Every finding on record at Timberland Ridge Nursing & Rehabilitation

Based on observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure medications were securely stored. This affected nine residents (#12, #22, #25, #31, #33, #34, #40, #51, and #53). This had the potential to affected nine other residents residing on the memory care care who were independently mobile and had cognitive impairments. The facility census was 62. Findings include: 1. Observation on 01/20/26 at 10:12 A.M. revealed a medication cart unlocked parked on the west hall. On top of the medication cart were eight medication cups with medications (pills) in each individual cup. There were letters written on each cup. There were no staff near or monitoring the medications on top of the unlocked medication cart. Observation on 01/20/26 at 10:15 A.M. revealed Licensed Practical Nurse (LPN) #300 approached the medication cart after exiting a resident room (Resident #1's room). LPN #300 confirmed she left the medication cart unlocked with eight medication cups with pills in each of them on top of the medication cart, unsupervised in the hall. LPN #300 stated she normally presets the residents' medications for 11:00 A.M. administration. LPN #300 revealed she wrote names (either first or last) on the outside of each medication cup and she would go down the hall and pass them out. LPN #300 confirmed, as she read the name on each cup, Resident #22 had three pills in a medication cup, Resident #40 had two pills, Resident #31 had one pill, Resident #51 had 11 pills, Resident #12 had one pill, Resident #34 had three pills, Resident #53 had two pills and Resident #25 had three pills. LPN #300 then picked up the medication cup for Resident #22, walked in Resident #22's room taking the medication cart with her and handed Resident #22 the medication cup. Interview on 01/20/26 at 10:20 A.M. with the Director of Nursing (DON) revealed nurses should not preset medications and medications were to be administered at the time they were prepared, one resident at a time.2. Record review for Resident #33 revealed an admission date of 09/10/24. Diagnoses included dementia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was severely cognitively impaired.Observation and interview on 01/21/26 from 8:58 A.M. to 9:03 A.M. revealed on the memory care unit, Licensed Practical Nurse (LPN) #302 was sitting behind the nursing station. LPN #302 revealed her medication pass was completed. Continued observation revealed Resident #33 was lying in bed in her room (located near the end of the hall) with the bedroom door open in the memory care unit. The bedside table was positioned in front of her. On top of the bedside table was a medication cup with nine medications including capsules and a variety of pill sizes. Resident #33 rambled incoherently when spoken to and was unable to answer simple yes or no questions. There were no staff was near Resident #33 or her room.Interview on 01/21/26 at 9:04 A.M. with LPN #302 confirmed she left Resident #33's nine medications in her room, unsupervised for her to self-administer. LPN #302 stated Resident #33 takes her pills herself, and LPN #302 leaves the medications for the resident and Resident #33 does not like to be supervised when taking medications. Interview on 01/21/26 at 4:56 P.M. with the Director of Nursing (DON) confirmed Resident #33 was severely cognitively impaired and resided on the Memory Care Unit. The DON revealed there were no residents residing in the facility who could self-administer their own medications. The DON said Resident #33 would not be appropriate to self-administer her own medications. The DON revealed the nursing staff were required to wait with the residents until all medications were administered. Review of the facility policy titled Medication Storage dated 07/23/19 revealed medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members authorized to administer medications. This was an incidental finding discovered during the complaint survey.

Based on record review, observations, and resident and staff interviews, the facility failed to ensure the residents who were dependent on staff for toileting hygiene received timely assistance with incontinence care. This affected two (Residents #13 and #42) of three residents reviewed for incontinence care. The facility census was 62.Findings include:1. Record review for Resident #42 revealed an admission date of 10/03/25. Diagnoses included unspecified fracture of the lower end of the right femur, muscle weakness, and need for assistance with personal care.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively intact. Resident #42 was frequently incontinent of bowel and bladder and was dependent on staff for toileting hygiene.Review of the care plan dated 11/14/25 revealed Resident #42 had an alteration in elimination, and was completely incontinent of bowel and bladder. Interventions included to provide incontinence care as needed. Interview on 01/20/26 at 3:40 P.M. with Resident #42 revealed at times the staff do not change her when she was incontinent and make her wait to be changed for long periods of time. Resident #42 stated last week she told the certified nursing assistant (CNA) that she needed changed and the CNA told her it was meal time and the resident needed to stop needing assistance during this (meal) time. The resident said she didn't plan to require assistance during meal time but she 'accidentally' had a bowel movement and the CNA made her wait until after meal time. Resident #42 revealed she did not know how long she had to wait, but it felt like a long time and she did not like not like waiting so long before getting changed.Observation and interview on 01/21/26 at 10:00 A.M. revealed Resident #42 was lying in bed. Resident #42 revealed she was wet with urine and no one checked her for incontinence or changed her yet today.Interview on 01/21/25 at 10:03 A.M. with CNA #341 revealed she was Resident #42's primary CNA. CNA #341 revealed the CNAs including herself started their shifts at 6:00 A.M. and worked until 6:00 P.M.; CNA #341 confirmed she did not check Resident #42 yet for incontinence and revealed she would do her first set of rounds after breakfast, then again before lunch for a total of about four times in a 12-hour shift. CNA #341 revealed she was getting ready to do Resident #42 for the first time this shift.Observation on 01/21/25 at 10:05 A.M. of incontinence care for Resident #42 provided by CNAs #341 and #348 revealed Resident #42's brief was saturated with urine, the peri area and buttocks was deep red. Resident #42 yelled, ouch as the CNA cleansed the peri area. Interview on 01/21/26 at 11:02 A.M. with CNA #342 revealed she routinely checked and changed her residents three times in a 12-hour shift.Interview on 01/21/26 at 4:32 P.M. with CNA #348 stated if residents need changed, they were not allowed to change them during meals. CNA #348 revealed no patient care was allowed from the time the meal cart arrived on the floor until the last tray was picked up and returned to the meal cart which was usually approximately an hour. CNA #348 confirmed she recalled Resident #42 asking her to change her soiled brief the previous Sunday she worked. CNA #348 stated she did remember Resident #42 asking her to provide incontinence care on a Sunday and it was during mealtime. CNA #348 remembered telling Resident #42 she had to wait until after meal service. CNA #348 revealed she did not recall how long after the meal Resident #48 continued to have to wait to be changed and reiterated, It's the rule, they cannot change briefs during meals because they have to pass trays and feed residents or residents complain of cold food. Interview on 01/21/26 at 4:40 P.M. with Licensed Practical Nurse (LPN) #323 stated they were not allowed to do patient care during meals including changing a resident, that has always been the 'rule'. 2. Record review for Resident #13 revealed an admission date of 09/04/25. Diagnoses included muscle weakness, type two diabetes mellitus, and abnormalities of gait and mobility.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Resident #13 was always incontinent of bowel and bladder and was dependent on staff for toileting hygiene.Review of the care plan for Resident #13 dated 11/14/25 revealed alteration in elimination, completely incontinent of bowel and bladder. Interventions included to provide incontinence care as needed.Interview on 01/20/26 at 3:54 P.M. with Resident #13 revealed she requested her certified nursing assistant (CNA) #360 an hour ago to be changed and CNA #360 said to her before the CNA brings meal trays around she would change her. Resident #13 revealed she had a bowel movement and needed changed.Interview on 01/20/26 at 5:22 P.M. with Resident #13 revealed the staff still has not changed her. Resident #13 said she cannot be provided incontinence care during meals. Resident #13 was supposed to need incontinence care before the meal started, and her call light was on, and was still waiting. Observation revealed Resident #13's call light was on. Resident #13 revealed she was upset she had to sit all that time in her bowel movement.Interview on 01/20/26 at 5:24 P.M. with Registered Nurse (RN) #330 confirmed she was Resident #13's charge nurse and revealed both her CNAs were feeding other residents and it took a long time for staff to provide care to the residents.Observation and interview on 01/20/26 at 5:32 P.M. revealed CNAs #360 and #335 were walking up the hall. CNA #360 revealed Resident #13 never asked her to change her earlier. CNA #335 revealed she normally worked night shift and on night shift, Resident #13 normally used her call light when she wanted changed and she never refused because she was the one who called for assistance. Resident #13 confirmed she requested CNA #360 to change her earlier. CNA #360 rolled her eyes and said no you didn't and this was the first time the CNA was hearing this. Resident #13 said firmly, No you remember, she asked the CNA and the CNA said she would come back before dinner. CNA #360 rolled her eyes and did not respond verbally. Observation of peri care revealed Resident #13 was saturated. There was stool in the peri area. CNA #360 wiped Resident #13 two times from the buttocks area up through the vaginal area revealing heavy stool with each wipe then turned Resident #13 revealing a large bowel movement. Resident #13 had multiple creases on her buttocks, back and upper thighs due to the wrinkled sheets/pad. The buttocks and thighs were red. CNA #360 confirmed while cleaning Resident #13, she only wiped the front two times and wiped from her bottom up revealing stool with each wipe. Interview on 01/21/26 at 4:42 P.M. with the Director of Nursing (DON) revealed staff were allowed to change residents during meals and residents were to be checked and changed every two hours and as needed. This deficiency represents non-compliance investigated under Complaint Number 2702159.

Based on observations, review of a manufacturer insert, staff interviews, record review, and facility policy review, the facility failed to ensure a medication error rate of less than five percent (%). Three errors were observed in 25 opportunities resulting in a 12% error rate. This affected three (Resident #14, #17 and #31) of three residents observed for medication administration. The facility census was 62. Findings include:1. Record review for Resident #14 revealed an admission date of 09/25/20. Diagnoses included type two diabetes mellitus with hyperglycemia.Review of the care plan dated 10/06/20 revealed Resident #14 was at risk for hypo/hyperglycemia episodes. Interventions included insulin as ordered.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact and had diabetes mellitus.Review of the physician order for Resident #14 revealed an order with a start date 09/01/22 for Novolog FlexPen solution pen injector 100 units per milliliter (ml), inject as per sliding scale: If 151 to 200 give two units.Observation on 01/21/26 at 12:04 P.M. of medication administration with Licensed Practical Nurse (LPN) #307 revealed LPN #307 confirmed Resident #14's blood sugar was 151. LPN #307 removed Resident #14's Novolog FlexPen from the medication cart, placed a needle on the Novolog FlexPen then dialed in two units of insulin. Observation revealed LPN #307 then administered the two units of insulin to Resident #14. LPN #307 confirmed she never primed the Novolog FlexPen before administering the insulin and revealed she never primed insulin pens because they were preset when dialed in.Interview on 01/21/26 at 12:16 P.M. with the Director of Nursing (DON) revealed nurses need to prime the insulin pen prior to dialing up the amount to be administered. Review of the NovoLog insulin insert provided by the facility titled How to use your NovoLog FlexPen revealed take the cover cap off the syringe, screw the needle on the FlexPen, dial two units, hold the syringe with needle pointing up and tap reservoir gently to move air bubbles to top of needle. Press the push button on your syringe as far as it will go until a drop of insulin appears. Make sure your dose selector is set at zero, dial the number of units you need to inject.2. Record review for Resident #31 revealed an admission date of 04/23/24. Diagnoses included acute respiratory failure, muscle weakness, acute and chronic congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD) with acute exacerbation.Review of the care plan dated 03/03/25 revealed Resident #31 had respiratory deficiencies or abnormalities of pulmonary function related to COPD, CHF, and respiratory failure. Interventions included to administer aerosol treatments as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had moderate cognitive impairment. Resident #31 had debility and cardiorespiratory conditions.Review of the physician orders for Resident #31 revealed an order with a start date of 12/26/25 for breztri aerosphere inhalation aerosol (triple combination inhaler designed for long-term maintenance treatment of COPD) 160-9-4.8 micrograms (mcg)/ACT, two puffs inhale orally two times a day related to COPD with acute exacerbation, administer with spacer, rinse mouth after use with water, do not swallow. Breztri was scheduled to be administered rise (6:00 A.M. to 9:00 A.M.) and bedtime (7:00 P.M. to 10:00 P.M.)Review of the medication administration record for January 2026 revealed Resident #31 missed one dose of breztri aerosphere inhalation aerosol on 01/21/26 for the morning administration (6:00 A.M. to 9:00 A.M). Observation on 01/21/26 at 8:18 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #323 did not have breztri aerosphere inhaler to administer to Resident #31. LPN #323 confirmed the medication was not available and she would need to reorder it from the pharmacy.Interview on 01/22/26 at 12:30 P.M. with Respiratory Therapist (RT) #299 confirmed she worked with Resident #31 and revealed the medication breztri is a bronchodilator, and it opens up the airways and it should be administered to the resident as ordered.3. Record review for Resident #17 revealed an admission date of 04/29/23. Diagnosed included Alzheimer's disease and muscle weakness.Review of the care plan dated 10/25/24 revealed Resident #17 was at risk for alteration in comfort, generalized pain and comorbidities. Intervention included medications as ordered to manage pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired. Resident #17 received a scheduled pain medication program. Review of the physician orders for Resident #17 revealed an order with a start date of 08/19/25 for capsaicin external cream 0.1% (used to relieve nerve pain in the joints, applied to both knees) apply to joints topically every shift for pain. Capsaicin external cream was scheduled to be administered twice a day, 6:00 A.M. to 9:00 A.M. and 7:00 P.M. to 10:00 P.M.Review of the medication administration record for January 2026 revealed Resident #17 missed one dose of capsaicin external cream 0.1% on 01/21/25 for morning administration (6:00 A.M. to 9:00 A.M.).Observation on 01/21/26 at 8:38 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #302 did not have capsaicin external cream 0.1% to administer to Resident #17. LPN #302 confirmed the capsaicin cream would be reordered from the pharmacy and would be delivered later that evening.This was an incidental finding discovered during the survey.

Based on observation, resident and staff interview, pharmacy interview, and record review, the facility failed to ensure Resident #13's physician orders were followed and her medication was available for administration. This affected one (Resident #13) of five reviewed for medication administration. The facility census was 67.Findings include:Review of Resident #13's medical record revealed an admission date of 09/04/25. Diagnoses included obesity - class III and type two diabetes mellitus (DM) with diabetic neuropathy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact and did not reject care during the seven-day assessment look-back period.Review of Resident #13's physician orders dated 11/05/25 revealed Zepbound subcutaneous solution 2.5 milligrams (mg) per 0.5 milliliter (ml), inject one pen needle subcutaneously one time a day every Tuesday for DM. Last week of injection, please notify the Nurse Practitioner (NP).The care plan dated 11/14/25 included Resident #13 had the potential for alteration in nutrition related to diagnoses. Resident #13 was on the medication Zepbound for weight loss. Interventions included to administer medications as ordered.The Medication Administration Record (MAR) dated 12/02/25 revealed Zepbound subcutaneous solution 2.5 mg per 0.5 ml, inject one pen needle subcutaneously one time a day every Tuesday for DM was not administered at lunchtime as ordered.The progress note dated 12/02/25 at 2:55 P.M. revealed Zepbound was on order.Interview on 12/02/25 at 4:33 P.M. with Resident #13 revealed she was on a weight loss shot and she should have received it between 11:00 A.M. and 1:00 P.M. today. Resident #13 stated she asked Licensed Practical Nurse (LPN) #233 where her shot was and was told it was not at the facility and was on order. Interview on 12/03/25 at 8:19 A.M. with Assistant Director of Nursing (ADON) #290 revealed Resident #13's Zepbound medication was expensive and the Administrator had to give his approval for it to be filled and delivered to the facility by the pharmacy.Interview on 12/03/25 at 10:05 A.M. with the Administrator revealed he received a call yesterday (12/02/25) from the pharmacy and they needed approval because Resident #13's prior authorization did not go through. The Administrator stated he approved Resident #13's Zepbound on 12/02/25 and he did not know who should have made sure the Zepbound was available for administration. The Administrator stated going forward, Resident #13's Zepbound would be ordered on Mondays and it would be administered to Resident #13 on Wednesdays. The Administrator stated the ADON would be responsible to make sure Resident #13's Zepbound was available for administration.Interview on 12/04/25 at 11:13 A.M. with Pharmacy Representative #310 revealed the pharmacy received a refill request on 12/02/25 through the electronic system for Resident #13's Zepbound. When the pharmacy processed the request, it was not covered by Resident #13's insurance, the facility was contacted and the Administrator authorized the pharmacy to send one Zepbound pen.This deficiency represents non-compliance investigated under Complaint Number 2643181.

Based on observation, staff interview, record review, and review of the facility policy, the facility failed to ensure the residents received timely and appropriate incontinence care. This affected one (Resident's #31) of four residents reviewed for skin integrity. The facility census was 67.Findings include:Review of Resident #31's medical record revealed an initial admission date of 06/10/25 and a re-entry date of 09/03/25. Diagnoses included urinary tract infection, diabetes mellitus without complications, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had moderate cognitive impairment. Resident #31 required substantial to maximal assistance with toileting hygiene, bathing, and personal hygiene and was frequently incontinent of urine and bowel.Review of Resident #31's care plan dated 09/14/25 revealed Resident #31 had an alteration in elimination and was frequently incontinent of bowel and bladder. Resident #31 would be clean, dry and odor free. Interventions included to provide incontinence care as needed.Observation on 12/02/25 at 10:33 A.M. revealed Certified Nursing Assistant (CNA) #242 was providing Resident #31's incontinence care. Resident #31 had two incontinence briefs on and both were saturated with urine and Resident #31 had a bowel movement. A folded blanket under Resident #31, used as a reusable chux pad (an absorbent waterproof pad) was wet with urine and the urine was dried around the edges. CNA #242 removed Resident #31's two briefs, the wet chux pad and threw them on the floor without using a plastic bag. Resident #31 had a moderate, formed brown bowel movement, and when CNA #242 cleansed his buttocks and sacral area redness was noted. CNA #242 stated it looked like Resident #31 had not had his brief changed in a long time. CNA #242 finished providing incontinence care, she did not remove her soiled gloves and touched Resident #31's closet door and took items out of his closet with soiled gloves. With soiled gloves on CNA #242 touched Resident #31's clean bed linens, his pillow and the door handle to his room. CNA #242 left the room and removed her soiled gloves after leaving and put them in a trash container. CNA #242 confirmed she had soiled gloves on when she touched furniture, bed linens and door handles while in Resident #31's room.Interview on 12/02/25 at 10:45 A.M. with the Director of Nursing (DON) revealed CNA #242 told her Resident #31 was wearing two incontinence briefs and she touched Resident #31's closet door, clean bed linens, his pillow and the door handle to his room while wearing soiled gloves. The DON confirmed Resident #31 should not have been wearing two incontinence briefs.Review of the facility policy titled Skin Incontinence Care Protocol revised 09/2017 revealed the facility would provide incontinence care for the resident to assist in maintaining skin integrity, preventing skin breakdown, controlling odor and providing comfort and self-esteem for the resident. After each incontinent episode perform proper hand hygiene and wear gloves when providing incontinence care. This deficiency represents non-compliance investigated under Complaint Number 2625673.

Based on observation, staff interviews, record review, and review of the facility policy, the facility failed to ensure Resident #37's care planned interventions were implemented and skin impairments were identified and treated timely. This affected one (Resident's #37) of four residents reviewed for skin integrity. The facility census was 67.Findings include:Review of Resident #37's medical record revealed an admission date of 10/03/25 and diagnoses included non-infective gastroenteritis and colitis and cerebral palsy.Review of Resident #37's admission Skin assessment dated [DATE] revealed Resident #37 had a stage I pressure ulcer (skin is intact but shows damage from prolonged pressure, appearing as a persistent red, reddish-blue, or purplish area that doesn't turn white (blanch) when pressed), the skin was intact, non-blanchable, and there was erythema (reddening of the skin caused by inflammation).Review of Resident #37's physician orders revealed on 10/04/25, an order to apply house moisture barrier ointment to peri area, buttocks, coccyx after incontinent episodes and as needed. On 10/06/25, an order to complete head to toe skin check to be completed every day shift every Monday, Thursday for skin.Review of Resident #37's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had severe cognitive impairment. Resident #37 had impairment on both sides of upper and lower extremities, was dependent on staff for toileting hygiene, bathing, dressing and personal hygiene. Resident #37 required substantial to maximal assistance to roll to the left and right sides and return to lying on his back on the bed. Resident #37 had an indwelling catheter and was always incontinent of bowel. Resident #37 did not have moisture associated skin damage (MASD). Resident #37 did not reject care during the seven-day assessment look-back period. Review of Resident #37's Wound Care notes written by Wound Nurse Practitioner (WNP) #306 and dated 11/05/25 included Resident #37's sacrum Stage I pressure injury showed complete epithelialization with no signs of infection or inflammation. Healing was complete and the wound was now fully closed. Review of Resident #37's care plan dated 11/14/25 included Resident #37 had an alteration in elimination and was incontinent of bowel and bladder. Resident #37 would be clean, dry and odor free. Interventions included to monitor for skin redness and irritation and notify nursing; provide incontinence care as needed.Review of Resident #37's Wound Care notes written by WNP #306 and dated 11/26/25 did not reveal evidence Resident #37's sacrum was evaluated.Review of Resident #37's progress notes dated 11/26/25 through 12/02/25 did not reveal evidence Resident #37 had skin impairment of the lower back, buttocks, hips, and sacral area.Review of Resident #37's Treatment Administration Record (TAR) dated 12/01/25 revealed a head to toe skin check completed every day shift every Monday and Thursday was checked off it was completed on 12/01/25 by Licensed Practical Nurse (LPN) #262. On 12/01/25 apply house moisture barrier ointment to peri area, buttocks, coccyx after incontinent episode and as needed every shift for preventative was checked off it was completed on day shift (no time was documented) by LPN #262. On 12/01/25 cleanse sacrum with soap and water and apply Triad paste every shift for wounds for prevention was checked off it was completed on day shift (no time was documented) by LPN #262. Observation on 12/02/25 at 9:55 A.M. of Resident #37 revealed Certified Nursing Assistant (CNA) #242 was preparing to provide incontinence care for Resident #37. Resident #37 was lying on his back in bed and he was lying on a low air loss mattress. The low air loss mattress pump revealed a red light was showing the pump had a low pressure, and there was no alarm sounding. CNA #242 confirmed the low air loss mattress pump had a low pressure reading. CNA #242 began providing incontinence care and when she removed Resident #37's incontinence brief and had him turn onto his right side multiple long, dark, red marks about three to four inches long and a half inch wide were seen on his left hip and upper outer area of his left thigh. CNA #242 stated she usually worked on another nursing unit and was not familiar with Resident #37 and did not know if he had the marks previously. Resident #37's lower back had a very large reddened area covering both sides of his lower back and there were many, scattered open areas, and many of the scattered open areas had a small amount of fresh blood draining from them. Resident #37's buttocks were very reddened, raw and had scattered open areas draining a small amount of fresh blood. CNA #242 stated the reddened areas on Resident #37's lower back and buttocks did not look like new areas. Resident #37 grimaced when asked if his bottom hurt, and CNA #242 stated Resident #37's lower back and buttocks looks really bad. Resident #37 had a moderate amount of formed, brown stool in his incontinence brief and when CNA #242 cleaned his buttocks the area was very red, with open areas that were bleeding. The surveyor asked LPN #262 to come into Resident #37's room. LPN #262 stated the reddened, open, bleeding, scattered areas on Resident #37's lower back and buttocks does not look new, and no CNAs had told her about it. LPN #262 directed CNA #242 to apply barrier cream to Resident #37's lower back, buttocks and sacral area, and she would call Wound Nurse (WN) #307 so she could evaluate the areas. LPN #262 confirmed Resident #37's low air loss mattress pump was showing a red light that stated low pressure. LPN #262 was not sure how long the light was on because the pump usually sounded an alarm when it wasn't working properly, and there was no alarm sounding. LPN #262 stated she would tell WN #307 about the malfunctioning low air loss mattress pump. CNA #242 applied barrier cream and stated she did not think Resident #37's incontinence brief was changed for a long time. Observation on 12/02/25 at 11:12 A.M. of Resident #37 with WN #307 confirmed Resident #37 had large, reddened areas of his lower back, buttocks and sacrum, with many scattered open areas, and confirmed the long red marks on Resident #37's left hip and outer area of his left thigh. WN #307 indicated a small cup with paste in it and stated she brought Triad paste to apply to Resident #37's areas. WN #307 stated Resident #37's skin was very friable, she brought a basin with warm water with body wash soap and cleansed Resident #37's lower back, sacrum, buttocks. WN #307 stated Resident #37 had a generalized fungal rash with MASD, and the reddened areas blanched well. WN #307 stated it definitely looked like a fungal rash and was caused by moisture. WN #307 stated when she made wound rounds with WNP #306 they always looked at Resident #37's sacral area because he was at high risk for skin breakdown, and on 11/26/25 his sacral area, lower back and buttocks did not look this way and were clear. WN #307 confirmed there was no evidence Resident #37's sacral area was evaluated in Resident #37's wound care notes dated 11/26/25 documented by WNP #306 because when the wound healed it dropped off, and did not show up anymore. WN #307 stated she did not chart on residents who were seen by WNP #306, she wasn't sure why, it was a decision made by the corporate office, and it could be due to charting variance. WN #307 indicated that although Resident #37's sacral wound was healed the prevention order to cleanse the sacrum was still in place because that way I know a nurse is still checking on him. WN #307 stated if a nurse found a resident with a skin issue, they filled out a non-pressure skin assessment on paper, and notified her they filled a paper out on the resident. WN #307 stated she was not notified Resident #37 had a skin issue, but the skin issue could have happened very quickly. WN #307 confirmed Resident #37's low air loss mattress pump had a red light stating low pressure, and she would try to fix the problem after his care was completed. Interview on 12/02/25 at 12:00 P.M. with CNA #303 revealed she took care of Resident #37 on 12/01/25 and he had redness on his lower back and buttocks and she put cream on it. CNA #303 stated she told the nurse, but she could not remember which nurse she told.Interview on 12/02/25 at 1:00 P.M. with LPN #262 revealed she did not remember if an CNA told her Resident #37 had a reddened, irritated lower back, sacrum and buttocks.Interview on 12/02/25 at 3:05 P.M. with CNA #241 revealed Resident #37's bottom and lower back were red when she took care of him over the weekend (11/29/25 and 11/30/25). CNA #241 stated she applied barrier cream when she changed him, but she did not remember if there were open areas. CNA #241 indicated she did not tell the nurse Resident #37 had a reddened back and bottom because she thought the nurse knew about it.Interview on 12/02/25 at 3:41 P.M. with CNA #207 revealed she worked on 11/27/25 and when she changed Resident #37's incontinence brief, he had a reddened bottom. CNA #207 stated I am sure I told the nurse about it, but she could not remember which nurse she told. CNA #207 stated the aide charting was not specific and there was nowhere to chart redness. Interview on 12/02/25 at 4:14 P.M. with LPN #281 revealed she did not remember being told Resident #37 had a reddened lower back and buttocks.Interview on 12/03/25 at 10:22 A.M. with LPN #262 revealed the CNAs washed, cleansed, and applied cream to Resident #37's sacral area when they provided incontinence care. LPN #262 stated if the cream was ordered by a physician, she put the cream in a cup and gave it to the CNAs to apply, or they could use the pink house barrier cream which was kept in Resident #37's drawer in his room. LPN #262 stated she did not look at Resident #37's sacral area when the aides changed him, and the aides told her if there was a skin issue. LPN #262 stated she checked off on Resident #37's TAR it was done, but she did not actually look at Resident #37's sacral area and buttocks. LPN #262 stated the aides were good and knew to tell her if Resident #37 had a skin issue.Interview on 12/03/25 at 11:24 A.M. with WN #307 revealed Resident #37's low air loss mattress pump was not working properly and his low air loss mattress was being replaced today. WN #307 stated she checked the mattress and Resident #37 had no negative effects from the low air loss mattress not working properly.Review of the facility policy titled Incontinence Care Protocol dated 09/2017 included the facility would provide incontinence care for the resident to assist in maintaining skin integrity, preventing skin breakdown, controlling odor and providing comfort and self-esteem for the resident. Report reddened areas or skin breakdown to the nurse.This deficiency represents non-compliance investigated under Complaint Number 2625673.This is an example of continued non-compliance from the survey dated 10/29/25.

Based on record review, staff interviews, pharmacist interview, and review of the facility policy, the facility failed to ensure Resident #101 was free from significant medication errors. This affected one (Resident #101) of five residents reviewed for medication administration. The facility census was 67. Findings include:Review of Resident #101's medical record revealed an admission date of 10/08/25. Diagnoses included Parkinson's Disease without dyskinesia and anxiety. Resident #101 was discharged from the facility on 10/12/25.Review of Resident #101's admission assessment and Baseline Care Plan dated 10/08/25 included Resident #101 was confused and disoriented and unaware of safety needs. Resident #101 was anxious and received antianxiety medication. Review of Resident #101's physician orders dated 10/08/25 revealed alprazolam (Xanax) oral tablet 0.25 milligrams (mg), give one table by mouth every 12 hours as needed for anxiety.Review of Resident #101's Medication Administration Record dated 10/08/25, 10/09/25, 10/10/25, 10/11/25 and 10/12/25 did not reveal alprazolam 0.25 mg, give one tablet by mouth every 12 hours as needed for anxiety was administered to Resident #101.The progress notes dated 10/12/25 at 11:46 A.M. included a girl and a guy visited Resident #101. They were not Resident #101's Power of Attorney (POA) and they were filming (with their cell phones) and arguing with the aides. Resident #101 was asked if she felt abused, and she stated no and if she felt safe and the answer was yes. Resident #13's physician was contacted and notified she needed anxiety medication and a prescription was needed. The police were called and were present in the facility. Resident #101's family was present and stated they wanted to sign Resident #13 out of the facility against medical advice (AMA). The Director of Nursing (DON) and Resident #13's physician were notified. Review of Resident #101's late entry progress note dated 10/12/25 at 6:54 P.M. revealed on 10/11/25 at 6:50 P.M., the family requested anxiety medication be administered to Resident #101. Resident #101 was noted to be fidgeting with her fingers only and had observable signs of anxiety. Resident #13's physician was notified that Resident #13 needed a prescription for Xanax 0.25 mg, one tablet every 12 hours as needed. Per the physician (unidentified), have pharmacy call for a verbal. The facility pharmacy was contacted and notified they needed to call the physician for a prescription. Interview on 12/01/25 at 3:53 P.M. with Pharmacist #311 revealed Resident #101's alprazolam (Xanax) was never filled because the pharmacy never got a valid prescription. Pharmacist #311 stated the pharmacy followed up three times and sent three communications to Resident #101's physician and one of them on 10/12/25 was marked urgent. Pharmacist #311 indicated the pharmacy never received a response from Resident #101's physician. Pharmacist #311 stated there were no notes in the pharmacy records indicating nurse's from the facility called about Resident #101's Xanax. Pharmacist #311 stated on 10/12/25 the pharmacy stopped the follow up for Resident #101's alprazolam because they received an order to discontinue Resident #101's medications because Resident #101 left the facility AMA. Pharmacist #311 stated Resident #101's alprazolam order was first received on 10/11/25 and the communications started on 10/11/15. Pharmacist #311 could not say why the pharmacy did not receive Resident #101's order for alprazolam on 10/08/25 when it was ordered. Interview on 12/01/25 at 4:05 P.M. with the Director of Nursing (DON) revealed alprazolam 0.25 mg was kept in the facility starter supply area, the physician could call or fax the order in, and as soon as that was done the facility could get authorization to administer alprazolam to Resident #101. The DON stated she was not employed at the facility when Resident #101 resided there and she could not speak to why Resident #101's alprazolam was not filled on 10/08/25 when it was ordered.Interview on 12/01/25 at 4:29 P.M. with Licensed Practical Nurse (LPN) #281 revealed Resident #101's husband was her POA. LPN #281 stated she admitted Resident #101 to the facility, and she started Resident #101's admission and the night shift nurse was supposed to finish it. LPN #281 stated she did not know what happened after she left and did not know if Resident #101's alprazolam was ordered and filled. Resident #101 had visitors while she resided in the facility and they asked many questions that the facility staff could not answer because they were not her POA. The visitors would get upset when their questions would not get answered. LPN #281 stated 10/11/25 and 10/12/25 were days close to a holiday and the nurses could not reach the nurse practitioner or the physicians. Neither the nurse practitioner or the physicians responded to faxes and telephone calls relating to the residents. LPN #281 stated it was a really weird weekend and it was unusual not to be able to contact nurse practitioners or physicians. LPN #281 indicated a meeting was held after that weekend because they could not get the physicians to respond to their faxes and telephone calls. LPN #281 stated she thought the problem was because the facility did not have a schedule stating which physician or nurse practitioner was on call. LPN #281 stated she thought Resident #101 had anxiety after the police were called and the family was arguing with everyone. LPN #281 stated Resident #101 became withdrawn and was more quiet than usual. Resident #101 was not smiling and she usually smiled a lot, and she was shaking. LPN #281 stated Resident #101 had Parkinson's disease and sometimes would shake, but she thought this time the shaking was caused by her anxiety, and she was just not herself. By the time LPN #281 arrived to Resident #101's room, there was so much arguing, and she did not know what caused the arguing. Interview on 12/02/25 at 10:55 A.M. with the Administrator confirmed there was a meeting after the 10/11/25 and 10/12/25 weekend when the physicians were unable to be contacted. The Administrator stated over the weekend, the facility got everything they needed as far as she knew and they had to repost what the on call schedule was after that. The Administrator stated he did not have an answer for what happened that weekend because the former DON was no longer working at the facility and she handled the problem. The Administrator stated if the nurse practitioner was not on call, then one of the physicians should have been on call, and he was not sure what happened.Review of the facility policy titled Guidelines for Medication Orders dated 06/21/17 revealed medications were dispensed by the pharmacy only upon receipt of a clear, complete order, signed by an authorized licensed prescriber. Verbal orders were received only by legally authorized individuals from an authorized prescriber and cosigned on the next prescriber visit, or as required by state regulations and facility policy.This deficiency represents non-compliance investigated under Complaint Number 2643181.

Based on observation, resident and staff interviews, record review, and review of the facility policy, the facility failed to ensure Resident #13's care planned interventions were implemented and failed to ensure Resident #13 had a comprehensive fall evaluation completed timely. This affected one (Resident #13) out of three residents reviewed for falls. The facility census was 67.Findings include:Review of Resident #13's medical record revealed an admission date of 09/04/25. Diagnoses included sepsis, obesity, and type two diabetes mellitus with diabetic neuropathy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Resident #13 had no impairment of the upper and lower extremities and required substantial to maximal assistance for bathing and was dependent for toileting and personal hygiene. Resident #13 required substantial to maximal assistance for the ability to come to a standing position from sitting in a chair, wheelchair or on the side of the bed. Resident #13 did not reject care during the seven-day assessment look-back period.Review of Resident #13's Fall Risk Evaluation dated 10/28/25 revealed Resident #13 was at risk for falls.Review of Resident #13's care plan dated 11/14/25 revealed Resident #13 was at risk for falls related to muscle weakness, obesity, shortness of breath and other diagnoses. Resident #13 would minimize potential risk factors related to falls. Interventions included to educate Resident #13 on proper hand placement during sit-to-stand transfers to promote safety; encourage Resident #13 to use assistive devices properly; transfer and change positions slowly; provide rest periods.Interview on 12/01/25 at 5:20 P.M. with the Director of Nursing (DON) revealed when a resident had a fall the nurse would assess the resident for an injury, would check vital signs, would check to see if the resident hit their head and initiate neuro checks if indicated. The nurse would ask if the resident had pain, and if they had difficulty moving an extremity etcetera. IDON #308 stated if the resident had pain there should be something documented about it. The physician or nurse practitioner would be notified. If the resident had a severe injury they would be sent to the hospital for evaluation. The investigation would be completed in risk management with the details of the fall. There should be a fall assessment and a pain assessment completed, and a physical assessment completed in the progress notes. The DON stated the facility charted by exception, meaning charting is done if there were concerns but otherwise no charting was required to be done. Charting might not be done post fall if there were no issues. There was no template for a post fall assessment. Review of Resident #13's Fall report dated 12/02/25 at 4:00 P.M. revealed Resident #13 was being transferred via sit-to-stand and during the transfer she began to slide out of the lift. Certified Nursing Assistant (CNA) #241 lowered Resident #13 to the floor and made Licensed Practical Nurse (LPN) #233 aware of the situation. Resident #14 was placed in bed via a mechanical lift. No injuries were noted. Resident #13's responsible party and Nurse Practitioner (NP) #309 were notified. Resident #13's level of pain was documented as a zero on a pain scale of zero being no pain and ten being the worst pain, and Resident #13 was oriented to person, situation, place and time.Observation on 12/02/25 at 4:33 P.M. of Resident #13 revealed she was lying in bed with the head of her bed elevated, was pleasant and had an anxious look on her face. Resident #13 stated she was shook up because she just had a fall from a sit-to-stand lift about a half hour ago. Resident #13 indicated she told CNA #241 she did not have a good grip on the sit-to-stand with her hands but CNA #241 was impatient and kept going without checking to make sure her hands had correct placement. Resident #13 stated she could feel her hands giving out and she was telling CNA #241 I am falling, I am falling but CNA #241 just kept going. Resident #13 indicated she could feel the belt around her chest was not tight, she could feel it slipping and she slipped out of the holster, slid down, and slammed her right knee into the sit-to-stand lift then plopped on the floor kind of hard on her back and butt. Observation of Resident #13's right leg revealed about a three inch circular, reddened area by Resident #13's right knee. Resident #13 stated after it happened the aides and nurses did not pay attention, CNA #241 told me you did not fall, you slipped out, and my vital signs including my blood pressure were not checked. Resident #13 stated no one asked me if I had pain and her back and butt were hurting and she was sore all over. Resident #13 stated her pain level after the fall was a six out of ten, on a pain scale of zero (no pain) to 10 (most severe pain). Resident #13 stated she had high anxiety and after she fell and was on the floor she was worried staff would hurt her when they assisted her off the floor. Resident #13 insisted she wanted Assistant Director of Nursing (ADON) #290 to come to the room to help, and fought with them for ten minutes and they finally got him. ADON #290 indicated a mechanical lift had to be used to assist Resident #13 to bed. Resident #13 stated she had not received medication for pain or anxiety and no staff had been back to check on her since she fell and was assisted into bed. Resident #13 put her call light on and five minutes later CNA #303 entered the room to answer the light. Resident #13 asked CNA #303 if she told the nurse she needed Tylenol for pain, and she wanted to see ADON #290 about another medication she was supposed to receive. CNA #303 stated she had not told the nurse Resident #13 asked for Tylenol because she was helping another resident and she would tell her now. CNA #303 confirmed Resident #13 had about a three inch circular reddened area by her right knee. Interview on 12/02/25 at 4:52 P.M. with CNA #241 revealed Resident #13 slid down the sit-to-stand, and she lowered her to the floor by the back of Resident #13's pants. CNA #241 stated Resident #13 was hyperventilating, she cried a lot and she is a hot mess. CNA #241 indicated she had to swing her around and Resident #13 slid out of the sit-to-stand. CNA #241 stated Resident #13 said I don't trust you people, and we got her up using the mechanical lift. CNA #241 indicated she was not sure about Resident #13's knee and did not see her hit her knee. CNA #241 stated she does not want to move, it is her, she is lazy, and she is a hot mess. CNA #241 had an angry look on her face during the interview. Review of Resident #13's medical record including progress notes, assessment tabs, vital signs, Fall Investigation, and Fall report did not reveal evidence Resident #13's vital signs were checked from 12/01/25 at 5:25 P.M. through 12/04/25 at 12:55 P.M. Resident #13's vital signs were not checked at the time of the fall. There was no evidence a comprehensive pain assessment was completed at the time of the fall. There was no evidence follow up pain checks were completed from 12/02/25 at 4:00 P.M. through 12/03/25 at 8:11 A.M. There was no evidence a physical assessment was completed in the progress notes. The Fall Investigation and the Fall report did not include evidence of staff witness statements and there was no evidence a statement was collected from Resident #13.Review of Resident #13's progress notes dated 12/02/25 at 8:15 P.M. included Resident #13 was being transferred via the sit-to-stand and during the transfer she began to slide out of the lift. CNA #241 lowered Resident #13 to the floor and made LPN #233 aware of the situation. Resident #13 was assisted to bed using a mechanical lift. No injuries were noted. Review of Resident #13's Fall Investigation dated 12/03/25 included to complete the Fall Investigation Form and the Incident/Accident Report at the time of a fall (the fall was on 12/02/25). The suspected cause of fall was failure to follow instructions regarding hand placement. Resident #13 fell from a standing position. Resident #13's floor was clean, dry, uncluttered. Resident #13 slid out of bed during assisted transfer using a sit-to-stand lift and the CNA lowered her to the floor. The new intervention was to discontinue Resident #13's sit-to-stand transfers until therapy could review and educate Resident #13 on proper hand placement during sit-to-stand transfers.Interview on 12/03/25 at 8:19 A.M. of ADON #290 revealed on 12/02/25 CNA #241 was transferring Resident #13 using the sit-to-stand lift and she slid out of it onto the floor. ADON #290 stated he had no read the report and did not know details. ADON #290 stated when he walked in Resident #13's room she was sitting on the floor with her right side against the bed and she wanted us to lift her up, but for safety reasons we used the mechanical lift to assist her off the floor. ADON #290 indicated he left the room after she was assisted off the floor and did not assess Resident #13 after her fall because the nurse did it. Before ADON #290 left the room he tried to console Resident #13 because she was anxious.Observation and interview on 12/03/25 at 8:33 A.M. of Resident #13 with ADON #290 revealed Resident #13 was lying in bed with the head of her bed elevated about 45 degrees. Resident #13 stated she was very sore today, especially her butt and knee and she finally received Tylenol on 12/02/25 around 6:00 P.M. and it only relieved her pain a little bit. Resident #13 stated she hit her right knee on the sit-to-stand when she fell and I feel beat up. Resident #13 indicated she told CNA #241 the belt around her chest was not tight enough and CNA #241 ignored her. Resident #13 could not get her hands placed correctly on the bar and when she fell her fingernails pulled off. Observation of Resident #13's left hand revealed three of her artificial fingernails had been pulled off and were not seen. ADON #290 confirmed three fingernails on Resident #13's left hand had been ripped off when she fell. Resident #13 kept telling CNA #241 her holster was not fastened correctly and she was going to fall and CNA #241 was in a rush, ignored her told her no, you are not. Resident #13 stated she was too sore to go to her Physical Therapy appointment today, and ADON #290 told her he would let therapy know. Resident #13 stated CNA #241 got so mad when I fell, and she fell from a full stand. Observation of Resident #13's right knee area revealed some abrasions were noted, and a faint redness of the area could be seen.Interview on 12/03/25 at 9:39 A.M. with the Director of Nursing (DON) revealed Nurse Practitioner (NP) #309 was contacted and would evaluate Resident #13 sometime today (12/03/25). The DON stated therapy told her CNA #241 was competent with the sit-to-stand lift, and the sling was being checked today to make sure it was safe to use the sit-to-stand. The DON stated the sit-to-stand would not be used to assist Resident #13 with transfers until therapy could evaluate and clear her to use the sit-to-stand. The DON stated pain assessments were found in the residents' assessment tab in the electronic medical record. When asked questions about Resident #13's fall on 12/02/25, the DON stated she was still reviewing the fall and could not answer specific questions. Interview on 12/03/25 at 10:05 A.M. with the Administrator revealed on 12/02/25 at the time of Resident #13's fall, he was walking in the hall by her room looking for a nurse when CNA #241 told him Resident #13 fell and wanted ADON #290 to come to the room to help. The Administrator indicated CNA #241, Licensed Practical Nurses (LPNs) #262 and #233, and two other staff were in the room assisting Resident #13 after her fall. The Administrator stated he heard Resident #13 yelling I can't, I can't, don't do that and staff were reassuring her. The Administrator stated Resident #13 could be difficult and he felt the staff did a good job assisting Resident #13 after her fall.Review of the facility policy titled Fall Management dated 10/17/16 revealed residents who received a fall would receive prompt medical attention. Immediate needs would be quickly assessed and responded to. A plan would be identified and implemented as necessary to protect the resident and/ or others from recurrence. Management of falls included the resident would be assessed for injuries, vital signs and provided with prompt medical attention as needed. The charge nurse gathered and recorded as much pertinent data as possible related to the fall. This deficiency represents non-compliance investigated under Complaint Number 2625673.

Based on observation, medical record review, policy review, and interview, the facility failed to develop and implement a comprehensive, individualized and effective nutrition/hydration plan to prevent weight loss and dehydration for Resident #12. This affected one resident (#12) of three residents reviewed for significant weight loss. The census was 65. Actual harm occurred on 10/01/25 when Resident #12, who had moderate cognitive impairment, was at moderate risk for malnutrition, required cues and assist with eating, and had a care-planned intervention to monitor and provide hydration as prescribed, was assessed to weigh 189.4 pounds representing a 17.3 pound or 8.3 percent (%) severe weight loss in two weeks. The resident was transferred to the hospital (on 10/01/25) and admitted with a change in mental status secondary to dehydration with a five-day hospital stay requiring intravenous fluids. Prior to the hospitalization, the facility failed to ensure ongoing weight monitoring was completed and failed to implement adequate interventions to address the resident's decrease in meal intakes resulting in the weight loss. Findings include:Review of the medical record for Resident #12 revealed an original admission date of 06/10/25, discharge date of 07/27/25 to the hospital, then readmission date of 09/03/25 from another skilled nursing facility (SNF). Resident #12's diagnoses included dementia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes, muscle weakness, epilepsy and chronic viral hepatitis C. Resident #12 resided on the secured memory care unit.Review of the weight summary from Resident #12's prior admission of 06/10/25 to 07/27/25 in the weights/vitals tab in the electronic medical record (EMR) revealed the resident weight 211 pounds on 06/10/25, 215 pounds on 06/24/25, 215.5 pounds on 07/01/25 and 215.3 pounds on 07/15/25.Review of an admission Assessment and Baseline Care Plan dated 09/03/25 (with a lock date of 09/18/25) revealed Resident #12 was confused, unaware of safety needs and needed assistance with meals. Resident #12's most recent weight was documented to be 206.5 pounds from 09/17/25. There was no evidence that Resident #12 was edematous upon admission.Review of the physician orders from September 2025 revealed Resident #12 was ordered hydrochlorothiazide (a diuretic medication) oral capsule 12.5 milligrams give one capsule by mouth once time a day for edema. The order began on 09/04/25.Review of the Skilled Nursing Note dated 09/06/25 timed 5:51 A.M. revealed there was no evidence Resident #12 had worsening edema or a change in fluid intake.Review of the Skilled Nursing Note dated 09/06/25 timed 11:12 P.M. revealed there was no evidence Resident #12 had worsening edema or a change in fluid intake.Review of the Skilled Nursing Note dated 09/07/25 timed 8:20 P.M. revealed there was no evidence Resident #12 had worsening edema or a change in fluid intake.Review of the Skilled Nursing Note dated 09/10/25 timed 5:44 P.M. revealed there was no evidence Resident #12 had worsening edema.Review of the encounter note dated 09/10/25 timed 11:09 A.M. for date of service of 09/05/25 authored by Nurse Practitioner (NP) #906 revealed there was no evidence Resident #12 was edematous.Review of an encounter note dated 09/10/25 timed 11:10 A.M. for date of service of 09/09/25 authored by NP #906 revealed there was no evidence Resident #12 was edematous.Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #12 was moderately cognitively impaired, used a walker and a manual wheelchair for mobility, had no natural teeth and required (staff) setup or clean-up assistance with eating. There was not a recorded weight included in the assessment.Review of a Malnutrition Risk assessment dated [DATE] revealed Resident #12 was at moderate risk for malnutrition.Review of the Nutrition assessment dated [DATE] authored by Diet Technician Registered (DTR) #860 revealed Resident #12's most recent weight was 215.3 pounds from 07/15/25. The assessment revealed Resident #12 had fair-good intake majority of meals per nursing aide intake records. The resident fed self meals with cues and assist as needed. Resident #12's estimated calorie, protein, and fluid requirements were not calculated. DTR #860 wrote would assess estimated needs when admission weight available. Goals: weight without unplanned significant changes (5% in 30 days, 10% in 180 days) and intakes of at least 75% most meals provided. There was no evidence Resident #12 had edema/accumulation of fluid.Review of the potential for alteration in nutrition and hydration care plan dated 09/11/25 revealed Resident #12 was at risk for malnutrition with a goal of no signs or symptoms of dehydration/electrolyte imbalance/fluid overload. Interventions included: assistance with meals as needed, monitor for signs and symptoms of dehydration and weights per protocol.Review of the Skilled Nursing Note dated 09/12/25 timed 8:42 P.M. revealed there was no evidence Resident #12 had worsening edema or a change in fluid intake.Review of an encounter note dated 09/14/25 timed 4:38 P.M. for date of service of 09/12/25 authored by NP #906 revealed there was no evidence Resident #12 was edematous.Review of an activities of daily living (ADL) care plan dated 09/14/25 revealed Resident #12 may require assistance with ADL's and may be at risk for developing complications associated with decreased ADL self-performance related to hemiplegia, diabetes, vascular dementia, epilepsy and hepatitis C. Interventions included: eating - supervision and cueing.Review of an alteration in elimination care plan dated 09/14/25 revealed Resident #12 was frequently incontinent of bowel and bladder. Interventions included to monitor and provide hydration as prescribed.Review of the medical record revealed required hydration levels were not prescribed and no interventions were implemented to monitor the resident's hydration (as noted in the plan of care). Review of the weight summary in the weights/vitals tab in the electronic medical record revealed Resident #12 weighed 206.5 pounds on 09/17/25.Review of the encounter note dated 09/17/25 timed 3:41 P.M. for date of service of 09/15/25 authored by NP #906 revealed there was no evidence Resident #12 was edematous.Review of the Nutrition and Fluids recording for September 2025 in the task tab of EMR revealed there was no fluid intake amounts recorded for the entire month of September 2025 and revealed the following decreased meal intakes on the following dates:25% of lunch and 1% to 25% of dinner on 09/23/251% to 25% of breakfast and lunch on 09/24/2525% of breakfast and 1% to 25% of lunch on 09/25/251% to 25% of breakfast and lunch and there was no amount recorded for dinner on 09/26/25Refused breakfast on 09/27/2525% of breakfast and there was no amount recorded for dinner on 09/29/251% to 25% at breakfast and there were no amounts recorded for lunch or dinner on 09/30/25There was no evidence of any updates to the resident's plan of care or new interventions during this time to address the resident's decreased meal intakes. Review of a health status note dated 09/23/25 timed 1:54 P.M. revealed family spoke with this nurse regarding resident changes noted. The resident's family felt the resident had something going on with him related to speaking less, eating less and having no motivation in therapy. This nurse spoke with nurse practitioner (NP) who ordered labs and a urinalysis and culture and sensitivity. The NP also stated she would review the resident's medications and see if an antidepressant was needed.Review of the resident's medical record revealed no evidence DTR #860 was notified of the decrease in meal intakes.Review of a speech therapy treatment encounter note dated 09/24/25 authored by Speech Language Pathologist (SLP) #908 revealed saw resident during breakfast on this date. Resident with intake of only cold cereal. Provided moderate cueing to increase oral intake, but resident refused anything else on tray today.Review of an encounter note dated 09/24/25 timed 11:18 AM. for date of service of 09/23/25 authored by NP #906 revealed no evidence Resident #12 was edematous.Review of the Lab Results Report dated 09/24/25 revealed Resident #12's blood urea nitrogen (BUN) was 31 (7 to 25 normal range) and BUN/creatinine ratio was 28 (6 to 22 normal range).Review of the health status note dated 09/25/25 timed 4:48 A.M. revealed NP #906 notified of lab results. Awaiting response.Review of the health status note dated 09/26/25 timed 8:43 A.M. revealed NP #906 was in today. New order for Citalopram (anti-depressant) 20 milligrams daily. Resident appeared to be sad and food intake had decreased. Spoke with resident's daughter who was in agreement with new order.Review of the encounter note dated 09/27/25 timed 8:09 P.M. for a date of service of 09/26/25 authored by NP #906 revealed per nursing staff, the resident appeared to be depressed with low mood and decreased engagement noted. There was no evidence of weight change. Plan: start Citalopram (an anti-depressant medication) 20 milligrams daily to augment depression treatment and continue Remeron (an anti-depressant medication) 15 milligrams at bedtime.Review of the psychiatry physician progress note dated 09/29/25 revealed staff noted Resident #12 had been weak and unable to sit unsupported in bed and was mostly in bed. Resident #12's appetite was low. Assessment/plan: Vascular dementia with mood disturbance - suspect that prior to seizure patient might have had another cerebrovascular accident (CVA). Suspect that resident was not suffering from underlying depression but rather apathy related to cerebrovascular accident (CVA).Review of the speech therapy treatment encounter notes dated 09/29/25 authored by SLP #908 revealed upon arrival, resident with a full plate in front of him and no attempt to eat anything. SLP asked resident if he would like any of the food and resident just shrugged his shoulders. Attempted to provide resident with bites via spoon from SLP. Resident made a face that would suggest he did not like it. When SLP asked, he just shrugged his shoulders and stated that would be fine but did not attempt to feed self anymore and did not accept any more bites from SLP. Provided resident with several food options and resident shrugged shoulders for all options. Attempted to put ice in his Boost that he had available to make it more palatable, but resident continued to make a digested face when drinking. Educated on importance of continued intake and resident stated he would agree to continue taking sips of his Boost throughout morning. SLP discussed decreased intake with nurse who reported the resident had recently started a depression medication and believed him to be depressed which may be affecting intake.Review of the speech therapy treatment encounter notes dated 10/01/25 authored by SLP #908 revealed Resident #12 provided with a snack this morning which he required mod-max cues to self-feed. Resident with increased mastication time for regular textures, but adequate prior to swallow. Saw resident at lunch on this date as well. Resident with minimal attempts to self-feed. Was able to use head nods to let SLP know which foods he would like to eat and was agreeable to allow SLP to provide bites via spoon. SLP educated nurse on need for increased assistance with feeding. Record review revealed no new nutritional/hydration interventions were initiated at this time.Review of the weight summary in the weights/vitals tab in the electronic medical record revealed Resident #12 weighed 189.2 pounds on 10/01/25 (a 17.3-pound or 8.3% weight loss in two weeks).Review of the health status note dated 10/01/25 timed 2:24 P.M. revealed Resident #12 chewed up food then spit out food, flat affect. This nurse notified Physician #905 requesting electroencephalogram (EEG) (a procedure that measured the electrical activity of the brain). The note revealed the nurse was waiting on return call.Review of a health status note dated 10/01/25 timed 4:04 P.M. revealed Resident #12 was confused, not eating, unable to walk, not talking. The NP ordered for the resident to go to emergency room for evaluation (recent cerebrovascular accident (CVA), possible recent seizure). 911 called and resident transferred to hospital for evaluation.Review of a hospital After Visit Summary revealed Resident #12 was admitted to the hospital from [DATE] to 10/05/25 with diagnosis and treatment of altered mental status suspect secondary to dehydration. The note included initially urinary tract infection (UTI) was suspected but was ruled out. The resident was also noted to have dehydration with an elevated BUN to creatinine ratio. Urine specific gravity > 1.04. The hospital record included the resident's daughter reported that patient was started on diuretics for leg edema in last one week at extended care facility (ECF). Currently not on any diuretics. Treated with intravenous hydration. At discharged , no diuretics. Currently no edema.Review of Resident #12's medical record revealed the resident returned to the facility on [DATE] and was not weighed on this date of readmission. Review of a Nutrition assessment dated [DATE] authored by DTR #860 revealed Resident #12 was at risk for malnutrition due to.diuretic treatment, recent hospitalization, UTI, decreased intake, and significant weight loss (SWL). Resident #12 had a weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a prescribed weight-loss regimen. The resident was flagging as a significant weight loss of 5.2%/10.9 pound loss in 30 days. Weight loss was not desirable. Resident had moisture-associated dermatitis on buttocks upon readmission. Supplement recommended to support skin healing. Nutritional interventions included weights as ordered and a recommendation to start 240 milliliter of nutritional supplement, Boost Glucose Control once a day. Review of Resident #12's physician orders revealed diabetic house supplement (Boost) was started 10/14/25, nine days after being readmitted to the facility. Review of the weight summary in the weights/vitals tab in the EMR revealed Resident #12 weighed 190.3 pounds on 10/14/25 and weighed 189.4 pounds on 10/21/25. Observation on 10/27/25 at 6:50 A.M. revealed Resident #12 was lying in bed and had no bottom teeth. There were no fluids observed within the resident's reach.Observation on 10/27/25 at 8:14 A.M. revealed CNA #840 served Resident #12's breakfast meal. CNA #840 placed a clothing protector on Resident #12 and the resident's bed was raised to a higher position. CNA #840 put jelly on the toast and placed the tray over top of the bed. The meal consisted of oatmeal, toast, a banana, milk, orange juice and water. Resident #12 was able to eat the banana independently. The resident began eating in bed. At 8:25 A.M., CNA #840 was standing next to the resident's bed feeding oatmeal to him. Observation on 10/27/25 at 8:43 A.M. revealed Resident #12 was lying in bed. There were no fluids within reach.Interview on 10/27/25 at 9:45 A.M with DTR #860 revealed it was facility protocol to obtain weekly weights for four weeks after admission for all residents. DTR #860 verified the facility did not obtain an admission weight for Resident #12, verified Resident #12's weight was not obtained until 09/17/25 and verified a weight was not obtained on or around 09/24/25. DTR #806 requested a weight via email from the Director of Nursing, Assistant Director of Nursing (ADON) #825 and ADON #909 on 09/08/25. ADON #825 and ADON #909 responded on the same day, and they were writing up the staff who did not get his weight, they were furious and they would make sure the weight was done. DTR #860 verified Resident #12 had a 17.3 pound weight loss from 09/17/25 to 10/01/25.Observation on 10/27/25 at 9:50 A.M. revealed Resident #12 was observed for wound care. There were no fluids within the resident's reach.Observation on 10/27/25 at 10:54 A.M. revealed Resident #12 was lying in bed with his eyes closed. There were no fluids within the resident's reach.Observation on 10/27/25 at 11:45 A.M. revealed Resident #12 was lying in bed with his eyes closed. There were no fluids within the resident's reach.Interview on 10/27/25 at 12:00 P.M. with SLP #908 revealed around 09/24/25, Resident #12 had decreased meal intake, was staring off into space and wasn't being himself.Interview on 10/27/25 at 12:50 P.M. with the Administrator (with the DON present) verified the facility did not obtain an admission weight for Resident #12 and verified a weight was not obtained until 09/17/25. The Administrator reported a belief that the scale used to weigh Resident #12 was inaccurate/ off. However, the Administrator was unable to provide a reason why the two weights on different dates were stable 189 to 190 pounds following the resident's readmission on [DATE].Interview on 10/27/25 at 2:30 P.M. with Resident #12's mother revealed she had noticed whenever she would bring food into Resident #12, he would eat like he hadn't been eating. The mother indicated on 10/01/25, Resident #12 wasn't feeling good, he wasn't' responding and Resident #12's mother talked to the nurse to notify the nurse that something was wrong. During the interview, Resident #12's mother stated, they (the staff) would set his food tray out and leave him to feed himself.Interview on 10/27/25 at 2:45 P.M. with the DON verified Resident #12 had a decrease in meal intake around 09/24/25 and verified DTR #860 was not notified of the resident's decreased meal intake.Interview on 10/27/25 at 3:45 P.M. with Resident #12's daughter (first emergency contact) revealed Resident #12 needed assistance with meals and set-up assistance with meals. Resident #12's daughter voiced concerns the resident's meals would be left on his bedside table and the lid would sometimes be left on.Interview on 10/27/25 at 4:55 P.M. with the DON verified Resident #12's weight was not obtained when he readmitted on [DATE] and a weight was not obtained until 10/11/25. The DON did not provide a reason as to why a readmission weight was not obtained. Interview on 10/28/25 at 11:10 A.M. with Physician #905 revealed Resident #12 had very slight edema during September 2025. Resident #12 was prescribed hydrochlorothiazide for blood pressure control. Physician #905 revealed he was notified Resident #12 had a 17 pound weight loss and was aware the resident had decreased oral intake and indicated speech therapy was working with the resident. When Physician #905 was asked if 12.5 milligrams of hydrochlorothiazide would cause a 17 pound weight loss in two weeks with very slight edema, Physician #905 responded, no.Review of the facility's Weight Monitoring policy revealed the facility would ensure all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that that was not possible or resident preference indicate otherwise. A comprehensive nutritional assessment was completed upon admission to identify those at risk for unplanned weight loss/gain or compromised nutritional status. Information gathered from the nutritional assessment and current dietary standards of practice were used to develop an individualized care plan to address the resident's specific nutritional needs, including the resident's personal goals and preferences. Interventions were implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. A weight monitoring schedule was developed upon admission for all residents. Newly admitted residents' weight will be monitored as close to weekly as possible for the initial 4 weeks and at least monthly thereafter. At the direction of the practitioner in collaboration with the facility, weights may be monitored more frequently as clinically indicated. Newly recorded weights were compared to the previous recorded weights. A significant weight change is defined as:a. 5% change in one monthb. 7.5% change in three monthsc. 10% change in six monthsSignificant changes in weight are reported to the practitioner.This deficiency represents non-compliance investigated under Complaint Number 2649063.

Based on record review and interview, the facility failed to ensure wound care was provided for #68's wound. This finding affected one resident (Residents #68) of four residents reviewed for wounds.Findings include:Review of Resident #68's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including paraplegia, chronic respiratory failure, osteomyelitis and major depressive disorder.Review of Resident #68's Skin Integrity Care Plan revealed an intervention dated 12/17/23 to assess pain and provide treatments per the physician's orders.Review of Resident #68's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #68's Pressure Skin Grid dated 10/18/25 revealed a vascular rear left calf wound first identified 10/18/25 which measured 3 cm length by 2 cm width by 0.3 cm depth with small serosanguineous drainage. There was no evidence treatment for the wound was put in place immediately. Review of Resident #68's physician orders revealed an order dated 10/21/25 (three days later) to cleanse the left calf with normal saline, apply xeroform, cover with a dry dressing every night shift on Tuesday, Thursday and Saturday.Review of Resident #68's MARS and TARS from 10/18/25 through 10/20/25 revealed the no wound care to the left calf wound. Review of Resident #68's progress note dated 10/21/25 at 1:40 P.M. revealed the resident's heart rate was 154 upon assessment. The resident received as needed metoprolol blood pressure medication and complained of feeling short of breath after the metoprolol. His heart rate decreased to 88 and the reassessment noted by the nurse practitioner revealed the heart rate increased to 160. The resident was sent to the emergency room.Review of Resident #68's Attending History and Physical (hospital paperwork) dated 10/22/25 revealed the [AGE] year-old male presented with generalized malaise tachycardia occasional chest pain and not feeling well on 10/22/25. The resident was recently evaluated by the urologist and prescribed antibiotics for a suspected urinary tract infection (UTI). He was found to be hypotensive with a blood pressure of 83/58 and takes midodrine chronically. The resident was tachycardic with atrial flutter, evaluated by intensive care and cardiology. A chest x-ray shows concern for pneumonia. The diagnoses list included a left lower extremity wound (no sizing or staging was available).Review of Resident #68's Orthopedic Progress Note (hospital paperwork) dated 10/27/25 revealed the chief complaint was a left posterolateral superficial wound with concomitant cellulitis. The documentation also indicated the resident had an unstageable pressure injury to the right heel (hospital acquired), right calf xerosis cutis (hospital acquired) and unstageable pressure injury to the left calf.Interview on 10/28/25 at 12:45 P.M. with RN WN #902 confirmed Resident #68's wound care from 10/18/25 to 10/20/25 revealed no evidence wound orders were placed in the medical record or wound treatments were completed for the posterior left calf.Review of the Skin Assessment policy revised 03/15/24 revealed it was the intent of the facility to provide necessary care to prevent the development of pressure injuries unless the resident's clinical condition demonstrates that the development was unavoidable. Residents with pressure injuries shall receive necessary treatment and services to promote healing, prevent infection, and prevent new injuries from developing which was consistent with professional standards of practice.This deficiency represents non-compliance investigated under Complaint Number 2649063.

Based on record review and interview, the facility failed to ensure physician orders were obtained and wound care provided for Resident #28's pressure ulcer wounds. This finding affected one resident (Residents #28) of four residents reviewed for wounds.Findings include:Review of Resident #28's medical record revealed the resident was admitted on [DATE] with diagnoses including muscle weakness, other abnormalities of gait and mobility and cerebral palsy.Review of Resident #28's Alteration in Skin Integrity Care plans dated 10/10/25 revealed to assess for pain and provide treatments per the physician's order. Review of Resident #28's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment.Review of Resident #28's Wound #1 Pressure Skin Grid form dated 10/06/25 revealed the resident had a stage one sacrum pressure wound first identified 10/02/25 (earliest stage of skin damage caused by pressure with intact, non-blanchable erythema and/or pain) which measured 5 centimeters (cm) length by 4 cm width by 0 cm depth. The resident was admitted with the sacrum pressure wound.Review of Resident #28's Wound #2 Pressure Skin Grid form dated 10/06/25 revealed the resident had a right ankle deep tissue injury (DTI) first identified on 10/02/25 which measured 2 cm length by 2.5 cm width by undermined depth (a DTI was a localized area of damage to the skin and underlying soft tissue, caused by intense and/or prolonged pressure, or pressure combined with shear). The resident was admitted with the right ankle pressure wound.Review of Resident #28's Wound #3 Pressure Skin Grid form dated 10/06/25 revealed the resident had a left ankle stage three pressure wound (a full-thickness skin loss involving damage of subcutaneous tissue that may extend into underlying muscle) first identified 10/02/25 which measured 2 cm length by 1 cm width by 0.2 cm depth. The resident was admitted with the left ankle pressure wound.Review of Resident #28's Wound #4 right plantar foot blister first identified on 10/06/25 which measured 2.9 cm length by 1.9 cm width by 0.1 cm depth with moderate serous drainage. The blister was in facility acquired.Review of Resident #28's Wound #5 left planter foot blister first identified on 10/06/25 which measured 3.5 cm length by 3.5 cm width by 0 cm depth. The blister was in facility acquired.Review of Resident #28's medication administration records (MARS) and treatment administration records (TARS) and physician orders from 10/03/25 to 10/27/25 did not reveal evidence of a physician order or wound care to the left ankle on 10/03/25, 10/04/25 and 10/05/25; the DTI to the right ankle on 10/03/25, 10/04/25 or 10/05/25; or the stage one to the sacrum on 10/03/25, 10/04/25 or 10/05/25.Interview on 10/27/25 at 1:58 P.M. with Registered Nurse (RN) Wound Nurse (WN) #902 confirmed wound care orders or treatments were not in place for Resident #28's pressure wounds to the sacrum, the right ankle or the left ankle from 10/03/25 to 10/05/25.Review of the Skin Assessment policy revised 03/15/24 revealed it was the intent of the facility to provide necessary care to prevent the development of pressure injuries unless the resident's clinical condition demonstrates that the development was unavoidable. Residents with pressure injuries shall receive necessary treatment and services to promote healing, prevent infection, and prevent new injuries from developing which was consistent with professional standards of practice.This deficiency represents non-compliance investigated under Complaint Number 2649063.

Based on observation, record review and interview, the facility failed to ensure Resident #12 received podiatry services in a timely manner. This finding affected one (Resident #12) of four resident records reviewed for auxiliary services.Findings include:Review of Resident #12's medical record revealed the resident was initially admitted on [DATE], sent out to the hospital on [DATE], sent to a rehab center on 08/04/25 and readmitted to the facility on [DATE] with diagnoses including muscle weakness, vascular dementia and epilepsy. Review of Resident #12's auxiliary services form dated 10/14/25 revealed a consent for vision, podiatry, dental and audiology. Observation on 10/27/25 at 9:24 A.M. with Certified Nursing Assistants (CNAs) #806 and #850 of Resident #12's activities of daily living (ADLs) including dressing and incontinence care did not reveal concerns. The resident appeared clean, and the fingernails appeared clean. Further observations revealed the resident's right and left great toes were long with thickened, yellow toenails.Interview on 10/27/25 at 9:28 A.M. with CNA #806 confirmed Resident #12 had thickened yellowed toenails on the bilateral great toes.Interview on 10/27/25 at 10:49 A.M. with Social Services Designee (SSD) #883 revealed Resident #12 was a skilled patient who was admitted on [DATE], went out to the hospital on [DATE] for a suspected cerebrovascular accident (CVA), was transferred to another facility for rehab on 08/04/25 and transferred back to the current facility on 09/03/25. She stated she was unaware the resident required dental or podiatry services until a care conference which was completed on 10/24/25.A second interview on 10/27/25 at 1:44 P.M. with SSD #883 confirmed a consent for auxiliary services was not obtained when the resident was admitted on [DATE]. She confirmed a consent for services was obtained on 10/14/25 for Resident #12 to see the dentist, audiologist, podiatrist and optometrist. Interview on 10/27/25 at 2:08 P.M. with Regional Nurse (RN) Regional #904 revealed the facility did not have a specific policy related to podiatry services.Interview on 10/27/25 at 2:24 P.M. with the Administrator confirmed the podiatrist's last visit to the facility was on 09/30/25 and the next visit should be 10/28/25.This deficiency represents non-compliance investigated under Complaint Number 2649063.

Based on record review, the CASPER Payroll Based Journal Staffing Data Report for the Second Quarter of 2025 (01/01/25 to 03/31/25), staffing schedules, posted staffing information, and staff interview, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 63 residents residing in the facility.Findings include: Review of facility staffing schedules, posted staffing information, and the CASPER Payroll Based Journal Staffing Data Report for the Second Quarter of 2025 (01/01/25 to 03/31/25) revealed there was no evidence of Registered Nurse (RN) coverage eight hours a day on 01/04/25, 03/16/25, 08/02/25, and 08/03/25.Interview on 08/07/25 at 2:45 P.M. with the Administrator verified the facility did not have a the required RN coverage and/or any evidence of eight hours of RN coverage in the facility on 01/04/25, 03/16/25, 08/02/25, and 08/03/25.

Based on observation and interview, the facility failed to maintain a sanitary dumpster area. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include:Observation on 08/04/25 at 8:53 A.M. with Dietary Manager (DM) #825 revealed significant debris including gloves, cardboard, and empty medication packaging on the ground surrounding dumpsters. Interview on 08/04/25 at the time of observation with DM #825 confirmed findings and indicated the maintenance department was responsible for ensuring the area remained clean.

Based on interview and record review, the facility failed to ensure the required members of the quality assessment and assurance (QAA) committee participated at least quarterly as required. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include:Review of Infection Preventionist (IP) Training Certificate dated 10/24/24 revealed IP #833 was the facility's IP. Review of the Quality Assurance and Performance Improvement (QAPI) sign in sheets from 10/16/24, 01/22/25, 04/02/25, 06/18/25, and 07/16/25 revealed no evidence of participation by the facility's IP. Review of undated facility QAPI Plan revealed the QAA committee members included the IP. Interview on 08/12/25 at 10:04 A.M. with the Administrator confirmed IP #833 had not been attending QAPI meetings. The Administrator indicated the facility's IP was also the Receptionist. The Administrator indicated IP #833 provided a report to the Director of Nursing (DON) to present at the QAPI meetings. Interview on 08/12/25 at 10:20 A.M. with IP #833 confirmed she had not been attending QAPI meetings. IP #833 indicated she had been in the position since she obtained her IP certificate in October 2024.

Based on observation, interview, and facility policy review, the facility failed to ensure a safe smoking environment. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include: Observation of the resident smoking session on 08/06/25 at 9:09 A.M. revealed Resident #36 and Resident #52 were supervised by Business Office Manager (BOM) #868 in the smoking area at thee back of the building across the parking lot. The two residents began to smoke. There were four cigarette butts in the smoking area. At 9:17 A.M., Dialysis Technician (DT) #921 walked out of the building, stood next to the door, lit a cigarette, and began smoking. DT #921 was observed talking on the phone and flicking her cigarette ashes. There was a trash receptacle next to the facility door, however there was no approved cigarette disposal. DT #921 walked across the parking lot out of view (next to the smoking area) and walked back into the building without a cigarette butt. Interview on 08/06/25 at 9:19 A.M. with DT #921 verified she was smoking next to the exit door and stated she put the cigarette butt in her pocket. DT #921 rummaged through her pockets and could not find the cigarette butt. DT #921 then stated she put the cigarette butt in the trash can and continued to talk on the phone. Interview on 08/09/25 at 9:50 A.M. with BOM #868 and the Administrator verified the cigarettes on the ground. The Administrator stated employees are to smoke in the smoking area or in their cars. Review of the policy Resident Smoking revised 10/21/22 revealed smoking is only allowed in areas of the facility that are designated smoking areas. Safety measures for the designated smoking area included but were not limited to provision of ashtrays made of noncombustible material and safe design and be located away from exits and common space utilized by other residents in order to protect non-smoking residents from second-hand smoke.

Based on observation, interview, and facility policy review, the facility failed to maintain infection control procedures during incontinence care and failed to ensure enhanced barrier precautions (EBP) were maintained during medication administration through a gastrostomy tube. This affected one resident (#9) out of five residents reviewed for infection control. The facility census was 63. Findings include: Review of the medical record revealed Resident #9 had an admission date of 09/23/21. Diagnoses included cerebral infraction, a stroke, chronic respiratory failure, gastrostomy, tracheostomy, hemiparesis effecting the right side and heart failure. a. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #9 was cognitively impaired and dependent on staff for activities of daily living. The assessment identified the resident always incontinent of bowel and bladder. Observation of Resident #9's incontinence care on 08/06/25 at 10:47 A.M. revealed Certified Nursing Assistant (CNA) #880 and #851 gathering incontinence supplies, washing hand, and donning gowns and gloves. While providing care, CNA #880 took a new incontinence pad off the tray table and placed it on the bed. The incontinence pad fell off the bed and onto the floor, and CNA #880 picked it off the floor and proceeded to place it underneath Resident #9. Interview with CNA #880 on 08/06/25 at 11:00 A.M. verified she picked the incontinence pad off the floor and placed it under Resident #9. Review of the facility policy titled Perineal Care dated 10/02/07 stated the purpose is to provide care to genitalia and rectal area, to prevent broken skin and infection, to provide comfort and cleanliness, and prevent body odors. b. Review of Resident #9's physician's orders revealed a physician order for enhanced barrier precautions dated 03/12/25 and orders for the following medications to be given via gastrostomy tube (a surgically placed tube through the abdominal wall that provides access to the stomach): Baclofen 5 milligram (mg) tablet, aspirin 81mg capsule, buspirone 5mg tablet, escitalopram 20mg tablet, furosemide 40mg tablet, famotidine 20mg tablet, metoclopramide 5mg tablet, and sucralfate oral suspension 1 gram/10 milliliters. All medications had instructions to administer per gastrostomy tube. Observation of Resident #9 medication administration on 08/07/25 at 7:29 A.M. with Licensed Practical Nurse (LPN) #859 revealed signage in the room noting gowns were to be worn when accessing medical devices such as a gastrostomy tube. LPN #859 was observed administering medications through Resident #9's gastrostomy tube without wearing a gown. Interview on 08/07/25 at 8:04 A.M. with LPN #850 verified a gown was not worn while accessing Resident #9's gastrostomy tube and administering medications. Review of the policy Infection Prevention and Control Program dated 11/28/17 revealed it was the policy of the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. The RNs and LPNs supervise direct care staff in daily activities to assure appropriate precautions and techniques are observed, assess the resident's isolation needs, initiate appropriate precautions, and consult with the Medical Director and/or the resident's attending physician. This deficiency represents noncompliance investigated under Complaint Number 1401762 (OH00164467).

Based on record review and interview the facility failed to develop a person-centered care plan for smoking. This affected one resident (Resident #36) of 26 reviewed for care planning. The facility census was 63.Findings include: Review of the medical record for Resident #36 revealed an admission date of 07/03/25. Diagnoses included syncope, dysphagia, difficulty in walking, hypertension, anxiety, adult failure to thrive and depression. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #36 had impaired cognition and required supervision from staff for activities of daily living. Review of the care plan dated 07/10/25 revealed no evidence of a care plan for smoking. Review of the smoking assessment dated [DATE] revealed the resident did not require staff assistance or any smoking devices while smoking. Observation of smoking on 08/06/25 at 9:09 A.M. revealed Business Office Manager (BOM) #868 lit Resident #36's cigarette. Resident # 36 was independent with holding his cigarette and asked BOM #868 to put the butt in the cigarette disposal. Interview on 08/06/25 at 4:30 P.M. with the Director of Nursing (DON) verified Resident #36 had no care plan for smoking. Review of the facility policy Resident Smoking revised 10/21/22 revealed all residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. All residents are to be supervised while smoking.

Based on observation, interview, review of facility Self-Reported Incidents (SRI) and corresponding investigation, and facility policy review, the facility failed to provide timely incontinence care to Resident #9. This affected one resident (#9) out of three residents reviewed for activities of daily living. The facility identified nine residents to be incontinent who resided on the [NAME] unit. The facility census was 63. Findings include: Review of the medical record revealed Resident #9 had an admission date of 09/23/21. Diagnoses included cerebral infraction, a stroke, chronic respiratory failure, gastrostomy, tracheostomy, hemiparesis effecting the right side and heart failure. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #9 was cognitively impaired, non-verbal, and dependent on staff for activities of daily living. The assessment identified the resident was always incontinent of bowel and bladder. Review of a SRI dated 07/14/25 revealed the facility reported an allegation of potential neglect/mistreatment of Resident #9. On 07/14/25 at 4:30 P.M., it was reported to the Assistant Director of Nursing (ADON) that Resident #9 had no Certified Nursing Assistant (CNA) enter his room to check and change him on Saturday [07/12/24]. Review of an undated witness statement authored by Licensed Practical Nurse (LPN) #887 revealed she was assigned Resident #9 and was unaware the resident was not checked on 07/12/25. Resident #9 ' s call light never went off. LPN #887 stated she could not watch the CNAs on the [NAME] hallway. LPN #887 stated she went in Resident #9 ' s room and he never showed any distress and she did not notice anything else.Review of a witness statement authored by CNA #842 dated 07/15/25 revealed she was assigned to the [NAME] hallway, along with CNA #805. The two CNAs discussed the room assignments and agreed CNA #805 would care for Resident #9. CNA #842 stated she did not witness Resident #9's call light on in the room. During the shift, the two CNAs worked together and assisted each other as a team. CNA #842 was unaware of any incident. Review of a witness statement authored by CNA #800 revealed she worked on the night of 07/12/25 and found Resident #9 heavily soiled around 9:30 P.M. CNA #800 changed Resident #9's brief and adjusted his linens, joked with him, and proceeded on his assignment. Review of a witness statement for CNA #805 dated 07/17/25 revealed CNA #805 stated they discussed the assignment with CNA #842 and Resident #9 ' s room was never part of the agreed upon room assignments. CNA #805 stated she never worked the room assignment and denied intentionally not providing care to Resident #9. CNA #805 denied any knowledge of Resident #9 putting on his call light during the shift. CNA #842 would have never not provided care and will ensure better communication.Interview on 08/04/25 at 2:35 P.M. with a family member of Resident #9 revealed there was a camera in Resident #9's room and per camera footage dated 07/12/25, Resident #9 went 17 hours with no incontinence care provided. The family member reported the nurse entered the room three times to administer medications and provide tracheostomy care, but there was no incontinence care provided. Interview on 08/06/25 at 4:30 P.M. Administrator revealed he received an allegation of possible neglect on 07/14/25 from a family member of Resident #9 who stated that Resident #9 did not receive any care. The Administrator initiated a SRI and an investigation was initiated. Throughout his investigation, it was discovered there was a missed communication with room assignments and which CNA would be providing care to Resident #9. The Administrator reported the CNAs involved would not intentionally fail to provide care to Resident #9. The Administrator was not able to identify any staff member who provided incontinence care to Resident #9 on 07/12/25. Interview on 08/08/25 at 9:15 A.M. with CNA #842 stated at the beginning of the shift it was discussed that CNA #805 would provide care to the South [NAME] hallway and four rooms on the [NAME] hall that included Resident #9 room. CNA #842 stated Resident #9's call light never went off. CNA #842 denied providing any incontinence care to Resident #9 during her shift.Interview on 08/07/25 at 9:33 A.M. with LPN #887 revealed the nurse worked the [NAME] hallway on 07/12/25. Resident #9 ' s room was located on the [NAME] hall. LPN #887 stated they went into Resident #9 ' s room three times to give medication and provide tracheostomy care. However, LPN #887 did not provide Resident #9 with any incontinence care. LPN #887 stated Resident #9 was asked if he needed anything else, and he blinked twice indicating no. LPN #887 stated it was very hard to monitor the CNAs as the [NAME] hall had a heavy medication pass.Review of the facility policy titled Perineal Care dated 10/02/07 stated the purpose is to provide care to genitalia and rectal area, to prevent broken skin and infection, to provide comfort and cleanliness, and prevent body odors.This deficiency represents noncompliance investigated under Complaint Numbers 2568148, 2566992, 1401766 (OH00165165), and 1401764 (OH00165142).

Based on interview, record review, and policy review, the facility failed to ensure residents received appropriate and timely care after a fall resulting in a fracture. This affected one resident (Resident #19) of three residents reviewed for care. The facility census was 65. Findings Include: Medical record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, repeated falls, urinary retention, bradycardia, arthritis, and high blood pressure. Review of Resident #19's physician's orders revealed an order dated 05/08/23 for hydrocodone - acetaminophen 5-325 milligrams (mg) (an opioid pain medication) three times daily. Review of the Medicare quarterly Minimum Data Set 3.0 assessment, dated 11/21/24, revealed Resident #19 was severely cognitively impaired, needed moderate assistance from staff for toileting and maximum assistance for showering. Review of the nurses' notes revealed on 12/25/24 at 8:01 P.M. Registered Nurse (RN) #219 found Resident #19 on the floor. RN #219 assessed Resident #19 and the resident complained of pain to her right hip with movement and was unable to move her right leg from front to back or up and down. Resident #19 was able to move all her other extremities. RN #219 assisted Resident #19 to her recliner and then notified Nurse Practitioner (NP) #400 who ordered a right hip x-ray. Further review of the nurses' notes revealed on 12/26/24 at 7:50 A.M. RN #224 administered Resident #19's scheduled pain medication. RN #224 along with two other aides transferred Resident #19 to her bed. At 12:00 P.M. radiology arrived to take the x-ray. At 12:16 P.M. RN #224 notified NP #400 Resident #19 had a fractured femur and NP #400 gave an order to transfer Resident #19 to the hospital. At 12:53 P.M. Resident #19 left for the hospital and were she was admitted to the hospital for hip surgery. Review of the fall investigation dated 12/25/24 revealed on 12/25/24 at 7:20 P.M. Registered Nurse #219 was administering evening medications when she entered Resident #19's room and found the resident on the floor. RN #219 asked Resident #19 what happened, and the resident said she was trying to get to her bed. Resident #19 was lying on the floor between her recliner and wheelchair. Resident #19 complained of pain to her right hip area. RN #219 notified NP #400 regarding the fall. NP #400 ordered a right hip x-ray. Radiology was notified at 8:09 P.M. Telephone interview with NP #400 on 01/21/25 at 9:45 A.M. revealed the nurse (RN #219) had called her to notify her of Resident #19's fall and that she was having hip pain. NP #400 said she ordered a STAT (immediate) hip x-ray. NP #400 was not aware that the x-ray had not been taken until 12/26/24 at 12:00 P.M., approximately 17 hours after the injury was noted. Telephone interview with RN #224 on 01/21/25 at 3:04 P.M. revealed on 12/26/24 after receiving morning shift report she went straight to Resident #19's room. RN #224 noticed Resident #19 was in more pain than she usually was. Resident #19 was also very soiled due to being incontinent. RN #224 and two aides transferred Resident #19 to bed utilizing a tarp. Once Resident #19 was in bed they provided incontinence care and put her in clean and dry clothing. Resident #19 was due for her scheduled pain medication which RN #224 administered. RN #224 was surprised Resident #19 had not been transferred to the hospital prior to this time because RN #224 observed the right leg was externally rotated and she had a fractured hip. Once the x-ray results were faxed to the facility Resident #19 was transferred to the hospital around 1:00 P.M. Interview with the Regional Nurse on 01/21/25 at 5:45 P.M. confirmed Resident #19 fell on [DATE] at 7:20 P.M. and did not receive the STAT hip x-ray until 12/26/24 between 11:00 A.M. and 12:00 P.M. Review of the facility's Change of Condition policy, revised April 2013, revealed a change of condition was defined as a deterioration in the health, mental, or psychosocial status of a resident related to a life-threatening condition, a significant alteration in treatment, or a significant change in the resident's clinical condition or status. Life threatening conditions include broken bones. This deficiency represents noncompliance investigated under Complaint Number OH00160893.