Jamestown Place Health And Rehab

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure dignity and respect were shown to residents who needed help to eat. This affected three (#25, #26, #7) of three residents reviewed for assistance with eating. The census was 34.Findings Included:1.Medical record review for Resident #25 was admitted on [DATE REDACTED]. Medical diagnoses included encephalopathy and non-Alzheimer's dementia.Review of the quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #25 was severely cognitively impaired. Her functional status was dependent for eating, toileting, bathing and bed mobility. She was non-applicable for transfers. 2.Medical record review for Resident #26 revealed an admission date of 05/27/21. Medical diagnoses included quadriplegia, neurogenic bladder, diabetes, and cerebrovascular attack.Review of Resident #26's quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed she was cognitively intact. Her functional status was dependent for eating, toileting, bed mobility, and non-applicable for transfers. She was always incontinent for bowel and bladder.3. Medical record review revealed Resident #7 was admitted on [DATE REDACTED]. Medical diagnoses included cancer, anemia, and hypertension.Review of the quarterly MDS assessment dated [DATE REDACTED] revealed Resident #7 had moderate cognitive impairment and required a helper to set up and clean meals.Observation of the dining room on 09/11/25 at 11:00 A.M. revealed Resident #3, #20, and #7 among unidentified residents sitting at the dining table waiting for lunch. At 11:10 A.M. lunch was given to these residents, and they started eating.

Observation of Resident #25 on 09/11/25 at 11:01 A.M. revealed she was brought to the dining room table and wasn't served lunch and assisted to eat until 11:46 A.M. Observation of Resident #26 on 09/11/25 at 11:03 A.M. she was in the dining room and waiting to be fed and then at 11:10 A.M. revealed the resident was getting fed. Observation of Resident #7 on 09/11/25 from 11:10 A.M. to 11:45 A.M. revealed she was not sitting close enough to the table and had to be cued to eat. At 11:50 A.M. this resident was cued to eat her lunch and slid up to the table so she could reach her meal. Interview with Certified Nursing Aide (CNA) #106 on 09/11/25 at 12:16 P.M., verified she was the only aide in the dining area and had two people to assist with eating and another one had to be cued to eat. She confirmed it took a while for Resident #25 to be fed while the other residents were eating and stated it wasn't a dignified experience for the residents.

Review of the policy titled Resident Rights dated 2001 revealed employees shall treat all residents with kindness, respect, and dignity.This was an incidental finding under Complaint Number 2593977.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

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Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Jamestown Place Health and Rehab

4960 US 35 East Jamestown, OH 45335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0565

Honor the resident's right to organize and participate in resident/family groups in the facility.

Level of Harm - Minimal harm or potential for actual harm

Based on review of the resident council minutes, staff and resident interviews, and policy review the facility failed to ensure resident council concerns had a resolution. This affected two (#13 and #29) of two residents reviewed for resident council. The facility identified not all of the residents were able to attend resident council. The facility census was 34.Findings Included:Review of Resident Council Minutes revealed:On 06/23/25 there was a complaint noted about the facility driveway needed the cracks fixed.On 07/21/25 there was a complaint noted about the facility driveway still needed fixed. On 08/25/25 there was a complaint noted a resident's wheelchair got stuck in a hole out front and the resident could hardly get out of

the hole. The resident's voiced in this resident council meeting they felt like nothing was done about their concerns when the administration was made aware of the concerns. Interview with the Resident Council President #13 on 09/15/25 at 10:32 A.M., revealed the resident council does not receive timely answers to their complaints, if they even answer them at all. The Resident Council President #13 said there were cracks in the black top driveway and she gets tumbled around when driving around in her electric wheelchair. She further revealed Resident #29 was stuck in their wheelchair out in a crack in the black top driveway. Interview with the Activity Director (AD) #38 on 09/15/25 at 1:21 P.M., revealed she conducted the council meetings and if there were any concerns she gave them to the Administrator. She verified the resident council complaints were not addressed timely if answered at all. Interview with Resident #16 on 09/15/25 at 1:33 P.M., revealed she was stuck in the cracks of the blacktop driveway once but was able to get herself unstuck. Resident #16 could not remember when this happened. Interview with Resident #29 on 09/15/25 at 1:53 P.M., revealed he had gotten stuck in the cracks in the driveway before unsure when it was. He revealed he had told the facility numerous times about it and had not received a resolution.Review of the policy titled Resident Council dated 02/01/21 revealed the facility supports residents' rights to organize and participate in the resident council. The quality assurance and performance improvement (QAPI) committee will review information and feedback from the resident council as part of their quality review. Issues documented on council response forms maybe referred to the QAPI committee, if applicable.

This deficiency represents an incidental finding investigated under Complaint Number 2580867 and

1. 2593977. Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Jamestown Place Health and Rehab

4960 US 35 East Jamestown, OH 45335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, record review, staff and resident interview, and policy review the facility failed to ensure there was a homelike environment. This affected 11 (# 20, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) out of 11 reviewed for the environment. The facility census was 34.Findings Included:

Observation of Resident #13's room on Winter Hall on 09/15/25 at 8:16 A.M., revealed the bathroom light made a loud screeching noise, the faucet leaked in the sink, and the hot water temperature was 82.7 degrees Fahrenheit. Interview with Resident #13 on 09/15/25 at 8:17 A.M., revealed the light in her bathroom had been screeching for about five or six days, and an aide knew about it, however the resident could not remember her name. Resident #13 reported the water in her bathroom had not been hot for about three weeks and the aides would give her washcloths that were lukewarm, and they would apologize for it when they had to provide care when the washcloth wasn't hot. Review of the following resident's rooms on Winter Hall on 09/15/25 at 8:30 A.M., revealed:Resident #9's bathroom hot water temperature was 88 degrees Fahrenheit and the faucet leaked.Resident #10's bathroom hot water temperature was 85 degrees Fahrenheit and the faucet leaked. Resident #11's bathroom hot water temperature was 85 degrees Fahrenheit. Resident #12's bathroom hot water temperature was 85.5 degrees Fahrenheit, and the faucet leaked. Resident #14's bathroom hot water temperature was 85.2 degrees Fahrenheit. Resident #15's bathroom hot water temperature was 88.3 degrees Fahrenheit, and the faucet was leaking. Resident #16's bathroom hot water temperature was 85.2 degrees Fahrenheit, and the faucet was leaking. Resident #17's bathroom hot water temperature was 85 degrees Fahrenheit. Resident #18's bathroom hot water temperature was 85 degrees Fahrenheit.Observation of Residents #20's room revealed the bathroom sink was leaking. There was a potential trip hazard that went from the bedroom to the bathroom that looked like

it had been repaired with a cement room divider that was raised off the floor approximately 3/4's of an inch.

Interview and observations with the Maintenance Man (MM) #117 on 09/15/25 at 8:45 A.M., verified all the above-mentioned residents' room environment concerns. He reported he had been off sick for two weeks and returned on 09/15/25. He revealed he had received text messages about the water temperatures while

he was off sick but could not remember who he told about them. Interview with Resident #18 on 09/15/25 at 1:43 P.M., revealed she had not had hot water in her bathroom in a while. She said when the aides gave her a washcloth or provided care the washcloth was lukewarm.Observation of the black top parking lot on 09/15/25 at 12:00 P.M., revealed there were cracks in the cement. Observation of the sidewalk coming out of the facility on the right-hand side revealed the sidewalk was broken up and had chunks of cement laying

on the walk. Interview on 09/15/25 at 12:15 P.M., with the Corporate Registered Nurse (CRN) #300 revealed the parking lot should have been taken care of and verified the cracks in the black top and the chunks of cement on the sidewalk. There was a policy requested but the facility said they go by standard protocol which was never provided. This deficiency represents non-compliance investigated under Complaint Number 2580867 and 2593977

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Jamestown Place Health and Rehab

4960 US 35 East Jamestown, OH 45335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on medical record review, staff interview, and policy review revealed the facility failed to ensure a resident elopement was reported to the state agency. This affected one (#20) of two residents reviewed for elopement. The facility census was 34.Findings Included: Medical record review for Resident #20 revealed

an admission date of 10/13/23. Medical diagnoses included non-Alzheimer's dementia, seizure disorder, and schizophrenia.Review of the progress notes dated 05/01/24 revealed Resident #20 had a history of eloping from home.Review of the care plan dated 04/03/25 revealed Resident #20 was identified as an elopement risk and would be wearing a wander guard alarming device. Interventions to prevent elopement included: to monitor placement and function of the wander guard alarming device every shift, provide redirection from the lobby area when visitors were leaving, and redirect the resident from the doors.Review of the medical record dated 04/12/25 revealed Resident #20 eloped from the facility at approximately 7:45 A.M., went to a gas station 0.2 miles away, got into a truck with a man, the gas station manager knew, who asked him to take her to the other side of town. The station manager discovered the resident was from the facility and asked the man driving the resident across town to take her back to the facility. Resident #20 was taken back to the facility at approximately 8:25 A.M. Interview with the Administrator on 09/15/25 at 3:00 P.M., verified she had not filed a Self-Reported Incident (SRI) because she felt there was no neglect for Resident #20, even though the resident was cognitively impaired. She reported the resident left the facility.

Review of the policy titled Abuse Policies and Procedures dated 04/01/21 revealed to report any allegations within timeframes required by federal requirements. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.This deficiency represents non-compliance investigated under Complaint Number 2583977.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Jamestown Place Health and Rehab

4960 US 35 East Jamestown, OH 45335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677

investigated under Complaint Number OH002593977

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Jamestown Place Health and Rehab

4960 US 35 East Jamestown, OH 45335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679

under Complaint Number 2593977.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Jamestown Place Health and Rehab

4960 US 35 East Jamestown, OH 45335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and the door was functioning properly for the wander guard on the resident's ankle. She said there had been audits of the door functionality and she received education on the elopement policy and elopement drills. Interview with LPN #69 on 09/11/25 at 2:49 P.M., revealed she was helping feed a resident on 04/12/25 and heard the door alarm go off at the front door and heard someone turn it off. She went back to feeding her resident. She said the gas station manager called the facility a short time later and said Resident #20 had been at the station and asked a man, the manager knew, to give her ride to the other side of town. As he was driving Resident #20 to the other side of town the station manager figured out Resident #20 was from the facility and asked him to return the resident to the facility. She confirmed she only heard the door alarm go off and not the wander guard alarm. She stated apparently the wander guard alarm was only going off on one side of the door. She said there had been audits of the doors and she received education on the elopement policy and elopement drills. Review of the policy titled Elopement and Wandering dated 03/01/29 revealed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.Policy Interpretation and Implementation1. If identified as at risk for wandering, elopement, or other safety issues,

the resident's care plan will include strategies and interventions to maintain the resident's safety.2. If a resident is missing, initiate the elopement/missing resident emergency procedure:a. Determine if the resident is out on an authorized leave or pass;b. If the resident was not authorized to leave, initiate a search of the building{s} and premises; andc. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and {as necessary} volunteer agencies {i.e., emergency management, rescue squads, etc.}.4. When the resident returns to the facility, the director of nursing services or charge nurse shall:a. examine the resident for injuries;b. contact the attending physician and report findings and conditions of the resident;c. notify the resident's legal representative {sponsor};d. notify search teams that the resident has been located;e. complete and file an incident report; andf. document relevant information in the resident's medical record.The deficient practice was corrected on 04/24/25 when the facility implemented the following corrective actions: On 04/12/25 a head count was initiated and it was determined it was only Resident #20 who was missing. A skin check was completed on Resident #20 with no concerns. Resident #20 was placed on one-to-one supervision. The physician was notified and assessed no changes in medications at

the time for Resident #20. Assessments were completed for residents who had wander guard alarming devices with no identified concerns. Elopement education was started, elopement drill was completed, and statements from all staff in the building were collected. A statement was provided by the previous Maintenance Man was provided that the wander guards were working on 04/12/25.On 04/12/25 education was provided to the staff by the Administrator on initiating elopement/missing resident emergency procedures. Determine if the resident was out on an appointment or leave of absence, initiate a search of

the building in and out, and notify the administrator, the Director of Nursing (DON), the physician and the family. Education on the policy was provided to the staff.On 04/12/25 elopement drills were completed on 04/12/25, twice on 04/15/25, 04/16/25, 04/17/25, and 04/18/25. On 04/14/25 door alarm audits were initiated, and it was discovered door alarms were working, but the wander guard alarm was not functional at

the main entrance and the employee entrance. The vendor was contacted for the wander guard alarm.On 04/15/25 through 04/24/25 the door alarms were audited for functionality twice a day. The repairs were made to the door on 04/17/25. On 04/17/25 the door alarms passed and on 04/21/25 the door alarms passed. This deficiency represents non-compliance investigated under Complaint Number OH002593977

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Jamestown Place Health and Rehab

4960 US 35 East Jamestown, OH 45335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

peripheral vascular disease, renal insufficiency, diabetes, and cerebrovascular accident. Resident #3 had a significant weight loss but was stabilizing. Review of the admission MDS dated [DATE REDACTED] revealed Resident #3 was severely cognitively impaired. His functional status was dependent for eating, substantial/maximal for toileting and bathing. He was partial/moderate assistance for bed mobility, and transfers.Review of the care plan updated 07/29/25 revealed Resident #3 was at risk for malnutrition as evidenced by chronic disease, peripheral vascular disease, gastroenteritis, bronchitis, depression, hypertension and dysphagia.

Interventions were to monitor weights as ordered, provide diet as ordered-mechanical soft diet. Review of

the orders dated 09/05/25 revealed to provide a magic cup supplement during lunch for Resident #3.Observation of Resident #3 on 09/11/25 at 11:34 A.M., the lunch meal revealed the resident was eating his meal independently, there was no magic cup supplement on his tray and no one gave him one to eat at

this time. Interview with Certified Nursing Aide (CNA) #90 on 09/17/25 at 3:05 P.M., verified she had not given Resident #3 a magic cup with his lunch and was not aware he was supposed to have one.Interview with the Dietary Manager (DM) #86 on 09/17/25 at 3:11 P.M., revealed she had not been putting the magic cup supplement on Resident #3's tray at lunch because she was not aware he was supposed to have it on

the tray for lunch. Review of the policy titled Weight Assessment and Intervention undated revealed to develop and implement pertinent approaches for the weight loss. This deficiency represents non-compliance investigated under Complaint Number OH002593977.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Jamestown Place Health and Rehab

4960 US 35 East Jamestown, OH 45335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of the daily staffing, observation and staff interview the facility failed to ensure there was enough staff to assist residents to eat. This affected three (#25, #26, and #7) of three residents reviewed for staffing. The facility census was 34. Findings Included:Review of the daily staffing dated 09/11/25 revealed there were two nurses, and three Certified Nursing Assistants (CNA)'s to take care of 34 residents. There was one CNA who was out of the facility taking a resident to dialysis. The affected three (#25, #26, and #7) of three residents reviewed for assistance with eating.1.Medical record review for Resident #25 was admitted on [DATE REDACTED]. Medical diagnoses included encephalopathy and non-Alzheimer's dementia.Review of

the quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #25 was severely cognitively impaired. Her functional status was dependent for eating, toileting, bathing and bed mobility. She was non-applicable for transfers. 2.Medical record review for Resident #26 revealed an admission date of 05/27/21. Medical diagnoses included quadriplegia, neurogenic bladder, diabetes, and cerebrovascular attack.Review of Resident #26's quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed she was cognitively intact. Her functional status was dependent for eating, toileting, bed mobility, and non-applicable for transfers. She was always incontinent for bowel and bladder.3. Medical record review revealed Resident #7 was admitted on [DATE REDACTED]. Medical diagnoses included cancer, anemia, and hypertension.Review of the quarterly MDS assessment dated [DATE REDACTED] revealed Resident #7 had moderate cognitive impairment and required a helper to set up and clean meals.Observation of the dining room on 09/11/25 at 11:00 A.M., revealed Resident #3, #20, and #7 among unidentified residents sitting at the dining table waiting for lunch.

At 11:10 A.M. lunch was given to these residents, and they started eating. Observation of Resident #25 on 09/11/25 at 11:01 A.M. revealed she was brought to the dining room table and wasn't served lunch and assisted to eat until 11:46 A.M. Observation of Resident #26 on 09/11/25 at 11:03 A.M. she was in the dining room and waiting to be fed and then at 11:10 A.M. revealed the resident was getting fed. Observation of Resident #7 on 09/11/25 from 11:10 A.M. to 11:45 A.M. revealed she was not sitting close enough to the table and had to be cued to eat. At 11:50 A.M. this resident was moved closer to the table so she could reach her meal and cued to eat her lunch. Interview with Certified Nursing Aide (CNA) #106 on 09/11/25 at 12:16 P.M., verified she was the only aide in the dining area and had two residents who required assistance with eating and another one had to be cued to eat. She reported there was not enough staff to feed the residents timely, and it was like this every day. She said the other aides had to feed residents down the halls. Attempted to get a staffing policy the Regional Director of Clinical Services revealed they followed standard practice. This deficiency represents non-compliance investigated under Complaint Number

1. 2593977. Event ID:

Facility ID:

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