Tri-State Village Nrsg & Rhb

Inspectors wroteBased on interview and record, the facility failed to ensure a significant change in condition was documented in the medical record for one (R2) resident. This failure affected one (R2) of four residents reviewed for change in condition.

Inspectors wroteBased on observation, interview and record review the facility failed to assess, monitor and treat residents with multiple pressure ulcers for 2 of 3 residents (R3 and R4) This deficient practice resulted in R3 being hospitalized for necrotizing fasciitis of the wound bed.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident with a history of falls was monitored during a transfer for one of three residents (R2) reviewed for falls. Findings Include:On 3/10/2026 at 1:30pm R2 said that on 3/3/2026 , his CNA sat him up on the side of the bed, went to retrieve the mechanical lift he could not hold his balance and slid to the floor. On 3/11/2026 at 12:58pm , V14(Certified Nursing Assistant-CNA) said she sat R2 on the side of the bed and went to retrieve the mechanical lift R2 yelled, she ran over to him and lowered him to the floor then went for assistance. On 3/12/2026 at 11:30am, V12(Restorative Nurse/Fall Coordinator) said R2 is a high risk for falls and should not be left alone on the side of the bed. [...]

Inspectors wroteBased on observations, interviews, and record reviews, this facility failed to provide the necessary care and services to prevent a stage 3 sacral pressure ulcer from recurring, assess and document wound conditions, perform weekly wound assessments with measurements for one resident (R1) out of three residents reviewed for pressure ulcers. On 10/1/25 R1's stage 3 sacral pressure ulcer reopened; wound measured 2.9cm (centimeters) x 0.6cm x 0.1cm. On 11/14/25, R1's wound declined; wound measures 3cm x 4,3cm x 0.4cm with 50% slough and 50% granulation tissue.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and facility assessment and assure competency of each employee for proper transferring technique to safely transfer residents. This includes gait belt use training for all nursing staff and mechanical lift training for 7 Certified Nursing Assistants. This failure affected one resident R3 and has the ability to affect all 76 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to transfer a resident safely and in line with facility protocols, which resulted in R3 falling while staff were transferring R3 from the chair to bed. This failure applied to one (R3) of four residents reviewed for falls.

Inspectors wroteBased on interviews, observations, and records reviewed the facility failed to identify and evaluate nutrition interventions for one resident. This affected one of one resident R2 reviewed for nutrition in sample of 72. This failure resulted in R2 having a significant unplanned weight loss of 16.7% in 4 months.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure they had insulin pen needles for resident's insulin administration for (R5, R28, R54, R55) four of four residents reviewed for pharmaceutical services.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their medication labeling, Storage of medications and insulin administration policies by not discarding expired insulin and eye drops, ensuring open date and expiration dates were labeled on insulin pens, and ensuring all insulin pens were labeled with residents name for four ( R5, R54, R64, R67) of four residents reviewed for medication storage.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure shower room water was within normal temperature range between 100 -110 degree (fahrenheit) for one of two shower rooms. This failure has the potential to affect all 52 residents on the shared unit.

Inspectors wroteBased on interviews and records reviewed the facility failed to provide staff with training for dementia care and cognitively impaired residents. This failure has the potential to affect 42 residents with diagnosis of Dementia or Cognitive Impairments in the facility, in a sample of 72 residents.

Inspectors wroteBased on interview and records reviewed the facility has not obtained a new PASSAR for a resident with onset of symptoms and diagnosis of Bipolar Disorder. This affected one of four residents (R4) reviewed for PASSARs in a sample of 72 residents.

Inspectors wroteBased on interviews and records reviewed the facility failed to offer showers for two (R60 and R5) of four residents in a sample of 72 reviewed for ADL assistance.

Inspectors wroteBased on interview and record review, the facility failed to transcribe and initiate a verbal order by not ordering an ultra sound as requested by the nurse practitioner for one of one residents (R30) review for quality of care in a sample of 72. Finding Includes: R30's brief interview for mental status dated 4/22/25 documents a score of fifteen which indicates cognitively intact. Nurse Practitioner progress note dated 4/25/25 documents: infected cyst to right side of neck: Assessment and Plan: Local infection of skin and subcutaneous infection - R30 has a sebaceous cyst but it was noted today that cyst is reddened and swollen. Progress Note dated 4/25/25 documents: Writer (V11) notified by staff member of large bump on patients neck. Writer went to assess and observed large abscess on right side of patient's neck. Assess is tender to touch and painful. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their dressing policy by not providing an as needed dressing after who was diagnosis with a stage 4 sacral pressure ulcer after having an episode of diarrhea. This affected one of three residents (R11) reviewed for dressing changes. Findings Include: R11 had the diagnosis of stage 4 sacral pressure ulcer. Physician orders sheet dated 3/30/25- 4/30/25 documents: Site-Coccyx: cleanse wound with wound cleanser. Apply calcium alginate to wound bed, apply bed skin prep to peri-wound cover with dry dressing daily and as needed (prn) if loose or soiled. On 4/28/25 at 12:33pm, during a body assessment with V4 (nurse), R11 was observed with a large amount of watery stool in her incontinence brief. V4 cleaned R11. R11 sacrum wound was observed without a dressing. [...]

Inspectors wroteBased on interview and records review, the facility staff failed to ensure one resident who has a diagnosis of dementia with a history of falling, was safely positioned in bed before turning away from the resident while providing direct resident care. This affected one of one resident (R7) reviewed for safety while providing care. This failure resulted in R7 sustaining a fall from the bed to the floor with facial swelling and being transported to the hospital for one of two reviewed for falls.

Inspectors wroteBased on interviews and records reviewed the facility failed to develop a plan of care to address behavioral health services for one resident after returning from a psychiatric evaluation. This affected one of two residents (R4) reviewed for behavioral services.

Inspectors wroteBased on interviews and record review the facility failed to implement its protocol for antibiotic use and failed to monitor actual antibiotic use for one resident. This affectes one of two residents (R28) reviewed for receiving antibiotic.

Inspectors wroteBased on interviews and records reviewed the facility failed to provide their designated number of staff to provide resident care. This failure has the potential to affect all 76 residents in the facility.

Inspectors wroteBased on interview and records reviewed the facility failed to meet Payroll Based Journal requirements for staffing. This failure has the potential to affect all 76 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to a cognitively impaired resident and provide adequate monitoring of exit doors. This failure affected one of three residents (R1) reviewed for elopement in a sample of three. This failure resulted to an Immediate Jeopardy. The Immediate Jeopardy began on 04/14/2025 at 2:30PM when R1 exited through the locked dining room door without the door alarm going off, went to the patio/courtyard, exited the patio/courtyard gate, and did not come back. V2 (Director of Nursing) and V3 (Assistant Administrator) were notified of the Immediate Jeopardy on 04/18/2025 at 2:18PM. The facility presented an acceptable removal plan, and the immediacy was removed on 04/23/2025. The surveyor conducted an onsite investigation on 04/23/2025 to confirm the removal plan was implemented. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy on resident rights by not ensuring a package delivered to the resident was unopened. This failure applied to one (R1) of three residents reviewed for resident rights.

Inspectors wroteBased on interviews and records reviewed the facility failed to prevent resident to resident inappropriate touching. This affected two of three residents (R3 and R4) reviewed for abuse. This failure resulted in R4 inappropriately touching R3 in the dining room.

Inspectors wroteBased on interview and record review the facility failed to develop a baseline plan of care for monitoring and assessing a resident diagnosed with acute respiratory failure, obesity hypoventilation, shortness of breath that required a bipap machine when sleeping. This affects one of three residents reviewed for baseline plan of care.

Inspectors wroteBased on interview and record review, the facility failed to develop an effective plan with interventions to prevent or reduce the risk of falling for a resident diagnosed with Dementia, wandering behaviors and identify as a high fall risk with balance problems while standing. This affected one of three residents reviewed for falls and fall prevention. This failure resulted in R2 having eight falls, seven of which were unwitnessed and one fall resulting in right periorbital soft tissue swelling and right scalp hematoma with contusion of face and scalp. Findings Include: R2 was diagnosed with Dementia, lack of coordination and need for assistance with personal care. R2's Fall risk observation dated 4/10/24 documents: disoriented times three (person, place, and time) and balance problems while standing, high risk. R2's Care Plan dated 4/12/24 documents: [...]

Inspectors wroteBased on interview and record review the facility failed to provide, evaluate, and reevaluate the effectiveness of the motorized wheelchair safety/training/education to reduce the risk of injuries for one resident. This affected one of one resident (R1) reviewed for safe use of the motorized wheelchair. This failure resulted in R1 having multiple accidents attempting to maneuver the wheel motorized wheelchair. R1 sustained a fractured toe, and a laceration to the leg requiring 6 sutures.

Inspectors wroteBased on observations, interviews, and records reviewed the facility failed to respond to one resident's request for assistance after he activated his call light within 3-5 minutes. This affected one of three (R7) residents reviewed for call light response times. This failure resulted in a delay of 17 minutes.

Inspectors wroteBased on observations, interviews, and records reviewed the facility failed to provide assistance to a dependent resident wanting to change position into a sitting position. This affected one of three residents (R7) reviewed for staff assistance with activities of daily living. This failure resulted in R7 not receiving any assistance for 17 minutes.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow it's policy on discarding expired house stock medication for one of one medication rooms reviewed for medication storage and labeling. This deficient practice has the potential to affect all 23 residents receiving medication from the south wing medication room.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their smoking policy by not providing supervision for smokers during the 5:00 PM and 7:00 PM smoking breaks. This failure affected 5 residents (R49, R29, R46, R17, and R18) of 5 reviewed for smoking in a total sample of 17. The facility also failed to provide a privacy bag to residents with catheters for 2 (R37 and R169) of 2 residents reviewed for catheters in a total sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to follow the Purposeful Rounding Policy by not rounding on residents on a regular basis to meet their needs. This failure affected 1 resident (R54) of 3 residents reviewed for call lights/incontinence care (nursing care) in a total sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to perform routine checks on a resident with automatic implantable cardiac defibrillator (AICD) for one of one resident (R52) reviewed for quality of care in a sample of 17.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date tube feeding bottles before administering it for two of two residents (R24, R169) reviewed for tube feeding in a sample of 17.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its infection control policy by failing to initiate isolation protocol for a bed bug infestation for one (R44) of one resident reviewed for infection control in a sample of 17 residents.

Inspectors wroteBased on interviews and records reviewed the facility failed to conduct a thorough investigation to explain the origin of bruising for one resident. This affected one of three residents (R5) reviewed for injury of unknown origin. This failure resulted in unexplained black and blue bruising to R5's face and R5 being sent to the local hospital ICU/intensive care unit for treatment.

Inspectors wroteBased on interview and record review the facility failed follow physician orders for the administration of IV/intravenous medication and obtaining lab blood draw. This failure affected two of three residents (R12, R15) reviewed for physician orders. This failure resulted in R12 not receiving the IV medication for approximately 9 days being sent to the hospital after a change in condition. R12 was diagnosed and treated at the hospital for Sepsis and UTI (urinary Tract Infection).

Inspectors wroteBased on observation, interview and record review the facility failed to notify the physician of a change in condition of the skin for a resident at risk for skin breakdown. This affects one of three residents (R11) reviewed for physician notification of change in skin. This failure resulted in delayed notification, treatment orders, assessments, and consults.

Inspectors wroteBased on observation, interview and record review the facility failed to provide effective bathing, grooming and oral care. This affected two of three residents (R6, R18) reviewed for staff assisted ADL/Activities of Daily Living Care. This failure resulted in R6 having a dark, dry substance in mouth size greater than half dollar, and dry flaky skin.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their skin and wound management policy for a resident at risk for skin alteration and conduct a comprehensive assessment, monitoring, documentation, notify the physician of skin breakdown, obtain treatment orders, failed to ensure the low air loss mattress was implemented. This affected two of three residents (R6, R11) reviewed for pressure sore prevention.

Inspectors wroteBased on observations, interviews, and records reviewed the facility failed to ensure fall prevention interventions were implemented to include the use of a skid pad while up in the wheelchair. This affected one of three (R4) residents reviewed for fall prevention interventions.

Inspectors wroteBased on interview and record review the facility failed to protect the resident right to have the resident representative participate in care plan meeting for 1 of 3 resident (R6) reviewed for care plan meeting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's request to obtain assistance in obtaining the legal and/or social services necessary to have his guardianship status legally re-evaluated and maintain his highest practical well-being. This failure affected one (R1) of one resident reviewed for resident rights and has resulted in R1 suffering psychosocial harm as a result of not being able to leave the facility on pass status and having his phone taken away; this was further exhibited by R1 calling the police due to feelings of imprisonment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility: 1. failed to follow their policy and procedures for dementia care/behavior management by not ensuring a certified nursing assistant discontinued providing care and at a later time reapproached a resident (R3) with dementia who became physically aggressive while receiving care; 2. failed to follow facility policy and immediately assess and notify a physician for one resident (R2) who experienced head pain after having an unwitnessed fall; and 3. failed to follow their Medication Administration Policy by preparing mediations in advance for several residents at the same time. These failures applied to 17 (R2, R3, R7-R21) of 17 residents reviewed for nursing care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for dementia/behavior care planning by not ensuring a care plan for a resident who exhibits physically aggressive behavior towards staff included comprehensive personalized interventions for behaviors. This failure applied to one (R3) of six residents reviewed for care planning.

Inspectors wroteBased on interviews and record review, the facility failed to follow prevent a staff to resident incident of abuse. This affected one of three residents (R1) reviewed for abuse. This failure resulted in R1 diagnosed with dementia being involved in a verbal altercation with staff which escalated to V3 throwing a meal tray at R1. Using the reasonable person concept would cause R1 to be fearful of V3's impulsive and abusive behavior. Findings Include: Initial State Agency reportable, reads in part: with occurrence date of 9/28/23. Family member of another resident reported to the nurse that they observed an activity aide throw food at the resident. Nurse immediately provided for safety and redirected the activity aide away from residents and contacted administrator. Nursing performed head to toe assessment with no noted injury or skin alteration. R1 denied any pain or distress. [...]

Inspectors wroteBased on interview and record review the facility failed to provide incontinence care at least every two hours. This affected one of three residents (R1) reviewed for ADL care.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its policy related to documentation, monitoring and physician notification related to bowel movement for one (R26) of three residents reviewed for quality of care. This deficiency resulted in R26 complaining of constipation for several days before being sent to the emergency room for further evaluation and subsequently found to have fecal impaction in the rectum.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for handling clean equipment and utensils by not storing clean equipment in a sanitary manner; failed to follow their policy for wearing personal protective equipment by not wearing face masks properly; failed to follow their employee sanitary practices by not ensuring dietary staff were wearing hair restraints properly; and failed to follow their food storage policy by not ensuring dented cans were properly stored away from food inventory. These failures have the potential to affect all 61 residents currently in the facility.

Inspectors wroteBased on observation and record review the facility failed to follow their garbage disposal policy by not keeping a garbage can that was stored in the kitchen covered with a lid in order to prevent attracting insects. This failure has the potential to affect all 61 residents receiving food from the facility kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their policy and procedures for weight management by not consistently implementing identified interventions of providing cueing and encouragement during meals, not consistently documenting meal intakes, not monitoring meal intakes as ordered, not monitoring weight changes as ordered, not notifying the physician of significant weight changes, not implementing interventions recommended by dietitian, and not ordering blood work for monitoring of nutrition status. This failure resulted in significant weight loss for four (R19, R37, R42, and R264) of nine residents reviewed for nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were five medication errors out of 36 medication opportunities resulting in 13.89% medication error rate. This failure affected four residents (R15, R19, R51 and R53) observed during the medication pass task.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy for following therapeutic diets by not ensuring meals are prepared according to recipe to prevent including excess sodium for residents on a no added salt diet. This failure applied to eight of eight residents (R17, R34, R36, R37, R39, R52, R53, and R264) reviewed for therapeutic diets and has the potential to affect all 15 residents in the facility who receive no added salt diets.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who required assistance with Activities of Daily Living (ADLs) was treated with dignity and respect while being assisted with toileting. This failure applied to one (R18) of 18 sampled residents reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly document, investigate, and follow-up on a resident's concern/grievance. This failure affected one (R18) of 18 sampled residents reviewed for grievances.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their facility protocol related to incontinence care and assistance with personal hygiene for residents assessed to require staff assistance with ADLs (activities of daily living). This failure applied to two (R10 and R19) of 18 sampled residents reviewed for activities of daily living.