Every finding on record at Wright Rehabilitation and Healthcare Center

Based on observations, staff interviews, and review of facility food safety policy, the facility failed to ensure food and food preparation services were protected from potential contamination. This had the potential to affect all residents in the facility that received food from the kitchen, except one resident (#95) with an active NPO (nothing by mouth) order during the survey. The facility census was 78. Findings include: 1. Observation on 03/02/26 at 10:50 A.M. revealed one red bucket and one green bucket stored on the floor of the kitchen at the end of the food service line, adjacent to the prep sink and juice machine. Both buckets were observed holding washcloths in liquid solutions. Interview on 03/02/26 at approximately 10:51 A.M. with Dietary Manager #259 revealed the buckets stored on the floor were for detergent and sanitizer solutions that hold washcloths used to wipe down kitchen equipment such as food prep counters. Further interview at this time revealed Dietary Manager #259 believed the floor was likely not the best storage location for washcloths/sanitizer solution intended to clean kitchen surfaces. Additional interview at this time revealed the buckets of sanitizer solution and washcloths are usually stored directly on the floor due to a limited amount of space in the kitchen. 2. Observation on 03/03/26 at 9:45 A.M. revealed one large bag of partially thawed raw chicken thighs sitting in the rinse compartment of the three-compartment sink, with no water running. Further observation at this time revealed signage posted each compartment of the sink that indicated the sink was intended for washing, rinsing, and sanitizing utensils as well as other food service equipment. Another observation at this time revealed kitchen utensils were soaking in sanitizer solution in the sanitize compartment of the sink, next to the rinse compartment that was holding the bag of raw chicken. Interview on 03/03/26 at 9:50 A.M. with Dietary Manager #259 revealed kitchen staff regularly use the three-compartment sink for thawing foods, as the prep sink nearest to the food service line has a spray nozzle attached to the faucet that does not allow for a continuous flow of water to thaw foods. Further interview at this time revealed Dietary Manager #259 acknowledged the three-compartment sink is intended for washing, rinsing, and sanitizing utensils and other food service equipment rather than thawing foods. Review of the facility policy titled The Four Acceptable Methods for Thawing Food revealed acceptable methods for thawing foods include in a refrigerator at a temperature of 41 degrees Fahrenheit or lower, thawing in a microwave oven, thawing by submerging food under running potable water at a temperature of 70 degrees Fahrenheit or lower, or thawing as part of the cooking process. 3. Observation on 03/05/26 at 10:55 A.M. revealed the inside of the ice machine located in the activities room was visibly dirty with brown debris accumulating on the inside of the ice machine while holding ice. Interview on 03/05/26 at 10:55 A.M. with Licensed Practical Nurse (LPN) #253 revealed the ice in the ice machine was used for residents, and the inside of the ice machine appeared visibly dirty despite monthly cleanings. The facility confirmed all residents in the facility receive food from the kitchen, except one resident (#95) who has an active NPO order.

Based on observations, staff interviews, and review of a facility recipe for pureed food, the facility failed to ensure pureed food was prepared to the proper consistency and texture before serving the food to residents. This had the potential to affect seven (#15, #17, #7, #21, #26, #43, and #61) residents identified by the facility with pureed texture dietary orders. The facility census was 78. Findings include: Observation on 03/04/26 at 10:20 A.M. revealed [NAME] #320 placed seven scoops of diced ham into a food processor, along with an unidentified amount of chicken broth to begin making the pureed ham entree for lunch service. Further observation at this time revealed [NAME] #320 added two spoons of powdered thickening additive to the food processor, after the cook asked to be handed a teaspoon to measure powdered thickening additive. Interview on 03/04/26 at 10:20 A.M. with [NAME] #320 revealed they were unsure of the exact amount of chicken broth they added in with the ham to start pureeing the food, they believed the amount of broth added was around one-half liquid cup. Further interview at this time with [NAME] #320 and Dietary Manager #259 verified that the spoon used for adding thickening additive was not a true teaspoon intended for measuring foods, rather it was a spoon like the kind that would be used as part of meal service for residents. Observation on 03/04/26 at approximately 10:23 A.M. revealed [NAME] #320 added two more spoons worth of powder food thickening additive to the food processor with the ham and chicken broth mix. Interview on 03/04/26 at 10:28 A.M. with [NAME] #320 revealed they were seeking an applesauce like smooth texture for the pureed ham, and the finished pureed ham should have no distinguishable pieces of ham remaining on the palate when tasting the puree. Further interview at this time revealed [NAME] #320 usually tastes the pureed foods they prepare in the kitchen to be able to ensure the food is at the proper consistency and texture prior to serving the food to residents. Observation of tasting the pureed ham on 03/04/26 at 10:31 A.M. revealed small pieces of ham were felt on the palate and with swallowing the food. Interview on 03/04/26 at 10:31 A.M. with [NAME] #320 revealed they could sense small pieces of ham remaining in the pureed ham mix when they tasted the food. Interview on 03/04/26 at 10:31 A.M. with Food Service Director #301 revealed the pureed ham texture did appear to be somewhat soupy, but they expected the pureed blend to thicken while being held in a hot holding unit before the puree was going to be served at lunch. Observation on 03/04/26 at 10:35 A.M. revealed [NAME] #320 placed the food back in the hot holding unit without ensuring the pureed ham was free of small pieces in the mixture. Observation of tasting the pureed ham again on 03/04/26 at 11:42 A.M. during lunch service revealed small pieces of ham were still detectable on the palate after the majority of the pureed ham had dissolved with swallowing the food. Interview on 03/04/26 at 11:44 A.M. with Food Service Director #301 revealed they could sense small pieces of ham remaining in their mouth after tasting the pureed ham. Further observation at this time revealed that the Food Service Director #301 wasn't sure if the remaining pieces they felt on their tongue was end pieces of rind/skin of the ham, though they did not believe any pureed ham with small pieces remaining had been served to residents yet. Observation on 03/04/26 at 11:46 A.M. revealed three Residents (#21, #17, and #43) had been served pureed ham for lunch. The facility confirmed there are seven (#15, #17, #7, #21, #26, #43, and #61) residents who have pureed texture dietary orders. Interview on 03/04/26 at 12:00 P.M. with Speech Language Pathologist (SLP) #302 revealed pureed food should not have any pieces left to chew, and when pureed food dissolves in a resident's mouth, there should not be any pieces of food left in their mouth. Interview on 03/04/26 at 12:20 P.M. with SLP #302 revealed they went and tried the pureed ham without surveyors present, although pureed hotdogs had been prepared in place of the pureed ham due to the remaining small pieces left in the ham. Interview at this time revealed SLP #302 believed the puree was acceptable, although there were still small particles in the pureed ham when they tasted it. Review of the facility provided recipe for Pureed Baked Ham (no date) revealed the consistency of pureed ham should be checked consistently until the food product is smooth, lump free, and extremely thick.

Based on medical record review and staff interview, and family interviews, the facility failed to provide a written notification of a room change. This affected one (#95) of one residents reviewed for room changes. The facility census was 78. Findings include: Record review for Resident #95 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: aphasia, vascular dementia, hallucinations, altered mental status, esophageal obstruction. Review of Minimum Data Set (MDS) admission assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 07. This resident was assessed to be dependent with all care. Resident has a feeding tube. Review of the care plan dated 02/25/26 revealed vascular dementia with mood disturbance, psychotic disturbance, and anxiety. Review of Resident #95's progress notes revealed there was no documentation regarding the resident being moved to a different room, family notification or a written notice was given. Interview on 03/05/26 at 1:25 P.M. with Director of Nursing (DON) and Administrator revealed facility decided to move Resident #95 to Memory Care Unit (MCU) due to wandering. Interview on 03/05/26 at 1:32 P.M. with Social Services (SS) #217 revealed SS #217 notified Resident #95's family around 7:30 A.M. to 8:00 A.M. of Resident #95 moving to the MCU due to wandering into other rooms in the last couple of days. Interview on 03/05/26 at 1:40 P.M. with Resident #95's daughter revealed she was notified by phone at 8:45 A.M. regarding Resident #95 moving to the MCU. Resident #95's daughter left the facility at 2:10 P.M. and stated she had not received a written notification of room change.

Based on medical record review, observation, family interview, staff interview, and facility policy, the facility failed to maintain a clean and home-like environment. This affected one (#93) of two residents review for the physical environment. The facility census was 78. Findings include: Record review for Resident #93 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: Calculus of bile duct with cholangitis or cholecystitis without obstructive, chronic obstructive pulmonary disease, sepsis and Alzheimer's disease. Review of Minimum Data Set (MDS) admission assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 07. MDS admission was in progress. Observation on 03/02/26 at 12:06 P.M. revealed a two-inch round pile of flower potted soil substance that stood one-inch high was under the middle of Resident #93's bed more towards to head of the bed. Three small spots were located under the bed in line with the large spot. One round dust ball under the wall heating system beside Resident #93's bed was found on the floor. Interview on 03/02/26 at time of finding with Resident #93's family revealed Resident #93's family had requested three times since admission to housekeeping for floor to be swept and floor was never swept. Resident #93's family stated, Housekeeping only comes in to get trash and clean the toilet ever since we have been here. Interview on 03/02/26 at 3:22 P.M. with Housekeeper #284 revealed rooms are to be cleaned daily by sweeping, taking trash out, and cleaning bathroom. Housekeeper #284 confirmed Resident #93's room needed swept. Interview on 03/04/26 at 1:11 P.M. with Housekeeper #292 revealed rooms are to be cleaned daily by sweeping, taking trash out, and cleaning bathroom. Housekeeper #292 confirmed Resident #93's room needed swept. Review of an undated facility policy Housekeeping/Environmental Services revealed cleaning scheduled are developed and implemented to assure that each area of our facility is maintained in a safe, clean and comfortable manner.

Based on medical record review and staff interview, the facility failed to provide assessments and monitoring of a resident who tested positive for Coronavirus Disease 2019 (COVID-19). This affected one (#92) of one residents reviewed for COVID-19. The facility census was 78. Findings include: Record review for Resident #92 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: encephalopathy, vascular dementia, chronic obstructive pulmonary disease, and bronchitis. Review of Minimum Data Set (MDS) admission assessment dated in progress revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 99. This resident was assessed to be bladder incontinent. Review of the care plan dated 02/28/26 revealed Resident #92 had COVID-19 with interventions which include lab/cultures/diagnostic testing as ordered and report results to physician. Review with resident the importance of good handwashing, assist as needed. Encourage fluids unless contraindicated, monitor and report to physician signs/symptoms of dehydration (poor skin turgor, dry mucous membranes, increased heart rate, sunken eyes, decreased urinary output, difficult breathing, hypotension). Monitor for elevated temperature. Droplet isolation precautions; wear full personal protective equipment (PPE) while providing direct care. Review of progress notes revealed Resident #92 tested positive for COVID-19 on 02/28/26 and placed in droplet isolation. Care plan was updated on 02/28/26 with an intervention to monitor for elevated temperature due to COVID-19. Tympanic temperatures for Resident #92 were 98.9 degrees Fahrenheit on 02/27/26 at 8:43 P.M. and 98.0 degrees Fahrenheit on 03/01/26. Further review of Resident #92's medical record revealed there was no daily or shift-by-shift monitoring related to symptoms of dehydration, for elevated temperatures and/or respiratory symptoms were completed.Interview on 03/04/26 at 3:36 P.M. with Administrator verified no symptom management was completed for Resident #92 who tested positive for COVID-19. Interview on 03/04/26 at 4:14 P.M. with Director of Nursing (DON) verified no symptom management was completed for Resident #92 who tested positive for COVID-19.

Based on record review, staff interviews, and policy review, the facility failed to complete a proper bed rail assessment, including measurements of the air mattress and obtaining proper consent. This affected one (#96) out of one residents reviewed for siderails. The facility census was 78. Findings include: Review of the medical record of Resident #96 revealed an admission date of 07/22/25 with diagnoses of unspecified intracapsular fracture of right femur, subsequent encounter for closed fracture with routine healing, spondylopathy in diseases classified elsewhere, cervical region, dysphagia, oropharyngeal phase, wedge compression fracture of fifth lumbar vertebra, subsequent encounter for fracture with routine healing and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the care plan dated 08/19/25 revealed Resident #96 had activities of daily living (ADL) self-care performance deficit related to severe lower back pain, unsteadiness on feet, dementia, insomnia, L5 compression fracture, and closed sub-capital fracture of right femur with intervention of 1/2 siderail use for repositioning and bed mobility. Review of the 01/20/26 admission Bed Rail Evaluation revealed informed consent was obtained from Resident #96. Review of the End of PPS Part A Stay Minimum Data Set (MDS) dated [DATE] revealed Resident #96 had severe cognitive impairment and required substantial assistance with bed mobility. Review of the incident investigation on 02/04/26 for Resident #96 revealed resident was found lying up against the right side bedrail with light bruising noted to the right side of the neck. Resident was guarding the right side (rib area) and tenderness was present. Side rails were removed. Physician ordered stat x-rays for the ribs on the right side. Review of the x-rays completed on 02/05/26 revealed age indeterminate right rib fractures. Interview on 03/09/26 at 10:31 A.M. with Registered Nurse (RN) #257 confirmed Resident #96 was found laying up against the right siderail in her bed on 02/04/26 and was complaining of pain. Interview confirmed resident had notable bruising to the right side of her neck. The physician was notified and an x-ray was ordered. Interview also confirmed Resident #96 was unable to describe what happened due to resident had dementia. Interview on 03/09/26 at 12:14 P.M. with the Director of Nursing (DON) confirmed Resident #96 had a brief interview for mental status (BIMS) of 07, which means the Resident #96 has severe cognitive impairment. Interview with the DON confirmed the facility had Resident #96 sign a consent for siderails on 01/20/26 and she should not of signed consent due to severe cognitive impairment. The DON confirmed the facility did not do proper measurements on the air mattress. The DON confirmed Resident #96 was unable to describe what happened on 02/23/26 when she was found laying against the siderail on an air mattress. Review of the Use of Bed Rails policy, dated September 2022 revealed bed rails will be used when appropriate and after an assessment is completed. This deficiency represents non-compliance investigated under Complaint Number 2742722.

Based on record review and staff interviews, the facility failed to ensure residents did not receive unnecessary medications, when one resident received antibiotics without a an adequate indication for use. This affected one (#10) out of six residents reviewed for unnecessary medications. The facility census was 78. Findings include: Review of the medical record revealed an admission date of 03/11/22 with diagnoses of Alzheimer's disease with late onset, chronic kidney disease, stage 3, essential (primary) hypertension, anxiety disorder, and major depressive disorder, recurrent, severe with psychotic symptoms. Further review revealed Resident #10 did not have a diagnosis of or history of diverticulitis or diverticulosis. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had moderate cognitive impairment and was not on an antibiotic. Review of the physician's progress noted dated 02/27/26 revealed resident was lethargic and wanted to sleep a lot, medication reduction was ordered. There was no documentation of Resident #10 having diverticulitis or diverticulosis. Review of the nurses note dated 02/28/26 at 5:33 A.M. revealed Resident #10 complained of severe left abdominal pain during the night, physician contacted and ordered Augmentin 875/125 mg twice daily for seven (7) days for diverticulitis. Review of the physician order dated 02/28/26 revealed and order for Augmentin 875/125 mg every 12 hours for seven (7) days for diverticulitis. Review of the general note dated 03/02/26 at 12:03 P.M. revealed Resident #10 was seen by the physician who reviewed the abdominal x-rays and they were negative for diverticulitis. Review of the care plan dated 03/06/26 revealed resident has an infection and is on antibiotic for diverticulitis. Telephone call on 03/03/26 at 10:28 A.M with Resident #10's guardian, confirmed Resident #10 has never had a diagnosis of diverticulitis or diverticulosis. Interview on 03/04/26 at 8:25 A.M. with Licensed Practical Nurse (LPN) / Infection Preventionist (IP) #246 confirmed Resident #10 is on Amoxicillin-Pot Clavulanate Tablet 875-125 MG twice daily for diverticulitis for seven (7) days which started on 02/28/26. Interview also confirmed the physician ordered the antibiotic based on resident symptoms, not testing results. Interview also confirmed the physician was has not contacted to discontinue the antibiotic due to not having proper testing for diagnoses and use of the antibiotic. Interview on 03/09/26 at 2:21 P.M. with the Director of Nursing confirmed there is not a policy for discontinuing medications that do not have a proper diagnosis for use.

Based on medical record review, staff interview, and facility policy, the facility failed to ensure behaviors were documented in a resident's medical record. This affected one (#95) out of three residents reviewed for medical record documentation. The facility census was 78. Findings include: Record review for Resident #95 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: aphasia, vascular dementia, hallucinations, altered mental status, esophageal obstruction. Review of Minimum Data Set (MDS) admission assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 07. This resident was assessed to be dependent with all care. Resident has a feeding tube. Review of the care plan dated 02/25/26 revealed vascular dementia with mood disturbance, psychotic disturbance, and anxiety. Review of Resident #95's progress notes revealed there was no documentation regarding wandering events or behaviors, Interview on 03/02/26 at 4:11 P.M. with Certified Nursing Assistant (CNA) #239 revealed Licensed Practical Nurse (LPN) #220 brought Resident #95 from west hall to memory care on the day of admission due to behaviors and stated Resident #95 needed to be a one on one. Resident #95 was kicking, punching, slapping and trying to get out of wheelchair. Interview on 03/05/26 at 1:25 P.M. with Director of Nursing (DON) and Administrator revealed facility decided to move Resident #95 to Memory Care Unit (MCU) due to wandering into multiple female rooms and was scaring female residents early this morning. DON stated Resident #95 was hard to redirect. The DON and Administrator confirmed there was no documentation of wandering in Resident #95's medical record. Interview on 03/05/26 at 1:32 P.M. with Social Services (SS) #217 revealed SS #217 notified Resident #95's family around 7:30 A.M. to 8:00 A.M. of Resident #95 moving to MCU due to wandering into other rooms in the last couple of days. SS #217 confirmed Resident #95's behavior was not documented in the medical record. Interview on 03/05/26 at 2:50 A.M. with LPN #241 revealed Resident #95 wandered around the east unit, got out of his wheelchair and was touching a mechanical lift (Hoyer). LPN #241 suggested a wander guard to DON in the A.M. just for safety. Resident #95 did not exit seeking. LPN #241 confirmed Resident #95's behavior was not documented in the medical record. Review of undated facility policy Charting and Documentation revealed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medial record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on record review, policy review, witness statements, physician notes and staff interviews, the facility failed to prevent sexual abuse of one Resident (#11) of three reviewed. The facility census was 82. Findings include:1.Review of the medical record for Resident #11 revealed an admission date of 06/05/25. The resident was admitted with diagnoses including aphasia following stroke, paraplegia, anxiety and neuromuscular dysfunction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. Resident #11 required set up for eating and was dependent for bed mobility, transfers, and toileting hygiene. Review of the progress note dated 11/11/25, written by Registered Nurse (RN) #111, revealed an unnamed Certified Nursing Assistant (CNA) alerted a female resident (Resident #10) was observed in Resident #11's room with her hand on his penis stroking up and down. Resident #11 was documented to inform the unnamed CNA he was awoken by the female resident and did not ask for it to happen. The residents were separated immediately. Review of the social service progress note dated 11/12/25 at 9:27 A.M. revealed the social worker spoke to Resident #11 and offered a telehealth visit from Company #1 and he agreed. Additional review of social service progress notes revealed on 11/12/25 at 12:53 P.M., social services offered a second service from Company #2 and Resident #11 agreed to this as well. The note further documented an unnamed counselor with Company #2 informed social services Resident #11 was feeling embarrassed and felt the incident was his fault.Review of the 11/21/25 psychiatric evaluation from Company #1 revealed Resident #11 reported a female resident was sexually inappropriate with him the previous evening. The residents were separated and the facility was monitoring the situation closely and he was pleased with that.Review of the written statement of RN #111 revealed CNA #103 informed RN #111, Resident #10 was in Resident #11's room, with her hand on his penis stroking up and down. The residents were separated, and Resident #10 was placed on one-on-one supervision. RN #111 interviewed Resident #11 who informed her he was awoken from his sleep by Resident #10 touching his penis, he stated he did not ask for it to happen, and he asked her to stop. Resident #10 stopped when CNA #103 entered the room.Review of the written statement of CNA #103 revealed while doing rounds, he observed Resident #10 go into Resident #11's room and CNA #103 observed Resident #10 stroking Resident #11's penis. Once CNA #103 was observed entering the room, Resident #10 immediately stopped and covered up Resident #11. Resident #10 was removed and returned to the Memory Support Unit (MSU).2. Review of the medical record for Resident #10 revealed admission date of 03/15/22. The resident was admitted with diagnoses including alcohol dependence with alcohol induced persisting dementia, stroke, aphasia following stroke, schizophrenia and Wernicke's encephalopathy. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a BIMS score of 15 indicating intact cognition. She required set up assistance with eating, bed mobility, transfers, and toileting hygiene. Review of the care plan revealed Resident #10 was a supervised smoker, was an elopement risk, and had aggressive behaviors.Review of the progress note dated 11/11/25 at 8:45 P.M. RN #111 documented an unnamed CNA alerted her Resident #10 was observed in another resident's room (Resident #11) with her hand on his penis stroking up and down. Resident #11 asked Resident #10 to stop, and she did not stop until the staff member entered the room. The residents were separated immediately, and Resident #10 was placed on one-on-one supervision.Review of the progress note dated 11/12/25 at 1:57 P.M. revealed Resident #10 had a telehealth appointment with Company #1 regarding the recent sexual incident. Resident #10 agreed not to touch another resident inappropriately and monitoring would continue.Review of the 11/21/25 psychiatric evaluation from Company #1 revealed Resident #10 stated she and Resident #11 had been in a relationship but if he didn't want to date anymore, she would not bother him. She agreed not to touch Resident #11 if he did not want to be touched. The note documented staff had reported Resident #10 touched Resident #11 inappropriately and he did not want it to occur.Interview on 11/19/25 at 9:12 A.M. with Assistant Director of Nursing (ADON) #102 revealed staff reported Resident #10 was observed entering Resident #11's room by CNA #103. It was reported to ADON #102, CNA #103 witnessed inappropriate touching of Resident #11 and Resident #10 mirrored in the window. ADON #102 verified Resident #10 resided in MSU which he acknowledged was a locked unit. ADON #102 explained the incident occurred during a smoke break and ADON #102 explained Resident #10 reported she was cold, so staff permitted her to go back into the facility unsupervised, which allowed her the opportunity to enter Resident #11's room.Interview on 11/19/25 at 11:25 A.M. with Laundry Assistant (LA ) #108 revealed there were two residents on the MSU who were smokers. She shared the residents were to be observed at all times while they are out of the unit.Interview on 11/19/25 at 11:31 A.M. with Social Worker (SW) #110 revealed she was informed during morning meeting on 11/12/25 of an incident of inappropriate touching by Resident #10 to Resident #11, an investigation was initiated, and the police were contacted. SW #110 spoke to both residents, and both agreed to a telehealth appointment with Company #1. SW #110 denied knowledge of a previous incident by Resident #10 of sexual behavior towards any resident at the facility.Interview on 11/19/25 at 12:36 P.M. with the Director of Nursing (DON) and Administrator revealed on 11/11/12, the DON was contacted by CNA #103 and informed of inappropriate touching of Resident #11 by Resident #10. CNA #103 reported he witnessed Resident #10 enter Resident #11's room and when he went to investigate, he observed Resident #10 touching Resident #11's penis mirrored in the window. Resident #10 stopped as he entered the room and she was escorted back to the MSU and placed on one-on-one supervision. Upon investigation, it was discovered during the 8:30 P.M. smoke break on 11/11/25, Resident #10 informed LA #112 she was cold and wanted to wait inside the activity room (right inside the smoke door) until smoke break was over. LA #112 agreed, and after smoke break when Resident #10 was not in the activity room it was assumed, she had gone back to the unit. The police were notified on 11/12/25 and a report was filed. The Administrator shared Resident #11 had stated he did not wish to file charges; however the police chose to proceed with charges. The case remains open. Both residents received an assessment by Company #1, and Resident #10 was discharged on 11/12/25 to Behavioral Hospital #3. The DON and Administrator each verified it was the expectation of the staff assigned to smoke breaks observe the MSU residents at all times until returned and secured back inside the unit.Interview on 11/19/25 at 1:04 P.M. with Resident #11 revealed Resident #10 had come into his room after smoking and touched him inappropriately. He shared he was disturbed by this action as he was asleep and was awoken by her touching him.Review of the facility policy, Abuse Investigation and Reporting dated 11/21 documented residents had the right to be free from abuse, neglect and misappropriation.This deficiency represents non-compliance investigated under Complaint Number 2671345.

Based on record review and staff interviews, the facility failed to ensure residents residing in a secure memory care unit were observed when outside the unit. This affected one Resident (#10) of three reviewed. The facility census was 82. Findings include:Review of the medical record for Resident #10 revealed admission date of 03/15/22. The resident was admitted with diagnoses including alcohol dependence with alcohol induced persisting dementia, stroke, aphasia following stroke, schizophrenia and Wernicke's encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She required set up assistance with eating, bed mobility, transfers, and toileting hygiene.Review of the care plan revealed Resident #10 was a supervised smoker, was an elopement risk, and had aggressive behaviors.Review of the progress note dated 11/11/25 at 8:45 P.M., Registered Nurse (RN) #111 documented an unnamed Certified Nursing Assistant (CNA) alerted her Resident #10 was observed in another resident's room (Resident #11) with her hand on his penis stroking up and down. Resident #11 asked Resident #10 to stop, and she did not stop until the staff member entered the room. The residents were separated immediately, and Resident #10 was placed on one-on-one supervision.Interview on 11/19/25 at 9:12 A.M. with Assistant Director of Nursing (ADON) #102 revealed staff reported Resident #10 was observed entering Resident #11's room by CNA #103. ADON #102 verified Resident #10 resided in the Memory Support Unit (MSU), which he acknowledged was a locked unit. ADON #102 explained during a smoke break, Resident #10 reported she was cold, so staff allowed her to go back into the facility unsupervised, which allowed her the opportunity to enter Resident #11's room.Interview on 11/19/25 at 11:31 A.M. with Social Worker #110 revealed she was informed Resident #10 had entered Resident #11's room after she was left unattended by staff. She explained Resident #10 required the locked MSU due to her elopement risk.Interview on 11/19/25 at 12:36 P.M. with the Director of Nursing (DON) and Administrator revealed on 11/11/12 the DON was contacted by CNA #103 and informed he witnessed Resident #10 enter Resident #11's room. Upon investigation, it was discovered during the 8:30 P.M. smoke break on 11/11/25 Resident #10 informed Laundry Aid (LA) #112 she was cold and wanted to wait inside the activity room until smoke break was over. LA #112 agreed, and after smoke break when Resident #10 was not in the activity room it was assumed, she had gone back to the unit. The DON and Administrator each verified it was the expectation of the staff assigned to smoke breaks observe the MSU residents at all times until returned and secured back in the unit.

Based on observation, medical record review, staff interview, and policy review the facility failed to ensure a resident was sent out to the hospital in a timely manner after a fall with a fracture. This affected one (#90) of three residents reviewed for falls. The facility also failed to ensure incontinent care was provided per standard this affected one, (#38) of three reviewed for incontinent care and had the potential to affect the 58 residents the facility identified as being incontinent. The census was 89. Findings included: Medical record review for Resident #90 revealed an admitted [DATE]. Admitting diagnoses were multiple fractures of ribs with routine healing, ulcerative colitis, non-Alzheimer's dementia, anxiety, and depression. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was moderately cognitively impaired. Her functional status was set up or clean-up assistance for eating, toileting, bed mobility, and transfers were partial/moderate assistance. She was frequently incontinent with her bowel and bladder. Review of the progress notes dated 01/17/25 at 4:45 P.M. revealed Resident #90 had a fall in her room when she saw a little girl trying to get her personal belongings. The resident attempted to get the little girl to stop messing with her belongings and the resident leaned forward to get her away and fell out of the bed. The resident complained of pain in her left leg and minor swelling but said it only worsened when her leg was moved. Interventions were for a urine dip and x-ray to her left leg. Review of the physician orders dated 01/17/25 revealed a Stat X-ray of left knee, left femur, left hip, unilateral with pelvis when performed. There wasn't any evidence there was an order for a urine dip. Review of the Medication Administration Record dated 01/17/25 revealed the resident's pain level was documented as a zero out of 10 and a three out of 10. Review of the progress notes from 01/17/25 at 4:45 P.M. to 01/18/25 11:48 A.M. revealed there wasn't any evidence the X-ray company had been called about the X-ray for Resident #90. Review of the dispatch record on 01/17/25 revealed they were informed of an X-ray at 5:50 P.M. and a technician was assigned to the order, but the X-ray wasn't completed until 01/18/25 at 11:48 A.M. and at the time the technician said the femur was fractured. Review of the care plan dated 01/17/25 for Resident #90 revealed the resident was at risk for falls related to bladder and bowel incontinence, decreased strength and endurance, weakness, history of falls, history of self-transfers, and decreased safety awareness. Review of the progress note written by Registered Nurse (RN) #101 dated 01/18/25 at 1:11 P.M. revealed the family was called to inform them of the broken femur and they were dismayed with the facility on the phone and asked why the treatment wasn't given sooner. The nurse explained she wasn't the nurse taking care of Resident #90 on 01/17/25 and the facility was trying to get everything ready for the transfer of the resident. The interview with the Director of Nursing (DON) on 02/20/25 at 11:08 A.M. revealed the X-ray for Resident #80 was ordered and should have been completed within four hours of the time it was ordered. She stated the urine dip wasn't ordered or completed for the resident. She confirmed this was a delay in treatment for the resident. She said the nurse who took care of Resident #90 on 01/17/25 no longer worked at the facility. The nurse resigned to take another job, and it wasn't a result of this episode. Interview with RN #101 on 02/20/25 at 11:40 A.M. revealed she worked on 01/18/25 on day shift and stated the night shift did not tell her in report anything about the fall Resident #90 had on 01/17/25 or that the X-ray company had not been into the facility. She stated a friend came to the nursing station and wanted her to look at Resident #90's leg and she discovered it was swollen, reddened and warm to touch. She stated the resident was in pain, but she medicated her with Tylenol on that morning. She denied the resident was crying out in pain. Review of the policy entitled Falls dated 09/01/21 revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. In conjunction with the Physician, staff will identify and implement relevant interventions. 2. Medical record review for Resident #38 revealed an admitted [DATE]. Medical diagnoses included diabetes, renal insufficiency, and seizure disorder. Review of the quarterly minimum Data Set (MDS) dated [DATE] revealed Resident #38 was severely cognitively impaired. Her functional status was substantial/maximal assistance for eating and transfers, dependent on toileting, partial/moderate assistance for bed mobility. She was coded on this assessment as being always incontinent for bowel and bladder. Review of the care plan dated 12/07/24 revealed Resident #38 was incontinent for bowel and bladder. Interventions included: assist for toileting needs, monitor for signs and symptoms of urinary tract infection, monitor peri-area for redness and irritation, and provide peri-care after each incontinence episode. During observation of incontinence care for Resident #38 on 02/19/25 at 1:19 P.M. revealed Certified Nursing Aide (CNA) #110 donned gloves and proceeded to provide the care and used a washcloth and wiped up in the labia area once. He proceeded with the care and turned the resident over and wiped the anal area which had feces present in the area. Interview with CNA #110 on 02/19/25 at 1:21 P.M. confirmed he wiped up in the labia area, but stated he was trained to wipe down on the sides of perineum and wipe up in the labia area. Review of the policy entitled (Perineal Care) dated 09/01/21 revealed the following: Steps in the Procedure 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside stand within easy reach. 4. Put on gloves. 5. Instruct the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary. 6. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (l) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Do not reuse the same washcloth or water to clean the urethra or labia. (3) Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (Note: If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.) (4) Gently dry perineum. c. Instruct or assist the resident to turn on her side with her top leg slightly bent, if able. c. Rinse wash cloth and apply soap or skin cleansing agent. d. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or water to clean the labia. e. Rinse thoroughly using the same technique as described in e above. (5) Remove gloves and discard into designated container. Wash and dry your hands thoroughly. This deficiency represents non-compliance investigated under Complaint Number OH00161840.

Based on medical record review, staff interview and policy review the facility failed to ensure an X-ray was ordered and implemented in a timely manner. This affected one (#90) of three residents reviewed for X-rays. The census was 89. Findings included: Medical record review for Resident #90 revealed an admitted [DATE]. Admitting diagnoses were multiple fractures of ribs with routine healing, ulcerative colitis, non-Alzheimer's dementia, anxiety, and depression. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was moderately cognitively impaired. Her functional status was set up or clean-up assistance for eating, toileting, bed mobility, and transfers were partial/moderate assistance. She was frequently incontinent with her bowel and bladder. Review of the physician orders dated 01/17/25 revealed a Stat X-ray of left knee, left femur, left hip, and unilateral with pelvis when performed. Review of the progress notes from 01/17/25 at 4:45 P.M. to 01/18/25 11:48 A.M. there wasn't any evidence the X-ray company had been called about the X-ray for Resident #90. Review of the dispatch record on 01/17/25 revealed they were informed of an X-ray at 5:50 P.M. and a technician was assigned to the order, but the x-ray wasn't completed until 01/18/25 at 11:48 A.M The interview with the Director of Nursing (DON) on 02/20/25 at 11:08 A.M. revealed the X-ray for Resident #80 was ordered and should have been completed within four hours of the time it was ordered. She confirmed the Stat X-ray was not completed within the four hours and confirmed the X-ray didn't get completed until 01/18/25 at 11:48 A.M. Review of the policy entitled Request for Diagnostic Services undated revealed orders for diagnostic services will be carried out as instructed by the physician's order. This deficiency represents non-compliance investigated under Complaint Number OH 00160894.

Based on medical record review, observations, staff interview and policy review the facility failed to ensure proper infection control was maintained during incontinence care. This affected one (#38) of three residents reviewed for incontinence. The facility identified there were 58 residents who were incontinent. The census was 89. Findings included: Medical record review for Resident #38 revealed an admitted [DATE]. Medical diagnoses included diabetes, renal insufficiency, and seizure disorder. Review of the quarterly minimum Data Set (MDS) dated [DATE] revealed Resident #38 was severely cognitively impaired. Her functional status was substantial/maximal assistance for eating and transfers, dependent on toileting, partial/moderate assistance for bed mobility. She was coded on this assessment as being always incontinent for bowel and bladder. Review of the care plan dated 12/07/24 revealed Resident #38 was incontinent for bowel and bladder. Interventions included: assist for toileting needs, monitor for signs and symptoms of urinary tract infection, monitor peri-area for redness and irritation, and provide peri-care after each incontinence episode. During observation of incontinence care for Resident #38 on 02/19/25 at 1:19 P.M. revealed Certified Nursing Aide (CNA) #110 donned gloves and proceeded to provide the care and used a washcloth and wiped up in the labia area once. He proceeded with the care and turned the resident over and wiped the anal area which had feces present in the area. He retrieved some lotion and applied the lotion to the bottom of the resident. The CNA did not change his gloves prior to applying the lotion to the resident skin. Interview with CNA #110 on 02/19/25 at 1:21 P.M. confirmed he didn't change his gloves prior to putting on the lotion to the resident's bottom and stated he was never told to change his gloves in between a dirty to clean task. Review of the policy entitled (Perineal Care) dated 09/01/21 revealed the following: Steps in the Procedure 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside stand within easy reach. 4. Put on gloves. 5. Instruct the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary. 6. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (l) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Do not reuse the same washcloth or water to clean the urethra or labia. (3) Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (Note: If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.) (4) Gently dry perineum. c. Instruct or assist the resident to turn on her side with her top leg slightly bent, if able. c. Rinse wash cloth and apply soap or skin cleansing agent. d. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or water to clean the labia. e. Rinse thoroughly using the same technique as described in e above. (5) Remove gloves and discard into designated container. Wash and dry your hands thoroughly.

Based on medical record review, interview, and policy review, the facility failed to follow physician orders for wound care dressing. This affected one (Resident #85) of three residents reviewed for wound care. The facility census was 83. Findings include: Review of the medical record revealed Resident #85 was admitted to the facility on [DATE] and was discharged on [DATE] . Diagnoses included unspecified fracture of the left lower leg, essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, hypothyroidism, hyperlipidemia, other heart failure, hypokalemia, generalized anxiety disorder, type II diabetes, and insomnia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #85 was at risk for skin breakdown. Review of the medical record revealed a physician's order dated 07/26/24 for ace wraps to stay on bilateral lower extremities until surgery follow up appointment on 08/08/24 at 8:15 A.M. Review of the nurse's note dated 08/01/24 revealed a late entry indicating a Sate tested Nursing Assistant (STNA) called the Assistant Director of Nursing (ADON) into the shower room to ask her if she could help remove the xeroform that was stuck to the resident's left ankle. ADON asked STNA who said the boots and ace wraps could be removed as per the surgeon they were to stay in place at all times until follow up. STNA stated the nurse told her that they could come off for the resident's shower. ADON educated staff that boots and ace wraps are to stay on at all times until follow up with surgeon. Areas wrapped with same treatments as before they were removed, and notified the physician's office of removal and received no new orders. During an interview on 09/03/24 at 4:08 P.M. Assistant Director of Nursing (ADON) #154 verified Resident #85 had surgical wounds and the ace wraps were removed on 08/01/24 by an STNA to give the resident a shower, against physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00156618.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of Self-Reported Incidents, and staff interviews the facility failed to ensure resident medications were not misappropriated. This affected two (Residents #32, #84) of three reviewed for misappropriation. The facility census was 80. Findings include: 1. Review of the medical record for Resident #32 revealed an admitted [DATE]. Medical diagnoses included but were not limited to Chronic Obstructive Pulmonary Disease (COPD), type two diabetes mellitus, anxiety, and rheumatoid arthritis. Review of Resident #32's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. Resident #32 required maximum assistance with toileting, bed mobility, transfers and supervision for eating. Review of physician orders for Resident #32 revealed an order for Oxycodone (pain medication) 10 milligram (mg) tablet every six hours as needed for pain. Review of the November Medication Administration Record (MAR) for Resident #32 revealed no documentation the medication was given on 11/11/23. Review of the narcotic sign out sheet for Resident #32 revealed 10 mg of Oxycodone was documented as given eight times on 11/11/23 by Licensed Practical Nurse (LPN) #110. Review of the Self-Reported Incident (SRI) completed 11/17/23 revealed a Registered Nurse (RN) reported concerns about a narcotic count sheet for Resident #32. Interview with Resident #32 revealed she only gets pain pills in the morning and night and to the best of her knowledge, she did not receive any extra pain medications. LPN #110 was interviewed and stated, She screwed up and gave residents too much medication. On 11/10/23, LPN #110 had documented eight pills being given on the narcotic sheet, but there was no documentation on the MAR that extra pills were given. It was also discovered that another resident (Resident #84) on the same date was dispensed six pills of Oxycodone 10-325 mg. Interview with the Medical Director revealed if the amounts were given as documented, the residents would have been lethargic, which they were not. LPN #110 was terminated, and the facility substantiated the allegation of misappropriation. 2. Review of the medical record for Resident #84 revealed an admitted [DATE]. Medical diagnoses included but were not limited to lung cancer, chronic obstructive lung cancer, and bipolar disorder. Review of Resident #84's admission MDS assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 12 indicating impaired cognition. The resident required set up for eating, bed mobility, transfers, and toileting Review of the physician orders for Resident #84 revealed an order for Oxycodone-Acetaminophen (pain medication) 10-325 mg one tablet every four hours as needed. Review of the November MAR revealed Resident #84 was given one Oxycodone-Acetaminophen on 11/11/23 at 12:09 A.M., 2:05 P.M., and 7:00 P.M. Review of the narcotic sign out sheet for Resident #84 revealed Oxycodone was documented as given six times on 11/11/23 by LPN #110. Interview on 12/14/23 at 9:41 A.M. with the Director of Nursing (DON) and the Administrator revealed they were contacted by Assistant Director Of Nursing (ADON) #105 regarding a concern for the amount of narcotics documented as given on the narcotic sheet for Resident #32. The DON shared she interviewed Licensed Practical Nurse (LPN) #110 who informed her she made medication errors by giving too much pain medication. The DON requested LPN #110 have a drug screen done, LPN #110 agreed and the test was negative, she was taken off the schedule as the investigation continued. Initially the error was believed to be a documentation error until during the investigation a second resident's (Resident #84) narcotic concern was identified. LPN #110 was terminated, the Pharmacy, Ohio Board of Nursing and the Police were notified. The facility continued to assist them in their investigations. Plans of Correction were discussed at Quality Assurance and Performance Improvement (QAPI) and implemented. Review of the SRI completed 11/20/23 revealed on 11/10/23, it appeared Resident #84 was given five extra Oxycodone 10/325 mg within a 12-hour period from review of the narcotic sheet and MAR. Interview with LPN #110 revealed, She screwed up and gave the resident too much medication. Interview with the Medical Director and Physician's Assistance revealed they did not receive a call from LPN #110 to administer extra pain medication. The facility substantiated the allegation of misappropriation. The deficient practice was corrected on 11/17/23 when the facility implemented the following corrective actions: LPN #110 was terminated. Staff education was provided on medication administration, following physician orders, signing as needed narcotics on the Electronic Medical Record (EMAR) as well as controlled substance log by 11/16/23. 30 day look back of controlled substance record for all residents on affected unit by 11/14/23. Pain assessments were completed for residents on the effected unit by 11/14/23. Audits of three residents narcotic record and EMAR weekly for four weeks starting week 11/17/23 and ending week 12/11/23.

Based on record review and staff interviews, the facility failed to ensure medications were given as ordered. This affected one (Resident #32) of three residents reviewed for medication administration. The facility census was 80. Findings include: Review of the medical record for Resident #32 revealed an admitted [DATE]. Medical diagnoses included but were not limited to Chronic Obstructive Pulmonary Disease (COPD), type two diabetes mellitus, anxiety, and rheumatoid arthritis. Review of Resident #32's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. The resident required maximum assistance with toileting, bed mobility, transfers, and supervision for eating. Review of physician orders for Resident #32 revealed an order for Furosemide (diuretic) 40 milligrams (mg) daily, Levothyroxine (thyroid) 125 micrograms (mcg) daily, Omeprazole (reflux) 20 mg daily, Baclofen (pain) 10 mg every eight hours, Gabapentin (nerve pain) 300 mg every eight hours, Ipratropium-Albuterol 0.5-2.5 mg per (/) 3.0 milliliter (ml) solution, one inhalation every six hours. Review of the November Medication Administration Record (MAR) revealed Furosemide (diuretic) 40 milligrams (mg) daily, Levothyroxine (thyroid) 125 micrograms (mcg) daily, Omeprazole (reflux) 20 mg daily scheduled for 5:45 A.M. was not documented as given on 11/09/23, 11/11/23, 11/13/23, and 11/24/23. Baclofen (pain) 10 mg every eight hours, Gabapentin (nerve pain) 300 mg every eight hours, Ipratropium-Albuterol 0.5-2.5 mg per (/) 3.0 milliliter (ml) solution, one inhalation every six hours scheduled for 6:00 A.M. was not documented as given on 11/09/23, 11/11/23, 11/13/23, and 11/24/23. Interview on 12/27/23 at 4:16 P.M. with Assisted Director of Nursing (ADON) #105 verified missing documentation of medications for Resident #32. ADON #105 shared LPN #105 worked on 11/09/23 and 11/11/23 and LPN #109 worked on 11/13/23 and 11/24/23 and the facility was unable to provide documentation the medications had been given as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00148467.

Based on record review and staff interview, the facility failed to provide specific and specialized training staff working on the Memory Care unit. This had to potential to affect 15 (#11, #22, #23, #30, #40, #44, #47, #48, #49, #52, #53, #54 ,#58, #324 #325) of 15 residents residing on the Memory Care unit. The facility census was 78. Findings include: Employee record review revealed State tested Nurse Assistant (STNA) #433 was hired on 10/18/21. Further review of the employee file for STNA #433 revealed no evidence of receiving training specific to the Memory Care Unit upon hire to the facility or since. Employee record review revealed STNA #479 was hired on 09/13/21. Further review of the employee file for STNA #479 revealed no evidence of receiving training specific to the Memory Care Unit upon hire to the facility or since. Employee record review revealed STNA #487 was hired on 02/27/23. Further review of the employee file for STNA #487 revealed no evidence of receiving training specific to the Memory Care Unit upon hire to the facility or since. Employee record review revealed STNA #493 was hired on 02/27/23 . Further review of the employee file for STNA #493 revealed no evidence of receiving training specific to the Memory Care Unit upon hire to the facility or since. Interview on 03/15/23 at 4:15 P.M., with the Business Office Manager (BOM) #451 manager confirmed the facility has a speciality unit known as the Memory Care Unit that specializes in cognitive impaired residents with dementia. BOM #451 confirmed the facility failed to provide training for the speciality unit for new employees. BOM #451 stated the facility will schedule new employees to work on the Memory Care Unit during orientation. However, BOM #451 was unable to provide any type of verification of the orientation hours. BOM#451 confirmed the facility does not provide any other type of training for the Memory Care unit. Review of the policy titled, Dementia Care, dated September 2021, revealed the facility is committed to providing the highest quality of life through providing excellent care to our residents diagnosed with dementia and present with dementia related behaviors while preserving their dignity and self-respect.

Based on observations, medical record reviews, staff and resident interviews, and policy review, the facility failed to ensure residents needs were met by answering call lights in a timely manner. This affected two (#124 and #126) of two residents reviewed for call lights. The facility census was 78. Findings included: 1. Medical record review for Resident #124 revealed an admitted ,d+[DATE], with diagnoses including stroke and arthritis. Review of 5-day admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #124 was cognitively intact. Her functional status was limited assistance for bed mobility and transfers. She was a supervision for eating and extensive assistance for toilet use. She was always continent for bowel and bladder. Observation on 03/13/23 at 1:49 P.M., revealed Resident #124 was in bed and pulled her call light because she had to go to the bathroom. At 1:54 P.M., Hospitality Aide (HA) #419 came into the room and asked what Resident #124 needed and Resident #124 stated she had to go to the bathroom. HA #419 stated someone would be with her shortly and turned off the call light. At 2:22 P.M., Resident #124 again turned on the call light and at 2:29 P.M., Resident #124 was finally assisted to the bathroom. Interview on 03/13/23 at 3:05 P.M., with State tested Nursing Aide (STNA) #464 revealed HA #419 did tell her Resident #124 had to go to the bathroom, but she was busy doing a bed bath. STNA #464 stated she told HA #419 to let another STNA #463, know to help Resident #124, but she was doing a bed bath too. STNA #464 stated the expectation for answering a call light would be less than seven minutes. STNA #464 stated she didn't ask the nurse to help her with the call lights, because they were busy and doesn't expect them to drop what they are doing to help her with a call light. 2. Medical record review for Resident #126 revealed an admitted [DATE], with diagnoses including metabolic encephalopathy, and chronic obstructive pulmonary disease (COPD) Review of Admission MDS assessment dated [DATE] revealed Resident #126 was cognitively intact. Her functional status was extensive assistance for bed mobility, transfers, and toilet use with two-person assistance. She was supervision for eating. Observation on 03/13/23 at 2:07 P.M., revealed Resident #126 pulled her call light because she had to go to the bathroom. STNA #465 came into the room and turned off the call light and told Resident #126, she would have to wait to go to the bathroom since STNA #463 was busy with another resident. At 2:15 P.M., Resident #126 could be heard yelling in the hall saying help and STNA #465 went into her room Resident #126 was stating she had to go to the bathroom and STNA #465 stated, you have to wait because the other aide was busy with another resident and I promise I will be back. At the time of observation, the RN #429 was seen standing at the nursing station and the aide did not ask for help. At 2:21 P.M., a housekeeper goes into the room and the resident asks her to take her to the bathroom and the housekeeper stated I can't get you up, but they will be here soon. At 2:24 P.M., both aides come to help the resident up to the bathroom. Interview on 03/13/23 at 2:45 P.M., with STNA #465 revealed she had to wait for the other aide to help her get Resident #126 up to the bathroom. STNA #465 confirmed she didn't want to ask the nurse who was standing at the nursing station because she was busy. STNA #465 stated she likes to answer the call lights in less than seven minutes. Interview on 03/13/23 at 3:00 P.M.,with Resident #126 revealed the staff are not timely in answering the call light and she had to go to the bathroom urgently. Resident #126 stated she felt angry when the staff wouldn't answer the call light in a timely manner. Resident #126 stated she didn't want to be in the facility anymore. Review of undated policy titled Call Light revealed the purpose of the call light was to respond to the resident's requests and needs. When you answer the call light make sure you do what the resident asks of you if permitted and you cannot fulfill the request, ask the nurse supervisor for help.

Based on record review, staff interviews and policy review, the facility failed to honor a resident's choice and physician order related to advance directives. This affected one (#73) of three residents reviewed for advance directives. The facility census was 78. Findings include: Record review for Resident #73 revealed she was admitted to the facility on [DATE], and died at the facility on [DATE]. Her diagnoses included diabetes mellitus 2, hypoglycemia, cardiac murmur, altered mental status, essential primary hypertension, Alzheimer's Disease, and dysphagia. Review of Resident #73's care plan for code status, dated [DATE], revealed she was a full code. An intervention was listed as, periodically review advance directives with the resident/family, initiated [DATE]. Review of physician visit dated [DATE], for Resident #73 revealed the physician reviewed advanced directives during the visit. Implication of new code status reviewed with patient/representative and understanding was verbalized. Code status has been updated to DNRCC-A (do not resuscitate comfort care-arrest). Review of the physician orders for Resident #73 revealed an order for an Advance Directive change, dated [DATE], Do Not Resuscitate Comfort Care Arrest (DNRCC-A). Review of Resident #73's Advance Directive Form titled, DNR Comfort Care, dated [DATE], revealed a physician signed the form for Resident #73 stating she was a DNRCC-Arrest. Review of the progress notes dated [DATE] at 9:55 A.M., for Resident #73, revealed Resident #73 was found with no vital signs. No signed DNR in facility or on file, 911 called and Cardiopulmonary Resuscitation (CPR) initiated at 10:00 A.M. Resident was pronounced deceased at 10:32 A.M. by Paramedic. Interview on [DATE] at 10:47 A.M., with Licensed Practical Nurse (LPN) #420 confirmed she was the nurse working on [DATE] when Resident #73 was found with no vital signs. LPN #420 stated the staff was unable to locate DNRCCA form for Resident #73. LPN #420 stated she was on the phone with the Director of Nursing (DON) and was advised to call a full code and start CPR. LPN #420 reviewed and confirmed the Advance Directive form for Resident #73 stated Resident #73's code status was marked DNRCC-A and signed by the physician on [DATE]. LPN #420 stated she was not sure where that form was located on the morning of Resident #73's death. Review of the policy titled, Advanced Directive, dated [DATE], revealed it is the resident's right to formulate an Advance Directive, and to accept or refuse medical or surgical treatment. Any decision making will be documented in the resident's medical record and communicated to the interdisciplinary team.

Based on record review, resident and staff interviews, and policy review, the facility failed to complete an investigation related to potential misappropriation of a resident's personal belongings. This affected one (#46) of three residents reviewed for potential misappropriation. The facility census was 78. Findings include: Record review for Resident #46 revealed she was admitted to the facility on [DATE]. Her diagnoses included diabetes mellitus 2, cellulitis, benign neoplasm of colon, gastro-esophageal reflux disease, chronic kidney disease, pneumonia, osteomyelitis, and insomnia. Review of the admission Minimum Data Set (MDS) assessment, dated 01/24/23, revealed Resident #46 was cognitively intact. Further review of the MDS assessment revealed Resident #46 required extensive assistance from staff with transfers, dressing, toilet use, and personal hygiene. Resident #46 required limited assistance from staff with eating. Interview on 03/13/23 at 11:34 A.M., with Resident #46 revealed the resident reported missing items including several pairs of pants and tops missing from the date of her admission on 01/19/23. Resident #46 stated she reported the missing personal items to Social Worker (SW) #417 and nothing has been done regarding the missing items. Resident #46 stated she was not aware of the need to write her name in her clothing until she brought in additional clothing in and believes that is why her clothing is missing. Interview on 03/15/23 at 5:09 P.M., with Social Worker (SW) #417 confirmed Resident #46 told her about the missing items in January of 2023. SW #417 stated Resident #46 told her she was missing a top and several pairs of capris pants. SW #417 stated she told laundry about Resident #46's missing clothing, however, forgot to follow up on the missing items. SW #417 stated Resident #46 did not write her name on the tags of her clothing and this is why Resident #46's clothing is missing. SW #417 stated the facility identified an issue with new admission resident's clothing not getting marked and debated on who will complete the task. SW #417 believed the facility was going to assign State tested Nurse Aides (STNA) to mark new admission resident clothing, however, she is not sure. SW #417 confirmed the facility failed to complete an investigation regarding Resident #46's missing clothing. Review of the facility policy titled, Abuse Investigating and Reporting, dated September 2021, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to locale, state, and federal agencies and thoroughly investigated by facility management.

Based on observation, record review and interview, the facility failed to administer pain and anti-anxiety medications timely and as prescribed to five residents (#129, #19, #78, #60, and #63) who experienced severe pain and anxiety. 61 of the facility's 85 residents were prescribed pain medication and 24 residents received anti-anxiety medications. The facility's failure to administer pain medications timely and as prescribed resulted in harm to Resident #129 as she did not have prescribed pain medications for two days status [REDACTED]. Findings include: 1. Review of the Patient Transfer Form dated 10/05/12 indicated Resident #129 was readmitted to the facility on [DATE] following left hip replacement with constant throbbing pain. The Physician's admission orders [REDACTED]. Record review revealed Resident #129 was prescribed [MEDICATION NAME] 40 mg but did not receive the prescribed doses on 10/13/12 at 9:00 A.M. and 9:00 P.M., on 10/14/12 at 9:00 A.M. Nurse's notes dated 10/14/12 at 12:30 P.M. revealed the facility spoke with the pharmacy about the [MEDICATION NAME] 40 mg prescription being rejected by the resident's insurance company and a new order to hold the [MEDICATION NAME] 40 mg until available. Nurse's notes timed 1:00 P.M. indicated the facility spoke with the physician to inform him of the pharmacy's recommendation to replace [MEDICATION NAME] 40 mg with [MEDICATION NAME] Extended Release or [MEDICATION NAME]. Nurse's notes timed 4:00 P.M. indicated the recommendations were faxed to the physician's office. Nurse's notes timed 4:20 P.M. indicated the physician was notified the resident was rating her pain a 10 on a 1 to 10 scale and no pain medications were available due to pharmacy delivery. The physician ordered [MEDICATION NAME] 60 mg due to pain. Nurse's notes 6:00 P.M. patient complained of nausea and the [MEDICATION NAME] was given. During interview on 10/15/12 at 4:55 P.M., Resident #129 indicated the facility was out of her ordered pain medication over the previous weekend (October 13 and 14, 2012) and she was not administered the ordered medication. Resident #129 indicated she was in constant severe pain, was severely nauseated, had tremors and was unable to take a shower for four days due to the severe pain and nausea she experienced. During interview on 10/17/12 at 11:00 A.M., LPN #55 stated she did not know why Resident #129 did not receive pain medication as ordered on [DATE] and 10/14/12. During interview on 10/17/12 at 11:45 A.M., the Medical Director acknowledged he was contacted on 10/14/12 regarding Resident 129's pain and indicated he had concerns related to the facility's availability of pain medications. 2. Review of medical record indicated Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 frequently experienced severe pain and received medications routinely and as needed for pain. On 10/17/12 at 4:00 P.M., Resident #19 was heard asking Licensed Practical Nurse (LPN) #101 if the pharmacy delivered his [MEDICATION NAME] (a narcotic pain medication) injection, and stated he had a severe migraine headache. LPN #101 indicated the pharmacy had not delivered the [MEDICATION NAME] and told Resident #19 he had to wait for the pharmacy to deliver the medication. During interview immediately following the observation, LPN #101 verified Resident #19 complained of a migraine headache at approximately 12:00 P.M. on 10/17/12 and the physician ordered [MEDICATION NAME] 30 milligrams (mg) to be administered via intramuscularly injection. Resident #19 and the resident had to wait on the medication because it was not available in the emergency medication supply box. LPN #101 stated neither the physician or the pharmacy was informed the prescribed injection was unavailable at the time the physician ordered the medication. Medical record review revealed a physician's telephone order dated 10/17/12 to discontinue the [MEDICATION NAME] 30 mg intramuscular injection and to administer [MEDICATION NAME] 10 mg by mouth. During interview on 10/17/12 at 5:20 P.M., LPN #101 confirmed the physician changed the [MEDICATION NAME] injection to [MEDICATION NAME] oral when notified the injection was unavailable at 4:00 P.M. on 10/17/12. The October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. The medical record did not indicate whether the [MEDICATION NAME] administered at 5:00 P.M. on 10/17/12 was effective for Resident #19. During interview on 10/18/12 at 10:30 A.M. Resident #19 confirmed he had a migraine headache on 10/17/12 and had to wait "forever" for pain medication, described "forever" as "too long" and indicated the wait was five hours or more. Resident #19 indicated he often had to wait for pain medication after requesting it. 3. Review of the medical record indicated Resident #78 was admitted to the facility on [DATE] following hospitalization for a right humerus fracture, intractable pain and acute kidney failure. Review of hospital discharge instructions dated 09/30/12 indicated Resident #78 was prescribed [MEDICATION NAME], a narcotic pain medication, 5/325 mg one tab every four hours as needed for pain. The physician's orders [REDACTED]. Review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review confirmed Resident #78 was not administered [MEDICATION NAME] routinely every four hours as physician ordered. Observation on 10/17/12 at 1:30 P.M. revealed Resident #78 complained of intense pain and indicated pain prevented her from participating in physical therapy. During interview on 10/17/12 at 5:30 P.M., the Director of Nursing (DON) verified the physician's orders [REDACTED]. 4. Review of medical record indicated Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #60 was in moderate pain almost constantly and received medications routinely and as needed for pain. Review of medical record revealed Resident #60 was prescribed but did not receive [MEDICATION NAME] on 10/02/12 at 9:00 P.M. and also on 10/03/12 at 9:00 A.M. A nurse's medication note on 10/02/12 indicated the medication was out of stock. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., on 10/07/12 at 9:00 A.M. and 9:00 P.M., on 10/08/12 at 9:00 A.M. and 9:00 P.M. Review of the medical record revealed a physician's orders [REDACTED]. During interview on 10/15/12 at 4:54 P.M., Resident #60 indicated he did not feel the staff treated him with respect and dignity because when he requested pain medications staff ignored his requests and made him wait long periods of time for the requested pain medications. Resident #60 was unsure why he had to wait for his pain medication. During interview on 10/17/12 at 11:00 A.M., LPN #55 confirmed Resident #60 did not receive [MEDICATION NAME] because the facility did not have the medication to administer as prescribed and also confirmed the resident's [MEDICATION NAME] 20 mg was held because the facility did not have the medication to administer as prescribed. 5. Medical record review for Resident #63 revealed admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. A nurses note entry dated 08/11/12 at 9:00 A.M. documented the resident requested her Klonopin and no Klonopin was available. The resident became agitated, began pacing and saying she needed her anxiety medicine. A second entry at 11:00 A.M. the resident requested to go to the hospital because, "something is wrong." The nurse then called the pharmacy and requested the medication be brought on a stat order. The nurses note indicated the resident was given the Klonopin at 1:00 P.M., four hours after it was requested. During interview on 10/16/12 at 3:50 P.M. Licensed Practical Nurse (LPN) # 67 stated Resident #63 does have a physician order [REDACTED]. LPN # 67 stated the resident takes it daily and usually will just ask for it when she needs it. When interviewed on 1016/12 at 4:00 P.M. LPN #10 verified the nurses notes indicated the resident anti-anxiety medication was not available when the resident requested it and affirmed the note also indicated the resident was showing signs of anxiety while the medication was unavailable. LPN #10 stated she did not know why the resident's Klonopin had not been available when she needed. During interview on 10/17/12 at 9:00 A.M. the Medical Director stated over the past two to three months the facility had some problems with getting controlled substances from the pharmacy due some changes with the pharmacy's procedures.

Based on record review, staff interview and observation,, the facility failed to implement necessary interventions to prevent the development of an avoidable stage III pressure ulcer. This affected one (Resident #95) of three residents reviewed for pressure ulcers. The facility identified five residents with pressure ulcer, three that were acquired in the facility. Findings include: Review of the medical record revealed Resident #95 was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Review of the care plan dated 12/24/10 for skin integrity documented the resident had the potential for impaired skin integrity related to [MEDICAL CONDITION]. Interventions included to observe skin integrity during morning and evening care; bathe/shower per schedule; and evaluate skin weekly. The resident had a physician's orders [REDACTED]. Review of May 2011 and June 2011 Treatment Administration Records (TAR)documented weekly skin checks on Thursday during 7-3 shift and indicated to document the condition of the skin using a code, with (1) as no problem, (2) treatment in progress and (3) see nurses notes. The weekly skin checks were documented as completed from 05/05/11 through 06/16/11 without any code documenting the condition of the resident's skin. The nursing notes dated 05/05/11 through 06/16/11 contained no documentation of the skin condition. Review of interdisciplinary progress note/care conference notes dated 06/15/11 indicated the resident's skin is intact and well. Review of nurse's notes dated 06/20/11 at 7:00 A.M. stated state tested nursing assistants reported finding a wound on right heel. The wound was evaluated by the treatment nurse, measured, and a treatment initiated. The physician was notified and ordered [MEDICATION NAME] cream to the wound and Keflex, an antibiotic, 500 milligrams by mouth three times a day for 7 days. Review of treatment nurse's notes dated 06/20/11 stated it was brought to the treatment nurses's attention by nursing staff the resident has "an open area" on the right heel. An assessment was performed by the treatment nurse. The assessment reveals resident does in fact have a Stage III pressure ulcer. The affected area currently measuring 1.0 centimeters (cm) by 1.5 cm by 0.2 cm. Area presenting as a beefy red crater with pallor wound edges. Surrounding tissue red in color and slow to blanch. Treatment implemented by this nurse: a heel lift boot put in place to help alleviate pressure. Resident was started on antibiotic as preventative. Referral to therapy for wheel chair positioning and possible diathermy to affected heel. The resident had a care plan dated 06/20/11 for wound infection to stage III ulcer right heel as evidenced by redness. Interventions included provide off loading of wound site and treatment as ordered. Review of interdisciplinary progress notes/care conference notes dated 06/21/11 indicated a stage III ulcer to right heel due to pressure. The notes stated a treatment had been implemented and the resident's shoes are off at this time. Review of the minimum data set (MDS) assessment dated [DATE] indicated the resident had moderately impaired cognition for daily decision making skills with short and long term memory problems. She required the extensive assistance of two staff for bed mobility and transfer with functional limitation in range of motion for both upper and lower extremities on one side. Doppler studies were completed on 06/23/11 to assess the resident's circulation in her legs. The study showed normal Doppler signals throughout, no evidence of arterial insufficiency. Review of pressure ulcer record dated 06/27/11 indicated the Stage III ulcer measured 1.0 x 1.3 x 0.1, but is healing slowly, subtle progress, and the physician was notified at that time. Review of physician's progress note dated 06/29/11 indicated Resident #95 presents with [DIAGNOSES REDACTED]. The course has been progressively worsening and is of moderate intensity. Associated symptoms include arthralgias (joint pain). Review of pressure ulcer record dated 07/05/11 indicated the Stage III ulcer measured 1.0 cm x 1.2 cm x 0.1 cm, and was healing well with good progress. Observations of Resident # 95 on 07/05/11 at 11:33 A.M., 07/06/11 at 5:30 P.M. and on 07/07/11 at 1:25 P.M. revealed she was sitting in her room in her wheelchair. She had her right arm elevated on a tray and a heel lift boot was on her right foot, resting on top of the foot rest. Wound care was observed on 07/07/11 at 8:40 A.M. by licensed practical nurse (LPN) #56, who was the facility wound nurse. Registered Nurse #86 (RN) assisted with the dressing change. During the observation of the treatment there was no drainage on the old dressing nor no odor noted. The pressure ulcer was noted on the outer aspect of the right heel. The area was circular reddish-brown in color measuring approximately 1 cm x 1 cm x 0.2 about the size of a quarter. The surrounding edges were noted with dry flaking skin and the surrounding skin color was pink. LPN # 56 cleansed the wound with wound cleanser, patted the area dry and applied Maxsorb AG silver to the wound bed, covering the area with a 4 x 4 gauze and abdominal pad. The dressing was then secured with [MEDICATION NAME] and tape. LPN # 56 indicated the nurses on the unit do routine skin assessments and that he only does treatments on residents who current skin issues. He further stated that the aides document any skin concerns on the shower sheets and he has to check the shower sheets for any skin issues. After reviewing the sheets, he signs them off and then turns them into the Director of Nursing (DON). He stated he had no shower sheets for the month of June 2011 for Resident #95, that they had been turned in to the DON. At the time of the observation LPN # 56 stated he believed the pressure ulcer was related to positioning and friction. He also verified that when the pressure ulcer was found it was a stage III. RN # 86 stated she believed the pressure ulcer was caused poor positioning in the previous wheelchair the resident was using and therapy had evaluated her for a different wheelchair. During interview on 07/07/11 at 1:43 P.M. the DON stated she could not locate any shower sheets for Resident #95 for June 2011. She further indicated that she did not understand how a Stage III ulcer was found on 06/20/11 when a nurse had documented a clear skin assessment on 06/17/11. She stated discovering a pressure ulcer as a stage III was a "red flag" to her that something was wrong. She stated that the nurses are suppose to document a numerical value on the treatment record when they complete the skin assessments. She said the nurses were confused and thought they only had to initial the skin assessments were completed. She verified that without the numerical value, one could not know what the nurse had found on the assessment. She further verified that there were no nurses' notes as to the assessment of the skin. On a follow up interview at 2:13 P.M. the DON stated if Resident #95's foot had been elevated while in the wheelchair, it would have decreased the risk of her developing a pressure ulcer.