Chi Franciscan Villa

Inspectors wroteBased on interviews, observations, record reviews, and facility policy review, the facility 1.) failed to attach wheelchair footrests during transport for one of six residents (Resident (R) 46) who was transported by Certified Nurse Aide (CNA) 1 which resulted in the resident's right foot being dragged under her wheelchair, requiring hospitalization, further medical treatment and harm. 2.) The facility also failed to reassess the safety of R4's slide board transfers after implementing an air mattress with inflated bilateral bolster which altered the transfer surface and had the potential to cause a fall and injury. This failure had the potential to increase the risk of accidents with the potential for injury. A total of 32 residents were included in the sample.

Inspectors wroteBased on observation, interviews, and policy reviews, the facility failed to follow proper sanitation methods for the prevention of foodborne illnesses when staff did not wear hair restraints while working in the kitchen. The facility failed to ensure the kitchen was maintained in a sanitary condition. Specifically, the facility failed to label, date, and store food properly. Finally, the facility failed to ensure [NAME] 2's personal drink was not left in the kitchen refrigerator. This failure increased the risk of foodborne illness and had the potential to affect 82 of 84 residents who ate food from the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure garbage was properly contained which would affect 86 census residents and staff in the facility. This had the potential to attract pests.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to: 1.) ensure proper personal protective equipment (PPE), was donned (put on) by Certified Nurse Aide (CNA) 6 prior to entering into (Resident (R) 33's room who was under contact precaution; 2.) failed to post proper Transmission Based Precautions (TBP) signage for neutropenic isolation for R58; and 3.) failed to ensure Housekeeping Aide (HA)1 transported soiled linens without placing these items in a plastic bag. This increased the likelihood that infectious organisms could be transmitted from residents to staff, other residents, or the environment.

Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to ensure injuries and injuries of unknown origin were reported timely for two of three residents (Resident (R) 21 and R46 out of a total sample of 32 residents. This deficient practice had the potential for harm from unrecognized abuse by not identifying injuries of unknown origin. (Cross reference F689)

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure appropriate Activities of Daily Living (ADLs) to maintain appropriate hygiene for two residents (Resident (R) 81 and R25) reviewed for ADLs out of a total sample of 32 residents. This failure had the potential for the residents to have unmet hygiene needs and affect resident care.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to provide appropriate tube feeding management for one resident (Resident (R) 10) reviewed for tube feedings out of a total sample of 32 residents. This failure had the potential for the resident and others receiving liquid nourishment via tube feedings to receive outdated nourishment and created the risk for infection.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to ensure an opened vial of Tuberculin (TB) Purified Protein Derivative was labeled when opened with an expiration date in one of two medication rooms reviewed for storage and labeling. This deficient practice had the potential for inaccurate TB testing due to the vial potentially being expired and ineffective.

Inspectors wroteBased on review of the facility policy, resident-specific meal service documents, and menu records, the facility failed to provide meals consistent with neutropenic precautions for one out of one resident (Resident (R) 58), out of a survey sample of 32, by serving fresh fruits and vegetables despite the resident's need to avoid those foods. The facility's failure to provide meals consistent with neutropenic isolation precautions placed the resident at increased risk for exposure to foodborne pathogens. (Cross Reference F880)

Inspectors wroteBased on clinical record reviews and staff interviews, the facility failed to ensure the clinical records were complete for two of five residents (Resident (R) 73 and R76) reviewed for vaccination status out of a total sample of 32 residents. This had the potential for the residents not to receive accurate care. (Cross Reference F883)

Inspectors wroteBased on interview, record review, facility policy review, document review and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer two of five residents (Residents (R) 73 and R76) reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. This practice had the potential to increase the risk for residents to contract pneumonia.

Inspectors wroteBased on observations, interviews and record review the facility did not ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure injuries and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing for 1 of 2 (R4) residents reviewed for pressure injuries. R4 developed a facility acquired stage 3 pressure injury on her left buttock and an unstageable Deep Tissue Injury (DTI) on her right lateral ankle. Surveyors had observations of care plan interventions not in place and R4's feet were observed not to be offloaded during survey.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 2 (R6 and R5) of 4 received adequate supervision and assistance devices to prevent and be free of accidents. R6 did not have a low bed in place and experienced a fall that resulted in sutures and a closed face fracture. R5 was not provided with supervision per R5's care plan to ensure safety while eating and to prevent choking.

Inspectors wroteBased on interview and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident potentially affecting 86 of 86 residents in the Facility. * The Facility had documented low staffing ratios in the month of October.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that 1 (R7) of 7 residents reviewed was treated with respect and dignity. On 2/17/26, at 9:58 AM, Surveyor observed R7 being wheeled down the hallway in a shower chair to the shower room wearing a hospital gown with R7's left hip and side of buttocks exposed.

Inspectors wroteBased on record review and interview, the facility did not establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights, ensuring that all written grievance decisions include the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, and any corrective action taken or to be taken by the facility as a result of the grievance for 1 of 2 (R4) residents reviewed for grievances. R4's family filed a grievance on 8/14/25. There was no evidence of follow-up or resolution of the grievance with R4's family.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act, the facility did not report 1 of 1 allegations of misappropriation to the State Survey Agency during the required timeframe. R1's spouse reported to the facility on [DATE] that R1's wedding ring was missing. The wife contacted the police department 12/3/25. This was delayed in being reported to the State Survey Agency until 12/9/25.

Inspectors wroteBased on observation, record review and interviews, the facility did not develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 9 (R5) residents reviewed. R5 has been sent to the hospital repeatedly for behavior of pulling out her own tracheostomy tube. A care plan with interventions for this behavior was not developed or implemented. In addition, tracheostomy care and treatment are not included in the Facility Assessment.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R3) of 2 residents reviewed for Activities of Daily Living (ADL) assistance received the necessary services to maintain ability to practice good grooming and personal hygiene. R3 is scheduled for showers twice a week and did not receive showers on 7/26/25, 8/9/25, 8/13/25, 8/23/25, 8/27/25, 8/30/25, 9/6/25, 9/10/25, 9/17/25, 9/20/25, 10/4/25, 10/8/25, 10/11/25, and 10/15/25.

Inspectors wroteBased on interview and record review, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice for 1 (R1) of 2 residents reviewed for quality of care. R1 pulled out their catheter prior to a fall on 11/30/25. The catheter was reinserted and hematuria was noted. R1 was on an antiplatelet and an anticoagulant. There is lack of documentation that R1 was being monitored for bleeding due to being on blood thinning medications. R1 was sent to the hospital later for hematuria.

Inspectors wroteBased on record review and interview, the facility did not ensure a resident representative written request for a medical record was granted. This was observed with 1 (R3) of 1 resident record requests reviewed. * R3's Representative requested, in writing, a copy of R3's medical record. When initially requested, R3 was responsible for themself and decisions and R3's Representative was not eligible to receive the records. In the day's following the request and denial, R3's Power of Attorney for Health Care (POAHC) status was reviewed and activated naming R3's Represebtative as the POAHC. The facility did not address the request for records given the change in R3's POAHC status.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents remained free of accident hazards and each resident received adequate supervision and assistance devices to prevent accidents for 2 (R1 and R2) of 3 residents reviewed for accidents. *R1 rolled out of bed while receiving cares on 10/15/2025 that resulted in a closed displaced intertrochanteric fracture of the right femur. *R2 did not have reminder signs placed in R2's room or trip hazards removed from R2's room per care plan, and did not have an accurate fall risk assessment completed on 10/9/2025.

Inspectors wroteBased on record review, interview and policy review, the facility failed to notify the resident's representative (RR) of a newly developed pressure ulcer injury for one (Resident (R)1) of four residents reviewed for pressure ulcer review in the sample of five.

Inspectors wroteBased on record review and interview, the facility failed to maintain a complete and accurate medical record for one (Resident (R)1) of five sample residents.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to follow infection control guidelines during tracheostomy care for one resident (Resident (R)1) out of five residents that were reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R) reviewed for elopement (R16.)Facility elopement assessment upon R16's admission indicated R16 was an elopement risk. The facility did not pick up on this conclusion and did not put measures in place to prevent elopement. On 06/09/2025, R16 eloped from the facility, fell on the railroad tracks approximately 0.4 miles from the facility, and was brought to R16's family members house/R16's former home by persons who found R16. The facility was not aware of R16's elopement until R16's family member notified the facility that R16 had eloped to R16's family members house and sustained a fall. [...]

Inspectors wroteBased on interview and record review the facility did not ensure resident was free from misappropriation of property for 14 of 14 residents reviewed for misappropriation.*The Facility identified multiple medication discrepancies involving Registered Nurse (RN)-D. The Facility did not ensure misappropriation of resident's narcotic medications did not occur and did not ensure resident's narcotic medications were accounted for appropriately.

Inspectors wroteBased on interviews and record review, the facility did not ensure an allegation of Narcotic Medication Misappropriation was thoroughly investigated for 1 of 2 Facility Self Reports to the State Agency.* 9 (R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14 and R15) of 14 residents were not interviewed by the Facility for pain outcomes after the Facility identified narcotic medication discrepancies.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 2 Facility Reported Incidents was submitted to the State survey agency timely. *On 05/30/2025, The Facility was made aware of a possible diversion of narcotic medications. The facility did not report this to the State Survey Agency until 06/02/2025.

Inspectors wroteBased on interview, record review, and review of the Scope of Practice for Nutrition and Dietetics Technician, Registered (NDTR), the facility failed to ensure the Dietary Technician (DT) had oversight/supervision by the Registered Dietician (RD) to meet the assessment and ongoing needs of the residents for two residents (Residents (R)3 and R6) out of a total sample of 13 residents. This failure placed all residents at risk of unidentified nutritional needs.

Inspectors wroteBased on interview, record review, review of the facility policy, and the resident assessment instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one (Resident (R3) in a total sample of 13. The facility failed to accurately code the correct weight on the quarterly assessment and the correct documentation of the number of wounds on the discharge return anticipated assessment. This failure placed residents at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview, record review, and review of the facility policy , the facility failed to ensure showers were provided for two residents dependent on staff for care (Residents (R1, R3) out of a total sample of 13 residents. This failure placed the residents at risk of skin breakdown and a diminished quality of life.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure there was oversight/supervision from the Registered Dietician (RD) of the Dietary Technician (DT) for one resident (Resident (R)6) of three residents reviewed in a total sample of 13 residents. This failure placed the resident at risk of further weight loss and a diminished quality of life.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to utilize enhanced barrier precautions (EBP) during wound care for one resident (Resident (R)8) of three sampled residents reviewed for pressure ulcers out of a total sample of 13. This failure placed the residents at risk of developing complications from an infection.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents remain free of accident hazards and each resident receives adequate supervision and assistance devices to prevent accidents for 2 (R10 and R41) of 9 residents reviewed for accidents. * R10 had a fall on 12/5/2024 that was not thoroughly investigated. R10 had a fall on 12/12/2024 that resulted in a left subdural hemorrhage and laceration to left upper forehead requiring 3 (three) sutures. * R41 had a fall on 10/21/2024 that was not thoroughly investigated.

Inspectors wrote3.) R4 was readmitted to the facility on [DATE] with diagnosis that includes new pressure injuries, an unstageable to left plantar foot, a stage 4 pressure injury right dorsal first toe, neuromuscular dysfunction of the bladder, urogenital implants dysphagia, resistance to multiple antibiotics. R4's Quarterly Minimum Data Set (MDS) assessment, dated 12/22/2024, documents a brief interview for mental status (BIMS) score of 7, indicating that R4 has severe cognitive impairment R4's Urinary Catheter care plan, dated 10/29/2022 (revision on: 9/23/2024) with a target date of: 3/29/2025, documents: I have a 16 F (French) cubic centimeter suprapubic catheter: neurologic bladder, retention. Under the Interventions section in the urinary catheter care plan, it documents: Position catheter bag and tubing below the level of the bladder and away from entrance room door. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming, personal and oral hygiene for 2 (R33 & R45) of 18 residents reviewed for bathing. * R33 was observed to have dirty fingernails, facial hair, uncombed hair and had not had a shower or bed bath in 30 days. * R33 was not offered or assisted with repositioning. * R33 was not assisted with cutting up R33's food per R33's plan of care. * R45 was observed to have long dirty fingernails, poor oral hygiene and only had 3 bed baths or showers in the last 30 days.

Inspectors wroteBased on interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (R22) of 18 reviewed for change of condition. On 10/21/2024 R22 had blood noted in R22's brief. No assessment was completed, and R22's physician was not notified. On 10/23/2025 R22 had another episode of blood in R22's brief. No assessment was completed, and R22's physician was not notified.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 3 (R45, R41, R73) of 5 residents reviewed with pressure injuries. *R45's wound treatments were not consistently being marked as completed in R45's Treatment Administration Record (TAR) or documented in R45's Electronic Health Record (EHR) as being completed. * R41 was readmitted to the facility on [DATE] and was assessed to have a pressure injury to the sacrum area. A treatment was not initiated until 12/18/2024 and the facility did not document wound treatments as being completed per physician orders. R41 did not have refusals documented or a revised care plan to indicate R41 refused wound treatments. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure the necessary services to provide respiratory care were consistent with professional standards of practice for 1 (R10) of 2 residents reviewed for respiratory care. * R10 had continuous oxygen via nasal canula set at 3 L (liters)/min (minute) during the survey. R10's oxygen tubing was not labeled and did not have humidification attached. There was no respiratory/oxygen care plan for R10, despite R10 having an order for oxygen 2-5 L via face mask as needed.

Inspectors wroteBased on observation, interview, record review, the facility did not ensure that 1 of 4 residents (R1) was free from verbal and mental abuse. Certified Nurse Aide (CNA) D intentionally moved R1's call light out of his reach and closed his door, thereby taking away R1's ability to summon assistance in the event of an emergency or need. CNA D reported her actions to RN E (Registered Nurse); however, RN E did not report the incident to the Administrator. This allowed CNA D to work 3 shifts at the facility following the incident before she was suspended. The facility's failure to ensure residents were free from abuse created a finding of immediate jeopardy that began on 10/19/24. Surveyor notified the Nursing Home Administrator (NHA) of the immediate jeopardy on 11/8/24 at 11:10 a.m. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report an allegation of abuse immediately to the Administrator. Failure to report an allegation placed all residents at risk as the accused staff person was allowed to work throughout the building. CNA D refused to provide cares to R1, removed R1's puff activated call light, and shut R1's room door. CNA D reported her actions to RN E. RN E did not report the allegation of abuse to NHA A (Nursing Home Administrator). CNA D was allowed to continue to work with residents for an additional 3 shifts before it was reported to administration.

Inspectors wroteBased on interview and facility policy review, the facility failed to ensure only licensed nursing staff administered medications to residents who resided on one of two units (Heritage). This failure placed the residents on the Heritage unit at risk for negative outcomes due to the potential for medication errors.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents were free from verbal abuse for three of seven sampled residents (Resident (R) 3, R4, and R5). All three residents sustained verbal abuse from two different staff members. These failures placed the residents at risk of psychosocial harm.

Inspectors wroteExamples 3 and 4. Falls: The facility policy, entitled Falls - Clinical Protocol, revised March 2018, states: Assessment and Recognition . 2. In addition, the nurse shall assess and document/report the following: a. Vital signs b. Recent injury, especially fracture or head injury c. Musculoskeletal function . d. Change in condition or level of consciousness e. Neurological status f. Pain g. Frequency and number of falls since last physician visit h. Precipitating factors- details of how fall occurred. i. All current medications, especially those associated with dizziness or lethargy. j. all active diagnoses 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. 5. The staff will evaluate, and document falls that occur while the individual is in the facility. 6. Falls should be categorized as: a. [...]

Inspectors wroteBased upon interview and record review, the facility did not ensure they provided consistent staff to meet the resident needs for the 76 residents residing in the facility at the time of the survey. During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered in the fiscal year quarter 3, 2023 (April-June) for low weekend staffing.

Inspectors wroteBased on interview, observation and record review, the facility did not ensure 4 (R70, R48, R68 and R56) of 7 residents reviewed for pressure injuries received care, consistent with professional standards of practice, to prevent pressure injuries and promote healing. ~ R56 had a pressure injury to her coccyx that healed 4/27/23. The facility documented the treatment continued until 7/23/23 when R56 was admitted to the hospital, except for many refusals documented. When R56 was readmitted on [DATE], the coccyx wound was not assessed until 8/3/23. During survey, wound care to multiple wounds and pressure injury to coccyx was observed. The nurse never completed the wound care to the coccyx wound. Also, Pressure Reducing Mattress was not set to the correct settings making pressure reduction ineffective. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that all medications were labeled in accordance with standard of practice for 3 of 3 medication carts (Skylight East, South, North) and 1 of 2 medication storage rooms (Skylight South) with the potential to affect 35 of 76 residents residing in those units.

Inspectors wroteBased upon observation and interview, the facility did not ensure 1 (R29) of 1 residents reviewed for self administration of medications was assessed prior to staff leaving medications at bedside for a resident. Facility nursing staff were observed preparing R29's medications and leaving them with R29 when R29 stated they wanted to take the medications when they had breakfast. R29 was not assessed to self administer their medications.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure 1 (R70) of 18 residents sampled were reasonably accommodated to provide access to a call light. R70's call light was not accessible to R70 on 5 observations during the survey.

Inspectors wroteBased on record review and interview the facility did not ensure advanced directives were in the residents medical record for 1 (R68) out of 18 sampled residents. * R68's Do not resuscitate consent form was not placed in her medical record after it was signed. It was found in a pile waiting to be scanned into the computer in medical records which are not always accessible to nursing staff.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R9) of 4 residents with allegations of abuse or injuries of unknown origin had these allegations reported to the state agency. On 10/4/23 R9 was discovered to have a bruise to the left breast and left forearm. R9 wasn't able to tell staff how the bruise occurred. R9's bruises meet the definition of an injury of unknown origin and the facility did not report this to the state agency.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R9) of 4 residents with allegations of abuse or injuries of unknown origin had a thorough investigation completed. On 10/4/23 R9 was discovered to have a bruise to the left breast and left forearm. R9 wasn't able to tell staff how the bruise occurred. R9's bruises meet the definition of an injury of unknown origin and the facility did not conduct a thorough investigation into R9 bruise.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 (R56) of 2 residents reviewed for non-pressure injuries received care based upon acceptable standards of practice. R56 had 2 areas of Moisture Associated Skin Damage (MASD) to her Left Buttocks and Upper Left Thigh. When R56 was readmitted from the hospital, the wounds were not assessed timely. R56 refused to see the Wound MD for assessments but agreed to weekly head to toe assessments by staff. The staff did not measure or assess the wounds during these weekly assessments and the wound team did not reapproach R56 for the weekly assessments, leading to missing multiple weeks of measurements. During survey, observations of infection control breaks during wound care were observed. 2 new wounds were noted during wound care that were not reported to Wound MD or Wound Team. [...]

Inspectors wroteBased on observations, interviews, and record review the Facility did not ensure 3 (R2, R56 and R68) of 3 Residents reviewed received appropriate treatment and services related to catheter care. *R2 has a suprapubic (SP) catheter. R2's collection bag was observed multiple times laying directly on the floor by R2's bed and without an anchor device to hold the tubing in place. R2's catheter tubing was observed stretched with tension in the tubing line and R2 was pulling at tubing. R2 has MD orders for a dry dressing to suprapubic site. R2's suprapubic site observed multiple times with no dressing on it. *R56 has an indwelling urinary foley catheter. R56's catheter bag was observed being emptied with multiple breaks in infection control. *R68 has an indwelling urinary foley catheter. R68's collection bag was observed laying directly on the floor.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that it maintained a medication error rate below 5 percent during observations of medication administration affecting 2 (R8 and R29) of 2 residents observed. Three medication errors were observed out of twenty-six opportunities, for a total error rate of 11.54 %. * R8 was administered Cetirizine 10 milligrams (MG) from a bottle where the expiration date rubbed off bottle in addition R8's order was for 5 MG and she was given 10 MG. R8 was also not given her Flonase as ordered. R29 was given Monifloxacin eye drops after the discontinue date of 11/25/23.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that staff performed proper hand hygiene and infection control for 2 (R8, R70) of 3 residents observed during the medication pass observation. * A Medication Aide was observed not wearing gloves to administer eye drops to R8 and did not wash her hands after the administration. The Medication Aide then went and preformed a blood glucose check for R70 without washing her hands between residents

Inspectors wroteBased on observations, record review and staff interview, the facility did not always ensure that they posted the nurse staffing data, to include the date, resident census, and the total actual hours worked by Registered Nurses, Licensed Practical Nurses and Certified Nurses Aides, on a daily basis. This has the capability to affect all 76 residents which is the total census upon survey entrance. This is evidenced by: On 11/30/23 01:00 PM Surveyor made observations of the front entrance near reception area. It was noted the nurse staff posting was dated for Tuesday 11/28/23 and noted the census to be 93 resident census. Surveyor conducted a review of the facility's schedules and coinciding nurse staff posting hours for April 1, 2023 through June 30,2023. It was noted that the census was documented at 93 residents for each day. The facility is only licensed for 90 beds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement its policy and procedure to inhibit abuse, neglect, and mistreatment of residents which had a potential to affect all 11 residents residing on the unit. The facility did not implement its policy and procedures to safeguard residents by removing the certified nursing assistant (CNA)-H from patient care when R1 accused CNA-H of abuse on 8/12/2023. R1 did not have monitoring or care plan revision to monitor psychosocial or long term effects from the accusation of abuse.