Every finding on record at Autumn Lake Healthcare at Windsor

Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to notify the State Agency timely of an allegations of mistreatment. The findings include: Resident #1's diagnoses included heart failure, anxiety and depression. The Resident Care Plan (RCP) dated 12/3/2025 identified ADL self-care performance deficit. Interventions directed to encourage to discuss feelings about self-care deficit, encourage to participate to fullest extent in each interaction and to use call bell for assistance. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of twelve out of fifteen, indicative of moderate cognitive impairment and was dependent with toilet hygiene, ADLs, transfers, manual wheelchair use, and partial/moderate assistance with bed mobility, and had no behaviors (no hallucinations or delusions) in the prior seven (7) days. Psychiatric APRN note dated 12/31/2025 indicated asked to see patient urgently via telehealth for eval. Resident #1 alleged a man I grew up with came in my room on a gurney and touched my ankle and leg. I think he was trying to rape me. No distress was noted during the exam. Resident #1 reported another resident, a man in his 40s with short black hair came into his/her room and touched his/her ankle which awoke him/her. Resident #1 states that he told her not to scream and began running his hand up his/her leg. Stated that this is someone he/she grew up with but cannot remember his name. Resident #1 also states he rolled in on a gurney. This is different than his/her original report. After complete evaluation, it appears patient most likely had a nightmare or delusion. Resident report eating and sleeping well. Significant confusion noted, and anxiety mild, but stable. Plan monitor behaviors for concerns, continue plan of care. Record review failed to identify a nursing note regarding the request for the psychiatric APRN to see Resident #1 for the allegation described by the APRN note dated 12/31/2025. Review of email sent to the Administrator from the Ombudsman, dated 3/10/2026 at 10:48 AM, requested information be provided to Resident #1's responsible party regarding the investigation on the 12/31/2025 statements on rape allegation. Further, the Ombudsman requested to be informed of the allegation. Review of social service typed note, provided by the Administrator, dated 12/31/2025 identified Resident #1 alleged a man she grew up with had come into his/her room at night and tried to rape him/her. Resident #1 stated they started touching his/her ankles and Resident #1 screamed. Review of social service typed note provided by the Administrator, dated 12/31/2025 identified she interviewed two (2) residents that resided on Resident #1's unit to ask if they had seen any males in the hallway or hear any screaming. Review of the State Agency Facility Licensing & Investigations Section (FLIS) system failed to identify the allegation of abuse was reported to the State Agency. Review of facility documentation failed to identify the facility completed an incident report for the allegation. Interview with the Acting/Interim DNS (DNS #2) and Administrator on 4/14/2026 at 12:45 PM identified the Administrator and DNS #2 were not sure if an allegation of abuse by Resident #1 on 12/31/2025 had an associated accident and investigation report or if the allegation was reported to the State Agency. DNS #2 stated he had only been covering as DNS for about three (3) weeks, and although he was aware of the allegation, he stated that he did not submit a reportable event for the allegation. The Administrator stated she was aware of the allegation, but she did not submit a reportable event. The Administrator stated that DNS #1 was no longer at the facility and she and DNS #2 would look for DNS #1's files for the investigation regarding the allegation made by Resident #1 on 12/31/2025. Interview and record review on 4/14/2026 at 11:53 AM with DNS #1 (former DNS) identified she was the facility DNS from March 2025 until March 2026, and she remembered Resident #1 and the allegation of abuse Resident #1 made on 12/31/2025. The DNS stated there was no facility investigation conducted. She stated that social services was involved and psychiatry services saw Resident #1. Administrator #2 was covering at the time of the allegation due to vacations, and Administrator #2 and RN #2 (corporate RN) determined Resident #1 was having a dream and at that time the facility decided not to report the allegation to the State Agency based on the psychiatric evaluation. On 4/14/20256 at 12:33 PM interview and record review with SW #1 identified she was notified that on 12/31/2025 after lunch, but was unsure of the time, that Resident #1 made an allegation of abuse/mistreatment. SW #1 stated she was advised to investigate and to notify the DNS of the results. Resident #1 told SW #1 that someone from his/her past had touched him/her, but did not say anything about a gurney, and she believed psych services saw the resident within an hour. SW #1 indicated after her investigation, she provided a written statement to the DNS. Interview on 4/14/2026 at 12:45 PM with acting DNS #2 and Administrator identified the Administrator did not know where Resident #1's 12/31/2025 investigation report was or if the facility even had one. The Administrator stated she was unaware if an incident report and investigation was completed, or if it was reported to the State Agency, and did not know if the facility had any staff statements or an incident report. DNS #2 stated he did not know if the facility had any staff statements or an incident report. The Administrator stated DNS #1 left recently and she did not know where anything was, and both the Administrator and DNS #2 indicated they did not know if there were accident and incident reports and where they were stored. On 4/14/2026 at 1:11 PM, interview with DNS #2 and the Administrator identified the Administrator stated they were notified of the allegation when they received an email from the Ombudsman during March 2026 that indicated a family member had notified the Ombudsman of the allegation. The Administrator had a soft file in her office regarding the allegation, and DNS #2 had a separate soft file in his office regarding the allegation. Review of the soft files identified statements were included that were dated 12/31/2025. The Administrator stated she directed DNS #1 to notify the State Agency, and she was aware that DNS #1 did not notify the State Agency. The Administrator stated she discussed the matter with the Regional Administrator #2 and RN #2 (corporate), and that DNS #1 had characterized the incident as a non-reportable allegation involving contact with the resident's ankle. The Administrator stated a meeting was held on 3/11/2026 with the Regional Administrator #2 and RN #2 with direction given to DNS #1 to report the allegation. The Administrator stated she directed DNS #1 to notify the State Agency, and she was aware that DNS #1 did not notify the State Agency. The Administrator stated DNS #1 resigned on 3/23/2026 and although DNS #2 assumed the role at that time, the State Agency was not notified of the allegation that the facility was aware of on 12/31/2025. The Administrator stated the allegation should have been reported within the two (2) hours after the facility became aware, in accordance with facility policy. Review of the State Agency Facility Licensing & Investigations Section (FLIS) system identified the State Agency was notified of the allegation on 4/14/2026 at 7:19 PM. Review of facility Abuse, Neglect and Exploitation Policy directed in part. Abuse means willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. An alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified time frames: immediately, but not later than 2 hours after the allegation is made.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure a thorough investigation was completed timely after an allegation of mistreatment. The findings include: Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure a thorough investigation was completed timely after an allegation of mistreatment. The findings include: Resident #1's diagnoses included heart failure, anxiety and depression. The Resident Care Plan (RCP) dated 12/3/2025 identified ADL self-care performance deficit. Interventions directed to encourage to discuss feelings about self-care deficit, encourage to participate to fullest extent in each interaction and to use call bell for assistance. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of twelve out of fifteen, indicative of moderate cognitive impairment and was dependent with toilet hygiene, ADLs, transfers, manual wheelchair use, and partial/moderate assistance with bed mobility, and had no behaviors (no hallucinations or delusions) in the prior seven (7) days. Psychiatric APRN note dated 12/31/2025 indicated asked to see patient urgently via telehealth for eval. Resident #1 alleged a man I grew up with came in my room on a gurney and touched my ankle and leg. I think he was trying to rape me. No distress was noted during the exam. Resident #1 reported another resident, a man in his 40s with short black hair came into his/her room and touched his/her ankle which awoke him/her. Resident #1 states that he told her not to scream and began running his hand up his/her leg. Stated that this is someone he/she grew up with but cannot remember his name. Resident #1 also states he rolled in on a gurney. This is different than his/her original report. After complete evaluation, it appears patient most likely had a nightmare or delusion. Resident report eating and sleeping well. Significant confusion noted, and anxiety mild, but stable. Plan monitor behaviors for concerns, continue plan of care. Record review failed to identify a nursing note regarding the request for the psychiatric APRN to see Resident #1 for the allegation described by the APRN note dated 12/31/2025. Review of email sent to the Administrator from the Ombudsman, dated 3/10/2026 at 10:48 AM, requested information be provided to Resident #1's responsible party regarding the investigation on the 12/31/2025 statements on rape allegation. Further, the Ombudsman requested to be informed of the allegation. Review of social service typed note dated 12/31/2025 identified Resident #1 alleged a man she grew up with had come into his/her room at night and tried to rape him/her. Resident #1 stated they started touching his/her ankles and Resident #1 screamed. Review of social service typed note dated 12/31/2025 identified she interviewed two (2) residents that resided on Resident #1's unit to ask if they had seen any males in the hallway or hear any screaming. Review of facility documentation failed to identify the facility completed an incident report and investigation for the allegation. Interview and record review on 4/14/2026 at 11:53 AM with DNS #1 (former DNS) indicated she was the facility DNS from March 2025 until March 2026, and she recalled Resident #1 and the allegation of abuse on 12/31/2025. The DNS stated there was no facility investigation completed. Social services was involved, psychiatry services saw the resident, and it was determined by Administrator #2 (filling in for current Administrator at the time) and RN #2 (corporate) that the resident was having a dream. On 4/14/2026 at 1:11 PM, interview with DNS #2 and the Administrator identified the Administrator stated they were notified of the allegation when they received an email from the Ombudsman during March 2026 that indicated a family member had notified the Ombudsman of the allegation. The Administrator had a soft file in her office regarding the allegation, and DNS #2 had a separate soft file in his office regarding the allegation. Review of the soft files identified one (1) file had six (6) staff statements were included that were dated 12/31/2025. The statements had staff names written on the top in the same handwriting. Two (2) staff statements had no staff names, and none of the statements were signed. The other soft file had thirteen (13) staff statements dated 12/31/2025 with names on the top of the page similar to the first soft file, and none of the statements were signed. Interview failed to identify a facility incident report was completed with a thorough investigation to include a review of the documents, statements, and social services and psychiatry notes. The Administrator indicated an incident report and investigation should have been completed. Interview failed to identify why a thorough investigation was not completed, including staff statements with names and signatures. The facility Accident and Incidents Policy dated 10/27/2025 directed that an incident was any occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. Review of facility Abuse, Neglect and Exploitation Policy directed in part, abuse means willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Investigation of alleged abuse, neglect and exploitation: an immediate investigation is warranted: identifying and interviewing all involved persons, including the alleged victim, others who might have knowledge of the allegations, providing complete and thorough documentation of the investigation.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure social service support visits were provided timely after an allegation of abuse. The findings include: Resident # 1's diagnoses included heart failure, anxiety and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of twelve out of fifteen, indicative of moderate cognitive impairment and was dependent with toilet hygiene, ADLs, transfers, manual wheelchair use, and partial/moderate assistance with bed mobility, and had no behaviors (no hallucinations or delusions) in the prior seven (7) days. Psychiatric APRN note dated 12/31/2025 indicated asked to see patient urgently via telehealth for eval. Resident #1 alleged a man I grew up with came in my room on a gurney and touched my ankle and leg. I think he was trying to rape me. No distress was noted during the exam. Resident #1 reported another resident, a man in his 40s with short black hair came into his/her room and touched his/her ankle which awoke him/her. Resident #1 states that he told her not to scream and began running his hand up his/her leg. Stated that this is someone he/she grew up with but cannot remember his name. Resident #1 also states he rolled in on a gurney. This is different than his/her original report. After complete evaluation, it appears patient most likely had a nightmare or delusion. Resident report eating and sleeping well. Significant confusion noted, and anxiety mild, but stable. Plan monitor behaviors for concerns, continue plan of care. Further review identified the RCP was updated on 12/31/2025 to indicate Resident #1 had a history of a trauma that occurred during childhood. Interventions directed social service one to one (1:1) visits as needed for support and reassurance, encourage family involvement and support, encourage verbalization of feelings, and offer psych services as needed. Record review identified that the last social service note was dated 12/23/2025; there were no SS notes related to the 12/31/2025 allegation of mistreatment, or the delusion documented by the psychiatric APRN. Interview and record review on 4/14/2026 at 10:47 AM with SW #1 identified the facility received an email from the Ombudsmen on 12/31/2025 that alleged Resident #1 was raped. The DNS requested SW #1 speak with the resident and Resident #1 told her that it was someone in his/her past. SW #1 stated she did not write a SS note, and she did not provide any additional follow-up or support visits to Resident #1 regarding the incident. Although SW #1 was aware of the allegation, interview failed to identify why the SW visit was additional support visits were not provided. Interview and record review on 4/14/2026 at 12:45 PM with DNS #2 and the Administrator identified social services saw Resident #1 on 12/31/2025 after the allegation was made. Interview identified the last social service note was dated 12/23/2025, and that the social worker interviewed Resident #1 and provided a statement related to the allegation. Interview failed to identify why the SW visit was additional support visits were not provided. Review of facility Abuse, Neglect and Exploitation Policy directed in part, to provide emotional support and counseling to the resident during and after the investigation, as needed.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident's #93, #23 and #99) reviewed for abuse, the facility failed to ensure Resident #93 was free from verbal and physical abuse by his/her roommate Resident #41, and failed to ensure Resident 23 and 99, who were roommates, were free from abuse from each other. The findings include: 1a. Resident #93 was admitted to the facility in May 2024 with diagnoses that included schizophrenia, psychosis, and adjustment disorder. The clinical record identified Resident #41 had a room change to Resident #93's room on 3/13/25. The care plan dated 4/28/25 identified Resident #93 had potential for impaired thought processes related to difficulty expressing him/herself. Interventions included communicating with the resident and his/her resident representative regarding his/her needs. The quarterly MDS dated [DATE] identified Resident #93 had intact cognition. A psychiatric supportive services note by SW #3 on 11/8/25 identified Resident #93 reported ongoing issues with his/her roommate. A nurse's note dated 11/10/25 at 7:52 PM by RN #5 (7:00 AM – 3:00 PM RN Supervisor) identified Resident #93 requested to be transferred to another room, the room transfer was completed, and Resident #93's representative was notified. b. Resident #41 was admitted to the facility in September 2004 with diagnoses that included schizophrenia, dementia, and anxiety disorder. The annual MDS dated [DATE] identified Resident #41 had moderately impaired cognition. A nurse's note dated 7/7/25 at 7:34 AM by LPN #5 (11:00 PM – 7:00 AM charge nurse) identified Resident #41 was observed at 5:00 AM having a verbal altercation with his/her roommate. LPN #5 identified the altercation occurred without a reason, and that Resident #41 continued with behaviors despite attempts at redirection, and that Resident #41 was observed yelling at other residents in the unit hallway. The note further identified that Resident #41 was observed by 3 facility staff kicking his/her roommate in the hallway. LPN #5 identified she notified her supervisor and that a referral to be seen by psychiatry in the morning had been placed. Review of Resident #41's care plan failed to identify a revision or interventions related to the resident-to-resident altercation documented by LPN #5 which occurred on 7/7/25. A psychosocial evaluation note dated 7/7/25 identified that Resident #41 displayed rudeness towards his/her roommate and aggression towards staff overnight. The note further identified that individual psychotherapy would be provided 1 – 5 times monthly to reduce emotional symptoms. A psychiatric evaluation note dated 7/8/25, by APRN #4, identified she was asked to see Resident #41 due to agitated behaviors per nursing. APRN #4 identified no signs of delusions, auditory or visual hallucinations, agitation or aggression. APRN #4 further identified no changes were recommended based on her evaluation. A nurse's note dated 10/21/25 at 5:13 AM by LPN #5 identified Resident #41 was observed up all night yelling and screaming at his/her roommate for no reason. LPN #5 identified she attempted to redirect Resident #41 with no result. Review of a Behavioral Health Visit Request/Follow Up Log identified a note on 10/21/25 which identified Resident #41 was up all night yelling at his/her roommate for no reason and accosting him/her for coughing. A medical APRN note dated 10/31/25 identified Resident #41 during the visit, Resident #41 was mildly anxious, ambulating the hallway asking where is my roommate. The note further identified that staff reported Resident #41 had a recent escalation in behaviors that included yelling and screaming at his/her roommate during the night and being disruptive. The note also identified that redirection was not successful, and that Resident #41 was seen by the psychiatric provider with an increase of Risperdal ordered. Review of a facility grievance form dated 11/12/25 (two days after the room change) identified Resident #93 requested a room change due to verbal abuse by his/her roommate. An undated letter addressed to the administrative office, which was attached to the grievance form was signed by Resident #93. The grievance form was completed by SW #1 (Social Work Director) and signed by Resident #93, SW #4, and the Administrator, and identified that the resident's room was changed and the resident reported that things were better following the change. Review of the letter (attached to the grievance dated 11/12/25) written and signed by Resident #93 identified the following. Resident #41 abuses me verbally and has hit me a few times. I fight back and hopefully won't get violent and be in trouble for it. He/she does it every day when I enter the room or leave and when I go to my closet. He/she is a homosexual and I am not. I want a different room. Interview with Resident #93 on 2/24/26 at 3:18 PM identified he/she had been in the same room with Resident #41 since March 2025. Resident #93 identified beginning sometime in the summer, Resident #41 began to make indirect romantic verbal advances towards him/her (Resident #93) that made him/her feel uncomfortable. Resident #93 identified once he/she rejected the advances, Resident #41 became more aggressive, and would intermittently yell at him/her for no reason. Resident #93 identified that over time, the yelling escalated from intermittent episodes to constant yelling overnight, and then occasionally included being hit or kicked by Resident #41. Resident #93 identified that by the time he/she had written the letter to the Administrator in November 2025, Resident #41 was yelling overnight several times a week, and anytime Resident #93 attempted to access his/her closet, which was located near the door and Resident #41's bed, Resident #41 would approach from behind and shove Resident #93 into the closet door. Resident #93 identified that he/she had reported the incidents several times to multiple nursing staff, but they had instructed Resident #93 to tell Resident #41 he/she did not want to talk and to stop the behavior. Resident #93 identified he/she tried but that only made Resident #41's behavior worse. Resident #93 identified that he/she would often sit in the hallway to avoid Resident #41 and only go in his/her room as necessary, but it did not help and the behaviors continued. Resident #93 reported he/she feared Resident #41 and did not feel safe while in the same room with him/her and so he/she wrote a letter to the Administrator and asked for a room change. Resident #93 identified no staff had ever offered to move him/her to another room prior to the letter, and after the room change, a staff member who he/she could not remember, followed up once to make sure the new room was working out. Interview with SW #1 on 2/26/26 at 9:05 AM identified she began working at the facility on 11/10/25 and was shadowing SW #4 for the first few days. SW #1 identified that SW #4 had outstanding grievances that needed to be completed and to help SW #4 out, she completed the grievance form for Resident #93's request for a room change but did not address the issue herself. SW #1 was unable to identify if Resident #93's allegation of abuse was addressed outside of his/her request for a room change and reiterated that it was SW #4's responsibility. Interview with the Administrator on 2/26/26 at 9:07 AM identified she received a letter from Resident #93 related to a room change but didn't read the letter from Resident #93 because she could not read the handwriting. The Administrator directed SW #4 to address it as a grievance and she did not make any attempt to discuss or review the letter with Resident #93, and was unaware that the letter, addressed to her, included allegations of daily verbal and physical abuse by Resident #41. The Administrator further identified she was unaware of the incidents documented in Resident #41's clinical record related to verbal and physical altercation with Resident #93 on 7/7/25 or verbal altercation on 10/21/25. Interview with RN #5 (7:00 AM – 3:00 PM supervisor) on 2/26/26 at 10:55 AM identified he assisted with Resident #93's room change but was not sure why Resident #93 had made the request. RN #5 identified based on his recollection, Resident #93 had approached him sometime during the day on 11/10/25 to request the room change. RN #5 identified he was unsure who he spoke to about the issue. RN #5 identified that he was not aware of Resident #93's grievance or the allegations of abuse by Resident #41 or yelling overnight by Resident #41, and that he was not aware of any issues between the residents. RN #5 identified that when Resident #93 was moving his/her belongings to the new room on 11/10/25, he did recall Resident #41 asking him where his/her roommate was going and said (I love my roommate). Interview with NA #3 on 2/26/26 at 11:43 AM identified that she worked on the 11:00 PM – 7:00 AM shift but did not recall being assigned to Resident #41 and Resident #93's unit. NA #3 identified that while she was not assigned to the residents, it was common knowledge with the nursing staff throughout the facility that Resident #41 would confront Resident #93 with aggressive behaviors on a regular basis. NA #3 identified she never saw Resident #41 become physical with Resident #93 on 7/7/25 but did witness on multiple occasions Resident #41 yelling at Resident #93 overnight, and witnessed Resident #41 go directly into Resident #93's face and yell on multiple occasions. NA #3 identified it was very hard to redirect Resident #41 away from Resident #93 and to deescalate the behaviors. NA #3 also identified that while she did not observe Resident #41 attempt to hit or kick Resident #93, Resident #41 had attempted to hit her in the past but stopped before actually striking her. NA #3 identified that Resident #41 was verbally abusive to Resident #93, and the behavior had gone on for several months in 2025. NA #3 also indicated that Resident #93 had reported to her she was afraid of Resident #41. NA #3 identified Resident #41 felt disrespected because Resident #93 would not speak with him/her, and that caused Resident #41 to escalate and begin yelling. NA #3 identified that she reported behaviors to the unit charge nurse but was unable to provide any specifics on the nurse or when she reported the issues. NA #3 reported that staff at the facility would attempt to redirect Resident #41 but a room change was not attempted prior to 11/10/25. NA #3 indicated she was not aware of any other interventions to protect Resident #93, and that she never observed Resident #93 being aggressive or instigating any altercations with Resident #41. NA #3 also identified that it was the longstanding culture of the nursing staff, including the nurse aides and licensed nurses, to ignore Resident #41's behaviors and not address the issues, which was likely why Resident #93 had to self-request the room change. Interview with SW #3 on 2/26/25 at 12:17 PM identified that Resident #93 had reported issues with Resident #41, however the issues were that Resident #93 found Resident #41 to be annoying. SW #3 identified Resident #93 reported Resident #41 was loud and she had a hard time sleeping because of this, but did not report any physical abuse, safety or inappropriate behavior. Interview with APRN #4 on 2/26/26 at 1:26 PM identified that she was not aware of any issues related to Resident #41 and Resident #93, including any issues related to physical or verbal altercations. Interview with the DNS on 2/26/26 at 1:42 PM identified that she had been the DNS of the facility since March 2025. The DNS identified that she was not aware of any issues between Resident #41 and Resident #93, was not aware of the incidents on 7/7/25 or 10/21/25, and was not aware of the letter written by Resident #93 to the Administrative office in November 2025 which alleged daily abuse by Resident #41, and was not aware why Resident #93 requested a room change. The DNS identified that following the incident on 7/7/25, the residents should have been placed in separate rooms for safety and if Resident #41 did not respond to redirection, the resident should have been sent to the hospital for psychiatric evaluation. The DNS also identified that the medical and psychiatric providers should have been notified of every incident between the residents as well as the resident representatives, and that social work should have been involved. Interview with LPN #5 on 2/27/26 at 6:38 AM identified there had been an ongoing issue between Resident #41 and Resident #93 for several months in 2025. LPN #5 identified she observed that Resident #41 wanted to be close friends with Resident #93, but Resident #93 was not interested in any friendship or interactions with Resident #41. LPN #5 identified that Resident #41 responded to the rejection by becoming angry and aggressive towards Resident #93, and Resident #41 appeared to fixate on Resident #93 and would often ask where Resident #93 was when he/she left the room. LPN #5 identified that the staff were aware of the issues between Resident #41 and Resident #93, and that it regularly occurred during the evening and overnight shifts, but that she was the only nurse who would document Resident #41's behaviors towards Resident #93 as other nursing staff did not want their names associated with the incidents. LPN #5 identified that on 7/7/25, she observed Resident #41 kick and slap Resident #93 while he/she was in the hallway. LPN #5 could not recall who the other 3 staff were who were present during the incident. LPN #5 identified that she, along with the 3 staff, separated Resident #41 and Resident #93 following the incident. LPN #5 identified she notified the RN supervisor of the incident. LPN #5 indicated it may have been RN #5 (7:00 AM – 3:00 PM RN Supervisor) or RN #6, a prior 11:00 PM – 7:00 AM supervisor who is no longer employed at the facility. LPN #5 identified that she recalled assessing Resident #93 following the incident but did not document. LPN #5 identified that she put a request in the Behavioral Health Visit Request/Follow Up Log for Resident #41 to be seen following the incident, and no further action was taken on her part. LPN #5 also identified she was present for the incident on 10/21/25, and Resident #41 was yelling all night at Resident #93 and did not respond to any redirection by staff. LPN #5 identified she was unsure if she notified the supervisor, but that she placed another request in the Behavioral Health Visit Request/ Follow Up Log for Resident #41 to be seen. LPN #5 identified she had repeatedly notified the DNS and prior Administrator of the issues with Resident #41 and Resident #93, and they were aware of the incidents between the residents. LPN #5 also identified that she would often place requests in the Behavioral Health Visit Request/Follow Up Log when Resident #41 would have behaviors overnight and would attempt to redirect Resident #41, but this often did not work. LPN #5 was unable to identify any additional interventions related to Resident #41 and Resident #93, or why she failed to document any incidents or subsequent assessments in Resident #93's clinical record. Interview with the Medical Director on 3/11/26 at 10:56 AM and review of Resident #93's clinical record, grievance, and letter requesting a room change identified that he was recently notified by the DNS at a medical director meeting that Resident #41 and Resident #93 were placed in separate rooms, but he was not made aware of the specific issues that prompted the room change. In review of the nurses note dated 7/7/25 with the Medical Director he identified he had not been notified that Resident #41 had yelled at and kicked Resident #93 and he was not aware that Resident #41 had also slapped Resident #93, which was ascertained during a staff interview. The Medical Director identified he was not aware of any additional incidents, including the 10/21/25 verbal altercation, or the letter written by Resident #93 and given to the Administrator on 11/10/25 which alleged daily verbal and physical abuse by Resident #41. The Medical Director identified first and foremost, he would expect all staff to keep the residents safe and this would include a room change separating Resident #41 and Resident #93 immediately following the incident on 7/7/25. The Medical Director also identified Resident #41 and Resident #93 should have had physical assessments by a medical provider to determine if they were harmed as a result of the incidents, and to determine if there was a medical cause for Resident #41's behavior. The Medical Director identified that an accident and incident investigation should have been completed, the state agency should have been notified immediately following the incidents, and psychiatric follow-up should have been provided. Further, the residents care plans should have been updated and a root cause analysis should have been done to determine the cause of the incident. The Medical Director identified that the facility had open beds, and if the residents had been separated following 7/7/25, the incident on 10/21/25 and allegations identified by Resident #93 in the letter to the Administrator would not have occurred. The Medical Director also identified that it was completely unacceptable to make a note in a resident's chart regarding any verbal or physical altercation and not do anything else. The Medical Director identified at a minimum, the residents should have been separated and assessed to ensure they were safe. Although attempted, an interview with RN #6 and SW #4 was not obtained. The facility policy on Abuse, Neglect and Exploitation directed that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. The policy also directed an alleged violation was a situation or occurrence observed or reported by staff, resident, relative, or others but had not yet investigated and if verified, could be an indication of noncompliance of federal requirements with abuse. The policy further directed mental abuse included, but was not limited to, humiliation, harassment, threats of punishment, or deprivation, and physical abuse included, but was not limited to, hitting, slapping, punching, biting, and kicking. The policy also identified that possible indicators of abuse included but were not limited to resident reports of abuse, verbal abuse of a resident overheard, physical abuse of a resident observed, and psychological abuse of a resident observed. The policy further identified that an immediate investigation was warranted when suspicion of abuse or reports of abuse occur. The policy also identified that the facility would make efforts to ensure all residents were protected from physical and psychosocial harm as well as additional abuse during and after an investigation. Examples included but were not limited to responding immediately to protect the alleged victim and the integrity of the investigation, examining the alleged victim for any sign of injury including a physical exam or psychosocial assessment, increased supervision of the alleged victim and residents, room changes if necessary to protect the resident from the alleged perpetrator, protection from retaliation, provide emotional support and counseling to the resident during and after the investigation if needed, and revision of the residence care plan if the residents medical, nursing, physical, mental, or psychosocial needs change as a result of an incident of abuse. The policy also directed that reporting of all alleged violations to the Administrator, state agency, Adult Protective Services and all other required agencies including law enforcement when applicable, should be done immediately but not later than two hours after an allegation was made, if the events that cause the allegation involve abuse. 2a. Resident #99 was admitted to the facility in December 2022 with diagnoses that included schizoaffective disorder and dementia. Review of the facility census identified Resident #99 was moved to Resident #23's room effective 3/12/25. The quarterly MDS dated [DATE] identified Resident #99 was moderately cognitively impaired and independent with bed mobility, transfers and ambulation. The care plan dated 10/19/25 identified Resident #99 had an actual mood problem related to dementia, schizoaffective disorder and anxiety. Interventions included monitoring mood, provide supportive psychotherapy and administer medications as ordered. A social service note dated 2/9/26 at 6:12 PM identified Resident #99 requested a room change due to roommate compatibility. A voice message was left for the responsible party with awaiting call back. A social service note dated 2/11/26 identified the requested room change would not take effect as intended because the proposed new roommate's representative was not in agreement. b. Resident #23 was admitted to the facility in March 2022 with diagnoses that included cerebral infarction (stroke)and major depressive disorder with mood disturbances. The annual MDS dated [DATE] identified Resident #23 was cognitively intact and required one person assist with bed mobility, two person assist with transfers and utilized a motorized wheelchair. The care plan dated 10/19/25 identified Resident #23 had a mood problem related to major depressive disorder with interventions that included psychiatric consultation for behavioral concerns and supportive services. A social service note dated 2/9/26 identified Resident #23 reported not getting along with his/her roommate and requested the roommate be moved. A social service note dated 2/11/26 identified the requested room change would not take effect as intended because the proposed new roommate's representative was not in agreement. Resident #23 was referred to psychiatry for support. Social services plan was to follow up as needed and education was provided to both residents. Review of the clinical record and facility documentation failed to identify the circumstances leading up to the room change request. Interview with Resident #99 on 2/24/26 at 8:26 AM identified he/she had frequent altercations with Resident #23 who often cursed at him/her and keeps the TV too loud. Resident #99 indicated in recent days, while in their room, Resident #23 yelled the F word at him/her. In response, Resident #99 grabbed Resident #23's leg momentarily. Resident #23 informed Resident #99 he/she would be reporting the assault, but he/she had heard nothing further. The frequent altercations have left Resident #99 feeling anxious and upset, often not wanting to stay in his/her room and subsequently the resident has made requests for placement at an alternate facility. Resident #99 further identified he/she had also been making repeated requests for a room change with nothing being done to honor his/her request. Interview with Resident #23 on 2/24/26 at 8:36 AM identified he/she did not get along with Resident #99. Resident #23 indicated an altercation over the TV volume had taken place between the two residents on 2/22/26 in their room at approximately 2:30 AM. Resident #23 said the F word to Resident #99 who in response, grabbed Resident #23's right foot with both hands. Resident #23 told Resident #99 that he/she was going to report him/her for assault. Resident #23 did eventually report the incident to NA #4, but no further action was taken. Interview with the Director of Social Services on 2/24/26 at 8:46 AM identified Resident #23 and Resident #99 were roommates who did not get along. Resident #99 complained Resident #23 kept the TV too loud and Resident #23 complained about Resident #99's perfume. On 2/9/26, Resident #99 had called Resident #23 the B word. Both residents were socially separated following the altercation and seen by psychiatry. Referrals have been made for Resident #99 to be transferred to an alternate facility which was under review. The Director of Social Services further indicated she would have to refer to the facility's policies for abuse to determine any further required procedures. Interview with NA #4 on 2/24/26 at 10:17 AM identified while the resident-to-resident incident that occurred on 2/22/26 was not reported to her, it was known that Resident #23 and Resident #99 did not get along. NA #4 had observed the two residents yelling at each other, with Resident #23 often swearing at Resident #99. These incidents were reported to the nurse who did their best to separate the two residents. Interview with LPN #8 on 2/24/26 at 2:24 PM identified she was routinely assigned to Resident #23 and 99's unit during the 7:00 AM to 3:00 PM shift. LPN #8 indicated Resident #23 and Resident #99 frequently got in verbal altercations. Resident #99 would call Resident #23 the B word and Resident #23 would say the F word to Resident #99. LPN #8 separated the two residents and reported the incidents to the Director of Social Services in recent weeks. Interview with NA #7 on 2/24/26 at 2:28 PM identified she was routinely assigned to Resident #23 and 99's unit during the 7:00 AM to 3:00 PM shift and has heard Resident #99 call Resident #23 the B word, and Resident #23 say the F word to Resident #99. Subsequent interview with the Director of Social Services on 2/24/26 at 2:50 PM identified for any allegation of resident-to-resident mistreatment, both residents were to be placed on 1:1 supervision until cleared by psychiatry, the physician and responsible party were to be notified, and the incident documented in the clinical record. The Director of Social Services identified that social service was responsible for obtaining resident statements, conducting follow-up for three days as a supportive measure and updating the care plan. The Director of Social services clarified that on 2/9/26 Resident #99 called Resident #23 the B word, in turn Resident #23 said the F word to Resident #99. The Director of Social Services further identified that while she did notify the Director of Nursing and Administrator, she did not implement the other measures or completely document the incident in the clinical record when the allegation of resident-to-resident verbal mistreatment was first identified on 2/9/26 and indicated she was not as familiar with the policies as required. A subsequent interview with Resident #23 on 2/25/26 at 7:15 AM identified Resident #23 often crossed his/her legs as a layer of protection when having an altercation with Resident #99. Resident #23 indicated altercations were frequent, however, the resident felt that Resident #99 had crossed the line when it became physical and told Resident #99 he/she could report him/her for assault. Resident #23 further identified there had been another recent incident earlier in the month that occurred in the hall. LPN #8 was present and separated the two residents. Resident #23 was aware that LPN #8 reported the incident to the social worker and was told there was going to be a room change, which never occurred. Interview with the DNS on 2/25/26 at 9:30 AM identified she was not previously notified of any other incidents that occurred between Resident #23 and Resident #99 prior to 2/24/26 and there was no prior incident reports related to resident-to-resident altercations. The DNS indicated for any resident-to-resident altercation, she would expect the two residents to be immediately separated, with notification to the nursing supervisor and herself. Interview with LPN #7 at 2/25/26 at 3:15 PM identified in recent weeks, she overheard Resident #99 say the F word to Resident #23. The residents were separated and the social worker was notified. Review of the facility policy for Resident Rights directs that residents receive care and treatment that is adequate, appropriate and in compliance with state and federal regulations. A review of the facility policy for Abuse directs that the facility provides protections for the health welfare and rights of each resident to develop and implement policies that prohibit and prevent abuse. Abuse is defined as the willful infliction of injury, pain and mental anguish caused by verbal abuse defined as any oral, written gestured communication or sounds that will fully include disparaging and derogatory terms to residents or their families, or within hearing distance regardless of age, ability to comprehend or disability.

Based on review of facility documentation and interviews, the facility failed to ensure accurate staffing data was entered in the Payroll Based Journal (PBJ) during FY Quarter 4 2025 (July1 -[DATE]). The findings include: Review of the PBJ Staffing Data Report dated FY Quarter 4 2025 (July1 -[DATE]) identified that the facility triggered for a one star staffing rating, no RN hours on the following dates: 9/19/25, 9/20/25, 9/22/25, 9/23/25, 9/24/25, 9/25/25, 9/26/25, 9/27/25, 9/29/25, and 9/30/25, and failure to have licensed nurse coverage 24 hours/day on the following dates: 9/19/25, 9/20/25, 9/22/25, 9/23/25, 9/24/25, 9/25/25, 9/26/25, 9/27/25, 9/29/25, and 9/30/25. Review of the Daily Staffing documents dated: 9/19/25, 9/20/25, 9/22/25, 9/23/25, 9/24/25, 9/25/25, 9/26/25, 9/27/25, 9/29/25, and 9/30/25 identified the facility did have RN coverage and licensed nurse coverage 24 hours a day. Interview with the Regional Administrator/Director on 2/27/26 at 12:30 PM identified that the PBJ data submitted for FY Quarter 4 was completed by the previous owner, and that she could not speak to the process for PBJ data submission, nor its accuracy, completed by the facility prior to the change of ownership (11/1/25). The Payroll Based Journal policy directs that the facility is to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. The responsibilities for data submission include the Administrator, HR director, and Director of Nursing to be responsible for verifying the accuracy of the staffing data that is submitted to CMS using various facility audit forms and/or payroll vendor reports.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 3 of 3 residents, (Resident #12, 69 and 79) reviewed for activities of daily living (ADL) and who were unable to care for themselves, the facility failed provide basic care including bathing and toileting between 7:00 AM - 12:00 PM after the nurse aide assigned to provide care was reassigned and that information was not communicated to other staff. The findings include:1. Resident 12 was admitted to the facility in August 2025 with diagnoses that included stroke and dementia.The quarterly MDS dated [DATE] identified Resident #7 was severely cognitively impaired, required two person assist with bed mobility, transfers and toileting needs, was incontinent of bowel and bladder, was at risk for the development of pressure ulcers and had no unhealed pressure ulcer.The care plan dated 12/3/25 identified Resident #12 had a potential or actual skin integrity impairment and potential problem with urinary incontinence related to benign prostatic hyperplasia, BPH (enlarged prostate that can contribute to urinary frequency). Interventions included turning and repositioning four times during the shift and providing care after each incontinent episode. 2. Resident #69 was admitted to the facility in January 2024 with diagnoses that included spondylosis (degenerative spine disease) and difficulty walking.The annual MDS dated [DATE] identified Resident #69 was cognitively intact and required one person assist with bed mobility, transfers, bathing and toileting needs, was frequently incontinent, was at risk for the development of pressure ulcers and had no unhealed pressure ulcer.The care plan dated 1/11/26 identified Resident #69 was at risk for complications related to incontinence, history of urinary tract infections, an ADL deficit and impaired skin integrity. Interventions included checking every two hours and assisting with toileting as needed, provide assist of one with bathing dressing/ toileting needs and encourage resident to reposition four times each shift. 3. Resident #79 was admitted to the facility in December 2025 with diagnoses that included Parkinson's disease and stroke.The admission MDS dated [DATE] identified Resident #79 was moderately cognitively intact, required one person assist with bed mobility, transfers, and toileting, was incontinent of bladder and bowel, was at risk for the development of pressure ulcers and had no unhealed pressure ulcers.The care plan dated 12/30/25 identified Resident #79 was at risk for skin breakdown and incontinent. Interventions included providing two person assist for toileting and checking for incontinence routinely and as needed.Interview with LPN #1 on 2/27/26 at 11:50 AM identified NA #13 began her assignment at 7:00 AM and left the facility at 10:00 AM without completing her resident assignments and without informing her. This resulted in several residents not receiving assistance with bathing and incontinent care. LPN #1 indicated she was just learning this information and was adjusting the nurse aide assignments accordingly. LPN #6 was not previously informed that NA #13 would be leaving the facility at 10:00 AM.Observation and facility documentation review with the Administrator and RN #2 on 2/27/26 at 1:00 PM identified 3 of 8 residents, Resident #12, 69 and 79, who had been assigned to NA #13, were still in bed, in johnny coats and wet with urine.Interview with RN #5 on 2/27/26 at 1:19 PM identified he was the assigned nursing supervisor during the 7:00 AM to 3:00 PM shift. RN #5 indicated that a resident who was scheduled for a medical appointment in the community did not have a staff member assigned to go with the resident when transportation arrived just prior to 10:00 AM. RN #5 decided in the moment, to re-assign NA #13 to accompany the resident to the medical appointment but did not to notify LPN #6 of the change.Interview with NA #8 at 2/27/26 1:45 PM identified she assisted the night shift aide in incontinent care at 6:30 AM for Resident #79, but provided no other care for him/her, Resident #12 or Resident #69 until re-assigned after 12:00 PM.Interviews with NA #9 and NA #19 on 2/27/26 at 2:00 PM identified they had not provided any care to Resident #12, Resident #69 or Resident #79 prior to being assigned to do so at 12:00 PM,.Interview with RN #2 on 2/27/26 at 1:57 PM identified she would expect the nursing supervisor to notify the charge nurse if a nurse aide was removed from an assignment so adjustments could be made to ensure all residents receive the necessary care.Interview with NA #13 on 2/27/26 at 3:30 PM identified she was assigned the 'float' assignment consisting of 8 residents. NA #13 provided morning care to 5 of the 8 residents but confirmed she did not provide any incontinent or bathing assistance to Resident #12, Resident #69 and Resident #79 before being re-assigned. NA #13 indicated she was informed by RN #5 at 10:00 AM to accompany another resident on a medical appointment and left immediately thereafter without first notifying the charge nurse or letting anyone know about the status of her assignment. NA #13 had no previous knowledge that she would be reassigned to go to an appointment with another resident until 10:00 AM.Subsequent to Resident #12, 69 and 79 not receiving care due to NA #13's reassignment, a quality assurance performance improvement (QAPI) plan was initiated with immediate review of staffing schedules and patient assignments, staff reassignment to ensure all residents had nurse aide coverage and the wound nurse immediately completed skin assessments which identified no new skin integrity issues. A plan for ongoing surveillance was implemented to review staffing, verify nurse aide assignments each shift and notify the DNS/Administrator of gaps with the DNS/designee to review daily staffing sheets for 30 days.Review of the facility policy for ADL care directed the facility to provide appropriate treatment and services to ensure ADL needs are met daily. Each resident's physical functioning will be assessed, the assistance needed will be included in the care plan and utilized when providing care.

Based on review of facility documentation, facility policy, facility assessment, and interviews, for 5 of 5 nurse aides (NA #8, 15, 16, 17, and 18) and 2 of 2 licensed nurses (LPN #5 and #8), reviewed for sufficient and competent nurse staffing, the facility failed to ensure the staff had demonstrated competencies necessary to care for resident's needs, from the last standard survey ([DATE]) through the change of ownership of the facility on [DATE]. The findings include: Review of NA #8's personnel file identified that he/she was hired in [DATE]. The personnel file failed to identify documentation that annual competencies had been demonstrated from the last standard survey [DATE]. After the facility changed ownership on [DATE], NA #8 completed an in-service on the 2026-2027 mandatory education on [DATE]. Review of NA #15's personnel file identified that he/she was hired in [DATE]. The personnel file failed to identify documentation that annual competencies had been demonstrated from the last standard survey [DATE]. After the facility changed ownership on [DATE], NA #15 completed an in-service on the 2026-2027 mandatory education on [DATE]. Review of NA #16's personnel file identified that he/she was hired in [DATE]. The personnel file failed to identify documentation that annual competencies had been demonstrated from the last standard survey [DATE]. After the facility changed ownership on [DATE], NA #16 completed an in-service on the 2026-2027 mandatory education on [DATE]. Review of NA #17's personnel file identified that he/she was hired in [DATE]. The personnel file failed to identify documentation that annual competencies had been demonstrated from the last standard survey [DATE]. After the facility changed ownership on [DATE], NA #17 completed an in-service on the 2026-2027 mandatory education on [DATE]. Review of NA #18's personnel file identified that he/she was hired in [DATE]. The personnel file failed to identify documentation that annual competencies had been demonstrated from the last standard survey [DATE]. After the facility changed ownership on [DATE], NA #18 completed an in-service on the 2026-2027 mandatory education on [DATE]. Review of LPN #5's personnel file identified that he/she was hired in February 2024. The personnel file failed to identify documentation that annual competencies had been demonstrated in 2025. After the facility changed ownership on [DATE], LPN #5 completed an in-service on the 2026-2027 mandatory education on [DATE]. Review of LPN #8's personnel file identified that he/she was hired in [DATE]. The personnel file failed to identify documentation that annual competencies had been demonstrated in 2025. After the facility changed ownership on [DATE], LPN #8 completed an in-service on the 2026-2027 mandatory education on [DATE]. Interview with the MDS Coordinator/Interim Staff Development and Infection Control Nurse (LPN #6) on [DATE] at 1:48 PM identified that when she began her employment at the facility in [DATE], there was no documentation of nursing staff education or competency evaluations available under the prior owner. LPN #6 indicated that, in collaboration with the IDT and regional team, a mandatory in-service/competency fair was initiated and implemented, for all nursing staff; additionally monthly and as needed education had been implemented including education on droplet precautions and PPE during the facility's influenza and Covid-19 outbreaks in 12/25 and 1/26. Interview with the DNS on [DATE] at 3:07 PM identified that she had worked at the facility since [DATE] and while the annual mandatory education packet was provided to staff by Human Resources, in 2025, they were unable to locate the documentation of the education, as the prior owner had removed/taken the documentation for nursing staff education. The DNS indicated that under the prior owner, she would provide education to staff on things that were new to the facility, and she would make observations of staff during care, but there was no formal process for evaluating licensed nurse or nurse aides for competencies. The DNS further indicated that under the new facility ownership, a mandatory education and skills fair (2026-2027 Mandatory Inservice) had already been implemented for nursing staff, which included education provided by the regional team, staff development, and RNs from sister facilities, as well as hands-on return demonstrations, of licensed nurses and nurse aides, for competency evaluation. Interview with the Human Resources Director on [DATE] at 8:25 AM identified that she was unable to locate any nurse staffing educational or competency documentation from 2025, prior to the change of ownership. The Competency Evaluation policy directs the facility to evaluate each employee to ensure they meet appropriate competencies and skills for performing their job. Initial competency is evaluated during the orientation process, an employee remains on orientation until all competencies are verified and subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of training program, and/or job performance evaluations. The Nursing Services and Sufficient Staff policy directs that the facility must ensure licensed nurses have specific competencies and skill sets necessary to care for the resident's needs as identified through the resident assessments and described in the plan of care, and the facility must ensure that nurse aides are able to demonstrate competency and skills and techniques necessary to care for resident's needs, as identified through resident assessments and as described in the plan of care. Although requested the Facility Assessment (prior to the Facility Assessment updated on [DATE]) was not available for review. The Facility assessment dated [DATE] directs the facility must have sufficient training with the appropriate competencies and skill sets to provide nursing and appropriate related services to assure resident safety and maintain the highest practicable physical, mental and psychosocial well-being of each resident determined by the resident assessments and individual plans of care considering the number, acuity and diagnosis of the facility's resident population. The facility provides staff training/education and competencies that are necessary to provide care and support needed for the resident population. The training/education and competency/skill sets are generally provided upon hire, during monthly in-servicing/training, annual in-service/training, whenever an area of concern is identified, or new areas are identified based on resident diagnosis and/or clinical condition. The facility provides training on topics and competencies that include but are not limited to: resident rights and facility responsibilities, abuse, neglect, and exploitation including reporting procedures and fear of retaliation, Elder Justice Act, customer service, HIPAA, bloodborne pathogens, sexual harassment, MSDS, OSHA, emergency preparedness, elopement, values and standards, workplace violence, CPR/abdominal thrust, pain, falls, body mechanics, fire safety, care/management for people with dementia, person centered care, and behavioral health training.

Based on review of facility documentation, facility policy, and interviews, the facility failed to ensure 5 of 5 nurse aides (NA #8, 15, 16, 17, and 18) received a performance evaluation at least once every 12 months, from the last standard survey (3/12/24) through 2/24/26. The findings include: Review of NA #8's personnel file identified that he/she was hired in August 202. The personnel file failed to identify documentation that an annual performance evaluation was completed from 3/12/24 through 2/24/26. Review of NA #15's personnel file identified that he/she was hired in October 2018. The personnel file failed to identify documentation that an annual performance evaluation was completed from 3/12/24 through 2/24/26.Review of NA #16's personnel file identified that he/she was hired in September 2007. The personnel file failed to identify documentation that an annual performance evaluation was completed from 3/12/24 through 2/24/26.Review of NA #17's personnel file identified that he/she was hired in [NAME] 2004. The personnel file failed to identify documentation that an annual performance evaluation was completed from 3/12/24 through 2/24/26.Review of NA #18's personnel file identified that he/she was hired in October 2018. The personnel file and failed to identify documentation that an annual performance evaluation was completed from 3/12/24 through 2/24/26.Interview with the DNS on 2/27/26 at 8:48 AM identified that performance evaluations for all nursing staff, including nurse aides, had been completed in 2025, but they were unable to locate the evaluations after the change of ownership. The DNS identified that the 2025 process for completing annual performance evaluations was that the DNS evaluated the RN supervisors, the RN supervisors evaluated the charge nurses, and the charge nurses evaluated the nurse aides; the completed evaluations were placed in the employee's personnel file with Human Resources (HR). The DNS further identified that the prior company had taken most of the HR files. The DNS identified that since the change of ownership (10/2025) the new company has started the process for completing annual evaluations, but they have not yet implemented it. The Evaluation Process policy directs the facility to review the work performance of employees with a formal written evaluation. The following procedure will be followed for employee performance evaluations: at the end of each month, the human resource department will notify the department manager of evaluations due for the following month, performance evaluations will be used in determining any promotions, demotions, transfers, terminations, salary/wage adjustments etc. Evaluation forms are to be returned to the manager at least one week prior to the employees appraisal date whenever possible, the manager/supervisor is to complete the employee evaluation form, after the evaluation has been reviewed by the administrator, the manager/supervisor will meet with the employee to review and discuss the evaluation, once the evaluation review is complete, the employee and manager should sign the evaluation form. Original evaluation tools are to be forwarded to the Human Resource department to be processed and placed in the appropriate personnel file. The In-Service Training Program, Nurse Aide policy directs all nurse aides shall participate in regularly scheduled in service training classes. The facility will complete a performance review of nurse aides at least every 12 months. In-servicing will be based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews.

Based on observation, review of the clinical record, facility documentation, facility policy and interview the facility failed to ensure its medication error rate was not 5 percent or greater. The findings include. During the recertification survey 2/24/26 - 2/27/26 the survey team observed 5 residents during medication administration with 35 opportunities for errors. There were 3 observed medication errors making the medication error rate 8.57%. 1. Resident #19 was admitted to the facility in October 2020, diagnosis included with diagnoses that included hypothyroidism.Physician's order dated 2/21/26 directed to administer Levothyroxine 112mcg daily, Vitamin C 500mg daily, Vitamin D 25mg daily, and Ferrous Sulfate Oral Solution 300 (60 Fe) mg/ml give 5ml daily.a. Observation during medication administration on 2/26/26 at 10:04 AM identified that LPN #4 administered Levothyroxine 112mcg, Vitamin C 500mg, Iron (Ferrous Sulfate) tablet 325mg/65mg (medication error), and Vitamin D 25mg. b. Review of the Levothyroxine blister pack on 2/26/26 (used by LPN #6 to administer the Levothyroxine) identified the following directions from the pharmacy.Take this medication at least 4 hours before taking Antacids, Iron or Vitamin/Mineral Supplements. Take this medicine on an empty stomach preferably 1/2 to 1 hour before breakfast. Interview with RN #2 on 2/26/26 at 2:00 PM identified that the Levothyroxine should be administered at 6:30 AM. Subsequent to surveyor inquiry on 2/26/26 the administration time of the Levothyroxine was changed to daily at 6:00 AM, and a TSH and Iron level were ordered. 2. Observation on 2/27/26 at 9:24 AM identified LPN #10 administered medications to Resident #111 however, omitted the administration of the physician ordered Cholecalciferol 1000units. The medication administration policy identified medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Administer medication as ordered and in accordance with manufacturer specifications. Medications requiring administration on an empty stomach include Levothyroxine.

Based on observation, review of facility policy, and interviews, for 4 of 4 medication carts, the facility failed to maintain medication carts in a clean and sanitary manner. The findings include:a. Observation of the medication cart on Center South on 2/25/26 at 1:30 PM with DNS, RN #2 (Vice President of Clinical Operations), and LPN #1 identified an accumulation of loose medication pills and/or blister pack back covers at the bottom of fifth drawer. Interview on 2/25/26 at 1:30 PM with LPN #1 indicated she was not aware of the loose medication pills and/or blister pack back covers at bottom of medication drawer. LPN #1 indicated it is the responsibility of all the nurses to keep the medication cart clean at all times. b. Observation of the medication cart on Center North on 2/25/26 at 1:59 PM with DNS, RN #2 (Vice President of Clinical Operations) and LPN # 2 identified an accumulation of loose medication pills and/or blister pack back covers at the bottom of fifth drawer. Interview on 2/25/26 at 1:59 PM with LPN #2 indicated she was not aware of the loose medication pills and/or blister pack back covers at bottom of medication drawer. LPN #2 indicated it is the responsibility of all the nurses to keep the medication cart clean at all times and after themselves. c. Observation of the medication cart on North on 2/25/26 at 2:05 PM with DNS, RN #2 (Vice President of Clinical Operations) LPN #3 identified an accumulation of loose medication pills and/or blister pack back covers at the bottom of fifth drawer. Interview on 2/25/26 at 2:05 PM with LPN #3 indicated she was not aware of the loose medication pills and/or blister pack back covers at bottom of medication drawer. LPN #3 indicated it is the responsibility of all the nurses to keep the medication cart clean at all times. d. Observation of the medication cart on South on 2/25/26 at 2:10 PM with DNS, RN #2 (Vice President of Clinical Operations) and LPN #4 identified an accumulation of loose medication pills and/or blister pack back covers at the bottom of fifth drawer. Interview on 2/25/26 at 2:10 PM with LPN #4 indicated she was not aware of the loose medication pills and/or blister pack back covers at bottom of medication drawer. LPN #4 indicated it is the responsibility of all the nurses to keep the medication cart clean at all times.Interview on 2/25/26 at 2:15 PM with the DNS identified she was not aware the medication carts were not being cleaned. The DNS indicated the expectation of the facility is that all nurses clean the medication carts at the end of their shift and/or the medication carts are clean at all times. The DNS indicated education and in-service will be given to the nursing staff.Review of the facility storage of medications policy identified the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation review of facility documentation, facility policy and interviews, the facility failed to ensure resident designated water pitches were clean and sanitized routinely. The findings include:Interview with Resident #23 on 2/24/26 at 8:36 AM identified water pitchers were not routinely cleaned and instead, reused daily. Resident #23 had previously complained to staff (unidentified), but the practice continued.Observation on 2/24/26 at 8:36 AM identified an ice cooler on a utility cart at the end of the hall, with no clean water pitchers. Various staff lifted the lid using an ice scooper inside to obtain ice to fill water pitchers before returning to a resident room, with one staff member filling three unmarked water pitchers before heading down the hall towards the resident rooms.Observation on 2/25/26 at 7:04 AM identified the ice cooler at the end of the hall, no clean pitchers.Observation on 2/25/26 at 9:34 AM identified a staff member scooping ice into a water pitcher and returning to a resident room.Observation on 2/26/25 at 10:25 AM identified the ice cooler at the end of the hall, no clean water pitchers.Interview with NA #6 on 2/26/25 at 10:25 AM identified water pitchers were not washed often and that nurse aides must ask. When requesting replacement water pitchers, staff were told there were not enough.Interview with Dietary Aide #1 on 2/26/26 at 10:50 AM identified she routinely operated the dishwasher beginning at 6:00 AM as part of her assignment. Dietary Aide #1 indicated the nurse aides working the 11:00 PM - 7:00 AM shift previously would bring the water pitchers to the kitchen in the morning for cleaning; however, this process had not occurred in the past five months. Instead, water pitches were only cleaned when requested but not routinely.Interview with the Food Service Director (FSD) on 2/26/26 at 10:52 AM identified both nursing staff and dietary staff shared responsibility to ensure residents receive clean water pitchers daily. The FSD indicated there had been shortages of water pitchers and lids, so water pitchers were not changed out routinely adding he had to obtain lids from central supply as early as the preceding day. Instead, existing water pitchers were cleaned if nursing staff made the request.Observation of the storage cabinet where the water pitchers were stored identified approximately 20 water pitchers were stacked in the cabinet with lids stacked to the side.Further interview and tour of central supply with the FSD in the food service storage area and central supply identified one box (100 count each) of water pitchers with lids. One box was opened with an undetermined amount. While the FSD indicated he obtained lids form the open box, he was unable to explain why the new water pitches were not being utilized.Interview and review of facility documentation with Central Supply Staff #1 on 2/26/26 at 11:02 AM identified she assumed central supply responsibilities in November 2025. At that time, she was informed there was a shortage of water pitchers and ordered one box (100 pieces). Central Supply Staff #1 was unable to account for any water pitchers ordered and stored separately.Review of supply order invoices identified the following:Order invoice dated 11/21/25 included one box (100 count) of water pitchers and lids with a shipping date of 11/24/25.A second supply order invoice dated 11/25/25 included one box (100 count) of water pitchers and lids with a shipping date of 11/26/25.A third supply order invoice dated 12/25/25 included one box (48 count) of water pitchers and lids.Interview with the Administrator on 2/26/26 11:07 AM identified clean water pitchers were provided to the residents on a weekly basis. The Administrator indicated she was aware of a shortage November 2025 and directed staff to obtain additional water pitchers. The Administration further identified that while audits were conducted to ensure residents were receiving clean water pitchers, she was unable to provide documentation of such.Interview with Resident #48 on 2/26/26 at 2:06 PM identified his/her water pitcher was replaced/cleaned when requested, not done on a routine basis.Interview with Resident #5 on 2/26/26 at 2:10 PM also identified his/her water pitcher was replaced/cleaned when requested, not done on a routine basis.Interview with NA #2 on 02/27/2026 at 6:30 AM identified she routinely worked the 11:00 PM to 7:00 AM shift. NA #2 indicated water pitchers were cleaned/replaced upon resident request and not completed routinely.Review of the facility policy for Food and Nutrition Policies and Procedures directed that water pitchers be collected at the bedside by nursing, a minimum of one time weekly and delivered to the Food and Nutrition Service employees. Pitchers and tumblers are to be sanitized in the dish machine, returned to nursing stations and distributed/stored until needed.

Based on review of facility documentation, facility policies, and interviews, the facility failed to ensure an antibiotic stewardship program was in place that included a standardized tool for infection surveillance and a system for periodic review, from the last standard survey (3/12/24) through the change of ownership (11/1/25). The findings include: Review of the Antibiotic Stewardship binder with documentation dated 3/1/25 through 2/23/26 failed to identify, that from 3/1/25 through 10/31/25, the facility was using a standardized tool when assessing residents for infection and failed to identify that a feedback system was in place for educating prescribing practitioners on their antibiotic utilization patterns and facility infection rates. Review of November 2025, December 2025, and January 2026 (February 2026 in process) Monthly Infection Reports identified infection surveillance, broken down by body systems and percentages rates, was being tracked. During an interview with the MDS Coordinator/Interim Staff Development and Infection Control Nurse (LPN #6) and the Regional Clinical Leader on 2/26/26 at 11:00 AM, LPN #6 identified that she began working at the facility in November 2025, and when she arrived there was no standardized tool in place for infection surveillance, and subsequent to the change of ownership, the facility began utilizing McGeer criteria for infection surveillance. LPN #6 further indicated that there was no documentation available, from the prior owner, that periodic review and reporting on antibiotic surveillance and infection surveillance to appropriate members of the interdisciplinary team such as the medical providers and nursing staff, had occurred nor was there documentation of education being provided to nursing staff about antibiotic stewardship, prior to the change of ownership. LPN #6 identified that during the December 2025 Medical Staff meeting, the monthly infection reports were reviewed, and the reports will be reviewed again at the upcoming March Medical Staff Meeting. The Regional Clinical Leader indicated that there was no data available from the previous owner (prior to 11/1/25) to include in the statistical analysis, but it was their goal to have monthly infection rate and antibiotic usage data reviewed, then build up to quarterly, and then yearly for the IDT review. Interview with the DNS on 2/26/26 at 3:07 PM identified that she was hired in March 2025, and that from her time of hire until the change of ownership (11/1/25), the facility was without a full-time Infection Control Nurse (ICN), and that the prior owner oversaw the Infection Control Program. The DNS indicated that there was no documentation available that the facility had used a standardized tool for infection surveillance, and that during Medical Staff meetings, infection and antibiotic surveillance data was not reported on to the IDT. The DNS identified that during the Medical Staff Meetings, active infections would be reported, but antibiotic reconciliation and provider antibiotic ordering data were not presented, and the prior owner would report that the ICN position was open and that the facility was actively trying to hire an ICN. The Antibiotic Stewardship policy directs the purpose of the antibiotic stewardship program is to monitor the use of antibiotics in the residents. Orientation, training, and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. The Infection Prevention and Control Committee (IPCC) policy directs that the objectives of the infection prevention and control program were to: assist in the development and implementation of written policies and procedures for prevention and control of infections among residents and personnel, provide the facility guidelines for a safe and sanitary environment, review, establish and monitor environmental infection control approaches, develop isolation precaution protocols, identify situations that may result in employees exposure to blood, bodily fluids, or other potentially infectious materials, help develop an effective employee health program, develop infection prevention and control orientation and in service training programs for all levels of facility personnel, develop policies and procedures for the surveillance and monitoring of infection control practices, and review and help monitor the medical waste management plan. The IPCC will advise administration about ensuring that records are maintained to document the following, in part, in-service training records and findings made during surveillance of antibiotic usage patterns. The IPCC shall meet whenever necessary, or its functions will be covered by the QAPI committee, at least monthly overtime. Committee meetings will cover at least: Directives from health department, surveillance reports of infections or infectious in communicable diseases, surveillance reports of antibiotic usage and antibiotic susceptibility patterns, policy reviews and revisions, current infection control/prevention concerns, environmental infection control concerns, changes in regulations, antibiotic utilization patterns, and emergence of antibiotic resistant organisms, measures to prevent infections or exposures in the future, and in- service training program.

Based on review of facility documentation, facility policy and interviews, the facility failed to designate an infection preventionist (IP) at least part time to monitor the facility infection control program. The findings include:Review of the facility infection control program identified there no designated IP.Interview and facility documentation review with the Administrator on 2/24/26 at 2:03 PM identified that no designated IP had been assigned since 1/19/23. Various staff had intermittently assisted, including LPN #6, employed since November 2025 and the DNS who was recently certified on 2/7/26. The Administrator indicated there were ongoing efforts to recruit for the position; however, facility documentation identified the position had been posted on just one occasion, 10/22/25. The Administrator further identified a candidate was hired for the position and was anticipated to begin on 3/4/26. The Administrator was unable to provide documentation through schedules or punch records demonstrating designated time for the management infection control program or LPN #6's oversight.Review of the policy for Infection Preventionist directed the facility to employ one or more qualified individuals with the responsibility for implementing the facility's infection prevention and control program (IPCP). The individual is designated by the facility to be responsible for the IPCP, qualified by education, training in infection control and prevention, have experience or certification, must be employed at least part time, with the amount of time determined by the facility assessment and needs for its IPCP.Review of the facility assessment identified the facility maintained an IP and IPCP with no formal hours detailed.

Based on review of facility documentation, facility policy, facility assessment, and interviews, the facility failed to ensure 5 of 5 nurse aides (NA #8, 15, 16, 17, and 18) reviewed for sufficient and competent nurse staffing, completed the minimum required 12-hours of in-service education, annually, from the last standard survey (3/12/24) through the change of ownership (11/1/25). The findings include: Review of NA #8's personnel file identified that he/she was hired in August 2021. The personnel file failed to identify documentation that the minimum required 12-hours of in-service education had been completed between the last standard survey, 3/12/24 and 1/31/26, 22 months. Review of NA #15's personnel file identified that he/she was hired in October 2018. The personnel file failed to identify documentation that the minimum required 12-hours of in-service education had been completed between the last standard survey, 3/12/24 and 12/29/25, 21 months. Review of NA #16's personnel file identified that he/she was hired in September 2007. The personnel file failed to identify documentation that the minimum required 12-hours of in-service education had been completed between the last standard survey, 3/12/24 and 1/4/26, 21 months. Review of NA #17's personnel file identified that he/she was hired in July 2004. The personnel file failed to identify documentation that the minimum required 12-hours of in-service education had been completed between the last standard survey, 3/12/24 and 1/30/26, 22 months. Review of NA #18's personnel file identified that he/she was hired in October 2018. The personnel file failed to identify documentation that the minimum required 12-hours of in-service education had been completed between the last standard survey, 3/12/24 and 1/31/26, 22 months. Interview with the MDS Coordinator/Interim Staff Development and Infection Control Nurse (LPN #6) on 2/26/26 at 1:48 PM identified that when she began her employment at the facility in November 2025, there was no documentation of nursing staff education available, and she could not speak to how many hours of in-service education the nurse aides had received, under the prior owner. LPN #6 indicated that, in collaboration with the IDT and regional team, a mandatory in-service was initiated, for all nursing staff which covered educational topics such as: resident rights, HIPAA, dignity and privacy, abuse, retaliation, cultural diversity, customer service, pain, dementia, hand hygiene, quality and environmental grounds, infection control/prevention, precautions in MDROs, personal protective equipment, occupational exposure to TB, bloodborne pathogens, elopement, fall prevention, abdominal thrusts/Heimlich, hazardous materials, lockout/tag out, fire prevention, electrical safety, emergency preparedness, active shooter, workplace violence, sexual harassment, corporate compliance, agronomics and body mechanics, antibiotic stewardship, and COVID-19, which she estimated to account for 2-3 hours of education. Additionally, in-person education had also been provided and documented when opportunities had been identified, from November 2025 through February 2026. Interview with the DNS on 2/26/26 at 3:07 PM identified that she had worked at the facility since March 2025 and while an annual mandatory education packet was provided to staff by Human Resources, in 2025, they were unable to locate the binder for in-servicing education documentation, as the prior owner had removed the binder and documentation of the nursing staff education, and she was unable to identify if nurse aides had received 12 hours of in-service education. The DNS further indicated that under the new facility ownership, a mandatory education and skills fair (2026 - 2027 Mandatory Inservice) had already been implemented for nursing staff, which included education provided by the regional team, staff development, and RNs from sister facilities. Interview with the Human Resources Director on 2/27/26 at 8:25 AM identified that she was unable to locate nurse staff education documentation from 2025, prior to the change of ownership. The In-Service Training Program, Nurse Aide policy directs all nurse aides shall participate in regularly scheduled in-service training classes. The facility will complete a performance review of nurse aides at least every 12 months. In-service training will be based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews. Annual in-services must ensure the continuing competence of nurse aides, be no less than 12-hours per employment year, address areas of weakness as determined by nurse aid performance reviews, address the special needs of the residents as determined by the facility staff, include training that addresses the care of residents, cognitive impairment, and include training and dementia management and abuse prevention. All training classes attended by employees shall be entered on their respective employees' record of in-service by the person designated by the supervisor and records shall be filed in the employee's personnel file. Although requested, the Facility Assessment (prior to the change in ownership; updated on 11/13/25) was not available. The Facility assessment dated [DATE] directs the facility requires in-service training for nurse-aides. In-service training must be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year.

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 6 residents (Resident #16 and 110) reviewed for grievances, the facility failed to ensure the residents were treated in a respectful and dignified manner. The findings included: 1. Resident #16 was admitted to the facility in January 2026 with diagnoses that included muscle wasting and atrophy, dementia, history of falling, and congestive heart failure.The care plan dated 1/16/26 identified Resident #16 had a self-care performance deficit. Interventions included providing assistance in completing ADL tasks as needed, offer toileting every 2-3 hours while awake and staff to check for incontinence and assist with changes routinely and as needed.The resident grievance form dated 1/21/26 identified Resident #16 indicated he/she requested a blanket on 1/20/26 at 4:00 PM which was not provided until the following morning by another staff member. Resident #16 also indicated he/she requested a bedpan and was informed by staff that bedpans were not used at the facility. The resolution was staff education regarding customer service, social work support and weekly follow-up. The admission MDS dated [DATE] identified Resident #16 had intact cognition, was frequently incontinent of bowel and bladder, required supervision or touching assistance with roll left and right, and required partial/moderate assistance with toilet transfer.Review of the all-staff meeting form dated 1/23/26 identified the agenda included customer service and mutual respect in the workplace for colleagues, visitors, vendors, providers, and residents. Review of the in-service training sheet (no date or time) identified to reinforce professional conduct, respectful communication and compliance with facility expectations when interacting with residents, families, coworkers, and management. Customer service expectations: Maintain respectful, professional behavior at all times. Follow assigned duties and instructions as directed. Respond promptly and appropriately to requests. Control tone, language, and body language regardless of stress or disagreement.Review of the staff in-service sign-in forms failed to reflect documentation that NA #15, 21, 23, 24, LPN #7, and #13 had signed in-service sign-in forms or received the education. The facility could not verify attendance for these staff members. Review of the clinical record and facility documentation failed to reflect that the allegation made by Resident #16 regarding requesting a blanket and bedpan had been addressed or investigated.Interview with the DNS on 3/11/26 at 11:00 AM identified she was not aware that Resident #16 had requested a blanket on 1/20/26 at approximately 4:00 PM and had also requested a bedpan that was not provided during the shift. The DNS indicated she had not reviewed the resident grievance form dated 1/21/26 and had not investigated the allegations documented on the grievance form. The DNS indicated the Administrator had informed her during the morning meeting to provide staff with an in-service regarding customer service. The DNS indicated that she was not aware that the following staff members had not received the customer service in-service: NA #15, 21, 23, 24, LPN 7, and 13. The DNS indicated that going forward she would review resident grievance forms and investigate any allegations related to customer service. The DNS indicated she was unaware which nurse aide was assigned to Resident #16 or which staff member failed to provide the resident with an extra blanket or informed the resident that no bedpan was available. The DNS indicated the facility has adequate supply of extra blankets and bedpans. The DNS indicated the resident should have been provided with an additional blanket if requested. The DNS indicated staff should not inform residents that bedpans are unavailable.Interview with the Administrator on 3/11/26 at 11:30 AM identified she was aware of the resident grievance form dated 1/21/26. The Administrator indicated that an all staff meeting was held on 1/23/26 and the agenda included customer service and mutual respect in the workplace for colleagues, visitors, vendors, providers, and residents. The Administrator indicated that she had informed the DNS during a morning meeting to provide staff with an in-service regarding customer service. The Administrator indicated she was not aware the DNS had not reviewed the resident grievance form dated 1/21/26 or conducted an investigation. Interview with NA #24 on 3/13/26 at 4:12 PM identified he has been employed by the facility since September 2021 and works per diem. NA #24 indicated he was assigned to Resident #16 during 3:00 PM - 11:00 PM shift on 1/20/26. NA #24 indicated he was not familiar with the resident. NA #24 indicated he does not recall Resident #16 requesting a blanket or a bedpan from him during that shift. NA #24 indicated the facility does have extra blankets and bedpans. Interview with NA #23 on 3/13/26 at 4:29 PM identified she has been employed by the facility since 8/15/25. NA #23 indicated she was not assigned to Resident #16 during 3:00 PM - 11:00 PM shift on 1/20/26. NA #23 indicated she does not recall Resident #16 requesting a blanket or a bedpan from her during that shift.Interview with LPN #13 on 3/13/26 at 4:33 PM identified she has been employed by the facility since 11/11/24. LPN #13 indicated she does not remember if she was assigned to Resident #16 during 3:00 PM - 11:00 PM shift on 1/20/26. LPN #13 indicated she does not recall Resident #16 requesting a blanket or a bedpan from her during that shift. LPN #13 indicated the facility does have extra blankets and bedpans.Interview with NA #15 on 3/13/26 at 4:45 PM identified she has been employed by the facility since 10/5/18. NA #15 indicated she was not assigned to Resident #16 during 3:00 PM - 11:00 PM shift on 1/20/26. NA #15 indicated she does not recall Resident #16 requesting a blanket or a bedpan from her during that shift.Interview with LPN #7 on 3/13/26 at 4:50 PM identified she has been employed by the facility since 9/29/25. LPN #7 indicated she does not remember if she was assigned to Resident #16 during 3:00 PM - 11:00 PM shift on 1/20/26. LPN #7 indicated she does not recall Resident #16 requesting a blanket or a bedpan from her during that shift. LPN #7 indicated the facility does have extra blankets and bedpans.Attempts to interview NA #21 were unsuccessful.Review of the resident bill of rights identified the resident has the right to dignity, respect, and freedom: To be treated with consideration, respect, and dignity. Right to participate in one's own care: Receive adequate and appropriate care. 2. Resident #110 was admitted to the facility in December 2025 with diagnoses that included legal blindness, muscle wasting and atrophy, repeated falls, lumbar radiculopathy, and right knee osteoarthritis.The care plan dated 12/16/25 identified Resident #110 was at risk for skin breakdown related to immobility. Interventions included offer toileting every 2-3 hours while awake. Staff to check for incontinence and assist with changes routinely and as needed.The admission MDS dated [DATE] identified Resident #110 had intact cognition, was occasionally incontinent of bladder, frequently incontinent of bowel, and required partial/moderate assistance with toilet transfer and toileting hygiene.The care plan dated 12/22/25 identified Resident #110 had incontinent episodes. Interventions included conducting incontinence checks and providing care as needed. Encourage to use call light for assistance with toileting. Toilet resident as needed.The physician's order dated 1/1/26 directed to provide the resident with assist of one for bed mobility and stand, pivot, and transfer to wheelchair, and with ADL's and toileting and wheelchair level. Further, ambulation only with therapy.The resident grievance form dated 1/12/26 identified Resident #110 indicated that on 1/12/16 at approximately 5:00 AM, he/she rang the call light requesting a bedpan. According to the grievance documentation, the nurse aide instructed the resident to use his/her brief instead of providing a bedpan and subsequently, Resident #110 soiled his/her brief. Resident #110 indicated peri care was later provided. Resident #110 indicated the nurse aide said (shouldn't you be sleeping at this time). The Administrator and resident representative were notified. The resolution included providing education to staff regarding customer service, and the Social Worker to follow up with the resident.Review of the nursing home customer service handout sheet (no date and time) identified customer service is the act of providing residents, families, and visitors with respectful, helpful, and compassionate care while meeting their needs and expectations. Treat everyone with dignity. Address needs and questions promptly.Review of the staff in-service sign-in forms failed to reflect documentation of signature for NA #20 indicating the facility could not verify attendance for the staff member.Review of the weekly skin evaluation form dated 1/19/26 identified Resident #110 had no open areas or wounds.Review of the clinical record and facility documentation failed to reflect that the allegation was address or investigated.Interview with the DNS on 3/11/26 at 11:45 AM identified she was not aware that Resident #110 had requested a bedpan that was not provided at 5:00 AM on 1/12/26. The DNS indicated she had not reviewed the resident grievance form dated 1/12/26 and had not conducted an investigation regarding the allegations documented on the grievance form. The DNS indicated the Administrator had informed her during the morning meeting to provide staff with an in-service regarding customer service. The DNS indicated that she was not aware that the following staff member had not received the customer service in-service: NA #20. The DNS indicated that going forward she would review resident grievance forms and investigate any allegations related to customer service. The DNS indicated she was unaware which nurse aide had been assigned to Resident #110 at the time of the incident. The DNS indicated that Resident #110 should not be instructed to urinate or have a bowel movement in a brief, as this would be a dignity concern. The DNS indicated that when Resident #110 requested to use the bathroom, the nursing staff should have assisted him/her to the bathroom or provided a bedpan rather than instructing the resident to urinate or have a bowel movement in the brief.Interview with the Administrator on 3/11/26 at 11:55 AM identified she was aware of the resident grievance form dated 1/12/26. The Administrator indicated that she had informed the DNS during a morning meeting to provide staff with an in-service regarding customer service. The Administrator indicated she was not aware the DNS had not reviewed the resident grievance form dated 1/12/26 or conducted an investigation. Interview with NA #20 on 3/13/26 at 1:58 PM identified she has been employed by the facility since 11/12/24. NA #20 indicated she was assigned to Resident #110 on 1/11/26 on the 11:00 PM - 7:00 AM shift. NA #20 indicated on 1/12/26 at approximately 5:00 AM Resident #110 had rang the call light and requested to go to the bathroom. NA #20 indicated Resident #110 asked to be transferred into the wheelchair and taken to the bathroom. NA #20 indicated she explained to Resident #110 that it was not safe to transfer him/her into the wheelchair and take him/her to the bathroom. NA #20 indicated Resident #110 requires an assist of one with transfers. NA #20 indicated she instructed Resident #110 to soil the brief and that she would provide incontinent care afterward. NA#20 indicated she was not aware that Resident #110 had reported incident to the Social Worker. NA #20 indicated the nurse aides are allowed to make judgement calls regarding transferring residents from bed to wheelchair or wheelchair to bed. NA #20 indicated she did not feel it was safe to transfer Resident #110 and made a judgement call not to perform the transfer. NA #20 indicated she continued to provide care to Resident #110 until the resident was discharged home. NA #20 indicated she did not notify the RN supervisor or the floor nurse that the resident was not safe to transfer bed to wheelchair with assistance of one staff member. NA #20 indicated she did not recall telling the resident, (shouldn't you be sleeping at this time). Interview with LPN #11 on 3/13/26 at 2:42 PM identified she is from the agency. LPN #11 indicated she was not aware of Resident #110 having rung the call light for the bedpan and NA #20 instructed the resident to soil the brief. LPN #11 indicated RN #10 and NA #20 did not inform her of the issue during the 11:00 PM - 7:00 AM shift.Interview with RN #10 on 3/16/26 at 8:55 AM identified he worked on 1/11/26 during the 11:00 PM - 7:00 AM shift as the RN supervisor. RN #10 indicated he was an agency staff and that it was his first time working at the facility. RN #10 indicated he was not aware that NA #20 told Resident #110 to go to the bathroom in his/her brief. RN #10 indicated NA #20 should have offered a bedpan to Resident #110 and should not have instructed the resident to soil the brief. RN #10 indicated NA #20 should have notified LPN #11 or him if Resident #110 was not safe to transfer from the bed to the wheelchair to use the bathroom.Attempts to interview NA #21 were unsuccessful.Review of the resident bill of rights identified right to dignity, respect, and freedom: To be treated with consideration, respect, and dignity. Right to participate in one's own care: Receive adequate and appropriate care.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #99) reviewed for resident rights, the facility failed to honor the residents request for a room change due to negative interactions with his/her roommate. Subsequently, the resident and his/her roommate had a resident-to-resident altercation. The findings include:Resident #99 was admitted to the facility in December 2022 with diagnoses that included schizoaffective disorder and dementia.The quarterly MDS dated [DATE] identified Resident #99 was moderately cognitively impaired and independent with bed mobility, transfers and ambulation.The care plan dated 10/19/25 identified Resident #99 had an actual mood problem related to dementia, schizoaffective disorder and anxiety. Interventions included monitoring mood, providing supportive psychotherapy and administering medications as ordered.Review of the grievances included a handwritten note from Resident #99 to an unidentified staff member requesting a room change due in part that he/she and roommate both hate each. This was attached to a separate resident grievance dated 11/10/25 and completed and signed by the Administrator, Nurse's note dated 1/26/26 at 6:15 PM identified Resident #99 engaged in a verbal altercation with his/her roommate. For de-escalation purposes, Resident #99 was relocated to an alternate room for the night. Management was to review and a decision pending. The resident representative was updated.Nurse's note dated 1/27/26 at 5:15 AM identified Resident #99 was observed in his/her original room at the beginning of shift, slept through the night with no behaviors.Social service note dated 2/9/26 at 6:12 PM identified the resident requested a room change due to roommate compatibility. A voice message was left for the resident representative with awaiting call back.Social service note dated 2/11/26 identified the requested room change would not take effect as intended peer's responsible party was not in agreement.Interview with Resident #99 on 2/24/26 at 8:26 AM identified he/she had frequent altercations with Resident #23 who often curses at him/her and keeps the TV too loud. Resident #99 indicated in recent days, while in their room, Resident #23 yelled the F word at him/her. In response, Resident #23 grabbed his/her leg momentarily. The frequent altercations have left Resident #99 feeling anxious and upset, often not wanting to stay in his/her room and had made requests to an alternate facility. Resident #99 further identified she had also been making repeated requests for a room change with nothing being done to honor his/her request.Interview with the Director of Social Services on 2/24/26 at 8:46 AM identified Resident #23 and Resident #99 were roommates who did not get along. Resident #99 complains Resident #23 keeps the TV too loud and Resident #23 complains about Resident #99's perfume. On 2/9/26, Resident #99 had called Resident #23 the B word. Both residents were 'socially' separated following the altercation and seen by psychiatry. Referrals have been made for Resident #99 to be transferred to an alternate facility which was under review The Director of Social Services further indicated she would have to refer to the facility's policies for abuse to determine any further required procedures.Interview with the Administrator on 2/25/26 at 9:59 AM identified although the handwritten room change request from Resident #99 was attached to a grievance she completed and signed dating back to 11/10/25, she stated she had not previously seen the note.Subsequent interview with the Director of Social services on 2/27/26 at 2:06 PM identified her hire date was 11/10/25. Therefore, she had not seen the handwritten request for a room change by Resident #99. A room change was planned following the verbal altercation on 2/9/26. However, the responsible party of the alternate roommate did not agree, and the facility census was at capacity so Resident #99 was not moved. The Director of Social Services further identified she did not explore any other room options to honor Resident #99's request at that time or any other time following an altercation.Review of the facility daily census dated 2/9/26 through 2/24/26 identified a capacity of 108 beds and between 100 and 105 occupied beds with no documented bed holds.Review of the facility policy for Room Changes directs that changes room and/or roommate assignments may change when considered necessary and/or when requested by the resident or resident representative. Reasons for a change in room or roommate could include incompatibility of residents in a shared room. Requests for changes in room or roommate should be communicated to the Social Service Designee. Prior to making a room/roommate assignment change, all persons involved including residents and their representatives, will be given advance notice of such a change as is possible, informing the resident and family as soon as possible of the room or roommate change, involving the resident in the decision and selection of a room or roommate when possible.The facility may make an emergency change in room or roommate assignment should it become necessary for the safety, health and well-being of the resident.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #93) reviewed for abuse, the facility failed to notify the physician and the resident representative of verbal and physical abuse by Resident #41 and for 2 of 5 residents (Resident #74 and 90) reviewed for nutrition, the facility failed to notify the physician of a significant weight gain in a timely manner. The findings include: 1a. Resident #41 was admitted to the facility in September 2004 with diagnoses that included schizophrenia, dementia, and anxiety disorder. The annual MDS dated [DATE] identified Resident #41 had moderately impaired cognition. A nurse's note dated 7/7/25 at 7:34 AM by LPN #5 (11:00 PM – 7:00 AM charge nurse) identified Resident #41 was observed at 5:00 AM having a verbal altercation with his/her roommate (Resident #93). LPN #5 identified the altercation occurred without a reason, and that Resident #41 continued with behaviors despite attempts at redirection, and that Resident #41 was observed yelling at other residents in the unit hallway. The note further identified that Resident #41 was observed by 3 facility staff kicking his/her roommate in the hallway. LPN #5 identified she notified her supervisor and that a referral to be seen by psychiatry in the morning had been placed. A psychosocial evaluation note dated 7/7/25 identified that Resident #41 displayed rudeness towards his/her roommate and aggression towards staff overnight. The note further identified that individual psychotherapy would be provided 1 – 5 times monthly to reduce emotional symptoms. A psychiatric evaluation note dated 7/8/25, by APRN #4, identified she was asked to see Resident #41 due to agitated behaviors per nursing. APRN #4 identified no signs of delusions, auditory or visual hallucinations, agitation or aggression. APRN #4 further identified no changes were recommended based on her evaluation. A nurse's note dated 10/21/25 at 5:13 AM by LPN #5 identified Resident #41 was observed up all night yelling and screaming at his/her roommate for no reason. LPN #5 identified she attempted to redirect Resident #41 with no result. Review of a Behavioral Health Visit Request/Follow Up Log identified a note on 10/21/25 which identified Resident #41 was up all night yelling at his/her roommate for no reason and accosting him/her for coughing. A medical APRN note dated 10/31/25 identified during the visit, Resident #41 was mildly anxious, ambulating the hallway asking where is my roommate. The note further identified that staff reported Resident #41 had a recent escalation in behaviors that included yelling and screaming at his/her roommate during the night and being disruptive. The note also identified that redirection was not successful, and that Resident #41 was seen by the psychiatric provider with an increase of Risperdal ordered. b. Resident #93 was admitted to the facility in May 2024 with diagnoses that included schizophrenia, psychosis, and adjustment disorder. The clinical record identified Resident #41 had a room change to Resident #93's room on 3/13/25. The care plan dated 4/28/25 identified Resident #93 had potential for impaired thought processes related to difficulty expressing him/herself. Interventions included communicating with the resident and his/her resident representative regarding his/her needs. The quarterly MDS dated [DATE] identified Resident #93 had intact cognition. A psychiatric supportive services note by SW #3 on 11/8/25 identified Resident #93 reported ongoing issues with his/her roommate. A nurse's note dated 11/10/25 at 7:52 PM by RN #5 (7:00 AM – 3:00 PM RN Supervisor) identified Resident #93 requested to be transferred to another room, the room transfer was completed, and Resident #93's representative was notified. Review of a facility grievance form dated 11/12/25 (two days after the room change) identified Resident #93 requested a room change due to verbal abuse by his/her roommate. An undated letter addressed to the administrative office, which was attached to the grievance form was signed by Resident #93. The grievance form was completed by SW #1 (Social Work Director) and signed by Resident #93, SW #4, and the Administrator, identified that the resident's room was changed and the resident reported that things were better following the change. Review of the letter (attached to the grievance dated 11/12/25) written and signed by Resident #93 identified the following. Resident #41 abuses me verbally and has hit me a few times. I fight back and hopefully won't get violent and be in trouble for it. He/she does it every day when I enter the room or leave and when I go to my closet. I want a different room. Interview with Resident #93 on 2/24/26 at 3:18 PM identified he/she had been in the same room with Resident #41 since March 2025. Resident #93 identified beginning sometime in the summer, Resident #41 began to make advances towards him/her (Resident #93) that made him/her feel uncomfortable. Resident #93 identified once he/she rejected the advances, Resident #41 became more aggressive, and would intermittently yell at him/her for no reason. Resident #93 identified that over time, the yelling escalated from intermittent episodes to constant yelling overnight, and then occasionally included being hit or kicked by Resident #41. Resident #93 identified that by the time he/she had written the letter to the Administrator in November 2025, Resident #41 was yelling overnight several times a week, and anytime Resident #93 attempted to access his/her closet, which was located near the door and Resident #41's bed, Resident #41 would approach from behind and shove Resident #93 into the closet door. Resident #93 identified that he/she had reported the incidents several times to multiple nursing staff, but they had instructed Resident #93 to tell Resident #41 he/she did not want to talk and to stop the behavior. Resident #93 identified he/she tried but that only made Resident #41's behavior worse. Resident #93 identified that he/she would often sit in the hallway to avoid Resident #41 and only go in his/her room as necessary, but it did not help and the behaviors continued. Resident #93 reported he/she feared Resident #41 and did not feel safe while in the same room with him/her and so he/she wrote a letter to the Administrator and asked for a room change. Resident #93 identified no staff had ever offered to move him/her to another room prior to the letter, and after the room change, a staff member who he/she could not remember, followed up once to make sure the new room was working out. Interview with SW #1 on 2/26/26 at 9:05 AM identified she began working at the facility on 11/10/25 and was shadowing SW #4 for the first few days. SW #1 identified that SW #4 had outstanding grievances that needed to be completed and to help SW #4 out, she completed the grievance form for Resident #93's request for a room change but did not address the issue herself. SW #1 was unable to identify if Resident #93's allegation of abuse was addressed outside of his/her request for a room change and reiterated that it was SW #4's responsibility. Interview with the Administrator on 2/26/26 at 9:07 AM identified she received a letter from Resident #93 related to a room change but didn't read the letter from Resident #93 because she could not read the handwriting. The Administrator directed SW #4 to address it as a grievance and she did not make any attempt to discuss or review the letter with Resident #93, and was unaware that the letter, addressed to her, included allegations of daily verbal and physical abuse by Resident #41. The Administrator further identified she was unaware of the incidents documented in Resident #41's clinical record related to verbal and physical altercation with Resident #93 on 7/7/25 or verbal altercation on 10/21/25. Interview with RN #5 (7:00 AM – 3:00 PM supervisor) on 2/26/26 at 10:55 AM identified he assisted with Resident #93's room change but was not sure why Resident #93 had made the request. RN #5 identified based on his recollection, Resident #93 had approached him sometime during the day on 11/10/25 to request the room change. RN #5 identified he was unsure who he spoke to about the issue. RN #5 identified that he was not aware of Resident #93's grievance or the allegations of abuse by Resident #41 or yelling overnight by Resident #41, and that he was not aware of any issues between the residents. RN #5 identified that when Resident #93 was moving his/her belongings to the new room on 11/10/25, he did recall Resident #41 asking him where his/her roommate was going and said (I love my roommate). Interview with NA #3 on 2/26/26 at 11:43 AM identified that she worked on the 11:00 PM – 7:00 AM shift but did not recall being assigned to Resident #41 and Resident #93's unit. NA #3 identified that while she was not assigned to the residents, it was common knowledge with the nursing staff throughout the facility that Resident #41 would confront Resident #93 with aggressive behaviors on a regular basis. NA #3 identified she never saw Resident #41 become physical with Resident #93 on 7/7/25 but did witness on multiple occasions Resident #41 yelling at Resident #93 overnight, and witnessed Resident #41 go directly into Resident #93's face and yell on multiple occasions. NA #3 identified it was very hard to redirect Resident #41 away from Resident #93 and to deescalate the behaviors. NA #3 also identified that while she did not observe Resident #41 attempt to hit or kick Resident #93, Resident #41 had attempted to hit her in the past but stopped before actually striking her. NA #3 identified that Resident #41 was verbally abusive to Resident #93, and the behavior had gone on for several months in 2025. NA #3 also indicated that Resident #93 had reported to her she was afraid of Resident #41. NA #3 identified Resident #41 felt disrespected because Resident #93 would not speak with him/her, and that caused Resident #41 to escalate and begin yelling. NA #3 identified that she reported behaviors to the unit charge nurse but was unable to provide any specifics on the nurse or when she reported the issues. NA #3 reported that staff at the facility would attempt to redirect Resident #41 but a room change was not attempted prior to 11/10/25. NA #3 indicated she was not aware of any other interventions to protect Resident #93, and that she never observed Resident #93 being aggressive or instigating any altercations with Resident #41. NA #3 also identified that it was the longstanding culture of the nursing staff, including the nurse aides and licensed nurses, to ignore Resident #41's behaviors and not address the issues, which was likely why Resident #93 had to self-request the room change. Interview with SW #3 on 2/26/25 at 12:17 PM identified that Resident #93 had reported issues with Resident #41, however the issues were that Resident #93 found Resident #41 to be annoying. SW #3 identified Resident #93 reported Resident #41 was loud and she had a hard time sleeping because of this, but did not report any physical abuse, safety or inappropriate behavior. Interview with APRN #4 on 2/26/26 at 1:26 PM identified that she was not aware of any issues related to Resident #41 and Resident #93, including any issues related to physical or verbal altercations. Interview with the DNS on 2/26/26 at 1:42 PM identified that she had been the DNS of the facility since March 2025. The DNS identified that she was not aware of any issues between Resident #41 and Resident #93, was not aware of the incidents on 7/7/25 or 10/21/25, and was not aware of the letter written by Resident #93 to the Administrative office in November 2025 which alleged daily abuse by Resident #41, and was not aware why Resident #93 requested a room change. The DNS identified that following the incident on 7/7/25, the residents should have been placed in separate rooms for safety and if Resident #41 did not respond to redirection, the resident should have been sent to the hospital for psychiatric evaluation. The DNS also identified that the medical and psychiatric providers should have been notified of every incident between the residents as well as the resident representatives, and that social work should have been involved. Interview with LPN #5 on 2/27/26 at 6:38 AM identified there had been an ongoing issue between Resident #41 and Resident #93 for several months in 2025. LPN #5 identified she observed that Resident #41 wanted to be close friends with Resident #93, but Resident #93 was not interested in any friendship or interactions with Resident #41. LPN #5 identified that Resident #41 responded to the rejection by becoming angry and aggressive towards Resident #93, and Resident #41 appeared to fixate on Resident #93 and would often ask where Resident #93 was when he/she left the room. LPN #5 identified that the staff were aware of the issues between Resident #41 and Resident #93, and that it regularly occurred during the evening and overnight shifts, but that she was the only nurse who would document Resident #41's behaviors towards Resident #93 as other nursing staff did not want their names associated with the incidents. LPN #5 identified that on 7/7/25, she observed Resident #41 kick and slap Resident #93 while he/she was in the hallway. LPN #5 could not recall who the other 3 staff were who were present during the incident. LPN #5 identified that she, along with the 3 staff, separated Resident #41 and Resident #93 following the incident. LPN #5 identified she notified the RN supervisor of the incident. LPN #5 indicated it may have been RN #5 (7:00 AM – 3:00 PM RN Supervisor) or RN #6, a prior 11:00 PM – 7:00 AM supervisor who is no longer employed at the facility. LPN #5 identified that she recalled assessing Resident #93 following the incident but did not document. LPN #5 identified that she put a request in the Behavioral Health Visit Request/Follow Up Log for Resident #41 to be seen following the incident, and no further action was taken on her part. LPN #5 also identified she was present for the incident on 10/21/25, and Resident #41 was yelling all night at Resident #93 and did not respond to any redirection by staff. LPN #5 identified she was unsure if she notified the supervisor, but that she placed another request in the Behavioral Health Visit Request/ Follow Up Log for Resident #41 to be seen. LPN #5 identified she had repeatedly notified the DNS and prior Administrator of the issues with Resident #41 and Resident #93, and they were aware of the incidents between the residents. LPN #5 also identified that she would often place requests in the Behavioral Health Visit Request/Follow Up Log when Resident #41 would have behaviors overnight and would attempt to redirect Resident #41, but this often did not work. LPN #5 was unable to identify any additional interventions related to Resident #41 and Resident #93, or why she failed to document any incidents or subsequent assessments in Resident #93's clinical record. Although attempted, an interview with RN #6 and SW #4 was not obtained. Review of Resident #93's clinical record failed to reflect that the physician and resident representative had been notified of the witnessed verbal and physical abuse on 7/7/25, the verbal abuse on 10/21/25, or the grievance dated 11/12/25. Further, the clinical record failed to reflect the physician and resident representative had been notified of the letter Resident #93 wrote to the administrative office that identified daily abuse by the roommate. Interview with the Medical Director on 3/11/26 at 10:56 AM and review of Resident #93's clinical record, grievance, and letter requesting a room change identified that he was recently notified by the DNS at a medical director meeting that Resident #41 and Resident #93 were placed in separate rooms, but he was not made aware of the specific issues that prompted the room change. In review of the nurses note dated 7/7/25 with the Medical Director he identified he had not been notified that Resident #41 had yelled at and kicked Resident #93 and he was not aware that Resident #41 had also slapped Resident #93, which was ascertained during a staff interview. The Medical Director identified he was not aware of any additional incidents, including the 10/21/25 verbal altercation, or the letter written by Resident #93 and given to the Administrator on 11/10/25 which alleged daily verbal and physical abuse by Resident #41. The Medical Director identified first and foremost, he would expect all staff to keep the residents safe and this would include a room change separating Resident #41 and Resident #93 immediately following the incident on 7/7/25. The Medical Director also identified Resident #41 and Resident #93 should have had physical assessments by a medical provider to determine if they were harmed as a result of the incidents, and to determine if there was a medical cause for Resident #41's behavior. The Medical Director identified that an accident and incident investigation should have been completed, the state agency should have been notified immediately following the incidents, and psychiatric follow-up should have been provided. Further, the residents care plans should have been updated and a root cause analysis should have been done to determine the cause of the incident. The Medical Director identified that the facility had open beds, and if the residents had been separated following 7/7/25, the incident on 10/21/25 and allegations identified by Resident #93 in the letter to the Administrator would not have occurred. The Medical Director also identified that it was completely unacceptable to make a note in a resident's chart regarding any verbal or physical altercation and not do anything else. The Medical Director identified at a minimum, the residents should have been separated and assessed to ensure they were safe. The facility policy on Abuse, Neglect and Exploitation directed that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. The policy also directed an alleged violation was a situation or occurrence observed or reported by staff, resident, relative, or others but had not yet investigated and if verified, could be an indication of noncompliance of federal requirements with abuse. The policy further directed mental abuse included, but was not limited to, humiliation, harassment, threats of punishment, or deprivation, and physical abuse included, but was not limited to, hitting, slapping, punching, biting, and kicking. The policy also identified that possible indicators of abuse included but were not limited to resident reports of abuse, verbal abuse of a resident overheard, physical abuse of a resident observed, and psychological abuse of a resident observed. The policy further identified that an immediate investigation was warranted when suspicion of abuse or reports of abuse occur. The policy also identified that the facility would make efforts to ensure all residents were protected from physical and psychosocial harm as well as additional abuse during and after an investigation. Examples included but were not limited to responding immediately to protect the alleged victim and the integrity of the investigation, examining the alleged victim for any sign of injury including a physical exam or psychosocial assessment, increased supervision of the alleged victim and residents, room changes if necessary to protect the resident from the alleged perpetrator, protection from retaliation, provide emotional support and counseling to the resident during and after the investigation if needed, and revision of the residence care plan if the residents medical, nursing, physical, mental, or psychosocial needs change as a result of an incident of abuse. The policy also directed that reporting of all alleged violations to the Administrator, state agency, Adult Protective Services and all other required agencies including law enforcement when applicable, should be done immediately but not later than two hours after an allegation was made, if the events that cause the allegation involve abuse. The facility policy on Accident and Incidents directed that an incident was any occurrence or event that caused trouble or disrupted the normal procedure of the facility. The policy further directed that following an accident or incident, the charge nurse or designee was responsible to examine the victim, notify the physician of the incident, and notify the resident representative of the incident. The policy further directed the charge nurse, or designee, must investigate immediately and the following data must be included in the Accident investigation report form: The date and time the incident took place. The circumstances surrounding the incident. The names of any witnesses and their account of the incident. The injured person's account of the incident. The time the injured person's attending physician was notified, time of response, and instructions. The date and time the injured person's resident representative was notified and by whom. Disposition of the injured person. Corrective action taken. Other pertinent data as necessary or required Signature and title of the person completing the report. Submission of the report to the DNS. The facility policy on Change in a Resident's Condition or Status directed the nurse would notify the resident's attending physician or an on-call physician when there was an incident involving a resident or there was a significant change in the resident's physical/emotional/mental condition. The policy directed that a significant change of condition was a major decline in the resident status that would not normally resolve itself without intervention by staff. The policy also directed that the nurse would notify the resident representative when the resident was involved in any incident that resulted in an injury, there was a significant change in the resident's physical, mental or psychosocial status. 2. Resident #74 was admitted to the facility in February 2020 with diagnoses that included severe morbid obesity due to excess calories, diabetes, hypothyroidism, and celiac disease. The quarterly MDS dated [DATE] identified Resident #74 had severely impaired cognition and required setup or clean-up assistance with eating. The weights summary dated 12/23/25 identified Resident #74 weighed 140.2 lbs. Review of the nutrition evaluation dated 12/24/25 identified Resident #74 was on a regular diet and was independent with meals. Resident #74 was very selective about what he/she eats. Glucerna was offered at breakfast and lunch. Resident #74 refused supplement. Resident #74 realized significant weight loss over a 180 day period. The resident was informed of the weight loss. Weekly weight times four weeks and follow up. Documentation indicated the resident's skin was intact at the time of review. Continue to monitor and follow up as needed. The weights summary dated 12/31/25 identified Resident #74 weighed 145.8 lbs. The weights summary dated 1/6/26 identified Resident #74 weighed 145.0 lbs. The weights summary dated 1/12/26 identified Resident #74 weighed 145.8 lbs. The physician's order dated 2/1/26 directed to provide a regular diet and thin liquids consistency, weigh the resident every week for 4 weeks and then monthly unless otherwise indicated. The weights summary dated 2/3/26 identified Resident #74 weighed 179.2 lbs., a 33.4 lbs. weight gain over 23 days. The dietitian note dated 2/9/26 at 2:32 PM identified Resident #74 had a weight gain. Weight changed from 145.8 lbs. on 1/12/26 to 179.2 lbs. on 2/3/26. Request a weight recheck and follow up. Review of the clinical record and nurse's note dated 2/9/26 through 2/16/26 failed to reflect documentation of a weight recheck and follow up. The note failed to reflect documentation that the physician and the resident representative were notified of the weight gain. The weights summary dated 2/17/26 identified Resident #74 weighed 181.8 lbs. Review of the nurse's note dated 2/17/26 through 2/26/26 failed to reflect documentation that the physician and the resident representative were notified of the weight gain. Review of the nutrition evaluation dated 2/25/26 identified Resident #74 was on a regular diet and was independent with meals. The resident's intake varies and that the resident has been asking for ice cream with every meal, and he/she receives cold cereal as well as oatmeal with breakfast. Resident #74 agreed to stop ice cream at each meal and will have ice cream only at lunch. Resident #74 agreed to have only oatmeal at breakfast. Resident #74 was educated regarding diagnoses of diabetes but insisted he/she is not diabetic and requested a regular diet. Current weight 181.8 lbs. Start weekly weight times four weeks. Interview with RN #5 (nursing supervisor) on 2/27/26 at 8:37 AM identified he was not aware of Resident #74's weight gain. RN #5 indicated the charge nurse was to notify him of any weight discrepancies. RN #5 indicated he was going to reweigh and assess Resident #74. RN #5 indicated he would notify the APRN and the resident representative. Interview with the Dietitian on 2/27/26 at 8:59 AM identified she was responsible for reviewing the resident weights and she was aware of Resident #74's weight gain. The Dietitian indicated she reviewed Resident #74's weights, and identified a weight gain on 2/3/26, and documented a progress note on 2/9/26 requesting a weight recheck. The Dietitian indicated she notified the nursing staff including the RN Supervisor and the DNS that Resident #74 required a weight recheck; however, the weight was not rechecked. The Dietitian indicated that significant weight changes are discussed during the facility's risk meeting and that Resident #74's weight gain was discussed. The Dietitian indicated she assessed Resident #74 on 2/25/26 regarding a weight of 181.8 pounds. The Dietitian indicated that on 2/25/26 she provided the APRN with a list of residents who had significant weight changes. The Dietitian identified Resident #74's weight gain would be considered significant given the weight gain happened in 23 days, and she would have expected to be notified to provide recommendations. Interview with the DNS on 2/27/26 at 9:14 AM identified she was not aware of Resident #74's weight gain of 33.4 lbs. The DNS indicated that the nurse aide obtains resident weights at the beginning of each month and reports the weight to the charge nurse, who documents the weight in the resident's clinical record. The DNS indicated that if there is a discrepancy in a resident's weight, the nursing supervisor reweighs and assesses the resident. The DNS indicated the supervisor is responsible for notifying the physician and/or the APRN and the resident representative of significant weight changes. The dietitian is also notified and assessed the residents. The DNS indicated during the facility risk meeting, the dietitian discusses residents with weight concerns. The DNS indicated that the dietitian did not discuss Resident #74 during the risk meeting. Interview with APRN #2 on 2/27/26 at 10:20 AM identified she was not notified of Resident #74's weight gain of 33.4 lbs. in 23 days. APRN #2 indicated it is the responsibility of the licensed nurses and the supervisors to notify her of any changes in the residents. APRN #2 indicated she will assess Resident #74 and review the weights. Subsequent to surveyor inquiry, an RN, and APRN assessment were performed. The change in condition note dated 2/27/26 at 1:18 PM identified weight gain assessment by RN supervisor and APRN. Resident #74 indicated that weight gain and weight loss that is not the first time there is nothing wrong with that. The DNS was notified and resident representative was called with no answer. The APRN note dated 2/27/26 identified an assessment of Resident #74 was performed regarding a weight gain, review of blood sugar, and abdominal folds redness. The note documented a current weight of 181.8 pounds. Resident #74 denied shortness of breath or difficulty breathing. Edema to the left lower extremity was noted as significantly improved. Lung sounds were documented as clear bilaterally with normal respiratory effort. The plan included obtaining daily weights for 14 days, notifying the MD/APRN if weight increased greater than 3 pounds in one day, and obtaining stat labs. Although attempted, an interview with LPN #2 was not obtained. Review of the facility change in a resident's condition or status policy identified the facility shall promptly notify the resident, his or her attending physician, and representatives of changes in the resident's medical/mental condition and/or status. Review of the facility acute condition changes/RN assessment – clinical protocol policy identified as part of the initial assessment, the physician/RN will help identify individuals with a significant risk for having acute changes of condition during their stay. The nursing staff will contact the physician based on the urgency of the situation. Review of the facility weight assessment and intervention policy identified the nursing staff will measure resident weight on day of admission and/or readmission, the day after and weekly times 4. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded in each resident's medical record. Any weight change of 5 lbs. less or more since the last weight assessment will be retaken. If the weight is verified and is determined a weight loss, nursing will consult the Dietitian, MD and the resident representative. The dietitian will review the unit weight record monthly and as needed to follow individual weights trends over time. 3. Resident #90 had diagnoses that included type II diabetes and anemia. The quarterly MDS dated [DATE] identifi

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident #93, 23 and 99) reviewed for abuse, the facility failed to report allegations of abuse to the state agency according to regulatory requirement and facility policy. The findings include: 1a. Resident #41 was admitted to the facility in September 2004 with diagnoses that included schizophrenia, dementia, and anxiety disorder. The annual MDS dated [DATE] identified Resident #41 had moderately impaired cognition. A nurse's note dated 7/7/25 at 7:34 AM by LPN #5 (11:00 PM – 7:00 AM charge nurse) identified Resident #41 was observed at 5:00 AM having a verbal altercation with his/her roommate. LPN #5 identified the altercation occurred without a reason, and that Resident #41 continued with behaviors despite attempts at redirection, and that Resident #41 was observed yelling at other residents in the unit hallway. The note further identified that Resident #41 was observed by 3 facility staff kicking his/her roommate in the hallway. LPN #5 identified she notified her supervisor and that a referral to be seen by psychiatry in the morning had been placed. Review of the accident and incident reports and state agency reportable event portal regarding the 7/7/25 incident identified the facility did not complete an accident and incident report or report the allegation of abuse to the state agency. A psychiatric evaluation note dated 7/8/25, by APRN #4, identified she was asked to see Resident #41 due to agitated behaviors per nursing. APRN #4 identified no signs of delusions, auditory or visual hallucinations, agitation or aggression. APRN #4 further identified no changes were recommended based on her evaluation. A nurse's note dated 10/21/25 at 5:13 AM by LPN #5 identified Resident #41 was observed up all night yelling and screaming at his/her roommate for no reason. LPN #5 identified she attempted to redirect Resident #41 with no result. Review of the accident and incident reports and state agency reportable event portal regarding the 10/21/25 witnessed all night screaming by Resident #41 at Resident #93 identified the facility did not complete an accident and incident report or report the verbal abuse to the state agency. Review of a Behavioral Health Visit Request/Follow Up Log identified a note on 10/21/25 which identified Resident #41 was up all night yelling at his/her roommate for no reason and accosting him/her for coughing. A medical APRN note dated 10/31/25 identified Resident #41 during the visit, Resident #41 was mildly anxious, ambulating the hallway asking where is my roommate. The note further identified that staff reported Resident #41 had a recent escalation in behaviors that included yelling and screaming at his/her roommate during the night and being disruptive. The note also identified that redirection was not successful, and that Resident #41 was seen by the psychiatric provider with an increase of Risperdal ordered. b. Resident #93 was admitted to the facility in May 2024 with diagnoses that included schizophrenia, psychosis, and adjustment disorder. The care plan dated 4/28/25 identified Resident #93 had potential for impaired thought processes related to difficulty expressing him/herself. Interventions included communicating with the resident and his/her resident representative regarding his/her needs. The quarterly MDS dated [DATE] identified Resident #93 had intact cognition. A nurse's note dated 11/10/25 at 7:52 PM by RN #5 (7:00 AM – 3:00 PM RN Supervisor) identified Resident #93 requested to be transferred to another room, the room transfer was completed, and Resident #93's representative was notified. Review of a facility grievance form dated 11/12/25 (two days after the room change) identified Resident #93 requested a room change due to verbal abuse by his/her roommate. An undated letter addressed to the administrative office, which was attached to the grievance form was signed by Resident #93. The grievance form was completed by SW #1 (Social Work Director) and signed by Resident #93, SW #4, and the Administrator, and identified that the resident's room was changed and the resident reported that things were better following the change. Review of the letter (attached to the grievance dated 11/12/25) written and signed by Resident #93 identified the following. Resident #41 abuses me verbally and has hit me a few times. I fight back and hopefully won't get violent and be in trouble for it. He/she does it every day when I enter the room or leave and when I go to my closet. I want a different room. The form also identified that Resident #41's resident representative was notified of the grievance, that local law enforcement was not notified, and that the grievance did not result in a state agency reportable event. Review of the accident and incident reports and state agency reportable event portal regarding the grievance dated 11/12/25 and the undated letter from Resident #93 to the administrative office identified the facility did not complete an accident and incident report or report the allegation of verbal and physical abuse to the state agency. Interview with Resident #93 on 2/24/26 at 3:18 PM identified he/she had been in the same room with Resident #41 since March 2025. Resident #93 identified beginning sometime in the summer, Resident #41 began to make advances towards him/her (Resident #93) that made him/her feel uncomfortable. Resident #93 identified once he/she rejected the advances, Resident #41 became more aggressive, and would intermittently yell at him/her for no reason. Resident #93 identified that over time, the yelling escalated from intermittent episodes to constant yelling overnight, and then occasionally included being hit or kicked by Resident #41. Resident #93 identified that by the time he/she had written the letter to the Administrator in November 2025, Resident #41 was yelling overnight several times a week, and anytime Resident #93 attempted to access his/her closet, which was located near the door and Resident #41's bed, Resident #41 would approach from behind and shove Resident #93 into the closet door. Resident #93 identified that he/she had reported the incidents several times to multiple nursing staff, but they had instructed Resident #93 to tell Resident #41 he/she did not want to talk and to stop the behavior. Resident #93 identified he/she tried but that only made Resident #41's behavior worse. Resident #93 identified that he/she would often sit in the hallway to avoid Resident #41 and only go in his/her room as necessary, but it did not help and the behaviors continued. Resident #93 reported he/she feared Resident #41 and did not feel safe while in the same room with him/her and so he/she wrote a letter to the Administrator and asked for a room change. Resident #93 identified no staff had ever offered to move him/her to another room prior to the letter, and after the room change, a staff member who he/she could not remember, followed up once to make sure the new room was working out. Interview with the Administrator on 2/26/26 at 9:07 AM identified she received a letter from Resident #93 related to a room change but didn't read the letter from Resident #93 because she could not read the handwriting. The Administrator directed SW #4 to address it as a grievance and she did not make any attempt to discuss or review the letter with Resident #93, and was unaware that the letter, addressed to her, included allegations of daily verbal and physical abuse by Resident #41. The Administrator further identified she was unaware of the incidents documented in Resident #41's clinical record related to verbal and physical altercation with Resident #93 on 7/7/25 or verbal altercation on 10/21/25. Interview with RN #5 (7:00 AM – 3:00 PM supervisor) on 2/26/26 at 10:55 AM identified he assisted with Resident #93's room change but was not sure why Resident #93 had made the request. RN #5 identified based on his recollection, Resident #93 had approached him sometime during the day on 11/10/25 to request the room change. RN #5 identified he was unsure who he spoke to about the issue. RN #5 identified that he was not aware of Resident #93's grievance or the allegations of abuse by Resident #41 or yelling overnight by Resident #41, and that he was not aware of any issues between the residents. RN #5 identified that when Resident #93 was moving his/her belongings to the new room on 11/10/25, he did recall Resident #41 asking him where his/her roommate was going and said (I love my roommate). Interview with NA #3 on 2/26/26 at 11:43 AM identified that she worked on the 11:00 PM – 7:00 AM shift but did not recall being assigned to Resident #41 and Resident #93's unit. NA #3 identified that while she was not assigned to the residents, it was common knowledge with the nursing staff throughout the facility that Resident #41 would confront Resident #93 with aggressive behaviors on a regular basis. NA #3 identified she never saw Resident #41 become physical with Resident #93 on 7/7/25 but did witness on multiple occasions Resident #41 yelling at Resident #93 overnight, and witnessed Resident #41 go directly into Resident #93's face and yell on multiple occasions. NA #3 identified it was very hard to redirect Resident #41 away from Resident #93 and to deescalate the behaviors. NA #3 also identified that while she did not observe Resident #41 attempt to hit or kick Resident #93, Resident #41 had attempted to hit her in the past but stopped before actually striking her. NA #3 identified that Resident #41 was verbally abusive to Resident #93, and the behavior had gone on for several months in 2025. NA #3 also indicated that Resident #93 had reported to her she was afraid of Resident #41. NA #3 identified Resident #41 felt disrespected because Resident #93 would not speak with him/her, and that caused Resident #41 to escalate and begin yelling. NA #3 identified that she reported behaviors to the unit charge nurse but was unable to provide any specifics on the nurse or when she reported the issues. NA #3 reported that staff at the facility would attempt to redirect Resident #41 but a room change was not attempted prior to 11/10/25. NA #3 indicated she was not aware of any other interventions to protect Resident #93, and that she never observed Resident #93 being aggressive or instigating any altercations with Resident #41. NA #3 also identified that it was the longstanding culture of the nursing staff, including the nurse aides and licensed nurses, to ignore Resident #41's behaviors and not address the issues, which was likely why Resident #93 had to self-request the room change. Interview with APRN #4 on 2/26/26 at 1:26 PM identified that she was not aware of any issues related to Resident #41 and Resident #93, including any issues related to physical or verbal altercations. Interview with the DNS on 2/26/26 at 1:42 PM identified that she had been the DNS of the facility since March 2025. The DNS identified that she was not aware of any issues between Resident #41 and Resident #93, was not aware of the incidents on 7/7/25 or 10/21/25, and was not aware of the letter written by Resident #93 to the Administrative office in November 2025 which alleged daily abuse by Resident #41, and was not aware why Resident #93 requested a room change. The DNS identified that following the incident on 7/7/25, the residents should have been placed in separate rooms for safety and if Resident #41 did not respond to redirection, the resident should have been sent to the hospital for psychiatric evaluation. The DNS also identified that the medical and psychiatric providers should have been notified of every incident between the residents as well as the resident representatives, and that social work should have been involved. The DNS identified that investigations should have also taken place on 10/21/25 and 11/10/25, and both incidents should have been reported to the state agency immediately. Interview with LPN #5 on 2/27/26 at 6:38 AM identified there had been an ongoing issue between Resident #41 and Resident #93 for several months in 2025. LPN #5 identified she observed that Resident #41 wanted to be close friends with Resident #93, but Resident #93 was not interested in any friendship or interactions with Resident #41. LPN #5 identified that Resident #41 responded to the rejection by becoming angry and aggressive towards Resident #93, and Resident #41 appeared to fixate on Resident #93 and would often ask where Resident #93 was when he/she left the room. LPN #5 identified that the staff were aware of the issues between Resident #41 and Resident #93, and that it regularly occurred during the evening and overnight shifts, but that she was the only nurse who would document Resident #41's behaviors towards Resident #93 as other nursing staff did not want their names associated with the incidents. LPN #5 identified that on 7/7/25, she observed Resident #41 kick and slap Resident #93 while he/she was in the hallway. LPN #5 could not recall who the other 3 staff were who were present during the incident. LPN #5 identified that she, along with the 3 staff, separated Resident #41 and Resident #93 following the incident. LPN #5 identified she notified the RN supervisor of the incident. LPN #5 indicated it may have been RN #5 (7:00 AM – 3:00 PM RN Supervisor) or RN #6, a prior 11:00 PM – 7:00 AM supervisor who is no longer employed at the facility. LPN #5 identified that she recalled assessing Resident #93 following the incident but did not document. LPN #5 identified that she put a request in the Behavioral Health Visit Request/Follow Up Log for Resident #41 to be seen following the incident, and no further action was taken on her part. LPN #5 also identified she was present for the incident on 10/21/25, and Resident #41 was yelling all night at Resident #93 and did not respond to any redirection by staff. LPN #5 identified she was unsure if she notified the supervisor, but that she placed another request in the Behavioral Health Visit Request/ Follow Up Log for Resident #41 to be seen. LPN #5 identified she had repeatedly notified the DNS and prior Administrator of the issues with Resident #41 and Resident #93, and they were aware of the incidents between the residents. LPN #5 also identified that she would often place requests in the Behavioral Health Visit Request/Follow Up Log when Resident #41 would have behaviors overnight and would attempt to redirect Resident #41, but this often did not work. LPN #5 was unable to identify any additional interventions related to Resident #41 and Resident #93, or why she failed to document any incidents or subsequent assessments in Resident #93's clinical record. Interview with the Medical Director on 3/11/26 at 10:56 AM and review of Resident #93's clinical record, grievance, and letter requesting a room change identified he was not made aware that Resident #41 had slapped Resident #93, which was ascertained during a staff interview or of any additional incidents, including the 10/21/25 verbal altercation, or the letter written by Resident #93 and given to the Administrator on 11/10/25 which alleged daily verbal and physical abuse by Resident #41. The Medical Director identified that he was recently notified by the DNS at a medical director meeting that Resident #41 and Resident #93 were placed in separate rooms, but he was not made aware of the specific issues that prompted the room change. The Medical Director identified that an accident and incident investigation should have been completed, the state agency should have been notified immediately following the incidents, and psychiatric follow-up should have been provided. In review of the nurses note dated 7/7/25 with the Medical Director he identified he had not been notified that Resident #41 had yelled at and kicked Resident #93 and he was not aware that Resident #41 had also slapped Resident #93, which was ascertained during a staff interview. The Medical Director identified he was not aware of any additional incidents, including the 10/21/25 verbal altercation, or the letter written by Resident #93 and given to the Administrator on 11/10/25 which alleged daily verbal and physical abuse by Resident #41. The Medical Director identified first and foremost, he would expect all staff to keep the residents safe and this would include a room change separating Resident #41 and Resident #93 immediately following the incident on 7/7/25. The Medical Director also identified Resident #41 and Resident #93 should have had physical assessments by a medical provider to determine if they were harmed as a result of the incidents, and to determine if there was a medical cause for Resident #41's behavior. The Medical Director identified that an accident and incident investigation should have been completed, the state agency should have been notified immediately following the incidents, and psychiatric follow-up should have been provided. Further, the residents care plans should have been updated and a root cause analysis should have been done to determine the cause of the incident. The Medical Director identified that the facility had open beds, and if the residents had been separated following 7/7/25, the incident on 10/21/25 and allegations identified by Resident #93 in the letter to the Administrator would not have occurred. The Medical Director also identified that it was completely unacceptable to make a note in a resident's chart regarding any verbal or physical altercation and not do anything else. The Medical Director identified at a minimum the residents should have been separated and assessed to ensure they were safe. Although attempted, an interview with RN #6 and SW #4 was not obtained. Review of facility documentation identified accident and incident reports regarding alleged and witnessed verbal and physical abuse of Resident #93 by Resident #41 not been filed during all of 2025. Review of the state agency reportable events portal failed to identify any incidents regarding alleged and witnessed verbal and physical abuse of Resident #93 by Resident #41 had been reported in 2025. The facility policy on Abuse, Neglect and Exploitation directed that abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. The policy also directed an alleged violation was a situation or occurrence observed or reported by staff, resident, relative, or others but had not yet investigated and if verified, could be an indication of noncompliance of federal requirements with abuse. The policy further directed mental abuse included, but was not limited to, humiliation, harassment, threats of punishment, or deprivation, and physical abuse included, but was not limited to, hitting, slapping, punching, biting, and kicking. The policy also identified that the facility would make efforts to ensure all residents were protected from physical and psychosocial harm as well as additional abuse during and after an investigation. The policy also directed that reporting of all alleged violations to the Administrator, state agency, adult Protective Services and all other required agencies including law enforcement when applicable should be done immediately, but not later than two hours after an allegation was made, if the events that cause the allegation involved abuse. 2a. Resident #99 was admitted to the facility in December 2022 with diagnoses that included schizoaffective disorder and dementia. The quarterly MDS dated [DATE] identified Resident #99 was moderately cognitively impaired and independent with bed mobility, transfers and ambulation. The care plan dated 10/19/25 identified Resident #99 had an actual mood problem related to dementia, schizoaffective disorder and anxiety. Interventions included monitoring mood, provide supportive psychotherapy and administer medications as ordered. b. Resident #23 was admitted to the facility in March 2022 with diagnoses that included stroke and major depressive disorder with mood disturbances. Nurse's note dated 3/12/25 identified Resident #99 moved to Resident #23's room and was adjusting to the new room. The annual MDS dated [DATE] identified Resident #23 was cognitively intact and required one person assist with bed mobility, two person assist with transfers and utilized a motorized wheelchair. The care plan dated 10/19/25 identified Resident #23 had a mood problem related to major depressive disorder with interventions that included psychiatric consultation for behavioral concerns and supportive services. For Resident #99, a social service note dated 2/9/26 at 6:12 PM identified he/she requested a room change due to roommate compatibility. A voice message was left for the responsible party with awaiting call back. For Resident #99, a social service note dated 2/11/26 identified the requested room change would not take effect as intended as the new roommates responsible party was not in agreement. For Resident #23, a social service note dated 2/9/26 identified Resident #23 reported not getting along with his/her roommate and requested the roommate be moved. For Resident #23, a social service note dated 2/11/26 identified the requested room change would not take effect as intended as the new roommates responsible party was not in agreement. Interview with Resident #99 on 2/24/26 at 8:26 AM identified he/she had frequent altercations with Resident #23 who often curses at him/her and keeps the TV too loud. Resident #99 indicated in recent days, while in their room, Resident #23 yelled the F word at him/her. In response, Resident #99 indicated he/she grabbed Resident #23's leg momentarily. The frequent altercations have left Resident #99 feeling anxious and upset, often not wanting to stay in his/her room and had made requests to an alternate facility and a room change with nothing being done to honor her request. Interview with the Director of Social Services on 2/24/26 at 8:46 AM identified Resident #23 and Resident #99 were roommates who did not get along. Resident #99 complains Resident #23 keeps the TV too loud and Resident #23 complains about Resident #99's scent. On 2/9/26, Resident #99 had called Resident #23 the B word. Both residents were 'socially' separated following the altercation and seen by psychiatry. When asked, the Director of Social Services indicated she would have to refer to the facility's policies for abuse to determine the required procedures. Interview with Resident #23 on 2/24/26 at 8:36 AM identified he/she did not get along with Resident #99. Resident #23 indicated an altercation over the TV volume had taken place between the two residents on 2/22/26 in their room at approximately 2:30 AM. Resident #23 said the F word to Resident #99 who in response, grabbed Resident #23's right foot with both hands. Resident #23 told Resident #99 that he/she was going to report him/her for assault. Interview with NA #4 on 2/24/26 at 10:17 AM identified while the resident-to-resident incident that occurred on 2/22/26 was not reported to her, it was known that Resident #23 and Resident #99 did not get along. NA #4 had observed the two residents yelling at each other, with Resident #23 often swearing at Resident #99. These incidents were reported to the nurse who did their best to separate the two residents. Subsequent interview with the Director of Social Services on 2/24/26 at 2:50 PM clarified that on 2/9/26 Resident #99 called Resident #23 the B word, and in turn Resident #23 said the F word (F you) to Resident #99. The Director of Social Services further identified she notified the Director of Nursing and Administrator when the allegation of resident-to-resident verbal mistreatment was first reported to her on 2/9/26. A subsequent interview with Resident #23 on 2/25/26 at 7:15 AM identified Resident #23 often crossed his/her legs as a layer of protection when having an altercation with Resident #99. Resident #23 indicated altercations were frequent, however, the resident felt that Resident #99 had crossed the line when it became physical and told Resident #99 he/she could report him/her for assault. Resident #23 further identified there had been another recent incident earlier in the month that occurred in the hall. LPN #8 was present and separated the two residents. Resident #23 was aware that LPN #8 reported the incident to the social worker and was told there was going to be a room change, which never occurred. Interview and facility documentation review with the DNS on 2/25/26 at 9:30 AM identified she had not been notified of any other incidents that occurred between Resident #23 and Resident #99 prior to 2/24/26 and there was no prior incident reports related to resident-to-resident altercations. The DNS indicated for any resident-to-resident altercation, she would expect the two residents to be immediately separated, with notification to the nursing supervisor and herself. Interview with the DNS on 2/25/26 at 9:30 AM identified she had not been previously notified of any ongoing resident-to-resident verbal altercations between Resident #23 and Resident #99 prior to 2/24/26 and further identified there were no incident reports or reporting to the state agency related to those resident-to-resident altercations. The DNS indicated for any resident-to-resident altercation, she would expect the two residents to be immediately separated, with notification to the nursing supervisor and herself. Interview with the Administrator on 2/25/26 at 9:59 AM identified she was unaware of the ongoing resident-to-resident verbal altercations including the incident on 2/9/26 which had not been reported to her. The Administrator indicated that the incident on 2/9/26 should have been reported to the state agency. Review of the facility policy for Abuse directs that the facility provides protections for the health welfare and rights of each resident to develop and implement policies that prohibit and prevent abuse. All alleged violations are to be reported to the Administrator, state agency, adult protective services and all other required state agencies such as local law enforcement immediately, but no later than two hours after the allegation is made if the events result in serious bodily injury , or 24 hours – if the alleged violation involves neglect, exploitation , mistreatment , or misappropriation of resident property; and does not result in serious bodily injury.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident #93, 23 and 99) reviewed for abuse, the facility failed to ensure the allegations of abuse were thoroughly investigated and the residents protected from future abuse. The findings include: 1a. Resident #41 was admitted to the facility in September 2004 with diagnoses that included schizophrenia, dementia, and anxiety disorder. The annual MDS dated [DATE] identified Resident #41 had moderately impaired cognition. A nurse's note dated 7/7/25 at 7:34 AM by LPN #5 (11:00 PM – 7:00 AM charge nurse) identified Resident #41 was observed at 5:00 AM having a verbal altercation with his/her roommate. LPN #5 identified the altercation occurred without a reason, and that Resident #41 continued with behaviors despite attempts at redirection, and that Resident #41 was observed yelling at other residents in the unit hallway. The note further identified that Resident #41 was observed by 3 facility staff kicking his/her roommate in the hallway. LPN #5 identified she notified her supervisor and that a referral to be seen by psychiatry in the morning had been placed. Review of facility documentation regarding the 7/7/25 verbal and physical abuse identified no investigation had been completed nor was Resident #93 removed from the room or protected from future abuse. A psychiatric evaluation note dated 7/8/25, by APRN #4, identified she was asked to see Resident #41 due to agitated behaviors per nursing. APRN #4 identified no signs of delusions, auditory or visual hallucinations, agitation or aggression. APRN #4 further identified no changes were recommended based on her evaluation. A nurse's note dated 10/21/25 at 5:13 AM by LPN #5 identified Resident #41 was observed up all night yelling and screaming at his/her roommate for no reason. LPN #5 identified she attempted to redirect Resident #41 with no result. Review of facility documentation regarding the 10/21/25 witnessed all night screaming by Resident #41 at Resident #93 identified no investigation had been completed, nor was Resident #93 removed from the room or protected from future abuse. Review of a Behavioral Health Visit Request/Follow Up Log identified a note on 10/21/25 which identified Resident #41 was up all night yelling at his/her roommate for no reason and accosting him/her for coughing. A medical APRN note dated 10/31/25 identified Resident #41 during the visit, Resident #41 was mildly anxious, ambulating the hallway asking where is my roommate. The note further identified that staff reported Resident #41 had a recent escalation in behaviors that included yelling and screaming at his/her roommate during the night and being disruptive. The note also identified that redirection was not successful, and that Resident #41 was seen by the psychiatric provider with an increase of Risperdal ordered. b. Resident #93 was admitted to the facility in May 2024 with diagnoses that included schizophrenia, psychosis, and adjustment disorder. The care plan dated 4/28/25 identified Resident #93 had potential for impaired thought processes related to difficulty expressing him/herself. Interventions included communicating with the resident and his/her resident representative regarding his/her needs. The quarterly MDS dated [DATE] identified Resident #93 had intact cognition. A nurse's note dated 11/10/25 at 7:52 PM by RN #5 (7:00 AM – 3:00 PM RN Supervisor) identified Resident #93 requested to be transferred to another room, the room transfer was completed, and Resident #93's representative was notified. Review of a facility grievance form dated 11/12/25 (two days after the room change) identified Resident #93 requested a room change due to verbal abuse by his/her roommate. An undated letter addressed to the administrative office, which was attached to the grievance form was signed by Resident #93. The grievance form was completed by SW #1 (Social Work Director) and signed by Resident #93, SW #4, and the Administrator, and identified that the resident's room was changed and the resident reported that things were better following the change. Review of the letter (attached to the grievance dated 11/12/25) written and signed by Resident #93 identified the following. Resident #41 abuses me verbally and has hit me a few times. I fight back and hopefully won't get violent and be in trouble for it. He/she does it every day when I enter the room or leave and when I go to my closet. I want a different room. The form also identified that Resident #41's resident representative was notified of the grievance, that local law enforcement was not notified, and that the grievance did not result in a state agency reportable event. Review of facility documentation regarding the 11/12/25 grievance and the undated letter from Resident #93 to the administrative office alleging daily abuse identified no investigation had been completed. Interview with Resident #93 on 2/24/26 at 3:18 PM identified he/she had been in the same room with Resident #41 since March 2025. Resident #93 identified beginning sometime in the summer, Resident #41 began to make advances towards him/her (Resident #93) that made him/her feel uncomfortable. Resident #93 identified once he/she rejected the advances, Resident #41 became more aggressive, and would intermittently yell at him/her for no reason. Resident #93 identified that over time, the yelling escalated from intermittent episodes to constant yelling overnight, and then occasionally included being hit or kicked by Resident #41. Resident #93 identified that by the time he/she had written the letter to the Administrator in November 2025, Resident #41 was yelling overnight several times a week, and anytime Resident #93 attempted to access his/her closet, which was located near the door and Resident #41's bed, Resident #41 would approach from behind and shove Resident #93 into the closet door. Resident #93 identified that he/she had reported the incidents several times to multiple nursing staff, but they had instructed Resident #93 to tell Resident #41 he/she did not want to talk and to stop the behavior. Resident #93 identified he/she tried but that only made Resident #41's behavior worse. Resident #93 identified that he/she would often sit in the hallway to avoid Resident #41 and only go in his/her room as necessary, but it did not help and the behaviors continued. Resident #93 reported he/she feared Resident #41 and did not feel safe while in the same room with him/her and so he/she wrote a letter to the Administrator and asked for a room change. Resident #93 identified no staff had ever offered to move him/her to another room prior to the letter, and after the room change, a staff member who he/she could not remember, followed up once to make sure the new room was working out. Interview with the Administrator on 2/26/26 at 9:07 AM identified she received a letter from Resident #93 related to a room change but didn't read the letter from Resident #93 because she could not read the handwriting. The Administrator directed SW #4 to address it as a grievance and she did not make any attempt to discuss or review the letter with Resident #93, and was unaware that the letter, addressed to her, included allegations of daily verbal and physical abuse by Resident #41. The Administrator further identified she was unaware of the incidents documented in Resident #41's clinical record related to verbal and physical altercation with Resident #93 on 7/7/25 or verbal altercation on 10/21/25. Interview with RN #5 (7:00 AM – 3:00 PM supervisor) on 2/26/26 at 10:55 AM identified he assisted with Resident #93's room change but was not sure why Resident #93 had made the request. RN #5 identified based on his recollection, Resident #93 had approached him sometime during the day on 11/10/25 to request the room change. RN #5 identified he was unsure who he spoke to about the issue. RN #5 identified that he was not aware of Resident #93's grievance or the allegations of abuse by Resident #41 or yelling overnight by Resident #41, and that he was not aware of any issues between the residents. RN #5 identified that when Resident #93 was moving his/her belongings to the new room on 11/10/25, he did recall Resident #41 asking him where his/her roommate was going and said (I love my roommate). Interview with NA #3 on 2/26/26 at 11:43 AM identified that she worked on the 11:00 PM – 7:00 AM shift but did not recall being assigned to Resident #41 and Resident #93's unit. NA #3 identified that while she was not assigned to the residents, it was common knowledge with the nursing staff throughout the facility that Resident #41 would confront Resident #93 with aggressive behaviors on a regular basis. NA #3 identified she never saw Resident #41 become physical with Resident #93 on 7/7/25 but did witness on multiple occasions Resident #41 yelling at Resident #93 overnight, and witnessed Resident #41 go directly into Resident #93's face and yell on multiple occasions. NA #3 identified it was very hard to redirect Resident #41 away from Resident #93 and to deescalate the behaviors. NA #3 also identified that while she did not observe Resident #41 attempt to hit or kick Resident #93, Resident #41 had attempted to hit her in the past but stopped before actually striking her. NA #3 identified that Resident #41 was verbally abusive to Resident #93, and the behavior had gone on for several months in 2025. NA #3 also indicated that Resident #93 had reported to her she was afraid of Resident #41. NA #3 identified Resident #41 felt disrespected because Resident #93 would not speak with him/her, and that caused Resident #41 to escalate and begin yelling. NA #3 identified that she reported behaviors to the unit charge nurse but was unable to provide any specifics on the nurse or when she reported the issues. NA #3 reported that staff at the facility would attempt to redirect Resident #41 but a room change was not attempted prior to 11/10/25. NA #3 indicated she was not aware of any other interventions to protect Resident #93, and that she never observed Resident #93 being aggressive or instigating any altercations with Resident #41. NA #3 also identified that it was the longstanding culture of the nursing staff, including the nurse aides and licensed nurses, to ignore Resident #41's behaviors and not address the issues, which was likely why Resident #93 had to self-request the room change. Interview with the DNS on 2/26/26 at 1:42 PM identified that she had been the DNS of the facility since March 2025. The DNS identified that she was not aware of any issues between Resident #41 and Resident #93, was not aware of the incidents on 7/7/25 or 10/21/25, and was not aware of the letter written by Resident #93 to the Administrative office in November 2025 which alleged daily abuse by Resident #41, and was not aware why Resident #93 requested a room change. The DNS identified that following the incident on 7/7/25, the residents should have been placed in separate rooms for safety and if Resident #41 did not respond to redirection, the resident should have been sent to the hospital for psychiatric evaluation. The DNS also identified that the medical and psychiatric providers should have been notified of every incident between the residents as well as the resident representatives, and that social work should have been involved. The DNS identified that investigations should have also taken place on 10/21/25 and 11/10/25, and both incidents should have been reported to the state agency immediately. Interview with LPN #5 on 2/27/26 at 6:38 AM identified there had been an ongoing issue between Resident #41 and Resident #93 for several months in 2025. LPN #5 identified she observed that Resident #41 wanted to be close friends with Resident #93, but Resident #93 was not interested in any friendship or interactions with Resident #41. LPN #5 identified that Resident #41 responded to the rejection by becoming angry and aggressive towards Resident #93, and Resident #41 appeared to fixate on Resident #93 and would often ask where Resident #93 was when he/she left the room. LPN #5 identified that the staff were aware of the issues between Resident #41 and Resident #93, and that it regularly occurred during the evening and overnight shifts, but that she was the only nurse who would document Resident #41's behaviors towards Resident #93 as other nursing staff did not want their names associated with the incidents. LPN #5 identified that on 7/7/25, she observed Resident #41 kick and slap Resident #93 while he/she was in the hallway. LPN #5 could not recall who the other 3 staff were who were present during the incident. LPN #5 identified that she, along with the 3 staff, separated Resident #41 and Resident #93 following the incident. LPN #5 identified she notified the RN supervisor of the incident. LPN #5 indicated it may have been RN #5 (7:00 AM – 3:00 PM RN Supervisor) or RN #6, a prior 11:00 PM – 7:00 AM supervisor who is no longer employed at the facility. LPN #5 identified that she recalled assessing Resident #93 following the incident but did not document. LPN #5 identified that she put a request in the Behavioral Health Visit Request/Follow Up Log for Resident #41 to be seen following the incident, and no further action was taken on her part. LPN #5 also identified she was present for the incident on 10/21/25, and Resident #41 was yelling all night at Resident #93 and did not respond to any redirection by staff. LPN #5 identified she was unsure if she notified the supervisor, but that she placed another request in the Behavioral Health Visit Request/ Follow Up Log for Resident #41 to be seen. LPN #5 identified she had repeatedly notified the DNS and prior Administrator of the issues with Resident #41 and Resident #93, and they were aware of the incidents between the residents. LPN #5 also identified that she would often place requests in the Behavioral Health Visit Request/Follow Up Log when Resident #41 would have behaviors overnight and would attempt to redirect Resident #41, but this often did not work. LPN #5 was unable to identify any additional interventions related to Resident #41 and Resident #93, or why she failed to document any incidents or subsequent assessments in Resident #93's clinical record. Interview with the Medical Director on 3/11/26 at 10:56 AM and review of Resident #93's clinical record, grievance, and letter requesting a room change identified he was not made aware that Resident #41 had slapped Resident #93, which was ascertained during a staff interview or of any additional incidents, including the 10/21/25 verbal altercation, or the letter written by Resident #93 and given to the Administrator on 11/10/25 which alleged daily verbal and physical abuse by Resident #41. The Medical Director identified that he was recently notified by the DNS at a medical director meeting that Resident #41 and Resident #93 were placed in separate rooms, but he was not made aware of the specific issues that prompted the room change. The Medical Director identified that an accident and incident investigation should have been completed, the state agency should have been notified immediately following the incidents, and psychiatric follow-up should have been provided. Although attempted, an interview with RN #6 and SW #4 was not obtained. The facility policy on Abuse, Neglect and Exploitation directed that abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. The policy also directed an alleged violation was a situation or occurrence observed or reported by staff, resident, relative, or others but had not yet investigated and if verified, could be an indication of noncompliance of federal requirements with abuse. The policy further identified that an immediate investigation was warranted when suspicion of abuse or reports of abuse occur. The policy also identified that the facility would make efforts to ensure all residents were protected from physical and psychosocial harm as well as additional abuse during and after an investigation. The policy also directed that reporting of all alleged violations to the Administrator, state agency, adult Protective Services and all other required agencies including law enforcement when applicable should be done immediately, but not later than two hours after an allegation was made, if the events that cause the allegation involved abuse. The policy directed that investigation of alleged abuse should include: Identifying staff responsible for the investigation. Exercising caution when handling evidence that could be used in a criminal investigation. Investigating different types of alleged violation. Identifying and interviewing all alleged involved persons, including the alleged victim, alleged perpetrator, witnesses, and others that might have knowledge of the allegations. Focus the investigation on determining if abuse, neglect, exploitation, or mistreatment had occurred, the extent, and cause. Provide a complete and thorough documentation of the investigation. The facility policy on Accident and Incidents directed that an incident was any occurrence or event that caused trouble or disrupted the normal procedure of the facility. The policy further directed that following an accident or incident, any employee witnessing an incident involving a resident must report such an occurrence to their immediate supervisor as soon as practical, and the charge nurse must be informed of all incidents. The policy further directed the charge nurse or designee must investigate immediately and the following data must be included in the accident investigation report form: The date and time the incident took place. The circumstances surrounding the incident. The names of any witnesses and their account of the incident. The injured person's account of the incident. The time the injured person's attending physician was notified, time of response, and instructions. The date and time the injured person's resident representative was notified and by whom. Disposition of the injured person. Corrective action taken. Other pertinent data as necessary or required. Signature and title of the person completing the report. Submission of the report to the DNS. 2a. Resident #99 was admitted to the facility in December 2022 with diagnoses that included schizoaffective disorder and dementia. The quarterly MDS dated [DATE] identified Resident #99 was moderately cognitively impaired and independent with bed mobility, transfers and ambulation. The care plan dated 10/19/25 identified Resident #99 had an actual mood problem related to dementia, schizoaffective disorder and anxiety. Interventions included monitoring mood, provide supportive psychotherapy and administer medications as ordered. b. Resident #23 was admitted to the facility in March 2022 with diagnoses that included stroke and major depressive disorder with mood disturbances. Nurse's note dated 3/12/25 identified Resident #99 moved to Resident #23's room and was adjusting to the new room. The annual MDS dated [DATE] identified Resident #23 was cognitively intact and required one person assist with bed mobility, two person assist with transfers and utilized a motorized wheelchair. The care plan dated 10/19/25 identified Resident #23 had a mood problem related to major depressive disorder with interventions that included psychiatric consultation for behavioral concerns and supportive services. Review of the grievance log identified a handwritten note from Resident #99 dated 11/10/25 (attached to a separate resident grievance), in which Resident #99 requested a room change due in part to his/her roommate, Resident #23, both hate each other. No action was taken. Nurse's note dated 1/26/26 at 6:15 PM identified Resident #99 engaged in a verbal altercation with his/her roommate Resident #23. For de-escalation purposes, Resident #99 was relocated to an alternate room for the night. Management was to review and a decision was pending. Nurse's note dated 1/27/26 at 5:15 AM identified Resident #99 was observed back in his/her original room at the beginning of shift and slept through the night with no behaviors. Psychiatric Consultation dated 1/27/26 identified Resident #99 was evaluated post verbal altercation with his/her roommate. A room change was requested at the time. Resident #99 denied feelings of depression, anxiety, feeling fearful or distressed and was determined not to be at risk for self-harm/harm to others. For Resident #99, a social service note dated 2/9/26 at 6:12 PM identified he/she requested a room change due to roommate compatibility. A voice message was left for the responsible party with awaiting call back. For Resident #99, a social service note dated 2/11/26 identified the requested room change would not take effect as intended as the new roommate's responsible party was not in agreement. For Resident #23, a social service note dated 2/9/26 identified Resident #23 reported not getting along with his/her roommate and requested the roommate be moved. For Resident #23, a social service note dated 2/11/26 identified the requested room change would not take effect as intended as the new roommate's responsible party was not in agreement. Interview with Resident #99 on 2/24/26 at 8:26 AM identified he/she had frequent altercations with Resident #23 who often curses at him/her and keeps the TV too loud. Resident #99 indicated in recent days, while in their room, Resident #23 yelled the F word at him/her. In response, Resident #99 indicated he/she grabbed Resident #23's leg momentarily. The frequent altercations have left Resident #99 feeling anxious and upset, often not wanting to stay in his/her room and had made requests to an alternate facility and a room change with nothing being done to honor her request. Interview with the Director of Social Services on 2/24/26 at 8:46 AM identified Resident #23 and Resident #99 were roommates who did not get along. Resident #99 complains Resident #23 keeps the TV too loud and Resident #23 complains about Resident #99's scent. On 2/9/26, Resident #99 had called Resident #23 the B word. Both residents were 'socially' separated following the altercation and seen by psychiatry. When asked, the Director of Social Services indicated she would have to refer to the facility's policies for abuse to determine the required procedures. Interview with Resident #23 on 2/24/26 at 8:36 AM identified he/she did not get along with Resident #99. Resident #23 indicated an altercation over the TV volume had taken place between the two residents on 2/22/26 in their room at approximately 2:30 AM. Resident #23 said the F word to Resident #99 who in response, grabbed Resident #23's right foot with both hands. Resident #23 told Resident #99 that he/she was going to report him/her for assault. Interview with NA #4 on 2/24/26 at 10:17 AM identified while the resident-to-resident incident that occurred on 2/22/26 was not reported to her, it was known that Resident #23 and Resident #99 did not get along. NA #4 had observed the two residents yelling at each other, with Resident #23 often swearing at Resident #99. These incidents were reported to the nurse who did their best to separate the two residents. Subsequent interview with the Director of Social Services on 2/24/26 at 2:50 PM clarified that on 2/9/26 Resident #99 called Resident #23 the B word, and in turn Resident #23 said the F word (F you) to Resident #99. The Director of Social Services further identified she notified the Director of Nursing and Administrator when the allegation of resident-to-resident verbal mistreatment was first reported to her on 2/9/26. The Director of Social Services indicated she did not implement the other measures or completely document the incident in the clinical record when the allegation of resident-to-resident verbal mistreatment when first identified on 2/9/26 and indicated she was not as familiar with the policies as required. A subsequent interview with Resident #23 on 2/25/26 at 7:15 AM identified Resident #23 often crossed his/her legs as a layer of protection when having an altercation with Resident #99. Resident #23 indicated altercations were frequent, however, the resident felt that Resident #99 had crossed the line when it became physical and told Resident #99 he/she could report him/her for assault. Resident #23 further identified there had been another recent incident earlier in the month that occurred in the hall. LPN #8 was present and separated the two residents. Resident #23 was aware that LPN #8 reported the incident to the social worker and was told there was going to be a room change, which never occurred. Interview and facility documentation review with the DNS on 2/25/26 at 9:30 AM identified she had not been notified of any other incidents that occurred between Resident #23 and Resident #99 prior to 2/24/26 and there was no prior incident reports related to resident-to-resident altercations. The DNS indicated for any resident-to-resident altercation, she would expect the two residents to be immediately separated, with notification to the nursing supervisor and herself. Interview with the DNS on 2/25/26 at 9:30 AM identified she had not been previously notified of any ongoing resident-to-resident verbal altercations between Resident #23 and Resident #99 prior to 2/24/26 and further identified there were no incident reports or reporting to the state agency related to those resident-to-resident altercations. The DNS indicated for any resident-to-resident altercation, she would expect the two residents to be immediately separated, with notification to the nursing supervisor and herself. Interview with the Administrator on 2/25/26 at 9:59 AM identified she was unaware of the ongoing resident-to-resident verbal altercations including the incident on 2/9/26 which had not been reported to her. The Administrator indicated that the incident on 2/9/26 should have been reported to the state agency. Review of the clinical record and facility documentation failed to identify a thorough investigation had been completed including details of the frequent altercations between Resident #23 and Resident #99, statements from staff about the altercations, and how the facility protected the residents from each other to mitigate future abuse. The facility policy on Abuse, Neglect and Exploitation directed that abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. The policy also directed an alleged violation was a situation or occurrence observed or reported by staff, resident, relative, or others but had not yet investigated and if verified, could be an indication of noncompliance of federal requirements with abuse. The policy further identified that an immediate investigation was warranted when suspicion of abuse or reports of abuse occur. The policy also identified that the facility would make efforts to ensure all residents were protected from physical and psychosocial harm as well as additional abuse during and after an investigation. The policy also directed that reporting of all alleged violations to the Administrator, state agency, adult Protective Services and all other required agencies including law enforcement when applicable should be done immediately, but not later than two hours after an allegation was made, if the events that cause the allegation involved abuse. The policy directed that investigation of alleged abuse should include: Identifying staff responsible for the investigation. Exercising caution when handling evidence that could be used in a criminal investigation. Investigating different types of alleged violation. Identifying and interviewing all alleged involved persons, including the alleged victim, alleged perpetrator, witnesses, and others that might have knowledge of the allegations. Focus the investigation on determining if abuse, neglect, exploitation, or mistreatment had occurred, the extent, and cause. Provide complete and thorough documentation of the investigation. The facility policy on Accident and Incidents directed that an incident was any occurrence or event that caused trouble or disrupted the normal procedure of the facility. The policy further directed that following an accident or incident, any employee witnessing an incident involving a resident must report such an occurrence to their immediate supervisor as soon as practical, and the charge nurse must be informed of all incidents. The policy further directed the charge nurse or designee must investigate immediately and the following data must be included in the accident investigation report form: The date and time the incident took place. The circumstances surrounding the incident. The names of any witnesses and their account of the incident. The injured person's account of the incident. The time the injured person's attending physician was notified, time of response, and instructions. The date and time the injured person's resident representative was notified and by whom. Disposition of the injured person. Corrective action taken. Other pertinent data as necessary or required. Signature and title of the person completing the report. Submission of the report to the DNS.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Resident #3, 8, 74, and 107) reviewed for hospitalization, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified in accordance with regulatory requirements when the residents were transferred to the hospital. The findings include: 1. Resident #3 was admitted to the facility in June 2017 with diagnoses that included Parkinson's disease.A nurse's note dated 10/2/25 identified that at 12:20 AM Resident #3 was transferred to the hospital and was readmitted on [DATE]. A nurse's note dated 11/11/25 at 1:19 PM identified Resident #3 was transferred to the hospital and readmitted on [DATE]. A nurse's note dated 11/19/25 at 3:11 PM identified Resident #3 was transferred to the hospital and readmitted on [DATE]. 2. Resident #8 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. A nurse's note dated 9/12/25 at 4:34 PM identified Resident #8 was transferred to the hospital and readmitted on [DATE]. A nurse's note dated 11/14/25 at 11:02 PM identified at 7:00 PM Resident #8 was transferred to the hospital. 3. Resident #74 was admitted to the facility in February 2020 with diagnoses that included diabetes.A nurse's note dated 11/14/25 at 7:16 PM identified Resident #74 was transferred to the hospital and readmitted on [DATE]. A nurse's note dated 11/26/25 at 10:41 Resident #74 was transferred to the hospital. 4. Resident #107 was admitted to the facility in June 2025 with diagnoses that included pleural effusion.A nurse's note dated 12/9/25 at 8:48 PM identified Resident #107 was sent to the hospital and readmitted on [DATE]. A nurse's note dated 1/9/26 at 3:22 PM identified Resident #107 was sent to the hospital and was readmitted on [DATE]. A nurse's note dated 1/30/26 at 1:37 PM identified Resident #107 left the facility at 8:00 AM for a physician appointment. Resident #107 did not return to the facility on the first shift.A nurse's note dated 1/30/26 at 8:07 PM identified a resident representative approached RN #5 and informed RN #5 that Resident #107 was transferred to the hospital from the Oncology clinic. Interview with the Administrator on 2/26/26 at 7:25 AM identified she was unable to provide documentation demonstrating that the Office of the State Long-Term Care Ombudsman had been notified when Residents #3, 8, 74, and 107 were transferred to the hospital. Review of hospitalizations indicated the State Long-Term Care Ombudsman were not notified of the residents who were transferred to the hospital between November 1, 2025, through January 31, 2026. The Administrator indicated she was not aware the list of residents transferred to the hospital had not been submitted. The Administrator further indicated that SW #1 is responsible for notifying the Office of the State Long-Term Care Ombudsman monthly of residents who had been transferred to the hospital. The Administrator indicated she would educate SW #1 on the process for submitting the list to ensure all residents transferred to the hospital are reported going forward. Interview with SW #1 on 2/26/26 at 9:45 AM identified she was responsible for sending the monthly transfer to hospital form to the Office of the State Long-Term Care Ombudsman. SW #1 indicated she did not send the monthly transfer to hospital form for the months of November 1, 2025, through January 31, 2026. SW #1 was unable to provide documentation demonstrating that the Office of the State Long-Term Care Ombudsman had been notified of residents transferred out to the hospital for the year 1/1/25 through 10/31/25. Interview with the DNS on 2/26/26 at 10:00 AM identified SW #1 was responsible to notify the Office of the State Long-Term Care Ombudsman of any resident that was transferred to the hospital, and she was not aware the notifications were not being done monthly.Review of the facility transfer, and discharge (including AMA) policy identified it is the policy of this facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such. The facility will maintain evidence that the notice was sent to the Ombudsman.

Based on observations, clinical record reviews, review of facility documentation, review of policy and staff interviews for 1 of 5 sampled residents (Resident # 60) reviewed for abuse, the facility failed to ensure the resident was free from abuse and failed to protect other residents following a resident-to-resident altercation resulting in the finding of Immediate Jeopardy and for 4 of 10 residents (Resident # 36, # 43, # 70, # 76), reviewed for abuse, the facility failed to ensure the residents were free from mistreatment. The findings included: An observation on 2/28/24 at 1:09 PM, in the dining room identified Resident #76 was standing over Resident #60 who was sitting in a wheelchair in front of her/him delivering three to four blows with a closed fist to the top of Resident #60's head while Recreational Staff #1 was attempting to stand between the two residents. Other staff members responded immediately, and the two residents were separated. Resident #60 was immediately removed from the area and staff stayed with Resident #76 who remained in the area still agitated and yelling but no longer physically aggressive. 1. Resident #60's diagnoses included dementia and cerebral infarction (stroke). The quarterly MDS assessment 12/6/23 identified Resident #60 required one person assist with bed mobility, transfers, ambulated with assist of one and a rolling walker or wheelchair. The Resident Care Plan (RCP) dated 12/19/23 identified Resident #60 had impaired cognitive function related to dementia and limited physical mobility related to cerebral vascular accident (CVA). Interventions directed to monitor and report changes in cognitive function and provide ADL assistance with mobility as needed. 2. Resident#76's diagnoses included depression and chronic kidney disease. The quarterly MDS assessment dated [DATE] identified Resident #76 as severely cognitively impaired, did not demonstrate physical behavior towards others and required supervision with ambulation. The RCP dated 10/15/23 identified Resident #76 as independent with ADL skills including ambulation and had a history of resident-to-resident physical altercations. Interventions directed to provide close and distant monitoring, psychosocial support and provide a calm, quiet environment. A video surveillance dated 2/28/24 at 1:14 PM identified after the resident-to-resident altercation at 1:09 PM on the same day, Resident #76 was escorted by Licensed Practical Nurse, LPN #4 through the lobby and back to his/her room. At 1:15 PM LPN #4 was observed entering the lobby area again alone. At 1:16 PM Resident #76 returned to the lobby area before making his/her way back towards the dining area at 1:17 PM. Resident #76 was then greeted by Social Worker, SW #2 and went to her office. Resident # 76 then exited SW # 2's office and was observed returning to the dining room where there were more than five residents remaining. Resident #76 sat down in a chair along the wall within 3 feet of two other residents without staff supervision which resulted in a finding of Immediate Jeopardy. Resident #60 's nurses note dated 2/28/23 at 10:05PM identified at 1:30PM the resident was heard yelling from the dining room where it was witnessed Resident #60 was yelling with another resident (Resident #76) and was hit multiple times in the head and arm by Resident #76. The two residents were separated immediately. Emergency Medical Services (EMS) were called, social worker, medical and police were notified. Resident #60 was escorted back to his/her room with staff until EMS arrived and subsequently transferred to the emergency room for an evaluation. A subsequent nurses' note dated 2/29/24 at 12:41 PM identified s/he returned from the hospital at approximately 11:55 PM skin warm to touch, no bruising noted, purpura to the back of right hand. Lung sounds clear to auscultation, drenched with urine with no swelling noted and no signs of discomfort. Resident #76's Advanced Practice Registered Nurse (APRN) progress note dated 2/28/24 identified Resident #76 was in the dining room and observed by staff in a verbal altercation with Resident # 60. Resident # 76 was observed striking Resident # 60 on his/her head and arm. The residents were immediately separated and returned to their rooms on different units. Resident #76 was placed on one-to-one continuous observation. A hospital discharge summary dated 2/28/24 identified s/he was cleared by psychiatry before returning to the facility with no medication changes. Resident #76 was scheduled to be evaluated by psychiatry on 2/29/24. A subsequent nurses note dated 2/29/2024 at 1:09AM identified Resident #76 was back at the facility appeared to be calm and remained on 1:1 enhanced supervision. An interview with Recreational Staff #1 on 2/28/24 at 1:24 PM and 2: 21 PM identified residents in the dining area were involved in unstructured activities after lunch which did not require staff supervision. Resident #76 and Resident #60, both Spanish speaking and known to be friends, were sitting next to each other playing a game of Dominos. Recreational Staff #1 heard Resident #76 and Resident #60 conversing during the game while coming in and out of the room but did not understand what was being said. Recreational Staff #1 entered the room and observed Resident #60 push the dominos away from him/herself and Resident #76 and stood up from the chair and started yelling just as Recreational Staff #1 walked over to intervene, Resident #76 began delivering blows to the top of Resident #60's head who was sitting in a wheelchair. Recreational Staff #1 stated she stood between Resident #76 and Resident #60 to intervene and began calling out but was unable to prevent Resident #76 from continuing to deliver blows to Resident #1's head. Additional staff arrived to intervene, and the two residents were separated. Recreational Staff #1 removed Resident #60 from the area to receive medical attention. Recreational Staff #1 stated Resident #76 was known to have exhibited aggressive behavior towards other residents in the past while playing dominos and had reported the problem to the Recreation Director with no resolution. An interview with the Director of Nursing Services, DNS on 2/28/24 1:29 PM identified she had instructed LPN #4 to escort Resident # 76 back to h/her room and stay with h/her until EMS arrived. An interview with LPN #4 on 2/28/24 at 1:34 PM 2/29/24 at 10:48 AM identified she was directed by the DNS to bring Resident #76 back to h/her room following the altercation but needed to leave h/her to provide care to another resident on her assigned unit. LPN # 4 further indicated she left Resident #76 alone in h/her room following an altercation with Resident # 60. An interview with the Recreation Director on 2/28/24 at 2:56 PM identified Resident #76 loved playing Dominos and was competitive. There were times Resident #76 would yell at other residents while playing Dominos and that defusing and redirecting usually worked. If not, residents would be separated. The Director of Recreation stated Recreation Staff #1 did bring up the game of Dominos as a concern in the past, but the consensus was Resident #76 liked to play so dominos was provided without any additional intervention. A subsequent interview with the DNS on 2/28/24 at 3:07 PM identified she was aware of past resident to resident altercations centered around the game of Dominos and had set up additional rooms, purchased additional [NAME] games and indicated staff to be aware when Resident #76 was playing with Dominos. An interview with the Director of Maintenance on 2/28/24 at 4:01 PM identified he translated for Resident #76 when speaking with local law enforcement following the resident-to-resident altercation on 2/28/24. Resident #76 indicated he/she was playing Dominos with Resident #60 who began making moves in the game that made Resident #76 angry and was sworn at before slapping Resident #60. The facility failed to ensure a resident, Resident #60 was free from physical mistreatment resulting in a resident-to-resident altercation during a game where it was previously known to staff Resident #76 demonstrated increased aggressive behaviors while playing and had a previous resident altercation over the game and failed to protect other residents by providing enhanced supervision of Resident #76 until he was transferred to the Emergency Department for an evaluation following an assault of another resident. A review of the facility policy for Abuse directed that the facility maintains a zero-tolerance policy for any form of abuse including physical abuse defined as hitting, slapping, pinching kicking or controlling behavior through corporal punishment. The Administrator was presented with the Immediate Jeopardy Template on February 29, 2024, at 2:33 PM for F 600 Free from Abuse and Neglect. The facility submitted a removal plan on February 29, 2024, at 6:36 PM. The removal plan included the following: 1. The Interdisciplinary Team (IDT) will review daily the clinical record or observations to ensure no resident is exhibiting aggressive behavior or harm to another resident. 2. Staff will immediately separate any resident-to-resident altercations and remove both from area and de-escalate the situation. 3. Resident with be placed on frequent checks including but not limited to 1:1 until cleared by psychiatric services. 4. Ongoing assessment will include but not limited to offer or seek alternate placement as needed if determine that resident is still exhibiting behaviors that put other at risk. 5. Facility will continue to monitor Resident # 76 and any other resident for triggers that may cause harm or injuries from resident-to-resident altercations and provide safety interventions including but not limited to 1:1 and every 15-minute check of monitoring until behavior is safe. 6. Review and re-educate staff on abuse policy and revise as necessary 7. Staff will stay with the aggressor until additional interventions are implemented to ensure the safety of other residents. 8. Both the Social Worker and Director of Recreation are meeting with residents to ensure no other resident is harmed or fearful. 9. The IDT team will continue to have ongoing evaluations of residents to ensure no resident is susceptible to harm from another resident weekly times four and monthly thereafter. Additionally, noted the person responsible for monitoring the plan action was Administrator /Designee. 3. Resident #36's diagnoses included dementia, intellectual disability, and aphasia (difficulty communicating or understanding). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 as cognitively intact and independent with activities of daily living (ADL) including ambulation. The Resident Care Plan (RCP) dated 9/29/23 identified Resident #36 attended scheduled programs and expressed interest in more activities. Interventions directed to continue to invite and encourage participation in appropriate activities. An Advanced Practice Registered Nurse (APRN) note dated 11/7/23 at 1:03 PM identified Resident # 36 was involved in a resident-to-resident altercation with another resident, Resident #76 the evening prior at 4:15 PM in the resident dining room. Resident #36 was struck on the back of the neck by Resident #76 with no reported injuries. A Psychiatric Evaluation dated 11/7/23 identified Resident #36 had a recent altercation with another resident, Resident #76, was unclear of the details, appeared calm and cooperative with no new medication changes. Resident#76's diagnoses included depression and chronic kidney disease. The quarterly MDS assessment dated [DATE] identified Resident #76 as severely cognitively impaired, did not demonstrate physical behavior towards others and required supervision with ambulation. The RCP dated 10/15/23 identified Resident #76 as independent with ADL skills including ambulation and had a history of resident-to-resident physical altercations. Interventions directed to provide close and distant monitoring, psychosocial support and provide a calm, quiet environment. A nurse's note dated 11/7/23 at 8:11 PM identified a resident was heard in the dining area yelling in Spanish and being aggressive. Another resident, Resident #36 was assisting in cleaning a table when Resident #76 became agitated and hit h/her on the back of the neck. Two staff members were hit while attempting to separate the two residents. Resident #76 was moved to a separate area, emergency services activated, and Resident #76 was subsequently transferred to the emergency department for further evaluation. The hospital After Visit Summary dated 11/6/23 identified Resident #76 was psychiatrically cleared for return to the facility with no medication changes and recommendations to follow up with providers. A Psychiatric Evaluation dated 11/7/23 identified Resident #76 was sent to the hospital for physical aggression after hitting another resident. Resident #76 was prescribed an increase in Trazadone (medication used for the treatment of depression) and recommendations for a neurocognitive psychiatric evaluation. A Police Case/ Incident Report dated 11/7/23 at 8:09 PM identified on 11/6/23 at approximately 4:10 PM the police responded to the facility following a report of a resident to staff and resident to resident incident where Resident #76 was reportedly playing Dominos when a staff member told Resident #76 it was time for dinner. Resident #76 became upset and lashed out because s/he did not want to put away the game of Dominos. A facility Reportable Event Summary dated 11/10/23 identified on 11/6/23 at 4:15PM in the dining area, Resident # 36 was struck in the back by Resident #76 when attempting to clean up after a game of dominos. Resident #76 was transferred to the emergency room (ER) for further evaluation, returned to the facility following medical clearance and received medication adjustments on 11/7/23 after being evaluated by in-house psychiatry. Resident #36 and Resident #76 resided on separate units and the [NAME] activity was moved to another room to facilitate additional space for card playing prior to supper time. An interview with Recreational Staff #1 on 2/28/24 at 1:24 PM and at 2: 21 PM following a subsequent resident-to-resident incident during a game of Dominos identified Resident #76 was known to have exhibited aggressive behavior towards other residents in the past while playing dominos and had reported the problem to the Recreation Director with no resolution. An interview with the Director of Nursing on 2/28/24 at 3:07 PM and 3/4/24 at 11:35 AM identified Resident #76 was evaluated by psychiatry following the incident and was prescribed medication adjustments following the incident. Another room outside of the dining room where the incident had occurred was designated for use for Dominos, however residents were not required to use the room for that purpose. The DNS indicated she would expect residents to be free from abuse. 4. Resident #70's diagnoses included hemiplegia (weakness) and hemiparesis (paralysis) following a cerebral infarction (stroke). The quarterly MDS assessment dated [DATE] identified Resident #70 was cognitively intact, required extensive two person assist with bed mobility, transfers, one person assist with locomotion on the unit using a wheelchair. The Resident Care Plan (RCP) dated 4/11/23 identified Resident #70 had limited physical mobility and had a history of being verbally abusive and combative telling people to get out of the way so s/he can navigate the hallways. Interventions included providing assistance of two and analyze times, places, circumstances, triggers and what de-escalates the behavior and document. Resident #70 nurse's note dated 6/1/23 identified a resident-to-resident altercation had taken place between Resident #70 and Resident #26 and a police investigation was ongoing. 5. Resident #26' diagnoses included borderline personality disorder and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #26 as cognitively intact, did not express any indicators of psychosis, required one person assist with bed mobility, transfers and was independent with locomotion with the use of a wheelchair. The RCP dated 5/22/23 identified Resident #26 had a history of loud outbursts, past resident to resident physical abuse and often threw things at staff. Interventions directed to approach with two staff members for loud outbursts, call police and address behavior and inappropriateness immediately with resident. Resident #26's nurse's note dated 6/1/23 at 7:55PM identified a resident-to-resident altercation that took place at 7:45 PM. Resident #26 reported Resident #70 ran over h/her right lower leg while trying to pass, doing it on purpose. Resident #70 reported Resident #26 was calling h/her names because s/he was unable to get by in the hallway calling Resident #70 a B and a MF. Resident #70 stated s/he accidentally hit Resident #26 with the wheelchair because s/he was close. The Director of Nursing was notified, and a skin check was completed. Resident #26 complained of pain in the right lower leg. The right leg was able to move without limitations. An x-ray was scheduled, and police notified. An investigation statement dated 6/1/23 completed by Maintenance Staff #1 (former staff) identified at approximately 7:40 PM, Resident #26 was observed asking Resident #70 to move h/her wheelchair so s/he could go down the hall. Resident #70 attempted to move the wheelchair so Resident #26 could pass but ran over Resident #26's foot by accident. Resident #26 screamed and began cursing at Resident #70 and then threw water on h/her. Radiological Results for Resident #26 dated 6/2/23 identified x-rays of the right tibia/fibula (lower leg bones) were negative. A facility Reportable Event Summary dated 6/8/23 identified on 6/1/23 at 7:40PM, Resident #70 and Resident #26 were both in the hallway trying to get by each other. Resident #70 was in an electric wheelchair and in the process of trying to move the wheelchair s/he accidentally hit Resident #26's leg. Resident #26 had a glass of water, in a medicine cup in h/her hand and threw it at Resident #70. No injuries were noted to either resident. The residents were separated immediately and would continue to be seen by medical, psychiatry, and social services. Resident #70 and Resident #26 were educated to offer space to others when ambulating in common areas. Staff were directed to monitor for inappropriate interactions or escalation of the residents and separate as necessary or deescalate. An interview with the Director of Nursing (DNS) on 3/4/24 at 11:35 AM identified she would expect residents to be free from abuse, the care plan updated to reflect the individualized need and the resident(s) to receive support from social services following the event. Efforts to interview the (former) Maintenance Staff #1 were unsuccessful. 6. Resident #43's diagnosis included depressive episodes and dementia. Resident #43's was admitted on [DATE] to the facility. Resident #43 was verbally appropriate, had adequate hearing and adequate vision with glasses. A Brief Interview for Mental Status (BIMS) dated 12/6/2024 indicated resident #43 had mild cognitive impairment. The baseline care plan from admission with no date of completion, indicated in part Resident #43 was admitted with depression, dementia and was sad/crying. 7. Resident # 250's diagnoses included diabetes mellitus, psychotic disorder, and schizophrenia. The quarterly MDS assessment dated [DATE] identified cognition intact and independence with ambulation. The facility Reportable Event (RE) form dated 12/8/22 at 9:20 AM indicated Resident #43 alleged Resident #250 came to the door of the resident's room and verbally threatened to cause sexual harm. A Reportable Event Report dated 12/8/22 at 9:20 AM indicated another Resident #29 accused Resident #250 of touching his/her thigh while making verbal sexual advances. The report further indicated the facility immediately initiated an hourly check on Resident #250, and staff were educated to be vigilant of any inappropriate behavior. The Reportable Event Report also indicated Resident #250 was seen by psychiatric services and provided counseling and police were notified and came in to talk with the resident. An interview with the DNS on 2/28/24 at 10:40AM indicated copies of the police report were not requested as Resident #250 did not return from the hospital. Although, the DNS indicated he/she found the abuse allegations against Resident #250 were unsubstantiated indicating Resident #43 most likely was repeating something else heard outside the room. The DNS indicated Resident #29's incident may have happened days before. The conclusion was made without the additional evidence of interviews conducted by the police. The DNS agreed to obtain copies of the police report (2 years later). The police reports incident date 12/8/2022 at 10:17AM, 1:47PM and 7:00PM obtained after surveyor inquiry indicated in part Resident #250 did touch Resident #29's shoulder in a platonic way as they were hanging out but did not touch Resident #29 or show an imprint of his/her genital area. The officer advised Resident #250 to leave Resident#29 alone and if he/she continued to speak to Resident # 29 he/she could be arrested for harassment. The reports further indicated Resident #250 admitted to the police officer he/she told Resident #43 he/she wanted to rape Resident #43. The report further indicated Resident #43 did not want to press charges. The social service note dated 12/9/22 at 2:33 PM identified the Social Worker (SW) did a follow up visit with resident to see how s/he was doing after the alleged allegation of one of her/his peers. Resident # 43 was informed that Resident # 250 was no longer in the facility, so s/he does not have to fear. Resident # 43 stated that she was very happy Resident # 250 gone and s/he does not have to listen to her/him. Additionally, the resident was seen by psychiatric APRN and assured all safety measures were in place. The facility policy labeled Resident Abuse and Neglect indicated in part a summary of the facts, actions taken, conclusions and specific plan of correction are documented on the Incident/Accident investigation in the medical record and ensure the outcome is completed within 5 working days. The dates of completion of the police reports indicated 12/10 22 at 9:11 AM, 9:59 AM, and 10:19 AM (within 5 working days (12/14/2022) and could have been requested by the facility for use in their investigation. Interview with the DNS on 3/4/24 at 2:30 PM identified to hourly checks were safety measures put in place to address the resident-to-resident incident. 8. Resident #76's diagnoses that included traumatic brain injury, major depressive disorder, and seizures. The annual MDS assessment dated [DATE] identified Resident #76 as moderately cognitively impaired and required set up or clean up assistance for eating and required partial assistance for toileting and showering. The assessment noted the resident was independent for mobility. The MDS assessment further identified Resident #76 had 1 occasion of verbal behavioral symptoms. 9. Resident # 61's diagnoses included high blood pressure, chronic kidney disease and dementia. The quarterly MDS assessment date 12/27/22 identified Resident #61 as severely cognitively impaired and required limited assistance of one for eating, toileting and personal hygiene and was independent for dressing. The MDS assessment further identified Resident #61 did not display any verbal or physical behavioral symptoms towards other residents. a. A review of the Accident and Incident Report (A & I) form dated 2/13/23 at 7:00 AM identified a possible physical altercation that happened between Resident #76 and Resident #61. Resident #76 had slight left eye bruising and discoloration and stated Resident #61 hit h/him. The incident was unwitnessed, and police were called. The police report dated 2/13/2023 at 8:34 AM indicated Resident #76 was attempting to go to sleep when Resident #61, who was also his/her roommate was watching TV, and Resident #76 states that s/he stood up to turn the TV off and when s/he did, s/he was struck in the eye, fell to the ground and kicked in the right rib area while on the ground. Resident #76 and Resident # 61 were separated. The attending officer indicated that he observed Resident #76 ' s bruised left eye and bruised right ribs. Resident #61 stated to officers that s/he did not recall the event. Although the facility investigation indicated no bruising to the right ribs, police identified it. A review of the Reportable Events page findings for the state agency dated 2/17/2023 at 12:00 AM indicated Resident #76 was upset because h/her roommates TV was loud early in the morning. An argument occurred and Resident #76 was hit in the face by Resident #61. Resident #61 was moved back to h/his original room, on another wing. Resident #76 was seen by medical, social work, and psychiatry. Resident #76 was offered ear plugs or headphones for when their roommate is watching TV. The event was identified as resident to resident abuse without injury. b. A review of the A & I formed dated 6/4/23 at 7:45 PM identified that an argument over the TV occurred where Resident #76 asked resident #7, their roommate to turn down the TV. It is unclear whether Resident #76 tried to take the remote or attempted to turn the TV down, when Resident #7 pushed Resident #76, and both residents were hitting/punching each other. The residents were separated from each other, and the police were called. A hematoma was noted on the eye of Resident #76. The police report dated 6/4/23 at 6:44 PM indicated Resident #76 was trying to sleep when Resident #7, who was their roommate, turned the TV on in the room. Resident #76 asked Resident #7 to turn the volume of the TV down and Resident #7 turned the volume up. Resident #76 stated s/he stood up to turn the TV off and was pushed by Resident #7. Resident #7 stated s/he tried to keep the remote away from Resident #76 when Resident #76 fell . Resident #7 indicated to officers that s/he did not mean to push Resident #76. No injuries were identified by officers. A review of the Reportable Events page findings for the state agency dated 6/8/23 at 12:00 AM indicated Resident #76 became mad when Resident #7 would not turn the TV down after being asked. Resident #76 and Resident #7 began to argue when Resident #76 was pushed by Resident #7, and they proceeded to hit each other in the face. No injuries were noted to either resident in the report. Resident #7 was moved to another room and wing. Education regarding space in common areas was given. Resident #76 plan directed to continue to be seen by medical, psychiatry, and social work. Staff were to monitor for inappropriate interactions or escalation of the resident and separate as necessary or deescalate. The event was identified as resident to resident abuse without injury. Interview on 2/29/24 at 11:24 AM with the DNS indicated after the 2/13/23 resident to resident altercation that the facility provided Resident #76 with earplugs and headphones to help with the noise. A review of the facility Resident Abuse and Neglect policy (no date) directs the facility to maintain a zero-tolerance policy for any forms abuse, neglect, and exploitation of a resident. It further states that all residents have the right to be free from abuse, neglect, and exploitation. 46046 48364

Based on clinical record review, observations, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff transferred the resident in accordance with the plan of care. The findings include: Resident #1's diagnoses included cerebral infarction, dementia, adult failure to thrive, anxiety disorder, and disorders of bone density and structure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment and required extensive assistance of two (2) staff for transfers. The Resident Care Plan (RCP) dated 2/5/2023 identified Resident #1 had a self-care deficit related to weakness, dementia, history of subdural hematoma, seizure disorder, failure to thrive, weakness, and cerebral infarction. Interventions directed to transfer resident by a Hoyer lift with assist of two (2) staff. A nursing note written by the DNS dated 4/7/2023 at 11:56 PM identified the DNS was requested to see Resident #1 related to complaints of left leg pain. The note indicated swelling of the left knee, the leg was rotated out, and Resident #1 was unable to move the leg. Resident #1 indicated it happened when he/she was transferred into bed. New orders were obtained for an x-ray. Review of the Radiology Result Report dated 4/8/2023 at 4:37 AM identified Resident #1 had a fracture involving the left distal femur with no displacement identified. Review of the hospital discharge summary dated 4/8/2023 identified x-ray results indicated a left acute, mildly displaced fracture of the left inferior pubic ramus (part of the pelvic bones), and a slightly angulated fracture of the distal femoral metaphysis with marked osteopenia (bone loss). Resident #1 was seen by orthopedics, and recommendations for non-weight bearing of the left leg with use of a knee immobilizer, and to follow up with orthopedic physician in one (1) week. Directions further included to administer Lovenox (blood thinner) 40 mg daily for six (6) weeks. Interview with NA #1 on 4/25/2023 at 10:10 AM identified on 4/7/2023, Resident #1 requested to be transferred back into bed. NA #1 indicated he went to find additional help to assist with the Hoyer transfer, but all staff on the unit were busy. NA #1 identified although he knew he should have two (2) staff for the transfer, he decided to transfer Resident #1 via the Hoyer lift by himself, so the resident to not have to wait any longer. NA #1 indicated Resident #1 was slouched in the wheelchair, he straightened the resident first and then performed the Hoyer lift transfer with no issues or concerns noted. Once Resident #1 was in bed, he/she complained of left knee pain. NA #1 immediately notified the nurse. NA #1 identified a Hoyer lift transfer is performed with two (2) people and he should have waited for another staff member to assist with the resident transfer. Interview with Resident #1 on 4/25/2023 at 11:45 AM identified his/her leg bumped into the side of the bed during the transfer on 4/7/2023 by NA #1. Interview with MD #1 on 4/25/2023 at 12:25 PM identified they type of fracture Resident #1 experienced could be caused by trauma. Interview with DNS on 4/25/2023 at 2:00 PM identified two (2) staff are required for Hoyer lift transfers, and upon assessing Resident #1 on 4/7/2023 his/her left knee was swollen, and the leg was externally rotated. The DNS indicated NA #1 did not follow Resident #1's plan of care for transfers, and performed a Hoyer lift transfer by himself. The DNS indicated she expected staff to follow resident's plan of care, and indicated NA #1 should have waited for additional assistance prior to transferring Resident #1. DNS identified NA #1 and all staff have received education regarding Hoyer lift transfers and audits were initiated. Review of the Care Plan Policy directed in part, the care plan will describe the services that are to be furnished (to the resident) to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being and any services that would otherwise be required but are not provided due to the resident's exercise of rights, including the right to refuse treatment.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 9) reviewed for pain, the facility failed to ensure a resident received prescribed pain medication in a timely manner, failed to implement any further interventions when pain relief was ineffective resulting in severe pain. The findings include: Resident #9 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was without cognitive impairment, required extensive assist with bed mobility, transfers, personal care and had experienced frequent pain. The care plan dated 8/25/21 identified Resident #9 experienced generalized pain with interventions that included pain medications as ordered and therapy as tolerated. The physicians ' orders dated 9/5/21 directed to administer [MEDICATION(S)]-acetaminophen ([MEDICATION(S)]) 10-325 Milligrams (MG) every 6 hours for severe pain. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing progress note dated 9/5/21 at 7:39PM indicated the Tylenol was ineffective with no further documented intervention. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing progress note dated 9/6/21 at 8:26AM noted the physician was updated on depletion of [MEDICATION(S)] ([MEDICATION(S)]-Acetaminophen), with the closure of the pharmacy due to the holiday. Received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 5MG was administered with a documented 0 on the pain scale for the second shift. [MEDICATION(S)]-acetaminophen 10-325 MG restarted 9/8/21 2:00AM following 5 missed doses and a pain level of 0 at the time the medication was resumed. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol 975 MG was administered 9:01AM with good effect. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication restarted on l 10/21/21 8:00PM following 4 missed doses and a pain level of 6 at the time the medication was resumed. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol was repeated at 10:37AM which was effective and 6:40PM which was not effective with no other interventions. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The dose was repeated at 10:46AM, also documented as ineffective with a pain level of 7 with no further intervention at that time. The physicians ' orders dated 1/31/22 directed [MEDICATION(S)] 5MG every 6 hours was prescribed 1/31/22 through 2/1/22 until [MEDICATION(S)] comes in. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol 975 MG was administered with documented good effect. An observation and interview on 3/7/21 at 11:01AM with Resident #9 identified a staff Registered Nurse (RN #5) in the room with Resident #9. Upon RN #5 exiting, Resident #9 was observed crying stating the facility had run out of his/her pain medication and that this occurred every 3-4 weeks. Resident #9 indicated the last dose was administered at midnight. At that time, the nurse said she would request a refill from pharmacy if she had time. Resident #9 indicated s/he had no pain medication for 6:00AM and that the nurse (RN #5) came in and said she ordered the medication from the pharmacy and the medication would not be delivered to the facility until 5PM. Resident #9 had indicated Tylenol was administered but did not help. Resident #9 indicated s/he had a pain level of 7. An interview on 3/7/22 at 11:30AM and 12:10PM with RN #5 identified she worked as a nursing supervisor for the day shift. RN #5 indicated she was made aware by Resident #9 that s/he had no pain medication ([MEDICATION(S)]-acetaminophen) left after receiving the last dose at 12:00AM on 3/7/22 and had none at 6:00 AM. RN #5 indicated no other nursing staff reported the depleted stock. RN #5 contacted the pharmacy who told her the order would be delivered at 5:00PM. RN #5 indicated she was in the room informing Resident #9 when approached by this surveyor. RN #5 was told by Resident #9 s/he was in pain and was crying. RN #5 indicated she did not contact the medical on call doctor for an alternate medication or request a stat delivery for Resident #9 as she need to cover working the floor for another nurse who left. RN #5 indicated she would call for a stat delivery and later discussed with the Advanced Practice Registered Nurse (APRN) on arrival to the facility at 12:00PM who ordered [MEDICATION(S)] 5 MG for one dose which Resident #9 did not want and instead would receive Tylenol 1000 MG. An interview on 3/7/22 at 11:40AM with Pharmacist #1 identified orders for pain medications were sent when requested. Routine turnaround times depend on when called in stat (immediate) orders were sent within 4 hours. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 3/7/22 at 12:40PM with the Administrator and DNS and 3/8/22 at 9:40AM with the DNS identified while having no specific policy, nurses were expected to re-order when there were generally 7 pills left. While the preferred medication was not available, Resident #9 was offered alternatives. The Administrator and DNS were aware Resident #9 had run out of pain medication in the past and verbal education was provided to the staff at that time. However, the DNS could not explain why the pain medication was not ordered timely. The APRN progress note dated 3/7/22 at 1:12PM noted awaiting [MEDICATION(S)] delivery from the pharmacy for Resident #9. Called pharmacy to start medication now. Since medication was scheduled, would likely treat with other forms of pain medication. [MEDICATION(S)] had been effective and Resident #9 stated s/he would like to continue using. A plan was in place to administer extra Tylenol (1000MG), administer [MEDICATION(S)]-acetaminophen every six hours for severe pain when available. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 3/8/22 at 11:41AM with Licensed Practical Nurse (LPN #4) identified she worked the overnight shift from 3/6/22 through 3/7/22. When coming on shift, LPN #4 noticed there was one [MEDICATION(S)]-acetaminophen 10-325 MG left. LPN #4 asked the off going nurse giving report if anyone ordered a refill of the medication and the nurse did not know. LPN #4 notified the Nursing Supervisor but became too busy to follow up with her. An interview on 3/8/22 at 12:14PM with LPN #1 identified she could not recall the night of 9/5/21 when Resident #9 ran out of medications but stated it happened all the time. LPN #1 indicated she knew to order medications when low or notify the Nursing Supervisor so medications can be ordered. Efforts to reach the Nursing Supervisor who worked the 11-7 shift 3/6/22 into 3/7/22 was unsuccessful. Although requested a policy for maintaining pain medication was requested, none was provided.

Based on a clinical record review, a review of facility documentation, staff interviews, and a review of the facility policy for one sampled resident (Resident #1) who was reviewed for change in condition, the facility failed to ensure that life saving measures were provided promptly when the resident was found to be unresponsive and not breathing which resulted in the finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order dated [DATE] directed a full code. The admission Minimum Data Set (MDS) assessment dated [DATE] identified intact cognition, extensive assistance of one person for bed mobility, toilet use, personal hygiene and extensive assistance of two staff members for transfers. The [DATE] care plan dated identified the resident as a full code with interventions that included to allow the resident to discuss his/her feelings regarding their advanced directive. Review of the resident expression of treatment preference documentation dated [DATE] indicated Resident #1's wishes included initiation of cardiopulmonary resuscitation (CPR) if he/she was without respirations or a pulse. The documentation also indicated if the resident developed an acute illness and required acute care monitoring, he/she should be transferred to a hospital. The nurse's notes dated [DATE] at 3:15 AM identified the facility received a call at 2:30 AM from Resident #1's responsible party indicating Resident #1 was on the phone with emergency personnel requesting to be transferred to the hospital. Resident #1 was assessed, by RN #2 (Nursing Supervisor). The resident complained of feeling shaky. RN #2 assessed the residents vital signs and checked his/her blood sugar and documented that all the results were within normal limits. [MEDICATION(S)] 10 milligrams (mg), by mouth, was administered for anxiety at 3:00 AM at which time the resident indicated he/she was feeling better and did not want to be transferred to the hospital. Review of the clinical record between the hours of 3:25 AM through 5:25 AM identified a reassessment of the resident's condition or a response regarding the effectiveness of [MEDICATION(S)] that was administered on [DATE] at 3:00 AM was not conducted. Additional nursing notes dated [DATE] at 7:36 AM indicated at approximately 5:30 AM RN #2 was called to Resident #1's room and the resident was observed to be unresponsive and absent a pulse. The notes failed to reflect the time CPR was initiated. Review of the emergency medical personnel documentation dated [DATE] indicated a call was received from the facility at 5:55 AM and emergency personnel entered the building at 6:02 AM. Upon arrival to the facility Resident #1was found lying on his/her bed with a backboard underneath the resident and CPR was not in progress. The resident's pupils were fixed and dilated. Resident #1 was negative for rigor and lividity and the carotid pulse was absent on palpation. The facility staff reported Resident #1 was a full code. The report further indicated that upon Emergency Medical Service (EMS) inquiry as to why CPR was not conducted, LPN #4 stated, I'm not sure. It didn't seem like a nice thing to do to him/her. The resident was pronounced deceased at 6:27AM at the facility by the emergency service personnel in collaboration with the Emergency Department at a local hospital. Review of the facility incident report dated [DATE] indicated it was reported to the facility on [DATE] that life safety measures were not in progress for Resident #1 when emergency personnel arrived at the facility. Review of LPN #4's written statement indicated on the morning of [DATE] sometime after 5:30 AM Resident #1 was observed to be unresponsive to verbal and noxious stimuli, absent a heart rate and respirations. The resident's pupils were fixed, and a gag reflex was not present. The statement further identified that blood had pooled and mottled to the resident's lower extremities. The Nursing Supervisor was called. LPN #4's written statement indicated she left the room to obtain the crash cart and RN #2 activated EMS. The resident was then placed on back board to initiate CPR. LPN #4's statement also indicated she attempted to administer CPR but was unable to provide effective compressions secondary to obesity. Several attempts were made to contact LPN#4, however were unsuccessful. During an interview with NA#1 on [DATE] at 11:31 AM indicated on the morning of [DATE] during rounds she observed Resident #1 in bed not breathing and she informed LPN #4 of the resident's condition. LPN#4 who was at nursing station when NA #1 informed her of Resident #1's condition, indicated she was aware that Resident #1 was unresponsive and not breathing. NA #1 could not recall the time she made rounds on that day. During an interview with RN #2 on [DATE] at 4:02 PM identified on [DATE] at approximately 2:30 AM Resident #1's responsible party called the facility and indicated Resident #1 was on the phone with EMS requesting a transfer to the hospital. An assessment was conducted at that time, and Resident #1 identified he/she was feeling better and no longer wished to be transferred to the hospital. RN#2 indicated somewhere between 5:40 AM to 5:50 AM LPN #4 approached the supervisor's office and stated Resident#1 was unresponsive and not breathing. At that time LPN #4 and RN #2 went to Resident #1's room and he/she was observed without a pulse and/or respiration. RN #2 further indicated that LPN #4 and RN #2 left the resident's room and returned to the nursing office to check the resident's code status. LPN #4 and RN #2 returned to the room with the crash cart. RN#2 indicated Resident #1 was positioned on a bed board and she witnessed LPN#4 performed three (3) compressions. RN #2 then left the room to call EMS and await their arrival. RN #2 re-entered Resident #1's room with the emergency medical technician (EMT). LPN#4 was observed in the room with Resident #1 however, she was not performing CPR. During further interview with RN#2 she indicated she did not page the facility staff identifying that emergency assistance was required for Resident #1 and/or call other nursing staff in the facility to assist with Resident #1 when he was observed to be unresponsive and not breathing as the experience was traumatic. In an interview with NA#2 on [DATE] at 9:32 AM she indicated on the morning of [DATE] during morning rounds sometime after 5:40 AM LPN#4 indicated Resident #1 was gone, and she needed assistance with positioning him/her in the bed. NA#2 identified Resident #1 was not breathing however his/her body was still warm. During an interview with the Director of Nursing (DON) on [DATE] at 1:50 PM she indicated the residents code status was in the paper chart at the nursing station and could also be found in the electronic record. The DON indicated it is the responsibility of the charge nurse to check the paper chart for the resident's code status as that was the closest location to the resident. The DON also identified when the resident was found unresponsive the charge nurse should have paged an immediate alert to notify all the staff of the emergency. The facility personnel would then be directed to the location and provide assistance as needed. The DON would have expected another staff member to assist EMS personnel into the bluiding so that RN #2 could have ensured and/or assisted with continuous life saving measures. Review of the facility policy entitled Cardiopulmonary Resuscitation directed in part when a cardiopulmonary resuscitative code was initiated, EMS services must be called, and CPR must be continued until the EMS team arrives and assumes responsibility for the CPR process. Although Resident #1 was found unresponsive at approximately 5:40 AM the staff failed to timely implement necessary emergency protocol measures that included paging for immediate assistance, calling EMS, performing CPR timely and continuously until the EMS team assumed the care of Resident #1. On [DATE], when the facility was aware of the deficient practice, a corrective action plan was implemented which included, the verification of the residents code status from a source (electronic or paper medical record) closest to the location of the event, reviewing the facility policy that directed the immediate notification of an emergency to staff, Cardiopulmonary Resuscitation drills (CPR), education related to initiating and continuing CPR until the Emergency Medical Service (EMS) team arrived and assumed responsibility for the CPR process, and the care of the resident.

Based on observations, record review, facility documentation and staff interviews for four of four residents (Residents #1, #2, #3 and #4) who had been recently admitted to the facility and were receiving a specialized treatment in the community three times a week, the facility failed to implement the necessary transmission-based precautions to prevent and control the spread of COVID-19, resulting in a finding that constituted Immediate Jeopardy. The findings include: Interview with the Director of Nursing and the Facility Administrator and review of the facility's COVID-19 Tracking Line List on 5/22/20 at 11:00 AM indicated the seventy-nine residents who currently resided in the facility were cohorted on four units that were designated as the following: a unit with residents who were COVID-19 positive, a unit with residents who had recovered from COVID-19 and two COVID-19 negative units. A tour of the North Unit and further review of the facility's COVID-19 Tracking list with the Director of Nursing on 5/22/20 at 11:45 AM identified that although the North Unit had been designated as a negative unit, four of the sixteen residents residing on the unit (Residents #1, #2, #3, #4) were receiving a specialized treatment in the community and had experienced possible exposure to COVID-19. Record review identified that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An inter-agency patient referral report dated 5/19/20 directed that the resident receive [MEDICAL TREATMENT] every Tuesday, Thursday, and Saturday at 3:45 PM. Further record review identified that Resident #1 received [MEDICAL TREATMENT] in the community on 5/21/20. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Further record review identified that Resident #2 received [MEDICAL TREATMENT] in the community on 5/15/20, 5/18/20, 5/20/20 and 5/22/20. Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. An inter-agency patient referral report dated 5/11/20 further identified a [DIAGNOSES REDACTED]. The inter-agency referral report directed that the resident receive [MEDICAL TREATMENT] every Monday, Wednesday and Friday. Further record review identified that Resident #3 received [MEDICAL TREATMENT] in the community on 5/13/20, 5/15/20, 5/18/20, 5/20/20 and 5/22/20. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An inter-agency patient referral report dated 5/15/20 directed that the resident receive [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday. Further record review identified that Resident #4 had received [MEDICAL TREATMENT] in the community on 5/16/20, 5/19/20 and 5/21/20. Observations made on the North Unit on 5/22/20 at 11:50 AM identified Nurse Aide #1 leaving the room of Resident #4 with soiled linen without the benefit of personal protective equipment except for a KN95 facemask. Further observations failed to identify any signage with instructions regarding the specific transmission-based precautions that were required for Resident #4 or the necessary personal protective equipment (PPE) (e.g. protective gowns, face shields) or isolation carts containing supplies that were to be used when providing care. Interview with NA #1 immediately following the observation on 5/22/20 at 11:50 AM indicated she thought the North Unit was a COVID-19 negative unit, and there were not any residents on the unit who were being provided with transmission-based precautions. NA #1 further stated she had been informed that since the North Unit was a COVID-19 negative unit, it was not necessary to wear personal protective equipment except for a facemask and gloves while providing care to residents. NA #1 further indicated that there had not been any isolations carts with personal protective equipment on the unit when she reported for duty on the first shift on 5/22/20. Interview with Housekeeper #1 on 5/22/20 at 12:05 PM identified that although she was wearing a surgical mask which was covered by a cloth mask, she was unaware of a need to wear any additional personal protective equipment (e.g. isolation gown, face shield) while cleaning the rooms of Residents #1, #2, #3 and #4. Interview with LPN #1 on 5/22/20 at 12:20 PM indicated that she thought the residents on the North Unit were COVID-19 negative. LPN #1 stated she had been informed that only a surgical facemask and gloves were needed when providing care to the residents on the Unit. LPN #1 further identified that isolation carts containing personal protective equipment (PPE) had not been on the North Unit when she arrived at work for the first shift on 5/22/20. She stated that at approximately 11:00 AM she was informed Residents #1, #2, #3, #4 were to be observed for possible symptoms of COVID-19 for fourteen days, and at that time the facility began to place isolation carts with PPE outside resident rooms. Interview with the Director of Nursing and Facility Administrator on 5/22/20 at 12:55 PM indicated they were under the impression that if a resident had two COVID-19 negatives tests at the hospital prior to admission, the residents were to be monitored for signs and symptoms of COVID-19 every shift but did not require transmission-based precautions. Further interview with the Director of Nursing and the Facility Administrator on 5/22/20 at 3:50 PM indicated that prior to the surveyor's unannounced visit on 5/22/20, the Administrator had contacted the Medical Director via email to obtain direction regarding the precautions that were to be implemented for residents receiving specialized treatments in the community. The Administrator indicated that she had not received a response. Subsequent to surveyor inquiry, the use of the necessary personal protective equipment was initiated, signage that identified the need for transmission-based precautions was posted on residents' doors, isolation carts with necessary personal protective equipment were placed outside resident rooms, and the re-education of the staff on duty was initiated. A plan was established for the immediate re-education of all staff in all departments who were on duty at the time and the re-education of all staff before the start of their shift. According to the Centers for Disease Control and Prevention (CDC),) Coronavirus Disease 2019, updated May 11, 2020, nursing home residents should be cohorted on separate units or areas: positive, negative and exposed. Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Cloth face coverings are not considered PPE and should not be worn when PPE is indicated. CDC guidance also identified that nursing homes should establish a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Based on observations and review of facility documentation subsequent to surveyor inquiry, Immediate Jeopardy was removed on 5/22/20 at 4:35 PM.

Based on review of the clinical record, review of facility policies, review of facility documentation, and interview, for one of three residents reviewed for pressure ulcers, Resident #137, the facility failed to ensure that a comprehesive, individualized plan of care was developed and/or implemented timely to prevent the worsening of a community acquired pressure ulcer. The findings include: 1a. Resident #137 (R #137) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the documentation from the acute care hospital dated 6/4/14 identified that R #137 was discharged from the hospital to the facility with a Stage I pressure area on the coccyx. The admission assessment dated [DATE] identified that R #137 was admitted to the facility with a 1.5 by 0.2 by 0.0 centimeters (cm) Stage I pressure ulcer on the coccyx. A Braden scale assessment dated [DATE] identified R #137 with a score of twelve, indicative of high risk for pressure ulcer development. The admission documentation further identified that R #137 was totally dependent on staff for bed mobility. Review of an assessment dated [DATE] identified that R #137's pressure ulcer was now described as a Stage II pressure ulcer with the same measurements as documented on 6/4/14 and with no visible necrotic tissue. Review of the clinical record including physician admission orders [REDACTED]. b. Review of the weekly skin check dated 6/10/14 identified that the resident's Stage II PU measured 0.4 by 0.2 by less than 0.1 cm. Physician orders [REDACTED]. The weekly skin check dated 6/24/14 identified that R #137's pressure ulcer had increased in size and now measured 0.6 cm by 0.6 cm by 0.1 cm. Physician orders [REDACTED]. Review of the weekly pressure ulcer report dated 7/1/14 identified that R #137's pressure ulcer was now unstageable and measured 1.5 cm by 1.5 cm with 25% to 50 % of the wound with necrotic tissue and with a small amount of thin, serosanguineous drainage. Physician orders [REDACTED]. Although physician orders [REDACTED].#137 be out of bed daily for only two hours and be positioned side to side when in bed, the clinical record lacked documentation to reflect that an individualized positioning schedule was implemented prior to the worsening of R #137's coccyx pressure ulcer. Facility policy directed in part that residents at risk for developing pressure ulcers would be assessed upon admission. Preventive measures and healthy skin interventions would be utilized and included repositioning at intervals determined by resident risk but at a minimum of every two hours. c. Physician orders [REDACTED].#137's coccyx wound followed by silver gel. R #137 was seen by the wound specialist on 7/2/14 for a now described Stage III pressure ulcer on the coccyx. Measurements were documented as 1.6 cm by 1.1 cm by 0.2 cm with light serous exudate. R #137's wound was debrided with post debridement depth measured at 0.3 cm. Directions post consultation included to provide a dry protective dressing and silver hydrogel. Although R #137's pressure ulcer had progressed to a Stage III as of 7/2/14, placement of an alternating air mattress was not implemented until 7/8/14 when physician orders [REDACTED]. Review of the clinical record lacked documentation to reflect that a therapeutic and/or other pressure relieving mattress was implemented prior to the worsening of R #137's coccyx pressure ulcer. Facility policy directed in part that residents at risk for developing pressure ulcers would be assessed upon admission and that preventive measures included initiation of a therapeutic mattress as indicated.

Based on clinical record reviews, review of facility documentation and interviews for one of four sampled residents (Resident #132) who had a decline in nutritional status, the facility failed to monitor weights according to the facility's policy and/or implement interventions to prevent a weight loss. The findings include: Resident #132 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The admission resident care plan dated 5/14/13 identified that Resident #132 was at risk for nutritional decline related to the diabetes mellitus and a body weight below the desired range. Interventions included to provide and encourage the intake of fluids, obtain weights and record, monitor and evaluate weight changes and to notify the Registered Dietician, family and physician of significant weight changes. The admission Minimum Data Set assessment dated [DATE] identified that Resident had no cognitive impairments, mood symptoms included a poor appetite, feeling down, depressed or hopeless and had a weight of 117 pounds (lbs). The May 2013 Treatment Administration Record (TAR) indicated weekly weights were to be obtained on Tuesdays on the 7-3 shift, (5/14/13 (day of admission), 5/21/13 and 5/28/13). The June 2013 TAR failed to identify a fourth weekly weight that was to be obtained on 6/4/13. A Medical Nutrition Therapy assessment dated [DATE] identified Resident #132 weighed 117 lbs, the ideal body weight was to be 145 lbs, the resident was underweight, had an oral intake of 75% of meals on average and to offer snacks and fluids between meals. The assessment further indicated a concern that the Basal Metabolic Index (BMI) was 17.8 less than 19 (ideal range >22). A nutritional note dated 5/21/13 indicated Resident #132 expressed to nursing that he/she was hungry and large portions were requested at all meals and the dietary service was aware of the request. Review of the TAR and the Individual Resident Weight History sheet dated May 2013 identified that weekly weights were not obtained until a monthly weight was obtained on 6/5/13 indicating a weight of 111.8 lbs (a weight loss of 5.2 lbs or 4.5 %). A weight obtained on 6/12/13 was 112 lbs and a subsequent weight obtained on 6/18/13 (35 days after admission indicated a weight of 110 lbs, a 7 pound weight loss or 6%). Review of the Registered Dietician notes failed to reflect that the weight loss was addressed and/or the dietician was aware of the 6% weight loss in over a month. Review of the clinical record failed to reflect that new interventions were initiated until 7/12/13 when Glucerna 120 milliliters twice a day was ordered. A weight obtained on 7/18/13 identified that Resident #132 had weighed 102 lbs, a fifteen pound weight loss in two months. Review of the facility's policy for Nutritional Risk, Nutritional Problem and/or Significant Change on 9/17/13 indicated a patient who demonstrates a risk for decline in nutritional status and/or is identified as having a nutritional problem will have appropriate interventions established and implemented to improve or maintain nutritional status. Interview with the Registered Dietician (RD) on 9/17/13 at 8:50 AM identified that the facility's guidelines for weight loss would be a 5% loss in one month. The RD indicated per her calculations, Resident #132 had a weight loss of 6% in 35 days and the documentation for meal intake of 50-100% was inconsistent with the actual weight loss. The RD identified that if she were aware of the weight loss, she would have interviewed the resident, reviewed any medication changes, checked for [MEDICAL CONDITION] and reviewed prior weights and food preferences. Interview with the Director of Nurses (DON) and the Regional Registered Nurse on 9/17/13 at 9:15 AM indicated the facility policy was to weigh residents weekly times four weeks upon admission and to document on the TAR or the weekly weight sheet on the nursing unit. A subsequent interview with the DON on 9/17/13 at 11:10 AM indicated documentation of the weekly weights could not be found.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #6) reviewed for a hospital transfer, the facility failed to monitor and/or assess to ensure that sufficient fluid intake was provided to maintain proper hydration. The findings include: Resident #6's [DIAGNOSES REDACTED]. The hospital discharge summary dated 6/10/13 identified that upon arrival to the emergency department on 5/30/13 the resident's blood pressure was 60/35, the mucous membranes were dry, the Blood Urea Nitrogen (BUN) level was 70 (normal range 8-21), the creatinine level was 2.3 (normal range 0.4-1.1) and Resident #6's baseline creatinine was 0.9. The note indicated that the hospitalization was prolonged due to worsening [MEDICAL CONDITION] and Resident #6 was noted to be hypernatremic with a Sodium level of 152 (normal range 136-145). Upon discharge the BUN was 25 and the creatinine 0.7. The facility's admission patient nursing evaluation dated 6/10/13 identified that the oral assessment identified the mucosa was moist, pink without [MEDICAL CONDITION] and/or ulcerations and good oral hygiene. The medical nutrition therapy assessment dated [DATE] identified that Resident #6 reported a good appetite and the estimated fluid needs were between 1520 cubic centimeters (cc) to 1825 cc. The nutritional goals were to maintain a stable weight, oral intake greater than or equal to 75% at most meals, signs and symptoms fluid imbalance and/or dehydration, and improve skin integrity. The resident care plan dated 6/11/13 identified the resident was at risk for nutritional decline related to abnormal biochemical data, [DIAGNOSES REDACTED]. Interventions directed to encourage and/or provide intake of fluids throughout the day and to notify the dietician, family and physician of any signs and/or symptoms of dehydration. Blood work drawn on 6/11/13 identified that the BUN was 25 and the creatinine 0.8. The admission Minimum Data Set assessment dated [DATE] identified that Resident #6 had severe cognitive impairments and memory recall, exhibited signs and symptoms of [MEDICAL CONDITION] i.e. difficulty focusing, disorganized thinking and hallucinations, was independent with eating after set up and received a mechanically altered therapeutic diet. The nurse's note dated 6/26/13 at 4:10 PM identified that Resident #6 had increased behavior, was accusatory and rude to staff. The 6/27/13 at 3:50 PM nurse's note indicated that Resident #6 was rude to staff and had a very negative affect and outlook. Upon further review of the nurse's notes from 6/27/13 through 6/29/13 failed to reflect documentation of the resident's behavior. The nurse's note dated 6/29/13 at 6:25 PM identified that Resident #6 was very lethargic during the 3-11 PM and 7-3 PM shifts, not taking medication, oral intake decrease and the resident was arousable but confused. The indicated that the nurse had swabbed the oral cavity times three to keep the lips and oral mucosa moist, the physician was notified of the change in condition and laboratory specimens were ordered. The change in condition report identified that on 6/30/13 at 1:00 AM the laboratory called with abnormal blood work levels, the BUN was 86, the creatinine 1.7 and the potassium was 7.0. Subsequent to physician notification Resident #6 was transferred to the emergency department and admitted with diagnoses, in part that included dehydration, [MEDICAL CONDITION], [DIAGNOSES REDACTED], and acute [MEDICAL CONDITION]. Review of the individual resident meal intake record from 6/10/13 through 6/30/13 identified the following meal consumption percentage for the fifty seven meals Resident #6 was served: 100% two meals, 75% five meals, 50% thirty-three meals, 25% ten meals and one refused meal, five meals failed to reflect documentation of the of the percentage consumed. The record failed to indicate of the percentage what food versus fluids was. The hospital discharge summary dated 7/5/13 identified that upon arrival to the hospital Resident #6's tongue was very dry and that upon questioning it was found that the resident was not eating and drinking for awhile, there was some anorexia and also some dysphagia which was quite common for Resident #6 and the resident was vigorous hydrated. Review of facility hydration policy indicated that resident shall be assessed for risk of hydration and/or dehydration upon admission, quarterly and with a significant change or more frequently if needed. The fluid I&O measurement policy directs that residents identified as a high risk for dehydration, residents on ordered fluid restrictions, physician's orders [REDACTED]. Interview and review of the clinical record with the Director of Nurses (DON) on 9/20/13 at 1:20 PM, the DON indicated that Resident #6 had an ileoconduit, the resident's intake and output should have been monitored to ensure that Resident #6 had received sufficient amount of fluids to prevent dehydration. The clinical record failed to reflect documentation that the resident's Intake and Output (I&O) had been monitored from 6/10/13 through 6/30/13. In an interview with the Corporate Registered Nurse on 9/20/13 at 1:20 PM she indicated that when the resident had dry lips and mucous membrane on 6/29/13, bloodwork was ordered. Interview with Registered Nurse (RN) #2 on 9/20/13 at 1:25 PM identified that Resident #6's I&O was not monitored therefore no documentation was available.