Every finding on record at The Haven of St. Elmo

Based on observation, interview and record review, the facility failed to establish and maintain an effective infection prevention and control program to identify infectious disease symptoms as well as track, report, treat and isolate infected residents to prevent urinary tract infections for 4 (R1, R3, R6, R23) of 4 residents reviewed for infection control. This failure has the potential to affect all 33 residents in the facility. This failure resulted in R1 being admitted to the hospital on [DATE] for developing sepsis related to a urinary tract infection (UTI), R3 admitted to the hospital on [DATE] with developing a complicated urinary tract infection, and R23 being admitted to the hospital on [DATE] with an acute metabolic encephalopathy secondary to UTI complicated by bilateral ureter stents and history of UTI caused by a multidrug-resistant organism.The failure resulted in an Immediate Jeopardy which was identified to have begun on 3/29/26 at 10:30 am when R23 returned to the facility after a hospital admission with a diagnosis of a urinary tract infection with an organism of a multidrug-resistant organism and was not placed on contact precautions. V1 (Administrator) was notified of the Immediate Jeopardy on 6/9/26 at 3:19 PM. The immediacy was removed on 6/10/26, but noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:1. R1's admission Record documents an admission date of 02/19/2026 with diagnoses including sepsis due to Escherichia Coli (E. Coli), urinary tract infection, bacteremia, type 2 diabetes mellitus, unspecified dislocation of right hip, depression, hypothyroidism, venous insufficiency, and obstructive sleep apnea. R1's MDS (Minimum Data Set) dated 05/18/2026 documents a BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. The same MDS documents that R1 is occasionally incontinent of urine and frequently incontinent of bowel. R1's Care Plan documents a focus area of the resident has the diagnosis of sepsis due to E. Coli and is in need of antibiotic medication (initiated 05/14/2026). Corresponding interventions include antibiotic therapy per doctors' orders, encourage fluid intake, monitor, document, and report to medical doctor signs and symptoms of urinary tract infection. There are no Focus areas or interventions related to Enhanced Barrier Precautions documented in R1's Care Plan prior to 06/04/2026. R1's Progress Note dated 05/06/2026 at 12:33 P.M documents R1 was sent to the hospital emergency department for evaluation and treatment for cough and congestion. R1's Progress Note dated 05/06/2026 at 6:13 P.M. documented R1 was admitted to the hospital with a urinary tract infection. R1's After Visit Summary from the local hospital dated 05/14/2026 documented R1 was admitted on [DATE] to the hospital with a primary diagnosis of sepsis secondary to urinary tract infection (UTI) and diagnoses including open wound to the buttock, complicated UTI, pneumonia due to infectious organism, and bacteremia. R1's hospital urine culture with a collection date of 05/06/2026 documented the result as 50,000-100,000 col/ml (coliform/milliliter) Escherichia Coli probable Extended Spectrum Beta Lactamase Producer (ESBL) and > (greater than) 100,000 col/ml Gamma hemolytic strep. On 06/02/2026 at 10:30 A.M. during a tour of the facility, R1's room was observed to not have any signage indicating R1 was on isolation or Enhanced Barrier Precautions. R1's room did not have a Personal Protective Equipment (PPE) station outside of the room. On 06/03/2026 at 1:32 PM, V19 (Certified Nurse Assistant) sanitized hands prior to knocking on R1's door and explained that she is going to provide perineal care. V19 then closed the door for privacy. V19 already had supplies set up on bedside table. V19 placed gloves on her hands and removed R1's sheet and placed a barrier sheet under R1. V19 placed a washcloth in the basin that had water in it. V19 removed the washcloth from the basin, picked up the perineal wash bottle and sprayed it onto the washcloth. V19 took the washcloth in her right hand and spread R1's legs apart with her left hand. V19 then used her left hand to expose R1's perineal area. V19 washed R1's right side of her perineal area with the washcloth. V19 used her left hand to fold the washcloth. V19 used her left hand to expose R1's perineal area, V19 used her right hand with the washcloth to clean the left side of R1's perineal area. V19 then used her left hand, wearing the same gloves, to pull a plastic bag from her pants pocket, opened the plastic bag and placed it on the floor. V19 then placed the washcloth in the bag. V19 grabbed a new washcloth with her right hand, wearing the same gloves, and placed it in the basin with water. V19 removed wash cloth from basin with both hands, still wearing the same gloves, and grabbed the peri spray bottle with her left hand and sprayed the washcloth in her right hand with perineal cleaner. V19 then cleaned R1's middle perineal area, folded washcloth with both hands and cleaned the middle area again. V19 placed wash cloth in plastic bag located on the floor. V19 grabbed a new washcloth with her right hand and placed it in the wash basin with water. V19 removed the washcloth with her right hand and wiped R1's middle perineal area. V19 placed the washcloth in the clear plastic bag. V19 then took a dry washcloth and dried R1's perineal area. V19 then rolled resident and removed barrier. V19 placed sheet on R1 turned resident and placed wedge under R1's left side. V19 removed gloves, picked up basin, gathered trash and left room. V19 took basin to soiled utility room down the hall and disposed of used items. V19 sanitized hands upon exiting soiled utility room. During this observation of perineal care V19 was observed to be wearing the same pair of gloves throughout the care. V19 did not sanitize hands after doffing gloves and exiting the room. V19 only sanitized after exiting the soiled utility room. On 06/03/2026 at 1:43 P.M., V19 stated that she provided the care for R1 just like the facility policy says to. V19 stated the policy does not instruct them to change gloves until the end of care. On 06/04/2026 at 9:47 AM, V2 (Director of Nursing) was observed completing wound care for R1's open wound. During this observation V2 did not wear a gown to provide care. On 06/04/2026 at 10:03 AM, V2 stated R1 should have been on enhanced barrier precautions due to the wound to her coccyx. V2 stated she is not sure why R1 is not on enhanced barrier precautions. On 06/04/2026 at 10:28 A.M., V2 stated she has placed R1 on enhanced barrier precautions at this time. R1's Order Summary Report documents an active order dated 06/05/2026 for ENHANCED BARRIER PRECAUTIONS with diagnoses of wound and history of ESBL (Extended-Spectrum Beta-Lactamase). On 06/09/2026 at 11:56 P.M., V9 (Assistant Director of Nursing/Infection Preventionist) stated she was not aware that R1's urine culture in the hospital resulted in ESBL. V9 stated if she would have been aware of the culture results, R1 would have been placed in isolation upon returning from hospital. The facility's Infection Surveillance Report dated 5/1/26 to 5/31/26 documents that R1 has a UTI with an infection onset date of 5/14/26 and documents an order for Ertapenem Sodium Solution Reconstituted 1 gram. R1's Care Plan with a revision date of 6/4/26 documents an added Focus area of R1 has an abrasion to her right buttock and is in need of wound care (initiated 06/04/2026). Corresponding interventions include ensure thorough skin and peri care with each toileting event and or episode of incontinence care, pressure reducing mattress to bed, wound consult and care per wound nurse practitioner, monitor and record wound healing progress (initiated on 06/04/26). R1's Care Plan also documents a Focus area added of the resident is on enhanced barrier precautions (EBP) related to history of ESBL and wound (initiated 06/04/2026). Corresponding interventions include: educate visitors on necessary precautions needed, follow facility's infection control and enhanced barrier precautions policies / procedures when cleaning / disinfecting room, handling soiled and or contaminated linen, gown and glove use when performing high-contact resident activity, have adequate PPE (Personal Protective Equipment) available, practice good handwashing and use principles of infection control and enhanced barrier precautions. All interventions for this focus area were documented to be initiated on 06/04/2026. 2. R3's admission Record documents and admission date of 05/28/2024 with diagnoses including encephalopathy, urinary tract infection, ESBL, Parkinson's Disease, dysphagia, and acute kidney failure. R3's MDS dated [DATE] documents a BIMS score of 11 indicating R3 is moderately cognitively impaired. The same MDS documents that R3 has an indwelling urinary catheter. R3's Order Summary Report documented an active order dated 04/21/2026 for ENHANCED BARRIER PRECAUTIONS indwelling foley catheter and history of ESBL (Extended-Spectrum Beta-Lactamase) and an active order for foley catheter care every shift and as needed and to change indwelling catheter tubing monthly. R3's Care Plan documents a Focus area of R3 has the diagnosis of urinary tract infection and ESBL and is in need of antibiotic therapy to treat his condition (initiated 05/06/2026). Corresponding interventions include intravenous antibiotic medication, monitor and report back to the nurse any noted UTI symptom complications, and promote daily hydration to include several glasses of water or juice. All interventions were implemented on 05/06/2026 for this focus area. R3's Care Plan also documents a focus area of enhanced barrier precautions related to indwelling catheter and history of ESBL. Corresponding interventions include educate staff/resident/family on enhanced barrier precautions as needed, gown and glove during high contact resident care activities (such as dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting), and maintain enhanced barrier precautions for the duration of their stay or until the indwelling medical device that placed them at higher risk. All interventions listed for this focus area were documented as initiated on 04/24/2024. R3's Progress Note dated 05/03/2026 at 9:19 A.M. documented R3 had decreased level of consciousness, lethargy and altered mental status this morning when the certified nurse assistants went to get R3 up for breakfast. R3's urine is tea colored with a strong odor. R3 sent to hospital for evaluation and treatment. R3's Progress Note dated 05/03/2026 at 12:13 P.M. documented R3 was admitted to the hospital with a diagnosis of complicated urinary tract infection. R3's After Visit Summary from the local hospital dated 05/06/2026 documented that R3 was admitted to the hospital with the diagnoses of complicated urinary tract infection, infection due to ESBL producing E. Coli, and urinary retention. R3's hospital urine culture dated 05/03/2026 documented culture results 50,000 – 100,000 col/ml E Coli probable Extended Spectrum Beta-Lactamase, > 100,000 col/ml Serratia Fonticola, and >100,000 col/ml Proteus Mirabilis. On 06/03/2026 at1:24 PM, an EBP sign and PPE (personal protective equipment) supplies were observed outside of R6's room notifying staff and visitors of completing hand hygiene, including before entering and leaving room, and staff to wear required PPE during high-contact resident care, including providing hygiene, changing briefs or assisting with toileting. V17 (Certified Nurse Assistant) sanitized hands and donned a gown and gloves prior to entering R3's room. V17 explained to R3 that she was going to perform catheter care and removed R3's cover. V17 assisted R3 to lift and place a barrier underneath his bottom. V17 started catheter care without doffing dirty gloves, completing hand hygiene, or donning new gloves. V17 unlatched R3's catheter secure strap. V17 reached into the wash basin on the bedside table that had washcloths in it and pulled a washcloth out. With both hands, V17 wrung the washcloth out. V17 then grabbed the no rinse soap with her left hand and sprayed it on the washcloth that she was holding with her right hand. V17 grabbed R3's penis with her left hand and cleaned it with the washcloth. V17 was observed with dirty gloves, grabbing a clean washcloth from the basin and wrung the washcloth out with both hands. V17 grabbed the no rinse soap with her left hand and sprayed the washcloth. V17 then grabbed R3's penis with her left hand and cleaned around the center and then discarded the washcloth in a trash bag. V17, with dirty gloves, grabbed a washcloth from the basin and wrung it out with both hands. V17, with dirty gloves, then grabbed the no rinse soap with her left hand and sprayed it on the washcloth. V17 cleaned the indwelling catheter tubing and discarded the washcloth. V17 with dirty gloves, grabbed a new washcloth from the basin and wiped off the no rinse soap. V17 discarded the washcloth and with dirty gloves grabbed a clean towel. V17 dried R3's perineal area and catheter tubing. V17 discarded the towel and without discarding her gloves, sanitizing her hands and donning new gloves, placed tubing back in catheter strap on R3's leg. V17 covered R3 up. V17 removed her gown, removed her gloves and placed new gloves on. V17 stated she put new gloves on to go dump basin in soiled utility room. V17 dumped water from basin in R3's bathroom and took it to soiled utility room. Upon exiting the soiled utility room V17 sanitized her hands. On 06/03/2026 at 1:30 P.M., V17 stated she followed the policy and changed her gloves when the policy told her to. V17 stated she does not have to change her gloves until the end of the procedure. V17 stated the policy did not say that one hand had to be kept clean during the catheter care. 3. R23's admission Record documented an admission date of 11/13/2025 with diagnoses including urinary tract infection, site not specified, other artificial openings of urinary tract status, hematuria, unspecified, resistance to multiple antimicrobial drugs, muscle wasting and atrophy, other lack of coordination, calculus of ureter and anxiety disorder, unspecified. R23's MDS dated [DATE] documented a BIMS Score of 13 indicating R23 is cognitively intact. Section GG documents that R23 is dependent (helper does all the effort) for toileting hygiene and showering/bathing self. Section H, under Appliances documented an indwelling catheter in place, Urinary Continence documented not rated, resident had a catheter and Bowel Continence documented frequently incontinent (2 or more episodes of bowl incontinence, but at least one continent bowel movement). R23's Care Plan documented a focus area of general weakness and unsteadiness. R23 needs staff assistance to meet his toileting needs with an intervention to monitor and report to the nurse any noted symptoms of UTI (Urinary Tract Infections) such as: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns with a start date of 4/2/2026. R23's Progress Note dated 3/23/2026 at 11:55 PM by V18 (LPN) documented R23 admitted to local emergency room related to pneumonia, urinary tract infection, and chronic obstructive pulmonary disease exacerbation. R23's After Visit Summary from the local hospital dated 3/26/2026 to 3/29/2026 documented a reason for admission.urinary tract infection. R23's Urine Culture and Sensitivity result from local hospital dated 3/23/2026 documented culture urine (abnormal) (susceptibility) Specimen: Urine, Voided Collected: 03/23/26 5:05 PM and updated: 03/26/26 at 7:06 AM culture results of 50,000-100,000 COL/ML. Escherichia coli probable extended spectrum bet lactamase producer, susceptibility Escherichia coli. No colonized culture noted. R23's Progress Note dated 4/22/2026 at 7:50 AM by V3 (Registered Nurse/RN) documented sent to local ER (emergency room) via ambulance for confusion. R23 was up all night going through other resident's closets and attempting to crawl into the wrong bed in the wrong room.V16 (physician) and V9 (ADON) notified of transfer. R23's Progress Note dated 4/22/2026 at 12:15 PM by V9 documented resident admitted to local hospital for complicated UTI. R23's After Visit Summary dated 4/23/2026 to 5/21/2026 documented an admission diagnosis of blood in urine of unknown cause. Genitourinary: indwelling catheter in place draining orange colored urine. Under Assessment /Plan documents acute metabolic encephalopathy secondary to UTI complicated by ureter stents and history of UTI caused by ESBL. Under Results documents urine bacteria, unspecified with culture result of >100,000 COL/ML, gram negative rods. No colonized culture noted. R23's Progress Note from out-of-town hospital dated 5/7/2026 at 8:44 AM by V23 (Physician) documented under history and physical: R23 initially presented to the outside hospital emergency department with acute worsening confusion and hallucinations concerning acute metabolic encephalopathy in the setting of suspected complicated urinary tract infection. He had recently been treated at the nursing facility with oral cephalexin (Keflex) for presumed UTI prior to presentation. Given his history of ESBL urinary infections, there was concern for resistant infection, and he was subsequently started on IV meropenem at the outside hospital after urinalysis returned abnormal; urine cultures remain pending at the time of transfer. R23's Physician Orders documented a discontinued order of enhanced barrier precautions with no directions specified for order with a discontinued date of 3/5/2026, contact precautions for MRSA (Methicillin-resistant staphylococcus aureus) with a start date of 5/26/2026 and a discontinued date of 5/29/2026, and contact precautions for ESBL(Escherichia coli probable extended spectrum bet lactamase) in urine with a start date of 5/29/2026 and discontinued on 6/9/2026. On 06/04/2026 at 1:50 PM, V9 (ADON) stated R23 had returned to the facility on 5/21/2026 with an indwelling catheter in place. V9 stated, R23 had been admitted to the hospital for a complicated urinary tract infection with a bacteria organism of extended spectrum beta-lactamase producing Escherichia Coli (ESBL) on 4/22/2026. V9 stated, ESBL can be caused by poor hand hygiene during catheter care. V9 stated, R23 is on an active antibiotic order of Ertapenem Sodium Solution Reconstituted 1 gram intravenously every 24 hours for ESBL producing e-coli UTI until 06/05/2026. On 06/05/2026 at 9:53 AM, V12 (Family) stated R23 had been admitted to the facility almost a year ago. V12 stated, R23 has had multiple urinary tract infections (UTI's) over the last few months. V12 stated, R23 did go to the local hospital around 3/23/2026 for confusion and he was diagnosed with UTI. V12 stated, he did return to the facility a few days later then went back out to the local hospital for confusion on 4/23/2026 and was sent to another hospital up north for further treatment and evaluation. V12 stated, staff does assist R23 with incontinence care. On 06/05/2026 at 10:17 AM, V9 (ADON) stated, R23 had been on an antibiotic for a skin infection that finished up on 3/15/2026. V9 stated, R23 had been sent to the local emergency room on 3/23/2026 related to confusion and admitted with multiple diagnoses including a urinary tract infection. V9 stated, R23 returned to the facility on 3/29/2026 and she did not follow up on R23's UTI with organism of ESBL (Escherichia coli probable extended spectrum beta lactamase producer) and probably should have. V9 stated, R23 did not have any contact precautions in place for ESBL upon reentry to the facility on 3/29/2026. V9 stated, she does not typically follow up with infections when they get treated in the hospital, even if symptoms started in the facility. V9 stated, R23 did get transferred to the local hospital on 4/22/2026 related to confusion and was admitted to the hospital for further treatment and evaluation. V9 stated, R23 had been diagnosed with a UTI in the local emergency room with organism of gram-negative rod on 4/23/2026. V9 stated, R23 had an indwelling catheter placed at this time and was then transferred to another hospital up north for further treatment. V9 stated, when R23 returned to the facility on 5/21/2026, the facility put contact precautions in place related to ESBL in the urine and continued intravenous antibiotics until 6/5/2026. V9 stated, R23 did not have orders placed for his catheter, catheter care, and documentation in his care plan until 6/2/2026. V9 stated, she will need to contact V16 (Physician) today to see when R23 should have an indwelling catheter exchanged. V9 stated, there are no orders in place at this time and no discharge instructions from the hospital on 5/21/2026. On 06/05/2026 at 11:30 AM, catheter care on R23 by V13 (Certified Nurse Assistant/CNA) and V2 (Director of Nursing/DON) was observed. V13 was observed with a gown and gloves on prior to entering R23's room and V2 applied personal protective equipment that included a gown and gloves. V13 knocked on R23's door prior to entering. V13 used both gloved hands to move the bedside table over to R23's bed and then went over to the blinds and closed the blinds. V13 returned back to R23's bedside table, removed blanket, and R23's pants while wearing the same gloves. V13 started catheter care without doffing dirty gloves and completing hand hygiene. V13 took rinse free soap bottle from V2 and sprayed spray directly to R23's urinary meatus area. V13 replaced the rinse free bottle on the bedside table, grabbed a clean washcloth, dipped it in the basin of water, wrung out the cloth with both hands and cleaned R23's meatus area by using her left hand to pull the foreskin back and clean area with her right hand, then discarded cloth in a trash bag that is sitting on the clean field next to water basin. V13 observed doffing gloves, completing hand hygiene and donning new gloves. V13 observed taking a new washcloth, dipped it in the water basin, wrung out cloth with both hands, pulled back foreskin and cleaned R23 meatus and catheter tubing. R23's discarded dirty wash cloth in trash bag that is sitting on the clean barrier next to water basin. V13 returned catheter tubing in catheter tube holder grabbed a new washcloth to dry R23's penile area and catheter without doffing dirty gloves, completing hand hygiene and donning new gloves. V13 then asked V2 if she should remove her gown at this time or wait until she had cleaned up the bedside table. V2 directed V13 to change her gloves then clean up bedside table. V2 observed doffing dirty gloves and donning new gloves with no hand hygiene, then cleaned off the bedside table, handing the water basin to V2 to hold. V13 asked V2 if she should take her gown off at this time and V2 gave her directions to remove gown. V13 doffed her dirty gown and gloves with no hand hygiene, donned new gloves and took the water basin from V2 to walk it to the soiled utility room. On 06/05/2026 at 11:36 AM, V2 (DON) stated V13 should have doffed her gloves, completed hand hygiene and donned new gloves prior to starting R23's catheter care and again during cleaning once V13 had contaminated gloves. On 06/05/2026 at 12:25 PM, V14 (Regional Nurse) stated he just got off the phone with V6 (Vice President of Operations) who stated the catheter care policy had been reviewed by the corporate office and it did not meet standards for infection control practices. On 06/05/2026 at 12:30 PM, V15 (Medical Director) stated, with the lack of standard infection control practices, not following up on infections/organisms with the right antibiotic, not following or initiating enhanced barrier precautions or contact precautions, this does have the potential to affect all residents in the facility. V15 stated, the lack of standard infection control practices does have the potential to spread infections to all residents, and it does appear that reeducation is needed. On 06/09/2026 at 10:30 AM, V21 (Regional Nurse) stated the facility follows the Center Disease Control and Prevention (CDC) guidelines on antibiotic stewardship and only recheck urine if a resident had signs and symptoms of a urinary tract infection. V21 stated, it would depend on whether there was a new case of ESBL or not, if they would place a resident on enhanced barrier precautions or transmission-based precautions and it would be the facility's discretion. On 06/09/2026 at 12:01 PM, V15 (Medical Director) stated with the lack of standard infection control practices urinary tract infections can lead to sepsis and hospitalizations for residents. The CDC website, https://www.cdc.gov/sepsis/about/index.html, under What is Sepsis documents Sepsis is the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to sepsis most often start in the: Gastrointestinal tract, Lung, Skin, or Urinary Tract. Without fast treatment, sepsis can quickly lead to tissue damage, organ failure, and death. The facility's Infection Control Spreadsheet documented R23 on line 22 with a bacterial infection of sepsis, unspecified with an infection site of urinary tract with no organism listed with an onset date of 2/23/2026. The facility's Infection Surveillance Report dated March 01, 2026 – March 31, 2026, documented 5 UTI's for the facility with no documentation of R23's infection, signs or symptoms, status of infection, organism or antibiotic. The facility's Infection Control Spreadsheet documented a 6-month period from 12/9/2025 to 6/2/2026 with 27 urinary tract infections and 7 urinary tract infections missing documentation of the organism. 4. R6's admission Record documented an admission date of 12/30/2025 with diagnoses including obstructive and reflux uropathy, unspecified, retention of urine, unspecified, muscle wasting and atrophy, other lack of coordination, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R6's MDS dated [DATE] documented a BIMS Score of 09 indicating R6 is moderately cognitively impaired. Section GG documents R6 requires substantial/ maximal assistance with toileting hygiene and showering/bathing self. Section H, under Appliances documented an indwelling catheter in place, Urinary Continence documented as not rated, resident had a catheter and Bowel Continence documented frequently incontinent (2 or more episodes of bowl incontinence, but at least one continent bowel movement). R6's Care Plan had a focus of required enhance barrier precautions (EBP) related to an indwelling catheter with interventions in place of follow facility's infection control and enhanced barrier precautions policies/procedures when cleaning/disinfecting room, handling soiled and/or contaminated linen, disinfecting equipment, gown and gloves are to be used when performing high-contact resident contact activity, practice good handwashing, use principles of infection control and enhanced barrier precautions with a start date of 2/16/2026. On 06/03/2026 at 11:13AM, an EBP sign and PPE (personal protective equipment) supplies was observed outside of R6's room notifying staff and visitors of completing hand hygiene, including before entering and leaving room, and staff to wear required PPE during high-contact resident care, including providing hygiene, changing briefs or assisting with toileting. V17 (Certified Nurse Assistant/CNA) and V2 (Director of Nursing) were observed entering R6's room with no hand hygiene or PPE applied. V17 (CNA) was observed donning gloves with no hand hygiene prior to starting R6's catheter care. V17 moved the bedside table with both gloved hands closer to R6's bedside. V17 turned to R6, pulled his blankets down then removed R6's pants and pulled down his incontinent brief. V17 assisted R6 to lift and placed a barrier underneath his bottom. V17 started catheter care without doffing dirty gloves, completing hand hygiene, donning new gloves or donning of a protective gown. V17 was observed with dirty gloves, placing a clean washcloth in the water basin, wrung the washcloth out with both hands then pulled back R6's foreskin with her left hand and wiped R6's meatus area and catheter tube with right hand. V17 then discarded the washcloth in a trash bag. V17, with dirty gloves, grabbed a new washcloth, dipped it in the water basin, wrung out the washcloth with both hands, picked up the non-rinse soap bottle, sprayed the soap on the washcloth, used her left hand to retract foreskin and used right hand to clean R6's meatus area and catheter tube without doffing dirty gloves, completing hand hygiene, donning new gloves and continuing to not wear a protective gown. V17, with dirty gloves, grabbed a new washcloth from the bedside table to dry R6's meatus area and catheter tube without doffing dirty gloves, completing hand hygiene, and donning new gloves. V17 observed doffing gloves and donning new gloves without hand hygiene prior to removing barrier under R6, then assisted to pull up his incontinence brief and pants. On 06/03/2026 at 11:25 AM, V17 (CNA) stated EBP is used to help not spread infections or contamination. V17 (CNA) stated, she should have worn PPE during catheter care and completed hand hygiene, however the facility policy directs staff that she does not have to change gloves until after care is completed. V17 stated, R6's does have a lot of UTI's. On 06/03/2026 at 11:52 AM, V2 (Director of Nursing/DON) stated V17 should have been using PPE during catheter care. On 06/03/2026 at 12:19 PM, V1 (Administrator) stated his expectations are for all staff to follow EBP and infection control practices per policy. On 6/3/2026 at 2:25 PM, V9 (Assistant Director of Nursing/ADON) stated she is the infections preventionist and does track all infections, organisms and antibiotics for the facility. V9 stated, she enters the information into the infection surveillance report. On 06/04/2026 at10:56 AM, V6 (VP/Vice President of Operations) stated she sent the facility's catheter care policy and procedure to the corporate office for review of infection control standards of practice. V6 stated, she had been discussing with V14 (Regional Nurse) and V1 (Administrator) that 19 urinary tract infections are a lot in a 6-month timeframe. R6's Progress Note dated 1/29/2026 at 1:06 PM by V7 (LPN) documented R6 had been admitted to the local hospital with acute kidney injury and urinary tract infection. R6's Urine Culture results dated 1/29/2026 documented a culture result of >100,000 COL/ML Proteus Mirabilis and 50,000 – 100,000 COL/ML of Morganella Morganii. R6's Progress Note dated 3/25/2026 at 9:19 AM by V7 (LPN) documented R6's on an antibiotic for UTI without SE (side effects) noted. Indwelling catheter patent, draining yellow urine and voices no complaints of pain or discomfort. R6's Progress Note dated 4/2

Based on interview, observation, and record review, the facility failed to complete skin and wound assessments for a resident at risk for skin breakdown, failed to notify the physician of a new wound, and failed to identify worsening of a wound for 1 (R1) of 1 residents reviewed for pressure ulcers in the sample of 25. This failure resulted in R1 developing a stage 2 pressure ulcer that worsened to the right buttock and developed a new stage 2 pressure ulcer to the left buttock.The Findings Include:R1's admission Record documents R1 was admitted to the facility on [DATE] with diagnoses including sepsis due to Escherichia Coli, urinary tract infection, bacteremia, type 2 diabetes mellitus, unspecified dislocation of right hip, depression, hypothyroidism, venous insufficiency, and obstructive sleep apnea.R1's MDS (Minimum Data Set) dated 05/18/2026 documented R1's BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. The same MDS documents that R1 is occasionally incontinent of urine and frequently incontinent of bowel. The MDS section for Skin Conditions documents that R1 is at risk for the development of pressure ulcers/injuries and that R1 does not have a pressure ulcers/injuries. Under Other Ulcers, Wounds and Skin Problems documents that R1 has Moisture Associated Skin Damage. Under Skin and Ulcer/Injury Treatment, the following are checked: Pressure reducing device for bed and application of nonsurgical dressings.R1's Care Plan documents an added Focus area of due to R1's history of pressure ulcers, reduced mobility and incontinence, R1 is at an increased risk of skin pressure breakdown (initiated 03/05/2026). Corresponding include ensure through skin and peri care with each toileting event and or episode of incontinence care, ensure turning and repositioning to meet R1's needs, Nursing skin assessment weekly, CNA's (Certified Nursing Assistant) to monitor and report on skin condition during routine care, pressure reducing mattress to bed, and wound consult and treatment per doctors orders should one occur.R1's Progress Note dated 05/06/2026 documented V16 (Physician) was at the facility and saw R1. R1 was sent to the local hospital for evaluation and treatment related to chest congestion and cough.R1's Progress Note dated 05/06/2026 documented that R1 was admitted to the hospital with diagnosis of a urinary tract infection.A photograph in R1's local hospital records shows an open area to R1's right buttock. The photograph is labeled Wound 5/6/26 Coccyx. This indicates that R1 had an open area to the right buttock upon admission to the local hospital.R1's Progress Notes from the local hospital authored by V22 (Nurse Practitioner) documented on 05/07/2026 that R1 had a Stage 2 pressure ulcer to the left buttock.R1's After Visit Summary from the local hospital, documents a hospital stay dated 05/06/2026-05/14/2026, documented an order for coccyx wound care: remove soiled dressings, cleanse with wound cleanser, pat dry, apply Thera honey to wound bed and cover with foam border dressing daily.R1's electronic health record does not have an assessment upon R1's readmission to the facility on 5/14/26 or any documentation that R1 has a wound to the coccyx or buttocks area.On 06/02/2026 at 10:30 A.M. during a tour of the facility, R1's room was observed to not have any signage indicating R1 was on isolation. R1's room did not have a Personal Protective Equipment (PPE) station outside of the room.R1's Braden Scale For Predicting Pressure Sore Risk dated 05/14/2026 documents a Braden Score of 15 and a Category of At Risk. The Braden Assessment further documents the following: Sensory Perception: Slightly limited. Moisture: Very moist. Activity: Chairfast. Resident ability to walk severely limited or nonexistent. Cannot bear own weight and /or must be assisted into chair or wheelchair. Mobility: Slightly limited makes frequent though slight changes in body or extremity position independently. Nutrition: Adequate. Friction and shear: Potential problem.R1's Order Summary Report documents a treatment order dated 05/16/2026 documenting: Treatment -coccyx wound care-cleanse with wound cleanser, pat dry, apply thera honey to wound bed, cover with foam dressing every shift.R1's May 2026 TAR (Treatment Administration Record) documented R1 did not receive any wound care until 05/16/2026.R1's Electronic Medical Record did not have any skin assessments to review.On 06/04/2026 at 3:03 P.M., V3 (Registered Nurse) stated when she completed R1's treatment on 5/16/2026, the area to the right buttock has a small spot to it and slough. V3 stated the area was roughly the size of a pencil eraser. V3 stated when she completed the treatment on 5/25/2026 and 5/26/2026, she noticed the wound was bigger and looked worse. V3 stated she did not notify anyone because she assumed that R1 was being followed by the wound care company. V3 stated she was not aware that it was not being measured or the wound company wasn't following the resident. V3 stated she would have notified someone if she would have known that the wound company was not following the resident at this time.R1's Progress note dated 06/04/2026 documented R1 was seen by V10 (Physician Assistant).R1's Wound Assessment Plan dated 06/04/2026 authored by V10 (Physician Assistant) documented Wound type: abrasion, Wound location Right buttock wound onset date: 06/04/2026, depth of tissue involvement partial thickness, wound measurement: 1.8 cm (Centimeters) long, by 0.9 cm wide by 0.2 cm deep, exudate minimal serosanguineous. Comments: present upon readmission from hospitalization.R1's Order Summary Report contains a treatment order dated 06/04/2026 documenting: Treatment - wound care for right buttock - clean with wound wash, apply Medi honey to wound bed, cover with dry dressing change daily and as needed.On 06/04/2026 at 8:30 A.M., V1 (Administrator) presented the wound log to this surveyor. The wound report period is documented dates of 05/01/2026 - 05/31/2026 and 06/01/2026 - 06/03/2026. R1 is not listed on the wound log for having a wound.On 06/04/2026 at 9:47 AM, V2 (Director of Nursing) was observed completing wound care for R1. V2 was not observed donning appropriate PPE including gown during wound treatment. There was a small amount of drainage observed to old dressing. R1's wound right buttock was red and there was granulation tissue observed. R1's left buttock was red and had the appearance of shearing. After the dressing change was completed to the right buttock, V2 applied barrier cream to R1's left buttock.On 06/04/2026 at 10:03 AM, V2 stated R1 should have been on enhanced barrier precautions, for her wound to her coccyx. V2 stated she is not sure why R1 is not on enhanced barrier precautions.On 06/04/2026 at 10:28 A.M., V2 stated she has placed R1 on enhanced barrier precautions.On 06/04/2026 at 12:38 P.M., V9 (Assistant Director of Nursing) stated that the resident was readmitted from the hospital with the area to the right buttock. V9 stated the hospital called the area to the wound a skin tear. V9 stated she was on vacation for a week and when she returned from vacation the wound had deteriorated. V9 stated that is why the wound group saw her today. V9 stated they were not measuring it and the nursing staff were monitoring it. V9 stated the facility was using the treatment that the hospital discharged R1 back on. V9 stated when V10 (Physician Assistant) saw R1 today she did not change the order. On 06/04/2026 at 1:31 P.M., V11 (Licensed Practical Nurse / MDS) stated the MDS completed on 05/18/2026 documented that R1 only had moisture associated skin damage. V11 stated he did not assess R1's skin condition. V11 stated the day he did the MDS, he asked the nurse who was caring for R1, the condition of her skin. V11 stated he does not remember which nurse it was that he asked about R1's skin.On 06/04/2026 at 1:48 P.M. V10 (Physician Assistant) stated she was made aware today that she needed to see R1. V10 stated she was told R1 was readmitted from the hospital with the wound. V10 stated she was not aware that R1 was readmitted on [DATE] or that she had a previous stage 3 pressure ulcer to that area that had healed. V10 stated she was told by the facility that R1's hospital discharge documented the area as a skin tear / abrasion and that is why she coded it as an abrasion today. V10 stated if she knew R1's history she would have coded the wound as a Stage 2 pressure ulcer. V10 stated the treatment would stay the same even if she would have coded it as pressure ulcer.On 06/04/2026 at 1:53 P.M. V9 (Assistant Director of Nursing) stated she was on vacation from 05/22/2026 - 05/26/2026. V9 stated when she returned from vacation and completed R1's treatment to her coccyx she observed it to be bigger in size than before she was on vacation. V9 stated she notified the wound company today to see R1. V9 stated she did not notify the primary care physician of the wound deterioration. V9 stated she should have notified the physician. V9 stated she would consider the wound a pressure ulcer and a stage 2 by physical assessment. V9 stated the wound was not measured prior to today. V9 stated wound assessments are supposed to be completed weekly. V9 stated she realized yesterday that R1 has not had a skin assessment since April.On 06/04/2026 at 2:20 P.M. V1 stated that while V9 was on vacation no staff reported to her that R1's wound was deteriorating. R1's progress note dated 06/09/2026 documented V10 was notified of area to left buttock that had opened. New order received to clean with wound wash, apply Medi honey and cover with a dry dressing.On 06/11/2026 at 12:15 P.M. V9 stated R1's wound was on the right buttock upon readmission from the hospital. On 06/11/2026 at 15:11 P.M. V7 (Registered Nurse) stated she helped readmit R1. V7 stated she helped complete the assessments but does not remember the specifics about the resident.R1's Wound Assessment Plan authored by V10 dated 06/11/2026 documented wound location : left buttock, wound type: pressure injury, pressure injury stage upon completion of visit: 2, wound measurement 0.9 cm long by 0.4 cm wide by 0.2 cm deep.On 06/12/2026 at 10:51 A.M. attempted to call V26 (Agency Nurse). Voicemail left for a return call.On 06/12/2026 at 12:04 P.M. V10 stated when she assessed R1 on 06/04/2026, she does not recall there being a skin concern on the left buttock. V10 stated the facility notified her on 06/09/2026 of a new open area to the left buttock. V10 stated she gave verbal orders that day for a dressing. V10 stated she saw the wound on 06/11/2026 and did not change the orders.R1's Order Summary Report documents an active order dated 06/05/2026 for ENHANCED BARRIER PRECAUTIONS diagnosis wound and history of ESBL (Extended-Spectrum Beta-Lactamase).R1's Care Plan documents an added Focus area of R1 has an abrasion to her right buttock and is in need of wound care (initiated 06/04/26). Corresponding interventions include ensure thorough skin and peri care with each toileting event or episode of incontinence care, pressure reducing mattress to bed, therapeutic diet per doctor's order, and wound consult and care per wound nurse practitioner, monitor and record wound healing process. All interventions for this focus area were documented to be initiated on 06/04/26.The facility policy titled Pressure Ulcer and Wound Prevention/Management Program with an updated date of 09/30/2025 documented under the section titled Purpose: To identify residents who are at risk for pressure ulcers and skin breakdown, to prevent pressure ulcers and skin breakdown, to provide a guideline for the appropriate nursing management of skin breakdown when it occurs.2. Residents will have a head-to-toe skin assessment upon admission, readmission, at the time of transfer/discharge, and prior to/return from leave of absence by a licensed nurse. 4. Skin assessments will be completed weekly or as ordered for residents who are mild and moderate, high and severe risk for breakdown. 8. Braden Pressure Risk Scale will be completed upon admission/readmission and weekly for four weeks. Mild Risk - a resident who scores 15-18 on the Braden Risk Assessment is considered to be at mild Risk for development of pressure ulcers, unless determined to be at higher risk by clinical assessment by the nurse, physician or dietitian.

Based on interview, observation and record review the facility failed to follow standards of practice for antibiotic use for 2 (R7, R23) of 2 residents reviewed for antibiotic stewardship in the sample of 25. This has the potential to affect all 33 residents living in the facility. Findings included:1. R7's admission Record documented an admission date of 8/6/2024 with diagnosis including type 2 diabetes mellitus with hyperglycemia, retention of urine, overactive bladder, benign prostatic hyperplasia with lower urinary tract symptoms and dysphagia.R7's MDS (minimum data set) dated 5/15/2026 documented a BIMS (Brief Interview for Mental Status) Score of 04 indicating R7 is severely cognitively impaired. Section GG documents R7 is Dependent for assistance with toileting hygiene and showering/bathing self. Section H under Urinary Continence is documented with frequently incontinent.R7's Care Plan documented a focus area of general weakness, unsteadiness and endurance and is in need of staff assistance to meet his toileting needs with an intervention including to ensure through skin and peri care with each toileting event and or episode of incontinence care with monitor and report to the nurse any noted symptoms of UTI such as: flank pain, changes in color or clarity of urine with a start date of 10/20/2024.On 6/3/2026 at 2:25 PM, V9 (Assistant Director of Nursing/ADON) stated she is the Infection Preventionist and does track all infections, organisms and antibiotics for the facility. V9 stated, she enters the information into the infection surveillance report. V9 stated, she does review all information when she enters the information. V9 stated, she does not have R7's microbiology report dated 4/3/2026 with culture and sensitivity. V9 stated, she would need to call the local hospital to have them send over his results. The facility's Infection Control Spreadsheet documented R7 on line 35 with a urinary tract infection with no organism listed, current medication for treatment of ciprofloxacin 500 milligram tablet and an onset date of 4/3/2026.R7's Progress Note dated 4/3/2026 at 4:30 PM by V7 (LPN) documented R7 returned from local emergency room with an indwelling catheter placed. R7's to start ciprofloxacin tomorrow.R7's Medication Administration Report dated April 2026 documented with a start date of 4/4/2026, ciprofloxacin tablet 500 milligrams (Ciprofloxacin HCl) Give 1 tablet by mouth two times a day for UTI until 04/13/2026.On 06/05/2026 at 10:58 AM, V9 brought R7's microbiology report dated 4/3/2026 that she just received from the hospital. R7's microbiology results dated 4/3/2026 documenting a final report of Methicillin-Resistant Staphylococcus Aureus with a susceptibility result of ciprofloxacin being resistant to the organism. 2.R23's admission Record documented an admission date of 11/13/2025 with diagnoses including urinary tract infection, site not specified, other artificial openings of urinary tract status, hematuria, unspecified, resistance to multiple antimicrobial drugs, muscle wasting and atrophy, other lack of coordination, calculus of ureter and anxiety disorder, unspecified.R23's MDS dated [DATE] documented a BIMS Score of 13 indicating R23 is cognitively intact. Section GG documents that R23 is dependent (helper does all the effort) for toileting hygiene and showering/bathing self. Section H, under Appliances documented an indwelling catheter in place, Urinary Continence documented not rated, resident had a catheter and Bowel Continence documented frequently incontinent (2 or more episodes of bowl incontinence, but at least one continent bowel movement).R23's Care Plan documented a focus area of general weakness and unsteadiness. R23 needs staff assistance to meet his toileting needs with an intervention to monitor and report to the nurse any noted symptoms of UTI (Urinary Tract Infections) such as: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns with a start date of 4/2/2026.R23's Urine Culture and Sensitivity result from local hospital dated 3/23/2026 documented culture urine (abnormal) (susceptibility) Specimen: Urine, Voided Collected: 03/23/26 5:05 PM and updated: 03/26/26 at 7:06 AM culture results of 50,000-100,000 COL/ML. Escherichia coli probable extended spectrum bet lactamase producer, susceptibility Escherichia coli. No colonized culture noted.The facility's Infection Surveillance Report dated March 01, 2026 - March 31, 2026, documented 5 UTI's for the facility with no documentation of R23's infection, signs or symptoms, status of infection, organism or antibiotic from his urine culture results dated 3/23/2026.On 06/05/2026 at 10:17 AM V9 (ADON) stated, R23 had been on an antibiotic for a skin infection that finished up on 3/15/2026. V9 stated, R23 had been sent to the local emergency room on 3/23/2026 related to confusion and admitted with multiple diagnoses including a urinary tract infection. V9 stated, R23 returned to the facility on 3/29/2026 and she did not follow up on R23's UTI with organism of ESBL (Escherichia coli probable extended spectrum beta lactamase producer) and probably should have. V9 stated, she does not typically follow up with infections when they get treated in the hospital, even if symptoms started in the facility.The facility's Infection Control Spreadsheet documented R23 on line 22 with a bacterial infection of sepsis, unspecified with an infection site of urinary tract, an order for antibiotic of ceftriaxone Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 24 hours for infection for 6 Days in sodium chloride 0.9% solution 50ml (milliliters) with a -Start Date-02/24/2026 and no organism listed with an onset date of 2/23/2026 to verify if R23 had been on the appropriate antibiotic.R23's Medication Administration Record dated February 1st-28th, 2026 documented ceftriaxone sodium solution reconstituted 2 GM (grams) use 2 grams intravenously every 24 hours for infection for 6 Days in sodium chloride 0.9% soln (solution) 50ml -and administered on 2/24/26 through 2/28/2026.R23's Medication Administration Record dated March 1st- 31st, 2026 documented ceftriaxone sodium solution reconstituted 2 GM (grams) use 2 grams intravenously every 24 hours for infection for 6 Days in sodium chloride 0.9% soln 50ml -and administered on 3/1/2026.As of 6/12/26, no documentation was received on the urine culture or sensitivity collected on 2/23/2026 from facility during survey. The facility's Infection Control Spreadsheet documented a 6-month period from 12/9/2025 to 6/2/2026 with 27 urinary tract infections with antibiotics listed and 7 urinary tract infections missing documentation of organism to verify if residents had been on appropriate antibiotic.The facility's Long Term Care Application for Medicare/Medicaid form dated 6/3/2026 documented 33 residents residing in the facility. The facility's Antibiotic Stewardship Program Guideline (reviewed4/29/2025) documented under Purpose: the purpose of antimicrobial stewardship is to promote the appropriate use of antimicrobials by selecting the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration and route of administration to improve patient outcomes, while minimizing toxicity and the emergence of antimicrobial resistance. The purpose of the antimicrobial stewardship program is to improve antimicrobial stewardship practices and to monitor outcomes and antimicrobial use. Documented under Objective: .potential benefits include the following reduce the rates of facility-acquired infections and reduce risk of clostridium difficile infections, disruption of normal flora, and the emergence of multidrug-resistant organisms. Under Guidelines documents Tracking: the facility will monitor antibiotic use and outcomes from antibiotic use.

Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple occupancy resident bedrooms for 4 (R9, R10, R19 and R24) of 4 residents reviewed for room size in a sample of 25.On 6/5/26 at 10:00 AM, V1 (Administrator) stated the dementia unit rooms 23, 24, 25, 26, 27, 28, 29, 30, 31 and main hall rooms (not on the dementia unit) 17, 18, 19, 20, 21, 22 were all waivered rooms and don't meet the proper room size requirements. On 6/5/26 at 10:15 AM, R19 and R24's double occupancy room was observed with V1, who stated the room was less than 80 square feet per resident bed. V1 used the measuring tape to measure the length and width of R19 and R24's room and stated it was 11 by 14 feet, indicating that the room was 177 square (sq.) feet (ft.), or 77 sq. ft. per bed. The measurements did not include the closet. At that time, R19 was in her room and stated she had no issues with the room size. The room contained two beds, two nightstands, a recliner, 2 chest of drawers, a wheelchair, 2 walkers and 2 over the bed tables. At this time, R19 and R24 were roommates and were present in the room with no concerns. On 6/5/26 at 10:25 AM, R9 and R10's double occupancy room was observed with V1, who stated the room was less than 80 sq ft per resident bed. V1 measured the room and it measured the same size of 11 by 14 feet for a total of 177 sq ft., or 77 sq. ft. per bed. The measurements did not include the closet. The room contained two beds, a chest, two over the bed tables and two nightstands. R10 was present in the room and voiced no concerns regarding the room size. An undated facility room roster provided by V1 (Administrator) on 06/2/26 documented R9, R10, R19, and R24 reside in the waivered rooms measured by V1.Resident Council meeting minutes for the last 6 months documented no complaints or concerns related to the size of the rooms.

Based on observation, interview, and record review, the facility failed to administer an antianxiety medication for 1 (R1) of 3 residents reviewed for medication errors in the sample of 9. The failure resulted in R1 developing withdrawal symptoms including nausea, vomiting, shaking, agitation, and being admitted to the local hospital for 2 days.This past noncompliance occurred between 4/22/26 and 4/29/26.Findings include: R1's admission Record documented an admission date to the facility on 9/27/2024 and included diagnoses of type 2 diabetes mellitus without complications, unsteadiness on feet, cerebral infarction, unspecified, insomnia and anxiety disorder, unspecified.R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1's cognition is intact. Under Section N, High-Risk Drug Classes the MDS documented R1 takes an antianxiety medication.R1's Care Plan documented a Focus Area of diagnosis of anxiety and is in need of anti-anxiety medication to treat his condition with interventions that included anti-anxiety medication per doctor's orders.R1's Physician Order Summary (POS) documented a discontinued order of Diazepam 5 MG (milligram) tablet by mouth four times a day (8:00 AM, 12PM, 4PM, 8PM) related to anxiety disorder with a start date of 9/22/2025 and a discontinued date of 4/28/2026.On 5/6/2026 at 10:25 AM, V4 (Family) stated she came to the facility on 4/26/2026 around 7:00 PM because R1 told her on the phone that he was not feeling well. V4 stated she had known R1 had not been getting his Diazepam for 3-4 days prior to this day. V4 stated R1 takes Diazepam 5mg four times a day for agitation, and the facility had not been able to get his medication refilled. V4 stated she had asked several days in a row about the medication and had been told that they were waiting for a script to be signed from V7 (Physician). V4 stated when she arrived at the facility on 4/26/2026, R1 was weak, shaking, nauseated, had vomited and stated he could not eat the last 2 days. V4 stated she requested R1 be sent to the local emergency room. V4 stated R1 was admitted to the local hospital for a few days with a diagnosis of withdrawal from diazepam. V4 stated R1 returned to the facility on 4/28/2026 and the facility had received the medicine by the time R1 returned.On 5/6/2026 at 10:30 AM, R1 stated he had been taking Diazepam 5mg by mouth four times a day since he was about [AGE] years old. R1 stated it helps him to not be agitated. R1 stated he had not been getting the medication for a few days around 4/23/2026, but he did not know why. R1 stated he could tell he wasn't getting the medicine because he continued to be agitated, and it increased instead of decreased like it does when he takes his medicine. R1 stated he went to the local emergency room on 4/26/2026 where they admitted him for having withdrawals from not taking his Diazepam for 3-4 days. R1 stated he had been weak, nauseous, unable to eat, very agitated and had vomited once.On 5/6/2026 at 10:48 AM, V5 (Registered Nurse/RN) stated she has had direct patient care with R1. V5 stated she remembers R1 not having his Diazepam available and sent a script to V7 (Physician) sometime on 4/20/2026. V5 stated she believes there were multiple requests sent to V7's office with no return script that week. V5 stated V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) also requested R1's Diazepam be refilled to V7's office. V5 stated V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) also requested the Diazepam be refilled to V7's office. V5 stated R1's Diazepam 5mg by mouth four times a day was received at the facility on 4/28/2026. V5 stated she did not contact V7's office to verify if the script had been received. V5 stated she probably could have called V8 (Medical Director) to fill this prescription, but she did not. V5 stated R1 went out to the local hospital on 4/26/2026.On 5/6/2026 at 10:55 AM, V3 (ADON) stated she does not work on Mondays or Fridays. V3 stated she was working on narcotic counts for residents on 4/21/2026 when V5 (Registered Nurse/RN) made V3 aware that V5 had sent a script to V7's (Physician) office for the refill of R1's Diazepam 5MG by mouth four times a day, and V3 stated she believed it was around 4/20/2026. V3 stated within the next few days she was notified R1 was out of his Diazepam and was waiting on a script to be signed by V7. V3 stated she sent a script to V7's office on 4/23/2026 to refill R1's Diazepam 5MG by mouth four times a day. V3 stated R1 went to the local emergency room on 4/26/2026 and was admitted for withdrawal symptoms from not receiving his Diazepam.On 5/6/2026 at 11:00 AM, V2 (DON) stated was made aware that V4 (Family) wanted R1 sent out to the local emergency room on 4/26/2026 because he had been out of his Diazepam 5MG by mouth four times a day since 4/22/2026 at 8:00 PM. V2 stated R1 was admitted to the local hospital for withdrawal symptoms from not taking his Diazepam.On 5/6/2026 at 11:15 AM, V6 (Licensed Practical Nurse/LPN) stated she worked on 4/24/2026 through 4/26/2026 and had direct patient care with R1. V6 stated she came in on 4/24/2026 and received report that R1 had been without his Diazepam 5MG by mouth four times a day for a few days and the facility was waiting on a script from V7 (Physician). V6 stated R1 was admitted to the local hospital on the evening of 4/26/2026 with withdrawal symptoms from not taking his Diazepam.On 5/6/2026 at 11:21 AM, V1 (Administrator) stated his expectation is for nursing staff to follow the facility policy and procedures on medication administration, physician orders, and follow-up in a timely manner.On 5/6/2026 at 11:42 AM, V7 (Physician) stated R1 went to the local emergency room on 4/26/2026 for withdrawals of not having his Diazepam as ordered. V7 stated he had been out of town when the facility faxed the script to his office. V7 stated the facility should have reached out to V8 (Medical Director) or V9 (On-Call Physician) if there were any issues with refilling R1's medication. V7 stated his office notified the facility on 4/24/2026 that V7 had not been in the office and the facility's pharmacy does not allow a nurse practitioner signature for this medication. V7 stated once the facility was notified, they should have reached out to V8 or V9 in a timely manner.On 5/6/2026 at 1:22 PM, V3 (ADON) stated she does weekly narcotic reviews and places orders for refills on medications. V3 stated Diazepam 5 MG tablet is available in the facility emergency kit but could not be accessed without R1 having an active script on hand at the facility pharmacy.On 5/6/2026 at 1:22 PM, the facility emergency kit was observed with V3 present and showed Diazepam 5 MG tablets available.On 5/7/2026 at 9:05 AM, V6 (LPN) stated R1 did not complain of any symptoms of withdrawal from his Diazepam to her until 4/26/2026. V6 stated R1 complained of shakiness, agitated, etc. V6 stated she notified V2 (DON) on 4/24/2026 that she was unable to get R1's Diazepam.On 5/7/2026 at 9:22 AM, V12 (RN) stated she worked on 4/26/2026 when R1 went to the local emergency room. V12 stated V4 (Family) requested R1 be sent to the local emergency room because he had been without his Diazepam for a few days. V12 stated until then, she was not aware that R1 was out of his medication. V12 stated R1 had symptoms of shakiness and complained of anxiety. V12 stated she sent R1 to the local emergency room with V4 as requested.R1's Progress Notes dated 4/22/2026 at 9:43 PM by V13 (LPN), 4/23/2026 at 8:12 AM by V14 (RN), 4/23/2026 at 12:00 PM by V14 (RN), 4/23/2026 at 5:03 PM by V14 (RN), 4/24/2026 at 12:29 AM by V13 (LPN), 8:46 AM by V6 (LPN), 11:39 AM by V6, 3:52 PM by V6, 8:36 PM by V12 (RN), 4/25/2026 at 8:28 AM by V6, 11:08 AM by V6, and 4:57 PM by V6 (LPN) all documented R1's diazepam 5mg tablet by mouth four times a day was not available, waiting on order, or waiting on script.R1's Medication Administration dated April 1st - April 30th documented Diazepam 5MG tablet by mouth four times a day was not administered on 4/22/2026 at 9:43 PM by V13 (LPN), 4/23/2026 at 8:12 AM by V14 (RN), 4/23/2026 at 12:00 PM by V14 (RN), 4/23/2026 at 5:03 PM by V14 (RN), 4/24/2026 at 12:29 AM by V13 (LPN), 8:46 AM by V6 (LPN), 11:39 AM by V6, 3:52 PM by V6, and 8:36 PM by V12 (RN), and 4/25/2026 at 8:28 AM by V6, 11:08 AM by V6, and 4:57 PM by V6 (LPN).R1's Progress Note dated 4/26/2026 at 1:38 AM by V12 (RN) documented R1 had complaints of shaking, diarrhea, sinus drainage into chest, and congestion. (V4) was here and wanted to escort resident to the hospital at 7:20PM. This RN just received a call from the local emergency room stating they are keeping R1 with a diagnosis of Diazepam withdraw.R1's Progress Note dated 4/26/2026 at 6:20 AM by V6 (LPN) documented R1 was admitted to the hospital.R1's local hospital After Visit Summary dated 4/26/2026 - 4/28/2026 documented under Reason for admission: Valium (Diazepam) withdrawal.The facility's policy Medication Administration (effective date 10/25/2014) documented under Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Under Procedure:.Administration.2) Medications are administered in accordance with written orders of the prescriber.According to https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/013263s094lbl.pdf, Diazepam is a benzodiazepine that exerts anxiolytic, sedative, muscle relaxant, anticonvulsant and amnestic effects. Withdrawal symptoms, similar in character to those noted with barbiturates and alcohol have occurred following abrupt discontinuance of diazepam. These withdrawal symptoms may consist of tremor, abdominal and muscle cramps, vomiting, sweating, headache, muscle pain, extreme anxiety, tension, restlessness, confusion and irritability.Prior to the survey date, the facility took the following actions to correct the non-compliance:1. Actions taken to correct deficiencies dated 4/28/2026Resident was sent to the hospitalNew fax machine acquiredNurse Practitioner to provide backup to provider when provider is not available.2. Actions taken to identify other potential residents affected by the deficient practice dated 4/28/2026: a. All current residents that receive antianxiety medication are at risk for deficient practice.3. Actions taken to ensure proper practice continues dated 4/28/2026:Audit completed of all residents taking antianxiety medication in the facility to ensure all residents antianxiety medication available.Education to nursing staff on the process for controlled medication ordering.Director of Nursing/Designee will audit antianxiety medication availability for residents daily for 1 week, 3 times a week for 2 weeks, and weekly for one month.4. Actions taken to ensure the deficient practice does not recur, dated 4/29/2026:On April 29, 2026, the interdisciplinary team reviewed the medication error to determine contributing factors and implement corrective actions. The event was analyzed to identify opportunities for improvement in medication administration and communication processes. There are steps that have been put in place to reduce the risk of recurrence and to promote safe and effective medication practices for all residents. Trends will be reported to the Quality Assurance Committee for review with any identified deficiencies to have further corrective action implemented as needed.

Based on observation, interview, and record review, the facility failed to ensure timely acquisition of a medication refill resulting in missed doses of a controlled substance for 1 (R1) of 3 residents reviewed for pharmacy services in the sample of 9. This past noncompliance occurred between 4/22/26 and 4/29/26. Findings included:R1's admission Record documented admission to the facility on 9/27/2024 and included diagnoses of type 2 diabetes mellitus without complications, unsteadiness on feet, cerebral infarction, unspecified, insomnia, and anxiety disorder, unspecified. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1's cognition is intact. Under Section N, High-Risk Drug Classes, the MDS documented R1 was taking an antianxiety medication. R1's Physician Order Summary (POS) documented a discontinued order of Diazepam 5 MG (milligram) tablet by mouth four times a day (8:00 AM, 12PM, 4PM, 8PM) related to anxiety disorder with a start date of 9/22/2025 and a discontinued date of 4/28/2026. On 5/6/2026 at 10:25 AM, V4 (Family) stated she had come to the facility on 4/26/2026 around 7:00 PM because R1 told her on the phone that he was not feeling well. V4 stated she knew R1 had not been getting his Diazepam for 3-4 days prior to this day. V4 stated R1 takes Diazepam 5mg four times a day for agitation, and the facility had not been able to get his medication refilled. V4 stated she had asked several days in a row about the medication and was told that they were waiting for a script to be signed from V7 (Physician). On 5/6/2026 at 10:30 AM, R1 stated he had been taking Diazepam 5mg by mouth four times a day since he was about [AGE] years old. R1 stated it helps him to not be agitated. R1 stated he had not been getting the medication for a few days around 4/23/2026, but he did not know why. R1 stated he could tell he wasn't getting the medicine because he continued to be agitated, and it increased instead of decreased like it does when he takes his medicine. On 5/6/2026 at 10:48 AM, V5 (Registered Nurse/RN) stated she has direct patient care with R1. V5 stated she remembered R1 not having the Diazepam available and sent a script to V7's (Physician) sometime on 4/20/2026. V5 stated she believes there were multiple requests sent to V7's office with no return script that week. V5 stated V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) also requested the Diazepam be refilled to V7's office. V5 stated R1's Diazepam 5mg by mouth four times a day was received at the facility on 4/28/2026. V5 stated she did not contact V7's office to verify if the script had been received. V5 stated she probably could have called V8 (Medical Director) to fill this prescription, but she did not. On 5/6/2026 at 10:55 AM, V3 (ADON) stated she does not work on Mondays or Fridays. V3 stated she was working on narcotic counts for residents on 4/21/2026 when V5 (Registered Nurse/RN) made V3 aware that V5 had sent a script to V7's (Physician) office for the refill of R1's Diazepam 5MG by mouth four times a day, and V3 stated she believed it was around 4/20/2026. V3 stated within the next few days she was notified R1 was out of his Diazepam and was waiting on a script to be signed by V7. V3 stated she sent a script to V7's office on 4/23/2026 to refill R1's Diazepam 5MG by mouth four times a day. V3 stated V7 responded to her message via text on 4/28/2026 that he saw the script on 4/24/2026 that V3 sent, however, he had been out of the office. V3 stated V2 (DON) took over getting R1's Diazepam refilled after the 4/28/2026 message. V3 stated the nursing staff should have followed up on R1's refill request and if V7 had not been in the office, the nursing staff should have contacted the on-call physician or V8 (Medical Director) to refill the prescription. On 5/6/2026 at 11:00 AM, V2 (DON) stated she was made aware that V4 (Family) wanted R1 sent out to the local emergency room on 4/26/2026 because he had been out of his Diazepam 5MG by mouth four times a day since 4/22/2026 at 8:00 PM. V2 stated R1 was admitted to the local hospital for withdrawal symptoms from not taking his Diazepam. V2 stated the nursing staff should have followed up on R1's refill script in a timely manner. V2 stated the nursing staff could have reached out to V11 (Psych Physician) or V8 (Medical Director) to refill R1's medication. On 5/6/2026 at 11:15 AM, V6 (Licensed Practical Nurse/LPN) stated she worked on 4/24/2026 through 4/26/2026 and had direct patient care with R1. V6 stated she came in on 4/24/2026 and received report that R1 had been without his Diazepam 5MG by mouth four times a day for a few days and the facility was waiting on a script from V7 (Physician). V6 stated she called V7's office and they returned a call to her to notify her that they were unable to send a script to the facility's pharmacy. V6 stated she then requested them to send it to her. V6 stated the office called back and notified her they sent the script around 4:30 PM. V6 stated their pharmacy called and notified her the script had not been signed by a physician and by that time, V7's office was closed. V6 stated on 4/26/2026 she attempted to get R1's Diazepam refilled by V9 (On-Call Physician) but he was not near a fax machine or printer. V6 stated she did not reach out to V8 (Medical Director) to request a refill for R1's medication because she is still new and learning about who she could call or reach out to in this type of situation. On 5/6/2026 at 11:21 AM, V1 (Administrator) stated his expectation is for nursing staff to follow the facility policy and procedures on medication administration, physician orders, and follow-up in a timely manner. On 5/6/2026 at 11:42 AM, V7 (Physician) stated R1 went to the local emergency room on 4/26/2026 for withdrawals due to not having his Diazepam as ordered. V7 stated he had been out of town when the facility faxed the script to his office. V7 stated the facility should have reached out to V8 (Medical Director) or V9 (On-Call Physician) if there were any issues with refilling R1's medication. V7 stated his office notified the facility on 4/24/2026 that V7 had not been in the office and the facility's pharmacy does not allow a nurse practitioner's signature for this medication. V7 stated once the facility had been notified, they should have reached out to V8 or V9 in a timely manner. On 5/6/2026 at 1:22 PM, V3 (ADON) stated she does weekly narcotic reviews and places orders for refills on medications. V3 stated Diazepam 5 MG tablet is available in the facility emergency kit but could not be accessed without R1 having an active script on hand at the facility pharmacy. On 5/6/2026 at 1:22 PM, the facility emergency kit was observed with V3 present and showed Diazepam 5 MG tablets available. On 5/7/2026 at 9:22 AM, V12 (RN) stated she worked on 4/26/2026 when R1 went to the local emergency room. V12 stated V4 (Family) requested R1 be sent to the local emergency room because he had been without his Diazepam for a few days. V12 stated until then, she was not aware R1 had been out of this medication. V12 stated R1 did have symptoms of shakiness and complained of anxiety. V12 stated she sent R1 to the local emergency room with V4 (Family) as requested. V12 stated she explained to V4 that the facility had not been able to get R1's Diazepam 5mg script signed by V7 (Physician), it was the weekend so they would not be able to get it filled. V12 stated she was aware that the facility pharmacy would take a verbal order from the physician, but they were unable to reach V7. V12 stated she thinks there may have been a nurse practitioner on call, but they did not reach out to them because they would just send them to the local emergency room for further evaluation. V12 stated she is not sure if she could have called V8 (Medical Director) to have R1's script filled. On 5/7/2026 at 12:23 PM, V15 (Pharmacist) stated the pharmacy company does have documentation showing a script for R1's Diazepam 5MG by mouth four times a day with R1 being on this medication for a while. V15 stated the documentation showed a script had been sent to them on 4/24/2026 by V7's office but had not been signed. V15 stated the pharmacy did notify the facility and physician's office the script had not been signed. V15 said the facility received a signed script on 4/27/2026. V15 stated the pharmacist would have accepted a verbal order by a physician or nurse practitioner with appropriated credentials to refill R1's Diazepam. V15 said with an active order on file and the medication being available in the emergency kit, R1 could have received his medication. The facility's Controlled Substance Prescriptions (effective date 10/14/2026) documented under Policy: Before a controlled drug can be dispensed, the pharmacy must be in a receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribe. Verbal orders for controlled medications are permitted for class II-controlled drugs only in emergency situations. The facility's Emergency Pharmacy Service and Emergency Kits (effective date 10/14/2026) documented under Policy: Emergency pharmacy services is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved Emergency Medication Kit/Box or by special order from pharmacy. The pharmacy supplies emergency mediations including emergency drugs, antibiotics, controlled substances, and products for infusion in limited quantities in compliance with applicable state and federal regulations to serve the immediate clinical needs of the residents. Documented under Procedures: A. Telephone/fax numbers for emergency services are posted at nursing stations. B. The dispensing pharmacy is called if an emergency arises requiring immediate pharmacist consultation concerning appropriateness of therapy, drug information, etc. Prior to the survey date, the facility took the following actions to correct the non-compliance dated 4/28/2026:1. Actions taken to correct deficiencies.a. Resident was sent to the hospitalb. New fax machine acquiredc. Nurse Practitioner to provide backup to provider when provider is not available. 2. Actions taken to identify other potential residents affected by the deficient practice dated 4/28/2026:a. All current residents that receive antianxiety medication are at risk for deficient practice. 3. Actions taken to ensure proper practice continues dated 4/28/2026:a. Audit completed of all residents taking antianxiety medication in the facility to ensure all residents antianxiety medication available.b. Education to nursing staff on the process for controlled medication ordering.c. Director of Nursing/Designee will audit antianxiety medication availability for residents daily for 1 week, 3 times a week for 2 weeks, and weekly for one month. 4. Actions taken to ensure the deficient practice does not recur, dated 4/29/2026:On April 29, 2026, the interdisciplinary team reviewed the medication error to determine contributing factors and implement corrective actions. The event was analyzed to identify opportunities for improvement in medication administration and communication processes. There are steps that have been put in place to reduce the risk of recurrence and to promote safe and effective medication practices for all residents. Trends will be reported to the Quality Assurance Committee for review with any identified deficiencies to have further corrective action implemented as needed.

Based on interview and record review, the facility failed to ensure residents were free from resident to resident sexual and physical abuse for 3 of 3 residents (R1, R2 and R3) reviewed for abuse in the sample of 6. Findings include:1. The Facility's Final Reportable Event dated 4/16/2026 documented in part: R2 an [AGE] year-old female with a BIMS (Brief Interview for Mental Status) score of 5 and a diagnosis of Alzheimer's disease was observed engaging in inappropriate sexual behavior of an oral nature with R1 a [AGE] year-old male with a BIMS score of 2 and a diagnosis of dementia. Upon discovery, staff immediately intervened and separated both residents. There was no evidence of force, coercion, threat, or distress observed in either resident at the time of the incident. Investigation confirmed R1 and R2 had an established friendly relationship and had not previously demonstrated sexually inappropriate behavior. Based on the findings this incident is not substantiated as willful abuse.R1's admission Record documented an admission date of 8/04/2025 and included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, which indicates moderate cognitive impairment. R1's Care Plan had a focus area documented of R1 is at risk for abuse due to dementia that included reporting all instances of alleged abuse to the abuse coordinator. R1's Progress Note dated 4/8/2026 at 5:49 PM by V6 (Registered Nurse/RN) was lined out for incomplete documentation but included: Res (resident) found in female res room with his penis in her mouth. Res separated and this res sat in DR (dining room) with staff. No adverse effects noted. This note had a strike out date of 4/10/2026 at 9:04 AM. R1's Progress Note dated 4/8/2026 at 5:49 PM by V6 (RN) documented Late Entry: Res found in female res room. Res separated and this res set in DR with staff. No adverse side effects noted.R2's admission Record documented an admission date of 1/16/2026 and included diagnoses of Alzheimer's disease, unspecified, anxiety, dementia in other disease classified elsewhere, without unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, which indicates severe cognitive impairment. R2's Care Plan had a focus area documented of R2's has the diagnosis of dementia and is noted to have impaired cognitive function and behavioral complications. Interventions that included monitor for and report to the nurse any noted changes in R2's cognitive function such as: changes in her decision making ability, memory, recall, general awareness, difficulty expressing herself, difficulty understanding others, changes in level of consciousness or mental status. R2's Progress Note dated 4/8/2026 at 6:05 PM by V6 (RN-Registered Nurse) was lined out for incomplete documentation but included: at 5:49 PM, CNA (Certified Nursing Assistant) noted male res (resident) in this res room. His penis was in her mouth. Res separated with this res becoming upset and hit CNA. Res then came out of room. Attempted to go out locked unit door. When she couldn't get out the door she called this nurse a son of a b***h and hit her in the jaw. Res then went to room and did not come out. This note had a strike out date of 4/9/2026 at 10:28 AM. R2's Progress Note dated 4/8/2026 at 6:05 PM by V6 documented Late Entry: at 5:49 PM CNA noted male res in this res room. Res separated with this res becoming upset and hit CNA. Res then came out of room. Attempted to go out locked unit door. When she couldn't get out the door she called this nurse a son of a b***h and hit her in the jaw. Res then went to room and did not come out.On 4/21/2026 at 12:53 PM, when R1 was asked about an incident with him and R2, R1 stated he had never participated or seen any inappropriate behavior and does not even know who R2 is.On 4/21/2026 at 12:56PM, when R2 was asked about an incident between her and R1, R2 stated she had not witnessed or participated in any inappropriate behavior and does not remember anyone coming into her room with her.On 4/21/2026 at 1:18 PM, V11 (Certified Nursing Assistant/CNA) stated she had been sitting at the dining room table charting after dinner on 4/8/2026 when V13 (Dietary Aide) asked her if it was normal for R1 and R2 to walk off together. V11 stated, she got up to go see where R1 and R2 went because they have been known to exit seek. V11 stated, when she walked out of the dining room, she noticed R2's door was shut. V11 stated, when she opened R2's door, R2 was sitting on her bed with R1 standing in front of her with his pants down and her mouth on his penis. V11 stated, she immediately asked R1 and R2 to stop with R1 pulling up his pants and R2 started growling at her. V11 stated, R1 went out to the dining room with her and R2 stayed in her room. V11 stated, she did report the incident to V6 (RN). On 4/21/2026 at 2:46 PM, V13 (Dietary Aide) stated she had been sitting with residents on the secured unit in the dining room. V13 stated, R1 and R2 had been sitting in the dining room and had been talking. V13 stated, she noticed R1 and R2 walked off together and went to R2's room and she noticed they shut the door so she notified V11 (CNA) that R1 and R2 should not be doing that. V13 stated, V11 went straight to R2's room and when she opened the door. V11 told both residents to stop. V13 stated, R1 went to dining room to sit while V6 (Registered Nurse) went to assess R2 and R1, then called both families. On 4/22/2026 at 9:33 AM, V6 (RN) stated, she had been working on 4/8/2026 when she overheard V11 (CNA) say stop, we don't do that here and separated R1 and R2. V6 immediately notified her of what she had witnessed between R1 and R2. V6 stated, she went to assess R2. V6 stated, R2 was upset that V11 separated her and R2. V6 stated, R2 started to walk towards the door, turned around and slapped her. V6 stated, R2 then when back to her room. On 4/22/2026 at 11:12 AM, V1 (Vice President of Operations) stated, it is her expectation all staff follow the facility's policies and procedures. V1 stated, the facility had completed a reassessment of R1's BIMS score and he is severe cognitively impaired.3. R3's admission Record documented an admission date of 8/28/2025 and included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other muscle spasm, depression, unspecified, anxiety disorder and bipolar II disorder. R3's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicates R3 is cognitively intact. R3's Care Plan documented a focus area of R3 is at risk for abuse due to stroke with interventions that included report all instances of alleged abuse to the abuse coordinator.On 4/21/2026 at 12:47 PM, R3 stated R1 did come into his room last week on 4/13/2026, slammed his door and when he asked R1 to open his door back up, R1 slapped him across the face. R3 stated, he reported the incident to V18 (Licensed Practical Nurse/LPN) and V19 (Certified Nursing Assistant/CNA) they removed R1 from his room. On 4/22/2026 at 3:58 PM, V19 (Certified Nurse Assistant/CNA) stated, she did work the evening R1 and R3 had an altercation. V19 stated, she had been down the hallway assisting another resident when she noticed R1 entering R3's room. V19 stated, she started down the hallway and attempted to redirect R1 out of R3's room. V19 stated, before she got to R3's room, R1 had slammed the door and she did hear R3 yell, Hey. V19 stated, by the time she opened the door, R1 and R3 were separated with R3 saying R1 just slapped him and R1 holding his hand and rubbing it. V19 stated, R1 was saying something about he can't tell me to leave the bathroom. V19 stated, the hallway bathroom is across from R3's room so she believes R1 had gotten confused about which door he went in to use the bathroom. V19 stated, she did notify V18 (LPN-Licensed Practical Nurse) of the incident and R3 told V19 the same story he told her. R1's Progress Note dated 4/13/2026 at 7:02 PM by V18 (LPN) documented R1 had been up walking about the facility. R1 entered another male resident room and slams the door shut behind him. Staff had been alerted and observed R1 standing in another resident room yelling out and R3 stated that R1 had stricken him in the face. V19 (CNA) was able to redirect R1 out of R3's room and offered a snack and drink. R1 is currently sitting in dining room, awaiting new orders. Will continue to keep close observation and encourage R1 to stay out of other residents room without their permission. R3 had no documentation in his electronic health record about the physical altercation between him and R1. On 4/22/2026 at 11:12 AM, V1 (Vice President of Operations) stated, it is her expectation all staff follow the facility's policies and procedures. V1 stated, the facility had completed a reassessment of R1's BIMS score and he is severe cognitively impaired.The Facility's Final Reportable Event dated 4/20/2026 documented an investigation that had been completed into the physical altercation between R1 and R3 that occurred on 4/13/2026. The facility's Abuse Prevention Policy (undated) documented this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, deprivation of goods and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and mistreatment of residents.

Based on interview and record review, the facility failed to report allegations of sexual abuse and physical abuse to the administrator immediately for 2 (R1 and R3) of 3 residents reviewed for abuse in the sample of 6. Findings included:1. R1's Progress Note dated 4/8/2026 at 5:49 PM by V6 (Registered Nurse/RN) was lined out for incomplete documentation but included: Res (resident) found in female res room with his penis in her mouth. Res separated and this res sat in DR (dining room) with staff. No adverse effects noted. This note had a strike out date of 4/10/2026 at 9:04 AM. On 4/22/2026 at 11:12 AM, V1 (Vice President of Operations) stated, she received an email on 4/9/2026 from V3 (Director of Nursing/DON) notifying her of the interaction between R1 and R2 the evening before. V1 stated, V2 did communicate in the email that R1 and R2 had been in R2's room, when V11 walked in and found R2 sitting on the bed with R1 standing in front of her with his pants down and R2 having her lips on R1's penis. 2. R1's Progress Note dated 4/13/2026 at 7:02 PM by V18 (Licensed Practical Nurse/LPN) documented R1 had been up walking about the facility. R1 entered another male resident room and slams the door shut behind him. Staff had been alerted and observed R1 standing in another resident room yelling out and R3 stated that R1 had stricken him in the face. V19 (Certified Nursing Assistant/CNA) was able to redirect R1 out of R3's room and offered a snack and drink. R1 is currently sitting in dining room, awaiting new orders. Will continue to keep close observation and encourage R1 to stay out of other residents room without their permission. On 4/21/2026 at 12:47 PM, R3 who was alert to person, place and time stated, R1 did come into his room last week on 4/13/2026, slammed his door and when he asked R1 to open his door back up, R1 slapped him across the face. R3 stated, he reported the incident to V18 (LPN), and they removed R1 from his room. On 4/22/2026 at 12:06 PM, V16 (Licensed Practical Nurse/LPN) stated, she had been made aware of the physical altercation between R1 and R3 on 4/14/2026 when she came in that morning. V16 stated, she had been notified by V17 (Registered Nurse/RN) that R3 stated R1 had gone into his room, slammed his door and struck him on the evening of 4/13/2026. V16 stated, V1 had not been notified until 4/14/2026 about the altercation and that is when the investigation started. On 4/22/2026 at 12:15 PM, V3 (Director of Nursing/DON) stated, she had been contacted the evening of 4/13/2026 by V17 (RN) notifying her that R1 went into R3's room and slammed his door. V3 stated, no one reported to her of R1 hitting R3 at that time. On 4/22/2026 at 12:54 PM, V1 stated she was notified by V16 via email on 4/14/2026 that R1 and R3 had an alleged physical altercation that took place in the evening before on 4/13/2026. R1's Progress Note dated 4/14/2026 at 9:48 AM by V16 (LPN) documented 7:56 AM V3 (DON) updated on incident, 8:06 AM V1 notified of incident, 8:16 AM family notified of incident, 8:40 local police department called and awaiting call back.The facility's Abuse Prevention Policy (undated) documented Under Procedures: V. Internal Reporting Requirements and Identification of Allegations, Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of physical abuse for 1 (R3) of 3 residents reviewed for abuse in the sample of 6. Findings include: R1's Progress Note dated 4/13/2026 at 7:02 PM by V18 (Licensed Practical Nurse/LPN) documented R1 had been up walking about the facility. R1 entered another male resident room and slams the door shut behind him. Staff had been alerted and observed R1 standing in another resident room yelling out and R3 stated that R1 had stricken him in the face. V19 (Certified Nursing Assistant/CNA) was able to redirect R1 out of R3's room and offered a snack and drink. R1 is currently sitting in dining room, awaiting new orders. Will continue to keep close observation and encourage R1 to stay out of other residents room without their permission. On 4/21/2026 at 12:47 PM, R3 who was alert to person, place and time, stated R1 did come into his room last week on 4/13/2026, slammed his door and when he asked R1 to open his door back up, R1 slapped him across the face. R3 stated, he reported the incident to V18 (LPN) and V19 (CNA) and they removed R1 from his room.On 4/22/2026 at 3:58 PM, V19 (Certified Nurse Assistant/CNA) stated, she did work the evening R1 and R3 had an altercation. V19 stated, she had been down the hallway assisting another resident when she noticed R1 entering R3's room. V19 stated, she started down the hallway and attempted to redirect R1 out of R3's room. V19 stated, before she got to R3's room, R1 had slammed the door and she did hear R3 yell, Hey. V19 stated, by the time she opened the door, R1 and R3 were separated with R3 saying R1 just slapped him and R1 holding his hand and rubbing it. V19 stated, R1 was saying something about he can't tell me to leave the bathroom. V19 stated, the hallway bathroom is across from R3's room so she believes R1 had gotten confused about which door he went in to use the bathroom. V19 stated, she did notify V18 (LPN) of the incident and R3 told V19 the same story he told her. V19 stated, she had not received any in-services from V3 (Director of Nursing/DON) on 4/9/2026 and she did not get questioned or asked to write a statement for the physical altercation between R1 and R3 on 4/13/2026 from the facility.On 4/23/2026 at 9:18 AM, V3 (DON) stated V18 (LPN) and V19 (CNA) did not come to the first in-services dated 4/9/2026 and she did not follow up with them to review the in-services. V3 stated, the investigation for R1 and R3's physical altercation had been sent in its entirety to her knowledge to surveyor. V3 stated, she had not been asked by V1 to gather statements from V18 or V19 on the physical altercation dated 4/13/2026. On 4/23/2026 at 9:26 AM, V1 (Vice President of Operations) stated it is her understanding that all documents for R1 and R3's physical altercation had been sent from the facility to the surveyor. V1 stated, she believed per V16 (LPN) that V18 (LPN) had been in-serviced on 4/9/2026. V1 stated, she was unaware of V19 (CNA) being present during R1 and R3's altercation and does not have a statement from V19. V1 stated, she used V18's progress note dated on 4/13/2026 as her statement. The facility provided no documentation on V19's statement of the physical altercation that took place on 4/13/2026 or In-service sheets with V18's (LPN) or V19's (CNA) signature on them for the 4/9/2026 in-services given by V3 (DON). On 4/22/2026 at 12:24 PM a message was left for V18 (LPN) via telephone with no returned call. On 4/23/2026 at 8:02 AM, 8:12 AM and 1:55 PM left messages for V18 (LPN) via telephone with no returned call. The facility's Abuse Prevention Policy (undated) documented Under Procedures: VII. Internal Investigation: 4. Investigation Procedures. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed.

Based on interview and record review the facility failed to ensure sufficient staff to meet the needs of the residents timely. This failure has the potential to affect all 46 residents currently residing at the facility. Findings include:1.R1's admission Record with a print date of 8/21/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy, adult failure to thrive, mild protein calorie malnutrition, diabetes mellitus, mild intellectual disability, anemia, cognitive communication deficit, hemiplegia, hemiparesis, history of falls, edema, dementia, and peripheral vascular disease. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 07, indicating a severe cognitive deficit. R1's Order Recap Report dated 6/1/25 to 8/31/25 includes the following physician orders. Insulin Glargine subcutaneous solution 100 unit/ml (milliliters) (Insulin Glargine) Inject 5 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus with Hyperglycemia .Start Date: 07/04/2025 .The facility Medication Admin Audit Report dated 8/1/25 to 8/21/25 documents R1's Insulin Glargine ordered to be administered at bedtime was administered late on 8/4/25, 8/7/25, 8/15/25, and 8/17/25. 2. R2's admission Record with a print date of 8/21/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include muscular dystrophy, methicillin resistant staphylococcus aureus, diabetes, quadriplegia, anemia, depression, hypertension, colostomy, and acquired absence of right and left leg below the knee. R2's MDS dated [DATE] documents a BIMS score of 14, indicating R2 is cognitively intact. R2's Order Summary Report Active Orders as of 8/21/25 includes the following physician orders. Insulin Glargine solution Pen-injector 100 unit/ml Inject 70 unit two times a day for diabetes. Start Date: 07/17/2025 .Colestid Oral Tablet .Give 1 tablet by mouth two times a day related to hyperlipidemia. Start Date 06/28/25 .Enoxaparin Sodium Injection Prefilled Syringe Kit 40 mg (milligrams)/0.4 ml .Inject 40 milligram intramuscularly at bedtime for Prophylaxis .Start Date: 06/28/2025 .Sertraline HCL Oral Tablet 100 mg .Give 100 mg by mouth at bedtime for depression .Start Date: 06/28/2025 .Melatonin Oral tablet 3 mg .Give 4.5 mg by mouth at bedtime for insomnia .Start Date: 06/28/2025 Apixaban Oral Tablet 5 mg .Give 1 tablet by mouth two times a day for Blood Thinner .Start Date 08/13/2025 .Metoprolol Tartrate Oral Tablet 25 mg .Give 0.5 tablet by mouth two times a day related to Essential (Primary) Hypertension .Start Date: 08/20/2025 Trazadone HCL Oral Tablet 50 mg .Give 1 tablet by mouth at bedtime for sleep .Start Date: 08/13/2025 Potassium Chloride ER Tablet Extended Release 20 MEQ (milliequivalent) Give 1 tablet by mouth two times a day for hypokalemia .Start Date: 08/13/2025 The facility Medication Admin Audit Report dated 8/1/25 to 8/21/25 documents the following medications were administered late to R2 1.Insulin Glargine on 8/2 - 8/5, 8/9 - 8/11, 8/14 - 8/16, 8/18, 8/19, and 8/21/25. 2. Colestid on 8/2 - 8/5, 8/9 - 8/11, and 8/13 - 8/20. 3. Enoxaparin on 8/5, 8/13, 8/14, 8/19, and 8/20. 4. Sertraline on 8/5, 8/14, 8/18, 8/19, and 8/21. 5. Melatonin on 8/5, 8/13, 8/14, 8/18, 8/19, and 8/20. 6. Apixaban on 8/13-8/19. 7. Metoprolol on 8/13 - 8/18 and 8/20. 8. Trazadone on 8/13, 8/14, and 8/17. 8. Potassium Chloride on 8/13- 8/16, 8/18 - 8/20. 3. R3's admission Record with a print date of 8/21/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include paraplegia, immobility syndrome, vitamin deficiency, Alzheimer's disease, and peripheral vascular disease. R3's MDS dated [DATE] documents a BIMS score of 13, indicating R3 is cognitively intact. R3's Order Summary Report dated 8/21/25 includes the following orders, Keppra Oral Tablet 1000 MG . Give 1000 mg by mouth at bedtime for unspecified convulsions .Start Date: 4/11/2025 .hydroxyzine HCL Oral Tablet 25 mg .Give 25 mg by mouth at bedtime for anxiety disorder Start Date 04/11/2025 .Aricept Oral Tablet 10 mg .Give 10 mg by mouth at bedtime for dementia .Start Date: 04/11/2025 . Trazadone HCL Oral Tablet 50 mg .Give 0.5 tablet by mouth at bedtime for depression Start Date: 04/11/2025 Divalproex Sodium Oral Tablet Delayed Release 125 mg .Give 125 mg by mouth at bedtime for unspecified convulsions .Start Date: 04/11/2025 .Mucinex Oral Tablet Extended Release 12 Hour .Give 1 tablet by mouth at bedtime for cough/congestion .Start Date: 04/11/2025 .Levothyroxine Sodium Oral Tablet 125 mcg (micrograms) .Give 125 mcg by mouth in the morning for hypothyroid .Start Date: 04/11/2025 .The facility Medication Admin Audit Report dated 8/1/25 to 8/21/25 documents the following medications were administered late to R3. 1. Keppra on 8/3 and 8/15, 2. hydroxyzine on 8/3, 8/15, 8/16, and 8/18, 3. Aricept on 8/3 and 8/15, 4. trazadone on 8/3 and 8/15, 5. divalproex on 8/3 and 8/15, 6. Mucinex on 8/3 and 8/15, 7. levothyroxine on 8/16 and 8/18/25. On 8/21/25 at 8:16 AM, V7 (Registered Nurse/RN) stated they don't have enough staff to meet the needs of the residents timely. V7 stated she works night shift and the bedtime medications (8 pm and 9 pm) don't get administered until 10 pm or 11pm. V7 stated there are 46 residents with three currently in the hospital. V7 stated she has four medication administration passes on night shift (two full and two partial). V7 stated they have three Certified Nurses working on night shift and one nurse. On 8/21/25 at 3:40 PM, V8 (Licensed Practical Nurse/LPN) stated she worked night shift and she was late administering medications at times because they only had one nurse for the 46 residents and she wasn't able to get all of the medications administered in the allowable time frame. On 8/21/25 at 2:32 PM, V2 (Director of Nurses/DON) stated they have one nurse on night shift and two on day shift. V2 stated she wasn't aware medications were not being administered within the ordered time frame until this surveyor asked for the report. V2 stated she thought they had enough staff but need to work on communication and some other things. The facility schedule was reviewed from 8/1 to 8/31/25 and documents one nurse working from 7 pm to 7 am. The facility undated Staffing Policy documents .It is the policy of this facility to provide an adequate number of staff to successfully implement resident functions to meet resident needs.

Based on interview and record review the facility failed to follow physician orders for administration of treatments to wounds for 1 of 3 (R1) residents reviewed for pressure ulcers in the sample of 11. Finding include:R1's admission Record with a print date of 8/21/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy, adult failure to thrive, mild protein calorie malnutrition, diabetes mellitus, mild intellectual disability, anemia, cognitive communication deficit, hemiplegia, hemiparesis, history of falls, edema, dementia, and peripheral vascular disease. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 07, indicating a severe cognitive deficit. This same MDS documents R1 is dependent on staff for bed mobility and transfers. This MDS documents R1 has current pressure ulcers and is at risk of developing pressure ulcers. R1's current Care Plan documents Focus areas of, The resident has Stage 2 pressure ulcer left and right buttocks or potential for pressure ulcer development r/t (related to) Hx (history) of ulcers. Date Initiated: 06/30/2025. This Focus area includes interventions of, Administer treatments as ordered and monitor for effectiveness. Date Initiated: 06/30/2025 . Follow facility policies/protocols for the preventions/treatment of skin breakdown. Date Initiated: 06/30/2025 The resident requires a low air loss mattress et (and) w/c (wheelchair) cushion on bed et w/c Date Initiated: 06/30/2025 This same Care Plan documents a Focus area of The resident has diabetic ulcer of the Lt (left) heel r/t diabetes. Date Initiated: 06/05/2025. This Focus area includes interventions of, Heel boots at all times Treatments as per order. Follow up with Wound Care Physician as scheduled. Monitor for s/s (signs/symptoms) of infections until healed. Date Initiated: 06/05/2025 .Wound Dressing Lt Heel. Treatment as per order. Date Initiated: 06/05/2025 R1's Wound Specialist (V6) note dated 6/9/25 documents, Patient with PMH (past medical history): L (left) side ischemic CVA (cerebrovascular accident), anemia, HTN (hypertension), hypercholesterolemia, sepsis, UTI (urinary tract infection), HTN, DM2 (diabetes mellitus), failure to thrive, left carotid stenosis, who presents for evaluation and management of wound. Significant contributors for increased risk of wound incidence and/or imped healing include but not limited to diabetic and vascular complicating factors, generalized muscle weakness, impaired mobility, and inevitable effects of aging This Wound Specialist note documents under Wound Assessment(s) Wound #1 Left, Posterior Heel is an acute Deep Tissue Pressure Injury persistent non-blanchable deep red, maroon or purple discoloration Pressure ulcer acquired 6/3/2025 and has received a status of Not Healed measurements 2.3 cm (centimeters) length x 1 cm width with no measurable dept no slough and no eschar present Wound Orders: Wound #1 Left, Posterior Heel. Cleanse wound with: wound cleanser. Topical Treatment: Apply betadine, Primary Dressing/Apply: Bordered gauze Treatment Goals: Patient Assessment and Chronic Contributing Conditions: Due to the medical complexity of this patient any skin breakdown is a clinically expected outcome. Assessment: Healing is expected to be delayed due to identified barriers to healing. Barrier(s) to healing: Dementia/Impaired cognition. Diabetes, Impaired mobility, Inevitable effect(s) of aging. Malnutrition, Vascular issues R1's Order Recap Report dated 6/1/25 to 8/31/25 documents a physician order for Left ext (exterior) heel- Betadine daily leave OTA (open to air) every day shift for Diabetic Foot ulcer Start Date 06/05/2025. R1's Treatment Administration Records (TAR) dated 6/1/25 to 6/30/25 documents a physician order of, left ext heel- betadine daily leave OTA every day shift for Diabetic Foot ulcer Start Dated 06/05/2025.D/C (discontinue) Date: 06/24/2025. On 8/21/25 at 2:05 PM, V4 (Assistant Director of Nurse/ADON) stated she wasn't sure why V6 (Wound Specialist) progress note documented an order to cover the wound on the left heel with a border foam dressing. V4 stated when they did the treatment with V6 they left it open to air. V4 stated she should have clarified the order. R1's Wound Specialist note dated 6/23/25 documents under Wound Assessments, .Wound #2 Buttock gluteal fold is an acute Partial Thickness Dermatologic/Rash acquired on 06/16/2025 and has received a status of Not Healed measurements are 7.5 cm length x 8 cm width x 0.01 cm depth .no slough and no eschar present. The wound is improving .Wound Orders: Wound #2 Buttock gluteal fold, Cleanse wound with: Wound cleanser .Apply barrier cream/ointment daily .Additional Orders: .Barrier cream/ointment 3 x (times) per day and after incontinent episodes Due to the medical complexity of this patient any skin breakdown is a clinically expected outcome .R1's Order Recap Report dated 6/1/2025 to 8/31/2025 documents the following physician orders, Buttocks- apply A & D ointment q (every) shift et (and) after incont (incontinent) everyday and night shift for MASD (moisture associated skin damage .Start date 06/17/25 .R1's TAR dated 06/01/2025 to 06/30/2025 documents a physician order of, Buttocks- MASD- apply A & D ointment q shift et (and) after incont (incontinence) every day and night shift for MASD Start Date: 06/17/2025 This TAR documents initials indicating the ointment was administered twice daily. On 8/21/25 at 2:05 PM, V4 (ADON) stated the barrier cream the facility uses is A & D ointment. V4 stated R1's physician order was to apply the ointment every day and night shift. After reviewing R1's Wound Specialist notes documenting the order to apply the barrier cream three times daily, with V4 she stated the facility nursing staff works 12 hour shifts so the facility only has two shifts. V4 stated she should have clarified the order. R1's TAR dated 6/1/2025 to 6/30/2025 documents a physician order for Silver sulfadiazine External Cream 1 % (Silver Sulfadiazine/SSD) Apply to buttocks topically every day and night shift for preventative. Start Date: 06/03/2025 D/C Date: 06/17/2025. R1's Wound Specialist progress note dated 7/7/25 documents under Wound Assessments, .Wound #2 Buttock gluteal fold is an acute Partial Thickness Dematologic/Rash acquired on 06/16/2025 and has received a status of Not Healed .measurements are 3.8 cm length x 6.5 cm width x 0.01 cm depth .The wound is improving. Under Wound Orders this progress note documents the following order, Apply barrier cream/ointment .Bordered foam or ABD (abdominal pads) with tape .R1's TAR dated 7/1/25 to 7/31/25 documents a physician order of, Silver Sulfadiazine Cream 1% apply to left et (and) rt (right) buttocks topically every day shift for stage 2 pressure ulcer cover with comfort foam dressing. Start Date: 07/07/2025 D/C Date 07/14/25 there are initials indicating this treatment was administered on 7/7, 7/9, 7/10, 7/12, and 7/13/25. There is no physician order documented for Silver Sulfadiazine treatment on R1's Wound Specialist progress notes. On 8/12/25 at 2:05 PM, after reviewing R1's 6/1 to 6/30/25 TAR with V4 (ADON) this surveyor asked where the order for the SSD came from since it wasn't documented on R1's Wound Specialist progress notes, V4 (ADON) stated V6 (Wound Specialist) told her to apply SSD to R1's buttocks while he was at the facility assessing R1. V4 stated she didn't know why it wasn't documented as an order on V6's notes. After reviewing R1's 7/1 to 7/31/25 Wound Specialist notes with V4, this surveyor asked where the order for the SSD came from since it wasn't documented on R1's Wound Specialist progress note and V4 stated she wasn't sure why the SSD remained on R1's 7/1-7/31/25 TAR. On 8/21/25 at 12:28 PM, V6 (Wound Specialist) stated he treated R1's wounds/pressure ulcers. V6 stated when he assessed R1's areas the facility implemented interventions to prevent breakdown and promote healing. V6 stated R1's wounds were a combination of pressure and diabetic/arterial wounds. V6 stated with R1's mental status and comorbidities he didn't think the areas of skin breakdown were avoidable. V6 stated R1 didn't like to keep the heel protectors in place, she was very thin, she wasn't eating well, and she had loose stools. V6 stated not getting the treatments as he ordered could have a negative impact on the healing process but he wasn't sure how significant the errors that occurred would have been. V6 stated he assessed R1's wounds on 8/11/25 and there was no signs/symptoms of infection. V6 stated with R1's age and overall physical condition he didn't believe she had the physiological ability to heal the pressure ulcer to her left heel.

Based on interview and record review the facility failed to ensure medications were administered in the time frame ordered for 3 of 3 (R1, R2, and R3) residents reviewed for medication administration in the sample of 11. Findings include:1.R1's admission Record with a print date of 8/21/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy, adult failure to thrive, mild protein calorie malnutrition, diabetes mellitus, mild intellectual disability, anemia, cognitive communication deficit, hemiplegia, hemiparesis, history of falls, edema, dementia, and peripheral vascular disease. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 07, indicating a severe cognitive deficit. R1's Order Recap Report dated 6/1/25 to 8/31/25 includes the following physician orders. Insulin Glargine subcutaneous solution 100 unit/ml (milliliters) (Insulin Glargine) Inject 5 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus with Hyperglycemia .Start Date: 07/04/2025 .The facility Medication Admin Audit Report dated 8/1/25 to 8/21/25 documents R1's Insulin Glargine ordered to be administered at bedtime was administered late on 8/4/25, 8/7/25, 8/15/25, and 8/17/25. 2. R2's admission Record with a print date of 8/21/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include muscular dystrophy, methicillin resistant staphylococcus aureus, diabetes, quadriplegia, anemia, depression, hypertension, colostomy, and acquired absence of right and left leg below the knee. R2's MDS dated [DATE] documents a BIMS score of 14, indicating R2 is cognitively intact. R2's Order Summary Report Active Orders as of 8/21/25 includes the following physician orders. Insulin Glargine solution Pen-injector 100 unit/ml Inject 70 unit two times a day for diabetes. Start Date: 07/17/2025 .Colestid Oral Tablet .Give 1 tablet by mouth two times a day related to hyperlipidemia. Start Date 06/28/25 .Enoxaparin Sodium Injection Prefilled Syringe Kit 40 mg (milligrams)/0.4 ml .Inject 40 milligram intramuscularly at bedtime for Prophylaxis .Start Date: 06/28/2025 .Sertraline HCL Oral Tablet 100 mg .Give 100 mg by mouth at bedtime for depression .Start Date: 06/28/2025 .Melatonin Oral tablet 3 mg .Give 4.5 mg by mouth at bedtime for insomnia .Start Date: 06/28/2025 Apixaban Oral Tablet 5 mg .Give 1 tablet by mouth two times a day for Blood Thinner .Start Date 08/13/2025 .Metoprolol Tartrate Oral Tablet 25 mg .Give 0.5 tablet by mouth two times a day related to Essential (Primary) Hypertension .Start Date: 08/20/2025 Trazadone HCL Oral Tablet 50 mg .Give 1 tablet by mouth at bedtime for sleep .Start Date: 08/13/2025 Potassium Chloride ER Tablet Extended Release 20 MEQ (milliequivalent) Give 1 tablet by mouth two times a day for hypokalemia .Start Date: 08/13/2025 The facility Medication Admin Audit Report dated 8/1/25 to 8/21/25 documents the following medications were administered late to R2 1.Insulin Glargine on 8/2 - 8/5, 8/9 - 8/11, 8/14 - 8/16, 8/18, 8/19, and 8/21/25. 2. Colestid on 8/2 - 8/5, 8/9 - 8/11, and 8/13 - 8/20. 3. Enoxaparin on 8/5, 8/13, 8/14, 8/19, and 8/20. 4. Sertraline on 8/5, 8/14, 8/18, 8/19, and 8/21. 5. Melatonin on 8/5, 8/13, 8/14, 8/18, 8/19, and 8/20. 6. Apixaban on 8/13-8/19. 7. Metoprolol on 8/13 - 8/18 and 8/20. 8. Trazadone on 8/13, 8/14, and 8/17. 8. Potassium Chloride on 8/13- 8/16, 8/18 - 8/20. 3. R3's admission Record with a print date of 8/21/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include paraplegia, immobility syndrome, vitamin deficiency, Alzheimer's disease, and peripheral vascular disease. R3's MDS dated [DATE] documents a BIMS score of 13, indicating R3 is cognitively intact. R3's Order Summary Report dated 8/21/25 includes the following orders, Keppra Oral Tablet 1000 MG . Give 1000 mg by mouth at bedtime for unspecified convulsions .Start Date: 4/11/2025 .hydroxyzine HCL Oral Tablet 25 mg .Give 25 mg by mouth at bedtime for anxiety disorder Start Date 04/11/2025 .Aricept Oral Tablet 10 mg .Give 10 mg by mouth at bedtime for dementia .Start Date: 04/11/2025 . Trazadone HCL Oral Tablet 50 mg .Give 0.5 tablet by mouth at bedtime for depression Start Date: 04/11/2025 Divalproex Sodium Oral Tablet Delayed Release 125 mg .Give 125 mg by mouth at bedtime for unspecified convulsions .Start Date: 04/11/2025 .Mucinex Oral Tablet Extended Release 12 Hour .Give 1 tablet by mouth at bedtime for cough/congestion .Start Date: 04/11/2025 .Levothyroxine Sodium Oral Tablet 125 mcg (micrograms) .Give 125 mcg by mouth in the morning for hypothyroid .Start Date: 04/11/2025 .The facility Medication Admin Audit Report dated 8/1/25 to 8/21/25 documents the following medications were administered late to R3. 1. Keppra on 8/3 and 8/15, 2. hydroxyzine on 8/3, 8/15, 8/16, and 8/18, 3. Aricept on 8/3 and 8/15, 4. trazadone on 8/3 and 8/15, 5. divalproex on 8/3 and 8/15, 6. Mucinex on 8/3 and 8/15, 7. levothyroxine on 8/16 and 8/18/25. On 8/21/25 at 8:16 AM, V7 (Registered Nurse/RN) stated they don't have enough staff to meet the needs of the residents timely. V7 stated she works night shift and the bedtime medications (8 pm and 9 pm) don't get administered until 10 pm or 11pm. V7 stated there are 46 residents with three currently in the hospital. V7 stated she has four medication administration passes on night shift (two full and two partial). V7 stated they have three Certified Nurses working on night shift and one nurse. On 8/21/25 at 3:40 PM, V8 (Licensed Practical Nurse/LPN) stated she worked night shift and she was late administering medications at times because they only had one nurse for the 46 residents and she wasn't able to get all of the medications administered in the allowable time frame. On 8/21/25 at 2:32 PM, V2 (Director of Nurses/DON) stated they have one nurse on night shift and two on day shift. V2 stated she wasn't aware medications were not being administered within the ordered time frame until this surveyor asked for the report. V2 stated she thought they had enough staff but need to work on communication and some other things. The facility Medication Administration Policy dated 10/25/2014 documents, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . Five Rights- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered

Based on interview and record review the facility failed to administer sliding scale insulin and monitor blood sugars as directed per physician's orders for 1 (R6) of 1 resident reviewed for insulin in a sample of 39. This failure resulted in R6 being sent to the emergency room for hyperglycemia. Findings include: R6's Admission Record documents an admitted [DATE] with diagnoses including: type 2 diabetes mellitus with ketoacidosis without coma, dysphagia, lack of coordination, major depressive disorder, dementia, anxiety disorder, and acute kidney failure. R6's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview of Mental Status) score of 12 indicating R6 has moderate cognitive impairment. R6's Progress Note dated 12/25/24 at 6:30 AM documents res (resident) accu check results read Hi called V26-Physician) on call service (Nurse Practitioner) gave order to send to ER for eval and tx (treatment). R6's Progress Note dated 12/30/24 at 2:10 PM documents res (resident) transported back to facility per (name of local hospital) transport readmitted to special care (room #) R6's Clinical Physician Orders with a print date of 5/14/25 documents an order for HumaLOG KwikPen 100 unit/ML solution pen injector with directions listed as: inject as per sliding scale: if 150-199 = 2 units; 200-249 = 4 units; 250-299 = 6 units; 300-349 = 8 units, greater than 349 administer 10 units retest your blood glucose in 4 hours recorrect if necessary, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with ketoacidosis without coma with an order and start date of 12/31/2024. R6's December 2024 MAR (Medication Administration Record) documents the order for HumaLOG KwikPen 100 unit/ML solution pen injector per sliding scale as documented on the Clinical Physician Order Sheet does not document any initials indicating that the sliding scale insulin was not administered at 0600 (6:00AM), 1100 (11:00AM), 1600 (4:00 PM), and 2100 (9:00 PM) on 12/31/24. R6's January 2025 MAR documents the order for HumaLOG KwikPen 100 unit/ML solution pen injector per sliding scale as documented on the Clinical Physician Order Sheet does not document any initials indicating that the sliding scale insulin was not administered at 0600 (6:00AM), 1100 (11:00AM), 1600 (4:00 PM), and 2100 (9:00 PM) on 1/1/25, 1/2/25, 1/3/25 and at 0600 (6:00 AM) on 1/4/25. R6's December 2024 and January 2025 MAR's both document that R6 was receiving the following insulin as ordered: HumaLOG KwikPen 100 unit/ML solution pen injector, inject 5 units subcutaneously before meals with an order date of 12/30/24 and Insulin Glargine Solostar 300 unit/mL solution, inject 40 units subcutaneously at bedtime with an order date of 12/5/24. R6's December 2024 and January 2025 MAR and R6's Weights and Vitals Summary documents the following blood sugars: 12/31/24 at 1800 (6:00 PM) 216 and 1/1/25 at 1800 (6:00 PM) 225. R6's Progress Note dated 01/02/25 at 6:36 PM documents (R6's) BS (blood sugar) was 541. (V26-Physician) wanted her sent to the hospital. This nurse (V24-Registered Nurse) had not been doing sliding scale insulin due to order not being acknowledged. Therefore, order looked discontinued. There were no other blood sugars documented on12/31/25 through 1/2/25 when R6 was sent to the hospital for further evaluation. R6's Progress Note dated 01/03/25 at 12:29 AM documents: patient arrived back at facility at approximately 9:34 PM via (ambulance service) from ED (Emergency Department) gave 10 units of humalog while there, no new orders given. Patient pants were soaked in urine upon arrival. Blood sugar is 314. Patient was changed and washed and is laying in bed with eyes closed. All safety protocols in place at the time of exiting. R6's hospital After Visit Summary dated 1/2/25 documents the reason for visit as hyperglycemia and a diagnosis of diabetes. Under Medications Given it documents Insulin regular (Novolin R/Humulin R) last given at 7:41PM. On 05/15/25 at 1:05 PM, V20 (Licensed Practical Nurse) stated she has worked frequently at the facility for about the last three months, since mid January. After reviewing R6's Electronic Health Record, V20 stated she can see where R6 went to the hospital due to high blood sugars. V20 stated she can see where she had an order for sliding scale dated 12/31/24 and it was discontinued and another order dated 12/31/04 that was not confirmed until the 01/04/25 and she did not receive any sliding scale for those days. V20 said she does not know why the order was not confirmed in the Electronic Health Record on 12/31/24 and she does not know why she was not receiving the sliding scale insulin because R6 is a brittle diabetic. On 05/16/25 at 3:23 PM, V26 (Physician) stated he would not know specifically without looking at R6's record to know if not receiving her sliding scale insulin would have prevented R6 from going to the emergency room , but she does have an order for sliding scale insulin. V26 said he would expect R6 to receive the order as directed and if her blood glucose was low she would not get insulin. R6 is a delicate diabetic and her blood glucose is hard to manage in an outpatient setting. On 05/19/25 at 8:10 AM, V1 (Administrator) stated the orders that residents had prior to going to the hospital should always be reviewed when the orders are reentered into the system to make sure that none are missed. R6 should have received the sliding scale insulin.

Based on interview and record review the facility failed to ensure sufficient staff to provide timely care to the residents. This has the potential to affect all 42 residents who currently reside at the facility. Findings Include: The facility Resident Matrix dated 5/12/25 documents 42 resident currently reside at the facility. 1. R20's Admission Record with a print date of 5/14/25 documents R20 was admitted to the facility on [DATE] with diagnoses that include hypertension, repeated falls, pain, and kidney stones. R20's MDS (Minimum Data Set) dated 2/20/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R20 is cognitively intact. This same MDS documents R20 requires supervision or touching assistance for toilet transfer and partial/moderate assistance for toilet hygiene. R20's current Care Plan documents a Focus area of Due to (R20)'s general weakness and unsteadiness, He is in need of staff assistance to meet his toileting needs. Date Initiated: 07/03/2023. The interventions documented for this Focus area include, .Provide assistance for toileting due to (R20)'s general weakness and history of falling and to ensure proper toileting hygiene. Date Initiated: 07/03/2023. On 5/12/25 at 1:37 PM, R20 stated they don't have enough staff, especially on the weekend. R20 stated it takes up to a half hour for them to answer the call light at times. R20 stated he had incontinent episodes waiting for staff to assist him to toilet. 2. R21's Admission Record with a print date of 5/14/25 documents R21 was admitted to the facility on [DATE] with diagnoses that include muscle wasting and atrophy, lack of coordination, acute kidney failure, and chronic pain syndrome. R21's MDS dated [DATE] documents a BIMS score of 15, which indicates R21 is cognitively intact. This same MDS documents R21 requires substantial/maximal assistance for toilet hygiene and toilet transfer. R21's current Care Plan documents a Focus area of, Due to (R21)'s general weakness, unsteadiness and endurance, she is in need of staff assistance to meet her toileting needs. Date Initiated: 04/13/2023. This Focus area includes, .Assist (R21) to the restroom every 2 hours or sooner upon request. Date Initiated: 04/13/2023 . On 5/12/25 at 10:58 AM, R21 stated it takes a long time for staff to answer the call lights. R21 stated she had incontinent episodes waiting on staff to assist her to toilet. R21 stated, it happens all the time. On 5/13/25 at 11:22 AM, V10 (CNA) stated they don't always have enough staff to meet the needs of the residents. V10 stated the call lights aren't always answered timely. On 5/14/25 at 2:45 PM, V13 (Transport CNA) stated she works day shift and on a good day they have two to three CNA's working on the skilled unit and one CNA on the Alzheimer's unit. V13 stated multiple times they have had non-certified staff monitoring the residents on the Alzheimer's unit. This surveyor reviewed the staffing sheets that document they always have three or more CNA's on skilled and one CNA on the Alzheimer's unit and V13 stated it was probably due to call in's and the staffing sheets not being updated. V13 stated call lights aren't answered timely and toileting isn't always timely. V13 stated she isn't sure how care gets provided on the Alzheimer's unit when the staff monitoring the unit at times aren't certified. On 5/14/25 at 11:17 AM, V15 (Housekeeper) stated she has monitored the residents on the Alzheimer's unit when they haven't had certified staff to do it. V15 stated she doesn't provide care for them she just monitors them. V15 stated she had only done it once for 2-3 hours. V15 stated she had not been trained on behaviors and couldn't provide care such as bed checks. V15 stated she passed ice and cleaned while she was monitoring the residents. V15 stated she would glance in the resident rooms to check on them while she was sweeping. On 5/14/25 at 10:36 AM, V19 (Housekeeping/Laundry) stated they always cover call in's when they have them. V19 stated she had come in when they were short staffed and monitored the Alzheimer's unit but couldn't remember the specific day. V19 stated she cleaned on the unit while she was monitoring it. V19 stated she covered the unit from 8 PM to 3 AM. V19 stated the CNA's from the skilled unit did the bed checks and there were no issues/concerns while she was monitoring the unit. On 5/14/25 at 1:00 PM, V2 (Director of Nurses) stated they don't have enough staff to meet the needs of the residents timely. V2 stated they have issues with staffing on nights and weekends. V2 stated there was one day they only had one agency CNA (Certified Nursing Assistant) from 7:00 to 7:30. When asked if two CNA's could timely provide care to the residents on the skilled care unit, V2 stated it would be hard to answer the call lights timely. V2 stated they are supposed to have a shower aid but they don't always. V2 stated then they were supposed to have a CNA that floated to assist both units but that also fell through the cracks. V2 stated two CNA's are not enough to meet the needs of the residents timely. V2 stated they have approximately 34 residents on skilled care and 5 or 6 of them require assist of two staff for care. On 5/15/25 at 3:04 PM, V1 (Administrator) reviewed the May 2025 schedules with this surveyor and stated they had three CNA's working on day shift. V1 compared the daily staffing sheet to the schedule and stated the daily staffing sheets were not accurate. V1 stated three CNA's are not enough to meet the needs of the residents timely. V1 stated the daily staffing sheets should reflect the accurate staffing numbers and they are not. The facility April 2025 schedule document one CNA working from 7 AM to 7 PM and one CNA working from 10 AM to 7 PM on 4/14/25 and one CNA working from 7 PM to 7 AM on 4/4/25 and 4/18/25. The facility May 2025 schedule documents one CNA working from 7 AM to 7 PM and one CNA working from 11 AM to 7 PM on 5/9/25. The Facility Assessment Tool dated 2/24/25 documents the facility average daily census is 40-45 residents with 18 beds on the alarmed dementia unit and 42 long term care beds. The Tool documents they Total number needed or average range for certified nursing assistants is four from 7 AM to 7 PM and three from 7 PM to 7 AM.

Based on observation, interview, and record review the facility failed to protect the rights of 4 of 4 residents (R6, R20, R21, and R39) reviewed for dignity in the sample of 39. Findings Include: 1. R20's Admission Record with a print date of 5/14/25 documents R20 was admitted to the facility on [DATE] with diagnoses that include hypertension, repeated falls, pain, and kidney stones. R20's MDS (Minimum Data Set) dated 2/20/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R20 is cognitively intact. This same MDS documents R20 requires supervision or touching assistance for toilet transfer and partial/moderate assistance for toilet hygiene. R20's current Care Plan documents a Focus area of Due to (R20)'s general weakness and unsteadiness, He is in need of staff assistance to meet his toileting needs. Date Initiated: 07/03/2023. The interventions documented for this Focus area includes, .Provide assistance for toileting due to (R20)'s general weakness and history of falling and to ensure proper toileting hygiene. Date Initiated: 07/03/2023. On 5/12/25 at 1:37 PM, R20 stated they don't have enough staff, especially on the weekend. R20 stated takes up to a half hour for them to answer the call light at times. R20 stated he had incontinent episodes waiting for staff to assist him to toilet. 2. R21's Admission Record with a print date of 5/14/25 documents R21 was admitted to the facility on [DATE] with diagnoses that include muscle wasting and atrophy, lack of coordination, acute kidney failure, and chronic pain syndrome. R21's MDS dated [DATE] documents a BIMS score of 15, which indicates R21 is cognitively intact. This same MDS documents R21 requires substantial/maximal assistance for toilet hygiene and toilet transfer. R21's current Care Plan documents a Focus area of, Due to (R21)'s general weakness, unsteadiness and endurance, she is in need of staff assistance to meet her toileting needs. Date Initiated: 04/13/2023. This Focus area includes, .Assist (R21) to the restroom every 2 hours or sooner upon request. Date Initiated: 04/13/2023 . On 5/12/25 at 10:58 AM, R21 stated it takes a long time for staff to answer the call lights. R21 stated she had incontinent episodes waiting on staff to assist her to toilet. R21 stated, it happens all the time. On 5/13/25 at 11:22 AM, V10 (CNA/Certified Nursing Assistant) stated they don't have enough staff to meet the needs of the residents timely. V10 stated the call lights aren't always answered timely. On 5/14/25 at 2:45 PM, V13 (transport CNA) stated call lights aren't answered timely and toileting isn't always timely. On 5/14/25 at 1:00 PM, V2 (Director of Nurses) stated they don't have enough staff to meet the needs of the residents timely. V2 stated they have issues with staffing on nights and weekends. V2 stated with two CNA's on the skilled care unit it would be hard to answer the call lights timely. The facility Answering Call Light policy dated 8/2008 documents, The purpose of this procedure is to respond to the resident's requests and needs 8. Answer the resident's call as soon as possible . 3. On 5/15/25 at 9:00 AM, R20 was sitting outside the facility, under the pavilion, smoking cigarettes, with peers and staff present. R20 was wearing a plastic safety apron that went from his neck/shoulder area to his knees. R20's current Care Plan documents a Focus Area of (R20) desire to continue to be a cigarette smoker. This same Focus Area documents the following interventions, Assist (R20) with his money management for his cigarette use and other things he desires to do .(R20) does need assistance to smoking area but does not need supervision while smoking Facility smoking assessments to be completed to determine if (R20) can manage his own tobacco products and smoke safely Instruct about smoking risks and hazards and about smoking cessation aids that are available Observed clothing and skin for signs of cigarette burns R20's Smoking-Safety Screen report dated 4/14/25 documents R20 does not need adaptive equipment and/or the facility to store the lighter and cigarettes. This same screening documents R20 is safe to smoke independently. On 05/15/25 at 10:55 AM, R20 stated, ever since the guy burnt himself the smokers have had to wear smoking aprons. R20 stated he does not like to wear the apron; he would prefer not to. R20 stated he had never burned himself or had any accidents. R20 stated he had not been reassessed that he was aware of since mid April. 41610 4. R6's Admission Record documents an admitted [DATE] with diagnoses including: type 2 diabetes mellitus with ketoacidosis without coma, dysphagia, lack of coordination, major depression disorder, dementia, depression, anxiety disorder,and acute kidney failure. R6 Minimum Data Set (MDS) dated [DATE] documents a BIMS summary score (Brief Interview of Mental Status) of 12 indicating resident is moderately cognitively impaired. On 05/15/25 at 11:35 AM, R6 stated she has to wear an apron now to smoke and does not know why. She does not want to wear it and she did not before. She does not know what changed. She has not burned herself. R6's Smoking Safety Screen dated 04/14/25 documents: 7. resident need for adaptive equipment with 7a. smoking apron, 7b. cigarette holder, 7c. supervision, and 7d. one-on-one assistance listed and none marked. 7e. other has nothing typed in the box, 9. service plan is used to assure resident is safe while smoking with yes marked. Letter F. can be supervised if needed 2. team decision: 1. safe to smoke without supervision is marked 3. rationale/conditions: can be supervised if needed typed in. R6's care plan documents a focus area of R6 has the desire to smoke cigarettes with a date initiated of 06/22/2024 with an intervention of resident will require supervision while smoking with an initiated date of 06/22/2024. 5. R39's Admission Record documents an admitted [DATE] with diagnoses including: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle wasting and atrophy, lack of coordination, type 2 diabetes mellitus, anxiety disorder, and cerebral infarction. On 05/07/25 at 2:30 PM, R39 was outside smoking wearing a smoking apron. On 05/08/25 at 9:30 AM, R39 was outside smoking wearing a smoking apron. R39's Smoking Safety Screen dated 04/14/25 documents: 7. resident need for adaptive equipment with 7a. smoking apron, 7b. cigarette holder, 7c. supervision, and 7d. one-on-one assistance listed and none marked. 7e. other has she needs help lighting her cig typed in. 8. does resident need facility to store lighter and cigarettes with no marked, 9. service plan is used to assure resident is safe while smoking with no marked. Letter F. resident does need assistance to light cig in windy conditions 2. team decision: 1. safe to smoke without supervision is marked 3. rationale/conditions: she is safe knows how to handle her cig just lighting it in windy condition is hard and needs assistance in and out of the building typed in. R39's Smoking Risk Observation dated 04/14/25 documents: 11. Identify if resident is with A. Independent smoker marked and signed by V28 (Social Services Director). On 05/15/25 at 11:40 AM, R39 is alert and oriented to person, place, and time stated, she has to wear an apron to smoke now and she does not like it. She doesn't like wearing the apron. She has never burned herself before or had any problems but after another resident burned themselves they all had to wear an apron to smoke. She does not remember being reassessed after the incident with the other guy but after that happened she has to wait to go out and has to wear an apron. R39's care plan documents: a focus area of: R39 desires to continue to smoke cigarettes with a date initiated of 03/12/2025 with interventions of: utilize smoking apron per doctor's orders with an initiated date of 04/23/25 and will follow smoking schedule with a date initiated of 03/13/2025. On 5/15/25 at 2:22 PM, V4 (Care Plan Coordinator) stated he did not put on R39's care plan, that was V28 (social Services) that put that her care plan. On 5/15/25 at 2:15 PM, V28 (Social Services Director) stated she redid all of the smoking assessments a few weeks ago for the change of ownership. V28 stated they had an incident with a resident burning himself while he was smoking. V28 stated he had been assessed as being safe to smoke independently but burnt himself one day while she was off work so she didn't have all of the details. V28 stated when she came back to work she was notified of the incident and she spoke with V1 (Administrator). V28 stated V1 told her to order smoking aprons for every resident, they took all of their smoking paraphernalia and locked it up, and they all had to smoke at the same time with staff supervision. V28 stated R38 was seen by the wound specialist and the area healed with no issues. V28 stated she can see where that is taking their rights away and she didn't think R38, R20, and/or R6 required an apron or staff supervision to smoke safely. On 05/19/25 at 8:10 AM V1 (Administrator) stated, the physician order on R38's physician order sheet and care plan was due to the fact the facility called the physician and asked for the order for the smoking apron, they will have the order removed from her record.

Based on interview and record review the facility failed to ensure toileting assistance was provided timely for 2 of 3 (R20 and R21) residents reviewed for activities of daily living in the sample of 39. Findings Include: 1. R20's Admission Record with a print date of 5/14/25 documents R20 was admitted to the facility on [DATE] with diagnoses that include hypertension, repeated falls, pain, and kidney stones. R20's MDS (Minimum Data Set) dated 2/20/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R20 is cognitively intact. This same MDS documents R20 requires supervision or touching assistance for toilet transfer and partial/moderate assistance for toilet hygiene. R20's current Care Plan documents a Focus area of Due to (R20)'s general weakness and unsteadiness, He is in need of staff assistance to meet his toileting needs. Date Initiated: 07/03/2023. The interventions documented for this Focus area include, .Provide assistance for toileting due to (R20)'s general weakness and history of falling and to ensure proper toileting hygiene. Date Initiated: 07/03/2023. The facility Activities of Daily Living policy dated 2/2023 documents, Purpose: Based on comprehensive assessment of the resident and consistent with the resident's needs and choices, our facility provides necessary care and services to ensure that a resident's abilities in activities of daily living (ADL) living do not diminish unless the circumstances of the individual's clinical condition demonstrates that such decline was unavoidable. On 5/12/25 at 1:37 PM, R20 stated they don't have enough staff, especially on the weekend. R20 stated takes up to a half hour for them to answer the call light at times. R20 stated he had incontinent episodes waiting for staff to assist him to toilet. 2. R21's Admission Record with a print date of 5/14/25 documents R21 was admitted to the facility on [DATE] with diagnoses that include muscle wasting and atrophy, lack of coordination, acute kidney failure, and chronic pain syndrome. R21's MDS dated [DATE] documents a BIMS score of 15, which indicates R21 is cognitively intact. This same MDS documents R21 requires substantial/maximal assistance for toilet hygiene and toilet transfer. R21's current Care Plan documents a Focus area of, Due to (R21)'s general weakness, unsteadiness and endurance, she is in need of staff assistance to meet her toileting needs. Date Initiated: 04/13/2023. This Focus area includes, .Assist (R21) to the restroom every 2 hours or sooner upon request. Date Initiated: 04/13/2023 . On 5/12/25 at 10:58 AM, R21 stated it takes a long time for staff to answer the call lights. R21 stated she had incontinent episodes waiting on staff to assist her to toilet. R21 stated, it happens all the time. On 5/13/25 at 11:22 AM, V10 (CNA/Certified Nursing Assistant) stated they don't have enough staff to meet the needs of the residents timely. V10 stated the call lights aren't always answered timely. On 5/14/25 at 2:45 PM, V13 (transport CNA) stated call lights aren't answered timely and toileting isn't always timely. On 5/14/25 at 1:00 PM, V2 (Director of Nurses) stated they don't have enough staff to meet the needs of the residents timely. V2 stated they have issues with staffing on nights and weekends. V2 stated with two CNA's on the skilled care unit it would be hard to answer the call lights timely.

Based on observation, interview and record review the facility failed to provide a plan of care for a resident with dementia for one (R6) of one resident reviewed for dementia care in a sample of 39. Findings include: R6's Admission Record documents an admitted [DATE] with diagnoses including: type 2 diabetes mellitus with ketoacidosis without coma, dysphagia, lack of coordination, major depression disorder, dementia, depression, anxiety disorder,and acute kidney failure. R6 Minimum Data Set (MDS) dated [DATE] documents a BIMS summary score (Brief Interview of Mental Status) of 12 indicating resident is moderately cognitively impaired. R6's current Care Plan does not document any area addressing a diagnosis of dementia or care needs resulting thereof. On 05/12/25 at 10:17 AM, R6 was observed just sitting in the dining room on the Dementia unit at the table. R6 had nothing in front of her and was doing nothing but sitting. On 05/14/25 at 11:15 AM, R6 was observed just sitting in the dining room on the Dementia unit at the table. R6 had nothing in front of her and was doing nothing but sitting. On 05/15/25 at 11:40 AM, V13 (Certified Nurse Assistant) stated, R6 has her good days and R6 has her bad days with her cognition. On 05/15/2025 at 2:10 PM, V4 (Minimum Data Set Coordinator/Care Plan Coordinator) stated he would have to check R6's BIMS and her diagnoses to see if she should have a care need addressed on her care plan addressing the dementia. V4 stated R6 does not have anything on her care plan addressing her diagnosis of dementia or care needs regarding her dementia. On 05/19/25 at 8:10 AM, V1 (Administrator) stated, R6 should have had a plan for her dementia, they are reviewing all the care plans now, they are going to get a plan of care in place for R6. The facility policy dated 04/07 titled, Dementia-clinical protocol documents: 3. The staff and physician will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes. 4. The staff and physician will review the current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. 5. The staff and physician will jointly define the decision-making capacity of someone with dementia, including the extent to which the individual can participate in making everyday decisions and considerations about healthcare treatment choices, including life-sustaining treatments.

Based on observation, interview and record review the facility failed to ensure enhanced barrier precautions were followed for 2 of 3 (R12 and R34) residents reviewed for pressure ulcers in the sample of 39. Findings Include: 1. R12's Admission Record with a print date of 5/15/25 documents R12 was admitted to the facility on [DATE] with diagnoses that include a Stage 4 pressure ulcer of the sacrum. R12's MDS (Minimum Data Set) dated 2/17/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R12 is cognitively intact. R12's current Care Plan documents a Focus area of Enhanced barrier precautions r/t (related to) chronic wounds and indwelling catheter Date Initiated: 04/24/2024. This same Focus area includes the following interventions, .Gown and glove during high contact resident care activities such as dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care/use, wound care (any chronic skin opening). Date Initiated: 04/24/2024 . R12's Physician Order Sheet dated 10/15/24 documents a physician order of Enhanced Barrier Precautions indwelling foley cath (catheter) chronic wound, with a revision date of 4/3/25. On 5/14/25 at 1:30 PM, V14 (Licensed Practical Nurse/LPN) and V17 (Certified Nursing Assistant) were observed providing treatment to the Stage 4 pressure ulcer located on R12's sacrum. V14 and V17 donned gloves and administered the treatment per current standards of practice. V14 and V17 performed hand hygiene per current standards of practice during the treatment. V14 and V17 did not don a gown during the administration of the treatment. 2. R34's Admission Record with a print date of 5/15/25 documents R34 was admitted to the facility on [DATE] with diagnoses that include Stage 3 pressure ulcer of right hip, blister left foot, and laceration right foot. R34's MDS dated [DATE] documents a BIMS score of 03, indicating R34 has a severe cognitive deficit. R34's current Care Plan documents a Focus area of, Enhanced barrier precautions r/t chronic wounds Date Initiated: 05/06/2025. This same Focus area includes the intervention, .Gown and glove during high contact resident care activities such as dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care/use, wound care (any chronic skin opening). Date Initiated: 05/06/2025. R34's undated Physician Order Sheet documents a physician order for, Enhanced barrier precautions dx (diagnosis) chronic wound, with a revision date of 4/3/25. On 5/14/25 at 1:43 PM, V14 (LPN) and V18 (CNA) were observed administering treatment to R34's right heel. V14 administered the treatment per current standards of practice. V14 and V18 performed hand hygiene using current standards of practice. V14 and V18 did not don a gown while administering the treatment. On 5/15/25 at 10:30 AM, V14 (LPN) stated R12 and R34 are on enhanced barrier precautions and the should have worn a gown, gloves, mask, and goggles. The sign located outside R12 and R34's room documents, Enhanced Barrier Precautions Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. The facility Enhanced Barrier Precautions policy dated 3/21/24 documents, It is the practice of this facility to implement enhanced barrier precautions for the preventions of transmission of multidrug-resistant organisms. Definitions: Enhanced Barrier Precautions: refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO (multi-drug resistant organism) as well as those at increased risk of MDRO acquisition .

Based on observation, interview and record review the facility failed to provide at least 80 square feet per resident in two multiple occupancy resident bedrooms for 4 of 4 residents (R5, R20, R145, R146) reviewed for room size in a sample of 39. Findings include: Observation on 5/14/2025 at 9:00am revealed R5 and R20 share a bedroom with two beds, two dressers, a recliner, two walking assistive devices, two over the bed tables and had limited area to move around inside the room. Observations on 5/14/2025 at 9:05am revealed R145 and R146 share a bedroom with two bed, three small dressers, two over the bed tables, one recliner and had limited area to move around inside the room. On 5/14/2025 at 9:30am R5, R20, R145 and R146 all voiced no concerns with the size of their rooms during interviews. During a tour with V3 (Maintenance Director) on 5/14/2025 at 9:00am, V3 was asked to measure R5, R20, R145 and R146's bedroom sizes. V3 used a measuring tape to measure the length and width of R5 and R20's bedroom and stated, 11 by 14 feet (which is the equivalent to 154 sq. ft. (square feet)/77 sq. ft. per resident bed). At approximately 9:05am, V3 measured R145 and R146's bedroom with a tape measure and stated, 11 by 13.7 feet (which is the equivalent to 150.7 sq. ft./75.4 sq. ft. per resident bed). On 5/14/2025 at approximately 10:15am, V1 (Administrator) was asked if residents were notified during admission that some of the rooms in the facility did not meet the requirement of having 80 sq ft per resident, V1 stated no. V1 said rooms 19-31 did not meet the required 80 sq ft per resident bed and rooms 19-31 are all certified for double occupancy and were dually certified for Medicare and Medicaid. The facility's matrix with print date of 5/12/2025 documents verified that R5, R20, R145 and R146 currently reside in room [ROOM NUMBER]-31. Inquiries regarding the size of these rooms during the survey from 5/12/2025 to 5/15/2025 found no concerns or negative interviews from residents or families of residents who reside in the waivered rooms. Observations and measurements of these rooms during the survey, determined adequate space exists to meet the medical and personal needs of the residents living in these waivered rooms. Review of Resident Council Minutes form the past 6 months indicated no concerns related to the size of the rooms included in the waiver.

Based in interview and record review the facility failed to provided the services of a Registered Nurse for 8 consecutive hours per day 7 days a week. This failure has the potential to effect all 43 residents living at this facility. Findings Included: On 7/23/2024 at 1:10pm, V1 (Administrator) said the facility did not have the required 8 hours per day 7 days a week of Registered Nurse coverage. V1 said they did not have a policy for Registered Nurse coverage. On 7/22/2024 at 8:30am, V10 (Licensed Practical Nurse) said she worked the weekend of 7/20/24 and 7/21/24 and the facility did not have a Registered Nurse working on either of those days. V10 said frequently the facility does not have Registered Nurse coverage on the weekends she works. The facility nursing schedule for May, June and July of 2024 revealed the facility did not have the required 8 hours of Registered Nurse coverage for the following dates: 5/11, 5/25, 5/26, 6/8, 6/9, 6/22, 6/23, 6/29, 6/30, 7/6, 7/20, and 7/21. The Long Term Care Facility Application for Medicare and Medicaid (Form CMS 671) dated 7/22/24 documents there are 43 residents residing in the facility.

Based on interview and record review, the facility failed to provide the identified level of supervision and assistance required to prevent accidents for one (R1) of two residents reviewed for accidents and supervision in the sample of 53. This failure resulted in R1 falling in the hallway while being walked out of the restroom by 1 staff and sustaining a fracture of the left hip. Findings include: On 6/21/22 at 10:30 AM, V15 (Licensed Practical Nurse/LPN/Unit Director) stated that (R1) recently had a fall, sustained a hip fracture and the staples were removed a few days ago. On 6/23/22 at 1:05 PM, V1 (Administrator) said that V19 (Certified Nurse Aide/CNA) was the only staff present on 6/01/22 with (R1) at 4:00 PM when (R1) fell and sustained a left hip fracture. V1 said (V19) was the only witness and (V19) no longer works at the facility. V1 said the CNA (V19) reported the incident to V10 (Registered Nurse/RN) who was on duty and completed the assessment and documentation regarding (R1)'s fall of 6/01/22. A review of R1's electronic medical record was conducted. A Fall Initial Occurrence Note written 6/01/22 by V10 documents, Fall Description: Resident had a witnessed fall 6/01/22 at 4:00 PM. Location of Fall: hallway outside of bathroom. Resident being walked out of restroom and unable to bear weight on legs. Resident sat on floor, almost bringing CNA down with her. Assessment: Witnessed Fall - Did not strike head; neurological checks not indicated. Alert and disoriented per usual baseline. No changes in range of motion from normal baseline, no injuries observed. A Nurses Note dated 6/01/22 at 4:59 PM reads: Narrative: Resident sat on floor outside of restroom in hallway after using toilet. CNA states she would not walk all of a sudden and sat on floor, almost pulling CNA down with her. Resident refusing to put weight on left leg and rubbing it. ROM (Range Of Motion) intact. A Nurses Note dated 6/01/22 at 10:56 PM documents, Narrative: X-ray (Radiograph) arrived to facility around 10:00 PM. X-rays sent STAT (Immediately). Waiting on results. A Nurses Note dated 6/02/22 at 3:18 AM documents: 72 hour Follow up assessment post-fall. BP (Blood Pressure)180/88 - 6/1/2022 4:30 PM, Position: Sitting r (right)/arm T 97.5 - 6/1/2022 8:35 PM Route: Forehead (non-contact) P 98 - 6/1/2022, 4:30 PM Pulse Type: Regular R 18.0 - 6/1/2022, 4:30 PM O2 96.0 % - 6/1/2022, 8:36 PM Method: Room Air Resident is alert and disoriented per usual baseline. No new injuries noted on assessment. Pain scale 3 of 10. L (Left) hip area, new onset of pain. Medication administered for pain. Pain medication effective. New onset of limitation in ROM. Unable to complete ROM to R (Right) leg/hip at this x (time) d/t (due to) res (resident) grimacing when area touched. Bed in lowest position. Call light in reach. Non-skid socks/ footwear in place. Provided scheduled toileting assistance. Bed in lowest position. Call light in reach. No skin issues noted. On 6/02/22 at 5:30 AM, Nurses Note documents, Narrative: Rec'd (Received) results of hip x-ray. Impressions indicate Nondisplaced L (Left) intertrochanteric fracture et (and) [CONDITION(S)]. On 6/2/2022 at 7:15 AM, A Nurses Note reads, Narrative: (Name of Ambulance Company) here to transport res (resident) to (Name of Hospital). A Fall IDT (Interdisciplinary) Note dated 6/02/22 at 9:41 AM reads in part, Summary of the fall: CNA was assisting (R1) back to her room after toileting and in doing so, (R1)'s legs got weak and she started to set (sit) down and the CNA was unable hold her up before she fell to the floor. Root cause of fall: (R1)'s legs got weak while walking back to her room after completing toileting and she was unable to stand and started to sit down on the floor and the CNA was unable to hold her up before she fell to the floor. Intervention and care plan updated: Utilize staff assist of 2 during all toileting. R1's care plan documents the following Focus and Interventions in place prior to the fall incident of 6/01/22: Due to (R1)'s history of [CONDITION(S)] (Cardiovascular Accident/Stroke) with Left side weakness, general weakness and unsteadiness, (R1) is in need of staff assistance to complete ADL's (Activities of Daily Living) and Bathing. (Revised 04/15/2022). Interventions include: (R1) is in need of extensive assistance of 2 to complete toileting due to general weakness and unsteadiness. (Revised 04/15/2022). Due to (R1)'s history of falls, general weakness, unsteadiness and Left side weakness, (R1) is noted to be at an increased risk for falls. (Revised 04/15/2022). (R1) is in need of extensive assistance of 2 to complete transfers due to (R1)'s general weakness and unsteadiness. (Revised 04/15/2022). Do not leave (R1) unsupervised at any time during toileting. (Revised 04/15/2022) After R1's 6/01/22 fall, the following intervention was initiated on 6/02/22: Utilize staff assist of 2 during all toileting. This intervention was already in place as noted above, since the 4/15/22 revision date and prior to the fall of 6/01/22. R1's Admission MDS (Minimum Data Set) dated 3/14/22 documents Section C - Cognitive Patterns: R1 is rarely/never understood and moderately cognitively impaired for daily decision making. Section G - Functional Status: documents R1 requires extensive assist of 2+ persons for bed mobility, transfer, walking in room, walking in corridor and toilet use. A Hospital Discharge Summary for R1, dated 6/08/22, documents a hospital admitted [DATE] and discharge date of [DATE]. The Summary reads, in part, Reason for hospitalization : Left hip fracture. Hospital Course: [AGE] year-old female presented with onset of pain in her hip. She denies that she has sustained any fall. She denies any injury. Yesterday when being helped to the toilet patient slipped to the floor. X-ray was done to the left hip which showed nondisplaced left intertrochanteric fracture. Ortho proceed(ed) with operative intervention in the form of a left hip cephalomedullary nailing for both pain management as well as restoration of ambulatory capacity.