Every finding on record at Alpine Skilled Nursing and Rehabilitation Center

Based on observation, interview, record review, and facility policy review, the facility failed to follow infection control guidelines. Specifically, staff failed to properly disinfect goggles used in droplet precaution isolation rooms for 3 of 9 residents (Resident (R) 34, R51, and R77), failed to wear the required mask while in a droplet precaution isolation room for 1 of 9 residents (R34), and failed to ensure glucometer [blood sugar testing device] checks were performed in a manner to prevent infection for one resident (R60). These failures had the potential to result in the spread of infection to staff and residents.Findings include: 1. Review of R34's admission Record located under the Profile tab in the electronic medical record (EMR) indicated R34 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease and severe protein calorie malnutrition. Review of R34's Nursing Progress Notes located under the Progress Note tab in the EMR and dated 03/23/26 at 3:29 PM indicated R34 tested positive for COVID-19. During an observation on 03/30/26 at 9:53 AM, Certified Nursing Aide (CNA) 6 exited R34's room and removed the goggles she had worn while providing care to the resident. CNA6 wiped the goggles for 90 seconds with a Sani-Cloth wipe from the orange-top container and then placed the goggles directly into the isolation cart with clean, unused personal protective equipment (PPE). During an observation on 03/30/26 at 10:00 AM, Housekeeper (HSKP) 1 came out of R34's room, took off the goggles that she had worn into the resident's room, and began to clean them with a Sani-Cloth from the orange-top container for 90 seconds. After cleaning the goggles, HSKP1 placed them in the isolation cart with the unused, clean PPE. During an observation on 03/30/26 at 2:30 PM, Occupational Therapist (OT) was observed in R34's room assisting the resident with therapy wearing a surgical mask. 2. Review of R51's admission Record located under the Profile tab in the EMR indicated R51 was admitted to the facility on [DATE] with diagnoses of unspecified sequelae of other nontraumatic intracranial hemorrhage and atrial fibrillation. Review of R51's Nursing Progress Notes located under the Progress Note tab in the EMR and dated 03/25/26 at 3:31 PM indicated R51 tested positive for COVID-19. Review of R51's Physician Orders located under the Orders tab in the EMR indicated an order dated 03/25/26 which stated, Resident on Contact/Droplet Isolation 10-Day monitoring, COVID positive. During an observation on 03/30/26 at 10:05 AM, CNA6 exited R51's room and removed the goggles she had worn while providing care to R51. CNA6 wiped the goggles with a Sani-Cloth wipe from the orange-top container for 90 seconds and then placed the goggles directly into the isolation cart with clean, unused PPE. 3. Review of R77's admission Record located under the Profile tab in the electronic medical record (EMR) indicated R77 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease (COPD). Review of R77's Nursing Progress Notes located under the Progress Note tab in the EMR and dated 03/23/26 at 3:34 PM indicated R77 tested positive for COVID-19. Review of R77's Physician Orders located under the Orders tab in the EMR indicated an order dated 03/23/26 which stated, Resident on Contact/Droplet Isolation 10-Day monitoring, COVID positive. During an observation on 03/30/26 at 10:30 AM, CNA6 exited R77's room and removed the goggles she had worn while providing care to R77. CNA6 wiped the goggles with a Sani-Cloth wipe from the orange-top container for 90 seconds and then placed the goggles directly into the isolation cart with clean, unused PPE. During an interview on 03/30/26 at 10:45 AM, HSKP1 was asked how long she needed to clean the goggles she wore in a COVID-positive resident's room with a wet Sani-Cloth wipe from the orange-top container. HSKP1 stated, I don't understand what you are asking. During an interview on 03/30/26 at 10:50 AM, CNA6 was asked how long she needed clean the goggles with a wet Sani-Cloth wipe from the orange container before putting them in the isolation cart with the clean PPE items. CNA6 stated, I believe the time for the orange top is two to four minutes. During an interview on 03/31/26 at 3:10 PM, the Infection Preventionist (IP) stated the contact/cleaning time for the orange top container of Sani-Cloths is four minutes. The IP confirmed the staff should have cleaned the goggles with a wet Sani Cloth that came from the orange top container for four minutes. The IP was notified also of the OT wearing a surgical mask in R34's room, and she confirmed that the OT should have worn an N95 mask and not the surgical mask. Review of the undated facility's guide for Using the Correct Cleaning Wipes indicated, There are 3 approved wipes that should be used in the Facility to ensure infection control and prevention practice are happening at all time . Sani-Cloths Bleach [orange top] . contact time 4 mins. [minutes] . Review of the facility's policy Isolation-Transmission-Based Precautions, dated 01/09/26, indicated, . The Centers for Disease Control and Prevention (CDC) maintains a list of diseases, modes of transmission, recommended precautions, and recommendations for discontinuation . Droplet Precautions . Staff and visitors wear masks when entering the room . Review of the Infection Control Guidance: SARS-CoV-2 dated 06/24/24 and located at https://www.cdc.gov/covid/hcp/infection-control/index.html indicated, HCP [Healthcare Personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection . 4. Review of the admission Record located in the Profile tab of the EMR revealed R60 was admitted to the facility with a diagnosis of diabetes. During an observation on 04/01/26 at 4:51 PM, Licensed Practical Nurse (LPN) 2 was observed at the medication cart. LPN2 removed the glucometer machine from the top drawer on the left and placed the machine on top of the medication cart without a barrier. She then placed the machine into her left pocket and applied gloves without using hand sanitizer prior and proceeded into R60's room with her supplies. R60 then placed the machine on R60's overbed table. After acquiring the blood sugar results, LPN 2 returned to the medication cart and placed the glucometer back into the drawer without cleaning it. During an interview on 04/01/26 at 5:00 PM, LPN2 confirmed that she placed the glucometer on the resident's overbed table without a barrier and that she placed it back into the drawer on the medication cart without cleaning it first. LPN2 stated, I should have cleaned the glucometer with the specialized wipes that are on the cart. LPN2 was asked if she had attended any in-services on infection control for the medication pass. LPN 2 stated, It's been a while. During an interview on 04/01/26 at 6:14 PM, Licensed Practical Nurse/Unit Manager (LPNUM) 1 confirmed that LPN2 did not maintain infection control practices during a glucometer check.

Based on record review, interviews, document review, and review of McGeer's criteria, the facility failed to have an Antibiotic Stewardship Program consistent with current standards of practice for the prescribing of an antibiotic for 4 of 4 residents (Resident (R) 83, R33, R126, and R85) reviewed for antibiotic stewardship out of a total sample of 33 residents. This failure had the potential to result in the unnecessary use of antibiotics, increasing the risk of antibiotic resistance and adverse medication-related side effects for residents. Findings include:1. Review of R83's undated admission Record located under the Profile tab in the electronic medical record (EMR) indicated R83 was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). Review of R83's Nursing Progress Notes located under the Progress Note tab in the EMR indicated on 07/31/25 at 5:08 AM the nurse documented, . Dipstick Result: Leukocytes: +1 . There were no signs and symptoms documented as the reason for the dipstick of R83's urine to be tested. Review of R83's Physician Orders located under the Orders tab in the EMR indicated an order dated 07/31/25 for Ciprofloxacin (an antibiotic) 250 milligrams (mg) one tablet every 12 hours for infection for three days. Review of R83's Medication Administration Record (MAR) dated July and August 2025 and provided by the facility, indicated on 07/31/25 at 8:00 PM, R83 did not receive the first dose of Ciprofloxacin 250 mg due to the medication not arrived from pharmacy. R83 received the antibiotic twice a day on 08/01 and 08/02 and only one dose on 08/03/25. Review of R83's Urine Culture provided by the facility and dated 08/02/25 indicated Usual skin flora > [greater than] 100,000 cfu/ml [colony forming unit/milliliter] 3 or more organisms isolated, culture doubtful significance, please recollect. There was no further documentation in the EMR's entirety to indicate another urine culture had been obtained. Review of the facility's Infection Control Surveillance Log dated February 2025 through February 2026 and provided by the facility indicated R83 did not meet McGeer's criteria for this infection. During an interview on 04/02/26 at 2:15 PM, the Infection Preventionist (IP) and [NAME] President of Clinical Services (VPCS) 1 met with the surveyor to review the antibiotic usage for infections. The IP confirmed R83 did not have nursing documentation of signs and symptoms to support the urine dipstick that was performed on 07/31/25, that a repeat urine culture had not been collected as instructed on the urine culture result dated 08/02/25, and the antibiotic was not administered for the three days that it was ordered to be given to R83. VPCS1 confirmed the nurses should have documented the signs and symptoms prior to obtaining the urine dipstick for R83. 2. Review of R33's admission Record located under the Profile tab in the EMR indicated R33 was readmitted to the facility on [DATE] with the diagnosis of heart failure. Review of R33's Nursing Progress Notes located under the Progress Note tab in the EMR and dated 08/03/25 at 6:05 PM indicated, Given verbal order from NP [nurse practitioner] to collect a UA [urinalysis] at 1600 [4:00 PM]. Resident did not have any urine output the rest of day shift ending at 1800 [6:00 PM]. Gave report to night shift nurse to continue verbal order. Review of R33's EMR in its entirety did not reveal any documentation of the urinalysis results that had been ordered on 08/03/25. There was also no documentation of a urine culture result. Review of R33's Physician Orders located under the Orders tab in the EMR and dated 08/07/25 revealed an order for Bactrim DS [an antibiotic] Tablet 800-160 milligrams give one tablet every 12 hours for bacterial infection UTI [urinary tract infection] for seven days. Review of R33's MAR located under the Orders tab in the EMR, and dated August 2025, indicated R33 received one dose of the antibiotic on 08/07/25 at 9:00 PM, from 08/08/25 through 08/13/25, R33 received doses of the antibiotic every 12 hours, and then one dose of the antibiotic was given on 08/14/25 at 9:00 AM. Review of the facility's Infection Control Surveillance Log dated February 2025 through February 2026 and provided by the facility indicated R33 did not meet McGeer's criteria for this infection. During an interview on 04/02/26 at 2:15 PM, the IP and VPCS1 confirmed that R33 did not have a urinalysis or urine culture obtained prior to the administration of antibiotics. They stated this should have been collected to see if there was a true UTI or not. 3. Review of R126's admission Record located under the Profile tab in the EMR indicated R126 was readmitted to the facility on [DATE] with the diagnosis of urinary tract infection. Review of R126's Nursing Progress Notes located under the Progress Note tab in the EMR and dated 02/15/25 at 5:48 PM indicated, . UTI finished IV [intravenous] antibiotics at hospital. On Zyvox (an antibiotic) for five days . Review of R126's Physician Orders located under the Orders tab in the EMR and dated 02/15/25 indicated an order for Zyvox 600 mg every 12 hours for UTI for five days. Review of R126's EMR in its entirety did not have documentation of a time out for the use of this antibiotic used for a UTI or urinalysis and culture results from the hospital to support the documentation of an UTI. Review of R126's MAR located under the Orders tab in the EMR, and dated February 2025, indicated R126 received this antibiotic for three days instead of the five days that had been ordered on 02/15/25. During an interview on 04/02/26 at 2:15 PM, the IP and VPCS1 confirmed that when R126 was readmitted to the facility after being in the hospital with a UTI, there had not been a time out to discuss with the medical provider whether the antibiotic needed to be continued after the completion of the IV antibiotic that was given in the hospital. The IP also confirmed there was no documentation by the medical provider that benefits of having the antibiotic continued outweighed the risk of this being completed. The VPCS1 returned to the conference room at 3:30 PM and stated that they could not find any further documentation for R83, R33, R126 for their documented antibiotic usage. 4. Review of the admission Record located in the Profile tab of the EMR revealed R85 was admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of two limbs) and frequent urinary tract infections. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 12/31/25 revealed R85 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R85 was cognitively intact. The MDS indicated R85 had received an antibiotic during the seven-day observation period. Review of a Urinary Care Plan, revised 01/19/26, located in the Care Plan tab of the EMR revealed, R85 has a Urinary Tract Infection. There were no further updates to the Urinary Care Plan. Review of a Progress Note, dated 03/29/26, located in the Progress Notes tab of the EMR revealed, Approx [approximately] 0815 [8:15 AM] sent out to [hospital name] via [ambulance] due to fever, muscle aches, migraine, Nausea, feeling generally unwell and at the request of the resident provider and on call notified. Review of a Progress Note, dated 03/30/26, located in the Progress Notes tab of the EMR revealed, . Resident is alert and responsive. Able to make needs known. Resident has started Cefpodoxime Proxetil [an antibiotic] oral tablet 200 mg for UTI . During an interview on 04/01/26, the Infection Preventionist (IP) was asked if there had been an antibiotic time-out after R85 returned from the hospital and had she reviewed the urine culture to determine if the prescribed antibiotic was appropriate. The IP stated, Reports are pending. Lab cultures are usually sent to us. When we receive them, the admissions nurse will review it with the nurse from the hospital, and then she calls the physician and tells them what the order is and if they want to keep it or not. R85 has a lot of UTI's, and she did have a fever which was why she was sent to the hospital. During an interview on 04/02/26 at 3:30 PM, the IP provided the survey team with a copy of the urine culture report she had received which indicated mixed flora and therefore, would not have required an antibiotic. Review of the facility's policy Antibiotic Stewardship – Orders for Antibiotics, dated 01/09/26 indicated . Appropriate indications for use of antibiotics include: a. Criteria met for clinical definition of active infection or suspected sepsis; and b. Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). Empirical use of an antibiotic based on criteria of suspected sepsis may be appropriate. The staff and practitioner will document the specific criteria that support the suspicion in the resident's clinical record .

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medication at the bedside was assessed for self-administration for 1 of 33 sampled residents (Resident (R) 60). This failure placed the resident at risk of receiving more medication than prescribed.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R60 was admitted to the facility on [DATE] with a diagnosis of allergic rhinitis (commonly known as hay fever or nasal allergies).Review of an 02/13/26 Physician Orders located in the Orders tab of the EMR revealed, Fluticasone Propionate Nasal Suspension (allergy nasal spray) 50 MCG [micrograms] 1 spray in both nostrils in the morning for Allergies.Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 03/12/26 revealed R60 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R60 was cognitively intact.During an observation and interview on 03/30/26 at 8:21 AM, R60 was observed to have a bottle of fluticasone nasal spray on her over bed table. R60 was asked if she administered the medication herself. She stated, Yes. R60 was asked if staff had assessed her to determine if she was capable of self-administration of the medication. R60 stated, I think I signed a form, but they don't watch me.Review of the Comprehensive Care Plan located in the Care Plan tab of the EMR did not show a focus/goal/intervention for the self-administration of the medication.During an interview on 03/30/26 at 10:50 AM, the Director of Nursing (DON) was asked if R60 had been assessed for self-administration of the Fluticasone nasal spray. The DON looked at the computer and stated there was not a self-administration form.During a follow-up interview on 03/31/26 at 1:52 PM, R60 was asked if she continued to self-administer the nasal spray. R60 stated, No, they whisked it away yesterday. R60 was asked how long she had had the medication on her over bed table. R60 stated, I think it was after I returned from the hospital last week.During a follow-up interview on 03/31/26 at 1:55 PM, the DON stated, Our process is we get an order from the physician, do an assessment to ensure safety, provide a lock box for the medication, update the care plan, and mark the eMAR [electronic medication administration record] to self-administration. The DON further stated, What was interesting is that the nurse on the floor had the medication in her cart and had administered the medication to her that morning. I do not know how she had her own bottle at the bedside.Review of the facility's policy titled, Self-Administration of Medications, dated 02/01/19 revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the residents to do so.

Based on interviews, record review, and review of facility policy, the facility failed to ensure 1 of 33 sampled residents (Resident (R)114) was given the opportunity to make choices regarding his shower preference. This failure placed the resident at risk for a diminished quality of life.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R114 was admitted to the facility on [DATE] with a diagnosis of amyotrophic lateral sclerosis (ALS - a progressive neurodegenerative disease that destroys motor neurons in the brain and spinal cord), muscle weakness, and a need for assistance with personal cares.Review of the 02/06/26 Activity Interview for Daily Preferences located in the Assessments tab of the EMR, R114 was asked, How important is it to choose between a tub bath, shower, bed bath, or sponge bath. R114 responded, Somewhat important. R114 was asked, What type of bath do you prefer. R114 responded, Shower.Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/12/26 revealed R114 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R114's cognition was intact. R114 had range of motion impairment on both sides of his upper extremities and one side of his lower extremities and required substantial assistance with showering/bathing.Review of the 02/16/26 Activities of Daily Living [ADLs] Care Plan, located in the Care Plan tab of the EMR, revealed, [R114] has a Self-Care ADL [activities of daily living] performance deficit r/t [related to] Disease Process ALS. Interventions, dated 02/16/26 included, but were not limited to, Provide sponge bath when a full bath or shower cannot be tolerated, Bath/shower: resident will be offered bath/shower of choice on scheduled days and prn [as needed], The resident requires substantial/max [maximum][assistance] by (1) staff with bathing/showering as ordered, scheduled and as necessary.Review of the Tasks sheet, located in the Tasks tab of the EMR, revealed between 02/08/26 and 04/01/26, Certified Nurse Aides (CNAs) documented that R114 refused one shower/bed bath and received three partial bed baths, two full bed baths, and three showers.During an interview on 03/30/26 at 2:50 PM, R114 stated, I have been doing bed baths, but they are not as thorough. They use dry shampoo, but it would be nice to have my hair washed. R114 was asked what his preference was for bathing. R114 stated, A shower. I just recently found out they have a gurney shower bed, but they have not let me use it.During an interview on 03/31/26 at 2:30 PM, CNA7 stated, He [R114] has been physically tired and gets worn out. I am not sure why the change [to bed baths]. We do have a gurney for the showers, but they haven't been using it yet. I don't work on his bath days, but I do care for him on the other days. CNA7 was asked if R114 was not getting showers due to staffing issues. CNA7 stated, We are really struggling.During an interview on 04/01/26 at 10:30 AM, the Director of Nursing (DON) stated, If we have an extra aide, we utilize them as a shower aide, but I would love to have a shower aide all the time. I think there is more we can do about that. The DON confirmed that R114 had not been getting his preference of a shower consistently.Review of the facility's policy titled, Resident Rights, dated 02/01/19, revealed, The Resident has a right to make choices about aspects of his or her life in the Facility that are significant to the Resident.

Based on interview, record review, and review of facility policy, the facility failed to develop a care plan related to activities for 1 of 3 residents (Residents (R) 114) reviewed for activities out of a total sample of 33 residents. This failure placed residents at risk for a diminished quality of life.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R114 was admitted to the facility on [DATE] with a diagnosis of amyotrophic lateral sclerosis (ALS-a fatal progressive neurodegenerative disease).Review of the Activities Initial Assessment, dated 02/09/26, located in the Assessments tab of the EMR revealed that R114 enjoyed bingo, social events, being outside, one-to-one visits, movies, using his iPad, and audiobooks.Review of the Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/12/26 revealed R114 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R114 was cognitively intact.Review of the 02/16/26 Comprehensive Care Plan located in the Care Plan tab of the EMR revealed no focus, goal, or interventions/approaches for activities.During an interview on 03/31/26 at 3:14 PM, the Activity Director (AD) stated, There should have been an Activity Care Plan developed. The AD further stated, [R114] still likes to get up in his wheelchair and go to therapy first thing in the morning and come to activities later.Review of the facility policy titled, Care Plans, Comprehensive, Person-Centered, dated 02/01/19 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

Based on observations, interviews, record review, and review of the facility policy, the facility failed to ensure the Comprehensive Care Plan was updated/revised for 3 of 33 sampled residents (Residents (R) 8, R56 and R68). The facility failed to update/revise the Behavior Care Plan to include resident specific interventions/approaches for R8 and R56. In addition, the facility failed to update/revise the care plan related to respiratory services for R68. These failures placed residents at risk for unmet care needs and a diminished quality of life.Findings include: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R8 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, adjustment disorder with mixed disturbance of emotions and conduct (a stress-related condition combining emotional distress (anxiety/depression) with behavioral issues.) Review of the Behavior Care Plan located in the Care Plan tab of the EMR revealed, R8 is demonstrating/has potential for verbally aggressive behaviors AEB [as evidenced by] using inappropriate language, racial slurs directed towards staff, accusatory towards staff, and yelling out r/t cognitive communication deficit, MDD [major depressive disorder], and other psychoactive substance abuse, in remission, revised 11/20/25. Interventions/Approaches included the following: Analyze of [sic] key times, places, circumstances, triggers, and what de-escalates behavior and document, dated 09/18/25. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc., dated 09/18/25. Cares in Pairs, dated 01/12/26. Review of the Comprehensive Care Plan located in the MDS tab of the EMR revealed, R8 is resistive to care AEB refusing medications, refusing brief changes, meds [medications], peri [perineal] care, meals, bathing, or being turned and adjusted r/t [related to] adjustment to nursing home, revised on 02/10/26. Interventions/Approaches included the following:Cares in Pairs, dated 01/12/26.Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care, dated 09/16/25.Encourage as much participation/interaction by the resident as possible during care activities, dated 09/16/25 The Care Plans did not contain resident-specific interventions on how staff were to handle refusals or behaviors for R8. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 03/16/26 revealed R8 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R8 was moderately impaired in cognition. The MDS indicated R8 had verbal behaviors and rejected care one to three days out of seven days during the observation period. Review of a Progress Note, dated 03/27/26, located in the Progress Notes tab of the EMR revealed, Resident refused to be changed with CNA [certified nursing aide] multiple times, Nurse went in and educated resident on importance of being changed. Resident allowed CNA to change her twice throughout the day shift. Resident's urine was strong with a foul odor each time the CNA changed her. Roommate made a complaint to staff of a bad smell coming from resident. Nurse offered Resident a bed bath or shower. Resident refused. Review of an 03/29/26 IDT [interdisciplinary team] Note located in the Progress Notes tab of the EMR revealed, IDT team met to discuss this resident's yelling and cursing on 3/16 and 3/17/26. Will continue to follow the care plan. During an observation on 03/30/26 at 12:43 PM, R8 was observed lying in bed, covered with blankets. She answered some simple questions but did not want to continue the conversation. Her room had an overwhelming lingering body odor smell. During a follow-up observation on 04/01/26 at 10:55 PM, R8 was observed lying in bed covered with blankets. R8 was asked how she was feeling today. She stated, I am just tired. The body odor smell was gone. During an interview on 04/01/26 at 3:37 PM, the Director of Nursing (DON) stated, They [nursing staff] document in the progress notes her refusals, but the interventions/approaches are not in the Care Plan. There have been seven times she has refused psych services, but I see what you are saying, the interventions are not resident-specific. 2. Review of R56's admission Record, located under the Profile tab of the EMR, revealed he was originally admitted to the facility on [DATE] with diagnoses of paraplegia, muscle weakness, major depressive disorder, unspecified mood disorder, and anxiety. Review of R56's Care Plan Report, revealed a focus, revised 03/04/25, that R56 had a self-care activities of daily living (ADL) performance deficit due to activity intolerance and fatigue. Another focus, revised 03/04/25, revealed R56 had alterations in physical mobility due to impaired balance. An intervention was for staff to use a mechanical lift and two staff to transfer R56. A review of R56's annual MDS with an ARD of 03/07/26 and located under the MDS tab of the EMR, revealed R3's BIMS score was 15 out of 15, which indicated R56 had intact cognition. The MDS also indicated R56 was dependent on staff for mobility. During an interview on 04/01/26 at 4:46 PM, CNA9 stated R56 refused to get out of bed. She added he would request to get out of bed; she would get the mechanical lift, then he would change his mind. She stated she would ask again, and he would refuse. During an interview on 04/01/26 at 5:03 PM, CNA2 stated R56 would refuse to get out of bed. She said she referenced the care plan to see what the care needs were for each resident. CNA2 added she would expect the refusals to be care planned as R56 refused to get out of bed quite a bit. During an interview on 04/02/26 at 9:30 AM, the DON stated R56 refused to get out of bed often. She added that it should be care planned and that any nurse could add it to the care plan. 3. Review of R68's admission Record, located under the Profile tab in the EMR, revealed R68 was re-admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), hypertensive heart disease with heart failure, and functional quadriplegia (the complete inability to move due to severe physical disability or frailty, rather than direct brain or spinal cord injury). Review of R68's Care Plan Report, last revised 07/31/25, located under the Care Plan tab of the EMR, revealed a problem of resistive behaviors, [R68] is resistive to care AEB resisting ADL care, medications . wearing oxygen . r/t unspecified sequelae of nontraumatic intracerebral hemorrhage, vascular dementia mild with other behavioral disturbance, depression. The care plan included generalized interventions such as education and negotiating care timing; however, it lacked individualized interventions specific to oxygen refusal. Review of R68's quarterly MDS, with an ARD of 11/10/25, located under the MDS tab of the EMR revealed a BIMS score of seven out of 15, which indicated moderate cognitive impairment. During an observation on 03/31/26 at 9:40 AM, R68 was in bed without the nasal cannula in place. Oxygen was running at two liters per minute via concentrator, with tubing placed approximately one foot away and out of reach. On 03/31/26 at 9:46 AM, Licensed Practical Nurse (LPN) 2 entered the room to administer medications and did not assess for, or reapply, the oxygen. During an interview on 03/31/26 at 10:15 AM, LPN2 stated R68 always removes the nasal cannula and was unable to identify how long the oxygen had been off. During observation on 04/01/26 at 9:18 AM, R68 was observed with the nasal cannula incorrectly positioned, with the prongs next to his nose. R68 acknowledged needing assistance for proper placement. LPN2 agreed to assist but could not state how long the oxygen had been worn improperly. Review of the facility policy titled, Care Plans, Comprehensive, Person-Centered, dated 02/01/19 revealed, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan will: . Incorporate identified problem areas . Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision-making . When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers .

Based on record review and interview, the facility failed to initiate a care plan for heart failure, notify the physician of weight gain experienced in a five day period, follow and document the 1500 milliliter fluid restriction ordered, document why physician orders were not carried out by staff, and document a change in condition for one of one resident (Resident (R) 160) reviewed for congestive heart failure out of a total sample of 33 residents. Despite R160's diagnosis of congestive heart failure, recent six-pound weight gain in five days, and ordered fluid restriction, intravenous (IV) fluids were prescribed without documented reassessment of fluid status, intake/output monitoring, or evidence the order was carried out. These failures had the potential for R160 to experience fluid overload, decompensation, or the risk of rehospitalization.Findings include: Review of R160's admission Record located under the Profile tab in the electronic medical record (EMR) indicated R160 was admitted to the facility 03/21/26 with the diagnosis of NSTEMI (heart attack) and congestive heart failure (CHF) with bilateral pleural effusions. R160 also had a history of atrial fibrillation and chronic kidney disease stage III.Review of R160's hospital Discharge Summary located under the Misc tab in the EMR and dated 03/21/26 indicated that R160 had a thoracentesis [procedure used to remove excess fluid from the space between the lungs and chest wall] which resulted in 1.2 liters (L) of fluid drained from that site on 03/20/26. The discharge orders included for R160 to be on a 1500 milliliter (ml) daily fluid restriction.Review of R160's Social Service Note located under the Progress Note tab in the EMR and dated 03/24/26 at 1:27 PM indicated, BIMS [Brief Interview for Mental Status] completed by speech therapist on 3/23/26 with a score of three out of 15 indicating that this resident presents with severe cognitive impairment .1. Review of R160's admission Assessment located under the Assmnts tab in the EMR and dated 03/21/26 at 5:00 PM indicated that the resident had a primary diagnosis of heart failure for his most recent hospitalization. In response to, Have HF [heart failure] goals for treatment been established? the answer was No. In response to, If no, comments and plan to coordinate? there were no comments documented. Has HF care plan been initiated and reviewed? The answer was No.Review of the Baseline Care Plan provided by the facility, dated 03/23/26, indicated no documentation of CHF or of the 1500 ml fluid restriction.2. Review of R160's admission weight, dated 03/21/26, located under the Wts/Vitals tab in the EMR was documented as being 156 pounds hospital.Review of the Orders tab in the EMR revealed an order for weekly weights, dated 03/22/26. The order did not specify when to notify the provider of weight gain.Review of R160's Weight located under the Wts/Vitals tab in the EMR indicated on 03/26/26 the resident's weight was documented to be 162 pounds, which was a six-pound weight gain from the 156 pounds recorded five days earlier, on 03/21/26.Further review of R160's Progress Note tab in the EMR did not indicate the physician was notified of the six-pound weight gain in five days.During an interview on 03/31/26 at 2:17 PM, LPN3 stated that a six-pound weight gain in five days in a resident with CHF should be reported to the provider. 3. Review of the Orders tab in the EMR revealed an order for the 1500 ml fluid restriction dated 03/21/26 with no breakdown of how much fluid was able to be provided by nursing each shift and by dietary for each meal.Review of R160's Tasks tab of the EMR from 03/21/26 to 03/30/26 revealed the Certified Nursing Aides (CNAs) documented the amount of fluids they provided which R160 consumed each shift. There was no documentation of the fluids the nurses gave the resident during the medication passes. There was also no documentation of R160's output.During an interview on 03/31/26 at 2:45 PM, LPN6 was asked how the 1500 ml fluid restriction was divided between dietary and nursing. LPN6 stated she did not know and pulled up R160's EMR and began to read over the progress notes. LPN6 then stated, It looks like yesterday the dietician wrote that he was to have 1080 by dietary and 480 from nursing.4. Review of a Progress Note written by a provider, dated 03/29/26 at 3:14 PM and located under the Progress Note tab in the EMR, indicated, . patient seen for complaint of diarrhea . he was also receiving Lasix [diuretic medication], so he is likely be dry, he states he doesn't remember having diarrhea, poor historian, but feels fatigue and lethargic and dehydrated, low urine output, dry lips, skin tenting . will rx [prescribe] fluids . Plan: Diarrhea, unspecified type: ongoing diarrhea x 2 days from taking abx [antibiotics] with severe dehydration and fatigue and lethargy, low urinary output rx IV fluids x 3 days. Will continue to monitor urine .Review of the Medication Administration Record (MAR), for March 2026, located under the Orders tab in the EMR, revealed the order for IV fluids, Dextrose Intravenous Solution 5 % (Dextrose) Use 1 liter intravenously one time only for 120/hr [120 ml per hour] . for 1 Day, start date 03/30/26, was pending confirmation. Review of R160's Progress Note tab of the EMR on 03/31/26 did not have documentation of the resident receiving any IV fluids that were ordered. Further review of the nursing progress notes for R160 did not reveal any documentation of why IV fluids were not started as ordered on 03/30/26 nor of the emergency contact being notified of the change in condition to warrant the use of IV fluids.During an interview on 03/31/26 at 2:17 PM, when asked why the provider had ordered the resident to have IV fluids, LPN3 stated, I really don't know. It happened after I left my shift. LPN3 reported R160 did not receive the IV fluids. The nurse told me in report that the resident refused to be stuck for the IV.5. During an observation on 03/30/25 at 12:25 PM, R160 was lying in his bed and could be heard coughing from the hallway. At 12:30 PM, Licensed Practical Nurse (LPN) 3 was observed in R160's room taking his vital signs. The nurse stated that he was not feeling well. LP3 left the room to get a new oximeter, and R160 stated, I have chest pain. Resident appeared to be lethargic and was short of breath with exertion or when talking. LPN3 returned to the room and stated to the resident that his oxygen saturation was 92 percent and that he did not have a temperature. She also stated to the resident that she had called the nurse practitioner, and she would be coming to see him. At 12:40 PM, the nurse practitioner was observed going into the resident's room to assess R160.Review of R160's Progress Note tab in the EMR on 03/31/26 at 9:00 AM revealed there was no documentation in the EMR for the nurses' vital signs that were taken or the reason LPN3 had stated to the resident that the NP would be coming to see him. There was no documentation by the NP of her visit on 03/30/26 at 12:40 PM.During an interview on 03/31/26 at 2:17 PM, LPN3 stated that on 03/30/26, The CNA had told me that [R160] was complaining of having chest pain, so I went into his room. I took his vital signs, and there was nothing alarming about them, so I reported this to the NP. When asked if she had documented the vital signs and report of chest pain in the EMR, LPN3 stated, I may not have. I was probably busy and didn't get to it. But I have 24 hours by state law to get this documented. When asked if a resident complaining of chest pain was considered a change in condition, LPN3 stated yes, but in his case, he has some dementia. LPN3 stated that she gave a detailed verbal report to the next shift of R160's condition. During an interview on 03/31/26 at 3:18 PM, the Director of Nursing (DON) confirmed that a resident having chest pain would be considered a change in condition and that a note should be documented in the chart as soon as possible. The DON also confirmed that the note should reflect what the resident was stating, the vital signs of the resident, the nurse's assessments at that time, the provider being notified, any orders that they may have received and the notification of the emergency contact of the resident. When asked about expectations for a resident with a diagnosis of CHF with a pleural effusion that required a thoracentesis prior to admission who had a six-pound weight gain over five days, the DON stated that the nurses come and tell her when a resident has a weight gain and then it is discussed in the risk meeting on the following Monday. Later in the interview, the DON confirmed that this would be too long to wait and the nurse should notify the physician of the weight gain. The DON also stated that she emphasized to the nursing staff that they needed to document any changes as soon as they occur because if it is not documented it is not done. During an interview on 04/02/26 at 12:50 PM, the NP stated that she assessed R160 on 03/30/26 because the nurse had reported to her that he was having chest pain. The NP explained that R160 did not express to her that he was having chest pain but rather was having abdominal discomfort, and R160's abdomen appeared to be distended. The NP ordered medication for the abdominal discomfort but stated she did not make a note on the assessment due to R160 being seen earlier that day by another provider, and her assessment didn't reveal a lot of difference from that assessment that was performed. The NP stated, looking back, it should have been documented. The NP continued to explain that the on-call provider ordered the IV fluids, and she was not aware of the reasoning of why the IV fluids were ordered. The NP was asked if a resident with a recent weight gain of six pounds over five days with no intervention should be getting IV fluids. She stated, I don't know if the nurses made the provider aware of this or not. I cannot speak to why the provider decided this, but it would be concerning that the IV fluids were ordered to be given. The NP stated she was not aware that a provider had not been notified of the weight gain over a five-day period, that the IV fluids had not been administered when ordered, that the nurses were not recording their intakes, and that outputs were not recorded, but these were important things that should have been taken care of or performed by the staff.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure oxygen and respiratory therapies were administered in accordance with physician orders and professional standards of practice. The facility also failed to ensure staff recognized and intervened when ordered respiratory treatments were not delivered effectively for 2 of 33 sampled residents (Resident (R) 68 and R138). This deficient practice placed residents at risk for low oxygen levels, ineffective treatment, respiratory compromise, infection, and impaired cognition.Findings include:1. Review of R68's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R68 was re-admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), hypertensive heart disease with heart failure, and functional quadriplegia (the complete inability to move due to severe physical disability or frailty, rather than direct brain or spinal cord injury).Review of Physician Orders located in the EMR under the Orders tab revealed R68 had an order for oxygen at four liters per minute continuously, dated 09/16/25.Review of R68's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/10/25, located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated moderate cognitive impairment.Review of R68's Care Plan Report, located under the Care Plan tab of the EMR, revealed a problem of [R68] has oxygen therapy r/t [related to] CHF [congestive heart failure], Respiratory illness - emphysema, COPD, revised on 02/27/26, with an intervention, Oxygen Settings: O2 via nasal prongs as ordered continuously. Humidified, continuously.During an observation on 03/31/26 at 9:40 AM, R68 was observed in bed without the nasal cannula in place. The oxygen concentrator was set at two liters per minute, below the physician-ordered rate of four liters per minute. The oxygen tubing was out of the resident's reach.On 03/31/26 at 9:46 AM, Licensed Practical Nurse (LPN) 2 entered the resident's room to administer medications and did not assess oxygen use, ensure the nasal cannula was in place, or verify the oxygen was being delivered at the ordered rate.During an observation and interview on 03/31/26 at 10:15 AM, LPN2 stated the resident always removes the nasal cannula and was unable to identify how long the oxygen had not been in use. LPN2 confirmed the oxygen flow rate was set at two liters per minute and stated that R68 received oxygen at two liters per minute via nasal cannula continuously. LPN2 then reviewed R68's physicians orders and read aloud that the order was for four liters per minute.During a follow-up observation and interview on 04/01/26 at 9:18 AM, R68 was observed with the nasal cannula improperly positioned. The nasal cannula prongs were placed to the left side of the nose. R68 acknowledged the need for assistance by stating yes. LPN2 agreed to assist but could not state how long the oxygen had been worn improperly.During an interview on 04/01/26 at 1:03 PM, the DON stated that R68 always refused oxygen.2. Review of R138's admission Record, located under the Profile tab in the EMR, revealed R138 was re-admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia and unspecified dementia.Review of Physician Orders, located in the EMR under the Orders tab, indicated R138 was prescribed nebulizer treatments on 07/26/25.Review of R138's Care Plan Report, located under the Care Plan tab of the EMR, revealed a problem of [R138] has COPD, revised on 08/12/25, that included a care plan intervention has history of SOB [shortness of breath] when lying flat, offer pillows/head of bed elevated.Review of R138's quarterly MDS, with an ARD of 01/26/26, located under the MDS tab of the EMR revealed a BIMS score of seven out of 15, which indicated moderate cognitive impairment.During an observation on 04/01/26 at 9:20 AM, R138 was receiving a nebulizer treatment while lying flat on her back in bed. The nebulizer medication chamber and tubing were resting on the resident's chest rather than positioned upright to allow for proper medication delivery. No staff were present to monitor the treatment. With continuous observation of the resident, the nurse did not return to check on the resident and nebulizer treatment until prompted by the surveyor at 10:15 AM.During an observation on 04/01/26 at 10:15 AM, LPN1 turned off the nebulizer, wrapped the tubing around the machine, and placed it in the bedside drawer without cleaning the equipment.During interview on 04/01/26 at 11:30 AM, LPN1 stated the treatment had been initiated at 8:33 AM. The LPN acknowledged the resident should be positioned upright to ensure effective treatment and reduce risks such as impaired secretion clearance, aspiration, and respiratory distress. The LPN further acknowledged that failure to clean nebulizer equipment can lead to bacterial growth and increase the risk of respiratory infection.During interview on 04/02/26 at 9:51 AM, the Respiratory Therapist (RT) stated nurses may administer treatments; however, proper positioning, monitoring during treatment, and cleaning of equipment are necessary to ensure effectiveness and prevent complications. The RT stated failure to clean nebulizer equipment can result in contamination, reduced effectiveness, and increased risk of infections such as pneumonia or bronchitis.Review of the facility's policy titled, Respiratory Therapy Policy - Oxygen Use, dated 08/2024, indicated that respiratory therapists or clinical staff were responsible for ensuring oxygen was administered and delivered per physician's order and that respiratory equipment was properly maintained and sanitized.Review of facility training and competency records revealed nursing staff attended a skills fair that included respiratory therapy components; however, there was no documented evidence of competency validation specific to oxygen administration or nebulizer treatment techniques for LPN1 or LPN2.

Based on observation, record review, interview, and policy review, the facility failed to update physician orders and ensure medication labels accurately reflected the current route of administration of medication when a resident with a feeding tube began taking medications by mouth for 1 of 5 residents (Resident (R) 84) reviewed for medication administration out of a sample of 33 residents. This deficient practice placed the resident at risk for aspiration, ineffective medication delivery, and adverse outcomes related to improper route of administration.Findings include:Review of R84's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R84 admitted to the facility on [DATE] with diagnoses including aphasia following cerebral infarction and gastrostomy status.Review of R84's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/01/26, located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated severe cognitive impairment. Review of the Medication Administration Record (MAR), dated 03/01/26 to 03/30/26, located under the Orders tab in the EMR, revealed that R84 had twelve medications scheduled to be administered by mouth and three medications scheduled to be administered by gastrostomy tube (G-tube). The three medications scheduled to be administered by G-tube included: docusate sodium (stool softener) 100 milligrams (mg) daily, hydralazine HCl (blood pressure medication) 100 mg twice daily, and atorvastatin (cholesterol lowering medication) 80 mg at bedtime. In addition, G-tube flushes were scheduled twice daily.During an observation on 03/31/26 at 10:07 AM, Licensed Practical Nurse (LPN) 2 administered medications to include the docusate sodium and hydralazine to R84 by mouth, mixed in pudding. The medication labels for the docusate sodium and hydralazine were observed to reflect the route of administration to be via G-tube.During an interview on 03/31/26 at 10:11 AM, LPN2 confirmed the physician orders and medication labels indicated administration via G-tube. LPN2 acknowledged administering the medications by mouth and stated that the R84 did not receive anything by G-tube. The G-tube was only flushed for patency. LPN2 stated nursing staff were responsible for ensuring medication orders and labels reflected the correct route of administration and for obtaining clarification from the physician when discrepancies were identified.During an interview on 04/01/26 at 1:07 PM, the Licensed Practical Nurse Unit Manager (LPNUM) 1 indicated that she was unaware that R84's medication orders and labels were inconsistent. LPNUM1 said that the nurses were responsible for following the medication rights when administering medications. LPNUM1 said that safe medication administration was ensured by validating orders before administration by checking the orders against the labels. LPNUM1 said that a pharmacy consultant conducted cart audits for compliance; however, she was also responsible to periodically ensure medications were labeled and managed in a manner that supported safe administration.Review of the facility's policy titled, Liberalized Medication Administration - Policy & Procedure, dated 02/2023, indicated that nursing staff are required to follow the Five Rights of Medication Administration, including the right route, when administering medications.Review of the facility's policy titled, Storage of Medications dated 02/01/19, indicated that medications with missing, incomplete, or incorrect labels must be returned to the pharmacy for proper labeling prior to use.

Based on interview, clinical record review, and document review, the facility failed to protect a resident's right to a dignified existence without discrimination when a resident-to-resident verbal altercation involved the use of racial slurs for 1 of 11 sampled residents (Resident #11). This deficient practice had the potential to result in psychosocial harm. Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of bipolar disorder, unspecified. Resident #10's care plan included a focus initiated on 12/05/2024, documenting Resident #10 demonstrated a potential for verbally aggressive behaviors as evidenced by yelling out related to a cognitive communication deficit and bipolar disorder. A nursing narrative note, dated 05/28/2025, documented Resident #10 walked past another resident's room. The other resident was on the phone and yelled at Resident #10 to get away. Resident #10 yelled out a racial slur. The Nurse spoke with the other resident who confirmed the incident and verbalized doing their best to stay away from Resident #10, but Resident #10 kept coming back. The residents had a history involving the police. A communication note dated 05/29/2025, documented the Licensed Master Social Worker met with Resident #10 regarding the resident-to-resident interaction the previous day. They discussed the resident's ability to distance themselves from other people the resident may have a negative interaction with. Resident #11 Resident #11 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit and anxiety disorder, unspecified. Resident #11's care plan with a focus initiated on 04/28/2024, and last revised on 04/03/2025, documented Resident #11 was at risk for adverse consequences of post-traumatic stress disorder related to a history of abuse and racial trauma. The care plan was not updated after the 05/28/2025 incident. A communication note dated 05/29/2025, documented the Licensed Master Social Worker met with Resident #11 regarding the resident-to-resident interaction the previous day. They discussed the resident's ability to distance themselves from other people the resident may have a negative interaction with. Resident #11's clinical record lacked any other documentation related to the incident occurring on 05/28/2025. On 06/11/2025 at 1:59 PM, Resident #10 verbalized a few weeks prior, Resident #11 approached Resident #10 and called Resident #10 derogatory names. Resident #10 yelled racial slurs in return. On 06/11/2025 at 2:05 PM, Resident #11 verbalized Resident #10 walked by Resident #11's room, stopped in the doorway and used racial profanity. The facility then asked Resident #11 to move rooms and requested the residents stay away from one-another. On 06/11/2025 at 3:34 PM, a Certified Nursing Assistant (CNA) explained staff could view resident care plans to ascertain if resident needs changed and what actions staff were expected to take. The CNA explained Resident #10 had a history of yelling profanity. The CNA was unaware of any altercation between Residents #10 and #11. On 06/11/2025 at 3:43 PM, a Licensed Practical Nurse (LPN) verbalized two weeks prior Resident #11 was on the phone in the resident's room. Resident #10 stopped in Resident #11's doorway and used racial slurs toward Resident #11. The LPN explained the LPN was at the end of another hallway, heard the altercation, and was able to get to the residents quickly. Since the incident, Resident #11 began avoiding Resident #10. On 06/11/2025 at 6:32 PM, the Abuse Coordinator/Director of Nursing AC/DON confirmed the incident and verbalized using racial slurs would be considered racially abusive language, bullying and harassment. The AC/DON confirmed racism was a pervasive issue in the facility and verbalized in healthcare, racially discriminatory behavior was normalized. The AC/DON explained the facility could have offered talk therapy, reached out to Behavioral Health Services for additional interventions, and implemented care plans related to racial discrimination. The facility policy, titled Non-Discrimination, adopted 02/01/2019, documented the facility did not permit discrimination, bullying, abuse, or harassment on the basis of actual or perceived race. Discrimination of any form, including ethnic slurs would be promptly reported to the Administrator. The facility policy, titled Resident Rights, adopted 02/01/2019, documented residents had the right to be treated with respect and dignity. Cross reference with F610 and F657.

Based on interview, clinical record review, and document review, the facility failed to ensure an allegation of verbal abuse was investigated and reported to the State Agency (SA) for 1 of 11 sampled residents (Resident #11). This deficient practice had the potential to result in psychosocial harm due to allegations of abuse not being thoroughly investigated and protections not put in place to prevent future abuse. Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of bipolar disorder, unspecified. Resident #10's care plan included a focus initiated on 12/05/2024, documenting Resident #10 demonstrated a potential for verbally aggressive behaviors as evidenced by yelling out related to a cognitive communication deficit and bipolar disorder. A nursing narrative note, dated 05/28/2025, documented Resident #10 walked past another resident's room. The other resident was on the phone and yelled at Resident #10 to get away. Resident #10 yelled out a racial slur. The Nurse spoke with the other resident who confirmed the incident and verbalized doing their best to stay away from Resident #10, but Resident #10 kept coming back. The residents had a history involving the police. A communication note dated 05/29/2025, documented the Licensed Master Social Worker met with Resident #10 regarding the resident-to-resident interaction the previous day. They discussed the resident's ability to distance themselves from other people the resident may have a negative interaction with. Resident #11 Resident #11 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit and anxiety disorder, unspecified. Resident #11's care plan with a focus initiated on 04/28/2024, and last revised on 04/03/2025, documented Resident #11 was at risk for adverse consequences of post-traumatic stress disorder related to a history of abuse and racial trauma. The care plan was not updated after the 05/28/2025 incident. A communication note dated 05/29/2025, documented the Licensed Master Social Worker met with Resident #11 regarding the resident-to-resident interaction the previous day. They discussed the resident's ability to distance themselves from other people the resident may have a negative interaction with. Resident #11's clinical record lacked any other documentation related to the incident occurring on 05/28/2025. On 06/11/2025 at 1:59 PM, Resident #10 verbalized a few weeks prior, Resident #11 approached Resident #10 and called resident #10 derogatory names. Resident #10 yelled racial slurs in return. On 06/11/2025 at 2:05 PM, Resident #11 verbalized Resident #10 walked by Resident #11's room, stopped in the doorway and used racial profanity. The facility then asked Resident #11 to move rooms and requested the residents stay away from one-another. On 06/11/2025 at 3:43 PM, a Licensed Practical Nurse (LPN) verbalized two weeks prior Resident #11 was on the phone in the resident's room. Resident #10 stopped in Resident #11's doorway and used racial slurs toward Resident #11. The LPN explained the LPN was at the end of another hallway, heard the altercation, and was able to get to the residents quickly. Resident #11 has since been avoiding Resident #10. On 06/11/2025 at 5:55 PM the Abuse Coordinator who is the Director of Nursing (AC/DON) explained verbal abuse occurred when someone attacked or said something to make another person upset, particularly if the victim of the verbal abuse was vulnerable. The AC/DON verbalized it would not immediately be considered abuse if a staff member informed the AC/DON a resident raised their voice at another resident. The AC/DON verbalized the incident occurred in the hallway outside Resident #11's room. The two residents were yelling at one-another and the LPN on duty heard the commotion. The AC/DON explained because it was just a verbal altercation the facility did not do an official investigation, submit a Facility Reported Incident (FRI) report, nor make any notifications to the Ombudsman, the residents' families, or the Medical Director. On 06/11/2025 at 6:32 PM, the AC/DON explained a FRI investigation was to be completed within two hours of the facility being made aware. The AC/DON verbalized using racial slurs would be considered racially abusive language, bullying and harassment. The AC/DON confirmed racism was a pervasive issue in the facility and verbalized in healthcare, racially discriminatory behavior was normalized. The AC/DON explained when the AC/DON was informed of the incident on 05/28/2025, the AC/DON interviewed the LPN and determined the incident was not abuse. The AC/DON confirmed the verbal conversation with the LPN was not documented anywhere. The AC/DON verbalized there were multiple resident rooms between where the incident occurred and where LPN heard the incident down the hallway. The AC/DON did not speak with the residents involved, nor any other residents who may have heard. On 05/29/2025, one day after the incident, the Licensed Master Social Worker interviewed the residents and completed a trauma screening. There was no further investigation into the incident. The facility policy, titled Abuse Investigation and Reporting, adopted 02/01/2019, documented investigations into suspected abuse would include review of the resident's medical record and interviews with the reporter of the alleged abuse, witnesses, any involved residents, the physician, and the resident's family members. Notification would be made to the SA, the Ombudsman, the resident's representative, adult protective services, law enforcement, the resident's physician, and the Medical Director. All allegations of abuse would be reported no later than two hours. Cross reference with F550 and F657.

Based on interview, clinical record review, and document review, the facility failed to ensure a resident with a history of nicotine dependence had a care plan to address the resident's stated plans to continue smoking for 1 of 11 sampled residents (Resident #2). This deficient practice had the potential to result in facility staff being unaware of a resident's behavior and stated desire to continue smoking while wearing oxygen with the potential for the resident to suffer severe harm or death from burns as the result of smoking with oxygen in use from lack of care planned interventions to prevent adverse outcomes associated with the behavior. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including nicotine dependence, cigarettes, uncomplicated and chronic obstructive pulmonary disease, unspecified. A Facility Reported Incident (FRI), dated 06/06/2025, documented the resident's wheelchair was on fire in the facility parking lot and the resident was on the ground next to the wheelchair. The resident had black and red discoloration to the skin of the resident's upper legs, abdomen, nostrils, and hands. The resident was crying and verbalizing pain all over. The resident was transported to the hospital via ambulance. A Physician's Order, dated 04/21/2025, documented oxygen administered via nasal cannula at 2 liters per minute as needed. A Behavior Note, dated 04/28/2025, documented the resident had stated the resident would take the oxygen to go outside but it would be the facility's fault if the resident blows up. The resident planned to go outside to smoke. The resident's need for oxygen was reviewed and the resident became more upset. A Communication Note, dated 05/07/2025, documented the resident had stated the resident did not understand why others were able to smoke but the resident was not able to smoke. The dangers of smoking with oxygen were discussed with the resident. A Nursing Narrative Note, dated 05/13/2025, documented the resident became verbally aggressive when the resident was told the resident was on isolation when the resident wanted to go outside for a cigarette. The resident stated the resident would smoke in the resident's bathroom. A Mental Health Exam, dated 05/31/2025, documented the resident was frustrated because the resident had not smoked in two days. A Medication Order, dated 06/01/2025, documented nicotine transdermal patch, apply 14 milligrams transdermal one time a day to try to quit smoking. A provider's Progress Note, dated 06/04/2025, documented the resident was outside with smokers and was attempting to bum a smoke. The Care Plan for Resident #2 did not include a care plan related to the resident's risk factors of continuing to smoke while wearing oxygen. On 06/11/2025 at 11:58 AM, a Registered Nurse (RN) verbalized the resident had been told not to smoke on the facility property, but the RN was aware the resident had been seen smoking on property prior to the incident on 06/06/2025. The RN explained the RN had spoken to the resident on 06/05/2025 about the importance of quitting smoking. The RN verbalized the RN did not know if the resident's history of smoking on facility property would be care planned. On 06/11/2025 at 12:13 PM, the Director of Nursing (DON) verbalized the DON assumed the resident had been smoking while wearing oxygen on 06/06/2025, causing the fire and injuries to the resident. On 06/11/2025 at 1:51 PM, the DON verbalized the resident's history of smoking and risk factors associated with smoking while wearing oxygen could have been care planned. The facility policy titled Care Plan, Comprehensive Person-Centered, adopted 02/01/2019, documented the care plan would incorporate identified problem areas and their causes and develop targeted and meaningful interventions for the resident. FRI #NV00074424

Based on interview, clinical record review, and document review, the facility failed to ensure resident care plans were updated after a resident-to-resident altercation for 2 of 11 sampled residents (Residents #10 and #11). This deficient practice has the potential to result in a resident not receiving care and services to meet their needs and prevent further altercations and psychosocial harm. Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of bipolar disorder, unspecified. A nursing narrative note, dated 05/28/2025, documented Resident #10 walked past another resident's room. The other resident was on the phone and yelled at Resident #10 to get away. Resident #10 yelled out a racial slur. The Nurse spoke with the other resident who confirmed the incident and verbalized doing their best to stay away from Resident #10, but Resident #10 kept coming back. The residents had a history involving the police. A communication note dated 05/29/2025, documented the Licensed Master Social Worker met with Resident #10 regarding the resident-to-resident interaction the previous day. They discussed the resident's ability to distance themselves from other people the resident may have a negative interaction with. Resident #10's care plan included a focus initiated on 12/05/2024, documenting Resident #10 demonstrated a potential for verbally aggressive behaviors as evidenced by yelling out related to a cognitive communication deficit and bipolar disorder. Resident #10's care plan lacked a revision on or after 05/28/2025 regarding the resident-to-resident altercation involving the use of a racial slur. Resident #11 Resident #11 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit and anxiety disorder, unspecified. A communication note dated 05/29/2025, documented the Licensed Master Social Worker met with Resident #11 regarding the resident-to-resident interaction the previous day. They discussed the resident's ability to distance themselves from other people the resident may have a negative interaction with. Resident #11's care plan with a focus initiated on 04/28/2024, and last revised on 04/03/2025, documented Resident #11 was at risk for adverse consequences of post-traumatic stress disorder related to a history of abuse and racial trauma. The care plan was not updated after the 05/28/2025 incident. Resident #11's care plan lacked a revision on or after 05/28/2025 regarding the resident-to-resident altercation involving the use of a racial slur. Resident #11's clinical record lacked any other documentation related to the incident occurring on 05/28/2025. On 06/11/2025 at 1:59 PM, Resident #10 verbalized a few weeks prior, Resident #11 approached Resident #10 and called resident #10 derogatory names. Resident #10 yelled racial slurs in return. On 06/11/2025 at 2:05 PM, Resident #11 verbalized Resident #10 walked by Resident #11's room, stopped in the doorway and used racial profanity. The facility then asked Resident #11 to move rooms and requested the residents stay away from one-another. On 06/11/2025 at 3:34 PM, a Certified Nursing Assistant (CNA) explained staff could view resident care plans to ascertain if resident needs changed and what actions staff were expected to take. The CNA explained Resident #10 had a history of yelling profanity. The CNA was unaware of any altercation between Residents #10 and #11. On 06/11/2025 at 3:43 PM, a Licensed Practical Nurse (LPN) verbalized two weeks prior, Resident #11 was on the phone in the resident's room. Resident #10 stopped in Resident #11's doorway and used racial slurs toward Resident #11. The LPN explained the LPN was at the end of another hallway, heard the altercation, and reached the residents quickly. After the altercation, Resident #11 avoided Resident #10. The LPN verbalized being unaware of any new interventions implemented after the altercation. On 06/11/2025 at 6:32 PM, the AC/DON verbalized care plans allowed staff to communicate resident needs and prevent accidents from occurring or recurring. The AC/DON verbalized care plans should be updated to document racial trauma and behavior related to racial discrimination. The AC/DON was unsure if Resident #10 or #11's care plans were updated after the 05/28/2025 incident. The facility policy titled Care Plan, Comprehensive Person-Centered, adopted 02/01/2019, documented the care plan would incorporate identified problem areas and their causes and develop targeted and meaningful interventions for the resident. Cross reference with F550 and F610.

Based on interview, clinical record review, and document review, the facility failed to ensure a resident with a history of nicotine dependence and stated plans to continue smoking was adequately supervised to prevent the resident from experiencing a preventable accident while smoking with oxygen in place for 1 of 11 sampled residents (Resident #2) and two residents were not near Resident #2 while the resident was smoking with oxygen in place (Resident #3 and #4). This deficient practice had the potential to result in residents suffering burns causing severe pain and a decline in quality of life. Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including multiple sclerosis, muscle weakness (generalized), and chronic obstructive pulmonary disease, unspecified. Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified and pain, unspecified. Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including nicotine dependence, cigarettes, uncomplicated and chronic obstructive pulmonary disease, unspecified. A Facility Reported Incident (FRI), dated 06/06/2025, documented the resident's wheelchair was on fire in the facility parking lot and the resident was on the ground next to the wheelchair. The resident had black and red discoloration to the skin of the resident's upper legs, abdomen, nostrils, and hands. The resident was crying and verbalizing pain all over. The resident was transported to the hospital via ambulance. A Physician's Order, dated 04/21/2025, documented oxygen administered via nasal cannula at 2 liters per minute as needed. A Behavior Note, dated 04/28/2025, documented the resident had stated the resident would take the oxygen to go outside but it would be the facility's fault if the resident blows up. The resident planned to go outside to smoke. The resident's need for oxygen was reviewed and the resident became more upset. A Communication Note, dated 05/07/2025, documented the resident had stated the resident did not understand why others were able to smoke but the resident was not able to smoke. The dangers of smoking with oxygen were discussed with the resident. A Nursing Narrative Note, dated 05/13/2025, documented the resident became verbally aggressive when the resident was told the resident was on isolation when the resident wanted to go outside for a cigarette. The resident stated the resident would smoke in the resident's bathroom. A Mental Health Exam, dated 05/31/2025, documented the resident was frustrated because the resident had not smoked in two days. A Medication Order, dated 06/01/2025, documented nicotine transdermal patch, apply 14 milligrams transdermal one time a day to try to quit smoking. A provider's Progress Note, dated 06/04/2025, documented the resident was outside with smokers and was attempting to bum a smoke. The Care Plan for Resident #2 did not include a care plan related to the resident's risk factors of continuing to smoke while wearing oxygen. On 06/11/2025 at 11:58 AM, a Registered Nurse (RN) verbalized the resident had been told not to smoke on the facility property, but the RN was aware the resident had been seen smoking on property prior to the incident on 06/06/2025. The RN explained the RN had spoken to the resident on 06/05/2025 about the importance of quitting smoking. The RN verbalized the RN did not know if the resident's history of smoking on facility property would be care planned. On 06/11/2025 at 12:13 PM, the Director of Nursing (DON) verbalized the DON assumed the resident had been smoking while wearing oxygen on 06/06/2025, causing the fire and injuries to the resident. On 06/11/2025 at 12:36 PM, Resident #3 verbalized the resident had heard staff tell Resident #2 not to smoke many times, but the resident was regularly smoking in the parking lot. Resident #3 explained on 06/06/2025, Resident #2 was smoking in the parking lot and then the oxygen hose was on fire. Resident #3 saw Resident #4 get Resident #2 out of the resident's wheelchair and Resident #4 told Resident #3 to go get help. On 06/11/2025 at 12:41 PM, Resident #4 verbalized on 06/06/2025, Resident #2 was in the parking lot and attempted to light a cigarette. The resident explained everything was on fire. The resident verbalized the resident pulled Resident #2 out of the resident's wheelchair because the wheelchair was on fire and the resident wanted the oxygen tank attached to the wheelchair to be farther away from the residents. The resident explained the resident had seen Resident #2 smoking in the parking lot many times while wearing oxygen and had informed the office staff. On 06/11/2025 at 1:51 PM, the DON verbalized the resident's history of smoking and risk factors associated with smoking while wearing oxygen could have been care planned. The facility policy titled Care Plan, Comprehensive Person-Centered, adopted 02/01/2019, documented the care plan would incorporate identified problem areas and their causes and develop targeted and meaningful interventions for the resident. The facility policy titled Respiratory Therapy Policy - Oxygen Use, written 08/2024, documented clinical staff would ensure applicable precautions would be observed at all times. The facility policy titled Smoking Policy - Residents and Employees, adopted 03/2022, documented the facility was a smokefree environment, prohibiting smoking in all indoor and outdoor areas by residents. Residents refusing to follow safe smoking practices would be issued a 30-day notice for being a danger to self or others. FRI #NV00074424

Based on observation, interview, clinical record review and document review, the facility failed to ensure a comfortable ambient air temperature was provided to residents (Resident #59, #19, #76, #30, #123, #104, #1, #2, #106, and #41) using the communal shower rooms in 3 of 3 facility shower rooms with temperatures of 62.1 degrees Fahrenheit (F), 62.4 F, and 67.6 F. This deficient practice had the potential to cause residents widespread discomfort before, during and after showers. Findings include: Resident #59 Resident #59 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including need for assistance with personal care and polyneuropathy, unspecified. On 01/07/2025 at 8:03 AM, Resident #59 verbalized it was a little chilly in the shower room and it was not very comfortable. Resident #19 Resident #19 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including need for assistance with personal care and chronic obstructive pulmonary disease, unspecified. On 01/07/2025 at 8:07 AM, Resident #19 verbalized the resident had started showering in the sink in the resident's room because the shower room was not warm enough. Resident #76 Resident #76 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including need for assistance with personal care and unspecified sequelae of cerebral infarction. On 01/07/2025 at 8:11 AM, Resident #76 verbalized the shower room was always cold, and the resident would refuse to take a shower some days because the shower room was freezing. On 01/07/2025 at 8:53 AM, a Certified Nursing Assistant (CNA) verbalized residents had complained to the CNA about the shower room being too cold and the CNA had informed Maintenance. On 01/07/2025 at 8:55 AM, a Registered Nurse (RN) verbalized residents had told the RN the residents did not like the shower room because it was not warm enough. On 01/07/2025 at 8:57 AM, an LPN verbalized when residents complained about the temperature in the shower room the complaint was passed on to Maintenance. The LPN verbalized the LPN agreed with the resident complaints of the room being too cold and felt the shower rooms were chilly. 49557 Resident #30 Resident #30 was admitted to the facility on [DATE], with diagnoses including unspecified mononeuropathy of bilateral lower limbs and primary generalized osteoarthritis. On 01/07/2025 at 8:12 AM, Resident #30 verbalized Resident #30 had taken one shower since admission to the facility and had refused any more showers because the shower room was freezing. Resident #123 Resident #123 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unstable burst fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing and paraplegia, unspecified. On 01/07/2025 at 8:21 AM, Resident #123 verbalized the resident's last shower was approximately two weeks prior and the shower room was cold. 31739 Resident #104 Resident #104 was admitted to the facility on [DATE], with diagnoses including fracture of one rib, left side, subsequent encounter for fracture with routine healing, unspecified fracture of unspecified pubis, subsequent encounter for fracture with routine healing, difficulty walking, and muscle weakness. On 01/07/2025 at 8:07 AM, Resident #104 verbalized having used the shower room and the room temperature felt cold. The resident verbalized not liking when it was cold, and it should have been warmer. Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including paraplegia, unspecified, neuralgia and neuritis, unspecified, difficulty walking, and muscle weakness. On 01/07/2025 at 8:15 AM, Resident #1 verbalized having used the shower room and felt the room was cold resulting in the resident feeling uncomfortable. 43311 Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including metabolic encephalopathy and type two diabetes mellitus with diabetic nephropathy. On 01/06/2025 at 9:02 AM, Resident #2 explained the resident had complained of cold temperatures in the shower room since admission. The resident explained the resident had to decide to either shower and freeze or to not take a shower at all. The resident communicated the resident felt the resident had to suffer through the shower when the room did not feel as though there was any heat. Resident #2 expressed feeling dehumanized when the shower room was too cold for a shower. Resident #106 Resident #106 was admitted to the facility on [DATE], with diagnoses including non-Hodgkin lymphoma, unspecified, unspecified site, and muscle weakness, generalized. On 01/07/2025 at 8:08 AM, Resident #106 communicated the shower room was too cold and the resident hated the idea of going into the shower rooms. Resident #14 Resident #14 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including polyneuropathy, unspecified, other abnormalities of gait and mobility, and need for assistance with personal care. On 01/07/2025 at 8:13 AM, Resident #14 verbalized the shower room was freezing and not acceptable. Resident #14 verbalized reporting the cold shower room temperature to staff and the resident felt staff had not addressed the resident's concern as the resident felt the shower room was still too cold. Resident #14 explained the resident did not take showers in the shower rooms because of the cold ambient temperature and instead performed personal hygiene in the bathroom sink. Resident #41 Resident #41 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including polyneuropathy, unspecified, unspecified sequelae of cerebral infarction, other abnormalities of gait and mobility, and need for assistance with personal care. On 01/07/2025 at 8:14 AM, Resident #41 communicated the resident felt the shower room temperatures were too cold to use for a shower. On 01/07/2025, the following ambient temperatures were taken in each facility unit shower room with Maintenance staff present to confirm findings: -7:29 AM Boundary Peak communal shower room: 62.1 F -7:37 AM [NAME] communal shower room: 62.4 F -8:52 AM [NAME] Peak communal shower room: 67.6 F On 01/07/2025 at 7:38 AM, the Maintenance Director confirmed a shower room temperature of 62.1 to 62.4 degrees F was chilly and would not like to take a shower in those temperatures. The Maintenance Director verbalized the Maintenance Director had thought the shower room ambient temperatures were fixed when the heaters were replaced last year. On 01/07/2025 at 8:53 AM, the Engineering Manager confirmed the ambient temperature of the shower rooms were too cold. The Engineering Manager explained the Engineering Manager would not want to take a shower in a cold shower room. On 01/07/2025 at 9:01 AM, a Licensed Practical Nurse (LPN) communicated the ambient temperatures in the shower rooms were too cold for showers. On 01/07/2025 at 9:14 AM, the Administrator explained the Administrator was unaware of the shower room ambient temperatures registering so low and the Administrator would not feel comfortable taking a shower in a room at the same temperatures. The Administrator confirmed the Director of Engineering was responsible for facility maintenance oversight. On 01/07/25 at 9:58 AM, the Owner explained the Owner was aware of the low ambient temperatures in the shower rooms and resident complaints regarding the shower room temperatures. The Owner explained the facility had been waiting for the vendor to show up after being closed for two weeks over the holidays. The Owner confirmed Maintenance did not measure the temperatures in the shower rooms. The Owner explained the facility had tried raising the heat temperatures universally within the facility and it heated up the hallways but the shower rooms had remained cold. On 01/07/2025 at 10:41 AM, six out of seven Resident Council attendees communicated the residents felt the unit shower rooms were too cold for showering. On 01/07/2025 at 12:14 PM, the Director of Engineering explained becoming aware the thermostat was not identifying proper temperatures on 12/19/2024. The Director of Engineering verbalized the Director of Engineering had called a repair company and thought the issue was fixed. The Director of Engineering verbalized Maintenance staff had not communicated the continued issue with low ambient temperatures in the shower rooms to the Director of Engineering. A facility policy titled Resident Rights, adopted 02/01/2019, documented federal and state laws guaranteed certain basic rights to all facility residents. The resident had a right to a safe, clean, comfortable, and homelike environment, including receiving treatment and support for daily living safely. A facility policy titled Quality of Life-Homelike Environment, adopted 02/01/2019, documented residents would be provided with a safe, clean, comfortable and homelike environment. The facility staff and management would maximize the characteristics of the facility to reflect a personalized, homelike setting to include comfortable and safe temperatures (71 degrees F to 81 degrees F). A facility policy titled Maintenance Service, adopted 02/01/2019, documented maintenance service would be provided to all areas of the building, grounds, and equipment. Maintenance personnel functions included maintaining the heat/cooling system, plumbing fixtures, and wiring in good working order.

Based on observation and interview, the facility failed to ensure expired medications were removed from 2 of 3 medication storage rooms, and a wound care cart containing potentially hazardous opened treatment items remained secured. The opened items in the unsecured wound care cart had the potential to be available to resident's in and around the 400 Hall and the 400 Hall nurses' station. Findings include: Expired Medication On 01/09/2025 at 7:59 AM, the following expired medications were located in the [NAME] medication storage room: -Geri Care Iron Liquid Supplement, one 16 ounce (oz) bottle, expired 12/2024. -Tubersol tuberculin purified protein derivative five tub (T) unit (U) per 0.1 milliliters vial, three vials, all vials opened and unmarked with a date of opening. On 01/09/2025 at 8:03 AM, the Unit Manager (UM) confirmed the Iron Liquid Supplement had expired 12/2024. The UM also confirmed none of the three vials of Tubersol were marked with a date of opening and would be considered expired as there was no way of knowing how long the vials had been opened. The UM verbalized a multi-unit dose vial would be considered expired 30 days after the date of opening. On 01/09/2025 at 11:26 AM, one 16 oz bottle of Iron Liquid Supplement was located in the Boundary Peak medication storage room and had an expiration date of 12/2024. On 01/09/2025 at 11:30 AM, the Director of Nursing (DON) confirmed the bottle of Iron Liquid Supplement had expired 12/2024. The DON verbalized the consequences of taking an expired medication was the medication may cause an adverse reaction or not be as effective for treatment. The facility policy titled Storage of Medication, adopted 02/01/19, documented the facility did not use outdated drugs or biologicals. All outdated drugs were returned to the pharmacy or destroyed. 31739 Wound Care Cart On 01/05/2025 at 10:20 AM, a wound care cart located next to the nurses' station near the 400 Hall was unlocked. The nurses' station was unattended and there were no residents visibly in the area. The following opened items were located in the cart: -16-ounce bottle of Patrin Pharma H-Chlor 12 (sodium hypochlorite), 0.125 percent (%) solution, located in the second drawer. The bottle's label documented for topical use only, if swallowed contact poison control immediately. -50-gram jar of Dr. Reddy's SSD Silver Sulfadiazine 1% topical cream, located in the top drawer. The jar's label documented for topical use only, not for ophthalmic use. -100-gram tube of Cipla diclofenac sodium topical gel 1%, located in the top drawer. The tube's label documented for topical use only, not for ophthalmic use. On 01/05/2025 at 10:22 AM, the Licensed Practical Nurse (LPN) administering medications on the 400 Hall, confirmed the cart was unlocked and contained the opened items listed above. The LPN confirmed the items could have possibly been hazardous to a resident if consumed. The LPN verbalized the LPN did not have a key to the cart and the cart had been left opened as the LPN had scheduled wound care treatments to administer later in the day. The LPN confirmed the cart should have been locked and locked the cart. On 01/05/2025 at 11:32 AM, the Administrator verbalized additional keys of the wound care cart were made approximately two weeks previous, and all nursing staff were provided a key, including the LPN administering medications on the 400 Hall, to ensure the wound care cart remained locked when not in use. The facility policy titled, Storage of Medication, adopted 02/01/2019, documented nursing staff would be responsible for maintaining medication storage, carts would be locked when not in use, and carts shall not be left unattended if opened or otherwise potentially available to others.

Based on observation, interview, and document review, the facility failed to ensure the facility's electronic health record was not left open and accessible on a computer attached to a medication cart with a resident's identifiers and medication administration record visible while staff were not in attendance or sight of the cart for 1 of 21 residents residing on the 800 hall (Resident #15). This deficient practice had the potential to result in a resident's confidential information being accessed by unauthorized individuals including other residents or visitors without the resident's permission. Findings include: Resident #15 Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including major depressive disorder, recurrent, moderate and bipolar disorder, unspecified. On 01/06/2025 at 8:58 AM, a computer located on top of a medication cart on the 800-hall had information for Resident #15 including the resident's name, picture, and current medications with associated diagnoses visible. There was not a staff member in front of the cart or visible from the cart. On 01/06/2025 at 9:00 AM, a Certified Nursing Assistant (CNA) walked by the cart and verbalized the Registered Nurse (RN) was attending to a resident on the 600 hall. The RN came from the direction of the 600 hall and confirmed the RN had left the resident information visible on the computer when the RN had walked away from the medication cart. The RN verbalized the RN should have ensured the resident information was not visible when the RN had walked away from the medication cart. On 01/09/2025 at 10:53 AM, the Director of Nursing (DON) verbalized resident's personal information and medical records were private and should not have been visible on an unattended computer. The DON verbalized when records were left open and unattended the records could be accessed by others and staff were responsible for ensuring the resident's electronic health record was not accessible to unauthorized individuals. The facility policy titled Protected Health Information (PHI), Management and Protection of, adopted 02/01/2019, documented PHI would not be used or disclosed except as permitted by current federal and state laws. It was the responsibility of all personnel who had access to resident information to ensure such information was managed and protected to prevent unauthorized disclosure.

Based on observation, interview, clinical record review, and document review the facility failed to ensure a care plan was developed related to the care of a Foley catheter for 1 of 28 sampled residents (Resident #123). This deficient practice had the potential to result in residents not receiving care and services to meet their needs related to indwelling devices. Findings include: Resident #123 Resident #123 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unstable burst fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing and paraplegia, unspecified. On 01/06/2025 at 8:30 AM, Resident #123 had a Foley catheter in place. The drainage bag was secured to the bed frame, and clear yellow urine was in the bag. The resident verbalized the resident believed the drainage bag was not emptied often enough. A Minimum Data Set 3.0 (MDS) admission assessment, completed 11/06/2024, documented Resident #123 had an indwelling catheter. An MDS significant change in status assessment, completed 12/26/2024, documented Resident #123 had an indwelling catheter. On 01/07/2025 at 3:23 PM, during a review of Resident #123's Care Plan, the Care Plan included a focus area of enhanced barrier precautions related to catheter. Interventions included assessing the resident's comorbidities quarterly and as needed and enhanced barrier precautions per facility policy. The date initiated for the focus area and the interventions was 10/30/2024. The Care Plan lacked any other focus area, goals, or interventions related to care of the resident's catheter. On 01/09/2025 at 8:30 AM, a Licensed Practical Nurse (LPN) verbalized a Care Plan for a resident with a Foley catheter should include monitoring for signs and symptoms of infection, cleaning of the insertion site, assuring a privacy cover was in place over the drainage bag, keeping the drainage bag below the level of the bladder, and changing of the catheter. On 01/09/2025 at 1:42 PM, the Director of Nursing (DON) verbalized a Care Plan for a resident with a Foley catheter should include checking for kinks in the tubing, keeping the drainage bag off the floor, cleaning the catheter every shift, positioning the drainage bag below the level of the bladder, and observing for signs and symptoms of a urinary tract infection. The DON confirmed Resident #123 had a Foley catheter in place and a Care Plan should have been developed related to care of the resident's catheter. The DON reviewed Resident #123's Care Plan and verbalized a focus area related to care of the resident's catheter was added on 01/07/2024. On 01/09/2025 at 2:48 PM, the Regional MDS Nurse verbalized a Care Plan related to care of Resident #123's Foley catheter was developed 01/07/2025, however the resident had the catheter in place prior to 01/07/2025 and the Care Plan was not developed timely. The facility policy titled Care Plans, Comprehensive Person-Centered, dated 02/01/2019, documented the Interdisciplinary Team (IDT) would develop and implement a comprehensive, person-centered care plan for each resident. The care plan would include measurable objectives and timetables to meet the resident's needs, incorporate identified problem areas, and incorporate risk factors associated with identified problems. The IDT was to review and update the care plan when there was a significant change in the resident's condition, when the resident was readmitted to the facility from a hospital stay, and at least quarterly.

Based on interview, clinical record review, and document review the facility failed to ensure a care plan was updated to include new interventions for the prevention of falls for 1 of 28 sampled residents (Resident #448). This deficient practice had the potential to result in residents not receiving care and services to meet their needs and help prevent falls. Findings include: Resident #448 Resident #448 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including metabolic encephalopathy and other osteonecrosis, right femur. Fall Risk Evaluations dated 12/20/2024, 12/28/2024, and 01/02/2025 documented Resident #448 was a high risk for falling. A progress note dated 12/20/2024, documented Resident #448 had a fall. The resident reported the resident slipped during transfer and agreed to ask for assistance with transfers in the future. A progress note dated 01/02/2025, documented Resident #448 had a fall. The resident sustained no injuries. Resident #448's Care Plan included a focus area of fall risk related to confusion and deconditioning. The date initiated was 12/23/2024. Interventions included the following: -12/20/2024 Unwitnessed fall without injury. Remind resident to ask for help with transfers. -Follow facility fall protocol. -Neurological checks and vital signs per facility policy post fall. Notify physician of significant abnormalities. -Physical Therapy to evaluate and treat as ordered or as needed. The date initiated for all interventions was 12/23/2024. On 01/08/2025 at 10:36 AM, a Licensed Practical Nurse (LPN) verbalized Resident #448 was a high risk for falls due to confusion and being impulsive. The LPN recalled Resident #448 had a fall on 01/02/2024. The LPN verbalized to help prevent falls the LPN was checking on Resident #448 frequently and offering activities near the nurses' station to keep the resident busy. On 01/13/2025 at 9:50 AM, the Director of Nursing (DON) explained the facility's process when a resident fell was to assess the resident for injuries, assist the resident to a safe place such as a chair or the resident's bed, notify the resident's family and physician and document in a progress note. The facility's risk management team reviewed each fall and assured proper interventions were in place to help prevent future falls. The DON verbalized it was part of the facility's process to update the resident's care plan after a fall with new or revised interventions. The DON verbalized Resident #448 had fallen in the facility on 12/20/2024 and on 01/02/2025. The DON explained the resident was reaching for the resident's phone when the resident fell on [DATE]. The DON reviewed Resident #448's Care Plan and confirmed the Care Plan was not updated after the fall on 01/02/2025. The DON verbalized an intervention to place the resident's belongings within reach should have been added to the Care Plan. The facility policy titled Fall Prevention and Management, dated 02/01/2019, documented residents identified as high risk would be care planned and individualized precautions would be noted to avoid falls. Following a fall, staff were to make appropriate interventions to prevent reoccurrence of a fall or to minimize injury and update the resident's Care Plan.

Based on interview, clinical record review, and document review the facility failed to ensure physician ordered wound care was performed for 1 of 28 sampled residents (Resident #448). This deficient practice had the potential for a resident's wound to worsen and/or delay healing. Findings include: Resident #448 Resident #448 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including metabolic encephalopathy and other osteonecrosis, right femur. On 01/06/2025 at 9:05 AM, Resident #448 had a dressing covering the resident's right elbow. The dressing had a date of 01/05/2025 written on it. A physician's order dated 01/01/2025, documented wound treatment: clean right elbow skin tear with Normal Saline (NS), pat dry, apply xeroform sheet to area, cover with silicone dressing daily and as needed (PRN) if dressing becomes soiled or dislodged, every day shift. Resident #448's January Treatment Administration Record (TAR) lacked documented evidence wound care was provided to the resident's right elbow on 01/04/2025. On 01/08/2025 at 10:41 AM, a Licensed Practical Nurse (LPN1) verbalized Resident #448 had a wound on the resident's right elbow and floor nurses were providing wound care. The LPN1 explained the nurses documented wound care in the TAR or progress notes. On 01/09/2025 at 8:39 AM, an LPN2 confirmed the LPN2 was assigned to care for Resident #448 on 01/04/2025. The LPN2 verbalized Resident #448's TAR indicated the resident had a skin tear on the resident's right elbow. The LPN2 denied the LPN2 provided wound care to the resident's right elbow on 01/04/2025, and explained the LPN2 was unaware the resident had the wound until 01/09/2025. On 01/09/2025 at 10:55 AM, the Director of Nursing (DON) verbalized wounds could deteriorate or get worse if physician ordered wound care was not provided/performed. On 01/09/2025 at 1:52 PM, during an interview with the DON and the Administrator, the DON reviewed Resident #448's TAR and confirmed the TAR lacked documentation of wound care being provided to the resident's right elbow on 01/04/2025. The DON confirmed Resident #448 had an active physician's order for daily wound care and should have received wound care on 01/04/2025. The facility policy titled Skin and Wound Management, last revised 01/11/2024, documented each resident with skin breakdown would receive services and treatment to prevent infection and promote wound healing.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a bed fast resident with limited mobility received necessary care during a power outage resulting in actual harm when the resident developed a deep tissue injury for 1 of 10 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including paraplegia, unspecified, need for assistance with personal care, moderate protein-calorie malnutrition. A facility reported incident, dated 01/04/23, documented on 01/02/23, Resident #3 was found by the wound care provider and a nurse to have a new wound to the resident's sacral area and the resident's air mattress was deflated. On 01/18/23 at 9:15 AM, the Administrator verbalized the facility had a power outage starting on 12/31/22 between 3:00 PM and 4:00 PM, and the power was not restored until 01/03/23. The Administrator verbalized the plug for the air mattress had not been plugged into an emergency power outlet during the power outage. The Administrator confirmed the plug for the resident's air mattress was not plugged into an emergency outlet receiving power from the generator until after the resident's wound was discovered on 01/02/23. A Wound Care Specialist Nurse Practitioner note, dated 12/26/22, documented the resident had one wound to the resident's left great toe. A Wound Care Specialist Nurse Practitioner note, dated 01/02/23, documented the resident had developed a second wound. The new wound was a pressure sacral coccyx deep tissue injury measuring eight centimeters (cm) by 11 cm with moderate serosanguineous drainage. On 01/18/23 at 11:41 AM, the Wound Care Registered Nurse (RN) verbalized the deep tissue injury to Resident #3's sacral area was a new skin condition discovered after the power outage as a result of the deflated mattress. On 01/18/23 at 11:52 AM, the Administrator and the Director of Nursing (DON) verbalized the generator had been operational during the power outage, but the resident's air mattress was not plugged in to an emergency outlet with power supplied by the generator. On 01/18/23 at 12:21 PM, Resident #3 verbalized the staff did not check the resident's air mattress regularly. On 01/18/23 at 12:27 PM, an Licensed Practical Nurse was unable to find an emergency outlet in the room of Resident #3 and did not know what outlet the resident's air mattress would be plugged into to ensure the mattress remained inflated in the event of a power outage. On 01/18/23 at 12:39 PM, the Administrator verbalized Resident #3's room did not have an emergency outlet and the facility would have to run an extension cord from the resident's room into the hallway to the nearest available emergency outlet. On 01/18/23 at 3:23 PM, the DON verbalized the DON was the abuse coordinator for the facility. The DON verbalized any management in the facility during the power outage would have been responsible for checking to ensure medical equipment used by residents was plugged into an emergency power outlet. The DON verbalized the facility staff did not think of the resident's air mattress during the power outage. The DON verbalized the responsibility of checking the resident's air mattress was operating correctly was the responsibility of the bedside nurses, Certified Nurse's Assistants, and any staff entering the resident's room. The air mattress check would include pushing on the air mattress to ensure it was inflated and checking the settings. The DON verbalized the facility determined it was not neglect when an ordered treatment and checking the air mattress settings every shift was not completed for three days, resulting in a deep tissue injury. A Physician's Order dated 02/09/22, documented low air loss mattress on bed, confirm inflation every shift. The December 2022 and January 2023 TAR documented low air loss mattress on bed, confirm inflation every shift for wound care/pressure relief/redistribution. There was no documentation for the air mattress check for all of December 2022 through 01/10/23. The facility policy titled Emergency Procedure - Utility Outage, revised 08/2018, documented resident would remain safe and comfortable during a temporary loss of power. Staff would monitor residents to ensure they were safe and check resident-used medical equipment. The facility policy titled Recognizing Signs and Symptoms of Abuse/Neglect, revised 01/2011, documented the facility would not condone any form of resident abuse or neglect. Neglect was defined as failure to provide goods and services as necessary to avoid physical harm. Signs of actual physical neglect included inadequate provision of care. FRI #NV00067711

Based on observation, interview, clinical record review, and document review the facility failed to ensure a resident received the appropriate care to not develop a deep tissue injury (DTI) while in the facility resulting in actual harm for 1 of 10 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including paraplegia, unspecified, need for assistance with personal care, moderate protein-calorie malnutrition. A facility reported incident, dated 01/04/23, documented on 01/02/23, Resident #3 was found by the wound care provider and a nurse to have a new wound to the resident's sacral area and the resident's air mattress was deflated. On 01/18/23 at 9:15 AM, the Administrator verbalized the facility had a power outage starting on 12/31/22 between 3:00 PM and 4:00 PM, and the power was not restored until 01/03/23. The Administrator verbalized the plug for the air mattress had not been plugged into an emergency power outlet during the power outage. The Administrator confirmed the plug for the resident's air mattress was not plugged into an emergency outlet receiving power from the generator until after the resident's wound was discovered on 01/02/23. A Wound Care Specialist Nurse Practitioner note, dated 12/26/22, documented the resident had one wound to the resident's left great toe. A Wound Care Specialist Nurse Practitioner note, dated 01/02/23, documented the resident had developed a second wound. The new wound was a pressure sacral coccyx deep tissue injury measuring eight centimeters (cm) by 11 cm with moderate serosanguineous drainage. A Nursing Note dated 01/02/23, documented the writer did a skin sweep on the resident and discovered a sacral coccyx area had a pressure injury measuring eight cm by ll cm. The area was purple and had moderate serosanguinous drainage. On 01/18/23 at 11:41 AM, the Wound Care Registered Nurse (RN) verbalized the deep tissue injury to Resident #3's sacral area was a new skin condition discovered after the power outage. On 01/18/23 at 11:52 AM, the Administrator and the Director of Nursing (DON) verbalized the generator had been operational during the power outage, but the resident's air mattress was not plugged in to an emergency outlet with power supplied by the generator. On 01/18/23 at 12:21 PM, Resident #3 verbalized the staff did not check the resident's air mattress regularly. On 01/18/23 at 3:23 PM, the DON verbalized any management in the facility during the power outage would have been responsible for checking to ensure medical equipment used by residents was plugged into an emergency power outlet. The DON verbalized the facility staff did not think of the resident's air mattress during the power outage. The DON verbalized the responsibility of checking the resident's air mattress was operating correctly was the responsibility of the bedside nurses, Certified Nurse's Assistants, and any staff entering the resident's room. The air mattress check would include pushing on the air mattress to ensure it was inflated and checking the settings. A Physician's Order dated 02/09/22, documented low air loss mattress on bed, confirm inflation every shift. The December 2022 and January 2023 Treatment Administration Record (TAR) documented low air loss mattress on bed, confirm inflation every shift for wound care/pressure relief/redistribution. There was no documentation for the treatment for all of December 2022 through 01/10/23. The facility policy titled Emergency Procedure - Utility Outage, revised 08/2018, documented resident would remain safe and comfortable during a temporary loss of power. Staff would monitor residents to ensure they were safe and check resident-used medical equipment. The facility policy titled Pressure Ulcer Prevention and Management, undated, documented caregivers would communicate skin breakdown risk and a skin check would be completed daily. Staff would be trained on the prevention of pressure ulcers including pressure reduction and relief measures. FRI #NV00067711

Based on record review, document review and interview, the facility failed to follow a physician's order for repositioning and prevent the deterioration and infection of a resident's pressure ulcer for 1 of 8 sampled residents (Resident #8). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], with diagnoses including mild cognitive impairment, cellulitis of left lower limb, pressure ulcer of unspecified hip, unstageable, pervasive developmental disorder, symptomatic epilepsy and epileptic syndromes with complex partial seizures, cerebral atherosclerosis, degenerative disease of nervous system, contracture of muscle, unspecified site, and adult failure to thrive. A physician order dated 02/18/20, documented turn and reposition frequently and with routine care, every three hours. Resident #8's Point of Care History for Turning/Repositioning, Bed Mobility, Toileting, and Nursing Progress Notes for wound care/dressing changes dated from 06/23/20 to 08/04/20, documented the following three days as meeting the physician's order on repositioning: -07/04/20, documented Resident #8 was repositioned eight times within a 24-hour period. -07/06/20, documented Resident #8 was repositioned 10 times within a 24-hour period. -07/07/20, documented Resident #8 was repositioned eight times within a 24-hour period. The remaining 40 days from 06/23/20 to 08/04/20, lacked documented evidence repositioning occurred per the physician's order. A Wound Care Nurse Progress Note dated 06/23/20, documented Resident #8 had a left hip, stage 3 pressure ulcer. A Wound Care Nurse Progress Note dated 08/04/20, documented Resident #8's left hip pressure ulcer had progressed to a stage 4, with the wound bed presented red and increased drainage. A physician order dated 08/06/20, documented Keflex (cephalexin), 500 milligram capsule, one capsule every six hours, due to pressure ulcer of unspecified hip. On 09/02/20 at 10:07 AM, the Certified Nursing Assistant (CNA), verbalized Resident #8 was repositioned every two hours and the CNA documented each repositioning in the Point of Care section in the electronic record system. On 09/02/20 at 11:12 PM, the Registered Nurse (RN), responsible to provide wound care, verbalized the RN identified on 08/04/20 Resident #8 had fever and the resident's left thigh had turned red. The RN verbalized the pressure ulcer had become infected based on the wound drainage, and the RN had changed the resident's pressure ulcer status from stage 3 to stage 4. On 09/02/20 at 11:26 AM, the Director of Nursing (DON), verbalized Resident #8's hip pressure ulcer progressed quickly and confirmed it was classified as a stage 4 due to the infection. On 09/02/20 at 11:32 AM, the DON verbalized the DON would expect the resident to be repositioned per physician's order. The DON confirmed the physician's order for Resident #8 was to be repositioned every three hours. On 09/02/20 at 12:14 PM, the DON confirmed Resident #8's Point of Care History for Turning/Repositioning dated from 06/23/20 to 08/04/20, lacked documented evidence the resident was repositioned per the physician's order. The facility policy titled, Pressure Ulcers, dated 09/07/17, documented pressure ulcers would be treated in accordance with professional standards to heal and prevent pressure ulcers unless clinically unavoidable. The facility referenced Elsevier, Fundamentals of Nursing, Ninth Edition, copyrighted 2017. The facility policy titled, Positioning/Bed Mobility Program Initiating the Program, dated 01/01/20, documented nursing staff would assist patients/residents with repositioning to prevent skin breakdown, and to reposition the patient/resident as determined by the patients/resident needs.

Based on observation, interview, clinical record and document review, the facility failed to ensure resident grievances involving other resident ' s behaviors were resolved in a timely manner for 3 of 24 sampled residents (Resident #12, #11 and #10). Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The clinical record revealed the following: The Progress Notes from [DATE]-[DATE],indicated Resident #12 was on 1:1 supervision from [DATE] through [DATE]. A Social Services Note dated [DATE], indicated the resident was referred to psychiatry for depression and a competency evaluation for a referral for guardianship A Psychiatric Progress Note dated [DATE], revealed the resident had a history of [REDACTED]. The resident had a history of [REDACTED]. Social Service Note dated [DATE] through [DATE], indicated prior to skilled nursing facility admission, the resident was residing at a local weekly motel. The resident did not leave her room with any frequency and refused to be assisted up in to a chair to be taken to activities. The resident stated she was unhappy with her current room due to it was "too dark" due to the roommate not wishing to open the curtains during the day. Social Service Notes dated [DATE] through [DATE], indicated the Licensed Social Worker (LSW) met with resident at her bedside to discuss the resident was refusing blood sugar tests as well as all medications. The Resident was verbally aggressive toward the LSW and expressed she did not like the room assignment. The resident did not enjoy the company of her current roommate and stated "If I have to live like this for another twenty years I'd rather just die, so no I won't take my medications." The Resident was very tearful during interview and at times shouted "nobody here does anything for me - none of you care if I die so I might as well." LSW attempted to discuss with resident this was not the case and the facility wished to accommodate her as best we can when considering her healthcare needs. Resident shouted, "Well if you care get me out of here and away from that b****", pointing again towards her roommate's side of the room. The resident indicated the roommate did not like the TV volume loud at night. The resident indicated she should be able to watch TV at 1:00AM if she wanted. The LSW indicated the situation would be discussed with nursing staff to come to an amicable resolution. The resident declined to speak with a psychiatrist or Licensed Clinical Social Worker regarding her feelings of "not wanting to live like this" and not wanting to take her medications. A Nursing Note dated [DATE], indicated the resident was restless/anxious this evening. The resident was arguing with roommate again about the TV being too loud. The Resident did not comply with turning TV volume down stating when volume was too low she was unable to hear TV. A Nursing Note dated [DATE], indicated the resident was again very upset with roommate over air conditioning and screamed she never got what she needed and wanted to die. Nursing Notes between [DATE] and [DATE], indicated the resident was very anxious and upset, screaming at nursing staff and roommate multiple times during the the night. The resident flew into a rage when the Registered Nurse requested the volume turned off on the TV at 0130 and the resident continue to watch with closed captions. The resident began screaming so loudly, she woke several other surrounding residents. The resident was using obscenities and very disrespectful language toward staff and her roommate. A Nursing Note dated [DATE], revealed the resident was screaming at and about the roommate at start of, night. The resident was using foul language and calling her roommate foul names. The resident started banging a cup and screaming, "I'll keep you awake all night you b----". A Nursing Note dated [DATE], revealed the resident had many complaints about roommate and had verbal arguments with roommate twice this shift. A Social Services Note dated [DATE], indicated the resident was refusing medications and blood sugar testing, other than anti-anxiety medication and [MEDICATION NAME]. The resident revealed she was not going to stay here the next twenty or twenty-five years living like this. The resident indicated she would rather die than live like this. The resident indicated she did not want to commit suicide. The resident revealed she did not like her roommate and she could not watch her TV when she wished. The resident revealed she was not sure she wanted to talk to a psychiatrist at this time. A Social Services Note dated [DATE], revealed a psychiatry referral had been ordered for Resident #12 related to yelling out and non-compliant with care. A Psychiatrist Progress Note dated [DATE], indicated Resident #12 was alert, cooperative with evaluation, complained of shortness of breath, was angry at sleep disruption, had low energy and thoughts of wanting to die (with no suicidal ideation, no intent, and no plan to self-harm. The resident stated "I don't want to live this way. I am putting it in God's hands." On [DATE] in the afternoon, the "A bed" (bed by the door) in Resident #12's room, the light above the resident's bed was off and there was minimal light available. There was a roommate who occupied the bed closest to the window with a privacy curtain between the beds. There was no visible natural lighting from the window because the window cover was closed. On [DATE] throughout the day, the light above Resident #12's bed was off. There was no visible natural lighting from the window because the window cover was closed. On [DATE] in the morning, a Licensed Nurse indicated the light in Resident #12's room was usually turned off. The Nurse indicated it was because Resident #11 (the roommate) did not like the light. The Nurse verified Resident #11 frequently told Resident #12 to "Be quiet" and "Shut up". The Nurse indicated the Social Worker was supposed to find another room for Resident #12. On [DATE] at approximately 9:45 AM, Resident #12 indicated she did not like to sit in the dark all day, but the roommate "screams and screams at her" when she turns on the light. Resident #12 indicated the roommate also yells at her whenever she talks. Resident #12 indicated she gave up wanting to turn the light on anymore because of the screaming. On [DATE] at 1:00 PM, the Administrator indicated there was a problem between Resident #11 and #12 and thought the problem had been worked out. The Administrator indicated Resident #11 regularly yelled at staff and had been resistive to care. The Administrator indicated Resident #11 had a hard life. Resident #11 was in a concentration camp in Poland as a child. The Administrator revealed Resident #11 had conflicts with previous roommates. On [DATE] at 10:45 AM, the Social Worker indicated Resident #12 had been a roommate of Resident #11 for approximately 1 month. The Social Worker was aware of ongoing verbal disagreements including, Resident #12 wanted the window with sunlight and Resident #11 did not want to open the curtains or have light. Resident #12 had expressed a fear of the darkness. The Social Worker indicated he was waiting for a room with a window bed to be available in order to move Resident #12. The Social Worker indicated the room availability was unknown and could take weeks. Resident #11 Resident #11 was admitted [DATE] with [DIAGNOSES REDACTED]. The Physician's Progress Note dated [DATE] indicated Resident #11 was depressed and tearful, and "...The quality of her life is quite poor and she is very depressed." The facility's Progress Notes indicated severe cognitive impairment, and further indicated the following: A Social Service Progress Note dated [DATE] revealed the resident seemed to switch topics spontaneously and it was difficult to track the resident's train of thought. The resident would switch to speaking about growing up in German (language), and then switch to speaking about her privacy curtain, then switch to smiling while discussing her son. The residents thought process presented as disorganized. The resident described feeling as though staff was 'plotting against me. I can see it in their eyes when they walk by and that I have had 3 roommates in one month and they all died in this room because there is something bad. The resident was presenting with paranoid delusions. A Nursing Note dated [DATE] revealed the resident continued to present with disorganized thinking with paranoia, speaking of Germany and the occupation camps. A Nursing Note dated [DATE] revealed when awakened for medication administration, the resident would cry about some spilled water and the cushion for her wheelchair was not soft. The resident indicated she did not want to cry, but the tears keep coming. The resident stated she felt useless and should just die. A Nursing Note dated [DATE] revealed the resident was wakeful early in evening and teary. The resident revealed she could not sleep with roommate's TV on all night. The resident did complain of nightmares at times, stating, "It's about being in Poland during the war", and can often be heard crying out for help in her sleep or talking in foreign language. A Nursing Note dated [DATE] revealed the resident was crying at the beginning of the night shift and complained about the roommate's TV disturbing her and arguing with the roommate to turn the TV off. A Nursing Note dated [DATE], revealed Resident #11 complained of a headache and the roommate's habit of watching TV and keeping her light on all night was making it very difficult to rest and sleep. The resident and roommate engaged in a heated verbal exchange, each making accusations regarding the other's disruptive behavior. A Nursing Note dated [DATE], revealed Resident #11 continued to make derogatory comments to roommate and complains about her and would verbally insult her. Resident #11 was reminded to please not make comments to roommate and not respond to insults made to her. Resident #10 Resident #10 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The facility's Progress Notes indicated Resident #10 would inappropriately touch female staff and residents. Resident #10 frequently shouted at other residents, harassed, teased, and made crude remarks to female residents, used sexually inappropriate language, and spit (chewing tobacco) inside of the facility. On [DATE], the Wellington Unit Charge Nurse indicated Resident #10 frequently disobeyed the smoking rules, and chewed and spit out the tobacco on the floor inside the facility on a daily basis. The Charge Nurse further indicated she gave Resident #10 a cup to spit in and keep with him all the time because otherwise he would spit on the floor. On [DATE] at 10:45 AM, the Social Worker indicated Resident #10 spit on the floor in front of residents, and there were concerns brought up in resident council regarding Resident #10's spitting and cursing. On [DATE] at approximately 12:45 PM, a female resident who appeared very upset rushed up to the Nurse Consultant and the surveyor in the hallway, calling out loudly, "You have to do something about (Resident #10). He's out of control" and motioned toward the main dining room. Upon entering the dining room, there was no staff. There were multiple residents who appeared visibly upset. One female resident was sobbing and was unable to talk. Another female resident who could not verbalize was crying out loudly in jibberish and motioning with her arms frantically. Resident #10 was sitting at a table near the middle of the dining room, and repeatedly stated he wanted the male resident at another table to be moved so he could sit there. A female resident was sitting at a table next to Resident #10 and appeared visibly upset. An alert and oriented resident indicated, Resident #10 did this all the time. Resident #10 would pinch the ladies' bottoms, told dirty jokes and pulled the hair of a female resident all the time. A Certified Nursing Assistant (CNA) arrived at the dining room, and indicated Resident #10 had thrown his spit cup of chewing tobacco all over a female resident's arm. The CNA indicated, Resident #10 acted like this all the time. Resident #10 was wheeled out of the dining room by a Social Worker. On [DATE] at approximately 1:30PM, four alert and oriented residents revealed Resident #10 would pull a female residents hair every day and the resident would not leave her alone. Resident #10 threatens to pinch the ladies and the resident got rowdy at almost every meal. The residents indicated Resident #10 had been doing this for a couple of months. Resident #10 would tell dirty jokes, would yell and use foul language. The residents indicated the staff knew about Resident #10's behaviors, the staff would tell the resident to stop and would move the resident to another dining room. Resident #10 would spit on the floor inside the facility instead of the cup provided by staff. On [DATE] at 4:00 PM the Director of Activities indicated Resident #10 was disruptive, curses, and pesters a female resident during group activities. Resident #10 told inappropriate jokes. The Director of Activities indicated when Resident #10 became inappropriate the Director of Activities would tell him if he continued he would have to leave. If the resident still would not stop, I would tell him he may leave now and he wheels himself out. On [DATE] at 11:30 AM, the Administrator indicated Resident #10 did have behaviors such as cursing, telling inappropriate sexual comments to female residents, touching female residents, and yelling at residents. Resident #10 had to be told multiple times to stop. The Administrator indicated Resident #10 would chew tobacco in his room and would chew it inside the facility. The staff would try to confiscate his chewing tobacco, but he would hide it from the staff. The Administrator was not aware of any residents or staff saying Resident #10 pulled a female residents hair or pinches residents' bottoms. The Administrator indicated she would look at the situation with Resident #10 toward the female resident, whose hair he pulled as a behavior and not necessarily as abuse, and stated, "I would look at that situation as antagonizing her, not as abuse." The Progress Notes reviewed for the period of [DATE] through July of 2014 indicated Resident #10 had the following behaviors including: Frequent shouting at other residents, "harassed, teased, and made crude remarks" to female residents, made crude jokes and comments, used sexually inappropriate language, spit (chewing tobacco) inside of the facility and on the floors in public areas, put his snuff on his lower lip and moved from person to person (females) in the smoking area and asked each one to kiss him, spit at residents, pinched, grabbed and rubbed against female staff, rubbed a female resident's bare leg in the hallway, cursed at residents, threatened residents and staff with physical violence, pinched female resident's buttocks, pulled a female resident's hair repeatedly, told a female resident to pick up his feces on the bathroom floor, and handed a cup full of chewing tobacco spit to confused residents and told them to drink it. Resident #11 / Resident #12 On [DATE] between 9:00 AM and 11:00 AM, Residents #11 and #12 were observed sharing a room. Resident #11's bed was close to the window and the window covering was closed. There was a privacy curtain in the middle of the room separating the residents. Resident #12 indicated being at the facility for several months and was supposed to have hernia surgery which was canceled. The resident indicated most of the days had been spent lying in bed. While the resident was speaking the roommate yelled "shut up" on several occasions. Resident #12 reported missing seeing natural sunlight and explained the roommate had not liked sunlight or having the lights on. On [DATE] at 11:00 AM, a Licensed Practical Nurse (LPN) revealed the residents yelling in that room was common and social services were taking care of the situation. On [DATE] at 5:40 PM, Resident #12 was observed in a different room. The resident was smiling and reported feeling happy about the move. The resident reported the prior roommate had been mean, angry and spoke Polish most of the time. The resident was watching television and reported a goal of being able to walk out of the facility. Resident #20 Resident #20 was admitted to the facility on [DATE], for rehabilitation after a fall at home. The Resident's [DIAGNOSES REDACTED]. The resident was alert and oriented. On [DATE] at 12:45 PM, Resident #20 expressed concern for the safety of other residents in the facility related to the verbal and physical behavior of Resident #10. Resident #20 explained, Resident # 10 was out of hand, obscene and rude. Resident #20 had observed Resident #10 multiple times picking on small women who were often confused. In one observed incident Resident #20 explained Resident #10 pulled the hair of a small female resident. The resident told resident #10 to leave her alone but he continued to tell her dirty jokes and touched her until she started screaming and the facility staff intervened. Resident #20 described another incident in which Resident #10 was observed throwing the contents of a cup of chew (saliva resulting from chewing tobacco) on another resident and the facility had to break it up again. Resident #20 indicated the facility staff was aware of Resident #10's behavior and had banned him from certain areas of the facility. Resident #20 explained this did not stop Resident #10 who continued to enter these areas and pick on other residents. Review of Resident Council Minutes dated [DATE], documented by the Activities Director, confirmed the facility staff was aware of "concerns about (Resident #10) spitting and cursing." Review of the facilities Patient Information Handbook included a three page photo copied document titled, Resident's Rights Agreement (undated). This document contained the following information: - The resident has the following rights: "...13. Prompt efforts by the Facility to resolve grievances the resident may have, including grievances regarding the behavior of other residents...