Every finding on record at Villa Rosa Nursing and Rehabilitation, LLC

Based on record review and interview it was determined the facility failed to have a qualified full-time staff person to carry out food and nutrition services in the facility. This has the potential to affect all residents in the facility. The findings include:Review of anonymous complaint # 2963054 on 4/28/26 at approximately 1:00 PM revealed concerns including but not limited to menus, scheduled meal times, and alternate food items. During an interview on 4/29/26 at 11:29 AM the Administrator revealed that Staff #11 the Food Service Manager (FSM) was not in the facility, was out on extended medical leave since 1/29/26 and the facility was utilizing their dietician. He further revealed that the dietician was in the facility once per week. When asked who was overseeing the meal services and day to day operations of the kitchen he stated, myself and a remote dietician. He confirmed that he was not certified in food service management. He was asked to provide a schedule for the staff overseeing the day-to-day food service operations of the facility during the FSM's long term absence. The schedule revealed Staff #12 a Registered Dietician (RD) was onsite once per week for 8 hours and Staff #13 a FSM from a sister facility was onsite 1 time per week for 8 hours. The facility failed to have a qualified full-time staff person to oversee the food and nutrition services for the residents as required. These concerns were reviewed with the Administrator and the Director of Nursing on 5/1/26 at approximately 7:00 PM.

Based on record review and interviews it was determined the facility staff failed to conduct regular inspections of resident beds. This has the potential to affect all residents in the facility. The findings include:Review of anonymous complaint #2963504 on 4/28/26 at 1:00 PM revealed a concern regarding bed inspections. The surveyor was informed by the Administrator that the Director of Maintenance was not in the facility at that time. The facility's bed inspection logs were requested for review. On 4/29/26 at 11:29 AM, after several additional requests for the logs, the Administrator was asked if routine inspection of the beds was actually conducted. He indicated yes but we haven't kept very good records. During an interview on 4/29/26 at 11:50 AM the Director of Nursing (DON) and Administrator provided copies of maintenance logs dated from 1/2025 - 4/8/2026. Review of the logs at that time revealed concerns identified by staff related to a variety of areas and equipment in need of repair. However, the logs did not reflect routine inspection of the facility's beds as required. The Administrator indicated that when maintenance makes the bed repairs they also check to make sure the motors work. He confirmed that maintenance was not conducting routine inspections of the beds. Upon request of the facility policy and procedure for routine bed inspections the DON provided a policy and procedure for equipment and utilities management program which included a checklist for a 12-point monthly inspection of the beds. These concerns were reviewed with the Administrator and the Director of Nursing on 5/1/26 at approximately 7:00 PM.

Based on observation and interview it was determined the facility staff failed to maintain a safe functional and sanitary environment. This was evident for 8 of 8 resident hallways observed on both floors of the facility. The findings include:During a tour of the facility on 5/1/26 from 2:13 PM - 3:15 PM observation in the hallways of the A, B, C and D wings on both floors of the facility revealed:Broken, damaged, sagging and missing ceiling tiles. Missing covers over ceiling access panels. Areas of the plaster/drywall ceilings that were damaged or patched but not painted or otherwise sealed. [NAME] and black stains on plaster/drywall and tile ceilings. Dirty/stained/damaged ceiling fixtures including but not limited to vents, light fixtures and speaker covers. Square ceiling air handler units were located at intervals in several hallways. The units were low profile, with a vent like central air intake panel and louver type air outflow vents along the perimeter on all four edges. The air intake panel in every air handler was covered with thick brown/gray dust like substance. A black substance ranging from clusters of fine speckles to solid lines and patches was observed on the outflow louvers as well as other fixtures and the ceiling surrounding the air handler units. This was also evident for the air handler units located in the Solarium on the 2nd floor B wing. On the A Wing of the first floor, the surveyor observed a dried black substance on the wall and the fire exit door. The substance appeared to have seeped/flowed in a liquid form from the top of the wall along the ceiling to below the level of the handrail. The area extended from above the fire exit door approximately 7 feet, toward room [ROOM NUMBER]. Numerous pea sized dried black drip points were located on the underside of the door frame as well as the emergency exit light. The black substance smudged when rubbed. The above concerns were reviewed with Staff #9 the Maintenance Assistant on 5/1/26 at 5:21 PM. He was shown the black streaks on the wall, fire exit door and a speaker cover at the end of the hallway on First Floor A wing. He indicated the black substance was old oil and sediment that leaked from the HVAC system when a pipe burst in January 2026.He was shown discolored and damaged ceilings and ceiling tiles as well as the concerns related to the ceiling air handling units. He indicated that the brown and black discoloration on the ceilings was due to water damage, he acknowledged the missing and damaged tiles as well as the numerous areas that had been patched and spackled but not finished. He indicated that the air handler units needed to be cleaned and was not sure what the black substance on the blower louvers and surrounding ceilings and fixtures was. The above concerns were reviewed with the Administrator and Director of Nursing on 5/1/26 at approximately 7:00 PM. The DON observed a ceiling air handler unit with the surveyor and indicated that they would need to be cleaned.

Based on medical record review, and resident and staff interview, it was determined that the facility failed to include a copy of the written notification of transfer or discharge in the resident's medical record. This was evident for 1 (#4) of 3 residents reviewed for complaints. The findings include: On 4/27/26 at 10:08 AM, a review of complaint # 2808503 alleged the facility provided Resident #4 a verbal notice that s/he was to discharge from the facility on 3/18/26, however the facility failed to provide the resident with a written notice of discharge on [DATE] at 10:35 AM a review of Resident #4's medical record documented that the resident was admitted to the facility in the beginning of February 2026 following an acute hospitalization and discharged from the facility towards the end of March 2026. Continued review of the medical record failed to reveal evidence that the facility provided a written notification of discharge to Resident #4 prior to his/her discharge. On 4/29/26 at 1:52 PM, during an interview, Social Service Assistant (SSA) #1 stated that prior to his/her discharge, Resident #4 was made aware his/her rehabilitation goals at the facility had been met, therefore the insurance company denied further payment for the resident to stay at the facility after 3/17/28. After that date, Resident #4 would be discharged or would need to pay for his/her stay at the facility. At that time, SSA #1 indicated the resident was provided a copy of the letter of denial from the insurance company but had not been provided a written notification of discharge from the facility. On 5/1/26 at 12:45 PM, the Nursing Home Administrator (NHA) was made aware that no documentation found in the medical record to indicate a written notice of discharge, which included the reason for the action, the effective date, the location to which they were being discharged , and appeal rights had been provided to Resident #4 prior to his/her discharge. At that time the NHA acknowledged the concerns and indicated that when s/he was made aware of the impending discharge, Resident #4 had not agreed to leave, and would have been given a discharge notification if she did not agree to pay. No further documentation was provided to the surveyor by the time of exit from the survey on 5/1/26 at approximately 7:45 PM. On 5/4/26 at 10:46 AM, the surveyor received an email from the NHA stating that a notice of discharge that was given to Resident #4 on 3/18/26 based on a denial from her insurance company was attached to the email. Review of the email attachment revealed a Notice of Transfer or Discharge for Resident #4 with a discharge date of 3/18/26. The discharge notice, which was not signed by the resident, had not been found in the resident's medical record during the survey.

Based on review of staff records and facility staff interviews, it was determined the facility failed to ensure that all nursing staff had competency skill evaluations. This was evident for 5 Geriatric Nursing Assistants (GNA) (GNA #2, GNA #3, GNA #6, GNA #7, GNA#18) of 5 GNA records reviewed. The findings include:A nursing competency is a set of knowledge, skills and abilities (KSAs) needed for an individual to successfully perform various job duties. Centers for Medicare and Medicaid (CMS) guidance clarifies that competency cannot be demonstrated by documenting that staff attended a training or watched a video. A skills checklist must include a return demonstration (practical application) for physical skills.Relias training provides online learning, compliance, and performance management solutions for healthcare, offering accredited online courses and videos for staff development, mandatory compliance, and continuing education (CE).On 01/14/2026 at 12:36 PM, a review of 5 GNA's (GNA #2, GNA #3, GNA #6, GNA #7, GNA#18) employee files showed the facility utilized online training from Relias for the mandated 12 hours of annual training.On 01/14/2026 at 12:54 PM, an interview with the Assistant Director of Nursing (ADON), whose duties included staff education, revealed that she does not conduct annual return demonstration skill competency training with GNA staff. She stated she provides skill competency training when there is an issue with care provided by a GNA brought to her attention. She conducts a training at that time, using a skill checklist if the skill the GNA is providing is not done correctly. When asked about Registered Nurse (RN) or Licensed Practical Nurse (LPN) return demonstration competencies, the ADON stated she would look for the sign in sheets for the in-service. On 01/14/2026 at 2:31 PM, an Interview with Regulation Specialist confirmed there has been no return demonstration skill competencies documented for all nursing staff over last year. She was unable to find any in-service sign-in sheets for return demonstration skills competency training. On 01/14/2026 at 2:40 PM, the concern was brought to the Nursing Home Administrator.

Based on observations, interviews and record reviews it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety in the kitchen. This practice had the potential to affect all residents that eat food prepared by the facility's kitchen. The findings include: 1. During a tour of the Kitchen with the Dietary Manager on 1/05/2026 at 8:08 AM it was discovered to have food products that had been opened and undated, unsealed and had expired food products. During observation of the walk-in refrigerator the following items were found:A Vital Cuisine Mighty Shake with a use by date of 12/03/2025 which was removed by the Dietary Manager after finding. Tuna fish was found in a plastic container covered with plastic wrap and was not labeled with a date of opening or expiration date. Two strawberry pies wrapped in plastic that were not labeled with a date of opening or expiration date. A cup of fruit had been made and was not labeled with a date of production or an expiration date.A cup of pureed fruit had been made and was not labeled with a date of production or an expiration date.A stack of sliced pieces of cheese had been removed from the original packaging was wrapped in plastic, not labeled and had no date of opening or expiration date. During an observation of the reach-in refrigerator the following item was found: A package of Block and Barrel Fully Cooked Ham had been opened was labeled with a facility sticker with a use by date of 1/02 which was removed by the Dietary Manager after finding. During an observation of the door to the refrigerator on 1/05/2026 at 8:20 AM it was discovered to have a sign that stated, Everything must be labeled and Dated! During an interview with the Dietary Manager on 1/05/2026 AM at 8:23 AM she reported anything opened should be rewrapped and labeled with an expiration date. During continued observations in the Freezer on 1/05/26 at 8:25 AM there were items found:A box of Ravioli Cheese that had been opened and the bag was not resealed. A box of Oven Ready Par-fried Alaska [NAME] that had been opened and the bag was not resealed. [NAME] Dumpling Squares that had been opened and the bag was not resealed. During an interview with the Dietary Manager on 1/05/2026 at 8:32 AM she confirmed the items should have been sealed after being opened and labeled with an expiration date. During review of the facility Safe Food Handling Policy on 1/09/2026 at 10:38 AM it reported All foods removed from the original packaging are stored in a closed container or tightly wrapped package and labeled with the common name of the item and the date it was opened.During review of the facility Food Safety in Receiving and Storage Policy on 1/09/2026 at 10:42 AM it stated, Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with a use by date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded.2. During observation of the freezer with the Dietary Manager on 1/05/2026 at 8:25 AM it was discovered to have clumps of ice built up on the floor. Continued observation of the freezer's ceiling revealed multiple frozen drops of water hanging from the ceiling. An observation of the boxes of food under the freezer's fan revealed ice cycles hanging from the lid of a box of Anne's Dumpling Squares.During an interview with the Dietary manager on 1/05/2026 at 8:43 AM she advised the ice issues may be due to having a late shipment last week and staff were in and out of the freezer. During a review of the facility Food Safety in Receiving and Storage Policy on 1/09/2026 at 10:42 AM it stated to Store food away from sewer and water lines, drains, and condensation dripping from pipes or ceilings. During an interview with the Nursing Home Administrator on 01/14/2026 at 12:05 PM he reported he reported he thinks the ice buildup may be due to the door being left often while staff were inside the freezer. He advised he would have maintenance look at it.3. During an interview with the Dietary manager on 1/05/56 at 8:08 AM she reported the facility dishwasher had been inoperable due to a clogged drainage pipe since November, so dishes were being handwashed in the facility. During an interview with [NAME] #29 on 1/05/26 at 8:54 AM he reported the water in the dish washing sink doesn't get really hot, our water is set so no one can burn themselves.During an observation with the Dietician on 1/06/26 at 2:26 PM, she was using the kitchen thermometer to obtain readings of the water being used to wash the dishes. The readings showed the water already in the sink with the dishes being washed was 91.3 degrees Fahrenheit and after running a new hot fresh sink of water the temperature reached 104 degrees Fahrenheit.During an observation with the Maintenance Director on 1/08/26 at 9:15 AM using the facility infrared thermometer he obtained temperature readings when [NAME] #29 was observed washing dishes. The temperature of the water with the dishes being washed was 100.4 degrees Fahrenheit. Then he obtained a temperature while the water was running out of the spigot in the kitchen sink and the highest temperature obtained was 108 degrees Fahrenheit. During a review of the facility Emergency Preparedness Plan - Temporary Loss of Dishwasher Due to Drainpipe Clog on 5/09/25 at 10:42 AM it identified the facility will follow the 3-compartment sink policy and follow the Manual Cleaning and Sanitizing with a three-compartment sink instructions.During a review of the facility Manual Cleaning and Sanitizing with a Three-Compartment sink Policy on 5/09/25 at 10:48 AM it reported that in the 1st sink Equipment and utensils are thoroughly washed in the first sink in detergent solution of at least 110 degrees Fahrenheit. Wash water is kept clean and changed frequently.

citeBased on interview and observation, it was determined that the facility failed to (1) implement measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building's water systems, and (2) ensure proper storage of clean linens. These deficiencies were identified during the Infection Control review conducted as part of the annual survey and have the potential to affect all residents.The findings include:(1)Legionella is a type of bacteria commonly found in water systems that can cause Legionnaires' disease, a serious form of pneumonia, when contaminated water droplets are inhaled.On 01/12/2026 at 2:11 PM, an interview was conducted with the facility's Infection Preventionist (IP), who confirmed that there have been no reported cases of Legionella or other opportunistic waterborne pathogens at the facility.On 01/13/2026 at 9:42 AM, an interview was conducted with the Maintenance Director regarding the facility's water management practices. When asked how the facility prevents waterborne pathogens, including Legionella, he reported that the facility does not utilize any type of water treatment and does not conduct water testing for Legionella or other waterborne pathogens. When asked whether the water management system includes mixing valves, he reported that the system does not have mixing valves. When asked if the facility had experienced any outbreaks of Legionella or other waterborne pathogens, he reported that there had been none to his knowledge.On 01/13/2026 at 10:46 AM, a follow-up interview was conducted with the Maintenance Director. During the interview, he confirmed that the facility's water system does not have mixing valves. When asked how hot water is supplied for resident use, he explained that the facility uses a boiler to heat the domestic water. He reported that the boiler heats the water to approximately 120 degrees Fahrenheit before it is distributed throughout the building for resident use. He further confirmed that water temperatures likely decrease by the time the water reaches resident use areas and that the boiler does not heat the water above 120 degrees Fahrenheit.On 01/13/2026 at 11:03 AM, this surveyor conducted an interview with the Administrator. When asked whether the facility had measures in place to prevent the growth of Legionella or other opportunistic waterborne pathogens in the building's water systems, he reported that he was not sure and stated that he would need to obtain additional information.On 01/13/2026 at 2:37 PM, a follow-up interview was conducted with the Administrator. He confirmed that the facility has not had outside testing performed by a company for Legionella or other opportunistic waterborne pathogens. At that time, it was communicated that this is a concern, as the facility does not have preventive measures in place to reduce the risk of waterborne pathogens. It was also communicated that the Maintenance Director had confirmed to this surveyor that the facility does not have preventive measures in place to address Legionella or other opportunistic waterborne pathogens. The Administrator acknowledged and understood the concern.(2)On 01/12/2026 at 11:29 AM, this surveyor observed in the clean linen room that there was a large hole in the ceiling directly above the area where clean clothes are being folded. The hole exposed pipes, dust, and drywall. Photographs of the observation were taken at this time.On 01/14/2026 at 09:57 AM, this surveyor observed in the Laundry Room, within the clean linen area, two bins of clean linens left uncovered directly beneath a large hole in the ceiling. The hole exposed pipes, drywall, and dust. Photographs of the observation were taken at this time.On 01/14/2026 at 10:00 AM, this surveyor conducted an interview with the Housekeeping Services Manager regarding the observation of clean linens left uncovered beneath a hole in the ceiling. Photographs of the observation were shown to the Housekeeping Services Manager. He confirmed understanding of the concern, stated that he would address the issue promptly, and reported that he would review and reinforce expectations with laundry aide staff to ensure clean linens are kept covered.

Based on observations, interviews and record reviews, it was determined that the facility failed to ensure 1) medication carts were locked and resident health information was protected. This was found to be evident for 2 out of 3 medication carts observed and 7 out of 29 opportunities to protect resident health information, 2) a physician order was implemented. This was found to be evident for 1 (Resident #2) out of 1 Resident reviewed for physician orders, 3) behavior monitoring was conducted. This was found to be evident for 3 (Resident #56, #12 & #66) out of 3 Residents reviewed for behavior monitoring, and 4) medication was properly administered. This was found to be evident for 1 (Resident #22) out of 1 Resident reviewed for medication administration. It was determined that the facility failed to provide care that meets professional standards of practice during the recertification survey. The findings include: 1) On 01/08/2026 at 5:57 AM, during first-floor unit rounds on B-Wing, the surveyor observed a medication cart left unlocked and unattended. At the same time, an unlocked laptop with resident-specific information visible on the screen was observed unattended at the doorway of Room B140. On 01/08/2026 at 6:01 AM, during a medication administration observation with Registered Nurse (RN) #17, the surveyor observed the medication cart left open and the computer screen unlocked. This occurred in Room A104 at 6:01 AM, Room A108 at 6:04 AM, Room A117-B at 6:11 AM, Room A112 at 6:17 AM, Room D108-B at 6:24 AM, and Room D110-B at 6:26 AM01/08/2026 at 6:20 AM: The surveyor observed at the 1st floor lobby RN#17 left the medication cart open, and the computer screen unlocked and unattended, with residents' information visible. On 01/08/2026 at 6:32 AM, during an interview, RN #17 stated that the medication cart and computer screen are expected to remain locked at all times during medication administration. RN #17 confirmed leaving the medication cart open and the computer screen unlocked and unattended in the lobby while retrieving applesauce. On 01/12/2026 at 8:25 AM, during further observation on the second floor, the surveyor observed the B-Wing medication cart C open and unattended. On 01/12/2026 at 8:30 AM, during an interview, Licensed Practical Nurse (LPN) #20 stated, I was going to get medication from the medication room. The nurse further confirmed that the facility's expectation is for medication carts to always remain locked when not in use. The above concern was reviewed with LPN #20, who acknowledged the expectations. 2). On 01/14/26 at 9:16AM during a record review related to complaint , it was revealed that on 09/10/2025, Resident #2's physician ordered a Complete Blood Count (CBC) laboratory test for the diagnosis of pneumonia. The order was documented in the resident's medical record to monitor the resident's condition and to guide treatment. On 01/14/2026 at 9:20 AM, during a medical record review, it was revealed that the physician's order was not followed as written. On 01/14/26 at 12:20 PM, during an interview, the Assistant Director of Nursing (ADON) stated that physicians enter laboratory orders, and the receiving nurse transcribes the orders. The ADON further stated that the 11:00 PM–7:00 AM shift is responsible for ensuring the laboratory tests are completed, unless the order is designated as STAT. On 01/14/26 at 1:50 PM, during an interview, the ADON reported that Resident #2's laboratory test was not completed as ordered by the physician and stated that the reason was unknown. The surveyor informed the ADON and the Clinical Services Director of the above concerns, and both acknowledged receipt. 3) On 01/07/2026 at 8:28 AM, a review of Resident #56's medical record revealed diagnosis for depression, anxiety, and insomnia. Resident #56 had an order on their Treatment Administration Record (TAR) for: Behavior Monitoring Every Shift. On 01/08/2026 at 9:15 AM, a review of Resident #56 's TAR revealed Resident #56 was documented to have the highest number of behaviors at 20 observed on 12/20/25, there were no progress notes in the medical record for the type of observed behaviors on 12/20/25. A SBAR is a comprehensive nursing assessment done when there is a change in a Resident's condition. SBAR stands for Situation, Background, Assessment, and Request. The assessment prompts nurses to collect comprehensive information about a resident's change in condition in advance of calling a doctor to report the change. Behavior monitoring tools for psychotropic medications are structured systems used by healthcare teams and caregivers to track the efficacy and safety of medications prescribed for mental health and behavioral symptoms. These tools ensure that medications are used appropriately, at the lowest effective dose, and with minimal side effects. It is a holistic communication tool used by interdisciplinary teams in long-term care to report a resident's status, including behavioral distress and non-pharmacological attempts to the prescribing physician. On 01/09/2026 at 9:17 AM, an interview with Licensed Practical Nurse (LPN) #4 confirmed that when behaviors are documented on the TAR it is the facility's process to then document in a progress note the type of behaviors observed and applied interventions. If the behavior persists after interventions are implemented or is a newly observed behavior, then a SBAR is completed and notification sent to the medical provider. On 01/12/2026 at 8:57 AM, a review of Resident# 56's TAR revealed Behavior frequencies were documented on 12/06/25 for 3pm - 11pm, 12/10/25 3pm -11pm shift, 12/20/25 for the 7am-3pm shift, 12/20/25 for the 3pm -11pm shift, 12/21/25 3pm -11pm shift, 12/31/25 3pm -11pm shift, 01/09/26 3pm-11pm shift. The TAR does not indicate what behaviors were observed, only the number of times a behavior was observed. There were no progress notes in Resident #56's medical record for behaviors observed and documented on the TAR for the previous dates and shifts. On 01/13/2026 at 9:06 AM, Interview with the Director of Nursing (DON) confirmed that if there is an escalation of behavior there should be a progress note written. The progress note is what the psych consultants will review when they come to see the Resident. The DON stated that staff will call her at all hours to consult with her if a resident is expressing behaviors and she will tell them if they need a progress note. The DON is aware that the TAR only documents the number of episodes and not the actual behaviors. DON could not answer as to why on Resident #56 there were no progress notes on date / shifts where there were documented behaviors recorded on the TAR. On 01/07/26 at 9:58 AM, Resident #12 had active physician orders for Duloxetine 40 mg, one capsule orally once daily for depression; Escitalopram Oxalate 20 mg, one tablet orally once daily for depression; and Olanzapine 5 mg, one tablet orally once daily for anxiety. On 01/08/26 at 7:15 AM, during review unnecessary medication review of Resident #12's medical records and Medication Administration Record (MAR) for the period of December 2025 through January 8, 2026, it was revealed that the resident received the prescribed antipsychotic and antidepressant medications. Review of the MAR confirmed the medications were administered as ordered; however, there was no documented evidence of behavior monitoring, nor was there documentation of monitoring for effectiveness related to the antipsychotic therapy. Further review of Resident #12's medical records on 01/08/26 at 7:30 AM revealed no evidence of documentation regarding behavioral monitoring or assessment for side effects associated with the prescribed medications, indicating a lack of ongoing evaluation of the necessity and safety of the medication regimen. On 01/08/26 8:22 AM interview with Assistant Director of Nursing (ADON) regarding effective monitoring for antipsychotic medications, ADON stated that staff monitor effectiveness using behavior monitoring flow sheets and document any observed behaviors in the progress notes. On 01/08/26 8:28 AM the surveyor and ADON reviewed Resident #12's MAR and nursing progress notes. ADON confirmed that the resident has been receiving psychotropic medications; however, no behavior monitoring flow sheets or related documentation were found in the nursing progress notes. During an interview with the Director of Nursing (DON) on 01/08/26 at 9:55 AM, she stated that the expectation is for nurses to administer medications, document the effectiveness of the medications, monitor resident behaviors, complete assessments on the behavior assessment sheet, and notify the physician of any unusual changes. On 01/08/26 at 10:15 AM the surveyor informed the DON and Clinical Services Director of the above concerns, and both acknowledged receipt. On 01/12/26 at 3:00 PM, review of Resident #12's medical record revealed that physician orders were initiated for behavioral monitoring and effectiveness monitoring every shift. On 01/13/2026 at 6:30 AM, during an investigation regarding a verbal altercation involving Resident #66, a review of the resident's medical record revealed diagnoses of vascular dementia with psychotic disturbance, mood disturbance, and anxiety. Further review of the medical record on 01/13/2026 at 6:50 AM revealed there was no documentation assessing Resident #66's behaviors related to the diagnosis of Dementia with behavioral disturbance, and no behavior monitoring tool was in place to assess the resident's behaviors. On 01/13/2026 at 7:50 AM, during an interview, the Director of Nursing (DON) confirmed that Resident #66 has a diagnosis of dementia with behavioral disturbances, which include yelling and screaming at other residents, and that the resident prefers to protect his/her personal space. However, review of the medical record revealed there was no documented behavioral assessment, no behavior monitoring tool in place, and no care plan interventions addressing the resident's identified behaviors. On 01/13/2026 at 1:02 PM, the surveyor informed both DON and Clinical Service Director of the above concerns and both acknowledged receipt. On 01/14/2026 at 8:30 AM, the Regulatory Specialist and Clinical Service Director reported to the surveyor that a behavior monitoring tool and care plan had been initiated for the resident. A copy of the care plan and behavior monitoring sheet was submitted to the surveyor. 4) During an observation with Wound Nurse #23 on 1/08/26 at 10:34 AM it was discovered that Resident #22 had a patch on his/her midback that was dated 1/07/26. During an interview with Wound Nurse #23 on 1/08/26 at 10:38 AM she reported that the patch was a Lidocaine patch on the back of Resident #22. During a review of the medication orders for Resident #22 on 1/08/26 at 10:40 AM it was discovered that the resident did not have a doctor's order for him/her have a Lidocaine patch and had no documentation of a Lidocaine patch being applied in his/her medical record. During an interview with Unit Manager #28 on 1/08/26 at 11:34 AM he confirmed that Resident #22 had a Lidocaine patch on and there was no doctor's order for the resident to have the patch so it was removed by the Resident's nurse.During an interview with the Director of Nursing on 1/08/26 at 11:46 AM she confirmed that Resident #22 did not have a doctor's order so he/she should not have had a Lidocaine patch on his/her back. She added the Lidocaine patch required a doctor's order prior to placing it onto the resident and the order would need to be signed off after administration. During a review of the facilities Nursing Policies and Procedures: Medical Management Program on 1/14/26 at 10:42 AM it stated that Documentation of medications administered is completed according to State and Federal Requirements. The initials and verifying signature are generally required. The Policy continued with The authorized staff member validates the following information is documented in the Medication Administration Record (MAR): Correct physician's order and diagnosis for each medication. Medication and label are correct. The policy added, If applying a transdermal patch or giving an injection, the location of administration site must be documented, and sites must be rotated.

cite:Based on record review and interview, it was determined that the facility failed to educate and offer the COVID-19 immunization to residents. This was found to be evident for 4 (Resident #3, #6, #4 and #56) out of 5 Residents reviewed for vaccination status. The findings include:On 01/12/2026 at 9:32 AM, a record review revealed that Residents #3, #4, #6, and #56 did not have documentation of COVID-19 vaccine administration or refusal for 2025. Resident #3's last COVID-19 vaccine was 04/04/2022, Resident #4's was 11/20/2024, Resident #6's was 10/08/2022, and Resident #56's was 11/13/2021.On 01/12/2026 at 2:11 PM, this surveyor conducted an interview with the facility's Infection Preventionist (IP) regarding the process for offering COVID-19 vaccination to residents. The IP reported that each year she offers the vaccine to all residents, and that for the 2025-2026 season, she began offering COVID-19 vaccines in October. She stated that education is provided to residents at the time the vaccine is offered. When asked if refusals are documented, the IP reported that refusals are not documented when a resident declines after receiving education. She was unable to provide an explanation for this practice. It was communicated to the IP that this is a concern, as there is no documentation verifying that residents were offered COVID-19 education or had the opportunity to refuse the vaccine. The IP confirmed understanding of the concern.

Based on record reviews and facility staff interview, it was determined that the facility failed to ensure 1) the resident/resident representative received the bed hold notification form in writing. This was evident for 1 (resident #79) of 2 residents reviewed for transfers during the recertification survey and 2) the local ombudsman was notified of facility discharges. This was evident for 2 (Residents #76 & #80) of 2 residents reviewed for discharges during the recertification survey. The facility implemented effective and thorough corrective measures after discovering the delay in ombudsman reporting prior to the start of this survey. Therefore, this deficiency was found to be past noncompliant with a compliance date of [DATE]. The findings Include: 1) On [DATE] at 1:00 PM, a review of the Facility Reported Incident (FRI) #2598892 investigation revealed Resident #79 fell while self transferring out of the wheelchair to the toilet in the bathroom. 911 was activated and the Resident was transferred to the hospital on [DATE]. A long-term care bed hold reserves a nursing home bed for a resident temporarily absent for hospitalization or therapeutic leave, ensuring their return; state Medicaid rules vary, but often cover a set period (e.g., 7 days for Medicaid, private pay for extra days), requiring facilities to have written policies and provide residents notice of their rights to readmission and costs. On [DATE] at 9:33 AM, review of Resident #79's medical records showed a transfer summary was generated for the hospital transfer on [DATE]. The Resident's family, medical provider on call, and ombudsman were notified of the incident. There was no written copy of the facility's bed hold notification form in Resident # 79's medical records. A review of the facility's bed hold policy and procedure was conducted on [DATE] at 12:30 PM. It revealed that a copy of the bed hold policy is given to every Resident / resident representative at the time of admission to the facility. A copy of the bed hold form should be given to every resident /resident representative at the time of a resident's transfer outside the facility. On [DATE]/2026 at 12:45 PM, an interview with the Regulation Specialist confirmed there were no written copies of the bed hold notification form in Resident #79's medical record for the hospital transfer on [DATE]. 2) During a review of medical records on [DATE] at 9:36 AM for Resident #76 it was discovered that he/she was sent to the hospital on [DATE] and did not return to the facility. During a review of medical records on [DATE] at 6:31 PM for Resident #80 it was discovered that he/she expired while in the facility on [DATE]. During an interview with the Business Office Manager (BOM) on [DATE] at 11:26 AM she confirmed that the ombudsman had not been notified in a timely manner. The BOM advised she had started in August and was not aware that it was her responsibility to handle ombudsman notifications. She reported she had discussed the reporting concerns with the ombudsman after learning it was her duty and was now up to date. During review of a copy of an e-mail provided by the BOM on [DATE] at 11:33 AM it was discovered that the e-mail was sent to the ombudsman on [DATE] and was titled Discharges. The e-mail had attachments for discharged Residents for [DATE], [DATE], [DATE] and [DATE]. During further review of the October attachment included with the e-mail it was revealed that Resident #76 was identified as discharged to the hospital with return expected and Resident #80 was identified as expired. During a review of another copy of an e-mail provided by the BOM on [DATE] at 11:35 AM it was revealed that the Ombudsman was notified of the [DATE] discharges, hospitalizations and admissions via e-mail on [DATE] @ 9:59 AM. During an interview with the BOM on [DATE] at 11:36 AM she advised she had discussed the reporting concerns with the Ombudsman after learning it was her duty. She reported that she had submitted the discharges from [DATE] to [DATE] by e-mail to the Ombudsman which caught her up. She also reported she had also sent the discharges for December to the ombudsman in January. Based on the above actions taken by the facility and verified by surveyors on site, it was determined that the facility's deficient practice was past noncompliance with a compliance date of [DATE]

Based on interview and record review it was determined that the facility failed to ensure a resident was provided quarterly care plan meetings. This was evident for 3 (Resident#35,# 8 and #1) out of 26 Residents reviewed for care plan meetings during the recertification survey. The findings include: A Care Plan is used in nursing facilities to summarize a resident's health conditions and care needs. It is used to ensure resident's needs are met and consistent care is provided to the resident based on those needs. Care Plan meetings are meetings with a team of care providers (attending physician, a registered nurse with responsibility for the resident, nursing assistant with responsibility for the resident, dietary services, the resident, and the resident's representative if applicable) to ensure the plan is continually adjusted to meet the changing needs or concerns of residents. Care Plan meetings are required to be held quarterly and as needed. 1) During an interview with Resident #35 on 1/05/2026 at 2:20 PM he/she denied having any recent care plan meetings. During a medical record review for Resident #35 on 1/06/2026 at 1:41 PM it was discovered that Resident #35 had care plan meetings held on 8/20/2024, 5/27/2025, 8/29/2025 and 12/02/2025. He/she did not have any documented care plan meetings from 8/20/2024 – 5/07/2025. During an interview with Social Services Assistant #8 on 1/15/2026 at 10:55 AM he confirmed that Resident #35 had no additional care plan meetings from August 2024 through May 2025 and care plan meetings were missed. He reported he was not with the facility at the time the care plan meetings were missed. 2) During a medical record review for Resident #8 on 1/09/2026 at 7:52 AM it was discovered that Resident #8 had been admitted to the facility in April 2025 and the last two care plan meetings were completed on 5/07/2025 and 1/06/2026. He/she did not have any additional documented care plan meetings in 2025. During an interview with Social Services Assistant #8 on 1/15/2026 at 10:59 AM he confirmed that the last two care plan meetings for Resident #8 occurred on 5/07/25 and on 1/06/26 with no additional care plan meetings completed in 2025. He confirmed the care plan meetings should be completed quarterly and that Resident #8 had missed care plan meetings. 3) During an interview conducted on 01/06/2026 at 8:59 AM, Resident #1 reported that the last care plan meeting was conducted 6 months ago. A review of Resident #1's care plan meeting care conference notes conducted on 01/12/2026 at 9:23 AM revealed the Resident were provided quarterly care meetings on the following dates: 07/01/2025, 03/18/2025, 11/27/2024, 10/08/2024, 06/11/2024, 3/19/2024, ad 12/20/2023. During an interview conducted on 01/12/2026 at 9:51 AM, Social Service Assistant (SSA) #8 reported that Resident#1 had considered going home in October of 2025 and therefore they did not conduct a care plan meeting. He further stated that the Resident fell through the scheduling crack and would be scheduled this month (January 2026) for a quarterly care plan meeting.

Based on review of records and interviews, it was determined that the facility failed to ensure a comprehensive care plan was developed and implemented for 1 (Resident #7) out of 1 residents reviewed for care plans during the recertification survey. The findings include:Care plans provide direction for individualized care of the resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 01/12/2026 at 9:58 AM, review of Resident #7 records revealed medical orders for: Encourage oral fluid intake 300 ML(milliliters) every shift. Fluids to be provided by a Licensed Nurse every shift. Activities of daily living are basic routine tasks that most healthy individuals can perform without assistance. These activities include personal care tasks such as eating, dressing, bathing, toileting, managing continence, and transferring (moving from 1 position to another). The ability to perform activities of daily living is an essential measure of an individual's functional status. The inability to perform basic activities of daily living may lead to unsafe conditions and a poor quality of life.On 01/12/2026 at 10:00 AM, a review of Resident #7's care plan showed goals related to nutrition and Activities of daily living (ADLs) with interventions that include Monitor and encourage intake of meals - offer alternate if <75%; Provide assistance with meals/snacks as necessary - refer to Occupational Therapy (OT) for self-feeding review as needed, EATING: Assist of 1.Further review of the resident's care plans revealed the facility staff failed to develop and implement a care plan with specific interventions and approaches to manage the resident's risk for dehydration. The Minimum Data Set (MDS) is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified and care is planned based on these individualized needs. The Brief Interview for Mental Status (BIMS) is used to determine the Resident's attention, orientation, and ability to register and recall new information. The total possible BIMS score ranges from 00 to 15: 13-15 cognitively intact; 08- 12 moderately cognitively impaired; 00-07 severely cognitively impaired. On 01/12/2026 at 11:29 AM, a review of Resident #7's medical record showed: Minimum data set (MDS) quarterly assessment on 10/30/25 was triggered for Brief interview for Mental Status (BIMS) 02, Mechanically altered diet (chopped, bite size), speech therapy. Resident #7 was under speech therapy services from 02/14/2025 - 11/14/2025.

Based on medical record reviews, observations and interviews it was determined that the facility staff failed to follow procedures during wound care to a resident with a pressure ulcer. This was evident for 1 (#22) out of 5 residents reviewed for pressure ulcer care during the recertification survey.The findings include: A pressure ulcer, also known as a bed sore or decubitus ulcer, is a localized area of skin damage that develops when prolonged pressure or shear forces disrupt blood flow to the tissues resulting in damage to the underlying tissue. Pressure ulcers are staged based on their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full-thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater) or Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon). 1. During a medical record review 1/06/26 at 1:41 PM it was revealed that Resident #22 had a Stage IV sacral pressure ulcer (PU) since 12/2024 and was receiving wound care for the PU. During an observation with the Wound Nurse #23 on 1/08/26 at 10:34 AM it was discovered that Resident #22 had a dressing over the sacral pressure ulcer that was not dated to identify when the dressing had been placed.During an interview with Wound Nurse #23 on 1/08/26 at 10:38 AM she reported that the dressings should be dated when wound care is performed and new dressings are placed. She confirmed the dressings should have been dated with the date they were placed.During an interview with the Director of Nursing on 1/08/2026 at 11:48 AM she reported the expectations are for wound dressings to be dated upon application 2. During a medical record review for Resident #22 on 1/09/26 at 1:24 PM it was discovered that the resident had an order for wound care which ordered, Daily Wound Treatment: Clean wound to sacrum with Dakin's solution, pat dry, apply Alginate calcium with silver to wound bed, and cover with boarder gauze once every day. Further review of the Task Administration Record (TAR) revealed that the order for the Daily Wound treatment was not signed off as completed for Resident #22 on April 26, 2025, November 23 2025, December 20, 2025, and January 2nd, 2026. During an interview with the Assisted Director of Nursing (ADON) on 1/14/2026 at 11:29 AM she reported wound care treatment requires orders, and the orders should be signed off after wound care is completed. She added the wound care should be documented, while documenting color and size.During a review of the facility policy Wound Care Policies and Procedures - Dressing Wound Evaluation on 1/09/2026 at 12:32 PM it reported, With each dressing change the clinician should observe and document the following:A. General appearanceB. DrainageC. Surrounding skinD. Wound odor It also stated to Document all procedures performed and patient/resident response (including pain/discomfort to the resident) on the appropriate form.

cite:Based on record review and interview, it was determined that the facility failed to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress. This was found to be evident for 1 (Resident #61) out of 6 residents reviewed for allegation of neglect. The findings include:On 01/07/2026 at 11:01 AM, a record review of the facility's investigation file for a facility-reported incident of alleged neglect involving Resident #61 by Geriatric Nursing Assistant (GNA) #5 was conducted. The review showed that the initial report of the allegation was submitted to the Office of Health Care Quality on 10/29/2025 by the Administrator. The final investigation report was submitted to the Office of Health Care Quality on 11/04/2025, also by the Administrator. The report indicated that GNA #5 was suspended on 10/29/2025 and returned to work on 11/01/2025.A continued record review of the investigation file on 01/07/2026 at approximately 11:35 AM showed that the file included a statement from the Registered Nurse (RN) Unit Manager, dated 11/04/2025, as well as a separate statement from RN #30, also dated 11/04/2025.On 01/07/2026 at 2:21 PM, an interview was conducted with the Administrator regarding the course of the investigation. The Administrator confirmed that the investigation was completed on 11/04/2025. He also confirmed that GNA #5 was suspended from 10/29/2025 to 11/01/2025. When asked why GNA #5 was allowed to return to work prior to the completion of the investigation, he stated that by 11/01/2025, he had determined that the allegation of neglect could not be verified, and therefore the employee was permitted to resume work.On 01/07/2026 at 3:06 PM, an interview was conducted with both the Administrator and the Assistant Director of Nursing (ADON), who were involved with the investigation. It was discussed that the investigation was completed and submitted to the Office of Health Care Quality on 11/04/2025; however, GNA #5, who was accused of neglect, was allowed to return to work on 11/01/2025. Review of the facility's investigation file showed statements collected on 11/04/2025, including one from the RN Unit Manager and another from RN #30, which were part of the ongoing investigation. It was explained that because these statements were collected on 11/04/2025, the investigation was still in progress on 11/01/2025, and therefore GNA #5 returned to work before the investigation was completed. This was communicated as a concern because the purpose of suspending the accused staff member during an active investigation is to prevent the potential for any further abuse, neglect, exploitation, or mistreatment during the course of the investigation.

Based on observations, interview and record review, it was determined that the facility failed to ensure that 1) an allegation of neglect was reported to the Office of Health Care Quality no later than 2 hours after the allegation was made. This was evident for 1 (Resident #61) out of 6 residents reviewed for neglect allegations and 2) to report the malfunction of the HVAC heating system to the State Agency the Office of Health Care Quality (OHCQ) in a timely manner. This was found to be evident for 1 out 8 Facility Reported Incidents (FRI) reviewed during the recertification survey.The findings include: 1) On 01/05/2026 at 3:15 PM, this surveyor conducted an interview with Resident #61. When asked whether the Resident had ever felt mistreated by a staff member, Resident #61 reported mistreatment by Geriatric Nursing Assistant (GNA) #5. Resident #61 stated that this concern was communicated to a family member, who then reported the concern to the facility, although the Resident was unsure to whom the report was made. On 01/07/2026 at 11:01 AM, this surveyor conducted a record review of the facility's investigation file related to a facility-reported incident involving Resident #61. The review showed that an interview with Resident #61 was conducted on 10/27/2025 by the Registered Nurse (RN) Unit Manager, with the Social Worker Assistant #27 present as a witness. According to the interview documentation, Resident #61 was asked whether there were any concerns regarding a staff member. Resident #61 reported a concern involving GNA #5. When asked to describe the concern, Resident #61 stated that after requesting a brief change, GNA #5 covered the Resident with a blanket and did not change the brief. When asked when the incident occurred, Resident #61 reported that it happened approximately three weeks prior, but was unable to recall the specific date. On 01/07/2026 at approximately 11:30 AM, a continued record review of the facility's investigation file showed that the facility reported an allegation of abuse involving Resident #61 to the Office of Health Care Quality on 10/29/2025 at 1:39 PM. The report was submitted by the Administrator. On 01/07/2026 at 2:02 PM, this surveyor conducted an interview with RN Unit Manager. It was discussed the interview she had had with Resident #61. During the interview, she recalled that Resident #61 had reported an aide did not change him, that the GNA covered him up and left without changing him. When asked about what happened after this interview had taken place, she reports that she spoke with the Assistant Director of Nursing (ADON) about the interview. On 01/07/2026 at 2:21 PM, this surveyor conducted an interview with the Administrator to discuss the investigation into the allegation of abuse involving Resident #61. During the interview, the Administrator reported that he first became aware of Resident #61's concerns regarding GNA #5 after receiving a letter from the Resident's family member on 10/29/2025. Based on the information contained in the letter, the Administrator reported that an allegation of abuse was subsequently reported to the Office of Health Care Quality. During the interview, the Administrator was asked whether he was aware of an interview conducted on 10/27/2025 between Resident #61 and the RN Unit Manager; the Administrator reported that he was not aware that this interview had occurred. On 01/07/2025 at 2:52 PM, this surveyor conducted an interview with the ADON. During the interview, the RN Unit Manager's interview of Resident #61 on 10/27/2025 was discussed. The ADON reported that she did not recall this interview and stated that the first time she was made aware of Resident #61's concerns involving GNA #5 was upon receipt of a letter from the Resident's family member on 10/29/2025. On 01/07/2026 at 3:00 PM, during an interview with the Administrator and the ADON, this surveyor communicated concerns regarding the facility's failure to timely report an allegation of neglect. Record review showed that Resident #61 communicated an allegation of neglect to the RN Unit Manager on 10/27/2025; however, the Administrator and ADON were not made aware of the allegation on that date, and the allegation was not reported to the Office of Health Care Quality within the required two-hour timeframe. It was explained that, had the Administrator and ADON been informed of Resident #61's concern regarding GNA #5 following the RN Unit Manager's interview on 10/27/2025, the initial report of alleged neglect could have been made on that date rather than on 10/29/2025 after receipt of the family member's letter. 2) On 01/05/2026 at 7:30 AM the Survey team conducted an unannounced entry of the facility to conduct a recertification and complaint survey. The night Registered Nurse (RN) #17 advised the team to have a seat because he needed to contact the Administrator and Maintenance Director to assign the Survey team a room because the usual room (1st floor B-wing Solarium) did not have heat. At 8:19 AM Licensed Practical Nurse (LPN) #4 met the Survey team and moved the team from the lobby of the facility to a room on the second floor C-wing. On 01/05/2025 at 8:30 AM the Assistant Director of Nursing (ADON) met with the team and explained that the room that is usually assigned to the Surveyors did not have heat and that the Maintenance Director was working on the heat. During a review of a Facility Reported Incident (FRI) # 2709075 it was discovered that the facility reported on 01/05/2026 at 6:40 PM that the HVAC was not functional in the B-wing Solariums on the 1st and 2nd floor. On 01/05/2026 at the end of the day the Survey team was moved to the 1st floor B-wing Solarium. On 01/06/2026 at 6:00 AM, this Surveyor observed 2 of the 3 portable heaters on and spaced out across the room. The room was very cold and required this Surveyor to wear his/her coat throughout the day. From 01/06/2026 through 01/14/2026 the room was very cold on many of the days. The breaker would trip on most of the days cutting off the power to the portable heaters. The NHA attempted to turn on a wall heating unit however that unit was ineffective in heating the portion of the room it was located. During an interview conducted on 01/13/2026 at 10:09 AM, the Nursing Home Administrator (NHA) reported that he contacted the fire marshal and the Life Safety Code Coordinator to get direction on what type of portable heaters could be used to heat the 1st floor B-wing Solarium on 01/05/2026 following the entry of the Survey team. He then later that day reported the malfunctioning of the HVAC heating system on 01/05/2026 at 6:40 PM to OHCQ. The NHA explained that the HVAC heating system malfunctioned and that Corporate required 3 estimates to have the heating system repaired. The NHA stated that he had 2 estimates and was working on obtaining a third estimate. This Surveyor requested the documentation for the repair of the heating unit. During a review of the facility documentation provided by the NHA on 01/13/2026 at 11:00 AM, it was discovered that the facility received an estimate on 11/14/2025 for the repair of the heating system for the 1st and 2nd floor B-wing Solariums. During the continued review it was discovered that there was no other evidence of the 2nd estimate that the NHA had reported previously to the Surveyor. During an interview conducted on 01/13/2026 at approximately 1:15 PM, the NHA explained that the HVAC heating system malfunctioned in early November 2025. He stated that he had obtained 1 estimate of the 3 required for Corporate to repair the heating system in November 2025. He also stated that he had not obtained the 2nd estimate because he still needed to provide the contractor with additional information. When asked what the name of the 2nd contractor was the NHA could not recall. When asked why the facility did not report the malfunction of the heating unit until the Survey team entered the facility instead of when the heating system malfunctioned in early November of 2025, the NHA stated he did not have an explanation. The NHA acknowledged the delay in obtaining the 3 required estimates to repair the heating system and the delay in reporting the issue to the State Agency, the Office of Health Care Quality (OHCQ).

cite:Based on observation and interview, it was determined that the facility failed to ensure adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and safe environment. This was evident during the Infection Control review conducted as part of the annual survey. This deficiency has the potential to affect all residents.The findings include:On 01/12/2026 at 10:55 AM, this surveyor observed a large hole in the ceiling in the Laundry room, in the clean clothes drying area. The hole exposed pipes, dust, and drywall. Photographs of the observation were taken at this time.On 01/12/2026 at 11:29 AM, this surveyor observed a large hole in the ceiling in the clean linen folding room. There was a ceiling fan near the edge of the hole, and the hole exposed pipes, dust, and drywall. Photographs of the observation were taken at this time.On 01/14/2026 at 09:45 AM, this surveyor conducted an interview with the Maintenance Director regarding building maintenance and plumbing concerns. The Maintenance Director reported that he has observed ongoing leaks in the building since his employment began in 2014. He confirmed that there are currently no issues with mold despite the leaks. He explained that leaks are being repaired as they occur; however, a full plumbing replacement is needed, which has been delayed due to budget constraints and other priorities. He reported that these concerns have been communicated to the Administrator and discussed during morning meetings when leaks occur, although these discussions are not documented. When asked about the holes in the ceiling, he confirmed that the holes were created to access plumbing for repairs. He stated that the holes remain open due to limited maintenance staffing, which prevents timely repair of the ceiling with drywall.On 01/14/2026 at 09:57 AM, a dual observation was conducted with the Maintenance Director of holes in the ceiling in the Laundry/dryer room. The Maintenance Director confirmed that these holes were created last week to repair a leak. During the observation of the clean linen room, where clean clothes are folded, the Maintenance Director confirmed that the holes in the ceiling were created in December to address a separate leak.On 01/14/2026 at 1:00 PM, this surveyor conducted an interview with the Administrator regarding environmental concerns related to the ongoing leaks in the facility and the resulting holes in the ceilings. The Administrator acknowledged the concern and reported that he would begin utilizing a service to bring in a maintenance staff member on a rotating basis from other facilities to assist with maintenance issues, including repairing exposed ceilings.On 01/14/2026 at approximately 2:00 PM, the Administrator showed this surveyor photographs of maintenance staff repairing the holes in the ceiling of the Laundry/dryer room.

cite:Based on record review and interviews, it was determined that the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to resident who was discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This was evident for 1 resident (#11) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification. The findings include: The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services. The NOMNC (Notice of Medicare Non-coverage) informs the beneficiary of his or her right to file appeal of the decision and right to an expedited review of Medicare non-coverage of services. On 01/14/2026 at 2:15 PM, a review of the facility's SNF Beneficiary Protection Notification Review Worksheet indicated that Resident #11's last covered day under Medicare Part A was 07/11/25. The worksheet further indicated that the SNF Advance Beneficiary Notice (ABN) and the Notice of Medicare Non-Coverage (NOMNC) were not provided to the resident and/or resident representative as required. On 01/14/2026 at 2:36 PM, during an interview, the Business Office Manager confirmed that there was no record indicating Resident #11 was issued the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) or the Notice of Medicare Non-Coverage (NOMNC). On 01/14/2026 at 2:45 PM, the surveyor informed the Clinical Services Director and the Regulatory Specialist of the above concern. Both individuals acknowledged receipt of the information.

Based on observation, interviews, and record review it was determined that the facility failed to ensure an environment that promotes resident dignity. This was evident for 2 (Resident #56 and #61) of 2 residents observed for dignity during the recertification survey.The findings include: 1) On 01/05/2026 at 8:31 AM, the Surveyors observed Geriatric Nursing Assistant (GNA) #2 enter Resident #56's room without knocking or introducing herself. GNA #2 tried to quickly exit the room once she saw the Surveyors inside the room. During an interview conducted on 01/05/2026 at 8:31 AM, GNA#2 could not provide an explanation as to why she entered Resident #56's room without knocking or introducing herself. GNA #2 stated I saw the door closed and I came to see why. On 01/12/2026 at 12:50 PM, an interview with the Director of Nursing (DON) confirmed it is the facility's expectation for a GNA or any staff to knock on the door and wait for a response from the resident before entering the Resident's room. If the Resident is nonverbal, staff are to still knock and wait to see if there are any visitors inside the room to invite them in. Once the staff open the Resident's door, it is the expectation that they greet the Resident and introduce themselves and state why they are there. This was confirmed as the facility practice every time a staff member enters a Resident's room. 2) On 01/05/2026 at 3:15 PM, this surveyor conducted an interview with Resident #61. When asked whether he/she had ever felt mistreated by a staff member, Resident #61 reported mistreatment by Geriatric Nursing Assistant (GNA) #5. The resident explained that this staff member, instead of speaking directly, would use her fingers to communicate rather than verbally interacting. Resident #61 stated that he/she had shared this concern with a family member, who subsequently reported it to the facility, although the Resident was unsure to whom the report was made. On 01/07/2026 at 11:01 AM, a record review of the facility's investigation file for a facility-reported incident of alleged neglect involving Resident #61 by GNA #5 was conducted. The investigation file showed that Resident #61's Power of Attorney (POA) reported concerns to the facility, stating that GNA #5 had no communication with the resident, just pointing, and that the Resident became anxious at the mention of the GNA's name. In a statement dated 10/30/2025, GNA #5 reported that she used both verbal and non-verbal communication, including hand gestures, while providing care to Resident #61. The facility concluded the investigation with a determination that the allegation of neglect could not be verified. On 01/08/2026 at 9:13 AM, a record review of a psychiatric note dated 11/12/2025 for Resident #61 showed that the chief reason for the visit was patient seen due to patient-to-staff conflict. The note documented that the Resident reported feeling anxious when a particular staff member provided care. The Resident stated that the staff member did not communicate verbally, but instead used hand gestures, which caused the Resident to feel anxious. On 01/08/2025 at 9:43 AM, a follow-up interview was conducted with Resident #61. When asked about his/her experience with GNA #5, the Resident reported that this staff member communicated using hand gestures rather than verbal communication. When asked how this made him/her feel, the Resident stated that it made him/her feel offended. When asked if he/she felt disrespected by GNA #5, the Resident confirmed that he/she did, due to the use of hand gestures for communication. On 01/09/2026 at 1:38 PM, this surveyor conducted an interview with the Administrator to discuss the investigation into the allegation of neglect by GNA #5. The Administrator confirmed that the facility was able to substantiate that GNA #5 used non-verbal communication with Resident #61, as documented in her statement in the investigation file. He further confirmed that following the investigation, GNA #5 was educated not to use hand gestures or pointing when communicating with residents. It was discussed with the Administrator that multiple sources of documentation indicated Resident #61 experienced anxiety and offense when receiving care from GNA #5, including reports from the Resident's Power of Attorney, surveyor interviews with the Resident, and a psychiatric note stating the Resident felt anxious when a staff member used hand gestures while providing care. This was communicated as a concern for resident dignity, as it was confirmed that GNA #5's non-verbal communication caused Resident #61 to feel anxious, offended, and disrespected. The Administrator acknowledged and agreed that this was an issue impacting resident dignity.

cite:Based on medication administration observation, medical record review, and staff interviews, it was determined that licensed facility staff failed to maintain a medication error rate of less than five percent during the medication pass observation. This was evident for 2 Residents (#85 and #16) of 10 residents observed. A total of 29 medication administration opportunities were reviewed, resulting in a medication error rate of 10.34%. The findings include:On 01/08/2026 at 6:26 AM, during a medication administration observation with Registered Nurse (RN) #17, was observed crushing Resident #16's medications; Tylenol 325 mg, two (2) tablets, and pantoprazole 40 mg, one (1) tablet and administering them mixed in applesauce. On 01/08/2026 at 6:30 AM, during reconciliation of Resident #16's Medication Administration Record (MAR), the physician's orders indicated Tylenol 325 mg, two (2) tablets by mouth at 6:00 a.m., and Pantoprazole 40 mg, one (1) tablet by mouth at 6:00 a.m. There were no orders to crush the medications or mix them in applesauce. On 01/08/2026 at 6:40 AM, review of Resident #16's physician orders and Medication Administration Record (MAR) with RN #17 revealed no instructions to crush the medications. RN #17 confirmed that the medications were crushed prior to administration. On 01/08/2026 at 6:45 AM, during an interview, RN #17 stated that the medications for Resident #16 were crushed because the resident had difficulty swallowing. RN #17 confirmed that there was no physician's order to crush the medications. On 01/08/2026 at 7:00 AM, during an interview with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) regarding medication administration, the ADON stated that nurses are expected to follow physician orders during medication administration. The surveyor made the DON aware of the above concern and acknowledge receipt. On 01/12/2026 at 8:00 AM, during a medication administration observation with Licensed Practical Nurse (LPN) #25. Resident #85's physician order indicated Advair HFA 45/21 mcg, two (2) puffs by mouth twice daily, with instructions to rinse the mouth after use. LPN #25 administered only one (1) puff and did not offer the resident water to rinse the mouth as ordered. On 01/12/2026 at 8:05 AM, during review of Resident #85's Medication Administration Record (MAR) with LPN #25, it was revealed that two (2) puffs were documented as administered. LPN #25 confirmed that only one (1) puff had been given. Following surveyor intervention, LPN #25 returned to Resident #85, administered the second puff as ordered, and offered water for the resident to rinse his/her mouth. Further observation on 01/12/2026 at 8:12 AM with LPN #25, the physician's order for Balsam Peru Castor oil was to apply to affected fingers and toes daily for disorder of the skin and subcutaneous tissue for Resident #85. During medication administration observation, LPN #25 administered the ointment to the left and right fingers. On 01/12/2026 at 10:15 AM interview with resident #85 stated, they only apply it to my fingers, not my toes. My toes are the same as my fingers. On 01/12/2026 at 10:55 AM, surveyor reviewed Resident #85's physician's orders with LPN #25 and confirmed that the order was to apply the ointment to both fingers and toes. LPN #25 further confirmed that the ointment was applied only to the left and right fingers and not to the toes as ordered. On 01/12/2026 at 11:05 AM, the above concerns were brought to the DON and Clinical Services Director, and both acknowledged receipt.

citeBased on observation and staff interviews, it was determined that the facility failed to properly store medications, as evidenced by medications not being properly labeled or dated. This was evident in 1 of 2 medication rooms and 4 of 4 medication carts observed during the recertification and complaint survey. The findings include: On 01/12/2026 at 6:17 AM, during a medication cart observation on the 1st floor C and D-Wing with Registered Nurse (RN) #26, the surveyor observed opened medications without documented open dates or resident identification. Resident-specific medications included Resident #70's Albuterol and Ellipta inhalers, Resident #10's Albuterol inhaler, Resident #9's Simethicone (1 fl oz/30 mL), and Resident #1's Albuterol inhaler. Additional opened medications stored without identification or documented open dates included Calcium + D3 (1 bottle), Vitamin C 1000 mg (1 bottle), Vitamin D 125 mg (1 bottle), and Tylenol 500 mg (1 bottle). One Glucagon Emergency Kit with the label torn off was also observed without resident identification or a documented open date. On 01/12/2026 at 6:25 AM, during a 1st floor medication room observation with Registered Nurse (RN) #26, the surveyor observed 10 FA Sponge Swabs (Lot #20953) on the counter that were expired (Expiration Date: 09/2025). The above concerns were reviewed with RN #26, who acknowledged the findings and removed the swabs from the medication room. On 01/12/2026 at 6:45 AM, during a 2nd floor A and C wing medication carts observation with Licensed Practical Nurse (LPN) #4, the surveyor observed residents' medications open without documented open dates, including 1 Latanoprost Ophthalmic for Resident #86 and 1 bottle Lactulose Solution 10g/15 mL for Resident #72. Additional medications were observed open without identification or documented open dates, including 1 box Mucinex 12 hr Over the Counter (OTC), 1 bottle Polyethylene Glycol 3350, 1 bottle Milk of Magnesia, and 1 tube Mupirocin Ointment 2%. The above findings were reviewed with LPN #4, who acknowledged the observations. On 01/12/2026 at 7:01 AM, during an interview, the Director of Nursing (DON) stated that nurses are expected to ensure all bottled and over-the-counter medications are labeled once opened, that expiration dates are monitored, and that expired medications are promptly removed from the carts. The surveyor brought the above concerns to the DON's attention, and she acknowledged receipt.

Based on complaint, reviews of a closed medical record and staff interview, it was determined that the facility staff failed to provide a resident with a safe environment and enough supervision during care, to prevent the resident from rolling off the bed onto the floor and receiving an injury. This occurred for 1 of 11 resident reviewed during a complaint survey. The findings include: Resident #3 is a [AGE] year old female who was admitted to the facility on [DATE]. Resident #3 is totally dependent upon the facility staff for all aspects of her care. Resident #3 has been deemed cognitively impaired and is unable to protect herself from any potential accidents. Review of complaint MD 582 on 01/31/2013 revealed an allegation that resident #3 fell out of bed during care and suffered facial trauma. Review of resident #3's closed medical record on 01/31/2013 revealed nursing documentation, dated 12/05/2012 at 6:00 am, indicating that resident #3 was being assisted by GNA #1, and was observed on the floor with a hematoma under the left eye, and a laceration was noted to the left eyebrow. In an interview on 02/01/2013 at 5:45 am, GNA #1 stated that he was rendering morning care to resident #3 on the morning of 12/05/2012. GNA #1 stated he had rolled resident #3 onto her side towards him without assistance. GNA #1 stated he then walked over to the room sink to get a towel, and that is when resident #3 rolled out of bed onto the floor. GNA #1 stated that he notified the charge nurse immediately after resident #3 fell to the floor. Resident #3 was sent to the emergency room to be evaluated. Review of resident #3's hospital records, on 01/31/2013, revealed that resident #3 received a 3 centimeter laceration to the left eyebrow from the fall, which required sutures in the emergency room . In conclusion, GNA #1 failed to provide a safe environment for resident #3 during care on the morning of 12/05/2012 at 5:45, which allowed resident #3 to roll out of bed onto the floor, receive a 3 centimeter laceration to the left eyebrow and a hematoma under the left eye, which required a trip to the emergency room and suturing to the left eyebrow.

Based on complaint, reviews of a medical record and staff interview, it was determined the facility staff failed to provide a resident with a safe environment and enough supervision during care to prevent the resident from rolling off the bed onto the floor and receiving an injury. This occurred for 1 of 10 resident reviewed during a complaint survey. The findings include: Resident #9 is a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9 is totally dependent upon the facility staff for all aspects of her care. Resident #9 has been deemed cognitively impaired and in an end stage condition. Resident #9 is unable to protect herself from any potential accidents. Review of complaint MD 732 on 02/15/2012, revealed an allegation that resident #9 fell out of bed during care and suffered an intracranial bleed. Review of resident #9's medical record on 02/15/2012 revealed nursing documentation, dated 05/26/2011 at 10:00 am, indicating resident #9 was noted on the floor with a laceration noted to the right forehead. In an interview with GNA #1 on 02/17/2012 at 4:19 PM, GNA #1 stated she was rendering morning care to resident #9 the morning of 05/26/2011. GNA #1 stated she had rolled resident #9 towards her without assistance and that's when she felt the bed move. GNA #1 stated the bed kept moving and resident #9 fell off the bed onto the floor. GNA #1 stated she thought the bed was in a locked position. GNA #1 stated she contacted the charge nurse immediately after resident #9 fell to the floor. Resident #9 was sent to the emergency room to be evaluated. Review of resident #1's Self Care Activities of Daily Living care plan, dated 03/29/2011, revealed nursing interventions instructing the facility staff to use 2 staff members, at all times, to perform turning and repositioning, transfers, and bed making. Review of resident #9's hospital records, on 03/01/2012, revealed resident #9 received a 5 centimeter laceration to the forehead from the fall which required sutures in the emergency room . Further review of resident #9's hospital record revealed a CAT scan result, dated 05/26/2011, which indicated resident #9 had also suffered a small right subdural hematoma (bleeding in the brain). In conclusion, the GNA #1 failed to secure resident #9's bed and obtain assistance from another staff member prior to performing morning care to resident #9 on 05/26/2011 at 10:00 am. Resident #9 suffered a fall with a subsequent laceration to her forehead and a subdural hematoma.

Based on medical record review, interview of facility staff and review of the facility's investigations it was determined that the facility failed to ensure that residents were protected from accidents and injuries. This was evident for 2 of 34 sampled residents selected for review. The findings include: 1. The facility staff failed to ensure that a resident received appropriate care and services related to the safe administration of a Hydrocollator pack. Resident #86, [DIAGNOSES REDACTED]. The resident is cognitively impaired and dependent on staff for activities of daily living. The surveyor's review of the resident's medical record on February 16, 2011 revealed the following on January 18, 2011. The nurse documented that at 10:45 a.m. the resident was noted with an open blister and redness to her right inner knee. The Nurse further reported that there was a small amount of clear watery fluid draining from the blister. Further assessment by the nurse revealed that the area was painful when touched. The physician was notified and an order was received for treatment to the open blister. The documentation went on to state that the facility staff initiated an investigation to determine how the resident's injury occurred. It was determined that prior to the discovery of the injury, the restorative aid had applied a Hydrocollator pack to the resident's right lower extremity. A Hydrocollator pack is a form of moist heat that is frequently used by physical and/or occupational therapists. Complications from this form of heat therapy can include pain, skin rash and burns. The surveyor's reviewed the facility's Hydrocollator pack policy. The policy revealed that the Hydrocollator pack treatments are the responsibility of "all occupational therapy personnel involved in the care of patients receiving a Hydrocollator pack." Further review of the facility's procedure for administering Hydrocollator packs revealed the following documentation. The "patient ' s skin should be checked every five (5) minutes. More toweling is added if the skin appears red, or if the patient reports a hot rather than warm sensation." The surveyor interviewed the Rehabilitation Director on February 16, 2011 at 11:10 a.m. regarding the policy and what occurred. The Rehabilitation Director stated that the skin should be checked no less than every 7 minutes; as a burn can occur from the use of a Hydrocollator pack. The surveyor's interview of the restorative aid's and review of the restorative aid statement on February 16, 2011 at 1:15 p.m. revealed the following. On 1/18/11 at 9:00 a.m. the restorative aid applied the Hydrocollator pack to the resident's right lower extremity. In addition she documented in her statement that she checked the resident's skin 10 minutes after applying the Hydrocollator pack. After doing this she left the pack on for 10 more minutes before removing the pack. The facility staff determined that the resident sustained [REDACTED]. On February 16, 2011 the surveyor reviewed the wound care physician's documentation dated January 31, 2011 and February 7, 2011. The documentation revealed that the resident had a burn to her right lower extremity which measured 2.4 cm. x 5 cm. The wound was noted with scant, purulent exudate and had 80% thick, adherent, devitalized tissue and 20% slough. Further review of the medical record and staff interview revealed there was no physician's order for a Hydrocollator pack. In addition the facility was unable to determine who initiated therapy with the Hydrocollator pack. Also, no documentation existed that stated an evaluation for risk factors related to the use of a Hydrocollator pack was conducted. Risk factors include but are not limited to cognitive impairment, decreased sensation and temperature sensitivity. Additionally, the facility's staff failed to initiate a care plan identifying goals and interventions related to the safe administration of the Hydrocollator pack to the resident. The surveyor's interview of the Rehabilitation Director and the Director of Nursing on February 16, 2011 revealed the following. There was no documented evidence that the restorative aid had received instructions from the rehabilitation staff on the safe administration of the Hydrocollator pack to the resident. 2. The facility staff failed to obtain a physician's order for the resident to go on a leave of absence with family members. The facility staff failed to consult with the rehabilitation staff regarding whether or not the resident could be safely transferred in and out of the car by family members. Resident #121 has [DIAGNOSES REDACTED]. The resident is non-weight bearing and requires transfers with a Hoyer lift (a mechanical lift.) The transfers should also be executed with the assistance of two staff members. The surveyor reviewed the resident's care plan dated January 9, 2010 for ADL (activities of daily living. The care plan revealed that the resident is dependent on staff for bathing, dressing, toileting and mobility. The plan also documents that a Hoyer lift (a mechanical lift) should be used for transfers. Further review of the resident's medical record revealed [REDACTED]." The nursing progress notes revealed that the resident returned to the facility on the same day. The surveyor reviewed the facility's "Incident Report Investigation." The report revealed that on December 27, 2010 the resident presented with left ankle swelling. The physician was notified and gave a telephone order to x-ray the resident's left ankle. The x-ray result revealed that a fracture could not be ruled out. A follow-up x-ray of the resident's left ankle was obtained by the facility on January 4, 2011. The x-ray findings revealed a minimally displaced fracture of the distal fibula. The physician was notified and gave an order to transfer the resident to the emergency room for evaluation and treatment of [REDACTED]. The facility initiated an investigation of the resident's injury of unknown origin. Review of the facility's investigation revealed that the resident's daughter provided the following statement dated January 4, 2011: "On December 23, 2010, I spoke with the 2nd floor nursing station to request permission for my mom (name of resident) to leave the facility for a few hours on Christmas Day. Permission was granted and my son and I picked her up around 12:00 noon. When we arrived she was ready and waiting in the first floor lobby. My son and I (spent) about 20 minutes or more trying to get her in the car because she would not allow us to touch her legs. He picked her up and sat her in the front passenger seat for room to stretch her legs out. She moved her own legs around in the car after a long period of time." The surveyor's interviewed the Rehabilitation Director on February16, 2011at 11:30 a.m. regarding the incident. The interview revealed that there was no documented evidence that the rehabilitation staff ever evaluated the resident; for safe transfer in and out of the car by family members. In addition there was no documentation that family members received instructions on transferring the resident in and out of the car. Additionally, the facility staff failed to obtain a physician's order for the resident to go on a leave of absence with family members on December 25, 2010.