Every finding on record at Big Horn Rehabilitation and Care Center

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents' right to secure and confidential personal and medical records. The census was 73. The findings were: 1. Review of the medical record for resident #26 showed the resident received hospice facility's beginning on 1/2/26. Further review showed the hospice provided documented notes directly into the electronic medical record system. 2. Review of the medical record for resident #83 showed the resident received hospice facility's beginning on 1/21/26. Further review showed the hospice provided documented notes directly into the electronic medical record system. 3. Review of the medical record for resident #84 showed the resident received hospice facility's beginning on 2/5/26. Further review showed the hospice provided documented notes directly into the electronic medical record system. 4. Interview with the regional clinical director on 5/6/26 at 12:44 PM revealed the only hospice used prior to a change in operator, was given full access to the electronic medical record for all residents. 5. Review of the policy titled Resident Rights last revised on 6/10/25 showed .7. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records .b. The resident has a right to secure and confidential personal and medical records. i. The resident has the right to refuse the release of personal and medical records except as provided at S483.70 (i) (2) or other applicable federal or state laws .

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents' right to choose health care and providers of healthcare for 3 of 12 sample residents (#26, #83, #84) reviewed for hospice services. The findings were:1. Review of the medical record for resident #26 showed the resident received hospice services beginning on 1/2/26. Further review showed no evidence the resident was offered a choice in hospice provider. 2. Review of the medical record for resident #83 showed the resident received hospice services beginning on 1/21/26. Further review showed no evidence the resident was offered a choice in hospice provider. 3. Review of the medical record for resident #84 showed the resident received hospice services beginning on 2/5/26. Further review showed no evidence the resident was offered a choice in hospice provider. 4. Interview with the regional clinical director on 5/6/26 at 12:44 PM confirmed prior to the operator transition, residents on hospice were not given a choice for hospice provider. 5. Review of the policy titled Resident Rights last revised on 6/10/25 showed .5. Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: a. The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part .

Based on observation, medical record review, staff and family interview, and policy review, the facility failed to implement interventions and treatment for 4 of 4 sample residents (#1, #6, #69, #81) reviewed for a change in condition. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a BIMS score of 15 out of 15, which indicated intact cognition, and diagnoses which included metabolic encephalopathy, coronary artery disease, pulmonary hypertension, peripheral vascular disease, pneumonia, hyponatremia, and chronic respiratory failure. Review of the care plan last revised 4/30/26 showed a focus on safety with tobacco use, ADLs, nutrition related to esophageal obstruction and antidepressant medications. The following concerns were identified:a. Review of a progress note dated 2/1/26 and timed 6:45 AM showed the resident had an unwitnessed fall in his/her bathroom. Vital signs included with the note dated 2/1/26 and timed 6:35 AM were blood pressure (BP) of 150/90, heart rate (HR) of 81, respiratory rate (RR) of 22, temperature of 98.4 degrees Fahrenheit (F) and an oxygen saturation of 88% on 3 lpm via nasal cannula (NC). There was no evidence of a follow up assessment.b. Review of a progress note dated 2/1/26 and timed 7:09 PM showed the resident reported s/he had a fall but was in bed at the time the call light had been answered. The vital signs included with the note were a BP of 126/88, HR of 78, RR of 22, temperature of 98.4 degrees F and an oxygen saturation of 90% on 2 LPM via nasal cannula. Review of the vital signs record showed the recorded vital signs were dated 2/1/26 and timed 2:44 PM, and did not reflect the resident's status at time of the fall. There was no evidence the resident had been assessed following the fall.c. Review of a progress note dated 2/3/26 and timed 2:33 PM showed 3X [3 times] res to request staff to check [his/her] O2. 3 times [his/her] cannula was in [his/her] nares upside down or completely off. Nurse to place cannula in the correct position and requested res to breath deep with [his/her] nose, and out mouth. O2 was back to baseline in less than 10min. Res without respiratory distress. No cough. Res educated on position of cannula in nares. There was no evidence the resident's vital signs were taken or lungs were assessed.d. Review of a progress note dated 2/4/26 and timed 10:59 AM showed the resident refused his/her shower due to not feeling well. There was no evidence the resident had been assessed.e. Review of a progress note dated 2/4/26 and timed 12:48 showed floor nurse alerted this nurse resident not looking well, the resident could not respond verbally and had been on 3 lpm oxygen via NC. The resident's oxygen had been turned up to 5 lpm and was recorded at 88%. The resident had used accessory muscles with dyspnea, and lungs were auscultated as clear but diminished in bases bilaterally. Further review showed the resident was sent by ambulance for assessment and treatment following the assessment. f. Review of the Discharge summary dated [DATE] showed a transfer on 2/4/26 where the resident had been taken to the emergency department due to respiratory failure with oxygen saturations in the 50 % range, requiring oxygen at 10 liters per minute (lpm). Further review showed the additional oxygenation needs escalated to BiPAP assistance for respiratory failure, left lower lobe pneumonia, acute heart failure, and dry gangrene. The resident was treated with antibiotics, thoracentesis for a pleural effusion and diuretics.g. Review of a progress note dated 3/5/26 and timed 11:10 AM showed the resident was lethargic during medication pass. There was no evidence of vital signs or assessment.h. Review of a progress note dated 3/5/26 and timed 12:06 PM showed the resident was sent to the emergency room for lethargy, confusion and abnormal sodium level. There was no evidence of assessment or vital signs.i. Review of a late entry progress note titled progress note*NEW* dated 3/5/26 at 9 AM contained resident assessment and vital signs. Review of the progress notes showed a Late entry note for the incident dated 3/5/26 and timed 9 AM was added on 5/6/26, 62 days after the incident. j. Review of the hospital admission progress note dated 3/10/26 showed the resident had been admitted on [DATE] for hyponatremia with decreased serum osmolality, metabolic encephalopathy, and pulmonary edema. The resident required fluid restriction, diuresis, and a PICC line placement.k. Review of the late entry progress note titled progress note*NEW* dated 4/27/26 at 5:40 PM showed the resident had been found by a dietary aid unresponsive and an ambulance had been called. There was no evidence of an assessment or vital signs.l. Review of the hospital admission note dated 4/30/26 showed resident was admitted on [DATE] after s/he had an episode of unresponsiveness for 20 minutes with hypoxia. The admission diagnoses were encephalopathy, critical hypokalemia, hypomagnesemia, hyponatremia, new onset atrial fibrillation with RVR, and acute kidney injury. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #69 had a BIMS score of 14 out of 15, which indicated minimal to no cognitive dysfunction with diagnoses of chronic myeloid leukemia, coronary artery disease, seizure disorder, traumatic brain injury, and chronic obstructive pulmonary disease. Review of the care plan dated 2/3/26 indicated staff would evaluate his/her respiratory rate and effort, skin color, temperature and characteristics related to risk of impaired gas exchange. The following concerns were identified:a. Observation on 5/4/26 at 4:10 PM showed the resident was on the edge of his/her bed and had his/her hands on his/her knees leaned forward. The resident's respiratory rate was 30-40 times a minute and s/he had a grey pallor. Further observation showed the resident did not have oxygen on.b. Interview with medication assistant-certified (MA-C) #1 on 5/5/26 at 8:26 AM revealed the resident had been sent to the hospital due to respiratory failure.c. Review of the progress notes on 5/5/26 showed no evidence of documentation related to the transfer.d. Review of a progress note provided by the facility dated 5/6/26 and timed 5:14 PM showed LPN #1 documented for 5/4/26 at 11 PM the nurse went to check on the resident to get obtain vital signs and s/he had an oxygenation of 60% on 4 lpm NC with difficulty breathing. The nurse administered a breathing treatment when the resident became lethargic and would not respond to verbal stimuli. The note showed the nurse placed a call to on call and gathered transfer paperwork. Further review showed the nurse attempted to call his/her guardian but it was after hours. e. Interview with LPN #1 on 5/7/26 at 12 PM revealed on the afternoon of 5/4/26 the resident had been reported as unsteady on his/her feet which prompted her to assess the resident. She had him/her sit down and checked his/her oxygen and it was a little low. She checked on the resident a little later and she found him/her on the floor with an elevated temperature and an oxygen saturation in the 50-60's. The LPN revealed she provided the resident with a nebulizer treatment, and tried to contact the administrator, but was unsuccessfully. The LPN revealed she rechecked the resident's oxygen, which was 70%, and she then made the decision to send him/her to the emergency department. The LPN revealed she was the only one working on the unit at the time and was unable to notify the guardian and reported that at shift change to the next nurse. Further interview revealed she was asked by administration to come in on her day off to document the assessment and transfer. 3. Review of the admission MDS assessment dated [DATE] showed resident #81 had a BIMS score of 5 out of 15, which indicated severe cognitive impairment, and had diagnoses which included cervical spondylolysis, atrial fibrillation, coronary artery disease, diabetes, non-Alzheimer's dementia, and chronic obstructive pulmonary disease. Further review showed the resident was at risk for falls and had two or more falls since admission. The following concerns were identified:a. Review of the fall risk assessment dated [DATE] at 2:59PM showed a fall risk score of 12 which indicated the resident was at medium risk for falls.b. Review of a progress note dated 4/20/26 and timed 11:45 PM showed the resident had fallen and vital signs had been obtained. Further review showed the area of the template for resident assessment had been left blank.c. Review of the document titled N-Adv skilled evaluation created on 5/5/26 at 3:54 PM and dated for 4/23/26 at 3:35 PM showed an assessment that identified the resident had pain, confusion and unsteadiness on standing and no risks for safety concerns.d. Review of a progress note dated 4/25/26 and timed 1:24 PM showed housekeeping reported the resident was on the floor in the reception area. The resident's vital signs were taken, the resident assessment was within normal limits, and staff did not know if the resident hit his/her head. Further review showed no evidence follow up assessments were performed.e. Review of a progress note dated 4/30/26 and timed 5:16 AM showed the resident had been found on the floor outside his/her door with his/her back against the wall after staff had heard a loud crash. The resident had been found with hands on his/her head and complained of pain.f. Review of the interdisciplinary team event review meeting on 4/30/26 at 10:07 AM showed a review of the fall. The root cause had been identified as impaired cognition, weakness and self-transfers. The immediate intervention had been to perform a head-to-toe assessment where a new skin tear had been identified. g. Interview with the resident's representative #2 5/7/26 at 12:58 PM revealed for the 10 days the resident at the facility, she had checked on him/her daily and watched him/her decline. She revealed when she arrived on 4/30/26 the resident appeared to be in a high level of pain, which appeared to affect his/her cognition, and the resident was not acting at his/her baseline. The representative revealed the resident had been visibly disheveled, his/her brief was saturated, and the room smelled of urine. She revealed she observed swelling in his/her neck and the resident did not have his/her pain patch on. The representative revealed the facility stated they were going to run tests for him/her and nothing happened. The representative revealed she decided to call the ambulance for the safety of the resident and to get his/her pain addressed, however; the facility staff said they would call for her. She revealed she followed the resident to the hospital and reported s/he returned to his/her baseline after the pain was under control and the swelling in his/her neck went down. Further interview revealed she reported no vital signs had been taken or an assessment performed from the time she arrived at the facility until the time the resident was sent to the hospital. 4. Review of the quarterly MDS assessment dated [DATE] showed resident #6 had a BIMS assessment of 12/15 which indicated moderate cognitive impairment, and diagnoses which included cancer, coronary artery disease, heart failure, renal insufficiency, renal failure, or end-stage renal disease, obstructive uropathy, Alzheimer's disease, and non-Alzheimer's dementia. Review of the medical record showed the resident received a diagnosis of severe sepsis with septic shock on 12/1/25. The resident had an indwelling catheter. Review of the care plan last revised on 12/8/25 showed the resident had a risk of UTIs related to the foley catheter, urinary retention, and prostate cancer. Interventions in place were to monitor and record output, changes in amount, color, or odor of urine. The following concerns were identified: a. Review of a practitioner note dated 12/22/25 and timed 10:57 PM showed .This is a 81 y/o [identifier] being seen [sic] follow-up visit at Big Horn rehab. [S/he] returned to the facility yesterday after a hospitalization over the weekend for acute sepsis related to [his/her] UTI/prostate cancer. [S/he] has completed [his/her] vancomycin treatment at this time[sic] [Name] is pleasant siting up in [his/her] recliner and denies needs. [S/he} denies pain. Nursing denies acute mentation change. Trending vital signs stable. No fever night sweats or chills. Unfortunately, labs were not obtained .Urinary tract infection, site not specified, Sepsis, unspecified organism. No acute concern for systemic infection, cardiac or respiratorydistress[sic].b. Review of a progress note dated 12/26/25 and timed 5:46 AM showed thick cloudy output in Cath drainage bag. c. Review of a progress note dated 12/27/25 and timed 4:51 AM showed .This resident was complaining of pain and has had no output from [his/her] catheter since the previous shift had changed the urine bag [sic] The family had called several times to tell us we need to send [him/her] to the ER. I spoke with the ER nurse who stated she had spoken with the same family member and the ER nurse told the family we are capable of changing the catheter without a trip to the ER. I changed the foley catheter using sterol technic [sic]. The foley was draining well but had some bloody urine output. The resident complained of pain but the source of the pain appeared to be in his stomach area not [his/her] bladder.d. Review of the treatment administration record (TAR) for December 2025 showed on 12/24/25 the resident's output was 300 milliliters (mL) between 6 AM to 6 PM and 250 mL between 6 PM and 6 AM. On 12/25/25 the resident's output was 600 mL between 6 AM and 6 PM, 50 mL between 6 PM and 6 AM and 250 mL between 6 PM and 6 AM. On 12/26/25 the resident's output was 50 mL between 6 AM and 6 PM, and 120 mL between 6 PM and 6 AM. On 12/27/25 the resident's output was 550 mL between 6 AM and 6 PM, and 550 mL between 6 PM and 6 AM.e. Review of a progress note dated 12/28/25 and timed 9:58 AM showed .Resident did not get up for breakfast., Nurse did get [him/her] to take [his/her] meds. Received phone call from [name] who wanted us to send [him/her] to the hospital. Resident said [s/he] didn't want to go to hospital. Nurse called [name] and reported [his/her] response. V/s [vital signs] 98.2 = t [temperature] rsp [respirations] 24 bpm [beats per minute] pulse 82 ; 140/85; 02 [oxygen] 92% Nurse has called NOC [nurse on call] and reported Action. f. Review of a progress note dated 12/28/25 and timed 10:46 AM showed .Resident able to sit up 2 assist. washed face, changed shirt, drank 120 cc [cubic centimeters] fluid. with cuing. Nurse held glass, Assist of two to transfer to wheelchair, and then to recliner. Urine in cath bag cloudy grayish yellow, Noc [nurse on call] notified that resident will go to the hospital, Said [s/he] be right in. [name] notified of action . g. Review of a progress note dated 12/28/25 and timed 11:43 showed the resident was transferred to the ED at 12:45 PM. Further review showed no evidence of the resident's catheter output. h. Review of the emergency room (ER) final report dated 12/28/26 and timed 1:09 PM showed .Reportedly care team at BHR changed his/her foley yesterday but unfortunately caused traumatic injury and hematuria d/t inflating the balloon in the prostatic urethra. It has since been repositioned and is draining purulent urine .recently admitted [DATE] to 12/1/25 for sepsis d/t UTI .[S/he] is also found to have AKI [Acute Kidney Injury] with creatinine of 2.55 with baseline approximately 1.25 . h. Interview with the DON on 5/7/26 at 12:50 PM revealed the staff watched the resident's output for 1 shift, changed the resident's catheter, and initiated vitals. She confirmed the nurses did not always follow through with her expectations for assessments. Further interview confirmed only vitals were completed, and from 12/26/25 until the resident was sent to the hospital on [DATE], the ongoing assessment was not completed as expected. 5. Interview with the DON on 5/7/26 at 9:40 AM revealed she expected documentation for resident transfers to include a discharge note with the resident condition, vital signs, family notification, physician notification, nurse management notification, and a report to the facility and ambulance services. She revealed the documentation should be done immediately or within 24 hours. She revealed she expected vital signs to be performed when concerns for change of condition had occurred and the nurses had discretion on the appropriate clinical response after they assessed residents.

Based on observation, staff interview, review of manufacturer's instructions, and policy and procedure review, the facility failed to label medications with the date medications were opened and/or expired in 2 of 2 medication fridges. The findings were:1. Observation on [DATE] at 10:48 AM in the Rock Creek medication fridge showed an Ozempic 8mg/3ml pen with no opened on or discard on date.2. Interview with medication assistant-certified (MA-C) #1 on [DATE] at 10:49 AM confirmed the Ozempic pen was opened and used the day before and there was no opened on or discard on date written on it.3. Observation on [DATE] at 12:12 PM in the secure unit fridge, showed an opened Tubersol with no opened on or discard on date. Further observation showed an opened Ativan oral solution 2mg/ml with no opened on or discard on date.4. Interview with LPN #2 on [DATE] at 12:13 PM confirmed the Tubersol and Ativan were in use and there was no opened on or discard on dates on either. 5. Interview with the DON on [DATE] at 12:34 PM confirmed she expected an opened on or discard by date written on in-use multi dose vials. 6. Review of the manufacturer's medication guide, page 29, for Ozempic date last revised 1/2025 showed After first use of the OZEMPIC pen, the pen can be stored for 56 days at controlled room temperature 59 F to 86 F (15 C to 30 C) or in a refrigerator 36 F to 46 F (2 C to 8 C).7. Review of manufacturer's medication guide, page 2, for oral liquid Lorazepam showed Discard opened bottle after 90 days.8. Review of manufacturer's package insert, page 10, for Tubersol date last revised [DATE] showed A vial of TUBERSOL which has been entered and in use for 30 days should be discarded.9. Review of the facility policy titled Labeling of Medications and Biologicals dated [DATE] showed .8. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed (needle-punctured); b. All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

Based on medical record review and staff interview, the facility failed to ensure hospice services met professional standards for 3 of 12 sample residents (#7, #83, #84) reviewed for hospice services. The findings were:1. Review of the medical record for resident #7 showed the resident received hospice services beginning on 3/31/26. Further review showed no evidence the resident had a physician order for a hospice referral or evaluation. 2. Review of the medical record for resident #83 showed the resident received hospice services beginning on 1/21/26. Further review showed no evidence the resident had a physician order for a hospice referral or evaluation. 3. Review of the medical record for resident #84 showed the resident received hospice services beginning on 2/5/26. Further review showed no evidence the resident had a physician order for a hospice referral or evaluation. 4. Interview with the regional clinical director on 5/6/26 at 12:44 PM confirmed residents who were placed on hospice did not receive a physician order for eval and the hospice used at that time was given access to the medical record for all residents.

Based on observation, staff interview, and policy review, the facility failed to ensure infection prevention and control standards were implemented for 3 of 8 sample residents (#66, #69, #71) reviewed for resident care. In addition, the facility failed to implement infection prevention and control in 1 of 3 dining areas (main dining room) reviewed for meal service. The census was 73. The findings were:Related to Dining: 1. Observation on 5/4/26 beginning at 5:02 PM showed CNA #3 touched his hair then began handling the resident meal tickets. The CNA grabbed a bag of chips from a box on the tray cart and placed the bag of chips on top of a residents hamburger patty and top half of the hamburger bun. The CNA covered the plate with a cover an took it to resident #67 who was seated at a dining table. The CNA removed the cover and the resident removed the bag of chips from on top of his/her hamburger. Then with his exposed hand, the CNA grabbed the top of the resident's hamburger bun and applied jelly to the bun. The CNA placed the top of the bun on the burger and the resident ate the burger. No hand hygiene was performed until after the meal tray was delivered. After performing hand hygiene, the CNA pulled up his pants by touching the outside fabric and then began passing additional meal trays. At 5:11 PM the CNA touched his hair while applying a hairnet, then obtained a drink cup, holding it by the rim, and delivered the drink to a resident at a table. Without performing hand hygiene, the CNA returned to the steam table and continued passing meal trays. The CNA was observed adjusting his pants 3 times while passing 2 meal trays in which he touched the eating surface of each plate, before performing hand hygiene. At 5:15 PM, the CNA was observed placing another bag of chips on top of a burger patty and top bun, prior to delivering it to a resident. At 5:18 PM the CNA was observed touching his hair, and without performing hand hygiene, he obtained a coffee cup by grabbing the rim of the cup. The CNA filled the cup with coffee and delivered it to resident #55. At 5:23 PM the CNA was observed readjusting his pants and at 5:27 PM he was observed touching the back of his hair, and without per then obtained 3 drinking cups by touching the rims of each glass, filled the cups from a carafe near the coffee, and took them to the meal cart. The CNA obtained 3 plastic lids, touching each side of the lid, and placed the lids on the glasses. 2. Interview with the infection preventionist and DON on 5/7/26 at 9:27 AM revealed they would expect staff to perform hand hygiene after touching anything that would cause contamination, such as hair, skin, or clothing. Further they confirmed the CNA should not have touched resident meal items without performing hand hygiene. Related to soiled linens: 1. Observation on 5/4/26 at 2:49 PM showed resident #69 had linen with visible bowel movement incontinence. Continued observation showed: a. At 2:56 PM the resident's top blanket was pulled up over sheets by staff. b. At 3:10 PM the resident was on the bed resting which had pulled down the top blanket and soiled linen was visible. c. At 3:39 PM the resident laid on top of his/her oxygen cannula that was on top of his/her soiled sheets. d. At 4:17 PM the resident was sat on the edge of his/her bed, the nasal cannula had fallen on floor and housekeeping had picked it up off the floor and placed it on the resident. Related to oxygen cannulas 1. Observation on 5/5/26 starting at 8:25 AM showed resident #71's nasal cannula had fallen on the floor and was dated 4/19/26. The medication assistant-certified (MA-C) #1 entered the resident's room and did not pick up the cannula. CNA #4 entered the resident's room, removed the meal tray, and did not pick up the cannula. MA-C #1 entered the resident's room and administered the resident his/her inhaler, and tried to put the oxygen back on the resident after she picked it up off the floor and the resident declined. Continued observation showed: a. Observation on 5/6/26 at 9:11 AM showed the resident wore the oxygen tubing dated 4/19/26. b. Observation on 5/7/26 at 10:42 AM showed the oxygen tubing was dated 4/19/26 and the tubing was on the ground. 2. Observation on 5/5/26 at 2:52 PM showed resident #66's nasal cannula connected to oxygen concentrator was on the floor and was not dated. Continued observation showed: a. On 5/6/26 at 9:22 AM the resident's tubing to the concentrator was labeled 5/3/26 and was on the floor. b. Observation on 5/6/26 at 9:22 AM the resident's portable oxygen tubing was unlabeled. c. Observation on 5/7/26 at 10:50 AM the resident was wearing the oxygen tubing on the concentrator labeled 5/3/26. 3. Interview with the IP on 5/7/26 at 9:27 AM confirmed oxygen tubing should be changed and labeled weekly and as needed, or when visibly soiled. He stated staff who observed oxygen cannulas on the floor should not use them on residents, and were expected to replace the cannulas. Further interview confirmed soiled linens should be changed immediately. 4. Review of facility policy titled Oxygen Concentrator, last revised on 5/1/25 showed .5.c. Nurse responsibilities: i. change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

Based on medical record review, staff interview, and review of CDC recommendations, the facility failed to ensure the residents were immunized for pneumococcal disease in 5 of 5 sample residents (#66, #69, #1, #33, #4) reviewed for current vaccination status. The findings were:1. Review of medical records for residents' #66, #69, #1, #33 and #4 showed no pneumococcal conjugate vaccine had been assessed or offered.2. Interview with the IP on 5/7/26 at 12:32 PM confirmed there was no evidence of pneumococcal vaccination status.3. Interview with the IP on 5/7/26 at 9:27 AM revealed the facility process for immunizations immunizations were assessed and tracked on admission. The facility offered annual covid and influenza vaccines and documented results. He reported the facility had been delayed in an audit of pneumococcal vaccines due to the inability to access records.4. Review of the Center for Disease Control Recommended Adult Immunization Schedule for ages 19 years or older, last revised 2025 showed for routine adult vaccination age [AGE] years or older who have not previously received a dose of PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown should receive 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21.

Based on grievance review, resident, volunteer, and staff interview, state survey agency incident database review, and policy and procedure review, the facility failed to ensure allegations of abuse were reported timely for 1 of 3 sample residents (#55) reviewed for abuse allegations. The findings were: 1. Review of a Complaint/Grievance Report Form dated 2/26/26 showed the volunteer reported Verbal Abuse to residents during activity by activities employee [activities staff member #1] on 2/14/26. The grievance showed resident #55 called out bingo at which point [activity staff member #1] proceeded to yell at [him/her] and told [him/her] to stop interrupting her while she was talking. It continued for a couple of minutes at which time I stepped over and told [activities staff member #1] to stop yelling at [resident #55] as [s/he] was playing the game and telling her [s/he] has a bingo. She then started yelling at me telling me I was talking over her. I told her I was in fact talking over her to prevent her from yelling at residents. Further review showed the volunteer said 2 residents, resident #55 and resident #66, reported the activities staff member yells at them all the time and speaks to them the same way every time they play bingo. The following concerns were identified:a. Interview with resident #55 on 5/5/26 at 2:17 PM revealed s/he had an issue with activities staff member #1 in BINGO when she was rude to resident #55. The resident revealed s/he had complained about something in BINGO and the activities staff member was upset, then stormed out. The resident revealed activities staff member #1 in a smart-ass way said weren't you paying attention? The resident revealed the statement made him/her angry and s/he called the staff member names. Further interview revealed the staff member was terminated following the incident.b. Interview with facility volunteer #3 on 5/6/26 at 12:15 PM revealed on the day of the incident, she was at the facility with other resident family members, sorting cookies and balloons inside the doorway by the Rock Creek dining room and activities staff member #1 was calling Bingo in the Rock Creek dining room. She revealed she heard resident #55 call out Bingo and heard activities staff member #1 saying the resident was interrupting her. She revealed the activities staff member was speaking to the resident very loudly and rudely, and told the resident to stop interrupting her. She revealed she went around the corner and told the activities staff member to stop talking to the resident in that way and the activities staff member said [s/he] doesn't have a right to interrupt and then yelled at the volunteer. She revealed following the interaction, the activities staff member stormed off.c. Review of the state survey agency incident database showed no evidence the allegation was reported. 2. Interview with the regional clinical director on 5/6/26 at 4:36 PM confirmed the facility did not have evidence the allegation of verbal abuse was reported. She revealed the former employee filed a grievance regarding the incident and while looking into the incident, they learned about the allegation of verbal abuse toward the resident. She confirmed the incident should have been reported and revealed she was unsure why the incident was not reported. 3. Review of the policy titled Abuse, Neglect and Exploitation dated 7/25/25 showed .VII. Reporting/Response A. The facility will have written procedure that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were allowed to return following acute hospitalization for 1 of 4 sample residents (#82) reviewed for transfer and discharge. The findings were:1. Review of a progress note dated 3/11/26 and timed 8:33 PM showed resident #82 was transferred to the hospital emergency room due to altered mental status/increased confusion. The following concerns were identified:a. Review of the medical record showed no evidence a transfer/discharge notice was provided at the time of transfer.b. Review of a discharge MDS assessment dated [DATE] showed the resident's return to the facility was anticipated and the discharge was unplanned. Further review showed the discharge status was Short-Term General Hospital (acute hospital, IPPS).c. Interview with the DON on 5/7/26 at 9:45 AM revealed the resident did not return following the hospital transfer and the decision to not allow the return was financial. Further interview confirmed a discharge notice was not provided after transfer and revealed the facility did not assist in finding alternate placement.d. Interview with the business office manager on 5/7/26 at 10:54 AM confirmed the resident was not allowed to return to the facility following the hospital transfer; however, he revealed he thought the reason was due to insufficient staffing. 2. Review of the policy titled Transfer and Discharge (including AMA) last revised on 6/10/25 showed .10. Emergency Transfers to Acute Care .i. The resident will be permitted to return to the facility upon discharge from the acute care setting. j. Not permitting a resident to return following hospitalization constitutes a discharge. In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative before the discharge, and must also send a copy of the discharge notice to the Office of State Long-Term Care Ombudsmen. Notice to the Ombudsman will occur at the same time the notice to discharge is provided to the resident and resident representative, even though, at the time of the initial emergency transfer, only needed to occur as soon as practicable .

Based on medical record review, staff and guardian interview, the facility failed to provide a notice of transfer/discharge prior to a facility-initiated hospital transfer for 3 of 6 sample residents (#6, #69, #77) and failed to provide written information on the bed-hold policy to the resident or the resident's representative for 1 of 6 sample residents ( #77) reviewed for facility-initiated transfers. In addition, the facility failed to send a copy of the transfer/discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. The findings were: 1. Review of the medical record showed resident #6 was transferred to the hospital on [DATE]. Further review showed no evidence the facility had issued a written transfer/discharge notice to the resident and/or the resident representative. There was no evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the transfer. a. Interview with the Regional Clinical Director on 5/7/26 at 11:45 AM confirmed there was no evidence a transfer/discharge notice had been provided to resident #6. 2. Review of the medical record showed resident #69 was transferred to the hospital on 5/4/26. Further review showed no evidence the facility had issued a written transfer/discharge notice to the resident and/or the resident representative. a. Interview with LPN #1 on 5/7/26 at 12 PM revealed she did not notify the resident's guardian because she had been the only nurse on the unit and she did not have time. She stated she had reported to the next shift that the resident's guardian had not been notified. b. Interview with the resident's guardian on 5/7/26 at 3:11PM confirmed she had not been notified the resident was transferred to the hospital. 3. Review of the medical record showed resident #77 was transferred to the hospital on 3/4/26. Further review showed no evidence the facility had issued a written transfer/discharge notice and written information on the bed-hold policy to the resident and/or the resident representative. There was no evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the transfer. a. Interview with the Regional Clinical Director on 5/7/26 at 11:45 AM confirmed there was no evidence the bed-hold and transfer/discharge notices were provided to resident #77.

Based on observation, medical record review, resident representative and staff interview, and policy review, the facility failed to ensure individual activities of preference were provided to 1 of 3 sample residents (#80) reviewed. The findings were:1. Review of resident #80's care plan initiated on 4/24/26 showed s/he had a diagnosis of Alzheimer's disease, and was at risk for depression and impaired social interaction. Further review showed the resident will participate in social situations, activities of choice . The following concerns were identified: a. Interview with the resident's representative on 5/5/26 at 9:46 AM revealed the resident had not received activities at the facility. She reported the resident needed to stay busy, and s/he was unable to focus due to his/her diagnosis of dementia. She reported when she attempted to talk to activity staff about appropriate activities for the resident, they were always on their way to somewhere else. b. Observations throughout the survey showed the resident wandered in the halls and sat in the front lobby. The resident was not observed participating in facility activities. c. Interview with the DON on 5/7/26 at 1:12 PM revealed there was no record of activity participation for the resident. d. Interview with activity staff member #2 on 5/7/26 at 1:17 PM revealed she sat and talked to the resident once in a while, but she was the only person on the activity staff and did not have time.2. Review of the policy titled Activities dated 6/5/25 showed .9. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs .

Based on resident interview, staff interview, and medical record review, the facility failed to ensure that residents received care that accounted for resident preferences that mitigated triggers for past trauma for 1 of 8 sample residents (#66) reviewed for trauma informed care. The findings were:1.Review of the quarterly MDS assessment dated [DATE] showed the resident had a BIMS score of 13 out of 15 which indicated little to no cognitive impairment, and had diagnoses which included schizophrenia, anxiety, and post-traumatic stress disorder (PTSD).a. Interview with the resident on 5/4/26 at 3:21 PM revealed the s/he had requested to not have men bathe her/him due to PTSD from sexual assault in the past, and s/he has had to remind staff weekly of his/her preference.b. Review of the care plan dated 1/23/26 showed no identification of the resident's preference for female staff only to assist in the areas of personalized care, ADL's and bathing, and mood and behavior, and no identification of triggers for PTSD or the resident's preference of only having females assist with bathing.c. Interview with CNA #2 on 5/7/26 at 10:37 AM confirmed the resident preferred female staff due to past trauma.

Based on grievance review, resident, volunteer, and staff interview, and policy and procedure review, the facility failed to ensure allegations of abuse were thoroughly investigated for 1 of 3 sample residents (#55) reviewed for abuse. The findings were:1. Review of a Complaint/Grievance Report Form dated 2/26/26 showed the volunteer reported Verbal Abuse to residents during activity by activities employee [activities staff member #1] on 2/14/26. The grievance showed resident #55 called out bingo at which point [activity staff member #1] proceeded to yell at [him/her] and told [him/her] to stop interrupting her while she was talking. It continued for a couple of minutes at which time I stepped over and told [activities staff member #1] to stop yelling at [resident #55] as [s/he] was playing the game and telling her [s/he] has a bingo. She then started yelling at me telling me I was talking over her. I told her I was in fact talking over her to prevent her from yelling at residents. Further review showed the volunteer said 2 residents, resident #55 and resident #66, reported the activities staff member yells at them all the time and speaks to them the same way every time they play bingo. The following concerns were identified:a. Interview with resident #55 on 5/5/26 at 2:17 PM revealed s/he had an issue with activities staff member #1 in BINGO when she was rude to resident #55. The resident revealed s/he had complained about something in BINGO and the activities staff member was upset, then stormed out. The resident revealed activities staff member #1 in a smart-ass way said weren't you paying attention? The resident revealed the statement made him/her angry and s/he called the staff member names. Further interview revealed the staff member was terminated following the incident.b. Interview with facility volunteer #3 on 5/6/26 at 12:15 PM revealed on the day of the incident, she was at the facility with other resident family members, sorting cookies and balloons inside the doorway by the Rock Creek dining room and activities staff member #1 was calling Bingo in the Rock Creek dining room. She revealed she heard resident #55 call out Bingo and heard activities staff member #1 saying the resident was interrupting her. She revealed the activities staff member was speaking to the resident very loudly and rudely, and told the resident to stop interrupting her. She revealed she went around the corner and told the activities staff member to stop talking to the resident in that way and the activities staff member said [s/he] doesn't have a right to interrupt and then yelled at the volunteer. She revealed following the interaction, the activities staff member stormed off.c. Review of the state survey agency incident database showed no evidence an investigation of the incident was reported. 2. Interview with the regional clinical director on 5/6/26 at 4:36 PM confirmed the facility did not have evidence the allegation of verbal abuse was investigated. She revealed the former employee filed a grievance regarding the incident and while looking into the incident, they learned about the allegation of verbal abuse toward the resident. She confirmed the incident should have been investigated and revealed she was unsure why the incident was not reported and investigated. 3. Review of the policy titled Abuse, Neglect and Exploitation dated 7/25/25 showed .V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warrented when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur .

Based on resident and staff interview, the facility failed to ensure the activities program was directed by a qualified professional. The census was 73. The findings were: 1. Interview with resident #55 on 5/5/26 at 2:17 PM revealed the facility did not have an activity director and had been without for about a month. 2. Interview with the administrator and regional clinical director on 5/6/26 at 11:45 AM confirmed the facility did not have a qualified activity professional at that time; however, they revealed a new activity professional had been hired. They revealed the new director who would be starting was not qualified either and the program would be overseen by occupational therapy until qualification was met. 3. Interview with the regional clinical director on 5/7/26 at 12:32 PM revealed the activity program was not being overseen by a qualified person and the previous activity director left on 3/18/26.

Based on observation, staff interview, review of manufacturer's instructions, and facility policy review, the facility failed to ensure a sanitary environment in 1 of 1 kitchen. The findings were: 1. Regarding unsanitary items in the kitchen preparation area: a. Observation on 2/4/26 beginning at 9:15 AM showed the Traulsen refrigerator had visible grime and dried food particles on the surface, and a sticky handle when touched to open. The soap dispenser at the handwashing sink had a dark, reddish build-up on the pump. The ice machine scoop was placed on top of the machine next to packaged hair nets. 2. Regarding food safety: a. Observation on 2/4/26 beginning at 9:15 AM showed undated, unlabeled package of ham was found inside the Traulson refrigerator. The walk-in refrigerator did not show a temperature on the thermostat. A partially uncovered, undated bowl of crushed vanilla wafers was found on a bottom shelf of the walk-in pantry. There were no logs visible for the walk-in refrigerator and freezer. 3. Regarding monitoring dish machine temperature requirements: a. There were no temperature logs available for the Ecolab XL dishwashing machine.4. Interview with the assistant dietary manager on 2/4/26 at 10:15 AM confirmed there were no logs for dish machine temperatures. Further interview revealed the ice scoop was washed after each use and placed on top of the dish machine. He confirmed the ham was undated, and should have been labeled with the name of the food and date it was opened. He did not know what the spot on the soap dispenser was. He reported the temperature on the walk-in refrigerator should have been at 20 to 30 degrees, and he thought the dietary manager kept logs on the walk-in refrigerator and freezer. 5. Interview with the director of maintenance on 2/4/26 at 12:11 PM confirmed there were no temperature logs for the walk-in refrigerator or freezer, and the outside temperature of the refrigerator was incorrect. He reported he placed a thermometer in the walk-in and ordered a new thermostat. 6. Review of the [NAME] dish machine manufacturer's instructions provided by the NHA on 2/5/25 showed the minimum operating temperatures should be 150 degrees for wash and 180 degrees for sanitizing rinse.7. Review of the facility policy titled Monitoring of Cooler/Freezer Temperature, undated, and provided by the NHA on 2/5/26 showed .1. Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. A. Temperatures will be checked and logged daily by designated personnel. B. Logs will be changed out and filed each month. 2. All refrigerated storage must be maintained at or below 41 degrees F [Fahrenheit], unless otherwise specified by law. 3. All frozen storage must be maintained at or -4 degrees F, unless specified by law.9 Refrigerated food shall be labeled, dated, and monitored so that it is used by the use by date, frozen, or discarded, whichever is applicable.8. Review of the facility policy titled Sanitation Inspection, undated, and provided by the NHA on 2/5/26 showed .1. All food areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements.4. Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily.

Based on observation, staff interview, and resident and resident representative interview, the facility failed to provide a safe, clean, comfortable and homelike environment for 3 of 4 (Secure unit, 100, 400 halls) units reviewed. The findings were:1. Regarding homelike environment:a. Observation throughout the days on 2/4/26 and 2/5/26 showed no washcloths, bath towels. or hand towels in resident rooms on 3 of 4 units. b. Interview with resident representative for resident #1 on 2/5/26 at 10:20 AM revealed there was never any linen in the resident's room to assist with bathing when she visited. c. Interview with the director of housekeeping 2/5/26 at 11:30 AM revealed that clean linen was available in the clean supply storage for staff to stock rooms.d. Interview with RN # 1 on 2/5/26 at 11:45 AM revealed that staff will supply residents with hand towels and clean linen from the clean supply room when needed.e. Interview with the DON on 2/5/26 at 11:15 AM revealed staff were expected to stock resident rooms with washcloths and clean linen as required.f. Interview with the resident representative for resident #1 on 2/5/26 at 9:02 AM the resident resided in room [ROOM NUMBER] [in the secure unit] and during the resident's stay, there was no bathroom door in place. Review of the medical record showed the resident was at the facility for approximately 6 weeks from June 2025 to August 2025. Observation on 24/26 at 6 PM showed there was no resident residing in room [ROOM NUMBER]; however, there was still no bathroom door in place.2. Regarding safe, and clean environment:a. Observation on 2/4/26 at 10:33 AM showed broken tiles under both toilet riser legs in room [ROOM NUMBER] which appeared dirty and had a urine odor.b. Interview with resident # 2 on 2/4/26 at 4:35 PM revealed s/he reported the broken tile to maintenance over two months ago and was told the facility was waiting to repair the tile because they planned to remodel.3. Interview with housekeeper # 1 on 2/5/26 at 8:59 AM revealed maintenance would have been notified if there were objects requiring repair, which included doors. 4. Interview with housekeeper # 2 on 2/5/26 at 9:02 AM revealed maintenance and supervisory staff would be notified if items were in need of repair.5. Interview with the maintenance director on 2/5/26 at 11:18 AM confirmed he was aware of the broken tiles and revealed the repair was pending a remodel of the unit which was planned to start in March. Further interview revealed the bathroom door had been on order for a couple months.

Based on staff interview, the facility failed to ensure social services were provided to residents by a qualified social worker. The findings were:1.Interview with the SSD on 2/4/26 at 4:40 PM revealed she started the job in October 2025. Further interview confirmed her bachelor's degree was in criminal justice. She reported she reached out to the social worker in another facility if she had any questions, but did not have any regular scheduled meetings with her.2.Interview with the NHA on 2/5/26 at 1:55 PM revealed he assumed the SSD had someone she consulted with between her date of hire and now. Further interview revealed he did not have a facility policy on the required qualifications.

Based on staff interview, medical record review and policy review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 4 residents (#3) reviewed for accident hazards. The findings were:1. Review of the 1/2/26 quarterly MDS assessment for resident #3 showed s/he was admitted to the facility on [DATE], had a BIMS score of 11 out of 15, which indicated moderate cognitive impairment, and diagnoses which included Alzheimer's disease, Non-Alzheimer's dementia, and cancer. Further review showed the resident's mood interview revealed the resident had reported feeling down, depressed or hopeless for 12 to 14 days of the 14-day look-back period. The resident was coded as receiving an antipsychotic medication. Review of the resident's progress notes showed the resident reported s/he was going to leave the building. The following concerns were identified: a. Review of the medical record showed the resident's 8/11/25 elopement evaluation score was 0. b. Review of a progress note dated 11/6/25 and timed 1:06 PM showed the resident informed the SSD that s/he was going to leave the facility. The SSD called the Ombudsman and left a message, and the social services assistant called the Department of Family Services (DFS). The SSD advised the resident that if s/he left the building, she would call the police because s/he was not safe to leave. She left a message for the resident's power of attorney (POA) and spoke to the resident's son, who stated he could not take the resident and advised the resident to stay at the facility. c. Review of a progress note dated 11/6/25 and timed 2:02 PM showed the resident's POA told the resident she could not take him/her, and s/he needed to stay at the facility. The resident became angry and said s/he was leaving the facility. The resident returned to the television room. Further review showed the nursing staff would inform the SSD if the resident left. d. Review of a progress note dated 11/6/25 and timed 5:05 showed the resident declined his/her evening medications, and wanted to leave the facility. The nurse on duty, DON and SSD spoke with the resident. e. Review of a progress note dated 11/6/25 and timed 5:11 PM showed the nurse encouraged the resident not to pull out his/her foley catheter, and the resident was ranting about leaving and having his/her family member pick him/her up that night. The resident went into his/her room and shut the door. The nurse notified the DON who went to talk to the resident. f. Review of a progress note dated 11/6/25 and timed 5:15 PM showed the resident left his/her room with 2 bags of clothing, walked towards the lobby, and stated s/he was going home with family. The DON arrived to talk to the resident at that time. g. Review of a progress note dated 11/6/25 and timed 6:53 PM showed the SSD called the resident's POA to inform her that the resident had calmed down and was watching television when she left the office. During the phone call, the POA informed the SSD that the resident was at her home. The SSD called the DON to check if the staff had called the police. h. Review of a progress note dated 11/6/25 and timed 7:43 PM showed the SSD called the police department at 7 PM to inform them of the resident's situation and the address s/he could be located. i. Review of a progress note dated 11/6/25 and timed 8:40 PM showed at approximately 6:30 PM the staff had been unable to locate the resident, and elopement protocol was initiated within the facility immediately. The staff conducted a search of the facility and had been unable to locate the resident within the facility. Law enforcement had been notified by the SSD. The DON met with law enforcement and notified the NHA. The DON and law enforcement traveled to the reported location where the resident had been reported, and the resident was found with no visible injuries, and denied suicidal ideation. The resident initially refused to return to the facility. After approximately 30 minutes of conversation the resident agreed to return to the facility with the DON. Nursing staff were advised to initiate 15-minute checks, the DON verified all door alarms were on, and sat with the resident for approximately 60 minutes. Staff were to monitor the resident closely and report any behavioral changes. 2. Review of the resident's care plan initiated on 11/7/25 showed the resident was an elopement risk related to adjustment to the nursing home, impaired safety awareness, history of elopement attempts and leaving against medical advice (AMA). Interventions were to assess for fall risk, offer emotional and psychological support, orient resident to the environment, and reorient/validate and redirect the resident as needed.3. Review of the medical record showed no evidence additional supervision was implemented after the resident made statements regarding a desire to leave.4. Interview with the SSD on 2/5/26 at 2:05 PM revealed the resident had told the staff he wanted to leave, and the staff attempted to calm him/her down. She reported after she left for the evening, the resident showed up at his/her POA's home, and the DON was able to talk the resident into returning. She stated the resident signed against medical advice (AMA) papers the following day, and was picked up and taken to the hospital by the police. Further interview revealed the resident had apologized and was aware s/he had made a bad decision.5. Interview with the DON on 2/5/26 at 2:19 PM revealed the facility staff had made multiple attempts to contact the residents POA and family, both were verbal about their desire to not be involved in the resident's decision to leave the facility, and the resident's family informed the resident s/he was unable to return home. Following the elopement, the resident's POA rescinded their POA. The DON reported she had stayed with the resident for part of the evening prior to his elopement. Further interview revealed she was unsure if the resident had a wanderguard. 6. Review of the policy titled Elopements, undated, and provided by the NHA on 2/5/26 showed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.1. The facility is equipped with door locks/alarms to be used as necessary to help avoid elopements. 2. Staff are to be vigilant in responding to alarms in a timely manner. A. Monitoring and Managing Residents at Risk for Elopement Residents will be assessed for risk of elopement upon admission and throughout their stay by the interdisciplinary care plan team .c. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly.

Based on staff and family council president interview, and review of family council minutes, the facility failed to provide and support a private meeting space for family council meetings in 1 out of 12 months in the year 2025. Corrective measures were implemented prior to the survey and compliance was determined to be met on 4/29/25. The census was 66. The findings were:1. Interview with the family council president on 2/4/26 at 12:19 PM revealed the facility canceled the family council meeting and did not provide a meeting space for the month of March 2025. She further revealed there was a sign posted on the community board on 3/4/2025 that stated Family council meeting for March will be canceled. Look forward to seeing you in April, contact social services with any questions. S/he was then told by the former activity director that there wouldn't be a meeting in March and there might not be one in April because they were trouble makers. 2. Review of the family council meetings confirmed no meeting occurred in March 2025.3. Review of Family Council meeting minutes provided by the council president verified meetings were being held during the 3rd or 4th week of the month. Further review confirmed the issue had been resolved and monthly meetings had resumed since 4/29/25. 4. Interview with the NHA on 2/5/26 at 1:57 PM verified the facility had implemented corrective action and has provided space for family council meetings since 4/29/25.

Based on medical record review, staff interview, facility incident review, and policy review, the facility failed to implement interventions and treatment to prevent a decline in condition for 1 of 4 sampled residents (#1) reviewed for quality of care. This failure resulted in actual harm to residents #1. The findings were:1. Review of the admission MDS assessment dated [DATE] showed resident #1 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included cancer, diabetes mellitus, hypertension and arthritis. The following concerns were identified: a. Review of the facility incident report dated 9/23/25 showed the resident had been found on the floor following a fall in his/her room and had been assisted to a wheelchair by staff. The resident complained of nausea and numbness to the arms. The resident was transported to the ER in the facility van, accompanied by CNA #1 and the activities director, where s/he was diagnosed with cervical spine fractures of the 5th and 6th vertebrae. b. Interview with RA #1 on 10/22/25 at 10:32 AM revealed he found the resident on the floor in his/her room, unable to move his/her arms or legs, and he observed a small amount of blood behind his/her head. After alerting LPN #2 and the former DON, he was instructed to assist them in lifting the resident off the floor and into his/her wheelchair where s/he would be transported to the ER in the facility van. Further interview revealed emergency medical services were not notified. c. Interview with LPN #1 on 10/22/25 at 6:15 PM revealed she observed the resident on the floor, and s/he had a small amount of blood at the back of his/her head and complained of not being able to feel [his/her] arms while lying on the floor, and was not able to sit up without staff assistance. The resident was assisted to a wheelchair and driven to the ER in the facility van. She felt the resident was unstable in the wheelchair while riding in the van. d. Interview with LPN #2 on 10/23/25 at 2 PM confirmed the resident was found on the floor with a small amount of blood behind his/her head. He observed LPN #1 had assessed the resident's arm movements and lifted his/her head onto a pillow. He stated the resident was not able to sit up without staff assistance and was transferred to a wheelchair by staff. Further interview revealed the former DON told staff the resident had a head injury and was then transported to the ER in the facility van. e. Interview with CNA #2 on 10/23/25 at 11:12 AM revealed she was called into the resident's room and observed him/her on the floor. She assisted RA #1, LPN #2 and the former DON to lift the resident off the floor and into a wheelchair. She stated, It took all of us to lift [him/her] off the floor and into the chair because [his/her] legs weren't working, they were limp. She confirmed the former DON had the resident transported to the ER via facility van and did not call 911 because the ambulance was too expensive. f. Interview with the activities director on 10/23/25 at 11:20 AM revealed the former DON asked her to transport the resident to the ER following the fall because it was faster and easier than calling an ambulance. She revealed the resident had nausea and vomiting, was not alert, and had abnormal movements of his/her hands and feet. She confirmed she and CNA #1 transported him/her to the hospital, and the resident had leaned on CNA #1 during the van ride. g. Interview with CNA #1 on 10/23/25 at 11:57 revealed she had been asked by the former DON to accompany the resident to the ER in the facility van following a fall due to the expense of calling the ambulance. She observed the resident leaning forward in his/her wheelchair and talking with staff. She confirmed the resident leaned on her during the van ride and did not maintain his/her upper body balance. h. Review of the facility document titled Resident Abuse and/or neglect, dated 9/23/25, showed the NP was notified the date of the fall. 2. Interview with the facility NP on 10/23/25 at 1:11 PM revealed she had not been notified of the fall or a need to transport to the hospital. 3. Interview with the NHA on 10/23/25 at 11:20 AM revealed he had been informed the resident was found on the floor with blood coming from his/her head and was transported to the ER on e hour following the fall via facility van. Further interview confirmed that staff were expected to call 911 when resident's required higher level of care. 4. Review of the policy titled Fall Prevention Policy showed .9. When any resident experiences a fall, the facility will .d. notify the physician and family .

Based on medical record review, facility incident review, and staff interview, the facility failed to ensure that services provided met professional standards for 2 of 4 sampled residents (#1, #7) reviewed for quality of care. This failure resulted in actual harm to resident #1 and #7. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #1 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included cancer, diabetes mellitus, hypertension, and arthritis. Review of the facility incident report dated 9/23/25 showed the resident had been found on the floor following a fall in his/her room and had been assisted to a wheelchair by staff. The resident complained of nausea and numbness to the arms. The resident was transported to the ER in the facility van, accompanied by CNA #1 and the activities director, where s/he was diagnosed with cervical spine fractures of the 5th and 6th vertebrae. The following concerns were identified:a. Interview with RA #1 on 10/22/25 at 10:32 AM revealed he found the resident on the floor in his/her room, unable to move his/her arms or legs, and he observed a small amount of blood behind his/her head. After alerting LPN #2 and the former DON, he was instructed to assist them in lifting the resident off the floor and into his/her wheelchair where s/he would be transported to the ER in the facility van. Further interview revealed emergency medical services were not notified.b. Interview with LPN #1 on 10/22/25 at 6:15 PM revealed she observed the resident on the floor, the resident had a small amount of blood at the back of his/her head, s/he complained of not being able to feel [his/her] arms while lying on the floor, and was not able to sit up without staff assistance. The resident was assisted to a wheelchair and driven to the ER in the facility van. She felt the resident was unstable in the wheelchair riding in the van.c. Interview with LPN #2 on 10/23/25 at 2 PM confirmed the resident was found on the floor with a small amount of blood behind his/her head. He observed LPN #1 had assessed the resident's arm movements and lifted his/her head onto a pillow. He stated the resident was not able to sit up without staff assistance and was transferred to a wheelchair by staff. Further interview revealed the former DON told staff the resident had a head injury and was then transported to the ER in the facility van.d. Interview with CNA #2 on 10/23/25 at 11:12 AM revealed she was called into the resident's room and observed him/her on the floor. She assisted RA #1, LPN #2, and the former DON to lift the resident off the floor and into a wheelchair. She stated, It took all of us to lift [him/her] off the floor and into the chair because [his/her] legs weren't working, they were limp. She confirmed the former DON had the resident transported to the ER via facility van and did not call 911 because the ambulance was too expensive. e. Interview with the activities director on 10/23/25 at 11:20 AM revealed the former DON asked her to transport the resident to the ER following the fall because it was faster and easier than calling an ambulance. She revealed the resident had nausea and vomiting, was not alert, and had abnormal movements of his/her hands and feet. She confirmed she and CNA #1 transported him/her to the hospital, and the resident had leaned on CNA #1 during the van ride.f. Interview with CNA #1 on 10/23/25 at 11:57 revealed she had been asked by the former DON to accompany the resident to the ER in the facility van following a fall due to the expense of calling the ambulance. She observed the resident leaning forward in his/her wheelchair and talking with staff. She confirmed the resident leaned on her during the van ride and did not maintain his/her upper body balance. g. Review of the facility document titled Resident Abuse and/or neglect, dated 9/23/25, showed the NP was notified the date of the fall. 2. Interview with the facility NP on 10/23/25 at 1:11 PM revealed she had had not been notified of the fall or a need to transport to the hospital. 3. Interview with the NHA on 10/23/25 at 11:20 AM revealed he had been informed the resident was found on the floor with blood coming from his/her head and was transported to the ER on e hour following the fall via facility van. Further interview confirmed that staff were expected to call 911 when resident's required higher level of care. 4. Review of the discharge MDS assessment dated [DATE] showed resident #7 had modified independence which indicated difficulty in new situations only for cognitive skills for daily decision making, and diagnoses which included malnutrition, anxiety disorder, fracture of the upper end of the right humerus, fracture of the left ilium, chronic respiratory failure, muscle wasting and atrophy, major depressive disorder, and altered mental status. Further review showed the resident was dependent on staff for toileting hygiene, personal hygiene, to roll left and right, to sit from lying, and to reposition from lying to sitting on the side of bed. Further review showed the resident had a urinary catheter, and was always incontinent of bowel. Review of the care plan last revised on 8/27/25 showed the resident was dependent for transfers and required at least 5 people to assist to turn and reposition in bed, and maximum assistance by 5 to 8 staff for toileting and check and change. Further review of the care plan showed .Monitor/record/report to MD for s/sx [signs and symptoms] UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening or urine color, increased pulse, increased temp, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The following concerns were identified:a. Review of a progress note dated 9/9/25 at 12:20 AM by the NP showed .Clinical picture is inconsistent at this time. [S/He] has not had labs since early August. New orders: CBC, BMP, ESR and CRP. Exchange Foley and obtain urine specimen for urinalysis. Follow-up tomorrow for further evaluation. The patient is in no acute respiratory or cardiac distress at this time.b. Review of a progress note dated 9/10/25 at 12:13 AM by the NP showed .[S/He] reports [s/he] has had good appetite but has had a feeling of fever and chills. Trending vital signs stable. [S/He] does have a Foley catheter in place. CBC and CMP available for review. Urinalysis not obtained. [Resident #7] is resting quietly in bed and stable in no acute distress today.Follow-up tomorrow for urinalysis results. Nursing encouraged to obtain sample and sent [sic] to lab.c. Review of a progress note dated 9/10/25 at 12:55 PM by the NP showed . [Resident #7] is resting quietly in bed and stable in no acute distress today.Follow-up tomorrow for urinalysis results. Nursing encouraged to obtain sample and sent to lab. 9/11 d. Review of a progress note dated 9/19/25 at 1:38 PM by RN #2 showed extremely drowsy, slurred speech. normally able to awaken easily from sleep during day but abnormally drowsy since this nurse arrived on shift at 0600. Confusion unchanged, speech unclear. Vitals WNL [within normal limits]: blood pressure 85/58 manual, oxygen 94% 4L [liters] NC [nasal cannula], pulse 62, temp 98.4, RR [respiration rate] 18 even and unlabored. Resident repositioned, provider notified, will continue to monitor.e. Interview with RN #2 on 10/22/25 at 2:08 PM revealed she had written several days of documentation on the resident that were no longer in the resident's chart. She revealed the resident had not had very much urinary output during the last 5 days of his/her stay and RN #2 had been concerned about the resident's decline. She revealed LPN/staff development coordinator had decided to replace the foley catheter, which did help with output briefly. She revealed when she came on shift on 9/19/25, she had received a report that the resident did not have much urinary output and had been tired all night. She revealed during her shift on 9/19/25, the resident slept all day, had low urinary output, and mumbled but did not open his/her eyes when s/he was turned in bed. She revealed around 3 PM she called LPN/staff development coordinator to report the resident's change in condition and deterioration, and he told her to hold off until the night nurse came on shift to confirm her opinion because it would be an extreme transfer due to his/her size, and no large things were jumping out at the LPN/staff development coordinator. She revealed she reported to LPN/staff development coordinator she did not want to hold off on the transfer, and she was told not to contact the provider. She revealed her capacity to make a decision to send the resident to the hospital was limited by management, and decisions had to come from the provider. Further interview revealed when the night nurse, LPN #3, came on shift, he agreed with her assessment of the resident, and in 5 minutes a non-emergent transfer was called to transport the resident to the ER. f. Interview with the staff development coordinator on 10/22/25 at 3:26 PM revealed his opinion was that the resident was going septic because s/he had a permanent catheter and a positive UTI. Further interview revealed the resident had been at the point where s/he did not always answer questions and displayed mental changes, and did not have a temperature but did have a drop in his/her intellectual functioning. Further interview revealed when this behavior had been seen before, the first thing the facility checked for was a UTI.g. Interview with LPN #3 on 10/23/25 at 8:23 AM revealed he had come on shift the night the resident was transferred, and RN #2 had tried all day to get the resident sent to the hospital. He revealed administration staff wanted to wait until he arrived to send resident #7 to the hospital. Further interview revealed the resident was gray and ashen, and LPN #3 could not obtain a blood pressure from the resident before s/he was sent to the hospital.h. Interview with the NP on 10/23/25 at 1:04 PM revealed the resident had been treated for a UTI in August and she had ordered a UA on 9/9/25, which was not obtained. Further interview revealed she had not been alerted by nursing about the resident's change in condition on 9/19/25, prior to the resident being sent to the hospital.i. Interview with the staff development coordinator on 10/23/25 at 2:22 PM revealed he noticed the resident's catheter had leaked and his/her urine didn't look too good. He revealed the night nurse gave the recommendation after he noticed the resident's change of condition, and the resident was sent to the hospital. He confirmed he waited for LPN #3's opinion before sending the resident to the hospital because he did not see the resident enough to notice a change in behavior. Further he revealed he was not sure who obtained a UA on the resident.j. Interview with the DON on 10/23/25 at 10:48 AM confirmed the resident did not have a UA until he arrived at the hospital.k. Interview with the NHA on 10/23/25 at 11:45 AM confirmed that RNs have the autonomy to make a clinical judgment to send a resident to the hospital.3. Review of the policy titled Fall Prevention Policy showed .9. When any resident experiences a fall, the facility will .d. notify the physician and family .4. Review of the facility policy titled Notification of Changes showed .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complication. 3. Circumstances that require a need to alter treatment. This may include: New treatment. B. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition.

Based on medical record review, resident and staff interviews, facility performance improvement plan review, State Survey Agency incident database review, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 2 of 4 sample residents (#2, #4) reviewed for abuse allegations. This failure resulted in actual harm to resident #2 who sustained injuries during a resident to resident altercation. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 11/30/23. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #2 had a BIMS score of 5 out of 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's disease, seizure disorder, depression, and bipolar disorder. The MDS showed the resident had inattention and disorganized thinking, delusions, physical and verbal behavioral symptoms directed towards others, and wandered on 4 to 6 days during the 7 day look back period. Further review showed the resident was independent with mobility, did not require a wheelchair or walker, and had no skin conditions or skin treatments. Review of the care plan last reviewed on 10/30/23 showed the resident had a history of being verbally and physically aggressive, had poor safety awareness and judgement, wandered, and took psychotropic medications. Further review showed interventions which included assess and anticipate needs, analyze trends in behaviors, distraction and redirection, conduct hourly behavior monitoring log, intervene before agitation escalates, and distract the resident from wandering into other resident rooms. The following concerns were identified: a. Review of a progress note for resident #2 dated 11/30/23 and timed 1:47 PM showed . A maintenance employee informed me that two residents were in a confrontation. I went to the room where the residents were currently, [resident #4] was in [his/her] wheelchair and [resident #2] was sitting on [resident #4's] bed. When approached [resident #2] stated [s/he] was struck by [resident #4]. [Resident #4] broke into the conversation adding, yeah, and I'll do it again. A quick observation revealed no injuries but when asked [resident #2] stated [resident #4] had hit [him/her] in the face. I asked [resident #2] to vacate [resident #4] room. [Resident #4] stated [s/he] told [resident #2] to leave the room but [resident #2] refused and leaned in close to [resident #4's] face and yelled at [him/her] so, I hit [him/her] . b. Review of a progress note dated 12/1/23 and timed 8:46 AM showed . [resident #2] entered the room of another neighbor and sat on [his/her] bed. [S/he] then refused to leave. When the neighbor who lives in that room became upset [resident #2] got in [his/her] face and allegedly hit [him/her] in the head a couple of times. That neighbor became upset and in return stated that [s/he] hit [resident #2] in the nose. As soon as staff was alerted of event the two neighbors were separated and their safety was ensured. No skin impairments, With assessment it was noted that [his/her] nose appeared to be reddened and [s/he] did have a small amount of dried blood at the base of [his/her] left nostril . 2. Review of the quarterly MDS assessment dated [DATE] for resident #4 showed a BIMS score of 8 out of 15, which indicated moderate cognitive impairment, and diagnoses which included non-Alzheimer's disease, and anxiety. Further review showed the resident had behaviors which included delusions, physical and verbal behavioral symptoms towards others, and had no skin conditions or skin issues. Review of the care plan last reviewed on 11/2/23 showed verbal and physical aggression and interventions which included intervene before agitation escalates; increased rounding, and the resident received antidepressant medication due to verbal and physical aggression. The following concerns were identified: a. Review of a progress note dated 12/1/23 and timed 12:11 PM showed . [resident #4] was sitting in [his/her] room when another neighbor entered [his/her] room and refused to leave. [Resident #4] states that the other neighbor sat on [his/her] bed and then got in [resident #4's] face when [s/he] was asked to leave the room. [Resident #4] states the other neighbor struck [him/her] in the top of [his/her] head and the forehead. At that point [resident #4] then says [s/he] reached out and hit the other neighbor in [his/her] nose. Staff entered the room right after this and separated the neighbors and ensured they were both safe without injuries. [Resident #4] became upset when another neighbor entered [his/her] room and refused to leave. [Resident #4] states that the other neighbor got up in [his/her] face and then struck [him/her] in the head causing [resident #4] to be more upset resulting in [him/her] striking the other neighbor . b. Review of a progress noted dated 11/30/23 and timed 3:14 PM showed . After the incident this afternoon interdisciplinary team (IDT) met and the decision was made that [resident #4] would benefit from being moved off of [his/her] current hall into another one. [S/He] reported that [s/he] was concerned to be around a certain community member. With the room move it will ensure that they two community members will not have any further interaction . 3. Interview with housekeeper #7 on 12/20/23 at 11:17 AM revealed on 11/30/23 s/he witnessed resident #2 coming out of resident #4's bedroom with a bloody nose. 4. Review of the facility incident reported to the state survey agency on 11/30/23 showed resident #2 was struck in the face by resident #4, which resulted in a bloody nose. 5. Interview with resident #4 on 12/20/23 at 10:30 AM revealed s/he felt safe in the facility and liked his/her new room, but did not like it when people entered his/her room without permission. 6. Interview with the administrator on 12/20/23 at 4 PM revealed a plan of correction had been implemented on 11/30/23 after the facility investigation confirmed the abuse had occurred. 7. Review of the facility policy titled Abuse, Neglect and Exploitation implemented 10/18/23 showed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 8. Review of the facility's performance improvement plan of correction dated 11/30/23 showed corrective action included immediate separation of the residents, assessment, resident #4 was moved off the unit to a private room to ensure both of their safety. The facility contacted the physician, resident representative, ombudsman, law enforcement, and updated the care plans for both residents. The facility reported the incident to the state survey agency and initiated an abuse investigation which included staff and resident interviews. The facility's plan showed education to staff about assisting community members out of rooms that are not theirs. Both residents were placed on frequent checks. The facility's plan showed all residents were potentially at risk and an audit was done of all care plans on the secured unit to ensure individualized preventative measure were in place for potential abusive behavior. The facility's plan showed environmental changes were made on the secure unit to prevent residents from wandering into specific, potentially high traffic rooms. The facility's plan showed on 11/30/2023 education with all staff on what abuse and neglect was and who it was reported to. The facility's plan showed on 11/30/2023 behavior monitoring TARS and Tasks were added to the TAR and task bank to be used for future incidents and to determine if there were trends in when behaviors escalated facility wide. It had been activated to monitor these two specific residents. The findings will be reported to the Quality Assurance Performance Improvement (QAPI) committee. Care plans will be updated as needed. The facility's plan showed on 11/30/2023 The QAPI committee completed an ad hoc (for this situation) QAPI meeting to discuss interventions needed to protect both residents. Care plans of both residents were updated with new interventions. A room move was made, with family permission, to ensure both residents' safety. The facility's plan showed the NHA/DON or designee will be responsible to report to the monthly QAPI Committee a summary of findings for review and recommendations for three months. QAPI Committee will evaluate and determine the effectiveness of the plan to ensure substantial compliance is achieved and determine if further monitoring and evaluation was required. The DON/Designee will be responsible to follow up on any recommendations made by the QAPI Committee. The facility was determined to be in substantial compliance as of 11/30/23.

Based on observation, medical record review, staff interview, facility incident investigation review, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 8 sample residents (#6) reviewed with resident-to-resident altercations. This failure resulted in harm to resident #6 who was struck in the face with a belt, resulting in injury to the face. The findings were: 1. Review of the 4/10/23 quarterly MDS assessment showed resident #6 had a brief interview for mental status (BIMS) score of 0 out 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder. Further review showed the resident required extensive physical assistance of 1 person for locomotion on the unit, and wandering behavior was not exhibited. Review of the Trauma care plan last revised on 5/4/23 showed the resident had potential for trauma related behaviors related to altercation with another resident. Interventions included . [resident name] will be encouraged to keep [his/her] distance from resident [other resident's facility number]. [Resident #6] has a BIMS of 0 resulting in difficulty for [him/her] to retain education provided. Staff will monitor situation and remove [resident #6] from area if resident [other resident's facility number] is present . Review of the Secure Care Unit care plan last revised on 4/10/23 showed the resident was at risk for wandering and being unable to find his/her way back. Interventions included .Reorient/validate and redirect as needed . Review of the Behavior care plan last revised on 4/10/23 showed the resident had behavior problems and could become physically aggressive. Interventions included .Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed . The following concerns were identified: a. Review of a facility incident investigation report showed on 5/4/23 resident #6 and resident #1 were involved in an incident where resident #1 was identified as the alleged perpetrator. The incident report indicated the facility investigated physical abuse. The incident report showed One of the staff reported that she heard a scream from [resident #6] and seen the [resident #6] [NAME] [him/herself] out of [resident #1's] room, then [resident #1] slammed [his/her] door shut. When went [sic] in to interview [him/her] about it [s/he] states [s/he] hit the [resident #6] with [his/her] belt because [s/he] wasn't supposed to be in [his/her] room . b. Review of a Skin-Weekly Head to Toe Skin Checks assessment dated [DATE] and timed 8:31 PM showed resident #6 had an altercation with another resident which resulted in a skin tear to his/her lower lip. c. Observation on 5/11/23 at 9:46 AM showed resident #6 was in his/her wheelchair and independently moved throughout the unit. At that time, the resident interacted with resident #1 in the common area. No negative interaction between the residents was observed. d. Interview with LPN #1 on 5/11/23 at 3:18 PM revealed she was the nurse in the unit at the time of the altercation between resident #6 and resident #1 on 5/4/23. The LPN revealed she did not observe the altercation as she was down the hall in the living room and the CNA reported the incident to her. The LPN revealed the CNA reported she heard resident #6 scream and that the resident was bleeding from his/her mouth. The LPN revealed following the incident, resident #6 had a small skin tear to the left lower lip which she cleaned and treated. The LPN revealed she had the resident stay near her until s/he was assisted to bed. Further interview revealed resident #6 wanders a lot and often goes into other resident rooms. The LPN said the secure unit staff normally make sure a staff member is in the common areas, and to prevent additional incidents, staff would need to keep a better watch on resident #6. The LPN revealed she attempts to keep resident #6 where she can see him/her; however, those types of incidents happen really quickly. e. Interview with CNA #1 on 5/11/23 at 4:10 PM revealed on 5/4/23 she was in the shower room preparing to give someone a shower when she heard someone yell. When she left the shower room, she observed resident #6 being pushed out of resident #1's room. At that time, resident #6 had blood in his/her mouth. The CNA revealed she entered resident #1's room and asked if s/he hit resident #6. The CNA revealed resident #1 said yes, s/he hit resident #6 with his/her belt because s/he didn't want resident #6 in his/her room. The CNA revealed resident #1 confirmed resident #6 had not done anything to resident #1. Further interview revealed resident #6 often goes into other residents' rooms and staff try to keep him/her in sight. The CNA confirmed she assisted resident #6 to the nurse where the nurse performed an assessment and cleaned the resident's mouth. f. Interview with the administrator, DON, and SDC on 5/12/23 at 9:35 AM confirmed the altercation between resident #6 and resident #1 resulted in resident #6 being hit in the face with a belt which resulted in a split in the resident's lip. The administrator, DON, and SDC confirmed the resident was mobile in the wheelchair and liked to wander around the unit. The administrator, DON, and SDC revealed interventions which included a stop sign outside resident #1's room, notification of local police, moving a table frequently used by resident #6 when wandering, removal of the belt, and increased supervision were implemented following the altercation. 2. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program last revised April 2021, showed .The resident abuse, neglect, exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: . b. other residents; .

Based on medical record review, staff and resident interview, and policy and procedure review, the facility failed to ensure 1 of 5 sample residents (#1) reviewed for bowel management received the appropriate care and treatment to address constipation. This failure resulted in hospitalization and actual harm to the resident. The findings were: 1. Review of the 9/20/22 quarterly MDS assessment showed resident #1 was admitted to the facility on [DATE] with a diagnosis of cerebral palsy and had a BIMS score of 15/15 (cognitively intact). Further review showed the resident was always continent of bowel and required the extensive assistance of 2 or more staff members for toilet use and transfers. Review of the fluid maintenance care plan, last revised on 8/2/22, showed the resident was at risk for fluid maintenance issues related to impaired mobility, poor bowel regulation, history of urinary retention, and a history of constipation. The interventions included monitor bowel pattern to ensure [the resident] is having a regular bowel movement frequently that are soft and formed. Review of the medication administration record (MAR) showed the resident was prescribed psyllium husk powder (soluble fiber) every other day, for Bulk and regulate bowel movements with an order date of 5/19/21; bisacodyl (laxative) suppository, as needed, for 4 days with no bowel movement with an order date of 6/26/19; docusate sodium (laxative with stool-softening activity) capsule, as needed, every 12 hours for constipation with an order date of 1/6/20; an enema, as needed, for 5 days with no bowel movement with an order date of 6/26/19; Milk of Magnesia (laxative), as needed, for 3 days with no bowel movement with a start date of 6/26/19; MiraLax (laxative) powder, as needed, for constipation with an order date of 9/23/20; and Senna (laxative) tablet to be given every 24 hours, as needed, for constipation The following concerns were identified: a. Interview with the resident on 2/5/23 at 3:42 PM revealed s/he had been hospitalized for a bowel obstruction. The resident stated s/he attempted to hold in his/her bowel movements; however, was told by the physician that was not a good idea. An additional interview with the resident on 2/8/23 at 10:41 AM revealed s/he tried to hold in his/her bowel movements because the staff were slow to assist him/her and s/he did not want to be embarrassed. b. Review of the October 2022 bowel elimination documentation showed the resident had bowel movements (formed/normal; small in size) on 10/1/22 and on 10/6/22 (constipated/hard; large in size). The resident was given a bisacodyl suppository on 10/5/22 (day 4) which was noted as being semi-effective. Review of the October 2022 MAR showed no documentation the absence of a bowel movement had been addressed before day 4. c. Review of the October 2022 bowel elimination documentation showed the resident had bowel movements (constipated/hard; small in size) on 10/6/22 and on 10/11/22 (formed/normal; large in size). Review of the October 2022 MAR showed no documentation the absence of a bowel movement for 4 days had been addressed. d. Review of the October 2022 bowel elimination documentation showed the resident's next bowel movement, from the 10/11/22 date, occurred on 10/19/22 (constipated: large in size). Review of a 10/16/22 at 7:59 AM nurse's progress note showed Resident reports no BM [bowel movement] in 4 days previous to this morning. Yesterday resident refused Metmucil stating [s/he] will go No BM yesterday. Resident refuses Miralax this morning. No PRN [as needed] order for the fiber [s/he] did not think [s/he] needed yesterday. MAC [certified medication aide] and this writer went over resident's PRN orders. [The resident] agreed to try a Senna (laxative), agreed that if there is no BM by this afternoon/before dinner [s/he] will take some warm prune juice with Miralax added. However, review of the October 2022 MAR showed no documentation Senna or any other PRN medication for constipation was administered at any time between 10/16/22 and 10/27/22. e. Review of the October 2022 bowel elimination documentation showed the resident had a bowel movement on 10/20/22 (constipated/hard; large in size). No other bowel movements were documented after 10/20/22. Review of a nurse progress note dated 10/27/22 and timed 5 AM showed Resident not feeling well. Emesis frequently. Abdomen sore and enlarged. Resident given suppository with no results .Bowel sounds diminished. Review of the October 2022 MAR showed no documentation the absence of bowel movement for 6 days had been addressed, and no documentation a suppository waa administered. f. Review of the medical record showed the resident was transferred to the hospital on 10/27/23. g. Review of the resident's Patient Discharge Instructions from the hospital, dated 10/30/22, showed the resident had diagnoses which included small bowel obstruction and constipation. 2. Interview with the DON on 2/7/23 at 2:41 PM revealed it was the facility's expectation the bowel protocol be followed. Further, the DON confirmed there was no further documentation and the resident's physician had not been notified. 3. Review of the Bowel Movement Protocol, revised November 2020, showed Day 3 of No Bowel Movement Milk of Magnesia Suspension 1200 MG/15ML-administer 30 Ml Q [every] 24 hours PRN [as needed] no bowel movement in three (3 days); Day 4 of No Bowel Movement Bisacodyl Laxative Suppository 10 MG-Administer One (1) Suppository rectally Q 24 hours PRN no Bowel Movement in four (4) days; Day 5 of No Bowel Movement Enema Ready-To-Use Rectal Enema 7-19 GM/118 ML-Administer one (1) enema @ 24 hour PRN no Bowel Movement in five (5) days. If previous interventions are not effective and resident has not had an adequately sized Bowel Movement contact primary care provider for further orders and advisement.

Based on observation, medical record review, facility incident review, staff and resident interview, and policy and procedure review, the facility failed to ensure residents were free from abuse for 3 of 6 (#3, #7, #8) sample residents involved in resident to resident altercations. This failure resulted in actual harm to residents #3 and #7, who sustained injuries during resident to resident altercations. The findings were: 1. Review of a facility incident report dated 8/23/22 and timed 1:30 PM showed resident #7 asked resident #8, who was seated in a wheelchair in front of the vending machines, to move. Resident #7 then attempted to move resident #8's wheelchair which resulted in an altercation. Further review showed the administrator found resident #7 with his/her .right arm wrapped around the other resident's [resident #8] throat. The other resident was punching and scratching at [resident #7's] arm .[Resident #7] claims [s/he] went to walk around the other resident and was then attacked. The following concerns were identified: a. Review of a progress note for resident #7 dated 8/23/22 and timed 1:50 PM showed [Resident #7] assessed by DON and ADON after altercation with another resident. [Resident #7] sustained minor injuries. Injuries include: skin tear x 3 to right forearm, scratch to center of chest (appears to be scratch to mole/growth), and abrasion to left knee. Wounds cleansed and dressed. Resident reports pain of 2 out of 10. Resident refused further evaluation at ER or urgent care. Resident states 'my pride hurts more than anything'. Resident instructed to stay away from other resident. Resident verbalized understanding. Resident remained in room watching tv for the afternoon. b. Review of a progress note for resident #7 dated 8/23/22 and timed 4:45 PM showed This nurse and DON assessed resident after [s/he] was involved in an altercation with other resident. [S/He] has multiple new bruises to [his/her] right and left arms. A skin tear to the back of right hand, wrist, upper forearm and under arm close to elbow. Abrasion to the left knee. Mid sternum it appears that [s/he] abraded the top of a growth resulting in some bleeding. All wounds have been cleansed with dressings applied. Skin tears with present flaps were approximated and steri-stipped with dry dressing placed over strips. Orders have been obtained and updated for wound care. Will continue to monitor for any s/s of infection or deterioration. c. Review of a progress note for resident #8 dated 8/23/22 at 1:40 PM showed Resident assessed by ADON after altercation with another resident. Resident does not appear to have any injuries. Resident [#8] states that the other resident had a hold of [his/her] right thumb. No bruising noted at this time but will continue to monitor. Resident went to chapel for confessional with NHA [nursing home administrator]. Nursing to ensure both resident remain separated. d. Review of an incident report dated 6/11/22 and timed 2:30 PM showed resident #7 wanted to go the vending machine and resident #8 was blocking the hallway. Resident #7 tried to move the wheelchair of resident #8 by pushing his/her wheelchair, which resulted resident #8 screaming, yelling and hitting at resident #7. Review showed resident #7 received bruising to his/her forearm and knuckles. Resident #7 reported resident #8 grabbed his/her arm which caused bruising. Further review showed Victim has been educated that in future times, to not touch another resident's wheelchair and to ask for assistance when needed to move someone .The perpetrator has been known to yell at staff at times when they feel like they are trying to get [him/her] to move out of the way in the hallway . e. Review of a progress note for resident #8 dated 6/9/22 and timed 5:47 PM showed the resident became upset after another resident bumped his/her wheelchair accidentally. The resident began yelling following the incident. Staff attempted to deescalate the situation and asked the resident to stop yelling. Staff intervention resulted in the resident yelling vulgar statements at the staff member. f. Interview with resident #7 on 8/31/22 at 3:11 PM revealed s/he had been attacked twice in a common area by the same person who blocked the vending machines. Observation at that time showed the resident's bilateral arms were discolored and skin tears were present on both arms. g. Interview with the administrator, DON, ADON, and SDC on 9/2/22 at 9:23 AM revealed on 8/23/22 the administrator observed resident #7 on his/her knees with his/her arm around resident #8's neck. Resident #8 was hitting and grabbing resident #7's arm. At that time, resident #8 was positioned in a wheelchair, blocking the vending machines and the walk area. Further interview revealed they were unsure if any interventions were developed following the 6/11/22 altercation which occurred in the same area, however, interventions were implemented following the 8/23/22 altercation which included having resident #7's family bring in snacks to prevent vending machine use, placement of the residents on units on opposite sides of the building, discussions with the family of resident #7 about alternate placement due to psychological needs, a medication review, and a request to vendors to move to the vending machines to an alternate location. 2. Review of the 7/6/22 quarterly MDS assessment for resident #2 was coded as having physical behavioral symptoms directed toward others 4 to 6 days of the 7-day lookback period. Review of the resident's behavior care plan showed interventions, dated 1/3/22, that included Allow [resident] to make decisions about treatment regime, to provide sense of control .Encourage as much participation/interaction by [resident] as possible during care activities .Give clear explanation of all care activities prior to and as they occur during each contact .If [resident] becomes agitated take [him/her] away from the situation. Allow [resident] to express [his/her] emotions and be a listening ear to [his/her] frustrations .Praise [resident] when behavior is appropriate. Review of the 7/26/22 quarterly MDS assessment for resident #3 showed the resident was coded as wandering 1 to 3 days during the lookback period. The following concerns were identified: a. Review of a facility incident report dated 8/12/22 and timed 10:50 PM showed resident #2 hit resident #3 over the head with a foot pedal from a wheelchair. Resident #3 was self-propelling around the hallway while the nurse and CNA assisted another resident in their room. When the CNA and Nurse returned to the nurse's station, they heard a loud noise followed by resident #3 crying out in pain. The staff members exited the nurse's station and observed resident #2 holding a wheelchair foot pedal over his/her head and resident #3 was holding his/her head and was bleeding. Resident #3 sustained a small laceration to his/her head. b. Review of a progress note for resident #2 dated 8/12/22 and timed 11:30 PM showed Heard a yell from out in the hallway just after hearing a sound like something mechanical being hit. Ran to the hall an [sic] saw [identifier] res sitting in the hall in front of room [ROOM NUMBER] holding [his/her] head and cussing. Blood was dripping from between [his/her] fingers. [Resident #2] was in [his/her] w/c [wheelchair] in the doorway of [his/her] room with the foot pedal from a w/c raised over [his/her] head as though to strike the other res again. Removed res from harm's way, taking [him/her] into the office to perform first aide. After first aide complete, attempted to have [resident #2] surrender the foot pedal s/he was still holding. [S/He] refused to give it to this RN or the CNA and waved it in a threatening manner when we approached [him/her]. [S/He] was adamant we would not take the pedal from [him/her] and verbally threatened harm if staff attempted to take the pedal. After a several minute stand-off, this RN was able to retrieve the foot pedal from [resident #2]. Asked [resident #2] to please return to [his/her] room and CNA staff sat in with [him/her] x 30 minutes to help him calm [him/herself]. This RN attempted to ascertain what had occurred. [Resident #2] readily admitted [s/he] struck the other resident with the foot pedal. During conversation [resident #2] indicated the other resident was, coming at me, and indicated that [his/her] hands were up in front of [him/her]. Unable to determine if the other resident was trying to get into [resident #2]'s room or was simply passing by. Prior to the actual strike, there was no verbal interaction heard between the 2 residents. Encouraged [resident #2] to remain in [his/her] room until the other resident was assisted to bed. Snack was offered and [resident #2] remained calmly in [his/her] room. c. Review of a progress note for resident #3 dated 8/12/22 and timed 11:45 PM showed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Able to slow/stop the bleeding with several minutes of direct pressure . d. Review of the Behavior care plan for resident #2 last revised on 8/15/22 showed new interventions implemented were Resident to be monitored for escalation in behaviors to other residents that [s/he] knowingly does not like as resident had recent altercation with another resident. When both residents in the same common area, residents to be monitored and redirected from each other. e. Review of the Behavior care plan for resident #3 last revised on 8/15/22 showed new interventions implemented were Resident to be monitored recent altercation with another resident. When both residents in the same common area, residents to be monitored and redirected from each other. f. Interview with the administrator, DON, ADON, and SDC on 9/2/22 at 9:23 AM revealed the facility implemented 1-to-1 monitoring of resident #2 during the remainder of the shift following the altercation and the discussed the altercation with staff. Due to the residents' dementia, no additional interventions were implemented for either resident. 3. Review of the policy titled Abuse Prevention Program last revised 12/2016 showed .As part of the resident abuse prevention, the administration will: 1. protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on medical record review, staff interview, review of the facility policy and procedure, review of a facility performance improvement plan, and review of professional standards, the facility failed to ensure basic life support was administered to 1 of 1 sample resident (#10) who required and elected cardio-pulmonary resuscitation. This failure resulted in actual harm to resident #10, who went into [CONDITION(S)] and did not receive CPR. The findings were: 1. Review of undated WyoPOLST which was signed by resident #10 and located in the resident's medical record on [DATE] showed the resident elected to have CPR/attempt resuscitation if s/he was found to have no pulse and was not breathing. 2. Review of the resident's electronic medical record face sheet on [DATE] showed the resident's code status was listed as Full Code. 3. Review of a progress note for resident #10 dated [DATE] and timed 2:45 PM showed CNA's called to have nurse check on resident. Resident was lethargic, and was not verbalizing at anything at this time. Told other CNA/Med aide to go get other nurse [name] from Courtyard to come and check on resident. Please see her note on resident. 4. Review of a progress note dated [DATE] and timed 3:10 PM showed On-call nurse was called @ [at] 1510. [Name], RN called back and was told resident had passed. Was told to call family and on-call dr. On-call dr. called at 1522. Dr. [name] called @ 1526 and was told that resident had passed Family was called and talked to [name] @ 1530. Family called back @ 1533 and did not want to spend anytime with resident. Family said they will come in later to pickup residents clothes and other items. Family said they would call [name] funeral home to come and pickup resident. Coroner was called @ 1535. Coroner told this nurse that this was an unattended death. 5. Review of a progress note dated [DATE] and timed 3:24 PM showed Assessment of resident at 3:04, [resident name] absent of all vital signs, Skin warm and dry. Eyes fixed and dilated. No respirations, No responsive to verbal or tactile stimuli. 6. Review of a progress note dated [DATE] at 5:50 PM showed Notified that resident passed. The resident was full code, code was not called. AIT [name] called POA and explained the situation. POA verbalized they wanted the resident to pass peacefully but didn't have a chance to update POLST to DNR. POA understanding of resident's recent decline. POA provided information on the funeral home for the resident to be sent to. 7. Interview with MA-C #1 on [DATE] at 9:41 AM revealed on [DATE] she heard CNAs yell for the nurse. At that time, LPN #1 asked her to get RN #1 from another unit. MA-C #1 went and got the other nurse, returned to the unit to finish medication pass, then sat down to chart. The MA-C revealed approximately 5 minutes after the resident was found without a pulse she identified the resident had a full code status and notified the LPN and RN. The MA-C revealed neither nurse initiated CPR after learning the resident's code status. 8. Interview with RN #1 on [DATE] at 9:51 AM revealed the MA-C came to her unit and said the resident was short on breath. The RN finished the task she was performing and went to the resident's room approximately 3 minutes later. The RN revealed the resident was absent of vital signs at that time so she assessed the resident and pronounced his/her death. The RN began telling LPN #1 where to locate the procedure book and was told the resident was a full code. The RN said the code was identified approximately 5 minutes after she pronounced the resident's death. Further interview confirmed CPR was not initiated after the RN learned the resident's code status. 9. Interview with CNA #1 on [DATE] at 19:06 AM revealed the nurse asked her to obtain a weight on resident #10. When the CNA attempted to get the resident up, the resident went unresponsive. Further interview revealed the CNA was not on the unit when the resident's code status was identified. 10. Interview with LPN #1 on [DATE] at 10:57 AM revealed she had visited with the resident at approximately 2 PM in [DATE]. Following the interaction, the LPN asked the CNAs to obtain a weight on the resident. When the CNAs attempted to obtain the resident's weight, they reported the resident was weak. The LPN revealed when she went to the room the resident was gasping for air and she asked the MA-C to get RN #1. The LPN revealed the RN arrived to assess the resident between 5 and 10 minutes later, at which time, the resident was deceased . LPN #1 revealed the she was not told of the resident's code status until 20 minutes or half an hour after the resident was pronounced deceased . The LPN stated she learned of the code status when the on-call nurse asked why she did not initiate CPR. The LPN confirmed CPR was not performed when the resident was pronounced deceased or when the full code status was identified. Further interview with the LPN revealed she was suspended following the incident and she felt she did not receive adequate training prior to working independently at the facility. 11. Review of a Performance Improvement plan dated [DATE] showed on [DATE] a Resident with full code status reportedly had abnormal breathing and when checked on next was found without pulse. After approx. [approximately] 10 minutes was discovered to be Full Code. Staff did not respond accordingly, CPR was not initiated. Further review showed the plan of correction included interdisciplinary team will verify and update POLST of all resident, staff will be knowledgeable of Full Code precautions, staff will be proficient in performing life saving measure, and the facility will examine and improve ways to determine code status for clinical staff. 12. Interview with the administrator, DON, ADON, and SDC on [DATE] at 9:23 AM confirmed the performance improvement plan was not fully implemented and the facility planned to have it completed by the end of the month. 13. Review of the policy titled Emergency Procedure-Cardiopulmonary Resuscitation last revised ,d+[DATE] showed .3. Victims of [CONDITION(S)] may initially have gasping respirations or may appear to be having a [CONDITION(S)]. Training in BLS [basic life support] includes recognizing presentations of SCA [sudden [CONDITION(S)]] .6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g. rigor mortis) . 14. According to Perry, Potter, and Ostendorf in Nursing Interventions and Clinical Skills, 7th edition, 2020, page 812 .Immediate recognition of [CONDITION(S)] and activation of emergency medical response are critical. Early CPR and recommended health care team-level coordination that switches the provider who performs chest compressions every 2 minutes improves the performance of high-quality CPR (AHA, 2017).

Based on medical record review, staff interview, review of a facility performance improvement plan, and policy and procedure review, the facility failed to ensure residents received necessary wound treatment and services to promote healing for 1 of 3 sample resident (#1) with a pressure injury. This failure resulted in harm to resident #1, whose pressure injury went unassessed over a period of weeks, and deteriorated to a stage III pressure injury. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required total physical assistance of 2 people for bed mobility, transfers, dressing, toilet use, and personal hygiene. Further review showed the resident was at risk for development of pressure injuries, and had 1 unstageable pressure injury that was not present at the time of admission. Review of the Integumentary care plan last revised 5/17/22 showed resident #1 had a pressure ulcer to the coccyx and interventions included provide wound care/preventative skin care per order, every 2 hour position changes to ensure resident was not lying in one position for too long, every 2 hour check and change to ensure the resident was dry, skin checks weekly per facility protocol, document findings, and turn and reposition frequently to decrease pressure. The following concerns were identified: a. Review of a Head to Toe Skin Check dated 2/9/22 and timed 5 PM showed the resident had no new or existing pressure ulcers. Review of a Head to Toe Skin Check dated 2/16/22 and timed 6 AM showed the resident had an existing pressure ulcer; however, no location or description was provided. Review of the Head to Toe Skin Check documents from 2/23/22 through 8/31/22 showed the resident was listed as having a pressure ulcer on 24 out 25 assessments; however, wound measurements were documented only 4 times, a wound description was documented only 8 times, and wound stage was documented only 2 times. Further review showed there was no Head to Toe Skin Check performed on 4/6/22, 4/20/22, or 8/10/22. b. Review of the Weekly Pressure Ulcer Record from February 2022 to August 2022 showed the date of onset for a pressure injury to the coccyx was 2/24/22; however, there was no evidence of a weekly pressure ulcer monitoring from 2/24/22 until 3/18/22. At that time the pressure injury measured 1.2 centimeters (cm) by 1 cm by 0.1 cm and was listed as a stage II. Further review showed there were no documented assessments for 7 weeks between 3/24/22 and 5/13/22, 19 days between 5/20/22 and 6/1/22, and 11 weeks between 6/3/22 and 8/19/22. Review of the Weekly Pressure Ulcer Record dated 8/26/22 at 10:15 PM showed the coccyx wound measured 0.75 cm by 0.75 cm by 0.2 cm and was indicated to be a stage III pressure injury. c. Review of a progress note dated 8/19/22 and timed 2:41 PM showed Assessment of pressure ulcer to coccyx completed this afternoon. Wound continues to show positive progress with decrease in depth. Wound has approximately 2% epithelium, 50% yellow slough, 25% red granular tissue to wound bed with no maceration undermining or tunneling at this time . d. Observation of the wound with the ADON on 9/2/22 at 9:18 AM showed a small wound to the coccyx area of the resident. At that time the ADON described the wound as having scant slough. 2. Interview with the administrator, DON, ADON, and SDC on 9/2/22 at 9:23 AM revealed the facility discussed wounds daily, nurses were expected to perform weekly assessments, and nurses were expected to communicate deterioration or healing of wounds. Further interview revealed the team identified the lack of documentation during the survey and wrote a performance improvement plan to correct the identified issues; however, the plan not been implemented at that time. The ADON was going to take over weekly assessments to ensure consistent evaluation of wound progress, wound measurement, and treatment monitoring was performed. 3. Review of the performance improvement plan dated 9/1/22 showed the review of 3 resident charts with pressure injuries demonstrated 2 out of 3 charts were not compliant with weekly pressure assessments. Goals for correction included the ADON will have oversight for all pressure injuries and assessments, the ADON will create an audit tool to ensure weekly documentation, the ADON will complete weekly progress notes on pressure injuries, and the ADON will complete one on one education with nursing staff on wound care specific to each resident. 4. Review of the policy titled Big Horn Rehabilitation Wound Care Policy provided by the facility on 9/9/22 showed .8. Nurse will provide wound care per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse will notify the physician for any change in the patient condition or lack of progress. 9. Head to Toe Skin assessments will be completed weekly. 10. At least once every week, the wound assessment and documentation will include measurement of length, width, depth, and undermining and tunneling if present .

Based on observation, medical record review, staff interview, and facility record review, the facility failed to ensure accident hazards were identified and eliminated for 1 of 5 sample residents (#5) reviewed for incidents. This failure resulted in harm for resident #5, who suffered a burn. Correction measures were implemented by the facility and compliance was determined to have been met on 1/13/20. The findings were: Review of the medical record for resident #5 showed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated [DATE] showed a brief interview for mental status score of 5, indicating severe cognitive impairment. Review of the nursing note dated 1/11/20 and timed 11:27 PM showed Upon entering the room to administer (the resident's) PRN [MEDICATION NAME], I found both (his/her) feet resting on the heater. I then removed (the resident's) feet from the heater and noted it was not hot to touch. Assessing (the resident's) feet I found no abnormal warmth, visual inspection revealed no new skin tears, redness, or abnormal signs. I then placed (his/her) feet down on the bed and tucked the blanket under them. Review of the nursing note dated 1/12/20 and timed 12:23 AM showed the nurse .entered resident's room and visually identified that resident's feet were under (his/her) blanket and resident was resting comfortably. Interview with LPN #1 on 2/12/20 at 11:57 AM revealed the resident was typically cold and usually requested at least three blankets. The LPN further stated, This is the first time I have seen (the resident) put feet on the heater. Interview on 2/12/20 at 3:58 PM with CNA #1 revealed the resident had put his/her feet on the heater the first night after they had rearranged the room two months ago, stating, That night I removed (his/her) feet from the heater two or three times. I normally do my rounds at least four times a night. The CNA stated the resident had not put his/her feet on the register since that first night. The following concerns were identified: 1. Review of the nursing note dated 1/12/20 and timed 10:06 AM showed It was reported to this nurse by nursing assistant that resident had a large wound on (his/her) right lateral ankle and foot. This nurse then immediately assessed the resident, who was in bed lying supine, call bell cord in place and alert x3. Resident denied any pain and was not in any distress or immediate danger. Wound reported to nurse manager on duty. 2. Review of physician notes for resident #5 dated 1/13/20 showed Unfortunately, the night before last, (the resident) suffered a burn to the lateral portion of (his/her) right foot and heel after laying (his/her) foot on the heater repeatedly throughout the night .ASSESSMENT AND PLAN: 1. Superficial burn to the right ankle. 2. [MEDICAL CONDITION]. 3. Observation of the dressing change for resident #5 on 2/12/20 at 11 AM showed a burn measuring approximately 6 centimeters (cm) long by 2 cm wide. There were two focal sites, each 2 cm in diameter which showed [MEDICATION NAME] skin with a red base and pink healing rims. The area was dressed using sterile technique with [MEDICATION NAME] to the area of sloughing and calcium silver alginate to the area of red granular tissue. Review of the facility's corrective measures showed the following: a. Resident #5's room was rearranged so that the bed was not next to the register making it impossible for the resident to place his/her feet on the register. The maintenance director assessed the heat register and verified that it was operating appropriately. b. An audit of all residents with beds next to heat registers was performed. All rooms were rearranged to remove the hazard on 1/13/20. This constituted 15 of 81 beds. All heat registered were evaluated on 1/13/20. The highest temperature recorded was 103 degrees Fahrenheit. Environmental expectation is that no register exceed 108 degrees F. and all beds be at least 8 inches from heat registers. c. Nursing and therapy staff were educated on risk for entrapment and injury based on bed placement. Housekeeping was documented as training 9 staff on 1/13/20. Further review showed documentation of 73 staff members receiving training. d. The interdisciplinary team held an ad hoc meeting related to the potential for [MEDICAL CONDITION] in-room heat registers on 1/13/20. Review of the QAPI meeting agenda showed the topic was addressed on 1/29/20.

Based on observation, medical record review, staff interview, and review of facility policies, the facility failed to ensure the physician-ordered diet texture was provided for 1 of 7 sample residents (#1) reviewed for diets. This failure resulted in past non-compliance at actual harm to resident #1 who choked on food provided by the facility that was not the appropriate texture. The resident subsequently died . Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on [DATE]. The findings were: 1. Review of physician orders [REDACTED].#1 was mechanical soft texture .no bread per family request. Review of a [DATE] speech therapy evaluation showed the resident was assessed for a possible increase in diet texture. However, the assessment revealed the resident was not able to tolerate a regular texture diet. The assessment documented the resident had decreased oral sensation, oral disorganization leading to food pocketing, and the resident was not able to sufficiently clear the oral cavity. The speech therapist concluded the resident needed to remain on the mechanical soft diet. The following concerns were identified: a. Review of a nursing note dated [DATE] showed the resident attended a social activity and consumed a hot dog. The resident left the dining room and fell forward to the ground. Nursing staff initiated the [MEDICATION NAME] maneuver, the resident's dentures and excess food was removed from the oral cavity, and 911 was called. The resident left the facility via ambulance. Review of a nursing note dated [DATE] showed the resident had expired. b. Review of the facility's diet manual Healthcare Services Group, Diet Manual, Third Edition (2011, but reviewed by the facility's registered dietitian on [DATE]) showed the dysphagia diet level 2, mechanically altered, should include meat that did not exceed ,[DATE] inch cubes; meat should be served moistened, ground, or flaked. c. During an interview on [DATE] at 8:47 AM, speech therapist #1 stated she was the therapist who evaluated the resident on [DATE]. She stated the resident required a mechanical soft diet, and a regular hot dog on a bun was not appropriate for that diet. She stated the resident should have received no bread, and a ground hot dog in a bowl with mustard and ketchup. d. During an interview on [DATE] at 6:31 PM the administrator stated he was present for the incident on [DATE]. He stated he observed activity staff provide the resident a second hot dog (a regular hot dog on a bun). He stated the resident should not have received a regular hot dog because s/he was on a mechanical soft diet. He confirmed the resident choked on the hot dog and subsequently died . 2. Review of the facility's Abatement Plan and interview with the administrator and director of nursing (DON) on [DATE] at 8:10 AM revealed the facility reported the incident to the survey agency on [DATE] and implemented corrective actions to prevent re-occurrence. The actions taken by the facility included: a. Identified any other residents at the activity on [DATE] that potentially could have received food not in accordance with their diet. Residents were assessed for 72 hours (lung assessments and vital signs) and their physicians notified. b. All residents' diets were reviewed by the dietitian, dietary manager and speech therapist, and diet slips were reviewed to ensure they matched. c. An updated list of diet orders was to be provided to activity staff before any food-related event. d. Education was provided to all staff (verified by review of sign-in sheets; any remaining PRN staff were not allowed to work until they receive education). e. Audits completed at all activity events that serve food to ensure diets are followed (verified by reviewing audit sheets). f. Ad-hoc QAPI meeting on [DATE] and a second QAPI meeting on [DATE]. 3. No food-related activities were held during the survey, but observations of 2 of 2 meals showed residents received food in accordance with their diets.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure ongoing comprehensive assessments were completed as necessary for 1 of 3 residents (#6) who experienced falls, resulting in a delay in treatment for [REDACTED]. The findings were: Review of the 11/4/17 admission Minimum Data Set assessment showed resident #6 had [DIAGNOSES REDACTED]. Further, the resident had a brief interview for mental status score of 1 (severely cognitively impaired). The following concerns were identified: a. Review of the 1/1/18 Interdisciplinary Post Fall Review showed the resident had an unwitnessed fall. Review of the Fall Report QAPI Log for (MONTH) (YEAR) showed the resident fell at 6:10 PM on 1/1/18, and had Bruise/Hematoma and Complaints of Pain. However, review of the entire medical record showed the facility failed to perform neurological assessments. The review showed no evidence the facility completed any further assessments or recorded any additional vital signs until 1/2/18 at 3:06 PM (20 hours and 56 minutes after initial assessments). b. Review of the progress note dated 1/2/18 and timed 3:06 PM showed the resident was lethargic, pale, and mouth-breathing with shallow respirations. Further, the resident had a fever of 101.3 degree Fahrenheit, and oxygen saturation readings of 85-90%. The resident was transported to the hospital by emergency medical services at 3 PM. c. Review of the progress note dated 1/2/18 and timed 6:23 PM showed the hospital emergency room reported the resident had a nonsurgical fracture and was being transferred to another facility for hospice. d. Review of the 1/19/18 Record Request Notification completed by the health information manager showed the resident had a fall with [MEDICAL CONDITION]. e. Review of the facility policy titled Fall Management last reviewed (MONTH) (YEAR) showed .When a fall occurs the resident is assessed for injury by the nurse . Further review showed . in the event a resident has a fall and it has been determined they hit their head .or it cannot be determined if they hit their head . the nurse initiates the following actions . Neurological checks are completed and documented per instructions. f. Review of the Neurological Record form shows the following instructions: Frequency: every 30 min (minutes) times 4, every 1 hour times 4 hours, every 4 hours times 24 hours, every 8 hours for the remaining 72 hours, or as ordered by a physician. g. Interview with the DON on 1/18/18 at 3:45 PM confirmed her expectation was for residents with unwitnessed falls to have neurological assessments, and for residents with falls to have timely comprehensive assessments as required. She further confirmed the resident did not have neurological assessments and timely comprehensive assessments.

Based on medical record review, staff interview, specialty provider interview, and review of facility policies and procedures, the facility failed to ensure residents at risk for pressure ulcers received necessary treatment and services to prevent ulcers from developing and to promote healing of existing ulcers resulting in actual harm for 1 of 5 sample residents (#108) identified as being at risk for pressure wounds. The findings were: Review of the 4/5/16 quarterly MDS assessment showed resident #108 had [DIAGNOSES REDACTED]. The resident required the extensive assistance of two people for bed mobility and transferring. Additionally, the resident was determined to be at risk for developing pressure ulcers, but did not have unhealed pressure ulcers at the time of the assessment. Review of the medical record showed the resident had a history of [REDACTED]. Further review of the medical record showed the resident was sent to theER on [DATE], and admitted to the hospital with [REDACTED]. The following concerns were identified: 1. Review of the Weekly Pressure Ulcer Record dated 5/2/16 showed a wound had developed and was located on the left heel. The wound measured 2.0 cm (centimeters) by 2.0 cm (length by width) and the depth of the wound was unable to be determined (UTD). Further, it was described as deep purple possible DTI (deep tissue injury) to L (left) heel. No Drainage noted, non boggy heel. There was no documented pain associated with the wound. Interventions listed as being in place at the time included LAL mattress, pillows, heel protectors, and encourage meal and protein intake. The following was noted regarding the left heel wound: a. Review of a physician order dated 5/2/16 showed Left heal (sic) DTI Wound care every day shift cleanse with wound cleanser, skin prep to affected area and peri-wound. Review of the May 2016 TAR showed no evidence treatments were completed on 7 of 29 days. b. Review of the May 2016 TAR showed no evidence of treatments being completed on 5/21 or 5/22. Review of the Weekly Pressure Ulcer Record dated 5/23/16 showed the wound was larger and measured 4.2 cm by 3.6 cm, with the depth UTD. It was labeled as DTI, and continues to present black eschar, wound edges are well attached. Noted increase size related to [MEDICAL CONDITION] to LLE (left lower extremity). No signs (and) symptoms of infection noted. Interventions documented as being in place include LAL mattress, pillows, heel protectors, and cont. (continue) to encourage off loading . The documentation also showed pain related to the wound was identified at this time. c. Review of the June 2016 TAR showed no evidence scheduled treatments were completed on 6 of 27 days. d. Review of the Weekly Pressure Ulcer Record dated 6/6/16 showed the wound was larger and measured 7.5 cm by 7.2 cm, with the depth UTD. It was labeled as unstageable with full thickness dermal loss. Unable to determine depth r/t (related to) soft dark granular like tissue to wound bed. Heel boggy to tougch (sic), wound edge unstable, sloughing, macerated. 40% wound edge unattached. [MEDICAL CONDITION] well controlled with wraps. e. Review of the Weekly Pressure Ulcer Record dated 6/27/16 showed the wound had not improved and continued to measure 7.5 cm by 7.2 cm, with the depth UTD. It was labeled as unstageable, with 90% firm eschar covered, 5% granular perimeter, 5% adherent slough. Punched out wound appearance, wound edges separated from eschar exposing reddened granular tissue c (with) small adherent slough. Edges non-adherent to eschar, irregular, unstable, moist. Noted odor to old dressing, no odor p (after) wound cleansing. No (change) in treatment. Education r/t (related to) laying in LAL bed vs recliner to promote healing/ alignment of legs (and) feet . f. Review of the care plan showed the intervention Total off load of feet, no foot pedals while in w/c (wheelchair) was initiated on 6/30/16. g. Review of the Weekly Pressure Ulcer Record dated 7/14/16 showed the wound had not improved and continued to measure 7.5 cm by 7.2 cm, with the depth UTD. Further review showed 90% firm eschar, 5% granular perimeter, 5% soft yellow slough. No (change) noted to wound . 2. Review of the Weekly Pressure Ulcer Record dated 5/2/16 showed a wound had developed on the right inner ankle. It measured 2.0 cm by 2.0 cm, with the depth UTD. It was described as a DTI and was ruddy dark red fluid filled raised area. Intact no drainage known. Interventions documented as being in place at the time included LAL mattress, pillows, and encourage meal (and) protein intake. The following was noted regarding the right inner ankle wound: a. Review of the physician order dated 5/2/16 showed Right inner ankle DTI wound care as needed cleanse with wound cleanser, skin prep to peri-wound, Exuderm to cover, as needed AND every day shift every Mon, Wed, Fri cleanse with wound cleanser, skin prep to peri-wound, Exuderm to cover. Review of the May 2016 TAR showed the treatment was not documented as being completed on 2 of 12 days. b. Review of the May 2016 TAR showed no treatment was documented as being completed on Friday, 5/6/16. Review of the Weekly Pressure Ulcer Record dated 5/9/16 showed the wound continued to measure 2.0 cm by 2.0 cm, with the depth UTD. However, the wound had opened, and presents as a red ruddy wound bed with uneven wound edges. Surrounding skin is pink and slightly macerated. Interventions listed included LAL mattress and pillows. c. Review of the Weekly Pressure Ulcer Record dated 5/30/16 showed the wound continued to measure 2.0 cm by 2.0 cm, with a depth of 0.2 cm. Further review showed Wound bed continues to be a dark red 60% granular noted firm slough with stringy edges 35% slough. Increase eschar appearance noted wound edges remain light pink. Altered skeletal status taken into consideration. Staff educated on pillows to be used to prop feet into upright position as tolerated while maintaining off loading precautions. The documentation was unclear in describing the eschar. Interventions listed included LAL mattress and pillows. d. Review of the Weekly Pressure Ulcer Record dated 6/6/16 showed the wound measured 2.0 cm by 2.0 cm by 0.4 cm, and was described as a stage 3 pressure ulcer. The wound was described as Wound bed dark red, noted stringing adherent slough (and) necrosis to wound bed. Wound edges light pink in color, fragile, attached. Outer area intact. No neg (negative) (changes) . Additionally, it described 60 gran (granular tissue), 20% necrotic, 20% adherent slough. Interventions listed included LAL mattress and pillows. e. Review of the Weekly Pressure Ulcer Record dated 6/13/16 showed the wound measured 2.1 cm by 1.8 cm, with the depth UTD. Further review showed the wound was described as 80% eschar, 20% dark gran (granular) tissue and Crater wound bed, dark purple to black in color, moist, firm. Wound edges uneven, attached, dark pink. Outer tissue intact. No neg (negative) (changes). Education provided, resident resistant to lay down. Interventions listed included LAL mattress, pillows, and heel protectors. f. Review of the June 2016 TAR showed no evidence 4 of 13 scheduled treatments were completed. g. Review of the Weekly Pressure Ulcer Record dated 7/14/16 showed the wound continued to measure 2.1 cm by 1.8 cm, with the depth UTD. Further review showed Area remains unstageable, no (change) in wound size. 20% adherent slough, 5% necrotic tissue, 75% smooth unstable granular tissue. Noted improved wound edge attachment continues . 3. Review of the Weekly Pressure Ulcer Record dated 6/6/16 showed a new wound had developed, located on the resident's left lateral foot. The date of onset for the wound was recorded as 6/2/16; however, there was no evidence of a description of the wound prior to 6/6/16. On 6/6/16, the wound was described as a DTI, measured 14.4 cm by 4.3 cm, with the depth UTD. Further review showed area presents with fluid filled discolored area. Area non-boggy. Wound edge soft, stable. Surrounding skin pink, soft (and) adherent. MD (physician) notified 6/2/16, aware of Charco (sic) foot, altered skeletal status. No s/s (signs/ symptoms) infection. The following was noted with regard to the left lateral foot wound: a. Review of the Weekly Pressure Ulcer Record dated 6/20/16 showed the wound had opened and measured 18.0 cm by 8.0 cm, with the depth UTD. It was described as increased discoloration to wound edge noted/ note increased size. No redness or irritation to surrounding area. Wound covering/ skin flap remains firm. Small amount serosang (serosanguineous) drainage noted to old dressing. Visible area under skin flap noted as pink granular, moist (and) fragile. Plan to leave flap in place, stablize (sic) . b. Review of the Weekly Pressure Ulcer Record dated 7/14/16 showed the wound continued to measure 18.0 cm by 8.0 cm, with the depth UTD. Further, it was described as 65% slough/thin (and) adherent, 35% pink granular. Edges pink, soft, smooth, adherent. No (change) in size. [MEDICAL CONDITION] cont (continues) well controlled. New tx (treatment) as plan to keep wounds stable awaiting surgical intervention/amputation. 4. Review of a skin/wound note dated 6/2/16 showed .MD (physician) aware of complexities of wounds, discussed at rounds this AM. Agreeable with referring to Wound Care at this time . 5. Review of the Weekly Pressure Ulcer Record dated 6/6/16 showed a new wound had developed, located on the resident's right heel. The date of onset was recorded as 6/2/16; however, there was no evidence of a description of the wound prior to 6/6/16. At that time, the wound was described as a DTI, measured 7.2 cm by 6.2 cm, with the depth UTD. Additionally, it presents with fluid filled discolored area, boggy. Wound edge soft, unstable. Surrounding area pink, soft, unstable, sloughing. No redness or inflammation noted to surrounding area. Neuropathic in nature. The following was noted with regard to the right heel wound: a. Review of the Weekly Pressure Ulcer Record dated 6/13/16 showed the wound had opened, measured 7.5 cm by 8.5 cm, with the depth UTD. Further, it was described as 40% exposed, 60% nonviable skin flap remaining. Dark granular tissue noted to exposed wound bed . b. Review of the Weekly Pressure Ulcer Record dated 7/14/16 showed the wound continued to measure 7.5 cm by 8.5 cm, with the depth UTD. At that time it was described as 90% firm eschar, 5% granular perimeter, 5% soft yellow slough to perimeter. Wound edges noted to have increased stability/ firmness, increased adhesion. Foot remains warm to touch, no redness, no streaking, no neg (negative) (changes) . 6. Review of a purchase order showed a low air loss (LAL) mattress was ordered on [DATE]. Review of a nurse's note dated 3/31/16, described as a late entry for 3/30/16, showed wound nurse put an airbed in room for resident comfort. Today was reported that resident slept all night in bed with feet up. resident looks and feels much better today. The following concerns with the LAL were identfied: a. Although the LAL was listed as an intervention for the resident's wounds, review of a nurse progress note dated 4/9/16, timed 2:15 AM, showed the resident states (s/he) sleeps pretty well in (his/her) recliner and does not like the bed because (s/he's) always sliding out. b. Review of a nurse progress note dated 6/19/16 showed the resident wanted to sit in (his/her) recliner in a reclining position. Says (s/he) is very uncomfortable lying in (his/her) bed, the bed is too small for (him/her). Lying in bed causes increased pain. c. Between 4/9/16 and 6/6/16 the resident developed significant wounds on both feet. d. Telephone interview with the wound care nurse on 7/29/16 at 10:04 AM confirmed the resident did not like the air mattress. She revealed the resident reported lying flat in the mattress made it feel like a weight was pressing against his/her chest. She revealed the staff were not knowledgeable about the settings that could elevate the head of the mattress. She stated she educated the staff in mid-June regarding settings for the air mattress so they could adjust the air flow to make it more comfortable for the resident. The nurse further revealed adjusting the settings made a huge difference, and the resident was more compliant with using the bed after that point. 7. Interview with the wound clinic practitioner on 7/29/16 at 1 PM revealed the resident had been in the clinic on 6/16/16, where the wounds presented as pressure-related wounds. He stated the resident was at an extremely high risk for pressure wounds due to [DIAGNOSES REDACTED]. He added based on the way (the resident) looked in June, he was surprised they (the facility) waited that long to contact the wound clinic. He stated the clinic had previously seen the resident, in February of 2016, and the feet looked fine and were healing properly. He added after the June 2016 visit he referred the resident to a podiatrist for further evaluation. 8. Interview with the resident's podiatrist on 8/2/16 at 10:10 AM revealed he saw the resident in his practice in June and recommended a vascular consult for possible amputation of both feet. He stated at the time of the resident's appointment, the wounds were necrotic and decubitus in nature. He further stated, based on the resident's comorbidities, if (the resident) just sits there all day or lays in bed all day, it's bound to happen (development of wounds). 9. Interview with corporate RN #1 on 7/29/16 at 9:05 AM confirmed the resident's medical record did not show evidence of ordered treatments always being completed. 10. Review of the facility policy and procedure, titled Skin Management, revised 8/12, showed Unavoidable Pressure Ulcers: Per CMS guidelines, unavoidable means that the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. All of this must be clearly documented in the resident's clinical record.