Every finding on record at The Reserve at Spring Hill

Based on policy review, medical record review, hospital record review and interview, the facility failed to ensure residents received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection for residents determined to be at risk of skin breakdown for 1 of 3 (Resident #85) sampled residents reviewed for wounds. Resident #85 was admitted to the facility on [DATE], and readmitted on [DATE], with a right elbow surgical site wound and the use of a single use negative pressure wound therapy system dressing (Named system that uses vacuum suction to promote healing, generally kept in place for 7 to 14 days) covered by a soft splint. The facility failed to obtain orders for wound care to the site at the time of Resident #85's readmission to the facility on [DATE], or during the resident's stay at the facility, resulting in no assessment of the wound or wound care being administered to the right elbow surgical site for 67 days between 11/25/2025 and 2/2/2026. The facility's failure to obtain orders, assess, monitor, and provide and document treatments to Resident #85's right elbow, resulted in actual harm, when Resident #85 was admitted to the hospital on [DATE] and underwent a Right Olecranon (right tip of the elbow) hardware removal and bone debridement (scraping of the bone to remove infection and dead tissue related to infection) on 2/6/2026. The findings include: 1. Review of the facility policy titled, Skin Assessment, dated 1/1/2025, revealed .It is our policy to perform a full body assessment as part of our systematic approach to pressure injury prevention and management.A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified pressure injury.Consider the general status of the resident's skin, color, temperature, moisture status, sensory perception, skin texture/turgor, perfusion.Documentation of skin assessment: include date and time of the skin assessment, your name, and position title, Document observations ( .skin conditions, how the resident tolerated the procedure .). Document type of wound. Describe wound (measure, color, type of tissue in wound bed, drainage, odor, pain). Document other information as indicated or appropriate. Review of the facility policy titled, Transporting a Resident, dated 1/1/2026, revealed .it is the policy of this facility to provide residents safe, non-emergency transportation to doctor's appointments, activity outings, and any other trips the facility deems necessary.Facility will establish a process for requesting transportation and use of facility van/bus.Facility will ensure that residents who require an escort to appointments, due to cognitive or physical limitations, have arrangements made ahead of time. Escort may be a family member, friend, or staff member if availability allows. Review of the undated facility policy titled, Abuse, Neglect and Exploitation, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . 2. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE], with diagnoses including Displaced Fracture of Olecranon Process Right Ulna (a broken elbow tip where the bone fragments have separated), Periprosthetic Fracture around Internal Prosthetic Right Hip Joint (a broken bone around a joint replacement implant), and Cognitive Communication Deficit. Review of the facility Progress Note dated 11/5/2025 at 5:20 PM, revealed Patient [Resident #85] arrived to facility following a fall at home .Patient has open reduction internal fixation [ORIF], bilateral olecranon FX [fracture], non op [operatory] RT [Right] hip periprosthetic FX . Review of the facility Physician's Order dated 11/6/2025, revealed TREATMENT ORDER: Special Instructions: BILATERAL ELBOW SURGICAL DRESSINGS, MAY BE REMOVED IF SOILED OR LOOSE, PER SURGICAL ORDER, LEAVE DRESSING OFF AFTER THAT . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident was moderately cognitively impaired. Resident #85 had recent major surgery with surgical wounds and surgical wound care. Review of the facility Physician's Order for Resident #85's elbow surgical site wound dated 11/10/2025, revealed TREATMENT ORDER: Special Instructions: BILATERAL ELBOW SURGICAL INCISIONS, CLEANSE WITH WOUND CLEANSER, PAT DRY .SKIN PREP [helps medical devices and dressings stick securely while also shielding the wound] PERIWOUNDS [tissue immediately surrounding a wound], APPLY A LYER [LAYER] OF ADAPTIC [a sterile, non-adherent wound dressing that protects healing tissue, reduces pain during changes, and allows wound fluids to pass through to a secondary dressing] AND ABD [ABDOMINAL] PAD. WRAP WITH WHITE ACE WRAP Q [every] PRN [As Needed]. Review of the Medication Administration Record (MAR) Treatment Order revealed Resident #85 received elbow surgical site wound care as ordered on 11/10/2025 and 11/15/2025. Review of the facility Progress Note dated 11/12/2025 at 3:34 PM, revealed .transferred to and from appointment .Type of Appointment: Orthopedic . Review of the family complaint-initiated facility investigation for Resident #85 dated 11/12/2025, revealed facility staff documented, Resident #85 returned from an Orthopedic appointment with orders for a Post Op follow up appointment for bilateral elbow fractures on 11/18/2025 with (Named Orthopedic Surgeon #1) and a follow up appointment for a hip fracture on 12/10/2025 with (Named Orthopedic Surgeon #2). The facility was unsure if the appointment on 11/12/2025 was for Resident #85's elbows or hip or both. Review of the facility Progress Note for Resident #85 dated 11/18/2025 at 6:24 AM, revealed This nurse was made aware in shift change report that patients R [right] elbow has hardware exposure from previous sx [surgery]. Previous shift has steri-striped [thin adhesive strips used to pull the edges of a wound together] and covered area. This nurse contacted patients on call [Named Orthopedic Surgeon #2] for instruction. Awaiting return phone call. Review of the facility Physician's Orders dated 11/18/2025, revealed Resident #85 was sent to the ER for treatment related to right elbow hardware exposure at prior surgical site. Review of the Hospital History and Physical (H&P) Report for Resident #85 dated 11/18/2025, revealed .Right displaced fracture segment Ulnar olecranon with exposed hardware. Review of the Hospital Physician Attestation Note dated 11/18/2025 at 7:39 PM, revealed .Admit to Medicine and Surgery. Ortho [Orthopedic] consulted .keep NPO [nothing by mouth] for possible procedure in morning. Review of Hospital Orthopedic Surgeon #1's Operative Note for Resident #85 dated 11/19/2025 at 6:50 PM, revealed .An incisional VAC [vacuum] [a device known as a vacuum-assisted closure (VAC) applied over a wound to provide wound therapy to help the wound heal] was placed followed by a long-arm splint with the elbow in extension.plan to keep the incisional VAC for 1 week [11/19/2025 -11/26/2025], we will maintain elbow in full extension in a splint until wound healing has occurred . Review of the Hospital Progress Note, dated 11/21/2025 at 11:09 AM, revealed .s/p [status post or following] wound debridement, revision fixation [surgery to repair or replace previously placed hardware], anconeous rotational muscle [a small, triangular muscle located at the back of the elbow] flap 11/19 [11/19/2025], incisional VAC removal in 1 week, f/u [follow up] outp [outpatient] Tuesday [11/25/2025] if DC [discharged ] prior. Review of the Hospital Discharge Patient Medication Report for Resident #85 dated 11/24/2025 at 2:42 PM, revealed the Resident was discharged back to the facility. Review of the facility Progress Note for Resident #85 dated 11/24/2025 at 10:39 PM, revealed Resident #85 returned to the facility with a negative pressure wound vacuum dressing to the Right elbow. There was no documentation the facility contacted the elbow Orthopedic surgeon for wound care orders for the elbow surgical site. Review of the facility Observation Detail List Report for Resident #85 dated 11/25/2025 at 12:01 PM, by Nurse Practitioner (NP) #2 revealed .Patient was followed by Ortho in the hospital and underwent I&D [incision and Drainage] and revision of the ORIF with possible flap with a wound VAC placed.Patient right upper extremity dressing.Patient with recent wound dehiscence [splitting, bursting, or opening of a closed structure along a natural line or seam] of the right elbow requiring I&D as well as revision. Patient on antibiotic therapy with vancomycin until January. There was no documentation NP #2 followed up with the elbow Orthopedic surgeon for elbow surgical site wound care. Review of a facility Physician's Order for Resident #85 written by the Wound Care Consultant (Wound Nurse) and signed off by NP #1, dated 11/26/2026, revealed .Soft splint to rt. arm, DO NOT REMOVE. Surgical wound vac in place until Ortho [Orthopedic] follow up . There was no documentation NP #1 followed up with the elbow Orthopedic surgeon for elbow surgical site wound care. Review of the facility's admission note for Resident #85 dated 11/26/2025 at 11:02 AM, revealed Head to toe assessment completed. Pt has surgical wound vac to rt (right) upper extremity with a soft splint wrapped with ace wrap in place on admission . There was no documentation of an assessment of the surgical wound site or of the facility's attempt to contact the elbow Orthopedic surgeon for orders for the elbow surgical site wound care. Review of the facility Wound Management Detail Report for Resident #85 dated 11/26/2025 at 11:19 AM, revealed .surgical incision.Observation of surgical incision not done, site covered with surgical dressing . comments: Pt has soft splint to rt arm, surgical wound vac in place under splint. Review of the facility Observation Detail List Report, dated 11/30/2025 at 10:00 AM, by NP #1 revealed .she [Resident #85] continues with wound VAC intact . Review of the facility's Physician's Order for Resident #85 dated 12/2/2025, revealed [Named Wound Care Company] to consult for skin and wound conditions/prevention . Review of the facility's Physician's Progress Note for Resident #85 dated 12/4/2025 at 12:00 PM, revealed .Surgical wound infection status post I&D with ORIF revision on IV antibiotics with vancomycin [antibiotic used to treat severe infections] IV.follow-up with orthopedics .as scheduled . Review of the facility's Progress Note for Resident #85 dated 12/10/2025 at 12:30 PM, revealed Pt left facility to a post-op follow up appointment at [Named Clinic]. Pt is in manual w/c [wheelchair] being transported via facility van. Review of the facility Skin and Wound Note for Resident #85 dated 12/10/2025 at 1:18 PM, revealed .DATE OF SERVICE 12/9/2025.Residents right elbow surgical incision is currently covered by nonremovable wound vac. Dressing currently clean dry and intact. Follow-up with Orthopedic Surgery scheduled for 12/10/2025.There is no evidence of infection today upon assessment. If complications arise, staff understands to contact operating surgeon . Review of the family complaint-initiated facility investigation entry dated 12/10/2025, revealed .Patient had follow up ortho this day. She returned with orders for hip precautions and weight bearing as tolerated via [Named Orthopedic Surgeon #2] . The facility failed to follow up with the Orthopedic Clinic to obtain wound orders and/or obtain an Orthopedic follow-up appointment for the surgical wound to Resident #85's right elbow when she returned from her appointment on 12/10/2025 without wound care orders. Review of the facility's Physician's Progress Note dated 12/11/2025 at 11:00 AM, revealed .Follow-up orthopedics .as scheduled . Review of the facility Skin and Wound Note for Resident #85 dated 12/16/2025 at 1:32 PM, revealed .The patient has a surgical wound to right upper arm which is covered with a cast and acewrap [ace wrap is an elastic, stretchable, and reuseable bandage used to provide controlled, localized compression and support to injured body parts] There is no evidence of infection noted today upon assessment. If complication arise, staff understands to contact operating surgeon. Nonremovable wound vac noted to right upper arm. The surgeon is managing this wound . There was no documentation Wound Care had followed up with the Orthopedic Surgeon for wound care orders for the elbow surgical site. Review of the facility's Physician's Progress Note dated 12/18/2025 at 11:00 AM, revealed .Follow-up orthopedics .as indicated. The facility failed to ensure physician's orders were in place for wound care to the right elbow. The facility was unable to provide documentation Resident #85 received wound care to the right elbow surgical site for 27 days, from 11/24/2025 through 12/22/2025. Resident #85 was hospitalized from [DATE] to 12/25/2025 for an unrelated medical issue. Review of the facility's Physician's Orders for Resident #85 dated 12/24/2025, revealed .[Named Wound Care Company] to consult for skin and wound conditions/prevention .WEEKLY SKIN ASSESSMENT . There was no documentation Wound Care contacted the Orthopedic Surgeon for wound care orders for the elbow surgical site wound. Review of the Progress Note for Resident #85 dated 12/24/2025 at 5:03 PM, revealed report was called from [Named Hospital] .resident should be arriving at [7:00 PM] . Review of the Progress Note for Resident #85 dated 12/25/2025 at 2:40 AM, revealed patient returned from [Named Hospital] at 230 [2:30] ma [AM] this morning . There was no documentation the facility contacted the Orthopedic Surgeon to obtain wound care orders for the surgical wound to the right elbow upon Resident #85's readmission to the facility on [DATE]. Review of the MAR Treatment Order dated December 2025 revealed no treatment orders for the right elbow surgical site from 12/25/2025 through 12/31/2025. A weekly skin assessment was initialed as having been completed on 12/27/2025 with no narrative written to describe what was assessed. Review of the Progress Notes for Resident #85 dated 12/25/2025 through 12/31/2025 revealed there was no documentation related to the right elbow surgical site or the use of a wound vacuum system. Review of the Care Plan for Resident #85 dated 12/29/2025, revealed .Orthopedic - I am at risk for orthopedic complications related to osteopenia [bone density lower than normal], bilateral fracture of olecranon process s/p ORIF, periprosthetic fracture of R hip .Will have no acute orthopedic complications .Orthopedic follow-up as directed .Observe surgical site and report signs and symptoms of infection: redness, drainage, odor, tenderness, swelling, warmth of fever . Review of the facility Physician's Progress Note for Resident #85 dated 1/2/2026 at 12:00 PM, revealed .Cognitive decline, multifactorial in origin .Maintain current medications .Wound care as ordered .Follow-up orthopedics and infectious disease as scheduled .No further issues are noted upon review of the chart or discussion with nursing . There was no documentation the facility was providing elbow surgical site wound care. Review of the facility Progress Notes for Resident #85 dated 1/1/2026 through 1/15/2026, revealed there was no documentation related to the right elbow surgical wound or the use of a wound vacuum system. Review of the facility Observation Detail List Report for Resident #85 written by NP #1 dated 1/16/2026 at 1:00 PM, revealed .Her wound VAC is still in place to right elbow . There was no documentation of an assessment performed of the wound by NP #1. Review of the facility Progress Note for Resident #85 dated 1/20/2026 at 9:09 AM, revealed .Patients family cancelled appointment this day. They were not able to attend the appointment with her. Staff aware. There was no documentation the facility assisted the Resident with an escort in order for the Resident to attend the appointment on 1/20/2026 or followed up with the Orthopedic Surgeon related to orders for wound care to the right elbow. Review of the facility Observation Detail List Report for Resident #85 by NP #2, dated 1/20/2026 at 6:16 PM, revealed .Patient continues to require wound care to right elbow status post infection as well as revision she does have a wound VAC to the surgical incision. Review of the facility Progress Notes for Resident #85 dated 1/21/2026 through 1/31/2026, revealed no documentation related to the right elbow surgical wound or use of a wound vacuum. Review of the facility Progress Note for Resident #85 dated 1/23/2026 at 10:05 AM, revealed .Unit manager called the patient's son regarding her follow up appointment that needs to be re-scheduled. Voicemail left. Waiting on a call back. This is the third phone call to the son for the week. No call back received . The facility failed to provide documentation of attempts to arrange staff escort to appointments to ensure Resident #85 received follow up care to the right elbow surgical wound. Review of the MAR Treatment Order for Resident #85 for the month of January 2026, revealed no treatment orders for the right elbow surgical site from 1/1/2026-1/31/2026. The facility was unable to provide documentation Resident #85 received wound care to the right elbow surgical site for 40 days, from 12/25/2025 through 2/2/2026. Review of the family complaint-initiated facility investigation for Resident #85 entry dated 2/3/2026, revealed .Patient went to ortho follow up via [facility] Van .returned with appointment with note saying surgery 02/06/26 [2/6/2026] with [Named Orthopedic Surgeon #1] . and, stating Resident #85's daughter accompanied her to the Orthopedic appointment that day. On return to the facility the daughter informed the facility Resident #85 would require surgery to her right elbow on 2/6/2026 related to the surgical site wound vac dressing was still intact and it should have already been removed. The facility called the Clinic to obtain further information. Review of the facility Progress Note for Resident #85 dated 2/3/2026 at 3:16 PM, revealed .Per daughter, patient is having surgery on 2/6/2026. No further information is available at this time but daughter will let us know details as soon as they are available . Review of the facility Progress Note for Resident #85 dated 2/5/2026 at 12:34 PM, revealed .Patient is leaving with her daughter in law to be taken to [named Medical Center]. Report has been called to the ER.daughter in law is transporting patient. Review of the Hospital History of Present Illness report for Resident #85 dated 2/5/2026 at 3:46 PM, revealed Patient had bilateral olecranon fracture and underwent ORIF on 10/31/2025 .Right olecranon wound dehiscence with exposed hardware and failure requiring wound debridement, revision fixation and anconeus rotation muscle flap with wound VAC 11/19/25 [11/19/2025] .Reportedly has wound VAC in place for couple of months and noted to have wound infection. She was seen byyyyy [by] [Orthopedic Surgeon #1] on Clinic .Plan is for OR [surgery] tomorrow [2/6/2026] . Review of the Operative Note for Resident #85 dated 2/6/2026, revealed .Procedure .Right olecranon plate removal .Debridement of wound down to bone .She recently developed a new dehiscence of her right olecranon and exposure of the plate . Review of the Hospital's Hospitalist (a medical doctor who specializes exclusively in treating hospital patients) Discharge Summary for Resident #85 dated 2/16/2026 at 1:24 PM, revealed .Right olecranon wound infection .[Orthopedic Surgeon #1] did surgery again on 02/06/2026 [2/6/2026]: Right olecranon plate removal, Debridement of wound down to bone, Skin substitute application .surgical culture grew staph epi [Staphyloccus epidermidis] . During an interview on 5/6/2026 at 8:01 AM, the Administrator was asked what kind of wound vac Resident #85 had. The Administrator stated, .a [Named Brand Negative Pressure Wound Therapy System] drain I believe was on the wound.[Named wound care company] said without orders they would not touch the wound. The Administrator was asked did the staff do a visual assessment of the wound. The Administrator stated, . I'm not sure. The Administrator was asked if it was acceptable for Resident #85 to be in the building without orders for wound care for an extended period of time. The Administrator stated, .she had orders to go out to appointments. During an interview on 5/6/2026 at 12:00 PM, the Unit Manager was asked, when the order not to remove the splint was discontinued on 12/22/2025, by the Medical Director, should someone have gotten orders at that time to look at the right elbow dressing and to take the soft splint off and look at the skin underneath. The Unit Manager stated, .I can't answer that. The Unit Manager was asked, should daily assessments have been started after the order to not touch the soft splint was discontinued. The Unit Manager stated, .Yes, they should have. The Unit Manager was asked, could a nurse have contacted the surgeon and gotten verbal orders to address the right elbow dressing. The Unit Manager stated, .Yes, a nurse could have tried to get a verbal order, the wound care nurse should have made that call. The Unit Manager was asked did anyone try and arrange alternative transportation to the appointment on 1/20/2026 that was canceled due to son not being able to go with Resident #85, could a staff member have gone with the resident. The Unit Manager stated, .The resident has dementia and a family member had to be with her at the appointment.Son is POA [Power Of Attorney] for medical issues, I tried to call several times and left voice mails to reschedule the appointment with orthopedics, finally called daughter and she said she would contact him and have him call me, no call [was] received. I talked to my ADON [Assistant Director of Nursing] and he instructed me to set up the appointment and to call family and let them know [the] date and time.The [Named Facility] van took Resident [#85] to [the] appointment and family met them there on 2/3/2026.The POA was hard to get ahold of. During an interview on 5/6/2026 at 11:21 AM, the Director of Nursing (DON) was asked on 12/22/2025 when the order not to remove the splint was discontinued, should someone have gotten orders to look at the right elbow dressing and to take the soft splint off and look at the skin underneath. The DON stated, .Resident [#85] went to [the] hospital .on 12/22/2025 and returned 12/25/2025, that is why orders were discontinued. We did not receive any new orders for wound care when she came back. A full head to toe assessment should have seen the arm and questioned it. The DON was asked should daily assessments have been started after the order not to touch the soft splint was discontinued. The DON stated, .Yes, should have started assessments on right arm. The DON was asked could a nurse have contacted the surgeon and gotten verbal orders for wound care to the right elbow. The DON stated, .The wound care nurse handles all appointments with wounds, and dressing changes unless it's a weekend, the nurses on the floor do minor wounds during the week but major wounds are handled by the Wound Nurse [Wound Nurse Consultant (WCC)], the floor staff thought the Wound Nurse [WCC] was taking care of everything to do with the wound. The DON was asked did anyone try and arrange alternative transportation when the son could not take the resident to the appointment on 1/20/2026. The DON stated, .Patient has dementia and a family member had to be present with her at the appointment and during transportation.Unit Manager followed up to reschedule appointment on 1/23/2026, left voice mail, no response from son.Unit Manager does transportation arrangements for patients coming from hospital with already set dates for appointments, the Wound Nurse [WCC] does all wound appointments, the Wound Nurse [WCC] would let [the] Unit Manager know if no original follow up appointments with orthopedics were scheduled. The DON was asked did staff call Ortho (orthopedic) and attempt to get wound care orders when the appointment was cancelled due to no transportation, and if not, should they have. The DON stated, . yes, an attempt to get orders should have been made. The DON was asked should an attempt have been made on 11/24/2025 to get orders when resident #85 returned to facility with a wound vac and no orders. The DON stated, .Yes, the nurse should have tried to get orders or have the Unit Manager, or Wound Nurse [WCC] call. During an interview on 5/6/2026 at 1:52 PM, the DON was asked how often a splint should be removed and the area underneath be assessed for skin breakdown and circulation. The DON stated, .once a shift . The DON was asked did the facility have a wound care doctor or company, and if so, did they see this wound. The DON stated, .No. The DON was asked why not. The DON stated .it was a surgical wound with an order not to remove soft splint until follow up appointment; it was relayed to us that [Named Wound Care Company] will not touch a surgical dressing without orders to do so . The DON was asked should someone have called for orders. The DON stated, .Yes, we dropped the ball. The DON was asked do you have wound meetings. The DON stated, .not during that time period .did not have them while we were transitioning after the Prior Wound Care Nurse left, which was before the [Named Brand Negative Pressure Wound Therapy System] dressing was placed. The DON was asked would they have realized this wound was not being assessed or treated by discussing it in these wound care meetings. The DON stated, . we were not aware our new wound care company did not see surgical wounds until this incident occurred . The DON was asked how often do the physician or NP see the wounds. The DON stated, .when asked to, if something is wrong or there has been a change with the wound. The DON was asked did they see this one. The DON stated, .no. The DON was asked did anyone ask them to see this wound. The DON stated, .Not that I'm aware of. During an interview on 5/6/2026 at 1:30 PM, NP #1 was asked did you enter the order on 11/26/2026 for the soft splint not to be removed until after the Ortho follow up. NP #1 stated, .I did not enter it, but I did sign it. NP #1 was asked do you know who entered the order. NP #1 stated . [Named Wound Care Consultant] . NP #1 was asked did you assess Resident #85's wound under the soft splint. NP #1 stated, .No, I did not. NP #1 was asked were you asked to assess the wound and the dressing under the soft splint. NP #1 stated, .No, I was not. NP #1 was asked would you expect the nursing staff to call the orthopedic surgeon for orders for wound care to the surgical site. NP #1 stated, .Yes, we have a wound care NP, but since it's a surgical wound, I would call the surgeon . NP #1 was asked would you expect the nursing staff to do an assessment on the skin and circulation under a soft splint. NP #1 stated, .Yes, expect nursing staff to check pulse, coloring, tightness of splint .wound care nurse [WCC] should be looking at wounds and contacting me if there are any issues . During an interview on 5/6/2025 at 2:21 PM, Registered Nurse (RN) F was asked if someone should have tried to get orders for the care of Resident #85's right arm with surgical wound and vacuum system dressing. RN F stated, .didn't question the act there were no orders, we just kept waiting for her to go back to the doctor, you couldn't see under the splint.I would check if her hand was warm, pink in color. RN F was asked did Resident #85 complain about pain. RN F stated, .she had a hard time articulating [expressing] pain, she would get restless, not very verbal at all. During an interview on 5/6/2025 at 2:30 PM, Licensed Practical Nurse (LPN) A was asked if she had taken care of Resident #85. LPN A stated .took care of her occasionally .she was nonverbal and unable to answer questions .I didn't know she had the [Named Brand Negative Pressure Wound Therapy System] dressing until I had taken care of her several times, and one day I saw the box hanging out of her cast and asked what it was.asked question about it.I asked who was responsible for it.I was told Wound Nurse [WCC].The splint was very loose on her, but you couldn't move it, I tried to look in there one time and you couldn't see anything.I spoke to [the] wound care team, unit manager, I saw something red on the bed and I got the Wound Nurse [WCC].spoke to [Named RN F] and [Named Unit Manager] because it looked like it [the wound] was draining and they said it was spilt [spilled] cranberry juice, then I got [WCC] the Wound Nurse to look at it and she said it was spilt cranberry juice . During an interview on 5/6/2026 at 2:43 PM, Certified Nursing Assistant (CNA) G was asked if Resident #85 could verbally tell you if she was in pain. CNA G stated .she was nonverbal, could not point and show you where the pain was, she was restless and shake like having a panic attack.I was not allowed to touch the cast [splint], you couldn't see anything.some days she was smiling, most days she was agitated.don't want [the] tv on.didn't want to eat During an interview on 5/6/2026 at 3:26 PM, the Administrator was asked when the order not to remove Resident #85's splint was discontinued on 12/22/2025, should someone have gotten orders at that time to look at the right elbow dressing and to take the soft splint off and look underneath. The Administrator stated, .you need to do [a] full observation of [the] resident to get a good idea of what is going on with them. The Administrator was asked should daily assessments have started after the order to not touch the soft splint was discontinued. The Administrator stated .Yes, these should have been done . The Administrator was asked could a nurse have contacted the surgeon and got verbal orders to address the right elbow surgical wound. The Administrator stated .I don't know if you would call this a [an] oversight, there are things we could have done, some things differently, looking back.we did get orders on admission but not orders specific to the right arm site. The Administrator was asked did the facility have Wound Care meetings. The Administrator stated .[Named Prior Wound Care Nurse] stopped working here and a new person [WCC] started and with her learning everything there was a period of time when we didn't meet.[Named Prior Wound Care Nurse] left in October /November and with [Named Prior Wound Care Nurse] gone and the new wound care nurse it was too much for her at the beginning . The Administrator was asked who provided transportation to resident appointments, how was that arranged. The Administrator stated .I'm, not sure who does it. The Surveyor attempted to call the WCC on 5/6/2026 at 12:32 PM, and at 3:04 PM, for a phone interview with no response, voice messages left, no returned call.

Based on facility policy review, medical record review, review of the Controlled Drug Use Record, and interview, the facility failed to properly document narcotic medications signed in error or wasted, and failed to ensure drug destruction sheets were signed by 2 nurses for 3 of 4 (November 2025, December 2025 and January 2026) months reviewed. The findings include: 1. Review of the facility policy titled, Disposal of Medications and Medication-Related supplies, dated 11/18, revealed .When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason .It is destroyed in the presence of two licensed facility personnel as permitted by the regulations, and the disposal is documented on the accountability record/book .The person witnessing the destruction ensures that the following information is entered on the individual controlled substance accountability record/book .Date of destruction .Amount of medication destroyed .signatures of witnesses . 2. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE], with diagnoses including Anxiety, Depression and Pain. Review of the Physician Order dated 1/12/2026, revealed Hydrocodone-Acetaminophen (a medication used to treat pain) 10-325mg. Review of the Controlled Drug Use Record dated 1/12/2026, revealed .[Resident #76] .HYDRO/APAP [Hydrocodone/aspirin used for pain] 10-325MG [milligrams] .Amount Remaining 30 .Amount Removed for Destruction 30 Date: [left blank] Nurses Signature: [Left Blank] Counter Signature: [Unit Manager]. Review of the Controlled Drug Use Record dated 1/12/2026, revealed .[Resident #76] .HYDRO/APAP 10-325MG .Amount Remaining 22 .Amount Removed for Destruction 22 Date: [left blank] Nurses Signature: [Left Blank] Counter Signature: [Unit Manager]. Review of the Physician Order dated 1/12/2026, revealed Oxycodone 5 mg. Review of the Controlled Drug Use Record dated 1/12/2026, revealed .[Resident #76] .Oxycodone .[used for pain] 5MG .Amount Remaining 30 .Amount removed for Destruction 30 Date: [left blank] Nurses Signature: [Left Blank] Counter Signature: [Unit Manager]. Review of the Physician Order dated 1/12/2026, revealed Zolpidem 10mg. Review of the Controlled Drug Use Record dated 1/12/2026, revealed .[Resident #76] .Zolpidem [used for sleep] 10MG .Amount Remaining 1 .Amount Removed for Destruction 1 Date: [Left Blank] Nurses Signature: [Left Blank] Counter Signature: Left Blank]. Review of the Physician Order dated 1/22/2025, revealed Clonazepam 0.5 mg. Review of the Controlled Drug Use Record dated 1/22/2026, revealed .[Resident #76] .Clonazepam [used for anxiety] 0.5MG [Milligrams] .Amount Remaining 12 .Amount removed for Destruction 12 Date: [left blank] Nurses Signature: [Left Blank] Counter Signature: [Unit Manager]. Review of the Physician Order dated 1/22/2026, revealed Gabapentin 400 mg. Review of the Controlled Drug Use Record dated 1/22/2026, revealed .[Resident #76] .Gabapentin [used for seizures] 400MG .Amount Remaining 18 .Amount Removed for Destruction 18 Date: [left blank] Nurses Signature: [Left Blank] Counter Signature: [Unit Manager]. Review of the Controlled Drug Use Record dated 1/22/2026, revealed .[Resident #76] .Gabapentin [used for seizures] 400MG .Amount Remaining 30 .Amount Removed for Destruction 30 Date: [left blank] Nurses Signature: [Left Blank] Counter Signature: [Unit Manager]. Review of the Controlled Drug Use Record dated 1/22/2026, revealed .[Resident #76] .Gabapentin [used for seizures] 400MG .Amount Remaining 30 .Amount Removed for Destruction 30 Date: [left blank] Nurses Signature: [Left Blank] Counter Signature: [Unit Manager]. Review of the Physician Order dated 1/22/2026, revealed Hydrocodone-Acetaminophen 10-325mg. Review of the Controlled Drug Use Record dated 1/22/2026, revealed .[Resident #76] .HYDRO/APAP 10-325MG .Amount Remaining 22 .Amount Removed for Destruction 22 Date: [left blank] Nurses Signature: [Left Blank] Counter Signature: [Unit Manager]. Review of the Physician Order dated 1/22/2026, revealed Zolpidem 10mg. Review of the Controlled Drug Use Record dated 1/22/2026, revealed .[Resident #76] .Zolpidem [used for sleep] 10MG .Amount Remaining 13 .Amount Removed for Destruction 13 Date: 1/26/2026 Nurses Signature: [Left Blank] Counter Signature: [Unit Manager]. The facility failed to have two licensed staff sign off on the narcotic destruction logs. 3. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including Depression and Pain. Review of the Physician Orders dated 2/19/2026, revealed Oxycodone 5mg. Review of the Controlled Drug Use Record dated 2/19/2026, revealed .[Resident #77] .Oxycodone .5MG .Amount Remaining 3 .Amount Removed for Destruction 3 Date: 3/13/26 Nurses Signature: [Licensed Practical Nurse C] .Counter Signature: [Left Blank]. Review of the Controlled Drug Use Record dated 2/25/2026, revealed .[Resident #77] .Oxycodone .5MG .Amount Remaining 30 .Amount Removed for Destruction 30 Date: 3/13/26 Nurses Signature: [Licensed Practical Nurse C] .Counter Signature: [Left Blank]. The facility failed to have two licensed staff sign off on the narcotic destruction logs. 4. Review of the medical record revealed Resident #78 was admitted to the facility 10/19/2025, with diagnoses including Depression and Pain. Review of the Physician Order dated 1/19/2026, revealed Lorazepam (used for anxiety) 0.5 mg. Review of the Physician Order dated 1/19/2026, revealed morphine concentrate (used for pain) 1.0 ml (milliliter). Review of the Controlled Drug Use Record dated 1/20/2026, revealed .[Resident #78].LORAZEPAM.0.5 MG.Amount Remaining 2.Amount Removed for Destruction [Left Blank] Date: 2/13/2026.Nurse's Signature: [Illegible Staff Member].Counter Signature: [Left Blank]. Review of the Controlled Drug Use Record dated 1/23/2026, revealed .[Resident #78].LORAZEPAM.0.5 MG.Amount Remaining 30.Amount Removed for Destruction [Left Blank] Date: 2/13/2026.Nurse's Signature: [Illegible Staff Member].Counter Signature: [Left Blank]. Review of the Controlled Drug Use Record dated 2/13/2026, revealed . [Resident #78].Morphine Conc [Concentrate] 20 mg/ml.Amount Remaining 14.Amount Removed for Destruction: [Left Blank] Date: 2/13/2026.Nurse's Signature: [Illegible Staff Member].Counter Signature: [Left Blank]. The facility failed to have two licensed staff sign off on the narcotic destruction logs. 5. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] with diagnoses including Insomnia, Pain, and Anxiety. Review of the Physician Order dated 12/21/2025, revealed Morphine Concentrate 100mg/ml. Review of the Controlled Drug Use Record dated 12/24/2025, revealed .[Resident #79] .Lorazepam .Amount Remaining 20 .Amount Removed for Destruction [Left Blank] Date: [Left Blank] Nurses Signature: [Left Blank] .Counter Signature: [Illegible Staff Member] . Review of the Physician Order dated 12/24/2025, revealed Lorazepam 1 mg. Review of the Controlled Drug Use Record dated 12/22/2025, revealed .[Resident #79] .Morphine .Sol [solution] .Amount Remaining [Left Blank] .Amount Removed for Destruction [Left Blank] Date: [Left Blank] Nurses Signature: [Left Blank] .Counter Signature: [Left Blank] . The facility failed to have two licensed staff sign off on the narcotic destruction logs. 6. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE], with diagnoses including Depression, Pain, Depression, Insomnia, Neuropathy, Fracture of Acetabulum (the socket of the hip bone), Fracture of Right Pubis (bone forming the pelvis), and Fracture of Right Femur. Review of the Physician Order dated 11/11/2025, revealed Gabapentin 100mg. Review of the Physician Order dated 11/11/2025, revealed Tramadol (for pain) 50 mg. Review of the Controlled Drug Use Record dated 11/12/2025, revealed .[Resident #80].GABAPENTIN.100MG.Amount Remaining 7.Amount Removed for Destruction: [Left Blank] Date: [Left Blank].Nurse's Signature: [Left Blank].Counter Signature: [Left Blank]. Review of the Controlled Drug Use Record dated 11/13/2025, revealed . [Resident #80] .Tramadol.50MG.Amount Remaining: 10.Amount Removed for Destruction: [Left Blank] Date: [Left Blank].Nurse's Signature: [Left Blank].Counter Signature: [Left Blank]. The facility failed to have two licensed staff sign off on the narcotic destruction logs. 7. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE], with diagnoses including Depression, Pain, Falls, Fracture of Right Femur, and Fracture of Right Pubis. Review of the Physician Order dated 1/23/2026, revealed Oxycodone 5mg. Review of the Controlled Drug Use Record dated 1/23/2026, revealed .[Resident #81] .Oxycodone .5MG .Amount Remaining 14 .Amount Removed for Destruction [Left blank] Date: 3/19/26 Nurses Signature: [Left Blank] .Counter Signature: [Left Blank] . Review of the Physician Order dated 1/23/2026, revealed Oxycodone 5mg. Review of the Controlled Drug Use Record dated 1/23/2026, revealed .[Resident #81] .Oxycodone .5MG .Amount Remaining 30 .Amount Removed for Destruction [Left blank] Date: 3/19/26 Nurses Signature: [Left Blank] .Counter Signature: [Left Blank] . The facility failed to have two licensed staff sign off on the narcotic destruction logs. 8. Review of the medical record revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including Pain, Osteoarthritis, Macular Degeneration and Spinal Stenosis (abnormal narrowing). Review of the Physician Order dated 11/10/2026, revealed Tramadol 50 mg. Review of the Controlled Drug Use Record dated 11/10/2025, revealed .[Resident #82] .Tramdol [used for pain] .Amount Received 30 .Amount Removed for Destruction 30 Date: 11/23/25 Nurses Signature: [Left Blank] .Counter Signature: [Left Blank] . Review of the Physician Order dated 11/10/2026, revealed Tramadol 50 mg. The facility failed to have two licensed staff sign off on the narcotic destruction logs. 9. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE], with diagnoses including Pain, Depression, Anxiety, and Falls. Review of the Physician Order dated 1/23/2026, revealed Tramadol 50 mg. Review of the Controlled Drug Use Record dated 1/23/2026, revealed .[Resident #83].Tramodol.50MG.Amount Remaining: 16.Amount Removed for Destruction: [Left Blank] Date: [Left Blank].Nurse's Signature: [LPN D].Counter Signature: [Unit Manager]. Review of the Physician Order dated 1/14/2026, revealed Pregabalin [used for nerve pain] 100mg. Review of the Controlled Drug Use Record dated 1/14/2026, revealed .[Resident #83].PREGABALIN.100MG.Amount Remaining: 1.Amount Removed for Destruction: [Left Blank] Date: [Left Blank].Nurse's Signature: [LPN D].Counter Signature: [Unit Manager]. The facility failed to have two licensed staff sign off on the narcotic destruction logs. 9. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE], with diagnoses including Kidney Failure and Pain. Review of the Physician Order dated 11/25/2025, revealed Tramadol 50 mg. Review of the Controlled Drug Use Record dated 11/26/2025, revealed .[Resident #86].TRAMADOL.50MG.Amount Given.0.Amount Remaining: 11.[Not given wasted] [No signatures for wasted medication].Amount Removed for Destruction: 11 Date: 1-2-26.Nurse's Signature: [illegible LPN].Counter Signature: [illegible]. The facility failed to ensure licensed staff sign off on the narcotic destruction logs as witnessing destruction of unused narcotic medication. During an interview on 5/6/2026 at 8:55 AM, the Unit Manager was asked if there should be 2 signatures on the narcotic sheets for drug destruction. The Unit Manager stated, Yes. During an interview on 5/6/2026 at 9:05 AM, the Director of Nursing (DON) was asked if there should be 2 signatures on the narcotic destruction sheets when medications are put in the destruction box and if a medication is wasted. The DON stated, Yes. The DON was asked if the drug destruction policy is being followed. She stated, No. The DON was asked if she expected the Unit Manager to make sure the process is followed. She stated, Yes, she is a supervisor. The DON was asked if she was able to identify some of the signatures in the destruction logs that were not legible. She stated, I am not sure who some of them are .can't read them . During an interview on 5/6/2026 at 9:11 AM, the Administrator was asked if there should there be 2 signatures on the narcotic destruction sheet. He stated, Yes. The Administrator was asked if the drug destruction process was being followed. The Administrator stated, No.

Based on facility policy review, medical record review, and interview, the facility failed to provide evidence of a Monthly Regimen Review or physician acknowledgement of recommendations for 4 of 5 sampled residents (Residents #5, #6, #14, and #32) reviewed for unnecessary meds. The findings include: 1. Review of the facility policy titled, Medication Regimen Review, dated 1/1/2025, revealed .Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication .Review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities .The pharmacist shall document, either manually or electronically, that each medication regimen review has been completed .The pharmacist shall document either that no irregularity was identified or the nature of any identified irregularities .Each MRR shall be signed by the pharmacist .The pharmacist shall communicate any irregularities to the facility in the following ways .Written communication to the attending physician, the facility's Medical Director, and the Director of Nursing .Written communication from the pharmacist shall become a permanent part of the resident's medical record .The pharmacist shall communicate any recommendations and identified irregularities via written communication . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Dementia, Heart Failure, Chronic Respiratory Failure, Anxiety and Depression. Review of the Physician Orders dated 12/30/25, revealed .buspirone .7.5 mg [milligram] .1 tab [tablet] .Twice A Day .generalized anxiety disorder .duloxetine .capsule, delayed release .60 mg .1 cap [capsule] .Once A Day .depression .Drizalma Sprinkle (duloxetine) capsule, delayed [NAME] [release] sprinkle .20mg .1 capsule .oral Once An Evening .depression . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Resident #5 received medications including antianxiety, antidepressants, and diuretics. The facility was unable to provide the Medication Regimen Review for February 2026. Review of the Medication Regimen Reviews for March 2026, revealed .[Resident #5] is receiving the following medication: Buspar [for anxiety] 7.5 mg BID [twice a day]. This dose has been in place since 12/2025 and a review of the resident's chart does not reflect worsening. To reach minimal effective dose, please consider a trial dose reduction to Buspar 5 mg BID. If this anxiolytic is to be continued as written please document that the risk vs. [versus] benefits have been considered. Documentation related to clinically contraindicating a gradual dose reduction should include specific and individualized rationale for why the medication is medically necessary at the current dose . Review of the Medication Regimen Reviews for April 2026, revealed .[Resident #5] is receiving the following antidepressant: Cymbalta [for depression] 60 mg QAM [every morning] and 20mg HS [at bedtime]. This dose has been in place since 12/2025, and a review of the resident's chart does not reflect a worsening of depression. To reach the minimal effective dose, please consider a trial dose reduction to Cymbalta 30mg BID [twice a day]. If this antidepressant order is to be continued as written please document that the risk vs. benefits have been considered .Documentation related to clinically contraindicating a gradual dose reduction should include specific and individualized rationale for why the medication is medically necessary at the current dose . The facility was unable to provide a Medication Regimen Review signed by the physician for Resident #5 for February, March, or April of 2026. 3. Review of the medical record revealed Resident #6 was admitted to the facility 12/17/2025, with diagnoses including Dementia, Anxiety, Major Depressive Disorder, Epilepsy, and Atrial Fibrillation. Review of the physician orders dated 12/24/2025, revealed .trazodone tablet .50mg .25mg .Insomnia . Review of the physician orders dated 12/17/2025, revealed .amitriptyline tablet .10mg .2 tabs .Major depressive disorder .fluoxetine capsule .20mg .1 tab .Major depressive disorder . Review of the quarterly MDS assessment dated [DATE], revealed Resident #6 scored a 3 on the BIMS assessment, which indicated he was severely cognitively impaired. Resident #6 received medications including antianxiety, antidepressants, anticoagulant, and anticonvulsant medications. Review of the Medication Regimen Review for February 2026, revealed .[Resident #6] is receiving the following antidepressant: Trazadone 25mg HS. This dose has been in place since 12/2025, and a review of the resident's chart does not reflect a worsening of depression. To reach the minimal effective dose, please consider a trial dose reduction to Trazodone 12.5 mg HS. If this antidepressant order is to be continued as written please document that the risk vs. Benefits have been considered .Documentation related to clinically contraindicating a gradual dose reduction should and individualized rationale for why the medication is necessary at the current dose . Review of the Medication Regimen Reviews for March 2026, revealed .[Resident #6] is receiving the following antidepressant: Amitriptyline 20mg HS. This dose has been in place since 12/2025, and a review of the resident's chart does not reflect a worsening of depression. To reach the minimal effective dose, please consider a trail dose reduction to Amitriptyline 10mg HS. If this antidepressant order is to be continued as written please document that the risk vs benefits have been considered. Documentation related to clinically contraindicating a gradual dose reduction should include specific and individualized rationale for why the medication is medically necessary at the current dose . Review of the Medication Regimen Reviews for April 2026, revealed .[Resident #6] is receiving the following antidepressant: Prozac 20mg QD [every day]. This dose has been in place since 12/2025, and a review of the resident's chart does not reflect a worsening of depression. To reach the minimal effective dose, please consider a trial dose reduction to Prozac 10 mg QD. If this antidepressant order is to be continued as written please document that the risk vs. Benefits have been considered .Documentation related to clinically contraindicating a gradual dose reduction should include specific and individualized rationale for why the medication is medically necessary at the current dose . The facility was unable to provide a Medication Regimen Review signed by the physician for Resident #5 for February, March, or April of 2026. 4. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Osteoarthritis, Chronic Kidney Disease, Anxiety, Depression, Chronic Pain, and Collapsed Vertebra. Review of the quarterly MDS dated [DATE], revealed Resident #14 had a BIMS of 5, which indicated Resident #14 which indicated she was severely cognitively impaired. Resident #14 received medications including antidepressants, diuretics, and opioids. The facility was unable to provide the Medication Regimen Review for February 2026. 5. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE], with diagnoses including Major Depressive Disorder, Heart Failure, Diabetes, and Kidney Failure. Review of the admission MDS assessment dated [DATE], revealed that Resident #32 scored a 15 on the BIMS assessment, which indicated he was cognitively intact. He was on antipsychotics, antidepressants, opioids, antiplatelets, hypoglycemics, and anticonvulsant medications. Review of the Physician Orders dated 3/31/2026, revealed .insulin lispro insulin [medication used to lower blood sugar] pen.100 unit/mL [milliliters].Per Sliding Scale.If Blood Sugar is 150 to 200, give 2 Units.If Blood Sugar is 201 to 250, give 4 Units.If Blood Sugar is 251 to 300, give 6 Units.If Blood Sugar is 301 to 350, give 8 Units.If Blood Sugar is 351 to 400, give 10 Units.subcutaneous Before Meals and At Bedtime .Type 2 Diabetes. Review of the Medication Regimen Reviews for March and April 2026, revealed .[Resident #32] has an order for sliding scale insulin with blood glucose monitoring. Please consider switching to an alternative diabetes medication, such as metformin, linagliptin, or a GLP-1 to improve glucose control . The facility was unable to provide a Medication Regimen Review signed by the physician for Resident #32 for March and April of 2026. During an interview on 5/5/2026 at 2:15 PM, the Director of Nursing (DON) was asked for the Medication Regimen Review with resolutions for the last 3 months. The DON replied .I am trying to locate them but I can't find them .the pharmacy emails them to me, I print them off and give them to the nurses to put them in the book for the doctor to review when he makes rounds .they are then scanned into the EMR [Electronic Medical Record] and that did not happen . The DON was asked if she is unable to provide the Medication Regimen Review with resolutions for the last 3 months. The DON replied .that's right, I will keep looking though . During an interview on 5/5/2026 at 2:30 PM, the Administrator was asked if the facility should have been able to provide Medication Regimen Review's for the last 3 months when requested. He replied Yes .

Based on facility policy review, resident trust fund account review, medical record review, and interview, the facility failed to refund the resident's funds within 30 days of death or discharge for 2 of 2 (Resident #73 and #74) sampled residents reviewed for personal funds. The findings include: 1. Review of the facility policy titled, Resident Personal Funds, dated [DATE], revealed .Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility will convey within 30 days the resident's funds and final account of those funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State Law. 2. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE], with diagnoses including Depression, Anxiety, Burn of Second Degree of Left Thigh, Dementia, and Edema. Review of the Nurse's Note dated [DATE], revealed Resident #73 expired at the facility. Review of Resident #73's Resident Trust Fund Account revealed a refund check dated [DATE], for the remaining account balance of $270.07. The facility failed to refund the remaining balance to Resident's 73's estate within 30 days of death. 3. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE], with diagnosis of Pressure Ulcer of Sacral Region, Stage 2, Anxiety, Diabetes, Depression and Insomnia. Review of the Nurse's Note dated [DATE], revealed Resident #74 expired at the facility. Review of Resident #74's Resident Trust Fund Account revealed a refund check dated [DATE] for the remaining account balance of $100.00. The facility failed to refund the remaining balance to Resident #74's estate within 30 days of death. 4. During an interview on [DATE] at 8:20 AM, the Business Office Manager (BOM) was asked if resident trust fund balances should be refunded within 30 days of death or discharge. The BOM stated, .our policy states if they have a balance that is pending with insurance we hold those funds until the balance is paid, so we have those funds to pay that balance. Once that balance due is zero, we issue the checks . The BOM was asked if there is a timeframe that the resident's estate should be issued a check with the remaining balance. The BOM stated, No. During an interview on [DATE] at 8:44 AM, the Administrator was asked if resident trust fund balances should be refunded within 30 days of death or discharge. The Administrator stated, I am not sure .

Based on facility policy review, medical record review, observation, and interview, the facility failed to implement care plan interventions for 1 of 13 (Resident #28) sampled residents reviewed for falls. The findings include: 1. Review of the facility policy titled, Comprehensive Care Plans, dated 01/16/2026, revealed .facility to develop and implement a comprehensive person-centered care plan for each resident.services that are identified in the resident's comprehensive assessment and meet professional standards of quality .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions. 2. Review of medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Nondisplaced Fracture of Greater Trochanter of Right Femur, Periprosthetic (around implant) Fracture around Internal Prosthetic Left Hip Joint, Parkinson's Disease, Dementia, Repeated Falls, and Tremor. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he had moderate cognition impairment. Resident #28 used a wheelchair and walker for mobility and had a fall 2-6 months prior to admission. Review of the Care Plan dated 4/13/2026, revealed, .4/14/2026 .Fall mats at bedside for safety . Observation in Resident #28's room on 5/4/2026 at 10:03 AM and 5/5/2026 at 11:14 AM, revealed Resident #28 lying in bed and there were no fall mats at the bedside. During an interview on 5/5/2026 at 12:50 PM, License Practical Nurse (LPN) B was asked if the care plan reflects fall mats should they be in Resident #28's room. LPN B stated, .sometimes they move them out of the way so they can get around the room. LPN B was asked if they should be in place. LPN B stated, Yes.I am going to have someone get them in there now . During an interview on 5/5/2026 at 1:12 PM, the Director of Nursing (DON) was asked if fall mats are care planned should they be in place. The DON stated, Yes, if it is on his care plan, it should be.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards when sharps were left unsecured and unattended in 4 of 51 (Residents #33, #53, #64, and #75) sampled residents' rooms. The findings include: 1. Review of the facility policy titled, .Contaminated Sharps.,dated 4/5/2026, revealed .Contaminated Sharps.any contaminated object that can penetrate the skin including, but not limited to, needles.Universal precautions will be observed to prevent contact with blood or other potentially infectious materials. 2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Dementia, Lupus, and Hypertension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was moderately cognitively impaired. Resident #33 was coded as having no impairment in Range of Motion (ROM) of the upper extremities (shoulder, elbow, wrist, hand), as set up assistance for personal hygiene including shaving, and for the use of a wheelchair. Observations in the Resident #33's' room on 5/4/2026 at 10:29 AM, 1:58 PM, and at 3:28 PM, revealed a navy blue disposable razor in a basin on the bathroom sink unsecured and unattended. During an observation and interview on 5/4/2026 at 3:35 PM, Licensed Practical Nurse (LPN) A was asked if the razor should be unsecured in the resident's bathroom. LPN A stated, No. 3. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including Pneumonitis, Adult Failure to Thrive, Dementia, and Diabetes Mellitus. Review of the admission MDS assessment dated [DATE], revealed Resident #53 scored a 5 on the BIMS assessment which indicated he was severely cognitively impaired. Resident #53 was coded as having no impairment in ROM of the upper extremities and as set up assistance for eating. Observations in the Resident's room on 5/4/2026 at 10:34 AM, and at 2:02 PM, revealed a plastic cup with disposable lancets on top of the dresser unsecured and unattended. Observation in the Resident's room on 5/4/2026 at 2:38 PM, revealed Resident #53 was sitting up in his wheelchair and the plastic cup of lancets were within reach on top of the resident's dresser unsecured and unattended. During an observation and interview in the Resident's room on 5/4/2026 at 3:37 PM, LPN A was asked if lancets should be left unsecured in the resident's room. LPN A stated, We have always kept them in the resident's rooms as long as I have worked here. 4. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including Right Femur Fracture (a break in the long bone of the leg), Seizures, and Muscle Weakness. Review of the 5-Day MDS assessment dated [DATE], revealed Resident #64 scored a 14 on the BIMS assessment, which indicated he was cognitively intact. Observations in the Resident's room on 5/4/2026 at 9:56 AM, 1:37 PM, and at 3:26 PM, revealed a black and white disposable razor on the bathroom sink unsecured and unattended. During an observation and interview on 5/4/2026 at 3:32 PM, LPN A was asked if the razor should be left unsecured in the resident's bathroom. LPN A stated, No, his family probably brought this in. 5. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Hemiplegia, Diabetes, Depression, Hypertension, and Atrial Fibrillation. Review of the 5-day MDS assessment dated [DATE], revealed Resident #75 scored a 9 on the BIMS assessment which, indicated he was moderately cognitively impaired. Observations in the Resident's room on 5/4/2026 at 10:20 AM, and at 1:56 PM, revealed Resident #75 sitting up in his wheelchair and a plastic cup with disposable lancets was on top of the resident's dresser within the resident's reach unsecured and unattended. During an observation and interview on 5/4/2026 at 3:38 PM, LPN A was asked if lancets should be unsecured in the resident's room. LPN A stated, I'm unsure. During an interview 5/5/2026 at 12:57 PM, the Director of Nursing (DON) was asked should razors be left unsecured and unattended in resident rooms. The DON stated, No. The DON was asked where lancets should be stored. The DON stated, Lancets should be stored out of the residents reach or in the nurse's [medication] cart.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions as evidenced by inappropriate tray line serving temperatures. The facility had a census of 26 residents and 26 residents received a meal tray from the kitchen. The findings include: 1. Review of the facility's policy titled, Food Temperatures, dated 5/21/2012, showed, .hot foods items may not fall below 135 (symbol for degrees) F (Fahrenheit) after cooking .and reheated to at least 165 (symbol for degrees) F prior to serving .All cold food items must be maintained and served at a temperature of 41 (symbol for degrees) F or below . Observation in the Kitchen on 3/2/2020 at 12:05 PM, showed the following: A. Mechanical veal (meat extracted from the bone for a [MEDICATION NAME] texture) at 108 degrees F and reheated with a result of 145 degrees F. B. Three bean salad at 60 degrees F and returned to the cooler with a result of 48 degrees F. During an interview conducted on 2/2/2020 at approximately 12:15 PM, the Cook confirmed that the holding temperature for hot food should be 135 degrees Fahrenheit and once reheated, it should be maintained at 165 degrees Fahrenheit or greater. The Cook confirmed that the holding temperature for cold food should be 41 degrees Fahrenheit or below at all times.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by outdated food items, unlabeled and undated food items. The facility had a census of 21 with 20 of those residents receiving food items from the nourishment refrigerator. The findings include: 1. The facility's FOOD STORAGE policy dated 6/18/12 documented, .Date marking to indicate the date or day by which .food should be consumed .discarded .will be visible on all .food .All foods should be covered, labeled and dated .will be consumed by their safe use by dates .or discarded .check refrigerators daily to verify that foods are date marked and that food exceeding the 7-day time period are not being used or stored .REMEMBER: WHEN IN DOUBT, THROW IT OUT . 2. The facility's Kitchenettes and Pantries policy dated 2/5/12 documented .Rotate stock and remove outdated (including undated) items . Observations in the Ice Cream Parlor on 4/8/19 at 11:33 AM, revealed the following: (a) a bottle of nectar thick and clear with two dates on it, 1/21 and 2/27/19 (b) a resident's water pitcher with a light pink liquid with no name and date (c) a bottle of prune juice dated 2/25 (d) a pitcher of tea dated 3/24/19 Interview with the Culinary Director on 4/10/19 at 1:35 PM, in the Conference Room, the Culinary Director was asked should the bottle of nectar thick liquid with two dates of 1/21 and 2/27/19 have been discarded. The Culinary Director stated, 1/21 is when I received it, the 2/27/19 is the date it was opened . The Culinary Director was asked should the resident's water pitcher with a light pink liquid have been labeled and dated. The Culinary Director stated, Yes . The Culinary Director was asked should the bottle of prune juice dated 2/25 have been discarded. The Culinary Director stated, .2/25 was the date we received it in the kitchen. The Culinary Director was asked if the 2/25 date was the day it was opened. The Culinary Director stated, How do I know. The Culinary Director was asked should it be discarded. The Culinary Director stated, It should be discarded in 3 days. The Culinary Director was asked should the pitcher of tea dated 3/24/19 have been discarded. The Culinary Director stated, .it doesn't expire.

Based on medical record review, observation, and interview, the facility failed to provide reasonable accommodations to promote comfortable sleep for 1 of 16 (Resident #23) sampled residents reviewed. The findings include: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #23 had moderate cognitive impairment and required staff assistance for all activities of daily living. The Care Plan dated 3/13/19 documented, .Sleep Disturbance: risk for disturbed sleep pattern related to history of [MEDICAL CONDITION] and sundowning .Approach .Observe for pain and provide .positioning as needed .Provide comfortable environment to promote sleep . Review of the facility's grievance log for 2019 revealed no documentation of Resident #23's complaint about his bed. Observations of Resident #23 in his room on 4/8/19 at 10:44 AM, 11:52 AM, and 2:22 PM, and on 4/9/19 at 8:56 AM, 11:42 AM, and 3:23 PM, revealed Resident #23 seated in his recliner at the bedside. Interview with Resident #23 on 4/8/19 at 11:58 AM, in his room, Resident #23 stated he sleeps in his recliner. Resident #23 was asked why he did not sleep in his bed. Resident #23 stated, There's a rod or something across there (underneath mattress) that hurts my back . Interview with Registered Nurse (RN) #1 on 4/10/19 at 7:40 AM, in the 200 Hall, RN #1 was asked if she knew why Resident #23 slept in his recliner instead of his bed. RN #1 stated, Yes .on the bed there's a bar that runs across it by the hinge, and it hurts his back . Interview with the Clinical Director on 4/10/19 at 2:13 PM, in the Conference Room, the Clinical Director was asked what she would expect staff to do if a resident was unable to sleep in his bed because it caused him pain. The Clinical Director stated, They should've notified us so maybe we could do something different with the mattress or check to see what the reason is .It would be better to be fix the issue. Interview with Certified Nursing Assistant (CNA) #1 on 4/10/19 at 3:00 PM, in the 200 Hall, CNA #1 was asked if she was aware of the problem Resident #23 had with his bed. CNA #1 stated, Yes ma'am. He has been sleeping in his recliner.

Based on policy review, medical record review, and interview, the facility failed to notify the Ombudsman of a transfer for 1 of 4 (Resident #28) sampled residents reviewed for transfer/discharge requirements. The findings include: The facility's Notice of Transfer of Discharge policy dated 10/9/17 documented, .Copies of notices for emergency transfers must also still be sent to the ombudsman . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Progress Note dated 1/11/19 documented, .dr (doctor) called at 0925 .take her (Resident #28) to ER (emergency room ) . The facility was unable to provide documentation that the Ombudsman had been notified of Resident #28's transfer to the hospital on [DATE]. Interview with the Chief Nursing Officer (CNO) on 4/10/19 at 3:40 PM, in the Conference Room, the CNO was asked should the Ombudsman have been notified of Resident #28's transfer to the hospital. The Chief Nursing Officer stated, Yes.

Based on medical record review and interview, the facility failed to revise a care plan related to significant weight loss for 1 of 18 (Resident #128) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nutrition Observation note dated 4/5/19 documented, .Weight loss r/t (related to) recent hospital stay, [MEDICATION NAME] in hospital .11% (percent) x (times) 30d (days), 7.6% loss upon readmit .Will proceed to care plan related to nutrition risk d/t (due to) therapeutic diet and recent weight loss . Review of the comprehensive Care Plan dated 2/28/19 did not reflect Resident #128's significant weight loss. Telephone interview with the Registered Dietitian (RD) on 4/9/19 at 4:23 PM, the RD was asked if the comprehensive Care Plan should reflect Resident #128's significant weight loss. The RD stated, Yes . The RD was asked whose responsibility it was to ensure the care plan reflected the recent weight loss. The RD stated, Mine I usually go and check the care plan .that's my fault . Interview with the Clinical Director on 4/9/19 at 4:47 PM, in the Conference Room, the Clinical Director was asked if Resident #128's Care Plan should reflect her significant weight loss. The Clinical Director confirmed that the care plan should reflect significant weight loss.

Based on policy review, medical record review, and interview, the facility failed to follow their policy for fall management by not completing a fall investigation for 1 of 3 (Resident #127) sampled residents reviewed for falls. The findings include: 1. The facility's Fall Management policy dated 6/25/17 documented, .Fall prevention is achieved through an interdisciplinary approach of managing risk factors and implementing appropriate interventions to reduce risk for falls .Begin fact finding and complete a post-fall huddle to explore contributing factors .Complete a fall risk observation to identify any causes that may have contributed to the fall .Complete a root cause analysis .determine an intervention based on the root cause . 2. Medical record review revealed Resident #127 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Progress Notes dated 3/27/19 documented, .Resident slid off the bed .last night, resident was reportedly discovered supine adjacent to his bed . Review of the Care Plan dated 4/2/19 revealed Resident #127 was at risk for falls. Interview with the Clinical Director on 4/10/19 at 8:44 AM, in the Conference Room, the Clinical Director was asked to explain their process when a resident falls. The Clinical Director stated, When a fall occurs, the nurse is supposed to put an event in the computer which triggers us to begin the fall investigation .There was not an event entered in the computer for that fall on 3/26/19 . The Clinical Director was asked if a fall investigation was completed for this fall. The Clinical Director stated, No. The Clinical Director was asked if a fall investigation should have been completed. The Clinical Director confirmed a fall investigation should have been completed.

Based on medical record review, observation, and interview, the facility failed to follow the physician's orders for oxygen use for 1 of 1 (Resident #78) sampled residents reviewed for respiratory problems. The findings include: Medical record review revealed Resident #78 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #78 had an active [DIAGNOSES REDACTED]. Review of the Care Plan dated 4/5/19 revealed staff was to provide oxygen as ordered. The Physician's Orders dated 2/21/19 documented, .Oxygen at 2 liter/minute via (by way of) (nasal cannula using concentrator) . The hospital physician's Progress Notes dated 4/7/19 documented, .admission to (Named Hospital) on 3/28/19 for acute dyspnea .Was admitted to the intensive care unit .was [MEDICATION NAME] 10 kg (kilograms) of fluid and weaned down to 2 liters of O2 (oxygen) . Review of the Nursing Progress Notes revealed the resident was wearing 3 liters (L) of oxygen on the following dates: 3/1/19, 3/2/19, 3/3/19, 3/16/19, 3/17/19, 3/18/19, 3/19/19, 3/20/19, 3/21/19, 3/22/19, 3/23/19, 3/24/19, 3/25/19, 4/5/19, 4/6/19, 4/7/19, 4/8/19, 4/9/19, and 4/10/19. Review of the Nursing Progress Notes revealed the resident was wearing 4 L of oxygen on the following dates: 3/4/19, 3/5/19, 3/6/19, 3/7/19, 3/8/19, 3/9/19, 3/10/19, 3/11/19, 3/13/19, and 3/28/19. The Nursing Progress Notes dated 3/12/19 documented, .O2 sats (saturations) 89% (percent) and had pt (patient) close her mouth and breath (breathe) through her nose and it came up to 97% on her 3 liters O2 by nasal cannula . The Nursing Progress Notes dated 3/14/19 documented, .Nursing decreased the resident's oxygen from 4L to 3L today . The Nursing Progress Notes dated 3/15/19 documented, .Nursing decreased the resident's oxygen from 3L to 2L today . The Nursing Progress Notes dated 3/27/19 documented, .on 3L oxygen via nasal cannula .Nurse turned the oxygen up to 4L of O2 .Nurse then turned the oxygen up to 5L O2 .Nurse left the oxygen at 5L for a few minutes and then turned it back down to 4L . Observations in Resident #78's room on 4/8/19 at 2:24 PM, 4/9/19 at 11:42 AM, and 4/10/19 at 8:03 AM and 9:51 AM, revealed Resident #78 wearing oxygen at 3 liters per minute via nasal cannula. Interview with Registered Nurse (RN) #1 on 4/10/19 at 9:51 AM, in Resident #78's room, RN #1 confirmed Resident #78's oxygen flow rate was on 3 liters per minute. Interview with the Clinical Director on 4/10/19 at 2:16 PM, in the Conference Room, the Clinical Director was asked if it was acceptable for nurses to increase oxygen flow rates without a physician's order. The Clinical Director stated, No. They should be getting a physician's order.

Based on policy review, observation, and interview, the facility failed to ensure medications were securely locked and inaccessible to residents, unauthorized staff, and visitors in 1 of 4 (East Medication Cart) medication storage areas. The findings include: The facility's MEDICATION STORAGE IN THE FACILITY policy dated 1/1/18 documented, .Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications .permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access . Observations in the 100 Hall on 4/9/19 at 12:34 PM, revealed Registered Nurse (RN) #2 left the medication cart unlocked, entered a resident's room, and closed the door. Interview with RN #2 on 4/9/19 at 12:38 PM, in the 100 Hall, RN #2 confirmed that she left the medication cart unlocked. Interview with the Clinical Director on 4/10/19 at 2:19 PM, in the Conference Room, the Clinical Director was asked if it was acceptable for the nurse to leave the medication cart unlocked when she went in a room and closed the door. The Clinical Director stated, No.

Based on medical record review, observation, and interview, the facility failed to store tube feeding equipment in a sanitary manner for 1 of 1(Resident #22) sampled residents reviewed receiving tube feedings. The findings include: Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Observations on 4/8/19 at 11:29 AM, 2:00 PM, and 4:15 PM, revealed a white towel across the night stand table with a Bard Button Device and 60 cc (cubic centimeters) syringe laid on the towel. Interview with the Clinical Director on 4/9/19 at 4:08 PM, in the Conference Room, the Clinical Director was asked how should the syringe and Bard Button Device for enteral feeding be stored. The Clinical Director stated, The container that it comes in or a plastic bag. The Clinical Director was asked is it appropriate for the syringe and Bard Button Device to be laid out on a white towel on the side table. The Clinical Director stated, No.