Every finding on record at The Meadows at Osborn Park

Based on observation, staff interview, medical record review, review of manufacturer instructions, and review of facility policy, the facility failed to store and manage medications safely, including improper dating, disposal, labeling of multi-does and insulin medications, and leaving medication carts unsecured. This had the potential to affect all 119 residents residing in the facility.Findings include: 1. Observation on 06/23/26 at 7:10 A.M. of the medication storage room for cluster one with Licensed Practical Nurse (LPN) #314 revealed the medication storage refrigerator contained one 16-ounce container of Marzetti ranch vegetable dip that was opened and approximately two-thirds full and one 2.76 ounce Hillshire Farms snacking tray that was unopened. Neither of these items was dated and neither was labeled with whom they belong to. The medication storage refrigerator contained one-one milliliter (mL) vial of Tuberculin Purified Protein Derivative Diluted/aplisol, with a manufacturer expiration date of February 2027. The one mL vial was dated as being opened on 11/11/25 and was approximately one-half used. Interview on 06/23/26 at 7:10 A.M. with LPN #314 verified the medication storage refrigerator contained one 16-ounce container of Marzetti ranch vegetable dip that was opened and approximately two-thirds full and one 2.76 ounce Hillshire Farms snacking tray that was unopened. Neither of these items was dated and neither was labeled with whom they belong to. LPN #314 verified the medication storage refrigerator contained one-one mL vial of Tuberculin Purified Protein Derivative Diluted/aplisol, with a manufacturer expiration date of February 2027. The one mL vial was dated as being opened on 11/11/25 and was approximately one-half used. Interview on 06/23/26 at 7:16 A.M. with Registered Nurse (RN) #315 verified the medication storage refrigerator contained one 16-ounce container of Marzetti ranch vegetable dip that was opened and approximately two-thirds full and one 2.76 ounce Hillshire Farms snacking tray that was unopened. Neither of these items was dated and neither was labeled with whom they belong to. RN #315 verified food was not supposed to be stored in the medication storage refrigerator. RN #315 verified the medication storage refrigerator contained one-one mL vial of Tuberculin Purified Protein Derivative Diluted/aplisol, with a manufacturer expiration date of February 2027. The one mL vial was dated as being opened on 11/11/25 and was approximately one-half used. At 7:57 A.M., RN #315 verified Tuberculin Purified Protein Derivative Diluted/aplisol should be discarded 30 days after opening. Interview on 06/25/26 at 2:00 P.M. with the Administrator revealed it is the expectation that food is not stored in the medication storage refrigerator. Review of the manufacturers package insert for Tuberculin Purified Protein Derivative Diluted/aplisol revealed vials in use for more than 30 days should be discarded. Review of the facility policy titled Medications with Short Dating dated 01/29/25 revealed Tuberculin Purified Protein Derivative Diluted/aplisol must remain refrigerated and must be discarded 30 days after opening. Review of the facility policy titled Medication Storage: Storage of Medication dated January 2026 revealed all medications should be segregated from fruit juices, applesauce, and other foods used in administering medications. Any other foods such as employee lunches and activity department refreshments should not be stored in this refrigerator. 2. Observation on 06/23/26 at 7:29 A.M. of the medication cart for room numbers 201-222 revealed one-three mL NovoLOG (insulin) flex pen 100 units per mL (u/mL) for Resident #54, approximately one-half used, with a manufacturer's expiration date of 12/31/27, was marked as opened on 04/21/26. There was also one-three mL Lantus insulin pen for Resident #54 was opened and approximately one-half used and was not marked with the date which it was first opened. Interview on 06/23/26 at 7:30 A.M. with Licensed Practical Nurse (LPN) #334 verified one-three mL NovoLOG flex pen 100 u/mL for Resident #54, approximately one-half used, with a manufacturer's expiration date of 12/31/27, was marked as opened on 04/21/26. LPN #334 verified one-three mL Lantus insulin pen for Resident #54 was opened and approximately one-half used and was not marked with the date which it was first opened. Review of the manufacturer package insert for NovoLOG flex pen revealed after first use, store at room temperature and discard after 28 days. Review of the manufacturer package insert for Lantus insulin pen revealed after first use, store at room temperature and discard after 28 days. Review of the facility policy titled Medications with Short Dating dated 01/29/25 revealed NovoLOG flex pen must be discarded 28 days after opening and Lantus insulin pen must be discarded 28 days after opening. 3. Observation on 06/24/26 at 7:45 A.M. revealed Licensed Practical Nurse (LPN) #314 stepped away from the medication cart to administer medications to a resident and did not ensure the cart was secured by locking it. Interview on 06/24/26 at 7:52 A.M. with LPN #314 verified she stepped away from the medication cart she was responsible for to administer medications to a resident and did not ensure the cart was secured by locking it. LPN #314 stated, I forgot to lock my cart. Observation on 06/24/26 at 9:10 A.M. revealed a medication cart located at the 100-hall nurse station was unlocked and unattended. Interview on 06/24/26 at 9:20 A.M. with Licensed Practical Nurse #314 revealed she had left the medication cart unlocked and unattended, and the medications were accessible to anyone. Review of the facility policy titled Medication Storage: Storage of Medication dated January 2026 revealed in order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed to access medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access.

Based on record review, review of the mechanical lift and mechanical lift slings manufacturer's instructions, observation, resident and staff interviews, and policy review, the facility failed to ensure residents were transferred safely following physician orders and ensure staff were monitoring the mechanical lift slings for signs of damage. This had the potential to affect 39 residents (#4, #6, #7, #8, #9, #11, #12, #15, #22, #32, #33, #34, #38, #42, #45, #48, #51, #54, #59, #60, #65, #72, #74, #75, #76, #77, #88, #90, #94, #95, #99, #100, #104, #107, #108, #109, #112, #118, and #119) who the facility identified as requiring the use of a mechanical lift for transfers. The facility census was 119.Findings include:1. Review of Resident #65's medical record revealed an admission date of 10/24/18. Diagnoses included multiple sclerosis, paraplegia, muscle wasting and atrophy, and weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had intact cognition and was dependent on staff for chair to bed and bed to chair transfers. Review of Resident #65's care plan dated 04/16/26 revealed Resident #65 had an activities of daily living (ADL) self-care performance deficit related to multiple sclerosis, hemiplegia, and impaired balance. Interventions included to transfer Resident #65 utilizing the mechanical lift with two staff assistance and Resident #65 required extensive or total dependence by two staff members to move between surfaces as necessary. Review of Resident #65's physician orders dated 12/03/25 revealed an order for transfers requiring two staff members to use the mechanical lift.Observation on 06/23/26 at 2:26 P.M. revealed Certified Nurse Aide (CNA) #390 asked Resident #65 if he would like to be transferred into bed from his wheelchair. Resident #65 said yes and CNA #390 gathered the equipment to transfer Resident #65. CNA #390 went into Resident #65's room without any other staff members and independently transferred Resident #65 from the wheelchair into his bed.Interview on 06/23/26 at 2:35 P.M. with CNA #390 verified she independently transferred Resident #65 from his wheelchair into his bed. CNA #390 stated I know you are not supposed to transfer residents by yourself with the mechanical lift, but unfortunately that is what happens.Interview on 06/24/26 at 10:30 A.M. with Resident #65 verified CNA #390 had transferred him independently from his wheelchair into his bed on 06/23/26. Resident #65 stated the facility can be short of staff which causes one staff member to transfer him.2. Interview on 06/24/26 at 3:25 P.M. with Maintenance Director (MD) #382 revealed he had never ordered disposable slings and was unaware of where the disposable slings in the facility came from. MD #382 verified he did not monitor the integrity of the slings the facility used. MD #382 stated he only ordered slings from a brand named EZ Ways so that the mechanical lifts and the slings utilized in the facility were from the same reputable manufacturer.Observation on 06/24/26 at 3:32 P.M. revealed four mechanical lift slings in the laundry room that were frayed and worn. The tags on the four slings were worn and two of the tags were unreadable due to wear. There were two disposable slings hanging on shelves on the clean side of the laundry room.Interview on 06/24/26 at 3:35 P.M. with the Laundry Supervisor (LS) #396 verified the disposable slings on the clean side of the laundry room were washed and air dried. LS #396 verified there was no documentation regarding the monitoring of the mechanical lift slings and it was the responsibility of the laundry staff and the CNAs to monitor the integrity of the slings.Interview on 06/24/26 at 3:45 P.M. with the Dietary and Environmental Manager #338 verified the four slings in the laundry room were worn, frayed, and the tags were worn and faded or unreadable.Interview on 06/24/26 at 4:30 P.M. with the Service Department Representative (SDR) for EZ way smart lifts and slings #398 verified disposable slings were not to be laundered and if they were, the sling should be disposed of. Laundering a disposable lift sling would compromise the integrity of the sling and compromise the safety of the resident and could potentially result in harm or death. SDR #398 verified other brands slings should not be utilized with the EZ way smart lift because EZ way could not guarantee the safety of other slings being utilized with their lifts.Observation and concurrent interview on 06/24/26 at 4:45 P.M. with CNA #356 verified two holes in Resident #65's mechanical lift sling, one on each side near the head of the sling where the loops attached to the body of the sling.Observation and concurrent interview on 06/24/26 at 5:00 P.M. with CNA #397 verified the disposable slings were only used when other ones were not clean or available or when a resident was being sent to the hospital or to somewhere like dialysis. CNA #397 demonstrated how she would attach the disposable sling to the mechanical lift as the facility did not have a mechanical lift that would attach to the clip sling. The disposable sling had a clip and was meant to be used for mechanical lifts at the hospital. CNA #397 placed the metal rod of the mechanical lift through the top portion of the fabric that connected to the clip. CNA #397 demonstrated how the resident would be lifted.Interview on 06/25/26 at 10:22 A.M. with CNA #399 verified the facilities slings have been worn and frayed for some time and need to be replaced. Observation with CNA #399 verified Resident #33's mechanical lift sling was frayed, worn, and the tag was unreadable in some areas due to wear.Review of a facility document revealed Residents #4, #6, #7, #8, #9, #11, #12, #15, #22, #32, #33, #34, #38, #42, #45, #48, #51, #54, #59, #60, #65, #72, #74, #75, #76, #77, #88, #90, #94, #95, #99, #100, #104, #107, #108, #109, #112, #118, and #119 required the use of a mechanical lift for transfers. Review of the ARJO sling manufacturers instructions revealed disposable clip slings are a disposable product and cannot be washed. Furthermore, the disposable clip slings should be used with ARJO lift devices in accordance with the allowed combinations specified in the instructions for use. Before use, the sling should be inspected for signs of fraying, tearing, or other damage and if any damage is noted, the sling should not be used.Review of the EZ Way Smart Lift manufacturers instructions revealed EZ Way slings and harnesses are made specifically for EZ Way equipment. EZ Way recommends that only EZ Way slings and harnesses be used with EZ Way equipment. EZ Way recommends replacement of slings after one year or if the sling or harness shows any sign of damage or wear.Review of the undated facility policy titled Hoyer Lift revealed two staff members are required to perform a mechanical lift transfer. Furthermore, follow the manufacturer guidelines specific to the equipment.

Based on review of facility menus, record review, observations, and staff interviews, the facility failed to serve the correct food portions of pureed foods to the residents. This affected seven (#22, #32, #45, #60, #72, #74, and #104) of seven residents who were ordered pureed diets. The facility census was 119.Findings include:Review of the facility's spring menu revealed lunch being served on 06/23/26 consisted of three ounces of meatloaf.Observation and interview on 06/23/26 at 10:45 A.M. revealed [NAME] #391 prepared pureed meatloaf for residents and was using a two-and-a-half-ounce green scoop to portion the pureed food. [NAME] #391 revealed she planned to use a half-filled two-and-a-half-ounce green scoop to portion the pureed meatloaf into bowls. Subsequent observation revealed she obtained a four-ounce grey scoop and portioned the pureed meatloaf using full four-ounce scoops.Interview on 06/23/26 at 11:24 A.M. with Dietary Manager #338 confirmed portion sizes were dictated by the facility's seasonal menu, were the same regardless of mechanical alteration, and the portion of pureed meatloaf should have been three ounces.Facility record review revealed Residents #22, #32, #45, #60, #72, #74, and #104 were on a pureed diet.

Based on observation, staff interview, medical record review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of facility policy, the facility failed to ensure staff implemented Enhanced Barrier Precautions (EBP) during high-contact resident care activities for residents who had physician orders for EBP. This affected two (#51 and #74) of two residents reviewed for EBPs. The facility identified 35 residents with physician orders for EBP. The facility census was 119.Findings include:1. Review of the medical record for Resident # 51 revealed an admission date of 05/12/18 with diagnoses including multiple sclerosis, generalized muscle weakness, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51's cognition was moderately impaired and required substantial/maximal assistance or was dependent on staff for all functional abilities. Review of Resident #51's physician order dated 07/31/21 revealed an order for EBP every shift for history of Escherichia coli (E. coli) and ESBL (Extended-Spectrum Beta-Lactamase). Observation on 06/25/26 at 8:50 A.M. revealed a sign on the wall next to Resident #51's room advising that Resident #51 was in EBP and 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), and wound care (any skin opening requiring a dressing). Do not wear the same gown and gloves for the care of more than one person. Observation on 06/25/26 at 8:54 A.M. revealed Certified Nursing Assistant (CNA) #500 entered Resident #51's room to dress her and change her brief without first donning a gown. Observation on 06/25/26 at 9:01 A.M. revealed Licensed Practical Nurse (LPN) #343 entered Resident #51's room to assist CNA #500 with toileting, dressing, and apply topical cream to Resident #51's labia without first donning a gown. Interview on 06/25/26 at 9:20 A.M. with LPN #343 verified she assisted CNA #500 with toileting, dressing, and applied topical cream to Resident #51's labia without wearing a gown. LPN #343 verified Resident #51 was in EBP and she did not wear a gown to administer this care. Interview on 06/25/25 at 9:22 A.M. with CNA #500 verified she provided care to Resident #51, including toileting assistance and assistance with dressing, without wearing a gown. CNA #500 verified Resident #51 was in EBP and she did not wear a gown to administer this care. 2. Review of the medical record for Resident #74 revealed an admission date of 05/12/26. Diagnoses included complete traumatic amputation of right great toe, acute osteomyelitis, and vascular dementia, Review of Resident #74'd physician order dated 05/08/26 revealed an order for EBP every shift for CDC guidelines.Observation on 06/25/26 at 7:20 A.M. revealed a sign on the wall next to Resident #74's room advising Resident #74 was in EBP and 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), and wound care (any skin opening requiring a dressing). Do not wear the same gown and gloves for the care of more than one person. Observation on 06/25/26 at 7:23 A.M. revealed CNA #332 entered Resident #74's room to dress her and change her brief without first donning a gown. Observation 06/25/26 at 7:43 A.M. revealed CNA #366 entered Resident #74's room to assist CNA #332 with dressing and changing her brief without first donning a gown. Interview on 06/25/26 at 7:44 A.M. with CNA #332 and CNA #366 verified they dressed Resident #74 and changed her brief without donning a gown. CNA #332 revealed she didn't realize EBP were necessary for dressing a resident. CNA #332 revealed she was not aware that Resident #74 was ordered to be in EBP. Review of the facility policy titled Enhanced Barrier Precautions, most recently revised March 2024, revealed the purpose of EBP is to reduce the transmission of Multidrug-resistant Organisms (MDRO) when high contact resident care activities for residents with known to be colonized or infected with MDRO as well as those at increased risk to acquire MDRO. EBP is used in conjunction with standard precautions and requires use of a gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure accurate accountability of controlled substances by maintaining controlled substance records that reconciled with the actual quantity of medication on hand. This affected one (Resident #87) of one resident reviewed for control substance records.Findings include:Review of the medical record for Resident #87 revealed an admission date of 02/18/26. Diagnoses included generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated, 04/06/26 revealed Resident #87's cognition was moderately impaired. Review of Resident #87's physician order dated 12/01/25 for one milligram (mg) of lorazepam (a medication used to relieve anxiety) to be administered by mouth two times a day for anxiety and/or agitation. Observation 06/23/36 at 7:25 A.M. of the medication storage cart for rooms 101-112 revealed the controlled substance book count for Resident #87's lorazepam (anti-anxiety) was 14 tablets. The medication storage cart revealed the medication card for Resident #87's lorazepam contained 13 tablets.Interview on 06/23/26 at 7:27 A.M. with Licensed Practical Nurse (LPN) #365 verified the controlled substance book count for Resident #87's lorazepam was 14 tablets and the medication card for Resident #87's lorazepam contained 13 tablets.Review of the facility policy titled Medication Administration General Guidelines dated January 2025 revealed the individual who administers the medication dose, records the administration on the resident's MAR (medication administration record) immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.Review of the facility policy titled Medication Storage: Controlled Medication Storage dated January 2026 revealed at each shift change or when keys are surrendered, a physical inventory of all controlled substances, included refrigerated items, is conducted by two licensed nurses or approved individuals per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report.

Based on medical record review, observation, staff interview, and review of facility documents, the facility failed to ensure alternatives to bed rails were attempted and failed to provide ongoing monitoring and supervision for a resident who utilized a bed rail. This affected one (Resident #1) of one resident reviewed for bed rail safety. The facility census was 119.Findings include:Review of the medical record for Resident #1 revealed she was admitted on [DATE] with diagnoses including Alzheimer's disease and lack of coordination. The side rail acknowledgement, signed by Resident #1's representative on admission, revealed the facility would not allow the use of side rails unless there was a documented medical reason.Review of assessments for Resident #1 revealed one side rail assessment had been completed during her admission on [DATE]. The assessment indicated the use of side rails did not enable her to turn and reposition independently, were not essential to prevent skin breakdown, were not used as an assistive device, and did not restrict her movement.Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #1 was cognitively impaired and did not exhibit behaviors nor refusals of care. Resident #1 required supervision to moderate assistance with activities of daily living and mobility.Resident #1's medical record did not have documentation indicating alternatives to bed rails had been attempted.Observation on 06/25/26 at 10:45 A.M. revealed Resident #1 was resting in bed against her bed rail.Interview on 06/25/26 at 11:35 A.M. with the Director of Nursing (DON) confirmed Resident #1 did not have quarterly bed rail safety assessments documented, and nor was there documentation to support alternatives to bed rails had been attempted.Subsequent interview on 06/25/26 at 12:20 P.M. with the DON revealed the facility did not complete quarterly bed rail assessments for their residents, nor were alternatives to bed rails attempted. The DON confirmed alternatives should be attempted prior to implementing bed rails, and safety assessments should be completed quarterly. The DON stated there was no facility policy or procedure regarding the safe use of bed rails.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to ensure oxygen was administered per physician orders. This affected two residents (#60 and #94) of three residents reviewed for oxygen administration. The facility census was 119.Findings include:1. Review of Resident #60's medical record revealed an admission date of 09/17/25. Diagnoses included systolic congestive heart failure, chronic pulmonary edema, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. Review of the care plan dated 05/27/26 revealed Resident #60 required oxygen therapy related to congestive heart failure, emphysema, and COPD. Interventions included to administer oxygen via nasal cannula as ordered and to give medications as ordered by the physician. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had severely impaired cognition and required the use of oxygen. Review of Resident #60's physician orders revealed an order for oxygen at one liter via nasal cannula every shift.Observation on 06/22/26 at 11:07 A.M. of Resident #60's oxygen was noted to be administered at one and a half liters via nasal cannula.Interview on 06/22/26 at 11:09 A.M. with Licensed Practical Nurse (LPN) #374 verified Resident #60's oxygen was being administered at one and a half liters via nasal cannula.2. Review of Resident #94's medical record revealed an admission date of 03/28/24. Diagnoses included interstitial pulmonary disease, chronic obstructive pulmonary disease (COPD), dementia, parkinsonism, anxiety, and major depressive disorder. Review of the care plan dated 04/30/26 revealed Resident #94 had an alteration in respiratory status and difficulty breathing related to COPD, interstitial lung disease, and a history of pneumonia. Interventions included to administer oxygen via nasal cannula as ordered and to administer medication/puffers as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 had severely impaired cognition and required the use of oxygen therapy. Review of Resident #94's physician orders revealed an order for oxygen at three liters via nasal cannula to maintain oxygen saturation above 96 percent (%). Observation on 06/22/26 at 2:15 P.M. of Resident #94's oxygen revealed the oxygen to be being administered below two liters via nasal cannula.Interview on 06/22/26 at 2:18 P.M. with Licensed Practical Nurse (LPN) #374 verified Resident #94's oxygen was being administered at a little under two liters via nasal cannula.Review of the undated facility policy titled Oxygen Therapy revealed oxygen should be administered per the physician orders.

Based on medical record review, review of Centers for Disease Control and Prevention (CDC) guidance, observation, resident interview, and staff interview, the facility failed to provide a resident with a urinary catheter with the means to secure the catheter to prevent possible dislodgement. This affected one (#107) of three residents reviewed for catheter. The facility census was 119.Findings include:Review of Resident #107's medical record revealed an admission date of 02/02/23. Diagnoses included obstructive and reflux uropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #107 had intact cognition and required an indwelling catheter. Review of the care plan dated 05/21/26 revealed Resident #107 had a catheter related to immobility and obstructive uropathy with a goal of remaining free from catheter-related trauma through the review date. Observation and concurrent resident interview on 06/22/26 at 9:54 A.M. with Resident #107 revealed she did not have a catheter securement device. Resident #107 stated she was allergic to the adhesive in the catheter securement devices, and the facility had not provided a non-adhesive catheter securement device. Resident #107 stated she had not had a catheter securement device for approximately two months.Interview on 06/22/26 at 10:13 A.M. with Certified Nurse Aide (CNA) #392 verified Resident #107 did not have a catheter securement device for her indwelling urinary catheter.Review of the guidance from the CDC dated 09/16/19 and found at https://www.cdc.gov/infection-control/media/pdfs/Strive-CAUTI104-508.pdf revealed to maintain unobstructed urine flow, a catheter securement device should be used to anchor the catheter. Furthermore, catheter securement devices act as an anchor to prevent tugging and pulling which can cause irritation and inflammation.

Based on medical record review, resident and staff interviews, and policy review, the facility failed to provide a resident who was dependent on staff for showers/bathing received routine showers/bathing. This affected one (#64) of three residents reviewed for activities of daily living. The facility census was 119.Findings include:Review of Resident #64's medical record revealed an admission date of 08/28/25. Diagnoses included Parkinson's disease, major depressive disorder, weakness, anxiety, and muscle weakness.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had moderately impaired cognition and required partial or moderate assistance from staff with tub or shower transfers and for showering or bathing.Review of the care plan dated 05/28/26 revealed Resident #64 had an Activities of Daily Living (ADL) self-care performance deficit related to impaired balance, limited mobility, and Parkinson's disease. Interventions included Resident #64 required moderate assistance from one to two staff members for bathing.Review of Resident #64's showers sheets and electronic medical record (EMR) charting revealed Resident #64 was supposed to receive showers/bathing on Tuesdays and Thursdays. Resident #64 received a shower on 06/04/26 (Thursday), refused a shower on 06/09/26 (Tuesday), and did not receive another shower until 06/18/26 (Thursday). There was no documentation Resident #64 was offered shower/bathing for 06/11/26 (Thursday) and 06/16/26 (Tuesday).Interview on 06/22/26 at 11:21 A.M. with Resident #64 revealed he was lucky to receive one shower a week, and he wanted at least two showers a week. Furthermore, Resident #64 stated if he wanted a shower, he would have to tell the staff he wanted one or they would not offer one to him.Interview on 06/25/26 at 10:31 A.M. with Registered Nurse (RN) #315 verified the standard at the facility was for residents to receive showers twice a week or per the resident's preference.Interview on 06/25/26 at 11:22 A.M. with the Director of Nursing (DON) verified Resident #64 received a shower on 06/04/26, refused a shower on 06/09/26, and did not receive another shower until 06/18/26. The DON was unaware of why Resident #64 did not receive a shower during that time.Review of the facility policy titled Bathing Choice dated January 2021 revealed residents are interviewed to determine the frequency the resident would like to receive a bath or shower.This deficiency represents non-compliance investigated under Complaint Number 3005272.

Based on medical record review, staff interview, and policy review, the facility failed to ensure the resident's advanced directives were accurate in the paper and electronic medical record (EMR). This affected one (#86) of three residents reviewed for advanced directives. The facility census was 119.Findings include:Review of the medical record for Resident #86 revealed an admission date of [DATE]. Diagnoses included epilepsy, mild cognitive impairment, and chronic diastolic heart failure. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 had moderately impaired cognition.Review of Resident #86's care plan dated [DATE] revealed no documentation regarding advanced directives.Review of Resident #86's physician orders in the EMR dated [DATE] revealed an order for Do Not Resuscitate Comfort Care (DNR-CC) for advanced directives.Review of Resident #86's paper chart revealed a document stating Resident #86 was a Full Code.Interview on [DATE] at 8:25 A.M. with Registered Nurse (RN) #319 stated in the event a resident required Cardiopulmonary Resuscitation (CPR), she would reference the closest chart (paper chart or EMR) to determine the resident's advanced directives. RN #319 verified Resident #86 had DNR-CC in the EMR and a Full Code status document in the paper chart. RN #319 stated it was a group responsibility to update the paper chart, but thought social services would be the one to update the advanced directives in the paper chart.Interview on [DATE] at 10:33 A.M. with the Director of Social Services (DSS) #375 verified she did not update the residents' paper charts as this was the responsibility of the nurses on the unit.Review of the undated facility policy titled Advanced Directives revealed the facility staff would review and revise the advanced directive if requested by the resident or their responsible party.

Based on medical record review, observations, resident and staff interviews, and policy review, the facility failed to ensure a resident was treated with dignity when his wheelchair safety harness was visibly soiled. This affected one resident (#65) of three residents reviewed for dignity. The facility census was 119.Findings include:Review of Resident #65's medical record revealed an admission date of 10/24/18. Diagnoses included multiple sclerosis, paraplegia, muscle wasting and atrophy, weakness, and urinary incontinence. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had intact cognition and required substantial or maximal assistance from staff for personal hygiene. Review of the care plan dated 04/16/26 revealed Resident #65 had an activities of daily living (ADL) self-care performance deficit related to multiple sclerosis, hemiplegia, and impaired balance with interventions that included a vest to encourage upright posture/square in chair seating and to encourage Resident #65 to discuss his feelings about the self-care deficit.Observation and concurrent interview on 06/22/26 at 1:47 P.M. with Resident #65 revealed the safety harness for his wheelchair was visibly soiled. Resident #65 stated he would prefer it to be clean as it being soiled bothered him and was embarrassing.Observation and concurrent interview on 06/23/26 at 2:23 P.M. with Certified Nurse Aide (CNA) #390 verified Resident #65's safety harness for his wheelchair was visibly soiled.Observation on 06/24/26 at 10:30 A.M. revealed Resident #65's safety harness for the wheelchair was visibly soiled.Observation and concurrent interview on 06/25/26 at 10:09 A.M. with Certified Occupational Therapist Assistant (COTA) #395 verified Resident #65's safety harness for his wheelchair was visibly soiled.Review of the facility policy titled Resident Rights and Facility Responsibilities dated 10/17/19 revealed a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on medical record review, hospital record review, resident, family, staff, physician, and agency staff interviews, review of staff statements, and review of the facility policy, the facility failed to ensure safe mechanical lift transfers and further failed to adequately assess, timely notify the physician and resident representative, address resident pain, and conduct a thorough investigation following a fall from a mechanical lift. This resulted in Actual Harm to Resident #36 when on the morning of 04/22/26, the resident fell during a mechanical lift transfer and was found to have sustained a displaced fracture of the distal femur and a distal fifth metacarpal fracture of the left hand. Facility staff failed to thoroughly assess the resident at the time of the incident and the resident cried out in pain throughout the night. Subsequently, in the afternoon of 04/23/26, mobile X-rays were obtained. The facility did not review the X-ray findings until 04/24/26 which, based on a very limited study, showed a displaced fracture (a broken bone snapped into two or more pieces and moved to cause the ends to become misaligned) of the distal femur. Consequently, Resident #36 was transferred to the hospital on [DATE], at the request of her family, for further evaluation and treatment (two days after the initial injury). Further imaging at the hospital revealed Resident #36 had a closed displaced comminuted fracture (severe injury where the bone breaks in three or more pieces but does not break through the skin) of the left femur and a distal fifth metacarpal fracture of the left hand. Furthermore, the facility failed to ensure a complete, thorough, and accurate investigation was completed related to Resident #36's injury. This affected one (#36) of three residents reviewed for falls. The facility census was 122. Findings include:Review of Resident #36's medical record revealed an admission date of 05/19/23. Diagnoses included chronic kidney disease stage four, vascular dementia, presence of right artificial hip joint, and osteoarthritis. On 04/24/26, additional diagnoses of personal history of other diseases of the musculoskeletal system and connective tissue, age-related osteoporosis with current pathological fracture of the left femur and unspecified fracture of the fifth metacarpal bone of the left hand were added.Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/12/26, revealed Resident #36 had severe cognitive impairment. Further review revealed Resident #36 required the use of a mechanical lift for transfers and was unable to ambulate. Resident #36 was dependent on staff for activities of daily living (ADLs).Review of the care plan, initiated on 05/24/23, revealed Resident #36 had a focus area for an ADL self-care performance deficit related to dementia, impaired balance, limited mobility, musculoskeletal impairment, and shortness of breath. Interventions included extensive to dependent assistance by one to two staff to turn and reposition in bed and the resident was dependent on two staff to move between surfaces as necessary. On 10/22/25, and revised on 04/16/26, an intervention was implemented for Resident #36 to be transferred with a Hoyer (mechanical) lift with two staff assistance. Additionally, on 05/23/24 Resident #36 had a focus area related to limited physical mobility related to right artificial hip joint, weakness, and difficulty walking. Interventions included a wheelchair for locomotion, dependent on staff for locomotion in wheelchair, and monitor/document/report as needed any signs/symptoms of immobility: contractures forming or worsening, thrombus formation, skin breakdown, and fall related injury. Furthermore, on 04/24/26, a focus area was initiated for osteoporosis related to age and a pathological bone fracture of the left femur and left fifth metacarpal related to osteoporosis. Interventions included encourage intake of dairy products/physical activity and daily ambulation/weight bearing, give analgesics as needed for pain, monitor/document/report as needed signs and symptoms or complications related to osteoporosis, resident/family/caregiver teaching on fall prevention and lifestyle changes, and handle gently when moving or repositioning.Review of the physician orders revealed Resident #36 had the following orders: 04/28/25 and discontinued on 04/28/26, acetaminophen oral suspension 160 milligrams/milliliter (mg/ml), give 31.25 ml by mouth one time a day for left toe pain; 04/23/26, trazodone oral table 50 mg by mouth every four hours as needed for agitation/insomnia; 04/24/26, acetaminophen oral tablet 325 mg, give 650 mg by mouth four times a day for pain; 04/28/26, oxycodone oral table five mg, give one tablet by mouth every four hours as needed for pain until 05/02/26; and 04/29/26, monitor Resident #36 for signs and symptoms of pain and give (medication) as needed. The resident was unable to verbalize need for pain medication.Review of the Medication Administration Record (MAR) for April 2026 revealed Resident #36 was administered acetaminophen oral suspension one time on 04/22/26 for a pain level of four and one time on 04/23/26 for a pain level of seven. Additionally, Resident #36 was administered acetaminophen oral tablet on 04/23/26 at 1:00 P.M. for a pain level of five and at 5:00 P.M. for a pain level of one. No further pain medication administrations were documented.Review of a nursing progress note, dated 04/22/26 at 10:34 A.M. and authored by the Director of Nursing (DON), revealed a post incident analysis was completed and Resident #36 had a skin tear to the left lower forearm. Resident #36 was noted to be scratching her arm immediately prior. A head-to-toe assessment was completed and revealed no additional new areas. Review of a nursing progress note date 04/22/26 at 11:18 A.M. revealed Resident #36 was administered acetaminophen oral suspension 160 milligrams (mg) per five milliliters (ml). The note did not provide any information regarding the resident's pain or reason for the administration of acetaminophen.Additional review of Resident #36's progress notes revealed no additional entries on 04/22/26 related to any other incidents or concerns.Review of the nursing shift report sheet for 04/23/26 revealed Resident #36 had a skin tear to the left lower forearm. There was no mention of any other incidents or concerns for Resident #36.Review of a nursing progress note dated 04/23/26 at 1:53 A.M. revealed Resident #36 was administered acetaminophen oral suspension 160 mg per five ml. Further review revealed the progress note did not provide any information regarding the resident's pain or reason for the administration of acetaminophen.Review of a nursing progress note dated 04/23/26 at 2:36 A.M. revealed Resident #36 was administered acetaminophen oral suspension 160 mg per five ml. The note did not provide any information regarding the resident's pain or reason for the administration of acetaminophen.Review of a nursing progress note dated 04/23/26 at 9:05 A.M. revealed Licensed Practical Nurse (LPN) #208 notified Physician #500 of Resident #36 having increased behavior of yelling out help me, keeping her roommate awake, who stated this had escalated more in the past two weeks. Resident #36's Lexapro (antidepressant) was decreased due to the resident's daughter saying the resident was sleeping too much. LPN #208 spoke with the resident's daughter who explained Resident #36 would complain off and on of right hip/groin pain when at home. The resident had a right hip prosthetic and had frequent visits to orthopedics in the past with complaints of hip pain and was told there was really nothing they could do. Resident #36 was given Tylenol, but she got it more frequently than she did now and the daughter requested the facility schedule it for a while. Physician #500 ordered Tylenol 650 mg three times a day, as needed, and trazadone (antidepressant widely used off-label to treat insomnia).Review of a nursing progress note, dated 04/23/26 at 11:11 A.M. and authored by the DON, revealed during a Hoyer lift transfer with three direct care staff present, staff reported they heard a popping noise (not sure from where) and two stayed with the resident and one alerted the nurse. The nurse assessed the resident immediately and no abnormalities or signs/symptoms of pain were noted. The resident had an artificial joint replacement to the right hip. The resident was also noted to have a relevant diagnosis of osteoarthritis and history of fractures. The physician was contacted and ordered bilateral hip and bilateral knee X-rays as a precautionary measure. Resident representative notified and in agreement.Review of a nursing progress note, dated 04/24/26 at 9:58 A.M. and authored by the DON, revealed X-ray results were received and showed only a lateral view was submitted for the knee X-ray and Resident #36 was contracted. The conclusion was a very limited study, lateral view only submitted, and there was a displaced distal femoral fracture. Further review of the progress note revealed the results were reviewed with Physician #500, who reviewed the X-rays, patient history and medical records and diagnosed as a pathological fracture of the left distal femur with osteoporosis. The Physician stated that the resident had a diagnosis of osteopenia and bone demineralization with multiple fractures as far back as 2019 and this would have certainly progressed to osteoporosis. Physician #500 gave orders for Tylenol three times daily and he did not see value in sending the resident to the hospital, unless the resident's representative would like her sent. The area was wrapped with an Ace wrap as a conservative protective measure. The DON discussed this with the resident's representative, who initially stated that since the resident did not walk anyways, she did not feel it was necessary to send her to the hospital. The resident representative then decided to have Resident #36 transferred to the hospital and she would meet her there.Review of the Emergency Department (ED) note dated 04/24/26 at 10:19 A.M. revealed Resident #36 was being seen for a chief complaint of lower extremity injury and pain. Resident #36 presented to the ED after family requested transfer for evaluation of the left distal femur fracture, thought to be pathologic. Resident #36 was reportedly in a mechanical lift a couple of days ago at the facility when the staff members heard a pop. A mobile X-ray was completed, and a distal femur fracture was identified. The physician at the facility deemed it pathologic due to Resident #36 having a history of osteoporosis. Resident #36 was then placed in an Ace wrap for support and, per family request, transferred to the ED to evaluate for possible splint and further care for the fracture. Resident #36 was alert and oriented times one. Upon initial questioning Resident #36 denied pain; however, upon physical examination Resident #36 was complaining of pain to palpation of bilateral lower extremities.Review of the hospital Orthopedic Consult Note dated 04/24/26 revealed Resident #36 was not interactive during the encounter due to baseline dementia. The resident's daughter stated Resident #36 was in a mechanical lift at the facility and they heard a pop two days ago. The facility put an Ace wrap around the leg. However, the daughter was concerned and wanted it to be checked out further, so she requested Resident #36 be brought to the ED. Resident #36 was found to have a distal femur fracture on the left. The resident's daughter reported Resident #36 had not walked in several years and had essentially been bedbound but would get out of bed in a wheelchair for appointments or around the facility. The resident's left leg had some ecchymosis (bruising) near the knee. There was a palpable (could be felt) area of the femoral shaft near the skin around the knee. The foot was warm and perfused. Further review of the imaging and diagnostic results showed X-rays of the left knee/femur demonstrated a displaced comminuted supracondylar femur fracture. Significant displacement was noted to the shaft onto the distal fragment. A computed tomography (CT) of the left femur showed there was very little bone distally. The distal aspect of the shaft fragment was very close to the skin but there was no air to suggest an open fracture. The fracture did not appear amenable to fixation with a plate and screws due to poor bone quality. For the same reason, rod fixation was not a good option. The best option for Resident #36 was to adjust her leg and essentially splint in a knee immobilizer to try to get the bone away from the skin and then try to keep the resident comfortable. The physician did not feel there was a good surgical option and brought up amputation as a way to avoid issues with the fracture. Resident #36's daughter did not want to proceed with amputation and agreed to placing a knee immobilizer and manipulating the bone to have better alignment. With the assistance of ED staff, traction was then placed on the leg, and the bone was manipulated and placed in a knee immobilizer. Resident #36's daughter asked how an injury like this could happen. The physician's medical opinion was that a fracture like the one Resident #36 sustained was typically seen with traumatic events but not impossible to happen if the patient's entire weight was placed on the area enough (resident was non-ambulatory and transferred with a mechanical lift). A palliative care consult to discuss hospice was discussed. Pain management and nonoperative conservative treatment was in the best interest of Resident #36.An interview on 04/29/26 at 11:54 A.M. with Certified Nursing Assistant (CNA) #250 revealed she was not present in Resident #36's room at the time of the incident on 04/22/26 but was working. CNA #250 stated CNA #200 asked CNA #300 to assist with Resident #36. CNA #250 stated CNA #300 came out of Resident #36's room and asked LPN #310 to assess Resident #36. CNA #250 stated CNA #300 was tearful and scared. She reported to CNA #250 that Resident #36 had fallen out of the mechanical lift due to improper sling size and CNA #200 pulled too hard on the mechanical lift, resulting in Resident #36 falling forward. CNA #250 stated LPN #208 said no one was to speak about the incident and to keep quiet.An interview on 04/29/26 at 12:06 P.M. with CNA #400 revealed she did not work on 04/22/26 but when she returned to work on 04/23/26, she was told Resident #36 had fallen from a mechanical lift on 04/22/26. CNA #400 stated Resident #36 was crying in her room. She asked LPN #410 if Resident #36 was sent to the ED and LPN #410 stated he was unaware of any incident. CNA #400 stated CNA #300 told LPN #410 that she was not comfortable getting Resident #36 out of bed, and LPN #410 said to leave her in bed. CNA #400 stated Resident #36 continued to cry out in pain, without being assessed by the nurse. CNA #400 stated she updated Registered Nurse Supervisor (RNS) #215 on Resident #36 and RNS #215 stated there were no reports of any incidents with Resident #36. CNA #400 stated RNS #215 stated that Resident #36 needed an X-ray and the left leg looked broken. CNA #400 stated Resident #36's left leg was bruised at the knee, was swollen, and appeared to be misshaped.An interview on 04/29/26 at 12:17 P.M. with Resident #36's daughter and Power of Attorney (POA) revealed the facility called her on 04/23/26 and said the resident slipped in the mechanical lift and that they were going to do X-rays. The resident's daughter stated no further information was given until she went to the ED on 04/24/26. Resident #36's daughter stated she was going to call the Ombudsman due to feeling there was something the facility was not telling her pertaining to the resident's leg injury.Interview on 04/29/26 at 12:35 P.M. with CNA #300 revealed on 04/22/26, CNA #200 asked for assistance with transferring Resident #36 with a mechanical lift. CNA #300 stated CNA #200 had Resident #36 in bed with the mechanical lift sling under her. CNA #300 stated the sling appeared to be smaller than normal, but they were new, and she adjusted the sling to fit under Resident #36 better. CNA #300 stated CNA #200 was operating the mechanical lift. They were getting ready to transfer Resident #36 from the bed to the wheelchair when agency CNA #501 entered the room and asked for assistance with another resident. CNA #501 remained in the room and was going to help get the resident into the wheelchair. CNA #300 stated once CNA #200 lifted Resident #36 in the mechanical lift, she told CNA #200 to pull her out (pull the mechanical lift, with Resident #36 in the sling, out from under the bed). CNA #300 stated CNA #200 did a hard jerk on the mechanical lift and Resident #36 fell out of the sling feet first. CNA #300 stated she and CNA #501 caught the top half of Resident #36; however, the resident's legs hit the floor, causing her left leg to bend behind her. CNA #300 stated CNA #501 said she heard a loud pop and yelled out to get the nurse. CNA #300 stated Resident #36 was lowered to the ground. CNA #300 stated that during the event, Resident #36 was screaming help me and was crying in pain. CNA #300 stated LPN #208 and LPN #310 came into Resident #36's room and asked if the resident hit the floor. CNA #501 told both LPN #208 and LPN #310 that they lowered Resident #36 to the ground and heard a loud popping sound. LPN #208 asked Resident #36 if anything hurt and Resident #36 kept stating it hurts, it hurts. CNA #300 asked CNA #501 what she thought popped, and CNA #300 was told to be quiet by LPN #208. CNA #300 stated LPN #208 asked Resident #36 if she could move her arms and legs but she did not see LPN #208 complete a range of motion (ROM) assessment. CNA #300 stated LPN #208 looked to see if there was bruising. Further interview with CNA #300 revealed on 04/23/26, at the start of day shift, she was assigned Resident #36's hall. CNA #300 stated she asked LPN #410 how Resident #36 was and LPN #410 did not know anything had happened to Resident #36. CNA #300 told LPN #410 she did not feel comfortable getting Resident #36 out of bed and LPN #410 went into her room to attempt to help but Resident #36 was screaming out in pain anytime she was touched. CNA #300 stated Resident #36's left knee was swollen, bruised and did not look to be in the right place. CNA #300 stated on 04/24/26, she was asked to come to the DON's office where the DON stated Resident #36 was 95-years-old and had osteoporosis and the doctor signed off on it as a fractured leg. CNA #300 stated the DON had her sign a paper and she was not sure what it was for. CNA #300 stated the DON said the situation was going to be put to bed and they were not to talk about it further.An interview on 04/29/26 at 1:16 P.M. with CNA #200 revealed he had been a CNA for approximately a month. CNA #200 stated Resident #36 was on his get up list on 04/22/26 and he requested assistance from CNA #300 to transfer the resident from the bed to the wheelchair. CNA #200 stated CNA #501 was present in the room during the transfer. CNA #200 stated CNA #300 readjusted the sling. When lifting Resident #36 in the mechanical lift, a loud pop was heard, while the resident was still over the bed, and the resident stated she was having pain. CNA #200 stated the resident was placed back in bed and LPN #208 was notified. CNA #200 denied the resident fell from the mechanical lift.An interview on 04/29/26 at 2:36 P.M. with LPN #208 revealed she was notified on 04/22/26 that during a mechanical lift transfer for Resident #36, CNA #300 heard a loud pop. LPN #208 stated she asked Resident #36 if she could move her legs and Resident #36 stated she hurt all over. LPN #208 verified she did not complete range of motion, complete a head-to-toe assessment, or notify the physician or POA. LPN #208 denied being told that Resident #36 fell and stated there was no injury to Resident #36's left leg, which she confirmed was assessed by lifting up her pant leg to check for bruising.An interview on 04/29/26 at 2:47 P.M. with the DON revealed she denied an incident occurred on 04/22/26. The DON stated an incident occurred on 04/23/26 when a loud popping noise was heard while transferring Resident #36. The DON stated there were family members who worked at the facility and a couple of aides made the assumption that someone dropped the resident because she had a fracture. The DON stated she contacted the resident's daughter on 04/23/26 and asked if they could get an X-ray. The DON stated they did not feel there was an issue because the physician said the resident had osteopenia. An interview on 04/29/26 at 3:17 P.M. with RNS #502 revealed on 04/22/26 she was asked by LPN #208 to look at Resident #36 because she was complaining of pain. RNS #502 stated she asked Resident #36 if she was having issues with moving her legs. RNS #502 stated she touched Resident #36's chest and the resident said ouch. RNS #502 confirmed Resident #36 had dementia and severe cognitive impairment and was not able to communicate effectively. RNS #502 stated she pulled up Resident #36's left pant leg and noted swelling but did not see bruising and no further assessment was completed.A telephone interview on 04/29/26 at 4:15 PM with CNA #501 revealed she was an agency aide and 04/22/26 was the first time she worked at the facility. CNA #501 stated she entered Resident #36's room because she needed assistance with another resident. CNA #501 stated CNA #200 and CNA #300 were assisting Resident #36 in the mechanical lift, and she grabbed the wheelchair to help with putting the resident in the wheelchair. CNA #501 stated CNA #200 was operating the mechanical lift and pulled the lift forcefully out from under the bed, causing Resident #36 to fall from the mechanical lift sling. CNA #501 stated she and CNA #300 caught the top of Resident #36, however, both of the resident's legs hit the floor, with her left leg bending under her. At that time, CNA #501 stated a loud pop was heard and Resident #36 was yelling out in pain. CNA #501 stated Resident #36 was lowered to the ground and the nurse was requested. CNA #501 stated LPN #208 came in Resident #36's room and the resident was laying on the floor with a pillow placed under her head, and CNA #501 reported to LPN #208 that a loud pop was heard. CNA #501 stated there was instant bruising to Resident #36's left knee, and it appeared that her knee was not in the right position. CNA #501 stated she returned to the facility on [DATE] and asked a nurse how Resident #36 was and was told she was not to talk about it. CNA #501 stated she had to go to the DON's office and was told to sign a statement. CNA #501 stated she was not aware of what was on the statement and was told it pertained to the mechanical lift incident.An interview on 04/30/26 at 9:40 A.M. with RNS #215 revealed fall incidents were to be reported to the nurse. RNS #215 stated she did not work on 04/22/26 but on 04/23/26, CNA #250 and CNA #400 came to her office and asked if she heard about Resident #36. RNS #215 stated CNA #250 and CNA #400 reported on 04/22/26, Resident #36 was being transferred using a mechanical lift, slid out of the sling and a loud pop was heard. RNS #215 stated she went to Resident #36's room and assessed her, noting visible swelling, bruising and obvious misalignment of her left leg. She then went to LPN #208's office and stated the doctor needed to be notified immediately. LPN #208 told RNS #215 that Resident #36 only had hip pain. RNS #215 stated she then went to the DON's office and asked her if she knew what happened to Resident #36. RNS #215 stated the DON said Resident #36 was lowered to the ground on 04/22/26 and, since Resident #36 was bedbound, the doctor did not want to do anything. RNS #215 stated everyone was acting weird regarding the situation. RNS #215 stated she was asked to write a statement related to the incident, but she had not written one. During the interview, RNS #215 received a call from the DON, who requested she report to her office. A telephone interview on 04/30/26 at 10:07 A.M. with Physician #500 revealed the facility reported Resident #36 was yelling out and they were not sure why. He was uncertain of the date he was notified. It was reported there was a popping noise heard, but its origin was unknown, and the resident was screaming and agitated. Physician #500 told the facility to monitor the resident for signs of injury. Physician #500 stated Resident #36 was not mobile, and he was under the impression that Resident #36 had a non-displaced fracture (a bone break where the bone cracks but remains properly aligned, without shifting or separating) and further stated he did not feel Resident #36 needed pain medication since she was bedbound and did not ambulate on her leg. Physician #500 confirmed he was unaware Resident #36 had a left hand fifth metacarpal fracture or that the left femur fracture was a closed displaced comminuted distal femur fracture.An interview on 04/30/26 at 10:15 A.M. with Resident #114 revealed the resident was able to answer questions appropriately and was cognitively intact. Resident #114 revealed she was Resident #36's roommate on 04/22/26 and was in the room that morning. Resident #114 stated CNA #200, CNA #300, and CNA #501 were in the room assisting Resident #36 with a mechanical lift transfer. She stated the curtain was pulled, so she could not see anything, but she heard everything that had happened. Resident #114 stated she heard scuffling behind the curtain and then she heard CNA #300 say Oh my gosh we caught her. Resident #114 stated she overheard that Resident #36's feet were on the floor and her leg was bent. Resident #114 did not know what leg it was. Resident #114 further stated that on the night of 04/22/26, Resident #36 cried out in pain all night, adding it was so bad that she called the nurse and asked them to give Resident #36 something for pain.An interview on 04/30/26 at approximately 10:30 A.M. with the DON and Administrator revealed no staff reported Resident #36 fell from the mechanical lift on 04/22/26 and the staff signed a written statement that did not indicate a fall occurred and the popping sound was heard while the resident was still in the mechanical lift sling, elevated over the bed. The DON stated nursing assessed Resident #36 due to the reported popping sound and no injuries were identified. The DON stated the nurse completed a thorough assessment and they had no idea how the resident sustained a closed displaced comminuted distal femur fracture, adding the resident had osteoporosis and perhaps the fracture started as a hairline fracture. Concurrent review of the facility provided written statement dated 04/23/26 with the DON revealed CNA #200, CNA #300, CNA #501, and LPN #208 all signed a single typed statement that stated all three direct care staff reported they heard a popping noise and alerted the nurse. The resident was in a Hoyer sling at the time the popping noise was heard, elevated above the bed, when the resident moved/stretched her legs and the noise was heard. The nurse assessed the resident immediately and no abnormalities or signs/symptoms of pain were noted. The resident had an artificial joint replacement to the right hip. The resident was also noted to have relevant diagnoses of osteoarthritis and a history of fractures. The physician was contacted and requested to order bilateral hip and bilateral knee X-rays as a precautionary measure. Continued interview with the DON confirmed she wrote the single statement signed by the four staff, adding the statement was written based on staff interview. The DON and the Administrator stated the resident's fracture was pathological because she had osteoporosis.A follow-up interview on 04/30/26 at 10:56 A.M. with CNA #300 confirmed Resident #36 fell from the mechanical lift during transfer on 04/22/26. CNA #300 stated she helped catch Resident #36 when she fell, but her legs still hit the floor. CNA #300 stated she did not hear the popping noise; it was CNA #501 who heard it. CNA #300 stated she was called to the DON's office on 04/24/26 and told to sign the statement written by the DON and dated 04/23/26. CNA #300 stated she was not asked by the DON what had occurred and the DON had the statement already written when she was called to sign it. CNA #300 stated she felt intimidated, scared, and feared retaliation because there were three additional nurses in the DON's office, so she signed the statement. CNA #300 verified the signed statement was not an accurate account of the incident.A follow-up telephone interview on 04/30/26 at 4:15 P.M. with CNA #501 confirmed Resident #36 fell from the mechanical lift on 04/22/26. Although she and CNA #300 caught the resident, the resident's legs still hit the floor, with her left leg bending behind her (CNA #501 was on the left side of Resident #36). CNA #501 was uncertain if the resident hit her hand. CNA #501 stated she was never interviewed about the incident. She worked at the facility on 04/24/26 and was called to the DON's office to sign a statement written by the DON. CNA #501 stated several other people were in the room. CNA #501 stated she did not know what to do and was scared, so she signed the statement. CNA #501 stated every sentence in the statement was false. On 04/27/26, she contacted the DON at the agency she worked for and reported what had occurred because she did not feel right about what was happening with the incident. Review of a text message sent to the State Surveyor on 04/30/25 at 1:05 P.M. from Physician #500 revealed he confirmed he was not contacted about any concerns with Resident #36 until 04/23/26 at 8:00 A.M. when he was contacted by LPN #208. Physician #500 did not clarify what LPN #208 contacted him about. The text message further stated the facility told him three nurses looked at Resident #36 on 04/22/26, with no other information provided.A telephone interview on 05/01/26 at 10:25 A.M. with Registered Nurse (RN) #503, the agency DON, revealed it was procedure for facilities to notify the agency any time an incident occurred that involved agency staff. She stated the facility did not report the incident involving CNA #501 to them. On 04/27/26, RN #503 stated CNA #501 called and reported an incident that occurred at the facility. CNA #501 reported she was told she could not tell the agency, but she did not feel right about it. CNA #501 reported to RN #503 that Resident #36 had fallen out of a mechanical lift on 04/22/26. On 04/23/26, CNA #501 returned to the facility and Resident #36 was in pain and crying and the facility had not done anything for the resident and the same scenario occurred on 04/24/26. RN #503 stated she had CNA #501 write a statement regarding the situation, which stated Resident #36 fell from the mechanical lift during transfer on 04/22/26. RN #503 stated she called the facility and talked to a unit coordinator, who was not giving her direct answers, and stated the DON was not available. RN #503 stated CNA #501 reported the facility made her sign a statement and she was nervous because she was not sure what she signed. On 04/27/26 at 11:52 A.M, the facility's DON returned RN #503's call and stated there were employees in the facility who were related to residents and the statement that CNA #501 signed was stating that CNA #501 had nothing to do with the incident and was dismissing her from the incident. RN #503 stated she requested a copy of the statement and she still had not received it. RN #503 stated on 04/29/26, she received a phone call from the Administrator of the facility requesting CNA #501's phone number because state was in the building. RN #503 stated on 05/01/26, the Administrator called her again and stated that CNA #501 spoke with the State Surveyor, but what she spoke about was not in the statement. RN #503 stated the Administrator further stated that he was physically sick over the situation and he should have listened to his staff, as he was unaware that the situation took place. RN #503 reported the Administrator stated, I thought the staff were just believing hearsay.Review of the facility policy titled, Physician Communication Guidelines, undated, revealed for falls with musculoskeletal deformity, hip or leg pain, the doctor should be notified within one hour.Review of the facility policy titled, [NAME][TRUNCATED]

Based on medical record review, observation, and staff interview, the facility failed to maintain accurate medical records regarding documentation for nutritional supplements. This affected one (#52) of two residents reviewed for nutrition. The facility census was 95. Findings include: Review of Resident #52's medical record identified the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus without complications, iron deficiency, dementia, age-related osteoporosis, depression, anxiety, muscle weakness, and cognitive communication deficit. Review of Resident #52's current plan of care, revised 02/15/23, revealed the resident had a nutritional problem related to fracture of left femur, physical disability, fracture of left humerus, anemia, hypoosmolality/hyponatremia, therapeutic diet order for small portions per request, assist with meals, upper and lower dentures, history of falling, eats fifty-percent or less, advanced age, meal and/or supplement refusals, significant weight loss, decreasing weight trend, and resistant of staff encouragement at meals and with care. Goals included no significant weight changes and remaining free from dehydration as evidenced by good skin turgor, labs, etcetera. Interventions included monitoring percent of meals consumed, and supplements as ordered. Review of Resident #52's quarterly Minimum Data Set 3.0 assessment, dated 03/09/23, revealed the resident was severely cognitively impaired and required extensive assistance of two staff for bed mobility, transfers, and toileting. The resident required supervision of one staff for eating. The resident experienced weight loss of five-percent or more in the past month or loss of ten-percent or more in the last six months and was not on a prescribed weight-loss regimen. Review of Resident #52's dietary progress notes dated 03/10/23 revealed the resident sustained significant weight loss times six months, supplements and extra foods in place, Greek yogurt in place twice per day with breakfast and lunch for additional calories and protein, resident refused meals and supplements at times, Magic Cup supplement in place three times per day with meals, no edema, skin intact, and will continue to monitor. Review of Resident #52's physician orders for March 2023 identified orders for Magic Cup with breakfast and lunch, and Boost Breeze one time per day with breakfast for supplement. Review of Resident #52's intake record, dated 03/14/23 at timed 11:08 A.M., revealed the resident was documented as consuming between fifty-one percent and seventy-five percent of her lunch magic cup. Review of Resident #52's Medication Administration Record (MAR) for March 2023 revealed the resident was documented as receiving her Magic Cup with the lunch meal on 03/14/23. Review of Resident #52's intake record, dated 03/15/23 and timed 7:03 A.M. revealed the resident was documented as consuming between fifty-one and seventy-five percent of the Boost Breeze supplement. Review of Resident #52's MAR for March 2023 revealed the resident was documented as receiving her Boost Breeze supplement with the breakfast meal on 03/15/23. Review of Resident #52's intake record dated 03/15/23 and timed 1:41 P.M. revealed the resident was documented as consuming between twenty-six percent and fifty-percent of her lunch magic cup. Review of Resident #52's MAR for March 2023 revealed the resident was documented as receiving her Magic Cup with the lunch meal on 03/15/23. Observation of the lunch meal on 03/14/23 beginning at 12:29 P.M. revealed Resident #52 did not receive a Magic Cup with the lunch meal. Observation of Resident #52's lunch meal ticket revealed the meal ticket did not mention the Magic Cup. Interview on 03/14/23 at 1:00 P.M. with Dietary Manager #600 verified Resident #52 received a Magic Cup with her lunch meal. An unidentified State tested Nurse Aide (STNA) sitting next to where Resident #52 had been seated also verified she did not believe Resident #52 received a Magic Cup with her lunch meal. Observation of the breakfast meal on 03/15/23 beginning at 8:06 A.M. revealed Resident #52 never received the Boost Breeze supplement with her breakfast meal. Resident #52 finished eating breakfast and was assisted out of the dining area by staff. Observation of Resident #52's breakfast meal ticket revealed Boost Breeze was not listed on the ticket. Interview on 03/15/23 at 8:54 A.M. with Dietary Aide #602 verified Resident #52 did not receive the Boost Breeze supplement with her meal. Dietary Aide #602 reported Resident #52 never received Boost Breeze with breakfast and verified the breakfast meal ticket did not mention the Boost Breeze supplement. Observation of the lunch meal on 03/15/23 at 12:27 P.M. revealed Resident #52 did not receive a Magic Cup with the lunch meal. Resident #52 was assisted out of the dining room by staff. Interviews and observations on 03/15/23 at 1:07 P.M. with STNA #559, STNA #578, STNA #584, and Dietary Aide #584 revealed staff were in the dining area near where Resident #52 was seated for the lunch meal. All four staff members stated Resident #52 did not receive a Magic Cup with her lunch meal and only with her breakfast meal. Observation of Resident #52's lunch meal ticket revealed the Magic Cup was not listed on the ticket. Interview on 03/15/23 at 1:40 P.M. with Dietitian #610 verified Resident #52 was supposed to receive a Magic Cup with the breakfast, lunch, and dinner meals, and a Boost Breeze supplement with the breakfast meal. Dietitian #610 was notified Resident #52 had not received the aforementioned items with meals. Upon review of Resident #52's standing orders and meal tickets, Dietitian #610 reported the Magic Cup had not been showing up on Resident #52's lunch meal ticket because there were numerous other items listed on the ticket and there was not enough room on the ticket. Interviews on 03/15/23 at 2:52 P.M. with MDS Coordinator #522 and Dietitian #610 revealed Licensed Practical Nurse (LPN) #528 was contacted and reported Resident #52 sometimes received the Boost Breeze supplement while in a sitting area on the 300-unit prior to the breakfast meal. A follow-up interview on 03/16/23 at approximately 4:50 P.M. with the Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and Dietitian #610, revealed the facility had identified the issue regarding meals, supplements and accurate documentation.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure nutritional interventions were implemented per physician order and the plan of care, for residents identified at nutritional risk. This affected two (#39 and #52) of three residents reviewed for nutrition. The facility census was 95. Findings include: 1. Review of Resident #52's medical record identified the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus without complications, iron deficiency, dementia, age-related osteoporosis, depression, anxiety, muscle weakness, and cognitive communication deficit. Review of Resident #52's current plan of care, revised 02/15/23, revealed the resident had a nutritional problem related to fracture of left femur, physical disability, fracture of left humerus, anemia, hypoosmolality/hyponatremia, therapeutic diet order for small portions per request, assist with meals, upper and lower dentures, history of falling, eats fifty-percent or less, advanced age, meal and/or supplement refusals, significant weight loss, decreasing weight trend, and resistant of staff encouragement at meals and with care. Goals included no significant weight changes and remaining free from dehydration as evidenced by good skin turgor, labs, etcetera. Interventions included family participation in menu selection, assisting resident with meals as needed, monitoring percent of meals consumed, providing diet per order and honoring food preferences, Boost Breeze supplement, recommendation in place for full-fat Greek yogurt with breakfast and lunch to provide additional calories and protein due to weight trending down, Magic Cup twice per day with meals, and supplements as ordered. Review of Resident #52's quarterly Minimum Data Set 3.0 assessment, dated 03/09/23, revealed the resident was severely cognitively impaired and required extensive assistance of two staff for bed mobility, transfers, and toileting. The resident required supervision of one staff for eating. The resident experienced weight loss of five-percent or more in the past month or loss of ten-percent or more in the last six months and was not on a prescribed weight-loss regimen. Review of Resident #52's dietary progress notes dated 03/10/23 revealed the resident sustained significant weight loss times six months, supplements and extra foods in place, Greek yogurt in place twice per day with breakfast and lunch for additional calories and protein, resident refused meals and supplements at times, Magic Cup supplement in place three times per day with meals, no edema, skin intact, and will continue to monitor. Review of Resident #52's physician orders for March 2023 identified orders for small portions diet with regular texture and regular consistency including full fat Greek yogurt with breakfast and lunch, Magic Cup with breakfast and lunch, Mighty Shake two times per day for supplement, and Boost Breeze one time per day with breakfast for supplement. Observation of the lunch meal on 03/14/23 beginning at 12:29 P.M. revealed Resident #52 was served a deli-style sandwich which was cut in half, sliced green apples, cooked carrots, and apple sauce. The resident finished eating and staff assisted her out of the dining room. Resident #52 did not receive a Magic Cup or Greek yogurt with the lunch meal. Observation of Resident #52's lunch meal ticket revealed the resident was to receive full-fat Greek yogurt with lunch. The meal ticket did not mention the Magic Cup. Interview on 03/14/23 at 1:00 P.M. with Dietary Manager #600 verified Resident #52 received a Magic Cup or Greek yogurt with her lunch meal. An unidentified State tested Nurse Aide (STNA) sitting next to where Resident #52 had been seated also verified she did not believe Resident #52 received a Magic Cup or Greek yogurt with her lunch meal. Observation of the breakfast meal on 03/15/23 beginning at 8:06 A.M. revealed Resident #52 never received Greek yogurt or Boost Breeze with her breakfast meal. Resident #52 finished eating breakfast and was assisted out of the dining area by staff. Observation of Resident #52's breakfast meal ticket revealed Boost Breeze was not listed on the ticket. Full-fat Greek yogurt with breakfast was listed on the meal ticket. Interview on 03/15/23 at 8:54 A.M. with Dietary Aide #602 verified Resident #52 did not receive Greek yogurt with the breakfast meal. Dietary Aide #602 stated the Greek yogurt was stored in ice on top of the tray cart containing resident meal trays and staff must have forgotten to grab it. Dietary Aide #602 also verified Resident #52 did not receive the Boost Breeze supplement with her meal. Dietary Aide #602 reported Resident #52 never received Boost Breeze with breakfast and verified the breakfast meal ticket did not mention the Boost Breeze supplement. Observation of the lunch meal on 03/15/23 at 12:27 P.M. revealed Resident #52 did not receive a Magic Cup or Greek yogurt with the lunch meal. Resident #52 was assisted out of the dining room by staff. Interviews and observations on 03/15/23 at 1:07 P.M. with STNA #559, STNA #578, STNA #584, and Dietary Aide #584 revealed staff were in the dining area near where Resident #52 was seated for the lunch meal. All four staff members stated Resident #52 did not receive a Magic Cup with her lunch meal and only with her breakfast meal. Observation of Resident #52's lunch meal ticket revealed the Magic Cup was not listed on the ticket. Interview on 03/15/23 at 1:40 P.M. with Dietitian #610 verified Resident #52 was supposed to receive a Magic Cup with the breakfast, lunch, and dinner meals, full-fat Greek yogurt with the breakfast and lunch meals, and a Boost Breeze supplement with the breakfast meal. Dietitian #610 was notified Resident #52 had not received the aforementioned items with meals. Upon review of Resident #52's standing orders and meal tickets, Dietitian #610 reported the Magic Cup had not been showing up on Resident #52's lunch meal ticket because there were numerous other items listed on the ticket and there was not enough room on the ticket. Interviews on 03/15/23 at 2:52 P.M. with MDS Coordinator #522 and Dietitian #610 revealed Licensed Practical Nurse (LPN) #528 was contacted and reported Resident #52 sometimes received the Boost Breeze supplement while in a sitting area on the 300-unit prior to the breakfast meal. 46196 2. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE] with admitting diagnoses including Alzheimer's Disease, need for assistance with personal care and unspecified severe protein-calorie malnutrition. The MDS quarterly assessment dated [DATE] revealed the Resident #39 had severe cognitive impairment. The assessment revealed the resident required limited assistance for bed mobility, transfers, walking in his room or in the corridor, and locomotion on or off from the unit. The assessment revealed the resident required extensive assistance for personal hygiene, dressing and toileting. The assessment revealed the resident required supervision for eating, with physical assistance at times by one person. The care plan dated 01/01/23 revealed Resident #39 had a severely impaired cognitive function with interventions which included administer medications as ordered ask yes/no question to determine the resident's needs; and cue, reorient and supervise as needed. The care plan revealed the resident had nutritional problem or potential nutritional problem related partially to Alzheimer's Disease, with interventions which included to assess diet tolerance; assist resident with meals as needed, and encourage resident to eat or drink; and provide diet per order. This care plan also revealed a recommendation dated 12/12/22 for Boost supplemental drink served three times daily with meals due to significant weight loss. Medical record review for Resident #39 revealed a recorded weight on 03/01/23 of 145.6 pounds, and a recorded weight on 02/07/23 of 145.1 pounds, equaling a 0.34% weight gain within 30 days. The record showed a recorded weight on 09/01/22 of 153.0 pounds equaling a 4.84% weight loss within 180 days. Further medical records review for Resident #39 revealed an order for Boost was initiated on 12/12/22. On 03/13/23 at 12:34 P.M. an observation was made of Resident #39 seated at a table in the dining area on the secured memory unit. Resident #39 was seated at a table with only one other resident. Resident #39 was observed to have a soup bowl, a lunch meal on a plate, a small disposable container of pudding, and a small can of soda, which staff opened for Resident #39 and poured into a small, clear plastic cup. There were no supplemental food items served to Resident #39. It was observed Resident #39 had not consumed any food from the lunch meal plate. Resident #39 had consumed the pudding in total. Resident #39 had consumed 75-100% of the soup. Resident #39 drank all the soda which had been poured into the clear plastic cup. On 03/14/23 at 12:17 P.M. an observation was made on the secured memory care unit of the lunch meal delivery cart arrival. Staff immediately began delivering the lunch meals to residents. An observation was made of residents at the tables who were consuming a food item from a bowl, later identified as the soup for the day. Resident #39 was not located in the dining area. A staff member was heard at the entry to Resident #39's room, announcing the lunch meal was being served, and the staff member asked Resident #39 to come to the dining area. At 12:24 P.M. on 03/14/23 Resident #39 emerged from his room and ambulated to the dining area to sit for his lunch meal. Resident #39 did not receive a soup. Resident #39 received a lunch meal plate, an ice cream cup, and a small can of soda which a staff member opened and poured into a small clear plastic cup. There was no supplemental food item served with Resident #39's lunch meal. Resident #39 was observed to pick at the food on his plate. Resident #39 was observed to consume the ice cream in total. Resident #39 was observed to drink the soda from the cup. Resident #39 picked up his eating utensil several times and moved items about on his lunch plate. At 12:53 P.M., Resident #39's plate was observed to have no food taken from the plate by the resident. The ticket which accompanied Resident #39's meal was observed to read Boost eight ounces (oz). In an interview with State tested Nurse Aide (STNA) #570 on 03/14/23 at 12:53 P.M. an inquiry was made about the supplemental food item (Boost) on the meal ticket for Resident #39. STNA #570 looked at the meal ticket for Resident #39 and stated she thought she had given Resident #39 a Boost with his lunch meal. STNA #570 verified Resident #39 had not received Boost supplement with his lunch meal. STNA #570 then stated she did not know he was supposed to get Boost with his meals. Review of facility policy titled Philosophy and Standards of Clinical Care, dated 2021, revealed the facility would develop and consistently implement pertinent food and nutrition interventions.

Based on observation, staff interview, policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff donned and doffed personal protective equipment (PPE) appropriately to prevent the spread of infection. This affected three Residents (#08, #16, and #65) of four who who were dining in their room. Findings Include: Observation on 03/01/21 at 12:23 P.M., of the meal tray service revealed Licensed Practical Nurse (LPN) #100 was wearing a face shield and an N95 mask. LPN #100 put on a foot coverings, a gown, a hairnet and gloves, and took a tray off the cart and walked into the room of Resident #56, who was on a 14 day quarantine isolation, set the meal tray on the bedside table. LPN #100 removed her gown, gloves, foot coverings and hairnet, then washed her hands and exited the room and had not changed her mask or cleaned her face shield. LPN #100 delivered the next tray to Resident #08 who was in a 14 day quarantine. LPN #100 put on foot coverings, a gown, a hairnet, and gloves, entered the room with a meal tray and set it on the table. Resident #08's chair alarm sensor was defective and continued to sound. LPN #100 walked out of the room without removing any PPE, walked down the hallway through the double doors and asked a staff member to get a new chair alarm. LPN #100 walked back into Resident #08's room with the same PPE and set up the new chair alarm. LPN #100 removed her foot coverings, gown, gloves, and hairnet washed her hands and exited the room. LPN#100 had not changed her mask or cleaned her face shield. LPN #100 delivered a tray to Resident #65, who was in a 14 day quarantine. Once again, LPN #100 put on foot coverings, a gown, a hairnet and gloves and took the meal tray into the room. LPN #100 removed her foot covering, gown, gloves, hair net, washed her hands, walked out of the room, and had not changed her mask or cleaned her face shield. LPN #100 put on foot coverings, a gown, gloves, and a hairnet and entered the room of Resident #16 with a meal tray. LPN #100 removed here gown, gloves, foot coverings, and hairnet exited the room sanitized her hands and had not cleaned her face shield or changed her mask. Interview on 03/01/21 at 12:49 P.M., LPN #100 stated she was nervous and was unsure of the facility's policy for doffing PPE. Interview on 03/01/21 at 1:25 P.M., the Director of Nursing (DON) verified the above and stated the facility used the CDC guidelines for donning and doffing and LPN #100 would be educated on appropriate use of PPE. Review of the CDC's pamphlet titled Use personal protective equipment when caring for patients with Confirmed or Suspected COVID-19 revealed to don a gown, mask, eye protection and gloves prior to entering the room. When doffing PPE remove gloves, gown, and exit the patient's room. Perform hand hygiene then remove eye protection, remove face mask, and perform hand hygiene. Review of the facility policy titled Contingency plan for conservation of supplies eye protection, undated revealed while wearing gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe then fully dry.

Based on observations, review of dietary menus, review of dietary spreadsheets, and staff interviews, the facility failed to serve the identified portion sizes of pureed chicken to 12 residents (#4, #5, #9, #16, #23, #57, #59, #65, #76, #80, #93 and #94) who received pureed diets. The facility census was 119. Findings include: Review of the menu for the lunch meal on 02/03/20 identified the facility was serving chicken, mashed potatoes and green beans. Review of the spreadsheets for the lunch meal on 02/03/20 revealed pureed diets should receive a #10 scoop of pureed chicken. The facility provided a listing that identified size #10 scoop is equal to 3/8 cup or 3 ounce. Observation on 02/05/20 at 11:49 [NAME]M., Cook #114 was plating the noon meal. Cook #114 was observed to be utilizing a two ounce scoop for the pureed chicken for each of the residents receiving pureed diets. Interview on 02/05/20 at 12:02 P.M., Cook #114 confirmed she was not aware the facility menus had portion sizes listed and she just uses the same scoops for each meal. Interview on 02/05/20 at 12:04 P.M., Dietary Manager #115 confirmed the staff were not following the menu and spreadsheet for proper portion sizes. The facility identified 12 residents (#4, #5, #9, #16, #23, #57, #59, #65, #76, #80, #93 and #94) who received pureed diets.

Based on medical record review, observation, family interview, staff interview, and review of facility policy, the facility failed to ensure call lights were in reach for three (#45, #57, #65) of 24 residents reviewed for accommodation of needs. The facility census was 119. Findings include: 1. Review of medical record for Resident #45 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]., muscle weakness, ataxic gait, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/28/19, revealed Resident #45 was moderately cognitively impaired with behaviors that fluctuate in severity. Resident #45 was assessed as needing extensive assistance for function of bed mobility, transfers, and locomotion. The MDS revealed Resident #45 was assessed as needing extensive assistance for dressing, eating, toilet use, and personal hygiene. Observation on 02/03/20 at 09:53 [NAME]M. revealed Resident #45 was sitting in a recliner with his back to the door. Resident #45's call light was not in reach and was on the resident's bed about nine feet away from the resident. Interview on 02/03/20 at 09:53 [NAME]M. with Licensed Practical Nurse (LPN) #44 confirmed Resident #45's call light was not in reach, and the call light was attached to top corner of bed. Review of a facility policy titled Call Light, dated 1999 and revised (MONTH) 2008, revealed the staff are to be sure a resident's call light was positioned conveniently for the resident to use and have the resident demonstrate the use of the call light to be sure he/she understands the instructions. 2. Review of medical record for the Resident #57 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Observation on 02/04/20 at 11:29 [NAME]M. revealed Resident #57 was in bed. The call light was pinned between the wall and the bed, lying on the floor. Interview on 02/04/20 at 11:30 [NAME]M. with Resident #57's nephew revealed the call light was located between the bed and the wall, lying on the floor when he arrived. Interview on 02/04/20 at 11:32 [NAME]M. with LPN #44 verified Resident #57's call light was on the floor and not in the resident's reach. 3. Review of medical record for the Resident #65 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the annual MDS assessment, dated 12/19/19, revealed Resident #65 was severely cognitively impaired and dependent on staff for all activities of daily living. Observation on 02/04/20 at 11:35 [NAME]M. revealed Resident #65 was reclined in her wheelchair. Her spouse was sitting on the bed. The resident's call light was looped around the call light box hung on the wall. Interview on 02/04/20 at 11:39 [NAME]M. with the Maintenance Director (MD) #72 confirmed the call light was hung on the wall.

Based on medical record review, resident interview, family interview, and staff interviews, the facility failed to ensure residents were invited to participate in their care planning meetings. This affected one (#166) of four residents reviewed for participation in care planning. The facility census was 119. Findings include: Review of Resident #166's medical record identified admission to the facility occurred on 11/30/19 following hospitalization . [DIAGNOSES REDACTED].#166 was cognitively intact. The record contained no evidence Resident #166 had been invited to participate in care planning. Interview on 02/03/20 at 3:13 P.M., Resident #166 stated she had never been invited nor attended her care plan meetings, but would if she was asked. Interview on 02/05/20 at 9:18 [NAME]M., Licensed Social Worker (LSW) #87 identified the Minimum Data Set nurse completed the schedule for care planning conferences and she was in charge of inviting residents/families to the meetings. LSW #87 confirmed she a care plan meeting occurred for Resident #166 on 12/18/19. There was no evidence the family and or Resident #166 attended and or was invited to participate in the meeting. LSW #87 identified the care planning meetings are usually completed in the computer chart, however there were none in the computer for Resident #166. A telephone interview with Resident #166's daughter on 02/05/20 at 3:14 P.M. confirmed she had never been invited to attend any meetings regarding her mother's care. Resident #166's daughter stated her and her mother would attend any meetings regarding care and/or treatment.

Based on medical record review, review of facility policy, family interview, review of financial records, and staff interview, the facility failed provide the notice of bedhold policy upon discharge to the hospital for one (#166) of three residents reviewed for hospitalization . The facility census was 119. Findings include: Review of Resident #166's medical record identified admission to the facility occurred on 11/30/19. The record identified on 01/17/20 Resident #166 was sent to the hospital and admitted with a [MEDICAL CONDITION]. The record revealed a lack of bed hold policy notification at the time of hospital discharge. The record identified Resident #166 remained in the hospital from 01/17/20 through 01/22/20. Review of Resident #166's financial records revealed the resident paid privately for her nursing home stay. She was charged a bed hold for each day she was not in the facility during her hospital admission. Interview on 02/05/20 at 2:06 P.M., Fiscal Office Billing #71 stated she was only responsible to complete bed hold notifications for residents whom receive Medicaid. Fiscal Office Billing #71 confirmed she has no evidence Resident #166 and or her family had approved and or requested for her bed to be held, however she was charged the bed hold while she was in the hospital. Interview with Resident #166's daughter on 02/05/20 at 3:20 P.M. confirmed neither herself or Resident #166 were provided the bed hold policy and choice if they wanted to hold Resident #166's bed at the time of her discharge. Resident #166's daughter indicated she would not want to pay $200 a day, when her mother was not in the building getting care. Review of the facility policy titled Bed Hold Policy, dated 04/19, identified if the resident's payer source is one other than Medicaid, the resident or their sponsor will contact the facility if they will be holding the bed via telephone and or in person on the next business date following admission to the hospital. Facility at that time inform them of their financial responsibility in regards to the bed hold option.

Based on observations, medical records review, resident interview, and staff interview, the facility failed to honor resident choice on roommates and who to eat meals with for two (#62 and #85) of 24 sampled residents. The facility census was 119. Findings include: Review of Resident #62's medical records identified admission to the facility occurred on 11/19/19. Medical [DIAGNOSES REDACTED]. The record identified prior to admission to the facility Resident #62 lived with her sister (Resident #85) in the community. Interview on 02/03/20 at 9:28 [NAME]M., Resident #62 identified her sister, Resident #85, was admitted to the facility in (MONTH) and she wanted to be roommates with her. Resident #62 identified the facility has not made any efforts to try to accommodate the residents' wishes to room together. Resident #62 also stated when her sister and her go to the dinning room they were not permitted to sit next to one another because she required staff to fed her meals. Resident #62 confirmed she would like to sit next to her sister while they eat meals. Interview on 02/04/20 at 1:24 P.M., Resident #85 identified she was admitted in (MONTH) 2019 and was not offered to live in the same room with her sister (Resident #62). Resident #85 identified she lived with Resident #62 prior to admission and really would like to be in the same room with her now. Observation of the breakfast meal on 02/05/20 at 8:14 [NAME]M. identified Resident #62 was placed at the table with other resident's who need staff to feed them their meal. Resident #85, who was capable to feeding herself, was placed at a different table. Interview on 02/05/20 at 9:11 [NAME]M., facility Social Worker #87 identified Resident #62 and Resident #85 were separated as the facility thought this was the best for them. Social Worker #87 confirmed Resident #62 and Resident #85 were not provided the right to room together and or choices regarding where they sit in the dinning room.

Based on medical record review, observation, review of facility Self-Reported Incident report, staff interview, and review of facility abuse policies, the facility failed to ensure one (#5) of two resident reviewed for fractures remained free of staff to resident abuse. This resulted in actual harm when two State tested Nursing Assistants (STNA) held Resident #5 arm to provide nail care. This resulted in Resident #5 sustaining a fracture to the left upper arm. The facility identified two current residents with fractures, one related to abuse (Resident #5) and one related to an injury of unknown origin. The facility census was 126. Findings include: Review of Resident #5's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #5 was admitted with Hospice services and had a Do Not Resuscitate-Comfort Care status. The medical record revealed the resident had no cognitive impairments upon admission. Review of the nurses notes on 01/24/16 at 10:03 A.M. documented Resident #5's left arm was swollen with the front of the arm being reddened. Nurses notes at 7:34 P.M. Hospice provided new orders for an antibiotic. At 8:28 P.M., Resident #5 complained on left arm pain. The arm was swollen, reddened and slightly warm to the touch. Review of the nurses notes on 01/25/16 at 12:37 A.M. documented Resident #5's left arm had discoloration observed from the shoulder to the elbow. The area was warm to the touch. The nurses note indicates an X-ray was ordered at 2:44 P.M. The nurses note of 01/25/16 at 3:32 P.M. indicated the X-ray was obtained. The resident was noted to have severe pain when her left arm was touched. Review of an X-ray report dated 01/25/16 at 3:44 P.M., revealed Resident #5 a left humerus subacute to old fracture with incomplete healing. Review of the aftercare instructions from the local emergency room dated 01/25/16 at 6:38 P.M., revealed Resident #5 was assessed for the left humerus fracture and new orders were obtained. Review of the facility Self-Reported Incident (SRI) investigation, dated 01/25/16, revealed on 01/25/16, Resident #5's family had reported the staff had dressed the resident in regular clothing against her wishes and held her hands to cut her fingernails. The family reported they did not know the resident could raise her left arm to place it into a regular shirt due to an old injury. The SRI documented Resident #5 was interviewed regarding the allegation of staff dressing her against her will and holding her hands to trim her fingernails. Resident #5 stated STNA #11 and STNA #12 had cut her fingernails while holding her hands and had hurt her left arm Review of the SRI investigation documented a statement from STNA #11 which indicated on 01/23/16 she had trimmed Resident #5's fingernails. STNA #11 identified the resident's fingernails to be filed to a point, sharp, and jagged. STNA #11 indicated Resident #5 had allowed her nails to be cut. Review of the SRI investigation contained a statement from STNA #12. The STNA stated the resident's nails were curled under and dirty. The STNA denied holding the resident's arm. The SRI investigation revealed Resident #5 had fallen at a prior facility on 12/16/15. An X-ray obtained on 12/23/15 indicated Resident #5 had no acute fracture to her left arm. Review of the SRI investigation verified the facility had substantiated the allegation of physical abuse of Resident #5 by STNA #11 and STNA #12. The investigation documented the facility reached the conclusion based upon Resident #5 having no symptoms of swelling, bruising, increased temperature, or increased pain to the left arm upon admission. The conclusion was also based on conflicting statements provided by STNA #11 and #12 when compared with statements from other staff regarding Resident #5's nails and the STNA's explanations of the event were not consistent with the resident's normal behavior. The facility had concluded the suspicion of abuse due to the extent of the injury sustained to Resident #5's left arm and no other explanation for how the injury had occurred. Observation on 02/01/16 at 10:50 A.M. revealed Resident #5 was unresponsive. The resident's left arm was very swollen in comparison to the right arm. A sling was in place to the left arm. The visible portion of the left arm above the sling was uncovered with no bruising or redness noted at this time. Interview on 02/01/16 at 1:16 P.M., the Administrator verified the abusive actions toward Resident #5 from STNA #11 and STNA #12, which resulted in Resident #5 having a fractured left arm. The Administrator indicated both STNAs had been on administrative leave since the allegation of abuse was made on 01/25/16. The Administrator indicated the employment of both staff will be terminated. Interview on 02/01/16 at 4:52 P.M., STNA #11 stated she had been called to Resident #5's room to assist another staff with nail care. She indicated she had held the resident's arm to steady the resident's hand so the other staff did not cut resident's skin when trimming the nails. Review of the facility policy titled Abuse Investigation and Reporting, revised 11/2012, revealed the administrator was directly responsible for ensuring resident safety and well being. The policy identifies abuse to be the willful infliction of injury, or unreasonable confinement. Physical abuse includes the definition of controlling behavior through corporal punishment. Review of the facility policy titled Abuse Prevention, revised 11/2012 indicates the purpose of the policy was to prevent mistreatment, neglect, and abuse of residents. This deficiency substantiates Complaint Number OH 483.