Every finding on record at The Merriman

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record reviews, review of self-reported incident (SRI), review of facility investigations, review of weather data, review of local maps, review of the police report, interviews with staff and observations, the facility failed to provide adequate supervision/intervention to prevent Resident #50's elopement from the facility. This affected one resident (#50) out of three reviewed for incidents. The census was 45. Findings Include: Review of the closed medical record for Resident #50 revealed the resident was admitted on [DATE] and discharged on 08/09/26. Diagnoses included Wernicke's encephalopathy, alcohol abuse, anxiety disorder, and dementia. Review of care plan initiated on 01/30/26 revealed Resident #50 was as risk for elopement and wore a security bracelet. Interventions included administer medications as ordered, check function of security bracelet and redirect as needed. On 08/08/26 a new intervention was to provide one-on-one (1:1) monitoring. Review of elopement evaluation dated 07/02/26 for Resident #50 revealed he wandered, he had a history of elopement or an attempted elopement while at home and he used a security bracelet. Risk for wandering/elopement was identified. Review of August 2026 orders revealed an order to check the security bracelet for placement and function each shift since 01/30/26, and for 1:1 care on 08/08/26 through 08/09/26. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 was cognitively impaired. He wandered one to three days a week. He required supervision for showering and toileting and was independent with walking. Review of progress note dated 07/31/26, timed at 4:31 P.M. and authored by Agency Licensed Practical Nurse (LPN) #300 revealed Resident #50 attempted to jump the fence in the patio area multiple times. He was not easily redirected and 1:1 was ineffective. He refused medications when offered. He verbalized nothing is wrong. He was observed pacing hallways. Medical Director (MD) #253 gave an order to pink slip the resident due to being a danger to himself. Emergency Medical Services (EMS) to be called. The next progress note dated 08/01/26, timed at 4:53 P.M. and authored by LPN #300 revealed Resident #50 was calm and there were no attempts to elope. The notes revealed no documentation as to why the resident was not pink slipped per orders. Review of the psychiatry progress note on 08/07/26 revealed Resident #50 appeared anxious and remained confused with a short attention span and periodic delusions. He had poor insight and had not been sleeping at night. Staff reported he continued with exit seeking behaviors, was found out in patio area attempting to elope by climbing on the wall. His sister was pursuing guardianship. Medications were added or adjusted. Continued review of progress notes revealed a note on 08/07/26 at 8:17 P.M. authored by Agency Registered Nurse (ARN) #305 where she was informed that Resident #50 ran away from the facility. Management and local authorities had been made aware, and messages were left for MD #253 and Resident #50's sister. A note on 08/08/26 at 11:28 A.M. by LPN #230 revealed Resident #50 was brought back to the facility by police as he had been missing since the day before. MD #253, the resident's sister and the Director of Nursing (DON) were made aware. A note on 08/09/26 at 12:24 P.M. by the DON revealed resident agreed to transfer to a sister facility. The resident's sister was aware and the resident was transported at that time. Review of SRI #278039 file revealed it included Resident #50's face sheet with demographics and diagnoses and a copy of an email confirmation of the submission for the SRI dated 08/14/26 at 6:05 P.M. by former Administrator #500. A brief description of the incident revealed staff responded to an alarm and the resident was able to leave the property due to staff being unable to reach him before leaving. The SRI noted The resident has returned safely with no injury and one-on-one monitoring. All initial assessments, education and audits are in place. The narrative of the investigation revealed at approximately 8:30 P.M. the resident exited the facility through the ambulance entrance door. The resident ran out of the facility down the side street. Immediately upon hearing the alarm, the staff had responded as evidenced by the staff seeing the resident running from the facility toward the side street. CNA #274 followed the resident but could not keep up with him. CNA #260 left in her vehicle to search for the resident. At 8:45 P.M. the local police department was notified of the missing resident; at 8:52 P.M., the DON was notified of the resident leaving facility; at 8:58 P.M., all department heads were notified of the resident leaving the facility; at 9:00 P.M., the resident's sister was notified of the resident leaving the facility by the floor nurse and social services. The facility conclusion found evidence was inconclusive of neglect. All staff were re-educated on elopement, and an elopement drill was implemented. Local police received the complaint and [NAME] were used to search for the resident. There were no witness statements in the file. Review of facility investigation revealed the following information and timeline of events from 08/07/26: -The resident was wearing a dark gray/blue shirt, jeans, baseball cap and tennis shoes.-The resident was last seen on 08/07/26 at 7:00 P.M. walking in the hallways.-At approximately 8:30 P.M., the resident exited the facility through the ambulance entrance door. The resident held down the bar on the door causing the door to alarm and open and the resident ran out of the facility down the side street. -Within one minute, nursing staff had responded to the ambulance door alarm going off. Upon searching for the cause of the door alarm, STNA (unnamed) noticed the resident running down the side street. STNA #274 followed the resident but could not keep up with him. STNA #260 left in her vehicle to search for the resident.-8:45 P.M., the local police department was notified of the missing resident.-8:52 P.M., the DON was notified by text message of the resident leaving facility. -8:58 P.M., all department heads were notified of the resident leaving the facility.-9:00 P.M., the resident's sister was notified.-9:30 P.M., the Social Service Designee (SSD) and DON arrive to the facility, the facility was searched.-9:45 P.M., calls were placed to both numbers listed in the chart for the resident. The home phone was not in service and the cell phone was shut off.-10:07 P.M., MD #253 was notified.-10:15 P.M., the Administrator, SSD, Maintenance Director and DON went out to search for the resident. The Dietary Manager stayed at the facility.-10:20 P.M., the DON searched via car on the main street as far as the local hospital toward the east and then about 0.5 miles west of the facility by local nightlife/bars/restaurants.-10:45 P.M., SSD searched all local bars in the vicinity. Spoke with multiple police officers giving them a picture of the resident.-11:35 P.M., two local police officers arrived at the facility. One was on the phone with a detective. They were trying to ping the resident's cell phone without success. They were also going to use a drone. The officers reported there was a report about two hours prior of a local homeowner who reported someone was in their yard, but resident was scared away. The homeowner was not aware of a missing resident.-11:53 P.M., department heads continue to search for the resident. Review of facility investigation revealed the following information and timeline of events from 08/08/26: -1:18 A.M., department heads returned to the facility.-1:25 A.M., calls were placed to two local hospitals. -2:10 A.M., the department heads left the facility for the night. Nursing staff were educated to call the DON if the resident returned to the facility.-7:29 A.M., Resident #50 was returned to the facility by police officers; he was assessed with no injuries.-7:35 A.M., Resident #50 was placed on 1:1 by the DON until further notice. Review of weather data revealed the weather in the 44303 zip code on 08/07/26 overnight into 08/08/26 was a low of 69 degrees with rain showers. Review of the police report dated 08/07/26 revealed the event occurrence time of 7:45 P.M. with reported time of 10:40 P.M. (the time the police came in to take report). It was listed as a missing person/runaway. The report read they interviewed ARN #305. She stated Resident #50 had left the facility and was missing. She gave his diagnoses. She stated he left at approximately 7:45 P.M. by leaving through the side door of the facility. She stated he had never run away before. The officer also spoke to Resident #50's sister who stated he had dementia and had never run away before. An addendum to the report dated and timed 08/08/26 at 7:28 A.M. revealed the officer was dispatched to a neighborhood address in reference to a burglary. Upon arrival, Resident #50 was in the driveway. The resident was cooperative and thought he was at his cousin's house. Review of Google maps revealed the walking distance from the facility's front door to the address police picked him up from was a six-minute walk from the facility's front door. It was believed the resident left from a side door which would be about a minute less. Interview on 08/25/26 at 10:06 A.M. with Certified Nursing Assistant (CNA) #274 revealed she worked from 7:00 P.M to 7:00 A.M. on 08/07/26. She saw Resident #50 walking down the back hallway. He was walking in a daze. She stated she never went outside of the building to follow Resident #50. She stated He left. Some people went out, but she could not recall who. CNA #274 stated people started asking have you seen him? She stated the last time she saw him was about 7:30 P.M. and stated I don't remember if they brought him back at all. CNA #274 stated she received training and participated in the elopement drill within days of the residents elopement. Interview on 08/25/26 at 3:00 P.M. with CNA #288 revealed he worked on 08/08/26 when Resident #50 was brought back to the facility by the police. Resident #50 stated he went to his cousin's, and police did not offer additional information. CNA #288 stated the resident did not have his security bracelet on as he was his own decision maker and could take it off. CNA #288 stated he received training after the elopement on the policy and participated in an elopement drill. Interview on 08/25/26 at 3:09 P.M. with CNA #260 stated Resident #50 was her resident on 08/07/26. She stated he was not doing well that whole week stating he was manic, pacing, talking to himself and answering himself. She stated he was not his normal self and she reported it. He did have an appointment at the facility with psychiatry and she mentioned him trying to elope from the patio area (smoking area) that week. CNA #260 stated she was working in a section that was closed off by the fire doors (the facility was on fire watch at this time), and because the doors were closed, she did not hear the door alarm which was down the hall and then down a small hall. She also said she was in a room with a resident. The CNA did not know he was gone until the DON texted her at 8:52 P.M. asking where he was. She stated she did not see that text until between 9:00-9:30 P.M. She stated once the DON came to the building, she went to go get coffee in her car and started looking for him while she was out but she did not know what happened after that. She stated CNA #274 would not have gone out to follow Resident #50 because of her age but also because she did not drive. CNA #260 stated we're not allowed to transport residents anyway. She stated the nurses continued their medication pass and were saying to the CNAs that they should not follow the resident because they were not allowed to transport residents. CNA #260 said somehow they knew he was not in the building. Maybe someone saw him leave. CNA #260 stated she received training on elopement after the incident. Interview on 08/25/26 at 3:21 P.M. with LPN #230 revealed she worked on 08/08/26 from 7:00 A.M. to 7:00 P.M. She stated during report they simply said Resident #50 was not there. She was there when the police brought back Resident #50 at 7:29 A.M. She stated he would not come into the building initially for the police, but when she came out, he was willing to go in. She stated he would not shower but that she tried to assess him when he changed his shoes and she did not see any wounds. LPN #230 stated she receieved education on elopements after incident. Interview on 08/25/26 at 5:28 P.M. with Resident #50's sister revealed she was not his guardian at the time of the incident but was awarded guardianship on 08/12/26. She stated the facility was aware he tried to escape and she stated I don't know why they weren't watching him. She stated she received a call by the former SSD #277 on 08/07/26 at approximately 9:00 P.M. asking if she had seen her brother. Resident #50's sister stated she lived in the neighborhood where the nursing home was. She stated she went out looking for him. SSD #277 told her they were looking in the area bars and staff were driving the neighborhood. Resident #50's sister went to the facility around 2:00 A.M. and found SSD #277 in an office with two other staff. She stated SSD #277 seemed surprised to see her as they had spoken only minutes before on the phone. They told her they just came back from searching. Resident #50's sister stated she learned from the police he was seen on a doorbell camera in the neighborhood as the house owner called police to report it. Resident #50's sister mentioned a concern with LPN #230 prior to the incident stating she was rude. She said when she was visiting her brother on 08/05/26, Resident #50 was running from his sister. LPN #230 made the comment I have a job to do, I'm not chasing him down for you. Continued interview with Resident #50's sister revealed the former Administrator #500 told her after the elopement that he's not staying here. Resident #50's sister stated to the Administrator she needed to contact the court first because of pending guardianship and the Administrator ignored her. She stated the facility went to ask Resident #50 if he was willing to move to another facility (their sister facility with a secured unit about an hour away) and he said yes. The staff told her he was his own person at the time. She had since moved him back to this county closer to her. She stated she was never made aware of the possibility of the pink slip on 07/31/26. She also stated he did not have a cousin in Akron as that was where he told staff he went overnight. Interview on 08/25/26 at 5:35 P.M. with ARN #305 revealed she worked on 08/07/26 from 7:00 P.M. to 7:00 A.M. and was Resident #50's nurse. She stated I don't know about an alarm going off as they always go off. She stated she called the police, the residents sister and management. ARN #305 stated Resident #50 was on an unauthorized leave of absence. She stated she did not know if anyone went after him but they looked inside. She believed Resident #50 was at the facility at the beginning of her shift. She said those residents do what they want there. It's not a secured unit. Surveyor stated Resident #50 had a security bracelet on and the nurse replied oh, offering nothing further. Interview on 08/25/26 at 5:41 P.M. with ALPN #300 revealed she worked on 07/31/26 and wrote the note about pink slip. She stated when EMS came to the facility, Resident #50 had significantly calmed down. MD #253 stated to pink slip him and texted over a form with his signature, but EMS could not take him because it was not filled out right. Resident #50 refused to go on his own. She verified there was no information in the progress notes about why he was not pink slipped. Observation on 08/25/26 at 6:20 P.M. of the street on the side of the facility revealed it went downhill and curved to the right at the bottom. There were two streets off of the side street, both leading to the street of the house Resident #50 was found at. It was in a residential neighborhood. Resident #50 would not have to cross any busy roads within this neighborhood however he was only about a block from a busier road which led to a high traffic road. Interview on 08/26/26 at 8:08 A.M. with the DON revealed she first learned about the elopement on 08/07/26 at 8:52 P.M. She stated she was halfway to the facility while having that conversation then started calling other management. It was a 15-minute drive. Per the investigation, the DON stated Resident #50 exited through the ambulance entrance which was in a small hallway that also led to her office, the smoking area and therapy gym. She stated he knew to push the door for 15 seconds so it would open even though he had a security bracelet on. She said he could read. The DON stated when she spoke to ARN #305 on phone on 08/07/26 about the elopement, ARN #305 stated Resident #50 was not deemed incompetent. DON reminded her he had a security bracelet and a pending guardianship. ARN #305 stated It was her (ARN #305) job to make sure he was safe and the DON responded with well, you're not making him safe. You have to go after him. The nurse did not respond to her. The DON stated ARN #305 would not be allowed to return to the facility. The DON stated Resident #50 was returned to the facility on [DATE] at 7:29 A.M. when police brought him back. The DON stated CNA #274 was the one who told her and the Regional Nurse that she followed Resident #50 out the door and saw him going toward the side street, which did not correlate with CNA #274's interview. The DON also stated she was unaware that the nurses told the aides not to follow Resident #50 outside since they were not allowed to transport him back. She stated they could keep an eye on him and call the police if needed. When specifically asked if there were staff witness statements, she stated she did not know if any witness statements were done stating it was a long night. She stated she led the investigation, not former Administrator #500. Interview on 08/26/26 at 3:30 P.M. with Regional Maintenance Director #310 revealed the alarms on the doors were not recorded and there was no way to see how long it was going off or at what times. Interview on 08/26/26 at 5:00 P.M. with the DON and review of witness statements provided approximately two hours after clarifying a second time there were not any witness statements, revealed four witness statements dated 08/07/26 but not timed, typed and signed by the DON. The DON stated she found them in the Administrator's office. CNA #260's statement to the DON revealed Resident #50 was not in his room. The DON let CNA #260 know that she was made aware he left the building. CNA #260 stated she was going to drive the neighborhood. The DON stated she was on her way in and CNA #260 said CNA #274 had followed Resident #50 going down the side street. After the DON arrived and while in the office, CNA #274 came to the door and stated it was a crazy night. She stated she tried to keep up with Resident #50 but couldn't (the DON did not clarify if that meant within the building or outside the building). The witness statement to the DON by CNA #271 revealed she was providing care for another resident. She did a head count afterwards and she stayed at the facility. The witness statement to the DON by LPN #249 revealed he was not aware the resident had left the building as he was passing medications in the back hallway. He stated he called 911 immediately when he found out. The witness statement to the DON by CNA #274 read while sitting in the Administrator's office making phone calls and assigning staff tasks, CNA #274 came to the door and stated it had been a crazy night. She stated she had responded to the ambulance door alarming and saw Resident #50 running down the side street. She stated she tried to catch up with him, but she could not. The witness statement to the DON by ARN #305 revealed she last saw the resident at 7:00 P.M. walking down the hallway. ARN #305 stated the resident was able to make his own decisions and could leave when he wanted, that he had not been deemed incompetent. The DON informed ARN #305 the resident was going to a court hearing to determine guardianship and had an Expert Evaluation (a form used to apply for guardianship where a licensed professional, typically a medical doctor or a psychiatrist, completes it with their input on if a person needs a guardian or not) completed. The DON also educated ARN #305 that Resident #50 was an elopement risk and had a security bracelet on. ARN #305 stated she could not force him to stay in the building, and it was his right to leave. The DON stated she would not allow ARN #305 to return to the building. The DON said the facility was not aware of where Resident #50 was from 7:45 P.M. until 7:29 A.M. the next day and there was no statement from Resident #50. Review of the binder of facility's abatement plan regarding elopement revealed it included the timeline of events, root cause analysis, staff education on the elopement policy, weekly elopement drills, audits of all residents assessing elopement risks and updated care plans, testing of security bracelets and alarmed doors. It did not include any witness statements. There was staff education on 08/08/26 during ad-hoc QAPI meeting by the Administrator which revealed it was the responsibility of all staff to immediately respond to door alarms when triggered. It was staff's obligation to locate the alarming door then proceed to determine whether a resident had made an unauthorized exit. If an unauthorized exit was determined, staff were to proceed to follow the wandering and elopement policy. Review of root cause analysis on 08/08/26 by former Administrator #500, the DON, nurses, maintenance and the regional team members revealed they identified Resident #50 as someone who smoked which may have contributed to the situation as the exit door was near the patio door for smoking. They believed the resident wanted to go outside, he was able to read the door handle, and he was fast enough to elude staff. Review of the facility policy titled Wandering and Elopements, last revised on 04/2026, revealed the facility would identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wanderings, elopement or other safety issue, the resident's interventions will be implemented to maintain the resident's safety. If an employee observed a resident leaving the premises, they should attempt to prevent the resident from leaving in a courteous manner, get help from other staff and instruct another staff member to inform charge nurse or DON that the resident is attempting to leave or has left the premises. The deficient practice was corrected on 08/09/26 when the facility implemented the following corrective actions: -On 08/07/26, the Maintenance Director evaluated all exit doors to ensure alarms and security bracelets were functioning appropriately.-On 08/08/26, the root cause analysis was completed.-On 08/08/26 at 7:45 A.M., Resident #50 was assessed for injury by the charge nurse.-On 08/08/26, Resident #50 was placed on one-on-one monitoring-On 08/08/26, Resident #50's care plan was updated.-On 08/08/26, nursing updated the psychiatric provider.-On 08/08/26, Resident #50 was provided with increased opportunities to walk outside supervised with staff through activities.-On 08/08/26, visual cues were placed on the door where Resident #50 exited to indicate it was not the smoking area.-On 08/08/26 at 12:00 P.M., Minimum Data Set (MDS) Nurse #252 identified other residents at risk and all were re-assessed for elopement risk.-On 08/08/26, MDS Nurse #252 reviewed care plans for appropriate interventions of all residents at risk of elopement.-On 08/08/26, the DON re-evaluated all residents with security bracelets and functionality of the bracelet.-On 08/08/26, the Maintenance Director evaluated all exit doors to ensure alarms and security bracelets were functioning appropriately.-On 08/08/26 at 12:00 P.M., the Maintenance Director, Administrator and DON checked all doors in the facility for magnetic lock and alarm function which included four doors on skilled nursing unit.-On 08/08/26 at 4:00 P.M., the Administrator held an ad hoc QAPI meeting with all department heads (maintenance, activity director, social services, therapy, human resource (HR), business office manager housekeeping director, and medical director). They reviewed the plan to correct the incident and education on elopement and wandering policy.-On 08/08/26 beginning at 4:30 P.M., the Administrator, HR, scheduler and DON educated all staff on the elopement/wandering policy. Education was provided in person, via text, through the scheduling system and through phone calls.-On 08/08/26 at 5:00 P.M., the DON and Administrator conducted an elopement drill which resulted in no concerns.-On 08/08/26 at 5:15 P.M., HR provided education to the staffing agency to be provided to any agency staff to receive prior to working at the facility. This deficiency represents non-compliance investigated under Complaint Number 3171645.

Based on observation, interviews, record review, and policy review, the facility failed to ensure residents received timely incontinence care. This resulted in Actual Harm on 07/13/26 when Resident #6 was incontinent of urine and bowel and required staff dependence for toileting and hygiene services, went approximately 12 hours without receiving incontinence care and developed two wounds on her buttocks. This affected one resident (Resident #6) of three reviewed for incontinence. The facility census was 48.Findings Include:Review of the medical record for Resident #6 revealed an admission date 02/21/26. Diagnoses included malignant neoplasm of the unspecified part of right bronchus or lung, hypertensive heart disease with heart failure, and chronic pain and was receiving hospice services. Resident #6 was her own responsible party.Review of Resident #6's physician orders dated 02/22/26 was to apply house barrier cream topically to groin, bilateral buttocks or other needed areas with episodes of incontinence for skin prevention.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was moderately cognitive impairment. She was always incontinent of bowels and bladder and utilized a wheelchair.Review of the Functional Abilities assessment dated [DATE] revealed Resident #6 was dependent upon staff for toilet hygiene and toilet transfers. Review of the care plan dated 03/19/26 revealed Resident #6 was at risk and had an activity of daily living (ADL) self-performance deficit related to conditioning and weakness with disease progression and it noted an ADL decline was expected. Interventions for toileting hygiene stated the resident was able to perform toileting hygiene but required partial to moderate assistance. Resident #6 was able to complete personal hygiene but required substantial to maximal assistance. Review of the Point of Care documentation under tasks revealed the last documented evidence that incontinence care was completed for Resident #6 was on 07/12/26 at 9:37 P.M.Review of Resident #6's behavior documentation revealed from 07/02/26 through 07/15/26 she had no behaviors documented, including refusals of care.During an observation on 07/13/26 at 10:49 A.M., Resident #6 was up in her power wheelchair. Her incontinence pad was lying on her bed and was soiled with dry feces. Resident #6 was tearful. There was a strong odor of urine and feces in her room.During an interview on 07/13/26 at 10:49 A.M., Resident #6 tearfully explained that no one would change her. When she asked, they ignored her or told her that her aide was coming, but they would not come in. She said she felt like her bottom was broke with a rash that was killing me. She said she had been in the same incontinence brief for 12 hours. During an observation on 07/13/26 at 11:10 A.M., Certified Nursing Assistant (CNA) #385 asked Resident #6 if she had a bowel movement. He assisted her onto bed and laid her on her on the visibly soiled incontinence pad. When he removed Resident #6's incontinence brief, it was full of urine and feces. Resident #6 said at that time her buttocks were very sore and she felt like they were open. Upon observation she had two open wounds on her left buttocks that were pink in color with the first layer of skin removed. The areas appeared round and half the size of a dime.During an interview on 07/13/26 at 11:28 A.M., CNA #385 stated he was assigned to the hall Resident #6 was on. He usually waited for her to call for him before he went in. His shift started at 7:00 A.M. and this was the first time he checked on Resident #6 this day. He verified the soiled incontinence pad that smelled of urine was in the room and verified the heavily soiled incontinence brief.During an interview on 07/13/26 at 11:40 A.M., Licensure Practical Nurse (LPN) #250 verified the odor of urine in Resident #6's room. The new skin area was reported to LPN #250 at this time. She said she would assess the area. She said it was her expectation that staff should check Resident #6 for incontinence every two hours.Review of Resident #6's medical record revealed no documented evidence that a comprehensive initial wound assessment of the buttocks wound was completed on 07/13/26.Review of the progress notes revealed a late entry dated 07/15/26 at 10:19 A.M. by LPN # 250 that documented Resident #6 had superficial discoloration and chaffing to her inner bilateral buttocks. Incontinence cream was applied to the area. A message was left with hospice services, the wound nurse was notified and the resident was aware. The progress notes revealed no documented evidence of the wound measurements, drainage information, or wound descriptions.During an interview on 07/15/26 at 10:11 A.M., Hospice Registered Nurse (RN) #400 revealed she recently requested a care conference with the facility related to concerns she had with the quality of care and treatment Resident #6 was receiving. Hospice RN #400 stated Resident #6 had concerns with not timely receiving incontinence care. Hospice RN #400 also stated she had been in several times to find the resident in soiled incontinence briefs. She has not seen many changes from the care conference regarding her care concerns. Hospice RN #400 stated Resident #6 had a slow decline and was now fully dependent on incontinence care. She stated she was not notified of the new area to the resident's left buttocks. She visited Resident #6 today but did not look at the area because she didn't know about it.During an interview on 07/15/26 at 11:35 A.M., Assistant Director of Nursing (ADON) #216 stated Resident #6's hospice nurse requested a care conference on 06/24/26. She stated she was present at the conference, and she verified that concerns related to timely incontinence care were brought up. At this time, Resident #6 had also requested that CNA #385 no longer provide care for her, and she was afraid to ask for help due to the way staff treated her at times. ADON #216 verified she did not document in the medical record that the care conference took place. She said social services usually did that, but they did not have someone in that position at the time of the meeting. ADON #216 stated she relayed all the information to the Director of Nursing (DON) in a text message. She was unsure if the DON addressed the concerns.During an interview on 07/16/26 at 9:03 A.M., LPN #401 stated she was the wound nurse for the facility. She was not made aware of the new skin area on Resident #6 until 07/15/26 and had not yet had a chance to assess it herself.During an interview on 07/20/26 at 11:30 A.M., the DON stated she denied ever being made aware of the concerns from Resident #6's care conference. She said Resident #6 should have been provided with incontinence care every two hours, which is best practice and confirmed documentation showed she went over 12 hours without receiving documented incontinence care resulting in wounds. Additionally, the DON confirmed that the facility did not document the assessment regarding the area until two days after it was found and the assessment of the wound was not documented comprehensively.Review of the facility policy titled, Activities of Daily Living (ADLS) last reviewed 04/28/25 revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care), mobility (transfer and ambulation, including walking), elimination (toileting, incontinence care), dining (meals and snacks), communication (speech, language, and any functional communication systems), and bed mobility (turning, repositioning in bed) which is encouraged to the resident at least every two hours or as requested by resident. It also noted that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Numbers 3054313, 3006983, 2961251 and 2740378.

Based on record review, observation, interview, manufacturer guidelines, and facility policy review, the facility failed to ensure medications were securely stored and Tuberculin solution was dated when opened for use. This deficient practice had the potential to affect all residents residing in the facility. The facility census was 48.Findings Include:1) Review of Resident #8's medical record revealed admission date 10/14/25 and hospitalization date 07/09/26 with diagnoses including but not limited to Alzheimer's Disease, type two diabetes, heart failure, high blood pressure, depression and anxiety.Review of Resident #8's Self-Administration of Medication assessment dated [DATE] revealed Resident #8 required assistance with medication administration and was not approved to be self-administering medications.Observation on 07/14/26 at 7:54 A.M. revealed Resident #8's room door was open with multiple over the counter medication containers including Imodium, Aspirin, and Iron and three prescription bottles with several pills in each container sitting on the dresser beside the bed. Resident #8 is currently hospitalized .Interview on 07/14/26 at 8:00 A.M. with Licensed Practical Nurse (LPN) #502 verified the multiple medication containers sitting on the dresser in Resident #8's room. LPN #502 stated Resident #8 doesn't take most of the medications observed in her room.Review of the facility's policy titled Medication Storage dated 03/2026 revealed all drugs and biologicals will be stored in locked compartments under proper temperature controls.2) Observation on 07/14/26 at 11:14 A.M. revealed a vial of open Tubersol Tuberculin (TB) Solution in the door of the medication refrigerator. The vial was half full and was not in the original package and had no open date noted.Interview on 07/14/26 at 11:23 A.M. with LPN #250 verified the open vial of TB solution with no date and not in the original package. LPN #250 stated the vial should have been kept in the original package and should have been dated when opened to be used.Review of the manufacturer's guideline for Tubersol Tuberculin Solution revealed a vial of Tubersol which has been entered and in use for 30 days should be discarded.

Based on observation, staff interviews, and policy review, the facility did not ensure the kitchen and equipment were clean and sanitary. This had the potential to affect all residents. Facility census was 48. Findings include: Initial tour of the kitchen on 07/13/26 from 8:27 A.M. to 8:56 A.M. with Dietary Director #303 revealed the ice machine sanitation log was last completed on 06/16/26. Review of the temperature logs for the walk-in cooler and freezer revealed temperatures were last recorded on 06/30/26. Surveyor observed water pooling on the floor adjacent to the right side of the steam table which Dietary Supervisor #331 reported the water continued to pool on the floor even after mopping and believed the water came from the actual floor and not a floor drain. A dark substance that resembled mold was observed on the backsplash to on the left side of the three compartments sink as well as the wall behind the dishwasher which Dietary Supervisor #331 reported had been there for years. The floor under the dishwasher was visibly dirty with dirt and grime. Dietary Director #303 was unable to check the chemical sanitation level of the low temperature dishwasher due to not having test strips. All findings were verified by Dietary Director #303 and Dietary Supervisor #331 at the time of the observations.Observation on 07/14/26 at 8:40 A.M. revealed water pooled on the floor adjacent to the right side of the steam table. Dietary Director #303 located test strips to test the chemical sanitation levels in the dishwasher however the Hydrion Chloride test strips expired 07/01/26.Observation on 07/15/26 at 8:40 A.M. again revealed water pooled on the floor adjacent to the right side of the steam table. Interview and observation on 07/15/26 at 10:38 A.M with Corporate Maintenance Director #402 revealed estimate was obtained to repair the pooled water in the kitchen however it required digging up that area. No estimates were provided. When asked about the mold-like substance behind the dishwasher and on the backsplash Corporate Maintenance Director #402 reported it was dirt and not mold.Dining observation on 07/16/26 from 8:35 A.M. to 8:57 A.M. revealed residents were eating breakfast from Styrofoam to go containers. Interview on 07/16/26 at 9:01 A.M. with [NAME] #218 revealed the chemical sanitation in three compartment sink was not sanitizing dishes and was not being repaired until 07/22/26. Interview on 07/16/26 at 9:03 A.M. revealed Dietary Director #303 still had not obtained test strips for the dishwasher. Review of the Sanitation Policy dated 08/01/23 revealed the food service area should be maintained in a clean and sanitary manner and all kitchen, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. Review of the Food Storage Policy dated 08/12/23 revealed the internal air temperature of the refrigerator and freezer must be checked and recorded twice daily and logged.

Based on observation and interview, the facility failed to maintain access to the exit door and failed to maintain access to the fire extinguisher and the fire pull station in the back hallway. This had the potential to affect all residents residing in the facility. The facility census was 48.Findings Include:Observation on 07/15/26 at 7:36 A.M. revealed in the back hallway, where rooms 17 to 22 were located, there were two beds stored end to end on the left side of the hallway up against the wall. A manual wheelchair was located at the end of the second bed directly in front of the exit door, the fire pull station and the fire extinguisher box. There was approximately two-foot distance from the end of the second bed to the exit door and the fire pull station and fire extinguisher box was to accessible.Interview on 07/15/26 at 7:45 A.M. with Registered Nurse (RN) #510 verified the two beds and the manual wheelchair were blocking the exit door, the fire pull station and the fire extinguisher box. RN #510 stated I would find away to get the residents out in cause of evacuation.Interview on 07/15/26 at 12:02 P.M. with Maintenance Director (MD) #252 verified the two beds were still blocking the exit door. There was no manual wheelchair blocking the fire pull station or the fire extinguisher box. The Maintenance Director #252 stated the staff know better than to block the exit doors with medical equipment. These beds were not here the day before; someone must have moved them out overnight.This deficiency represent noncompliance investigated under Complaint Numbers 3006766 and 2961251.

Based on record review, review of census documentation, interview, observations, and policy review, the facility failed to ensure Resident #32's room was clean and homelike. Additionally, the facility failed to ensure reasonable care for the protection of the resident's property when Resident #11's dentures were lost during a room change. This affected two residents (#11 and #32) out of two residents reviewed for resident rights. Facility census was 48. Findings Include: 1. Record review revealed Resident #32 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, diabetes mellitus due to underlying condition with diabetic neuropathy, hyperlipidemia, and other seizures. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact, used a walker or wheelchair for mobility, required moderate assistance with toileting hygiene, showers, dressing lower body, putting on/taking off footwear, personal hygiene, and supervision for all transfers. Interview on 07/20/26 from 10:45 A.M. with Housekeeping Director #246 revealed there were two housekeepers on weekdays and one housekeeper on weekends, so rooms were to be cleaned daily. Observation during the interview with Housekeeping Director #246 revealed Resident #32's room was infested with gnats, had two plastic containers that contained food residue which sat on top of the air conditioning unit, wet clothing stuffed under the left side of the air conditioning unit which Housekeeping Director #246 reported Resident #32 used to soak up leaking water from the unit, and an overflowing garbage bag of dirty laundry which sat on the floor next to the air conditioning unit. Housekeeping Director #246 confirmed the observations. Review of the Environmental Services Inspection Policy dated August 2025 revealed it was the facility's policy to regularly monitor environmental services to ensure the facility was maintained in a safe and sanitary manner and assessed on a regular basis. 2. Review of Resident #11's medical record reveal admission date 11/25/25 with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), cocaine use, and anxiety. Review of Resident #11's physician orders revealed a diet order dated 11/25/25 for a regular diet, regular texture, thin liquids. Review of Resident #11's census documentation dated 03/04/26 revealed Resident #11 had moved from room [ROOM NUMBER] to room [ROOM NUMBER]. Review of Resident #11's quarterly [NAME] Data Set (MDS) assessment dated [DATE] revealed Resident #11 had moderately impaired cognition with a brief interview of mental status (BIMS) score of 13 out of 15, and no use of dentures or oral pain were marked. Observation on 07/14/26 at 2:39 P.M. revealed Resident #11 had no natural teeth or dentures. Interview on 07/14/26 at 2:40 P.M. with Resident #11 revealed during a room move in March 2026 the facility lost Resident #11's dentures. Resident #11 stated the facility was aware of the lost dentures. Resident #11 had a community dentist appointment on 06/06/26 for denture replacement requiring Resident #11 to pay for the replacement dentures. Resident #11 did not have the financial means to pay for the dentures. Interview on 07/14/26 at 3:30 P.M. with the Director of Nursing (DON) verified Resident #11's dentures were lost during the room move on 03/04/26 and the facility had not assisted Resident #11 in replacing the lost dentures. The DON stated Resident #11 had a dentist appointment scheduled for 07/15/26 for Resident #11 to begin the process of replacing the dentures and the facility would be paying for the replacement set of dentures. This deficiency represent noncompliance investigated under Complaint Numbers 3074566, 3054313, 3043947, 3006766, 2961251, 2747089, and 2740378.

Based on observation, interview, record review, and policy review, the facility failed to ensure ice water was offered routinely and at the frequency of resident requests for Resident #6, #12, and #30. This affected three residents (#6, #12, and #30) out of three residents reviewed for hydration. The facility also failed to ensure Resident #64 had routine meal intakes documented. This affected one resident (#64) out of four residents reviewed for dietary services. The facility census was 48.Findings Include: 1. Record review revealed Resident #64 was admitted on [DATE] with diagnoses of type I diabetes mellitus with diabetic neuropathy, chronic kidney disease stage III, protein calorie malnutrition, and hyperlipidemia. Review of the care plan initiated on 01/11/26 revealed one of Resident #64's diabetes interventions included monitoring for compliance with diet and documenting any problems. Review of the nutrition intake record for May 2026 revealed no meal intake was recorded for breakfast, lunch, and dinner on 05/02/26, 05/03/26, 05/07/26, 05/08/26, 05/09/26, 05/23/26, 05/24/26, 05/25/26, 05/26/26, 05/28/26, 05/29/26, 05/30/26, and 05/31/26. Review of the nutrition intake record for June 2026 revealed no meal intake was recorded for breakfast, lunch, and dinner on 06/01/26, 06/02/26, and 06/03/26. Interview on 07/16/26 at 3:40 P.M. with Regional Director of Clinical Operations #450 confirmed that meals were not recorded on the aforementioned dates. 2. Review of the medical record for Resident #6 revealed an admission date of 02/21/26. Diagnoses included but were not limited to malignant neoplasm of the unspecified part of right bronchus or lung, hypertensive heart disease with heart failure, and chronic pain. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The resident utilized a motorized wheelchair for mobility. Review of Resident #6's 06/29/26 care plan revealed she had an increased risk for constipation related to medication side effects. An intervention included to encourage the resident to drink fluids. The resident also had a care plan stating the resident was at risk for bowel and bladder incontinence, skin impairment and infection with an intervention to encourage fluids during the day to promote prompted voiding responses. Review of Resident #6's fluid intakes recorded in the plan of care documentation revealed from 07/08/26 until 07/15/26, the resident received 240 to 260 milliliters of fluid a day. Observation on 07/13/26 at 10:49 A.M. revealed an empty Styrofoam cup in Resident #6's room dated 07/11/26. Interview on 07/13/26 at 10:49 A.M. with Resident #6 stated the facility did not pass fresh water or ice. She stated she had to request it and sometimes it came and sometimes it didn't. Interview on 07/13/26 at 11:28 A.M. with Certified Nursing Assistant (CNA) #385 confirmed the empty Styrofoam cup in Resident #6's room dated 07/11/26. 3. Review of the medical record for Resident #12 revealed an admission date of 02/21/26. Diagnoses included but were not limited to diabetes mellitus type two, psychoactive substance abuse, chronic idiopathic constipation, anxiety disorder, fibromyalgia, bipolar disorder, and abnormalities of gait and mobility. Review of Resident 12's quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of13, which indicated the resident was cognitively intact. Review of Resident #12's care plan dated 06/09/26 revealed the resident had a history of occasional bowel and bladder incontinence with an intervention to encourage fluids during the day to promote prompted voiding responses. The resident was noted to also have an increased risk for constipation related to decreased mobility and a history of constipation with an intervention to encourage the resident to drink fluids. Interview on 07/13/26 at 2:29 P.M. with Resident #12 revealed staff did not offer or pass water to the residents. They were required to get it themselves. She revealed that yesterday (07/12/26) she asked Dietary Aide (DA) #325 for a cup of water and she said why the [expletive] are you knocking on this door. Don't knock [expletive] on this door and refused to give her water. Interview on 07/15/26 at 2:37 P.M. with [NAME] #319 revealed on 07/12/26, they were short staffed for dinner, and it was just him and DA #325 working. He stated DA #325 was yelling and was really upset. He told her to get ahold of herself, but she couldn't. She was yelling at the residents. He verified he did not see her obtain water for Resident #12. 4. Review of Resident #30's medical record revealed admission date of 06/11/24 with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), type two diabetes, and depression. Review of Resident #30's physician orders revealed an order dated 03/13/25 for increasing oral water intake up to 6 to 8 cups per day. Review of Resident #30's quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #30 had intact cognition with a brief interview mental status (BIMS) score of 13 out of 15, the resident had no difficulty with swallowing or choking and used a wheelchair for mobility. Observation on 07/14/26 at 10:33 A.M. revealed the utility room had a sign on the utility door reading, Staff Only. The room contained a cart with an empty ice chest and beside the ice chest there was a medium sized insulated water cooler half-filled with ice. Further observations on 07/13/26 and 07/14/26 revealed the cart was never outside the utility room with staff passing fresh ice and water. Observation on 07/14/26 at 10:41 A.M. revealed a half-filled Styrofoam cup of warm water sitting on Resident #30's bedside table dated 07/13/26 at 7:00 P.M. Interview on 07/14/26 at 11:00 A.M. with Registered Nurse (RN) #510 verified the half-filled Styrofoam cup of warm water sitting on Resident #30's bedside table. RN #510 stated night shift changed out the cups and filled them with fresh ice water. RN #510 stated it looked like she hasn't gotten any fresh ice water since last night. Interview on 07/14/26 at 4:08 P.M. with Certified Nursing Assistant (CNA) #385 verified the facility did not pass fresh ice water during shifts because the residents that were mobile came to the nurse's desk and asked for fresh ice water. Interview on 07/15/26 at 9:11 A.M. with the Director of Nursing (DON) stated her expectation was for staff to pass ice water each shift. She stated staff should be passing the ice water and not waiting for residents to ask. Review of the facility's policy titled Hydration/Fresh Water and Fluids dated 01/2020 revealed CNAs will provide fresh ice water to residents each shift. This deficiency represents non-compliance investigated under Master Complaint Number 3104157 and Complaint Numbers 3074566, 3054313, 3006766, 3006983, and 2740378.

Based on observation, interviews, medical record review, and policy review, the facility failed to ensure residents had the right to a dignified existence and self-determination, when care concerns were not documented and appropriately addressed. This affected one out resident (#6) out of one resident reviewed for care conferences. Additionally, the facility failed to ensure Resident #15 received breakfast daily. This affected one (#15) of three residents reviewed for meals. The facility census was 48.Findings include:1. Record review revealed Resident #15 was admitted [DATE] with diagnoses of end stage renal disease, chronic obstructive pulmonary disease, cirrhosis of liver, heart failure, and ventricular fibrillation. Review of the physician orders revealed Resident #15 had dialysis on Monday, Wednesday, and Friday with a pickup time of 6:30 A.M. Interviews with Resident #15 on 07/13/26 at 1:33 P.M. and 07/20/26 at 2:37 P.M. revealed she did not receive breakfast before dialysis on 07/13/26, 07/17/26, and 07/20/26.Interview on 07/14/26 at 8:51A.M. with Dietary Supervisor #331 revealed she was unaware Resident #13 went to dialysis because no one informed her. Dietary Supervisor #331 reported she sent breakfast trays at the regular scheduled time and confirmed it was not before dialysis. Interview on 07/20/26 at 2:40 P.M. with Dietary Director #303 confirmed Resident #13 did not receive a breakfast tray before dialysis on 07/17/26. Interview on 07/20/2026 3:23 P.M. with Dietary Director #303 confirmed Resident #13 did not receive a breakfast tray the morning of 07/20/26. Dietary Director #303 explained that kitchen staff prepared it however the aides never picked it up. Kitchen staff were advised to deliver the tray to Resident #13 if no one picked it up moving forward. Review of the Meal and Snack Hours and Frequency Policy dated 08/15/1923 revealed the facility provided three meals daily at regular times comparable to normal mealtimes in the community.2. Review of the medical record for Resident #6 revealed an admission date of 02/21/26. Diagnoses included but were not limited to malignant neoplasm of the unspecified part of right bronchus or lung, hypertensive heart disease with heart failure, and chronic pain. Review of Resident #6's care plan dated 03/19/26 revealed the resident was at risk and had an activity of daily living (ADL) self-performance deficit related to conditioning and weakness with disease progression. It noted the ADL decline was expected. Interventions for toileting hygiene stated the resident was able to perform toileting hygiene but required partial to moderate assistance and the resident was able to complete personal hygiene but required substantial to maximal assistance. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIM) score of 12 indicating moderate cognitive impairment. The MDS assessment also revealed the resident was always incontinent of bowel and bladder and utilized a wheelchair.Review of Resident #6's Functional Abilities assessment dated [DATE] revealed the resident was dependent for toileting hygiene and dependent for toilet transfers. Review of Resident #6's weekly wound assessment dated [DATE] revealed the resident had a left lateral leg trauma with a length of 7 centimeters (cm) width of 3.5 cm and a depth of 0.1 cm. The wound was noted to be declining.Review of the Point of Care documentation under tasks revealed the last documented evidence that incontinence care was completed for Resident #6 was on 07/12/26 at 9:37 P.M.During an observation on 07/13/26 at 10:49 A.M., Resident #6 was up in her power wheelchair. Her incontinence pad was lying on her bed and was soiled with dry feces. Resident #6 was tearful. There was a strong odor of urine and feces in her room.During an interview on 07/13/26 at 10:49 A.M., Resident #6 tearfully explained that no one would change her. When she asked, they ignored her or told her that her aide was coming, but they would not come in. She said she felt like her bottom was broke with a rash that was killing me. She said she had been in the same incontinence brief for 12 hours. During an observation on 07/13/26 at 11:10 A.M., Certified Nursing Assistant (CNA) #385 asked Resident #6 if she had a bowel movement. He assisted her onto bed and laid her on her on the visibly soiled incontinence pad. When he removed Resident #6's incontinence brief, it was full of urine and feces. Resident #6 said at that time her buttocks were very sore and she felt like they were open. Upon observation she had two open wounds on her left buttocks that were pink in color with the first layer of skin removed. The areas appeared round and half the size of a dime.During an interview on 07/13/26 at 11:28 A.M., CNA #385 stated he was assigned to the hall Resident #6 was on. He usually waited for her to call for him before he went in. His shift started at 7:00 A.M. and this was the first time he checked on Resident #6 this day. He verified the soiled incontinence pad that smelled of urine was in the room and verified the heavily soiled incontinence brief.During an interview on 07/16/26 at 9:03 A.M., LPN #401 stated she was the wound nurse for the facility. She verified that she did not believe wound care was being completed as ordered for the resident. She stated she would find bandages on the resident that were dated several days prior. She stated the nurses were documenting in the treatment record that they were completing the treatment, but they were not. During an interview on 07/15/26 at 10:11 A.M. with Hospice Registered Nurse (RN) #400 revealed she recently requested a care conference with the facility related to concerns she had with the quality of care and treatment Resident #6 was receiving. Hospice RN #400 stated Resident #6 had concerns with not timely receiving incontinence care and wound care. Hospice RN #400 also stated she had been in several times to find the resident in soiled incontinence briefs. She went on to say she had not seen many changes from the care conference regarding her care concerns.During an interview on 07/15/26 at 11:35 A.M., Assistant Director of Nursing (ADON) #216 stated Resident #6's hospice nurse requested a care conference on 06/24/26. She stated she was present at the conference, and she verified that concerns related to timely incontinence care were brought up. At this time, Resident #6 had also requested that CNA #385 no longer provide care for her, and she was afraid to ask for help due to the way staff treated her at times. ADON #216 confirmed CNA #385 had previously been told to work a different hall, but ADON #216 didn't realize he was still taking care of Resident #6. She verified CNA #385 was caring for and completed incontinence care for Resident #6 on 07/13/26. ADON #216 also verified she did not document in the medical record that the care conference took place. She said social services usually did that, but they did not have someone in that position at the time of the meeting. ADON #216 stated she relayed all the information to the Director of Nursing (DON) in a text message. She was unsure if the DON addressed the concerns.Continued review of Resident #6's medical record revealed no evidence that the facility held a care conference or documented the concerns or resolution attempts from her care conference meeting.Interview on 07/20/26 at 11:30 A.M. with the DON denied ever being made aware of the concerns from Resident #6's care conference and therefore had not addressed the issues discussed.This deficiency represents noncompliance investigated under Complaint Numbers 3054313 and 2740226.

Based on observation, interview, record review, review of facility self reported incidents, review of witness statements, and policy review, the facility failed to ensure Resident #12 was free from verbal abuse. This affected one resident (#12) out of five residents reviewed for abuse. The facility census was 48.Findings Include: Review of the medical record for Resident #12 revealed an admission date of 02/21/26. Diagnoses included but were not limited to diabetes mellitus type two, psychoactive substance abuse, chronic idiopathic constipation, anxiety disorder, fibromyalgia, bipolar disorder, and abnormalities of gait and mobility.Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact.Interview on 07/13/26 at 2:29 P.M. with Resident #12 revealed that yesterday (07/12/26) she asked Dietary Aide (DA) #325 for a cup of water and she said why the [expletive] are you knocking on this door. Don't knock [expletive] on this door and refused to give her water. She felt like the interaction was verbally abusive to her. She stated she reported it to Dietary Director #323 who stated she was going to look into it. She stated she made the report this morning after breakfast. Interview on 07/13/26 at 2:40 P.M. with Dietary Director #323 revealed Resident #12 came to her around 8:00 A.M. and stated DA #325 cursed at her. Dietary Director #323 told the resident she would follow up with her, but she had not had a chance to yet.Interview on 07/13/26 at 2:49 P.M. with the Administrator revealed Dietary Director #323 just now reported the incident, and she would complete an investigation and suspend DA #325 who was not at work today.Review of the Self-Reported Incident #276901 dated 07/13/26 and timed 3:38 P.M. revealed on 07/13/26, at around 11:45 A.M., Dietary Director #323 and the Director of Nursing (DON) notified this writer (the Administrator) that Resident #12 verbalized to them that on the weekend of 07/11/26 and 07/12/26, when she went to the kitchen to get water and a sandwich, the dietary aide [DA #325] swore at her and refused to accommodate her request. The investigation noted Not a single employee reported concerns regarding rude behavior or denying resident food or water, and the allegation of verbal abuse was unsubstantiated. Review of [NAME] #319's witness statement dated 07/13/26 revealed the kitchen was understaffed and they were overwhelmed. He noted DA #325 was cursing and slamming things. He kept trying to get her to calm down and nothing was working. At one point she went into the kitchen and told him that Resident #12 was talking about writing a bad review on the facility. [NAME] #319 asked Resident #12 what was wrong and she said she didn't give a [expletive]. He asked her if she was complaining about the food and if he could fix something else for her. She said she didn't know, but DA #325 was definitely cursing and conducting herself out of line.Interview on 07/15/26 at 2:37 P.M. with [NAME] #319 revealed on 07/12/26, they were short staffed for dinner, and it was just him and DA #325 working. He stated DA #325 was yelling and was really upset. He told her to get ahold of herself, but she couldn't. He stated she was yelling at the residents, he heard her yell Go away [racial slur] twice. He also heard her yelling [expletive] these mother [expletive]. He verified he knew the residents heard her and felt like she was being verbally abusive to them the way she was screaming and yelling. He went on to say she had a temper but, on this day, it was the worst he had ever seen. He also verified he did not see her obtain water for Resident #12.Follow up interview and observation on 07/15/26 at 3:29 P.M. with Resident #12 revealed on 07/12/26 she heard DA #325 say things like you all [racial slur] need to stop asking for [expletive] and you all [racial slur] get on my nerves, and I'm only here to collect unemployment. Resident #12 was observed as an African American. Interview on 07/22/26 at 9:12 A.M. with the Administrator revealed DA #325 was also African American. Review of the facility's policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 10/2025 revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Misappropriation of Resident Property, Exploitation or Mistreatment, including Injuries of Unknown Source, in accordance with this policy and to ensure that all individuals who report such incidents and allegations are free from retaliation or reprisal for reporting the incident. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology, such as through the use of photographs and recording devices to demean or humiliate a resident. This deficiency represents non-compliance investigated under Complaint Numbers 3006766 and 3006983.

Based on observation, interview, record review, review of Self-Reported Incidents, review of witness statements, and policy review, the facility failed to ensure an allegation of abuse was reported timely. This affected one resident (#12) out of five residents reviewed for abuse. The facility census was 48.Findings Include: Review of the medical record for Resident #12 revealed an admission date of 02/21/26. Diagnoses included but were not limited to diabetes mellitus type two, psychoactive substance abuse, chronic idiopathic constipation, anxiety disorder, fibromyalgia, bipolar disorder, and abnormalities of gait and mobility.Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact.Interview on 07/13/26 at 2:29 P.M. with Resident #12 revealed that yesterday (07/12/26) she asked Dietary Aide (DA) #325 for a cup of water and she said why the [expletive] are you knocking on this door. Don't knock [expletive] on this door and refused to give her water. She felt like the interaction was verbally abusive to her. She stated she reported it to Dietary Director #323 who stated she was going to look into it. She stated she made the report this morning after breakfast. Interview on 07/13/26 at 2:40 P.M. with Dietary Director #323 revealed Resident #12 came to her around 8:00 A.M. and stated DA #325 cursed at her. Dietary Director #323 told the resident she would follow up with her, but she had not had a chance to yet.Interview on 07/13/26 at 2:49 P.M. with the Administrator revealed Dietary Director #323 just now reported the incident, and she would complete an investigation and suspend DA #325 who was not at work today.Review of the Self-Reported Incident #276901 dated 07/13/26 and timed 3:38 P.M. revealed on 07/13/26, at around 11:45 A.M., Dietary Director #323 and the Director of Nursing (DON) notified this writer (the Administrator) that Resident #12 verbalized to them that on the weekend of 07/11/26 and 07/12/26, when she went to the kitchen to get water and a sandwich, the dietary aide [DA #325] swore at her and refused to accommodate her request. The investigation noted Not a single employee reported concerns regarding rude behavior or denying resident food or water, and the allegation of verbal abuse was unsubstantiated. Review of [NAME] #319's witness statement dated 07/13/26 revealed the kitchen was understaffed and they were overwhelmed. He noted DA #325 was cursing and slamming things. He kept trying to get her to calm down and nothing was working. At one point she went into the kitchen and told him that Resident #12 was talking about writing a bad review on the facility. [NAME] #319 asked Resident #12 what was wrong and she said she didn't give a [expletive]. He asked her if she was complaining about the food and if he could fix something else for her. She said she didn't know, but DA #325 was definitely cursing and conducting herself out of line.Interview on 07/15/26 at 2:37 P.M. with [NAME] #319 revealed on 07/12/26, they were short staffed for dinner, and it was just him and DA #325 working. He stated DA #325 was yelling and was really upset. He told her to get ahold of herself, but she couldn't. He stated she was yelling at the residents, he heard her yell Go away [racial slur] twice. He also heard her yelling [expletive] these mother [expletive]. He verified he knew the residents heard her and felt like she was being verbally abusive to them the way she was screaming and yelling. He went on to say she had a temper but, on this day, it was the worst he had ever seen. He also verified he did not see her obtain water for Resident #12. [NAME] #319 verified he did not report the incident even though he felt like DA #325 was being verbally abusive to the residents.Follow up interview and observation on 07/15/26 at 3:29 P.M. with Resident #12 revealed on 07/12/26 she heard DA #325 say things like you all [racial slur] need to stop asking for [expletive] and you all [racial slur] get on my nerves, and I'm only here to collect unemployment. Resident #12 was observed as an African American. Interview on 07/20/26 at 11:20 A.M. with the Administrator revealed all allegations of abuse, including verbal abuse, should be reported to her right away. She verified this was not done. Review of the facility's policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 10/2025 revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. All incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of resident property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. The Administrator/designee should be notified by informing him/her in person, calling via telephone, or sending an email or text message.This deficiency represents non-compliance investigated under Complaint Numbers 3006766 and 3006983.

Based on record review, observation, interview, and facility policy review, the facility failed to assess and implement smoking safety for residents. This deficient practice affected one resident (Resident #16) out of two residents reviewed for smoking safety. The facility census was 48.Findings Include:Review of Resident #16's medical record revealed admission date of 05/29/26 with diagnoses including pleural effusion, chronic obstructive pulmonary disease (COPD), high blood pressure, heart failure and cellulitis of lower leg.Review of Resident #16's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had moderately impaired cognition with a brief interview of mental status (BIMS) score of 10 out of 15 and used a wheelchair for mobility.Review of Resident #16's smoking safety assessment dated [DATE] revealed Resident #16 was assessed as a non-smoker.Review of Resident #16's care plan revealed no smoking care plan implemented until 07/14/26.Observation on 07/13/26 at 1:37 P.M. revealed Resident #16 was self-propelling himself in a wheelchair in the hallway going towards the resident smoking area. Resident #16 had a lighter and a half-burned cigarette in his hand.Observation on 07/13/26 at 2:01 P.M. revealed in Resident #16's room revealed a half-burned cigarette on the floor by the dresser and a half-burned cigarette on the floor under the bed. There was also a lighter on the floor under the bed.Review of Resident #16's updated care plan dated 07/14/26 revealed Resident #16 smoked cigarettes and verbalized adherence to the facility smoking policy, which included keeping smoking materials secured in his room.Interview on 07/14/26 at 4:12 P.M. with MDS Licensed Practical Nurse (LPN) #355 verified Resident #16's smoking assessment was inaccurate and the smoking care plan was implemented on 07/14/26. MDS LPN #355 stated every time the staff would interview Resident #16 for smoking safety, Resident #16 would state he was not a smoker.Review of the facility's policy titled Smoking revealed residents who are assessed and demonstrate the ability to smoke independently may keep smoking materials on their person while smoking or put away in their room.

Based on record review, interview, and facility policy review, the facility failed to ensure transportation was available for a dialysis dependent resident. This deficient practice affected one resident (#2) out of two residents reviewed for dialysis. The facility census was 48.Findings Include:Review of Resident #2's medical record revealed admission date of 10/30/25 with diagnoses including but not limited to end stage renal disease, renal dialysis, asthma, depression and type two diabetes.Review of Resident #2's quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #2 had moderately impaired cognition with a brief interview mental status (BIMS) score of 11 out of 15, he received dialysis and used a power wheelchair for mobility.Review of Resident #2's physician orders revealed an order dated 01/23/26 for transportation arriving Monday, Wednesday, Friday between 6:00 A.M. to 6:45 A.M. to [the dialysis] Center, to return at 11:15 A.M. with the resident back to facility via the [NAME] transportation van.Review of Resident #2's progress note dated 05/18/26 (Monday) at 9:09 A.M. revealed Resident #2 missed dialysis related to the transportation company having no driver for that day.Review of Resident #2's pre/post dialysis assessment listings revealed there were no pre/post dialysis assessments completed for Monday 05/18/26, Wednesday 05/20/26 or Friday 05/22/26 to review.Further review of Resident #2's medical record revealed no documented evidence of reasonable efforts to ensure the resident was able to receive dialysis services on 05/18/26, 05/20/26, and 05/22/26. Interview on 07/13/26 at 3:35 P.M. with Resident #2 revealed during the month of May 2026 he had missed dialysis treatments due to his insurance transportation not coming to transport him to dialysis and the dialysis center had called the facility checking on Resident #2 related to missing a week of dialysis treatments. Interview on 07/20/26 at 3:35 P.M. with the Director of Nursing (DON) verified Resident #2 did not receive dialysis treatments during the week of 05/18/26 to 05/22/26 due to having no transportation available. The DON stated Resident #2's insurance covered transportation and Resident #2 had used the covered transportation for the year. Review of the facility's policy titled Dialysis Transportation Contingency Policy revealed when scheduled insurance transportation does not arrive as planned, the facility will make reasonable efforts to ensure the resident receives treatment while maintaining resident safety, regulatory compliance, and appropriate documentation.This deficiency represents non-compliance investigated under Complaint Number 3021171.

Based on observation, interview, and record review, the facility failed to ensure the timely reordering of Resident #28's antianxiety medication. This affected one out of one resident's review for behavioral health services. The facility census is 48.Review of the medical record for Resident #28 revealed an admission date of 10/22/25. Diagnoses included but were not limited to panic disorder, psychoactive substance use, major depressive disorder, chronic pain, and insomnia.Review of Resident #28's quarterly Minimum Data Set (MDS) dated [DATE] revealed the residents Brief Interview for Mental Status (BIMS) score of 15 which indicated that a resident's cognitive function is intact. Review of Resident #28's care plan dated 06/09/26 revealed the resident had an alteration in mood related to depression, panic disorder, and anxiety with an intervention to administer medications as ordered. Monitor and document for side effects and effectiveness.Review of Resident #28's orders revealed an order for Alprazolam (Xanax) 0.25mg by mouth three times a day related to panic disorder. The order was dated 12/27/25.Review of Resident #28's progress notes revealed on 07/12/26 at 10:04 P.M. the residents Xanax 0.25mg was pending from pharmacy, On 07/13/26 at 1:12 PM the medication was not available. On 07/17/26 at 1:56 P.M. the medication was awaiting a new script. On 07/19/26 at 4:53 P.M. awaiting arrival from pharmacy and at 4:53 P.M. stated medication is not on hand. Review of Resident #28's Medication Administration Record (MAR) dated July 2026 revealed the resident did not receive her scheduled dose of Xanax 0.25 mg twice on 07/12/26, three times on 07/13/26, once on 07/15/26, once on 07/17/26, and twice on 07/19/26. Resulting in nine missed doses.Observation on 07/13/26 at 4:06 P.M. Resident #28 was sitting outside in her wheelchair. She appeared upset. When approached she became tearful.Interview in 07/13/26 at 4:06 P.M. Resident #28 reported she has currently gone two days without her scheduled medication (Xanax 0.25mg). She tearfully reported she is experiencing a lot of anxiety. She stated the facility does not stay on top of ordering her medication and this is a frequent occurrence.Interview on 07/14/26 at 10:42 A.M. Licensed Practical Nurse (LPN) #345 reported she contacted the pharmacy on Saturday and asked for them to send the medication. She reported she did not work on Monday but does currently have the medication but has not administered it to Resident #28 yet this morning.Observation on 07/14/26 at 11:15 A.M. of the medication storage in the facility with LPN #250 revealed the facility has eight Xanax 0.25 mg available to be can be pulled. Interview with LPN #250 revealed ideally if a medication is out they can pull with two nurses as long as they have access and approval from pharmacy. She verified this was not completed. Interview on 07/14/26 at 3:18 P.M. Assistant Director of Nursing (ADON) #216 reported that Resident #28's prescription ran out of refills. She reviewed the record and the facility did not attempt to get a new prescription until 07/13/26. She verified the medication was available in the contingency box but the nurses did not pull the medication.Interview on 07/20/2026 at 11:29 A.M. the facility DON revealed the facility had not obtained timely refills or pulled the medication from the contingency resulting in Resident #28 missing several doses of her antianxiety medication. This deficiency represents non-compliance investigated under Complaint Numbers 3006983, 3006766, and 2740378.

Based on record review and interview, the facility failed to schedule ordered diagnostic tests for residents. This deficient practice affected one resident (#16) out of one resident reviewed for diagnostic testing. The facility census was 48.Findings Include:Review of Resident #16's medical record revealed an admission date of 05/29/26 with diagnoses including pleural effusion, Chronic Obstructive Pulmonary Disease (COPD), high blood pressure, heart failure and cellulitis of lower leg.Review of Resident #16's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had moderately impaired cognition. Review of Resident #16's physician orders revealed an order dated 07/01/26 for bilateral venous doppler and bilateral arterial doppler for lower legs.Review of Resident #16's diagnostic results revealed there were no results from the doppler diagnostic testing ordered on 07/01/26 to review.Interview on 07/16/26 at 10:53 A.M. with the Assistant Director of Nursing (ADON) verified Resident #16's bilateral venous doppler and bilateral arterial doppler for lower legs had not been scheduled by the facility. The ADON stated the expectations for the nurses are to review the written physician orders and schedule the ordered testing. This deficiency represents non-compliance investigated under Complaint Number 2740378.

Based on observation, interview, and record review, the facility failed to ensure Resident #12 was scheduled for a dental appointment as recommended after experiencing dental pain and a tooth infection. This affected one (#12) out of two residents reviewed for dental services. The facility census was 48. Review of the medical record for Resident #12 revealed an admission date 02/21/26. Diagnoses included but were not limited to diabetes mellitus type two, psychoactive substance abuse, chronic idiopathic constipation, anxiety disorder, fibromyalgia, bipolar disorder, and abnormalities of gait and mobility.Review of Resident 12's quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact.Review of Resident #12's care plan dated 06/09/26 revealed she did not have a care plan related to her teeth or dental services.Review of Resident #12's treatment history report revealed her last dental exam was on 03/06/25. Review of Resident #12's progress note dated 04/24/26 created by Advanced Practice Registered Nurse #403 revealed the resident was being seen due to toothache and inflammation. The resident reported that it started a few days ago but has worsened. She has taken Tylenol for the pain but would also like something else. She had visible inflammation of the gum, and her tooth appeared in poor condition. Will order antibiotic and schedule an appointment with the dentist.Review of Resident #12's physician's orders revealed an order dated 04/24/26 for Amoxicillin (antibiotic) 500 milligram capsule to be taken by mouth twice daily for 10 days for a tooth infection.Observation on 07/13/26 at 2:27 P.M. of Resident #12 revealed two missing bottom front teeth.Interview on 07/13/2026 at 2:27 P.M. with Resident #12 revealed she had reported to the previous social worker that she needed to see a dentist due to issues with her teeth. She stated these issues included discomfort and missing teeth. She stated she has yet to see a dentist.Interview on 07/15/26 at 2:12 P.M. Resident #12 reported she had a partial denture at one point, but it has been missing and she also had a tooth on the top of her mouth that was recently infected that required an antibiotic.Interview on 07/15/26 at 12:11 P.M. Social Services Director #206 revealed she is unable to find evidence where Resident #12 was seen for a dental exam after her tooth infection. She reported she was last seen on 03/06/25.Interview on 07/15/26 at 4:09 P.M. the Director of Nursing (DON) verified Resident #12 was not assisted with making a dental visit after experiencing a tooth infection and tooth discomfort as recommended.

Based on record review, observations, interviews, and facility policy review, the facility failed to ensure infection control was maintained during transport of soiled linens and failed to ensure hand hygiene during incontinence care and Enhanced Barrier Precautions were implemented appropriately. This affected one resident (#16) out of one resident reviewed for wound care and affected one resident (#6) out of one resident reviewed for incontinence care. The facility census was 48.Findings Include: 1. Review of Resident #16's medical record revealed admission date of 05/29/26 with diagnoses including but not limited to cellulitis of lower leg, pleural effusion, high blood pressure, and heart failure. Review of Resident #16's physician orders revealed an order dated 07/02/26 for wound care to cleanse the right foot with normal saline or wound cleanser, apply Xerofoam, apply abdominal dressing and wrap with kerlix daily. There were no Enhanced Barrier Precautions (EBP) orders to review. a. Observation on 07/13/26 at 1:40 P.M. revealed Resident #16's room did not have EBP signage or Personal protective Equipment (PPE) available for the direct care of Resident #16. Interview on 07/16/26 at 9:13 A.M. with Licensed Practical Nurse (LPN) #345 stated Resident #16 was not on isolation or EBPs for his wounds. Interview on 07/16/26 at 10:23 A.M. with the Director of Nursing (DON) verified Resident #16 did not have EBP implemented. The DON stated the staff was to notify her of any residents with wounds and then EBPs would be implemented. b. Observation on 07/16/26 at 9:44 A.M. revealed the Assistant Director of Nursing (ADON) was completing the wound care to Resident #16's right lower leg and foot. The ADON removed her gloves and sanitized her hands. There were soiled bed linens on the floor by the door, the ADON picked up the pile of soiled bed linens with no gloves in place and carried the soiled linens to the dirty utility room and placed them in the soiled laundry cart. The ADON then left the soiled utility room without sanitizing or washing her hands. Interview on 07/16/26 at 9:55 A.M. with the ADON verified she had picked up the soiled bed linens without using gloves and transported them to the soiled utility room, placed them in the soiled laundry cart and left the room without sanitizing or washing her hands. The ADON stated she probably should have worn gloves and washed her hands afterwards. 2. Review of the medical record for Resident #6 revealed an admission date of 02/21/26. Diagnoses included but were not limited to malignant neoplasm of the unspecified part of right bronchus or lung, hypertensive heart disease with heart failure, chronic pain, and a leg wound. Review of Resident #6's July 2026 physician orders revealed an order dated 03/24/26 for Enhanced Barrier Precautions (EBP), due to a wound with instructions to be completed every shift. Review of Resident #6's the care plan dated 06/29/26 revealed the resident had a care plan related to EBP for wounds. Interventions included to keep EBP in place until wound was healed, notify resident/family/visitors/staff/volunteers of implementation of EBP, post a sign on door or wall outside the residents room to identify the need for EBP, supply gowns and gloves outside the residents room, and use gowns and gloves when providing high-contact resident care activities such as: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care/use/maintenance and wound care requiring dressings. Observation on 07/13/26 at 10:49 A.M., Resident #6 was up in her power wheelchair. Her incontinence pad was lying on her bed and was soiled with dry feces. Resident #6 was tearful. There was a strong odor of urine and feces in her room. Observation on 07/13/26 at 11:08 A.M. of the outside door to Resident #6's room revealed a sign posted to don personal protective equipment (PPE) related to EBP. A cart was next to the door with gowns and gloves. Observation on 07/13/26 at 11:10 A.M. revealed Certified Nursing Assistant (CNA) #385 entered Resident #6's room and asked the resident if she had a bowel movement. Without donning a gown or washing his hands, he applied gloves and assisted Resident #6 onto the bed and laid her on her on the dirty incontinence pad. When he removed Resident #6's incontinence brief, it was full of urine and feces. He completed the incontinence care using the same pair of gloves the whole time. After the care was completed, he removed the dirty pad, repositioned the resident, cleaned up, then removed his gloves and washed his hands. Interview on 07/13/26 at 11:28 A.M. with CNA #385 verified improper infection control practices and that he failed to don appropriate PPE prior to care. Review of the facility policy, Enhanced Barrier Precautions (EBP) dated 10/2025 revealed EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of [NAME] to staff hands and clothing.

Based on observation, interviews and policy review, the facility failed to ensure adequate and appropriate utensils were provided for resident meals. This affected seven residents (#1, #3, #13, #14, #19, #43, and #44) of seven residents reviewed for appropriate eating utensils being provided with meals. This had the potential to affect all 45 residents who received meals from the kitchen. The facility census was 45. Findings include: Observation on 01/22/26 at 8:14 A.M. revealed two Certified Nursing Assistants (CNAs) passing resident meal trays. Observation of the resident breakfast trays being passed by the CNA staff revealed only a metal spoon was present on each tray and there were no additional silverware or utensils present on the tray or offered to the residents. Observation on 01/22/26 at 8:23 A.M. revealed Dietary Aide (DA) #277 pushing an open cart containing approximately 15-20 meal trays that only had a plastic spoon sitting on top of a folded brown paper towel next to the covered plate.Interview on 01/22/26 at 8:25 A.M. with DA #277 revealed they did not have enough metal silverware for all the residents, so they sent plastic silverware to the remaining residents.Interview on 01/22/26 at 8:30 A.M. with DA #263 confirmed there was not enough silverware for all resident meal trays, so plastic silverware was used for at least half of the residents' trays for each meal. DA #263 additionally stated the kitchen had been out of napkins since 01/20/26 and had been using folded brown paper towels from the hand towel dispenser. DA #263 mentioned the facility sometimes ran out of juice cups for the residents and but there had been a shortage of silverware/utensils for at least six months.Review of the facility lunch menu for 01/22/26 revealed the lunch menu consisted of a chicken enchilada, Spanish rice, corn and black beans, a banana, and juice or milk.1. Review of the medical record for Resident #1 revealed an admission date of 10/02/25. Diagnoses included but were not limited to chronic obstructive pulmonary disease, chronic congestive heart failure, and type II diabetes mellitus. Resident #1 was noted to be cognitively intact, received a no concentrated sweets diet, and required set up for meals.Interview on 01/22/26 at 12:19 P.M. with Resident #1 revealed frequently he only receives a spoon, had previously received only a fork to eat soup with, and frequently received plastic silverware with meals. Observation at the time of the interview revealed Resident #1 had only a metal spoon on the lunch tray. 2. Review of the medical record for Resident #3 revealed an admission date of 02/17/25. Diagnoses included but were not limited to dementia, peripheral vascular disease, and atrial fibrillation. Resident #3 was noted to be cognitively intact, received a regular diet, and required set up for meals. Interview on 01/22/26 at 12:25 P.M. with Resident #3 revealed the resident sometimes only a spoon, and sometimes it was a plastic utensil. Observation at the time of the interview revealed Resident #3 only had a metal spoon on the lunch tray. 3. Review of the medical record for Resident #13 revealed an admission ate of 11/10/25. Diagnoses included but were not limited radiculopathy of the lumbar region, alcohol abuse and chronic post-traumatic stress disorder. Resident #13 was noted to be cognitively intact, received a regular diet, and was independent for eating.Interview on 01/22/26 at 12:43 P.M. with Resident #13 revealed he received plastic utensils for about half of his meals. Observation at the time of interview revealed Resident #13 had only a metal spoon on the lunch tray.4. Review of the medical record for Resident #14 revealed an admission date of 06/04/25. Diagnoses included but were not limited to chronic obstructive pulmonary disease, type II diabetes mellitus, and bipolar disorder. Resident #14 was noted to have intact cognition, received a regular mechanical soft diet, and required set up for meals.Interview on 01/22/26 at 12:34 P.M. with Resident #14 revealed the resident received plastic utensils at least once a week. Observation at the time of the interview revealed Resident #14 had only a metal spoon on the lunch tray.5. Review of the medical record for Resident #19 revealed an admission date of 12/12/25. Diagnoses included but were not limited to bipolar disorder with severe depression, type II diabetes mellitus, and hemiplegia and hemiparesis. Resident #19 was noted to be cognitively intact, received a carbohydrate-controlled diet, and was independent for eating. Interview on 01/22/26 at 12:38 P.M. with Resident #19 revealed the resident usually received plastic silverware, had previously only received a spoon to eat meat with, and had to eat it with his fingers. Resident #19 stated there were times no utensils had been sent with the meal tray. Observation at the time of the interview revealed Resident #19 had only a metal spoon on the lunch tray. 6. Review of the medical record for Resident #43 revealed an admission date of 04/24/23. Diagnoses included but were not limited to anxiety disorder, other psychoactive substance abuse, and severe protein-calorie malnutrition. Resident #43 was noted to be cognitively intact, received a regular diet, and was independent for eating. Interview on 01/22/26 at 12:10 P.M. with Resident #43 revealed sometimes he only received a spoon with which to eat items such as salad. Resident #43 stated he sometimes received plastic utensils and occasionally does not receive utensils at all with the meal. Observation at the time of the interview revealed Resident #43 had only a metal spoon on the lunch tray.7. Review of the medical record for Resident #44 revealed an admission date of 03/16/18. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction, epilepsy, and anxiety disorder. Resident #44 was noted to have moderate cognitive impairment, received a carbohydrate-controlled diet, and required set up for meals.Interview on 01/22/26 at 12:06 P.M. with Resident #44 revealed he does not always receive silverware with meals and frequently received plastic utensils with the meal tray. Observation at the time of the interview revealed Resident #44 had only a metal spoon on the lunch tray.Interview on 01/26/26 at 1:26 P.M. with the Administrator confirmed residents should receive the appropriate silverware for all meals.Review of the undated facility policy called; Use of Disposable Dishes/Flatware revealed resident meals shall be served using reusable dishes and flatware.This deficiency represents non-compliance investigated under Complaint Number 2693876.

Based on medical record review, hospital record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized skin management program to prevent incidents of neglect for Resident #20 and Resident #46. This resulted in Immediate Jeopardy and Actual Harm beginning on 10/21/25 after the facility failed to ensure Resident #46, a severely cognitively impaired resident who was dependent on staff for care, received timely and proper treat to prevent a significant deterioration to a wound to the resident's left lateral foot, resulting in the resident being transferred to the emergency department (ED) where he was admitted and treated with intravenous (IV) medications for severe sepsis. The Immediate Jeopardy and Actual Harm continued on 10/23/25 when the facility failed to ensure Resident #20, who required staff assistance for bathing and lower extremity dressing, was free of neglect when staff failed to timely identify and treat a right leg diabetic ulceration to the resident's right heel requiring hospitalization and a right above the knee amputation.On 11/10/25 at 11:22 A.M., the Administrator was notified Immediate Jeopardy began on 10/21/25 when Nurse Practitioner (NP) #500 first identified a worsening wound to Resident #46's left lateral foot resulting in hospitalization with severe sepsis and on 10/23/25 when the facility failed to identify and treat a right leg diabetic ulceration to his right heel for Resident #20 resulting in hospitalization and right above the knee amputation. The lack of systematic, comprehensive and effective skin management program resulted in situations of neglect for Resident #46 and Resident #20.In addition, concerns that did not rise to Immediate Jeopardy were identified when the facility failed to protect Resident #15 and Resident #47's right to be free from verbal abuse by staff. This affected four residents (#20, #46, #15, and #47) of 29 residents reviewed for abuse and neglect. The facility census was 45. The Immediately Jeopardy was removed on 11/18/25 when the facility implemented the following corrective actions: On 10/21/25 Resident #46 was transferred to the hospital and did not return to the facility. On 10/23/25 Resident #20 was transferred to the hospital for emergent treatment. The resident returned to the facility on [DATE]. Upon return, Resident #20 was re-assessed for pressure injury risk with a Braden scale, a skin assessment was completed, pressure reducing device were ordered and implemented and weekly skin assessments and wound care chart audits were implemented. On 10/23/25 the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #504 completed assessments on all residents. On 10/24/25, Regional Nurse #566 educated the DON and ADON #504 on wound identification, staging and dressing changes. Beginning on 11/06/25 the facility initiated a plan for the DON/designee to audit 100% of skin assessments, weekly wound reports, and dialysis communication logs for eight weeks. Inaccurate findings would be reported to the facility Quality Assessment and Performance Improvement (QAPI) committee. Audits would be reviewed in monthly QAPI meetings to assess processes and performance of staff through proper identification and compliance. On 11/07/25 Regional Nurse #566, the DON and ADON #504 initiated education for all nurses on accurate wound documentation, wound documentation process and wound rounding expectations. On 11/10/25, ADON #504 contacted the dialysis center to verify processes for return communication for residents with wounds or new orders. On 11/11/25, the facility implemented a Monthly Dialysis Foot Check form. This form would be sent to the Dialysis Center monthly by the DON/designee for communication when they do monthly skin checks. On 11/11/25 Regional Nurse #566, the DON and ADON #504 completed additional education and competencies for all licensed nurses related to wound identification and staging was completed. On 11/11/25 the DON and ADON #504 completed in-service education for Certified Nursing Assistant (CNA) staff on early reporting of skin changes. On 11/10/25 and 11/11/25, all full time and part time licensed nurses were evaluated for competencies and completed return demonstrations for wound assessment and documentation (for a simulated wound). Competencies were completed by the DON and ADON #504. Licensed staff off or who worked as needed (PRN) would have competencies evaluated before their next shift on the floor. On 11/11/25 the DON revised the facility Resident Return admission Checklist to include wound verification and order reconciliation for all returning residents. Education on the new form was provided to licensed nurses by the DON and ADON #504 on 11/11/25. The checklist would also be reviewed by the DON or ADON #504 upon admission. These would be monitored during any new admission or readmissions to facility. New staff would also be educated by the nurse training them on this form. On 11/12/25 the DON and ADON #504 provided education for all nursing and CNA staff on proper wound care and to alert nurse if a resident dressing had come off or needed replaced. On 11/14/25 the facility implemented staff training on the facility Abuse, Neglect & Misappropriation policy. The Administrator sent a message out to all staff on the definition of neglect on 11/14/25. Receptionist #808 was calling each staff person to educate, offer time for questions and express understanding. Following the education, the facility implemented a plan to randomly ask three staff members per week for four weeks about the definition of neglect. On 11/18/25 a root cause analysis was conducted related to the incidents of neglect. The facility identified the root cause of neglect for Resident #46 and Resident #20 was the facility's failure to provide ordered wound care and monitor wound status. There were no systems to verify treatment completion, escalate concerns, or ensure nursing accountability. Beginning on 11/19/25 the facility implemented a plan for the Administrator or designee to complete audits for three residents three times per week for four weeks then monthly for two months to identify potential areas of neglect to include showers, medication administration and wound care.Although the Immediate Jeopardy was removed on 11/18/25, the facility remained out of compliance at Severity Level 2 (no actual harm with harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance.Findings include:1. Review of the medical record for Resident #46 revealed an admission date of 07/29/25. Resident #46 was transferred to the hospital on [DATE] and did not return to the facility. Resident #46 had diagnoses including congestive heart failure, dementia, diabetes, muscle weakness and epilepsy. Review of the care plan dated 07/30/25 revealed Resident #46 was at risk of skin breakdown due to diabetes, cognitive decline and immobility. Interventions included administering treatments as ordered, assisting in turning and repositioning as needed, educating family and caregivers about causes of skin breakdown and following the facility protocol for the prevention and treatment of skin breakdown.Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was severely cognitively impaired. The assessment revealed the resident required (staff) set-up help for eating, substantial (staff) assistance for oral hygiene and was totally dependent on staff for toileting, showering, dressing and hygiene. The assessment revealed the resident was at risk for the development of pressure ulcers and had two unstageable deep tissue injuries (DTI), (a DTI is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) and one diabetic foot ulcer (DFU). Review of the wound assessment report dated 09/23/25 authored by Former Wound Nurse Practitioner (NP) #570 revealed Resident #46 had a new abrasion to his left foot which was acquired 09/23/25. The area was assessed to have 100% granulation (formation of new tissue during wound healing) and measured 8.0 centimeters (cm) long by 3.0 cm wide with 0.10 cm depth, with a moderate amount of thin, bright red drainage. Treatment was identified as cleansing the wound with saline, calcium alginate with silver (wound dressing used to promote healing and prevent infection), abdominal ABD (protective pad) and rolled gauze, secured with tape, daily and as needed (prn).Review of the weekly wound report dated 10/07/25 authored by Licensed Practical Nurse (LPN) #501, the facility's wound nurse, revealed the wound to Resident #46's left foot measured 6.0 cm long by 6.0 cm wide with 0.1 cm depth and was declining. There was no evidence the physician was notified of the condition of the wound, and no evidence wound treatments were in place. Review of the weekly wound report dated 10/14/25 authored by LPN #501 revealed the wound to Resident #46's left foot measured 7.0 cm long by 7.0 cm wide with 0.1 cm depth and was declining. There was no evidence the physician was notified of the condition of the wound, and no evidence that wound treatments were in place.Review of NP #500's note dated 10/21/25 revealed Resident #46 was seen for weekly wound follow-up care. The note revealed Resident #46 had a worsening wound to the left lateral foot with tunneling and exposed muscle. The wound was described as an arterial wound with full thickness, measuring 4.2 cm wide by 8.0 cm long and 0.2 cm deep with 10% granulation, 50% epithelial (outer layer of tissue), 10% slough (dead tissue which blocks healing) and 30% eschar (dead, dry tissue). A large amount of bloody, purulent (thick fluid or pus) drainage was noted to be present. NP #500 recommended Resident #46 be transferred to the hospital for treatment. Review of the treatment administration records (TAR) for September and October 2025 revealed no evidence of any type of wound treatment being in place to address Resident #46's left lateral foot wound. Review of Resident #46's hospital history and physical dated 10/21/25 revealed the resident was admitted and required treatment for severe sepsis as a result of worsening wounds. Review of an email communication between the Administrator and Resident #46's guardian dated 10/29/25 revealed the hospital expressed concerns for Resident #46's extensive wounds with the guardian and advised it was against medical advice for the resident to return to the facility (post-hospitalization). As a result, the guardian chose to move Resident #46 to a different skilled nursing facility.Interview on 11/05/25 at 9:48 A.M. with NP #500 revealed she assessed Resident #46 on 10/21/25 and identified the resident's wound dressings were not being changed daily as ordered. In addition, on this date the resident was hypotensive with a blood pressure of 88/48. NP #500 revealed she recommended the resident be transferred to the emergency department (ED) immediately for the wound to his left foot, which appeared to be septic. Interview on 11/05/25 at 12:45 P.M. with Licensed Practical Nurse (LPN) #501, who was identified as the wound care clinician on the facility staff roster, revealed she had been in this role for over a year. She stated she rounded with either the wound physician or wound nurse practitioner weekly. LPN #501 stated she only worked Tuesdays and did not work the rest of the week. She stated on Tuesdays when she rounded with NP #500, they assessed the wounds and applied treatments. She stated NP #500 would provide her with new orders as needed. LPN #501 stated she documented the weekly wound assessments in the computer but did not do the weekly skin assessments. She stated when the nursing staff observe a new skin impairment or a wound worsens, they were to update her so she can put them on the list to be seen on Tuesdays.Interview on 11/05/25 at 2:40 P.M. with LPN #501 revealed she documented Resident #46's left lateral foot wound on her weekly wound reports on 09/23/25, 09/30/25, 10/07/25 and 10/14/25 and knew what orders to include; however, she did not notify the physician of the wound or orders and did not add the treatment orders to the treatment administration record (TAR). She revealed she did not assess the wound, only obtained measurements, and then stated she notified facility administration. Interview on 11/05/25 at 3:39 P.M. with the DON and ADON #504 could not determine if they had or had not been notified of the wound to Resident #46's left lateral foot. Interview on 11/05/25 at 11:27 A.M. with Medical Director (MD) #569 revealed he spoken with NP #500 (date of conversation not provided) and learned she was not wound certified but stated she reported she had been following the residents with wounds, and consulting with her supervisor, who he believed was wound certified. The NP denied providing any direct care such as debridement. During the interview, MD #569 revealed he was never made aware of the wound to Resident #46's foot. (Additional information obtained during the survey revealed NP #500's supervisor was also an advanced practice NP, was located and licensed in Kansas not Ohio, and was not wound care certified).Interview on 11/06/25 at 2:11 P.M. with Certified Nursing Assistant (CNA) #547 revealed she had no knowledge of a wound to Resident #46's left foot. Interview on 11/13/25 at 7:35 A.M. with LPN #510 revealed she had no knowledge of a wound to Resident #46's left foot. Attempts to reach Resident #46's guardian on 11/06/25 and 11/10/25 were unsuccessful. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated October 2023, revealed neglect was defined as the facilities' failure to provide services to a resident necessary to avoid physical harm, pain or emotional distress, and the facility and its employees would identify, correct and intervene in situations where neglect was likely to occur.2. Review of the medical record for Resident #20 revealed an admission date of 04/19/23 with diagnoses including end stage renal disease, diabetes mellitus with circulatory complications, blindness to the right eye, need for assistance with personal care, and left below the knee amputation. Review of Resident #20's census record revealed he had not been discharged from the facility and re-admitted to the hospital since his admission on [DATE].Review of the care plan dated 06/03/25 revealed Resident #20 had diabetes mellitus. Interventions included for staff to inspect feet as needed for open areas, sores, pressure areas, blisters, edema or redness.Review of the care plan dated 06/03/25 revealed Resident #20 had impaired cognition as evidenced by deficits in memory, judgement and decision making. Interventions included to monitor/document/report to the medical provider any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status.Review of the care plan dated 06/03/25 revealed Resident #20 had a behavior problem related to being quick to anger, medication refusal, kicking on kitchen door, screaming when he wanted different food, refusal of care, refusal to follow diabetic diet, history of leaving the facility without informing staff and throwing plates on the floor. Interventions included offering choices about care on a daily basis to enhance a sense of control.Review of the care plan dated 06/03/25 revealed Resident #20 had end stage renal disease and was receiving (hemo)dialysis. Interventions included coordinating care with the dialysis center.Review of the care plan dated 06/03/25 revealed Resident #20 had self-care performance deficit related to activities of daily living (ADLs). The care plan revealed the resident needed partial to moderate assistance with showers and bathing, lower body dressing and putting on and taking off footwear.Review of the physician's orders for 08/01/25 through 10/23/25 revealed there were no treatment orders for Resident #20's right heel.Review of the weekly skin assessment dated [DATE] revealed staff documented Resident #20 had no new skin issues noted.Review of a dialysis center Foot Check Assessment form dated 08/25/25 revealed Resident #20 had an ulcer on his right heel. The dialysis center form noted under comments that (dialysis) staff had attempted to contact the facility about the ulcer on the resident's foot without success. Review of the weekly skin assessment dated [DATE] revealed staff documented Resident #20 had no new skin issues noted.Review of the weekly skin assessment dated [DATE] revealed staff documented Resident #20 had no new skin issues notedReview of the dialysis center Foot Check Assessment form dated 09/05/25 revealed Resident #20 had an ulcer on his right heel. The dialysis center form noted under comments that (dialysis) staff left a message for the Director of Nursing (DON) at the extended care facility about the ulcer.Review of the weekly skin assessment dated [DATE] revealed staff documented Resident #20 had no new skin issues noted. Review of Resident #20's Braden assessment dated [DATE] revealed the resident was assessed to be at low risk for developing pressure ulcers.Review of the weekly skin assessment dated [DATE] revealed Resident #20 had no new skin issues documented on the assessment form. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #20 had intact cognition (although the plan of care dated 06/03/25 noted the resident had impaired cognition), no rejection of care, needed partial to moderate assistance with lower body dressing and putting on and taking off footwear. There were no concerns or ulcers noted on the assessment. Review of the progress note from the physician's visit dated 09/17/25 for Resident #20 revealed Physician #569 was not aware of an ulcer to the resident's right heel on this date. Review of the weekly skin assessment dated [DATE] revealed staff documented Resident #20's skin was intact. Review of the weekly skin assessment dated [DATE] revealed Resident #20 had no new skin issues documented. Review of the weekly skin assessment dated [DATE] revealed Resident #20 had no new skin issues documented. Review of the weekly skin assessment dated [DATE] revealed Resident #20 had no new skin issues documented. Review of the progress note from the physician's visit dated 10/15/25 for Resident #20 revealed Physician #569 was not aware of a right heel ulcer on this date.Review of Resident #20's assessments revealed there was no weekly skin assessment completed on 10/21/25.Review of the body assessment sheet dated 10/23/25 revealed Resident #20 had a shower. There were open areas on the right foot noted.Review of an NP visit note on 10/23/25 at 11:21 A.M. revealed Resident #20 had been sent to the emergency department (ED) from dialysis on 10/22/25 due to a change in mental status during dialysis treatment. Resident #20 was then discharged back to the facility after stabilization. NP #500 stated today (10/23/25) it was noted Resident #20 was found to have a large foot ulcer on the bottom of his right foot with 90 percent (%) eschar tissue (dark dead tissue), copious amounts of bloody serosanguinous drainage and a foul odor. Resident #20's pulses were non-palpable during the evaluation. NP #500 transferred the resident to the ED for further evaluation and treatment.Review of the History and Physical (H&P) from the hospital dated 10/23/25 at 2:55 P.M. for Resident #20 revealed there were concerns for right lower extremity necrotizing soft tissue infection (a rare but severe bacterial infection that destroys skin, muscles, and underlying tissue). Resident #20 was noted to have pain in his right heel and have generalized fatigue. The right lower foot was noted with wet gangrene changes that probed to the bone with expressible purulence about the lateral foot. Radiographic imaging of the right foot and leg showed soft tissue swelling and subcutaneous emphysema in the region of the right ankle and foot, suspicious for an infectious process with necrotizing soft tissue infection considered. Diagnoses included sepsis. Resident #20 was admitted to the hospital, had a consultation for an orthopedic surgeon and intravenous antibiotics. Resident #20 underwent an emergency right above the knee amputation on 10/23/25 as a result of the resident's condition.Review of the orthopedic operative report dated 10/23/25 at 5:32 P.M. revealed the pre-operative diagnosis for Resident #20 was right leg diabetic ulceration and infection with concerns for early necrotizing fasciitis. Resident #20 presented with extensive plantar foot discoloration with necrotic tissue appreciated. There were chronic appearing changes appreciated about the gastric soleus complex (muscles to the back of the lower leg). Resident #20 was recommended for right knee amputation secondary to unsalvageable limb secondary to infection. Below the knee amputation was not an option due to the skin on the posterior lower extremity and extent of the infection. Interview on 11/05/25 at 7:49 A.M. with LPN #522 revealed she had worked at the facility for 90 days. She denied having knowledge of Resident #20's right heel ulcer prior to 10/23/25. She stated she never performed a weekly skin assessment on him and the nurse aides had never brought skin concerns to Resident #20's heel to her.Interview on 11/05/25 at 9:43 A.M. with NP #500 revealed she was not updated about Resident #20's right foot diabetic ulcer until 10/23/25. She stated when she went into the resident's room that morning, she could smell the odor from the (foot) wound. She stated the resident's sock was noted to be dripping a fluid from it and the entire bottom of his sock was wet. NP #500 stated the right foot ulcer had to have been present for an extended period of time. She was told by the facility staff Resident #20 would refuse showers and care at times; however, NP #500 stated she had been educating the staff on what to do if a resident refused so they follow up with the resident. NP #500 stated she had worked at the facility for approximately two months as the general NP. She stated over the last two weeks she started rounding with the facility nurse and caring for the wounds. NP #500 stated the facility nursing staff were not performing the wound treatments as ordered for the residents. She stated she believed the facility had a system breakdown with the wound management program.Interview on 11/05/25 at 12:45 P.M. with LPN #501, the facility wound nurse clinician, revealed she had been the wound nurse for over a year. LPN #501 stated the (floor) nursing staff do weekly skin assessments, document the findings under assessments and update her on changes of the resident's skin. She revealed she was not aware of Resident #20's right foot heel ulcer until 10/23/25. However, during the interview she stated the heel ulcer had to have been present for a long time (based on the appearance of the ulcer on 10/23/25). LPN #501 verified the nursing staff were not completing wound treatments or skin assessments as ordered for residents and felt there was a concern with the facility's wound management program.Interview on 11/05/25 at 3:39 P.M. with the DON revealed nursing staff had not identified the area on Resident #20's right heel prior to or on 10/23/25 but rather the NP did. The DON verified the nursing staff had not documented an assessment on 10/23/25 or observation of the right heel following the identification of the area. The DON also verified staff did not do a weekly skin check on 10/21/25. She stated she had begun audits on 10/23/25 for wound treatments and education as she had found issues with staff not completing treatments or assessments. During the interview the DON verified the weekly skin assessments for Resident #20 reflecting the resident's skin was intact with no evidence the resident was refusing to have skin assessments completed. Interview on 11/05/25 at 3:41 P.M. with LPN #504 revealed she had questioned the nursing staff related to Resident #20's right heel ulcer but all had denied seeing the wound prior to 10/23/25. LPN #504 was noted to have performed weekly skin assessments for Resident #20 on 09/23/25 and 09/30/25 noting no new skin issues. She stated she could not remember the weekly skin check but stated the resident did refuse care at times. The LPN then denied seeing Resident #20's right heel ulcer prior to 10/23/25.Interview on 11/06/25 at 8:11 A.M. with LPN #510 revealed she took care of Resident #20 on a regular basis. She stated she had not seen Resident #20's pressure ulcer until the morning of 10/23/25 when NP #500 wanted him transferred to the emergency room. The LPN was noted to have performed weekly skin assessments for Resident #20 on 08/19/25, 08/26/25, 09/02/25, 09/09/25, 09/16/25, 10/07/25 and 10/14/25. LPN #510 denied having seen the right heel ulcer. She would not provide any additional information during the interview.Interview on 11/06/25 at 11:12 A.M. with Resident #20 revealed the wound to his right foot/heel had been present for a long time although he could not remember the exact date it had started. Resident #20 stated he allowed staff to do weekly skin checks and had bed baths regularly with staff assisting him. During the interview Resident #20 stated he felt the facility had neglected him by not addressing his right heel ulcer.Interview on 11/06/25 at 2:30 P.M. with Dialysis Center Nurse #814 verified on 08/25/25 the dialysis center performed a foot assessment and noted a right foot heel ulcer to Resident #20's right foot. She stated dialysis staff attempted to phone the facility which was unsuccessful. She stated on 09/05/25 the dialysis center performed an additional foot assessment and noted the right foot heel ulcer was still present. She stated they again phoned the facility and left a message for the DON to return their call. She stated the DON never returned the phone call. Dialysis Center Nurse #814 stated on 10/06/25, the facility called and asked for dialysis center communication to be sent to the facility with every visit for Resident #20. She stated the facility had not requested documentation prior to that date.Interview on 11/12/25 at 11:25 A.M. with Physician #569 revealed he had not been updated about Resident #20's right heel ulcer until the resident was transferred to the hospital on [DATE]. He stated just prior to the interview, he had been updated by the Administrator that the facility did not have a wound physician or company that covered the wounds and that NP #500 had been rounding weekly for residents with wounds for the last two weeks. Physician #569 stated the facility updated him that NP #500 was not wound certified and he instructed the facility he would not sign off on the wounds because NP #500 was not wound certified. Physician #569 revealed concerns the facility staff did not keep him updated on resident changes in condition.Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/24/22 and last reviewed on October 2023, revealed neglect was the failure of the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility would ensure all staff were trained and qualified to meet the needs of residents and that resources were available to meet the needs of the residents.3. Review of the closed medical record for Resident #47 revealed the resident was admitted to the facility on [DATE] with diagnoses that included lumbago with right side sciatica, spinal stenosis, and anxiety disorder. Resident #47 discharged from the facility on 05/26/25.Review of the care plan dated 05/22/25 revealed Resident #47 had an activity of daily living (ADL) self-care deficit related to impaired balance and shortness of breath with interventions that included to participate to the fullest extent possible with each interaction.Review of the MDS 3.0 assessment dated [DATE] revealed Resident #47 was alert and oriented and was independent for ADL. Review of a facility self-reported incident (SRI) tracking number 261418 revealed an allegation of alleged verbal abuse was initiated by the facility on 06/09/25. Review of the SRI revealed CNA #549 was verbally aggressive with Resident #47 on 05/24/25. Review of the facility investigation dated 06/09/25, approximately 16 days after the alleged incident occurred, revealed CNA #542 (witness statement, undated) observed Resident #47 approach the nursing station upset about her medicine and cursing at staff. CNA #542 observed CNA #549 asking Resident #47 to not disrespect staff, stop calling him out of his name using the [expletive] word. CNA #542 revealed Resident #47 walked away and later returned to apologize.Review of an additional witness statement dated 06/10/25, approximately 17 days after the alleged incident occurred, revealed CNA #802 observed Resident #47 arguing with unidentified nurse because she wanted her medications. Resident #47 was observed being loud when CNA #549 told Resident #47 that she didn't have to yell and be rude. Resident #47 was then observed calling CNA #549 out of his name, continuing to be loud.Review of an additional witness statement written by CNA #565, undated, revealed CNA #549 and Resident #47 kept arguing because CNA #549 would not provide care for Resident #47 when working his assignment. CNA #549 would not answer call lights and when Resident #47 came up to ask CNA #549 to do something for her, CNA #549 began to argue with Resident #47. CNA #549 and Resident #47 continued to argue when Resident #47 called CNA #549 a [bitch] and mad he ain't one, when CNA #549 responded by saying Resident #47 had one more mother [expletive] time to call him a [expletive] CNA #549 was then observed to jump at Resident #47 stating he dare her to say it again and he was going to smack the [expletive] out of her. According to the witness statement, Resident #47 did not respond because she was scared. CNA #565 revealed she pulled her phone out to the side of her and was going to attempt to record CNA #549, but he did not do anything. CNA #565 revealed she asked CNA #549 what he was going to do, when CNA #549 stated he was going to smack the [expletive] out of Residebt #47 for disrespecting him. CNA #549 stated he did not give a [expletive] that Resident #47 was a resident and she could go and get whoever she wants to get. Resident #47 calmed down, and later when walking pass CNA #549, Resident #47 stated there go that [expletive] and CNA #549 responded by saying what [expletive] and Resident #47 and CNA #549 started arguing. CNA #565 revealed the unidentified nurse explained to CNA #549 that he could not argue with residents, but CNA #549 stated he didn't give a [expletive] CNA #565 revealed Resident #47 was upset about her medications because staff kept telling her to wait. CNA #565 revealed she observed Resident #47 getting her MiraLAX, when CNA #549 told the unidentified nurse I wouldn't give her [expletive] if I was you and Resident #47 then proceeded to throw the MiraLAX at the unidentified nurse and walked off. Further review of the SRI tracking number 261418 revealed on 06/09/25, the Administrator and DON contacted Resident #47 in regard to the alleged incident. Resident #47 informed the Administrator and DON that after CNA #549 witnessed her interaction with the unidentified nurse about her medications, CNA #549 became verbally aggressive telling her she can't treat others like that. Resident #47 revealed she called CNA #549 a wanna be [expletive] and CNA #549 stated I don't care about this job. Resident #47 revealed she and CNA #549 continued to exchange words until he told Resident #47 to go back to her room and not come back. Resident #47 then stated she would come back if she needed something.Further review of the SRI revealed on 06/09/25, the Admin[TRUNCATED]

Based on review of personnel files and interview, the facility failed to conduct background checks on all employees prior to hire, failed to conduct a review of the Nurse Aide Registry (NAR) for all employees prior to hire, failed to conduct a review of the abuse registry for all employees prior to hire, failed to conduct professional or personal reference checks for all employees prior to hire, and failed to maintain the background check log in a complete and accurate manner. This had the potential to affect all 45 residents residing in the facility.Findings include:1. Review of the personnel file for Certified Nursing Assistant (CNA) #549 revealed a hire date of 03/04/25. There was no evidence in the personnel file that the following were completed for CNA #549 prior to hire: background check, abuse registry check, nurse aide registry (NAR) check, and reference checks. In addition, CNA #549 had received disciplinary action write-ups for unsatisfactory work performance on 03/21/25, impeding other staff from performing their work duties on 04/16/25, use of profane or inappropriate or abusive language and inappropriate or unprofessional conduct behavior toward residents or visitors or employees on 06/18/25, and a deliberate non-performance of work duties on 07/16/25.Review of the facility's background check log revealed CNA #549 was not listed on the log for March 2025, which indicated no background check was completed.On 11/13/25 at 8:20 A.M., an interview with Human Resources (HR) Director #509 confirmed reference checks were not completed prior to hire. She stated reference checks were not completed because they could proceed with hiring individuals as long as two attempts had been made to complete the reference checks. HR Director #509 confirmed there was no evidence that NAR checks and abuse registry checks were completed.On 11/13/25 at 8:28 A.M., an interview with HR Director #509 confirmed CNA #549 was not on the background check log for March 2025 and there was no evidence in the personnel file that a background check had been completed. HR Director #509 stated CNA #549 was a re-hire and that a new background check should have been completed at the time of re-hire. HR Director #509 also stated CNA #549 had been involved in multiple self-reported incidents (SRIs) for abuse allegations and had multiple disciplinary action write ups in his file.On 11/13/25 at 1:14 P.M., an interview with Regional Director of Operations (RDO) #567 said in the past for reference checks, they attempted to call twice and the attempts were documented if there was no answer.On 11/13/25 at 1:21 P.M., an interview with the Administrator stated she did not know what the abuse registry was and said she thought it was the same thing as the NAR.2. Review of the personnel file for CNA #541 revealed a hire date of 06/18/24. There was no evidence in the personnel file that a background check and reference checks were completed for CNA #541 prior to hire.Review of the facility's background check log revealed CNA #541 was not listed on the log for June 2024, which indicated no background check was completed.On 11/13/25 at 8:20 A.M., an interview with HR Director #509 confirmed reference checks were not completed prior to hire. She stated reference checks were not completed because they could proceed with hiring individuals as long as two attempts had been made to complete the reference checks. On 11/13/25 at 9:26 A.M., an interview with the Administrator, with Regional Nurse #566 and RDO #567 present in the room, verified CNA #541 was not on the background check log for June 2024.On 11/13/25 at 1:14 P.M., an interview with RDO #567 said in the past for reference checks, they attempted to call twice and the attempts were documented if there was no answer.3. Review of the personnel file for Activities Assistant #821 revealed a hire date of 10/22/24. There was no evidence in the personnel file that the following were completed for Activities Assistant #821 prior to hire: abuse registry check, NAR check, and reference checks. Activities Assistant #821's employment was terminated on 04/18/25 after a verbal altercation with Resident #15.On 11/13/25 at 8:20 A.M., an interview with HR Director #509 confirmed reference checks were not completed prior to hire. She stated reference checks were not completed because they could proceed with hiring individuals as long as two attempts had been made to complete the reference checks. HR Director #509 confirmed there was no evidence that NAR checks and abuse registry checks were completed.On 11/13/25 at 1:14 P.M., an interview with RDO #567 said in the past for reference checks, they attempted to call twice and the attempts were documented if there was no answer.On 11/13/25 at 1:21 P.M., an interview with the Administrator stated she did not know what the abuse registry was and said she thought it was the same thing as the NAR.4. Review of the personnel file for Licensed Practical Nurse (LPN) #501 revealed a hire date of 09/06/05. There was no evidence in the personnel file that the following were completed for LPN #501 prior to hire: background check, abuse registry check, NAR check, and reference checks. LPN #501's orientation and onboarding training documents were signed and dated 11/11/25.Review of the facility's background check log revealed the log only included individuals hired from 2022 through 2025. There was no indication there was a background check log for anyone hired prior to 2022.On 11/12/25 at 1:56 P.M., an interview with LPN #501 stated management told her on 11/11/25 that they could not find her files and she had to sign all those documents again.On 11/12/25 at 2:01 P.M., an interview with HR Director #509 stated she had only been in the position for three months, and previous HR Director #822 did not maintain the files. HR Director #509 said she was in the process of going through employee files to fill in any missing information and confirmed LPN #501's file was missing almost everything. HR Director #509 said she re-educated LPN #501 on 11/11/25 and had LPN #501 sign all the paperwork again on that day. HR Director #509 confirmed there was no evidence of any abuse or neglect training in LPN #501's personnel file prior to 11/11/25. In an attempt to prove that LPN #501 had a background check, HR Director #509 opened the envelope labeled confidential that was in LPN #501's personnel file and discovered the enclosed background check did not belong to LPN #501. HR Director #509 was unable to provide evidence that a background check had been completed for LPN #501.On 11/12/25 at 3:48 P.M., an interview with the Administrator confirmed most of LPN #501's paperwork in the personnel file was signed on 11/11/25. The Administrator stated LPN #501 had worked at the facility for years and her personnel file had been lost due to multiple changes in ownership.On 11/13/25 at 8:20 A.M., an interview with HR Director #509 confirmed reference checks were not completed prior to hire. She stated reference checks were not completed because they could proceed with hiring individuals as long as two attempts had been made to complete the reference checks. HR Director #509 confirmed there was no evidence that NAR checks and abuse registry checks were completed.On 11/13/25 at 9:26 A.M., an interview with the Administrator, with Regional Nurse #566 and RDO #567 present in the room, confirmed the provided background check log did not include anyone hired prior to 2022.On 11/13/25 at 1:14 P.M., an interview with RDO #567 said in the past for reference checks, they attempted to call twice and the attempts were documented if there was no answer.5. Review of the personnel file for [NAME] #825 revealed a hire date of 10/04/23. There was no evidence in the personnel file that the following were completed for [NAME] #825 prior to hire: abuse registry check, NAR check, and reference checks. On 11/13/25 at 8:20 A.M., an interview with HR Director #509 confirmed reference checks were not completed prior to hire. She stated reference checks were not completed because they could proceed with hiring individuals as long as two attempts had been made to complete the reference checks. HR Director #509 confirmed there was no evidence that NAR checks and abuse registry checks were completed.On 11/13/25 at 1:14 P.M., an interview with RDO #567 said in the past for reference checks, they attempted to call twice and the attempts were documented if there was no answer.On 11/13/25 at 1:21 P.M., an interview with the Administrator stated she did not know what the abuse registry was and said she thought it was the same thing as the NAR.6. Review of the personnel file for LPN #824 revealed a hire date of 06/25/24. There was no evidence in the personnel file that the following were completed for LPN #824 prior to hire: abuse registry check, NAR check, and reference checks. Review of the facility's background check log revealed LPN #824 was not listed on the log for June 2024.On 11/13/25 at 8:20 A.M., an interview with HR Director #509 confirmed reference checks were not completed prior to hire. She stated reference checks were not completed because they could proceed with hiring individuals as long as two attempts had been made to complete the reference checks. HR Director #509 confirmed there was no evidence that NAR checks and abuse registry checks were completed.On 11/13/25 at 1:14 P.M., an interview with RDO #567 verified the NAR review for LPN #824 was timestamped 11/13/25 at 10:47 A.M. and RDO #567 stated at least we did it today. RDO #567 confirmed LPN #824 was not on the background check log for June 2024.On 11/13/25 at 1:14 P.M., an interview with RDO #567 said in the past for reference checks, they attempted to call twice and the attempts were documented if there was no answer.7. Review of the personnel file for CNA #558 revealed a hire date of 09/23/25. There was no evidence in the personnel file that reference checks were completed for CNA #558 prior to hire. The reference check forms indicated contacts were unable to be reached.On 11/13/25 at 8:20 A.M., an interview with HR Director #509 confirmed reference checks were not completed prior to hire. She stated reference checks were not completed because they could proceed with hiring individuals as long as two attempts had been made to complete the reference checks. On 11/13/25 at 1:14 P.M., an interview with RDO #567 said in the past for reference checks, they attempted to call twice and the attempts were documented if there was no answer.8. Review of the personnel file for CNA #554 revealed a hire date of 09/23/25. There was no evidence in the personnel file that reference checks were completed for CNA #554 prior to hire. The reference check forms indicated contacts were unable to be reached.On 11/13/25 at 8:20 A.M., an interview with HR Director #509 confirmed reference checks were not completed prior to hire. She stated reference checks were not completed because they could proceed with hiring individuals as long as two attempts had been made to complete the reference checks. On 11/13/25 at 1:14 P.M., an interview with RDO #567 said in the past for reference checks, they attempted to call twice and the attempts were documented if there was no answer.This deficiency was an incidental finding identified during the complaint investigation.

Based on record reviews, observations, interviews, review of personnel files, review of facility self-reported incident (SRIs), and facility policy review, the facility failed to be administrated in a manner that uses its resources effectively and efficiently to ensure resident safety, prevent neglect, as evidenced by the failure to provide proper wound care and ensure physician oversight for Residents #20 and #46, failure to conduct required pre-employment criminal background checks, Nurse Aise Registry (NAR) checks, abuse registry checks, and personal and professional background checks, failure to maintain an accurate background check log; failure to thoroughly investigate allegations of abuse, neglect, and misappropriation involving Residents #37, #41, and #50; and failure to maintain a safe environment free from illicit drugs, placing Residents #6, #7, and #12 at risk. This deficient practice demonstrated significant breakdowns in administrative oversight and had the potential to affect all 45 residents residing in the facility.Findings include: 1. During the complaint and partial extended survey, observations, record reviews and interviews resulted in concerns including but not limited to situations of neglect, resulting in Immediate Jeopardy and Substandard Quality of Care (SQC).The facility failed to provide proper wound care and ensure physician oversight for Residents #20 and #46 to prevent incidents of neglect.These concerns resulted in Immediate Jeopardy and actual harm on 10/21/25 when Nurse Practitioner (NP) #500 first identified a worsening wound to Resident #46's left lateral foot resulting in hospitalization with severe sepsis and on 10/23/25 when the facility failed to identify and treat a right leg diabetic ulceration to his right heel for Resident #20 resulting in hospitalization and right above the knee amputation. The lack of systematic, comprehensive and effective skin management program resulted in situations of neglect for Resident #46 and Resident #20.2. A situation of SQC (that did not rise to an Immediate Jeopardy level) was also identified on 11/13/25 when Human Resources (HR) Director #509 confirmed there was no evidence that NAR checks, background checks and abuse registry checks were completed for Certified Nursing Assistant (CNA) #549, who she confirmed had been involved in multiple SRIs for abuse allegations and had multiple disciplinary action write ups in his employee file, and confirmed background checks, abuse registry checks, NAR checks and/or reference checks were not completed for multiple staff, including CNAs #541, #554 and #558, Licensed Practical Nurses (LPNs) #501 and #824, Activity Assistant ##521 and [NAME] #825.3. Review of the facility SRIs revealed situations of alleged abuse, neglect and misappropriation were not thoroughly investigated including: a.) Review of the SRI tracking number (#) 264751 dated 09/02/25, labeled as neglect, revealed Resident #37 had $353 missing. Review of the facility investigation revealed similar residents at the facility were interviewed as well as two residents from the assisted living which is in an attached building. There were no staff interviewed to attempt to determine what happened to Resident #37's missing money. The Administrator stated she had not interviewed staff related to Resident #37's missing money and had not carried out a thorough investigation related to Resident #37's missing money. b.) Review of SRI tracking #261288 dated 06/05/25 revealed Resident #41 was outside smoking when he began arguing with Resident #55, an assisted living (AL) resident. During the exchange Resident #41 fell to the ground and reportedly poked Resident #55 in the eye. The facility unsubstantiated physical abuse occurred. The investigation revealed no evidence of the incident in Resident #41's medical record, no evidence of an assessment of Resident #41, and no evidence vital signs were obtained. Witness statements included in the investigation were conflicting; some saying Resident #41 did poke Resident #55 in the eye and one clearly indicating Resident #41 did not poke Resident #55 in the eye. The incident was first reported by Therapist #820, and no witness statement was obtained from him. The Administrator verified the investigation was not thorough.c.) Review of SRI tracking #257892 dated 03/05/25 revealed Resident #50 reported his wallet, identification (ID), debit card and $500 was missing from his room. The facility investigated the allegation by interviewing other residents, encouraging Resident #50 to keep important items in a lock box which the resident refused, and interviewing staff who had worked with the resident within the days prior to the allegation. Resident #50 could not recall when the items had gone missing. The facility unsubstantiated the complaint regarding misappropriation. The investigation revealed Resident #50 could not recall the exact date the items went missing, giving as many as three different dates within the week prior. Other residents were interviewed about whether they had seen Resident #50 with a wallet or large sums of money; however, no residents were asked if they had been missing any personal items, other than clothing, or large sums of money. The Administrator confirmed the investigation was not thorough.4. An unsafe environment was identified when a progress note dated 03/30/25 at 12:31 P.M. revealed Resident #7 had an unknown visitor in her room. Registered Nurse (RN) #800 attempted to go inside Resident #7's room, but the door was blocked. RN #800 looked through the crack in the door and observed the unknown visitor sitting down with his penis out with multiple bags of unknown substance and strings on the bedside table. Resident #7's boyfriend, Resident #6, was sitting in his chair on the opposite side of the bed. RN #800 contacted the Administrator and the local police department. Resident #7 was also caught having sex with her narcotic dealer in her room with her roommate, Resident #6, present. Resident's #6 and #7 were caught doing drugs together in their room. Resident #7 refused education on drug use including risk and benefits. No further interventions were provided.In addition, review of the urinary drug screening report, collected on 10/10/25, revealed Resident #12 tested positive for marijuana metabolite (cTHC), methadone, methamphetamine and cocaine metabolite. Review of the psychiatry progress note dated 10/29/25 at 1:00 A.M. revealed Resident #12 admitted to current daily marijuana use. Facility staff reported finding drug paraphernalia in Resident #12's room that was believed to be a cocaine pipe. Review of the nurse practitioner's note dated 11/11/25 at 1:26 P.M. revealed Resident #12 admitted to using crystal methamphetamine, and facility staff reported that Resident #12 had tested positive for cocaine. On 11/18/25 at 1:32 P.M., an interview with NP #500 confirmed drug access in the facility was a common problem among residents, and the facility was not doing anything about it. On 11/18/25 at 3:12 P.M., an interview with the Administrator verified the facility did not have a policy regarding residents testing positive for illicit substances, and their drug policy only indicated the physician would be notified of suspected use. The Administrator confirmed the facility had a contracted drug rehabilitation program in place and she was unable to explain why there was no facility policy addressing confirmed use of illicit substances among residents. On 11/19/25 at 10:13 A.M., an interview with Stepping Stones Qualified Behavioral Health Specialists (QBHS) #809 and #810 confirmed residents in the facility were having major substance abuse issues recently, and the facility had been clear of drugs for one year prior to current concerns. They stated the Administrator was notified of drug use and drug instruments found in resident areas, and the Administrator told them she had to build a case before she could do anything about it. On 11/19/25 at 10:46 A.M., an interview with the Administrator, with Regional Nurse #566 and Regional Director of Operations (RDO) #567 present in the room, verified illicit drug use in the facility had increased over the past several months. The Administrator also confirmed Resident #12 tested positive for methamphetamine on 11/13/25. On 11/19/25 at 2:53 P.M., an interview with the Administrator stated she had called the local police department on 11/04/25 to notify them of an allegation that a resident had $2,000 worth of methamphetamine. The Administrator claimed the dispatcher, whom she was unable to name, stated they would not send any officers to investigate. The Administrator did not provide any evidence of this call.Interview on 11/19/25 at 10:38 A.M. with QBHS #809 and #810 revealed they thought facility administration was not effective in supporting their efforts regarding resident drug and alcohol abuse. Several concerns had been brought to the Administrator, and the response had always been she would need to talk to corporate; there was never follow up from the Administrator beyond that discussion. Both QBHS #809 and #810 confirmed they had weekly meetings with the Administrator, and the DON and ADON #504 would attend when available. They would review residents and concerns regarding drug and alcohol use. The Administrator often took notes but did not seem to follow through with concerns that were discussed in these meetings.Interview on 11/19/25 at 10:46 A.M. with the Administrator revealed she did not feel there were communication concerns with Stepping Stones, and felt concerns brought up by Stepping Stones staff were addressed by facility administration. She denied Stepping Stones brought concerns regarding general care and treatment at the facility to her and confirmed they had weekly meetings but denied there was a formal agenda or summary of the meeting discussions. She was unable to state what concerns had recently been brought to her attention.5. On 11/12/25 at 12:31 P.M. the survey team was notified by Medical Director (MD) #569 he had officially resigned. He revealed there was too much going on at the facility that he was not informed of, and the Administrator could not tell him what his contract said regarding how much notice he had to work after giving notice of resignation.Interview on 11/13/25 at 2:29 P.M with Ombudsman #826 revealed she felt the facility was putting out fires to address concerns that had arisen in the facility; she felt the facility did not often follow through after a change was made, and there was an overall lack of oversight.Interview on 11/19/25 at 11:23 A.M. with RDO #567 revealed in light of the recent survey findings, corporate employees planned to spend more time overseeing the facility and had begun questioning if the clinical team was appropriate for the facility.Interview on 11/19/25 at 1:47 P.M. with the Administrator and Regional Nurse #566 revealed they could provide no evidence that concerns brought to their attention by the survey team including lack of documentation, alleged drug use in the facility, wound care, neglect, customer service and SRI's had ever been addressed through the quality assurance or QAPI program. They confirmed none of these issues have been identified by anyone in administration prior to the current survey. The Administrator confirmed the facility had not been working on any specific areas of improvement for several months. Review of the Administrator's personnel file revealed a hire date of 07/15/24. Review of the undated facility Job Description for the Administrator revealed the primary purpose of the position was to direct the day-to-day functions of the facility in accordance with federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure the highest degree of quality care can be provided to residents at all times. The description revealed that the Administrator was expected to plan, develop, organize, implement, evaluate and direct the facilities' programs and activities in accordance with guidelines issued by the Regional Director of Operations, and assist department directors in the development, use and implementation of departmental policies and procedures and professional standards of practice. The Administrator signed the job description on 07/15/24.Review of the undated Job Description for the DON revealed the primary purpose of the position was to provide direct nursing care to the residents, to supervise the day-to-day nursing activities performed by certified nursing assistants (CNAs), monitor the performance of CNAs and unlicensed personnel and to provide education and counseling. Supervision would occur in accordance with current federal, state and local standards, guidelines and regulations that govern the facility to ensure the highest degree of quality care is maintained at all times. The DON signed the job description, but it was undated.This deficiency was an incidental finding identified during the complaint investigation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, interview, and policy review, the facility failed to provide necessary intervention, including a bed of appropriate size for Resident #56 to prevent a fall with injury during personal care. Actual harm occurred on 12/16/24 when Resident #56, who was dependent on staff for incontinence care and personal hygiene sustained a fall out of bed while staff were providing incontinence care, resulting in a distal fracture to the end of her right femur and a closed distal fracture to the end of her left femur. The facility identified the resident needed a king bariatric bed rather than a queen (bed) as the root cause of the fall. This affected one resident (#56) of three residents reviewed for accidents. Findings include: Review of Resident #56's closed medical record revealed the resident was admitted on [DATE] and discharged on [DATE] with diagnoses including morbid obesity, major depressive disorder and poly osteoarthritis. Review of Resident #56's physician orders revealed an order dated 04/02/24 to use a mechanical (Hoyer) lift for transfers with two staff members; an order dated 07/03/24 for bilateral assist bars to the bed to enhance bed mobility per the resident's request every shift; and an order dated 08/29/24 for a low air loss mattress to the bed. Review of Resident #56's Occupational Therapy Discharge Summary from services provided 07/09/24 to 08/16/24 revealed the resident's highest practical level was achieved. The discharge recommendations indicated to discharge with staff assistance and the resident continuing with help. A restorative program was not indicated. The resident was independent with eating, setup/cleanup assistance with oral hygiene, dependent with toilet hygiene, required substantial/maximal assistance with dressing the upper body, was dependent with dressing the lower body, dependent with washing, dependent with showering/bathing and dependent with putting on and removing footwear. Review of Resident #56's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition; had no impairment on the upper extremities; impairment on both sides on the lower extremities; used a wheelchair mobility device; and was dependent (on staff) for showering, toileting, dressing and personal hygiene. Review of Resident #56's progress note dated 12/16/24 at 5:38 P.M. authored by Licensed Practical Nurse (LPN) #821 revealed the resident was being provided care and turned and repositioned. The resident slid) off the mattress and the certified nursing assistant (CNA) assisted her to the floor. The resident landed on one knee and complained of pain. She was transferred to the hospital. Review of Resident #56's Witnessed Fall form dated 12/16/24 at 5:00 P.M. revealed the resident was getting care and being turned and repositioned when she slid off the mattress and the CNA assisted her to the floor. Review of Resident #56's fall witness statement form dated 12/16/24 authored by CNA #845 revealed as the staff were changing the resident, she went to roll over and slid off the mattress and was guided down to the floor. Review of Resident #56's fall witness statement dated 12/16/24 authored by CNA #864 revealed when the staff were cleaning up the resident, she turned to the side and slid, and CNA #845 guided her to the floor. Review of an Orthopedic Surgery Consultation Note dated 12/16/24 at 9:27 P.M. revealed Resident #56 was evaluated for bilateral distal femur fractures sustained after a ground level fall. The resident had a past medical history of severe morbid obesity with a weight of 207.7 kilograms (kg) or 456.9 pounds. The resident stated she sustained a fall when her cleaning care was trying to get her out of bed, and she fell on both of her knees. The resident stated she had been bedbound for the past four years in which she used a wheelchair for two of those years. The resident was told she needed surgery; however, she declined the surgery after a thorough conversation about the risks and benefits of proceeding with the surgery versus declining the surgery. Review of Resident #56's progress note dated 12/17/24 at 2:34 A.M. authored by LPN #876 revealed the resident was admitted (to the hospital) for sepsis, distal fracture to the end of the right femur and a closed distal fracture to the end of the left femur. Interview on 01/06/25 at 7:32 A.M. with LPN #821 revealed on 12/16/24, staff were providing incontinence care for Resident #56 when the resident slid off the mattress and onto the floor. LPN #821 revealed more than one staff member was in the room with Resident #56, however CNA #845 was the resident's main caregiver at the time of the fall. LPN #821 confirmed Resident #56 had half side rails and her feet slid from the bed when the staff rolled her. Interview 01/06/25 at 8:11 A.M. with Therapy Supervisor #856 revealed Resident #56 required maximum assistance with activity of daily living (ADL) care and stated there were usually at least two staff required to assist the resident. Telephone interview on 01/06/25 at 3:24 P.M. with CNA #845, a CNA identified to be assisting with Resident #56's care on 12/16/24 when the resident fell out bed revealed there were three staff including herself who were providing care to the resident at the time of the incident. She stated CNA #864 and CNA Agency #983 were in the room with her and they were on one side of the bed while she was on the other. CNA #845 stated CNA #864 and CNA Agency #983 rolled Resident #56 towards her and the resident's foot and leg slipped off the bed and she was unable to hold the resident upright. The resident fell to the floor on one knee and was then lowered to the floor. The CNA denied the resident's half bed rail broke at the time of the incident. During the interview, the CNA revealed she was unsure how many staff members were required to provide care to Resident #56, but stated there were usually three to four staff members who were needed to assist with rolling the resident (in bed). During the interview CNA #845 stated she felt the resident needed a bigger bed. Telephone interview on 01/06/25 at 3:45 P.M. with CNA #864, who was also identified to be assisting with Resident #56's care on 12/16/24 revealed she was in the room with CNA #845 providing care (there were a total of three staff members present) and when the resident was rolled (in bed), her leg slipped out of bed and the resident went down to the floor on one knee. CNA #864 stated CNA #845 attempted to help the resident to the floor by guiding her with her body. She stated after the incident, they had the nurse evaluate the resident. Interview on 01/07/25 at 9:38 A.M. with the Director of Nursing (DON) revealed Resident #56 had a care plan in place for two or more staff for assistance with bed mobility and incontinence care and stated there were always more than two assisting. Review of a facility quality assurance program improvement plan related to Resident #56 and the fall sustained on 12/16/24 revealed the facility identified the resident needed a king bariatric bed rather than a queen (bed) as the root cause of the fall. Review of the Managing Falls and Fall Risk policy revised 08/2024 indicated the staff, with the input of the attending physician or nurse practitioner as needed, would implement a fall prevention plan to reduce the specific factor(s) of falls for each resident at risk or with a history of falls. This deficiency represents non-compliance investigated under Complaint Number OH00160814 and Complaint Number OH00160613. The deficient practice was corrected on 12/18/24 when the facility implemented the following corrective actions: On 12/16/24 the Administrator and Director of Nursing (DON) initiated a Quality Assurance and Performance Improvement (QAPI) plan to address Resident #56's fall. On 12/17/24 Resident #56 was transferred to the emergency room (ER). On 12/17/24 the DON ordered a new larger bed for Resident #56 that was delivered on 12/18/24. On 12/17/24 a whole house audit was completed to ensure appropriate mattress surface for bed mobility for all residents. From 12/17/24 to 12/18/24 staff education was completed related to bed mobility and safety concerns. From 12/18/24 to 01/10/25 staff interviews were completed to address if they felt they had enough room to turn residents in bed, with no issues noted. From 12/20/24 to 01/10/25 continuing audits were to ensure the corrective actions were effective, with no issues noted.

Based on record review and interview the facility failed to ensure Resident #28 received pain medication as ordered by the physician in a timely manner. This affected one out of seven residents reviewed for medication administration. The facility census was 45. Actual harm occurred when Resident #28, a newly admitted resident with significant injury resulting from a MVA, did not receive ordered narcotic pain medication for approximately 17.5 hours resulting in a lack of effective pain relief, nausea and severe pain for an extended period of time. Findings include: Record review revealed Resident #28 was admitted on [DATE] with diagnoses of thoracic vertebrae fracture, fracture of one left sided rib, fracture of the left fibula shaft resulting from a motor vehicle accident (MVA), intervertebral disc degeneration of the lumbar region, mild cognitive impairment, bone density disorder, urinary incontinence and depression. A review of Resident #28's nursing progress dated 04/17/23 indicated Resident #28 arrived to the facility and transferred to her bed. Resident #28 had bruising and skin tears to both arms, left knee sutures and a right leg splint. The nursing progress note indicated Resident #28 had a lot of bruising on hands, neck, lower abdomen, and left rib. The nursing progress note indicated Resident #28 had moderate pain and the physician was notified. A review of Resident #28's physician orders indicated an order dated 04/17/23 to administer Morphine 15 milligrams (mg) orally two times a day for pain with a start date of 7:00 P.M. and to administer Roxicodone 5 mg every six hours as needed for moderate pain for seven days and to start at 6:30 P.M. on 04/17/23. Review of Resident #28's Medication Administration Record (MAR) dated 04/01/23 to 04/30/23 indicated Resident #28 received a dose of acetaminophen 500 mg orally at 10:00 P.M. on 04/17/23. Resident #28 received the first dose of Roxicodone at 8:32 A.M. on 04/18/23 with a 10 out of 10 pain score (severe pain). The pain medication Morphine 15 mg to administer orally upon rising and at bedtime was not administered at bedtime on 04/17/23 or in the morning on 04/18/23. The MAR indicated the morphine medication was not available in the facility. An interview with Resident #28 on 04/18/23 at 5:10 P.M. indicated the facility was not ready when she arrived to the facility. Resident #28 stated she was in severe pain for over 12 hours without relief and only received acetaminophen (Tylenol) once which did not give her relief. Resident #28 indicated the staff had informed her she would need to wait for the narcotic pain medications (Morphine, Roxicodone) to be delivered the following morning because the medications were not available until pharmacy delivered them to the facility. An interview with Resident #28's caregiver on 04/18/23 at 5:19 P.M. indicated the caregiver walked in the Resident #28's room at approximately 8:30 P.M. to 9:00 P.M. on 04/17/23 and found Resident #28 with the bed completely lowered to the floor, soaking wet with urine, cold, and complaining of pain. Resident #28's caregiver stated the call light was sounding. Resident #28 informed the caregiver she wanted to leave the facility. Resident #28's caregiver stated she agreed to stay the night with Resident #28 to ensure she was cared for properly. The next morning on 04/18/23 the nurse informed her she was unable to administer Resident #28's narcotic pain medication (morphine, Roxicodone) due to the pharmacy had not delivered the medications to the facility yet. Resident #28's caregiver stated Resident #28 was nauseated and in severe pain by the time she finally received her first dose of pain medication in the morning on 04/18/23. An interview with Resident #28's sister on 04/18/23 at 5:36 P.M. indicated Resident #28 had not received her medications and was complaining of pain. The last dose of pain medication Resident #28 received was on 04/17/23 at 3:00 P.M. in the hospital. Resident #28's sister indicated Resident #28 had been in a motor vehicle accident and had numerous injuries and bone fractures and needed her pain medication. An interview with Licensed Practical Nurse (LPN) #62 on 04/19/23 at 10:07 A.M. indicated the pharmacy delivered medications approximately 24 hours after a resident was admitted . LPN #62 stated Resident #28's medications did not arrive until 7:00 A.M. on 04/18/23. LPN #62 indicated licensed nurses who were employed by the facility could remove pain medication and other significant medication from the secured medication storage by using their fingerprint. LPN #62 was employed by a staffing agency and was unable to remove medications from the secured medication storage, only licensed nurses employed by the facility were able to withdraw medications from the secured medication storage system. The agency nurses were required to ask a licensed nurse from the facility to withdraw medications from the secured medication storage system. LPN #62 stated during the night shift from 7:00 P.M. to 7:30 A.M. when there were only licensed nurses employed by the agency working in the facility, there was no one to ask to remove medications from the secured storage system and the resident had to wait until pharmacy delivered the medications to the facility. An interview with Regional Registered Nurse and Director of Nursing (DON) on 04/18/23 at 10:45 A.M. verified Resident #28 did not receive her physician ordered narcotic pain medication in a timely manner. An interview with State tested Nursing Assistant (STNA) #64 on 04/19/23 at 6:40 A.M. indicated she was working from 7:00 P.M. to 7:00 A.M. on the night Resident #28 was admitted to the facility. STNA #64 stated when the previous shift STNA had given her report she failed to alert her of Resident #28's admission earlier in the evening. STNA #64 was unaware Resident #28 needed assistance. STNA #64 stated Resident #28's caregiver arrived and informed the staff of the lack of pain medications available to administer to relieve Resident #28's pain. STNA #64 stated she provided incontinence care and tried to make Resident #28 as comfortable as possible. An interview with LPN #54 on 04/19/23 at 7:00 P.M. indicated she was assigned to care for Resident #28 during the night shift hours from 7:00 P.M. to 7:30 A.M. on 04/17/23 and stated Resident #28 was upset because her bed was not working and her room was cold. LPN #54 received report from the previous nurse who cared for Resident #28. LPN #54 indicated she was employed by a staffing agency and was unable to remove Resident #28's pain medications from the secured medication storage system and there was no licensed nurses employed by the facility available to request they remove the pain medications from the secured medication system. LPN #54 stated she called the pharmacy at approximately 4:00 A.M. for the Roxicodone pain medication to be delivered as soon as possible and the pain medication arrived at 7:30 A.M. on 04/18/23. LPN #54 stated she administered Resident #28 Tylenol for pain earlier in the evening on 04/17/23 which was somewhat effective and tried to keep her as comfortable as possible. Review of the facility policy and procedure titled Medication Administration dated 06/21/17 indicated medications would be administered by legally-authorized and trained persons in accordance with applicable, State, Local and Federal laws and consistent with acceptable standards of Practice. If a medication was unavailable, contact the pharmacy and document accordingly. This deficiency represents non-compliance investigated under Complaint Number OH00141465.

Based on observation, interview, record review, and review of facility policy on wound care, the facility failed to obtain diagnostic testing as ordered to identify and treat a possible infection of Resident #31's Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer of the sacrum. Actual harm occurred on 02/06/23 when Resident #31 was sent to the emergency room and admitted to the hospital for an infection of the sacral wound. This affected one (Resident #31) of two residents reviewed for pressure ulcers. The census was 41. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses including stage four pressure ulcer of the sacral region, history of osteomyelitis of the vertebra in the sacral and sacrococcygeal region, altered mental status, and anxiety disorder. Review of the Braden Scale Assessment, dated 11/22/22, revealed Resident #31 scored an 11 and was at high-risk for pressure ulcers. Review of the weekly skin assessment, dated 11/23/22, revealed Resident #31 had a sacral wound on admission. Review of the comprehensive Minimum Data Set (MDS) Assessment, dated 11/28/22, revealed Resident #31 was severely cognitively impaired and required extensive assistance or total dependence for activities of daily living (ADL). The assessment also indicated Resident #31 was at-risk for developing pressure ulcers and had one stage four pressure ulcer. Review of the wound care center notes, dated 12/05/22, revealed Resident #31's sacral wound was a Stage IV pressure ulcer, had exposed muscle, the wound bed was pink, there was a medium amount of serosanguinous (thin and watery fluid) drainage, and the wound measured 8 centimeters (cm) in length, 3 cm in width, and 1.5 cm in depth. Review of the care plan revised 01/17/23 revealed Resident #31 had pressure ulcers due to decreased hemoglobin and hematocrit, impaired nutrition, immobility, and non-compliance, she was admitted with a stage four pressure ulcer to the sacrum, and she received pro-stat twice daily. Interventions included administer medications as ordered, administer treatments as ordered, monitor wound healing and measure when possible, assess and document status of wound healing progress, report improvements and declines to the physician, educate resident on causes of skin breakdown, follow facility policies for the treatment of skin breakdown, inform resident and family of new skin breakdown, provide supplements as ordered to promote wound healing, monitor dressing to ensure it adheres, report loose dressing to the nurse, provide diet as ordered, report signs of infection to physician, obtain and monitor diagnostic work as ordered, report diagnostic results to physician and follow up as indicated, and treat pain per orders. Review of the wound care center notes, dated 01/23/23, indicated Resident #31's sacral wound was deteriorating, the wound bed consisted of pink tissue and slough, there was exposed muscle and bone, and there was a medium amount of serosanguinous drainage. A wound culture and x-ray were ordered to rule out osteomyelitis. Review of the physician's orders identified orders dated 01/23/23 for a sacral wound culture to be obtained at the bedtime dressing change and a sacral x-ray to rule out osteomyelitis. Review of the x-ray results, dated 01/23/23, for Resident #31 indicated there was no intrinsic bony abnormality and the soft tissues were unremarkable. There was no evidence the physician was notified of the results. Review of the medical record for Resident #31 revealed no wound culture results for 01/23/23 were identified. Review of the wound evaluation flow sheet, dated 01/25/23, indicated Resident #31's sacral wound was pink in color with no signs of infection and measured at 7 cm in length, 6 cm in width, and 3.5 cm in depth. Review of the wound care center notes, dated 01/30/23, indicated Resident #31's sacral wound was deteriorating, there was a medium amount of serosanguinous drainage, and there was a foul odor noted. The wound bed was 25% pink, 25% slough, and 50% necrotic tissue with exposed bone and muscle. A wound culture and x-ray were ordered to rule out osteomyelitis. Review of the wound evaluation flow sheet, dated 01/30/23, indicated Resident #31's sacral wound was pink in color, necrotic, and measured at 8 cm in length, 8 cm in width, and 4 cm in depth. Review of the physician's orders dated 01/30/23 identified orders for a lumbar sacral x-ray for osteomyelitis. Review of the x-ray results, dated 01/30/23, indicated there was degenerative changes at the L2 and L3 vertebrae and the paravertebral tissues (non-bony tissues around the vertebrae) were unremarkable. There was no evidence the physician was notified of the results. Review of the physician's orders dated 01/31/23 identified orders for a wound culture of sacrum. Review of the medical record for Resident #31 revealed no wound culture results for 01/31/23 were identified. On 02/06/23 at 11:35 A.M., observation of Resident #31 revealed she was screaming loudly while the wound care team was providing care including Resident #31's dressing change. On 02/06/23 at 12:05 P.M., observation of Resident #31's room revealed emergency medical services (EMS) was transporting her to the emergency room . Interview at the time of observation with Licensed Practical Nurse (LPN) # 501 revealed Resident #31 was being sent to the emergency room for wound care and possible osteomyelitis. Review of the wound care center notes, dated 02/06/23, indicated Resident #31's sacral wound was deteriorating, there was a medium amount of serosanguinous drainage, and there was a foul odor noted. The wound bed was 25% pink, 25% slough, and 50% necrotic tissue with exposed bone and muscle. The wound care center ordered to send Resident #31 to the hospital for osteomyelitis with bone palpable, malodorous, necrotic tissues, and to check for sepsis. Review of the wound evaluation flow sheet, dated 02/06/23, indicated Resident #31's sacral wound was pink in color with no infection, there was a foul odor, and the tissue was necrotic with bone prominent. The wound measured at 11 cm in length, 18 cm in width, and 3.5 cm in depth. Review of the progress note dated 02/06/23 at 2:06 P.M. revealed Resident #31 was sent to the emergency room for deterioration of the sacral wound with malodorous and necrotic tissue, osteomyelitis, and bone palpable. Review of the progress note dated 02/06/23 at 11:04 P.M. revealed Resident #31 was admitted to the hospital due to a wound infection. On 02/08/23 at 4:35 P.M., interview with Assistant Director of Nursing (ADON) #600 verified Resident #31 was sent to the emergency room for further evaluation of her wound. She also verified the wound evaluation flow sheet completed on 02/06/23 at 2:09 P.M. indicated Resident #31's sacral wound was pink in color with no infection. ADON #600 stated that assessment was incorrect because Resident #31 did have signs of infection, the wound was gray in color and malodorous. On 02/13/23 at 12:40 P.M., interview with Wound Nurse Practitioner (NP) #507 confirmed Resident #31's sacral wound had signs of infection and she had ordered wound cultures on 01/23/23 and 01/31/23 that the facility never completed. She also stated the facility never reported x-ray results to her after she ordered x-rays to rule out osteomyelitis. Wound NP #507 stated when she observed Resident #31's sacral wound on 02/06/23, it was getting worse and she ultimately sent Resident #31 to the emergency room for wound evaluation because the facility did not complete the diagnostic tests as ordered. On 02/13/23 at 2:56 P.M., interview with the Director of Nursing (DON) verified no wound cultures were completed for Resident #31's sacral wound. On 02/14/23 at 11:06 A.M., interview with Resident #31's sister stated her sacral wound was improving prior to admission to the facility and she does not feel the facility was providing appropriate care and treatment to treat the wound. She stated Resident #31's wound continued getting worse while a resident of the facility and that she ended up in the hospital because the wound got infected. Review of facility policy titled Wound Care Policy and Procedure, dated 08/2022, indicated wound treatments would be completed per physician orders. Review of facility policy titled Wound Treatment Management, dated 03/2021, indicated treatments would be provided in accordance with physician orders, treatments would be based on the type of wound and characteristics of the wound (including the presence of infection or need to address bacteria), the facility would follow specific physician's orders for providing wound care, and the changes of wound characteristics would be monitored to determine if modifications in treatments were needed.