Every finding on record at Boulder Post Acute

Based on observations and interviews the facility failed to ensure food was distributed and served under sanitary conditions in the main kitchen. Specifically, the facility to ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination in the main kitchen. Findings include:I. Failed to ensure ready-to-eat foods were handled in a sanitary manner. A. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24) and retrieved on 2/23/26 read in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissues, spatulas, tongs, single-use gloves or dispensing equipment. (2-301.15) Food employees shall clean their hands and exposed portions of their arms as specified under immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and before donning (putting on) gloves to initiate a task that involves working with food. (3-301.11) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. (3-304.15)B. Facility policy and procedureThe Dietary Employee Personal Hygiene policy, revised 2025, was provided by the nursing home administrator (NHA) on 2/19/25 at 11:04 a.m. The policy read in pertinent part, It is the policy of this facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food by foodservice employees. Hands must always be washed after using the restroom, eating or drinking, using tobacco products, coughing, sneezing, blowing nose, before putting on gloves, after removing gloves, and after engaging in other activities that contaminate the hands and gloves are to be worn and changed appropriately to reduce the spread of infection.C. ObservationDuring a continuous observation on 2/17/26, beginning at 11:35 a.m. and ending at 12:45 p.m., the following was observed during the service of the meal:Cook (CK) #2 was plating the food using utensils with bare hands. Without performing hand hygiene, he donned (put on) gloves sliced a hot dog and put it on the plate with the bun. He removed the gloves and went back to using utensils to serve, without washing his hands. He put on another pair of gloves, without washing his hands, to cut another hot dog and removed a bun from the bag the buns came in. He left the gloves on for the remainder of the service. During that time he picked up four grilled cheese sandwiches with the gloved hands, and used the same gloved hands to serve the food using the utensils. CK #2 used the same gloved hands to pull hot dog buns from their bag, open them with his gloved hands and plate the food. D. Staff interviewsThe dietary manager (DM) was interviewed on 2/19/26 at 10:00 a.m. The DM said she expected the dietary staff to put on gloves when touching food and to wash their hands before and after putting on the gloves. She expected that if the dietary staff put on gloves to handle food, the gloves would be removed after the single use and hands would be washed. The DM said she has provided in-services (training) on the topic of single use gloves and hand hygiene since she started three weeks ago.

Based on observations and interviews, the facility failed to ensure that all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for two of six medication carts. Specifically, the facility failed to ensure inhaler medications and multi-use vials of injectable medications were marked with the date when the medications were opened.Findings include:I. Professional referenceAccording to the haloperidol deconate injection package insert, retrieved on [DATE] from https//fresenius-kabi.com/content/dam/fresenius-kabi/ca/products/product-documents/iv-drugs/haloperidol-injection-usp_/Product%20Monograph.pdf.coredownload.inline.pdf, Multiple-dose vials: Discard unused portion 28 days after initial puncture.According to the Spiriva Respimat (tiotropium bromide) inhaler package insert, retrieved on [DATE] from https://content.boehringer-ingelheim.com/DAM68a8a6b5-4e9a-4508-85d3-af101205009/spiriva%20respimat-us-pi-pdf, After assembly, the Spiriva Respimat inhaler should be discarded, at the latest, three months after first use or when the locking mechanism is engaged, whichever comes first.According to the Stiolto Respimat (tiotropium bromide and olodaterol inhalationspray) inhaler package insert, retrieved on [DATE] from https://pro.boehringer-ingelheim.com/us/products/respiratory/bipdr/stiolto-respimat-pi#page=18, Three months after insertion of cartridge, throw away the Stiolto Respimat, even if it has not been used, or when the inhaler is locked, or when it expires, whichever comes first.II. Facility policy and procedureThe Storage of Medication policy, revised 2020, was received from the regional clinical resource at 10:44 a.m. on [DATE]. It revealed in pertinent part, Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.III. ObservationsOn [DATE] at 12:15 p.m. the second floor medication cart was observed with licensed practical nurse (LPN) #1. The following observations were made: -Two vials of haloperidol deconate 500 milligrams (mg)/5 ml vial for injection were not marked with the date they were opened; and,-One Spiriva (tiotropium bromide) inhaler was not marked with the date it was opened. On [DATE] at 3:20 p.m. the east third floor medication cart was observed with LPN#2. The following observations were made: -Two vials of haloperidol deconate 500 mg/5 ml vial for injection were not marked with the date they were opened;-One Spiriva Respimat (tiotropium bromide) inhaler was not marked with the date it was opened; and,-One Stiolto Respimat inhaler was not marked with the date it was opened.III. Staff interviewsLPN #1 was interviewed on [DATE] at 12:20 p.m. LPN #1 said the importance of having an open date on medications was to make sure the medication was still effective and not expired.LPN #2 was interviewed on [DATE] at 3:30 p.m. LPN #2 said the importance of writing the open date on the medications was to know when the medication would expire.The director of nursing (DON) was interviewed on [DATE] at 11:00 a.m. The DON said the open dates must be marked on medications to ensure medications were not expired and remained effective.

Based on observations, record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for two (#1 and #8) of five residents out of 43 sample residents. Specifically, the facility failed to:-Obtain orders for Resident #1's midline catheter (tube inserted into a vein to administer medication) dressing change;-Change Resident #1's midline catheter dressing in a timely manner; and,-Follow physician's orders for Resident #8's sliding scale insulin.Findings include: I. Failed to obtain orders for Resident #1's midline catheter dressing change and change the resident's midline catheter dressing in a timely manner A. Professional reference According to Basic Nursing Thinking, Doing and Caring Treas, L., & [NAME], K., & [NAME] M. (2022) Basic Nursing Thinking, Doing and Caring (3rd ed.), p. 3531, The replacement of transparent dressings should be done at least every five to seven days, or earlier as clinically indicated, for example when the dressing becomes damp, soiled or loose. B. Resident #1 1. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included gastrostomy (surgical procedure to make an opening for a feeding tube), epilepsy, Alzheimer's disease, dysphagia (difficulty swallowing) and pneumonitis due to inhalation of food and vomit. The 12/31/25 minimum data set (MDS) assessment indicated the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The staff assessment revealed the resident had memory problems with both long and short term memory. The MDS assessment indicated the resident was dependent on staff for all activities of daily living (ADL). 2. Observation On 2/16/26 at 4:45 p.m. licensed practical nurse (LPN) #7 entered Resident #1's room to change her midline catheter transparent dressing. LPN #7 confirmed the date on the dressing was 2/6/26, which was the date the midline catheter was placed, ten days prior. LPN #7 said a midline catheter dressing should be changed every seven to 10 days. 3. Record review The 2/6/26 nurse progress note documented a physician's order was given by Resident #1's physician for the resident to receive intravenous (IV) fluids. The resident's midline catheter was placed on 2/6/26. Review of Resident #1's February 2026 CPO revealed the following physician's orders: Normal saline flush intravenous solution 0.9 percent (%), use one liter IV one time only for dehydration for one day, ordered 2/6/6. Midline dressing change of the left arm, in the evening, every seven days, ordered 2/17/26. -The February 2026 CPO did not include physician's orders for midline catheter dressing changes for Resident #1 until 2/17/26 (during the survey), 11 days after the resident's midline catheter was placed. C. Staff interviews LPN #7 was interviewed 2/18/26 at 1:16 p.m. LPN #7 said a representative from the pharmacy came to the building to insert Resident #1's midline catheter and said the dressing should be changed every seven to 10 days, but there was no documentation of this in Resident #1's electronic medical record (EMR). LPN #7 said she followed up with the director of nursing (DON) and was told seven days was the standard of practice for the transparent dressing change. She said the physician's order to change the resident's midline catheter dressing was missed. The DON and the regional clinical resource were interviewed together on 2/18/26 at 3:50 p.m. The DON and the regional clinical resource both said the standard of practice for a transparent dressing change was seven days and as needed. The DON said Resident #1's dressing should have been changed seven days after the initial dressing was placed (on 2/6/26), so it should have been changed on 2/13/26. The DON said physician's orders addressing the midline catheter dressing should have been entered into Resident #1's EMR. II. Failed to follow physician's orders for Resident #8's sliding scale insulin A. Resident #8 1. Resident status Resident #8, age less than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included dementia with behavioral disturbance, type 2 diabetes with hyperglycemia and long-term use of insulin. The 12/17/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. The resident was independent for most ADLs. 2. Record review Review of Resident #8's February 2026 CPO revealed the following physician's orders: Lispro insulin injection solution 100 units/milliliter (ml), inject as per sliding scale: if blood sugar is 300 milligrams (mg)/deciliter (dl) to 349 mg/dl inject 6 units; 350 mg/dl to 400 mg/dl inject 8 units; 401 mg/dl to 449 mg/dl inject 10 units. Give injection subcutaneously (under the skin) every 12 hours as needed for hyperglycemia; ordered 3/31/25 and discontinued 2/18/26 (during the survey process). Glargine insulin solution 100 units/ml, inject 26 units subcutaneously in the morning for uncontrolled diabetes, hold if blood sugar is below 90 mg/dl; ordered 7/1/25. Check fasting blood sugar twice daily for diabetes; ordered 7/10/24 and discontinued 2/18/26 (during the survey process). If blood glucose is over 400 mg/dl or below 60 mg/dl notify the physician and make a nurse note each shift for glucose monitoring; ordered 7/7/25 and discontinued 2/18/26 (during the survey process). Review of Resident #8's medication administration records (MAR) from 10/1/25 through 2/19/26 did not reveal documentation to indicate the resident had received any administered doses of the sliding scale Lispro insulin solution. A progress note, dated 9/9/25 at 5:13 p.m., revealed Resident #8 was administered 6 units of Lispro insulin. The note documented Resident #8's blood sugar measured 302 mg/dl before his meal. A progress note, dated 12/30/25 at 7:43 p.m., revealed Resident #8's blood sugar was measured and found to be 310 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 12/31/25 at 7:40 p.m., revealed Resident #8's blood sugar was measured and found to be 322 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 1/1/26 at 7:27 p.m., revealed Resident #8's blood sugar was measured and found to be 336 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 1/4/26 at 7:24 p.m., revealed Resident #8's blood sugar was measured and found to be 330 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 1/11/26 at 7:17 p.m., revealed Resident #8's blood sugar was measured and found to be 307 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 1/13/26 at 7:22 p.m., revealed Resident #8's blood sugar was measured and found to be 330 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 1/18/26 at 7:20 p.m., revealed Resident #8's blood sugar was measured and found to be 320 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 1/20/26 at 7:23 p.m., revealed Resident #8's blood sugar was measured and found to be 346 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 1/21/26 at 7:28 p.m., revealed Resident #8's blood sugar was measured and found to be 310 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 1/25/26 at 7:23 p.m., revealed Resident #8's blood sugar was measured and found to be 319 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 2/1/26 at 7:44 p.m., revealed Resident #8's blood sugar was measured and found to be 314 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 2/4/26 at 7:32 p.m., revealed Resident #8's blood sugar was measured and found to be 346 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 2/10/26 at 7:29 p.m., revealed Resident #8's blood sugar was measured and found to be 366 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 8 units was not administered. A progress note, dated 2/11/26 at 8:04 p.m., revealed Resident #8's blood sugar was measured and found to be 328 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 2/17/26 at 7:47 p.m., revealed Resident #8's blood sugar was measured and found to be 304 mg/dl. -However, the sliding scale as-needed Lispro insulin dose of 6 units was not administered. A progress note, dated 2/18/26 at 5:07 p.m. (during the survey process), revealed a nursing staff member reviewed Resident #8's blood sugar history with his physician and received a physician's order to discontinue the resident's sliding scale insulin. B. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 2/18/26 at 1:50 p.m. LPN #4 said for residents with diabetes, the nursing staff would measure their blood glucose levels before meals. LPN #4 said Resident #8's blood sugar was measured twice a day, with both measurements conducted before meals. LPN #4 said the staff measured Resident #8's blood glucose levels after meals if indicated by any possible signs of hyperglycemia. LPN #4 reviewed Resident #8's physician's orders. LPN #4 said there was a physician's order to notify Resident #8's provider if his blood glucose level measured above 400 mg/dl or below 60 mg/dl. LPN #4 said this order referred to both blood glucose levels measured while the resident was fasting and those measured after meals as needed. LPN #4 said Resident #8 had an order to receive Glargine insulin once a day, and said he did not see any sliding scale insulin orders in the resident's CPO. LPN #4 said Resident #8's blood glucose levels fluctuated because he liked to eat a lot of snacks. LPN #4 said if Resident #8's blood glucose levels were measured and found to be too high or too low, he would notify his physician so they could monitor him more closely or adjust his insulin dosage for better coverage. Resident #8's primary care physician (PCP) was interviewed on 2/18/26 at 2:46 p.m. The PCP said he expected the nursing staff to follow the orders he put in place, or to contact him if they had any concerns or questions. The PCP said for diabetic residents, the nursing staff would ideally check their blood glucose levels after each meal, but said checking the resident's blood sugar twice a day was fine for some residents. The PCP said Resident #8 had refused care at times, so the nursing staff might be assessing his blood glucose level as often as he would allow them to. The PCP said if Resident #8's blood glucose level was measured and found to be over 300 mg/dl and the physician's order for sliding scale insulin was present in the CPO, he would have expected the nursing staff to either administer the insulin as ordered or call him to clarify the order. The PCP said the nursing staff might not have known the sliding scale insulin order was in the CPO. The PCP said he would not have wanted the nursing staff to administer the sliding scale insulin. -However, review of Resident #8's electronic medical record (EMR) did not reveal any communication between the nursing staff and the physician regarding clarification for the sliding scale insulin order. LPN #5 was interviewed on 2/19/26 at 8:58 a.m. LPN #5 said when residents with diabetes received new orders from the physician for insulin, she would look in their CPO to see if there were also orders to check the resident's blood glucose level prior to administering insulin. LPN #5 said the facility did not use sliding scale insulin orders but used long-acting insulin with set schedules. LPN #5 said if she saw a resident had an order for sliding scale insulin dosing, she would clarify the order first with the DON, then with the resident's physician. LPN #5 said the facility used agency staff and that some of the agency staff members were not the best at verifying physician's orders, so she tried to clarify orders whenever possible. The DON and the regional clinical resource were interviewed together on 2/19/26 at 12:46 p.m. The DON said the facility tried to avoid using sliding scale insulin orders, but said the nursing staff should follow the physician's order for sliding scale insulin if one was in place. The regional clinical resource said the expectation of the nursing staff would be to administer the insulin per physician's orders. The DON said she had reviewed Resident #8's EMR and saw there was a scheduled order to notify the physician if his blood glucose measurement exceeded certain parameters. She said she thought that was why Resident #8's blood glucose was being recorded in his progress notes. The DON said she provided the nursing staff with one-on-one education on medication errors on 2/18/26 (during the survey) and had notified Resident #8's physician. The DON said the sliding scale insulin order was supposed to be used based on Resident #8's fasting blood sugar measurements. The DON said she did not think the order specified whether the blood glucose measurement was supposed to be fasted or assessed at any time. The DON said if the nursing staff had noticed the sliding scale insulin order they would have clarified the order. The regional clinical resource said the nursing staff should have asked the physician for clarification regarding the sliding scale insulin order.

Based on record review and interviews the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#1) of one resident reviewed with a feeding tube out of 43 sample residents.Specifically, the facility failed to ensure Resident #1 received her tube feedings per physician's orders. Findings include:I. Facility policy and procedureThe Enteral Tube Feeding via Continuous Pump policy, dated November 2018, was provided by the nursing home administrator (NHA) on 2/18/26 at 11:26 a.m. The policy read in pertinent part, Verify that there is a physician's order for this procedure, review the resident's care plan and provide for any special needs of the resident, ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or this facility.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician's orders (CPO), diagnoses included gastrostomy (surgical procedure to make an opening for a feeding tube), epilepsy, Alzheimer's disease and dysphagia (difficulty swallowing). The 12/31/25 minimum data set (MDS) assessment revealed the resident had memory problems with both long and short term memory per staff assessment. The MDS assessment documented the resident was dependent on staff for all activities of daily living (ADL). The MDS assessment indicated Resident #1 received 51 percent (%) or more of her total calories through the feeding tube and her daily fluid intake was 501 cubic centimeter (cc) or more.B. Record reviewThe nutrition care plan, dated 10/7/25, documented Resident #1 had the potential for altered nutrition and/or hydration status related to the new gastrostomy tube (G tube), nothing by mouth (NPO) status, malnutrition, dementia and celiac disease. The pertinent interventions included administering nutrition related medications per physician order and monitoring for side effects, provide the enteral nutrition as ordered, monitoring the resident's intake and outtake, monitoring labs when available and reporting significant changes to the physician, observing for signs/symptoms of malnutrition and dehydration and report to physician as needed and the registered dietitian (RD) to reassess as indicated. The enteral nutrition care plan, dated 10/7/25, documented Resident #1 required enteral nutrition related to seizure disorder, malnutrition and NPO status. Pertinent interventions included administering medications through the G tube as ordered, NPO per physician's order, enteral nutrition as ordered, monitoring tolerance to enteral feeding, flush G tube with 30 milliliter (ml) water before and after medication administration and/or as ordered, elevating the head of bed to at least 30 degrees, monitoring for nausea/vomiting, abdominal distension or discomfort with each feeding and as needed, monitor labs when available and report significant changes to the physician, observing for signs/symptoms of malnutrition and dehydration, and referring to RD as indicated.Review of the February 2026 CPO revealed the following physician's orders:Administer Iso-source 1.5 per G tube through the pump. Rate was documented at 60 ml/hour (hr) for 20 hours. Starting at 8:00 a.m. and ending at 4:00 a.m. Administer total volume 1200 ml per 24 hours with free water flushes of 100 ml every six hours, ordered on 1/31/26 and discontinued on 2/5/26. Administer Iso-source 1.5 per G tube through the pump. Rate was documented at 60 ml/hr for 20 hours. Starting at 7:30 a.m. and ending at 3:30 p.m Administer total volume 1200 ml per 24 hrs with free water flushes of 100 ml every six hours, ordered on 2/5/26 and discontinued on 2/7/26.Administer Iso-source 1.5 per G tube through the pump. Rate was documented at 65 ml/hr for 20 hours. Starting at 7:30 a.m. and ending at 3:30 p.m. Administer total volume 1300 ml per 24 hours with free water flushes of 100 ml every six hours ordered on 2/8/26 and discontinued 2/19/26.Administer Iso-Source 1.5 per G tube through the pump. The rate was documented at 70 ml/hr x 20 hrs starting at 7:30 a.m. and ending at 3:30 p.m. Administer total volume 1400 ml per 24 hours with free water flushes of 100 ml every six hours, ordered on 2/19/26. Free water flushes through the feeding tube 100 ml every six hours, at 3:00 a.m., 9:00 a.m., 3:00 p.m. and 9:00 p.m. ordered on 2/5/26. Registered nurse (RN) #1's progress note, dated 2/1/26, documented at 11:33 a.m. revealed the volume from the tube feeding pump read 208 ml. The note documented the nurse administered 32 ml feed bolus (dose given all at one) to equal 240 ml. Resident #1's husband and daughter were in agreement. The note documented At 1:30 p.m. the nurse administered another food bolus of 50 ml and at 6:00 p.m. provided a food bolus of 45 ml per Resident #1's husband's request.-However, there was no physician's order for an as needed (PRN) bolus feeding. The progress note did not indicate the physician had provided an order for the bolus feeding or had been notified of the additional bolus feeding. There was no documentation the RD had been notified or consulted about the bolus feeding. RN #2's progress note, dated 2/2/26, documented Resident #1's tube feeding stopped at 3:30 a.m. and the resident received a total of 1050 ml tube feeding through the tube feeding pump. The nurse provided 150 ml bolus feeding in order to total 1200 ml of the feeding. -However, there was no physician's order for a PRN bolus feeding. The progress note did not indicate the physician provided an order or was notified of the additional bolus feeding. There was no documentation the RD had been notified or consulted about the bolus feeding. A nursing progress note, dated 2/2/26, documented Resident #1's tube feeding was paused during changes and repositioning and the tube feeding gets behind from the daily ordered intake. The nurse provided an additional 60 cc bolus at 4:00 p.m. Resident #1 began coughing and became nauseous. Her family refused anymore bolus feedings at that time.-However, there was no physician's order for a PRN bolus feeding. The progress note did not indicate the physician had provided the order for the bolus feeding or had been notified of the additional bolus feeding. There was no documentation the RD had been notified or consulted about the additional bolus feedings. C. Staff interviewsLicensed practical nurse (LPN) #7 was interviewed on 2/18/26 at 1:16 p.m. LPN #7 said Resident #1 was admitted with the G tube and continuous feeding for 20 hours. LPN #7 said the standard practice was to follow the physician's orders when treating a resident. She said the bolus feeding was decided on how much food was being provided in the 20 hours of continuous feeding compared to the total calculated amount the resident was supposed to receive. She said the feeding was turned off during personal care in order for staff to turn the resident and reposition her and the resident was not receiving the total amount of daily intake. She said the family had brought this to the nursing staff's attention. LPN #1 said there was no physician's order for the bolus feedings that were provided.The primary care physician (PCP) was interviewed on 2/18/26 at 2:30 p.m. The PCP said the RD had been monitoring the fluid and food intake closer than he had. He said he was aware of the bolus feeding after the nurses gave them. He said it would not be his preference to the bolus feeding with the continuous feeding. He said the nurses' should have followed the plan of the continuous feeding. The PCP said he did not think the bolus feedings caused any harm. He said he did not find the resident to be malnourished as evidenced by her lab work and weights. The PCP expected the nurses' to follow Resident #1's orders and was open to the nurses' calling to discuss orders or changes but in the end he expected orders to be followed. RN #1 was interviewed on 2/18/26 at 3:03 p.m. She said Resident #1 was on continuous tube feeding for 20 hours, off for four hours and then it was restarted. RN #1 said she discovered the resident was not meeting her caloric intake needs because of the time the feeding pump was turned off during personal care. RN #1 said she calculated how many mls she was behind and provided bolus feedings during her shift on 2/1/26 to catch up on the feeding intake amount. RN #1 said because Resident #1 had been receiving water boluses, which were scheduled four times a day; she did not feel she needed an order for the feeding boluses as she was not going over the recommended calculated feeding amount. She did not notify the RD or the PCP of the bolus feeding.RN #2 was interviewed on 2/28/26 at 3:19 p.m. RN #2 said she provided Resident #1 with a bolus of 130 ml per the family's request. She said she did call the on-call but did not receive a call back and proceeded with the bolus administration. RN #2 said she would not administer medications without a physician's order even if a family requested it, however she said she gave the bolus this time because Resident #1 did not receive her calculated amount of feeding for the day. She did not notify the RD or the PCP of the bolus feeding. The RD was interviewed on 2/18/26 at 4:38 p.m. The RD said she assessed the caloric needs of residents on feeding tubes based on their weight, nutritional needs and lab results. She said If a resident was showing signs or symptoms of malnutrition (weight loss or negative lab work) she would reassess the residents' needs and recalculate the feedings and increase the milliliter of food intake if needed. She said if a bolus was given she would expect there to be a physician's order for this. The RD said she would have expected to be notified of the bolus feeding or the calculations the nursing staff was using to provide the bolus feeding in order to reassess the resident, however; she was not notified of the bolus feedings until a few days later when she reassessed the resident's intake and changed the tube feeding order. The director of nursing (DON) and the regional clinical resource were interviewed together on 2/18/26 at 3:50 p.m. The DON said she expected the nursing staff to follow the PCP's orders. She said she was aware Resident #1 was on continuous feeding and said bolus feedings could be given to a resident who was on a continuous tube feeding to meet the needs of the resident. She said she would have expected the physician to be called to receive an order for the additional bolus feeding.

Based on record review, observations and interviews, the facility failed to ensure three (#53, #62 and #84) of three residents of 43 sample residents received food prepared in the form designed to meet their individual needs. Specifically, the facility failed to ensure Resident #53, Resident #62 and Resident #84, who were prescribed mechanically altered diets, had food prepared according to their diet orders.Findings include: I. Professional reference The International Dysphagia Diet Standardization Initiative (IDDSI) Patient Handout (January 2019), was retrieved on 2/24/26, from https://iddsi.org/Resources/Patient-Handouts It read in pertinent part, Level two mildly thick drinks may be used if thin drinks such as water, milk, and others flow too quickly for you to swallow them safely. Some milk shakes and thick shakes may be this thickness level already, but other drinks may need thickener added to reach the correct thickness level. Mildly thick drinks flow at a slower rate. Level five minced and moist food may be used if you are not able to bite off pieces of food safely but have some basic chewing ability. Some people may be able to bite off a large piece of food, but are not able to chew it down into little pieces that are safe to swallow. Minced and moist only need a small amount of chewing and for the tongue to collect the food into a ball and bring it to the back of the mouth for swallowing. It is important that minced and moist foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. These foods are eaten using a spoon or fork. Level six soft and bite-sized textures are used if you are not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow. Soft and bite-sized foods need a moderate amount of chewing, for the tongue to collect the food into a ball and bring it to the back of the mouth for swallowing. The pieces are bite-sized to reduce choking risk. Soft and bite-sized foods are eaten using a fork, spoon or chopsticks. An example of level six soft and bite-sized: Meat cooked tender and chopped, so pieces are no bigger than 1.5 centimeter (cm) by 1.5cm lump size. If food cannot serve soft and tender, serve as minced and moist. Level six soft and bite-sized, for safety avoid these food textures that pose a choking risk for adults who need level six soft and bite-sized food: Bread (no regular dry bread, sandwiches or toast of any kind). Use IDDSI level five minced and moist sandwich recipe to prepare bread; use pre-gelled 'soaked' breads that are very moist and gelled through the entire thickness; Hard or dry food include nuts, raw vegetables, dry cakes, bread, dry cereal; Crumbly bits include dry cake crumble, dry biscuits (add sauce to make these suitable); Large or hard lumps of food include casserole pieces larger than 1.5 centimeter (cm) x 1.5 cm, fruit, vegetable, meat, pasta or other food pieces larger than 1.5 cm x 1.5 cm. The International Dysphagia Diet Standardization Initiative (IDDSI) Framework: Food and Drink Testing of [NAME] Nutrition Products (January 2023), was retrieved on 2/26/26, from www.abbottnutrition.com/content/dam/an/abbottnutrition/pdf/clinical-resources/nutrition-by-life-stage/adult-nutrition/IDDSI. The review of the table content revealed that none of the Ensure products meet the criteria for level two, mildly thick liquids. II. Facility policy and procedure The Therapeutic Diet policy, dated October 2017, was provided by the nursing home administrator (NHA) on 2/19/26 at 11:04 a.m. It read in pertinent part, Diet orders should match the terminology used by the food and nutrition services department. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: altered consistency diet. If a mechanically altered diet is ordered, the provider will specify the texture modification. The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. Snacks will be compatible with the therapeutic diet. III. Resident #62 A. Resident status Resident #62, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, protein-calorie malnutrition, generalized muscle weakness and palliative care. The 11/26/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident was dependent on staff for most activities of daily living (ADL). The MDS assessment indicated the resident did not have signs and symptoms of a swallowing disorder and required a mechanically altered diet. B. Observations On 2/16/26 at 10:16 a.m. Resident #62 was sitting in a chair at a dining table in the common area with an open packet of saltine crackers in her hands and had crumbled one of the crackers onto the floor and into her shoes. At 1:05 p.m. CNA #3 spoke with Resident #62 to see if she wanted anything else to eat aside from the meal she had been served. CNA #3 offered Resident #62 chips, a granola bar or crackers. Licensed practical nurse (LPN) #6 was standing nearby and asked CNA #3 if Resident #62 had eaten her crackers from earlier, to which CNA #3 replied she had eaten four of her crackers. On 2/17/26 at 12:07 p.m. Resident #62 was served a lunch meal plate. The plate contained four meatballs approximately 1.5 inches in diameter, cooked spinach, mashed potatoes and noodles which were approximately 1.5 to 2 inches long. An unidentified staff member spoke with Resident #62 to see if she wanted to be seen by her physician, and when the resident refused, the staff member oriented Resident #62 to her meal tray before leaving. At 12:16 p.m. Resident #62 speared a meatball on her fork and attempted to feed herself. Resident #62 brought the meatball to her mouth and tried to take a bite of it but was unable to do so, and the meatball dropped into her lap and rolled onto the floor. C. Record review The February 2026 CPO revealed the following physician's order: Regular diet, Level 6 soft and bite-sized texture, thin liquids, ordered on 5/22/25. Resident #62's nutrition care plan, revised 11/26/25, revealed Resident #62 was at risk for altered nutritional status due to her cognitive deficits, history of malnutrition and vitamin D deficiency. Pertinent interventions included providing Resident #62 her diet, supplements and vitamins per physician's order and catering to her food preferences and offering alternatives as needed. D. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 2/18/26 at 1:03 p.m. CNA #3 said she had recently started working at the facility and had just finished her orientation. CNA #3 said she had mostly learned the differences between the different diet textures by looking at posters in the common area. CNA #3 said residents who had difficulty swallowing received pureed diet textures, and could not have regular texture food. CNA #3 said Resident #62 was on a soft and bite-sized or minced and moist diet texture. CNA #3 said residents on soft and bite-sized or minced and moist diet textures could have snacks including pudding, applesauce or ice cream. CNA #2 was interviewed on 2/18/26 at 1:31 p.m. CNA #2 said there were a lot of residents on her unit who received altered texture diets. CNA #2 said Resident #62 received an altered texture diet. CNA #2 said she relied on looking at the residents' meal tickets and the poster on the wall to know what diet texture the residents were ordered and what it should look like. CNA #2 said residents who received soft and bite-sized or minced and moist diet textures could have snacks including soft cookies or fig cookie bars. CNA #2 said if those snacks were unavailable, the residents could have ice cream, pudding or applesauce. CNA #2 said the facility provided a lot of education to the nursing staff on diet textures. Licensed practical nurse (LPN) #5 was interviewed on 2/19/26 at 8:58 a.m. LPN #5 said the facility provided in-services on the different diet textures often. LPN #5 said residents who were ordered to have a soft and bite-sized diet texture could have chopped up fruits, oatmeal cookies chopped up and served with milk, or pudding. The registered dietitian (RD) was interviewed on 2/19/26 at 9:35 a.m. The RD said as far as she knew, the staff members serving residents their trays were trained on the different diet textures. The RD said the dietary staff should check the resident's meal ticket while plating, and the dietary aides would check the meal ticket as well. The RD said she did not expect the nursing staff to check residents' plates as they were delivering them, as she thought the two checks in the kitchen should be sufficient. The RD said Resident #62 was receiving a soft and bite-sized diet. The RD said she would expect residents receiving a soft and bite-sized diet to have small pieces of food cut up to the size recommended by the IDDSI for each menu item. The RD said she would have expected for Resident #62's meatballs and pasta to be cut to the size recommended for her diet texture by the IDDSI. The RD said snacks for residents on a soft and bite-sized diet would need to be cut up into small pieces and be an appropriate texture for their diet. The RD said saltines would not be appropriate to serve a resident on a soft and bite-sized diet. The RD said the facility nursing staff were educated on the different diet texture guidelines during an all-staff meeting, but was not sure when the education was provided. The director of nursing (DON) and the regional clinical resource were interviewed together on 2/19/26 at 12:46 p.m. The DON said the facility had provided education on the different altered diet textures during an all-staff meeting, and the DM and RD had gone around the facility to do on-the-floor training with the facility staff at the time. The regional clinical resource said food served to residents receiving a soft and bite-sized diet texture needed to be able to be squished with a fork, and be cut into pieces smaller than 1.5 centimeters. The DON and the regional clinical resource said the nursing staff and any other staff serving meals should have an understanding of what the altered diet textures should look like. The DON and RCR said saltine crackers were not an appropriate snack for residents on a soft and bite-sized diet. IV. Resident #84 A. Resident status Resident #84, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included neurocognitive disorder with [NAME] bodies and dysphagia. The 1/1/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 11 out of 15. The resident was dependent on staff for most activities of daily living (ADL). The MDS assessment indicated the resident did not have signs and symptoms of a swallowing disorder and required a mechanically altered diet. B. Observations On 2/16/26 at 12:30 p.m Resident #84 was served chopped broccoli that did not meet the level five soft and bite sized IDDSI size recommendation of 1.5 cm by 1.5 cm. On 2/17/26 at 12:27 p.m. Resident #84 was served regular size noodles. C. Resident interview Resident #84 was interviewed on 2/16/26 at 1:48 p.m. He said he did not remember what he had for lunch. He said thickened apple juice was in his cup and he did not like it. He said he liked fruit punch, but did not get it. He said he would drink his protein drink if he can reach it. An unidentified CNA entered the room, opened a protein drink that was sitting on the table and offered it to the resident. -The unidentified CNA did not thicken the protein drink. D. Record review The February 2026 CPO revealed the following physician's order: Regular diet, soft and bite-sized texture, mildly thick liquids, ordered on 7/28/25. Resident #62's nutrition care plan, revised 7/29/25, revealed Resident #84 had difficulty chewing due to partial upper and lower dentures. Pertinent interventions included providing Resident #84 his diet, supplements and offering the diet as ordered. V. Resident #53 A. Resident status Resident #53, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included weakness on the right dominant side and dysphagia. The 1/1/26MDS assessment revealed the resident was cognitively impaired and a BIMS score was not conducted. The resident was dependent on staff for most activities of daily living (ADL). The MDS assessment indicated the resident did not have signs and symptoms of a swallowing disorder and required a mechanically altered diet. The resident was receiving hospice services. B. Observations On 2/16/26 at 11:23 a.m. resident in bed on his left side, facing the wall, unopened chocolate protein drink observed on the table away from bed. At 1:55 p.m. Resident #53 was served chopped broccoli that did not meet the level five soft and bite sized IDDSI size recommendation of 1.5 cm by 1.5 cm. C. Record review The February 2026 CPO revealed the following physician's order: Regular diet, level five minced and moist texture, mildly thick liquids, ordered on 4/23/25. Resident #53's nutrition care plan, revised 2/17/26, revealed Resident #53 was at risk for malnutrition due to a history of stroke and liver disorder. Pertinent interventions included providing Resident #53 his diet, supplements and offering diet as ordered. D. Staff interviews CNA #5 was interviewed on 2/17/26 3:50 p.m. She said Resident #84 was on a soft and bite size diet, and nectar thick liquids. She said all drinks are mixed for him by CNAs. She said she used two packages of thickener per one paper cup of liquid. She said they also had a thickener that was premade. She pointed to the thickened liquid on the hydration cart, the label read honey consistency. CNA #5 said Resident #53 was also on a soft and bite size diet. She said the minced and moist diet was almost the same but meant for residents who did not have teeth. She said the minced and moist was softer and had smaller pieces. She said all protein drinks should be thickened before given to both residents. CNA #3 was interviewed on 2/17/26 at 4:15 p.m. She said Resident #53 was on a moist and minced diet and thickened liquids. She said a protein drink was given to him once, yesterday (2/16/26) in case he wanted anything besides the meal. She said Resident #53 did not eat or drink anything that was offered for lunch on 2/26/26. The RD was interviewed on 2/19/26 at 11:30 p.m She said protein drinks should be served chilled to ensure thickened consistency. - However, the manufacturer's recommendation from the protein company indicated that none of their products meet the criteria for mildly thick liquids. Registered nurse (RN) #3 was interviewed on 2/9/26 at 1:30 p.m. She said Resident #84 was on a soft and bite size diet and thickened liquids. She said protein drink was not thickened, but should be given to the resident chilled as it has thickened consistency when chilled. She said all protein drinks were stored in the refrigerator. VI. Additional observations and interviews During continuous observation on 2/17/26, beginning at 11:35 a.m. and ending at 12:45 p.m., the following was observed during the meal service in the main kitchen: The posted menu indicated residents on a regular diet would receive noodles with meatballs and gravy, cooked spinach which was substituted for cooked broccoli, and a roll. The menu indicated hot dogs were available as an alternative. -At 11:35 a.m. through 12:45 p.m. cook (CK) #2 plated the food, dietary aide (DA) #1 wrapped the plates and DA #2 was placing the plates in the carts. -CK #2 served residents who were prescribed level six soft and bite sized, regular sized noodles. -There were two food bins for the noodles, one bin contained regular noodles and one bin contained noodles for the level five minced and moist diet. There was not a bin for chopped noodles to meet the level five soft and bite sized IDDSI size recommendation of 1.5 cm by 1.5 cm. -There were two bins for the cooked spinach. One bin contained regular cooked spinach and the other bin contained the pureed spinach. There was not a bin for chopped spinach to meet the level five soft and bite sized IDDSI recommended size 1.5 cm by 1.5 cm. CK #2 said there was a substitution for the vegetable and he did not have the extension for the spinach. -CK #2 had cut up a hot dog for a level six soft and bite sized diet, however; after plating there were several pieces that were not the recommended size of 1.5 cm x 1.5 cm on the plate. Upon prompting the plate was removed from service and the hot dog was cut up into smaller pieces. VII. Additional staff interviews DA #2 was interviewed on 2/18/26 at 9:00 a.m. She said she has not had the IDDSI training at this facility but was aware of different diet texture sizes from previous jobs. She said it was her job to double check the meal matched the diet ticket before placing them in the cart. CK #2 and DA #1 were interviewed together on 2/18/26 at approximately 10 a.m. DA #1 said she had not had any formal training on the IDDSI textures. She said her job was to wrap the plates with plastic wrap before they went into the cart and she checked that the meal matched the diet ticket. CK #2 said he had some texture training but mostly was learning from the other cooks on what to serve for the mechanically altered diets. The RD was interviewed on 2/19/26 at 9:33 a.m. She said she and the speech language pathologist (SLP) provided training on the IDDSI diet in the past, but was not sure if everyone had gone through the training. The RD said diet extensions provided the cook a resource to know what foods to plate for the different diets and textures and if there was a change to the menu the dietary manager (DM) was responsible to provide education to the servers on the extensions. The RD said there were checks in place during the meal service to ensure the meal matched the ticket. She said the cook was the first check as they plated the food, then the DA who wrapped the plate in plastic wrap was to ensure the meal matched the meal ticket and there was a third DA who was to check the plates against the meal ticket before placing the meals in the carts for delivery. The RD said all kitchen staff should be trained on diet and mechanically altered textures to avoid wrong diets/textures going to the residents. The RD said for the meal with noodles, meatballs and cooked spinach, she expected the noodles, and spinach to be chopped up. She said the meatballs and hot dogs should have been cut up for the soft and bite-sized diet to the level six soft and bite-sized size. The DM was interviewed on 2/19/26 at 10:00 a.m. The DM said meat, such as the meatballs and the hot dogs, should have been cut up to the correct size for the soft and bite-sized texture. The DM said since she started three weeks ago, she had trained the cooks on the IDDSI diets and planned on the rest of the dietary staff to go through the training. She has three scheduled training opportunities for all staff regarding the IDDSI diets. The DM said to ensure residents receive their correct diet and textures there were three people who check the plates before it goes to the floor, the cook who plated the food, the DA who wrapped the plates and another DA who puts the plate in the cart to be delivered.

Based on observations, record review, and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease.Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene while assisting residents with eating; and,-Don (put on) appropriate personal protective equipment (PPE) when entering Resident #1's room, who was on transmission-based precautions; and,-Ensure housekeeping staff followed appropriate infection control guidelines when cleaning residents' rooms. Findings include: I. Failed to ensure staff performed appropriate hand hygiene while assisting residents with eating A. Professional reference According to The Centers for Disease Control and Prevention's (CDC) Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 2/23/26 from https://www/cdc.gov/cleanhands/hcp/clinical-safety/index.html, Hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of germs, including those resistant to antibiotics. Clean your hands immediately before touching a patient and after touching a patient or the patient's surroundings. B. Facility policy and procedure The Hand Hygiene policy and procedure, dated 2025, was provided by the nursing home administrator (NHA) on 2/19/26 at 12:21 p.m. It read in pertinent part, Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hand hygiene will be performed between resident contacts and after assistance with personal body functions. C. Observations On 2/16/26 at 12:16 p.m. certified nurse aide (CNA) #2 was sitting in the dining room at a table assisting two unidentified dependent residents with eating. CNA #2 was alternating offering each resident a bite of food. -CNA #2 did not perform hand hygiene between assisting the two residents. On 2/17/26 at 12:13 p.m. CNA #2 was sitting at a dining table assisting an unidentified dependent resident with eating. CNA #2 stood up to help another unidentified resident unwrap her silverware, then continued assisting the first resident with eating. -CNA #2 did not perform hand hygiene before or after assisting the other resident with her silverware or before returning to assist the first resident with eating. At 12:17 p.m. CNA #2 was sitting in the dining room at a table assisting two unidentified dependent residents with eating. CNA #2 was alternating offering each resident a bite of food. -CNA #2 did not perform hand hygiene between assisting the two residents. At 12:25 p.m. CNA #2 wiped one unidentified resident's mouth with a napkin before returning to assist a different resident with eating. -CNA #2 did not perform hand hygiene between assisting the residents. D. Staff interviews The infection preventionist (IP) was interviewed on 2/19/26 at 12:21 p.m. The IP said the nursing staff should perform hand hygiene before entering the dining room, between each resident when passing out meal trays, and after the meal service was finished. The IP said staff members should perform hand hygiene after assisting each resident prior to moving to assisting the next resident. II. Failed to don appropriate PPE when entering Resident #1's the room, who was on transmission-based precautions A. Observations On 2/17/26 at 11:40 p.m. the sign on Resident #1's door read Contact precautions, everyone must wear gloves and gown before entering the room. -At 11:41 a.m. CNA #4 entered the resident's room without putting on a gown or gloves. -At 11:42 a.m. registered nurse (RN) #1 entered Resident #1's room without putting PPE on. RN #1 was holding a large syringe containing a red liquid. At 11:45 a.m. CNA #4 exited Resident #1's room, sanitized her hands, and left the area. -At 11:47 a.m. CNA #4 returned to the resident's room with extra linens and entered the room. CNA #4 again did not put on a gown or gloves before entering the room. B. Staff interviews RN #1 was interviewed on 2/17/26 at 1:05 p.m. RN #1 said Resident #1 was on enhanced barrier precautions (EBP)but she did not know why. She then said the resident was on contact isolation precautions and she did not know why. She said in both cases, whether the resident was on EBP or contact isolation precautions, a gown and gloves should be worn in the resident's room. RN #1 said she had a busy day and she did not read the sign on the resident's door which instructed staff to wear gloves and a gown before entering the room (see above). CNA #4 was interviewed on 2/17/26 at 1:10 p.m. CNA #4 said she put a gown and gloves on in the room, not outside because the resident was on contact precautions. She said the unit manager who was assigned to the resident's room changed the sign several times and it was confusing what precautions the resident was on. Licensed practical nurse (LPN) #7 was interviewed on 2/18/26 at 2:03 p.m. LPN #7 said she was a unit manager assigned to Resident #1's room. She said the resident was on contact precautions for multi-drug resistant organisms (MDROs) in the urine. She said the resident was on enhanced barrier precautions as well because she had indwelling devices such as a midline catheter and a gastrostomy tube. LPN #7 said both precautions required the same PPE of a gown and gloves. The IP was interviewed on 2/19/26 12:43 p.m. The IP said staff should have followed the precautions sign on Resident #1's door. She said the resident was on droplet and contact precautions on Monday (2/16/26), later she was only on the contact precautions and currently was only on enhanced barrier precautions. She said for droplet precautions, a mask must be worn and for contact precautions, a gown and gloves should be put on before entering the room. The IP said she was responsible for placing signs on the residents' doors for precautions and she provided education to staff when isolation precautions were initiated. However, she said at times, the task was delegated to the floor nurse when she was not available in the building. III. Failed to ensure housekeeping staff followed appropriate infection control guidelines when cleaning residents' rooms A. Professional reference According to the Lucasol One Step Hospital Grade Disinfectant manufacturer's guidelines, retrieved on 2/26/26 from https://lucasproducts.com/lucas-products-online-store/lucasol-one-step-hospital-grade-disinfectant-gallon/, Lucasol One Step Hospital Grade Concentrate Disinfectant has a 100% kill rate of bacteria, viruses, and fungus in 10 minutes. B. Observation On 2/18/26 at 10:05 a.m. housekeeper (HK) #1 was observed cleaning resident room [ROOM NUMBER]. She sanitized her hands and donned gloves, then grabbed a clean cleaning rag. She sprayed One Step Hospital Grade Disinfectant on the outer door knob and the entrance door, then immediately dried both areas sprayed with the cleaning rag. -HK #1 did not wait for the dwell time of 10 minutes before wiping off the disinfectant spray (see professional reference above). HK #1 proceeded to spray the sink with the same disinfectant and then immediately wiped the sink with the same cleaning rag. -HK #1 did not wait for the dwell time of 10 minutes before wiping off the disinfectant spray HK #1 retrieved a new cleaning rag, dropped it on the floor, picked it up and proceeded to clean the mirror. -HK #1 failed to obtain a new cleaning rag after dropping the initial cleaning rag on the floor prior to cleaning the mirror. HK #1 proceeded to spray the toilet bowl with the same disinfectant she had been using. She next used a toilet brush to clean the inside of the toilet bowl, the rim of the toilet, and then the bottom of the toilet seat lid. -HK #1 failed to clean the toilet from the cleanest area to the dirtiest area (the inside of the toilet bowl). HK #1 proceeded to sweep and mop the floor and then exited room [ROOM NUMBER]. C. Staff interviews HK #1 was interviewed on 2/18/26 at 10:20 a.m. HK #1 said she should have gotten a new cleaning rag when she dropped her other cleaning rag on the floor. She said she should have cleaned the outer bowl of the toilet and then the inner bowl of the toilet with the toilet brush. She should have disinfected all the doorknobs and handrails. The IP was interviewed on 2/19/26 at 12:20 p.m. The IP said HK #1 should clean areas from cleaner to dirtier surfaces. She said that there was a risk of greater contamination of surfaces when the process was not followed, which could cause illness. The corporate maintenance director was interviewed on 2/19/26 at 1:15 p.m. The corporate maintenance director said HK #1 should have waited for the appropriate dwell time when using the One Step Hospital Grade Disinfectant. The corporate maintenance director said HK #1 should have cleaned the toilet from the cleaner surface to the dirtier surface. The corporate maintenance director said the housekeeping supervisor would do education with HK #1.

Based on observations, record review and interviews, the facility failed to ensure an environment free of accident hazards for one (#1) of one resident reviewed for accidents/hazards out of 10 sample residents. Resident #1, who was at risk for elopement, required 15-minute safety checks due to inappropriate behaviors with staff and residents unrelated to his elopement risk. The staff on the fourth floor where Resident #1 resided were to observe Resident #1 and document his behaviors with the 15-minute safety checks. -However, the two certified nurse aides (CNA) and one licensed practical nurse (LPN) on duty the night of 4/11/25 failed to perform Resident #1's 15-minute safety checks per facility protocol (see nursing home administrator's (NHA) interview below). On 4/11/25 at approximately 8:14 p.m. Resident #1 rode an elevator in the facility from the fourth floor down to the first floor, walked to the front door, opened the front door, which set off an alarm, and left the facility. A staff member heard the alarm and looked out a window, however, the staff member failed to go outside and search for anyone. When the staff member did not see anyone outside, the door was relocked and the alarm was reset. At approximately 4:00 a.m. on 4/12/25 (almost eight hours after the resident left the facility through the front door, setting off the alarm) a CNA noticed Resident #1 was gone around 4:00 a.m. on 4/12/25, notified the LPN and the staff began a search for the resident. However, staff failed to notify the NHA about the missing resident until 6:13 a.m., over two hours after the staff initially noticed the resident was missing. The local police department was notified to help with the search. The police found Resident #1 at approximately 8:15 a.m., 12 hours after he left the facility. Resident #1 was sitting on a curb in a neighborhood, was confused and was unable to tell the police what had happened during the previous 12 hours. The police took Resident #1 to the local hospital where he was evaluated, determined to have no injuries and sent back to the facility. Resident #1 was immediately placed in the facility's secure unit for safety upon his return to the facility. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation from 5/7/25 to 5/13/25, resulting in the deficiency being cited as past noncompliance with a correction date of 4/12/25. I. Situation of serious harm The facility failed to respond to an alarm on 4/11/25 at approximately 8:15 p.m. when Resident #1 opened the front door on the first floor and left the facility. A staff member did not investigate when he heard the front door alarm. The staff member looked out a window, and when the staff member did not see anyone, the door was relocked and the alarm was reset. Additionally, the facility failed to conduct 15-minute safety checks on Resident #1 on 4/11/25, which resulted in the facility not identifying the resident was missing until 4:00 a.m. on 4/12/25. Resident #1 was wandering in the community for approximately 12 hours before the police found him sitting on a curb in a neighborhood at approximately 8:15 a.m. on 4/12/25. The facility's failure to ensure staff conducted 15-minute safety checks on Resident #1 and responded to a door alarm appropriately created a situation for the likelihood of serious harm. II. Facility plan of correction The corrective action plan implemented by the facility in response to Resident #1's elopement on 4/11/25 was provided by the NHA on 5/5/25 at 10:00 a.m. It revealed the following: A. Immediate action to correct the deficient practice for Resident #1 On 4/12/25 at 8:00 a.m. the facility conducted an investigation into the elopement of Resident #1. The facility interviewed all staff who were on duty, which included those who were responsible for the resident's direct care. The surveillance videos were reviewed to determine when the resident left through the front door, what happened with the staff member who did not go outside to investigate when the alarm went off and what the staff on the fourth floor had done from 8:00 p.m. on 4/11/25 until 6:00 a.m. on 4/12/25. Inspection of the door alarms determined the front door alarm had functioned properly. Resident #1 was taken to a local hospital by the police for a wellness check. The physician at the hospital documented the resident had no noted injury and was cleared to return to the facility. The facility managers, the medical director of the facility, and the representative for Resident #1 determined the resident needed to be placed in a secured unit. Placement was immediate upon the resident's arrival back to the facility from the hospital on 4/12/25. B. The facility identified deficient practice 1. The facility had been having difficulty with the door alarms going off randomly due to the wind. A company came out in March 2025 and assessed and repaired all doors leading to the exterior. Staff did not search the parking lot when the door alarm sounded on 4/11/25 around 8:00 p.m. Staff assumed that the alarm sounded due to another reason (see CNA #2's interview below). 2. Resident #1 had a history of exit seeking and had a care plan for the behavior. The resident was not placed on one-to-one supervision or placed in a secure unit with increased exit seeking behavior in the last month. The resident was already on 15-minute checks for behavior. However, the documentation on the 15-minute checks did not appear accurate. 3. Staff did not follow block assignments (caring for residents together as a team without a specific CNA being assigned to a specific group of residents). 4. Staff had a lack of education on the elopement/missing person policy, exit seeking behavior interventions and timely reporting of a missing person to the NHA. C. Immediate actions The NHA and the director of nursing (DON) were educated on appropriate interventions for residents with exit seeking behavior by the RDCS (regional director of clinical services) on 4/12/25. The IDT (interdisciplinary team) was educated by the NHA and the DON on 4/14/25 on appropriate interventions related to exit seeking behavior. The IDT reviewed and updated, if indicated, all residents for elopement risk and community risk assessment, completed on 4/15/25. The IDT reviewed the progress notes for the last 90 days for elopement attempts for residents determined to be at risk of elopement who were not in a secured unit. The IDT reviewed and updated the care plans for residents at risk of elopement, completed 4/16/25. The IDT reviewed all residents on 15-minute checks for any reason. Seven residents were identified. Progress notes and care plans for the last 90 days were reviewed for any unidentified concerns related to the reason they were on 15-minute checks or exit seeking, and care plans were updated as indicated, completed 4/15/25. Staff were educated on who was on 15-minute checks or one-to-one supervision and a list of those identified residents was placed in the residents' electronic medical records (EMR). The IDT updated the elopement binder, completed on 4/13/24 with a list of all residents at risk for elopement, their face sheets and a photo, if allowed. The binder is located at the front desk and lists are located in the communications tab in the EMRs. All facility doors were assessed and tested by the NHA on 4/12/25 for proper alarm function. On 4/12/25 the NHA added a camera and an extra noise chime to the first floor front door. On 4/12/25 staff on all shifts received education from the DON/designee on the process a missing person/elopement, timely notification of the nurse on call or NHA, process for 15-minute checks, door alarm response process, elopement and exit seeking behaviors and interventions and specific block assignments. Any staff, not on duty or on leave, will receive education on their next scheduled workday. Agency staff will be educated before the start of their shift. On 4/14/25 the regional director of maintenance assessed and tested all doors leading to the exterior for proper function and proper alarming. On 4/15/25 the staff will be educated on reporting to the NHA/DON residents who attempt to leave the facility. D. Actions to prevent occurrence/recurrence An elopement risk assessment will be completed on admission, change of condition, and quarterly by the IDT team. Residents determined at risk by the IDT will have a care plan in place to prevent elopement. The DON or designee will audit potential new admissions for elopement risk, determine if the facility can meet the resident's needs, and ensure a care plan with appropriate interventions is in place if appropriate. New staff hires will receive education on a missing person/elopement, timely notification of the nurse on call or NHA, process for 15-minute checks, door alarm response process, elopement and exit seeking behaviors and interventions, and specific block assignments, initiated 4/12/25. The NHA or designee will ensure the elopements binder is kept up-to-date with any new resident or change in resident elopement assessment. The NHA/designee will conduct monthly elopement drills with a designated missing resident and assess for timely staff reporting and response. The drills will be documented in a summary and include staff signatures. The drills will continue for six) months and thereafter as determined by the QAPI (quality assurance and performance improvement) committee. The NHA/designee will conduct weekly facility alarm drills, setting off the door alarms to assess for timely staff reporting and response. The drills will be documented in a summary and include staff signatures. The drills will continue for three months and thereafter, as determined by the QAPI committee. The DON/designee will audit all 15-minute check logs daily for three months, and weekly thereafter until determined by the QAPI committee there is substantial compliance that the logs are complete and signed by a licensed nurse. The audit will be documented on an audit tool. The DON/designee will conduct three random spot checks daily for three months, and weekly thereafter until determined by the QAPI committee there is substantial compliance to ensure the 15-minute check tool is accurate and matches the resident location/behavior. The DON audit will be documented on an audit tool. The unit managers will audit the progress notes five times per week for documented elopement attempts. The audit will be documented on an audit tool. Starting 4/15/25, the licensed nurses will sign off each shift on the 15-minute checks to ensure they are complete. Starting 4/l6/25, the licensed nurses on duty each shift will assign each CNA a block assignment of residents for the shift. The UM (unit manager) will spot check five times per week to ensure block assignments are in place and followed. The maintenance director (MTD) will conduct daily door alarm checks for proper function for one month, and weekly thereafter or as determined by the QAPI committee. The audits will be documented on an audit tool. A QAPI Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA (quality assessment and assurance) meeting for a minimum of three months or until the pattern of compliance is maintained. III. Facility policy and procedure The Elopements and Wandering Residents policy, undated, was provided by the NHA on 5/7/25 at 10:15 a.m. via email. It read in pertinent part, 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. Elopement occurs when a resident leaves the premises or a safe area without authorization ( an order for discharge or leave of absence) and/or any necessary supervision to do so. The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. Adequate supervision will be provided to help prevent accidents or elopements. Charge nurses and unit managers will monitor the implementation of interventions, response(s) to interventions, and document accordingly. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol. The designated facility staff will look for the resident. If the resident is not located in the building or on the grounds, the administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. IV. Resident #1 A. Resident status Resident #1, age 72, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), pre-diabetes, kidney disease, frontal temporal neuro cognitive disorder (a type of dementia, affecting the frontal and temporal lobes of the brain, responsible for behavior, personality, and language), gastro-esophageal reflux disease (GERD), muscle weakness and depressive episodes. The 1/29/25 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident did not reject care from staff. The resident was independent with eating, toileting, showering, and personal hygiene. The resident did not need any mobility devices to ambulate. The MDS assessment indicated the resident had not exhibited wandering behaviors and it was somewhat important for the resident to go outside when the weather was good. B. Resident representative's interview Resident #1's representative was interviewed on 5/7/25 at 3:27 p.m. via the phone. The representative said Resident #1 had a unique kind of dementia and required a lot of monitoring. The representative said she did not understand how the facility could not know the resident was missing for 12 hours. She said the family's biggest fear was that something could have happened to him. The representative said when the police found Resident #1, he was blocks away from the facility, sitting on a curb and he thought he was changing a tire on a truck. C. Record review Resident #1's elopement/exit seeking/wandering care plan, initiated 3/10/25 revealed the resident was at risk for elopement related to dementia and other cognitive impairment. Resident #1 had a history of attempting to exit doors by pushing on them until they opened. The goal was for Resident #1 to not wander out of the facility. Interventions included providing the resident with redirection as needed (initiated 3/10/25), placing the resident on the secure unit (initiated 4/14/25), following the facility protocol if a wandering or elopement attempt occurred (initiated 4/15/25) and placing a photo of the resident in the elopement binder (initiated 4/15/25). The 1/28/25 wander elopement risk assessment revealed Resident #1 scored a 10 which indicated he was an elopement risk. The resident also had no elopement attempts. The 4/12/25 wander elopement risk assessment, conducted after Resident #1 eloped from the facility, revealed the resident scored a 22 and was deemed an elopement risk. The 3/1/25 nursing progress note revealed Resident #1 was on 15-minute checks for inappropriate behaviors with staff and other residents. The 3/7/25 nursing progress note revealed the resident continued to be on 15-minute checks for inappropriate sexual behaviors. The 3/6/25 community safety awareness evaluation revealed Resident #1 was severely impaired to make decisions. The resident was a potential risk due to dementia, loss of direction, fall, and generalized weakness. It was not safe for the resident to leave the facility out on pass. -Review of Resident #1's 15-minute check logs from 8:00 p.m. on 4/11/25 until 1:45 a.m. on 4/12/25 revealed a CNA documented the resident was present in the facility, however, the facility's video surveillance revealed the CNA did not check on the resident during that time (see NHA interview below). -There was no documentation that 15-minute checks were completed after 1:45 a.m. on 4/12/25. On 4/12/25 the evaluation for the secured unit placement documented the resident needed a secured unit due to habitual wandering or would wander out of their environment and was unable to find their way back. It was signed by the team members required for secured placement and included the resident representative's signature. V. Staff interviews The NHA was interviewed on 5/8/25 at 10:00 a.m. The NHA said on 4/12/25, he and the DON, LPN #2 and several others from the management team came in to investigate Resident #1's elopement and determine how it happened. The NHA said he immediately checked all of the doors and their alarms. The NHA said all of the alarms were working properly, which was why he did not call the maintenance director to come in and fix anything. The NHA said he viewed the facility's surveillance cameras during his investigation and conducted staff interviews. The NHA said Resident #1 was observed going out the front door at approximately 8:14 p.m. on 4/11/25. The NHA said all staff should round on all residents every two hours for care, but the staff on the fourth floor did not round on residents as they were supposed to do on 4/11/25. The NHA said Resident #1 was to be observed every 15 minutes and have his behaviors documented. The NHA said a CNA on the fourth floor documented on the 15-minute documentation sheet that Resident #1 was observed as ordered. The NHA said the video surveillance revealed the CNA never checked on Resident #1 on 4/11/25. The NHA said one CNA from the fourth floor left the facility in her car around 2:30 a.m. on 4/12/25 and abandoned her shift. The NHA said the two CNAs and the one LPN who were on duty the night of 4/11/25 no longer worked at the facility due to disciplinary actions which stemmed from the 4/11/25 incident. The NHA said the fourth floor LPN was notified around 4:00 a.m that Resident #1 was missing. He said had the LPN notified all of the staff, the entire facility staff could have looked everywhere for the resident in 10 minutes and not the two hours it took to call him. The NHA said LPN #2 was the one who called the NHA and the police. The NHA said all staff on 4/12/25 were educated on proper procedures for elopement which included, elopement and wandering policies, two hour rounding on residents and what to do with block assignments (requirements for each area), 15-minute checks and documentation, door alarms and the procedures should an alarm go off and notifying the NHA of a missing person. The NHA said all staff in all departments were notified that no one was allowed to work their shift until all training was completed. The NHA said alternating members of the management team stayed each day for all shifts, and trained all staff who entered the building. The NHA said the facility used a phone notification system for all staff to receive the emergent training message. The NHA said all staff that were on vacation were also notified and the last staff member who was on vacation received their training by 4/18/25. The NHA said agency staffing companies were notified that all staff must review the agency staffing book of all procedures pertinent to the investigation, prior to their designated shift, and sign that they read the material. The NHA provided copies of all of the training, along with signatures of the staff, and audits done that began on 4/12/25. CNA #2 was interviewed on 5/12/25 at 10:52 a.m. CNA #2 said he was working on the first floor on 4/11/25 when he heard the doorbell and the alarm sound at the front door. He said when he came to the front door the alarm was going off but no one was at the door. He said he looked out the large window and decided no one was outside. He said he did not leave the building to search the parking lot or nearby areas for a resident. He said he did not tell anyone about the incident. He said he thought someone rang the doorbell and probably grabbed the door to open it which set off the alarm. He said he made sure the door was closed and the alarm was reset. He said since the incident, he had received a lot of training so that the incident did not happen again. He said the facility put up an extra camera on 4/12/25 that pointed towards the front door. He said the new camera was connected to a camera on the first floor so that the front door could be monitored more closely. He said the camera on the first floor was to be with the nurse either at the nurses station or on the medication cart. He said the new monitor had an added alarm in it that sounded if the front door was opened. The NHA and the DON were interviewed together on 5/12/25 at 11:55 a.m. The DON said CNA #2 was educated about missing persons and searching the parking lot and surrounding areas after an alarm sounded. The NHA said all new staff received all of the updated training before they began to work in the facility. The NHA said he believed the facility had completed a thorough investigation and ensured that all staff were properly educated, beginning on 4/12/25. The NHA said all residents were reviewed for safety interventions, and proper monitoring procedures were in place so that the situation that occurred on 4/11/25 did not occur again.

Based on record review and interviews, the facility failed to ensure two (#2 and #3) of four residents were free from abuse out of 10 sample residents. Specifically, the facility failed to ensure Resident #2 and Resident #3 were free from physical abuse by each other. On 4/16/25 Resident #2 attempted to strike Resident #3. Resident #3 responded by grabbing Resident #2. Both residents fell to the ground. Resident #3 sustained a left humerus (shoulder) fracture. Resident #2 sustained bruising to his arm and an abrasion to his back. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, 2024, was provided by the nursing home administrator (NHA) on 5/7/25 at 10:15 a.m. via email. It read in pertinent part, 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. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Serious bodily injury means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. II. Physical abuse between Resident #2 and Resident #3 on 4/16/25 A. Facility investigation The 4/16/25 facility investigation was provided by the NHA on 5/12/25 at 9:15 a.m. The investigation documented Resident #2 and Resident #3 resided on a secured unit. Resident #2 had severe cognitive impairment, impaired communication ability and weighed 150.6 pounds. Resident #3 was cognitively intact and had delusions and hallucinations in regards to self and others. Resident #3 weighed 268.2 pounds, which was over a 100 pound difference between the two residents. The investigation documented that on 4/16/25 at approximately 4:00 a.m., Resident #3 was sitting in a recliner in the dining room. Resident #2 entered the dining room with clothing from his room and placed his clothing on the tables. Resident #3 asked Resident #2 what he was doing. Resident #2 responded with something inaudible on the video surveillance, while he pointed his finger at Resident #3. Resident #3 got up out of his recliner and moved toward Resident #2. Resident #2 swung at Resident #3 but missed contact. Resident #3 said to protect himself before he put his arms around Resident #2, both men grappled and both fell to the ground. The nurse who was seated at a nurses station and was not in view of the dining room heard noise that came from the dining room. Upon investigation, the nurse found both Resident #2 and Resident #3 on the ground. The nurse separated the residents. Resident #2 sustained a bruise to the posterior right arm and a linear abrasion to the mid-spine. Resident #3 sustained a non-displaced fracture to the left humerus. Both residents were placed on 15-minute checks. The investigation documented that it was determined by the medical director (MD) and a psychiatrist, that Resident #2 had a gradual dose reduction (GDR) of Zyprexa medication from 2.5 mg (milligrams), and the decision was made to stop the medication completely in December 2024. Resident #2 was reviewed in the psychopharmacological meetings and it appeared to be successful for several weeks until a few days before the altercation. The investigation documented on 4/14/25 licensed practical nurse (LPN) #2 requested Resident #2 be put back on Zyprexa 2.5 mg and the GDR be stopped. The physicians agreed, based on Resident #2's behavior tracking. The Zyprexa was re-ordered for Resident #2. According to the physician's interviews, Zyprexa 2.5 mg, an antipsychotic medication had not been able to take effect in the two days from 4/14/25 until the incident on 4/16/25. The investigation documented Resident #2 and Resident #3 had not had an altercation with each other prior to the incident. B. Resident #2 1. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included bipolar disorder (mental illness) and alcohol-induced persisting dementia. The 4/4/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. He was independent with eating, toileting, personal hygiene and walking. 2. Record review The 12/17/24 interdisciplinary team (IDT) psychotherapeutic review revealed Resident #2's Zyprexa 2.5 mg was discontinued that day (12/17/24). The cognitive impairment care plan, revised 1/9/25 revealed Resident #2 had cognitive impairments, exhibited cognitive loss related to alcohol-induced persisting dementia. He had short and long term memory loss, disorganized thinking, difficulty with word finding at times and was only oriented to himself. Pertinent interventions included monitoring the resident for changes in cognitive status, notifying the physician if changes in cognitive status were noticed, providing cognitive therapy, administering medications as ordered and notifying the physician if the resident's behavior interfered with daily functioning. The 3/30/25 IDT psychotherapeutic review revealed Resident #2 was stable, with no change after the discontinuation of Zyprexa. The 4/14/25 nursing progress note, documented at 4:14 a.m., revealed Resident #2 had increased agitation, was difficult to redirect and continually paced from his room to the dining room. Another 4/14/25 nursing progress note, documented at 6:00 a.m., revealed Resident #2 again displayed increased agitation in the dining room, threw chairs and tipped a table. Another 4/14/25 nursing progress note, documented at 10:52 a.m. revealed the resident's agitation had increased The 4/14/25 behavioral progress note documented at 12:10 p.m., revealed Resident #2 voided in a trashcan in the dining room and when asked to stop he raised his voice and said no. Another 4/14/25 nursing progress note, documented at 2:10 p.m., revealed Resident #2 was more agitated than normal and he continued to pace the hallway. Another 4/15/25 nursing progress note, documented at 1:04 p.m., revealed Resident #2 was being monitored for Zyprexa use. Review of the April 2025 CPO revealed the following physician's order: Zyprexa oral tablet 2.5 mg, give at bedtime for angry outbursts, throwing chairs, and verbal aggression related to bipolar disorder, ordered 4/14/25. The 4/16/25 room notice notification revealed Resident #2 was moved to a private room due to increased agitation and paranoia about his belongings. At night he moved his belongings to the dining room to protect his items. The 4/16/25 nursing progress note, documented at 7:04 a.m., revealed Resident #2 was involved in a physical altercation with another resident (Resident #3) and fell to the floor. The residents were separated and placed on 15-minute checks. Resident #2 was assessed and denied any pain. The 4/18/25 nursing progress note revealed a follow-up head to toe skin assessment was completed on Resident #2 due to a fall that occurred on 4/16/25. The resident had a bruise to the back of his right arm measuring 5 centimeters (cm) by 4 cm by 0 cm. No open areas were noted. The resident denied pain. An abrasion to the resident's mid-spine measured 3 cm by 1.5 cm by 0 cm. The physician was notified. C. Resident #3 1. Resident status Resident #3, age less than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included alcohol induced persisting dementia, anxiety disorder, hypertension (high blood pressure), seizures, alcohol abuse and gastro-esophageal reflux disease (GERD). The 3/7/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident had delusions, misconceptions or beliefs that were firmly held, contrary to reality. The resident was independent with eating, toileting and personal hygiene. 2. Resident interview Resident #3 was interviewed on 5/12/25 at 11:30 a.m. Resident #3 said he was in pain due to the incident with Resident #2 and he required surgery for his shoulder. 3. Record review The behavior care plan, initiated 9/5/24 and revised 5/5/25, revealed Resident #3 could demonstrate agitation towards other residents, often due to his delusions and potentially altered perception. The resident required assistance with his activities of daily living (ADLs) related to his alcohol-induced dementia, delusional disorder and anxiety. The care plan documented the goal was that the resident would not demonstrate aggression towards others. Interventions included the staff were to seek to divert the resident's attention elsewhere and the staff were to work to anticipate triggers. The 4/16/25 nursing progress note, documented at 6:30 a.m. revealed Resident #3 had an altercation with another resident (Resident #2) and fell to the floor. Resident #3 said I couldn't help it. He was placed on 15-minute checks, denied injury and refused a body assessment. Another 4/16/25 nursing progress note, documented at 8:14 a.m., revealed Resident #3 complained of pain in his shoulder and an Xray was ordered. Another 4/16/25 nursing progress note, documented at 4:23 p.m., revealed the Xray was positive for a fracture of Resident #3's left humeral head (shoulder). Physician's orders were received for a sling and a referral to an orthopedic surgeon was made. The 4/23/25 IDT progress note revealed Resident #3 was not the aggressor in the incident with Resident #2. -However, the facility investigation documented Resident #3 wrapped his arms around Resident #2 and both fell to the ground (see facility investigation above). The 4/23/25 pain assessment revealed Resident #3 had frequent and almost constant pain. The resident revealed his pain level was a 8 out of 10 on a pain scale of 1-10 recorded as the highest. VI. Staff interviews The psychiatrist was interviewed on 5/8/25 at 3:45 p.m. The psychiatrist said he had worked as Resident #2's psychiatrist when he lived in the community and continued to be involved with his care when he was admitted to the facility. He said because of Resident #2's alcohol use, he had dementia and needed the level of care provided in the facility. The psychiatrist said the resident continued with a small dose of Zyprexa (2.5 mg) after doing previous successful GDRs. The psychiatrist said the facility's IDT team, along with his involvement, decided to discontinue Zyprexa in December 2024. He said the Zyprexa was discontinued for a few months with success. He said in April 2025, Resident #2 started to show aggressive behavior, which was not normal for Resident #2. He said it was not just a bad day in April 2025 and it seemed his baseline was off. He said a few days before the altercation, he decided to put Resident #2 back on the Zyprexa. The psychiatrist said the Zyprexa was restarted two days before the aggressive behavior incident happened with Resident #3. The psychiatrist said two days prior to the incident was not long enough for the Zyprexa to take effect. The psychiatrist said Resident #2 was now doing well after the Zyprexa was restarted. The psychiatrist said the reason for the incident was due to Resident #2 and the GDR of Zyprexa. The psychiatrist said he had been Resident #3's psychiatrist for several years. The psychiatrist said Resident #3 was very delusional. The psychiatrist said Resident #3 was not agreeable to any medication changes. The psychiatrist said in his opinion, Resident #3 was not the reason for the altercation with Resident #2. The NHA was interviewed on 5/12/25 at 9:15 a.m. The NHA said he reviewed surveillance videos, along with resident and staff interviews for the investigation. LPN #2 was interviewed on 5/12/25 at 11:14 a.m. She said the day of the altercation (4/16/25) between Resident #2 and Resident #3, she was in her car in the parking lot at approximately 4:30 a.m. She said she received a phone call from the nurse who separated the residents. She said she immediately came into the building and went to the floor where the altercation occurred. She said she immediately called the NHA. She said she and the NHA watched the video surveillance cameras. She said the video surveillance revealed Resident #2 attempted to punch Resident #3 but the punch did not hit Resident #3. LPN #2 said Resident #3 then grabbed Resident #2 like a wrestler would do and Resident #3 put his arms around Resident #2 and both residents fell to the ground. She said she had worked with Resident #2 for a long time and there had never been an incident like the one that occurred. She said a few days prior, the nursing staff had called the physician to restart Resident #2's Zyprexa . LPN #2 said as the Zyprexa was restarted, the staff knew to observe and let Resident #2 pace down the hallway while his medication took effect. She said that was two days prior to the incident and the medication was likely to not have taken effect yet. She said Resident #2 sustained a bruise on his back and a small skin abrasion on his arm. She said Resident #2 was placed back on Zyprexa and he was no longer agitated like he was prior to the incident. LPN #2 said the surgeon had cancelled two appointments with Resident #3 due to the surgeon's schedule and an appointment was rescheduled again. She said the resident's family member wanted an appointment to be made with a specific surgeon. The director of nursing (DON) was interviewed on 5/12/25 at 11:55 a.m. She said Resident #2 had not had any physical violence prior to the incident on 4/16/25. The DON said in the March 2025 IDT psychopharmacological meeting, Resident #2's medications and behaviors were discussed. The DON said Resident #2 was reviewed in the psychopharmacological meeting in March 2025 to determine if the resident was tolerating not being on Zyprexa. The DON said the IDT team determined in the March 2025 meeting that they would continue with the discontinuation of the Zyprexa to determine if it was a successful GDR or not. The DON said in April 2025, after monitoring Resident #2's behaviors, LPN #2 spoke to the psychiatrist about Resident #2. The DON said it was determined by the psychiatrist to put Resident #2 back on the Zyprexa 2.5 mg. The DON said that was two days before the altercation with Resident #3, which was not enough time for the medication to work. The social services director (SSD) was interviewed on 5/12/25 at 1:00 p.m. The SSD said Resident #2 had not had any physical violence before the incident on 4/16/25. The SSD said Resident #2 and Resident #3 had not had any altercations with any other residents since the incident on 4/16/25. The facility's medical director (MD) was interviewed on 5/13/25 at 10:00 a.m. via the phone. The MD said the psychopharmacological IDT meetings at the facility had a lot of clinical professionals which included himself and a psychiatrist. The MD said he had permission from the psychiatrist to speak about the situation with Resident #2. The MD said the team discussed a low dose of Zyprexa. The MD said the team discussed that bipolar disorder was not the problem for the Zyprexa, but rather Resident #2's alcohol use. He said Resident #2 was documented to be in a good mood, and slept well. He said the team used shared decision making with the insight from the psychiatrist who had worked with Resident #2 in the community prior to his admission into the facility. The MD said the discontinued Zypreza GDR happened in December 2024. The MD said for several months Resident #2 seemed to do well without the medication, until in April 2025, the facility staff noted behavioral issues, and the Zyprexa medication was added back for Resident #2. The MD said it was added back two days prior to the incident with Resident #3 on 4/16/25, which was not enough time for the medication to take effect. The MD said the medication currently worked for Resident #2. The NHA was interviewed again on 5/13/25 at 11:50 a.m. The NHA said all staff were educated about resident-to-resident abuse after the incident on 4/16/25. The NHA said the staff were educated to visually watch the residents and when a resident went to the dining room, a staff member needed to watch the residents. The NHA said Resident #2's Zyprexa took effect and his behavior was back to his baseline. The NHA said a recliner was put in Resident #3's room with his approval. The NHA said on 5/13/25 (during the survey) he purchased and installed a camera to be put into the dining room on the second floor (where the incident between Resident #2 and Resident #3 occurred). The NHA said the camera would be connected to a monitor that the nursing staff could utilize as needed to observe residents in the dining room.

Based on record review and interviews, the facility failed to ensure one (#1) of five residents was kept free from abuse out of five sample residents. Specifically, the facility failed to ensure Resident #1 was kept free from sexual abuse by Resident #2. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, revised 2024, was provided by the nursing home administrator (NHA) on 2/4/25 at 12:33 p.m. It read in pertinent part, 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. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include staff to resident abuse and resident to resident altercations. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include, but are not limited to, responding immediately to protect the alleged victim and integrity of the investigation, examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, increased supervision of the alleged victim and residents, room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, protection from retaliation, providing emotional support and counseling to the resident during and after the investigation, as needed and revision of the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse. II. Incident of sexual abuse between Resident #1 and Resident #2 on 1/4/25 The 1/4/25 abuse investigation documented Resident #1 had wandered into Resident #2's room and fell asleep on Resident's #2's roommate's bed. When Resident #2 returned to his room, he laid down next to Resident #1 and touched her in a sexual manner. During the rounds, certified nurse aide (CNA) #1 found the residents and immediately separated them. Both residents were placed on 15-minute checks. Resident #2 was placed on one-to-one observations. Later the same day, Resident #2 was moved to a unit on the second floor where his one-to-one continued and he was around more alert and oriented residents. The facility investigation documented that the sexual abuse was substantiated. II. Resident #2 - assailant A. Resident status Resident #2, age greater than 75, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbance and cognitive communication deficit. The 12/13/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairments per staff assessment. He required minimal assistance with all activities of daily living (ADL), and ambulated with a walker. The assessment indicated the resident did not have physical or verbal behaviors towards other residents. B. Record review The behavioral care plan, revised on 1/7/25, documented Resident #2 had displayed sexually inappropriate behaviors and touched other residents. Interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness of medications, behavioral monitoring every shift, providing firm redirection and two-person care, providing one-to-one supervision for the resident every shift, notifying the unit manager or director of nursing (DON) and the NHA if Resident #2 was seen alone without one-to-one supervision and if any inappropriate behavior occurred and providing a program of activities of interest to the resident. III. Resident #1 - victim A. Resident status Resident #1, age 72, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included dementia with behavioral disturbance and major depressive disorder. The 12/2/24 MDS assessment revealed the resident had severe cognitive impairments per staff assessment. She required supervision and minimal assistance with ADLs. She ambulated without assistance. B. Record review The behavioral care plan, initiated on 12/30/24 and revised on 1/6/25, documented Resident #1 was at risk for behavioral symptoms such as getting in other resident's beds or biting once agitated due to dementia. Interventions included maintaining a calm and slow approach, observing and documenting changes in behavior, providing reminders and checking on the resident every 15 minutes. A 1/4/25 nursing progress note documented Resident #1 was sleeping in Resident #2's roommate's bed. Resident #2 was noted to have his hands in Resident #1's pants pocket and was touching her on her hip and thigh. The residents were immediately separated. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/3/25 at 10:40 a.m. LPN #1 said she was the nurse working on the unit with Resident #1. She said she was an agency nurse and did not know much about Resident #1. She said Resident #2 did not reside in the same unit. She said the unit did not have any residents with sexually inappropriate behaviors. CNA #2 was interviewed on 2/3/25 at 11:05 a.m. CNA #2 said Resident #1 liked to walk and she occasionally entered rooms of other residents where she would fall asleep. She said Resident #1 was not aggressive and easily redirectable. She said the staff checked on her every 15 minutes, however she was very quick and could be anywhere at any time. CNA #2 said Resident #2 no longer resided on the same unit as Resident #1. LPN #2 was interviewed on 2/3/25 at 4:30 pm. LPN #2 said she was the unit manager for the unit where Resident #1 currently resided. She said Resident #1 wandered around the unit and occasionally entered other residents' rooms. She said the staff checked on the resident every 15 minutes to ensure that she was not in someone else's room. LPN #2 said after the incident on 1/4/25, Resident #2 was moved to the second floor where he could be around more alert and oriented residents. She said in addition, Resident #2 was placed on one-to-one monitoring for sexually inappropriate behaviors. The NHA was interviewed on 2/3/25 at 4:50 p.m. The NHA said Resident #2 had a history of sexually inappropriate behaviors and was previously placed on one-to-one monitoring in the past. He said after being on one-to-one for several weeks, he did not display sexually inappropriate behaviors, his medications were adjusted and he was removed from one-to-one monitoring. The NHA said after the incident on 1/4/25, the interdisciplinary (IDT) team decided that one-to-one monitoring was necessary for Resident #2 and it was initiated for an indefinite period. He said, Resident #2 was moved to a different unit where he would be around more alert and oriented residents.

Based on observations, record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being for one (#1) of five residents out five sample residents. Specifically, the facility failed to develop and implement effective dementia management focused interventions to prevent Resident #1 from wandering into other resident's rooms. Findings include: I. Facility policy and procedure The Dementia Care policy and procedure, undated, was provided by the nursing home administrator (NHA) on 2/4/25 at 12:33 p.m. It read in pertinent part, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. II. Resident #1 A. Resident status Resident #1, age 72, was admitted on [DATE]. According to the February 2025 computerized physicians orders (CPO), diagnoses included dementia with behavioral disturbance and major depressive disorder. The 12/2/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments per staff interview. She required supervision and minimal assistance with activities of daily living (ADLs). She ambulated without assistance. B. Record review The behavioral care plan, initiated on 12/30/24 and revised on 1/6/25, documented Resident #1 was at risk for behavioral symptoms such as getting in other resident's beds or biting once agitated due to dementia. Interventions included maintaining a calm and slow approach, observing and document changes in behavior, providing reminders and checking on the resident every 15 minutes. A 1/4/25 nursing progress note documented Resident #1 was sleeping in Resident #2's roommate's bed. Resident #2 was noted to have his hands in her pants pocket and touching her on her hip and thigh. Resident #1 showed no fear or anxious behavior. Resident #1 appeared comfortable. The residents were immediately separated. Cross reference F600 failure to protect Resident #1 from sexual abuse. A 12/26/24 nursing note documented Resident #1 was lying down in the (other) resident bed. The resident tried to get Resident #1 out of her bed and Resident #1 bit her on her left forearm. Residents were separated. Resident #1 was placed on 15 min checks. -No person centered dementia interventions were provided to Resident #1. C. Observations On 2/3/25 at 10:30 a.m. observations on the first floor unit were conducted. Resident #1 was not in her room. The resident's room did not have any personal pictures, items or signs to help the resident identify her room. At 10:35 a.m. Resident #1 was located by certified nurse aide (CNA) #2. Resident was asleep in another resident's room. The room belonged to two gentlemen who were not in the room. Resident #1 was woken up and taken to her room by CNA #2. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/3/25 at 10:25 a.m. LPN #1 said she was an agency nurse and did not know much about Resident #1. She said she could look up the care plan in her medical record. She said she did not know what Resident #1 looked like or where she was at the moment. She said she would ask the CNAs, because they knew residents well. CNA #2 was interviewed on 2/3/25 at 10:30 a.m. She said Resident #1 was not in the common area and not in her room. She said the resident probably fell asleep in someone else's room (see observations above). CNA #2 was interviewed a second time on 2/3/25 at 11:05 a.m. She said Resident #1 liked to walk and she occasionally entered rooms of other residents where she would fall asleep. She said Resident #1 was not aggressive and easily redirectable. She said the staff checked on her every 15 minutes, however she was very quick and could be anywhere at any time. She said she was aware of one altercation that Resident #1 had with other residents that occurred on 1/4/25. LPN #2 was interviewed on 2/3/25 at 4:30 pm. LPN #2 said she was the unit manager for the unit where Resident #1 currently resided. She said Resident #1 wandered around the unit and occasionally entered other resident's rooms. She said the staff checked on the resident every 15 minutes to ensure that she was not in someone else's room. She said some rooms had a stop sign at the entrance to prevent wandering residents from wandering. The NHA was interviewed on 2/3/25 at 4:50 p.m. The NHA said Resident #1 was on 15 minute checks by staff. He said he was aware that Resident #1 was found in another resident's room earlier today (2/3/25). He said the interdisciplinary team would review the interventions to identify why they were not being effective and would consider additional one to ensure Resident #1 was sleeping in her personal room.

Based on record review and interviews, the facility failed to ensure two (#2 and #3) of five residents out of nine sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #2 was kept free from abuse by Resident #3. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, revised October 2024, was provided by the nursing home administrator (NHA) on 10/23/24 at 12:33 p.m. It read in pertinent part, 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. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include staff to resident abuse and resident to resident altercations. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to, responding immediately to protect the alleged victim and integrity of the investigation, examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, increased supervision of the alleged victim and residents, room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, protection from retaliation, providing emotional support and counseling to the resident during and after the investigation, as needed and revision of the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse. II. Incident of physical abuse between Resident #2 and Resident #3 on 3/21/24 A 3/21/24 nursing progress note documented Resident #2 informed the nurse that Resident #3 pushed him on the chest and knocked him backwards, causing him to fall and hit his head on the floor. Upon a nursing assessment, a hematoma (pool of clotted blood that forms in an organ, tissue, or body space caused by a broken blood vessel) was identified on the right side of Resident #2's head. The progress note further documented Resident #3 indicated that Resident #2 came into his room and punched him in the left eye. Resident #3 made a gesturing motion to indicate that he pushed Resident #2 which caused Resident #2 to fall to the floor. Resident #3 said he went boom and then pointed to the floor. The nurse assessment revealed a small 1 centimeter (cm) by 1 cm hematoma to Resident #3's left lower eye and an abrasion to his left cheek. The 3/21/24 situation, background and review (SBAR) assessment documented a change in condition to the appearance of Resident# 3 with the noted bruise to the left lower eye and an abrasion. The interventions included frequent checks every 15 minutes, neurological checks and to separate the residents. The 3/21/24 abuse investigation documented Resident #2 said Resident #3 pushed him on his chest, knocked him down on his back and made him hit his head on the ground. Upon assessment completed by the nurse, Resident #2 was noted to have a small hematoma to the right side of the head. Resident #3 said Resident #2 entered his room and hit him in the face, for which Resident #3 responded by pushing Resident #2 in the chest, causing him to fall to the ground. Upon assessment, Resident #3 sustained a bruise and abrasion to the right eye. -The facility documented that the physical abuse was unsubstantiated because there was not a witness to the altercation, however both Resident #2 and Resident #3 had corresponding injuries that were consistent with their story. III. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbance and cognitive communication deficit. The 3/21/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He was independent with all activities of daily living (ADL). B. Record review The behavioral care plan, revised on 10/22/24 (during the survey), documented Resident #2 had a behavior problem of sexually inappropriate behaviors and touching other residents. He sometimes thought other residents were his wife. Interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness of medications, behavioral monitoring every shift, providing firm redirection and two person care, one-to-one supervision for the resident every shift, notifying the unit manager or director of nursing (DON) and the NHA if Resident #2 was seen alone without one-to-one supervision and if any inappropriate behavior occurred and providing a program of activities of interest to the resident. IV. Resident #3 A. Resident status Resident #3, age 68, was admitted on [DATE]. According to the October 2024 CPO, diagnoses included dementia with moderate agitation, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 6/11/24 MDS assessment revealed the resident was moderately cognitive impairment with a BIMS score of four out of 15. He required extensive to moderate assistance with ADLs. B. Record review The behavioral care plan, initiated on 5/31/23 and revised on 11/29/23, documented Resident #3 had episodes of being physically combative and abusive when he felt other residents were too close to him or invading his space. Resident #3 had hit or pushed others to get them away from him. Interventions included documenting behavioral episodes, maintaining a calm, slow and understanding approach, monitoring and reporting an increase in behaviors, monitoring Resident #3 when other residents were in close proximity as necessary and removing other residents if needed and notifying the physician and responsible party of episodes of aggression and abusive behavior. V. Staff interviews The NHA and the regional clinical consultant (RCC) were interviewed on 10/23/24 at 11:17 a.m. The NHA said he was the abuse coordinator for the facility and was responsible for directing the investigation for any allegation of abuse. He said physical abuse occurred when there was actual physical contact made. The NHA said he directed the physical abuse investigation between Resident #2 and Resident #3 on 3/21/24. He said he thought that the conclusion of unsubstantiated had been reached because there was no staff witness of the event. The NHA said, upon review of the investigation and the physical assessments conducted at the time of the incident, both resident's sustained injuries that were consistent with their version of the event that occurred on 3/21/24. He said based on his review of the investigation that day (10/23/24), he should have substantiated that physical abuse had occurred between Resident #2 and Resident #3 on 3/21/24.

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for two (#2 and #8) of five residents reviewed for abuse out of nine sample residents. Specifically, the facility failed to report two incident of potential sexual abuse involving Resident #2 and Resident #8 to the State Agency. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Response policy and procedure, revised October 2024, was provided by the nursing home administrator (NHA) on 10/23/24 at 12:33 p.m. It revealed in pertinent part, Reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies ( law enforcement when applicable) within specified times frames is required for all types of abuse, neglect, misappropriation of resident property and exploitation (including injuries of unknown origin), and thoroughly investigated by facility administrator. Findings of investigations are documented and reported. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility. II. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbance and cognitive communication deficit. The 3/21/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He was independent with all activities of daily living (ADL). B. Record review The behavioral care plan, revised on 10/22/24 (during the survey), documented Resident #2 had a behavior problem of sexually inappropriate behaviors and touching other residents. He sometimes thought other residents were his wife. Interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness of medications, behavioral monitoring every shift, providing firm redirection and two person care, one-to-one supervision for the resident every shift, notifying the unit manager or director of nursing (DON) and the NHA if Resident #2 was seen alone without one-to-one supervision and if any inappropriate behavior occurred and providing a program of activities of interest to the resident. III. Resident #8 A. Resident status Resident #8, age less than 65, was admitted on [DATE]. According to the 9/3/24 CPO, diagnoses included bipolar disorder, dementia with psychotic disturbance, other symptoms and signs involving cognitive functions and awareness, unspecified psychosis not due to a substance or known physiological condition and unspecified convulsions The 9/18/24 MDS assessment revealed the resident had short and long-term memory deficits and her daily decision making skills were severely impaired based on the staff assessment for mental status. She was dependent on staff for all ADLs. B. Record Review The care plan, revised on 9/23/24, documented that Resident #8 had altered cognition related to dementia with psychotic disturbance, bipolar disorder and psychosis manifested by impaired short and long term memory, safety awareness and decision making. The resident had a communication deficit that indicated the inability for Resident #8 to make her needs known. IV. Incident involving Resident #8 on 9/14/24 The 9/14/24 nursing progress note documented that at approximately 5:37 p.m., Resident #2 had used his hands to hold Resident #8's hands. Resident #2 kissed Resident #8's hands and then sat down next to her for about 45 minutes. Resident #2 was later observed going into Resident #8's room to see her. -The facility was unable to provide documentation that the incident had been investigated for potential sexual abuse. Cross reference F610 for failure to investigate potential abuse. -The facility was unable to provide documentation that the incident of potential sexual abuse was reported to the State Agency. V. Incident involving Resident #8 on 9/17/24 The 9/17/24 nursing progress note documented the nurse observed Resident #2 holding and rubbing the hand of the Resident #8. The nurse tried to redirect Resident #2 a few times. Resident #2 got upset and stated she is my wife. A certified nurse aide (CNA) observed Resident #2 touching Resident #8's leg and Resident #2 refused to move away from Resident #8. Resident #2 was separated from Resident #8 and a CNA arranged the table so that Resident #2 would not be able to come near her. The nurse practitioner visited on 9/17/24 and was provided an update of the incident. -The facility was unable to provide documentation that the incident had been investigated for potential sexual abuse. -The facility was unable to provide documentation that the incident of potential sexual abuse was reported to the State Agency. VI. Staff interviews The NHA was interviewed on 10/22/24 at 2:03 p.m. The NHA said the incidents involving Resident #2 and Resident # 8 on 9/14/24 and 9/17/24 should have been reported by staff and to the State Agency. The regional clinical consultant (RCC) was interviewed on 10/23/24 at 9:35 a.m. The RCC said an additional action item had been added to the facility's recent performance improvement plan (PIP) on 10/22/24 (during the survey) following the identification of the two unreported incidents involving Resident #2 and Resident #8. The RCC said the interdisciplinary team (IDT) would be reviewing progress notes five times a week to ensure no unreported incidents of potential abuse were documented. The NHA and the RCC were interviewed together on 10/23/24 at 10:53 a.m. The RCC said, prior to the survey, the facility had realized that facility staff had an issue with the understanding of what constituted neglect, abuse or exploitation and what a thorough investigation process should look like, including interviewing and reporting. She said a PIP was initiated on 10/11/24. -However, according to the RCC's previous interview (see above), the facility had implemented a new action item to the PIP, during the survey. The NHA said there were two abuse allegations involving Resident #2 which were not reported timely. The NHA said the abuse allegations were reported to the State Agency on 10/22/24 (during the survey). The NHA said abuse should be reported/investigated and responded to within 24 hours unless serious injury occurred. He said if a serious injury occurred, potential abuse must be reported within two hours.

Based on record review, the facility failed to investigate incidents of abuse involving two (#2 and #8) of five residents reviewed for abuse out of nine sample residents. Specifically, the facility failed to conduct investigations of two incidents of potential sexual abuse involving Resident #2 and Resident #8. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, revised October 2024, was provided by the nursing home administrator (NHA) on 10/23/24 at 12:33 p.m. It revealed in pertinent part, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, including those that may represent resident to resident abuse, and reported to the administrator immediately. II. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbance and cognitive communication deficit. The 3/21/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He was independent with all activities of daily living (ADL). B. Record review The behavioral care plan, revised on 10/22/24 (during the survey), documented Resident #2 had a behavior problem of sexually inappropriate behaviors and touching other residents. He sometimes thought other residents were his wife. Interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness of medications, behavioral monitoring every shift, providing firm redirection and two person care, one-to-one supervision for the resident every shift, notifying the unit manager or director of nursing (DON) and the NHA if Resident #2 was seen alone without one-to-one supervision and if any inappropriate behavior occurred and providing a program of activities of interest to the resident. III. Resident #8 A. Resident status Resident #8, age less than 65, was admitted on [DATE]. According to the 9/3/24 CPO, diagnoses included bipolar disorder, dementia with psychotic disturbance, other symptoms and signs involving cognitive functions and awareness, unspecified psychosis not due to a substance or known physiological condition and unspecified convulsions. The 9/18/24 MDS assessment revealed the resident had short and long-term memory deficits and her daily decision making skills were severely impaired based on the staff assessment for mental status. She was dependent on staff for all ADLs. B. Record Review The care plan, revised on 9/23/24, documented that Resident #8 had altered cognition related to dementia with psychotic disturbance, bipolar disorder and psychosis manifested by impaired short and long term memory, safety awareness and decision making. The resident had a communication deficit that indicated the inability for Resident #8 to make her needs known. IV. Incident involving Resident #8 on 9/14/24 The 9/14/24 nurse progress note documented that at approximately 5:37 p.m. Resident #2 had used his hands to hold Resident #8's hands. Resident #2 kissed Resident #8's hands and then sat down next to her for about 45 minutes. Resident #2 was later observed going into Resident #8's room to see her. An investigation related to the incident on 9/14/24 was requested on 10/22/24, during the survey process. -The facility was unable to provide documentation that an investigation had been completed following the abuse incident with Resident #2 and Resident #8 on 9/14/24. V. Incident involving Resident #8 on 9/17/24 The 9/17/24 nurse progress note documented the nurse observed Resident #2 holding and rubbing the hand of the Resident #8. The nurse tried to redirect Resident #2 a few times. Resident #2 got upset and stated she is my wife. A certified nurse assistant (CNA) observed Resident #2 touching Resident #8's leg and Resident #2 refused to move away from Resident #8. Resident #2 was separated from Resident #8 and a CNA arranged the table so that Resident #2 would not be able to come near her. The nurse practitioner visited on 9/17/24 and was provided an update of the incident. An investigation related to the incident on 9/17/24 was requested on 10/22/24, during the survey process. -The facility was unable to provide documentation that an investigation had been completed following the incident between Resident #2 and Resident #8 on 9/17/24. VI. Staff interviews The NHA was interviewed on 10/22/24 at 2:03 p.m. The NHA said the incidents involving Resident #2 and Resident # 8 on 9/14/24 and 9/17/24 should have been investigated. The regional clinical consultant (RCC) was interviewed on 10/23/24 at 9:35 a.m. The RCC said an additional action item to the facility's recent performance improvement plan (PIP) on 10/22/24 (during the survey) following the identification of two unreported incidents involving Resident #2 and Resident #8. The RCC said the interdisciplinary team (IDT) would be reviewing progress notes five times a week to ensure no unreported incidents of potential abuse were documented. The NHA and regional clinical consultant (RCC) were interviewed on 10/23/24 at 10:53 a.m. The RCC said, prior to the survey, the facility had realized that facility staff had an issue with the understanding of what constituted neglect, abuse or exploitation, the thorough investigation process including interviewing and reporting, and a performance improvement plan was initiated on 10/11/24. -However, according to the RCC's previous interview (see above), the facility had implemented a new action item to the PIP, during the survey. The NHA said all incidents of abuse or allegations of abuse should be investigated timely and he had initiated the investigation process of the 9/14/24 and 9/17/24 incidents and reported the incidents to the State Agency as well as contacted law enforcement.

Based on observations, record review and interviews, the facility failed to ensure one (#3) of three residents received treatment and care in accordance with professional standards of practice out of 15 sample residents. Specifically, the facility failed to: -Investigate, treat, and implement interventions to prevent wounds to the resident's knees; and, -Complete routine weekly skin assessments. Findings include: I. Facility policy and procedure The policies for skin management and accidents and injuries were requested from the director of nursing (DON) on 5/21/24 at 12:00 p.m. and were not received by the end of the survey (on 5/21/24). II. Resident #3 A. Resident status Resident #3, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included Huntington's disease (progressive breakdown of nerve cells in the brain leading to inability to control movement and cognitive changes), anxiety and a history of falls. The 2/14/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. He was dependent on staff for personal hygiene, toileting and dressing. He required moderate to partial assistance with transferring and bed mobility. B. Observation and interview On 5/20/24 at 11:13 a.m. Resident #3 was observed with certified nurse aide (CNA) #2. Resident #3 was sitting in his recliner. CNA #2 said the resident had a history of falls and she was concerned about his knees. She said he slid out of his recliner continuously and got up to walk without assistance frequently. CNA #2 rolled up the resident's sweat pants to reveal Resident #3's knees. The resident's right knee had a redness discoloration with three round scabbed areas approximately 1 cm (centimeter) in size around the knee cap. The outer right knee had a new appearing abraded area which was red and approximately 2 cm in size. The resident's left anterior knee had three scattered, round scabbed areas approximately 1 cm in size. CNA #2 said she had seen the resident bang his legs on the dining room table. She said she did not know what the plan was to prevent the skin injuries. CNA #2 went to her computer to check the kardex for a plan to prevent injuries to the resident's knees. She said there was no plan to prevent the injuries. CNA #2 said the nurse was aware of the injuries. Unit manager (UM) #1 was interviewed on 5/20/24 at 11:30 a.m. UM #1 said she was aware of the injuries on Resident #3's knees. She said she was unsure how the injuries occurred. She said the resident could be impulsive with uncontrolled movements. C. Record review Resident #3's skin assessments were reviewed for May 2024. -The 5/9/24 skin assessment was incomplete and did not document whether the skin was intact or there were injuries. -There was no skin assessment for the week of 5/16/24. -The resident's progress notes and evaluations were reviewed. There was no record of the skin injuries to the resident's knees. -There was no documentation to indicate the physician, resident, or medical durable power of attorney (MDPOA) were notified of the injuries to the resident's knees. The skin care plan, initiated 8/19/20, was reviewed. The care plan documented the resident was at risk of pressure injuries and abrasions and bruising due to uncontrolled movement and poor safety awareness. Interventions included educating the resident, family and caregivers as to causes of skin breakdown including transfers, positioning requirements, importance of taking care during ambulation and mobility, good nutrition and frequent repositioning,iInforming the resident, family, caregivers of any new area of skin breakdown, providing a pressure relieving mattress, monitoring nutritional status, monitoring and documenting any changes to the skin status, Obtaining laboratory or diagnostic work as ordered and performing weekly skin checks by a licensed nurse. -However, the change in the resident's skin status was not documented, the resident, family and provider were not notified of the injuries and the weekly skin assessments were not completed as ordered. D. DON interview The DON was interviewed on 5/20/24 at 12:01 p.m. The DON said Resident #3 was impulsive and she was aware of his knee injuries. She said the resident was supposed to wear knee pads to prevent injuries to his knees but he refused the knee pads. -However, The DON said she had reviewed the resident's progress notes and there was no documentation knee pads had been offered and refused. The DON said the nurses should have completed a risk management form and notified the provider and family of the skin injuries to the resident's knees. She said she was not aware that had not been completed. The DON said she had reviewed Resident #3's orders and care plan and there were no orders and no care plan for the knee pads. The DON said there was no skin assessment done for the week of 5/16/24. She said she thought the problem was with the electronic medical record system. She said she had audited the skin assessments today (5/20/24), when it was brought to her attention, and there were four residents who had missed skin assessments. IV. Facility follow up On 5/21/24 at 11:44 a.m. the DON provided a performance improvement plan (PIP) titled Nursing Weekly Skin Summaries, dated 5/21/24 (during the survey). The PIP documented education was to be completed for all nursing staff by 5/24/24. Nursing management was to audit 5 (five) times per week for 30 days and would review in upcoming QAPI (Quality Assurance Performance improvement) meetings. After 30 days, nursing management would review weekly and continue to report findings in QAPI until substantial compliance had been met. Skin assessments would be done every week on each resident by a licensed nurse in the facility. Education would be provided to nursing staff to put any injury/scab into risk management and the content of skin assessment. Daily monitoring orders would be put in the treatment administration record (TAR) until healed. The DON and the unit managers would meet with all nursing staff to provide education regarding the weekly skin summaries and the nursing teams obligation to complete them when they were scheduled. Nursing managers were to have a list of residents and when the residents' skin assessments were due. Nursing management was to audit the skin assessments everyday before the end of their shift to ensure that they had been completed. After 30 days, an audit would be conducted weekly until compliance had been met. The facility would continue to discuss the findings in QAPI meetings. -The PIP did not address investigating the cause of skin injuries.

Based on observations, record review and interviews, the facility failed to ensure meaningful activities designed to support residents physical, mental, and psychosocial well-being were provided for four (#100, #92, #97 and #70) of six residents out of 42 sample residents. Specifically, the facility failed to provide meaningful activities, including activities of personal choice, for Resident #100, Resident #92, Resident #97 and Resident #70. Findings include: I. Resident #100 A. Resident status Resident #100, age under 65, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included benign neoplasm of the brain, supratentorial (brain tumors), schizoaffective disorder and mild neurocognitive disorder. The 9/6/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required dependent assistance with chair/bed to chair transferred and tub/shower transferred. She required substantial/maximal assistance with sit to standing and toilet transferring. The assessment documented it was very important to the resident to be able to listen to music, be around animals such as pets, keep up with the news, do things with groups of people, do her favorite activities, go outside to get fresh air when the weather was good and participate in religious services or practices. B. Resident interview Resident #100 was interviewed on 3/07/24 at 10:06 a.m. Resident #100 said activities at the facility had not occurred at all in December 2023 and January 2024. She said activities did hand out the chronicle for residents to read every day but that was it. Resident #100 said activities started occurring again in February 2024 activities. Resident #100 said the facility had some activities scheduled in the evenings at 6:00 p.m., however, she said the activity staff were not around to lead the evening activities because they left for the day around 3:00 p.m. or 4:00 p.m. every day. She said the only big group activity that occurred was Bingo, which was scheduled twice a week, on Mondays and Fridays. Resident #100 said the activities staff used to take the residents out to the movies. She said the new activity director (AD) changed things and the residents did not get to go out to the movies anymore. She said the residents asked to go to Sonic for half price shakes and the new activity director told the resident's that there was no money to go and get shakes. She said the activities in the facility had not gotten better since the new AD started. Resident #100 was interviewed again on 3/7/24 at 2:30 p.m. Resident #100 said the facility told residents that activities and resident council could not occur during December 2023 and January 2024 because of a COVID-19 outbreak in the facility, however, she said residents had been allowed to eat their meals in the dining room and did not have to quarantine to their rooms during the outbreak. Resident #100 said the coloring activities that were provided were for kids. She said the activities staff had residents coloring a dog, cat, sun or something else simple Resident #100 said she did not think the AD did much all day for the residents' activities during the week. She said the activities assistant (AA) who worked the weekends did an amazing job with the activities. C. Record review Resident #100's activity care plan, revised on 2/23/24, documented the resident enjoyed going outside when the weather was nice, she enjoyed socializing with others and enjoyed eating ice cream. The resident also enjoyed participating in art though she needed assistance in doing so. The resident enjoyed participating in walks in her wheelchair. The resident went to church services from time to time. She enjoyed watching a variety of shows. She enjoyed going on outings to the movies and going to group activities like bingo, socials, participating in scrabble and chair yoga. She enjoyed watching TV (television) in her room and sitting in the hallways visiting with staff and others. She was part of the resident council and part of the facility's work program. The interventions included the activities team would give the resident a monthly calendar, activities team would make sure to invite the resident to group activities of interest and respect her right to refuse. D. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 3/12/24 at 10:15 a.m. LPN #3 said the activity staff handed out the daily chronicle to the residents in the morning. She said the activity staff also handed out snacks like ice cream and coffee to the residents. She said she had never been asked to help out with the activities. Certified nurse aide (CNA) #6 was interviewed on 3/12/24 at 10:21 a.m. CNA #6 said she saw the activity staff once a day passing out snacks or drinks to the residents. She said she had seen them handing out the daily chronicle. She said activities did not spend a lot of time with the residents on the unit. She said she had never been asked to help out with activities if they needed help. She said when they did not have enough help for activities the activity was canceled. The AD and AA #1 were interviewed together on 3/12/24 at 12:44 p.m. The AD said each floor of the building had different activities. She said activities were happening seven days a week. She said activities were scheduled in the afternoon and the last activity happened around 2:45 p.m. She said staff on the unit could do the evening activities. She said CNAs helped out with the activities at least once a day. The AD said evening activities should be happening more often. She said it was a work in progress to figure out what schedule of activities worked and what did not work. She said there were no outings on the weekends because there were not enough staff to help out. She said there were only two activities staff working in activities and AA #1 would help cover the weekend activities. The AD said activities were put on hold the week before Christmas 2023 and resumed in February 2024. She said in the morning both she and AA #1 went around with a cart with snacks, puzzles, reading books and games and then in the afternoon they did the same thing. The AD said residents needed to have their own money if they were going to go out for lunch. She said the facility did not provide a free lunch out to restaurants. She said activities had offered free things for residents to do, such as going to the park and on van rides. She said activities planned outings for residents twice a month. She said activities would provide a morning ride and an afternoon ride so more residents could get out. She said the residents pick the outings. The AD said she was trying to offer more activities but was in a staffing crisis as there were only two of them for the whole facility. She said she was trying to do what she could with what she had. 50315 II. Resident #92 A. Resident status Resident #92, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included bipolar disorder, generalized anxiety disorder and glaucoma (damage to the eye, leading to loss of vision). The 12/7/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. B. Resident interview Resident #92 was interviewed on 3/11/24 at 3:09 p.m. Resident #92 said she enjoyed watching movies, reading, walking outside and listening to music. She said she did not enjoy the group activities because her vision was impaired which made participating in the activities difficult and she did not get along with other residents. She said she enjoyed going to the front entrance of the building to talk with the receptionist. She said staff members from the activity department rarely assisted her there from the fourth floor where she lived. She said she felt that it was dangerous with her vision impairment and she did not feel comfortable going by herself to visit the receptionist. She said she was able to call for help when she needed it. She said there were activities she would enjoy that the staff had not provided to her such as reading to her, going outside and talking with staff. Resident #92 said she had talked to the nursing and activities staff about activities she would enjoy. She said there was a recent outing that she expressed interest to the activities staff in attending. She said she was told by the activities staff there was not enough room on the bus for her to go. She said she was very disappointed she was not able to go on the outing. C. Record review Resident 92's care plan, initiated on 11/20/2020 and revised 2/18/24, documented the resident enjoyed reading, sewing, doing puzzles, animals and spending time outside when the weather was nice. She enjoyed group activities such as bingo, trivia and the Game of Things. According to Resident #92's Interview for Daily and Activity Preferences, dated 10/5/22, it was very important for the resident to go outside to get fresh air when the weather was good. The activity logs from January 2024 and February 2024 were received by the AD on 3/12/24 at 11:30 a.m. According to the logs, resident #92 received no outside strolls in either month. D. Staff interviews LPN #1 was interviewed on 3/12/24 at 9:30 a.m. LPN #1 said Resident #92 stayed in her room most of the day but she had a resident job to post the menu daily. She said the resident had a vision impairment that required assistance to walk around outside her room and with activities. She said she enjoyed going to the first floor to talk with the receptionist, reading, listening to music and going outside. The AD was interviewed on 3/12/24 at 10:45 a.m. The AD said the activities staff offered group activities to all residents daily. She said Resident #92 had a vision impairment and enjoyed staying in her room to read and listen to music. She said group outings were limited depending on how many staff members there were to accompany the residents. III. Resident #97 A. Resident status Resident #97, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included acute pancreatitis (inflammation of the pancreas), dementia and seizures. The 12/16/23 MDS assessment revealed the resident had moderately impaired cognition with a BIMS score of 11 out of 15. B. Resident interview Resident #97 was interviewed on 3/6/24 at 2:54 p.m. Resident #97 said sculpting and glass blowing were his life's work and he would like to be able to work on his artwork daily. He said when he first got to the facility he brought tools with him to work on his artwork. He described the tool as something that heated up the material to sculpt with. He said the administrator took them away for safety concerns due to his seizure disorder and he had been asking for them back. Resident #97 said he was very frustrated and felt like they were treating him like a child. He said the activity staff used to offer supervision while he used his tools to heat up the sculpting material and work on his artwork but they did not come in and allow him to do that anymore. He said the only other activity he enjoyed was going outside to smoke. He said the activities staff members had never offered other tools or for him to work on the art outside of his room. C. Record review The activity logs from January 2024 and February 2024 for Resident #97 were received from the AD on 3/12/24 at 11:30 a.m. According to the logs, Resident #97 received a one on one activity for offering and providing activity materials one time in January 2024 and one time in February 2024. D. Staff interviews LPN #1 was interviewed on 3/12/24 at 9:30 a.m. LPN #1 said Resident #97 liked to go outside to smoke and stay in his room to work on artwork. She said the activity staff used to sit with him in his room while he worked on the artwork. She said she had not witnessed him working on his artwork with activity supervision in a while. She said he had a tool to use for his artwork that was taken away due to safety concerns with his seizure disorder. The AD was interviewed on 3/12/24 at 10:45 a.m. The AD said Resident #97 liked to work on sculpting and go outside to smoke. She said she kept his sculpting tool in her office and she often went into his room to set up a time to sit with him while he did his sculpting. She said he was often agreeable at first but when she went back to sit with him so he could do his artwork he often refused. She said she had not offered him a different kind of tool to meet his needs. 47818 IV. Resident #70 A. Resident status Resident #70, age 77, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included anxiety and depression. The 1/11/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. He was independent with all activities of daily living (ADL). B. Observation and resident interview Resident #70 was interviewed on 3/6/24 at 11:00 a.m. Resident #70 said the facility did not offer any activities. He said he enjoyed socializing when he could but he watched a lot of television because there was nothing to do. He said he liked hanging out in the hallway outside his room and talking to people or playing Bingo. On 3/11/24 at 9:30 a.m., Resident #70 was in the hallway near his room while a scheduled activity of Bingo was occurring in the communal dining area. He said he was unaware of the Bingo game and would have joined if he had known. Resident #70 walked to the communal area of the Bingo game but did not join in because he said he did not want to join in the middle of the game. C. Record review Resident #70's activity care plan, initiated on 10/12/2020 and revised on 1/24/24, revealed Resident #70 preferred independent leisure, spending time outside, smoking, going to socials, watching television and listening to music. He enjoyed reading mystery books and playing Bingo from time to time. The resident would participate in one to three structured groups of interest each week and continued being independent and structured his day with leisure activities of his choosing such as spending time outdoors, reading, socializing with peers or watching something on television. Pertinent interventions included staff inviting the resident to activities, reminding and encouraging the resident to participate in activities of interest and providing the resident with resources for independent activities. The 1/24/24 quarterly activity participation review indicated Resident #70 was participating in leisure and group activities. Resident #70 enjoyed reading, smoking, watching television, socials and playing Bingo. The March 2024 activity calendar indicated Bingo was played every Monday and Friday at 9:45 a.m. -The March 2024 activity tracking form indicated Resident #70 engaged in playing Bingo on 3/9/24. The tracking form was blank on Friday (3/1/24), Monday (3/4/24) and Monday 3/11/24. The tracking form did not indicate Resident #70 was invited and declined the activity. D. Staff interview CNA #5 was interviewed on 3/11/24 at 10:30 a.m. CNA #5 said she had not informed Resident #70 of the Bingo game scheduled that morning (3/11/24). She said she was not aware he enjoyed Bingo.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner in three of five nourishment rooms. Specifically, the facility failed to: -Ensure food was labeled and dated in the nourishment rooms; and, -Ensure personal food items belonging to staff were not kept in facility nourishment refrigerators. Findings include: I. Facility policy and procedure The Refrigerators and Freezers policy, revised November 2022, was provided by the director of nursing (DON) on 3/11/24 at 1:30 p.m. It read in pertinent part, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation All food is appropriately dated to ensure proper rotation by expiration dates. 'Received' dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. 'Use by' dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and 'use by' dates are indicated once food is opened. A. Observations and interviews During an initial building tour on 3/6/24 at 9:30 a.m., the nourishment refrigerator and freezer on the Three [NAME] unit contained the following items without labels or dates: Refrigerator: -A clear plastic bag containing six to eight peeled hard boiled eggs; -Five small red apples with visible wrinkles; and, -Several packets of ketchup, mustard and mayonnaise. Freezer: -A commercial brand burrito was labeled with the name of certified nurses aide (CNA) #2. Registered nurse (RN) #2 was interviewed on 3/6/24 at 10:00 a.m. RN #2 said it was acceptable for staff to use the resident nourishment refrigerators on the units because there was not a separate refrigerator for staff to store personal food at the facility. Licensed practical nurse (LPN) #4 was interviewed on 3/6/24 at 10:05 a.m. LPN #4 said staff were to put personal food in the staff refrigerator. She said nourishment refrigerators were used for storing resident food only and should be labeled with resident name and dated with when the food item was put in the refrigerator. LPN #3 was interviewed on 3/6/24 at 10:15 a.m. LPN #3 said facility staff had their own refrigerator and freezer in the break room of the East unit to store personal food items. On 3/12/24 at 9:00 a.m., the second floor nourishment refrigerator and freezer contained the following items: Refrigerator: -Two plates covered with clear plastic containing eggs, a meat patty and a bread item; -A bowl covered with clear plastic wrap containing oatmeal; -Two bowls covered with clear plastic wrap containing two hard boiled eggs each; and, -Two individual servings of Yoplait brand yogurt. Freezer: -One pint size ice cream container; -One gallon size ice cream container; -Two bags of Egglife egg white wraps; -One freezer popsicle (orange flavor); and, -One dish covered with a paper towel displaying an illegible word and that was dated 3/6. -Items were not dated or labeled to indicate who they belonged to or what the items were. Nurse manager (NM) #1 was interviewed on 3/12/24 at 9:00 a.m. NM #1 said the nourishment refrigerators on the units were used for storing food items belonging only to the residents and not staff. She said there was a designated staff refrigerator on the third floor in the staff breakroom. NM #1 was able to identify the egg white wraps as belonging to a resident, the two plates and one bowl covered with clear plastic, and two bowls containing hard boiled eggs as breakfast items from the morning of 3/12/24. NM #1 said she believed the ice cream and popsicle were from an activity but could not confirm that and the items were thrown in the trash along with the dish covered by a paper towel. On 3/12/24 at 9:15 a.m., the third floor nourishment refrigerator contained a bag displaying the word Lululemon. CNA #2 was interviewed on 3/12/24 at 9:15 a.m. She said the Lululemeon bag belonged to a staff member and contained food. CNA #2 said staff were allowed to use the nourishment refrigerators on the units to store personal food items. She said there was not a designated staff refrigerator. On 3/12/24 at 9:30 a.m., the fourth floor nourishment refrigerator contained the following: Refrigerator items: -Two reusable Walmart grocery bags; -One disposable plastic Safeway grocery bag; dated ?; -A box of microwave popcorn; -A plate covered with plastic wrap containing an english muffin and bacon, dated 3/11; -A small jar of hot sauce which had been opened but was undated; -A plastic bottle of french vanilla coffee creamer; -A pink transparent, reusable Blender Bottle; and,six -Six individual serving size Yoplait yogurts. Freezer items: -Two squeezable fruit pouches; -A small plastic container with a blue lid; and, -A frozen pizza. -Not all of the items were dated or labeled to indicate who they belonged to or what the items were. CNA #3 was interviewed on 3/12/24 at 9:30 a.m. CNA #3 said she believed the two Walmart bags belonged to staff members. She said the nourishment refrigerator was to be used for resident items only and staff had a designated refrigerator in the breakroom. She said she would attempt to find the owners of the items and if unsuccessful the items should be thrown out. D. DON Interview The DON was interviewed on 3/13/24 at 3:00 p.m. The DON said staff had their own refrigerator located in the break room for personal food items. She said staff should not use the nourishment refrigerators or freezers on any floor for storing personal food items. The DON said facility staff would be re-educated on the location of the staff refrigerator and that personal items were not to be stored in the nourishment refrigerators. She said employees would also be re-educated on the importance of labeling and dating all food items placed in nourishment refrigerators and freezers.

Based on interviews and record review, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#63) of three residents reviewed for PASRR out of 42 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR level II notice of determination for Resident #63. Findings include: I. Resident status Resident #63, age 72, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included cerebral infarction due to embolism of right cerebellar artery (stroke), schizophrenia, unspecified and vascular dementia. The 8/2/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15 and a patient health questionnaire (PHQ-9) score of seven, indicating mild depression. II. PASRR level II notice of determination for mental illness (MI) evaluation and facility failures The PASRR level II, dated 5/12/23, revealed the resident had been evaluated for mental illness (MI) due to a qualifying diagnosis of schizophrenia disorder. Specialized services were recommended included psychiatric case consultation and behavior management/therapy. III. Record review The behavioral care plan, revised 12/11/23, revealed Resident #63 has a behavior problem related to diagnosis of dementia, schizophrenia and history of cerebral infarction. The resident can become agitated quickly when being redirected. She will yell and scream, has grabbed at nursing staff or others and has been noted to kick on doors to get out of here. The resident has made the comment, I'll just shoot myself in the head when she was not allowed to smoke at one in the morning. Interventions included minute checks as indicated, giving the resident as many choices as possible about care and activities; monitoring for and documenting observed behavior and attempted interventions; keeping other residents out of the resident's way when she is agitated; suicide evaluation completed, the resident does not have access to a gun, when the resident becomes agitated; intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later; when redirecting, if the resident becomes agitated, give her space and allow her time to calm down, keeping her and other resident's safe, reapproach at a later time, approach in a calm manner; document behaviors and resident response to interventions. The March 2024 CPO revealed the following physician orders: -Risperdal 3 MG (milligrams)-give one tablet by mouth at bedtime for schizophrenia ordered on 8/16/23. -No orders for individual therapy or psychiatric case consultation were located. -A review of progress notes dated 7/6/23 to 3/12/24 failed to reveal any PASRR progress notes. -No social services notes were located regarding PASRR or recommendations. No PASRR progress notes showing communication with the State Mental Health Agency regarding a delay or inability to follow the recommendations were located. IV. Staff interviews The social service director (SSD) and social service assistant (SSA) were interviewed on 3/12/24 at 9:47 a.m. The SSA said admissions initiated the PASSR if a resident needed one. She said sometimes the hospital would start the PASSR but if it was not completed then admissions would initiate the PASSR. She said if the resident needed a PASSR level II then it would need to be completed within 180 days. She said once there were recommendations in place the SSD or the SSA were responsible for setting up services for the residents. The SSA could not find where the services were requested for Resident #63. The SSA said the facility physician was providing the necessary care for Resident #63. She said psych pharm evaluations were done regularly and the resident was being seen every three months. Licensed practical nurse (LPN) #5 was interviewed on 3/12/24 at 10:40 a.m. He said Resident #63 needed motivation to take her medications as she would refuse her medications often. He said the resident did not like anyone to approach her and sometimes she would get up and run away from staff. He said he approached the resident from a distance and would talk nicely. He said the resident would sometimes scream at him when he approached her. He said if the resident told him no then he would move on. He said the resident was verbally aggressive but had not been physical towards others. He said the resident would benefit from therapy services and talking to someone. Certified nurse aide (CNA) #4 was interviewed on 3/12/24 at 10:50 a.m. She said the resident could have an outburst at any time. She said the resident was easily angered and had frequent mood swings. She said the resident would scream or yell and say whatever was on her mind and then walk away. She said if the resident missed her cigarette break she would get mad. She said the resident had not been physical. She said sometimes the resident did not want to talk. She said it depended on the resident's mood if she would talk to a therapist. Nurse practitioner (NP) #1 was interviewed on 3/12/24 at 1:45 p.m. He said he came to the facility every two weeks to see residents. He said he did talk therapy and made medication changes. He said Resident #63 was not on his case load of residents to see. He said he spoke with the SSD and the SSA and they said they were going to send a referral for Resident #63. He said residents who were cognitively intact and had psychiatric trouble did well with talk therapy. He said some residents did not have family support and said behavioral support would be beneficial for residents needing it. He said he could introduce coping skills, decrease any behaviors and provide better validation. The director of nursing (DON) was interviewed on 3/12/24 at 3:32 p.m. She said a PASSR should be completed before the resident arrived at the facility. She said if the resident needed a PASSR level II completed then it would be completed once they were at the facility. She said the SSD or the SSA was responsible for making the appropriate referrals. She said the facility used behavioral health solutions or mental health partners for mental health services. She said she spoke with the SSD and the SSA today and they mentioned they were making a referral for Resident #63. The DON said the recommendations should have been implemented previously. She said it was concerning that the recommendations were not being followed from May 2023. The DON said she did not know how Resident #63 got missed and did not realize the resident was not being followed by anyone. She said the resident's primary doctor was monitoring and managing the medications for the resident.

Based on observations, record review and interviews, the facility failed to ensure treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#48) of four residents reviewed for quality of care out of 44 sample residents. Specifically, the facility failed to honor the resident's choice to be sent to the hospital upon her request. On 9/26/22 Resident #48 developed altered mental status and functional decline in mobility. The resident had difficulty communicating her thoughts, but expressed to multiple staff members that she needed to go to the hospital. Her request was not honored. Her condition continued to deteriorate, and she was hospitalized on [DATE] after the state of her health condition was brought to the attention of a nurse practitioner (NP) #2 by the resident's speech therapist (ST). In the hospital, the resident was diagnosed with a urinary tract infection (UTI), acute kidney injury, and lithium toxicity. After the resident returned from the hospital (10/10/22), she did not return to her baseline of functioning, her mental status fluctuated, and she expressed concerns to the ST and psychiatrist (PSY) about the nursing staff being inattentive to her concerns. Her condition continued to deteriorate mentally and physically, she was no longer able to express her thoughts and became completely dependent on staff for her care. By the end of October 2022, she had stopped eating and drinking. On the evening of 11/1/22 the ST found the resident in the hallway. The resident did not recognize the therapist and did not respond to her voice. Nursing notes for 11/1/22 revealed the resident's blood pressure was low, but there was no supporting documentation that blood pressure levels were communicated to the resident's physician. The ST reached out to the director of nursing (DON), and the resident was assessed by a unit manager on duty and was sent out to the hospital (17 hours after the initial drop in her blood pressure was documented), where she was diagnosed with acute encephalopathy (altered mental status), acute dehydration, lithium toxicity, acute renal failure and low blood pressure due to dehydration. In addition, the facility failed to investigate the concern of care the ST expressed to the DON on behalf of the resident prior to her hospitalization on [DATE]. Findings include: I. Resident #48 Resident #48, age 75, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included bipolar disorder, anxiety disorder, history of urinary tract infection, and dysphagia (swallowing difficulty). The 8/6/22 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of eight out of 15. The resident did not display delusions or hallucinations, and did not reject the care. She required supervision, oversight and encouragement from one person for bed mobility, transfers, dressing, personal hygiene and eating. The resident was occasionally incontinent of bladder and always continent of bowel. The 10/17/22 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 10 out of 15. The resident did not display delusions or hallucinations, and did not reject the care. She required extensive assistance of two or more individuals for bed mobility, transfers, dressing, personal hygiene and eating. The resident was frequently incontinent of bowel and bladder. II. Record review 1. Resident's status prior to hospitalization on [DATE] (change of condition) The 9/26/22 SBAR summary documented that the resident's condition changed, she had altered mental status and functional decline in mobility. Her vital signs were within normal limits. The resident's primary care physician (PCP) #1 was notified. The PCP #1's late entry note on 9/26/22 read, the visit was requested by nursing staff. The resident had increased lethargy and confusion. She had trouble finding her words and speaking today, her responses were slow. During assessment, the resident was sitting in a wheelchair, she was more lethargic, she had flat affect, no anxiety, she had difficulty answering questions with word finding difficulty. The plan of care was to check the labs and do a follow up visit on upcoming Thursday (9/29/22). On 9/27/22 Resident # 48 had an unwitnessed fall with no injuries on her way to the bathroom. On 9/28/22 urinalysis with culture and sensitivity were received from the lab with no indication of infection. Lithium levels were within normal limits. Renal functioning test was within normal limits as well. The nurses note on 9/28/22 documented, Resident is up ambulating with her walker today, but continues to be confused at times and finding it hard to find words. Resident states that she wants to go to the hospital. The writer explained to the resident that her blood work came back and looked good, the resident stated that she didn't care, she wanted to go to the hospital. Later documented, The resident is resting quietly and no longer talking of going to the hospital or calling 911. On the same day the resident's psychiatrist (PSY) was called regarding resident refusal of medications now due to her feet being 'to sticky' and that when he is in the building tomorrow, 9/29/22, he can possibly check in on the resident. The PCP #1's late entry note on 9/29/22 summarized the lab results stating no indication of urinary tract infection or any other infection, however the resident continued to say she was not feeling well and wanted to go to the hospital, but she could not state why she would need to be seen at the hospital. Plan of care was to continue to monitor the resident. Between 9/30/22 and 10/6/22 the resident had five falls with no injuries on 9/30/22, 10/4/22, 10/5/22 at 2:11 a.m. and at 9:47 a.m. 2. hospitalization on [DATE] The 10/6/22 at 5:38 a.m. nurses note documented that the resident was yelling help instead of using her call light. At 4:53 p.m. the note by licensed practical nurse (LPN #4) documented, At approximately 3 p.m. the CNA (certified nurse aide) came to this writer and stated that the therapists were in this resident's room and stated that they were going to send the resident out. This writer entered the room and there were three staff in with this resident from therapy, one was sitting on the bed next to this resident, this staff member stated that the resident was acting off, this writer stated that this was true and that she has been 'acting off' for a couple of weeks now, this staff member stated that the resident told her she wanted to go to the hospital. This resident has not stated to this writer or any other staff member today that she wanted to go to the hospital. Writer told the staff members that the (nurse practitioner) was coming to assess this resident today and that there was no order for her to be sent to the hospital. Writer then went to make a phone call to the (nurse practitioner) and asked her if she had ordered this resident to be sent to the hospital. The (nurse practitioner) stated no, that she was just a few minutes away and would assess her when she arrived. Writer then went back into the residents room and the resident was gone. This writer came out of the residents room and the speech therapist stated that they had taken the resident to the gym, she was worse and they were sending her out emergent. Later, the nurse manager from 4th floor came to this writer and stated that the resident was up on 4th and (nurse practitioner) was up there assessing her. This writer has been in and out of the residents (room) numerous times during this shift, the resident has been weaker and has required more assistance with toileting and ADL's (activities of daily living), the resident kept going to the bathroom and then getting stuck in her wheelchair in the bathroom and had to be assisted back to her bed. At 5:09 p.m. resident's vital signs were documented and they were normal. At 5:12 p.m. a nurse's note revealed that the resident was assessed by the nurse practitioner (NP) who ordered the resident to be sent to the hospital for evaluation and treatment. At 5:45 p.m. the resident was sent to the hospital. The note by the speech therapist (ST) on 10/6/22 at 7:35 p.m. documented that the resident demonstrated a significant decline in oral motor skills and mobility. The (ST) approached staff about having the resident to be evaluated to go out to the hospital. The NP note on 10/6/22 documented tha resident appeared fatigued and weak. She had no fever or chills, the rapid test for COVID was negative. -There were no notes by the nurse manager (NM) who was with the resident on 10/6/22. Hospital records were not available for review. The resident spent four days in the hospital, and returned to the facility on [DATE]. The NP note on 10/11/22 revealed the resident was readmitted from the hospital where she was diagnosed with a UTI, acute kidney injury, and lithium toxicity. The resident was to receive antibiotics through 10/16/22 for the UTI. 3. hospitalization on [DATE] The nurse's admission note on 10/10/22 revealed Resident #48 returned from the hospital on 10/10/22 and refused to take her medications that the nurse offered to her. After three attempts, the resident accepted her medications. On 10/11/22 at 5:00 p.m. the nurse's note read, resident has been yelling out 'Help!' periodically today and then when staff enter the room the resident isn't quite sure what she needs. Resident is alert and oriented one minute and then completely disoriented and unable to say anything that makes sense. On 10/12/22 at 8:45 a.m. the note read, Resident declined to swallow her medications this morning, she held them in her mouth and then spit them out. Resident did the same thing with her breakfast, she held bites in her mouth and then spit them out.While writer was passing medications the resident began to yell out 'I'll take a Valium', 'I'll take Klonopin' , 'I'll take Ativan' . Resident then asked the CNA to be taken to physical therapy because they said they would help me. The skilled nursing note on 10/12/22 at 5:25 p.m. documented, resident was Spitting out food and medications, continues to be a one person extensive assist with all ADL's and requires assistance with transfers. Resident is currently incontinent of the bladder. On 10/13/22 at 4:46 a.m. nurses note read, Resident yells out for 'help' or screaming versus using call light. Educated to use call light for assistance and the resident will verbalize understanding. Then yells out again stating she can't find a call light when she's holding it. Repeats statements with clear speech to mumbling and not making sense. -There was no assessment of change of condition for Resident #48 after her mental status changed, after she started to refuse medications, and continued to yell for help. -There was no nursing documentation that the above behaviors were communicated to the resident's PCP #1. On 10/13/22 at 6:20 p.m. Resident #48 had a fall with no injury. The same day on 10/13/22 the resident was assessed by PCP #1, seen at the request of the speech therapist to assess the condition of the resident. The PCP documented the following findings, (resident) had increased lethargy and confusion of sudden onset in late September. Evaluation was negative for acute illness. On October 6, she was lethargic in therapy. Therapists informed nursing that she should be sent to the ED for continued alteration in mental status. She was evaluated by nursing and by the (nurse practitioner); after discussion with all involved with seeing the resident, it was decided to send her to the (hospital). There are no records available for review from her hospitalization . She was apparently treated for urinary tract infection, dehydration, and lithium toxicity. Her last lithium level here was 1.0 on September 27. Today the speech therapist again reports that therapy staff is concerned that she has had a stroke. This concern is based on their observation that she is intermittently lethargic and is generally weak. When I entered her room she was sleeping. She roused easily and answered questions appropriately. She had some word finding difficulties but given enough time she could express herself. She continues to have urinary frequency but denies dysuria. She states that she doesn't feel that the antibiotics she got in the hospital have changed how she has been feeling. The plan of treatment included: (Resident) can state the month, year, and where she is. She has no unusual thoughts and has no delusions or auditory hallucinations during the visit. Psychiatrist will be seeing her today as well to assess her mood because some of her symptoms of loss of interest in therapy, poor short term memory, fatigue, and increased sleepiness could be symptoms of worsening depression. Will order head CT (computerized tomography) to rule out stroke but feel this is unlikely. -There was no additional documentation that the CT scan was scheduled and completed. The ST note on 10/16/22 documented that prior to the therapy, resident was found to be soaked in juice, needed assistance from CNA to get changed. Resident demonstrated significantly increased chewing time, chewing when there was no longer food in the mouth, pocketing on the left side that could only be resolved with maximum cuing. Resident's physician recommended a CT scan to rule out stroke. The skilled nurses note on 10/21/22 documented, Resident not using toilet and having increased incontinence episodes. She requires assistance of two people with a sit-to-stand lift for transfers. On 10/25/22 resident was assessed by PCP #2, who documented, The patient is being seen routinely and the chart has been reviewed and discussed with staff and provider. Staff endorsed that the patient cannot do anything, walk, stand or dress. Plan of care was to continue to monitor for side effects and general presentation per diagnosis. The skilled nurse's note on 10/26/22 documented, the resident was lethargic. The ST note on 10/27/22 documented, Met with resident's unit manager to advocate for resident moving to another unit due to how nursing treats resident, how resident feels on the unit, the kind of support resident needs. The ST note on the 10/30/22 documented, staff reports increased frustration with resident during meal times. Resident was yelling and CNAs have been leaving her in her room when she does not want to come down. Resident agreed to get up but was saying how her CNA was evil. Resident demonstrated more difficulty than usual talking, was weepy throughout. Only ate a few bites. Education to provide complete assistance with meals was communicated to the nursing staff. The 10/31/22 nurse's note read, Today resident is not swallowing any food and/or fluids, writer crushed residents medications and put them in yogurt, the resident had them in her mouth for quite some time and after a couple minutes of queuing the resident to swallow, the resident then just spit them out all over herself. The resident was taken to the dining room for lunch, the CNA tried to assist the resident eating, the resident again wouldn't swallow, the CNA tried to que the resident to swallow and theresident yelled 'I can't, I can't!' and then spit out the food/fluids all over herself again. Writer notified the provider that the resident needs to be seen today by the provider and possibly speak to the family regarding hospice. The resident, according to the weekend CNA's, was talking and using her wheelchair as before and now she's back to being alert and oriented to herself only, and unable to swallow. The PCP #1 note on 10/31/2 read, Earlier this month the speech therapist again reports that therapy staff is concerned that she has had a stroke. This concern is based on their observation that she is intermittently lethargic and is generally weak. She continues to have a waxing and waning course. In the mornings she is usually alert and cooperative; she becomes more confused and unable to participate with care and therapies as the day goes on. Today she is lethargic and emotionally volatile. She will be talking normally, then start to cry, then fall asleep. She cannot fully explain how she is feeling. Nursing reports that she would not swallow food at lunch. When I asked her about this, she stated that she didn't like the food so she spit it out. The head CT ordered on October 13th was never scheduled. I asked the staff again to get this scheduled as soon as possible. The plan of care included to recheck labs, ask staff to schedule head CT as soon as possible. On 11/1/22 at 3:36 a.m. a skilled nursing note documented that resident's blood pressure dropped to 92/60 (with normal being 120/80). The resident was alert. At 3:43 p.m. resident's blood pressure was 100/64, Resident (was) lethargic. Resident is sitting in her wheelchair with her eyes closed most of the time and yelling out continuously, staff unable to redirect resident, resident just screams louder when anyone tries to talk to her. Resident continues to state she can't swallow, the resident did take her medications today crushed in yogurt. -There was no documentation that the drop in the resident's blood pressure was reported to PCP #1 on 11/1/22 when it was initially taken or later during the day. The change of condition summary was completed on 11/2/22 (after the resident was discharged to the hospital). The resident's blood pressure at the time of discharge was recorded as 84/50. On 11/9/22 the ST assessment documented a summary of the resident's condition prior to the hospitalization . Before (the hospitalization ), over the course of approximately six weeks, the resident had progressed from regular thin to mechanical soft diet. On Tuesday, November 1st, it was reported by CNA and RN that the resident had not been able to chew foods or swallow food/drinks for four days (since 10/29/22). At this time, CNA staff with a nurse present reported having stopped feeding the resident for the previous four days and instead had been pouring thickened juice down the resident's throat. -At the time of the encounter with the therapist, the resident did not respond to her name, did not recognize the therapist and was not able to swallow water that was offered to her. The meal and fluid record for October 2022 revealed that the last documented meal and fluid intake for the resident was on 10/27/22. The record for 10/28/22 was left blank. On 10/29, 10/30, and 10/31/22 the meal and fluid intake record was marked with RR (resident refused) for all three shifts. 4. Hospital records Hospital admission records indicated Resident #48 was admitted to the emergency roiagnom on [DATE] at 9:57 p.m. (17 hours after her blood pressure dropped below the normal range). Primary admitting diagnoses included: -Acute metabolic encephalopathy-multifactorial including UTI, acute renal failure, lithium toxicity; -Acute dehydration; -Acute renal failure-in the setting of severe dehydration hypovolemia (low fluids in the body). -Hypotension (low blood pressure)-due to hypovolemia. Two litters of intravenous (IV) fluids were administered. -Hypernatremia (high levels of sodium)-due to dehydration -Acute cystitis (inflammation of the urinary bladder). -The resident's lithium medication was discontinued prior to the discharge from the hospital. On 11/6/22, after five days of hospitalization , the resident returned to the nursing facility. III. Resident interview The resident was interviewed on 12/1/22 at 3:45 p.m. The resident was in bed, and she responded to her name. She was alert and oriented to self and her surroundings. She recalled being in the hospital several times, stating the reason for hospitalization was lithium toxicity. She did not recall any details prior to her hospitalization s. She said she was treated well by staff and was happy with her care. She said her appetite was good and she was back to being able to eat independently, and independently use the bathroom. She said she continued to work with the ST, physical therapy (PT) and her psychiatrist. She was aware that her lithium was discontinued and she was on another medication that her psychiatrist recommended. IV. Staff interviews The ST was interviewed on 12/1/22 at 9:47 a.m. She said she has been working with Resident #48 frequently and knew her well. She said prior to the end of September 2022 Resident #48 was able to ambulate independently and she was mostly independent with all of her tasks. She said some time in mid-September 2022 the resident's mental status changed, she had several falls, became increasingly confused, was not able to follow instructions and often mentioned that she needed to go to the hospital, but nurses would not help her. She said the resident was yelling, screaming, spitting her food and not being able to swallow, which was not a baseline behavior for this resident. She said within a few weeks the resident went from being independent to requiring full assistance with meals and transfers. The ST stated that on multiple occasions she brought her concerns about the resident to the unit manager (UM) #2 and LPN #4 who was a primary nurse in the unit where the resident resided. She said LPN #4 would say that Resident #48 was faking her condition and it was part of her daily behavior. The same response was received from UM #2. The ST stated nursing staff who worked with the resident daily, disregarded the concerns that were brought to them, including the resident's request to be sent to the hospital. The ST stated she reached out to her supervisor, the director of nursing (DON) and the resident's PCP #1 on multiple occasions with the above concerns as she believed the resident's care was neglected. On 10/6/22 when she approached the resident in her room for therapy, the resident was lethargic, half way out of her bed, and stating that she needed to go to the hospital. She said she communicated to LPN #4 the resident's condition and her request. LPN #4's response was that she had no physician orders for hospitalization and was not aware that this resident needed to be hospitalized . NP #2 was contacted and the resident was sent to the hospital where she was diagnosed with a UTI, dehydration and lithium toxicity. After the resident came back from the hospital she did not return to her prior level of functioning. Her mental status fluctuated from being fully alert and oriented to being lethargic, not able to feed herself or go to the bathroom. The ST stated she approached the management team on several occasions mentioning that something was not right with the resident including the resident's relationship with her primary nurse, LPN #4. She said the response she received was that there were no other available rooms in the building and the resident could not be transferred to another unit. On 11/1/22 when the ST approached the resident in the hallway, the resident was sitting in her wheelchair with orange liquid all over her shirt. The resident did not respond to her name, she did not follow the directions, she did not recognize her therapist. The nurse and CNA on duty stated that the resident stopped eating and drinking since Saturday (10/29/22) and staff were trying to give her thickened orange juice with little success. They were suggesting a hospice evaluation. The ST stated she was not aware that the resident stopped eating and drinking three days ago and was concerned that nursing staff had not communicated that to her or the resident's PCP. The same evening the resident was sent to the emergency room , where she was diagnosed with encephalopathy, acute renal failure, acute dehydration, low blood pressure and lithium toxicity. After the resident was treated and returned to the nursing facility, she was transferred to another unit. Her mental status improved, she was alert and oriented to her surroundings. She regained her previous level of functioning, she was able to eat independently and take herself to the bathroom without assistance. LPN #4 was interviewed on 12/1/22 at 10:55 a.m. She said she knew the resident very well and worked with her when she was residing in this unit. She said Resident #48 was usually alert and oriented, some days she ambulated with a walker and some days used the wheelchair. She said on 10/6/22 the ST communicated to her that the resident asked to be hospitalized and she was not feeling well. The LPN stated she checked the resident's vital signs and they were normal. She said the resident did have difficulty talking earlier in the day and she already placed a call to NP #2 about that. She said Resident #48 was manipulative and most of the time was her usual self. She said the resident yelled at her sometimes, spit out her food and refused to take her medications. She said she did work on 11/1/22, but she did not recall the details of the resident's hospitalization . She said she was communicating with NP #2 and PCP #1 on several occasions, and that was a normal daily process. She believed that she communicated the drop in the resident's blood pressure to either NP #2 or PCP #1, but she could not locate the notes to confirm that. CNA #8 was interviewed on 12/1/22 at 11:20 a.m. She said she used to work with the resident when she was residing on the unit. She said before Resident #48 got sick she was able to ambulate with a walker independently, she ate by herself and was able to take herself to the bathroom. She said the resident did not have any behaviors, and was able to maintain a conversation. Later the resident declined; she became incontinent, requiring maximum assistance with all ADLs, including feeding. The DON was interviewed on 12/1/22 at 1:34 p.m. She provided a folder that included the resident's medical record, and a timeline of Resident #48's hospitalization and interviews with LPN #4 and CNA #8. She said the folder was put together for the purpose of establishing the timeline of events. It was completed today and it was not an investigation. She said interviews with CNA #8 and LPN #4 were conducted a while ago and documented on her computer. Today, the interviews were printed and signed by staff. Regarding Resident #48, she said at the end of September 2022 the resident was sent to the hospital due to pain with urination. The resident came back on antibiotics, and she did not regain her previous level of functioning. She said staff and management were communicating with her providers daily regarding her treatment. PCP #1 was aware of her mental status changes; she wanted her to complete the antibiotics. She said it was difficult to differentiate between the actual problem and the resident's behaviors. She said the resident would have a day when she was great and another day she would act as if she could not move. She said, No one was overly concerned about her condition. She said later the resident would have the behaviors that she would lay down and would not walk. Her behavior was wishy-washy depending who was in the room. The last weekend of October 2022 the resident was not herself, she would not eat or drink. The lab work was ordered by PCP #1 on 10/31/22 and was drawn on the morning of 11/1/22. The DON said, That night, about 6:00 p.m., I got an email from the ST about the concerns that she observed with the resident. She said she contacted a nurse manager who was on duty that evening. The nurse manager reported to her that the resident was not herself. She said the verbal order for hospitalization was obtained from NP #2 and the resident was sent to the hospital. She said a few minutes later that day they received lab results back that indicated the resident had critically high levels of lithium. The DON said she had a three way telephone call with the ST and her supervisor, the director of rehabilitation (DOR), where they discussed the concerns that ST brought in her email. She said the ST stated that facility staff were not taking the resident's condition seriously. The ST named specific staff members that she was concerned about. The DON said she interviewed the staff named in the email and their story was different. The DON said she did not talk to any other staff members (except the ones that were named in the email), she did not interview other residents or conduct any formal investigation regarding the concerns that the ST brought to her attention. She said she reviewed the resident's record and believed everything was documented appropriately and as needed, and she had not identified any concerns with the resident's care. She said the resident's intake records were showing that the resident was eating and drinking well and she had no reason to believe that it was not documented accurately. She said the DOR (who was no longer working in the facility) did voice concerns about the resident's care to her earlier (prior to the phone call on 11/1/22). She said she communicated all concerns directly to PCP #1, and she did not conduct her own investigation regarding nursing care. The psychiatrist (PSY) was interviewed on 12/1/22 at 2:34 p.m. He said he was following the resident for the last eight years. He said the resident had organized thinking, and at baseline was a pleasant and intelligent person. He said the resident was able to make her own decisions about medical care. The resident also had frequent mood episodes that were related to her diagnosis of bipolar disorder. Such episodes were usually presented as clinical depression, low moods, low motivation, excessive sleep or high anxiety. The manic episodes were manifested as a lack of sleep, pressured speech and inappropriate money spending. He said the resident could be irritable but not aggressive. He said he did observe her yelling and crying and it was typically related to the mood episode. He said during one of her sessions the resident shared what she was unhappy about the nurse who was working with her (LPN #4), and she would get back at the nurse by not taking the medications. He said it was only shared on one occasion. He said he did not report it to anyone in the facility as he thought it was not clinically significant. He said he believed that the resident did refuse medication on one occasion but he was not aware of any others. Regarding lithium toxicity, he said the resident was on the lithium medication for a long time and there was no reason to suspect that the dose was high. He believed the disbalance of the lithium levels was triggered by a blood pressure medication that the resident was started on in August 2022. He said dehydration could contribute to lithium toxicity but was not a primary factor in this case. He said the primary culprit was a blood pressure medication (Lisinopril) due to drug to drug interaction. Unit manager (UM) #1 was interviewed on 12/1/22 at 2:54 p.m. He said he was working in the evening of 10/6/22 when Resident #48 was hospitalized . He said he only knew the resident for the last three weeks. On the evening of 10/6/22 he received a text message from the DON who asked him to take a look at the resident as the ST notified her about the change in the resident's condition. He said he found the resident in the hallway with the ST, the resident was lethargic, and she was not wearing her oxygen. Her vitals were normal except for the oxygen saturation that was 85 (with normal being above 90). He said he provided oxygen for the resident and her oxygen went back to normal. NP #2 arrived, she assessed the resident, the rapid test was negative for COVID, and the decision was made to send the resident to the hospital non-emergently. He [NAME][TRUNCATED]

Based on observations, record review and interviews, the facility failed to maintain a comfortable environment for residents on three of five units. Specifically, the facility failed to ensure comfortable room temperature levels for Unit #1, Unit #2 and Unit #4. Findings include: I. Facility policy and procedure The Homelike Environment policy, revised February 2021, was provided by the regional clinical resource (RCR) on 12/1/22 at 3:14 p.m. It revealed, in pertinent part, The facility and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: comfortable and safe temperatures 71 F (farenheit)-81 F. II. Resident interview Resident #89 who was identified as interviewable by facility assessment was interviewed on 11/28/22 at 11:14 a.m. He said he was often very cold in his room. He said he had notified the maintenance department, but the issue had not been resolved. Resident #89 said he did not like to leave his room because the hallways were very cold. During the interview, Resident #89 was covered in two blankets. III. Observations During a continuous observation on 11/29/22 beginning at 11:01 a.m. and ended at 12:29 p.m. the following was observed: -At 11:36 a.m. the resident in room [ROOM NUMBER] said to an unidentified staff member that she was uncomfortable, because her room was cold. On 11/30/22 at 9:37 a.m. a tour of the building was completed with the maintenance associate (MA). The following was observed throughout the facility. A. The first unit -The hallway near room [ROOM NUMBER] registered at 61.9 F. -Inside room [ROOM NUMBER] registered at 70.2 F. -Above the double doors that lead to the outside smoking area was a two inch gap. B. The second unit -The hallway near room [ROOM NUMBER] registered at 57 F. -Inside room [ROOM NUMBER] registered at 64.2 F. -Inside room [ROOM NUMBER] registered at 70.7 F. C. The fourth unit -The hallway near room [ROOM NUMBER] registered at 70.7 F. -Inside room [ROOM NUMBER] registered at 63 F. IV. Staff interviews The MA was interviewed on 11/29/22 at 11:01 a.m. during the tour of the facility. He said the gap over the doors on the first unit likely led to the cool temperatures on the unit. He said he was going to fill the gap to help regulate the temperature of the unit. The MA said he noticed staff on the second floor unit often left the door to the outside smoking area open, which likely caused the unit to be cold. He said the staff needed to be educated on keeping the doors closed when the temperature outside was low to help regulate the temperature of the building. The MA said the building should be between 75 F and 80 F. The MA was interviewed again on 11/30/22 at 4:31 p.m. he said he was aware the temperatures of the building were sometimes low. He said he had not checked the temperature of the building prior to the tour of the facility on 11/29/22. The MA said he was aware a couple of residents had voiced concerns regarding the temperature of the building. The MA said he had suggested to move Resident #89 to a different room that might have been warmer than the room he was in. The MA said he had contacted an outside company to check the heating system in the last few weeks, but they did not show up to the appointment. The RCR, director of nursing (DON) and the nursing home administrator (NHA) were interviewed on 12/1/22 at 2:53 p.m. The NHA said the temperature of the building should be comfortable for the residents. THe DON said the interdisciplinary team had discussed moving Resident #89 to a different room that may be warmer, but it had not been completed yet.

Based on interviews, observations and record review, the facility failed to ensure three (#99, #11 and #77) of seven residents reviewed for activities of daily living of 44 sample residents were provided the necessary care and services to maintain or improve their level of functioning. Specifically, the facility failed to: -Ensure that Resident #99 and Resident #11 received regular showers; and, -Ensure that Resident #99 and Resident #77 received nail care. Findings include: I. Facility policy and procedure The Activity of Daily Living policy and procedure, revised March 2018, was provided by the nursing home administrator (NHA) on 12/01/22 at 4:44 p.m. It documented, in pertinent part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); d. dining (meals and snacks); and e. communication (speech, language, and any functional communication systems). If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated and revised as appropriate. II. Resident #99 A. Resident status Resident #99, age 64, was admitted on [DATE] and readmitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included unspecified dementia with behavioral disturbances, Wernicke's encephalopathy (degenerative brain disorder) and blindness in the left eye. According to the 9/21/22 minimum data set (MDS) assessment, the resident was unable to complete the brief interview for mental status (BIMS); however it showed that he had short-term and long-term memory impairment with severe impairment in making decisions regarding tasks of daily life. He required extensive assistance of one person with bed mobility, transfers, dressing, toileting and walking and set up for personal hygiene and bathing. He did not reject care. B. Observations On 11/28/22 at 2:20 p.m. Resident #99 hair was tangled and appeared greasy. His fingernails were long and jagged and had brown matter under them. On 11/29/22 at 1:09 p.m. the resident had the same appearance to his hair and nails. On 11/30/22 at 9:00 a.m. the resident had the same appearance to his hair and nails. On 12/1/22 at 11:03 a.m. CNA #3 confirmed that his hair was tangled and greasy and that his nails were long and had brown matter under his fingernails. C. Record review The activities of daily living (ADL) care plan, revised 10/12/22, documented the resident had a self-care deficit related to previous history of homelessness. It indicated that the resident may refuse showers if he needs encouragement and set up and limited assistance when he agrees to bathe. On bath day nails should be checked, cleaned and trimmed and as needed. Any changes should be reported to the nurse. Shower documentation for the month of November 2022 showed one refusal and zero indications of a shower received. The resident requested to have two showers a week. D. Staff interviews CNA #3 was interviewed on 12/1/22 at 11:05 a.m. She said the nurses performed resident nail care. She said that Resident #99 gets showered in the evenings. She said that staff documents all refusals and showers given in the resident's electronic medical record. Licensed practical nurse (LPN) #3 was interviewed on 12/1/22 at 10:45 a.m. She said the activities department did resident nails or the CNAs. She said Resident #99 needed coaching and cueing but he would participate in ADLs with staff persistence. The director of nursing (DON) was interviewed on 12/1/22 at 2:47 p.m. She said CNAs should perform resident nail care including trimming and cleaning, unless the resident was diabetic. She said showers should be performed twice a week unless the resident asked to shower more and it would be documented in the resident's record. She said Resident #99 was not diabetic and CNAs should perform nail care and set up showers and document refusals and showers in the resident's electronic medical record. III. Resident #11 A. Resident status Resident #11, age 62, was admitted on [DATE]. According to the November 2022 CPO, the diagnoses included unspecified dementia with behavioral disturbances, traumatic brain injury, anxiety and depressive episodes. According to the 9/22/22 minimum data set (MDS) assessment revealed the resident had severe impairment with a brief interview for a mental status score of seven out of 15. He required one-person assistance with set up only with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. B. Observations On 11/28/22 at 12:29 a.m. Resident #11 was unkempt, he had greasy hair, he had crumbs on his face and clothing had stains on them and had a distinct smell. On 11/30/22 a.m. Resident #11 appeared the same and in the same clothes. On 12/1/22 a.m. he was to be wearing the same clothes. His hair was greasy and his face had dark brown matter on it. C. Record review The activities of daily living (ADL) care plan, revised on 8/8/22, documented the resident had a self-care deficit related to dementia, brain damage, and seizure disorder. It indicated that the resident may refuse showers; he may need encouragement and set up and limited assistance when he agrees to bathe. Shower documentation for the month of November 2022 showed a refusal on 11/19/22 and 11/26/22. The resident requested two showers a week. -There was no other documentation showing when showers were performed or if resident was re-approached. D. Staff interviews CNA #3 was interviewed on 12/1/22 at 11:05 a.m. She said Resident #11 gets showered in the evenings. She said the staff documents all refusals and showers given in the resident's electronic medical record. Licensed practical nurse (LPN) #3 was interviewed on 12/1/22 at 10:45 a.m. She said that Resident #11 was easy to redirect and almost always participates in ADLs. She said CNAs were responsible for giving showers and documenting refusals and showers that were given in the resident's electronic medical record. The director of nursing (DON) was interviewed on 12/1/22 at 2:47 p.m. She said showers should be performed twice a week unless the resident asked to shower more and was documented in the resident's electronic medical record. She said CNAs should follow the care plan when assisting with showers. 46022 IV. Resident #77 A. Resident status Resident #77, age 76, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), the diagnoses included alcohol use with alcohol-induced persisting dementia, post-traumatic stress disorder, anxiety, cognitive communication deficit, depression and acquired absence of the right upper limb above the elbow (right arm amputation). The 9/9/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS with a score of five out of 15. He was independent with all ADLs. B. Observations and resident interview On 11/28/22 at 2:58 p.m. Resident #77 was sitting on his bed in his room. His fingernails were a half inch extended past the tip of his finger. There was black debris built-up under his five fingernails on his left hand. On 12/1/22 at 10:02 a.m. certified nurse aire (CNA) #8 confirmed Resident #77 had long fingernails that needed to be trimmed and cleaned. CNA #8 asked Resident #77 if he would like his fingernails trimmed and cleaned. Resident #77 responded yes. CNA #8 said she would notify the nurse to help Resident #77 clean and trim his fingernails. C. Record review The ADL care plan, initiated on 10/2/2020 and revised on 9/19/22, documented Resident #77 had the potential for self-care performance deficit related to alcohol induced dementia, post-traumatic stress disorder, anxiety, depression, macular degeneration to the right eye (vision impairment) and a right arm amputation. The interventions included, in pertinent part: resident #77 was able to complete his grooming and hygiene independently, but needed reminders and cueing. A review of Resident #77's nail care log in his medical record on 11/30/22 at 4:00 p.m., revealed the resident had not received nail care in the last 30 days. D. Staff interviews CNA #8 was interviewed on 12/1/22 at 10:02 a.m. She said the nurses were responsible for cutting the resident's fingernails. CNA #8 said when assisting residents with their showers she would help clean their fingernails. Licensed practical nurse (LPN) #6 was interviewed on 12/1/22 at 10:08 a.m. She said the CNAs were responsible for cutting the resident's fingernails. She said Resident #77 should have received help trimming and cleaning his fingernails. The director of nursing (DON), regional clinical resource (RCR) and nursing home administrator (NHA) were interviewed on 12/1/22 at 2:53 p.m. The DON said CNAs were responsible for trimming the resident's fingernails. The DON said Resident #77 was unable to trim his fingernails independently as he was missing his right arm. The DON said his nails should be kept trimmed and cleaned.

Based on interviews and record review, the facility failed to ensure six (#1, #3, #4, #5, #6 and #7) residents of seven sampled residents were kept free from physical abuse. Specifically, the facility failed to ensure interventions were re-evaluated following multiple incidents of resident to resident physical abuse and resident to staff physical abuse by Resident #2 to ensure residents were kept free from physical abuse by Resident #2; one incident which caused physical harm to Resident #1 resulting in a hospital evaluation and orbital surgery. Findings include: I. Facility policy and procedure The Abuse policy and procedure, reviewed (MONTH) (YEAR), was provided by the clinical consultant on 6/19/19 at 12:43 p.m. It revealed, in pertinent part, does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents . Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Providing a safe environment for the resident is one of the most basic and essential duties of our facility. Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychological well-being. Also, verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through use of technology. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment and willful neglect of the resident ' s basic needs. Each facility assesses each potential resident prior to admission. This assessment includes a behavior history. Persons with a significant history or high risk of violent behavior are carefully screened and assessed for appropriateness of admission. II. Resident #2 [NAME] Resident status Resident #2, age 68, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 6/11/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. He required supervision with bed mobility, transfers, dressing, toileting and personal hygiene. It indicated the resident had physical behaviors such as hitting, kicking, pushing, scratching, grabbing, etc. It indicated the resident's behaviors put others at significant risk for physical injury, intruded on the privacy and activity of others, and disrupted their care or living environment. It indicated the resident's behavior had gotten worse since the previous assessment. B. Record review The dementia care plan, revised on 4/12/19, revealed the resident had a [DIAGNOSES REDACTED]. It indicated the resident wandered and paced the hallway and went into other resident rooms. The resident had a history of [REDACTED]. The resident had delusions that female residents were stealing money from him. The interventions included: encourage resident to use the chair in the dining room that was against the wall so that other residents would not touch him to prevent physical aggression; redirect the resident from the resident area, monitor the resident for increased delusions, document the behavior and interventions provided; resident needs observation from time to time to prevent being intruded upon by other residents or wandering into other resident rooms. The impaired cognitive function care plan, revised on 5/14/18, revealed the resident had dementia and impaired thought processes. Interventions included the resident would be able to communicate his basic needs on a daily basis. The 6/7/19 interdisciplinary team (IDT) risk versus benefit statement for [MEDICAL CONDITION] medication use revealed the resident displayed aggression, violence and put other residents at risk. C. Incidents of physical abuse involving Resident #2 1. Incident on 2/27/19 The 2/27/19 nursing progress notes revealed Resident #1 and Resident #2 were observed sitting at the same table in the dining room. Both residents were pulling the table towards themselves. Resident #2 was observed reaching over the table and punching Resident #1 on the right side of his face twice. It indicated Resident #1 had noted swelling and bruising to the right side of his face. The resident had a 4.5 cm x 4 cm bruise to the right side of his cheek and a small abrasion to the right cheek and upper lip. Resident #1 received first aid of an ice pack and Tylenol was administered for pain. The physician was notified and ordered an x-ray to rule out a fracture. The 2/28/19 x-ray result revealed no acute fracture or dislocation to the facial bones. The 2/27/19 abuse investigation revealed the nurse noticed the right eye of Resident #1 was swollen with a black bruise. Resident #1 and Resident #2 were seated at the same table in the dining room. Resident #2 was pulling the table closer to him and the same time Resident #1 began pulling the table. Resident #2 was observed punching Resident #1 twice in the face. Staff intervened immediately and separated both residents. Resident #1 was administered first aid with an ice pack and pain medication. The interventions for Resident #2 included: occupational therapy for activities of daily living, a behavior modification program, modification to the resident ' s restorative program, and the activity program was reviewed to enhance the resident ' s mood as the resident reacts by physical aggression of punching other residents. 2. Incident on 3/18/19 The 3/18/19 nursing progress notes revealed Resident #3 yelled out, he hit me, he hit me. Upon staff intervention, Resident #3 stated that man over there punched me, pointing at Resident #2. A staff member witnessed Resident #2 pulling Resident #3 into the bathroom of a resident room. Resident #2 punched Resident #3 in the eye. Both residents were separated immediately by facility staff. It indicated Resident #3 was provided first aid, such as an ice pack to the resident's right cheek and scheduled Tylenol medication was provided. An assessment was completed and indicated redness noted to the right cheek, and a small light purple bruise to the corner of the right eye that measured 1.5 cm (centimeters) x 1.5 cm. It indicated the interventions were to separate both residents and provide re-direction to Resident #2. The 3/21/19 skin assessment revealed the resident had a noted bruise under the right eye. The measurements were 4.5 cm x 2 cm. It indicated the bruise had spread post physical aggression incident with Resident #2. It indicated the skin was intact and the bruise was dark purple with yellowing under the resident's right eye. 3. Incident on 4/3/19 The 4/3/19 nursing progress note revealed Resident #4 walked into the dining room and began to touch Resident #2. Resident #2 then punched Resident #4 in the chest several times and once to the mouth. Both residents were separated immediately and redirected away from each other. It indicated an assessment was completed for Resident #4 which revealed a reddened area to the right side of her chest. No other injuries were noted. It indicated a light colored bruise began to form on the resident ' s upper chest. The 4/7/19 IDT risk management review note revealed the facility put into place the following interventions from the incident between Resident #2 and Resident #4: Resident #4 was redirected to use the small dining room during meals and away from the main dining room, as Resident #4 had a history of [REDACTED]. The 4/3/19 abuse investigation revealed Resident #2 was moved to a location in the dining room where he can see in front of him and other residents are not able to approach him from behind. It indicated the resident should be checked every 15 minutes. 4. Incident on 4/12/19 The IDT risk management review progress note revealed a food server had entered the secured unit and was positioning the food cart in the dining area. Resident #2 was observed walking by the food server and swung his right arm and elbow at the food server ' s face, hitting him in the mouth. The food server sustained a cut to the upper lip with noted bleeding. The interventions included: education to the food server not to approach the resident from behind and rearrangement of the dining room so the resident would have his back to the wall. 5. Incident on 5/21/19 Resident #1 sustained a right orbital fracture and required a lens replacement which required surgical intervention from being punched in the eye by Resident #2. The 5/21/19 nursing progress note revealed Resident #1 was hit in the right eye by another resident. It indicated the resident's right eye was bleeding, swollen and the lens implant was hanging from the eye. The nurse practitioner was notified and ordered for the resident to be sent to the hospital for evaluation and treatment. The 5/21/19 abuse investigation revealed Resident #2 was standing in the hallway when Resident #1 tried to pass by in his wheelchair. Resident #2 punched Resident #1 in the right eye. Resident #1 was bleeding and taken to his room for further assessment. It indicated the facility moved Resident #2 to the secured unit on the second floor, as this was the second incident between Resident #2 and Resident #1. Resident #2 continued to be checked on by facility staff every 15 minutes indefinitely. Resident #1 was sent to the emergency room for further evaluation. The 5/24/19 nursing progress note revealed the resident returned from the hospital at approximately 2:00 p.m. It indicated the resident was treated for [REDACTED]. 6. Incident on 5/24/19 The 5/24/19 nursing progress notes revealed Resident #5 reported he was punched in the right side of his chest and left forearm by Resident #2. It indicated Resident #2 entered Resident #5 room and when Resident #5 asked Resident #2 to leave, Resident #2 punched Resident #5. The 5/24/19 abuse investigation revealed Resident #5 reported to the nurse, Resident #2 had entered his room the previous night (5/23/19). When Resident #5 asked Resident #2 to leave his room, Resident #2 punched Resident #5 left forearm and upper chest. Resident #5 was assessed with [REDACTED]. The interventions included to move Resident #5 to a private room, add a stop sign to the door to deter residents from wandering into his room, and a picture was placed outside Resident #2 door of boxing gloves as a marker to redirect the resident to his room. The facility continued 15 minute checks on Resident #2. 7. Incident on 6/3/19 The 6/3/19 nursing progress note revealed Resident #6 was hit, open handed to the left temple by Resident #2. It indicated Resident #6 had noted redness to the left side of the face. The 6/3/19 abuse investigation revealed facility staff witnessed Resident #2 punch Resident #6 with a fist to the left side of his face in the dining room. Staff immediately intervened and redirected Resident #2 away from the dining room. The interventions included: staff were provided education to minimize television programs with profanity content, chairs were rearranged to provide more space in between tables in the dining room, and the physician for Resident #2 conducted a medication review and adjusted the residents [MEDICAL CONDITION] medications. The facility continued 15 minute checks on Resident #2. 8. Incident on 6/6/19 The 6/6/19 nursing progress notes revealed Resident #7 was observed falling out of his wheelchair from the seated position in the doorway of his room. Resident #2 was observed walking out of Resident #7 room. Resident #7 stated, he hit me in the head. It indicated Resident #2 entered Resident #7s room and when Resident #7 pushed him out of his room, Resident #2 hit Resident #7 in the head. It indicated Resident #7 had redness noted to the right side of the head. The resident was assessed, supplied first aid, neurochecks initiated and given Tylenol for a headache. The 6/6/19 abuse investigation revealed staff observed Resident #7 falling out of his wheelchair in the doorway of his room. Resident #2 was observed standing in the doorway. Resident #7 reported Resident #2 hit him in the head. Resident #2 said Resident #7 pushed him. The interventions included: Resident #7 was placed on every 15 minute checks by staff; both residents were educated on physical and verbal altercations; offered range of motion, massage, relaxation and breathing techniques; imagery distraction, repositioning, aromatherapy, therapeutic touch, snack, beverage, redirection to the activity program, etc. The facility continued 15 minute checks on Resident #2. III. Failure to ensure interventions were re-evaluated following multiple incidents of resident to resident and resident to staff physical abuse by Resident #2 [NAME] Record review Resident #2 ' s medical record was reviewed on 6/19/19 at 2:38 p.m. It indicated the resident had been placed on 15 minute checks by staff following the third resident to resident physical altercation on 4/3/19. The resident remained on checks every 15 minutes until the survey process on 6/18/19, when he was placed on one to one monitoring with facility staff. During the time the resident was placed on checks every 15 minutes, the resident was involved in four additional physical altercations with other residents, one of which caused physical harm to a resident and required surgical intervention and one identified physical altercation with a staff member. The resident ' s medical record did not reveal the every 15 minute checks were re-evaluated for effectiveness, since the resident continued to be involved in physical altercations with other residents and staff. The facility failed to ensure the safety of the other residents by not re-evaluating every 15 minute checks on Resident #2 for effectiveness and to determine if increased monitoring should be established, such as one to one monitoring, which was put into place during the survey process on 6/18/19 for resident safety. IV. Staff interviews Certified nurse aide (CNA) #1, CNA #2 and licensed practical nurse (LPN) #1 were interviewed on 6/18/19 at 3:39 p.m. LPN #1 said if an altercation occurred between residents, the residents would be separated immediately, provide first aid and care if needed, residents would be placed on every 15 minute checks by staff, notifications would be made to the physician, nursing home administrator (NHA), director of nursing (DON) and the police. She said the nurse should document the incident in each residents' electronic medical record and complete the appropriate assessments. She said the CNAs were responsible for conducting the 15 minute checks and documenting them on the 15 minute check log. She said Resident #2 had been on every 15 minute checks for as long as the resident had been moved to the second floor. She said she was not sure if he was on every 15 minute checks prior to his move to the second floor secured unit. CNA #2 said Resident #2 had physically aggressive behavior toward other residents and staff members. She said the staff were constantly monitoring the resident because of his behavior. LPN #1 said the resident did not have an indicator of when he would be physically violent. She said he could be walking down the hallway, and be physically aggressive with another resident. She said that was what made Resident #2 so difficult to manage. She said the resident constantly walked around the unit and never stayed in the same place for very long. She said his dementia had progressed that he was unable to understand not to hit other people and had a hard time verbally communicating. She said she thinks the resident feels threatened when he is physically aggressive. She said there was no way to tell when the resident was feeling this way to prevent an altercation. CNA #1, CNA #2 and LPN #1 said they did not know if the 15 minute checks were ever re-evaluated for effectiveness. They said the resident had multiple physical altercations with other residents in between the 15 minutes they would check on the resident. They said they felt the 15 minute checks were not effective for the resident because the resident did not have an indicator of when he would be physically aggressive. The staff development coordinator (SDC), social services (SS) #1, unit manager (UM), DON and NHA were interviewed on 6/18/19 at 5:40 p.m. The SDC said Resident #2 was provoked with other residents being in his personal space. She said the other residents did not have to have a negative interaction for Resident #2 to respond with physical aggression. She said the resident was physically aggressive when approached from behind. She said some of their interventions following physical altercations with other residents included the resident sitting in a location where another resident could not approach him from behind. She said the resident frequently walked up and down the unit and it was impossible to always make sure another resident did not approach him from behind. The DON said the resident did not like to be touched unless he initiated the touching. She said when the resident was on the first floor secured unit, the staff would be in the dining area and in the hallway providing monitoring. She said two CNAs would do rounds throughout the unit. She said they kept staff in these locations because that was where most of the physical altercations occurred. The NHA said following the incident with Resident #1 on 5/21/19, Resident #2 was moved to the second floor secured unit. He said that was the second incident in which Resident #2 punched Resident #1 in the eye. He said Resident #2 was placed on every 15 minute checks prior to the resident being moved to the second floor secured unit. He said the 15 minute checks continued, indefinitely once the resident was moved. The SDC said the 15 minute checks were initiated to ensure Resident #2 was not getting too close to other residents. They acknowledged the resident continued to have multiple physically aggressive behaviors toward other residents in between the 15 minute check intervals. They said they did not know how long in between the checks the resident would have altercations. The NHA said that had not been logged or monitored. The NHA said the every 15 minute checks had not been re-evaluated by the IDT. He confirmed the resident did not have an indicator of when he would become physically violent. He confirmed the resident had been involved in four additional physically aggressive incidents with residents and one with a staff member since the 15 minute checks were initiated. He confirmed the resident was placed on one to one monitoring during the survey process to ensure the safety of the other resident's on the secured unit. He said the resident's behavior was discussed in (MONTH) 2019 during the [MEDICAL CONDITION] meeting and the resident was placed on an as needed (PRN) [MEDICATION NAME] medication. He acknowledged the 15 minute checks should have been re-evaluated for effectiveness. The clinical consultant was interviewed on 6/19/19 at 1:26 p.m. She said Resident #2 was sent to the hospital on [DATE] for a psychological evaluation. She said during the process of transferring the resident, he became physically violent and was admitted to the psychological ward for further treatment.

Based on observation, interviews and record reviews, the facility failed to ensure two of ten sample residents (#2 and #3) received the care and services necessary to attain and/or maintain their highest practicable level of well-being. Specifically: -The facility failed to provide resident #2 the care necessary to prevent skin breakdown. The resident entered the facility with an "open blister" to his right great toe. This area deteriorated, became painful and infected with maggots and new areas of skin breakdown with necrosis and infection developed. -The facility failed to ensure #3's pelvic belt was monitored for comfort and safety and that the resident was assessed after a fall. Cross reference F441 and F469 The findings include: 1. Resident #2, age 59, was admitted to the facility on [DATE], from the hospital. The face sheet of the same date indicated admitting [DIAGNOSES REDACTED]. a. Resident Status on Admission Review of the facility History & Physical dated 6/15/13 indicated the resident was seen in his room by the physician. The physician documented the resident had no open wounds or skin problems. The admission nursing assessment completed by a facility registered nurse and dated 6/11/13 indicated in the section titled "general skin condition" that the resident's skin was pink and intact. A picture area replicating the human body had a circle around the right great toe and the words open blister measuring 3cm x 2cm next to the toe area. A review of the document titled "3 day toileting pattern worksheet" indicated the worksheet was used to determine a resident's continence of bowel and bladder on a three day trial. The resident's trial began on 6/11/13 and was completed on 6/13/13. The words 'continent of bowel and bladder' were written at the top right corner of the document. The MDS dated [DATE] indicated in section G0600 the resident used a walker and wheelchair for ambulation. The MDS also indicated that the resident required only cuing and oversight with ambulation and transfers. b. Change of Condition Nursing progress notes, wound care documents, physician notes and podiatry progress notes from 6/11/13 to 10/3/13 documented the development and progression of three after admission. Progression of wounds: -6/11/13-admitted to the facility with a blister to the right great toe 2cmx3cm (wound #1). -6/25/13-resident saw facility podiatrist and received band aid and antibiotic ointment for wound #1. -6/26/13-blister and dead tissue to the right 5th toe 1.8cmx1cm. (Wound #2) -7/03/13-nursing progress notes indicated that the right great toe with toe nail split and bruising to the tip of the right great toe (wound #1). Education provided by nursing to the resident to wear non-skid socks. -7/03/13-Wound #2 blister to 5th right toe with black dead tissue present 1.5cmx1cm (1 week from previous assessment). -7/05/13-resident reporting increased pain to right foot and toes. Nursing documented the area was healing. -7/12/13-wound #1 was documented as base of nailbed black, drainage and sensitive to touch. No measurements were taken as the toe had necrosed and was no longer a viable part of the resident's body. -7/16/13-physician visit at facility staff request for wounds on toes of the right foot. The physician ordered diabetic shoes. No mention of wound #2. -7/17/13-Wound #1 identified by nursing as having a blister in nailbed of the right great toe with a large 1.5cmx1.6cm blood blister present. No signs of infection and surrounding skin dry and intact. -7/25/13-Resident saw facility podiatrist. The podiatrist documented that Wound #1 to the great right toe had an area of 1.5cmx1.0cm black eschar (dead) tissue and Wound #2 was painful to the resident and the area would need amputation. Resident was reported to have feces in his right foot sock when transported from the facility to the podiatrist. -7/26/13-Nursing documented that when the dressing was changed to wound #1, it was saturated with serosanguinous drainage, red and inflamed, the skin was macerated, the wound had signs of infection and the resident was wearing clean socks. -7/29/13-Wound #1 right great toe. Nursing documented the facility acquired wound is now 2cmx1.3cm and now has depth of 0.1cm. The wound had progressed from bruising to the tip of the toe to an open wound twice the size and now having depth (depth indicating the wound is no longer superficial in appearance). -8/3/13-Wound #1, to the right great toe has dead tissue with redness in the surrounding tissue and tender to touch. The resident was medicated with Tylenol for pain. -8/4/13-Resident complained of extreme pain to the right great toe area and was medicated with a narcotic pain reliever. -8/16/13-The resident's [MEDICATION NAME], a pain reliever, was increased by 200mg a day. The resident had been receiving 200mg twice daily and was increased to three times daily. -8/19/13-Nursing documented that the resident was complaining of severe pain to the right foot. The physician ordered a narcotic pain reliever [MEDICATION NAME] 5mg twice daily for pain as scheduled medication. -8/22/13-Wound #2 was documented by the nursing staff as 90% black eschar (dead) tissue with redness and inflammation to the surrounding tissue. -9/04/13-According to the progress note from the podiatrist dated 9/4/13, the facility called the podiatrist to report finding maggots in the resident's great right toe wound and wanted to know what to do. The facility reported to the physician that all the resident's socks were washed. The physician instructed the facility to clean the area and apply a topical ointment. -9/12/13-Wound #3. Nursing progress notes indicated the resident had a third wound to the right heel. This represented the second acquired wound since admission three months earlier. -9/18/13-Nursing documents that Wound #1 to the great toe is now 4cmx2.6cm (four times the size from the original blister). -10/3/13-Wound #2- waiting for amputation to the 5th toe of the right foot, Wound #1- toe is no longer viable part of the body with open area to the top, drainage, odor and cellulitic, and per the podiatry notes likely will need amputation as well. Wound #3 to the resident's right heel is being monitored by the facility. c. Facility Response Care plan review revealed the following problems were care planned to address the resident's needs: (1) Potential of infection related to the right foot and toes, dated 6/11/13 and updated 9/19/13. The goal was that the resident would be infection free with a target date of 6/27/13. The plan documented the resident was started on antibiotics on 8/29/13 for wound infections. (2) ADL deficits, dated 6/11/13 and updated 9/19/13. The goal was that the resident would maintain his current ADL status through the next review period of 6/27/13. The interventions listed included assisting the resident with showers, provide set up for bathing and encourage the resident to change clothes daily. The interventions included the statement that the resident was independent and needed no help with toileting. (3) Alteration in skin integrity, dated 6/11/13 and updated 9/19/13. The goal was the resident would have no complications from his wounds. The target date was 6/27/13. Interventions included: appointments with outside podiatry and surgeons, keep the area dry, and provide minimum assistance with bed mobility and treatment to wounds per orders. Another intervention documented included having the wound team assess the resident's wounds weekly and as needed. d. Failures in Facility's Response (1) Record Review a) See care plans above; the care plans lacked information on the treatment plan for the resident's wounds, interventions to prevent complications and to minimize pain. See below; the facility failed to take steps to minimize friction and to protect the wounds on the resident's right foot. In addition, the facility failed to take steps to keep the resident's wound and bandages clean. b) Review of podiatry documentation revealed the facility failed to consistently implement podiatry orders. Specifically: A podiatry appointment dated 7/10/13 indicated that the resident was to have a topical ointment applied to the great toe and the 5th toe of the right foot once daily. The document further indicated that the facility was informed of the treatment plan. A podiatry appointment dated 9/6/13 indicated that the resident was evaluated for follow up after the facility reported maggots in the right great toe wound. The document indicated that the facility was re-instructed regarding keep the resident's wounds clean and free of fecal matter and maggots. c) Review of the resident's treatment records revealed the facility failed to consistently perform ordered treatments A review of the resident's treatment record for the months of August 2013 indicated the resident received the ordered treatment for 12 days in a month of 31 days. A review of the resident's treatment record for the month of September 2013 indicated the resident's treatment ordered daily was completed by the facility twice in the month of 30 days. d) Review of the pain assessment document revealed the facility failed to timely assess the resident's pain The pain assessment located in the medical record indicated that the document had been filled out twice since admission to the facility. The document indicated that the dates the resident was assessed as 7/22/13 and 9/19/13. But see record review above; records revealed resident complained of pain and required increased pain medication starting 8/13/13. There was no documentation his pain was reassessed until 9/19/13. e) Review of the resident's "Clinical conditions and primary risk factors for wound development" assessments revealed the facility failed to recognize the resident's risk for wound development. Specifically: A document labeled "Clinical condition primary risk factors for wound development" authored by a facility registered nurse and dated on admission to the facility 6/12/13 (see admitted above 6/11/13), indicated that the resident scored "20," reflecting no risk for developing a wound, although see above, the resident's [DIAGNOSES REDACTED]. Another "Clinical condition primary risk factors for wound development" assessment dated [DATE], after the resident had experienced two new areas of skin breakdown after admission revealed the resident again scored "20" representing no risk for wound development. (2) Observations a) Wound Care On 10/2/13 at 8:35 a.m., resident #2 was observed sitting in his wheelchair next to his bed. His right foot had a dirty brown bandage wrapped up towards his leg approximately two inches above the ankle. The bandage had a visible yellow stain at the outer edge near the 5th toe area. On 10/2/13 at 9:45 a.m., the resident was observed seated in a wheelchair in his room. The sock on his left foot was dirty. The bandage covering the resident's right foot was dirty and an unknown brown substance was visible on the outer edge of the bandage. On 10/3/13 at approximately 9:45 a.m., a dressing change to the resident's right foot and toe area was observed as preformed by the licensed practical nurse (LPN) on duty. -The current bandage to the great right toe was removed. The bandage was observed to have medium yellow and odiferous drainage oozing from the area. There were approximately ten flies in the room at the time of the dressing change. -The LPN retrieved a basin for soaking the resident's right foot. The basin was located between the resident's privacy curtain, a dresser and a television stand. The basin was not wrapped in a protective sleeve and was used "as is," that is, without rinsing or cleaning. The LPN placed the resident's right foot in the basin which was filled with warm and soapy water. -The LPN was observed swatting flies away from the resident's basin while the resident's foot was soaking. Three flies were observed on the edges of the basin. The nurse did not change the water after the flies were observed. The wound appearances were as follows: -Wound #2 to the 5th right toe was observed to be ready for amputation; the entire toe was black in color and there was no obvious blood flow to the area. -Wound #1 to the right great toe was observed to have no living tissue above the middle joint of the toe. The area where the blister originated and the maggot was found was missing from tissue maceration and decay. The area of the wound had an extremely offensive odor and thick yellow drainage leaking from the tip of the toe. The resident's foot and ankle were red in color indicating possible cellulites. -Wound #3 to the right heel area was observed to be red and non-blanchable and the surrounding tissue was observed to be soft and mushy. b) Pressure and Friction The resident was observed at various times of the day during the investigation of 10/2/13 to 10/8/13 in his wheelchair in his room and in the hallway. The resident's wheelchair did not have foot pedals and the resident was observed placing his feet to the ground to self propel his wheelchair. The resident's right foot with wound #3 was observed to make contact with the ground every time the resident self propelled his wheelchair. (3) Interviews On 10/2/13 at approximately 2:00 p.m., the resident was interviewed. He stated, "if you are not sick, dying or old, they don't care about you." He said staff did not always soak his foot or change his dressing on a daily basis. He said he was aware that staff had found maggots in his wound. He further stated that his right foot hurt all the time and the pain reliever the facility give him did not work all the time. On 10/2/13 at approximately 9:15 a.m., resident #2's family member was interviewed. -The family member said resident #2, prior to admission, had not had any wounds on either foot. -The family member stated, "I found out that the resident had maggots in his wound when I took the resident to a specialist for an appointment regarding his vascular [MEDICAL CONDITION]. The physician told me that the facility had found maggots in his wounds." -The family member stated that when she picked up the resident for his podiatry appointment, the resident had feces in the cuffs of his socks. When the specialist removed the resident's socks to assess the area, there were feces in the bandage covering the resident's wounds. She said the podiatrist shared that having feces in a wound could possibly attract more flies and produce more maggots. She stated that when she went to visit the resident she noticed flies in the facility. -The family member said she was not aware staff was soaking the resident's right foot, stating she had never seen the facility use the basin even though she was aware there was a doctor's order for foot soak prior to bandage changes. On 10/3/13 at approximately 9:15 a.m., the unit manager, a registered nurse/RN, was interviewed. -The RN said, on 9/4/13 at approximately 10:00 a.m., she was doing the dressing change for the resident's right toe area and noticed a maggot at the end of the resident's great right toe wound. She called the physician for further assistance and orders. -The RN said she was aware that the resident had fecal matter in his socks in the area of the wounds. She stated that the facility would shower the resident prior to outside appointments. -The RN stated the flies could be bad but it depended on the floor of the facility. The 4th floor, where the resident resides, has more flies because of the smoking door used by all residents and staff in the facility. On 10/3/13 the director of nursing (DON) was interviewed. The interview revealed that the facility had not a nurse on staff that was certified in wound care for the last six months. The previous wound nurse had stepped down from the wound nurse position and was now a floor nurse. a) Additional Facility Failures Cross reference F441; observations and interviews revealed additional failures in maintaining a sanitary environment and staff implementation of infection control practices. Cross reference F469; additional observations and interviews revealed failure to control flies in resident care areas. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to hospice care on 11/10/12. The most recent Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had unclear speech, rarely or never made self understood and usually was able to understand others. She had short- and long-term memory problems and her cognitive skills for daily decision-making were documented as severely impaired. The resident required total assistance with all activities of daily living (ADLs). a. Pelvic Belt (1) Record Review - Plan for use of pelvic belt Care plan review revealed the resident's care plan for altered mobility status read, "Resident requires Broda chair (a specialized chair with adjustable seat tilt and back recline) with pelvic belt to maintain comfort (and) positioning (secondary to) continuous movements (chorea) r/t (related to) [MEDICAL CONDITION]'s disease." -Under goals, it read, "Res(ident) will be safe and comfortable" -Under approaches read in pertinent part: pelvic belt in use to maintain positioning in chair to maximize comfort for resident and safety; involuntary mvmts (movements) are severe and cause her to move into positions that are not optimal when sitting when pelvic belt not present; and release pelvic belt every (two hours) and prn (when needed). (2) Record review, observations and interview - Failure to ensure resident safety and comfort with pelvic belt Record Review There was no safety assessment in the record for the resident's use of the pelvic belt which per <http://rehabmart.com/product/pelvic-slider-control-restraint> is secured behind the wheelchair with waist straps, and between the patient's legs, while resident is in the Broda chair. See care plan above; the care plan failed to address how tight the pelvic belt should be for the resident's safety and comfort or how often placement of the belt should be assessed by staff. Observation On 10/7/13 at 10:52 a.m., the resident was observed near the nurses' station, sitting in her Broda chair. The chair was tilted. -The resident was secured to the chair in pelvis area with a pelvic belt. The belt was very tight, cutting in to resident's stomach bare skin as the resident's shirt was riding up above the pelvic belt. -The unit medication nurse (a licensed practical nurse/LPN) was asked to assess the placement of the belt and she was unable to put her hand between the restraint and resident's skin to tuck the resident's shirt in. The LPN asked a certified nurse aide (CNA) to reposition the resident. Interviews On 10/7/13 at 2:12 p.m., the CNA (see above) stated she had been taking care of the resident since her move from another unit on 7/2/13. She said she did not receive an inservice or any kind of education about resident's disease and proper positioning in Broda chair using the pelvic belt. She stated that when the resident was transferred from her bed to the Broda chair, the chair was reclined to semi-supine position and the resident's belt was tied to the back of the chair. Then, the back of the chair was lifted to semi sitting position and tilted. She said staff did not check how tight the belt was against resident's stomach. b. Assessment Post - Fall On 10/3/13 at 9:20 a.m., the medication nurse (LPN) stated resident #3 sustained several bruises and abrasions after her fall on 9/22/13. Record Review: Review of resident's Care Plan for risk for injury from falls revealed several pages with multiple falls documented. Review of the resident's medical records on 10/3/13 and 10/7/13 revealed Hospice Services Nursing Visit Note dated 9/25/13 and documented "two areas of healing abrasions to bilateral knees areas with healing scabs." Review of the facility incident report on 10/7/13 revealed the resident fell out of her bed on 9/22/13 at 9:00 a.m. The resident was transferred back to her bed with assistance of two CNAs. There was no documentation the resident was assessed by a nurse for injuries right after her fall and before being transferred back to bed. The Injury of Unknown Origin Investigation dated 9/22/13 at 11:30 a.m. (reported by CNA) revealed bruises and abrasions on upper anterior and lateral knees, right posterior forearm, left posterior elbow, left shoulder posterior and forehead. The Employee Interview documented: "When getting up (resident's name) for lunch we noticed abrasions on (resident's name) shoulder, arms and legs. We notified the nurse .... She also had a hematoma on her hip." The documentation revealed the night shift staff (two CNAs) did not observe the above bruises and abrasions that morning before resident's fall. A nurses' note dated 9/22/13 documented "Skin assessment completed revealing, 4cm (centimeter) x 2.5 cm abrasion to right upper anterior knee with 3 cm by 3 cm brown colored bruise just posterolateral to the abrasion. Noted 1 cm by 1 cm abrasion to right upper lateral knee. Noted 1 cm by 2.5 cm dry scabbing abrasion to left lateral knee, 1 cm by 0.5 cm abrasion to left lateral knee. Right posterior forearm with 0.5 cm by 0.5 cm scab. Left posterior elbow with 2 cm by 1 cm abrasion and 1 cm by 1 cm abrasion. Left upper posterior lateral forearm abrasions measures 2.5 cm by 1 cm. Bruise to left forehead 2 cm by 2 cm. left posterior upper shoulder with 4 cm by 3.5 cm abrasion and 1.5 cm by 1 cm abrasion. Left lower lip reddened with swelling present." Interviews: On 10/7/13 at 2:15 p.m., a CNA who was caring for the resident on 9/22/13, stated that on 9/22/13 approximately at 11:30 a.m., when she was getting the resident out of bed for lunch, she discovered several bruises all over the resident's body. She notified the nurse right away; however, the nurse did not evaluate resident's injuries at that time. On 10/8/13 at 11:58 a.m., the Assistant Director of Nurses (ADON) stated she was responsible for falls investigations in the facility and she would expect the nurse on the unit to immediately and thoroughly assess resident's injuries, abrasions and bruises after the fall. On 10/8/13 at 12:40 p.m., the DON stated that the unit nurse did not assess the resident for injuries after her fall on 9/22/13. She added that she came to the facility in the afternoon that day (a few hours after resident's fall) to assess resident for injuries.