Every finding on record at Willows Center

Based upon record review, resident interviews and staff interviews, the facility failed to protect residents from sexual abuse and neglect. This was found to be true for three (4) of four (4) residents reviewed during the long term care survey process, based on complaints. Resident identifiers: #24, #87, #23 and #33. Facility census: 88. Findings included: Findings include: a) Resident #33 The facility's policy, entitled OPS300 Abuse Prohibition, was reviewed. Section 6.3 of the policy states: If the suspected abuse is patient to patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. 6.3.1 The Center will provide adequate supervision when the risk of patient-to-patient altercation is suspected. 6.3.2 The Center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. 6.3.3 The patient representative and physician will be notified and any follow-up recommended will be completed. 6.3.4 Options for room changes will be provided based on the situation. 6.3.5 The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted. A record review for Resident #33 revealed a nursing Progress Note dated 12/22/25 at 12:15 PM, which indicated: A skin check assessment was performed by the staff nurse and wound nurse. Resident #33 exhibited bilateral dry feet, which the resident reported as itchy, scratching the areas during the examination. The attending physician was notified, and an order for lotion was obtained. Record review further revealed that on 12/19/25, Resident #33 reported to NA #20 that she had been reporting a rash on her feet for several days and that no action had been taken by staff. The facility failed to ensure that this allegation was immediately reported internally so that required regulatory notifications could take place. The allegation was not submitted to the appropriate State Survey Agency until 12/22/25, three days after the initial report. During an interview on 08/12/26 at approximately 10:20 AM, the Administrator stated: He was unaware that Resident #33 made the allegation of neglect to NA #20 on 12/19/25. He also stated that NA #20 did not report the allegation to facility leadership until 12/22/25. b) Resident #24 The state agency received a report of sexual abuse of Resident #24 by Resident #77. Resident #77 grabbed Resident #24's breast. The facility substantiated the complaint based upon their investigation of the incident. The Nursing Home Administrator completed the investigation. Resident #77 was admitted to the facility on [DATE], with a primary diagnosis of dementia. The resident also has diagnoses of anxiety disorder, disorientation, major depressive disorder, restlessness and agitation. The resident is under the care of a psychiatrist. A review of resident #77's medical record documents two previous incidents of behaviors prior to this incident: -01/13/26 Change in condition evaluation for increased confusion and disorientation, verbal and physical aggression. Resident was yelling and threatening to strike roommate. He pushed a nurse aide. A new physician order was obtained for one-to-one (1:1) monitoring through the night. -01/28/26 Change in condition evaluation for verbal aggression. Resident exhibiting verbal aggression with another resident. Due to behaviors, the resident's clinician prescribed: -Cimetidine Oral Tablet 400 MG (Cimetidine/Tagamet)Give 1 tablet by mouth two times a day for Inappropriate sexual behaviors. The order was dated 01/08/26. Resident #77 was care planned for behaviors prior to the first change in condition being completed. The care plan stated: (Resident #77) has a tendency to exhibit sexually inappropriate behavior related to: Cognitive Loss/DementiaDate Initiated: 01/08/2026Created on: 01/08/2026Revision on: 01/12/2026 (Resident #77) will return to a normal libido and sexual functioning secondary to pharmacologic treatment.Date Initiated: 01/08/26Created on: 01/08/26Revision on: 05/12/26Target Date: 10/21/2026 Evaluate the nature and circumstances of the sexually inappropriate behavior, such as past experiences, triggers/stimulation, involvement with others, patterned, etc. and adjust approaches appropriately.Date Initiated: 01/08/26Created on: 01/08/26 Evaluate need for Psych/Behavioral Health consult.Date Initiated: 01/08/26Created on: 01/08/26When sexually inappropriate behaviors occur, approach the resident/patient in a calm, unhurried manner; reassure as necessary.Date Initiated: 01/08/26Created on: 01/08/26Social Services visits to provide support, as needed.Date Initiated: 01/08/26Created on: 01/08/26Divert resident by giving alternative objects or activitiesDate Initiated: 01/08/26Created on: 01/08/26Familiarize resident with own belongings and surroundingsDate Initiated: 01/08/26Created on: 01/08/26 Listen to resident and try to calmDate Initiated: 01/08/26Created on: 01/08/26 In the five-day follow-up report from the facility, it stated the residents were immediately redirected and Resident #77 was put on 15-minute checks. Skin assessments were completed on both residents. Both residents were interviewed by the Nursing Home Administrator (NHA) on 03/06/26, and neither remembered the incident. Documentation in the medical record under physician orders indicated every 15-minute check x 72 hours, start date 02/27/26, end date 03/02/26. There was no documentation in the medical record or the facility's investigation file of the 15-minute safety checks. On 08/12/26 at 1:05 PM, the surveyor asked the NHA for any additional documentation concerning the staff who were interviewed, as well as documentation of the 15-minute safety checks on Resident #77. The NHA stated he would check with medical records to see if there was anything that had not been scanned into the medical record. These records were not located. There was a change of condition assessment conducted on 02/27/26 on both of the residents. Documentation from the medical record of Resident #24 revealed a recommendation to monitor the resident. Resident #77's medical record also documents a change in condition on 02/27/26, with the situation noted as resident touched another resident's breast. The physician's recommendation was to place the resident on 15-minute safety checks. There was no documentation in the facility's investigation file or the medical record of the 15-minute safety checks being performed. This surveyor interviewed Resident #24 on 08/12/26 at 1:20 PM. She went on to say that she talks with a counselor. I asked if it helped and she said no. c) Resident #87 The facility reported another sexual abuse on 03/18/26, involving Resident #77, where the victim was Resident #87. Resident #87 was sitting near the nurses' station on 03/18/26 at 8:49 PM when Resident #77 got up, approached Resident #87, pulled on her arm, and grabbed her breast. A nurse aide witnessed the event and told Resident #77 to stop and go sit down. Staff removed Resident #77 from the area. The incident was reported to the Director of Nursing and the Medical Director. The report stated both residents were seated in the lobby area near the nursing station. In the five-day follow-up report, the facility substantiated the complaint based upon their investigation of the incident. The Nursing Home Administrator completed the investigation. The facility implemented 15-minute safety checks on Resident #77 on 03/18/26 at 8:45 PM. These continued for 72 hours per physician order. All other residents with a BIMS of eight or greater were interviewed for sexual abuse. These were documented in the facility's investigation file. A skin assessment was performed on resident #87. This is verified by progress notes in the medical record. Prior to this incident Resident #77 had a history of verbal and physical aggression. These were documented in his medical record under change in condition evaluations as follows: 01/13/26 Physical and verbal aggression - yelling and threatening to hit his roommate. Pushed a Nurse Aide. 01/28/26 Verbal altercation with another resident. 02/27/26 Sexual abuse on Resident #24 The resident's care plan was updated on 03/09/26. Increased rounding to ensure safety r/t (related to) behaviors.Date Initiated: 03/09/26Created on: 03/09/26Revision on: 03/09/26 Resident's dosage of Cimetidine (Tagamet) was doubled. An interview was conducted with Resident #87 on 08/12/26 at 1:30 PM. The resident was asked about the incident. The resident stated she did not remember this happening to her. The facility reported a third sexual abuse of a resident identified as Resident #23, with Resident #77. This incident happened on 03/31/26. In the initial report of allegations, it was stated that Resident #77 touched Resident #23 in an inappropriate manner that made her feel uncomfortable. Staff reported the incident, but no names were identified. A review of the facility investigation file did not contain any witness statements. On the five-day follow-up report, the facility substantiated this as abuse. Following the 03/31/26 incident, the resident's clinician placed an order for Resident #77 to be on continuous supervision, beginning 03/31/26 and ending on 04/02/26. Continuous supervision was discontinued on 04/02/26, at which time the facility implemented 15-minute safety checks. The resident remained on 15-minute safety checks until 04/06/26. The resident was sent to an acute care inpatient behavioral health facility on 04/08/26, where he was provided intensive treatment and released back to the facility on [DATE]. An interview was conducted with the NHA on 08/12/26 and Market Lead Clinical Specialist (MLCS) #8 at 1:50 PM. The surveyor asked the NHA if Resident #77 exhibited another episode of repeated sexual behavior, what would the facility do? The NHA responded, We will follow our policy, report it, and place him on 1:1 supervision. The surveyor then asked how the resident was recommended to go to a behavioral health hospital. NHA responded that the physician recommended it in their Interdisciplinary Team) IIDT meeting because his behavior was not changing. The facility abuse policy stated: 6.3.5 The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was kept free of accident hazards and failed to provide adequate supervision to prevent potential serious injury or death for three (3) of three (3) residents observed outdoors during active severe weather (Residents #23, #85, and #29). Specifically, facility leadership knowingly allowed residents to remain outside in an open outdoor structure during an active thunderstorm with heavy downpours and lightning. Resident identifiers: #23, #85, and #29. Facility Census 88.The findings include:a) On 08/10/26 at approximately 1:00 PM, an observation was conducted during an active thunderstorm characterized by heavy downpours and visible lightning strikes in the immediate vicinity. Three (3) residents (Residents #23, #85, and #29) were observed sitting under an open outdoor shelter on facility grounds, actively smoking cigarettes. The shelter consisted of an open-frame structure providing overhead rain cover but lacking enclosed walls or grounded surge/lightning protection systems. No facility staff were outdoors monitoring or supervising the residents during this active weather event.On 08/10/26 at approximately 1:05 PM, an interview was conducted with the Director of Nursing (DON) Regional Leader. When questioned about residents remaining outdoors during an active thunderstorm with lightning, the DON Regional Leader stated that it was at their staff/facility discretion when residents were able to smoke in inclement weather. At this time, a request was made for the facility's smoking and severe weather/inclement weather policies.On 08/10/26 at approximately 1:14 PM, an interview was conducted with the Administrator. During this interview, the thunderstorm and active lightning continued outside. The Administrator confirmed the DON Regional Leader's statement, stating it was at the facility's discretion when residents could be outside. When asked directly by this surveyor if it was normal practice for residents to be outside during a thunderstorm with active lightning, the Administrator stated, They had a roof over them.Review of National Weather Service (NWS) guidelines for severe weather safety indicates that open shelters (such as pavilions, gazebos, or covered patios) do not provide protection against lightning strikes and that outdoor activities should cease immediately upon the presence of thunder or lightning.

Based on record review as well as staff interviews, The facility failed to ensure resident's property was not taken or used without permission. Specifically three (3) packs of cigarettes that had to be replaced. This was discovered during the normal long term survey complaint process and effected one (1) out of five (5) residents reviewed. Resident identifiers # 89. Census 88.Findings include:a) Resident #89On 08/10/26 a record and chart review was conducted for Resident #89. It was determined that Resident #89 filed a grievance with the facility about missing three (3) packs of cigarettes. The grievance was filed on 06/04/26 and accepted by the Social Service Director. The facility determined the items were missing and used $21.60 from facility petty cash to replace them. A receipt from Go-Mart for $21.60 matched the disbursement and showed that three (3) packs of cigarettes were purchased on 06/04/26.Review of the cigarette tracking log showed multiple missing entries, across many days. The room where cigarettes were stored was the clean utility room up front by the nurses station. Anyone with the code can access this room. The cigarettes themselves were in a metal box with a lock. However, when surveyors checked this box, it was not locked.In an interview with the facility Administrator on 08/10/26 at approximately 2:35 PM about the missing items, they said the resident had filed that grievance, and the facility was unsure where or even if the resident actually had three (3) packs go missing. However, in the resident's interest, it was best to just replace them.

Based upon staff interviews and record review, the facility failed to follow the grievance policy regarding resident / resident representative's concerns related to pest control. This was found to be true for one (1) of one residents reviewed during the complaint survey process. Resident identifiers: #87. Facility census: 88.Findings included: a) Resident #87A review of the grievances and concerns log presented by the facility on 08/10/26 in the afternoon, found no complaints or concerns logged by the facility for bed bugs for the last twelve months. Interviews were conducted with the two (2) staff members who sat at the facility's front desk on 08/11/26 at 9:20 AM. Receptionist #1, was asked if she remembered Resident #87's daughter in March come to the front desk to report bed bugs in her mother's room. Receptionist #1 stated she did not, but did remember hearing about the bed bugs. Staff member #2 was asked the same question. She responded she did remember speaking with the daughter about the bed bugs in March, but does not remember a specific date in March.A review of the grievance/concerns log finds the facility recorded no complaints or grievances for the month of March. The complaint on the bed bugs was noted to have been received by Staff member #2 in March 2026, yet was not recorded on the grievance/concern log for the month of March, 2026.

Based on observation, staff interview, and operation policy the facility failed to report alleged violations related to neglect within prescribed time frames. This is true for one (1) of three (3) allegations of abuse and neglect. Resident identifier: #33. Facility census:88 Findings included:a) Resident #33Record review of the facility's policy titled, Abuse Prohibition, showed:Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, Injuries of unknown origin, or misappropriation of patient property, is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked. Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, Injuries of unknown origin, or misappropriation of patient property must report to outside agencies.The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injury of unknown source, exploitation, and misappropriation of property. The center must ensure that all staff are aware of reporting requirements and must support an environment in which covered individuals report a reasonable suspicion of a crime. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the administrator of designee will perform the following.Report allegations involving abuse (physical, verbal, sexual, mental) not later than 2 hours after the allegation is made. Report allegations to the appropriate state and local authority.Initiate an investigation within 24 hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent.Record review of an investigation for neglect revealed that on 12/19/25, Resident #33 reported to Nurse Aide (NA) #20 that she had been reporting a rash on her feet for several days and nothing had been done. Further review indicated that this allegation of neglect was not reported to the appropriate state agencies until 12/22/25.A record review found a progress not dated 12/22/25 at 12:15 PM:Note: Skin check assessment performed on resident by this nurse and wound nurse. The resident appears to have Bilateral Dry Feet that the resident reports as itchy; itching started during the assessment. The Physician was Notified. An Order for Lotion was obtained.During an interview, with the Administrator, on 08/12/26 at approximately 10:20 AM, he stated he was not aware Resident #33 had made the allegation of neglect to NA #20 on 12/19/25. NA #20 did not report the allegation until 12/22/25.

Based upon record review and interviews with staff and residents, the facility failed to perform complete thorough investigations of sexual abuse and prevent the abuse from occurring again. This was found to be true for two (2) of two incidents reviewed during the long term care survey process. Resident identifiers: #24, #23. and #77. Facility census: 88.Findings included:a) Resident #24 The state agency received a report of alleged sexual abuse of Resident #24 by Resident #77 on 02/27/26. On 08/10/26, a surveyor arrived at the facility to investigate the complaint and requested the investigative file for the Facility Reported Incident (FRI). The investigative file provided by the facility included the following:Initial reporting of allegations to the state agency;Adult Protective Services (APS) mandated reporting form;Email verification of initial reports sent to the state agency, APS, and the ombudsman;Medical record face sheets for Resident #77 and Resident #24;Five-day follow-up report and email verification of its submission;Handwritten statements from the Nursing Home Administrator (NHA) regarding interviews with Resident #24 and Resident #77, dated 03/06/26;A typed summary of the investigation and results from the NHA, dated 03/06/26. Although the five-day follow-up report documented that staff were interviewed, the investigative file contained no documentation of these interviews. While the report indicated that 15-minute safety checks were implemented for Resident #77, no documentation of these checks was found in either the resident's medical record or the investigative file. During an interview on 08/12/26, the NHA stated he would search for the safety check documentation and witness statements. Later that day, the survey team reviewed preliminary deficiencies with the NHA. On 08/13/26, the NHA returned the file with three handwritten statements (dated 03/06/26) involving two nurse aides and an LPN. The NHA admitted these were found in a separate folder and were written by him, not the staff members themselves.b) Resident #23 On 03/31/26, the state agency received an allegation that Resident #77 attempted to touch the breast of Resident #23. Although the five-day follow-up was completed timely by the NHA, the investigative file cited staff as witnesses without identifying specific names or providing statements. Additionally, the facility failed to conduct interviews with other residents to determine if the abuse was more widespread. During an interview on 08/12/26, the NHA confirmed that no other residents had been interviewed regarding potential abuse. On 08/12/26, Resident #23 confirmed the incident, stating she felt disrespected and irritated by Resident #77's behavior. She reported smacking his hand away and telling him to stop.

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for three (3) of five (5) resident rooms reviewed during the complaint survey process. The facility failed to keep the Packaged Terminal Air Conditioners (PTACs) in resident rooms [ROOM NUMBER] in good condition. Facility Census: 92.On 03/10/26 at approximately 9:15 .a.m., the State Agency (SA) observed debris in the upper vent of the PTAC unit in resident room [ROOM NUMBER].On 03/10/26 at approximately 9:18 a.m., the SA observed debris and a black like substance in the upper vent of the PTAC unit in resident room [ROOM NUMBER].On 03/10/26 at approximately 12:30 p.m., the SA observed debris in the upper vent of the PTAC unit in resident room [ROOM NUMBER].During an interview on 03/10/26 at approximately 1:15 p.m. the facility Administrator verified these findings. These findings were also acknowledged with the Administrative staff upon exit on 03/10/26 at approximately 3:30 p.m.

Based on observation and staff interview, the facility failed to dispose of garbage and refuse properly. One (1) of two (2) dumpsters was found to be overflowing with garbage bags, making it impossible for the dumpster lid to properly close. The other dumpster had sliding doors that were not completely closed. This was a random opportunity for discovery that has the potential to affect every resident at the facility. Facility census: 92. Findings included:a) Disposal of Garbage / Refuse was not properly contained in dumpsters with lids or otherwise covered. On 12/16/25 at 8:38 AM, two surveyors asked the Director of Dining to take them to the trash dumpsters located outside. She acknowledged the dumpster lids should be closed at all times when not in use, and they were not.

Based on resident interview, staff interview, and operation policy the facility failed to take actions to thoroughly investigate an alleged violation related to, abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and take corrective action following the investigation. Resident identifier #1, #108, #109, #98, #74, #105, #104, and #102. Facility census: 92. Findings include: Record review of the facility's policy titled, Abuse Prohibition, showed: - The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injury of unknown source, exploitation, and misappropriation of property. The center must ensure that all staff are aware of reporting requirements and must support an environment in which covered individuals report a reasonable suspicion of a crime. - Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the administrator of designee will perform the following. - Report allegations involving abuse (physical, verbal, sexual, mental) not later than 2 hours after the allegation is made. - Report allegations to the appropriate state and local authority. - Initiate an investigation within 24 hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent. a) Resident #1 A record review found an allegation from an interview on 08/21/25 where Resident #1 with a Brief Interivew Mental Status (BIMS) score of 15 alleged neglect within the facility. A facility reported incident was completed 09/04/25 with action notes: Investigation has been initiated at this time. A statement dated 09/04/25 from Resident #1 revealed it was a follow up from her complaint on 08/21/25 where statements were made to a staff member with regards to being left soiled for four (4) hours. She stated that she soiled herself at 3:00 PM on 08/20/25 and was not assisted until 7:00 PM. She also stated that staff did not want to assist her with meals. A review of an investigation revealed that the issue was reported to required state agencies on 09/04/25. Continued review of the reportable found no witness statements from the employees or other residents residing in the facility that may have knowledge of the allegation. Subsequent review found a 5-day follow-up stating a body audit was completed, no injury noted. After investigation, it was found to be unsubstantiated due to inconsistency in the statements between resident and staff. During the interview on 12/22/25 at approximately 9:30 AM the Administrator verified that there were no documentation or statements from all staff working at the time or other residents that may have knowledge of the allegation. He also verified they have been working on other complaints that was not investigated prior to him taking over as Interim Administrator. b) Resident #35 A record review found an allegation of physical abuse reported on 06/05/25 Resident #35 reported that she never received a breakfast tray and someone shoved her by the shoulders. A review of an investigation revealed that there is no documentation that the incident was reported to all required state agencies. Subsequent review found an extension Request filed on 06/11/25. Continued review of the reportable found no witness statements from the employees or other residents residing in the facility that may have knowledge of the allegation. Subsequent review found no documented 5-day follow-up. During the interview on 12/22/25 at approximately 9:30 AM the Administrator verified that there were no documentation or statements from all staff working at the time or other residents that may have knowledge of the allegation. He stated that there was no other documentation to provide on the incident. He also verified they have been working on other complaints that was not investigated prior to him taking over as Interim Administrator. c) Resident #109 A record review found an allegation of sexual abuse reported on 12/09/24 Resident #109 reported that the night shift Charge Nurse touched her and she does not feel safe. A review of an investigation revealed that there is no documentation that the incident was reported to all required state agencies. Continued review of the reportable found no witness statements from the employees or other residents residing in the facility that may have knowledge of the allegation. Subsequent review found a five 5-day follow-up on 12/17/24 with no verification it was sent to required agencies. The conclusion stated that Resident #109 asked that the male charge nurse not provide care for her. During the interview on 12/22/25 at approximately 9:30 AM the Administrator verified that there were no documentation or statements from all staff working at the time or other residents that may have knowledge of the allegation. He also verified they have been working on other complaints that were not investigated prior to him taking over as Interim Administrator. d) Resident #98 On 11/05/24, an initial reporting of an allegation of neglect regarding Resident #98 was reported to all required entities. The initial reporting stated as follows: Nursing assistant [NA] [#125] provided a statement on 11/2/2024 regarding the care of resident [#98]. He reported that a week and one half ago he noticed that [Resident #98] was developing a red spot on his tailbone. In his statement he reported telling the nurse [#154] that he thought the resident was developing a pressure sore. He reported after being off for a few days. He came back and when providing care to the resident, the area got worse and was starting to open. He again reported to the nurse [#154] about the area. The nurse told [NA #125] she would look at it later. [NA #125] told her again at shift change and her response was to look at it the next day. [NA #125] reported the next day he asked her if she had looked at the area. Her response was not yet and that she would. [NA #125] reported telling one of the other nurses on night shift that way they knew. Every time [NA #125] mentioned it to the nurse [#154] she did nothing about it. The allegation was thoroughly investigated and interviews were obtained. An unsigned investigative note concluded I feel as this was a communication mishap and technology error causing this event. The note stated an order for wound treatment had been entered, but the order did not carry over to the Treatment Administration Record (TAR) for nursing staff to complete the order. The corrective action was educate nursing staff regarding turning and repositioning. On 12/18/25 at 11:02 AM, the Director of Nursing confirmed the corrective action to educate nursing staff regarding turning and repositioning did not address the communication and technology errors that had occurred regarding Resident #98's pressure ulcer. No further information was provided through the completion of the survey process. e) Resident #74 During a record review on 12/17/25, the incident involving Resident #74 that was initially filed 01/06/25 showed multiple missing items that were required to be sent in as well as maintained in the records for each incident reported. The review revealed the initial report and five (5) day follow-up were missing. The file contained four (4) statements with handwritten names on top, none are dated or signed by anyone involved. Neither who was interviewed nor who did the interview could be confirmed by reviewing the statements. It also had two (2) performance improvement plans, noted to only be counseling with no follow-up. On 12/17/25 at approximately 11:44 AM spoke with administrator about the missing information and they said, I will do his best to get the items that are missing to me. No further information was provided prior to exiting the facility on 12/22/25. f) Resident #105 During a review of Incident with Resident #105 that Initially was reported on 08/07/25. It showed the facility filed two (2) extensions, the first one on 8/15/25 stating more time was needed to complete the investigations, and then a second on 09/05/25 due to management changes. This delayed the investigation almost one month (30 days) from the time it took place. The facility did perform skin checks on Resident #105 on 08/12/25, with no issues of note. This was four (4) days after the incident occurred. No skin issues were noted prior or after in the chart. Interview with Resident #105 and others took place on 09/10/25. Due to the extensions delaying the facility from talking with residents for almost thirty (30) days after the incident took place the residents were unable to recall what took place and could not verify or un-verify the allegations. The five-day follow-up revealed the incident was unsubstantiated but showed no supporting documentation on how the facility came to this conclusion, or what was done to correct the issue and prevent future occurrences form happening again. When interviewing the administrator on 12/17/25 at approximately 9:45 AM they stated, I walked into all these, and I know some were not done to the best of their ability. We are working to do a better job and ensuring all investigations are done to the best possible standard. g) Resident #104 During an audit of the Facility reported incidents (FRIs) conducted on 12/16/25 it was revealed that the facility did not take all necessary action to come to a complete conclusion and/or create a plan of action to prevent these events from occurring again. Statements were taken from multiple people, both residents and staff. These were deemed inconclusive by the facility, due to them containing conflicting information. There were no secondary interviews conducted, no follow ups to clarify discrepancies and/or verify statements given. Documentation was missing dates, times and signatures of people involved. Twenty-one (21) statements were taken, and all were missing from these pieces of information. They were all just stamped with a [NAME and TITLE] stamp on a line. The documents all contained four questions of a yes or no (closed ended) type and no follow ups asked. A five-day follow-up was completed and in file dated 10/10/25 stating a call light audit would be completed for seven (7) days and then randomly thereafter. There was no record of this being done in the file nor could it be produced when asked. During an interview with the administrator on 12/16/25 at approximately 4:12 PM they stated that they do not have a way to perform a call light audit on the system they have, but they did do manual ones as needed. The administrator was unsure if they had copies of them placed in the files. This was later confirmed that they were not in the files and copies could not be located the for this surveyor. No other information was contained in the file or presented prior to the exit on 12/22/26. h) Resident #102 On 10/04/25, Resident #102 reported she was left soiled for an extended period of time. The resident had capacity to make medical decisions. She had a Brief Interview for Mental Status (BIMS) score of 15, indicating that she was cognitively intact. An investigation was initiated. Skin checks were completed for residents with a BIMS score of seven (7) and below with no new occurrences noted. Residents with a BIMS score of eight (8) and higher were interviewed. Staff interviews were conducted as well. After investigation, the facility found their investigation to be inconclusive due to conflicting statements. IDT team determined to do a call light audit for seven (7) days then random times after to ensure call lights are answered timely. During record review, on 12/22/25 at 9:30 AM, there was no evidence that the facility had asked Resident #102 anything other than the three (3) written yes or no questions that were asked of all residents with a BIMS of eight (8) or higher: On 10/04/25, did staff leave you wet for extended periods of time? On 10/04/25, did you receive your medication in a timely manner? On 10/04/25, did you receive fresh ice water? Resident #102 was known to be cognitively intact and may have been able to identify the staff member assigned to her care on the day in question. Additionally, the resident may have been able to provide more context about how long her call light was on before being answered and if her needs had been addressed at that time. Review of the facility's call light audit for seven (7) days revealed the following dates and times: 10/10/25 at 10:00 AM 10/11/25 at 12:00 PM 10/12/25 at 1:05 PM 10/13/25 at 9:00 AM 10/14/25 at 8:00 AM 10/15/25 at 2:00 PM 10/16/25 at 5:00 PM There was no evidence additional call light audits at random times were completed as per the facility's corrective actions listed in their five (5) day follow-up. During an interview on 12/22/25 at 10:20 AM, the Surveyor pointed out: Staff had specifically asked Yes or No questions but did not supply more information in the written narrative if a resident responded with a yes. Staff had narrowed the date of ever being left wet for extended periods of time to only 10/04/25. This questioning would not have afforded a resident to answer in the affirmative if they had been left wet and unattended on a different day. Staff had completed the call light audits on day shift hours only. This would not have ensured the call lights were being answered timely at other times of the day or throughout the night. There was no evidence found during the record review that the facility had completed additional call light audits at random times as per the facility's corrective actions listed in their five (5) day follow-up. The Administrator remained silent and made no comment.

Based upon record review and staff interviews the facility failed to report the results of investigations within approved time frames to the state survey agency(SSA). This was discovered during the Long term care survey process, during the review of Facility reported incidents (FRIs). This was found to be true for one (1) out of thirty (30) residents reviewed. Resident #74 and #108. Census: 92 Finding include: a) Resident #74 During record review of Facility reported incidents (FRIs) on 12/17/25, file with this FRI #242295 was missing the five day follow up. The initial report was received 01/06/25. This would make the five day needing to be submitted by 01/11/25 at 11:59 PM at the latest. There was no record of it anywhere in the file or of a attempt to transmit a copy to anyone that is required to be notified ie. Fax transmittal sheet or email attachment by that deadline time. The file only contained four (4) statements, none are dated or signed by anyone either interviewed or doing the interviewing. As well as two (2) Performance improvement plans (PiPs), both were non disciplinary in nature and only suggested counseling no correction or follow up noted. When talking with the Administrator on 12/17/25 at approximately 11:44 AM about FRIs missing information and he said he will do his best to get the items that are missing for me. He knew that there are a lot of issues with them from the previous administration and is working to do better on them since he has been over the facility. Not further items for this file were presented prior to surveyors exiting the building on the final survey day of 12/22/25. b) Resident #108A record review found an allegation of physical abuse reported on 06/05/25 Resident #108 reported that she never received a breakfast tray and someone shoved her by the shoulders. A review of an investigation revealed that there is no documentation that the incident was reported to all required state agencies. Subsequent review found an extension Request filed on 06/11/25. Continued review of the reportable found no witness statements from the employees or other residents residing in the facility that may have knowledge of the allegation. Subsequent review found no documented 5-day follow-up. During the interview on 12/22/25 at approximately 9:30 AM the Administrator verified that there were no documentation or statements from all staff working at the time or other residents that may have knowledge of the allegation. He stated that there was no other documentation to provide on the incident. He also verified they have been working on other complaints that was not investigated prior to him taking over as Interim Administrator.

Based on record review and staff interview, the facility failed to develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical and nursing needs. This was a random opportunity for discovery. Resident identifier: #38, #39. Facility census: 92.a) Resident #39 An electronic medical record review was completed on 12/18/25 at 11:00 AM. Resident #39 was admitted to the facility on [DATE]. Review of Resident #52's care plan identified the following: A Focus Area, initiated on12/08/25, which stated: Resident/Patient requires assistance/is dependent for ADL care in _______________ (specify: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to: Recent_______ (illness, fall, hospitalization, etc.) resulting in _______ (fatigue, activity intolerance, confusion, etc.) A Goal Area, initiated on 12/08/25, which stated: Resident/Patient will improve current level of function in: ________ (specify: bathing, grooming/personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) by next review as evidenced by improved ADL scores. An Intervention Area, initiated on 12/08/25, which stated: Provide resident/patient with _________ (specify: set-up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of _____. Provide resident/patient with _________ (specify: set-up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of _____ (specify #) for eating. Provide resident/patient with _________ (specify: set up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of ______ (specify #) for toileting: Provide resident/patient with _________ (specify: set-up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of ______ (specify #) for dressing. Provide resident/patient with _________ (specify: set-up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of _____ (specify #) for personal hygiene (grooming). Provide resident/patient with _________ (specify: set-up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of _____ (specify #) for bathing. During an interview on 12/22/25 at 9:50 AM, the Director of Nursing (DON) acknowledged the care plan had numerous areas left blank and was not person-centered. She stated that the initial care plan should have been completed within 72 hours of admission. It is still not completed as of 12/22/25 at 9:50 AM. b) Resident #38 A record review on 12/16/25 of Resident #38's chart revealed that Resident #38 was admitted to the facility on [DATE]. The care plan on file is dated to be created on 1/18/23 with a revision date of 11/14/25. No updates to the plan were made only acknowledging the revision. The care plan also is also not specific to the resident with no mention of name, age, or gender specific information that would make this care plan person-centered. The care plan uses vague terminology such as resident, monitor for decline. On page four (4) of the care plan (CP) in the focus column it states While in the facility, resident/patient states that is important that s/he has the opportunity to. The nursing staff did not go back into the CP and edit the form to show the correct gender of Resident #38. On the same page it also states Resident will plan and choose to engage in preferred activities. But, no choices or preferences are noted. The facility uses a preformatted CP to help with initial planning for each resident. However, these documents need to be updated with correct information and preferences of each resident. This was not done for Resident #38. During an interview with the Administrator on 12/16/25 at approximately 3:42 PM they stated, All care plans should be resident specific and updated on a regular basis.

Based on observation, record review, resident, and staff interview. The facility failed to assist dependent Residents with activities of daily living (ADL's) in accordance with the resident's assessed needs for care. This is true for three (3) of eight (8) residents reviewed for ADL's care. Resident Identifiers: #30, #49 and #72. Facility census: 92. Findings Included:a) Resident #49 On 12/15/23 at 11:28 AM Resident #49 stated that she does not get showers or baths as ordered or her preference. She stated that she is supposed to get two showers a week. She continued to state that the staff say they don't have enough staff to give her a shower. A review of Resident #49's ADL documentation found only two (2) showers on 11/21/25 and 12/09/25 also noted seven bed baths noted in 30 days. No Refusals noted.During an Interview on 12/17/23 at 10:30AM the Director of Nursing (DON) verified there was no documentation that Resident #49 received showers as scheduled. b) Resident #30Observation on 12/15/25 at 12:23 PM of Resident #30 found his hair appeared oily, dirty and uncombed.During an interview 12/15/25 at 12:23 PM, Resident #30 stated that he does not get very many showers. Subsequent Observation on 12/17/25 8:45 AM found that his hair still appeared oily, dirty and uncombed. A review of Resident #30's ADL documentation found only one (1) shower on 12/02/25 and four (4) bed baths noted in 30 days. No refusals were noted. During an Interview on 12/17/23 at 10:30AM the Director of Nursing (DON) verified there was no documentation that Resident #30 received showers as scheduled. c) Resident #72 During an interview 12/16/25 at 11:12 AM, Resident #72s medical power of attorney (MPOA) stated that the resident does not get showers. She continued to say that the staff tell her that Resident #30 does not like to get up, so they just do bed baths. She stated that her mom needed her showers and always preferred to get a shower and to be clean. A review of Resident #72's ADL documentation found only two (2) showers on 11/29/25 and 12/12/25 also eight (8) bed baths noted in 30 days. No refusals noted. During an Interview on 12/17/23 at 10:30 AM the Director of Nursing (DON) verified there was no documentation that Resident #72 received showers as scheduled.

Based on record review and staff interview, the facility failed to provide care in accordance with accepted professional standards of practice. This deficient practice had the potential to affect five (5) of 28 residents reviewed in the long-term care survey sample. For Resident #3, the facility failed to obtain vital signs as ordered by the physician. For Resident #69, the facility failed to follow physician-ordered medication parameters. For Resident #96, the facility failed to perform neurological checks after unwitnessed falls. For Residents #38 and #72, the facility failed to ensure coordination of care for residents receiving hospice services. Resident Identifiers: #3, #69, #96, and #38. Facility Census: 92. Findings included: a) Resident #3 On 09/28/25 at 9:16 PM, a nursing progress note stated Resident #3 reported chest pain. The resident's pulse rate was 104 beats per minute and irregular. The on-call provider was notified. According to the progress note, the provider ordered vital signs every four (4) hours for 48 hours. The on-call provider note written on 09/28/25 at 1:00 AM stated the physician had been contacted on 09/28/25 at 9:16 PM. The physician recommended more frequent vital signs (every four hours) for at least the next 48 hours to monitor heart rate. No order for vital signs every four (4) hours was entered. Review of Resident #3's vital signs showed vital signs had been obtained on the following dates and at the following times: - 09/28/25 at 9:16 PM - 09/28/25 at 9:33 PM - 09/29/25 at 2:00 AM - 09/29/25 at 9:38 AM - 09/29/25 at 10:50 AM On 9/29/2025 at 10:50 AM, the resident was transferred to the hospital at his request. The resident remained in the hospital until 10/02/25. On 12/17/2025 at 10:04 AM, the Director of Nursing (DON) stated she was unable to find documentation of vital signs for Resident #3 between 09/29/25 at 2:00 AM and 9:38 AM. The DON confirmed Resident #3's vital signs were not obtained every four (4) hours as ordered by the physician. No further information was provided through the completion of the survey process. b) Resident #69 Review of Resident #69's physicians' orders showed an order written on 10/01/25 for hydralazine 50 milligrams (mg) by mouth every 24 hours as needed for hypertension for systolic blood pressure greater than 150 or diastolic blood pressure greater than 90. The medication was to be held on dialysis days. The resident received dialysis treatments on Mondays and Fridays. Review of Resident #69's Medication Administration Records (MARs) for 10/01/25 through 12/17/25 showed physicians' orders were not followed on the following dates: - On 10/08/25, the resident's blood pressure was 156/86, but the resident did not receive hydralazine as ordered. - On 10/17/25, the resident received hydralazine for blood pressure of 162/87. However, this was a Monday, a dialysis day, when the medication was ordered to be held. - On 10/27/25, the resident received hydralazine for blood pressure of 162/87. However, this was a Monday, a dialysis day, when the medication was ordered to be held. - On 10/31/25, the resident received hydralazine for blood pressure of 152/83. However, this was a Friday, a dialysis day, when the medication was ordered to be held. - On 11/08/25, the resident's blood pressure was 155/71, but the resident did not receive hydralazine as ordered. - On 11/14/25, the resident received hydralazine for blood pressure of 153/82. However, this was a Friday, a dialysis day, when the medication was ordered to be held. - On 11/28/25, the resident received hydralazine for blood pressure of 159/88. However, this was a Friday, a dialysis day, when the medication was ordered to be held. - On 12/07/25, the resident's blood pressure was 165/77, but the resident did not receive hydralazine as ordered. On 12/17/25 at 12:32 PM, Registered Nurse (RN) #54 confirmed physicians' orders were not followed regarding Resident #69's hydralazine. No further information was provided through the completion of the survey process. c) Resident #96 The facility's policy titled, Falls Management with effective date 09/15/01 and revision date 10/01/25 stated any patient who sustained an injury to the head from a fall and/or has a fall unwitnessed by staff would be observed for neurological abnormalities by performing neurological checks. Resident #96 experienced a fall on 10/03/24 at 1:27 PM. The progress note stated, This nurse observed resident lying on his left side in his floor beside his bed. Vitals obtained and resident assisted back to bed X 2 assist via Hoyer lift. Resident states that he was trying to pick up his water pitcher out of the floor. Water pitcher observed busted in floor. Xray of thoracic/lumber/right hip/right ankle ordered. The e-interact change in condition for this fall stated, This is resident's second fall today. First fall at 0800. There was no progress note or change in condition for this fall. However, there was an incident report for 10/03/24 at 8:45 AM which stated, This nurse was called to resident room due to resident being observed sitting in the floor beside his bed. Vitals obtained and resident assisted back to bed x 2 assist via Hoyer lift. Resident states that he slid out of bed trying to pick up his cup that fell in the floor.No injuries observed at time of incident. The resident's medical records contained no documentation of neurological checks following the resident's falls on 10/03/24. On 12/22/2025 at 11:09 AM, the Director of Nursing (DON) was unable to provide neurological checks obtained after the resident's falls on 10/03/25. She confirmed these falls were documented as being unwitnessed. A change in condition note written on 11/05/25 at 7:17 PM stated in part, Staff notified this nurse resident was on the floor this nurse observed resident laying on his left side on the floor resident c/o [complained of] pain 10/10 in his rt [right] arm and rt ankle received an order to transfer resident to ED [emergency department] for evaluation. The incident form for 11/05/24 stated, This nurse was in the soiled laundry room, heard a yell, came out and in the room across the hall saw the resident on the floor with [staff name redacted] entering the room. Pt [patient] was lying on his left side and stated that his ankle hurt. I saw that he had a skin tear on his right upper arm and was later wrapped with abd pad and Kerlix. There was a knot on the back of his head. Resident stated he was reaching for the floor and landed on the floor. The resident's medical records contained no documentation of neurological checks following the resident's fall on 11/05/24. On 12/18/2025 at 10:36 AM, the DON was unable to provide neurological checks after the resident's fall on 11/05/24. She agreed neurological checks should have been documented immediately after the fall, before the resident was transferred to the hospital, due to the resident's hematoma to the back of the head. No further information was provided through the completion of the long-term care survey process. d) Resident #38 A record review on 12/16/25 of Resident #38's chart revealed that Resident #38 was admitted to the facility on [DATE] with a fair prognosis under skilled nursing care and then immediately ordered hospice care under (name of hospice) for the diagnosis of Terminal DX for Comfort. The facility has no record of the Hospice admission agreement or any other documentation signed by either Resident #38, their medical power of attorney (MPOA) and/or the facilities medical / social service staff, in either electronic format or in the hard copy binders for each resident. The only signed document on file was a long term care status form denoting routine hospice care. Also, the facility did not have any record of the Amedisys Hospice treatment plan for Resident #38; the expected medication set for a Hospice patient was not on Resident #38's MAR. The only orders pertaining to comfort on record in Resident #38's E-chart were as follows: This order was placed in the chart on 11/4/25: OXYCODONE HCL 100 MG/5 ML CONC GIVE 1 ML BY MOUTH EVERY 1 HOUR(S) AS NEEDED (20MG) - ordered by MD and signed off electronically by the pharmacy. There is no indication that these medications were given per the MAR or paper documentation. This order was placed on 11/8/25: DO NOT RESUSCITATE (DNR). Selective treatments. No artificial means of nutrition desired. During an Interview with social worker #105 on 12/16/25 at approximately 2:41 PM they stated, All the hospice records are placed into a hard chart behind the nurses' desk of the hall that resident is on. They then walked the surveyor to the area and searched for the file (it wasn't there). They then stated they would call the hospice agency and make sure they get all the paperwork for the Resident #38 as soon as possible. Follow up with Social Worker (SW) #105 at approximately 3:35 PM, They stated there is a file on E-chart called Long term care Status form uploaded on 11/6/25. It showed (name) as the hospice provider. Review of document titled Long term care status form: Shows (name of hospice) as the provider, but no outline of care plan or actions to be taken. Just Routine hospice is checked. Requested hospice agreement from (name of hospice) copy of orders and care plan. Nothing received from facility before exit on 12/22/25

Based on record review, resident interview, and staff interview, the facility failed to provide services to dialysis residents in accordance with professional standards of practice. There was no documentation that the resident's dialysis access site was monitored for one (1) of two (2) residents reviewed for the care area of dialysis. Resident Identifiers: #69. Facility Census: 92. Findings included:a) Resident #69 The facility's policy titled Dialysis: Hemodialysis External Catheter Evaluation and Maintenance with effective date 07/01/01 and revision date 07/01/25 stated, The licensed nurse is responsible for evaluating and maintaining the external hemodialysis catheter site for patients with an external hemodialysis catheter. The facility's policy titled Dialysis: Hemodialysis (HD) Provided by a Certified End-Stage Renal Disease (ESRD) Facility with effective date 10/01/18 and revision date 08/07/23 stated, After receiving dialysis, Center staff must provide monitoring and documentation of: the patient's vascular access site(s) to observe for bleeding or other complications. On 12/15/2025 at 1:09 PM, Resident #69 stated he received dialysis through a Permacath dialysis catheter (a tunneled catheter) in his right chest area. He stated he also had an arteriovenous fistula (access beneath the skin) in his left arm that was not being used for dialysis yet. Review of Resident #69's physicians' orders showed orders to monitor the arteriovenous fistula site for bleeding, edema, and signs and symptoms of infection. The arteriovenous fistula was also to be assessed for bruit (a sound of blood flow heard with a stethoscope) and thrill (a palpable vibration). The presence of a bruit and thrill indicate the fistula is safely functioning. There were no orders to monitor the site or the dressing of the Permacath for complications such as infection or bleeding. The resident was not care planned for monitoring of the Permacath. The medical records contained no documentation of monitoring for the Permacath site. On 12/17/25 at 12:32 PM, Registered Nurse (RN) #54 confirmed there was no documentation that Resident #69's Permacath site was monitored.No further information was provided through the completion of the survey process.

Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles. Multiple medications stored in a medication cart and the medication room were unlabeled and undated. This practice had the potential to affect more than a limited number of residents. Facility census: 92.Findings include:a) Medication room [ROOM NUMBER]An observation of the facility's Main Medication Room, on [DATE] at 9:30 AM, revealed a refrigerator contained the following:-One (1) box Influenza Vaccine open, not dated or labeled.-One (1) opened container of Hepatitis B Vaccine not dated or labeled.-One (1) opened container of Covid 19 Vaccine not dated or labeled.An interview with Registered Nurse (RN) #21, on [DATE] at 9:30 AM, revealed the medications should have been labeled with a name and an open date as soon as they were opened by the staff.b) 100 Hall Medication roomAn observation of the 100 Hall Medication, on [DATE] at 9:45 AM, revealed the following:-One (1) opened container of [NAME] expired [DATE].-Two (2) Ear wax removal expired [DATE]-One (1) opened container of Vancomycin not dated or labeled.-One (1) zynormef Infusion tubing expired [DATE]An interview with Registered Nurse (RN) #21, on [DATE] at 7:55 AM, revealed all the medications should have been labeled with a name and an open date as soon as they were opened by the staff.

Based on food tray temperatures and resident interviews, the facility failed to serve food to residents that was palatable and at an appetizing temperature. Based on resident interview and staff interview, the facility failed to ensure hot foods were served hot and cold foods were served cold. This failed practice was true for four (4) of five (5) hallways tested for milk temperatures on the beverage carts and food tray temperatures for one (1) of one (1) meal trays tested throughout the survey process Facility census: 92.a) This surveyor asked the Director of Dining to temp the milk that was located on the west hall beverage cart on 12/15/25 at 12:45 PM. The temp was 54 degrees F. The Director of Dining acknowledged the temp was above the Food and Drug Administration (FDA) food code temp of 41 degrees F. On 12/17/25 at 12:15 PM the surveyor asked employee #152 for the temperatures of the lunch menu food items. He stated that the cook writes them on the production sheet. He then gave me a copy of the production sheet and stated that the cook did not write them down. 12/15/2025 at 12:00 PM , Resident #58 said, The food is terrible, they have not updated any meal preferences with me, I asked the manager almost (3) three months ago The food is cold, we are last to get meals sometimes they run out , I usually do not get what I ask for. When they send us food, generally it is all mixed together. 12/15/25 at 12:50PM , Resident #58's meal was served. Resident #58's meal was Turkeyburger, with lettuce, tomato and baked beans on plate, observation: baked beans running on plate under Hamburger Bun. Resident #58 informed this surveyor I wish they would have put those beans in a bowl. 12/15/25 1:30PM , Resident #58.Staff interview with Food Service Director, questioned her if she or anyone had updated Resident #58's meal preferences, she informed this surveyor, No I have not Spoke with Food Service Director (FSD), reviewed meal presentation for this lunch- she viewed the plate for Resident #58 and FSD confirmed the baked beans were running into the hamburger bun,

Based on observations, resident interviews and staff interviews, this facility failed to ensure meal preferences were obtained, updated and followed per policy and or best practice as provided per District Manager for Food and Nutrition. This was a random finding during the Annual Long Term Care Survey Process. Facility Census 92 Resident identifiers #58, #31, #37Findings include: 12/15/2025 12:00PM , Resident #58. Resident interview The food is terrible, they have not updated any meal preferences with me, I asked the manager almost (3) three months ago to come talk with me 12/15/25 12:50PM , Resident #58, meal served, Resident meal was Turkeyburger, with lettuce, tomato and baked beans on plate, per resident This is what I ordered, I am glad ,observation: baked beans running on plate under Hamburger Bun. Resident #58 informed this surveyor I wish they would have put those beans in a bowl. 12/15/25 1:30PM Staff interview with Food Service Director, questioned her if she or anyone has updated resident #58 meal preferences, she informed this surveyor No I have not Spoke with Food Service Director, reviewed meal presentation for this lunch- Food Service Director viewed the plate for Resident #58 and confirmed the baked beans were running into the hamburger bun, 12/17/25 1:00PM Record review, resident interview, staff interview. Meal preferences have not been updated, resident # 58 complaining no updates were made and she requested for the food service director to meet with her, #37 complaining no one has met with her for awhile, and #31 complaining no one has met with him. (no capacity), Resident # 37 initial meal preference done 10/19/21, an update on 03/25/22 and update on 04/02/24. Resident #58 initial preference done 03/21/25. Resident #31 has not had a preference done, written on form no capacity. Staff interview with Dining Service Director and District Manager for food service regarding these concerns. District manager informed this surveyor Our best practice is to meet with the resident initially, then follow up if concerns, requests or significant changes occur. If a resident lacks capacity we still attempt to interview for preferences, if unable to interview social services are made aware and they attempt or reach out to family Policy for Dining and Food Preference in part reads The Dining Service Director, or designee, will interview the resident or resident representative to complete a Food Preference Interview within 72 hours of admission.

Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect more than an isolated number of residents. Facility census: 92. Findings include: a) 12/16/25 8:30 AM during an observation of food delivery carts five (5) of five (5) each had food debris on the bottom shelves, outside of the cart along bottom of doors, and along outside of each cart was a dried substance. 12/16/25 9:00 AM during a staff interview, district manager for food and nutrition, reviewed the five (5) of five (5) food delivery carts and confirmed there was food debris on the bottom shelves, outside of the cart along bottom of doors, and along outside of each cart dried substance. On 12/15/25 at 11:40 AM the surveyor completed an initial walkthrough of the kitchen. The Director of Dining (DOD) accompanied the surveyor during and acknowledged the following findings to be accurate. The dish machine log was missing temperatures for two (2) meals. The toaster had debris and needed to be cleaned. One (1) box of food thickeners was open to air and did not have an open or use by date. One (1) trash can located near the preparation table with the can opener did not have a lid on it while not in use. The mixer bowl was not covered while not in use. The knife rack was soiled. One (1) block of margarine sitting on the countertop were open to air and was not dated properly. One (1) package of hamburger buns did not have an open date. The outside of the coffee maker was soiled. There was one (1) measuring cup of sugar open to air and not labeled or dated properly. The can opener was soiled. One (1) opened package of white cake mix with no open or use by date. Three (3) opened packages of grape drink mix without an open or use by date. One (1) bowl of tossed salad not labeled or dated properly. Two (2) steam table pans with sliced and diced ham not labeled or dated properly. There was no liner in the trash can locate at the handwashing sink. There was no lid on the trash can located near the steam table while not in use. While the lunch meal is being served. Three (3) food storage containers were sitting directly on the floor under the prep sink. The meat slicer was not covered while not in use. The food storage container lids were wet nesting in a bussing bin. One (1) outdated container of tomato soup in the walk-in cooler dated for use by 12/14/25. One (1) container of cream of wheat in the walk-in cooler dated for use by 12/14/25. One (1) container of chicken & dumplings in the walk-in cooler dated for use by 12/12/25. One (1) container of ranch dressing in the walk-in cooler dated for use by 12/13/25. One (1) container of ricotta cheese in the walk-in cooler dated for use by 12/13/25. The fan cover in the walk-in cooler has debris present. Four (4) cases of frozen food sitting directly on the freezer floor. One (1) opened bag of chicken tenders in the freezer without an open or use by date. One (1) Ziploc bag of raisin toast located in the kitchen outdated with a use by date of 12/08/25. The ceiling vents located in the kitchen were dusty and rusty. This surveyor asked the Director of Dining to temp. the milk that was located on the west-hall beverage cart at 12:45 PM. The temp was 54 degrees F. The Director of Dining acknowledged the temp was above the FDA food code temp of 41 degrees F. One (1) gallon of whole milk outdated in the East / [NAME] nourishment room refrigerator with a use by date of 12/14/25. One (1) pint of whole milk outdated in the South nourishment room refrigerator with a sell by date of 11/21/25. On12/26/25 at 8:38 AM two surveyors were accompanied by the Director of Dining outside to where the two (2) trash dumpsters were located. One of the sliding doors was not completely closed on one dumpster and the lids were not completely closed on the second dumpster. The Director of Dining stated the doors should be closed and are not. 12/17/25 at 8:55 AM This surveyor made a second visit to the kitchen. On 12/17/25 at 8:55 AM observation revealed the fan in the dish room was soiled with debris. There were four (4) full size sheet pans sitting directly on the floor in the dish room. There was one (1) clean tray of 9 oz bowls sitting on top of the hand-washing sink in the dish room. Employees are documenting wrong sanitizer PPM on the low temperature dish machine log. Ecolab test strips indicate these four options 10 ppm, 50 ppm, 100 ppm and 200 ppm. For the month of December, they documented 150, 160, 170, 175 and 180 for every PPM that was documented. The surveyor spoke to the Registered Dietician (RD), Director of Dining, District Manager. The RD, Director of Dining and the District Manager acknowledged the deficient practice and said they would educate the staff on the proper way to test and document per their policy and procedure. On 12/17/25 at 11:42 AM observation revealed the cornstarch containers lid was not on securely and Employee #81 verified it should be and fixed the issue. On 12/17/25 at 11:48 AM the three (3) compartment sink log was not filled out for dinner ware washing on 12/16/25 or breakfast ware washing today 12/17/25. It was currently being used. Employee #152 verified that it should have been temped and the sanitizer PPM should have been documented. 12/17/25 at 12:00 PM On 12/17/25 at 12:00 PM there was no lid on the trash can in the dish room. Employee #152 stated it should be on when not in use, and he put it on.

Based on facility documentation and staff interviews, the facility failed to have required quarterly meetings. Additionally, the facility did not have required attendees present or sign in at the Quality Assessment and Assurance (QAA) meeting. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 93.Findings included: a) QAA Record review of the facility's documentation of QAA Meeting Agenda and Minutes revealed no meeting was conducted in the first quarter or the third quarter of 2025.During an Interview 12/22/25, at 11:30 AM the Administrator verified the required members did not sign in for the quarterly QAA meetings and there was no documentation of QAA meetings in the first and third quarter. No other information was provided prior to the end of the survey.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. This deficient practice affected three (3) of 28 residents reviewed in the long-term care survey sample. Resident identifiers: #2, #96 and #69. Facility census: 92. Findings included: a) Resident #2 Record review on 12/17/25 at 10:36 AM revealed the facility failed to ensure an accurate care plan for Resident #2. The wrong name was used in this resident's care plan. This finding was confirmed with the administrator on 12/17/25 at 10:30 AM. b) Resident #69 Review of Resident #69's physician's orders showed an order written on 10/23/25 for No BP (blood pressures) or needle sticks in left or right arm due to dialysis access. Utilize thigh cuff for BP. This order was written because the resident had an arteriovenous (AV) dialysis fistula in his left arm and a Permacath dialysis catheter in his right chest area. On 12/17/2025 at 11:38 AM, Resident #69 stated staff used his leg and not his arms to obtain blood pressure readings. He stated his left arm was used for blood pressures until the fistula was placed in October 2025. After the fistula was placed, his leg was used to obtain blood pressure readings. Resident #69's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 10/21/25 showed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #69's physician's evaluation of capacity dated 05/07/25 showed the resident had capacity to make medical decisions. Resident #69's vital signs summary documented the resident's arm was used for blood pressure readings on the following dates at the following times: - On 12/09/25 at 9:51 AM, the left arm was documented as being used. - On 11/27/25 at 8:31 AM, the right arm was documented as being used. - On 11/09/25 at 7:44 AM, the right arm was documented as being used. - On 11/08/25 at 8:05 AM, the right arm was documented as being used. - On 11/07/25 at 8:12 AM, the right arm was documented as being used. - On 11/06/25 at 8:55 AM, the right arm was documented as being used. - On 11/05/25 at 8:33 AM, the right arm was documented as being used. - On 11/04/25 at 7:59 AM, the right arm was documented as being used. - On 11/02/25 at 8:29 AM, the right arm was documented as being used. - On 11/01/25 at 8:42 AM, the right arm was documented as being used. - On 10/31/25 at 7:27 AM, the right arm was documented as being used. - On 10/30/25 at 7:43 AM, the right arm was documented as being used. - On 10/29/25 at 7:48 AM, the right arm was documented as being used. - On 10/28/25 at 12:28 PM, the right arm was documented as being used. - On 10/27/25 at 7:32 AM, the right arm was documented as being used. - On 10/26/25 at 7:54 AM, the right arm was documented as being used. - On 10/25/25 at 7:38 Am, the right arm was documented as being used. On 12/17/25 at 12:32 PM, Registered Nurse (RN) #54 stated the documentation was incorrect for the above-listed blood pressure readings. She stated the resident would not have allowed staff to use his arm for blood pressure readings. She stated these blood pressure readings should have indicated the resident's leg was used to obtain the blood pressure readings. No further information was provided through the completion of the survey process. b) Resident #96 Review of Resident #96's medical records showed a Physician Determination of Capacity form signed by the physician on 06/02/24. The portion of the form for the physician to check whether the resident has or lacks sufficient mental or physical capacity to appreciate the nature and implication of health care decisions was not completed. Both the option that the resident has capacity and the option that the resident lacks capacity were blank. However, diagnoses that deem the resident incapacity were checked, along with the nature of the incapacitation. The diagnoses were chronic obstructive pulmonary disorder and cardiovascular disease. The nature of incapacitation was cognitive loss and inability to understand or make medical decisions. The expected duration of incapacity was long term. A previous Physician Determination of Capacity form dated 06/04/23 indicated Resident #96 did not have capacity to make medical decisions. On 12/18/25 at 10:38 AM, the Director of Nursing confirmed Resident #96's Physician Determination of Capacity form was not fully completed. No further information was provided through the completion of the survey process.

Based on medical record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed for accidents was free from neglect. A test eligible nursing assistant (TENA) failed to put up the side safety rail on a shower bed. The resident fell off the shower bed to the floor, sustaining C1 and C2 (first and second cervical vertebrae) vertebral fractures and a nasal fracture. Prior to the incident, the TENA was trained to put up the safety rail and to provide safety measures during resident care. The TENA neglected to implement these safety measures resulting in harm to the resident. Resident identifier: #93. Facility census: 92. Findings include: a) Resident #93 Review of incident reports revealed on 10/07/13 at 6:35 p.m., this resident was transferred from a wheelchair to a shower bed using a mechanical lift by Employee #79, a test eligible nursing assistant (TENA). According to the report, the TENA failed to put up the side safety rail on the shower bed. The TENA turned away to move the mechanical lift out of the way. When the TENA turned back around, Resident #93 was falling from the shower bed and hit the floor. The written statement from Employee #79 stated (typed as written): "I, (Employee #79), was going to give (Resident #93) a shower. Me and the aide (Employee #20) brought her to the shower room and used the mechanical lift to put her on the shower bed. We got her on and (Employee #20) brought the chair out of the shower room. I was bringing the lift out. As I was pushing the lift out, I turned around to look at (Resident #93) and saw her grabbing the air. We didn't put the rail up before we moved the chair and lift, I saw her grab and roll over, so I ran to her, but it was just a second too late and she fell out and landed on her side, then hit her head. I immediately ran to get the nurse and went back to hold her head up." The written statement from Employee #20 stated (typed as written): "I assisted CNA (certified nursing assistant) with transferring (Resident #93) onto shower bed with hoyer lift. I asked CNA if she needed help undressing resident and she replied no. I told CNA that I would take residents chair back to her room and change residents linens. CNA said OK and I got half way down Far East hallway and CNA yelled at me to come back that resident had fallen off shower bed. I immediately got her nurse and charge nurse. " A late entry nurse's note, dated 10/07/13 at 18:35 (6:35 p.m.), described the nurse observed the resident lying on the floor of the shower room at 6:35 p.m. on 10/07/13. The note indicated a moderate amount of blood was on the floor and the resident's head. A laceration was noted to the midline of the resident's forehead from her hairline to her eyebrow line. A small laceration was also noted to the bridge of the resident's nose. The resident was assessed for any further injures while a staff member stabilized the resident from movement of head, neck and shoulders. The resident was noted to be spitting out blood from her mouth and a small amount of blood was seeping from her bilateral nares (nostrils). The emergency medical technicians (EMTs) arrived and transported the resident to the local emergency room (ER). The medical record entry, dated 10/08/13 at 00:09 (12:09 a.m.), indicated a call to the local ER revealed the resident was being admitted to the hospital with [REDACTED]. Review of the resident's current care plan indicated the resident had a history of [REDACTED]. The KARDEX, the specific individualized instructions for the resident's care used by nursing assistants, stated (typed as written): "Resident requires total assist with transfers to w/c with use of mechanical lift (450/Medium/purple pad)." Another section stated (typed as written): "Resident requires total assistance with bathing, grooming, dressing, and bathing." There was documentation of education provided to Employees #20 and #79 on 10/08/13, after the resident fell , stating (typed as written): "Resident must be in eyesight when on shower bed & siderails & wheels locked @ all times. Safety is always first. " An interview was conducted with the Corporate Nurse Aide Instructor, registered nurse (RN), (Employee #140) on 10/17/13 at 10:25 a.m. She was asked if the State approved nurse aide training program used by the corporation included instruction regarding the use of shower equipment, and supervision of dependent residents in bathing. She said it did, and provided items used in the training entitled, "Safety measures for tub baths and showers." These instructions included the statement, "Do not leave weak or unsteady persons unattended." This was also included on a post test. The "Mosby's Textbook for Nursing Assistants", the primary resource utilized in nurse aide training classes at the facility, included instructions for safety. On page 342 there were instructions to: "Protect the person from falls, chilling and burns." Instructions on page included: ". . . lower the sides to transfer the person from the bed to the trolley. Raise the side rails after the transfer." The curriculum for the nursing assistant training program included both written post tests for each section as well as required return demonstrations of tasks, including transfers and bathing. Review of records found test eligible Nursing Assistant #79 received her training at the facility using this curriculum just prior to her hire date of 08/19/13. .