Every finding on record at Westgate Hills Rehab & Healthcare CTR

Based on interview, observation, and record review, it was determined that the facility failed to have evidence that an allegation of sexual abuse was thoroughly investigated for 1(Resident #1) of 1 residents reviewed for alleged sexual abuse. The findings include: On 7/1/26 at 10:40 AM, a record review related to Complaint #3047565 and Incident #3027259 was conducted. The events pertained to the same resident and incident. It was revealed that Resident #1 was admitted to the facility on [DATE]. The active order summary dated 7/1/26 listed diagnoses including, but not limited to: depression, adjustment disorder with depressed mood, muscle weakness, chronic deep vein thrombosis/pulmonary embolism history, and multiple musculoskeletal conditions. The active orders included a neurology consult for evaluation for dementia dated 6/3/26, after the alleged incident that occurred on 5/28/26. On 7/1/26 at 10:50 AM, the review of Resident #1's care plan revealed that Resident #1 had impaired cognitive function or impaired thought processes related to a Brief Interview for Mental Status (BIMS) score less than 13. The care plan included interventions to maintain the resident's routine, provide consistent caregivers as much as possible to minimize confusion, monitor/report changes in cognitive function, and support communication of basic needs. Review of the care plan also revealed Resident #1 had an Activities of Daily Living (ADL) self-care performance deficit related to impaired balance. The care plan documented that Resident #1 required two-person assistance for bed mobility and dressing, and a full mechanical lift transfer. On 06/03/26, after the alleged incident, the care plan was updated to include Resident prefers no male CNAs. On 7/1/26 at 11:00 AM, review of the care plan further revealed a psychosocial well being focus related to Alleged Staff to Resident Sexual Interaction (5/28/26), initiated 05/29/26. Interventions included allowing Resident #1 time to answer questions and verbalize feelings, perceptions, and fears; psych consult; and Resident prefers female caregiver only. On 7/1/26 at 11:05 AM, a review of the facility-reported (Incident #3027529) revealed the facility identified the allegation type as sexual. The report documented that on 5/28/26 at approximately 9:10 PM, Certified Nurse Aide (CNA) #1, reported to Licensed Practical Nurse (LPN) #1 that Resident #1 stated they were inappropriate while providing ADL care. The report documented that the administrator was notified at 9:31 PM, and the incident was submitted to the Office of Health Care Quality on 5/28/26 at 10:35 PM. The initial report documented no serious bodily injury, no injury noted at that time, and no changes observed from Resident #1's baseline. The report documented that the assigned CNA was immediately placed on administrative leave and that notifications to MD/NP, resident representative, police, and ombudsman, as well as resident and staff interviews, were pending at the time of the initial report. On 7/1/26 at 11:15 AM, a review of the facility's follow-up investigation report revealed the facility concluded the allegation of sexual abuse was unsubstantiated. The facility documented that Resident #1 had a BIMS score of 6 and was care planned for impaired cognition. The facility's conclusion stated Resident #1 told LPN #1 that CNA#1 was inappropriate while care was being provided and that, due to how care was provided, they thought they were being raped. The report also stated that during the police interview, Resident #1 reportedly stated they did not report any allegations to anyone. On 7/1/26 at 11:25 AM, the follow-up report documented that Resident #1's Primary Care Provider (PCP) assessed Resident #1 on 5/29/26. The report stated Resident #1 reported they were sleeping, woke up, and someone was playing with their private area. The report stated the PCP did not identify trauma, bruising, redness, pain, or evidence of insertion. The report also documented the psych NP noted baseline forgetfulness/cognitive impairment, and that Resident #1 did not have a confirmed diagnosis of dementia, with the facility to follow up with neurology. On 7/1/26 at 11:30 AM, a review of CNA #1's written statement revealed CNA #1 documented that they entered Resident #1's room to change Resident #1, and during care, Resident #1 stated CNA #1 touched them inappropriately. Staff #1 documented that they immediately stopped care and reported to the nurse.On 7/1/26 at 11:33 AM, the review of LPN #1's handwritten statement revealed CNA #1 came to the nursing station and reported Resident #1 accused them of something while they were changing Resident #1. LPN #1 documented that CNA #1 refused to state what Resident #1 had accused them of. LPN #1 documented that they and CNA #2 went to Resident #1's room, and Resident #1 stated CNA#1 tried to rape them. LPN #1 documented that they instructed CNA #1 not to return to Resident #1's room and that CNA #2 completed Resident #1's care.Review of CNA #2's written statement revealed CNA #2 was asked to come into Resident #1's room after a situation occurred. CNA #2 documented that Resident #1 was very uncomfortable with CNA #1 changing them, and CNA #2 completed Resident #1's care after LPN #1 directed CNA #1 to leave the room.On 7/1/26 at 11:40 AM, a review of the Situation, Background, Assessment and Recommendation (SBAR) Communication Form dated 5/28/26 at 10:08 PM and completed by LPN #2 revealed that Resident #1 initially alleged CNA #1 touched them inappropriately while providing perineal care following an incontinence episode. Resident #1 was lying on their bed at the time. Resident #1 alleged that she felt like CNA #1 was trying to rape her. The SBAR is concluded with a statement from LPN #2 that Resident #1 reportedly denied that CNA #1 got in bed or on top of them and denied that CNA #1 exposed themself or disrobed. The SBAR documented no visible injuries, Resident #1 denied pain, the physician was notified, and police reportedly interviewed Resident #1, who reportedly stated they did not make complaints or allegations. The investigation file contains officer contact information, badge number, and police report number, but no evidence of the report obtained by Baltimore County Police. On 7/1/26 at 11:45 AM, a review of staff abuse questionnaires dated 6/2/26 revealed staff were asked whether they saw a staff member touch Resident #1 inappropriately while care was being provided in Resident #1's room, and whether Resident #1 reported to them that a staff member touched her inappropriately while care was being provided. Multiple staff answered No. However, the investigation did not document whether those staff were present in Resident #1's room during the care interaction or whether their responses were based on direct observation of the care provided by CNA #1.One staff questionnaire documented that Resident #1 reported they felt uncomfortable and that the concern was reported to Certified Medication Aide (CMA) #1. CMA #1's questionnaire documented that Resident #1 informed CMA #1 and other unit staff regarding the incident and accused CNA #1 of rape. CMA #1 provided a written statement (Complaint #3047465) regarding the incident on 5/28/26 detailing observing CNA #1 approaching the nursing station at approximately 9:02 PM after exiting Resident #1's room. CMA #1 explains that CNA #1 stated Resident #1 was accusing them of rape. CMA #1 explained that they assessed Resident #1, and the resident stated CNA #1 got on top of them, told them to be quiet, and tried to insert their penis. Resident #1 stated CNA #1 jumped off of them after they yelled for them to stop. CNA #1 jumped off the right side of the bed and pulled up his pants, according to Resident #1's statement provided to CMA #1. On 7/1/26 at 11:50 AM, the surveyor entered the unit. The unit staffing assignment listed CNA #1 as working on the unit, and the surveyor observed Staff #1 on the floor. Review of the assignment revealed CNA #1 was not assigned to Resident #1. Resident #1 was observed at 11:52 AM participating in a movie activity in the dining/day room area. On 7/1/26 at 11:55 AM, the surveyor interviewed Resident #1. Resident #1 appeared to have baseline confusion. However, Resident #1 provided an account that was generally consistent with the complaint statement and CMA #1's written statement. Resident #1 stated CNA #1 was inappropriately touching them, was on top of them, and attempted to insert his penis. Resident #1 stated that when they yelled for CNA #1 to stop and get off of them, CNA #1 jumped off the bed, pulled their pants up, and rushed out of the room. Resident #1 stated they still saw CNA #1 on the unit. Resident #1 also stated they felt safe in the facility and that staff who provided their care treated them with dignity and respect.On 7/1/26 at 1:50 PM, during an interview with the Nursing Home Administrator (NHA) stated the facility relied on CNA #1's self-report, LPN #2's assessment note, staff statements, the police interaction, lack of physical findings, Resident #1's BIMS score, and Resident #1's inconsistent statements to conclude the allegation was unsubstantiated. The NHA stated CNA #1 reported the incident themself and stated Resident #1 was uncomfortable with them providing care. The NHA stated that staff statements included in the investigation file were handwritten and obtained independently.On 7/1/26 at 2:02 PM, the NHA also expressed concern that CMA #1 was a disgruntled employee with a history of progressive disciplinary issues. The NHA expressed concern that CMA #1 did not immediately provide the written statement in accordance with the facility's abuse reporting protocol, but instead left it under the NHA's door. The NHA also stated concern that Resident #1 may have been coached and that the language used by Resident #1 was uncharacteristic of Resident #1's baseline. The facility did not provide evidence that coaching was confirmed or that it investigated and resolved the concern before concluding the allegation was unsubstantiated.On 7/1/26 at 2:37 PM, upon further review of the facility's investigation file, there were materially different accounts of the allegation. These included:Resident #1 accused CNA #1 of inappropriate touching during care.Resident #1 reportedly stated CNA #1 tried to rape them.Resident #1 reportedly stated they woke up to someone playing with their private area.Resident #1 later reportedly denied to police making any complaints or allegations.Resident #1 reportedly denied that CNA #1 got in bed/on top of them or exposed/disrobed themself.Resident #1 told the surveyor on 7/1/26 during an interview at 11:53 AM that CNA #1 was on top of them, touched them inappropriately, attempted to insert their penis, pulled up their pants, and left when they yelled for them to stop.Although the facility identified reasons to question Resident #1's allegation, including cognitive impairment, inconsistent statements, lack of visible injury, and staff questionnaires, the facility did not provide evidence that it reconciled these materially conflicting accounts before concluding the allegation was unsubstantiated.On 7/1/26 at 3:10 PM, the review of the investigation revealed that the facility's conclusion appeared to rely on the least serious version of the allegation that Resident #1 was uncomfortable with the way CNA #1 provided care without documented analysis explaining why more serious accounts in the investigation file were discounted.The facility was not required to substantiate the allegation solely because Resident #1 made a report. However, the facility was required to provide evidence that the allegation had been thoroughly investigated. The investigation file contained materially conflicting evidence regarding the nature of the allegation. The facility did not provide documented evidence showing how it reconciled Resident #1's allegation, CNA #1's self-report, LPN #1's statement, LPN #2's assessment note, CNA #2's statement, provider documentation, police-related documentation, staff questionnaires, Resident #1's cognitive impairment, and Resident #1's later statement to the surveyor before concluding the allegation was unsubstantiated. Therefore, the facility failed to have evidence of a thorough investigation of the allegation.

Based on observation and interview, the facility failed to ensure resident menu tickets were followed. This was evident for 1 of 1 kitchen tray line observation during an annual survey.The findings include:1) On 05/20/2026 at 11:46 AM, an observation revealed the kitchen lunch tray line started.On 05/20/2026 at 11:48 PM, an observation of the dessert prepared for the lunch tray line was brownies.During the lunch tray line, the surveyor observed the following residents had meal tickets that indicated cake with icing, but received a brownie on their lunch tray:Resident #16, #2, #78, #34, #11, #44, #26, #95, #42, #66, #93, #109, #53, #103, #90, #19, #36, #108, #68, #52, #51, #58, #121, #30, #97, #54, #61, #35, #92, #79, #50, #67, #7, #86, #37, #110, #80, #41, #96, and #33.On 05/20/2026 at 1:16 PM, an interview with the Food Services Director (Staff #18) revealed that they did not have enough cake to provide the residents based on the planned meal menu tickets so they served brownies. The surveyor reviewed the concern.2) On 05/20/2026 at 11:52 AM, the surveyor observed Resident #72's menu ticket which indicated, diet cookies, as the dessert. The surveyor observed a brownie be placed on the tray and sent to the unit for the resident to eat.3) On 05/20/2026 at 11:53 AM, the surveyor observed Resident #46's menu ticket which indicated, fresh fruit. Further observation failed to reveal fresh fruit was placed on the tray.4) On 05/20/2026 at 11:53 AM, the surveyor observed Resident #74's menu ticket which indicated, fresh fruit. Further observation failed to reveal fresh fruit was placed on the tray.5) On 05/20/2026 at 11:54 AM, the surveyor observed Resident #109's menu ticket which indicated, do not send sugar. Further observation revealed two packets of sugar on the tray.6) On 05/20/2026 at 12:00 PM, the surveyor observed Resident #103's menu ticket which indicated, does not like chicken thighs,. Further observation revealed chicken thighs (the planned lunch entree) were plated and placed on the residents tray.7) On 05/20/2026 at 12:06 PM, the surveyor observed Resident #51's menu ticket which indicated, banana, orange, and chocolate milk or chocolate milk shake. Further observation failed to reveal chocolate milk (which was present on the beverage cart at time of lunch tray observation) nor a chocolate shake, banana, or orange was placed on the residents tray.8) On 05/20/2026 at 12:11 PM, the surveyor observed Resident #61's menu ticket which indicated, no gravy. Further observation of the resident's plate revealed gravy was poured on top of the chicken thigh.9) On 05/20/2026 at 12:17 PM, the surveyor observed Resident #54's menu ticket which indicated, alternative entree. Further observation of the resident's plate revealed chicken thighs (the planned entree).10) On 05/20/2026 at 12:23 PM, the surveyor observed Resident #110's menu ticket which indicated, fruit cup. Further observation of the resident's plate failed to reveal a fruit cup was placed on the resident's tray.11) On 05/20/2026 at 12:25 PM, the surveyor observed Resident #96's menu ticket which indicated, banana, and ice water. Further observation of the resident's tray failed to reveal a banana or ice water was placed on the tray.12) On 05/20/2026 at 12:29 PM, the Food Services Director (Staff #18) indicated that they had run out of au gratin potatoes (the planned meal starch). On 05/20/2026 at 12:29 PM, the surveyor observed Staff #18 plate Resident #96's food. Further observation revealed the resident received regular mashed potatoes.13) On 05/20/2026 at 12:29 PM, the Food Services Director (Staff #18) indicated that they had run out of chicken thighs (the planned main entree). At the same time, observation of Resident #5's meal ticket revealed, chicken thighs. The surveyor observed veal plated as the main entree and placed on the resident's tray.On 05/20/2026 at 1:16 PM, an interview with the Food Services Director (Staff #18) revealed that the cook reviews the resident menu meal tickets and were expected to prepare special requests. She further indicated the expectation was to prepare the tray/plate as indicated on the resident meal menu ticket. The surveyor reviewed the concerns noted above.

Based on interview and record review, it was determined that the facility failed to have accurate and complete medical records. This was found to be evident for 1) 5 (#1, #7, #10, #63, and #85) of 10 residents reviewed for advanced directives, 2) 2 (Resident #42 and #74) out of 2 residents reviewed for smoking, 3) 1 (#25) out of 1 resident review for accurate medical diagnosis in the medical record, and 4) 1 (#88) resident reviewed for accurately documented treatment during the annual survey.The findings include: 1) On 05/18/2026 at 11:21 AM, review of Resident #1's medical record revealed a document titled, MQS: Social Services Assessment - V11, dated 1/9/2026 revealed under section A1. the resident did not have an advanced directive and under section A3. advanced directives had not been reviewed. Further review of the document and medical record failed to reveal indication that the resident was offered information to formulate an advanced directive. On 05/18/2026 at 11:31 AM, review of Resident #10's medical record revealed a document titled, MQS: Social Services Assessment - V11, dated 1/9/2026 revealed under section A1. the resident did not have an advanced directive and under section A3. advanced directives had not been reviewed. Further review of the document and medical record failed to reveal indication that the resident was offered information to formulate an advanced directive. On 05/18/2026 at 11:35 AM, review of Resident #85's medical record revealed a document titled, MQS: Social Services Assessment - V11, dated 1/9/2026 revealed under section A1. the resident did not have an advanced directive and under section A3. advanced directives had been reviewed. Further review of the document and medical record failed to reveal indication that the resident was offered information to formulate an advanced directive. On 05/18/2026 at 11:38 AM, review of Resident #7's medical record revealed a document titled, MQS: Social Services Assessment - V11, dated 1/9/2026 revealed under section A1. the resident did not have an advanced directive and under section A3. advanced directives had been reviewed. Further review of the document and medical record failed to reveal indication that the resident was offered information to formulate an advanced directive. On 05/18/2026 at 11:50 AM, review of Resident #63's medical record revealed a document titled, MQS: Social Services Assessment - V11, dated 1/9/2026 revealed under section A1. the resident did not have an advanced directive and under section A3. advanced directives had been reviewed. Further review of the document and medical record failed to reveal indication that the resident was offered information to formulate an advanced directive. On 05/19/2026 at 7:19 AM, an interview with the Director of Social Services (Staff #5) revealed that when residents were admitted and/or readmitted , the facility would ask them if they had an advanced directive. She further indicated that if a resident did not have an advanced directive they would offer them information to formulate one. During the same interview, when asked if it was documented when they offered a resident information to formulate one she said it could be in a progress note. The surveyor asked for Staff #5 to bring any further documentation for the residents noted above that would indicate information was offered to formulate an advanced directive once they noted they did not have one. On 05/20/2026 at 9:40 AM, the surveyor reviewed the concern with the Acting Director of Nursing and she indicated that she understood. 2) On 05/19/26 at 12:13 PM, the surveyor performed a record review. Resident #42's and #74's care plans had conflicting interventions regarding smoking. One intervention stated Resident #42 and #74 are able to smoke independently, follow facility policy, and store all smoking materials in their room. The second intervention stated the facility would store Resident #42 and 74's nicotine products and supplies. On 05/19/26 at 12:25 PM, the surveyor reviewed Resident #74's Medication Administration Record (MAR). Resident #74 had two active orders that were conflicting but were being signed by day and night shifts: - Change Oxygen Tubing, Humidifier, and clean filter weekly on Tuesday and as needed for soiling or damage. Every night shift (every Tuesday). Date and label tubing and humidifier bottle. Start date: 07/22/2025 2300 - Change Oxygen Tubing, Humidifier, and clean filter weekly on Wednesday and as needed for soiling or damage. Every day shift (every Tuesday). Date and label tubing and humidifier Bottle. Start Date: 06/11/2024 0700 On 05/20/26 at 9:50 AM, LPN #11 was interviewed. The surveyor inquired about Resident #74's MAR and how staff determined which oxygen tubing order to follow. LPN #11 stated that the day shift order was correct but staff still signed both orders. LPN #11 could not provide an explanation for how he/she determined this. On 05/20/26 at 10:12 AM, the Director of Nursing acknowledged the concern. 3) A record review on 05/19/2026 at 12:19 PM, did not contain a medical diagnosis for Resident #25 related to Glaucoma. The resident's care plan referred to a glaucoma diagnosis and a medication order referred to a glaucoma diagnosis. On 05/19/2026 at 1:19 PM the Director of Nursing (DON) was asked to provide information of when Resident #25's glaucoma diagnosis was made and why it wasn't documented under medical diagnoses. On 05/20/2026 at 9:23 AM, the DON acknowledged the concern that Resident #25 had no active diagnosis for glaucoma on the record. The DON explained that although Resident #25 has physician notes on the chart that referred to the glaucoma diagnosis, it had not been updated in the record. 4) On 05/18/2026 at 7:28 AM, the surveyor observed Resident #88 lying in bed with lower extremities exposed. The surveyor observed the resident's skin appeared rough, cracked, and flaky. A review of the resident's medication administration record (MAR) on 05/18/2026 at 12:11 PM, revealed a physician's order instructing staff to apply Aquaphor ointment to both upper and lower extremities twice daily. Further review indicated that a staff member documented administration of the Aquaphor ointment during the 10:00AM administration time. A follow up observation of Resident #88 was conducted on 05/18/2026 at 2:18 PM, and again on 05/19/2026 at 7:14 AM. During each observation, the surveyor observed the resident in bed with the extremities exposed. The resident skin continued to appear rough, cracked, and flaky. A review of the residents' MAR on 05/19/2026 at 2:19 PM revealed the Licensed Practical Nurse (LPN) #27 documented applying Aquaphor ointment during the 10:00 AM administration time. However, the surveyor's observation of the resident at 2:35 PM revealed findings that contradict with the documented treatment. During an interview with LPN #27 on 05/19/2026 at 2:35PM, the LPN stated that the resident is ordered for Aquaphor ointment to be applied twice daily. The surveyor asked whether she applied the treatment to the resident extremities. The LPN stated that she had not because she was waiting for the nursing assistant to bathe the resident first. The surveyor then asked why she documented administration of the Aquaphor ointment although it was not done. The LPN could not provide an explanation. On 05/19/2026 at 2:50 PM, the surveyor reviewed the observation and medical record concerns with the Administrator.

Number of residents sampled: Number of residents cited: Based on record review and interviews, it was determined that the facility failed to ensure annual performance review and regular in-service education were conducted for certified nurse aides (CNA)1. This deficient practice was evident for 2 of 5 CNA1 employee files reviewed during the annual survey.The findings include:On 05/20/2026, a review of CNA1 #9 and CNA1 #12's employee files failed to show documented evidence of an annual performance review and related in service education based on the outcomes of the 2025 performance review.During an interview conducted with Human Recourse (HR) #16 on 05/20/2026 at 11:42 AM, she explained that CNA1's annual performance review are completed yearly based on the employee's hire month. She further stated that unit managers and/or Director of Nursing are notified of upcoming annuals performance reviews that are due. The surveyor informed HR #16 of the missing annual performance reviews and related in service education for CNA1 #9 and CNA1 #12. HR #16 stated she would continue to searching for the missing documents and follow up with the surveyor.On 05/21/2026 at 9:39 AM, HR#16 acknowledged the facility was unable to provide documented evidence of annual performance review and related in-service education for CNA1 #9 and CNA1 #12.

Based on record review and interviews, it was determined that the facility failed to formulate an advance directive for a resident. This was evident for 1 (Resident # 74) out of 6 residents reviewed for advance directives.The findings include:On 05/18/26 at 12:03 PM, the surveyor performed a record review for Resident #74 and could not locate an advance directive. The resident's Social Services Assessment stated that advance directives had not been reviewed and the resident did not have one.On 05/19/26 at 7:21 AM, Staff #5 was interviewed. Staff #5 stated that advance directives are documented on admission or created as needed. Staff #5 referred the surveyor to the Social Service Assessment and progress notes for advance directive documentation . On 05/19/26 at 9:08 AM, Staff #5 informed the surveyor that he/she could not find an advance directive for Resident #74. Staff #5 stated that he/she did not ask or offer Resident #74 an advance directive during Resident #74's last quarterly care plan meeting. On 05/19/26 at 9:15 AM, the Director of Nursing acknowledged the concern.

Based on medication administration observation, medical record review and staff interview, it was determined the facility failed to ensure a medication error rate of less than 5 percent during the medication pass observation. This finding was evident for 5 medication errors out of 26 opportunities which resulted in a medication error rate of 19%. Facility stock supply medications- Are mostly common over the counter medications in multidose containers to be shared amongst residents that are prescribed those medications. Examples would be vitamins and/or supplements. Aspirin Enteric-Coated (EC) or Delayed-Release (DR) is a form of aspirin with a special coating that prevents the tablet from dissolving in the stomach. Instead, it passes into the small intestine, where it is absorbed. This form is designed to prevent stomach irritation, ulcers, and gastrointestinal bleeding. The findings include: On 5/21/26 at 7:39 AM, the surveyor observed Certified Medicine Aide (CMA) #23 prepare medications for Resident #106. During the preparation CMA #23 took one table of the facility's stock vitamin C that was 250mg. The surveyor observed CMA #23 given Resident #106 this medication with the rest of the morning medications prepared. Next the surveyor reviewed Resident #106's Medication Administration Record (MAR) to reconcile the medications observed given to medication orders. On review the surveyor noted that the ordered dose for Ascorbic Acid (vitamin C) was 500mg not 250mg. On 5/21/26 at 8:14 AM, the surveyor observed CMA #23 prepare medications for Resident #104. CMA #23 took 1 tablet of 81mg chewable aspirin and 400mg tablet of guaifenesin from the stock medication. The surveyor observed CMA #23 given Resident #104 both of these medications with the rest of the morning medications prepared. Next the surveyor reviewed Resident #104's Medication Administration Record (MAR) to reconcile the medications observed given to medication orders. On review the surveyor noted that the ordered form of aspirin was Enteric-Coated, however, Resident #104 was given the chewable form. On further review Resident #104's order for guaifenesin was for extended release and 600 mg, however, Resident #104 was given 400 mg without the extended release form. On 5/21/26 at 1:14 PM, the surveyor conducted an interview with CMA #23. During the interview CMA #23 confirmed that the incorrect dose and/or form was given from the floor stock medication. On 5/21/26 at 8:27 AM, the surveyor observed CMA #24 prepare medications for Resident #40. Right before administering the medications to Resident #40 CMA #24 asked Resident #40 if he/she was having any pain. Resident #40 stated he/she had a headache and agreed to receive Tylenol in addition to scheduled morning medications. Next the surveyor observed CMA #24 return to the medication cart and add two tablets of 325mg Acetaminophen (Tylenol) to the medications prepared for Resident #40 and return to administer them. Next the surveyor reviewed Resident #40's Medication Administration Record (MAR) to reconcile the medications observed given to medication orders. On review the surveyor noted that the ordered form of aspirin was Delayed Release however, Resident #40 was given the chewable form. On further review it was noted that the Tylenol given was not signed off as given on the MAR. On 5/21/26 at 1:15 PM, the surveyor conducted an interview with CMA #24. During the interview CMA #24 confirmed that the incorrect form of aspirin was given from the floor stock medication and that she had forgotten to sign out the Tylenol that was administered. She stated she would sign them out now. On 5/21/26 at 1:24 PM, the surveyor updated the acting Director of Nursing (DON) of the concerns during the medication administration.

Based on observation and interview it was determined that the facility failed to ensure food was stored in accordance with professional standards of practice for food service safety. This was evident during the initial tour of the kitchen upon entry into the facility. The findings include:On 05/18/2026 at 7:08 AM, an initial observation of the kitchen refrigerator revealed a ziplock bag of approximately 5 pizza slices, 2 peanut butter and jelly sandwiches which indicated use by 5/16/26, and an opened container of tomato juice, all of which were opened, without a label or date.On 05/18/2026 at 7:10 AM, an initial observation of the kitchen freezer revealed whole grain breaded alaska [NAME] square (fish patty), tilapia filet which looked to to freezer burnt, golden breaded veal (a type of meat) and beef patties, and biscuits which were all opened exposed to the freezer air, without a label or date.On 05/18/2026 at 7:13 AM, an initial observation of the kitchen dry storage room revealed 3, 4lb containers of peanut butter, ground nutmeg seasoning, pickling spice seasoning, 2 seasoning containers of parsley flakes, thyme, garlic salt, kansas city steak seasoning, fish seasoning, italian seasoning, black pepper, ground ginger, barbeque seasoning, and cajun seasoning, which were all opened, without a labeled date.On 05/18/2026 at 7:24 AM, an interview with Dietary Aide (Staff #27) revealed the expectation of staff when opening a new container of an item for the first time was to label it with the date and make sure it was sealed closed. She further indicated when they prepare items such as sandwiches, or put away extra food, it would be the same expectation.On 05/18/2026 at 9:53 AM, an interview with Food Services Director (Staff #18) revealed the manager was in charge to ensure items were labeled and dated, as well as tossing items past their best by date. The surveyor reviewed the concern.

Based on record review and staff interviews, it was determined that the facility staff failed to ensure and maintain hospice documentation was available in the resident's medical records. This deficient practice was evident for 1 (Resident #3) of 2 residents reviewed for hospice services during the annual survey.The findings include:During an interview with Resident #3 on 05/18/2026 at 9:25 AM, when asked whether hospice services were being received, the resident replied, no. However, review of the resident medical records identified the resident as receiving hospice services.On 05/21/2026 at 7:13 AM, a review of the resident's electronic medical records (EHR) failed to show evidence of a hospice plan of care, hospice medications orders, hospice physician orders, a hospice election form, and physician certification of terminal illness. The surveyor informed the Administrator of the missing documents. The Administrator stated she would follow up with the medical records department and provide an update to the surveyor. On 05/21/26 at 11:40 AM, the Director of Nursing (DON)#2 informed the surveyor that she had to contact the hospice service provider to obtain hospice records for Resident #3. The surveyor inquired whether the facility had maintained the hospice documentation prior to the surveyor's request. The acting DON#2 reiterated that she had to reach out to the resident's hospice service provider to obtain the hospice document.On 05/21/2026 at 1:21 PM, the DON #2 provided the surveyor with the resident's hospice comprehensive care plan report. The DON #2 stated that the hospice nurse brought the document to the facility that day. The DON #2 also provided copies of the hospice consent and electron form, hospice physician medication orders, hospice physician orders, and physician certification of terminal illness.Review of the documents indicated they were transmitted to the facility on [DATE] at 12:47 PM. The DON #2 acknowledged that the required hospice documentation was not available in the resident's medical records prior to the surveyor's request.

Based on observation and interviews, it was determined that the facility failed to follow standard precautions and enhanced barrier precautions. This was evident in 1) 1 (CMA #24) out of 1 staff members observed during the infection control task, 2) 1 (#6) out of 1 resident, and 3) 1 out of 2 observations of shared equipment disinfection during medication administration observed during the annual survey.The findings include: 1) On 5/21/26 at 8:39 AM, the surveyor observed Certified Medication Aide (CMA) #24 prepare medications for Resident #108. The surveyor observed CMA #24 bring Resident #108 his/her medication, however Resident #108 stated he/she was not feeling well and did not want to take the medications at that time CMA #24 asked if she could take Resident #108's blood pressure. Resident #108 agreed the blood [NAME] was taken using a portable blood pressure machine. On 5/21/26 at 8:55 AM, the surveyor observed Certified Medication Aide (CMA) #24 prepare medications for Resident #84. The surveyor observed CMA #24 bring Resident #84 his/her medication and prior to administration asked if she could take Resident #84's blood pressure. Resident #84 agreed and the surveyor observed CMA #24 utilize the same portable blood pressure machine and cuff used from Resident #108. No disinfecting of the machine or cuff was noted between uses. On 5/21/26 at 9:10 AM, the surveyor conducted an interview CMA #24. During the interview CMA #24 confirmed that it is the expectation to disinfect equipment between resident use and that she had just forgotten. 2) Enhanced Barrier Precaution (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. On 05/18/2026 on 7:56 AM, the surveyor observed EBP sign posted on the door of Resident #6's room. The surveyor entered the room and observed Certified Nursing Assistant1 (CNA1) #6 providing care without wearing a personal protective gown. The surveyor also observed a clear plastic bag containing soiled linen located on the left side of the resident's bed. The surveyor exited the room. When CNA1 #6 exited the room carrying the clear plastic bag of soiled linen, the surveyor inquired about the EBP sign posted on the resident's door and asked whether the resident was currently on EBP precaution. CNA1 #6 confirmed the resident was on EBP and stated the resident had been placed on EBP for a small wound that had since healed. She further stated that the resident doesn't have any viruses or anything like that. A review of Resident #6's electronic health record (EHR) on 05/19/2026 at 10:12 AM, revealed the resident was admitted to the facility on [DATE]. Further review revealed a physician's order dated 01/15/2026 instructing staff to assess and document the resident's hemodialysis port site three times daily. A physician's order dated 03/20/2026 directed staff to provide treatment for the resident's left hip wound daily. An additional physician's order dated 03/29/2026 instructed staff to administer enteral feedings through a feeding tube four times daily. Further review revealed a physician's order dated 04/14/2026, instructed staff to implement EBP for Resident #6 for the presence of a hemodialysis port and left hip wound. On 05/19/2026 at 2:50 PM, the surveyor reviewed the observation and EHR concerns with the Administrator. 3) Standard precautions refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. Standard precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, regardless of whether they contain visible blood, non-intact skin, and mucous membranes may contain transmissible infectious agents. Furthermore, equipment or items in the resident's environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents. Standard precautions include hand hygiene, proper selection and use of personal protective equipment, safe injection practices, respiratory hygiene/cough etiquette, environmental cleaning and disinfection, and reprocessing of reusable resident medical equipment. On 05/20/2026 at 9:30 AM, the surveyor observed a towel on the floor in the [NAME] hallway. LPN #11 stated the towel was on the floor due to a spill from a food cart. Shortly after, Staff #20 was observed assessing the spill, touching the dirty towel with his/her bare hands while he/she held onto a pair of gloves. Staff #20 proceeded to the clean utility closet where he/she touched the door handle, retrieved the clean supplies, put his/her gloves on, and cleaned the spill. On 05/20/26 at 10:00 AM, the surveyor interviewed the Infection Preventionist (IP). The IP stated that the expectation is for all staff to perform proper hand hygiene. On 05/20/26 at 10:05 AM, the Administrator and the IP acknowledged the concern.

Based on record review and interview, it was determined that the facility failed to flush a gastrostomy tube in accordance with professional standards of practice. This was found to be evident for 1 (#12) out of 1 resident reviewed for gastrostomy tube flushing. The findings include:During a record review on 5/20/2025 at 8:30 AM, the surveyor noted an order written on 2/5/2025 at 18:00 that read, Flush G-Tube Q 6 Hours four times a day for hydration There was no mention of what or how much to flush the gastrostomy tube with.During an interview on 5/20/2025 at 9:30 AM, the Director of Nursing acknowledged the concern and stated, The order is incomplete. It should have specified the amount in the order.

Based on record review and observation, it was determined that the facility failed to ensure staff maintain professional standards of practice when an active order was signed off. This was evident for 1 (Resident #9) of 3 residents reviewed for pressure ulcers.The findings include:On 05/18/2026 at 12:01 PM, review of Resident #9's medical record revealed a skin and wound progress note dated 5/15/26 at 9:11 AM, that indicated the resident has a sacral wound and a wound on their buttock, both of which were noted to be stage 3 pressure ulcers.At the same time, further review of Resident #9's medical record revealed an active order to turn and reposition the resident every two hours, and as needed. On 05/19/2026 at 8:17 AM, an observation of Resident #9 revealed the resident was in bed lying on their back. On 05/19/2026 at 10:26 AM, an observation of Resident #9 revealed the resident was in bed lying on their back. On 05/19/2026 at 12:36 PM, an observation of Resident #9 revealed the resident was in bed lying on their back. On 05/20/2026 at 7:03 AM, an observation of Resident #9 revealed the resident was in bed lying on their back. On 05/20/2026 at 9:02 AM, an observation of Resident #9 revealed the resident was in bed lying on their back. On 05/20/2026 at 11:02 AM, an observation of Resident #9 revealed the resident was in bed lying on their back.On 5/22/2026 at 9:35 AM, review of the Treatment Administration record revealed the order was signed off on 5/18/26 and 5/19/26 day shift which indicated the turn and reposition was done throughout the shift.On 5/22/2026 at 9:38 AM, an interview with Licensed Practical Nurse (Staff #26) revealed that the nurse and geriatric nursing assistant assigned to a resident were expected to turn and reposition the resident as ordered throughout the shift. Further interview revealed she would also ask the geriatric nursing assistant assigned to the resident if they had turned and repositioned the resident throughout the shift and that was when they signed off on the order as completed.On 5/22/2026 at 9:40 AM, the surveyor reviewed the concern with the Acting Director of Nursing and she indicated that she understood.

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to hold care plan meetings after the completion of the Minimum Data Set assessment. This was evident for 2 (Resident #4 and #88) out of 2 residents reviewed for care planning during the survey.Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team.The findings include:1) On 5/18/26 at 2:13 PM, the surveyor reviewed Resident #4's progress notes and noted on 3/20/26 Social Worker (SW) #5 wrote that a care plan meeting was scheduled for 3/24/26 at 11 AM. The surveyor on unable to find any other documentation to indicate a care plan took place after this date. Next the surveyor reviewed Resident #4's Minimum Data Set (MDS) assessments and noted Resident #4 had a MDS quarterly MDS assessment on 4/27/26. On 5/20/26 at 1:28 PM, the surveyor intervened SW #5. During the interview SW #5 stated that the care plan meeting scheduled on 3/24/26 was moved to 4/1/26 per family request. She further stated no additional care plan meetings were held and that care plan meeting are suppose to occur after MDS assessments. 2) During an interview with the Social Worker (SW) #5 on 05/18/2026 at 1:37PM, the SW #5 explained the facility's care plan meeting process, including who attends and the frequency of care plan meetings. She stated that meetings are conducted quarterly, annually, and at the request of the resident and/or resident representative. The surveyor inquired about Resident #88's care plan meetings and informed SW #5 that seven months lapsed between meeting. The SW #5 acknowledged that the resident's care plan was conducted outside the required quarterly timeframe and stated the previous social worker failed to conduct meeting regularly. On 05/19/2026 at 8:50 AM, the SW #5 provided the surveyor with a social work progress note dated 04/05/2026 , indicating that an Interdisciplinary Team care plan meeting was scheduled for 04/21/2026.

Based on record review and interviews, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with the comprehensive person-centered care plan and professional standards of practice. This was evident for 3 (Resident #11, #16 and #74) out 76 residents reviewed during the annual survey. The findings include: 1) On 5/18/26 at 1:43 PM, the surveyor reviewed Resident #11's medical record. The review revealed an order for Resident #11's right elbow to have wound treatment with betadine solution and to be covered with foam dressing daily starting on 4/17/25. Next the surveyor reviewed the April and May Treatment Administration Records (TAR)s. The surveyor noted several days were left blank and are listed as follows: 4/17/26, 4/23/26, 4/27/26 4/29/26 4/30/26, 5/6/26, 5/8/26, 5/12/26, and 5/13/26. 2) On 5/18/26 at 7:49 AM, the surveyor conducted an interview with Resident #16. During the interview Resident #16 alleged that his/her dressing changes were not always completed. On 5/18/26 at 1:15 PM, the surveyor reviewed Resident #16's medical record the review revealed Resident #11 had an order written 5/7/26 for wound care to the right lateral (outer) foot to be completed every day. Additionally on 5/7/26 an order was placed for wound care to the sacrum to be done every day shift. Next the surveyor reviewed the May Treatment Administration Records (TAR). The surveyor noted 3 days were left blank for both the foot dressing and the sacral dressing; 5/8/26, 5/12/26 and 5/13/26. On 5/21/26 at 9:20 AM, the surveyor conducted an interview with the acting Director of Nursing (DON). During the interview the surveyor reviewed the concern about multiple days of treatments not being documented as completed. The acting DON stated she would look into the concern. At the time of exit no additional documentation was provided as to rationale for the treatments not documented as completed. 3) On 05/20/26 at 9:40 AM, the surveyor reviewed Resident #74's electronic health record. Resident #74 has diagnoses of Chronic Obstructive Pulmonary Disease (COPD), asthma, acute and chronic respiratory failure, and dependence on supplemental oxygen. Resident #74's Medication Administration Record (MAR) included assessments and treatments he/she was supposed to receive as ordered. The lack of ongoing clinical assessments and identification of changes in condition makes it challenging to attain or maintain, or improve the resident's highest practicable physical, mental and psychosocial well-being. The following assessments and treatments were not signed off as completed by staff for various dates in May 2026: - Advair Diskus, Aerosol Powder Breath Activated, 100-50 MCG/DOSE (Fluticasone-Salmeterol) 1 inhalation inhale orally every 12 hours for Asthma. - Is the resident short of breath when lying flat? Check every shift. - Apply oxygen at 5L/ Minute via nasal cannula every shift (related to COPD). - Apply foam ear protectors to oxygen nasal cannula tubing. Check for placement every shift (related to COPD). - Appraise and observe patient every shift for changes in physical/mental condition every shift. On 05/20/26 at 9:55 AM, LPN #11 claimed staff completed the required treatments and assessments, but could not explain the numerous blank entries in the MAR. On 05/20/26 at 10:12 AM, the Director or Nursing acknowledged the concern.

Based on record review and interview, it was determined that the facility failed to develop and implement patient-centered comprehensive care plans to meet the needs of residents. This was found to be evident for 1 (#13) out of 8 residents reviewed for comprehensive care plans. The findings include: During a record review on 05/19/2026 at 10:00 AM, the surveyor noted a diagnosis for dementia by did not find a care plan for dementia care for Resident #13. The surveyor requested the Director of Nurses (DON) provide a care plan for dementia. On 05/19/2026 at 11:11 AM, the DON stated the facility did not have a care plan for dementia care and the expectation is that there should be one.

Based on record reviews and interviews, it was determined that facility staff failed to ensure the residents' diagnosis and clinical needs were accurately captured at the time of admission and during assessment modifications. This deficient practice was evident for 2 (Resident #6, Resident #67) of 2 residents reviewed for accuracy of assessment during the annual survey. The findings include: Minimum Data Set (MDS) is a standardized, comprehensive clinical assessment tool used in Medicare and Medicaid-certified nursing homes. It evaluates a resident's physical, psychological, and clinical functional status to determine individual care plans, quality measure scores, and Medicare reimbursement. 1.) A review of Resident #6's electronic health record (EHR) on 05/19/2026 at 10:32 AM, revealed the resident was transferred to the hospital in December 2025 and readmitted to the facility January 2026. Review of the resident's admission MDS assessment indicated the resident received hemodialysis. However, the assessment failed to indicate access site through which the resident received hemodialysis. On 5/20/2026 at 10:19 AM, during an interview with the MDS Coordinator #14, the surveyor inquired about resident admission assessment process and what types of hemodialysis access sites are captured during the admission assessment. The MDS Coordinator stated she does not code dialysis catheter or ports. She further stated that she only will code catheters or ports for residents receiving chemotherapy, antibiotics, or intravenous fluids. 2.) A review of Resident #67 medical records on 05/22/2026 at 9:16 AM, revealed the resident transitioned to hospice services on 11/24/2025. Further review of the MDS assessment completed on 12/05/2025 indicated that hospice care was noted, however, the MDS Coordinator failed to update and accurately capture the resident's specific hospice diagnoses. On 05/22/2026, the surveyor presented the MDS concerns to MDS Coordinator #14 and Administrator. Both acknowledged the concern related to the MDS assessments.

Based on observation, medical record review, review of facility's policy and interview, it was determined that the facility staff failed to ensure residents received respiratory care consistent with professional standards of practice by providing oxygen at flow rate inconsistent with prescribed orders. This was evident for 2 (Resident #46 and #10) of 3 residents reviewed for respiratory care.Nasal cannula- a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels.The findings include:1) On 5/18/26 at 8:23 AM, the surveyor observed Resident #46's oxygen concentrator (the machine that delivers supplemental oxygen) dialed at 4.5 liters of oxygen per minute (l/min). No humidification bottle was noted. The nasal cannula tubing was directly attached to the concentrator. No label was noted on the tubing. Shortly after this observation, Licensed Practical Nurse (LPN) #4 walked into the room. The surveyor asked LPN #4 what Resident #46's ordered rate of oxygen was and LPN #4 stated he would look up the order to confirm. On return to the room LPN #4 stated it was supposed to be at 3 l/min and adjusted the oxygen level to the appropriate rate after assessing the resident. He asked the Resident if he/she had adjusted the rate. Resident # 46 responded that he/she had not adjusted the rate and the concentrator was out of reach to do so. Next the surveyor reviewed Resident #46's oxygen orders. An order was placed on 8/8/25 for 3 l/min of oxygen via nasal cannula. Additionally, an order was also placed on that same day for the oxygen tubing and humidifier to be changed weekly as well as cleaning the filter. The order stated to date/label oxygen tubing and humidification bottle on the date changed. On review of the Treatment Administration Record (TAR) it was noted staff were signing off both tubing and humidification bottle changed and labeled weekly on Mondays. 2) On 5/20/26 at 11:27 AM, the surveyor reviewed Resident #46's care plan. The review revealed Resident #46 had a care plan for oxygen use with an interventions that stated to add humidity as needed. On 5/21/26 at 7:35 AM, the surveyor observed Resident #46's oxygen at 3 l/min, however there was no humidification bottle. Resident #46 stated that he/she had a preference to not have humidification. Next the surveyor reviewed the policy titled Oxygen Administration. The equipment noted as necessary was a humidification bottle. Further in the policy it states to be sure there is water in the humidification jar and that the water level is high enough that the water bubbles as oxygen flows through. On 5/21/26 at 11:45 AM, the surveyor conducted an interview with the acting Director of Nursing (DON). During the interview the surveyor reviewed the observations of the incorrect rate being administered as well as the concern that staff were documenting that they were changing the humidification bottle when Resident #46 did not utilize it. The acting DON stated that the care plan and order should have been updated to what the Resident was currently receiving. On 05/18/2026 at 7:46 AM, an initial observation of Resident #10's oxygen revealed it was at 3.5 liters per minute (the amount of oxygen the resident received in a minute). On 05/19/2026 at 8:10 AM, review of Resident #10's medical record revealed an active order for oxygen at 2 liters per minute. On 05/19/2026 at 8:19 AM, an observation of Resident #10's oxygen revealed it was at 3.5 liters per minute. On 05/19/2026 at 8:21 AM, the surveyor requested dual observation of the oxygen level with Licensed Practical Nurse (Staff #15). Staff #15 indicated the oxygen level was at 3.5 liters per minute. On 05/19/2026 at 8:34 AM, during an interview with Staff #15, the surveyor requested for her to look at the active order for Resident #10 to confirm the amount of oxygen they were ordered for. She confirmed the resident was ordered for 2 liters per minute. On 05/20/2026 at 9:41 AM, the surveyor reviewed the concern with the Director of Nursing and she indicated that she understood.

Based on record review and staff interviews, it was determined that facility staff failed to ensure a resident's representative was provided with a written notice of transfer. This deficient practice was evident for 1 (Resident #6) of 3 residents reviewed for transfer notice requirements during the annual survey. The findings include:A review of Resident #6's electronic health record (EHR) on 05/19/2026 at 10:32 AM, revealed the resident was transferred to the hospital in December 2025. Further review of the EHR indicated the resident lacked decision-making capacity. The medical records failed to show evidence that the resident's representative was provided with a written notice of transfer.During an interview with the Social Worker (SW)#5 on 05/19/2026, the SW explained the facility's written transfer notice process. She stated, if the resident's representative is not present at the time of transfer, staff will contact the resident's representative by phone and mail a transfer notice to the representative. The surveyor requested documentation indicating that Resident #6's representative was provided with a written notice of transfer.On 05/19/2026 at 11:19 AM, the Director of Nursing (DON) #2 informed the surveyor that the facility had no evidence or documentation indicating that written transfer notice was provided to the resident's representative.

Based on observation and interview, it was determined that the facility failed to protect the dignity of residents. This was found to be evident for 2 (5/18/2026 and 5/20/2026) out of 4 observations of the assignment board on the first floor. The findings include:On 05/18/2026 at 9:18 AM, the surveyor observed the staffing board at the first floor nurses station that read, Feeders listed as Rooms 103, 115, 116, 119, 108 in the upper left hand corner.An observation of the staffing board on 5/20/2026 at 7:20 AM, revealed the word Feeders under Employee Name and the following room numbers 103,108, 115, 119 next to the assigned nurses name. During an interview on 05/20/2026 at 8:58 AM, Unit Manager LPN #15 stated, We should never use the word feeder on the assignment board. Staff are supposed to use the word assist.The Director of Nursing acknowledged the concern and stated staff should never refer to residents as Feeders on 05/20/2026 9:37 AM.

Based on record reviews and interviews it was determined that the facility failed to identify and notify the Resident's health care Responsible Party (RP)/Guardian of a change to the Resident's plan of care and involved them in the consent process. This was found evident in 4 (Resident #11, #4, #88 and #6) out of 76 residents reviewed for resident rights and representative involvement during the annual survey.The findings include:1) On 5/18/26 at 8:01 AM, the surveyor observed Resident #11 in his/her room in bed with a handrail on the right side of the bed and a half rail on the other side. Next the surveyor reviewed Resident #11's medical record. The review revealed a note written by Social Worker (SW) #5 on 4/16/26 that stated Resident #11 was intermittently confused and that the writer could not contact the listed RP due to the number being invalid. On further review it was revealed that on 4/14/26 nursing staff assessed the necessity of bed rails for Resident #11 and documented that bed rails were currently on bed and recommended that therapy evaluation for further need. The assessment indicated that bilateral grab bars were indicated and also initiated a care plan with an intervention that stated to educate resident and resident RP on the risks and benefits of bed rails, but not limited to entrapment. Below the intervention it was marked that education had been provided to the Resident (Resident Representative) for all care plan interventions related to safety. No further documentation as to who was educated was noted. On 5/21/26 at 7:20 AM, the surveyor reviewed the facility's policy titled, Bed Safety and Bed Rails. The policy stated that before using bed rails for any reason, the staff shall inform the resident or Representative about the benefits and potential hazards associated with bed rails and obtain informed consent. On 5/21/26 at 1:51 PM, the surveyor interviewed the acting Director of Nursing (DON) during the interview the acting DON confirmed that Resident #11's RP did not give consent to the use of bed rails prior to the application. 2) On 5/18/26 05/18/2026 9:16 AM, the surveyor called the number that was listed as spouse and Resident's Responsible Party (PR) in Resident #4's medical record. The son of the spouse answered and stated that the name listed was his name but his parent was the RP of Resident #4 and gave the surveyor their number. Additionally listed were names of 1 son and 1 daughter. Next the surveyor reviewed Resident #4's progress notes. A note dated 3/30/26 from Social Worker (SW) #5 stated that the writer contacted the spouse to schedule a care plan meeting and left a message and also the son to inform him of the care plan meeting scheduled. Next the surveyor reviewed the change in condition notes. Below are the dates and notifications. 3/20/26- Son's name (surveyor called on day one) 3/24/26-Spouse -no name given progress notes stating spouse spoke to Nurse Practitioner. 3/31/26- Son's name (surveyor called on day one) left voicemail return call pending Next the surveyor reviewed the care plan invitation sent for a care plan meeting. The invitation stated Dear (son's name surveyor contacted on day one)-Responsible Party. On 5/20/26 at 2:44 AM, the surveyor conducted an interview with Social Worker (SW) #5. During the interview the surveyor reviewed the concern that RP listed in Resident #4's medical record was not Resident 4's actual RP. SW #5 confirmed that the name and number provided in the medical record was not the RP and that the spouse was. She further stated that the spouse had been in the facility several weeks before leaving and was involved in Resident #4's plan of care. She confirmed that there was no reference to his/her name or number in the medical record if the facility needed to get a hold of him/her. On 5/21/26 at 9:34 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the surveyor reviewed the concern that on two of the change of conditions the staff contacted the wrong RP and until the surveyor inquired the wrong PR was listed in Resident #4's medical record. 3) On 05/18/26 at 9:51 AM, a review of Resident #88's medical record revealed an admission date of 06/23/2025, with multiple diagnoses, including cognitive communication deficit and intellectual disabilities. Further review of the electronic health records (EHR) failed to show evidence of an appointed guardian for Resident #88. On 05/19/26 at 08:50 AM, during an interview, the Social Worker (SW) #5, stated that Resident #88 was admitted to the facility without decision making capacity. She reported she believed the previous social worker had contacted the resident's family regarding guardianship. The SW #5 further stated she was unsure whether the facility had obtained the guardianship documentation. The surveyor requested that the SW #5 review the resident's records to determine whether documentation was present and provide any available guardianship documents. A review of Resident #88's EHR on 05/18/2026 revealed a SW progress note dated 11/25/2025, indicating staff informed the resident's family member that the facility required an appointed healthcare guardian to make healthcare decisions for Resident #88. Further review of the EHR failed to show any evidence of additional attempts by the facility to obtain guardianship documents. On 05/19/2026 at 8:50 AM, the SW #5 provided the surveyor with a social work progress note dated 04/05/2026, indicating that an interdisciplinary care plan meeting was scheduled for 04/21/2026, with the resident's guardian. The SW#5 further stated that this progress note was the only documentation she could locate and acknowledged that the facility did not have guardianship documents for Resident #88. 4) A review of Resident #6's EHR on 05/18/2026, revealed the resident was admitted to the facility in February 2024. Days after admission, the physician certified that the resident lacked decision making capacity. Further review of records failed to show evidence of an appointed healthcare guardian. On 05/19/2026 at 9:13 AM, during an interview with the SW#5, the surveyor inquired about Resident #6's healthcare guardian. The SW stated a family member is the resident's decision maker and confirmed the resident lacked decision making capacity. The SW acknowledged that the medical records failed to show evidence of an appointed healthcare guardian and acknowledged there was no documentation indicating staff helped with obtaining a healthcare guardian.

Based on observation and interview, it was determined the facility failed to provide palatable food at an appetizing temperature. This was evident for 1 out of 1 observation of a kitchen tray line and test tray.The findings include:On 05/20/2026 at 11:46 AM, the surveyor observed the kitchen tray line for lunch begin.On 05/20/2026 at 12:33 PM, the test tray plate was prepared.On 05/20/2026 at 12:36 PM, the test tray plate arrived at the unit.On 05/20/2026 at 12:46 PM, the last resident lunch tray was delivered.On 05/20/2026 at 12:47 PM, the surveyor requested Assistant Dietary Director (Staff #19) who was present to take the temperature of the food on the test tray plate. The temperatures were as follows: Tilapia (a type of fish) was 108.5 degrees Fahrenheit, mashed potatoes and gravy were 116.2 degrees Fahrenheit, and sauteed mixed squash was 130.7 degrees Fahrenheit. On 05/20/2026 at 12:50 PM, two surveyors tested the entree and sides, which failed to be a palatable taste and at an appetizing temperature.On 05/20/2026 at 1:28 PM, the surveyor reviewed the concern with the Food Services Director (Staff #18).

Based on medical record review and staff interview it was determined the facility failed to maintain the safety of a resident, identified as a fall risk, who was also at risk for increased bleeding due to anticoagulant therapy, and who suffered a fall and expired due to a subdural hematoma. This was evident for 1 of 19 residents (#10) reviewed during this complaint survey. The findings included: Resident #10 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. heart is pumping out blood) of 10% - 15%, Venous Thrombosis (blood clot in lower extremities), and Pulmonary Emboli (blood clot in the lungs). A Fall Risk assessment dated [DATE] indicated the resident was a moderate risk for falls and noted the resident was unable to independently come to a standing position, was confined to a chair and oriented. Another Fall Risk Assessment was completed on [DATE] after the resident was found sitting on the floor. Documentation noted it was a fall without injury and neuro checks were initiated. This assessment noted changes, including the resident was no longer confined to a chair and the gait analysis showed the resident exhibited jerking or instability when making turns, had a decrease in muscle coordination, and strays off the path of walking. In addition, the assessment noted a decline in cognition (memory) and was occasionally incontinent of bladder, a decline from the Fall Risk Assessment conducted on [DATE]. The [DATE] assessment did not note the administration of Antihypertensive medication (Lisinopril and Metoprolol), Narcotics (Methadone), or Diuretics (Lasix) which may contribute to dizziness, drowsiness, and/or confusion which increases the risk for falls. This assessment also did not note the history of falls. Nursing Progress notes reported the following: -on [DATE] at 3:01 AM it was noted that staff assisted the resident extensively with nursing care; -on [DATE] at 11:16 AM it was reported the resident ambulated to the bathroom as needed and his/her gait remained unsteady. It was unclear from the documentation if the staff were assisting the resident to the bathroom or if he/she was going independently. The Admission MDS assessment dated [DATE] revealed the following: the facility staff coded the resident in Section G Functional Status G0110 B Transfers as a ,[DATE] (extensive assistance of 2 staff), in section I Toileting as a ,[DATE] (limited assistance of 1 staff), and in Section G0300 E Surface to Surface Transfer as not steady, only able to stabilize with human assistance. A Nursing Progress note dated [DATE] at 8:54 AM reported the resident required assistance with Activities of Daily Living and mobility. The MDS Assessment noted the use of a wheelchair and a walker. The Minimum Data Set (MDS) is a comprehensive multi-disciplinary assessment tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. Health Status Notes dated [DATE] at 11:16 AM and [DATE] at 5:13 PM, reported the resident ambulated to the bathroom as needed, his/her gait remained unsteady and safety precautions were maintained. The only precaution noted was that the room was free of clutter. The level of assistance and supervision provided was not noted. On [DATE] at 11:43 PM a Health Status Note reported the resident was observed sitting on the floor leaning on the night stand. The fall was unwitnessed as reported by the GNA who observed the resident on the floor when passing by the resident's room. The resident's roommate reported the resident was coming from the bathroom, unassisted, when he/she fell . No injuries were reported and according to the documentation the resident denied hitting his/her head, but facility staff initiated neuro-checks. Neuro checks are used to assess an individual's neurological functions and level of consciousness, after an injury, in order determine whether or not individual is functioning properly and reacting appropriately to the tests being performed. Another Fall Risk Assessment was completed after this fall which categorized the resident as a moderate risk for falls. The assessment failed to include the history of falls (2), Diuretics, Antihypertensives, Narcotics and the use of an assistive device as risk factors. The resident required supervision with the use of a rolling walker. A Health Status Report dated [DATE] at 8:25 AM reported a new onset of jerking seizure like movement and noted the resident was lethargic and unresponsive. A telephone order dated [DATE] at 8:37 AM directed staff to transfer the resident to the hospital via 911 for evaluation of seizure like movement and unresponsiveness. A Care Plan Note dated [DATE] at 5:11 PM reported the resident remained unsteady and ambulated to the bathroom without difficulty. It was reported that safety precautions were maintained, however specific interventions were again, not noted. A Death Certificate completed on [DATE] reported the resident expired on [DATE] at 5:50 PM at the hospital. The cause of death was Subdural Hemorrhage (collection of blood between the covering of the brain (dura) and the surface of the brain) caused by a fall. The findings were discussed with the Director of Nursing on [DATE] at 2:13 PM. Cross reference F309

Based on administrative and medical record review and staff and resident interviews, it was determined the facility failed to 1) provide adequate supervision to ensure the safety of cognitively impaired residents (Residents #1, #3 and #4) who were assessed as elopement risks, 2) provide evidence that clear guidelines for the management and supervision of residents determined to be at risk for elopement were implemented 3) thoroughly investigate all instances of elopement, and 4) ensure that necessary equipment to assist staff in identifying a point of egress for a resident intending to exit the facility was properly maintained. This resulted in Resident #1 eloping from the facility on 8/15/16 for an undetermined period of time, Resident #3 exiting the facility without authorization on 6/13/16 and Resident #4 exiting the facility without authorization on 8/24/16. This was evident for 3 of 9 residents reviewed during this investigation.Based on the findings, related to complaint MD 134, on 8/25/16 at 2:25 PM, an Immediate Jeopardy was identified. The facility submitted a plan of removal on 8/25/16 at 6:15 PM, and the plan was accepted and the immediacy removed on 8/25/16 at 7:30 PM. After removal of the immediacy, the deficient practice continued with the potential for more than minimal harm with a scope/severity of D level for the remaining residents. The findings include:Elopement is when a resident does not have pre-authorization to leave the facility, but does so intentionally and the resident's location is unknown.The Wander Guard management system is utilized to protect residents, at risk for wandering and elopement. If a resident wearing a Wander Guard bracelet signaling device passes through a monitored area, an alarm sounds to alert staff of a possible departure. The Wander Guard alarm will continue to sound until staff respond to the door to reset the alarm. The Minimum Data Set (MDS) is a comprehensive multi-disciplinary assessment tool completed by facility staff that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. 1) Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The resident had a surrogate decision maker and the medical record contained 2 certificates of incapacity.Review of a quarterly MDS Assessment completed on 5/24/16 revealed facility staff coded the resident in Section C Cognitive Patterns Section C1000 Cognitive Skills for Daily Decision Making as 2 (moderately impaired- decisions poor; cues/supervision required); and Section C1300 indicated the resident displayed disorganized thinking, continuously. An Elopement Risk Assessment completed on 4/5/16 reported the resident made multiple attempts to elope and an assessment completed on 5/31/16 noted the resident was an elopement risk. Review of the residents care plan failed to reveal a description of the exit seeking behavior, frequency with which the resident engaged in exit seeking behavior and adjustments to the level of supervision when necessary to maintain the resident's safety. One of the interventions noted in the care plan was to, Identify the pattern of wandering to determine if it is purposeful, aimless, or escapist and is it an indication of the need for more exercise. There was no indication that staff monitored the resident to determine if there was a pattern to his/her wandering. Another intervention directed staff to offer pleasant diversions such as food, activities, and television. It was not clear from reviewing the care plan what activities were found to successfully distract the resident. Medical record review failed to reveal an evaluation of the interventions to determine if they were effective in managing the resident's risk for elopement.Review of a complaint, #MD 134 on 8/23/16, revealed Resident #1 eloped from the facility on 8/15/16 despite having a wander guard bracelet in place and the presence of a receptionist to monitor the front entrance of the facility. Review of the facility's investigative findings failed to reveal how the resident was able to exit the facility unobserved for an undetermined amount of time.Staff #12 reported in a written statement, dated 8/16/16, that while conducting rounds between 4:00 AM and 5:00 AM on 8/15/16, he/she observed the resident getting on the elevator to go to the first floor. Staff #12 reported he/she went to the first floor and brought the resident back to the second floor. Staff #12 also reported that as she/he passed the nurses station, he/she told the nurse that the resident was trying to get out of the building again. Medical record review and staff interview failed to reveal a formalized and documented plan to increase supervision or implement other interventions, after this incident of exit seeking.In a written statement, Staff #13, the assigned nursing assistant, stated that she/he made rounds on his/her assigned residents on the morning of 8/15/16 and that Resident #1 was not present. Staff #13 reported placing the resident's breakfast tray on his/her table at 7:30 AM, but later noticed the resident did not return to the unit to eat breakfast. Staff #13 noted he/she reported this to Staff #5 who responded that the resident was probably on the first floor in the smoking area.Review of a written statement by Staff #5 revealed he/she searched for the resident to administer medication and went to the smoking area where the resident was, reportedly, located. Staff #5 discovered the resident was not in the smoke area and a facility wide check was initiated. The resident was finally located outside. The exact location was not noted in the investigative documentation. A progress note written by Staff #5 on 8/15/16 at 11:50 AM, reported the resident returned to the facility after elopement in stable condition. It was not noted where the resident was found or by whom. The Elopement Risk Assessment completed on 8/15/16 reported the resident stated she/he wanted to go home. In interview with the surveyor on 8/23/16 at 9:15 AM Staff #5, the resident's assigned nurse on 8/15/16, stated the resident engaged in exit seeking behavior and states she/he did not want to be here. He/she stated facility staff do not know how the resident exited the building. The surveyor inquired how residents are monitored, and Staff #5 stated staff check on residents every 2 hours.During an interview with the surveyor on 8/23/16 at 9:05 AM the resident stated he/she went outside to take a walk and no one knew he/she was going out. The resident stated in a subsequent interview on 8/24/16 at 2:30 PM, he/she just wanted some fresh air.In interview with Staff #5 on 8/23/16 at 11:50 AM he/she was asked if the resident was placed on close observation upon return to the unit. He/she replied that staff did check in with the resident periodically, but did not state specific time intervals or produce written documentation indicating an increased level of supervision or monitoring.During an interview with the surveyor on 8/23/16 at 2:00 PM the Director of Nursing (DON) stated facility staff believe the resident exited through the delivery entrance doors, however no one observed the resident exiting the building. The DON was unclear if the Wander Guard alarm sounded when the resident exited the building.Staff interviews, medical and administrative record reviews revealed staff failed to provide adequate monitoring and supervision for a resident at risk for elopement and failed to increase the level of supervision for Resident #1 after he/she was noted to engage in exit seeking behavior on the morning of 8/15/16. Furthermore, when the resident successfully eloped on 8/15/16, the resident's level of supervision was again not increased despite the facility's failure to determine how the resident exited the facility, unobserved. 2) Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Further investigation of complaint (#MD 134) on 8/23/16 revealed facility staff failed to maintain adequate supervision for Resident #3 who was determined to be at risk for elopement. Review of the MDS assessments dated 4/12/16 and 7/5/16 assessed the resident with a BIMS (brief interview for mental status) score of 6 out of 15. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. An Elopement Risk Assessment completed on 1/19/16 indicated the resident was an elopement risk and the reason given was, she/he wants to go out to Social Services. Elopement Risk Assessments completed on 7/7/16 and 8/3/16 indicated the resident had the potential to elope due to behaviors. The behaviors were not described. Medical record review revealed 3 instances of Elopement for Resident #3. A nursing document dated 11/16/15 reported the resident eloped outside via the main door of the facility and had a high tendency to elope with every opportunity. A nursing progress note dated 1/4/16 reported a delivery person came into the facility to deliver take out. The writer noted the resident followed the delivery person out of the facility and was resistive to returning to facility. Medical record review on 8/24/16 revealed Resident #3 exited the facility without authorization on 6/13/16. A nurse's note dated 6/13/16 reported the resident was found outside the facility by two visitors and it took 25 minutes to persuade the resident to return to his/her room. Medical record review revealed a care plan, created on 12/23/14 that did not indicate the plan was reviewed and/or revised after the elopements on 11/16/15, 1/4/16, or 6/13/16. A Quarterly Care Plan Review note dated 8/17/16 reported the plan of care would be continued for 90 days. A list of residents determined to be at risk for elopement indicated the resident had a Wander Guard applied on 8/3/16. Review of the resident's elopement risk assessments indicated he/she had the potential to elope due to behaviors that were not described. The frequency and triggers for elopement behaviors were not clearly identified with evidence of ongoing assessment and adjustments to the resident's care plan to maintain safety. In interview with the surveyor on 8/24/16 at 4:26 PM the Director of Nursing confirmed the facility did not investigate or report this incident. 3) Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. An Elopement Risk Assessment completed on admission, in August 2016, determined the resident was not an elopement risk. The resident was reassessed on 8/19/16 and determined to be an elopement risk. The assessment noted a Wander Guard was applied and the responsible party was notified of this action. Documentation did not indicate why the resident was reassessed and determined to be at risk on 8/19/16. Nursing documentation did not contain a description of the behaviors that indicated the Resident was at risk for elopement. On 8/24/16 Resident #4 exited the facility as other resident's family members were entering and exiting the facility, despite wearing a Wander Guard bracelet. The resident was escorted into the facility from the parking lot. During an interview with the surveyor on, 8/25/16 at 1:05 PM, Staff #9 reported he/she was at the desk when Resident #4 exited the building. Staff #9 stated in interview that he/she would initiate the elopement code if he/she noted a resident trying to leave the building or if a resident who is deemed an elopement risk passes through the first set of double doors to the reception area. According to the facility report Staff #9, noticed a familiar face that might be a resident in the crowd, as others exited the facility. Family members called from the parking lot to let Staff #9 know the resident was outside. Staff #9 confirmed during the interview that he/she had an elopement binder which contained pictures of those residents assessed as elopement risks.Despite the application of a Wander guard bracelet, the presence of a receptionist in the lobby area and the availability of the elopement binder containing pictures of those resident at risk for elopement, Resident #4 exited the facility and progressed to the parking lot when family members notified the receptionist that the resident was out of the facility. 4) In addition to the break in supervision and monitoring it was noted throughout the survey that staff's response to the Wander Guard alarm was not consistent and the annunciator panels that assist staff in identifying which exit door a resident may have opened, was not functioning properly. On 8/24/16 the surveyor accompanied Staff #3 on a tour to test the Wander Guard alarms at each exit. The alarms at the main entrance and the second floor exit, near the rehabilitation center, were delayed. The alarms did not activate until Staff #3 passed through the doorways, rather than on approach, as expected. Staff #3 stated the sensitivity of the alarms needed to be adjusted. In addition, when the alarm was triggered on the first floor, it cannot be heard by staff on the second floor and vice versa. This was confirmed in interview with Staff #5 on 8/25/16 at approximately 2:00 PM.The location of the alarm was supposed to register on the annunciator panels located on the first and second floor nurses' stations. The surveyor accompanied Staff #3 to the first floor nurses station to test the system on 8/25/16 at 1:50 PM. Staff #3 stated when the alarm was activated a button would light on the panel next to the exit door that was opened. The surveyor observed that the buttons corresponding to the time clock, doors to the main lobby and main lobby exits remained lit and did not blink when the alarms triggered. On 8/25/16 at 1:50 PM the wander guard alarm sounded several times and staff from the first floor unit did not take any action. The volume of the alarm was hard to distinguish from the resident's bedroom call bells. The second floor annunciator panel only identified two exits, the Belmont and North stairs. Staff #5 reported the annunciator panel only lit when residents activated their bedroom call lights. This malfunctioning system increased the amount of time it takes staff to identify the area a resident may have exited.On 8/23/16 at approximately 10:45 AM an interview with the Director of Nursing (DON) revealed there were 8 residents identified as being at risk for elopement and wearing the Wander Guard bracelet. Three of eight residents were able to exit the facility despite wearing the bracelets. Because of these systems failures, an immediate jeopardy situation was identified by the Office of Health Care Quality on 8/25/16 at 2:25 PM. The facility submitted a plan of removal on 8/25/16 at 6:15 PM. The plan to remove the immediacy included but was not limited to the following: placing a monitor with walkie-talkie and elopement book was stationed in the foyer area, all residents with Wander Guard devices were checked for function and placement, and education of facility staff on the facility policy on elopement. The plan was accepted and the immediacy removed on 8/25/16 at 7:30 PM

Based on medical record review and interview of facility staff, it was determined that the facility failed to provide appropriate care and services to prevent pressure sores from developing and/or worsening. This was evident in 1 of 27 sampled resident selected for review. The findings include: Resident #43 is a [AGE] year old female with a [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. . . multiple open area open blister to left and right heels (open blood blisters), right inner buttocks, and sacrum open Stage 2. Dressings applied to all areas." There is no further assessment of the resident's pressure sores. A thorough assessment would include documentation of the size and appearance of the wounds. Pressure sore means ulceration and/or necrosis of tissues overlying a bony prominence that has been subjected to pressure, friction or shear. The staging system presented below is one method of describing the extent of tissue damage in the pressure sore. Pressure sores cannot be adequately staged when covered with eschar or necrotic tissue. Necrotic tissue is the result of death of areas of tissue. Stage I - A persistent area of skin redness (without a break in the skin) that is nonblanchable. Stage II - A partial thickness loss of skin layers either dermis or epidermis that presents as an abrasion, blister, or shallow crater. Stage III - A full thickness of skin is lost, exposing the subcutaneous tissues - presents as a deep crater with or without undermining adjacent tissue. Stage IV - A full thickness of skin and subcutaneous tissue is lost, exposing muscle and/or bone. The nurse documented on the admission care plan dated 1/27/10, that the resident had actual skin breakdown to the left and right heels and inner buttocks. The nurse failed to initiate interventions to promote healing and prevent worsening of the resident's pressure ulcers. Review of the physician's orders [REDACTED]. There were no orders for treatment to the resident's sacrum. On 1/28/10, a physician's orders [REDACTED]. On 1/29/10, a physician's orders [REDACTED]. New orders were written to cleanse the sacrum with normal saline solution and apply [MEDICATION NAME] every Monday and Thursday and apply skin prep to the left and right heels two times per day. Review of the Pressure Ulcer/Skin Committee documentation dated 2/1/10, revealed that the resident's left heel had eschar (necrotic tissue) which measured 8.7 x 5, the right heel had eschar which measured 10 x 4.7 and the buttocks was now a Stage 3 and measured 11 x 4.5 x 0.1 (depth). It was further documented that the resident's wounds had worsened. It was also documented that the buttocks were being treated with Santyl, a [MEDICATION NAME] agent. However, the resident continued to receive [MEDICATION NAME] to her sacral area. Additionally, on 2/1/10, a new stage 2 pressure ulcer was noted on the resident's right foot near the ankle and measured 4 x 5.3 x <0.1. Review of the physician's orders [REDACTED]. The physician also ordered a Clinitron bed or equivalent. A Clinitron bed is a specialized bed used to promote healing of stage 3 or 4 pressure ulcers. Review of the treatment administration record and interview of the Director of Nursing revealed the orders were not transcribed to the treatment administration record (TAR) on 2/3/10, nor was the resident provided with a Clinitron bed or equivalent. Review of the Pressure Ulcer/Skin Committee documentation dated 2/9/10 revealed that the resident's left heel had eschar which measured 8.3 x 5, the right heel had eschar which measured 10 x 4.7, the buttocks measured 12 x 4.8 . 0.1 and the right foot near the ankle had eschar which measured 3.7 x 5 x <0.1. It was further documented that the right foot near the ankle, left heel and buttock wounds had worsened. Review of the TAR revealed the resident continued to receive [MEDICATION NAME] to the buttock wound even though the Pressure Ulcer/Skin Committee documented that the resident was receiving Santyl to the buttock wound. On 2/10/10, a second physician's orders [REDACTED]. Between 1/27/10 through 2/10/10, there is no documented evidence that the resident was being turned and repositioned every 2 hours, nor was there documented evidence that the resident's heels were floated at all times. Review of the Pressure Ulcer/Skin Committee documentation dated 2/17/10, revealed that the resident's right foot near ankle wound had worsened and the buttock/sacral wound now had slough and eschar in the center measuring 4.2 x 6.3 x 0.3 and was worsening. On 2/17/10, a physician's orders [REDACTED]. On 2/24/10, a physician's orders [REDACTED]. An order was given for an air mattress top prevent skin breakdown. Review of the treatment administration record and interview of the Director of Nursing revealed that the resident never did have a Clinitron bed and did not get a specialty air mattress until 2/24/10. In summary, the facility staff failed to implement appropriate interventions in a timely manner when the resident was readmitted to the facility on [DATE], with multiple pressure sores. The resident continued to receive [MEDICATION NAME] the the buttock/sacral area 1/27/10 through 2/17/10, despite worsening of the pressure ulcer; there is no documented evidence that the resident was turned and repositioned every 2 hours 1/27/10 through 2/10/10; there is no documented evidence that the resident's heels were floated at all times; and, the facility staff failed to provide the resident with a Clinitron bed or equivalent that was ordered by the physician on 2/3/10 until 2/24/10, 21 days after it was ordered. On 3/9/10, the resident was hospitalized due to a non-healing, foul smelling sacral pressure ulcer as well as both of her heels.

Based on observation, medical record review and interview of facility staff, it was determined the facility staff failed to provide adequate preventive care to prevent a decline in the resident's range of motion and decline in ADL (activities of daily living) function. This was evident in 2 of 27 sampled residents selected for review. The findings include: Resident #43 is a [AGE] year old with a [DIAGNOSES REDACTED]. Observation of the resident 5/24/10 through 6/8/10, revealed the resident is bedbound. The resident is unable to turn and position herself. The resident's bilateral lower extremities were observed to be contracted at the hips and knees. The resident was not observed with any orthopedic devices for positioning. Review of the MDS (Minimum Data Set), an assessment tool revealed that as of 12/12/09, the resident had no limitation or loss of range of motion and no change in ADL (activities of daily living) function. Review of the Assessment of Contracture Risk Assessment revealed that the resident had a score of 7. The assessment tool indicates that a score of 7 or above should be considered at risk and that the Facility Contracture Protocol should be implemented. Discussion with the Assistant Director of Nursing on 6/2/10 revealed the facility has no such protocol. review of the resident's medical record revealed [REDACTED]. The resident continued to receive occupational therapy through 1/19/10. On 1/20/10, the resident was hospitalized and treated for [REDACTED]. The resident was readmitted to the facility on [DATE]. Review of the physician's orders [REDACTED]. Review of the nursing admission assessment and care plan revealed that the resident had contractures. However, there is no assessment of the location or severity of the resident's contractures. A contracture is an abnormal shortening of muscle tissue, rendering the muscle highly resistant to passive stretching. Contracture management includes physical and occupational therapy and may include the use of orthopedic braces. Exercise helps prevent and reduce contractures. Range of motion (ROM) exercises are very important in prevention of contractures and should be performed on a daily basis. Further review of the resident's medical record and interview of the second floor unit manager and the Director of Rehabilitation Services revealed that the resident did not receive physical therapy, occupational therapy or restorative nursing care. Review of the MDS dated [DATE], revealed that the resident had range of motion limitations to her bilateral feet and legs and she had experienced a decline in ADL function. Review of the Assessment of Contracture Risk revealed that the resident had a score of 12. A care plan was initiated on 2/8/10 due to potential alteration in function. Interventions included range of motion exercises daily. Despite a decline in the resident's ROM and decline in ADL function, and despite an increase in the Assessment of Contracture Risk, there is no documented evidence that the resident received treatment to manage/prevent worsening of her contractures and ADL function. On 3/9/10, the resident was hospitalized due to infected pressure sores. Review of the hospital history and physical revealed that the resident had flexion contractures in her knees and hips. The resident was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed that the resident's ADL function had deteriorated. Review of the Assessment of Contracture Risk revealed that the resident had a score of 15. Despite documented evidence of contractures and a decline in ADL function, there is no documented evidence that the resident received treatment to manage/prevent worsening of her contractures and ADL function. The resident was hosptalized on [DATE], and treated for [REDACTED]. When the resident was readmitted to the facility she had a physician's orders [REDACTED]. However, interview of the second floor unit manager and the Director of Rehabilitation Services revealed the resident did not receive occupational therapy and there is no documented evidence that the resident received any treatment to manage/prevent worsening of her contractures and ADL function. The resident was hosptalized on [DATE], and treated for [REDACTED]. A physician's orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. There is no documentation of the physical therapist's evaluation. Under "Results of Interdisciplinary Rehab Screen, the physical therapist documented "Refer to restorative service for ROM all 4 limbs especially knees. Will order splints for knees." As of 6/8/10, there is no documented evidence that the resident's bilateral lower extremity contractures were ever thoroughly assessed and there were never any interventions implemented including rehabilitation therapy or restorative nursing care to prevent worsening of contractures or decline in ADL function since the resident was first noted with contractures on 1/17/10. Interview of the 3 - 11 second floor nurse caring for the resident on 6/8/10 revealed that each time the resident returned from the hospital, her contractures had worsened and ADL function had further declined. The nurse further indicated that was why she initiated the order for a physical and occupational therapy evaluation on 5/21/10. Interview of the resident's attending physician on 6/9/10, confirmed that the resident's function had declined. Further interview of the resident's attending physician revealed that the physician was not aware that the resident had not received physical or occupational therapy since 1/27/10. The physician further indicated that the resident should have received rehabilitation therapy after her hospitalization s. After surveyor intervention, a physician's orders [REDACTED]. 2. Resident #92 was admitted with [DIAGNOSES REDACTED]. According to the medical record, the resident is alert and dependent on staff for all care. A contracture is defined as a tightening of the muscle, tendon, ligament or skin that prevents normal movement. During a medication pass observation 5/24/10, the resident was observed in bed with contractures of both hands and no splinting devices were noted in place. The resident continued to be observed without splinting devices until the afternoon of 6/2/10. Review of the medical record on 6/1/10, revealed the resident was admitted in 2/2008 with contractures of both hands. Review of the admission orders [REDACTED]. A contracture risk assessment was noted in the chart which revealed the resident was at high risk for contractures. The resident's score was 12 and 13. The assessment tool indicates that a score of 7 or above should be considered at risk and that the Facility Contracture Protocol should be implemented. Discussion with the Assistant Director of Nursing on 6/2/10 revealed the facility has no such protocol. Continued review of the medical record revealed the hand splint order was in place until March 8, 2010, when the physician ordered a palm protector to the right hand. Further review of the medical record and interview with the director of Rehab services on 6/2/10 at 10:45 a.m., did not reveal a reason why the left hand was no longer receiving a splinting device. During an interview with the unit nurse manager during the afternoon of 6/2/10, the unit manager pointed out the palm protector was in place. She could provide no reason as to why the device was not in place prior to this or why the left hand no longer was receiving a splinting device. Further review of the medical record revealed an order dated 5/14/09 for "PT/OT screen, ev (evaluation) and treat as indicated hand contractures". Interview with the director of Rehab services on 6/4/10, revealed that he was not aware that another OT/PT screen was ordered and that his records do not indicate that the screen was done. The palm protector was observed on the resident each day for the duration of the survey, however, it was noted to be incorrectly applied. This was brought to the attention of the unit nurse manager who accompanied the surveyor to the bedside. She could not open the hand to correctly apply. She then obtained an order for [REDACTED].