25 at 10:14AM the surveyor conducted another interview of the Director of Nursing who stated the following information to surveyors: the care plan of 1-2 assist was in error, the nurse toggled 1-2, It was corrected on the care plan. When the surveyor further inquired as to the toggling required, the Director of Nursing stated: s/he (Licensed Practical Nurse #19) wrote that. On 7/18/25 at 10:30AM the surveyor reviewed documentation provided by the facility's Administrator and DON which revealed the following care plan intervention for Resident #84 which was revised by the Director of Clinical Informatics #20 on 7/17/25: TRANSFER: The resident requires Mechanical Lift/Hoyer transfer by 2 staff assistance for transfers.

Based on record reviews and interviews, it was determined that the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment. This was evident for 3 residents (#161, #3, #55) out of 9 residents investigated during the survey.The findings include:Enhance Barrier Precautions (EBP): Enhanced Barrier Precautions are used as an infection control intervention that uses targeted gown and glove use during high-contact resident care activities in nursing homes to reduce the transmission of multidrug-resistant organisms (MDROs).1. On 07/15/2025 at 3:30 PM during the surveyor's follow-up observation rounds of the 1st Floor [NAME] Unit, while also accompanied by the Unit Manager #22, Resident #55 was observed in the room from the hallway through the completely ajar door and no privacy curtain in use. There was an Enhanced Barrier Precaution sign present on the door. Resident #55 was seated in a wheelchair next to the door-side bed, while Wound Nurse #21 sat cross-legged directly on the bare floor and had dressing gauze supplies directly on the bare floor while performing wound care to the resident's left lower extremity; no protective barrier was observed on the floor under the staff or the dressing supplies.On 07/15/2026 at 3:31 PM the surveyor conducted an interview of Unit Manager #22 who confirmed the same observation of the Wound Nurse #21 and the wound care supplies on the bare floor during dressing changes to Resident #55 left lower extremity. Unit Manger #22 stated Wound Nurse #22 would be reported to the Director of Nursing #2.On 07/16/2025 at 3:46 PM surveyor conducted an interview with Director of Nursing #2, who stated that the wound care dressings were redone, and specimens were taken of the wound, and Wound Nurse #21 received disciplinary actions.On 07/22/25 at 1:30 PM during record review it revealed Wound Care #21 received a final written warning for being observed on 07/15/25 doing a heel dressing with resident in chair. Supplies were on the floor and in-service training 'Infection Control-Skills Validation' on 07/16/25.2. On 07/15/25 9:25 AM During observation rounds, no Enhanced Barrier Precautions signs were observed on the door of Resident #161 & #3.On 07/16/25 9:09 AM During medical record review it revealed Resident #161 orders for Enhanced Barrier Precautions related to dialysis catheter. Use precautions during high-risk activities No room restriction is required every shift; ordered on 07/09/25 at 19:00.On 07/16/25 9:15 AM During medical record review it revealed Resident #3 orders for Enhanced Barrier Precautions related to multiple wounds. Use precautions during high-risk activities No room restriction is required every shift; ordered on 06/27/25 at 19:00.On 07/23/25 at approximately 3:00PM the surveyor shared the concern of maintaining infection control and prevention for the residents during the exit conference with the facility's Administrator, Director of Nursing, and Executive Director.

Based on record reviews and interviews, it was determined that the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents. This was evident for 1 unit out of 9 units investigated during the survey.The findings include:1. On 07/15/25 at 9:21 AM during observation rounds on 1st Floor [NAME] the surveyor observed rooms 164, 166, 168, and 170 bathroom vents were with approximate 1 thick gray fuzzy matter. On 07/15/2025 10:30 AM during interview Unit Manager #22 notified of findings and was informed a request for cleaning was mentioned at the last Ops Meeting in June. On 07/15/2025 at 12:15 PM during interview Nursing Home Administrator #1 and review of facility records it revealed the Ops meeting minutes, held 06/20/25 indicated Nursing Updates: vents in 1K need to be cleaned.2. On 07/15/25 at 9:22 AM during observation rounds on 1st Floor [NAME] Unit the surveyor observed in room [ROOM NUMBER] bathroom with a gouged-out area to the wall approximately 1 1/2 ft. x 1/2 ft. with visible plaster disruption to the wall adjacent to the toilet just above the cove base.On 07/15/25 at 10:30 AM during interview with Unit Manager #22, who was notified of hole in room [ROOM NUMBER] bathroom wall and agreed it was not like a comfortable environment.3. On 07/15/25 at 10:15 AM during observation rounds on 1st Floor [NAME] Unit the surveyor observed in room [ROOM NUMBER] bathroom an over-the-toilet commode with chipped paint revealing brown area to the lateral bar that would potentially meet a resident's lower extremity while commode in use.On 07/15/25 at 11:00 AM during interview with Unit Manager #22, who was notified of chipped paint revealing brown area to lateral bar on over-the-toilet commode in room [ROOM NUMBER] bathroom and agreed this it was not like a comfortable environment.On 07/23/25 at approximately 3:00PM the surveyor shared the concern of maintaining a safe, functional, sanitary, and comfortable environment for residents during the exit conference with the facility's Administrator, Director of Nursing, and Executive Director.

Based on review of a facility reported incident with documentation, medical record review, and staff interview, it was determined the facility failed to protect a vulnerable adult from physical abuse. Due to this deficient practice Resident #34 suffered physical harm. This was evident for 1 (#34) resident reviewed for 27 facility reported incidents reviewed during a complaint survey. The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. The facility's plan and action were verified during this survey; therefore this deficiency was found to be past noncompliance with a compliance date of 10/16/23. The findings include: On 3/27/25 at 3:03 PM a review of facility reported incident MD00198080 alleged that on 10/5/23 at approximately 9:00 AM, GNA #16 was providing morning care to Resident #34. Resident #34 was swinging his/her arms at GNA #16, and LPN #15 witnessed the interaction. According to GNA #16, LPN #15 came running in the room, got close to Resident #34, then walked back to close the door. LPN #15 came back rushing and slapped Resident #34 in the face hard on the right side at the top of the face. LPN #15 allegedly stated, don't you ever [expletive] do that again. Isn't there something you need to say? You need to apologize. Review of the documentation in the facility report revealed that Resident #34 was a resident with a diagnosis of paraplegia, epilepsy, intellectual disability and aphasia following a nontraumatic subarachnoid hemorrhage in 2019 along with multiple co-morbidities. Review of the facility's investigation documented a written statement from GNA #16 dated 10/6/23 that stated, yesterday, on October 5, 2023, I [name of GNA #16] witnessed the nurse [name of LPN #15] slap the resident [name of Resident #34] in the face. It was between 8:30 AM and 9:00 AM. The note continued to document that GNA #16 was getting Resident #34 dressed for breakfast and the resident wanted his/her socks on because his/her feet were getting cold. GNA #16 told the resident no because his/her foot had to get a bandage. Resident #34 kept asking and GNA #16 kept saying no. GNA #16 documented that the resident turned to the side and when he/she turned around he/she went to swing at GNA #16 but wasn't close enough. LPN #15 saw what was going on and came running in. LPN #15 came close to Resident #34 then walked back to close the door. LPN #15 came back rushing and slapped Resident #34 in the face hard on the right side at the top. Resident #34 became quiet. After LPN #15 yelled at the resident he left and GNA #16 finished getting Resident #34 ready. GNA #16 documented, I was scared to speak because of retaliation. GNA #16 documented that LPN #15 created a hostile environment and was always loud and yelling, so she didn't want him to do anything to her. GNA #16 documented that Resident #34, didn't deserve that. No matter how mad you get that the resident hitting is wrong and should never happen. [He/she] didn't deserve that. I had to speak up, so it didn't happen again. GNA #58 documented in a written statement that she saw LPN #15 slam the door. When [name of GNA #16] came to me the next day and told me what happened, I told her to report the incident immediately. GNA #58 also documented that she was joking with a resident and asked the resident if he/she was staying up past 2 PM and the resident stated no because when he/she did the other day, LPN #15 yelled at him/her. Review of Resident #34's medical record revealed a 10/6/23 at 10:47 AM physician's progress note that documented, chief complaint, patient was seen for c/o (complaint of) headache after being struck in [his/her] head. The assessment/plan documented, headache after being struck - pending ER transfer to r/o (rule out) head injury or other acute process. Continue Acetaminophen. A 10/7/23 at 10:34 AM physician's note documented, I was asked to evaluate the patient. Patient was reportedly abused by a staff member. Patient was not reported to have any significant injuries. Patient however was referred to the emergency room for evaluation. Patient has returned from the emergency room . No significant abnormalities were found. Patient had a CT scan of the head and C-spine which were unremarkable. On 3/31/25 at 2:45 PM an interview was conducted with GNA #16. GNA #16 stated that she was trying to clean Resident #34 up and the resident was in a mood and was trying to hit her. GNA #16 stated she tried to redirect. GNA #16 stated the power had gone out and all of a sudden she saw LPN #15 in the room and LPN #15 slapped Resident #34 in the face and she was stunned. He cussed at the resident and left the room. GNA #16 stated Resident #34 was holding his/her face, and his/her face was red, and Resident #34 had a look on his/her face like he/she was used to it, and it wasn't the first time it happened. GNA #16 stated she asked Resident #34 if he/she was ok. GNA #16 stated, I had never seen that before. The surveyor asked GNA #16 if she reported it immediately and she stated, no, I did not tell anyone because I was scared because [name of LPN #15] was very confrontational, revenge, he is tit for tat. The next day when I came to work is when I reported it. It happened between 8 and 9 in the morning. The rest of the day [name of LPN #15] went on carefree like nothing happened. GNA #16 stated, I told the nurse the next day and I just went to administration because I was so nervous. I reported it to the infection nurse first. I asked for the DON (Director of Nursing) and then I reported it to the Nursing Home Administrator. I was very emotional. They took the necessary steps, and I wrote my statements. I had to go to the Board of Nursing and give my statement again. GNA #16 stated that she was educated after the incident about reporting immediately. Cross Reference F609 On 4/1/25 at 10:47 AM an interview was conducted with the DON who confirmed the incident was not reported timely by the staff member. The DON was not employed at the facility at the time of the incident. Review of LPN #15's personnel file revealed LPN #15 was initially a GNA back in 2012 at the facility. On 10/28/13 he was written up for behavior. On 4/11/13 he was written up for being rude and insubordinate and on 11/19/13 was given a written warning with suspension due to intimidation and insubordination. On 3/25/14 he was written up because he was overheard using language that was not appropriate to one of the residents. On 4/11/17 he received verbal counseling for speaking harshly. LPN #15 became an LPN, and on 1/9/19 was put on an action plan for performance as he left medications in a resident's bed. On 8/12/21 he refused to acknowledge an RN, ICP (infection control practitioner) when instructed on the requirement for wearing a face shield while the facility was in a COVID-19 outbreak. He had an insubordinate attitude. On 8/28/23 he received a performance management write up. The facility's administration reported LPN #15 to the Board of Nursing after the incident on 10/6/23. Review of the nurse educator's binder for sign-in sheets for education revealed abuse training in October 2023. There was a paper that said, please read and sign! All staff! The training began on 10/6/23 and continued to 10/16/23.

Based on reviews of facility reported incidents, complaint, record review, and interview, it was determined the facility failed to report allegations of abuse to the regulatory agency, the Office of Health Care Quality (OHCQ) within 2 hours of the allegation and failed to report bruises of unknown origin to OHCQ. This was evident for 12 (#22, #24, #47, #4, #56, #34, #42, #7, #21, #25, #19, #36 ) of 71 residents reviewed during a complaint survey. The findings include: 1) On 3/26/25 at 11:47 AM a review of facility reported incident MD00195422 was conducted. The Executive Director was contacted by licensed practical nurse (LPN) #84 who stated the family of Resident #22 alleged that geriatric nursing assistant (GNA) #85 handled Resident #22 abruptly while providing care on 8/10/23. Review of the facility's investigation revealed the alleged incident happened on 8/10/23 at 11:00 AM. This is when the nurse became aware of the incident. Review of the email confirmation to OHCQ revealed the initial report was not submitted until 8/10/23 at 7:02 PM, which was not within 2 hours of alleged abuse. On 4/1/25 at 10:43 AM the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the findings. 2) On 3/26/25 at 1:30 PM a review of facility reported incident MD00204743 was conducted. Resident #24 alleged on 4/13/24 at approximately 7:30 PM the GNA pushed him/her onto the bed and then lifted Resident #24's legs up into the bed and said the resident needed to go to bed. The resident felt the GNA should not have put him/her to bed. Review of the facility's investigation revealed the charge nurse was informed on 4/15/24 at approximately 11:00 AM. The Nursing Home Administrator was notified on 4/15/24 at approximately 12:45 PM. Review of the email confirmation revealed the initial report was not sent to OHCQ until 4/15/24 at 6:12 PM, which was not within 2 hours of alleged abuse. On 4/1/25 at 10:42 AM an interview was conducted with the DON. The DON confirmed that it was not reported timely. Reviewed the regulation with the DON who stated she would start educating staff. 3) On 3/27/25 at 9:26 AM a review of facility reported incident MD00192305 was conducted. Resident #47 alleged to the weekend supervisor that on 5/14/23, LPN #77 grabbed and shouted at the resident. Review of the email confirmation to OHCQ revealed the initial report was not sent in until 5/15/23 at 12:32 PM. The weekend supervisor failed to notify the facility's administration on 5/14/23 when he became aware of the incident. On 4/1/25 at 10:47 AM an interview was conducted with the ADON. She stated the supervisor did not call right away and that he sent an email. We got notified on Monday. He should have called immediately. 4) On 3/27/25 at 10:40 AM a review of facility reported incident MD00213903 was conducted. Resident #4 alleged that staff tried to strangle him/her and choke him/her to death. This was reported to the nurse on 1/23/25 at 7:00 PM. Review of the facility's investigation revealed an email confirmation dated 1/24/25 at 12:12 PM of when the initial report was sent to OHCQ. The incident was not reported within 2 hours of alleged abuse. On 4/8/25 at 2:11 PM an interview was conducted with the DON who confirmed the findings. 5) On 3/27/25 at 11:10 AM a review of facility reported incident MD00189796 was conducted. On 3/3/23 the Director of Rehabilitation was made aware by a therapist working with Resident #56 that the resident was intimidated and afraid of GNA #82. On 3/6/23, upon receiving notification via email from the Director of Rehabilitation, the nurse manager brought GNA #82 into the office for an interview regarding the concerns and was suspended pending investigation. Review of the email confirmation for the initial self-report to OHCQ documented the report was sent on 3/6/23 at 5:02 PM. The Director of Rehabilitation failed to immediately report the concerns to administration. On 3/27/25 at 11:31 AM the NHA informed the surveyor that the Director of Rehabilitation was no longer at the facility and confirmed the findings. 6) On 3/27/25 at 3:03 PM a review of facility reported incident MD00198080 was conducted. GNA #16 alleged that LPN #15 slapped Resident #34 in the face, hard, on the right side at the top on 10/5/23 at approximately 9:00 AM. Review of the facility's investigation revealed administration did not become aware of the incident until the next morning on 10/6/23. On 3/31/25 at 2:45 PM an interview was conducted with GNA #16 who stated, no, I did not tell anyone because I was scared because [LPN #15] was very confrontational. GNA #16 stated, I told the nurse the next day and I just went to administration because I was so nervous. On 4/1/25 at 10:47 AM the DON confirmed the incident was not reported timely. 7) On 3/28/25 at 7:59 AM a review of facility reported incident MD00191414 was conducted. Resident #42 alleged on 4/17/23 that during care GNA #88 was screaming at the resident and was rough when she assisted Resident #42 in bed causing pain to the right wrist. Review of the facility's investigation revealed the incident happened on 4/17/23 at 6:30 PM. An email was sent to the previous Director of Nursing from RN #87 on 4/17/23 at 8:22 PM documenting the incident. Review of the email confirmation as to when the initial report was sent to OHCQ was dated 4/18/23 at 10:21 AM which was not within 2 hours of the alleged abuse. On 4/1/25 at 10:43 AM the DON confirmed it was not reported timely. 8) On 3/31/25 at 8:34 AM a review of complaint MD00212199 was conducted. The complainant alleged that Resident #7 was hit by his/her aide. The complaint alleged Resident #7 had a bruise on his/her face from the incident. The complaint also alleged that the story was changed and now was saying the aide hit the resident by accident while being changed. Review of a 11/22/24 at 2:30 PM SBAR (change in condition note) documented, around 0815 writer was called to room by GNA. GNA had just walked into the room and noticed bruising to left peri-orbital region with a small gash to left eyebrow. Resident initially stated that [he/she] was hit with a dish. Then stated that [he/she] was turned over (in bed) and hit [his/her] head. A 11/22/24 at 3:33 PM nursing progress note documented, Has bruising to left eye, inner canthus of eye and on bridge of nose and spreading to upper cheek. A 11/22/24 at 7:11 PM provider note documented assessment and plan, left eye hematoma: unknown etiology. Nursing staff believed this might have likely occurred during repositioning. A 11/26/24 at 10:19 PM provider note documented, left eye hematoma: unclear etiology. Ecchymosis extending to left jaw, periorbital area and nasal bridge. Ophthalmology consult pending for further evaluation. On 4/3/25 at 3:27 PM the DON was interviewed and asked if the incident was reported to OHCQ. The DON stated no because she determined it was from the side rail, the way the resident was lying in bed, and she stated that they put padding on the side rails. On 4/4/25 at 1:00 PM Nurse Practitioner (NP) #56 was interviewed and stated she did a head to toe assessment on the resident and that the resident had dementia so really couldn't follow instructions. NP #56 stated it was a significant bruise. I am not sure how it got there. I could not say it was from the side rail. That is why I wanted [him/her] to be seen by an ophthalmologist. I am not really sure what happened. On 4/7/25 at 9:50 AM an interview was conducted with LPN #60. LPN #60 was asked why she put a late note in the medical record. The note was dated 11/21/24 at 9:23 AM but not put into the medical record until 11/27/24 at 10:31 AM. LPN #60 stated, I felt like I needed to protect myself. When I came back to work and I saw the bruise I thought, what happened to [him/her], and I know the family would make a big deal. I was told that when they got [him/her] up from the bed that [he/she] hit her eye on the side rail. [He/she] is the type of person that fights. On 4/7/25 at 3:20 PM the issue was discussed with the NHA who stated, we know how it happened; it was because of the way [he/she] was leaning up against the side rail. 9) On 4/1/25 at 8:05 AM a review of facility reported incident MD00206143 was conducted. Resident #21 alleged to the unit manager and to security that a GNA on Saturday, May 25, 2024, on the 3:00 PM to 11:00 PM shift, assisted the resident with incontinency. According to the resident, the incontinent brief was left off and the resident urinated on him/herself. The resident alleged that after he/she put the call light on, GNA stated If you press the button again, I am going to drag you off this bed. Review of the facility's investigation documented that the facility staff became aware on 5/28/24 at 11:30 AM. Review of the email confirmation to OHCQ, the initial report was not submitted until 5/28/24 at 6:36 PM, which was not within 2 hours of the allegation of abuse. On 4/1/25 at 10:47 AM an interview was conducted with the DON. The DON confirmed that it was not reported within 2 hours. The DON stated she thought they had 24 hours to report alleged abuse. 10) On 4/1/25 at 9:21 AM a review of facility reported incident MD00204323 was conducted. Resident #26 alleged on 3/30/24 that the GNA was removing the resident's clothes for bed and the GNA pulled the resident's clothes hard. Resident #26 had a typed statement that documented, I do not want her again. She was rough. Resident #26 had multiple contractures due to spastic cerebral palsy. Resident #26 did not report the incident to the nurse manager until 4/2/24 at 9:00 AM. Review of the email confirmation of the initial report sent to OHCQ documented it was not sent until 4/3/24 at 7:51 PM. On 4/8/25 at 2:12 PM an interview was conducted with the DON who confirmed the incident was not reported timely. 11) On 4/1/25 at 10:21 AM a review of facility reported incident MD00194802 was conducted. Resident #42's daughter alleged to the facility that Resident #42 was in the hospital and informed the daughter that he/she was upset because of a relationship with a nurse at the facility and alleged possible elder abuse. Review of the facility's investigation revealed that the facility was notified on 7/25/23. Review of the email confirmation of when the initial report was sent to OHCQ documented it was sent on 7/26/23 at 4:06 PM, which was not within 2 hours of being notified. Additionally, review of the facility's investigation revealed a statement from GNA #78 that on 7/23/23 GNA #78 told LPN #79 that Resident #42 had a crush on him/her. I then told LPN #80 and LPN #81 to report this because the patient would report to someone. The incident was not reported to nursing administration. On 4/8/25 at 2:20 PM an interview was conducted with the ADON. The ADON stated they found out the next day. The ADON stated that staff should have reported it immediately. On 4/1/25 at 10:42 AM the report was reviewed with the DON. The DON confirmed that it was not reported timely. Reviewed the regulation with the DON who stated she would start educating staff. 12) On 4/1/25 at 2:16 PM a review of facility reported incident MD00206651 was conducted. Resident #19 alleged that GNA #86 was rough when helping the resident while trying to stand. Review of the facility's investigation revealed an email from RN #87, dated 6/12/24 at 8:42 PM, that was sent to the Nursing Home Administrator that stated Resident #19 alleged GNA #86 was rough with the resident. Review of the email confirmation that was submitted to OHCQ when the initial report was sent was dated 6/13/24 at 2:56 PM. The report was not submitted within 2 hours of alleged abuse. On 4/3/25 at 12:21 PM the DON confirmed that the report was not sent to OHCQ within 2 hours of alleged abuse. 34484 13). Review of Resident #36's medical record on 3/27/25 revealed the Resident was admitted to the facility in 2017 with a diagnosis to include dementia. Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life. Further review of Resident's medical record revealed from 8/29/23 until 9/26/23 the Resident was observed to have 3 different bruises. a) A nurse's note on 8/29/23 at 2:21 PM stated GNA (geriatric nursing assistant) reported new area on patient's right side of neck. RN assessed 1.2 cm by 6 cm. Bruise noted with no swelling or pain. b) A nurse's note on 9/5/23 at 12:19 PM stated reported by hospice aide that resident has a bruise to bottom lip. Upon assessment a 0.2 cm bruise observed to the center of bottom lip. c) A nurse's note on 9/26/23 at 10:40 AM stated at 7:05 AM Resident observed to have a bruise 1.5 cm by 1.0 cm to left outer eye. No swelling or evidence of pain. Interview with the Administrator on 4/2/25 at 8:00 AM confirmed the facility had no evidence 3 injuries of unknown origin were reported to the Office of Health Care Quality.

Based on review of facility administrative records, facility investigations, complaint, medical record review, and staff interview, it was determined the facility failed to thoroughly investigate incidents of alleged abuse, neglect, and bruises of unknown origin. This was evident for 10 (#22, #65, #47, #4, #56, #42, #7, #26, #19, #36) of 71 residents reviewed during a complaint survey. The findings include: 1) On 3/26/25 at 11:47 AM a review of facility reported incident MD00195422 was conducted. The Executive Director was contacted by licensed practical nurse (LPN) #84 who stated the family of Resident #22 alleged that geriatric nursing assistant (GNA) #85 handled Resident #22 abruptly while providing care on 8/10/23. Review of the facility's investigation revealed a typed statement from a Sister that documented Resident #22 kept saying, I hate that woman; I don't want her to touch me again. When the nurse went in the room with GNA #85, Resident #22 appeared frightened when she saw GNA #85. A written statement from the nurse documented that the resident said he/she was hit and afraid he/she was going to fall. The resident got visibly upset and documented that GNA #85 was the aide. There were no other resident or staff interviews about the care that GNA #85 gave to residents to be able to determine if this was a pattern with GNA #85 and if other residents felt the same way. On 4/1/25 at 10:43 AM the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the findings. 2) On 3/26/25 at 11:47 AM a review of complaint MD00205135 was conducted. On 4/27/24 Resident #22 stated, she beat me up. Review of the facility investigation revealed the 2 Sisters that oversaw the residents on the unit were interviewed along with GNA #89. There was 1 written statement from LPN #90. There were no other staff or resident interviews or assessments done. On 4/3/25 at 12:39 PM an interview of both the DON and ADON was conducted. The DON stated that they felt the bruising was from the way the resident gripped the armrests of the wheelchair, and that the resident was always very anxious and afraid of falling. Since they determined that the bruising was from how the resident gripped the wheelchair, they did not feel the need to interview other residents or staff. 3) On 3/27/25 at 7:56 AM a review of facility reported incident MD00177782 revealed the family member of Resident #65 and Resident #65 alleged that Geriatric Nursing Assistant (GNA) #4, who took care of Resident #65 in the morning, used foul language and hurt the resident's arm. Staff #5 wrote a statement on 4/19/22 that documented on 4/19/22 at 7:45 AM Staff #5 walked into Resident #65's room and the resident was teary and stated the GNA yelled at the resident. Staff #6 wrote a statement on 4/19/22 that documented that Resident #65 was taken closer to the manager's office and offered to tell the manager what happened with Resident #65. Staff #6 documented the resident said no because the resident told others and nothing happened. This made the resident afraid that the person would find out. Staff #6 documented that the resident expressed that the person has been doing this and the resident has told before and the person is still allowed to work with the resident. Further review of the investigative packet failed to produce documentation that any other residents on the unit were interviewed about the care they received from GNA #4. On 3/27/25 at 8:08 AM an interview was conducted with the Nursing Home Administrator (NHA). The NHA was asked what the process was for investigating allegations of abuse. The NHA stated, see who the complaint involves, involve certain departments, but most of the time it is nursing. Typically nursing takes the lead, talk to resident, family member, staff. And then move forward. Look at employee personnel files to see if there is a history of allegations about the staff member. The NHA was asked if they ever interview other residents on the unit and she said it depended on the complaint. They will interview residents on a GNAs assignment but typically would look at the employee's personnel file to see if there were other write-ups or incidents regarding care. The NHA was asked if they did not do resident interviews how would they know if there were any other complaints. As in Resident #65, the resident was afraid to speak up. What if other residents were afraid to speak up. The NHA expressed understanding of interviewing other residents. 4) On 3/27/25 at 9:26 AM a review of facility reported incident MD00192305 was conducted. Resident #47 alleged to the weekend supervisor that on 5/14/23, LPN #77 grabbed and shouted at the resident. Review of the facility's investigation revealed a hand written statement from LPN #77 that documented the events of 5/14/23, an email from the social worker, and 2 typed interviews of Resident #47. There were no other staff interviews. There was no statement from the weekend supervisor and there were no other resident interviews from the unit that Resident #47 resided on. On 4/1/25 at 10:47 AM an interview was conducted with the ADON who confirmed the findings. 5) On 3/27/25 at 10:40 AM a review of facility reported incident MD00213903 was conducted. Resident #4 alleged that staff tried to strangle him/her and choke him/her to death. This was reported to the nurse on 1/23/25 at 7:00 PM. Review of the facility's investigation revealed a statement from a GNA on the 3-11 shift, a statement from staff coming on duty at 7:00 PM, a nurse that was on the medication cart, and a nurse that had just come on duty at 7:00 PM. The abuse investigation form documented, resident had a fall in the evening. When questioned about the fall, [he/she] reported to this writer that the GNA strangled [him/her] while changing [his/her] clothes and then hit [him/her] in the neck. There was no documentation that resident's on the unit were interviewed about the care that GNAs gave and if they felt safe or assessed if they were non-verbal or unable to cognitively communicate with staff. On 4/8/25 at 2:11 PM an interview was conducted with the DON. The DON confirmed that residents on the unit were not interviewed during the investigation. 6) On 3/27/25 at 11:10 AM a review of facility reported incident MD00189796 was conducted. On 3/3/23 the Director of Rehabilitation was made aware by a therapist working with Resident #56 that the resident was intimidated and afraid of GNA #82. On 3/6/23, upon receiving notification via email from the Director of Rehabilitation, the nurse manager brought GNA #82 into the office for an interview regarding the concerns and was suspended pending investigation. Review of the facility's investigation failed to produce any other staff or resident interviews. The investigation was incomplete. On 3/27/25 at 11:31 AM an interview was conducted with the NHA who stated that the information the surveyor had was the investigation. There were no other staff or resident interviews. 7) On 3/28/25 at 7:59 AM a review of facility reported incident MD00191414 was conducted. Resident #42 alleged on 4/17/23 that during care GNA #88 was screaming at the resident and was rough when she assisted Resident #42 in bed causing pain to the right wrist. Review of the facility's investigation revealed the incident happened on 4/17/23 at 6:30 PM. Review of the investigation revealed 6 staff members were interviewed including the accused GNA. There were no interviews of residents that resided on the unit to determine if they felt safe and if they ever had any abuse issues. On 3/28/25 at 9:16 AM an interview was conducted with the DON and ADON. The ADON stated, I immediately let the DON know if there are any accusations and I do a self-report, skin assessment, do interviews of GNAs and prior GNAs that worked with the resident prior to the assigned GNA, to validate at what point the incident could have occurred. I make notifications to the provider, and I let the family know. The self-report has to be done within 2 hours. I check in with other residents. Say it is other residents that have not spoken up and the social worker can get involved and interview them. On 4/1/25 at 10:43 AM the DON confirmed the findings. 8) On 3/31/25 at 8:34 AM a review of complaint MD00212199 was conducted. The complainant alleged that Resident #7 was hit be his/her aide. The complaint alleged Resident #7 had a bruise on his/her face from the incident. The complaint also alleged that the story was changed and now was saying the aide hit the resident by accident while being changed. Review of a 11/22/24 at 2:30 PM SBAR (change in condition note) documented, around 0815 writer was called to room by GNA. GNA had just walked into the room and noticed bruising to left peri-orbital region with a small gash to left eyebrow. Resident initially stated that [he/she] was hit with a dish. Then stated that [he/she] was turned over (in bed) and hit [his/her] head. A 11/22/24 at 3:33 PM nursing progress note documented, Has bruising to left eye, inner canthus of eye and on bridge of nose and spreading to upper cheek. A 11/22/24 at 7:11 PM provider note documented assessment and plan, left eye hematoma: unknown etiology. Nursing staff believed this might have likely occurred during repositioning. A 11/26/24 at 10:19 PM provider note documented, left eye hematoma: unclear etiology. Ecchymosis extending to left jaw, periorbital area and nasal bridge. Ophthalmology consult pending for further evaluation. On 4/3/25 at 3:27 PM the DON was interviewed and asked if the incident was reported to OHCQ. The DON stated no because she determined it was from the side rail, the way the resident was lying in bed, and she stated that they put padding on the side rails. The DON stated, there was not an investigative report or anything. What is in the chart is what we investigated. On 4/4/25 at 1:00 PM Nurse Practitioner (NP) #56 was interviewed and stated she did a head to toe assessment on the resident and that the resident had dementia so really couldn't follow instructions. NP #56 stated it was a significant bruise. I am not sure how it got there. I could not say it was from the side rail. That is why I wanted [him/her] to be seen by an ophthalmologist. I am not really sure what happened. On 4/7/25 at 3:20 PM the issue was discussed with the NHA who stated, we know how it happened; it was because of the way [he/she] was leaning up against the side rail. On 4/8/25 at 9:25 AM the NHA gave the surveyor a write up of the situation. The concern on the write-up documented, we did not report to OHCQ as we were able to interview staff, ask the resident immediately on finding the bruise, and the bruise matched to the area of the bedrail. The note continued, While at first [he/she] said a dish was thrown, [he/she] then said [he/she] thought [he/she] hit [his/her] head on the bedrail. There were no staff interviews provided. The NHA documented in the write up, Two officers came in to the facility, spoke to the DON, LNHA, Nurse manager and saw the resident. With the level of dementia, the resident could not state what happened. The NHA stated that the police could not substantiate the allegation. Cross reference F609 9) On 4/1/25 at 9:21 AM a review of facility reported incident MD00204323 was conducted. Resident #26 alleged on 3/30/24 agency GNA #83 was removing the resident's clothes for bed and GNA #83 pulled the resident's clothes hard. Resident #26 had a typed statement that documented, I do not want her again. She was rough. Resident #26 had multiple contractures due to spastic cerebral palsy. Review of the facility's investigation revealed a typed statement from the resident. There were no staff interviews and there were no other resident interviews that resided on the unit. On 4/8/25 at 2:12 PM an interview was conducted with the DON who confirmed that other residents on the unit were not interviewed if they felt safe or had any problems with GNA #83 and there were no staff interviews. 10) On 4/1/25 at 10:21 AM a review of facility reported incident MD00194802 was conducted. Resident #42's daughter alleged to the facility that Resident #42 was in the hospital and informed the daughter that he/she was upset because of a relationship with a nurse at the facility and alleged possible elder abuse. Review of the facility's investigation revealed the facility conducted staff interviews but failed to conduct any interviews of residents that were under the care of LPN #79. On 4/8/25 at 2:20 PM the ADON confirmed that they did not interview any residents under the care of LPN #79. 11) On 4/1/25 at 2:16 PM a review of facility reported incident MD00206651 was conducted. Resident #19 alleged that GNA #86 was rough when helping the resident while trying to stand. Review of the facility's investigation revealed an email from RN #87, dated 6/12/24 at 8:42 PM, that was sent to the Nursing Home Administrator that stated Resident #19 alleged GNA #86 was rough with the resident. A concern form was filled out by the previous social worker that documented the Resident #19's daughter emailed the unit social worker and unit manager with direct care staff concerns. The daughter reported a GNA gripped the resident too hard and was rough with the resident. The daughter reported she would call the police if incidents continue. There was a typed statement from the unit manager and 2 typed statements from the DON. There were no other staff interviews and there were no interviews of residents that resided on the unit asking if they felt safe or if anyone had ever been rough with them. The investigation was incomplete. On 4/3/25 at 12:21 PM an interview was conducted with the DON who stated that they did not have any resident interviews or any other staff interviews. 34484 12) Review of Resident #36's medical record on 3/27/25 revealed the Resident was admitted to the facility in 2017 with a diagnosis to include dementia. Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life. Further review of Resident's medical record revealed from 8/29/23 until 9/26/23 the Resident was observed to have 3 different bruises. a) A nurse's note on 8/29/23 at 2:21 PM stated GNA (geriatric nursing assistant reported new area on patient's right side of neck. RN assessed 1.2 cm by 6 cm. Bruise noted with no swelling or pain. b) A nurse's note on 9/5/23 at 12:19 PM stated reported by hospice aide that resident has a bruise to bottom lip. Upon assessment a 0.2 cm bruise observed to the center of bottom lip. c) A nurse's note on 9/26/23 at 10:40 AM stated at 7:05 AM Resident observed to have a bruise 1.5 cm by 1.0 cm to left outer eye. No swelling or evidence of pain. Interview with the Administrator on 4/2/25 at 8:00 AM confirmed the facility had no evidence 3 injuries of unknown origin were thoroughly investigated to include staff and resident interviews. On 4/7/25 at 9:18 AM an interview was conducted with the social worker (SW). The SW was asked if she was involved in abuse investigations. The SW stated that they would ask her if she could talk to the resident. The SW stated, I don't always hear if something has happened. They usually want me to ask the resident particular questions. They have had me interview other residents. It has not been all the time and not standard to interview other residents on the unit. They will have me interview aides. To be honest, unless I am directed to do it, I am not involved.

Based on observations, interviews with staff, and review of complaint, it was determined that the facility failed to store food and monitor temperatures in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: 1. The facility staff failed to ensure food is served to residents at temperatures to ensure food safety. On [DATE] at 12:29 PM the Surveyor observed lunch meal service to the Residents on the 1 [NAME] nursing unit. At that time the facility staff were setting up meal service and residents were seated in the dining room. After the residents were all served in the dining room the facility staff began to prepare trays for residents who dine in their room at 1:06 PM. At that time the Surveyor requested a test tray and took temperatures. At the same time Staff #36 also took temperatures of the same test tray using a facility's thermometer. Hot foods are to be maintained at 135 degrees or warmer and cold foods are to maintained at 41 degrees or below. The minestrone soup was measured by Staff #36 to be 119 degrees. The fried chicken was was measured by Staff #36 to be 119 degrees. The macaroni and cheese was measured by Surveyor to be 135 degrees. The broccoli was measured by Staff #36 to be 100 degrees. The pudding was measured by Staff #36 to be 74 degrees. The milk was measured by Staff #36 to be 46 degrees. Observation revealed the soup, fried chicken, broccoli, pudding and milk were not at the proper food safety temperatures on the test tray. The observations were confirmed by Staff #36. Findings were reviewed with the Administrator on [DATE] at 1:30 PM. 2. Food was not stored in the kitchen per professional standards. a) Observation in the kitchen freezer #3 on [DATE] at 10:59 AM with Staff #67 revealed chicken nuggets and hot dogs that were wrapped in plastic with no expiration date on the package. Findings were reviewed with the Administrator on [DATE] at 1:30 PM. 31145 On [DATE] at 1:00 PM a review of complaint MD00208499 alleged there was molded food and expired food constantly being handed out to residents and that the dinner area was very unsanitized. 3. Food was not dated and labeled in the kitchen refrigerator and freezer. On [DATE] at 1:30 PM a tour of the kitchen was conducted. Prior to touring the kitchen, the surveyor informed Staff #30, the Director of Dining and the Chef, Staff #29. Observation was made in refrigerator #7 of a storage cart inside the refrigerator to the right of the door that was holding boxes, eggs, and a container of brown ground meat. The second tray pan had mashed potatoes. There were no dates on the eggs, ground meat or mashed potatoes. There was left over ziti dated ,d+[DATE] on the shelf. Staff #29 and #30 stated that they were using those items for lunch and did not need to date them. Review of the menu that was given to the surveyor on [DATE] at 1:22 PM from Staff #67, documented for lunch was chicken rice soup, cheese pizza, tossed salad and dressing and pudding. The alternative was roast beef and Swiss cheese sandwich. Observation was made in Freezer #8 of a hamburger in a box that was open to air and not covered. On [DATE] at 1:22 PM Staff #67, the patient service manager, was interviewed and said, anything that goes in that refrigerator needs to be dated and labeled regardless of when it goes in the refrigerator. The surveyor explained to him what Staff #29 and #30 stated and he said, No, it must be dated and labeled. 4. Facility staff failed to store foods in nourishment/dining rooms on the units in a sanitary manner. On [DATE] at 1:25 PM in the 4 P dining room was a refrigerator/freezer. In the freezer was a Coke cup with red contents that was not dated or labeled. Next to the refrigerator was a counter where food was served. There was a cell phone on the counter and a Coke drink cup on the counter with no name or date. Dietary Aide #31 was interviewed and stated we don't know whose drink it is. The refrigerator is cleaned out about twice per week. On [DATE] at 2:10 PM observation was made in the 3P dining room of a black pocketbook, 2 drinks in plastic cups and a white plastic bag sitting on the counter where food was served. The cups and food were not dated and labeled. In the 3P refrigerator/freezer in the common room at the end of the hall (solarium) was a McDonalds cup filled to about an inch from the top with no name or date on the cup. The sign on the refrigerator door stated, for resident use only. There was also a blue/purple/orange lunch tote with an empty container on top of a half full Tupperware container. There was no name on the lunch tote. In the hallway outside of room [ROOM NUMBER]P sitting on the handrail was an air freshener, a Chobani peach yogurt and chocolate ensure that they were both warm to the touch. On [DATE] at 2:22 PM the unit manager was informed. On [DATE] at 10:05 AM observation was made of the Unit P dining room. There was a cell phone on the food serving counter next to a plastic cup of mandarin oranges. On [DATE] at 2:26 PM the Director of Nursing was informed of all observations. On [DATE] at 8:35 AM an interview was conducted with the Infection control nurses, Staff #62 and #63. Both confirmed that personal items on the counter where food was being served was a sanitary and infection control concern. On [DATE] at 1:53 PM the Nursing Home Administrator was informed about food storage concerns.

Based on review of the facility's and vendor's pest control logs and interviews, the facility failed to maintain an effective pest control program. This was evident for 3 of 8 nursing units (1P, 3P and 3S) and the kitchen during a complaint survey. The findings include: During investigation of multiple complaints from resident families regarding mice sightings in the facility on nursing units 1P, 3S and 3P, the surveyor reviewed on 4/7, 4/8 and 4/9/25 the facility's and vendor's pest control logs from 1/1/25 until 4/8/25 and completed interviews. 1. Review of the facility's pest control logs revealed the following: a) On 1/10/25 facility staff stated they disposed of a dead mouse in room [ROOM NUMBER] last evening b) On 1/30/25 facility staff stated moving recliner chairs in Rooms 315 & 324 there were a lot of mouse droppings. c) On 3/7/25 facility staff stated night nurse stating residents complaining about mice in rooms. d) On 4/4/25 facility staff stated residents states seeing 2 mice in room [ROOM NUMBER] and 148. e) On 4/4/25 facility staff stated mouse seen in room [ROOM NUMBER] last evening ran behind dresser. 2. Review of vendor's pest control logs revealed the following: a) 1/7/25 3 dead mice in kitchen b) 1/14/25 7 dead mice in kitchen c) 1/25/25 3 dead mice in kitchen d) 1/28/25 4 dead mice in kitchen e) 2/4/25 4 dead mice in kitchen e) 2/11/25 2 dead mice in kitchen f) 2/18/25 3 dead mice in kitchen e) 2/25/25 1 dead mouse in kitchen f) 3/4/25 rodent droppings in kitchen, activity in bait stations g) 3/11/25 4 dead mice in kitchen h) 3/18/25 mice captured in upstairs chapel area along with holes found in wall under radiators i) 3/25/25 3 dead mice in kitchen j) 4/1/25 3 dead mice in kitchen k) 4/8/25 2 dead mice in kitchen 3. Interview with Residents on 1P, 3S and 3P nursing units. a) 4/4/25 Resident in room [ROOM NUMBER] stated in the last week, saw a mouse twice run under my bed b) 4/8/25 Resident in room [ROOM NUMBER]A stated 2 days ago saw mouse running in room c) 4/8/25 Resident in room [ROOM NUMBER]A stated couple weeks ago saw a mouse about inch long run under dresser d) 4/8/25 Resident in room [ROOM NUMBER] stated when staff were in room few nights ago the staff told me they saw a mouse e) 4/8/25 Resident in room [ROOM NUMBER] states has 3 bait stations in room and has asked to be checked but doesn't believe anyone has. f) 4/8/25 Resident in room [ROOM NUMBER] states saw a mouse in room few weeks ago g) 4/8/25 Resident in room [ROOM NUMBER]A states saw a mouse 2 days ago h) 4/8/25 Resident in room [ROOM NUMBER]A states saw a mouse 2 days ago at night i) 4/8/25 Resident in room [ROOM NUMBER] states has seen mice in the room running on the floor under dresser but 3 weeks ago looked over and there was a mouse in his/her wheelchair j) 4/9/25 Resident in room [ROOM NUMBER] states has seen mice recently in the evening and night. 4. Interview with resident's family member 4/3/25 8:34 AM Anonymous-the family took a video of the mice chasing each other in the resident's room and just saw 2 mice in the room the other night so they kept their feet off the ground. 5. Interviews with Staff. a) 3/31/25 at 10:17 AM Interview with Staff #52 states they have mice off and on but more since the construction. b) 4/2/25 at 10:40 AM Interview with Staff #26 states has seen mice from time to time. c) 4/2/25 at 10:42 AM Interview with Staff #27 states there are mice off and on but has seen them more recently. During interview with Director of Environmental Services (Staff #61) on 4/7/25 at 12:09 PM, Staff #61 states the pest control vendor comes once a week and more often if needed. The areas we are have problems with mice currently are 3S, 1P and the kitchen. During interview with Staff #61 on 4/9/25 at 10:45 AM, after reviewing vendor pest control logs, the Surveyor reviewed the concerns noted by vendor that are not addressed timely. Staff #61 states he gets the vendor reports and shares the findings with Director of Facilities. Reviewed the vendor report on 3/5/25. Reviewed with Staff #61 on 3/5/25 the vendor had an observation of a gap in the floor in the kitchen. Staff #61 stated it is being fixed today. Of note over 1 month from when vendor observed. During interview with Director of Facilities (Staff #69) on 4/9/25 at 12:12 PM reviewed concerns noted by vendor that are not addressed timely. Staff #69 states he does not get the reports from the vendor but does communicate with Staff #61. Staff #69 shown vendor reports and reviewed on 3/18/25 the vendor noted mice in the chapel and holes in wall by the left and right radiator. Staff #69 shown vendor reports on 3/25/25, 4/1/25 and 4/8/25 that show the same picture of a hole in the wall in the kitchen. At that time Staff #69 took photos of the reports and stated would request to receive the vendor reports in the future so he can ensure all items are addressed timely. The findings were reviewed with the Administrator on 4/9/25 at 12:35 PM.

Based on administrative and medical record review and facility staff interview, it was determined the facility failed to ensure the safety of a functionally and cognitively impaired resident who sustained a fracture while being transferred from the wheelchair to the bed and ensure timely assessment of the resident's complaint of pain. This was evident for 1 of 12 residents reviewed during this complaint survey. The findings include: Medical record review, on 10/6/17, revealed Resident #8 was a long-term care resident with [DIAGNOSES REDACTED]. Review of the Lifting, Transfer and Bed Mobility assessment dated [DATE] revealed the resident was to be transferred using a gait belt. A gait belt is a device used by caregivers to transfer care receivers with mobility issues from one position to another or from one location to another. Review of a facility reported incident (MD 343) on 10/6/17 revealed Resident #8 complained of right leg pain on 6/30/17 and an x-ray confirmed, on 7/3/17, a comminuted [MEDICAL CONDITION] distal tibial shaft (tibial shaft fracture occurs along the length of the bone, below the knee and above the ankle) and an oblique [MEDICAL CONDITION] fibular shaft (the most common type of fracture at the ankle). A comminuted fracture is a break or splinter of the bone into more than two fragments. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma. The Annual MDS assessment dated [DATE] revealed the facility staff coded the resident in Section G Functional Status G0110A Bed Mobility and B Transfers as requiring the extensive assistance of 1 staff (extensive assistance means the resident is involved in the activity but staff provide the weight-bearing support). The facility staff coded the resident in Section C100-Cognitive Skills for daily Decision Making as a 3 (severely impaired, never/rarely made decisions). The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. The MDS assessment is part of a broader RAI (Resident Assessment Instrument) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of the ADL Record revealed that on 6/19/17 through 6/25/17 (excluding 6/23/17) and 6/27/17, the resident was coded as being independent with transfers on the 7-3 shift and on 6/28/17- 6/30/17, the resident was coded as being totally dependent for transfers on the 7- 3:30 shift. Surveyor review of the facility's investigative findings on 10/6/17 revealed a statement by GNA #1 that while transferring Resident #8 back to bed after dinner he/she noted the resident needed more assistance than usual. GNA #1 reported the resident yelled out and complained of ankle pain. During an interview with the surveyor on 10/10/17 at 11:35 AM, GNA #1 stated he/she has cared for this resident in the past but it had been a long time since s/he last cared for this resident as he/she generally floats throughout the building. GNA #1 reported she/he was told the resident could stand and pivot from the wheelchair to the bed with assistance. When asked how she/he received report on the resident, he/she stated information was given by the charge nurse. GNA #1 said she/he instructed the resident to scoot to the edge of the chair and had doubts about the resident being able to transfer so s/he placed her/his arms under the resident's arms. In the midst of the transfer, the resident was noticeably unsteady. GNA #1 reported during this interview that s/he did not use a gait belt to assist with the transfer or seek assistance. GNA #1 reported that during the transfer from the wheelchair to the bed he/she thought the resident's leg may have been caught on something or he/she may have hit her/his leg on the wheelchair. The resident complained of pain and GNA #1 immediately notified Staff #3 (nurse) of the incident and the resident's complaint of pain. GNA #1 stated he/she went back to check on the resident later and the resident was still complaining of pain. GNA #1 stated he/she approached the nurse three times to request that he/she evaluate the resident. GNA #1 stated since this incident, nursing staff are required to have a gait belt available at all times and use them during transfers. In addition, GNA #1 reported nursing staff have received gait belt training in the last few weeks. In a written statement, dated 6/30/17, LPN #1 reported that he/she did assess the resident but did not notice swelling or bruising of the leg/ankle. LPN #3 reported he/she stretched the resident's leg and she/he complained of knee pain but she/he declined pain medication. Further medical record review failed to reveal documentation of this incident on 6/30/17. In addition, there was not an assessment of the resident's condition, notification to the physician and responsible party, or a plan for further evaluation and/or treatment. A Nursing Note dated 7/1/17 at 10:16 PM reported that at 7:40 PM GNA #3 notified LPN #2 that Resident #8 had a large bruise on the right leg and complained of pain with movement. The physician was notified and x-rays of the right hip and leg were ordered. A Nursing Note dated 7/2/17 at 5:28 AM reported x-rays of the right leg and hip were taken at 2:00 AM. In addition, it was noted that the resident's leg was painful to touch and Tylenol was administered. The x-rays were negative for fractures. On 7/3/17 at 2:41 AM, RN #1 reported the resident was found crying in pain at the beginning of the 11 PM shift and was medicated with Tylenol. The resident's right leg remained bruised and painful to touch or with any type of movement. A nursing note dated 11/3/17 at 3:21 PM reported that the x-ray results of the right foot and ankle were positive for fracture. The x-rays confirmed a comminuted [MEDICAL CONDITION] distal tibial shaft (tibial shaft fracture occurs along the length of the bone, below the knee and above the ankle) and an oblique [MEDICAL CONDITION] fibular shaft (the most common type of fracture at the ankle). The resident was transported to the emergency room for further evaluation and treatment of [REDACTED]. Although the facility's investigative documentation identified the event that lead to the fracture, there was no evidence that other factors were examined to include transfer and positioning techniques, staffing patterns to ensure the resident received care with the prescribed number of staff, the need for periodic re-evaluation of transfer status, process for communicating resident needs from shift to shift and staff competency when providing care to residents. In addition, there was no evidence that the communication failures were thoroughly examined to prevent reoccurrence of a delay in evaluation and treatment for [REDACTED].

Based on medical and administrative record review as well as interview with staff, the facility failed to ensure a residents safety related to a fall in 1 of 3 medical record reviews. The findings include: Resident # 1 was admitted to the facility with [DIAGNOSES REDACTED]. The resident is unable to voluntarily move his left arm and leg due to paralysis as a result of the CVA. The resident has a care plan for ADL (activities of daily living) initiated on 7/31/12. The Care plan indicates the resident is totally dependent on staff for his daily care and is a one person physical assist for personal hygiene. On 3/14/2013 an onsite visit to the facility was conducted as a result of a complaint investigation submitted to the Office of Health Care Quality (OHCQ) on 2/13/2013. The complaint indicated that the resident had slipped out of the tub chair on 1/7/13 hit his head on the wall resulting in a transfer to the hospital where the resident required 5 staples to the back of the head and 9 sutures on the left cheek. The resident also sustained a subdural hematoma. The surveyor, Director of Nursing Services and the unit manager at the request of the surveyor went into the tub room where the incident occurred to inspect the tub and lift chair. The lift chair has a single seat belt device strap that is positioned across the lap utilizing two D-rings to secure the individual into the seat. Once the resident is secured properly into the chair, the chair is then lifted mechanically (via a foot pedal) up and into the tub. Once the bathing process is finished, the resident is again lifted mechanically via foot pedal out of the tub. Surveyor review of administrative records report titled " Memorandom " revealed: " (Name of resident) was in the process of being transferred from a Century Tub to his personal chair. GNA(GNA #1) stated that while in the process of transferring (name of resident) from the tub to the wheelchair, (name of resident) was belted in the tub chair as was required but as the chair was swung around, (name of resident) started to slip out from under the belt. When (name of resident) stomach hit the buckle, the buckle opened and (name of resident) fell to the floor and struck his head causing laceration. " The surveyor conducted a telephone interview, 3/14/2013 at 3:26p.m with GNA#1 who assisted the resident with his bath on 1/7/2013 revealed; " I gave him a bath-10minutes approximately he was sliding somewhat in the water. After that I raised him up and dried off top of body. I lifted legs out of tub, he began to slide, I held onto his stomach. While I was reaching for pedal with my foot to lower him and then he slid more, belt popped and he slid to the floor. " Proper positioning of the resident, sitting upright and the seatbelt securely fastened prior to elevating the resident out of the tub is the responsibility of the staff to ensure the resident is safe and free of accidents. Based on GNA #1 ' s statement, the resident was not positioned in the chair properly prior to being lifted out of the tub.