Every finding on record at Wickliffe Country Place

Based on record review and interview, the facility failed to ensure timely notification was made to the family when a resident left the faciity on an unauthorized leave. This affected one (Resident #1) of three residents reviewed for supervision. The facility census was 135. Findings include:Review of Resident #1's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, unspecified convulsions and aphasia following a cerebral infarction.Review of Resident #1's medical record revealed the resident's daughter was power-of-attorney (POA) for care.Review of Resident #1's behavior care plan revealed an intervention dated 01/30/26 to monitor and document observed behavior and attempted interventions.Review of Resident #1's physician orders revealed an order dated 04/06/26 for a wander check placement and function every shift.Review of Resident #1's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment.Review of the Neglect Self-Reported Incident (SRI) Form Tracking #277940 dated 08/06/26 at 11:00 P.M. revealed the resident was a [AGE] year-old female with a history of chronic left cerebral vascular accident (CVA) resulting in expressive aphasia and cognitive communication deficits, seizure disorder and other chronic medical conditions. On 08/06/26 at approximately 11:00 P.M., staff determined the resident was unaccounted for. A Code [NAME] was initiated immediately, an extensive search of the facility and grounds was conducted, and law enforcement was promptly notified. Law enforcement successfully located the resident using cellular phone location data at the private residence of Resident #8's daughter. Resident #8 was alert and oriented, was independently mobile and owned and operated his own vehicle. Based on the investigation, Resident #1 had been planning her return to Georgia for approximately one week, enlisted the assistance of other residents, accepted money to facilitate her travel, arranged transportation through Resident #8 and travel to a predetermined destination where she intended to remain until Resident #8 could retrieve her. These actions reflect purposeful planning and intentional decision-making rather than wandering, becoming lost, or exiting the facility because of confusion or impaired cognition. The SRI was unsubstantiated.Review of Resident #1's police Incident/Offense Report form with a date of 08/05/26 at 11:41 P.M. (time received); 08/05/26 at 11:55 P.M. (time dispatched); 08/05/26 at 11:55 P.M. (time arrived); and 08/06/26 at 12:19 A.M. (time cleared). The report revealed Resident #8 continued to deny knowing anything about Resident #1's whereabouts. After speaking with Resident #8 for a little bit, the resident advised the officer he would make a call and figure out where Resident #1 was. Resident #8 advised the police officer that Resident #1 was at his daughter's apartment. The police arrived at the apartment and located Resident #1. Resident #1 was removed from the facility by Resident #8 was observed in the living room of the apartment with an unknown female. The resident was escorted out of the apartment and then detained in handcuffs due to her being uncooperative. The resident was brought to the emergency department (ED) to be evaluated, and the resident did not want to tell officers who took her to the apartment. The resident stated she did not like the nursing home facility. On 08/06/26 around 12:35 P.M., the Director of Nursing (DON) called for an update on Resident #1. The DON was advised that Resident #1 was located and taken to the hospital for an evaluation.Review of Resident #1's progress note dated 08/06/26 at 2:11 A.M. revealed the staff were unable to reach the daughter and a message was left on the voicemail.Review of Resident #1's progress note dated 08/06/26 at 3:58 A.M. revealed the daughter was provided an update of the resident left out of the building on an unauthorized leave and the daughter had voiced that the resident had left the previous facility and stated she had no concerns.Review of Resident #1's progress note dated 08/06/26 at 1:26 P.M. revealed a late entry. The resident returned to the facility and a skin assessment was completed. The skin remains intact with no injury. The resident denied discomfort or pain. The wander guard had been placed on the resident's right leg. Vitals were stable and the resident was resting in her room.Interview on 08/10/26 at 6:01 A.M. with Resident #1 who was not able to be interviewed. She kept repeating that she wanted to go home.Interview on 08/10/26 at 6:26 A.M. with the DON revealed Resident #8 had cut the wander guard off Resident #1 and took the resident out of the building to the daughter of Resident #8. The DON confirmed that Resident #1's daughter was notified on 08/06/26 at 2:11 A.M. of the resident's unauthorized leave of absence from the building. The DON confirmed the daughter returned the phone call on 08/06/26 at 3:58 A.M. The notification to Resident #1's daughter of the resident's unauthorized leave of absence occurred approximately three hours after the resident was confirmed to have left the facility which was not timely.Telephone interview on 08/10/26 at 8:38 A.M. with Resident #1's daughter revealed she was contacted in the middle of the night to let her know that the resident had eloped and she called the facility back at 4:00 A.M. She stated she wanted to know how Resident #1 got a pair of scissors to cut off the wander guard and what the staff were doing to prevent the resident from leaving the building. She was upset that the resident had eloped, and she stated she had told the facility that the resident had poor judgment, and she wanted to keep the resident safe.Review of the Change in a Resident's Condition policy dated 01/06/25 revealed the facility shall notify the resident, the attending physician, physician assistant or nurse practitioner, and representative (sponsor) of changes in the resident's medical/mental condition.This deficiency represents non-compliance investigated under Control Number 3136120 and Complaint Number 3125028.

Based on record review and interview, the facility failed to provide adequate supervision to prevent a resident from leaving the facility on an unauthorized leave of absence with another resident. This affected one (Resident #1) of three residents reviewed for supervision. The facility census was 135.Findings include:Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, unspecified convulsions and aphasia following a cerebral infarction.Review of the census line revealed Resident #1 was admitted to the secured unit on 01/14/26 and placed on the regular hall on 01/16/26. Resident #1's daughter was power of attorney (POA) for care.Review of Resident #1's behavior care plan revealed an intervention dated 01/30/26 to monitor and document observed behavior and attempted interventions.Review of Resident #1's physician orders revealed an order dated 04/06/26 for a WanderGuard (an electronic safety monitoring technology) check placement and function every shift.Review of Resident #1's WanderGuard care plan revealed interventions dated 06/23/26 to document wandering behavior and attempt diversional interventions.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 exhibited severe cognitive impairment.Review of Resident #1's quarterly Wandering/Elopement Worksheet dated 06/26/26 revealed the resident had a WanderGuard in place but was not high risk for elopement (scored two and a score greater than five was high risk).Review of Resident #1's medication administration record (MAR) and treatment administration record (TAR) dated from 07/01/26 to 08/10/26 revealed the WanderGuard check function every shift was three shifts (days, evenings and nights). On 07/01/26 on evening it was documented as n, on 07/04/26 on evening it was documented as n, on 07/08/26 on evening it was documented as n, on 07/12/26 on evening it was documented as n, and on 08/03/26 on nights it was documented as n.Review of the Neglect Self-Reported Incident (SRI) Tracking Number 277940 dated 08/06/26 at 11:00 P.M. revealed on 08/06/26 at approximately 11:00 P.M., staff determined Resident #1 was unaccounted for. A Code [NAME] (missing resident) was initiated immediately, an extensive search of the facility and grounds was conducted, and law enforcement was promptly notified. Law enforcement successfully located the resident using cellphone location data at the private residence of Resident #8's daughters house. Resident #8 was alert and oriented, was independently mobile and owned and operated his own vehicle. Based on the investigation, Resident #1 had been planning her return to Georgia for approximately one week, enlisted the assistance of other residents, accepted money to facilitate her travel, arranged transportation through Resident #8 and traveled to a predetermined destination where she intended to remain until Resident #8 could retrieve her. These actions reflect purposeful planning and intentional decision-making rather than wandering, becoming lost, or exiting the facility because of confusion or impaired cognition.Review of the police Incident/Offense Report form with a date of 08/05/26 at 11:41 P.M. (time the call was received); 08/05/26 at 11:55 P.M. (time the police dispatched); 08/05/26 at 11:55 P.M. (time the police arrived at the facility); and 08/06/26 at 12:19 A.M. (time the incident cleared). The report revealed Resident #8 continued to deny knowing anything about Resident #1's whereabouts. After speaking with Resident #8 for a little bit, the resident advised the officer he would make a call and figure out where Resident #1 was. Resident #8 advised the police officer that Resident #1 was at his daughter's apartment. The police arrived at the apartment and located Resident #1. Resident #1 was removed from the facility by Resident #8 was observed in the living room of the apartment with an unknown female. The resident was escorted out of the apartment and then detained in handcuffs due to her being uncooperative. The resident was brought to the emergency department (ED) to be evaluated, and the resident did not want to tell officers who took her to the apartment. The resident stated she did not like the nursing home facility. On 08/06/26 around 12:35 P.M., the Director of Nursing (DON) called for an update on Resident #1. The DON was advised that Resident #1 was located and taken to the hospital for an evaluation.Review of Resident #1's progress note dated 08/06/26 at 2:11 A.M. revealed the staff were unable to reach the daughter and a message was left on the voicemail.Review of Resident #1's progress note dated 08/06/26 at 3:58 A.M. revealed the daughter was provided an update of the resident left out of the building on an unauthorized leave and the daughter had voiced that the resident had left the previous facility and stated she had no concerns.Review of Resident #1's ED progress note dated 08/06/26 revealed the [AGE] year-old female with disorientation and confusion, unable to provide a coherent history. History was limited by her mental status, obtained directly from her. The resident ran away from the memory care facility and was pink slipped by the police department (PD) for asking to buy cocaine. The resident escaped from her facility and was found 25 minutes away. When the police found the resident, she asked the police officer for cocaine. Upon arrival at the ED, the resident was tearful. The Registered Nurse (RN) attempted to do an assessment on the resident but when the RN started asking questions, the resident put her hand in RN's face and refused to answer any questions. The resident's mental status appeared to be at baseline per the chart review. The hospital contacted her facility who accepted her back. The resident discharged with transportation.Review of Resident #1's after visit summary dated 08/06/26 revealed the reason for the visit was runaway. The diagnoses included dementia with other behavioral disturbances. Nothing else was listed on the form.Review of Resident #1's progress note dated 08/06/26 at 1:26 P.M. revealed a late entry. The resident returned to the facility and a skin assessment was completed. The skin remains intact with no injury. The resident denied discomfort or pain. The WanderGuard had been placed on the resident's right leg. Vital signs were stable and the resident was resting in her room.2. Review of Resident #8's medical record revealed the resident was admitted on [DATE] and discharged on 08/06/26 with diagnoses including emphysema, chronic diastolic congestive heart failure and muscle weakness.Review of Resident #8's medical record revealed the resident received a 30-day notice on 07/20/26 (rescinded on 07/27/26) because the resident was too independent to be in the facility and the resident agreed to work with the discharge planning.Review of Resident #8's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #8's progress note dated 08/06/26 at 10:00 A.M. revealed the Social Service Designee (SSD) #808 met with the patient in regard to discharge. The resident wished to discharge from the current facility to another skilled facility. The resident was discharged .Interview on 08/10/26 at 5:25 A.M. with Licensed Practical Nurse (LPN) #801 revealed she had observed Resident #8 and Resident #1 in the dining room around 9:00 P.M. LPN #801 confirmed on 08/05/26 around 11:00 P.M. she went into Resident #1's room and the resident was not there. She stated she went back to the dining room and did not locate the resident and called a code brown and called the DON, the police and began searching for the resident. She confirmed she worked from 7:00 P.M. to 7:00 A.M. and the resident did not return on her shift.Interview on 08/10/25 at 5:52 A.M. with SSD #808 revealed she was aware Resident #1 got out of the building and the police were called. She confirmed staff looked for the resident and did not believe the resident sustained any injuries.Interview on 08/10/26 at 6:01 A.M. with Resident #1 who was not able to be interviewed. She kept repeating that she wanted to go home.Interview on 08/10/26 at 6:26 A.M. with the DON revealed Resident #8 had cut the WanderGuard off Resident #1 and took the resident out of the building to the daughter of Resident #8. The DON confirmed Resident #8 had a car in the parking lot and was able to drive the resident to the daughter's house (of Resident #8). The DON denied any injuries when the resident was returned on 08/06/26 around 1:00 P.M. The DON was unclear of where the scissors came from that removed Resident #1's wander guard.Telephone interview on 08/10/26 at 8:38 A.M. with Resident #1's daughter revealed she was contacted in the middle of the night to let her know that the resident had eloped and she called the facility back at 4:00 A.M. She stated she wanted to know how Resident #1 got a pair of scissors to cut off the WanderGuard and what the staff were doing to prevent the resident from leaving the building. She was upset that the resident had eloped, and she stated she had told the facility that the resident had poor judgment, and she wanted to keep the resident safe.Telephone interview on 08/10/26 at 9:01 A.M. with Resident #8 who denied he had taken Resident #1 out of the building. He stated he saw the resident around 9:00 P.M. in the dining room and then he went and had a shower and went to bed.Interview on 08/10/26 at 9:07 A.M. with the acting Administrator confirmed the video surveillance on the front doors did not work.Telephone interview on 08/10/26 at 9:15 A.M. with Sergeant #814 revealed the police department were notified on 08/05/26 around 11:00 P.M. that Resident #1 was missing from the facility. Sergeant #814 confirmed their police investigation confirmed Resident #8 had removed Resident #1 from the facility and drove the resident (using his own car which was parked at the facility) to his daughter's house. Sergeant #814 denied their department was pressing charges against Resident #8. Sergeant #814 confirmed Resident #1 was pink slipped to the hospital and did not know if the resident had a rape kit completed.Interview on 08/10/26 at 9:42 A.M. with Nurse Practitioner (NP) #815 revealed Resident #1 did not have an admitting diagnosis of behaviors or dementia to keep her on the secured behavioral unit and that was why the resident was moved to the general floor with a WanderGuard. NP #815 denied she had ever observed Resident #1 exit seeking. She stated Resident #8 was admitted for therapy services.An additional telephone interview on 08/10/26 at 10:50 A.M. with Resident #8 who stated he would not provide the daughter's phone number. He stated he had two daughters Linette and Faith but refused to provide last names or phone numbers to the daughters. He stated he was just finding a safe haven for Resident #1 because she was miserable at the facility.A telephone interview on 08/10/26 at 1:09 P.M. with Attending Physician #816 and the physician stated Resident #1 was impaired, but he did not feel it was severe cognitive impairment. Attending Physician #816 also revealed he had not noted anything in the behavior of Resident #8 towards Resident #1.Review of the policy titled Code [NAME] Elopement and Wandering Prevention, dated 07/15/25 revealed it was the policy of the facility that all residents deemed to be at risk for elopement from the facility were placed on the facility elopement prevention program.This deficiency represents non-compliance investigated under Complaint Number 3136120.

Based on medical record review, facility self-reported incident (SRI) review, facility policy review, facility investigation review, hospital record review, interdisciplinary team (IDT) summary review, and staff interview, the facility failed to protect the resident's right to be free from physical abuse by another resident. This affected one resident (Resident #162) of four residents reviewed for abuse. The facility census was 128.Actual harm occurred on 10/26/25 when Resident #162 sustained nasal bleeding and fractures of the maxilla and nasal bone after being struck by Resident #161. Resident #162 experienced significant injury, and the facility did not implement timely interventions or notify a physician despite documented increases in Resident #161's behaviors on 10/18/25, 10/21/25, 10/24/25, and 10/25/25, failing to protect Resident #162 from foreseeable harm. Findings included:Review of the medical record revealed Resident #162 was admitted to the facility on [DATE] from a psychiatric hospital stay. The resident had diagnoses including but not limited to dementia, adjustment disorder, chronic obstructive pulmonary disease, type 2 diabetes mellitus, hypertension (high blood pressure), and cerebral infarction (stroke).Review of Resident #162's MDS 3.0 admission assessment dated [DATE], revealed a BIMS score of 03 (severe cognitive impairment), and no mood symptoms, psychosis, or behavior symptoms. The resident was supervision/touch assistance for all activities of daily living (ADL) apart from set up assistance for eating. The resident required supervision for ambulation (walking). Review of the medical record revealed Resident #161 was admitted on [DATE] with a history of traumatic brain injury and documented behavioral symptoms. On 10/13/25, nursing staff documented inappropriate resident room entry, taking other residents' belongings, wandering, and sexually inappropriate comments; however, the Medication Administration Record (MAR) documented no behaviors that day. On 10/14/25 and 10/16/25, progress notes again described sexual comments, difficulty with redirection, entering other residents' rooms, and taking food from others. On 10/18/25, multiple notes documented explicit sexual comments, invasion of personal space, and a verbal threat to slap another resident. Despite this escalation, there was no documentation of physician notification, and the MAR continued to record no behaviors for all shifts on 10/18/25. On 10/20/25, the resident's psychiatric nurse practitioner noted complaints from nursing about an unsafe environment, but no mention was made of the threat toward another resident. On 10/21/25, Resident #161 made additional verbal threats, including stating the intent to spit on staff, while also grabbing another resident's hand. Again, the MAR documented no behaviors for all shifts that day. Continued verbal aggression, sexually inappropriate statements, and inability to be redirected were documented on 10/24/25 and 10/25/25, including threats to smack and spit on another resident. There remained no evidence that the physician or administration was notified, the care plan was revised, or additional interventions were implemented to address Resident #161's increase in aggressive behaviors.Review of the progress notes for Resident #162, revealed on 10/26/25 at 10:27 A.M., the resident was struck in the nose from another resident (Resident #161) that resulted in bleeding. Compression and cold compress were applied, and an x-ray of the nose ordered. Review of the radiology (x-ray) of the facial bones results report dated 10/27/25, revealed possible minimally displaced fracture of the nasal bone. The MAR documentation every shift to monitor the presence or absence of behaviors noted no behaviors on 10/26/25 on the day shift.Review of the self-reported incident (SRI) form for alleged physical abuse, tracking #266795, dated 10/26/25, revealed Resident #161 had been agitated, stating he ran out of cigarettes and struck Resident #162 in the face. The initial report indicated Resident #162 suffered no harm, pain or mental anguish as a result of alleged incident. The final summary of the incident revealed Resident #162 had some bleeding from his nose, and x-ray was ordered that resulted in minimal displacement of Resident #162's nose. Further, the summary revealed Resident #162 suffered no harm and Resident #161 had no intent to cause harm to Resident #162. Review of the facility IDT summary for a resident-to-resident altercation, dated 10/26/25 and signed by the administrator on 10/26/25, revealed no mention of Resident #161 threats to physically hit another resident, taking food from another resident, create an unsafe environment for staff, or sexual inappropriate verbal aggression and threat to spit on a residents family member prior to the incident on 10/26/25. The report did indicate the actual nasal and maxillary fractures of Resident #162 diagnosed on [DATE].Review of the facility IDT summary specific to Resident #161 dated 10/26/25 and signed by the administrator, revealed on 10/25/25, the nursing staff identified an increase in inappropriate behaviors, including foul language, sexually inappropriate comments, verbal harassment of residents, visitors, and staff, and threats directed toward another resident. Staff followed the care plan interventions, monitored the resident's behaviors, redirected as indicated, documented the incidents, and all interventions were effective.Review of Resident #162's NP #613 progress note dated 10/27/25 at 9:15 A.M. revealed the resident had swelling to the bridge of the nose and ecchymosis (bruising) under the right eye. The resident was sent to the emergency room for a computed axial tomography (CT) scan (specialized x-rays) to confirm if a fracture was present. Review of Resident #162's NP #163 progress note dated 10/28/25 at 12:19 P.M., and the hospital after visit summary dated 10/27/26, revealed a closed fracture of the maxilla (a bone of the mid face) and the nasal bone.Review of the staff statements, dated 06/29/26 at 3:30 P.M., provided by the DON, revealed a written statement by LPN #272 that Resident #161 was verbally aggressive to staff and redirected times three. Resident #161 became verbally aggressive to other residents. Resident #161 rose from his chair walking towards Resident #162. LPN #272 was assisting Resident #161 back to his chair and Resident #162 got up and ran towards Resident #161 and hit Resident #162.Review of the statement by CNA #247 (no date), revealed Resident #161 hit Resident #162 in the nose and the residents were separated with nurse assistance.Interview on 06/30/26 at 10:41 A.M. with LPN #272 revealed she was the nurse on the unit the day of the incident. Resident #161 called the staff expletive and [expletive] has a fat [expletive]. The staff were able to redirect him and he sat in a chair in the common area where other residents were at a table. Resident #162 was sitting on a couch across the room (approximately 25-30 feet) from where Resident #161 was sitting. Resident #130 told Resident #161 that he should not talk to the staff that way. Resident #161 responded, Shut up [expletive]. I'll slap the [expletive] out of you. LPN #272 revealed this is when Resident #162 got up from the couch and started walking towards Resident #161, to protect Resident #130. LPN #272 redirected Resident #162 back to the couch and while doing this, Resident #161 got up and ran towards Resident #162 and hit him. When asked if Resident #161 acted with intention to harm, LPN #272 stated she felt Resident #161 knew what he was doing. When Resident #161's mother visited, he was a different person. Interview on 07/01/26 at 8:45 A.M. with the DON, reviewed the nursing notes, nurse practitioner notes, and care plan for Resident #161. The DON verified Resident #161's nurses notes indicated the resident exhibited increased behaviors toward others on 10/18/25, 10/21/25, 10/24/25, and 10/25/25, and the physician was not notified. Further, the DON verified the nurse practitioner notes prior to the incident, and the care interventions for Resident #161 were not followed when the resident exhibited the increased behaviors and the physician was not notified if the resident was a danger to self or others as per the care plan. The DON verified the care plan for Resident #161 was not updated with the new behaviors of verbal threats to slap and spit on other residents and verified the inconsistency between the SRI #266795 investigation and the medical record. The DON verified Resident #161 hit Resident #162 in the face and Resident #162 was diagnosed with a nasal/maxillary fracture following the altercation.Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property (reviewed 01/06/25), revealed the residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. Abuse was described as the willful infliction of injury, unreasonable confined, intimidation, or punishment with resulting physician harm, pain, or mental anguish. Prevention measures included ongoing assessment and care planning for appropriate interventions and monitoring of residents with behaviors, including verbal aggression, physical aggression, sexual aggression, taking or touching another person's property, wandering into other resident rooms, self-injurious behaviors, communication disorder and those residents totally dependent upon staff for care. Further, the policy revealed if a resident is accused or suspected of abuse, the facility will ensure other residents are protected and other interventions implemented such as immediate transfer or discharge if indicated. Follow up investigation for resident-to-resident abuse are referred to the facility interdisciplinary team to determine appropriate intervention(s).This deficiency represents non-compliance investigated under Complaint Number 3050538, 2788113, and 2648399.

Based on observation, interview and record review the facility failed to ensure that food was prepared using methods that preserved its nutritional value, flavor, and appearance. This had the potential to affect all 124 residents who received meals from the kitchen, as four residents in the facility were not to receive nutrition by mouth (Residents #20, #30, #84, and #106). The facility census was 128.Findings include:Interview on 06/22/26 at 11:07 A.M. revealed Resident #45 stated the food was bland and had no taste.Interview on 06/22/26 at 12:04 P.M. revealed Resident #148 stated the food was horrible, the pork was tough to chew and cold.Review of the Day 5 diet spreadsheet for 06/25/26 revealed that the regular diet included chicken parmesan, spaghetti with marinara sauce, Italian blend vegetables, garlic toast, chef's choice fruit, 2% milk, and 1/2 cup of juice.Review of facility Dining Manager Chicken Parmesan recipe revealed the chicken parmesan was to have breadcrumbs, parmesan cheese, garlic powder and oregano coated on the chicken breast and the breast was to be seared. The chicken breast was covered with mozzarella cheese and marinara sauce. Review of facility Dining Manager recipe for Garlic Toast recipe revealed garlic powder and melted butter was to be brushed on each slice of bread and baked until toasted.Observation on 06/25/26 at 11:30 A.M. of the tray line revealed that the chicken breast served as Chicken Parmesan was not breaded and did not contain mozzarella cheese, as required by the facility's recipe.Observation on 06/25/26 from 11:30 A.M. to 12:32 P.M. revealed that the facility prepared a test tray to be observed on the last cart leaving the kitchen and delivered to the final unit. The last tray was passed as part of this observation.On 06/25/26, the food cart reached Unit E at 12:29 P.M., and all trays were passed by 12:32 P.M. Regional Dining Manager #618 obtained food temperatures, which measured 176 degrees Fahrenheit for the Italian blend vegetables, 171 degrees Fahrenheit for the Chicken Parmesan, 183 degrees Fahrenheit for the spaghetti noodles, and 43 degrees Fahrenheit for the milk. The vegetables were observed to be pale in color and soggy. The Chicken Parmesan did not contain mozzarella cheese or breading as required by the recipe, and the breadstick was not toasted and lacked any garlic flavor. The Administrator confirmed that the breadstick had no garlic taste and commented that she believed residents were supposed to receive a plain breadstick rather than a garlic stick. An interview on 06/25/26 at 12:30 P.M. with the Regional Dining Manager confirmed that the vegetables did not have a pleasing taste and the breadstick did not have a toasted texture.Observation on 06/25/26 at 1:29 P.M. revealed the main dining room had the dining menu posted for residents that revealed residents were to receive Chicken Parmesan, spaghetti with [NAME] sauce , Italian blend vegetables, and garlic toast with a chef choice of fruit.Interview on 06/30/26 at 10:42 A.M. revealed Resident #128 stated the food upsets his stomach and did not have a good taste.Interview on 06/29/26 at 9:22 A.M. revealed Resident #152 stated the food was not cooked well in the facility.This deficiency represents non-compliance investigated under Complaint Number 2984600, 2975249 and 2799605.

Based on observation, interviews, and record review, the facility failed to ensure that food was stored and prepared according to professional standards. This had the potential to affect all 134 residents who received meals from the kitchen as four residents had orders not to receive nutrition by mouth (Residents #20, #30, #84, and #106). The facility census was 128.Findings include:1. Observation on 06/22/26 at 9:54 A.M. revealed that the reach in coolers and food-contact surfaces had a sticky coating on the handles and doors, as well as a visible film of food residue on the surfaces. The sanitizing solution used to wipe kitchen surfaces was also not at the appropriate concentration. Temporary Food Service Manager #621 tested the sanitizing bucket and found it measured 100 parts per million (PPM). Manager #621 stated the concentration should be between 300 and 400 PPM to properly sanitize food-contact surfaces.Observation on 06/22/26 at 10:00 A.M. with Regional Dining Manager #618 revealed that the reach in freezer contained an open clear bag of burgers exposed to air with no label or date. Frozen vegetables were found loose and scattered across the freezer floor. Additionally, a clear bag of cookie dough was observed open to air and was neither labeled nor datedObservation on 06/22/26 at 10:30 A.M. of the ice machine revealed the overhead light was out, requiring the Regional Dining Manager to use his cell phone flashlight to view the inside of the facility's ice machine. Inside the machine, a black, debris like substance measuring approximately six inches long and one inch wide was observed under the lid. The Regional Dining Manager confirmed the substance and stated the ice machine needed to be cleaned and the overhead light bulb needed to be replaced.Interview on 06/22/26 at 4:21 P.M. with [NAME] #622 verified he did not know the kitchen staff was to clean the ice machine.Review of facility policy titled, Production, Storage, and Dispensing of Ice, undated, revealed the ice dispenser would be cleaned and sanitized at least monthly as needed and the inside and outside of the machine would be cleaned.2. Observation on 06/23/26 at 9:35 A.M. revealed food debris on the backsplash in the food prep area, along with black grime buildup where the backsplash met the lip of the counter. Regional Dining Manager #618 verified the findings and stated the wall needed to be cleaned.Observation on 06/23/26 at 9:40 A.M. with Regional Dining Manager #618 revealed grease and burn stains on the back wall of the stove, as well as hardened grease on the side of the stove from previous drips.3. Observation on 06/24/26 at 4:28 P.M. with the Regional Dining Manager #618 revealed the Unit B resident nourishment refrigerator contained a half gallon of Silk soy milk with an expiration date of 05/14/26. Interview on 06/25/26 at 10:45 A.M. with the Assistant Director of Nursing #329 revealed she was not sure who was to clean the resident nourishment refrigerator on the units.Review of facility policy titled Food Safety and Sanitation, dated year 2017, revealed when a food package was opened the food item should be marked to indicate the open date and in order to assure the nutritional needs of the residents are met and that each facility maintained sanitary conditions.Review of facility Kitchen Cleaning List, undate , revealed ovens were to be clean inside and out, cooler doors wiped down all items dated and covered. Walls were to be wiped down.Review of facility policy titled Food Brought In From The Community , revised 01/06/25, revealed the facility permitted friends and family to provide food from outside the facility. Food and beverage brought in from the outside would be labeled with the resident's name and room number and dated by staff with the current date the item was brought in.

Based on record review and interviews the facility failed to ensure a licensed social worker worked full time in the facility. This had the potential to affect 127 residents in the facility. Findings include:Record review of timeline received from Senior Social Worker #615 revealed that the last day a licensed social worker worked full time in the facility was 02/10/26.Interview on 06/23/26 at 2:03 P.M. with Social Service Designee (SSD) #312 revealed that she had been working at the facility since 05/14/26 and will be testing for her social work license on 07/20/26. The senior social worker who had a licensed independent social work license had been overseeing work product. Interview on 06/25/26 at 12:46 P.M. with the Administrator revealed they could not provide specific times the Senior Social Work is scheduled to be in the building, they come as needed. Interview on 06/25/26 at 3:49 P.M. with the Senior Social Worker #615 revealed that they oversee SSD # 238 and #312. Senior Social Worker is available, but the social services designees do the day-to-day job duties. The Senior Social Worker revealed that they are in the building as often as the designees need them, but usually in the building three to five times a week.Interview on 06/29/26 at 9:30 A.M. with SSD #238 revealed they have been in the role for about a week. When they first started in March 2026 they were the SSD for a couple weeks and during those weeks they did care conferences, discharge planning, and minimum data set assessments. This past week the SSD #238 has been doing admission assessments and discharge planning.

Based on record review and interview, the facility failed to ensure resident code statuses were accurately reflected in both the paper medical record and the electronic medical record (EMR). This affected six residents (Resident #1, #4, #7, #39, #43 and #152) of 35 residents reviewed for advanced directives. The census was 128.Findings include: 1. Review of Resident #1's EMR revealed an admission date of [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, dependence on a respirator and heart failure. Resident #1 had an advanced directive physicians order dated [DATE] to be full code status which means all emergency life saving measures will be provided in the event of respiratory arrest or cardiac arrest.Review of the paper medical chart revealed there was nothing under the advanced directives tab or in the front of the chart.Interview on [DATE] at 1:55 P.M. with Licensed Practical Nurse (LPN) #302 confirmed the paper medical chart for Resident #1 did not contain advanced directives.2. Review of Resident #4's EMR revealed an admission date of [DATE]. Diagnoses included COPD, dependence on a respirator, hypertensive heart and chronic kidney disease with heart failure and with stage five chronic kidney disease or end stage renal disease. Resident #4 had an advanced directive physicians order dated [DATE] to be full code status.Review of the paper medical chart revealed there was nothing under the advanced directives tab or in the front of the chart.Interview on [DATE] at 1:55 P.M. with LPN #302 confirmed the paper medical chart for Resident #4 did not contain advanced directives.3. Review of Resident #7's EMR revealed an admission date of [DATE]. Diagnoses included COPD, DMII with diabetic peripheral angiopathy and anemia. Resident #7 had an advanced directive physicians order dated [DATE] to be Do Not Resuscitate Comfort Care-Arrest (DNRCC-Arrest) (a means a person would receive all emergency and medical care up until the time he or she experiences a cardiac or respiratory arrest, then all lifesaving measures would be stopped). Review of the paper medical chart revealed there was nothing under the advanced directives tab or in the front of the chart.Interview on [DATE] at 1:55 P.M. with LPN #302 confirmed the paper medical chart for Resident #7 did not contain advanced directives.4. Review of Resident #39's EMR revealed an admission date of [DATE]. Diagnoses included malignant neoplasm of the brain, personal history of malignant neoplasm of the prostate and adult failure to thrive. Resident #39 had an advanced directive physicians order dated [DATE] to be full code status.Review of the paper medical chart revealed there was nothing under the advanced directives tab or in the front of the chart.Interview on [DATE] at 1:55 P.M. with LPN #302 confirmed the paper medical chart for Resident #39 did not contain advanced directives.5. Review of Resident #43's EMR revealed an admission date of [DATE]. Diagnoses included acquired absence of kidney, chronic kidney disease stage three and obesity. Resident #43 had an advanced directive physicians order dated [DATE] to be full code status.Review of the paper medical chart revealed there was nothing under the advanced directives tab or in the front of the chart.Interview on [DATE] at 1:55 P.M. with LPN #302 confirmed the paper medical chart for Resident #43 did not contain advanced directives.6. Review of Resident #152 EMR revealed an admission date of [DATE]. Diagnoses included hypertensive heart and chronic kidney disease with heart failure and kidney disease stage three, DMII and personal history of other malignant neoplasm of skin. Resident #152 had an advanced directive physicians order dated [DATE] to be full code status.Review of the paper medical chart revealed there was nothing under the advanced directives tab or in the front of the chart.Interview on [DATE] at 1:55 P.M. with LPN #302 confirmed the paper medical chart for Resident #152 did not contain advanced directives.Review of the facility policy titled, Cardio Pulmonary Resuscitation (CPR) Protocol, dated [DATE], revealed advanced directive information is kept on the resident's medical record. One nurse goes to the nursing station and checks for Advanced Directives on the resident's chart. If the resident is a Full Code that nurse will dial 911 for emergency assistance.Review of the facility policy titled, Do Not Resuscitate Order, dated, revealed Do not resuscitate orders must be obtained by the resident's attending physician and the physician's order sheet maintained in the resident's medical record.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure a, clean, sanitary, homelike environment. This affected two resident's (Resident's #111 and #113) out of three reviewed for clean and sanitary resident rooms and had the potential to affect all residents who used the common area and wanted to know the time. The facility census was 128. Findings include: 1. Review of Resident #113's medical record revealed an admission date of 01/10/26 and diagnoses included emphysema, atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure and end stage renal disease.Review of Resident #113's care plan dated 01/23/26 included Resident #113 had an ADL self-care, mobility, functional ability performance deficit related to his diagnoses. Resident #113 would maintain current functional status related to ADL's. Interventions included Resident #113 required substantial to maximal assistance from sitting to lying; Resident #113 required substantial to maximal assistance to roll left and right.Review of Resident #113's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #113 was cognitively intact. Resident #113 used a wheelchair. Resident #113 required supervision or touching assistance for toileting hygiene, upper and lower body dressing and personal hygiene. Resident #113 required partial to moderate assistance for putting on socks and footwear. Resident #113 required supervision or touching assistance for the ability to transfer to and from a bed to a chair or wheelchair and the ability to get on and off a toilet or commode.Review of a Service Order from a roofing service company dated 06/15/26 included the roof technician inspected a leak area inside and MD #901 found the area on the roof. Multiple areas of flashing patches were pushing water. A hole was found from an animal at the firewall in the same area. The drain screen was off and the drain was holding water due to leaf debris, the drain was draining very slow and possible had a clog. Near the edge an area of coverstrip was found that was lifted and had a cut underneath. All areas were cleaned with membrane cleaner and all areas were repaired with flashing. Sealed all patches, cleared all drains of leaf debris on area of roof leak. There was lots of standing water on the roof. Review of a Service Order from a roofing service company dated 06/22/26 included the roof technician inspected leak area inside and leak area on roof and found multiple nail pops and rubber was cut at shingle to flat transition. Keyed out shingles and installed flashing in area of cut. Reinstalled shingles and caulked everything that was separated. Falling facia trim near peak was repaired. Interview on 06/22/26 at 7:42 A.M. with Maintenance Staff (MS) #260 revealed the roof started leaking and the facility had the roof repair company out about a month ago. MS #260 indicated there was a storm on 06/21/26, he arrived to the facility on [DATE] at around 6:30 A.M. MS #260 revealed the ceiling was dripping on Resident #113's bed and it was hardly wet at all. MS #260 confirmed Resident #113's ceiling had a hole in it and water was leaking from the hole onto Resident #113's bed. Observation on 06/22/26 at 10:13 A.M. with Resident #113 revealed he was lying in bed on his left side and was pleasant and answered questions appropriately. Resident #113 indicated every night his bed became wet from the rain because the ceiling was leaking. Resident #113 pointed up to the ceiling to show where the ceiling was leaking. Observation revealed a hole in the ceiling, above Resident #113's bed and the hole was near the wall. The hole in the ceiling was approximately eight to twelve inches in diameter and the edges were wet and blackened. Interview on 06/24/26 at 11:25 A.M. of the Administrator revealed on 06/21/26 she was in the facility and there was heavy rain and the roof was leaking in the common areas on the nursing unit Resident #113 resided on. The Administrator revealed staff used buckets and blankets to take care of rain water from the leaking roof. The roof was fixed on 06/22/26. The Administrator stated on 06/14/26 there was heavy rain, some leaking of the roof and the problem was fixed on 06/15/26 by 9:00 A.M. The Administrator stated Resident #113's sister called about his ceiling leaking on 06/22/26 and she had a conversation with Resident #113 about it. The Administrator indicated Resident #113 told her there was a day he woke up and water was dripping on him and staff pulled his bed away from the wall. Resident #113 told the Administrator that Maintenance Director (MD) #901 fixed the leak. The Administrator revealed there was a work order for Resident #113's ceiling repair but Resident #113 said nothing was actively falling or dripping on him. Interview on 06/25/26 at 6:31 A.M. with Certified Nursing Assistant (CNA) #387 revealed there was a heavy rain one to two weeks ago. The ceiling of the facility started leaking near the nurses station for the unit Resident #113 resided on. Resident #113 put his call light on and told CNA #387 his bed was wet and he did not know why. CNA #387 revealed the ceiling had a hole in it and was leaking over Resident #113's bed. CNA #387 indicated he told MD #901 that Resident #113's ceiling was leaking. The next day MD #901 told CNA #387 that he took care of the ceiling. It rained again and Resident #113's ceiling leaked again and CNA #387 put pads on the bed because the bed was wet, and told MD #901 the ceiling was still leaking. CNA #387 indicated the ceiling still looked like it leaked. CNA #387 revealed he offered to move Resident #113 to another room, but Resident #113 did not want to move. Interview on 06/25/26 at 1:32 P.M. with Resident #113 revealed his ceiling had the hole in it and it had been leaking for awhile and it leaked more than a couple weeks. Resident #113 indicated the ceiling had a hole in it since he moved to the room in February 2026. Interview on 07/01/26 at 9:48 A.M. of Maintenance Director (MD) #901 revealed he had only worked at the facility since March 2026 and was still getting acclimated to the facility. MD #901 indicated there was still a lot of maintenance work that needed done in the facility and he was doing his best to address it. 2. Review of Resident #111's medical record revealed an admission date of 02/25/26 and diagnoses included epilepsy, hepatic encephalopathy, and anxiety disorder, major depressive disorder and generalized muscle weakness. Review of Resident #111's admission Minimum Data Set assessment dated [DATE] included Resident #111 was cognitively intact. Resident #111 had upper body impairment on one side and required substantial to maximal assistance for toileting, upper and lower body dressing and was dependent for bed mobility. Observation on 06/30/26 at 1:30 P.M. with Resident #111 of his room revealed the nightstand next to the bed was not in good condition, was missing pieces of the finish and the drawers were crooked and did not open and close easily. The drawers also fell out of the nightstand easily when they were pulled open. Observation of the lamp in his room revealed there was a hole in the lamp shade. The wardrobe which held clothing was battered and was missing pieces of the finish. Resident #111 demonstrated that the window blinds did not close, stayed open all the time, and they were dirty and dust could be seen on the slats. Resident #111 indicated the toilet pressure was terrible and observation revealed it took two to three flushes to get the water to go down and flush properly. The toilet rocked when it was gently pushed on and rusty screws could be seen that attached the toilet to the floor. A light bulb was missing from the over the sink light, the bathroom mirror was chipped, and a vent cover in the ceiling was falling out of the ceiling on one side and a there was a large amount of dust and dirt on the vent cover. Resident #111's room walls had black scuff marks on them. Resident #111 indicated he wished his room did not look so shabby and even his mother commented on the state of disrepair his room was in. Observation on 06/30/26 at 1:30 P.M. of the common room with Resident #111 revealed the large clock on the wall was not working. Resident #111 indicated the clock had not worked for at least a month and he really wished it showed the correct time. Resident #111 indicated he used the common area a lot and it was frustrating not to know what time it was. Observation on 06/30/26 at1:35 P.M. with Regional Director of Clinical Services (RDCS) #910 confirmed the clock was not working in the common area. RDCS #910 confirmed the nightstand next to the bed was beat up looking, was missing pieces of the finish and the drawers were crooked and did not open and close easily. The drawers also fell out of the nightstand easily when they were pulled open. Observation of the lamp in his room revealed there was a hole in the lamp shade. The wardrobe which held clothing was battered and was missing pieces of the finish. Resident #111 demonstrated that the window blinds did not close, stayed open all the time, and they were dirty and dust could be seen on the slats. Resident #111 indicated the toilet pressure was terrible and observation revealed it took two to three flushes to get the water to go down and flush properly. The toilet rocked when it was gently pushed on and rusty screws could be seen that attached the toilet to the floor. A light bulb was missing from the over the sink light, the bathroom mirror was chipped, and a vent cover in the ceiling was falling out of the ceiling on one side and a there was a large amount of dust and dirt on the vent cover. Resident #111's room walls had black scuff marks on them. Interview on 07/01/26 at 9:48 A.M. of Maintenance Director (MD) #901 revealed he had only worked at the facility since March 2026 and was still getting acclimated to the facility. MD #901 confirmed the furniture in many resident rooms was beat up and needed replaced. New furniture was ordered, had been in the facility a few weeks but decisions had not been finalized about where in the facility the furniture was to used. MD #901 confirmed the clock in the common area was not working and was not showing the correct time. MD #901 revealed he could not fix the clock himself because it was too heavy and he would have to wait until someone could help him before he could fix it. Review of the facility policy titled Resident Rights and Facility Responsibilities dated 01/06/25 included residents had the right to a safe and clean living environment pursuant to the Medicare and Medicaid programs and applicable state laws and regulations prescribed by the public health council. This deficiency represents non-compliance investigated under Complaint Number 2799605, 2700113, 2699470.

Based on review of the medical record, staff interview, observation, and review of the facility policy the facility failed to ensure resident care conferences and revisions to comprehensive care plans were completed timely. This affected six residents (Resident's #6, #11, #61, #92, #140, and #159) of seven residents reviewed for care plan timing and revisions. Findings include: 1. Review of Resident #61's medical record revealed an admission date of 10/26/23 and diagnoses included Alzheimer's Disease with early onset, schizoaffective disorder depressive type, and generalized anxiety disorder. Review of Resident #61's Quarterly Minimum Data Set (MDS) assessment dated [DATE] included Resident #61 was cognitively intact. Resident #61 had no impairment of the upper and lower extremities. Resident #61 was independent for toileting and required supervision or touching assistance for upper and lower body dressing and personal hygiene, Resident #61 was independent to walk 150 feet in a corridor or similar space. Review of Resident #61's medical record including interdisciplinary care conferences (IDT) revealed she had a care conference on 08/28/25 and did not have another one until 06/25/26. Observation on 06/24/26 at 8:03 A.M. of Resident #61 revealed she was lying in bed and was dressed in jeans and a t-shirt. Resident #61 asked if she was going to make it. Interview on 07/01/26 at 12:08 P.M. of Senior Social Worker (SSW) #615 confirmed Resident #61 did not have an interdisciplinary care conference (IDT) completed from 08/28/25 through 06/25/26. Review of the facility policy titled IDT Care Conference and Documentation dated 01/06/25 included Interdisciplinary Care Conferences would be scheduled after admission and with Quarterly MDS of Significant Change MDS completion. Invitations would be sent to the residents and their family/responsible party. Each discipline would report on current resident status and progress toward goals during the conference. Goals would be reviewed and revised as needed and care plans would be updated. Resident and family/responsible party questions would be answered. Documentation would be in the electronic health record in the form of the IDT/Care Conference note or a narrative progress note. 2. Review of Resident #159's closed medical record revealed an admission date of 04/01/26 and diagnoses included fracture of the left patella, fracture around internal prosthetic left knee joint, end stage renal disease, dependence on renal dialysis and type two diabetes mellitus with diabetic chronic kidney disease. Resident #159 was discharged on 04/22/26. Review of Resident #159's admission Minimum Data Set assessment dated [DATE] included Resident #159 was cognitively intact. Resident #159 required substantial to maximal assistance with toileting hygiene, was dependent for bathing, and required partial to moderate assistance with personal hygiene. Review of Resident #159's medical record including interdisciplinary care conferences (IDT) did not reveal evidence Resident #159 had an interdisciplinary care conference while he resided at the facility. Review of Resident #159's IDT/Care Conference Note dated 04/07/26 revealed it was not completed. Interview on 07/01/26 at 12:08 P.M. of SSW #615 revealed the goal for completion of an admission care conference was the care conference should be completed within the first seven to ten days after admission. SSW #615 confirmed Resident #159 did not have an interdisciplinary care conference from 04/01/26 until his discharge 04/22/26. Review of the facility policy titled IDT Care Conference and Documentation dated 01/06/25 included Interdisciplinary Care Conferences would be scheduled after admission and with Quarterly MDS of Significant Change MDS completion. Invitations would be sent to the residents and their family/responsible party. Each discipline would report on current resident status and progress toward goals during the conference. Goals would be reviewed and revised as needed and care plans would be updated. Resident and family/responsible party questions would be answered. Documentation would be in the electronic health record in the form of the IDT/Care Conference note or a narrative progress note. 3. Resident #6 was admitted on [DATE] with relevant diagnoses that included depression, restlessness and agitation, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 quarterly Assessment (a federal tool for implementing standardized assessment and for facilitating care management in nursing homes) dated 06/04/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). The resident was independent in most activities of daily living (ADLs), with supervision/touch assistance with a shower/bath and set up assistance for putting on and taking off footwear. Medications coded in Section N of the MDS included antidepressants and opioid use. The antianxiety medication ordered on 05/29/26 was not coded. Review of Resident #6's physician medication orders included buspirone hydrochloride (HCL) tablet 5 milligrams (mg), one tablet by mouth twice a day for anxiety (an antianxiety medication), sertraline HCL 50 mg., one tablet by mouth one time a day for depression, and trazodone HCL 50 mg., give 75 mgs. by mouth at bedtime for insomnia, and oxycodone HCL tablet 5 mg., two tablets by mouth every 6 hours as needed for pain. The buspirone HCL 5 mg. tablet for anxiety was originally ordered on 05/29/26 by nurse practitioner (NP) #613. Review of the NP #613 progress notes dated 05/29/26, revealed Resident #6 complained of anxiety and not sleeping well, and agreed to begin the buspirone HCL medication. Review of the Medication Administration Record (MAR) for May 2026 and June 2026, revealed the resident received the antianxiety medication (buspirone HCL) twice daily as prescribed by the physician. Review of the care plans revealed a care plan focus (initiated on 02/19/26) for use of psychotropic medications related to depression. The care plan focus and the interventions were not updated to reflect the use of the added antianxiety medication from 05/29/26. Review of the interdisciplinary team (IDT)/Care Conference notes revealed a care conference was held on 06/04/26. Interview on 06/29/26 at 11:00 A.M. with MDS nurse #601, revealed MDS nurses do not attend care conferences. Social service arranges the care conference schedule. MDS nurses update the care plans, attend daily report meetings, review the 24 reports. MDS nurse #601 verified the absence of the coding for the antianxiety medication on the quarterly assessment dated [DATE], and the care plan not updated for the use of the antianxiety medication. Review of the facility policy titled, Psychotropic Drug Use (revised 04/28/25), revealed a detailed procedure the ordering, assessment, gradual dose reduction (GDR), monitoring, and documentation of psychotropic medications. Review of the facility policy titled, IDT Care Conference & Documentation (reviewed 01/06/25), revealed care plans will be updated as part of the care conference. 4. Resident #11 was admitted on [DATE] with relevant diagnoses of schizoaffective disorder, biploar disorder, type 2 diabetes mellitus, Crohn's disease, hyperlipidemia (high fat in the blood), and gastro-esophageal reflux disease. Review of the Minimum Data Set (MDS) 3.0 Quarterly assessment dated [DATE], revealed a BIMS was not assessed. Prior BIMS assessment (dated 12/04/25), revealed a score of 15 (cognitively intact). ADL assistance revealed the resident required set-up to substantial assistance depending on the task. Resident #11's physician medication orders revealed orders for buspirone HCL 5 milligram (mg) tablet (ordered 11/26/25), one tablet by mouth two times a day for anxiety (an antianxiety medication). Review of the care plan (dated 09/30/25) revealed a care plan for the use of psychotropic medications with potential for adverse reactions related to bipolar and schizoaffective disorder. The care plan interventions included such actions to monitor, document and report to the physician, signs and symptoms of depression unaltered by antidepressant medications. The care plan was not updated to reflect the diagnosis of anxiety or the antianxiety medication ordered on 11/26/25. Review of the interdisciplinary team (IDT) Care Conference notes dated 09/26/25 and 05/12/26, revealed evidence of a care conference. There was no quarterly care conference interdisciplinary team (IDT) care conference note for the MDS 3.0 Quarterly Assessment (dated 03/05/26) or progress notes in the medical record verifying a care conference took place. Interview on 06/29/26 at 11:07 A.M. with MDS nurse #601, verified the buspirone HCL order, care plan findings, and the absence of a care conference or notes in the clinical record referring to a care conference for the 03/05/26 MDS 3.0 Quarterly Assessment. Review of the facility policy titled, IDT Care Conference & Documentation (reviewed 01/06/25), revealed care conferences were scheduled after admission and with Quarterly MDS or Significant Change MDS completion. Documentation was made in PointClickCare (PCC, the electronic medical record) in the IDT/Care Conference Note or a narrative progress note. 5. Resident #92 was admitted to the facility on [DATE] with relevant diagnoses of chronic obstructive pulmonary disease (COPD), aphasia (difficulty speaking), history of ischemic attack and cerebral infarction (stroke), and convulsions. Resident #92 was originally admitted on [DATE] to Memory Lane (secured unit). On 01/16/26, Resident #92 was moved to a nonsecured unit. Review of the facility documentation titled, Notice of Room, Roommate or Physician Change dated 01/16/26, revealed the resident was transferred from the secured unit to a nonsecure unit. Further, the physician order for a secured unit was revised on 01/16/26. Review of the medical record physicians orders dated 04/06/26 revealed an order for a Wanderguard (an electronic device to monitor potential wandering/elopement) placement, and staff to check placement and function every shift. Review of the Treatment Administration Record (TAR) for April 2026, May 2026, and June 2026, revealed the Wanderguard was marked off by licensed nursing staff every shift as in place and functioning. Review of the care plan dated 01/15/26, revealed a care plan that required the special care unit for the safety of the resident and others related to psychiatric diagnoses. The care plan was not updated to reflect the room change that occurred on 01/16/26 or the placement of the Wanderguard ordered 04/06/26. Review of the Minimum Data Set (MDS) 3.0 Quarterly assessment dated [DATE], revealed a BIMS score of 00 (severe cognitive impairment). ADL assistance revealed the resident was mostly independent with set up assistance for eating and oral hygiene, and supervision for toileting hygiene, and independent with ambulation. Interview on 06/23/26 at 11:34 A.M. with the MDS nurse #601, verified the care plan not updated to reflect the room change off the secured unit on 01/26/26, or the intervention of the placement of the Wanderguard ordered 04/06/26. Interview on 06/25/26 at 7:30 A.M. with LPN # #290, verified the Wanderguard was intact to Resident #92's right ankle. Observation of Resident #92 throughout the annual survey 06/22/26 through 07/01/26, revealed a Wanderguard in place to the right ankle. Review of the facility policy titled, IDT Care Conference & Documentation (reviewed 01/06/25), revealed care plans will be updated as part of the care conference. 6. Resident #140 was originally admitted to the facility on [DATE], with a current readmission date on 01/13/26 with relevant diagnoses of type 2 diabetes mellitus with hyperglycemia; bilateral surgical amputation, diabetic retinopathy; end stage renal disease (dialysis services); chronic respiratory failure with hypoxia, obstructive sleep apnea, chronic congestive heart failure (CHF), atherosclerotic heart disease, atrial fibrillation, obesity, depression, hyperlipidemia (high fat in the blood), gout, anemia, history of pulmonary embolism, and history of falls and diabetic foot ulcers. Review of the MDS 3.0 quarterly assessment dated [DATE], revealed a BIMS score of 15 (cognitively intact), with behavior indicators of depressive symptoms. The resident required substantial to full assistance with most ADLs and was non ambulatory due to bilateral lower extremity amputation. Review of the MDS 3.0 schedule in the medical record, revealed a MDS quarterly assessment on 10/22/25 and 01/22/26. There were no notes in the medical record progress notes to indicate a care conference took place on those dates. Further, review of the interdisciplinary (IDT)/Care Conference Notes, revealed the last care conference note on 08/14/25.Interview on 07/01/26 at 1:06 P.M. with the SSW #615, revealed it was up to the resident who was her own responsible party, to decide who got contacted for care planning. The social worker schedules the care conferences and there is a notification sheet about the appointment. For visually impaired residents, the resident is told verbally of the appointment date and time. The appointment is coordinated with the resident, and the conference is held in the resident's room or an alternate location if the resident has a roommate and does not want the care conference in the room. The social worker verified the MDS quarterly assessments for 10/22/25 and 01/22/26, and no documentation in the medical record of a care conference for those dates. The SSW #615 stated that sometimes there are paper copies of the care conference that were not uploaded to the medical record.On 07/01/26, the care conference notes for the 10/22/25 and 01/22/26 were requested from the Regional Director of Operations (RDO) #616. The RDO #616 verified in an email dated 07/01/26 at 1:44 P.M. that there were no paper interdisciplinary team (IDT)/care conference notes for Resident #140 at that time. Review of the facility policy titled, IDT Care Conference & Documentation (reviewed 01/06/25), revealed care conferences were scheduled after admission and with Quarterly MDS or Significant Change MDS completion. Documentation was made in PointClickCare (PCC, the electronic medical record) in the IDT/Care Conference Note or a narrative progress note. This deficiency represents non-compliance investigated under Complaint Number 2998550 and 2788113.

Based on observation, interviews, and record review, the facility did not ensure residents received their ordered adaptive devices during meals as required. This affected five residents (Residents #04, #85, #89, #91, and #104) of the seven residents who had physician orders for adaptive feeding devices. The facility census was 128.Findings include:1. Review of electronic medical record revealed Resident #04 was admitted to the facility on [DATE]. Medical diagnosis included type two diabetes, chronic obstructive pulmonary disease, dependence on respirator and renal dialysis.Review of Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #04's cognition was intact. Resident #04 needed set up assistance for eating.Review of Resident #04's physician orders dated 03/03/26 revealed Resident #04 was to use a plate guard (food bumper to help residents eat independently) two handled spouted cup and bendable built up utensils with every meal.Review of Resident #04's Plan of Care date created 06/23/26 revealed Resident #04 was to have a plate guard, black built up utensils, adult spouted cup.Observation on 06/23/26 at 12:31 P.M. during meal service revealed Diet Technician #619 delivered a meal tray to Resident #04 in his room that had a standard plate, cup and silverware.Interview on 06/23/26 at 12:31 P.M. with Resident #4 revealed he did not have his plate guard, two handled spouted cup and bendable build up utensils on his tray and stated he needed the equipment so he could feed himself.Interview on 06/23/26 at 12:32 P.M. with Diet Technician #619 verified Resident #04 had physician orders that required a plate guard, two handled spouted cup and bendable built up utensils at every meal and the adaptive equipment was missing from the tray.2. Review of electronic medical record revealed Resident #85 was admitted to the facility on [DATE]. Medical diagnosis included type two diabetes, chronic obstructive pulmonary disease, dependance on respiratory and Parkinsons.Review of MDS 3.0 quarterly assessment dated [DATE] revealed Resident #85 needed assistance for set up of tray for eating and cognition was good.Review of electronic medical record physician orders dated 06/13/25 revealed Resident #85 was to use red foam tubing on eating utensils for all meals.Review of Resident #85's plan of care revised on 06/23/26 revealed Resident #85 was to have adaptive equipment red foam handle utensil for all meals.Observation on 06/23/26 at 12:45 P.M. with Registered Dietitian (RD) #620 revealed Resident #85 was observed in her room attempting to self-feed. Observation of the meal tray revealed standard utensils were provided instead of the required adaptive equipment.Interview on 06/23/26 at 12:46 P.M. with Registered Dietitian #620 verified Resident #85 had a physician order for red foam tubing on eating utensils for all meals and the tray ticket was noted a red foam handle was needed for all meals and verified Resident #85 received standard utensils.3. Review of medical record revealed Resident #89 was admitted to the facility on [DATE]. Medical diagnosis included dementia, hemiplegia, gastro esophageal reflux, abnormal weight loss and major depressive disorder.Review of MDS 3.0 quarterly assessment dated [DATE] revealed severe cognitive impairment and set up assistance was needed to eat.Review of Resident #89's physician orders dated 03/06/25 revealed Resident #89 was to have a plate guard provided for all meals.Review of Resident #89's plan of care created on 06/23/26 revealed Resident #89 was to receive adaptive equipment that included a plate guard.Observation on 06/23/26 at 12:45 P.M. with RD #620 revealed #89 was in his room feeding himself without the prescribed plate guard attached.Interview on 06/23/26 at 12:46 P.M. with RD #620 verified Resident #89 was ordered to have a plate guard provided at all meals and meal tray was observed not to have the plate guard attached.4. Review of medical record revealed Resident #91 was admitted to the facility on [DATE]. Medical diagnosis included convulsions, non-pressure ulcer of left foot, psychosis, amnesia, traumatic brain injury.Review of MDS 3.0 quarterly assessment dated [DATE] revealed Resident #91 had intact cognition and was dependent of staff for eating.Review of Resident #91's physician orders dated 06/06/24 revealed Resident #91 was to use a divided plate for all meals.Review of Resident #91's plan of care date created 06/12/14 revealed Resident #91 was to receive adaptive equipment of built up utensils and a divided plate.Observation on 06/23/26 at 12:48 P.M. with RD #620 revealed Resident #91 meal tray was in his room with a standard plate with no dividers provided.Interview on 06/23/26 at 12:49 P.M. with RD #620 verified Resident #91 had a physician order for a divided plate for all meals and Resident #91 was not provided a divided plate.5. Review of medical record revealed Resident #64 was admitted to the facility on [DATE]. Medical diagnosis included dysphagia, cerebral infarction, depression.Review of MDS 3.0 quarterly assessment dated [DATE] revealed Resident #64 had moderate cognitive impairment and was independent with feeding self.Review of Resident #64's physician orders dated 10/30/25 revealed Resident #64 was to use a Provale cup only (a regulated limited flow cup to prevent choking).Review of Resident #64's plan of care date created 06/23/26 revealed Resident #64 was of have adaptive equipment that included a Provale Cup.Observation on 06/23/26 at 12:45 P.M. with RD #620 revealed Resident #64 was observed in his room feeding himself. Observation of Resident #64's meal tray revealed a standard cup was provided that had no handles or a lid. Resident #64 stated he usually received a different cup than the cup provided.Interview on 06/23/26 at 12:47 P.M. with RD #620 verified Resident #64 had a physician order for a Proval cup and did not have the cup in his meal tray.Review of facility policy titled Accuracy and Quality of Tray Line Service , undated, revealed all meals would be checked by the nutrition and food service personnel for accuracy and by the employees serving the meals prior to serving to the individual.

Based on medical record review, staff interview, and policy review, the facility failed to ensure effective care planned interventions were implemented to promote Resident #161's highest practicable physical, mental, and psychosocial well-being. This affected one (Resident #161) of one residents reviewed for behavioral health. The facility census was 128. Review of the medical record revealed Resident #161 was admitted to the facility on [DATE] from an acute care hospital stay. The resident had relevant diagnoses of adult failure to thrive, focal traumatic brain injury (TBI), restlessness and agitation, hypertension (high blood pressure), and anemia.Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03 (severe cognitive impairment) and disorganized thinking. The resident was independent for all activities of daily living (ADL) apart from set up assistance for oral hygiene and putting on and taking off footwear. The resident was independent in ambulation (walking). No mood symptoms were present at the time of the admission assessment. Behavior symptoms included symptoms were not directed towards others, instances of rejection of care, and wandering.Relevant medications for Resident #161 included Seroquel (antipsychotic medication) oral tablet 25 milligrams (mg) one table by mouth every 6 hours as needed for agitation after 1:1, distraction, toileting, ruling out pain, and basic needs are provided and ineffective. Seroquel oral tablet 25 mg. one tablet by mouth two time a day for agitation, and Depakote (anticonvulsant medication used as a mood stabilizer) sprinkles 125 mg. oral capsule delayed release, give two capsules by mouth twice a day for behaviors related to traumatic brain injury (TBI).Review of the care plan for Resident #161 (created on 10/09/25), revealed the resident required the special care unit for the safety of the resident and others related to traumatic brain injury (TBI) with behaviors. Further review of the care plans revealed a care plan (initiated 10/14/25) for physical behaviors (urinating in trash cans, entering other residents' room without permission, touching their belongings, and opening the meal cart during mealtimes) related to poor impulse control, TBI, and verbalizing sexual inappropriate statements. An intervention included Monitor/document/report to MD of danger to self and others. (date initiated 10/14/25). The care plan was not updated since the initiation date of 10/14/25 and discontinued on 11/07/25 after the resident was discharged from the facility. Review of the progress notes dated 10/13/25 at 6:23 P.M. by Registered Nurse (RN) #631, revealed Resident #161 required redirection for inappropriate behaviors. Resident #161 entered other resident's rooms without permission, touched their belongings, and attempted to leave the unit. On 10/14/25 at 2:17 P.M. a progress note by Licensed Practical Nurse (LPN) #272, revealed the resident wandered into other resident rooms and at times was hard to redirect and made sexual comments toward staff. On 10/16/25 at 2:50 P.M., a progress note by LPN #272, revealed the resident made inappropriate sexual comments to staff and residents, was not redirectable at times, and took other residents meal trays and entered their room. On 10/16/25 at 9:20 P.M, a progress note by RN #365 revealed the was drinking other resident's cups of juice during dinner and verbal redirection was unsuccessful. On 10/18/25 at 7:16 A.M., a progress note by LPN #239, revealed the resident made explicit sexual comments and invasion of the personal space and was unable to be redirected. On 10/18/25 at 7:45 A.M., a progress note by Licensed Practical Nurse (LPN) #204, revealed the resident made inappropriate sexual comments and invaded her personal space. LPN #204 notified the police to make a harassment allegation. LPN #204 refused to work on the unit due to personal safety concerns and was reassigned to another unit. On 10/18/25 at 1:47 P.M., a progress note by LPN #290 revealed the resident threatened to slap a fellow resident. The resident was redirected by the nurse. There was no documentation that the physician or administrator was not notified of the threat to another resident. On 10/21/25 at 9:24 P.M, a progress note by LPN #357, the resident made verbal threats to a staff member that he would spit on the staff members face. The resident also held another resident's hand (resident not identified in the progress note) while reaching for their food in front of the family member. On 10/24/25 at 4:40 P.M., a progress note written by LPN #614, revealed the resident was verbally aggressive and sexually inappropriate with staff and residents, and not redirectable making the other residents and family uncomfortable. There is no documentation the physician or administrator were notified. On 10/25/25 at 2:46 P.M., a progress note written by LPN #272, revealed the resident used foul language towards other residents. The resident told another resident (not identified in the progress note) he was going to smack her and spit on her. Additionally, the wife of the roommate of Resident #161 had concerns when Resident #161 used foul language towards her and told her she had a dirty and smelly private area and he would spit on her. Further, the progress note revealed Resident #161 used foul language and made sexual comments towards staff. There was no documentation the physician or administrator were notified. On 10/26/25 at 2:36 P.M., a progress note by LPN #272, revealed Resident #161 was physically aggressive with another resident (not named in the note). Resident #161 was sent to the hospital via 911 and admitted with a diagnosis of agitation. Resident #161 did not return to the facility and was placed in an alternate facility. Review of the behavioral care plan did not identify Resident #161's behaviors of verbal aggression to physically hit or spit at residents.Review of the psychiatric progress notes (dated 10/13/25 at 4:57 P.M.) revealed the resident had behaviors that he urinated in trash cans, set off alarms, and wandered. Depakote sprinkles 250 mg. twice a day were ordered. Review of the nurse practitioner (NP) #626 on 10/14/25 at 10:30 A.M., revealed no acute issues or behaviors reported from nursing.Review of the Treatment Administration Record (TAR) for October 2025, revealed an intervention of every 15-minute checks for behavior monitoring every shift with a yes/no documentation. There was blank shift documentation for 10/18/25 night shift, 10/23/25 night shift, 10/25/25 evening shift. On 10/19/25, the day shift and evening shift documented 15 minutes checks were documented as no.Review of the psychiatric progress notes by NP #630 dated 10/20/25 at 12:39 P.M., revealed the nurses complained about the unsafe environment created by Resident #161's sexually explicit talks, and stalking behavior. There was no documentation regarding Resident #161 threat to slap another resident that occurred on 10/18/25. Further, the NP documented Resident #161 did not see his behavior as a problem. The NP increased the Depakote Sprinkles to 500 mg. twice a day.Review of the NP note dated 10/21/25 at 10:50 A.M. by NP #626, revealed no acute issues reported from nursing. Negative for behavioral problems and confusion.Interview on 07/01/26 at 8:45 A.M. with the DON, reviewed the nursing notes, nurse practitioner notes, and care plan for Resident #161. The DON verified the documented nurses notes in the medical record for 10/18/25, 10/21/25, 10/24/25, and 10/25/25 when Resident #161 had increased behaviors towards others, and the physician was not notified by the nursing staff on those dates. Further, the DON verified the findings in the nurse practitioner notes and the care plan intervention for Resident #161 was not followed when Resident #161 had increased behaviors towards others on 10/18/25, 10/21/25, 10/24/25, and 10/25/25 and the physician was not notified if the resident was a danger to self or others. Further, the DON verified the care plan for Resident #161 was not updated with the new behaviors of verbal threats to slap and spit on other residents. Review of the facility policy titled, Behavioral Monitoring of Residents (no date), revealed residents were monitored based on their behaviors and individual care plans, to ensure resident's with behavioral symptoms are observed appropriately for safety while maintaining dignity and independence. The policy identified three types of monitoring levels: routine, intermittent checks, and increased monitoring. The policy did not identify actions to take for worsened behaviors or threats to a resident's safety to self or others.

Based on review of the medical record review, staff interview, and policy review, the facility failed to timely report an allegation of misappropriation to the stage agency. This affected one resident (Resident #140) of four residents reviewed for allegations of abuse, neglect, or misappropriation. The facility census was 128. Findings include:Resident #140 was originally admitted to the facility on [DATE], with a current readmission date on 01/13/26 with relevant diagnoses of type 2 diabetes mellitus with hyperglycemia; bilateral surgical amputation, diabetic retinopathy; end stage renal disease (dialysis services); chronic respiratory failure with hypoxia, obstructive sleep apnea, chronic congestive heart failure (CHF), atherosclerotic heart disease, atrial fibrillation, obesity, depression, hyperlipidemia (high fat in the blood), gout, anemia, history of pulmonary embolism, and history of falls and diabetic foot ulcers.Review of the Minimum Data Set (MDS) 3.0 quarterly Assessment (a federal tool for implementing standardized assessment and for facilitating care management in nursing homes) dated 01/22/26, revealed a Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact), with behavior indicators of depressive symptoms. The resident required substantial to full assistance with most activities of daily living (ADL) and was non ambulatory due to bilateral lower extremity amputation.Review of the electronic medical record progress notes revealed on 02/15/26, Resident #140 was unresponsive, emergency protocol initiated, and sent to the emergency room via emergency medical services (EMS). Review of the electronic medical record progress notes January 2026 through 02/15/26, revealed no evidence related to a missing phone.Review of the [NAME] Police Incident/Offense Report #26-00438, revealed the mother of Resident #140 filed a lost property report of a cell phone on 03/12/26 at 10:30 A.M. that was missing since 02/15/26. According to the report, staff (unnamed) notified the mother that the resident's cell phone was wrapped in a blanket at the time of the resident's transport to the hospital. According to the mother, the hospital reported the phone was never at the hospital with Resident #140.Review of the facility Resident Grievance and Concern log July 2025 through May 2026, revealed no evidence of a missing phone for Resident #140.Interview on 06/22/26 at 9:50 A.M. with a family member, revealed Resident #140's mother filed a police report for Resident #140's missing cell phone after transfer to the hospital. The cell phone did not have the find my phone function activated.Interview on 06/24/26 at 12:57 P.M. with the Director of Nursing (DON) revealed Resident #140's daughter sent the DON a text message on 02/15/26 and reported the missing cell phone. The DON checked the resident room and did not find the cell phone and then notified the administrator the same day (02/15/26). The DON spoke with the daughter on 02/16/26 and 02/24/26 regarding the lost phone. The DON revealed the daughter only had concerns regarding the missing cell phone that had not been found.Interview on 06/24/26 at 12:42 P.M. with Administrator confirmed the DON did report the missing phone to her on 02/15/26, but she was waiting to see if the hospital found it, and verified she never submitted a self-reported incident (SRI) to the state agency. The Administrator revealed she opened an SRI for the missing phone on 06/24/26. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property (reviewed 01/06/25), revealed it was the facility's policy to investigate all alleges violations of abuse, neglect, misappropriation of resident property, exploitation or mistreatment, including injuries of unknown source, submit a report to the Ohio Department of Health, and investigate the allegation. This deficiency represents non-compliance investigated under Complaint Number 2745982 and 2648399.

Based on the review of the medical record, the facility self-reported incident (SRI) report, facility policy, the facility investigation report, hospital records, interdisciplinary team (IDT) summary, Resident #161 Administrator summary, and staff interview, the facility failed to thoroughly investigate resident to resident physical abuse between Resident #161 and Resident #162. This affected two residents (#161 and #162) of four residents reviewed for abuse. The facility census was 128.Findings included:Review of the progress notes for Resident #161 from 10/13/25 through 10/25/25, revealed the resident had behaviors of verbal aggression and physical threats towards staff and other residents, sexually inappropriate comments to staff, residents, and visitors, holding a resident's hand down and reaching for their food, and entering other resident rooms.Review of the self-reported incident (SRI) form for alleged physical abuse, tracking #266795 (dated 10/26/25), revealed Resident #161 had been agitated, stating he ran out of cigarettes and struck Resident #162 in the face. The initial report indicated Resident #162 suffered no harm, pain or mental anguish as a result of alleged incident. The final summary of the incident revealed Resident #162 had some bleeding from his nose, and x-ray was ordered that resulted in minimal displacement of Resident #162's nose. Further, the summary revealed Resident #162 suffered no harm and Resident #161 had no intent to cause harm to Resident #162. This report summary was inconsistent with medical record documentation and witness interview.Review of the facility SRI #266795 Resident to Resident facility investigation folder, revealed no staff statements regarding the incident. Review of the staff statements provided by the Director of Nursing (DON), revealed a written statement by Licensed Practical Nurse (LPN) #272 that Resident #161 was verbally aggressive to staff and redirected times three. Resident #161 became verbally aggressive to other residents. Resident #161 rose from his chair walking towards Resident #162. LPN #272 was assisting Resident #161 back to his chair and Resident #162 got up and ran towards Resident #161 and hit Resident #162.Review of the statement by CNA #247 (no date), revealed Resident #161 hit Resident #162 in the nose and the residents were separated with the nurse assistance.Review of the progress notes for Resident #162, revealed on 10/26/25 at 10:27 A.M., the resident was struck in the nose from another resident that resulted in bleeding. Compression and cold compress were applied, and an x-ray of the nose ordered. Review of the radiology (x-ray) of the facial bones results report dated 10/27/25, revealed possible minimally displaced fracture of the nasal bone.Review of the facility document titled, Physical Aggression Received report dated 10/26/25 for Resident #162, revealed an injury of epistaxis (nosebleed), but he denied pain.Review of the facility interdisciplinary team (IDT) summary, signed by the administrator on 10/26/25, revealed no mention of Resident #161 threats to physically hit another resident, hold a residents hand to take her food, create an unsafe environment for staff, or sexual inappropriate verbal aggression and threat to spit on a residents family member prior to the incident on 10/26/25. The report did indicate the actual nasal and maxillary fractures of Resident #162 that were diagnosed 10/27/25.Review of the IDT facility summary for Resident #161 and signed by the administrator on 10/26/25, revealed on 10/25/25, the nursing staff identified an increase in inappropriate behaviors, including foul language, sexually inappropriate comments, verbal harassment of residents, visitors, and staff, and threats directed toward another resident. Staff followed the care plan interventions, monitored the resident's behaviors, redirected as indicated, documented the incidents, and all interventions were effective. Further the summary identified physical aggression was a new behavior, with no known prior history of resident-to-resident physical aggression documented before the incident of 10/26/25. The summary (dated 10/26/25), included the hospital admission of Resident #161 on 10/27/25.Review of Resident #162's Nurse Practitioner (NP) #613 progress note dated 10/27/25 at 9:15 A.M., revealed Resident #162 had swelling to the bridge of the nose and ecchymosis (bruising) under the right eye. The resident was sent to the emergency room for a computed axial tomography (CT) scan (specialized x-rays) to confirm if a fracture was present. Review of Resident #162's NP #613 progress note dated 10/28/25 at 12:19 P.M., and the hospital after visit summary dated 10/27/26, revealed a closed fracture of the maxilla (a bone of the mid face) and closed fracture of the nasal bone Interview on 06/29/26 at 2:25 P.M. with the Regional Director of Operations (RDO) #616, confirmed there were no staff written statements relating to the event in the facility SRI investigation folder. Interview on 06/29/26 at 3:30 P.M. with the DON, revealed she keeps staff written statements for SRI's in a separate folder and provides the administrator with a copy. Review of the written statements revealed one LPN statement from LPN #272 statement and one CNA statement from CNA #247. A second CNA statement who worked the unit on the day of the incident was not taken. Further, the written statement by the LPN #272 revealed a different scenario than what was reported on the SRI. The CNA statement did not describe the actions of the resident prior to the incident, or interventions and supervision by the staff prior to the incident. Interview on 06/30/26 at 10:41 A.M. with LPN #272 revealed she was the nurse on the unit the day of the incident. Resident #161 called the staff expletive and [expletive] has a fat [expletive]. The staff were able to redirect him and he sat in a chair in the common area where other residents were at a table. Resident #162 was sitting on a couch across the room (approximately 25-30 feet) from where Resident #161 was sitting. Resident #130 told Resident #161 that he should not talk to the staff that way. Resident #161 responded, Shut up [expletive]. I'll slap the [expletive] out of you. LPN #272 revealed this is when Resident #162 got up from the couch and started walking towards Resident #161, to protect Resident #130. LPN #272 redirected Resident #162 back to the couch and while doing this, Resident #161 got up and ran towards Resident #162 and hit him. When asked if Resident #161 acted with intention to harm, LPN #272 stated she felt Resident #161 knew what he was doing. When Resident #161's mother visits, he was a different person. Interview on 07/01/26 at 8:45 A.M. with the DON, verified the findings of the nursing and nurse practitioner progress notes for Resident #161, the CT scan results of a fracture of the maxilla, the IDT summary, the physical aggression received report, and the inconsistency of the findings in the facility SRI report #266795. Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property (reviewed 01/06/25), revealed the investigation protocol included the resident, the accused, and all witnesses. Witnesses generally included anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. Further, follow up investigation procedure for Resident-to-Resident incidents were referred to the facility's interdisciplinary team to determine the appropriate intervention(s).

Based on record review and interview, the facility failed to ensure the interdisciplinary team addressed all of Resident #99's discharge needs to ensure a safe discharge. This affected one resident (Resident #99) of one resident reviewed for discharge.Findings include:Resident #99's closed medical record revealed the resident was admitted to the facility on [DATE] due to a fall at home and her husband being admitted to the hospital. Resident #99 diagnosis consists of fracture of upper end of left humerus, emphysema, anxiety, hypertension, alcohol abuse, history of falling, and need for assistance with personal care. Resident #99 admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of six out of 15 which confirmed severe cognitive impairment. Resident #99 ambulated independently, but can be unsteady at times, and needed assistance toileting and getting in and out of bed. Resident #99 was an elopement risk, and a wander guard was implemented on [DATE] due to unaware of safety and trying to exit facility. Speech therapy conducted a BIMS assessment on [DATE] which scored 11 out of 15 and Resident #99 complained of decreased memory and confusion. Social service note dated [DATE] reveals Resident #99 can be impulsive, forgetful, confused and cognitive impairment was noted. Resident #99 husband passed away while Resident #99 has been in the facility. Social services completed an additional BIMS assessment on [DATE] which confirmed a score of 6 out of 15 noting dementia, disorganized thinking, and difficulty focusing attention. On [DATE] the final BIMS was completed under skilled nurse's notes and reveals that Resident #99 has ok long and short term memory, able to recall location of room and staff faces, made appropriate decisions regarding daily life, is not easily distracted, has organized thinking, and doesn't have an altered level of consciousness. Review of the Social Service Quarterly assessment dated [DATE] in section C psychosocial changes reveal no box checked for personal loss or change in relationships, yet in the dialog box revealed husband passed away and that the resident is happy to go home. Review of Resident #99's Discharge Patient Centered Plan and Instructions signed at discharge on [DATE] revealed the facility therapy department recommended 24/7 assistance upon discharge. The plan did not address the resident being discharged home alone since her husband died.Review of Resident #99's medical record revealed it was absent of a physician's order for discharge.Interview on [DATE] at 9:25 A.M. with Resident #99's brother-in-law (BIL) revealed that physical and occupational therapy hadn't started yet for Resident #99 and was waiting to hear back from the private duty aide vendor on when they would be able to start services.Interview on [DATE] at 10:56 A.M. with Licensed Practical Nurse (LPN)/ Social Service Designee (SSD) #238 revealed Resident #99's BIL was going to set up home health, private duty aide services, and have a neighbor check in periodically on Resident #99. LPN/SSD also revealed that they don't have the name or telephone number of Resident #99 neighbor. LPN/SSD #238 conveyed the BIL lives about two and a half hours away, but LPN/SSD #238 believed that Resident #99 would be able to manage at home. Interview on [DATE] at 1:20 P.M. with Therapy Director confirmed that the discharge: Patient Centered Plan and Instructions revealed a recommendation for 24/7 assistance from the therapy department. An interview to Resident #99 was attempted via telephone on [DATE] at 1:39 P.M. revealing a message saying the mailbox is full and you are unable to leave a message.Interview on [DATE] at 2:06 P.M. with LPN/SSD #238 revealed that she was unaware that therapy recommended 24/7 care for Resident #99 at discharge. Interview on [DATE] at 2:09 P.M. with Therapy Director revealed the therapy department recommended 24/7 assistance due to the resident's alcohol use, decrease safety awareness, could possibly burn the house down as a smoker, impulsivity, moderately impaired cognition, and being confused daily.Interview on [DATE] at 3:04 P.M. with Medical Director revealed he was unaware the therapy department recommended 24/7 assistance. Medical Director revealed he doesn't need to keep the resident in the facility unless the social worker makes him aware. Medical Director could no recall if there was a physician's order for the discharge.Interview on [DATE] at 3:22 P.M. with Resident #99's BIL revealed the resident was still at home and they would be getting therapy for a few days a week and would also get private duty aides to come in about three days a week for about three to four hours at a time. Furthermore, the BIL revealed that private duty aides wouldn't be able to start services until [DATE], and the BIL said he would visit Resident #99 once a week. BIL also revealed that the facility did not receive any outside resources besides skilled services and private duty aide to help with the transition back to the community. Review of the facility policy titled Resident Transfer & Discharge Policy, updated date of[DATE], stated in Section C number 2, once a transfer is deemed appropriate the reason for the transfer will be documented in the record and the physician order will be obtained.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure activity outings outside of the facility were provided for the residents. This affected one resident (Resident #95) of two residents reviewed for activities. The facility census was 128. Findings include: Review of the Activity Calendar dated February 2026 through June 2026 did not reveal evidence outside outings were scheduled for the facility. The January 2026 Activity Calendar for the secured unit was provided and had an outing scheduled for the local library on 01/06/26 at 2:00 P.M. but the January 2026 Activity Calendar was not provided for the entire facility. Interview on 06/24/26 at 3:23 P.M. with Activity Director (AD) #619 revealed she and Activity Assistant (AA) #276 provided activities for the residents. AD #619 revealed she started working at the facility on 03/17/26 and provided a variety of activities for the residents. AD #619 revealed she did not drive the bus for outings outside the facility, and there was a problem getting the bus for outside activities for the residents. AD #619 indicated it had been brought up that the residents would like to have outings. AD #619 revealed the facility bus stayed at the facility but was borrowed by sister facilities a lot. The priority was taking residents to appointments, AD #619 had to work around appointments and there had been no outside outings since she started working at the facility on 03/17/26. AD #619 revealed she did not arrange or schedule appointments or outings because that was done by staff in central supply, but there was no one working in central supply right now. AD #619 indicated the residents asked her about going somewhere out of the facility. Interview on 06/25/26 at 12:05 P.M. with AA #276 revealed she began working at the facility in October 2025. AA #276 indicated when she first started working at the facility there were outside activities provided by the facility, and the person from central supply would schedule the outings. The person from central supply would be told what outings the residents wanted to do and she would schedule the bus for the day. AA #276 revealed the person from central supply left the facility around February of 2026 and since she left there was no one at the facility to schedule the outings. AA #276 indicated she did not remember who drove the bus for the outings outside of the facility. AA #276 revealed Former Activity Director (FAD) #960 left the facility around December 2025 or January 2026 and since then there had been no outside outings. Interview on 06/25/26 at 12:53 P.M. with the Administrator revealed the facility bus was shared with several sister facilities. The Administrator indicated she was managing the transportation schedule right now and a lot of residents had appointments and the use of the bus had to be prioritized for appointments. The Administrator stated the facility had a van and a bus and the van held one resident with a wheelchair and one other person and the driver. The bus could hold about three wheelchairs and a handful of residents. The Administrator confirmed the facility had not provided outings outside of the facility for a few months. The Administrator revealed the facility had a central supply position available and the central supply staff person coordinated transportation. Right now the Administrator and the Director of Nursing were coordinating transportation. Interview on 06/30/26 at 1:10 P.M. with Resident #95 revealed he was the Resident Council President. Resident #95 indicated the facility had not had any outings in a long time and residents wanted to go places like Wal-Mart, and Dairy Queen. Resident #95 stated again that they had not been anywhere in a long time and they wanted to go. Resident #95 indicated the residents spoke their opinions at the Resident Council Meetings and were told the facility would find a day to get them out to go somewhere. Resident #95 revealed the residents were told it would be on the calendar when there was an outing scheduled but no outings have been scheduled. Resident #95 indicated everyone had given up and stopped looking for an outing. Resident #95 stated going to Wal-Mart and Dairy Queen were simple outings and we need to get out of here! Resident #95 indicated the residents even liked just driving around and looking at the scenery and he loved to see the residents enjoying themselves. Review of the facility policy titled Resident Rights and Facility Responsibilities dated 01/06/25 included residents had the right of access to opportunities that enabled the resident, at the resident's own expense or at the expense of a third-party payer to achieve the resident's fullest potential, including educational, vocational, social, recreational, and habilitation programs.

Based on record review and interview, the facility failed to ensure Resident #22's blood glucose levels will properly monitored before administration of insulin in accordance with physician orders and care planned interventions, and failed to ensure Resident #113's cardiac medication was ordered and administered properly. This affected two residents (Resident #22 and Resident #113) out of five residents reviewed for quality of care. Findings include:1. Review of the medical record revealed Resident #22 was admitted on [DATE] with relevant diagnoses of type 2 diabetes mellitus with hyperglycemia (high blood sugar), chronic kidney disease, major depressive disorder, and hyperlipidemia (high fat in the blood). Review of the care plan (updated 05/09/24) for Resident #22, revealed a care plan for at risk for hyper/hypoglycemic reactions, abnormal lab values, diabetic ulcers, peripheral vascular disease, related to type 2 diabetes mellitus, chronic kidney disease, and use of antidiabetic medications. Relevant interventions included accu-checks (a type of blood glucose test) as ordered and give medications/insulin per physician order. Review of the Minimum Data Set (MDS) 3.0 Quarterly Assessment (a standardized assessment tool that measures health status in nursing home residents) dated 04/21/26, revealed a Brief Interview for Mental Status (BIMS) score of 05 (severe cognitive impairment), and activities of daily living (ADL) assistance ranging from set up assistance to dependent assistance for toilet hygiene, upper and lower body dressing, application of footwear, personal hygiene, and bed to chair transfer. Review of the active physician orders revealed medications for diabetes management included Lantus subcutaneous solution (ordered 03/25/26) 100 units/milliliter (ml). Inject 43 units subcutaneously every 12 hours for type 2 diabetes mellitus, Trulicity subcutaneous solution auto-injector 3 milligram (mg)/.05 ml, Inject 3 mg subcutaneously one time a day every Saturday for diabetes mellitus. Further, another medication ordered on 02/22/26 and discontinued on 06/22/26, revealed an order for Novlog FlexPen subcutaneous solution pen injector 100 units/milliliter (ml), Inject 21 units subcutaneously before meals for diabetes mellitus. Hold for blood glucose <150. Review of a new order on 06/22/26 revealed an order for Novlog FlexPen subcutaneous solution pen injector 100 units/milliliter (ml). Inject 24 units subcutaneously before meals for diabetes mellitus. Hold for blood glucose <150. Review of the Medication Administration Record (MAR) for April 2026, May 2026, and June 2026, revealed that in June 2026, blood glucose levels were documented with meals 06/01/26 through 06/22/26 12:00 P.M. Further review of the MAR on 06/22/26 at 4:00 P.M. 06/23/26 at 7:00 A.M, 11:00 A.M., and 4:00 P.M., 06/24/26 at 7:00 A.M, 11:00 A.M., and 4:00 P.M., and on 06/25/26 at 7:00 AM. and 11:00 A.M., revealed no documentation space on the MAR to record the blood glucose levels. Review of the nurses notes 06/22/26 through 06/25/26 and the medical record titled, Blood Sugar Summary log revealed the last blood glucose level documented was on 06/22/26 at 11:00 A.M. Review of Nurse Practitioner (NP) #613 progress note dated 06/25/26 for Resident #22, revealed the NovoLog insulin was increased from 21 units to 24 units three times a day due to high blood glucose levels and an increase in A1C (a blood test that measures average blood sugar levels over the past 2 to 3 months) blood levels. Interview on 06/25/26 at 3:25 P.M. with the Director of Nursing (DON), verified the physician orders for insulin, the absence of blood glucose readings in the medical record vital sign section, the nurses notes, and the medication administration record (MAR) on 06/22/26 at 4:00 P.M, on 06/23/26 at 7:00 A.M., 11:00 A.M., and 4:00 P.M., on 06/24/26 at 7:00 A.M., 11:00 A.M., and 4:00 P.M., and on 06/25/26 at 7:00 A.M. and 11:00 A.M. The insulin order was corrected on 06/25/26 at 3:30 P.M. by the DON to include the blood glucose reading to the MAR after surveyor intervention. Review of the facility policy titled, Medication Administration General Guidelines (revised December 2019), revealed medications were administered in accordance with the written orders of the prescriber, and the documentation of dosing parameters such as vital signs and lab values in the electronic MAR system. 2. Review of Resident #113's medical record revealed an admission date of 01/10/26 and diagnoses included emphysema, atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure and end stage renal disease. Review of Resident #113's care plan dated 01/15/26 and revised 01/23/26 included Resident #113 was at risk for decreased cardiac output and abnormal lab values related to atrial fibrillation, CHF (congestive heart failure), hyperlipidemia and hypertension. Resident #113 would not have signs and symptoms of decreased cardiac status as evidenced by no shortness of breath, no chest pain, vital signs within normal limits and no increased edema. Interventions included to give medications per physician order; monitor and document signs of shortness of breath and check Resident #113's oxygen saturation as needed and notify the physician or nurse practitioner if it was low; monitor for signs and symptoms of heart failure including dyspnea, shortness of breath, change in mental status, complaints of chest pain and increased edema. Review of Resident #113's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #113 was cognitively intact. Resident #113 used a wheelchair. Resident #113 required supervision or touching assistance for toileting hygiene, upper and lower body dressing and personal hygiene. Resident #113 required partial to moderate assistance for putting on socks and footwear. Resident #113 required supervision or touching assistance for the ability to transfer to and from a bed to a chair or wheelchair and the ability to get on and off a toilet or commode. Review of Resident #113's physician orders dated 04/22/26 revealed Resident #113 had a cardiology appointment scheduled on 04/27/26 at 11:15 A.M. Review of Resident #113's Medication Administration Record revealed Resident #113 had a cardiology appointment scheduled on 04/27/26 at 11:15 A.M. Review of Resident #113's After Visit Summary for a cardiology appointment dated 04/27/26 revealed orders to increase Entresto (used to treat chronic heart failure) to 49/51 mg twice daily. Start taking sacubitril-valsartan (Entresto) 49/51 mg twice daily. Stop taking sacubitril-valsartan (Entresto) 24-26 mg tablet. Resident #113's heart failure, heart failure with reduced ejection fraction, NYHA class 111 (marked limitation, comfortable at rest, less than ordinary activity causes symptoms), atrial fibrillation (irregular heart beat), edema of both legs, body mass index (BMI) 50.0-59.9 adult. Review of Resident #113's Medication Administration Record (MAR) dated 04/27/26 through 06/30/26 revealed Resident #113 received Entresto (sacubitril-valsartan) oral tablet 24-26 mg two times a day for CHF (congestive heart failure). Resident #113's Entresto was not increased to 49-51 mg twice daily per physician orders on 04/27/26. Review of Resident #113's medical record including progress notes and physician orders dated 04/27/26 through 06/30/26 did not reveal evidence orders written on 04/27/26 by Resident #113's cardiologist to increase his Entresto to 49-51 mg twice daily were implemented or discussed with his primary care physician or his cardiologist. Review of Resident #113's After Visit Summary for a local hospital ED visit dated 06/19/26 included Resident #113's reason for the visit was SVT (supraventricular tachycardia) and the diagnosis was irregular heartbeat. Follow-up with your cardiologist, Resident #113 had a cardiology visit scheduled for 0707/26 at 11:40 A.M. Ask your physician about medications including sacubitril-valsartan 49-51 mg tablet, take one tablet by mouth two times daily. Review of Resident #113's medical record revealed no evidence the physician reviewed his cardiac medications as recommended in the hospital after visit summary. Observation on 06/22/26 at 10:13 A.M. of Resident #113 revealed he was lying on his left side in his bed with the head of the bed slightly elevated. Resident #113 was pleasant and answered questions appropriately. Interview on 07/06/26 at 9:06 A.M. of the Director of Nursing (DON) revealed Resident #113 had a cardiologist appointment on 04/27/26 and he did not return to the facility with physician instructions from the visit. The DON indicated Resident #113's physician instructions (After Visit Summary) were sent to his online portal that gave direct access to his personal health records and the facility did not have access to the online portal. The DON confirmed the facility had a responsibility to follow-up to obtain the physician instructions from the cardiology visit but it was also the responsibility of Resident #113 to make sure the facility received the physician orders from the visit. The DON revealed providers were not always aware a resident lived in a long term care facility. The DON indicated she was able to get Resident #113's cardiology appointment After Visit Summary physician discharge instructions dated 04/27/26 from Resident #113's daughter. Review of Resident #113's progress notes dated 07/06/26 at 9:55 A.M. revealed the DON placed a call to Resident #113's Cardiologist regarding his Entresto. Resident #113 was to continue the current order until his appointment on 0707/26. Interview on 07/06/26 at 10:33 A.M. with the DON revealed she reviewed Resident #113's hospital ED After Visit Summary on 06/19/26 and contacted Resident #113's cardiologist about the increased dose of Entresto and was told Resident #113 had a cardiology appointment on 07/07/26 and his medications would be reviewed at the appointment. The DON confirmed on 06/19/26 when Resident #113 arrived at the facility from his ED visit he arrived with an After Visit Summary that had discharge instructions written including to ask Resident #113's physician about the medication sacubitril-valsartan 49-51 mg, take one tablet by mouth two times daily. The DON confirmed there was no evidence in Resident #113's medical record this was completed until she called Resident #113's cardiologist on 07/06/26. Review of the facility policy titled Medication Administration-General Guidelines dated 11/2021 included medications were administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. Medications were administered in accordance with written orders of the prescriber. This deficiency represents non-compliance investigated under Complaint Number 2998550, 2984600, 2788113, and 2700113.

Based on observation, interview, and record review, the facility failed to ensure pressure reducing interventions were in place at all times. This affected two residents (Resident #20 and Resident #149) of four residents reviewed for pressure ulcers. Findings include:1. Review of the medical record for Resident #149 admitted on [DATE] with diagnosis of acquired absence of left leg below the knee, surgical amputation aftercare, posthemorrhagic anemia, severe protein calorie malnutrition, type two diabetes, hypertension, and pulmonary vascular disease. Resident #149 had a surgical wound to left leg and a pressure ulcer on his coccyx. Resident #149 short and long-term memory were intact and could make informed decisions and could make needs known. Review of the physician orders for Resident #149 dated 06/11/26 revealed a skin prevention order for a low air loss mattress to the bed and to check function every shift.Observation on 06/22/26 at 12:11 P.M. of Resident #149's room revealed a semiprivate room with a navy blue mattress in front of B bed that was not Resident #149's. Resident #149 was observed to have a below the knee (BTK) amputation.Interview on 06/22/26 at 12:11 PM with Resident #149 revealed that the mattress lying on the floor by the other bed should be on his bed, and it has been on the floor for about two weeks. Resident #149 said the mattress is supposed to help me with my wounds. Someone brought it in here about two weeks ago and never came back to put it on the bed. Observation on 06/23/26 at 11:00 A.M. revealed the mattress still on the floor in Resident #149 room.Interview on 06/23/26 at 11:03 A.M. with Registered Nurse (RN) #398 confirmed that the mattress has been on the floor for a week in Resident #149 room. Interview on 06/23/2026 at 11:15 A.M. with Regional Director of Operations revealed the mattress on the floor in Resident #149 room was supposed to be in use for Resident #149 since 06/11/26. 2. Review of the medical record for Resident #20 admitted on [DATE] with diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting left dominant side, acute chronic respiratory failure with hypoxia, type two diabetes with diabetic neuropathy, chronic obstructive pulmonary disease, severe protein calorie malnutrition, dementia, pressure ulcer of right heel stage three, pressure induced deep tissue damage of left heel, and adult failure to thrive. Record review of physician orders for Resident #20 dated 05/16/26 revealed a skin prevention order to offload heels while in bed as tolerated.Review of Resident #20's nurse practitioner note dated 06/22/26 at 11:45 A.M. revealed the resident was alert and oriented times one which was his usual.Observation on 06/30/26 at 8:43 AM revealed Wound Nurse Practitioner and Licensed Practical Nurse (LPN) #600 finished the sacral dressing change, left the room and did not offload Resident #20 heels before they left the room.Interview on 06/30/26 at 8:43 AM with Wound Nurse (LPN #600) confirmed Resident #20 heels not offloaded and should be and the pressure relieving boots were on top of wardrobe cabinet.This deficiency represents non-compliance investigated under Complaint Numbers 2975249, 2721605, and 2699470.

Based on observation, interview, record review, review of Occupational Therapy Evaluation and Plan of Treatment, and review of the facility policy the facility failed to ensure Resident #113's care planned fall preventive interventions. This affected one resident (Resident #113) out of three residents reviewed for falls. The facility census was 128. Findings include:Review of Resident #113's medical record revealed an admission date of 01/10/26 and diagnoses included emphysema, atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure and end stage renal disease.Review of Resident #113's care plan dated 01/10/26 and revised on 01/12/26 included Resident #113 was a fall risk characterized by impaired mobility. Resident #113 would have no fall related injuries that required hospitalization through the review date. Interventions included bed in low position while in bed; encourage Resident #113 to call for assistance. Review of Resident #113's Occupational Therapy Evaluation and Plan of Treatment dated 01/12/26 included Resident #113 presented with impairments in balance, mobility, strength, and follow through. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention Resident #113 was at risk for falls, further decline in function, increased dependency upon caregivers, decrease in level of mobility and decreased participation with functional tasks. Resident #113 required partial to moderate assistance with shower/bathing and upper and lower body dressing. Resident #113 had falls six times in the past year with injury described as pain in bilateral lower extremities and lower back.Review of Resident #113's care plan dated 01/23/26 included Resident #113 had an ADL self-care mobility/functional ability performance deficit related to his diagnoses. Resident #113 would maintain current functional status related to ADL's. Interventions included Resident #113 required partial to moderate assistance with showering/bathing. Review of the facility incident log revealed Resident #113 had a fall incident on 04/10/26 at 4:30 P.M.Review of Resident #113's progress notes dated 04/10/26 at 5:04 P.M. included Licensed Practical Nurse (LPN) #223 answered the call light in the shower room and Resident #113 was sitting in a wheelchair and the shower chair had one leg broken. Resident #113 stated the shower chair broke and he got himself off the floor. Resident #113's vital signs including push and pulls were within normal limits. Resident #113 complained of pain from the right buttock down to the right knee. NP #613 was notified and x-rays were ordered and neuro checks were in place. All appropriate parties were notified.Review of Resident #113's Fall Review dated 04/10/26 at 6:30 P.M. included Resident #113 was a high fall risk. Resident #113 ambulated with problems and with devices and required partial physical support while standing. Resident #113 had three or more health conditions. Resident #113 complained of pain from the right buttock down to the right knee, the pain was new and it hurt a little bit. The immediate intervention was education was provided to call for help. X-rays were ordered and neuro checks were in place. All appropriate parties were notified. The facility IDT (interdisciplinary) team met for Resident #113's fall on 04/10/26. Resident #113 stated the shower chair broke. Resident #113's vital signs were within normal limits, no open or discolored skin areas noted. Neuro checks were started and were within normal limits. Immediate intervention was Resident #113 was assisted from the floor with one assist. The broken shower chair was red-tagged and all facility shower chairs were inspected for integrity. A new bariatric shower chair was ordered and Resident #113 was able to use an additional bariatric shower chair in the facility. The fall review did not address the resident being left alone in the shower room.Review of Resident #113's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #113 was cognitively intact. Resident #113 used a wheelchair. Resident #113 required supervision or touching assistance for toileting hygiene, upper and lower body dressing and personal hygiene. Resident #113 required partial to moderate assistance for putting on socks and footwear. Resident #113 required supervision or touching assistance for the ability to transfer to and from a bed to a chair or wheelchair and the ability to get on and off a toilet or commode.Observation on 06/22/26 at 10:13 A.M. with Resident #113 revealed he was sitting in a wheelchair, and was pleasant and answered questions appropriately. Resident #113 revealed he weighed 450 pounds and needed a sturdy shower chair. Resident #113 indicated one day in April the shower chair broke while he was taking a shower and he fell on the floor. Resident #113 indicated his side is still numb from the fall. Resident #113 revealed when he fell he was by himself in the shower room, he activated the call light and he was on the floor 15 minutes before Licensed Practical Nurse (LPN) #223 came to help him up. Resident #113 stated he was lying on the floor and it was dirty. Resident #113 indicated the aides leave him by himself all the time in the shower room and he does not tell them he wants to be alone in the shower room. Interview on 06/25/26 at 6:31 A.M. with Certified Nursing Assistant (CNA) #387 revealed he was working on 04/10/26 when Resident #113 had a fall in the shower room. CNA #387 revealed the shower chair was only built to hold a certain amount of weight, it was a plastic chair, and the leg broke while Resident #113 was taking a shower. CNA #387 revealed Resident #113 took showers and did not have the aides in the room. CNA #387 indicated Resident #113 was fine in the shower room by himself and while he was showering on 04/10/26 CNA #387 took a 15 minute break. CNA #387 revealed when he returned from his break the chair had broken and Resident #113 was in his wheelchair inside the shower room. CNA #387 indicated the shower chair that broke was supposed to hold 600 pounds and after it broke Resident #113 requested to use the therapy bariatric chair because it was sturdier and had metal legs. CNA #387 revealed Resident #113 did not tell him how long he was waiting for the call light to be answered after the chair broke.Interview on 06/25/26 at 2:59 P.M. of Director of Rehab (DOR) #720 revealed Resident #113 was not currently receiving therapy and his therapy ended on 02/25/26. DOR #720 indicated one of the goals of therapy was for Resident #113 to bathe himself and this would include washing at the sink. Resident #113 required moderate assist for lower legs and feet. DOR #720 revealed she knew Resident #113 fell because the shower chair broke and she spoke with the nursing staff and the Administrator about ordering the appropriate equipment. DOR #720 revealed it was equipment failure and she recommended a bariatric shower chair. DOR #720 indicated Resident #113 borrowed the therapy bariatric shower chair until the bariatric chair ordered by the facility was available. Interview on 06/29/26 at 10:30 A.M. of the Director of Nursing (DON) revealed residents used the shower room when they wanted to take a shower and the level of assistance was documented in the resident care plan. The DON revealed residents should always be supervised when they were in the shower room. The DON indicated the aides should stay and supervise while the resident showered and the curtain could be pulled to allow privacy but the aides should always be in the room. The DON revealed Resident #113 had a fall in the shower room because the shower chair broke. The DON revealed Resident #113 used the therapy bariatric shower chair for his showers and there was also a bariatric shower chair which replaced the broken chair. The DON indicated she was not sure if there was an aide in the shower room when Resident #113 fell.Interview on 06/29/26 at 3:17 P.M. with Nurse Practitioner (NP) #613 revealed Resident #113 had a fall on 04/10/26 and she saw him on 04/13/26. NP #613 indicated Resident #113's right knee pain was chronic and he had it before the fall on 04/10/26, but she did not know his body was numb or he was having pain because he did not tell her he was having these issues. NP #613 revealed she was surprised he had not told her because he told her when he had a problem.Review of the facility policy titled Falls-Clinical Protocol reviewed 01/06/25 included for an individual who fell, staff would attempt to define possible causes. A Fall Assessment and pain assessment were to be completed and the care plan would be reviewed and revised as appropriate.This deficiency represents non-compliance investigated under Complaint Number 3050538 and 2788113.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #113 had a comprehensive evaluation and care planned interventions for a significant childhood trauma. This affected one resident (Resident #113) out of three residents reviewed for trauma. The facility census was 128. Findings include: Review of Resident #113's medical record revealed an admission date of 01/10/26 and diagnoses included emphysema, atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure and end stage renal disease.Review of Resident #113's Social Service admission assessment dated [DATE] included Resident #113 responded yes to the question have you experienced or witnessed a traumatic event in your life. Resident #113 described the trauma as a car accident in my life, and he would like to speak with a mental health professional. The assessment stated Resident #113's care plan reflected his needs and wishes related to trauma.Review of Resident #113's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #113 was cognitively intact. Review of Resident #113's Social Service Quarterly assessment dated [DATE] included Resident #113 responded yes to the question have you experienced or witnessed a traumatic event in your life and described the trauma as homelessness. Resident #113 indicated he did not wish to speak with a mental health professional. Resident #113's care plan did not reflect resident's needs and wishes related to trauma.Review of Resident #113's care plan dated 01/16/26 and revised on 05/04/26 did not reveal evidence of a care plan related to trauma.Review of Resident #113's Psychiatric Note dated 05/26/26 included Resident #113 was seen on 01/27/26 for an initial psychiatric assessment and medication management. Resident #113 had trauma and revealed being shot at age [AGE] to 13, stabbed at age [AGE] to 16, and there was a severe motor vehicle accident involving his sisters during his adolescence. Resident #113 had a childhood assault in which he reported he was tied up, beaten, and severely injured by his peers. Resident #113 had an extensive history of childhood and adult trauma with ongoing guilt, emotional distress, anxiety, and depressive symptoms. Trauma-related symptoms were present; however, full PTSD criteria would be further assessed as treatment progressed. Resident #113's diagnoses included major depressive disorder, generalized anxiety disorder, insomnia disorder and unspecified trauma-and stressor-related disorder.Observation on 06/22/26 at 10:13 A.M. with Resident #113 revealed he was lying on his left side in his bed with the head of the bed slightly elevated. Resident #113 was pleasant and answered questions appropriately.Interview on 06/29/26 at 10:09 A.M. with Nurse Practitioner (NP) #613 revealed Resident #113 had a history of anxiety and she was not aware he had significant childhood trauma where he was stabbed, shot and tied up. NP #613 indicated Resident #113 never mentioned it when she talked to him. Interview on 06/29/2026 at 10:30 A.M. with the Director of Nursing (DON) revealed she was not aware Resident #113 had significant childhood trauma but it should be in his admission paperwork. The DON indicated she thought Social Services asked Resident #113 about his mental health including PTSD. The DON indicated she did not know Resident #113's psychiatric progress notes stated he had significant trauma as a child. Interview on 07/01/26 at 9:35 A.M. of Certified Psychiatric Nurse Practitioner (CPNP) #900 revealed she was still following up with Resident #113 to determine if she thought he had PTSD. CPNP #900 revealed she had not shared Resident #113's history with the staff but her psychiatric progress notes were available for staff to review. CPNP #900 indicated Resident #113 did not talk about his past traumas in depth, but discussed current stressors when she visits him. Interview on 07/01/26 at 12:40 P.M. with Senior Social Worker (SSW) #615 revealed when a resident was admitted there was a trauma question on the social service admission form. There was also a trauma question on the Quarterly assessment and social services followed the MDS calendar. SSW #615 indicated the question was have you ever experienced a traumatic event in your life. SSW #615 indicated if a resident stated they had trauma then they were connected with psychiatric services if they requested it. SSW #615 revealed there should be a trauma care plan and she confirmed Resident #113 did not have a trauma care plan completed timely. SSW #615 indicated the care plan should include things like if triggers were identified and interventions were implemented and if there was a trauma but the resident did not want to do anything. Other disciplines like nursing could add to the care plan as needed. SSW #615 revealed she spot checked assessments done by the Social Services Designees, she did not spot check Resident #113's assessments dated 01/14/26 and 04/15/26 and Resident #113's trauma was just missed. Review of the facility policy titled Resident Rights and Facility Responsibilities reviewed 01/06/25 included residents had the right upon admission and thereafter, the right to adequate and appropriate medical treatment and nursing care and to other ancillary services that comprised necessary and appropriate care consistent with the program for which the resident contracted.

Based on record review, observation, and interview, the facility failed to ensure a dignified homelike environment by knocking on the resident's door before entrance. The affected one resident (Resident #149) with the potential to affect five additional residents (#10, #81,#20, #108, and #88) residents out of 22 residents observed for dignity. The census was 127.Findings Include:Review of the medical record for Resident #149 admitted on [DATE] with diagnosis of acquired absence of left leg below the knee, surgical amputation aftercare, posthemorrhagic anemia, severe protein calorie malnutrition, type two diabetes, hypertension, and pulmonary vascular disease. Resident #149 had a surgical wound to left leg and a wound on his coccyx. Resident #149 short-and long-term memory are intact and can make informed decisions. Resident #149 could make needs known. Observation on 06/22/26 at 2:13 P.M. revealed Certified Nursing Assistant (CNA) #341 did not knock on Resident #149's door when entering the room to provide care. Furthermore, observation on 06/23/26 from 8:24 AM to 8:27 AM revealed STNA #341 failed to knock on the door of Resident #10, #81,#20, #108, and #88 before entering. Interview on 06/22/26 at 12:11 P.M. with Resident #149 revealed they don't knock on my door before they come in. Interview on 06/23/26 at 8:27 A.M. with CNA #341 revealed she knew she needed to knock on doors before entrance but stated I'm moving fast to take care of people.This deficiency represents non-compliance investigated under Complaint Number 2721605 and 2700113.

Based on observation, record review, interview, and policy review the facility failed to ensure appropriate interventions were implemented to timely identify pressure ulcers for Resident's #1 and #80. Actual Harm occurred on 09/08/22 when Resident #80, who required extensive assistance with two staff for bed mobility and transfers was observed to have a new unstageable pressure ulcer (full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar) to the right gluteal fold when first observed by Licensed Practical Nurse (LPN)/Wound Nurse #629. In addition Actual Harm occurred on 09/20/22 when Resident #1, who required extensive assistance of two staff for bed mobility, transfers, and toilet use was observed during wound rounds to have a new unstageable pressure ulcer across the bilateral glutei. This affected two residents (Resident's #1 and #80) of three residents reviewed for pressure ulcers. The facility census was 137. Findings include: 1. Review of the medical record for Resident #80 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 12/10/21 for Resident #80 revealed he was at risk for impaired skin integrity related to immobility. Interventions included Braden score quarterly and as needed, dry thoroughly between skin folds after cleansing, monitor between folds for redness, irritation, bleeding, malodor, etc., pressure redistribution cushion to chair, and pressure redistribution mattress to bed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 had impaired cognition. He required the assistance of two staff for bed mobility and transfers. He was frequently incontinent of bladder and always incontinent of bowel. He was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers at the time. Review of the quarterly Braden scale skin assessment dated [DATE] revealed Resident #80 was at mild risk for developing a pressure area as his sensory perception was slightly limited, he was rarely moist, his mobility was very limited, and he had a problem with friction and shear requiring moderate to maximum assistance in moving. Review of the form labeled, Weekly Ulcer/Wound Documentation - V6 dated 09/08/22 and completed by LPN/Wound Nurse #629 revealed Resident #80 had a new unstageable pressure ulcer to his right ischial tuberosity. Resident #80's pressure ulcer was unstageable as the area had slough in the base of the wound and a scant amount of thin green drainage with no foul odor. The unstageable pressure ulcer to Resident #80's right ischial tuberosity measured 2.0 centimeters (cm) in length by 1.5 cm in width. The wound base was covered with 100 percent (%) slough tissue. Review of the nursing noted dated 09/08/22 at 7:12 A.M. revealed a new skin alteration was noted to Resident #80's right gluteal fold when assisting him to bed. Resident #80 denied he had any pain or discomfort to the area. The area was cleansed with normal saline and a border gauze dressing was applied. The physician was notified, and no new orders were given at the time. Review of the nursing note dated 09/08/22 at 12:02 P.M. authored by LPN/Wound Nurse #629 revealed she was completing weekly wound tracking and assessment for Resident #80. Resident #80 was observed to have a pressure area to his right ischial tuberosity. LPN/Wound #629 indicated the pressure ulcer was unstageable related to slough being present. Review of the physician orders for September 2022 revealed Resident #80 had an order to cleanse right ischium area with normal saline or skin cleanser and pat dry with nonsterile two-by-two gauze, apply normal saline moistened collagen powder and cover with a border foam dressing daily. Review of the form labeled, Weekly Ulcer/Wound Documentation - V6 dated 09/13/22 and completed by LPN/Wound Nurse #629, revealed Resident #80's unstageable pressure ulcer to his right ischial tuberosity continued. The pressure ulcer measured 2.0 cm in length by 1.2 cm in width by 0.2 cm in depth. The whole wound base was visible with 100% granulated tissue, no slough, and a scant amount of thin straw-colored drainage. Observation on 09/22/22 at 10:19 A.M. with LPN/Wound Nurse #629 revealed Resident #80 had a pressure ulcer to his right ischial tuberosity with all the wound base visible with 100% granulation tissue present and scant amount of thin, straw-colored drainage. LPN/Wound Nurse #629 cleansed area with normal saline and patted dry with nonsterile two-by-twos, applied normal saline moistened collagen powder to the wound base, and applied a border foam dressing. Interview on 09/22/22 at 10:31 A.M. with LPN/Wound Nurse #629 stated on 09/08/22 staff told her Resident #80 had a new skin alteration and she assessed Resident #80. LPN/Wound Nurse #629 verified Resident #80's new skin alteration was found on his right ischial tuberosity and was classified as an unstageable pressure ulcer due to the presence of slough to the wound bed when first assessed. Review of the facility policy titled, Pressure Ulcer Prevention Protocols/Risk Assessment, dated 06/08/22, revealed no evidence of interventions to identify pressure ulcers at an earlier stage. 2. Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission assessment dated [DATE] revealed Resident #1 was at high risk for skin breakdown. Review of Resident #1's admission MDS 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact and required extensive assistance of two staff for bed mobility, transfers, and toilet use. Review of Resident #1's discharge return anticipated MDS 3.0 assessment dated [DATE] revealed Resident #1 was frequently incontinent of urine and bowel. Review of Resident #1's progress notes dated 08/25/22 at 7:19 A.M. revealed Resident #1 was admitted to the local hospital with severe [CONDITION(S)], urosepsis. Review of Resident #1's hospital records revealed [MEDICATION(S)] 125 milligrams (mg), oral liquid [MEDICATION(S)], (an antibiotic) was administered four times daily from 08/25/22 through 09/04/22 for [CONDITION(S)] (a bacterium that causes diarrhea and [CONDITION(S)]). Review of Resident #1's Readmission assessment dated [DATE] revealed Resident #1 was at severe risk for skin breakdown. Review of Resident #1's progress notes dated 09/08/22 through 09/20/22 did not reveal Resident #1 refused to have care provided except for 09/16/22 due to stomach cramping. Review of Resident #1's assessments from 09/08/22 through 09/20/22 revealed no documented evidence skin assessments (C1 Health Documentation) were completed. Review of Resident #1's care plan dated 09/09/22 included Resident #1 had the potential for alteration in skin integrity related to immobility, incontinence, [CONDITION(S)], moisture skin folds, and abdominal wound. Resident #1 liked to direct care despite staff attempting to provide care as ordered. Resident #1 denied frequent skin interventions stating that physicians have told her in the past not to do certain things although the physician told her otherwise. Resident #1 was followed by facility wound doctors and refused certain suggestions of care. The goal of the care plan included Resident #1 would not develop skin breakdown through the review date. Interventions included to keep bed linen clean, dry, and as free of wrinkles as possible. Observation on 09/19/22 at 1:13 P.M. of Resident #1 revealed she was lying in her bed, her hair was disheveled, tangled, and matted on the back of her head. Resident #1 stated she laid in in poop and pee for hours. Resident #1 stated she required staff assistance for her care, and she had sores and wounds because her care was not provided timely. Resident #1 stated she had sores on both legs, her rear end, thighs, and sores on her side where her creases were. Resident #1 indicated when staff cleaned her, they finished and left the room immediately, and did not ask her if she needed anything else. Resident #1 stated the staff just walked out of the room and did not come back. Resident #1 stated she was miserable, her legs jerk, and no one comes to help. Resident #1 stated she yelled out and staff did not come. Resident #1 stated staff have told her they would come back to help her, and no one returns to provide care. Resident #1 stated she had a lot of bowel movements and the poop just runs out of me as soon as they change me, I have another bowel movement. Review of Resident #1's physician orders dated 09/21/22 revealed orders to cleanse the wound (across gluteus) with normal saline or skin cleanser and pat dry with two nonsterile two by two gauze sponges; apply [MEDICATION(S)] (wound/burn gel that has antibacterial and bacteria resistant properties) followed by an abdominal (ABD) pad, and secure with tape; monitor for signs and symptoms of pain with dressing change; medicate with pain medication as needed and, or notify the physician if pain is present; every day shift for wound care and as needed. Review of Resident #1's physician wound notes dated 09/20/22 included Resident #1 had new bilateral gluteal wounds found on 09/20/22. The location of the wound was bilateral glutei and was unstageable. The tissue bed was 75 percent necrotic and 25 percent epithelial. Slough type was yellow, soft, and wound edges were attached. The wound measured 5.0 cm in length by 12.0 cm in width, and the depth was unable to be determined. Description of the wound was irregular ovoid, linear-shaped, full-thickness wound crossing the right and left glutei and contiguous (touching along a boundary or at a point; adjacent), with a base comprised of 20 percent purple discolored epidermis laterally on the right gluteus, and 80 percent pale soft adherent eschar; unable to assess drainage or odor due to feces, edges were irregular, defined and attached; the periwound (tissue surrounding the wound) was moist and soiled. Interview on 09/22/22 at 1:15 P.M. with STNA #755 revealed she was preparing to provide care for Resident #1, and this was the first time today she provided care for Resident #1 because she was very busy and did not have time previously. Observation on 09/22/22 at 1:15 P.M. of STNAs #669 and #755 providing incontinence care for Resident #1 revealed a towel was placed in Resident #1's left groin area. The towel had a large amount of liquid brown mucous drainage. STNA #755 stated Resident #1 requested the towel be placed in her left groin area due to large amounts of stool she was having. Resident #1 stated the towel kept the stool from going all over the place. STNA #755 stated Resident #1 usually had large amounts of loose watery diarrhea stools and it would mound up in her perineal area and there would be a huge pool of stool underneath her as well. STNA #755 stated today Resident #1 did not have the large diarrhea bowel movement she had in previous days. During incontinence care Resident #1 was rolled onto her side and a soiled dressing across Resident #1's buttocks was noted. LPN #820 walked into Resident #1's room, stood by the bed for approximately 10 minutes, stated something (unclear) then walked out of Resident #1's room. STNA #755 stated LPN #820 left to gather supplies to change the soiled dressing across Resident #1's buttocks. The dressing had brownish drainage saturating it and the edges were raised from the skin due to moisture. LPN #820 did not return to Resident #1's room for approximately 15 minutes and STNA #755 walked out of the room to find her. Resident #1 stated often staff say they are going to do something and do not follow through. STNA #755 walked back in the room and stated LPN #820 was on her way to the room. At 1:54 P.M. LPN #820 poked her head in the room and stated Wound Nurse (WN)/LPN #629 was on the way to change the dressing. STNAs #669 and #755 stood with Resident #1 lying on her right side waiting for WN/LPN #629 to arrive. Observation on 09/22/22 at 2:03 P.M. revealed WN/LPN #629 arrived for the dressing change and STNA's #669 and #755 positioned Resident #1 on her side. WN/LPN #629 stated she was notified by LPN #820 about the dressing change seven minutes ago, and LPN #820 could have changed the dressing. Resident #1's bottom was reddened and when the dressing was removed, a long red wound could be seen extending across Resident #1's bilateral buttocks. The wound was approximately eight inches long, about a half inch wide, and the wound tissue was red with streaks of white throughout. The drainage was reddish colored. WN/LPN #629 stated this was a new wound found on wound rounds with the wound physician on 09/20/22. WN/LPN #629 stated she ordered a low air loss mattress on 09/20/22, but Resident #1 refused the mattress. Resident #1 confirmed she did not want a low air loss mattress due to dizziness. Resident #1 currently was on a pressure reducing bariatric mattress. WN/LPN #629 stated the wound physician thought the pressure injury was due to Resident #1 lying on wrinkled sheets.

Based on observation, record review, and interview the facility failed to ensure appropriate care for pressure ulcers, failed to provide ordered care for pressure ulcers, failed to accurately document pressure ulcer locations, and failed to prevent the development of a pressure ulcer for Resident #54. This caused actual harm when Resident #54 developed a Stage 3 pressure ulcer (involving full-thickness tissue loss) in the facility on 09/13/21, had no documented orders or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (Resident #54) of three residents reviewed for pressure ulcers. The facility census was 128. Findings include: Record review for Resident #54 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #54's Treatment Administration Record (TAR) and orders for September 2021 revealed an order dated 06/06/21 for the coccyx wound for daily dressing changes including cleansing with normal saline, alginate layer, and covering with a foam dressing. There were no wound care orders or documentation of dressing changes on the TAR for a right or left buttocks wound. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was totally dependent on staff for bed mobility and toileting, and could not complete her mental status assessment. Review of a wound care progress note dated 09/13/21 identified a Stage 3 pressure ulcer measuring 3.0 centimeters (cm) by 1.5 cm by 1.0 cm on the right buttocks. Review of Resident #54's progress notes dated 09/15/21 revealed that the resident did not have any wound dressings in place and new dressings were applied (it did not specify which wounds this involved). A progress note dated 09/20/21 revealed an open area was noted to the resident's right buttocks. There was no dressing in place and the resident was laying on the Foley (indwelling urinary catheter) tubing. Review of Resident #54's weekly wound assessments revealed on 09/27/21 the Nurse Practitioner (NP) assessed a wound to the left gluteus (buttocks) which measured 4.0 cm by 3.0 cm across by 3.0 cm deep. The note indicated the wound had declined, and noted the dressing was not intact. The NP noted it was a Stage 3 pressure ulcer with moderate serosanguinous (blood tinged) drainage. The NP also assessed a Stage 4 pressure ulcer to the sacrum measuring 6.5 cm by 5.0 cm by 1.0 cm. Further review of the weekly wound assessments completed by facility staff revealed no documentation in September of a current left gluteal wound, but did document a right buttocks wound, including assessments and measurements. The assessments also identified a coccyx wound which was present on admission and assessed weekly, with no obvious decline in the month of September 2021. On 09/28/21 at 9:12 A.M. observation of catheter and incontinence care performed by State tested Nurse Aide (STNA) #301 and STNA #302 for Resident #54 revealed when they turned the resident to clean the buttocks, there was what appeared to be a Stage 4 pressure ulcer on the sacrum and a Stage 3 pressure ulcer on the left buttocks which were both open to air. There was a cloth towel beneath these wounds which the resident was laying on. There were no obvious wound care dressings on the towel or pad beneath it (which may be suspected if the dressings came off when repositioning the resident). Resident #54 was not interviewable. The above findings were verified with STNA #301 at the time of observation. The Director of Nursing (DON) entered during the procedure, cleaned the wounds, and applied alginate (to promote wound healing) and a foam dressing to each pressure ulcer. Interview with LPN (Licensed Practical Nurse) #201 on 09/28/21 at 10:20 A.M. revealed she was the responsible nurse for Resident #54 and had not seen her wounds yet today or provided any care which might involve dislodging or removing the dressings. Interview with the DON on 09/28/21 at 10:22 A.M. confirmed during catheter care, there was no dressing on either of the two pressure ulcers on Resident #54's sacrum or left buttocks. On 09/28/21 at 11:51 A.M. during interview the above findings were confirmed with the Administrator and DON; including discovery of a pressure ulcer of the left buttocks at a Stage 3, observation of the lack of wound dressings during catheter care, documentation of the lack of dressings in place in progress notes, the unclear location of the left vs right buttocks wound in facility documentation, and the lack of wound care orders or documentation of treatment provided for the left buttocks wound. At this time the DON confirmed that documentation related to a right buttocks wound was in error, and that the documentation regarding a right buttocks wound was meant to be of Resident #54's left buttocks wound.

Based on observations, interviews, and record reviews, the facility failed to have an effective Infection Prevention and Control Program (IPCP) to prevent the potential transmission of COVID-19 from the community to the facility. Observation on 12/02/20 revealed a facility State tested Nurse Aide (STNA) entered the facility and had direct resident (Resident (R) 4) contact without all required Personal Protective Equipment (PPE) and without being screened for the absence of signs and symptoms of COVID- 19. Also, the facility failed to ensure their employee and visitor screening tools were being reviewed and appropriate action was taken after an indication of a possible sign or symptom of COVID-19 and/or after an indication that an employee and/or visitor had been exposed to COVID-19. Additionally, observations on 12/01/20 revealed a Nurse Practitioner (NP), who was an outside provider, entered two residents' rooms (R2 and R3) who were on transmission-based precautions (TBPs) without donning all required PPE prior to entering the rooms. These facility failures had the potential to affect all residents who resided at the facility. The Immediate Jeopardy began on 11/27/20 when the facility failed to review the employee screening forms and address an employee who self-screened and marked yes to a COVID-19 symptom. On 12/02/20 at 9:30 PM, the facility's Administrator and Director of Nursing were notified and issued an Immediate Jeopardy at F880, Infection Control. The removal plan for the Immediate Jeopardy was validated on 12/04/20 through observations, interviews, and documentation review. The facility was notified that the Immediate Jeopardy was removed on 12/04/20 at 6:45 PM. After the immediacy removal, the noncompliance remained at a lower scope and severity level of no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy. Findings include: Review of the facility's policy titled, COVID-19 Back Door Quick Guide-Employees Only, updated 11/02/20, revealed .Facility is to have only 1 back door employee entrance with a screening station that includes screens, pens, thermometer .Employee to complete screen on entry into the facility but before entry into patient care area .if the employee answers yes to any of the signs and symptoms at the top of the screen, and yes to any of the questions at the bottom of the screen, the employee is to be tested for COVID-19 and sent home .if the exposure is negative and there is no fever, the employee should work . Continued review of the policy did not address the facility's front (main) entrance. Review of the undated facility document titled, New Admission Transmission Based Precautions Units A & E, revealed 1. Staff to enter facility with mask. 2. Complete screen and wash hands or use hand sanitizer. 3. DON {sic} (don or to put on) N95 mask and face shield. 4. DON {sic} a gown when entering a resident room for care. 5. DOFF {sic}( doff or toremove) gloves when done providing care. 6. DOFF {sic} gown and place in laundry bin. 7. Wash hands or use hand sanitizer. 1. The facility failed to ensure all staff are screened prior to entry into the facility. Review of R4's undated Admission Record, located in the resident's electronic medical record (EMR), under the profile tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R4's Clinical Physician Orders, located in the resident's EMR under the orders tab, revealed on 11/25/20 the resident was ordered to be on HEALTH-Transmission Based Precautions for 14 days after admission/readmission to screen for COVID-19: Follow CDC guidelines . Observation on 12/02/20 at 12:26 PM revealed Stated tested Nurse Aide (STNA) 3 entered the facility's front entrance pushing R4 into the building from the outside. Continued observation revealed STNA3 pushed R4 past the receptionist desk (upstairs screening station) to Unit A (quarantine unit). STNA3 then pushed R4 directly into his room and with her ungloved hands, placed the resident's bedside table in front of his wheelchair. Further observation revealed STNA3 washed her hands in the resident's restroom and exited the room. The resident's door had signage on the door (signage was added after concern of no signage on doors was identified by the surveyor on 12/01/20) which indicated the room was an isolationroom and required PPE of mask, gown, gloves, and face shield. STNA3 did not don a gown or gloves prior to entering the resident's room. Interview on 12/02/20 at 12:34 PM with STNA3 revealed she came into work on this date to transport R4 to a doctor's appointment. STNA3 stated she did not see the signage on the R4's door related to isolation and did not know PPE was to be worn in the resident's room. Continued interview with STNA3 on 12/02/20 at 2:39 PM revealed when she arrived at the facility that morning, she entered through the downstairs entrance of the facility. STNA3 stated she was not screened when she entered the basement entrance. Further interview with STNA3 revealed she took the elevator to the upstairs. STNA3 stated she wanted to ensure that R4 made it to his appointment on time, so she went straight to the unit and got R4 for his appointment. Additionally, STNA3 stated the facility had educated her to always go to the front receptionist's desk to be screened; however, there was no one at the receptionist desk that morning. Interview on 12/02/20 at 1:49 PM with the day shift receptionist revealed she was the person responsible for screening anyone who entered the facility after 8:30 AM. Continued interview revealed before 8:30 AM, either the nurse scheduler or the nursing supervisor was responsible for screening. The receptionist stated she did not remember screening STNA3 on 12/02/20 prior to STNA3 returning with R4 from his medical appointment. Interview on 12/02/20 at 2:24 PM with the Nurse Scheduler (NS) revealed she only screened employees who entered the downstairs entrance at the 3:00 PM shift. The NS stated all other employees were to be screened at the front receptionist desk. Interview on 12/02/20 at 3:05 PM with the Medical Director revealed STNA3 should not have entered the facility and worked without being screened. 2. The facility failed to ensure their employee and visitor screening tools were being reviewed and appropriate action taken. Review of the facility's screening form for STNA4 dated 12/02/20 revealed for the question Have you experienced the following possible signs/symptoms of COVID-19 (mark all that apply) STNA4 circled Yes for the following symptoms: muscle aches, headache, fatigue, abdominal pain, nausea and/or vomiting, diarrhea, and loss of taste or smell (new). During an interview on 12/02/20 at 1:49 PM, the Receptionist revealed she screened all morning shift staff who entered the facility after 8:00 AM. Continued interview with the Receptionist revealed prior to 8:00 AM, either the nurse scheduler or the nursing supervisor completed staff screening. The Receptionist stated if any staff person was going to answer yes to any of the symptoms on the screening form, they should not come into the facility. The Receptionist also stated if any of the staff marked yes to any of the symptoms on the form, she would call the Director of Nursing (DON) or the Infection Preventionist (IP). When reviewing STNA4's employee screening form dated 12/02/20, the Receptionist stated she did not screen the employee; however, the employee indicating she was experiencing seven COVID-19 symptoms was concerning. Further interview with the Receptionist revealed if she stepped away from the front desk, staff would complete the screening form and temperatures themselves. During an interview on 12/02/20 at 2:06 PM, LPN6, who was the assigned nurse for Unit C, revealed STNA4 was at work and assigned to the unit. Unit C is a non-quarantine unit of residents without COVID-19. During an interview on 12/02/20 at 2:30 PM, the Infection Preventionist (IP) revealed she was the one who screened STNA4 that morning. Continued interview revealed STNA4 did not have a fever but did state and indicate on the screening form she was still having symptoms of COVID-19. The IP also stated the STNA's physician (who is also the facility's medical director) released her to return to work. Further interview with the IP revealed STNA4 requested for the IP to send her home because of the symptoms; however, the IP denied her request. The IP stated she told STNA4 that because she did not have a fever and was not coughing, she had to work as scheduled. During an interview on 12/02/20 at 2:50 PM, STNA4 revealed she did circle the symptoms on the form because she was still having the symptoms. STNA4 stated she tested positive for COVID-19 on 10/21/20 and her symptoms had been continuous since the diagnosis. Continued interview with STNA4 revealed her physician told her she was not contagious and released her to come back to work on 11/09/20. STNA4 stated she returned to work on approximately 11/23/20. Review of the facility's COVID-19 Employee Symptom Screen and Potential Exposure Report Forms, dated 12/01/20, revealed five employee screening forms that were only partially completed not having all screening questions answered. Continued review of the screening forms revealed five additional screening forms of employees stating yes to the question Have you been in close contact with a person known to have COVID-19. Review of the facility's COVID-19 Employee Symptom Screen and Potential Exposure Report Forms, dated 12/02/20, revealed five forms were only partially completed not answering all screening questions related to symptoms of COVID-19 and exposure to COVID-19. Continued review of the screening forms revealed two additional screening forms of employees stating yes to the question Have you been in close contact with a person known to have COVID-19. During an interview on 12/02/20 at 7:38 PM, the IP revealed that the screening forms were not reviewed by anyone other than the screener. The IP stated if a person indicated yes to a symptom on the screening form, and there was no fever or cough, the screener was to let the person in the facility. According to the IP, the screener did not need to call her or the Director of Nursing (DON) for further assessment. Continued interview with the IP revealed if an employee had indicated they had been exposed to COVID-19 on the form, the screener should notify her or the DON. After reviewing the screening forms where employees had marked yes to the question Have you been in close contact with a person known to have COVID-19, the IP stated she or the DON should have been notified. The IP stated she had not been notified and was not aware of the exposures. During further interview, the IP verified the incomplete screening forms were not acceptable. During an interview on 12/02/20 at 7:54 PM, the DON revealed it was her expectation the screeners would review the screening forms after they were completed by the employees/visitors. The DON stated if an employee had a fever, the screener should call her or the IP. The DON also stated if they (employee/visitor) answered yes to any of the symptoms on the screening form and to either of the exposure questions, either she or the IP were to be notified. Continued interview with the DON revealed if an employee selected yes to a symptom such as a runny nose but marked no on the exposure questions; the screener should ask more questions. Further interview with the DON revealed if an employee marked no to all symptoms, but marked yes to an exposure question, she would expect the screener to call her or the IP. When reviewing the screening forms of employees who had marked yes to the question Have you been in close contact with a person known to have COVID-19, the DON stated the facility had told employees that without symptoms including a fever, they could still work if they had been exposed. During an interview on 12/02/20 at 8:16 PM, the Administrator revealed it was her expectation the screener would have reviewed the screening forms after screening residents. The Administrator stated if an employee answers yes to a symptom question and yes to one of the exposure questions, then it was her expectation the screener would call the nurse manager. The Administrator also stated a symptom alone or exposure alone would not trigger a call and employees could still work on any unit of the facility. During an interview on 12/02/20 at 3:05 PM, the Medical Director revealed per the CDC guidelines, after 14-days of onset of symptoms, a person was no longer contagious and could return back to work. When asked about STNA4 still having COVID-19 symptoms, the Medical Director stated she may be at high risk for herself (her health) but she was no longer contagious. The Medical Director stated he had no concerns with the STNA working with her symptoms. 3.The facility failed ensure an outside provider wore all the required PPE when caring for residents on quarantine. Review of the facility document titled, COVID-19 Transmission Based Precautions Quick Guide, updated 11/02/20, revealed post signage for Transmission-Based Precautions .Per CDC Guidelines, follow Transmission-Based Precautions. According to CDC guidelines, HCP (Healthcare Professionals) who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to standard precautions and use a NIOSH- approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. https://www.cdc.gov/coronavirus/2019- ncov/hcp/infection-control-recommendations.htm Review of the undated facility document titled, Outside Providers, revealed there were 16 outside providers that visited the facility at minimum monthly. Review of the COVID-19 Nursing Home Data revealed the facility's county positivity rate was high at 19.7% for the week ending on 11/25/20. During an interview on 12/01/20 at 11:51 AM, when asked what infection control practices were in place for new or re-admissions, the Administrator stated, TBP. When asked to clarify what TBP meant, the Administrator stated, Transmission-Based Precautions is all. The Administrator stated PPE of gowns, masks, face shields, and gloves was required to be worn in rooms of residents who were on TBPs and the gowns and gloves were to be discarded prior to going to the next resident. Review of R2's EMR Progress Notes, dated 11/06/20, revealed R2 was sent to the emergency room . Continued review of the resident's progress notes revealed R2 was readmitted to the facility on [DATE]. Review of R3's undated Admission Record, located in the resident's EMR, under the profile tab revealed R3 was admitted to the facility on [DATE]. Observation on 12/01/20 at 12:34 PM, revealed Nurse Practitioner (NP) 1 entered R2's room wearing PPE of a N95 respirator and eye protection. Continued observation revealed NP1 donned gloves after entering the resident's room. The NP did not don a gown before or while in the resident's room. The resident's door had a gray cloth PPE bag that contained gowns; however, the was no signage outside the resident's room to indicate the resident was on any type of transmission base precautions (TBP). Observation on 12/01/20 at 12:37 PM, revealed NP1 entered R3's room without donning a gown. After entering the resident's room, NP1 donned gloves. Continued observation revealed NP1 at the resident's bedside, examining the resident without wearing a gown. R3's door had a non-transparent gray cloth PPE bag that contained gowns. During an interview on 12/01/20 at 12:39 PM, NP1 revealed she was not employed by the facility but was at the facility to see residents for cardiology. Continued interview with NP1 revealed she was not aware that the residents on the unit (Unit A) were on TBP and PPE of a gown was required. NP1 stated there should have been signage on the residents' doors to let her know they were on TBP. Observation of all Unit A resident rooms on 12/01/20 at 12:46 PM, revealed all rooms had non-transparent PPE bins containing gowns on the doors; however, no rooms had any signage indicating TBPs. Review of the facility policy, COVID-19 Transmission Based Precautions Quick Guide, updated 11/02/20, revealed post signage for Transmission Based Precaution. Observation of all Unit E resident rooms on 12/01/20 at 12:50 PM, revealed all rooms had non-transparent PPE bins containing gowns on the doors; however, there was no signage on outside the rooms to indicate TBPs. During observations and interview on 12/01/20 at 1:40 PM, the DON confirmed that there was no signage on the units indicating TBPs were in place. During an interview on 12/01/20 at 1:33 PM, the IP revealed all new admissions and readmissions were placed 14-day quarantine on Unit A and Unit E to monitor for signs and symptoms of COVID-19. The IP also stated all PPE, including mask, face shield, gown, and gloves, must be donned prior to entering a resident's room on Unit A or Unit E. Further interview with the IP revealed going from room to room without all required PPE being donned and doffed appropriately increased the risk to spread infection. When the IP was asked how an outside provider would know if a resident who resided on Unit A or Unit E was on TBP, the IP stated, I don't know the answer to that. As a nurse, if I was coming into a building, on a unit, I would ask what protocols were in place. The IP also stated the facility followed CDC guidance related to TBP. During an interview on 12/01/20 at 2:40 PM, the Medical Director stated that the residents on Unit A and Unit E had PPE bags hanging on the door. When asked if there should be signage indicating the residents were on TBPs, the Medical Director stated it would make it clearer; however, everyone knows with the PPE bag hanging on the door that the room is an isolation room. The Medical Director stated NP1 going into the residents' rooms on Unit A without a gown on was very concerning to him because of the COVID-19 cases the facility has had. Continued interview with the Medical Director revealed NP1 placed residents at risk for COVID and any other infections. During an interview on 12/01/20 at 3:08 PM, the Administrator revealed it was her expectation NP1 would have followed the facility's TBPs. The Administrator stated NP1 should have followed the TBP because that was the policy and she was a healthcare provider. When asked if there should have been signage on the door to indicate TBP, the Administrator stated, I don't know what our policy states, I will have to look. During an interview on 12/01/20 at 3:23 PM, the DON revealed it was her expectation NP1 would have followed the facility's TBP guidelines. The DON stated in normal circumstances, there should be signage on the doors, but in this circumstance the entire unit was on precautions. The DON stated NP1 should have worn a gown to decrease the risk of transmission. Continued interview with the DON revealed when asked if the facility's policy indicated if there should be any type of signage on the resident's door, the DON stated, if it was a facility policy, I would have to look. During observation and interview on 12/01/20 at 3:30 PM, the DON verified that there was no signage on Unit A or Unit B to indicate rooms were on TBPs. The facility provided an acceptable plan for removal of the Immediate Jeopardy that was accepted on 12/04/20. The surveyor verified that the following actions were implemented to remove the immediacy: Downstairs entrance was eliminated and only one entrance to the facility. Reviewed education of screeners and interviewed screener validating the education provided. Reviewed education of all employees related to mandatory screening prior to working. Reviewed certified postage to outside providers informing them Units A and E were TBP units. Validated by observation that signage was on all TBP rooms. The survey team determined that the immediacy had been removed on 12/04/20.The Administrator and the DON were informed on 12/04/20 at 6:45 PM.

Based on interviews and record reviews, the facility failed to have an acceptable and updated immunization program in place to ensure residents were offered pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for residents over the age of 65 and for residents with an immunocompromising condition(s) for six of six residents sampled for immunizations (Resident (R) 2, R3, R5, R6, R8, and R9). The facility's failure to have an acceptable immunization program related to pneumococcal vaccinations placed all residents over the age of 65 and any resident with an immunocompromising condition at likely risk for serious harm or death related to the development of pneumonia. The Immediate Jeopardy began on [DATE] when the facility failed to request consent from the resident's representative for the pneumococcal vaccination. The resident later was hospitalized on [DATE] with pneumonia. Substandard Quality of Care (SQC) was identified at 42 CFR 483.80 Infection Control. On [DATE] at 7:54 PM, the facility Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy at F883, Influenza and Pneumococcal Immunizations. The removal plan for the Immediate Jeopardy was validated on [DATE] through interviews and documentation review. The facility was notified that the Immediate Jeopardy was removed on [DATE] at 6:45 PM. After the Immediacy was removed, the noncompliance remained at a lower scope and severity level of no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy. Findings include: Review of the Centers for Disease Control and Prevention (CDC) website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, revealed There are 2 types of pneumococcal vaccines available in the United States: Pneumococcal conjugate vaccine (PCV13 or Prevnar13®) and Pneumococcal [MEDICATION NAME] vaccine (PPSV23 or [MEDICATION NAME]®) .CDC recommends pneumococcal vaccination for adults 19 through [AGE] years old who have certain medical conditions or who smoke .CDC recommends you: Give 1 dose of PCV13 and 1 dose of PPSV23. Administer PCV13 first, then give the PPSV23 dose at least 8 weeks later . For anyone with any of the conditions listed below who has not previously received the recommended pneumococcal vaccines .HIV infection, [MEDICAL CONDITION] or nephroti[DIAGNOSES REDACTED] .CDC recommends you: Give 1 dose of PCV13 and 2 doses of PPSV23. Administer PCV13 first, then give the first PPSV23 dose at least 8 weeks later. Give the second dose of PPSV23 at least 5 years after the first dose of PPSV23 . For anyone with any of the conditions listed below who has not previously received the recommended pneumococcal vaccine: Alcoholism, Chronic [MEDICAL CONDITION], Chronic liver disease, [MEDICAL CONDITION], (including [MEDICAL CONDITIONS], and asthma), (and) Diabetes mellitus .CDC recommends you: Give 1 dose of PPSV23 .CDC recommends pneumococcal vaccination for all adults [AGE] years or older .All adults [AGE] years or older should receive 1 dose of PPSV23. In addition, clinicians should consider discussing PCV13 vaccination with their adult patients [AGE] years or older .and who have never received PCV13 before For adults [AGE] years or older .who want to receive PPSV23 ONLY: Administer 1 dose of PPSV23. Anyone who received any doses of PPSV23 before age 65 should receive 1 final dose of the vaccine at age 65 or older. Administer this last dose at least 5 years after the prior PPSV23 dose. For adults [AGE] years or older who .want to receive PCV13 AND PPSV23: Administer 1 dose of PCV13 first then give 1 dose of PPSV23 at least 1 year later .If the patient already received PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose . The following adults aged > [AGE] years are potentially at increased risk of exposure to PCV13 serotypes may consider regularly offering PCV13 to their patients aged > [AGE] years who have not previously received PCV13: Persons residing in nursing homes or other long-term care facilities . https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html Review of the Center for Disease Control and Prevention website titled, Pneumonia Can Be Prevented-Vaccines Can Help, revealed, CDC data showed that in the United States during 2017: 3 million people were diagnosed with [REDACTED]. Approximately 50,000 people died from pneumonia. Most of the people affected by pneumonia in the United States are adults. Vaccines and appropriate treatment (like antibiotics and [MEDICAL CONDITION]) could prevent many of these deaths . https://www.cdc.gov/pneumonia/prevention.html Review of the Center for Disease Control and Prevention website titled Causes of Pneumonia, revealed, .Common Causes of Pneumonia. Viruses, bacteria, and fungi can all cause pneumonia. In the United States, common causes of [MEDICAL CONDITION] pneumonia are influenza, respiratory [MEDICAL CONDITION] (RSV), and [DIAGNOSES REDACTED]-CoV-2 ([MEDICAL CONDITION] that causes COVID-19). A common cause of bacterial pneumonia is Streptococcus pneumoniae (pneumococcus) .Healthcare-associated pneumonia is when someone develops pneumonia during or following a stay in a healthcare facility. Healthcare facilities include hospitals, long-term care facilities, and [MEDICAL TREATMENT] centers . https://www.cdc.gov/pneumonia/causes.html Review of the facility's policy titled, Policy for Pneumococcal Vaccination of Residents, with references of Centers for Disease Control and Prevention dated 1999, revealed It is the policy of this facility that each resident or their responsible party will be asked on admission if they have previously had the pneumococcal vaccination and their age at the time of vaccination, i.e., [AGE] years of age. If there is no prior evidence of vaccination, the vaccine will be offered to the resident at that time. If an immunocompromised resident was [AGE] years of age or less at the time of initial vaccination and more than 5 years have elapsed since the initial vaccination, one booster dose of vaccine will be offered. In an immunocompromised resident, the vaccination should be repeated once if 5 years have elapsed since initial vaccination, regardless of age at the time of initial vaccination. Recommendations are available from the Centers for Disease Control and Prevention (CDC) on specific situations in which vaccination is indicated for persons not included in the categories above, as well as direction on additional booster doses of pneumococcal vaccine that may be recommended for certain high-risk groups .Pneumococcal candidates for revaccination: Persons vaccinated at <[AGE] years of age. 1. Review of R2's undated Admission Record revealed R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of R2's admission record revealed R2 was [AGE] years old. Review of R2's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed R2 to have a Brief Interview for Mental Status (BIMS) score of two out of 15 which indicated R2 was severely cognitively impaired. Review of R2's Immunization Audit Report, provided by the facility revealed, on [DATE] Unit Manager (UM) 7 documented for consent given Refused. The report did not reveal any documented evidence that R2's representative was contacted to give consent. Review of R2's EMR Progress Notes, dated [DATE], revealed R2 was transferred from the facility to the hospital with a chief complaint of fever, unresponsive with L (left) eye glaze. Continued review of R2's progress notes revealed R2 was readmitted to the facility on [DATE]. Review of R2's hospital Daily Progress Note-Medicine, dated [DATE] revealed, .DX: HAP (healthcare acquired pneumonia)- IV abx (antibiotics). Review of R2's hospital Daily Progress Note-Medicine, dated [DATE] revealed, .Persistent fevers. Persistent fevers, presumably due to pneumonia given no alternative source of infection identified .CT Chest Abdomen Pelvis with IV Contrast .Chest: Acute multilobar pneumonia predominatly (sic) in the right lung . Interview on [DATE] at 11:18 AM Social Worker (SW) revealed R2 was not his own decision maker and had not been his own decision maker during his initial admission. Interview on [DATE] at 11:34 AM with UM7 revealed during R2's admission there was no pneumococcal vaccination history available. Continued interview with UM7 revealed R2 shook his head no when asked if he wanted a pneumococcal vaccine. When asked if the resident's representative was contacted for consent for the pneumococcal vaccination,UM7 stated, The daughter was upset about her fathers' condition. I don't know if I spoke to her about the pneumonia vaccination. I can't remember. 2. Review of R3's undated Admission Record revealed R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of R3's admission record revealed R3 was [AGE] years old. Review of R3's Immunization Audit Report, provided by the facility, revealed R3 had received [MEDICATION NAME] Dose 1, given in [MEDICAL TREATMENT]. Continued review of the report revealed no additional information related to which pneumococcal vaccination had been administered in [MEDICAL TREATMENT]. During an interview on [DATE] at 1:25 PM, the DON revealed if a resident received the pneumococcal vaccination prior to their admission to the facility, it was her expectation the nurse would attempt to research which vaccination the resident received to know when they would get another dose. When asked when R3, who had immunocompromising conditions, would be eligible for another pneumococcal vaccination, the DON stated, I don't know, because she did not know what pneumococcal vaccination the resident had received on [DATE]. 3. Review of R5's undated Admission Record revealed R5 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the admission record revealed R5 was [AGE] years old. Review of R5's Immunization Record, provided by the facility, revealed R5 received [MEDICATION NAME] Dose 1, on [DATE]. The immunization record revealed no additional information of which pneumococcal vaccination R5 had received. Additionally, there was no documented evidence R5 had been offered the pneumococcal vaccination since [DATE]. Review of the facility's untitled COVID-19 line-listing, provided by the facility, revealed on [DATE] R5 was diagnosed with [REDACTED]. 4. Review of R6's undated Admission Record revealed R6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the admission record revealed R6 was [AGE] years old. Review of R6's Immunization Record, dated [DATE], provided by the facility, for [MEDICATION NAME] Dose 1, revealed Consent Refused had been documented on the document. Continued review of the resident immunization record revealed no documented evidence R6 had been offered the pneumococcal vaccination since [DATE]. Review of the facility's untitled COVID-19 line-listing, provided by the facility, revealed R6 was diagnosed with [REDACTED]. 5. Review of R8's undated Admission Record revealed R8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the admission record revealed the resident was [AGE] years old. Review of R8's Immunization Record, revealed R8 received [MEDICATION NAME] Dose 1, on [DATE]. The immunization record did not detail which pneumococcal vaccination the resident received. Additionally, there was no documented evidence R8 had been offered the pneumococcal vaccination since [DATE]. Review of the facility's untitled COVID-19 line-listing, provided by the facility, revealed R8 was diagnosed with [REDACTED]. 6. Review of R9's undated Admission Record revealed R9 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the admission record revealed R9 was [AGE] years old. Review of R9's Immunization Audit Report, provided by the facility, revealed R9 received [MEDICATION NAME] Dose 2, on [DATE]. The immunization record did not detail which pneumococcal vaccination had been administered. Continued review of the report revealed no documented evidence that R9 had been offered the pneumococcal vaccination since [DATE]. Review of the facility's Resident Infection Control Log, dated [DATE], revealed R9 was diagnosed with [REDACTED]. Review of the facility's untitled COVID-19 line-listing, provided by the facility, revealed R9 was diagnosed with [REDACTED]. During an interview on [DATE] at 12:27 PM, the Infection Preventionist (IP) revealed the facility offered newly admitted residents the first pneumococcal vaccination upon admission to the facility. The IP stated she believed the first pneumococcal vaccination dose was the Prevnar 23. The IP also stated to her knowledge the facility left it up to the resident's physician of which pneumococcal vaccination the residents received. Further interview with the IP revealed the facility did not have an updated policy that includes current guidelines of pneumococcal vaccination schedules. The IP stated she did not track when residents had the pneumococcal vaccination and when it was due again. The IP also stated an immunization report could be obtained from the EMR system, but the immunization policy did not include using the (electronic medical record) EMR for tracking purposes. The IP further stated she had never pulled an immunization report from the EMR. During an interview on [DATE] at 1:25 PM, the DON revealed there were two different pneumococcal vaccines the facility offered. Continued interview with the DON revealed each resident's physician would order the pneumococcal vaccination and the physician was the one who decided which vaccination the resident received. The DON stated the facility followed CDC guidelines related to pneumococcal vaccinations. When asked how the staff would know which pneumococcal vaccination a resident received, the DON stated they would have to go back and look at completed orders in the EMR. The DON verified the physicians' orders reviewed did not document which pneumococcal vaccine had been administered. During an interview on [DATE] at 1:52 PM, the Medical Director revealed usually the residents were admitted from the hospital and had received the pneumococcal vaccination in the hospital. The Medical Director stated the facility only used one of the pneumococcal vaccinations; however, he was not sure which vaccination they used. The Medical Director also stated it was his expectation the facility would have a system to track when the resident received the pneumococcal vaccination, which vaccination it was, and when it should be offered again. The Medical Director further stated the facility's long-term residents would receive a pneumococcal vaccination and then the resident should be offered it again in ten years. This information provided by the Medical Director does not follow current CDC guidelines for pneumococcal vaccination schedules. The facility provided an acceptable plan for removal of the Immediate Jeopardy that was accepted on [DATE]. The surveyor verified that the following actions were implemented to remove the immediacy: Reviewed revisions and validated that the pneumococcal policy had been revised. Reviewed the content of the education provided to the IP and Unit Managers (responsible for offering vaccinations to newly admitted residents) and validated through interview that education was provided. Reviewed the facility's pneumococcal vaccination tracking form. Reviewed the facility's audit of residents who were eligible for vaccination. The survey team determined that the immediacy had been removed on [DATE]. The Administrator and the DON were informed on [DATE] at 6:45 PM.

Based on review of the facility ' s investigation report, the police report, [MEDICAL TREATMENT] treatment records, termination report, facility Transportation Route sheets, resident records and interview of staff and residents, the facility failed to ensure Resident #34 was free from neglect when the resident was left in the locked facility van on a hot summer day for several hours. This resulted in Immediate Jeopardy for one (Resident #34) of three residents reviewed for transportation needs, of 156 residents in the facility who could be transported to outside appointments in the facility Ambulette van. On 07/02/12 at 5:00 P.M., the Administrator was notified Immediate Jeopardy began on 06/26/12 at 2:45 P.M. when the facility driver closed and locked the Ambulette van while a passenger remained inside. On 06/26/12, Resident #34 was locked inside the facility Ambulette van from 2:45 P.M. until 6:25 P.M. with the windows rolled up and the vehicle turned off. The outside air temperature was 77 degrees Fahrenheit (F), with a heat index of 78 degrees F. Resident #34 was sweating heavily and had sweat dripping off her head and face when rescued. Immediate Jeopardy was removed on 06/26/12 at 6:25 P.M. when Resident #34 was rescued from the Ambulette van. She was taken to the hospital for evaluation but sustained no serious injuries. On 06/26/12, Van Driver #3, was suspended and the facility Ambulette van was immediately taken out of service pending development of a new protocol. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 07/09/12 when the facility implemented the following corrective actions: ? On 06/27/12, Van Driver #3 was terminated from employment. ? On 07/03/12, the facility ' s new Ambulette Policy/Protocol dated 07/03/12 was initiated and included the use of a Transportation Log to document when residents left and returned to the facility when being transported by the facility Ambulette; driver was to complete a PM Check to ensure no residents remained on the Ambulette; and an emergency set of keys would be kept in Central Supply. ? On 07/03/12, 07/05/12, 07/06/12 and 07/09/12, 102 facility employees, including nurses, state tested nurse aides (STNAs) and ancillary staff, were inserviced on the Ambulette Policy/Protocol. ? On 07/05/12, a new van driver, Van Driver #10, was hired by the facility and trained on the Passenger Assistance Training Program. ? On 07/09/12, the Ambulette was put back into service. ? On 07/09/12, 07/10/12 and 07/11/12, the Resident Transportation Log and Ambulette Checklist were completed by staff and reviewed by the Administrator. Findings include: Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS 3.0) assessment dated [DATE] revealed Resident #34 was alert and oriented with no long or short term memory problems. She required the extensive assistance of at least one person for bed mobility, transfers, walking and dressing. She was not steady when moving from a seated or standing position or when making surface to surface transfers. Review of the June 2012 physician order [REDACTED].M. Review of the facility Transportation Route Sheet dated 06/26/12 revealed Residents #34 and #35 were transported from the facility to the local [MEDICAL TREATMENT] center at 8:20 A.M. Both residents were scheduled to be picked up from the [MEDICAL TREATMENT] center at 1:30 P.M. and returned to the facility. Review of [MEDICAL TREATMENT] treatment records dated 06/26/12 for Residents #34 and #35 revealed Resident #34 completed treatment at 1:21 P.M. and Resident #35 completed treatment at 2:28 P.M. Both residents were discharged back to the facility from the [MEDICAL TREATMENT] center. A nursing progress noted dated 06/26/12 at 9:42 P.M. and authored by the Director of Nursing (DON) revealed the charge nurse, Licensed Practical Nurse (LPN) #5, had become concerned earlier that evening when Resident #34 did not return to the facility from [MEDICAL TREATMENT]. LPN #5 had contacted the [MEDICAL TREATMENT] center and was informed Resident #34 and another resident were picked up from [MEDICAL TREATMENT] at approximately 2:15 P.M. LPN #5 contacted Van Driver #3, and learned Resident #34 was returned to the facility after her [MEDICAL TREATMENT] treatment. At approximately 6:15 P.M., LPN #5 and Nursing Supervisor #8 checked the facility van and observed Resident #34 inside the locked van. 911 was called. Van Driver #3 arrived at the same time as emergency personnel, and unlocked the van. Resident #34 was released from the van and transferred to the hospital for an evaluation. Review of the facility investigation report of the incident dated 06/27/12 revealed a call was placed to 911 and to Van Driver #3 after Resident #34 was found locked in the facility Ambulette van. The emergency squad arrived, followed by the van driver. The van was unlocked by Van Driver #3 and Resident #34 stated, "I was trying to get out." The resident was alert and oriented, but was visibly upset, shaking and notably sweating. She was transferred to the emergency room for an evaluation and returned to the facility at 10:30 P.M. after being treated for [REDACTED]." Review of a police report dated 06/26/12 revealed the police officer who responded to the facility's request for emergency assistance arrived at 6:25 P.M. He observed the inside of the Ambulette van was very hot, like a sauna, due to weather conditions. The outside temperature was 77 degrees F with 39% humidity. The heat index was 78 degrees F. The police officer discovered Resident #34 on the floor of the van, dressed in sweat pants and a buttoned up flannel shirt. The back of her shirt was saturated, and perspiration dripped to the floor from her head and face. Her left arm was wedged in the wheelchair between the left front wheel and the left leg support. Resident #34 complained of pain to her left arm and indicated she had fallen from her wheelchair in an attempt to get to a door or window to escape from the van. Review of the Supplemental Narrative portion of the police report dated 06/26/12 revealed the patrolman interviewed Van Driver #3. Van Driver #3 indicated that at approximately 2:45 P.M. on 06/26/12, she returned to the facility with Residents #34 and #35 in the van. She took Resident #35 into the facility, then returned to the van, shut off the vehicle and locked the doors, and went into the facility. Interview with LPN #4 on 07/02/12 at 2:04 P.M. revealed she worked the 7:00 A.M. to 3:30 P.M. shift on 06/26/12. She stated Resident #34 left for [MEDICAL TREATMENT] on 06/26/12 at approximately 8:30 A.M. She indicated Resident #34 had not returned from [MEDICAL TREATMENT] at 3:15 P.M. when she gave shift to shift report to the oncoming nurse, LPN #5. LPN #4 spoke to the facility ' s Transportation Scheduler #15 who told her Resident #34 would be "late" because the Ambulette driver was waiting for other residents. Transportation Scheduler #15 did not tell her when she could expect Resident #34 to return. LPN #4 informed LPN #5 that Resident #34 would return late from [MEDICAL TREATMENT]. Interview with LPN #5 on 07/02/12 at 2:55 P.M. revealed on 06/26/12, she worked the 3:00 P.M. to 11:30 P.M. shift . She indicated she received shift to shift report from LPN #4 on 06/26/12 and was informed Resident #34 was still out of the facility at an appointment because the van driver was behind schedule. She indicated she became concerned as it grew later and Resident #34 still had not returned. She called the [MEDICAL TREATMENT] center and was told Resident #34 had been transported back to the facility that afternoon. LPN #5 then called Van Driver #3 at home. Van Driver #3 told LPN #5 she had dropped off Resident #34 at the facility after her [MEDICAL TREATMENT] treatment. LPN #5 searched resident rooms but could not locate Resident #34. She notified Nursing Supervisor #8 who discovered Resident #34 was locked in the facility Ambulette van. Interview with Resident #34 on 07/02/12 at 10:15 A.M. revealed she was alert and oriented. When asked about the incident that occurred on 06/26/12, Resident #34 stated, "They left me there." She indicated she was sitting in her wheelchair in the back of the van when the driver took another resident out. She waited for about fifteen minutes, but the driver did not come back. She found a dustpan and hit the windows. She watched employees walk past the van on their way in and out of the facility, but believed she could not be seen inside the van because the windows were tinted. She indicated she tried to get out of the wheelchair, but her left arm got caught in the chair. She stated her left arm was still sore and she was not able to lift it all the way up over her head. Review of a facility Termination Report revealed Van Driver #3 was terminated on 06/27/12 for " poor work performance. " Review of the facility ' s new Ambulette Protocol initiated 07/03/12 revealed it included new tasks for the Ambulette driver to complete. These included completing a Resident Transportation Log when picking up and returning residents to the facility; the van driver was to complete a PM Check at the end of their shift to ensure no residents remained in the Ambulette; and the van driver was to complete the Ambulette Checklist at the end of their shift. Inservice and Education Program Records dated 07/03/12, 07/05/12, 07/06/12 and 07/09/12 documented 102 staff members were educated about the new Ambulette Protocol. Review of a Passenger Assistance Training Program certificate dated 07/05/12 revealed Van Driver #10 was trained on the program. Review of facility Resident Transportation Logs and Ambulette Checklists for 07/09/12, 07/10/12 and 07/11/12 revealed the Ambulette was placed back into service on 07/09/12. Nurses and Van Driver #10 completed the logs. Van Driver #10 completed the checklists. Both documents were reviewed by the Administrator. This deficiency substantiates Self Report Incident Investigation Number OH 164 and Complaint Number OH 146.