Every finding on record at Brookshire Post Acute

Based on record review, and interviews the facility failed to ensure that the Social Security benefits payee was the designated resident's legal representative, for one (#1) of three residents out of six sample residents. Specifically, the facility failed to receive authorization from Resident #1's legal representative to transfer social security benefits from the legal representative to the facility. Findings include:I. Facility policy and procedureThe Management of Residents' Personal Funds policy, revised March 2021, was provided by clinical resource consultant #1 on 8/12/26 at 4:50 p.m. via email. It read in pertinent part, Our facility manages the personal funds of residents who request the facility to do so. Resident funds may be managed by any of the following: The resident may manage his or her own personal funds; The resident may designate a representative to manage his or her personal funds; The resident may apply to the Social Security Administration to have a representative payee designated for purposes of federal and state benefits to which he or she may be entitled; and, Should the resident elect to have the facility manage his or her personal funds, it is authorized in writing by the resident or the resident's representative, and a copy of such authorization is documented in the resident's medical record.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included Alzheimer's disease with late onset, cognitive communication deficit, auditory hallucinations, dysphagia (trouble in swallowing), anxiety disorder, depression, and dementia with psychotic disturbances. The 6/30/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment. The resident had total dependence upon staff for most cares. The resident's preferred language was Korean and an interpreter was needed to communicate. B. Resident #1's representative interviewResident #1's representative was interviewed on 8/12/26 at 10:00 a.m. The representative said she was the power of attorney (POA) for the resident. The representative said since Resident #1 admitted into the facility over two years ago the representative had paid Resident #1's monthly bills on time to the facility. The representative said Resident #1 could not speak, was in a wheelchair, and needed staff to care for her 24 hours per day. The representative said she was the payee to receive Resident #1's Social Security benefits. The representative said Resident #1's Social Security monthly checks were deposited in an account that she set up for Resident #1. The representative said at the beginning of every month the Social Security office deposited Resident #1's money, and then the representative paid for the resident's expenses at the facility. The representative said around 3/3/26 there was no government money deposited into the resident's account. The representative said she initially thought there was identity theft, and that someone had stolen Resident #1's money. The resident's representative said around 3/3/26 she contacted the facility and spoke to the former business office manager to let the office know that something had happened with Resident #1's money. The representative said she told the former business office manager to not kick Resident #1 out, and that the representative would figure out the finances. The representative said it was later revealed the former business office manager knew what had happened but did not admit to changing the payee for Resident #1's money deposited at the facility and not with the representative. The representative said she contacted the police department, filed a report, and spoke with a detective to discuss identity theft.The representative said after she spoke with the police, she called the Social Security office and she was told by the Social Security office that someone had switched the payee for Resident #1, but the Social Security office could not tell her who switched the payee representative.The representative said she never gave anyone at the facility permission to change her financial responsibility to have Resident #1's benefit check deposited to the facility. The representative said she went back to the facility and told the former business office manager that the police were notified. The representative said it was then that the former business office manager admitted that she had called the Social Security office and changed Resident #1's payee. The representative said the former business office manager told her that she changed the payee source because was afraid the representative would not pay. The representative said when clinical resource consultant #2 (see interview below), who was in finance for the corporation, became involved there was an investigation. The representative said the facility received money from Social Security benefits for only for the month of March 2026. The representative said the payee went back to the POA for April 2026. C. Record reviewThe designation of authorized representative to handle Resident #1's Medicaid benefits was provided by clinical resource consultant #1 on 8/12/26 at 3:00 p.m. The resident's representative signed the document on 2/15/24 (two years prior to the incident). The document revealed that the resident's representative was the designated representative to act in the interests of the resident. The document revealed the resident's representative could cancel their authority by notifying the appropriate agencies in writing. III. Staff interviewClinical resource consultant #2 was interviewed on 8/12/26 at 3:13 p.m. Clinical resource consultant #2 said on 6/4/26 the resident's representative spoke to him about the former business office manager, and an investigation began into the financial matter. Clinical resource consultant #2 said during the investigation the former business office manager spoke to him and said Resident #1's representative had called the police. Clinical resource consultant #2 said he initially thought the former business office manager submitted the correct forms to legally change the payee source, but that was not true, and there was no documentation of any forms sent to Social Security during clinical resource consultant #2's investigation. Clinical resource consultant #2 said no forms that would be sent to the Social Security office to change the payee were ever found in the facility or in the financial systems of the company, or in Resident #1's medical records. Clinical resource consultant #2 said he felt the reason the situation happened was because the former business office manager and the resident's representative did not get along. Clinical resource consultant #2 said the resident's representative handled Resident #1's finances appropriately, always paid on time, and never mishandled any finances for Resident #1. Clinical resource consultant #2 said in the investigation it was discovered on 1/21/26 the former business office manager had the Social Security office change the payee to the facility without knowledge or permission from the resident's representative. Clinical resource consultant #2 said on 3/3/26 the Social Security office deposited Resident #1's money into the facility's account, not into the representative's account. Clinical resource consultant #2 said the resident's representative changed it back to the representative during the month of March 2026, and by April 2026 the payee returned to the resident's representative. Clinical resource consultant #2 said no payment changes ever affected Resident #1's medical care. Clinical resource consultant #2 said the former business office manager acted alone, and had no corporate approval to do what was done. Clinical resource consultant #2 said the employee was no longer employed at the facility or with the company. Clinical resource consultant #2 said the former business office manager had training to handle the situation in the legal way it should have been hanlded.Clinical resource consultant #2 said the former nursing home administrator (NHA) knew about the payee switch because he would have had to sign the authorization to do the direct deposit. The clinical resource consultant #2 said he did not think the former NHA knew what was going on, and that the former NHA did not work for the company any more. Clinical resource consultant #2 said he knew there would be legal repercussions due to what the former business office manager had done. Clinical resource consultant #2 said there was no staff education after the incident because he expected it was a one time occurrence.Clinical resource consultant #1 was interviewed on 8/12/26 at 4:00 p.m. Clinical resource consultant #1 said the former business office manager had corporate training on the code of conduct and business ethics. Clinical resource consultant #1 provided the education on fraud and abuse laws which was signed by the former business office manager on 10/28/24. Clinical resource consultant #1 said in order to change the legal representative to the facility there would have been required documents but the facility and its corporation were unable to find any documentation for Resident #1 during their investigation. Clinical resource consultant #1 said the former business office manager had not financially profited from the situation for themselves or the facility.

Based on interviews and record review, the facility failed to take steps to protect one (#1) of three residents from physical abuse out of six sample residents reviewed for abuse. Specifically, the facility failed to protect Resident #1 from physical abuse by Resident #2 on 10/15/25.Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy and procedure, revised 2001, was provided by the nursing home administrator (NHA) on 1/6/26 at 5:58 p.m. It read in pertinent part, The administrator is responsible for determining what actions are needed for the protection of residents. The individual conducting the investigation at a minimum observes the alleged victim including their interactions with staff and other residents and documents the investigation completely and thoroughly. The follow-up investigation report will provide sufficient information to describe the results of the investigation and indicate any corrective actions taken if the allegation was verified. II. Incident of physical abuse of Resident #1 by Resident #2 on 10/15/25 A. Facility investigation The 10/15/25 investigation revealed the nurse was called by a certified nurse aide (CNA) who was pointing at Resident #1's head. The nurse noticed Resident #1 was bleeding from an open skin wound on his top scalp. The dimension of the wound was about 0.4 inches (in) in length. Resident #1 said someone hit him with a cup. Resident #2, who was alert and oriented times two to three, verbalized not knowing how it happened but admitted having an altercation with Resident #1 who at the time was in the hallway and Resident #1 was found bleeding from his head. Resident #2 said everything went so fast. The registered nurse (RN) was notified, an assessment was done, vital signs were taken and neurological checks were initiated for Resident #1, per the facility's protocol. Resident #1 was treated with first aid and administered as needed Tylenol for pain management per the physician's recommendation. Resident #1 was taken to the director of nursing's (DON) office to be separated from Resident #2 and interviewed by the DON about the incident. Frequent checks were initiated. Resident #2 was then interviewed by the DON for more information on the incident. Frequent visual checks were initiated for Resident #2. The facility's conclusion revealed the facility and the staff acted quickly, appropriately and effectively to minimize the interaction between Resident #1 and Resident #2 who both resided in the secure unit. Camera footage was reviewed and revealed the incident had happened surprisingly, out of nowhere, with both male residents taking a part in escalating the situation. There did not appear to be any preconceived or knowing intent but more so a reaction. The occurrence did not result in serious bodily injury and both residents were able to enjoy lunch calmly shortly thereafter. Both residents were diagnosed with dementia and could not recall the event shortly afterward. -Review of the 10/15/25 investigation revealed there was no documentation to indicate there was immediate education to staff to keep Resident #1 safe and other residents safe while the investigation was in process. -Review of the 10/15/25 investigation revealed there was no root cause determined for why the incident occurred. B. Video footage of the 10/15/25 incident between Resident #1 and Resident #2The video footage of the 10/15/25 incident between Resident #1 and Resident #2 was reviewed on 1/6/26 at 4:10 p.m. with the NHA, DON and the regional nurse consultant. The video footage revealed Resident #2 was walking up and down the secured unit with a commercial grade plastic polypropylene reusable coffee mug in his hand. Resident #1 was sitting in a chair next to the door leading to the main facility. When Resident #2 walked back towards where Resident #1 was sitting, Resident #2 walked into Resident #1's personal space. Resident #1 put his right foot out and tripped Resident #2. Resident #2 did not fall, but walked back towards Resident #1 and hit the top of Resident #1's head with his coffee cup and then Resident #2 walked away. Resident #1 stood up and walked out of the camera view. Resident #1 was visibly upset based on his facial expressions. III. Resident #1 - victim A. Resident status Resident #1, age [AGE], was admitted on [DATE] and discharged on 10/17/25. According to the January 2026 computerized physician orders (CPO), diagnoses included vascular dementia, cognitive communication deficit, anxiety disorder and failure to thrive. According to the 10/9/25 admission assessment, the resident was alert and oriented times one to two and was able to make some needs known verbally. B. Record review The 10/15/25 nurse note revealed Resident #1 sustained a minor injury on the top of his scalp following a possible confrontation with Resident #2. A voicemail was left for the physician and the DON was notified. Resident #1 was stable after first aid was administered. Resident #1 reported no sign of pain at the time of the documentation and the facility would continue to monitor for any change in condition. The 10/16/25 nurse note revealed Resident #1 was being monitored for his scalp wound. Resident #1 did not complain of pain and no pharmacological treatment was given. Resident #1 slept through the night. The resident would continue to be monitored for any change in condition. The 10/16/25 physician note revealed Resident #1 was seen in his room. He was sitting on the side of the bed. Resident #1 was awake, alert and very hard of hearing. He appeared confused at baseline. As per staff, he had an altercation with another resident (Resident #2) where the other resident hit Resident #1 on the left side of his scalp. The residents were separated to avoid any further conflict. Resident #1 had his belongings in a bag and had been sitting with his belongings and not wanting to go back to his room. The resident was currently independent and ambulatory. Resident #1 did not know why he was in the facility. He was in the secure unit because he was prone to leaving the facility. He was currently stable with no acute distress and the facility would continue to monitor him closely. The 10/17/25 discharge summary revealed Resident #1 was discharged to another nursing facility in a city the resident preferred to live in. The summary revealed the resident constantly verbalized the desire to discharge to his preferred city and was wandering around the unit constantly. The skin condition revealed he had an abrasion on the top of his scalp on the left side related to an encounter with another resident. There was no evidence of bleeding. Resident #1 reported tenderness with palpation. -A review of Resident #1's electronic medical record (EMR) revealed there were no new interventions in place to protect him from Resident #2 following the incident on 10/15/25. -A review of Resident #1's EMR revealed there was no documentation Resident #1 was monitored after the incident for any indication Resident #1's baseline changed.IV. Resident #2 - assailant A. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the January 2026 CPO, diagnoses included dementia with behavior disturbance, bipolar disorder, cognitive communication deficit and unspecified mood disorder. According to the 10/14/25 minimum data set (MDS) assessment, the resident was cognitively impaired with a brief interview mental status (BIMS) score of eight out of 15. He was independent with oral hygiene, toileting and dressing. He required set up assistance with eating, showering and personal hygiene. The 10/14/25 MDS assessment revealed his cognitive patterns include inattention and disorganized thinking. The 10/14/25 MDS assessment revealed he had physical behaviors not directed toward others. B. Record reviewThe psychosocial behavior care plan, initiated 4/23/25 and revised 5/19/25, revealed Resident #2 had a diagnosis of dementia with behaviors and unspecified bipolar and related disorder. Resident #2 had exhibited verbal aggression towards staff and refused care. Resident #2 had a history of hostile and physically aggressive behavior prior to admission. Resident #2 had exhibited paranoid, suspiciousness, avoidance, irritability, agitation, persistence worry, preservation, conspiracy theories, grandiosity, mood lability and obsessiveness. Resident #2 had a history of several psychiatric hospitalizations and homelessness. Resident #2 refused medication and care. Interventions included activities assessment for diversional activities, administering medications as ordered, anticipating the resident's needs and meeting them promptly, documenting and recording behavioral episodes, encouraging the resident to verbalize feelings, establishing a rapport, providing simple direct reminders as indicated, reducing stimulation and social services visits as indicated. Additional interventions included if Resident #2 was agitated or aggressive, attempting to redirect the resident to another area in the facility for safety, reorienting the resident to the current situation, providing a safe and secure environment, offering to take the resident outside, offering a magazine or book to read, one-on one conversations with staff, offering coffee or juice. The 10/15/25 behavior note revealed Resident #2 said everything happened so fast he was not able to say what happened. He could not remember anything but he was scared and he thought someone was going to attack him. Resident #2 was sitting in the common area with no apparent distress and denied any pain. Resident #2 said he was not currently scared. Resident #2 was offered to use the outside patio or go to his room but he declined and verbalized feeling safe again. The 10/15/25 nurse note revealed the nurse interviewed Resident #2 about a possible altercation between Resident #2 and Resident #1. Resident #2 admitted what happened with Resident #1 and declined intentionally hurting Resident #1. Resident #2 said everything happened so fast. Both Resident #1 and Resident #2 were stable, alert and oriented times two. The resident's vital signs were within normal limits with no signs of discomfort noted at that time. The 10/16/25 physician note revealed Resident #2 was seen walking in the secure unit in the facility. He was currently cooperative with no acute distress. Per the staff, Resident #2 struck another resident (Resident #1) but said everything happened so fast he did not remember what happened. Resident #2 thought he was being attacked and asked why he struck the other resident. Neither Resident #2 or Resident #1 had no visible injuries bleeding or bruising and they were separated from each other. -A review of Resident #2's EMR revealed there were no new interventions in place to prevent another altercation with Resident #1. V. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 1/6/26 at approximately 3:00 p.m. LPN #1 said she knew a resident had aggressive behaviors by observing the resident in the unit and based on their diagnosis in their EMR. LPN #1 said there were physician's orders to track behaviors and what interventions were used. LPN #1 said if there was a resident-to-resident altercation she was told about it during shift change in a verbal report. She said she was familiar with Resident #2 and he had been in resident-to-resident altercations. LPN #1 said she was not working when the 10/15/25 incident occurred but she heard it was between Resident #2 and Resident #1. LPN #1 said Resident #2 had aggressive behaviors. LPN #1 said there was a time a couple months ago when Resident #2 was fixated on getting his car and wanting to go outside. LPN #1 said she tried to explain to Resident #2 that he did not have a car but he did not understand and his behavior escalated. LPN #1 said after that incident, she learned to meet him where he was. LPN #1 said the interventions were not documented in his chart. LPN #1 said if she suspected abuse, she first ensured the resident was safe, initiated a risk management file, completed a skin and pain assessment and notified the physician, family, the NHA and the police. LPN #1 said she also wrote a progress note. LPN #1 said the nurse initiated the intervention and sometimes it was a one-on-one for the assailant. LPN #1 said if there was a resident-to-resident altercation, she was told about it during shift change in a verbal report. She said she was familiar with Resident #2 and he was in resident to resident altercations.The NHA, the DON and the regional nurse consultant were interviewed together on 1/6/26 at 3:55 p.m. The NHA said he was the abuse coordinator. The NHA said if there was an incident of abuse, staff should first ensure the residents were safe and separate the residents. The NHA said the nurse should immediately notify the DON or unit manager and then the DON or unit manager should inform the NHA. The NHA said risk management was started by the unit nurse, the DON or the assistant director of nursing (ADON). The NHA said a progress note, skin assessment and pain assessment should be completed. The NHA said the family and physician were notified. The NHA said the interdisciplinary team (IDT) was responsible for implementing and determining the interventions. The regional nurse consultant said interventions were documented as a progress note. The DON said interventions were communicated to staff by physician's orders or verbal report or both. The DON said both the assailant and the victim were monitored post-incident by frequent checks and check-ins to see if the residents wanted to talk about the incident. The DON said social services talked with the assailant and the resident as well. The DON said the nurse did the check-in out in the dining area when administering medications or during an assessment. The NHA said the nurse should monitor for non-verbal queues.The DON said the monitoring should be for 72 hours. The DON said the monitoring should be documented as a progress note. The regional nurse consultant said the point of the monitoring was to see if the resident was continuing to do their day to day activities or if they were breaking away from their normal routine. The NHA said interventions were evaluated 72 hours by the IDT. The NHA said the intervention to keep the victim safe was Resident #1 spent time with the DON and the ADON in their office and had lunch with them. The NHA said after lunch they wanted to try to see how Resident #1 would do in the unit. The DON said Resident #1 forgot about the incident and he knew his head hurt. The NHA said Resident #2 spent most of his time in his room except for meals and staff were always in the dining area during meal time. The NHA said Resident #1 did not want to be in his room and he wanted to be in the common area. The NHA said if Resident #2 came out of his room, the intervention to keep Resident #1 safe was the staff was extra vigilant to ensure Resident #1 and Resident #2 did not interact. The NHA said the education to keep the residents safe and what the immediate interventions were was verbally and through shift to shift report. The DON said the nurse could read progress notes as well to determine what interventions were put into place. The NHA, the DON and the regional nurse consultant were interviewed together again on 1/6/26 at 5:30 p.m. The NHA said there should have been documentation to educate the staff on what safety interventions were in place to keep Resident #1 and Resident #2 safe. The NHA said there should have been new behavior interventions for Resident #2. The NHA said the IDT did discuss the incident but it was not documented. The DON said there should have been monitoring for Resident #1 after the incident. The NHA said the root cause of the 10/15/25 incident was not documented because the video footage showed what caused the altercation.

Based on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for one (#10) of five residents out of 10 sample residents. Resident #1, age less than 65, required total assistance with bathing, was non-verbal and was unable to move his arms and legs. On 10/10/25 at 3:55 p.m. certified nurse aide (CNA) #1 requested a nurse to look at Resident #1's skin in the Summit shower room. CNA #1 stated she was using a washcloth and the resident's skin flaked off. The washcloth was noted to be light brown in color and peeled skin was observed on the shower floor. The licensed practical nurse (LPN) and the assistant director of nursing (ADON) who looked at Resident #1's skin on 10/10/25 did not complete a full body assessment for Resident #1, did not notify the physician about the resident's skin condition upon discovery (see record review and interview below) and did not document their findings until the following day (10/11/25). Resident #1 did not receive a full body skin assessment until the next shift when registered nurse (RN) #1 assessed him, at approximately 7:30 p.m. on 10/10/25, and observed blisters on the resident's skin. The facility called to have the resident sent out and emergency medical services (EMS) arrived to transport the resident to the hospital at 8:54 p.m. At approximately 9:30 p.m. on 10/10/25 Resident #1 was admitted to the emergency room and subsequently diagnosed with second degree burns over 8 percent (%) of his total skin surface including his chest, back and right upper arm. He was assessed by a burn unit team at the hospital who determined that Resident #1 had a full thickness scald burn (skin injury caused by contact with hot liquids such as building water, steam or hot oil). The facility staff continued to use the Summit shower room for resident bathing on 10/11/25 (see ADON interview below) until the hot water was turned off later in the day on 10/11/25. The facility's investigation of Resident #1's burn incident included interviews with residents who also received a bath or shower on 10/10/25. Two residents reported previous sudden changes in water temperature during showers. During an inspection by an outside plumbing vendor on 10/11/25, high water temperatures were discovered in the Summit shower room, 146 degrees Fahrenheit (F), where Resident #1 received a shower on 10/10/25, and in five resident rooms (measured temperatures were 118 degrees F, 122 degrees F, 136 degrees F, 138 degrees F and 150 degrees F - see plumbing timeline below). Review of the facility's water temperature check logs during the survey revealed the facility had not checked water temperatures since 8/15/25 (see documentation below). Staff interviews during the survey further revealed staff had not received education after 10/10/25 and prior to the survey regarding residents' showers and appropriate water temperatures. Specifically, the facility failed to ensure hot water temperatures in residents' rooms and one of two shower rooms did not exceed safe temperatures. This failure resulted in Resident #1 sustaining second degree burns to 8% of his total skin surface, including his chest, back and upper right arm during a shower provided to the resident by CNA #1 in the Summit shower room.Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy The facility failed to effectively monitor hot water temperatures in residents' rooms and one of two shower rooms to ensure water temperatures did not exceed safe temperature ranges. On 10/10/25 at 3:55 p.m. Resident #1, who was completely dependent on staff for bathing and was non-verbal, was being provided a shower in the Summit shower room by CNA #1. CNA #1 noted the resident's skin was flaking off and alerted a LPN. The LPN and the ADON looked at the resident's skin, however, they did not complete a full body assessment, notify the physician of the resident's skin condition, or document the skin condition until 10/11/25. On 10/10/25 at approximately 7:30 p.m. RN #1 completed a full body skin assessment for Resident #1 and noted blisters on the resident's skin. The resident was subsequently transferred to the hospital for evaluation where he was discovered to have second degree burns over 8% of his total skin surface, including his chest, back and upper right arm. The facility continued to bathe residents in the Summit shower room on 10/11/25 until the water was shut off later that same day to determine if there was a problem with the hot water system. However, the facility failed to educate staff regarding safe hot water temperatures and the potential for burns or identify how consistent monitoring of hot water temperatures in residents' rooms and shower rooms would occur following the incident, until 10/16/25, during the survey. The facility's failure to ensure hot water temperatures in residents' rooms and one of two shower rooms did not exceed safe temperatures created serious harm for Resident #1 and the likelihood of serious harm to other residents if the situation was not corrected immediately. B. Facility notice of immediate jeopardy On 10/16/25 at 11:25 a.m. the nursing home administrator (NHA) on 10/16/25 at 11:25 a.m. was notified that the facility's failure to ensure hot water temperature in residents' rooms and one of two shower rooms did not exceed safe temperatures created a situation of serious harm for Resident #1 and the likelihood of serious harm to other residents if the situation was not immediately corrected. C. Facility plan to remove immediate jeopardy On 10/16/25 at 5:30 p.m. the NHA provided a plan to remove the immediate jeopardy situation. The removal plan read: Immediate action completed: -Resident #1 was discharged to the hospital on [DATE]. -On 10/11/25 the facility stopped use of showers until all water temperatures could be assessed by maintenance staff. -On 10/11/25 the nursing staff completed a skin assessment on all residents to assess further skin concerns. No further concerns were identified. -On 10/11/25 an external plumbing company assessed the hot water system. Based on the assessment, it was determined facility water temperatures were out of range. The hot water was immediately shut off, and a work order was placed to correct work. -On 10/16/25, the water policy was updated to reflect safe bathing temperatures at or below 100 degrees F with monitoring and signage was updated in the facility showers to reflect water temperature range for showers. Facility plan: -A paper audit tool was created and the maintenance director (MTD) or designees will complete temperature readings upon return of hot water in all resident room sinks and shower rooms will be assessed for hot water temperatures. Temperature for sinks will be below 120 degrees F and shower rooms will be at or below 100 degrees F. -Beginning on 10/16/25, the ADON/designee will educate additional staff prior to their next shift on safe bathing temperatures to be at or below 100 degrees F, what to do if a resident skin change was identified, timely notification to a provider for follow up, and Technology Enabled Life Safety (TELS) notification system of abnormal water temperatures. -On 10/16/25 the MTD installed a wireless water temperature monitor in both showers for staff to identify water temperatures prior to and/or during showering residents. -Beginning on 10/16/25, hot water temperatures will be monitored and documented in both shower rooms and four resident rooms twice daily for 30 days; four times per week at various times of the day for 30 days; two times per week at various times of the day for 30 days; and then weekly utilizing the TELS notification system. The NHA will implement a review with the Quality Assurance Performance Improvement (QAPI) committee to review and interpret all data findings. All audit findings will be reviewed at the monthly meeting for at least three months or until the compliance pattern is maintained. The facility provided the following documentation on 10/16/25: Skin assessments were conducted on all residents and were completed by 10/13/25 for all residents in the facility. The updated Safe Water Temperatures policy was provided by regional clinical resource #1 on 10/16/25 at 6:02 p.m. along with signage posted throughout the facility. The policy and updated signage was updated to reflect safe water temperatures at or below 100F. A paper audit tool was provided by regional clinical resource #1 on 10/16/25 at 6:02 p.m. The paper audit tool included a spreadsheet to assess water temperature twice per day for both shower rooms and for four sample resident rooms. Water monitoring audits began on 10/16/25 at 6:02 p.m. Education provided to the staff was provided by regional clinical resource #1 on 10/16/25 at 6:02 p.m. and included information on water temperature versus the time at which it could cause a burn, what changes in the skin to look for when bathing, safe water temperatures at or below 100 degrees F, staff reporting to physician within 30 minutes for any change of condition, and using the TELS system to notify maintenance of any issues. On 10/16/25 between 5:30 p.m. and 6:30 p.m. CNA #2, CNA #6, CNA #7 and LPN #1 were interviewed and confirmed they had received training on safe bathing temperatures and updated temperature monitoring equipment in the shower rooms. D. Removal of immediate jeopardy On 10/16/25 at 6:31 p.m. the NHA was notified that the immediate jeopardy was removed based on evidence of the facility's implementation of the above plan. However, deficient practice remained at a G level, actual harm that is not immediate jeopardy. II. Facility policy and procedure The Safe Water Temperature policy, revised 2025, was provided by the NHA on 10/15/25 at 9:45 a.m It read in pertinent part, It is the policy of this facility to maintain appropriate water temperatures in resident care areas. Direct care staff will monitor residents during prolonged exposure to warm or hot water for any signs of symptoms and will respond appropriately. Staff will be educated on safe water temperatures upon employment and on a regular basis. Thermometers will be available as needed for use by all staff. Staff will report abnormal findings, such as complaints of water being too cold or too hot, burns or redness, or any problems with water temperature (water is painful to touch or causes redness) to the supervisor and/or maintenance staff. Water temperatures will be set to a temperature of no more than 120 degrees Fahrenheit (F) or the state's allowable maximum water temperature. Maintenance staff will check water heater temperature controls and the temperature of tap water in all hot water circuits weekly and as needed. Documentation of testing will be maintained for three years and kept in the maintenance office. -The facility policy failed to include safe bathing temperatures for residents and safe temperature parameters in all hot water circuits. III. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included cerebral palsy, osteomyelitis of the vertebra, sacral and sacrococcygeal, cardiomegaly, shortness of breath, spastic quadriplegic cerebral palsy, dependence on supplemental oxygen, anxiety disorder, cognitive communication deficit and severe intellectual disabilities. The 9/26/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident was totally dependent on staff assistance with showers. He required a mechanical lift with two CNAs for transfers. B. Record review The activities of daily living (ADL) care plan, initiated 1/12/24, revealed Resident #1 had an ADL performance deficit related to cerebral palsy. Interventions included total dependence for toileting hygiene, showers, transfer mobility and weekly skin inspection. A skin assessment and a weekly nursing notes, dated 10/4/25 at 12:34 p.m. that Resident #1 had no new skin issues and his skin was clear and intact. A 10/10/25 at 4:00 p.m. late entry nursing progress note, written on 10/11/25 at 10:53 a.m. by the ADON, documented CNA #1 requested that a nurse go into the shower room to assess Resident #1 during the resident's scheduled shower. The ADON noted pink discoloration of the resident's body on his right torso, chest and upper inferior arm. The progress note revealed the ADON immediately checked the water temperature which was documented as comfortably warm. A white washcloth was noted to be light brown in color and peeled skin was noted on the shower floor. The ADON lightly touched the pink area to the resident's chest with no reaction from the resident. She observed CNA #1 for a short time while she resumed the shower with no further evidence of other skin issues. A 10/10/25 at 5:00 p.m. health status note documented Resident #1 had a large skin discoloration noted to his right axillary (space between upper arm and side of the chest wall) area during his shower with no drainage noted. A 10/10/25 at 9:30 p.m. health status note revealed a further assessment of Resident #1 was completed by the floor nurse at 7:30 p.m. and noted blisters at the edges of the resident's skin discoloration drainage. The ADON and the DON were notified. The DON instructed for the resident to be sent out to the hospital. A 10/10/25 at 10:20 p.m. nurses note documented that at approximately 9:45 p.m. the facility received a call from the emergency department (ED) asking questions about Resident #1's injuries. The note documented that it was reported by the day shift nurse that the resident's injuries were discovered during showers. The hospital's concern was why it took the facility so long to send the resident to the ED for evaluation and treatment. A 10/10/25 at 9:48 p.m. ED note documented an ED RN spoke with LPN #3 at the facility. LPN #3 told the ED RN that a day shift nurse reported that during bathing, the CNA on duty had noticed that Resident #1 had skin peeling. LPN #3 stated that upon her assessment at 8:00 p.m. she noted worsening skin discoloration, called the director of nursing (DON) and then transferred the resident to the ED. LPN #3 stated the resident was not taking any new medications and was not on any antibiotics. A 10/11/25 at 1:56 a.m. nursing alert note documented Resident #1 was admitted to the trauma burn intensive care unit at the hospital. A 10/11/25 hospital note documented Resident #1 was brought to the ED and then transferred to a burn unit. The resident's total burn skin area (TBSA) was 8% and the location of the burns were as follows: -Chest 3% TBSA, partial thickness, second degree burns; -Back 3% TBSA, partial thickness, second degree burns; and, -Right upper arm 2% TBSA, partial thickness. A 10/13/25 hospital progress note documented Resident #1 was seen by wound care (on 10/13/25) for an initial wound assessment. Assessment of the wounds revealed the resident's right upper extremity (RUE) and right flank had full thickness burns to areas and the resident's back had partial thickness wounds. The TBSA: 8% and the burn type was a scald. IV. Facility investigation The facility's investigation of the burn incident for Resident #1 was provided by the NHA on 10/15/25 at 9:45 a.m. The investigation included the following timeline of events that occurred on 10/10/15, based on facility camera review and staff interviews: At 3:43 p.m. CNA #1 brought Resident #1 to the Summit shower room. At 3:54 p.m. CNA #1 walked out of the shower room to the nurses' station and spoke to the ADON. LPN # 2 walked back to the shower room with CNA #1. At 3:55 p.m. LPN #2 came back to the nurses' station and the ADON went to the shower room. The shower was running and the ADON took a picture of Resident #1. At 3:57 p.m. the ADON exited the shower room and spoke to a RN and CNA #2. At 4:06 pm. CNA #1 left the shower room with Resident #1. CNA #1 and CNA #2 took Resident #1 to his room and transferred him to bed. At 4:13 p.m. CNA #1 and CNA #2 left Resident #1's room and CNA #1 immediately returned, leaving again at 4:19 p.m and quickly returning to his room again. At 4:22 p.m. CNA #1 left Resident #1's room. She returned at 4:27 p.m. and removed the shower chair from Resident #1's room. -The timeline documented no staff entered Resident #1's room between 4:22 p.m. and 7:29 p.m. At 7:29 p.m. LPN #3 entered Resident #1's room with medications and exited soon after. At 7:39 p.m. LPN #3 documented the resident's vital signs were within normal limits. At 8:12 p.m. CNA #1 entered Resident #1's room with the vital signs machine. At 8:13 p.m. LPN #3 entered Resident #1's room. At 8:14 p.m the ADON called LPN #3 to send the resident out to the ED. At 8:54 p.m. EMS entered the facility and transported the resident to the ED. The facility investigation included a hot water investigation and repairs beginning 10/11/25 to 10/14/25. The investigation included the following timeline of facility plumbing and water testing and repair: On 10/11/25 at approximately 11:00 a.m. an outside plumbing company inspected the facility's boiler system. At approximately 12:30 p.m. it was discovered the facility's hot water temperatures were out of range so the hot water was shut off to determine what steps were needed to correct the water temperatures. The documented water temperatures out of range were as follows: Summit shower room was 146 degrees F (location of Resident #1's shower on 10/10/25); room [ROOM NUMBER] was 150 degrees F, room [ROOM NUMBER] was 138 degrees F, room [ROOM NUMBER] was 136 degrees F, room [ROOM NUMBER] was 122.3 degrees F, and room [ROOM NUMBER] was 118.2 degrees F. On 10/11/25 at 6:00 p.m. the plumbing company determined the mixing valve for the facility's hot water was not functioning properly. At 7:00 p.m. work began to fix the facility's hot water system. On 10/12/25 at 2:00 p.m. the plumbing company found a faulty valve that allowed hot water back into the system without going through the mixing valve and determined that the storage tanks holding water needed to be replaced. At 2:15 p.m. approval was given to replace the faulty valve. On 10/13/25 new storage tanks were delivered and re-piping of the facility's plumbing continued. The facility investigation included resident and staff interviews as follows: Resident #6's interview on 10/11/25 documented that she noticed a sudden change in water temperature previously during a shower. She said while in the shower the water would become too hot or too cold and she did not know if that was reported but it did happen sometimes. Resident #7's interview on 10/11/25 documented he had previously noticed a sudden change in water temperature during a shower and all of a sudden the water became too hot. CNA #4's interview on 10/11/25 documented that CNA #4 said with the new shower, the water got hot and (staff) had to be careful adjusting the water. CNA #8's interview on 10/11/25 documented that CNA #8 said that on full heat, the water was too hot but with an adjustment, the temperature was ok. He said the facility's water temperature fluctuated a lot. CNA #2's interview on 10/11/25 documented that CNA #2 said the facility's water was too hot if not adjusted properly. CNA #1's interview on 10/11/25 documented that CNA #1 said as soon as Resident #1's skin started peeling, she notified a nurse. CNA #1 said she let the shower water warm up, and then began showering and washing Resident #1 with a washcloth. She said she checked the water prior to each time she rinsed the resident. She said the resident had been in the shower approximately 10 minutes when she noticed his skin starting to slough off. -The staff interviewed for the facility's investigation did not notify facility staff or management that the water was too hot if not adjusted properly (see interview below). V. Facility's water temperature monitoring and documentation The facility's water temperature check log was provided by the NHA on 10/15/25 at 3:45 p.m. The logs documented weekly monitoring of water temperatures in both facility showers, eight resident rooms, a mixing valve, two public restrooms, the kitchen and the laundry room. -The last hot water temperature checks were recorded on 8/15/25, and there were no hot water checks or temperatures recorded after 8/15/25. A 10/15/25 Temperature Audit Sheet was provided by the NHA on 10/15/25. Recorded water temperatures were as follows: Summit shower room was 114 degrees F, Summit shower room sink was 114 degrees F, Aspen shower room was 118 degrees F, Aspen shower room sink was 115 degrees F, room [ROOM NUMBER] was 117 degrees F , room [ROOM NUMBER] was 118 degrees F and room [ROOM NUMBER] was 117 degrees F. VI. Observations of facility water temperatures on 10/16/25 Water temperatures from random resident rooms and common areas were checked on 10/16/25. The findings revealed the following: At 11:10 a.m. the hot water temperature of the sink at the Summit nurses' station was measured and found to be 112.6 degrees F. At 11:15 a.m. the hot water temperature in the secured unit shower room was measured and it was found to be 109.6 degrees F. At 11:20 a.m. the hot water temperature of resident room [ROOM NUMBER] was found to be 104.4 degrees F. At 11:20 a.m. the hot water temperature of Resident room [ROOM NUMBER] was found to be 107.6 degrees F. VII. Staff interviews RN #2 was interviewed on 10/14/25 at 1:30 p.m. RN #2 said she did not provide resident showers, however, she assisted the CNAs when they asked for assistance. She said since the facility's hot water was shut off, she had asked a CNA to use the unit's microwave to heat up water to help give a bed bath to a resident. She said after heating the water in the microwave, she mixed it with cold water and tested the water temperature by testing it on the sensitive skin on her own hands to determine the appropriate temperature. RN #2 said she would ask the resident to feel the water as well. She said it was not the safest way to obtain and mix hot water, but sometimes they had to use whatever was available when a resident required a shower and there was no hot water. CNA #2 was interviewed on 10/14/25 at 2:52 p.m. CNA #2 said the facility had a situation on 10/10/25 and the facility turned off the hot water because they thought the water was too hot. CNA #2 said she dealt with a lack of hot water on 10/11/25 and was not sure why the hot water was still off on 10/15/25 (during the survey). CNA #2 said no one told her why the hot water was still off. CNA #2 said CNA #1 gave a resident a shower and it looked like the resident was burned and then sent out in an ambulance. CNA #2 said she was helping CNA #1 transfer the resident in and out of bed for his shower because he required the assistance of two people. CNA #2 said she saw Resident #1 after his shower on 10/10/25 and did not know if his skin discoloration was a burn. CNA #2 said the resident's skin looked really red but it looked like dead skin. CNA #2 said CNA #1 reported to the agency nurse she was worried because there was a lot of skin that fell off. CNA #2 said she wished the nurse on the shift had taken care of the issue and maybe stopped the process of the burn. CNA #2 said she did not see blisters on the resident at that time. CNA #2 said when she gave a resident a shower, she turned the water to medium warm and let the resident feel the water and however the resident reacted, she would adjust the water based on the resident's reaction. CNA #2 said if the water was too hot, a resident could flinch. CNA #2 said she started the shower with lukewarm water, she tested the water temperature on herself first and then watched the expressions of the non-verbal residents to see how they reacted. CNA #2 said she was not sure which facility staff would check the water temperatures in the shower. CNA #2 said both facility showers had one handle for temperature control. CNA #2 said she had not had any recent education on resident showers or water temperatures since Resident #1 went to the hospital. CNA #2 said she was not aware if the facility had had issues in which a resident was burned by water previously. The NHA, the ADON and regional clinical resource #1 were interviewed together on 10/15/25 at 2:00 p.m. The ADON said she was at the nurses' station on 10/10/25 when CNA #1 came out of the shower room and said she needed a nurse to come and look at Resident #1's skin. She said another nurse went into the shower room first. The ADON said the agency nurse came out of the shower room and said that she (the ADON) might want to go look at the resident. The ADON said the agency nurse did not give any indication of what the issue was at the time. The ADON said she went into the shower room to see the Resident #1. The ADON said she took a photo of Resident #1's skin in the shower room because they might have needed it for wound care and she wanted to show it to the DON. The ADON said that Resident #1's skin was something she had not seen before. The ADON said she had not been notified of any changes to Resident #1's skin prior to seeing him in the shower and he still had soap on his body. The ADON said CNA #1 told her she did not use a different facility soap for Resident #1's shower and the water was running when she (the ADON) went into the shower room. The ADON said Resident #1 was not making any noises, and if the resident was uncomfortable he would make noise. The ADON said the pitch of the noises the resident made indicated how he was feeling. The ADON said she put on a glove and lightly touched Resident #1's skin to see if he hurt or if it was bleeding, and in one area she lightly rubbed where the pink area ended to see if any more skin would come off. The ADON said CNA #1 finished the resident's shower and she asked CNA #1 to show her what she was doing when the resident's skin sloughed off. The ADON said she observed CNA #1 rub the resident with the towel and no more skin came off. The ADON said she wanted to talk to another nurse on duty to get another opinion, ask what she should do about it and ask if another nurse had seen something similar. The ADON said she documented her assessment of Resident #1 in the shower the next day as a late entry. The ADON said she thought the resident's issue was not urgent because the resident was not bleeding and she conveyed that to the assigned nurse on duty. The ADON said she did a full body skin check at that time she went into the shower. -However, the ADON did not document the assessment until 10/11/25, after Resident #1 had been sent to the hospital on the evening of 10/10/25 (see progress notes above). The ADON said the staff used non-verbal resident's reactions to their comfort level in the shower and the staff watched for those reactions. The ADON said there was one more resident shower provided on 10/11/25 before the facility knew there was an issue with the hot water temperature. Regional clinical resource #1 said Resident #1's skin issue was a discoloration and a skin discoloration did not require urgent notification to the provider. Regional clinical resource #1 said the residents interviewed during the facility investigation were interviewed because they also had a shower on 10/10/25 (the same day as Resident #1). The NHA said there should be weekly water logs completed and the MTD was responsible for completing the logs. The NHA said he was not sure if the facility was currently completing water temperature monitoring but the previous MTD used to complete that task (prior to 8/15/25). The MTD and the NHA were interviewed together on 10/15/25 at 3:42 p.m. The MTD said he had monitored water temperatures at the facility. The MTD said he went into the shower or residents' rooms, he waited a minute or two after turning on the water and then took the water temperature. The MTD said he waited and when the water started to get hot, he would hold the thermometer in the water until the temperature stopped rising. The MTD said he checked the water temperature in residents' rooms by randomly checking different rooms and he tried not to check the same room each week. He said he checked water temperatures in residents' rooms once weekly. The MTD said he checked the shower room water temperatures once a week. The MTD said he usually checked three to four rooms in different sections of the building. -However, there was no documentation of water temperature checks since 8/15/25 (see above). The MTD said he wanted the water temperature in residents' rooms to be between 106 degrees F to 110 degrees F and in the shower rooms he might let it go to 112 degrees F or 113 degrees F or a little bit warmer. The MTD said the investigation of Resident #1's burn incident was the first time he had heard the water suddenly became hot during a resident's shower. The NHA said there were 34 resident rooms in the facility and three to four rooms was 10 percent of the total to monitor. The NHA said the facility investigation was the first time he had heard the water suddenly became hot during a resident's shower. The NHA said any staff member could use the TELS system to put a maintenance work order in. RN #1 was interviewed on 10/15/25 at 4:27 p.m. RN #1 said at approximately 7:30 p.m. (on 10/10/25) she was completing an assessment of another resident. RN #1 said she finished assessing the other resident and LPN #3 asked RN #1 to go into Resident #1's room. RN #1 said she entered Resident #1's room and LPN #3 asked her to tell her what she (RN #1) saw. RN #1 said she looked at Resident #1's right side and observed an open wound bed. RN #1 said LPN #3 said she had to take a picture of the resident. RN #1 said she continued to assess the resident and noticed the resident had an open wound bed from his right nipple to just above the groin area, going all the way back and an irregular shaped wound that went toward the middle of his spine toward his incision. RN #1 said she noticed the outer edges of the wound of the skin were rolled, like the skin had just come off and had some blisters on it. RN #1 said an unidentified CNA told her an agency nurse was previously informed about Resident #1's skin issue earlier in the day. RN #1 said she was told by the same CNA that she thought the resident was really dirty, so when his skin started coming off in the shower, she started scrubbing harder. RN #1 said she was told by the CNA that she called the nurse into the shower and the nurse informed her there was nothing wrong. RN #1 said she told LPN #3 Resident #1 needed to be sent out immediately to the hospital. She said LPN #3 was consulting the AD

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety.Specifically, the quality assurance and performance improvement (QAPI) program committee failed to identify and address concerns related to accidents and safety of residents in which the facility failed to ensure hot water temperatures did not exceed safe temperature ranges that rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely.Findings include:I. Cross-reference citationCross-reference F689: The facility failed to ensure safe water temperatures, conduct and document a thorough assessment of a resident with a new skin condition and notify the resident's provider timely.II. Staff interviewsThe nursing home administrator (NHA) and regional clinical resource #2 were interviewed together on 8/16/25 at 6:00 p.m.The NHA said the maintenance director (MTD) was a newer staff member and started working at the facility in August 2025. The NHA said at that time, the Summit shower room was down and not working. The NHA said the Summit shower not working impacted the facility because the facility only had one working shower instead of two. The NHA said the MTD did take the temperature of the Summit shower on approximately 9/4/25 or 9/5/25, prior to the residents using the shower.Regional clinical resource #2 said she preferred the facility include water management to their QAPI minutes and review them at the QAPI meeting then further review everything submitted in TELS. The NHA said the QAPI committee met monthly. The NHA said each interdisciplinary team (IDT) member was to submit assigned information that he, the NHA, reviewed prior to the QAPI meeting. The NHA said the medical director attended the QAPI meeting and the IDT was required to attend. Regional clinical resource #2 and the NHA were interviewed together a second time on 10/16/25 at 6:00 p.m. The NHA said the paper audit tool created to monitor water temperatures was to be turned into him for review. The NHA said he would then scan the audit into the computer for an electronic record and keep the paper copy in the facility's plan of the correction binder. The NHA said all temperature monitoring would be sent to him for review. The NHA said the MTD knew he was supposed to be monitoring water temperatures but he did not record them. The NHA said facility staff could enter a work order into the TELS system (electronic submission system) that would be sent to maintenance to accept.

Based on observations and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to: -Ensure raw animal food was separated from ready to eat food; -Ensure expired food was discarded; and, -Ensure food was labeled and dated appropriately. Findings include: I. Failed to prevent food contamination The Colorado Retail Food Establishment Rules and Regulations, ([DATE]), retrieved on [DATE] read in pertinent part, Food shall be protected from cross contamination by separating raw animal food during storage, preparation, holding, and display from raw ready-to-eat food including fruits and vegetables. (Chapter ,d+[DATE]) A. Observations On [DATE] at 2:14 p.m, the main kitchen walk-in refrigerator had a cardboard box with five plastic bags of raw chicken thighs on the middle shelf. The chicken thighs were stored next to individual milk cartons. The raw chicken thighs were above a cardboard box of oranges, above a cardboard box of onions and above a cardboard box of apples. B. Staff interviews and observations The dietary manager (DM) was interviewed during a walk through of the kitchen walk-in refrigerator on [DATE] at 3:27 p.m. The DM said the box of chicken thighs should be separated from the ready to eat food. The chicken thighs remained in the same location (see observations above). The DM moved the cardboard box of chicken thighs to a metal rolling cart in the middle of the walk-in refrigerator. The nursing home administrator (NHA) was interviewed on [DATE] at 6:18 p.m. The NHA said the raw chicken thighs should have been separated from the fruits and vegetables to prevent cross-contamination. He said the raw chicken thighs should have been placed on a metal tray in case the plastic bags had a leak to prevent chicken thigh juices from dripping onto other food stored in the walk-in refrigerator. II. Failed to ensure expired food was discarded A. Professional reference The Colorado Retail Food Establishment Rules and Regulations, ([DATE]), retrieved on [DATE] read in pertinent part, The day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety. (Chapter ,d+[DATE]) B. Observations On [DATE] at 2:14 p.m., in the main kitchen walk-in refrigerator there was a square metal food storage container on the middle shelf on the left side of the refrigerator. The container was labeled with beef gravy, dated [DATE] and labeled with a use by date of [DATE]. C. Staff interviews The DM was interviewed on [DATE] at 3:27 p.m. The DM said the facility labeling system was to include the date the food was prepared and the use by date. She said the gravy that was labeled with a date of [DATE] and use by date of [DATE] indicated the gravy was prepared on [DATE] and it needed to be discarded on [DATE]. The NHA was interviewed on [DATE] at 6:18 p.m. He said he did not know how the kitchen labeling system worked. He said if the gravy was labeled to discard on [DATE], the gravy should have been discarded on [DATE]. III. Failed to ensure food was labeled and dated A. Professional reference The Colorado Retail Food Establishment Rules and Regulations, ([DATE]), retrieved on [DATE] read in pertinent part, A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request. (Chapter ,d+[DATE]) B. Observation On [DATE] at 2:14 p.m., in the main kitchen walk-in refrigerator, there was a square metal food storage container that was on the middle shelf on the left side of the refrigerator. The container had 13 individual plastic containers with a pureed food in them. The containers were not labeled with a date and without a common name of the food. C. Staff interviews The DM was interviewed on [DATE] at 3:27 p.m. The DM said food items removed from the original packaging should be labeled with the name of the food, when it was opened and a use by date. She said she did not know why the food items were not labeled. The NHA was interviewed on [DATE] at 6:18 p.m. The NHA said food items removed from the original packaging should be labeled with the name of the food, when it was opened and a use by date.

Based on record review and interviews, the facility failed to ensure a prompt resolution was provided to residents involved in group grievances. Specifically, the facility failed to provide a prompt and effective resolution for resident council members who repeatedly voiced concerns over staff conduct. Findings include: I. Facility policy and procedure The Resident Council Meetings policy (no revision date), was provided by the nursing home administrator (NHA) on 1/16/25 at 6:23 p.m. It revealed in pertinent part, The facility shall act upon concerns and recommendations of the council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the council. The Resident and Family Grievances policy (no revision date), was provided by the NHA on 1/16/25 at 6:23 p.m. It revealed in pertinent part, A resident or family member may voice grievances with respect to care and treatment, the behavior of staff, and other concerns regarding their stay at the facility. Grievances may be voiced by a verbal or written complaint to a staff member or grievance official, or a verbal complaint during resident council meetings. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. The staff will take any immediate actions needed to prevent further potential violations of any resident rights. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance, which includes acknowledgment of the complaint/grievances and actively working toward a resolution. II. Resident group interview A group interview was conducted on 1/15/25 at 10:40 a.m. with seven residents (#46, #26, #23, #44, #59, #51 and #2) who were identified as alert and oriented through facility and assessment. All the residents said that the night shift staff was loud, slammed doors and were disrespectful. Resident #51 and Resident #59 said staff yelled at night. Resident #46, Resident #51 and Resident #59 said that staff slammed doors at night on purpose. Resident #46 and Resident #59 said staff were frequently on their phones at work. Resident #59 said many staff were rude. The residents said they did not feel the facility provided sufficient resolutions to their continued concerns about staff conduct. III. Resident council meeting notes Review of the 7/16/24 resident council meeting notes revealed residents had concerns that call lights were being ignored, facility certified nurse aides (CNA) were rude, gossiped about residents and that staff argued in the dining room where residents could hear. Review of the 8/13/24 resident council meeting notes revealed that residents felt nursing staff slammed doors on purpose, were disrespectful, turned around their name tags so residents could not report them and that staff lied to residents. The residents repeated concerns regarding staff arguments in the dining room. The 8/13/24 resident council meeting notes documented that problem employees had been replaced. -However, the 8/13/24 resident council meeting notes indicated the residents continued to have similar concerns about staff behavior from the 7/16/24 resident council meeting, despite staff being replaced. There was no resident council meeting held in September 2024 due to a corporate transition. There were no resident complaints documented about nursing staff at the October 2024 resident council meeting. Review of the 11/24/24 resident council meeting notes revealed the residents had concerns regarding CNAs and nurses entering residents' rooms while on their cellular phones and complaining about their jobs to residents. -There was no documentation in the 11/24/24 resident council meeting notes to indicate how the facility planned to address the concerns voiced at the 11/24/24 meeting. Review of the 12/30/24 resident council meeting notes revealed residents continued to have concerns of CNAs on their cellular phones while at work. There was documentation in the 12/30/24 resident council meeting notes which identified what staff needed to be educated on in regards to residents' call lights and cellular phone use at work, and that all staff would be educated. -However, the staff education was not scheduled until 1/22/25, over three weeks from the time the concerns were identified in the resident council meeting (see interview below). IV. Grievances There were no grievance forms provided by the facility for the resident concerns brought up in the 7/16/24, 8/13/24 or 11/24/24 resident council meetings. A group grievance was filed on 12/30/24 by the social services director (SSD). The grievance revealed ongoing complaints regarding staff conduct on the Summit unit of the facility. Resident council attendees complained of staff ignoring call lights and being rude when answering, ignoring phone calls at the nurse's station and being loud and disruptive at night, which made it hard for residents to sleep. The proposed resolution was to include all staff education on the residents' concerns, including the answering of phones at the nurses station, answering resident call lights and treating residents respectfully. Audits of call light and nurses station phones were going to be conducted. An interdisciplinary team (IDT) review of concerns would begin on 1/1/25 and an all-staff meeting was scheduled for 1/22/25. Resident #51 signed the proposed resolution on 12/31/24 and acknowledged that the concerns would take longer than a week to resolve. V. Staff interview The SSD was interviewed on 1/16/25 at 6:11 p.m. The SSD said all resident council complaints were discussed at the quality assurance and performance improvement (QAPI) committee meetings. She said that she filed group grievance forms when requested by the resident council. She said sometimes the resident council members did not want to file a formal grievance, so she said the residents' concerns might only be discussed in a QAPI meeting. She said the first few times that complaints about rude staff were voiced, education was completed with individual staff or larger in-services were held for multiple staff. The SSD said she investigated the specific staff that multiple residents repeatedly complained about, and those staff members had since been terminated. She said that resolution was satisfactory to the complainants. She said that the resident council had worked with her towards a resolution regarding continued complaints about rude staff, call light wait times and use of cell phones. She said the proposed resolution was the upcoming all-staff mandatory meeting, of which the residents approved. -However, residents voiced concerns related to staff conduct during the survey (see resident group interview above).

Based on observations, record review and interviews, the facility failed to ensure three (#32, #60, #50) of five residents reviewed for activities out of 30 sample residents received an ongoing program of activities designed to meet the needs and interests, and promote physical, medical and psychosocial well-being. Specifically, the facility failed to offer and provide a personalized activity program for Resident #32, Resident #60 and Resident #50. Findings include: I. Facility policy and procedure The Activities policy, revised 2024 (no specified month), was provided by regional director of clinical services (RDCS) #2 on 1/16/25 at 5:50 p.m. It read in pertinent part, Facility-sponsored group, individual, and independent activities were designed to meet the interests of each resident as well as support their physical, mental and psychosocial well-being. Activities encouraged both independence and interaction within the community. II. Resident #32 A. Resident status Resident #32, age 84, was admitted on [DATE]. According to the January 2025 computerized physician order (CPO), diagnoses included dementia, insomnia, psychotic disturbance, mood disturbance and anxiety. The 12/13/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview (BIMS) score of zero out of 15. The assessment revealed the resident wandered four to six days during the seven-day assessment look-back period. The assessment revealed it was very important to the resident to listen to music she liked, to do her favorite activities, to go outside for fresh air when the weather was good and to participate in religious services and practices. The assessment revealed the resident did not refuse care. B. Resident's representative interview The resident's representative was interviewed on 1/13/25 at 10:50 a.m. The representative said she visited Resident #32 in December 2024. She said she was concerned the resident did not participate in activities. She said the resident wandered the secured unit frequently. She said the staff redirected the resident to take a nap during the daytime. She said she was concerned Resident #32 slept during the day because she did not participate in the facility's activities. C. Observations During a continuous observation on 1/14/25, beginning at 11:16 a.m. and ending at 2:26 p.m. the following was observed: From 11:16 a.m. to 11:39 a.m. Resident #32 wandered the secured unit hallways. At 11:39 a.m. an unidentified therapy aide walked the hallways with Resident #32. At 11:45 a.m. Resident #32 sat in a chair at a dining table. At 12:49 p.m. Resident #32 left her chair at the dining table and began wandering the secured unit hallways. No staff attempted to redirect the resident or engage her with any activities. At 1:23 p.m. certified nurse aide (CNA) #3 escorted the resident to her room, but did not engage her with any activities. At 1:37 p.m. activities assistant (AA) #1 and AA #2 started an activity called mellow music. Resident #32 was not encouraged by AA #1 or AA #2 to participate in the activity. During a continuous observation on 1/15/25, beginning at 8:52 a.m. and ending at 11:55 a.m. the following was observed: At 9:00 a.m. Resident #32 sat in a chair at a dining table in the dining area. At 9:11 a.m. Resident #32 left her chair and wandered the secured unit to her room. Staff did not offer to engage the resident in any activities. At 10:33 a.m. AA #1 and AA #2 started an exercise with two medium size inflatable balls. AA #1 and AA #2 engaged residents by tossing the ball back and forth. -However, AA #1 and AA #2 did not engage Resident #32 in the activity. At 11:23 a.m. Resident #32 walked into the dining area with licensed practical nurse (LPN) #3. LPN#3 told Resident #32 to follow her to a chair in front of a dining table so she could take her medications and get ready for lunch. Resident #32 remained in her chair until lunch was served. D. Record review The activities care plan, revised 3/28/24, revealed Resident #32 was independent and made her needs known to staff in her primary language of Vietnamese. The resident was Vietnamese speaking only. The resident liked to walk around the secured neighborhood, socialize with peers even if she could not understand them, listen to music, attend music therapy, social groups and gardens. The resident needed therapeutic one-on-visits to help with feelings of isolation, loneliness, and boredom related to unwillingness to participate in activities and to assist with cultural programming and opportunities. The goal was to participate in independent leisure activities, as well as one-on-one visits with staff. The resident would participate in group activities one to three times per week. Interventions include encouraging the resident to stay in the group for the duration of the time, providing clutter free spaces to walk safely throughout the secured unit, encouraging the resident to participate and socialize with peers, inviting the resident to actively participate in all activities she may enjoy and providing the resident with an activity calendar. -A review of Resident #32's electronic medical record (EMR) revealed no documentation that the resident had participated in leisure activities, one-on-one visits or group activities. -A request for Resident #32's paper activities participation record was made to the nursing home administrator (NHA) on 1/16/25 at 4:44 p.m. The NHA was unable to provide documentation of the resident's activity participation. III. Resident #60 A. Resident status Resident #60, age 70, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included dementia, mood disturbance, psychotic disturbance, anxiety and major depressive disorder. The 12/27/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of one out of 15. The assessment revealed the resident did not reject care. The resident wandered one to three days during the seven-day assessment look-back period. The 9/26/24 MDS assessment documented the resident was rarely/never understood and family/significant other was not available, therefore the resident's preferences for customary routines and activities was not assessed. B. Observations During a continuous observation on 1/15/25, beginning at 8:52 a.m. and ending at 11:55 a.m. the following was observed: At 9:00 a.m. Resident #60 was sitting in a chair in the dining room. At 9:01 a.m. Resident #60 tried to stand. LPN #3 told LPN #4 to keep an eye on Resident #60 because she tried to stand. LPN #4 took the resident to her room but did not engage the resident in any activities. At 9:02 a.m. Resident #60 came out of her room and an unidentified dietary aide assisted the resident to sit in a chair in the dining area. At 9:12 a.m. Resident #60 got up from the chair and began to wander through the secured unit. Staff did not attempt to redirect the resident or engage the resident in any activities. At 10:18 a.m. CNA #4 redirected Resident #60 to sit down but did not provide the resident with any activities. At 10:33 a.m. AA #1 and AA #2 started an exercise with two medium size inflatable balls. AA #1 and AA #2 engaged residents by tossing the ball back and forth. -However, AA #1 and AA #2 did not engage Resident #60 in the activity and the resident continued to sit in the chair at the dining table. At 10:43 a.m. AA #1 said the exercise was over and she would turn on a movie. The television was on the south side of the room facing the north side. Resident #60 was on the south side of the room facing the north side. -No staff attempted to encourage Resident #60 to move to watch the movie. C. Record review The activities care plan, revised 11/20/24, revealed Resident #60 needed activities consistent with her abilities and interests. The resident enjoyed aroma therapy, music, sensory activities, socializing, and dancing. Interventions included assisting the resident to and from activity locations as needed, assisting with in-room activities as needed and room visits for socialization. -A review of Resident #60's EMR revealed no documentation that the resident had participated in leisure activities, one-on-one visits or group activities. -A request for Resident #60's paper activities participation record was made to the NHA on 1/16/25 at 4:44 p.m. The NHA was unable to provide documentation of the resident's activity participation. IV. Resident #50 A. Resident status Resident #50, age 81, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included Alzheimer's disease, insomnia, unsteadiness on feet, a history of falling and cognitive communication deficit. The 12/27/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of two out of 15. The assessment revealed it was very important to the resident to listen to music he liked and somewhat important to have books, newspapers, and magazines to read, somewhat important to be around animals such as pets, somewhat important to do things with groups of people and somewhat important to do his favorite activities. B. Record review The activities care plan, revised 4/8/24, revealed Resident #50 was very friendly and liked to do arts and crafts, mostly making paper birds. He needed help to join group activities every day. The care plan goal was to participate in one to three activities of interest, including music groups, community meetings, trivia and game groups. Interventions included staff were to encourage and assist the resident in meeting and socializing with other residents and participating in all activities he may be interested in or would enjoy. -A review of Resident #50's EMR revealed no documentation that the resident had participated in leisure activities, one-on-one visits or group activities. -A request for Resident #50's paper activities participation record was made to the NHA on 1/16/25 at 4:44 p.m. The NHA was unable to provide documentation of the resident's activity participation. V. Staff interviews LPN #2 was interviewed on 1/16/25 at 12:24 p.m. LPN #2 said the activities director (AD) was responsible for carrying out the activities schedule. He said residents liked exercise activities and reading. He said he was not sure what activities Resident #50 liked to participate in. He said Resident #60 liked to participate in whatever activities were going on. He said Resident #32 liked to participate in music and karaoke activities and she liked to watch others participate in activities. LPN #2 said activities were important in the secured unit because the residents needed to be consistently engaged to distract the residents from negative thoughts. The AD was interviewed on 1/16/25 at 2:53 p.m. The AD said she was the social services director (SSD) and was filling in as the interim AD until a new AD was hired. She said the activities department was not staffed. She said the activities department was approved to have five activities staff members, including the AD, one assistant activities director, two full time activities assistants and one part time activities assistant. She said AA #1 was a CNA who transitioned to AA #1 in the past month. She said AA #2 started working at the facility on 1/13/25. The AD said if a resident participated in an activity, it was documented on a paper charting system. She said activities were determined based on the resident's preferences and their cognitive abilities. The AD said the current activities were based on the new hires abilities to conduct activities until they were trained. The NHA was interviewed on 1/16/25 at 6:46 p.m. The NHA said he was unable to provide accurate documentation on what activities were provided for Resident #32, Resident #60 and Resident #50. The NHA said he could not confirm if person-centered activities were provided for the residents.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the laundry room was free from multiple environmental concerns. Findings include: I. Observations An environmental tour of the facility was conducted on 1/16/25 at 9:15 a.m. The following observations were made: There was an area of wall damage at the bottom of the basement staircase on the left hand side. There was approximately two vertical feet of uncovered wall with exposed metal and a screw. Both were sharp to the touch. In the laundry room the following were observed: -There was damage to the sheetrock on the ceiling above and in front of the washing machine. It had fallen off the concrete above. The area was approximately four feet around. -There was chipped paint along the upper wall next to the washing machine. -There was a hole in the wall along the floor next to the laundry folding table. -The plastic floor trim near the laundry folding table was peeling. II. Staff interview The maintenance supervisor (MS) was interviewed on 1/16/25 at 10:30 a.m. The MS completed an environmental tour of the facility. He said there was damage to the sheetrock on the ceiling in front of the washing machine, chipped paint along the upper wall next to the washing machine, a hole in the wall along the floor next to the laundry folding table and the trim near the laundry folding table was peeling. The MS said the observed maintenance concerns had been present since he started in the position a few years ago. He said there were no work orders for the concerns, but the holes and wall damage along the stairwell were going to be repaired after the new washing machine was delivered. He said the extra space created at the bottom of the basement stairs and doorway was needed to accommodate the size of the machine. He said there was a signed proposal for the repairs to be done but he was not sure of the date that would occur. He said the repairs included tearing out the bottom three stairs and repairing the hole and entryway.

Based on record review and interviews, the facility failed to develop, implement and maintain an effective training program for staff based on the facility assessment and resident population for four of five certified nurse aides (CNA) reviewed. Specifically, the facility failed to: -Ensure CNA #5 and CNA #6 received training in abuse, dementia management, behavioral health management, infection control, communication, quality assurance and quality improvement (QAPI), compliance and ethics, and resident rights; and, -Ensure CNA #3 and CNA #4 received at least 12 hours of annual in-service training. Findings include: I. Record review A request for abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics and resident rights training was made on 1/14/25 for CNA #5 and CNA #6. CNA #5 was hired on 1/13/25. CNA #6 was hired on 1/12/25. -The facility was unable to provide documentation indicating CNA #5 and CNA #6 completed training for abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics and resident rights prior to providing direct care to residents independently. Record review of the daily schedule revealed CNA #5 worked in the secure unit on 1/13/25 from 2:00 p.m. to 10:00 p.m. Record review of the daily schedule reviewed CNA #6 worked in the secure unit on 1/12/25. A request for 12 hours of in-service training was made on 1/14/25 for CNA #3 and CNA #4. CNA #3 was hired on 2/1/23. -The facility was unable to provide documentation 12 hours of in-service training was completed in the past 12 months. CNA #4 was hired on 12/22/23. -The facility was unable to provide documentation 12 hours of in-service training was completed in the past 12 months. II. Staff interviews Regional director of clinical services (RDCS) #2 was interviewed on 1/16/25 at 10:52 a.m. She said CNA #5 and CNA #6 were hired through a staffing agency. She said the required training was requested by the staffing agency. The RDCS said the staffing agency did not require CNAs to complete any training abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics and resident rights. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 1/16/25 at 2:16 p.m. The DON said the facility held monthly staff meetings that included the CNAs. The DON said she could not confirm CNA #3 and CNA #4 had 12 hours of in-service training.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for two of five certified nurse aides (CNA) reviewed. Specifically, the facility did not complete a performance review for CNA #3 and CNA #4. Findings include: I. Record review CNA #3 was hired on 2/1/23. A request for a performance review was made on 1/14/25. -The facility was unable to provide documentation indicating a performance review for CNA #3 was completed in the past 12 months. CNA #4 was hired on 12/22/23. A request for a performance review was made on 1/14/25. -The facility was unable to provide documentation indicating a performance review for CNA #4 was completed in the past 12 months. II. Staff interviews Regional director of clinical services (RDCS) #2 was interviewed on 1/16/25 at 10:52 a.m. RDCS #2 said an annual performance review and in-service education were not completed for CNA #2 and CNA #4. RDCS #2 said she was not sure why the training had not been completed. The nursing home administrator (NHA) was interviewed on 1/16/25 at 2:16 p.m. The NHA said performance reviews should be completed annually based on the CNA's start date. The NHA said a performance review was not completed for CNA #3 and CNA #4. The NHA said she was not sure why the training had been completed.

Based on record review and interviews, the facility failed to ensure one (#47) of five residents out of 30 sample residents had the right to be informed of and participate in their treatment,the right to be informed, in advance, of the care to be furnished and the type of care giver or professional that would furnish care, the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Specifically, the facility failed to obtain a consent from Resident #47 or their legal representative for the use of an antipsychotic medication before its administration. Findings include: I. Facility policy and procedure The Psychoactive/Psychotropic Medication Use policy, dated May 2024, was provided by the nursing home administrator (NHA) on 1/21/25 at 11:31 a.m. The policy revealed psychoactive medications might be administered following federal and state regulations if the medication was necessary to treat a specifically diagnosed condition and was appropriately documented in the medical record. Additionally, behavioral interventions, unless contraindicated, would be used to meet the individual needs of the resident. The prescribing clinician would obtain informed consent from the resident (or, as appropriate, the resident representative) for use of a psychotropic medication. The resident or resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred. Prior to administration of a psychotropic medication, the prescribing clinician would obtain informed consent from the resident (or as appropriate, the resident representative), and document the consent in the medical record. A licensed nurse must verify that informed consent had been obtained from the resident or the resident's representative prior to administering psychotropic medication. A licensed nurse must also sign the consent form, declaring that the required material information has been provided. II. Resident #47 A. Resident status Resident #47, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included dementia, other behavioral disturbances, Alzheimer's disease, palliative care and depression. According to the 10/18/24 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The assessment indicated the resident was administered antipsychotic and antidepressant medications. B. Record review A physician's order dated 8/21/24 at 8:24 p.m., revealed to administer Sertraline (Zoloft) HCL (an antidepressant medication) 25 milligrams (mg) orally once a day for anxiety and restlessness for seven days and then give two tablets by mouth once a day for anxiety and restlessness. A care plan for antidepressants (black box warning) for the use of Zoloft revealed the resident was at risk for suicidal thinking or abnormal behavior with the use of an antidepressant medication was initiated on 11/9/24. The interventions included to administer medication as physician ordered, observe for signs or symptoms of anxiety, constipation, diarrhea, dizziness, dry mouth, headaches, nausea, suicidal ideation, stomach upset, trouble sleeping, trouble urinating, weakness and fatigue and/or weight gain. The medication administration records (MAR) for November 2024, December 2024 and January 2025 were reviewed. The MARs revealed the antidepressant medication was administered to Resident #47 as the physician ordered. -However, review of Resident #47's electronic medical record (EMR) revealed there was no consent form, which included the risks versus the benefits of the medication, signed by the resident or the resident's representative prior to the administration of the medication. III. Staff interviews The NHA, the director of nursing (DON), regional director of clinical services (RDCS) #1 and RDCS #2 were interviewed together on 1/15/25 at 5:04 p.m. The NHA, the DON, RDCS #1 and RDCS #2 agreed there was no consent for Resident #47's use of the antidepressant Zoloft. The first administration date of this antidepressant medication was on 8/21/24 and continued to the present. The NHA, the DON, RDCS #1 and RDCS #2 agreed a consent should have been obtained before the start of the medication. The NHA, the DON, RDCS #1 and RDCS #2 agreed the reason to acquire a consent prior to the administration of an antidepressant medication was to help the resident or their legal representative understand the diagnosis, side effects and the effective outcomes for the use of the medication.

Based on record review and interviews, the facility failed to inform one (#60) of three residents reviewed for beneficiary notices and appeal rights out of 30 sample residents of changes in their services covered by Medicare in a timely manner. Specifically, the facility failed to provide written notification of a Medicare Non-Coverage letter to the resident's representative that Medicare-covered services were ending for Resident #60 in a timely manner. Findings include: I. Facility policy and procedure The Medicare Advance Beneficiary and Medicare Non-coverage Notices policy, revised September 2022, was provided by the nursing home administrator (NHA) on 1/13/25 at 4:11 p.m. The policy revealed residents were informed in advance when changes would occur to their bills. If the resident's Medicare covered Part A stay or when all of Part B therapies were ending, a Notice of Medicare Non-Coverage (NOMNC) was issued to the resident at least two calendar days before benefits ended. II. Resident #60 A. Resident status Resident #60, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included cerebral infarction, metabolic encephalopathy, anxiety and major depression. According to the 12/27/24 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. The resident had inattention. The resident had difficulty focusing attention, including being easily distractible or having difficulty keeping track of what was said. This behavior was continuously present and did not fluctuate. The resident had disorganized thinking. The resident's thinking was disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). This behavior was continuously present and did not fluctuate. B. Record review The Skilled Nursing facility (SNF) Beneficiary Protection Notification Review revealed the resident's last covered Medicare Part A skilled service was on 10/31/24. The NOMNC was signed by the resident's legal representative on 10/31/24, which was the same day Resident #60's Medicare Part A benefits ended. The resident continued to reside in the facility. -However, the facility provided the NOMNC to Resident #60's legal representative on the same day the resident's Medicare Part A services ended, which was not sufficient notification that the current skilled nursing services would likely not be paid for by the Medicare provider and/or health plan and that the resident might have to pay for any services after this date (10/31/24). -Additionally, the untimely issuance of the NOMNC did not provide Resident #60's legal representative sufficient time to request for an immediate appeal of the discontinuation of skilled services, which ended on 10/31/24. III. Staff interviews The NHA, the director of nursing (DON), regional director of clinical services (RDCS) #1 and RDCS #2 were interviewed on 1/15/25 at 4:50 p.m. The NHA acknowledged Resident #60's last day of Medicare Part A skilled services was on 10/31/24 and that Resident #60's legal representative signed the NOMNC on 10/31/24. The NHA said the NOMNC should be provided to the resident or their representative at least two days in advance of the last day of skilled services coverage. The director of rehabilitation (DOR) was interviewed on 1/16/25 at 11:40 a.m. The DOR said, until September 2024, she was responsible for residents' beneficiary notifications. She said a resident or their legal representative should be notified 48 hours before the resident's last day of Medicare Part A skilled services was discontinued. The social services director (SSD) was interviewed on 1/16/25 at 2:13 p.m. The SSD said she was responsible for beneficiary notifications. She said residents or their representatives should be notified two days before the resident's Medicare Part A skilled services was discontinued.

Based on record review and interviews, the facility failed to develop a comprehensive care plan for two (#46 and #9) of six residents out of 30 sample residents for services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to: -Ensure a comprehensive care plan was developed to address Resident #46's use of an anticoagulant medication; and, -Ensure a comprehensive care plan was developed to address Resident #9's dental needs. Findings include: I. Facility policy and procedure The Comprehensive Person-Centered Care Plans policy, revised March 2022, was provided by regional director of clinical services (RDCS) #2 on 1/15/25 at 5:00 p.m. The policy revealed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan was developed within seven days of the completion of the required minimum data set (MDS) assessment (admission, annual or significant change in status), and no more than 21 days after admission. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan: included measurable objectives and timeframes; described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. The plan would include any specialized services to be provided as a result of pre-admission screening and resident review program (PASARR) recommendations; and which professional services were responsible for each element of care; included the resident's stated goals upon admission and desired outcomes; built on the resident's strengths; and reflected currently recognized standards of practice for problem areas and conditions. Care plan interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision-making. When possible, interventions addressed the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions changed. The interdisciplinary team reviews and updates the care plan: when there had been a significant change in the resident's condition; when the desired outcome was not met; when the resident had been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. The resident had the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals were documented in the resident's clinical record in accordance with established policies. II. Resident #46 A. Resident status Resident #46, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included morbid obesity, peripheral vascular disease, cellulitis of the right lower limb, chronic obstructive pulmonary disease, lymphedema (chronic condition that causes swelling), chronic diastolic (congestive) heart failure and essential hypertension (high blood pressure). The 11/8/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident received anticoagulant medications. B. Resident interview Resident #46 was interviewed on 1/13/25 at 10:59 a.m. Resident #46 said he was administered an anticoagulant medication. He was able to name the medication and said he had no excessive bruising from the use of the medication. C. Record review A physician's order, dated 3/23/24 at 7:01 a.m., revealed to administer Eliquis 5 milligrams orally twice a day for anticoagulation. Resident #46's administration record (MAR) for November 2024, December 2024 and January 2025 were reviewed. The resident was administered the anticoagulant medication according to physician orders. -Resident #46's electronic medical record (EMR) was reviewed on 1/14/25 at approximately 3:00 p.m. The EMR did not contain a care plan for the use of an anticoagulant with interventions. D. Staff interviews Regional director of clinical services (RDCS) #2 was interviewed on 1/15/25 at 1:56 p.m. RDCS #2 said the MDS assessment dated [DATE] revealed the resident was administered an anticoagulant. RDCS #2 said the resident did not have a care plan for the use of an anticoagulant medication. She said a care plan should have been developed for the use of the anticoagulant within 24-hours after the first administration. RDCS #2 said the care plan for the use of an anticoagulant would alert staff to monitor for bruising, bleeding and any therapeutic effects for the use of the medication. RDCS #2 said all nursing staff management were responsible for the development of care plans. She said resident care plans were monitored and reviewed at least quarterly with MDS assessments, resident care conferences and any changes of cognition. The minimum data set coordinator (MDSC) was interviewed on 1/16/25 at 8:30 a.m. The MDSC said the MDS dated [DATE] revealed the resident was administered an anticoagulant medication. She said she developed care plans for medications. She said resident care plans were reviewed quarterly and at any changes in the resident's condition. 48112 III. Resident #9 A. Facility policy and procedure The Dental Services policy, revised 2024, was provided by RDCS #2 on 1/16/25 at 5:50 p.m. It read in pertinent part, The dental needs of each resident are identified through the physical assessment and MDS (minimum data set) assessment processes, and are addressed in each resident's plan of care. Oral/dental status shall be documented according to assessment findings. Oral care and denture care shall be provided in accordance with identified needs and as specified in the plan of care. Staff shall be mindful of resident dentures when providing care and alert to situations where dentures may be displaced, such as common with residents with dementia or those known to remove dentures at will and place them in areas other than the denture cup. Referrals to dietician, speech therapist, physician, or dental provider shall be made as appropriate. B. Resident status Resident #9, age 70, was admitted on [DATE]. According to the CPO, diagnoses included dementia, anxiety, psychotic disturbance, mood disturbance, periodontal disease (a bacterial infection that affected the gums and jawbone) and disorder of teeth. The 10/1/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 12 out of 15. The assessment revealed the resident did not have dental issues and did not have corrective lenses. C. Resident interview and observation Resident #9 was interviewed on 1/13/25 at 2:46 p.m. Resident #9 said the dentist was here recently and the facility did not put her on the list to be seen by the dentist. She said she was upset the facility did not include her. The resident did not have glasses on and did not have dentures in her mouth. D. Record review The care plan was reviewed. -A review of Resident #9's comprehensive care plan, revised 1/15/25, did not reveal person-centered interventions to meet the resident's dental and vision needs. The 10/18/24 social service progress note revealed Resident #9 was seen by the dentist for a comprehensive exam and a full set of x-rays. The 10/29/24 admission social history assessment revealed the resident had a full set of dentures and did not have glasses. E. Staff interviews The social services director (SSD) was interviewed on 1/16/25 at 2:46 p.m. The SSD said she was responsible for ancillary services like dental services. The SSD said an assessment was completed when the resident was first admitted to the facility. The SSD said the assessments were not completed prior to her taking over as SSD. The SSD said she was the director for the last month. The SSD said Resident #9 needed dental services. The SSD said she was seen in October 2024 and was going to be seen again. The SSD said she left a message in the past week for the power of attorney to obtain consent. The SSD said there was not a care plan for dental services. The nursing home administrator (NHA), the director of nursing (DON) and RDCS #2 were interviewed together on 1/16/25 at 2:27 p.m. The DON said the SSD was responsible for dental and vision services. The DON said social services completed an assessment. RDCS #2 said all residents should be offered dental and vision services. The DON said dental and vision services should be care planned because once services were care planned, it was transferred to Kardex (an abbreviated care plan for staff). The DON said it was important to care plan dental services so the nursing staff knew on a daily basis if the resident wore glasses or had dentures. RDCS #2 said Resident #9 did not have a care plan for dental services.

Based on observations, record review and interviews, the facility failed to ensure one (#113) of three residents reviewed for assistance with activities of daily living (ADL) out of 30 sample residents received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure Resident #113 received assistance with showers in accordance with her physician orders. Findings include: I. Facility policy and procedure The Supporting Activities of Daily Living (ADL) policy, revised March 2018, was provided by the nursing home administrator (NHA) on 1/14/25 at 1:57 p.m. The policy revealed residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL). Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. If residents with cognitive impairment or dementia resisted care, staff would attempt to identify the underlying cause of the problem and not just assume the resident was 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 might be appropriate. II. Resident #113 A. Resident status Resident #113, age greater than 65, was admitted on [DATE] and discharged home on 9/16/24. According to the September 2024 computerized physician orders (CPO), diagnoses included vascular dementia, other disorders of the brain, major depression disorder, encephalopathy and mild neurocognitive disorder due to known physiological conditions with behavioral disturbances. The 6/28/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. The resident had inattention with difficulty in focusing attention, for example, being easily distractible or having difficulty keeping track of what was said. This behavior was continuously present and did not fluctuate. The resident had the ability to shower himself which included washing, rinsing, and drying himself (excluded washing of back and hair). The resident required setup or clean-up assistance. A staff member set up or cleaned up and the resident completed the activity. The staff member assisted only prior to or following the activity. B. Record review A physician's order, dated 3/26/24 at 2:56 p.m., revealed Resident #113's shower days were on Wednesdays and Saturday evenings. Staff were to write a progress note if the resident refused a shower. A care plan for Resident #113 refusing care at times was initiated on 9/18/24. The interventions were to educate staff on resident redirection and for staff to re-approach and provide care/assistance. The resident's electronic medical record (EMR) did not contain a care plan for ADLs that included showers. Review of Resident #113's EMR shower documentation for April 2024 revealed the resident received three showers and had two refusals out of eight opportunities for a shower. -There was no documentation in the EMR to indicate why the resident did not receive his other scheduled showers. -There was no documentation in the EMR to indicate why the resident refused his two showers or if the resident was re-approached at a later time. Review of Resident #113's EMR shower documentation for May 2024 revealed the resident received four showers and had no refusals out of nine opportunities for a shower. -There was no documentation in the EMR to indicate why the resident did not receive his other scheduled showers. Review of Resident #113's EMR shower documentation for August 2024 revealed the resident received four showers and had one refusal out of eight opportunities for a shower. -There was no documentation in the EMR to indicate why the resident did not receive his other scheduled showers. -There was no documentation in the EMR to indicate why the resident refused his one shower or if the resident was re-approached at a later time. III. Staff interviews The NHA, the director of nursing (DON), regional director of clinical services (RDCS) #1 and RDCS #2 were interviewed together on 1/15/25 at 5:11 p.m. The NHA, the DON, RDCS #1 and RDCS #2 reviewed Resident #113's shower documentation contained in the EMR for April 2024, May 2024 and August 2024 and agreed the resident had not received all of his showers. The NHA, the DON, RDCS #1 and RDCS #2 said residents should receive two or more baths/showers each week if they wanted them and if a resident refused a shower, the certified nurse aides (CNA) should ask the resident multiple times if they wanted a shower and then tell the nurse of the resident's refusal. The NHA, the DON, RDCS #1 and RDCS #2 said the nurse would then go ask the resident and offer a different time/date for the resident to take a shower. The NHA, the DON, RDCS #1 and RDCS #2 said if the resident still refused a shower, the nurse should write a progress note regarding the resident's refusal. The NHA, the DON, RDCS #1 and RDCS #2 said if a resident often refused a shower, it should be reflected in a care plan. CNA #3 was interviewed on 1/16/25 at 11:00 a.m. CNA #3 said she provided showers to residents. She said a resident should receive at least two showers per week. She said if a resident refused, she asked them several times during the shift if they wanted a shower. She said if a resident refused a shower, she would notify the nurse immediately. CNA #3 said when she came to work the next day, she would ask the resident again if they wanted a shower. She said she charted resident showers in the resident's EMR and on a shower sheet. She said she charted in the EMR during the shift or before the end of the shift. CNA #4 was interviewed on 1/16/25 at 11:06 a.m. CNA #4 said she provided showers to residents. She said a resident should receive two showers each week. She said if a resident refused a shower, she would ask the resident several times on that shift. She said she would tell the nurse immediately that the resident had refused showers. CNA #4 said during shift change, she would tell the oncoming CNAs that the resident refused. She said she documented showers in the resident's EMR and on the shower sheet. She said she charted after the shower was completed or before the end of the shift. RDCS #2 was interviewed on 1/16/25 at 11:34 a.m. RDCS #2 said there was no care plan for ADLs nor for bathing for Resident #113. She said a care plan should have been developed for ADLs and bathing.

Based on record review and interviews, the facility failed to ensure that the medical record was complete and accurate in keeping with accepted standards of practice for one (#63) of four residents reviewed for medical record accuracy out of 30 sample residents. Specifically, the facility failed to document Resident #63's toileting in an accurate and easy to understand manner. Findings include: I. Facility policy and procedure The Charting and Documentation policy, revised December 2022, was provided by regional director of clinical sciences (RDCS) #2 on 1/16/25 at 3:02 p.m. The policy revealed the services provided to the resident progress toward the care plan goals. Any notable changes in the resident's medical, physical, functional, or psychosocial condition observed by staff should be documented in the resident's medical record. The medical record was a format that facilitated communication between the interdisciplinary team. Documentation in the medical record might be entered electronically, manually on paper or a combination of both. The following information were examples of documentation that may be included in the resident medical record: objective observations, medications administered, treatments or services performed and changes in the resident's condition, if indicated. Entries included in the resident's clinical record should be made by licensed personnel such as registered nurses (RN), license practical nurses (LPN) and physicians/practitioners. To avoid confusion and promote consistency in charting and documentation of the resident's clinical record, only commonly used and understood abbreviations should be used. Documentation of procedures and treatments should include care-specific details, including items such as the date and time the procedure/treatment was provided, the name and title of the individual(s) who provided the care, the assessment data and/or any unusual findings obtained during the procedure/treatment, if applicable, whether the resident refused the procedure/treatment, notification of family, physician or other staff, if indicated and the signature and title of the individual documenting. I. Resident #63 A. Resident status Resident #63, age greater than age 65, was admitted on [DATE] and passed away at the facility on 12/8/24. According to the December 2024 computerized physician orders (CPO), diagnoses included dementia, chronic obstructive pulmonary disease, delusional disorder, cerebral infarct without residual deficits, anxiety, unsteadiness on feet and heart failure. The 11/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident required a staff member to provide all of the effort for toileting. The resident did not provide any effort to complete the toileting activity or the resident required the assistance of two or more staff members for the resident to complete the activity. B. Record review Resident #63 had a physician's order to toilet the resident every two hours for prompted toileting, ordered on 4/22/24 at 4:00 p.m., and discontinued on 10/31/24 at 4:18 p.m. The order was documented on the resident's treatment administration record (TAR). -The physician's order did not specify how staff were to document the resident had promoted toileting. Resident #63's Kardex (a patient care summary that provided nurses with a quick reference to a resident's key care information) received on 1/16/25 at 10:36 a.m., revealed staff was to toilet the resident as needed. A bedside commode was brought into the resident's room for toileting needs every two hours. Resident #63's TARs for August 2024, September 2024 and October 2024 were reviewed related to the physician's order for prompted toileting every two hours. The staff used the following notations (symbols) every two hours: N (no), Y (yes), NA (not applicable), + (plus), - (minus), 0 (zero), W (unknown delineation), WB (unknown delineation), D (unknown delineation), B (unknown delineation), R (unknown delineation), and P (unknown delineation). A care plan for Resident #63 being at risk for falls due to unawareness of safety needs, mobility deficit, and forgetfulness was revised on 12/9/24. The interventions included to anticipate the resident's needs. Staff were to supervise the resident at all times during toileting, and the resident was not to be left unattended in the bathroom. The resident would be provided a bedside commode after a physical therapy assessment and the resident was deemed able to use the commode. A care plan for Resident #63, who had a history of attempting to use the toilet outside of her toileting schedule was revised on 11/27/24. The interventions included the resident wore a tabbed brief for incontinence, staff were to follow the facility bowel protocol for bowel management and record bowel pattern movements each day. II. Staff interview The NHA, the director of nursing (DON), regional director of clinical services (RDCS) #1 and RDCS #2 were interviewed together on 1/15/25 at 5:30 p.m. Resident #63's TARs for August 2024, September 2024 and October 2024 were reviewed. The NHA, the DON, RDCS #1 and RDCS #2 agreed on the inconsistent methods (symbols) of staff documentation for the resident's toiling program every two hours. The DON said that the plus (+) symbol meant a bowel movement, the minus (-) symbol meant no bowel movement. However, the DON said she did not know the meaning of the other symbols the staff were documenting. The DON said Resident #63's physician's order did not tell the staff how to document the resident's toileting. The DON said the nurse that took the physician's order should have included in the physician's order how the staff should document the resident's toileting. The DON said, looking at the documentation for Resident #63's toileting program, she could not determine if the resident received toileting according to the physician's order due to the inconsistent methods (symbols) of documentation used by the staff.

Based on observation,record review and interviews, the facility failed to assist residents in obtaining routine or emergency dental services, as needed for one (#14) of two residents reviewed for dental services out of 30 sample residents. Specifically, the facility failed to ensure dental services were offered to Resident #14. Findings include: I. Facility policy and procedure The Dental Services policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 4:44 p.m. It read in pertinent part, It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. The dental needs of each resident are identified through the physical assessment and MDS (minimum data set) assessment processes, and are addressed in each resident's plan of care. Oral/dental status shall be documented according to assessment findings. Oral care and denture care shall be provided in accordance with identified needs and as specified in the plan of care. Referrals to dietician, speech therapist, physician, or dental provider shall be made as appropriate. For residents or resident representatives who do not wish to be referred for dental services: The physician shall be notified, the dietician shall be consulted to assess for any necessary change in diet and the resident's plan of care will be revised to reflect preferences. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record. II. Resident #14 A. Resident status Resident #14, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician's orders (CPO), diagnoses included spastic quadriplegic cerebral palsy (a condition that includes severe developmental delay, increased muscle tone and involuntary movements). The 10/4/24 minimum data set (MDS) assessment revealed the resident had short term and long term memory problems and had severely impaired cognition and decision making per staff assessment. He was dependent on staff for all care, including oral care. The MDS assessment did not indicate if the resident had any dental problems. B. Observation On 1/13/25 at 11:51 a.m., Resident #14 had a thick layer of white substance along his upper teeth and gum line. C. Record review The ancillary services care plan, revised 10/3/24, revealed a focus for ancillary services, which included dental needs. The goal was for visits to be reviewed quarterly. The intervention was for social services to monitor when Resident #14 was seen by ancillary providers in order to maintain compliance with regulations regarding frequency of ancillary visits ands. S social services was to notify ancillary providers if the resident needed to be seen prior to their visit. A review of the January 2025 CPO revealed the resident had a physician's order to receive dental consults and follow up as needed, ordered 7/26/23. Review of Residents #14's consent forms, revealed a signed ancillary consent form on 10/4/23 for audiology services only. -Review of Resident #14's electronic medical record (EMR) revealed the resident did not have a signed consent form for dental services. A social services progress note, dated 4/4/24, revealed Resident #14 agreed to ancillary services, including podiatry and dentistry. A dental referral to an outside facility for completing dental work under anesthesia had been requested and the facility was waiting on the resident's representative's approval. -However, there was no further documentation in Resident #14's electronic medical record (EMR) to indicate dental services or the referral had been discussed since 4/4/24. III. Staff interviews The social services director (SSD) was interviewed on 1/14/25 at 2:45 p.m. The SSD said she started in this position a month ago. The SSD said there was a facility dentist that came at least every other week and had a list of residents with specific needs. The SSD said the dentist did evaluate everyone. She said processes had changed since she took this position. She said she had completed an audit to see which residents needed ancillary services. She said all ancillary service providers, including dental, vision and audiology would now see every resident at the facility to start the process. She said needed consents were signed and the dentist came last Friday 1/10/25. -However there was no documentation that Resident #14 or his representative had been contacted regarding dental services. The SSD said she was surprised that there was no documentation in Resident #14's EMR about dental services. She said this resident was listed as needing ancillary services, so she was not sure why he had not been seen by a dentist in so long. The SSD said she put Resident #14 on the dentist's list for the coming week and that the dentist should know why the resident had not been seen recently. Licensed practical nurse (LPN) #5 was interviewed on 1/16/25 4:15 p.m. LPN #5 said she was not sure when the dentist came to the facility, but she knew it was often. She said if a resident had a new concern and the dentist was not in the facility, she wrote a progress note in the resident's EMR and called the resident's primary provider. She said the facility's providers were at the facility on Monday through Friday and also looked at the resident's teeth. She said she regularly cared for Resident #14 and there had been no concerns related to his teeth. She said his teeth were cleaned daily and as needed with a foam swab, oral moisturizer and water. She said for Resident #14, who could not swallow, oral swabs were preferred over toothbrushes. She said most of the certified nurse aides (CNA) and occupational therapists provided the resident with regular oral care because he was fully dependent on care. Regional director of clinical services (RDCS) #1 and the director of nursing (DON) were interviewed together on 1/16/25 at 4:43 p.m. RDCS #1 said that the standard was for residents to get oral care twice a day. RDCS #1 and the DON said there were guardianship concerns with Resident #14, so it was possible that someone did not want him to receive excessive treatments, but they were not certain. RDCS #1 said the resident's white coating along his gum line was calcium deposits, which happened when the teeth did not get regular scaling at the dentist's office. She said she did not think the resident would tolerate scaling. RDCS #1 said sometimes with residents who received enteral feedings (tube feedings) like Resident #14, staff did not remember that they needed dental care like the other residents. She said Resident #14 should have at least received dental screenings and thought the resident got lost in the shuffle after the facility changed ownership. She said there was a new system in place now to track such ancillary visits and that staff needed more education and teaching related to this.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for the medication storage room and one of two medication storage carts. Specifically, the facility failed to: -Discard medication on the medication cart that had been discontinued; and, -Discard medications that have expired. Findings include: I. Facility policy and procedure The Storage of Medications policy, revised November, 2020, was provided by the nursing home administrator (NHA) on 1/28/24 at 11:45 a.m. The policy heading included, the facility stores all drugs and biologicals in a safe, secure and orderly manner. Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. II. Observations On 1/24/24 at 10:58 a.m. the medication storage cart was reviewed with licensed practical nurse (LPN) #1. The LPN picked up Tiotropium Bromide/Olodaterol (Stiolto) inhaler for Resident #19 which contained a label showing an opened date of 10/12/23. The LPN placed the inhaler back in the compartment of the medication cart. At 1:15 p.m., the medication storage room was reviewed with LPN #1. In the refrigerator, the following medications were expired: -One Bisacodyl 10 milligram (mg) rectal suppository, expired February 2023; -One Acetaminophen 650 mg rectal suppository, expired November 2023; and, -Four Acetaminophen 650 mg rectal suppositories, expired January 2023. III. Record review The physician orders for Resident #19 revealed the Stiolto inhaler was discontinued on 11/14/23. IV. Staff interviews LPN #1 was interviewed on 1/24/24 at 1:25 p.m. She said she would discard the expired medications from the refrigerator. She said expired medications should not be given because they would not work as effectively. LPN #1 was interviewed on 1/24/24 at 4:30 p.m. She said she discarded Resident #19's Stiolto inhaler after learning it had been discontinued a few months ago. The director of nursing (DON) was interviewed on 1/25/24 at 9:35 a.m. He said expired medications found in the refrigerator should be discarded. He said the pharmacy did a facility audit for expired medications three weeks ago. He said the medication was to be removed from the medication cart on the same day it was discontinued.

Based on observations and interviews the facility failed to maintain a clean, comfortable and homelike environment for the residents on two of the two resident hallways and the secured unit. Specifically, the facility failed to ensure residents' rooms, bathrooms and shower rooms were odor free and received necessary repairs. Findings include: I. Facility policy and procedure The Homelike Environment policy, revised February 2021, was provided by the nursing home administrator (NHA) on 1/28/24 at 11:45 a.m. It revealed in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: -clean, sanitary and orderly environment; -inviting colors and decor; and -pleasant, neutral scents. The facility and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include: -institutional odors. II. Observations Observations conducted on 1/23/24 at 2:22 p.m. and 1/25/24 at 4:02 p.m. revealed the following: A. Individual resident rooms 1. room [ROOM NUMBER] the wall by the window was patched up and not repainted. 2. room [ROOM NUMBER] wall behind the dresser was patched up and not repainted. 3. room [ROOM NUMBER] the bathroom floor had water coming from the base of the toilet. The base of the toilet had brown matter around the screws and the toilet seat was missing. The bathroom had an odor of urine smell. 4. room [ROOM NUMBER] the wall by the window was peeling off, the bed next to the window the wall was scraped where the headboard was placed. Where the second bed was located the wall had paint chipped. 5. room [ROOM NUMBER] the bathroom floor was coming up, the base of the wall floor was patched up and not repainted. 6. room [ROOM NUMBER] the window ledge was chipped and broken and the metal rod was showing. The tile in the bathroom on the floor was missing. 7. room [ROOM NUMBER] before entering the room the wall outside was chipped off and needed to be repaired and repainted. 8. room [ROOM NUMBER] the room had an odor of urine smell, chipped paint on the walls by the beds and above the entrance doorway was a patched wall not repainted. The wall as you entered the room had a smear of brown matter on it by the foot of the bed. The bathroom toilet had rust around the toilet base and the bathroom walls were chipped. The toothbrushes in the cabinet were not labeled and placed side by side. 9. room [ROOM NUMBER] the outlet on the wall was chipped/broken and coming off the wall. 10. room [ROOM NUMBER] the walls were chipped and the curtain separating the beds had brown matter on it. B. Secured unit The dining room/activity room had an odor of urine smell and the disposable bins with dirty linen and soiled briefs were located in the hallway of the dining room/activity room. C. Showers Observation of one of the showers revealed tile missing on the shower wall, tile broken by the entrance of the door and a missing drawer from the sink. III. Environment tour and staff interview The environment tour was conducted on 1/24/24 at 4:25 p.m. with the nursing home administrator (NHA). Regarding all observations above, the NHA said the maintenance department should be doing tours of the facility every day. He said the maintenance department did not look at all the rooms. He said anyone could report repairs verbally to the maintenance or nursing staff could put an order in the electronic medical record system. He said he would have to find a way to move residents in order to paint the rooms. He said he was aware of some of the issues but was not aware of the concerns that were shown to him. He said renovations were ongoing. He said an air purifier was installed to help with the air in the secure unit. He said the disposable bins should not be left in the hallway by the dining room/activity room. He said staff could not prevent the residents from smearing things on the wall. 46851

Based on record review and interviews the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the QAPI program committee failed to identify failures within their performance improvement plans for repeat deficiencies cited and make the necessary changes to ensure the plan was effective. Findings include: I. Facility policy and procedure The Quality Assessment and Assurance Committee policy and procedure, revised January 2018, was provided by the nursing home administrator (NHA) on 1/22/24 at 2:00 p.m. It revealed, in pertinent part, Purpose: to evaluate facility quality indicators, identify quality issues, develop corrective action plans and evaluate any action plans for continuous quality improvement. Any concerns, trends or clusters identified should be listed on the QA Concerns List. Document the concern, goal and approaches and interventions to correct the concern on the QA Concern Action Plan. Review monthly any ongoing concerns until resolved. Develop new interventions as needed. II. Cross-reference citations Cross-reference F600: the facility failed to prevent physical abuse from Resident #46 to Resident #27. Cross reference F603: the facility failed to ensure Resident #18, who resided on the secured unit, had the required assessments and resident representative consent to justify such restrictions. Cross-reference F609: the facility failed to report an injury of unknown origin, bruising and scratches, on Resident #27 to the State Agency . Cross-reference F610: the facility failed to conduct an investigation to rule out abuse for injuries of unknown origin bruising and scratches on Resident #27. Cross-reference F688: the facility failed to have a restorative program for Resident #11 and Resident #50. III. Staff interviews The NHA, the director of nursing (DON) and the regional clinical consultant (RCC) were interviewed on 1/25/24 at 5:30 p.m. The NHA said the QAPI meetings were held monthly. He said he, the DON, the infection preventionist (IP), the social services, the dietary manager, the pharmacist and other members of the interdisciplinary team attended the meeting. He said each department presented a scheduled set of reports at each meeting and the facility attempted to identify the issues throughout the facility and discover trends. The NHA said if new areas of concern were identified, performance improvement plans (PIP) would be developed and discussed during the next QAPI meeting. The NHA said the facility was unaware their PIPs were not effective. He said the facility had not identified ongoing concerns for deficiencies cited during abbreviated surveys and a lack of effectiveness in the implementation in their PIPs. He said the facility lacked an effective performance improvement plan for the area of preventing abuse, reporting abuse, investigating abuse, ensuring appropriate placement of residents in the secured unit and an effective restorative program. He said the facility had a significant amount of turnover in recent months. He said the facility management failed to identify the roles of each staff member and put a different staff member into that role to ensure the facility maintained effective systems.

Based on observations and interviews, the facility failed to ensure one (#18) out of 25 sample residents had the right to a dignified existence. Specifically, the facility failed to ensure facility staff respected Resident #18's right to refuse a shower and provide him dignity after a shower by ensuring he was not exposed to other residents on the unit by wrapping him in a see-through sheet. Findings include: I. Facility policy and procedure The Dignity policy and procedure, revised February 2021, was provided by the nursing home administrator (NHA) on 1/28/24 at 11:45 a.m. It revealed in pertinent part, Residents are treated with dignity and respect at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility. When assisting with care, residents are supported in exercising their rights. For example, residents are: groomed as they wish to be groomed (hair styles, nails, facial hair); encouraged to attend the activities of their choice, including religious, political, civic, recreational, or social activities; encouraged to dress in clothing that they prefer; allowed to choose when to sleep, eat and conduct activities of daily living; and provided with a dignified dining experience. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Staff are expected to treat cognitively impaired residents with dignity and sensitivity. II. Resident #18 A. Resident status Resident #18, age 82, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, Parkinson's disease and insomnia. According to the 10/11/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status score of two out of 15. The resident required moderate assistance of one person for all activities of daily living (ADLs). It indicated that the resident did not exhibit any behaviors during the assessment period. B. Observations During a continuous observation on 1/23/24, starting at 12:00 p.m. and ended at 12:30 p.m., Resident #18 was observed in his room. An unidentified certified nurse aide (CNA) assisted the resident from his room to the dining room to eat lunch. -At 12:05 p.m. Resident #18 told facility staff he was waiting to eat lunch. -At 12:07 p.m. the facility staff began serving lunch in the dining room. -At 12:10 p.m. CNA #2 approached Resident #18, grabbed his wheelchair and started to wheel him backwards. She did not communicate what she was doing to Resident #18. Resident #18 said, Stop, I want to eat lunch. CNA #2 told him he needed to take a shower. Resident #18 said he wanted to eat lunch and did not want to shower. CNA #2 continued, ignoring Resident #18's wishes and took him to the shower room. On the way to the shower room, Resident #18 repeatedly said he did not want to take a shower. -At 12:18 p.m. CNA #2 assisted Resident #18 out of the shower room on a shower chair. The shower room was located next to the dining room. The resident was wrapped in a see through white sheet and was exposed while being wheeled back to his room. Twelve residents were sitting in the dining room. III. Staff interviews CNA #1 was interviewed on 1/25/24 at 9:05 a.m. CNA #1 said all residents had the right to refuse care. CNA #1 said staff should respect a resident's wishes when they were refusing care instead of continuing and ignoring their choice. CNA #1 said residents should be covered with a non-transparent fabric when being assisted from the shower room on the shower chair. CNA #1 said it was important to ensure each resident was provided dignity and respect. Licensed practical nurse (LPN) #2 was interviewed on 1/25/24 at 9:30 a.m. LPN #2 said Resident #18 resided in the secured unit. She said residents who resided in the secured unit were still able to exercise their resident rights, which included the right to refuse. She said residents were able to choose to have care at a later time and the facility staff should respect their choices. LPN #2 said the shower chairs were not enclosed and had multiple openings. She said residents should be covered up by a non-transparent covering when being transported in the shower chair to their room to ensure the resident was provided with dignity and respect. The director of nursing (DON) was interviewed on 1/25/24 at 11:10 a.m. The DON said residents were able to exercise their resident rights which included refusing care. He said if a resident did not want to shower, the facility staff should allow the resident to refuse and approach them at a later time. The DON said residents should be provided dignity after a shower. He said if the resident was not dressed in the shower room, then the resident should be covered by blankets or sheets that were not transparent. The DON said Resident #18 should have been allowed to eat his lunch prior to being provided a shower. He said CNA #2 should have ensured Resident #18 was covered in a non-transparent covering prior to being wheeled from the shower room to ensure he was not exposed to other residents on the unit.

Based on observations, record review, and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring and worsening for one (#1) of three out of seven sample residents. Specifically, a staff interview revealed that on 10/5/23, she notified a nurse that Resident #1 had a small open area on her coccyx. The facility failed to ensure the resident's skin breakdown was comprehensively assessed and had a physician-ordered treatment in place until 10/9/23, four days after the pressure injury was identified. The wound physician's assessment on 10/9/23 revealed an unstageable pressure injury to the coccyx with obscured full-thickness skin and tissue loss. The facility further failed to ensure ongoing care for the pressure injury and take steps to prevent the development of additional injuries through the development of person-centered interventions in her care plan. Findings include: I. Facility policy and procedure The Pressure Ulcers/Skin Breakdown policy and procedure, revised April 2018, was provided by the director of nursing (DON) on 10/18/23 at 8:00 a.m. It revealed, in pertinent part, The nursing staff should assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer (s). If a skin issue is noted, the nurse should describe and document/report the following: anatomical location, stage, size (length, width, depth), sinus tracts, undermining, presence of exudate or drainage, necrotic tissue (slough/eschar), granulation and epithelial tissue and the skin surrounding the ulcer. The physician should order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings and application of topical agents. II. Resident #1 status Resident #1, age 78, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included cerebral infarction due to thrombosis of the right middle cerebral artery, expressive language disorder, hemiplegia affecting the left non-dominant side, urinary incontinence, dementia without behavioral disturbance, and pain. The admission assessment, dated 6/21/23, revealed the resident's skin was intact and the 6/21/23 Braden scale for predicting pressure sore risk indicated the resident was at moderate risk for developing pressure injuries. The 7/14/23 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score of 12 out of 15. It indicated the resident was usually understood in expressing her ideas and wants and usually understood verbal content. It indicated she required extensive assistance of two people with bed mobility, dressing, toileting, and personal hygiene, extensive assistance of one person with eating, and total assistance of two people for transfers. It further indicated the resident was at risk for developing pressure injuries. It indicated the resident did not have any current pressure injuries. A. Observations 1. 10/11/23 On 10/11/23 at 9:15 a.m. Resident #1 was observed lying in bed, supine, with her arms folded at her chest and covered with a blanket. The head of the bed was raised at a 30 degree angle. A video device was observed on the over-bed table, facing the resident. -At 11:15 a.m. the resident was observed lying in bed in the same position, asleep. -At 12:30 p.m. the resident was observed lying in bed in the same position. Her head was positioned downward and she was awake. She said hi but was only able to answer yes or no questions. -At 1:15 p.m. the resident was lying in bed in the same position. Her lunch meal had been delivered and placed on the nightstand. -At 2:40 p.m. the resident was lying in the same position, with her head down and arms folded across her chest. -At 4:02 p.m. the resident was lying in bed, supine, awake, with her head down and her arms folded across her chest. The resident's daughter was sitting in a chair, near the resident's bed, giving her a drink. 2. 10/12/23 On 10/12/23 at 11:45 a.m., Resident #1's coccyx was observed with licensed practical nurse (LPN) #1. An ABD (abdominal) pad was observed on her coccyx with tape down two sides, dated 10/12/23. Removal of the ABD pad revealed a wound on the coccyx, larger in size than a quarter, covered with yellow and white exudate. The surrounding area was pink. B. Resident representative interview The resident's representative was interviewed on 10/11/23 at 4:02 p.m. She said that she was concerned about the resident's skin. She said she had a device in the resident's room that was able to show her video of her mother when she called. She said it was on the over-bed table and pointed at her mom's face so she could check in on her throughout the day. She said the resident usually remained in the same position throughout the day and was not repositioned. She said she was aware her mother was on hospice support, but she was concerned that by not repositioning the resident, her skin would continue to breakdown. The resident representative was interviewed again on 10/12/23 at 12:30 p.m. She said she received a voicemail on 10/5/23 at 10:33 a.m. from the nurse at the facility telling her the resident had a newly discovered skin concern to the coccyx. During the interview, the resident's representative played the message on her phone. It indicated the date and time (10/5/23 at 10:33 a.m.) and reported that the resident had a newly identified skin concern. II. Failure to ensure timely treatment and ongoing care for a newly developed pressure injury. A. Failure to ensure timely assessment and treatment upon discovery of the resident's pressure injury 1. Record review revealed that upon detection of the pressure injury on 10/5/23, a change of condition was not completed until 10/6/23, the next day. A full assessment was not completed until 10/9/23, four days after the wound was observed for the first time. Specifically: According to the voicemail from the nurse to the resident's daughter (see above), the coccyx wound was identified on 10/5/23. However, the situation, background, assessment, and recommendation (SBAR) documenting the resident had a change in her skin condition was dated 10/6/23. The intervention included wound care as ordered by the physician and encouraging repositioning as the resident was able to tolerate. However, it did not provide any additional information or assessment of the wound. Record review revealed a comprehensive assessment of the wound was not completed until 10/9/23. The skin and wound evaluation documented the resident had an in-house acquired unstageable pressure injury to the coccyx with 80% (percent) of the wound covered in slough and moderate serous drainage. The measurements were 21 cm area x 8.3 cm length x 3.5 cm width. The periwound was excoriated with fragile skin. It indicated the wound physician evaluated the wound on 10/9/23 and measured 4 cm x 9 cm x 0. The nurse educated the staff to reposition the resident as tolerated to reduce further skin breakdown. A review of the wound physician notes dated 10/9/23 revealed documentation the resident had an unstageable pressure injury to the coccyx with obscured full-thickness skin and tissue loss. The wound measured 4 cm in length x 9 cm in width with no measurable depth with an area of 36 square cm. There was a small amount of serous drainage noted with a wound bed with 80% slough and 20% epithelialization. 2. Record review revealed the facility failed to ensure treatment was put in place timely to address the resident skin breakdown. The treatment was not put into place until 10/9/23, four days after the initial detection of the pressure injury to the resident's coccyx. A review of the October CPOs and treatment administration record (TAR) did not reveal a treatment order upon the identification of the wound on 10/5/23 or 10/6/23. The October 2023 TAR documented the following treatment: -Stage 2 pressure ulcer to coccyx: cleanse with wound cleanser and apply medihoney and foam dressing every MWF and as needed everyday shift - ordered 10/9/23. -Silver Sulfadiazine external cream 1%: apply to the coccyx topically every day shift for wound care - ordered 10/10/23. B. Failure to ensure ongoing care of the resident's pressure injury The facility failed to ensure the comprehensive care plan included person-centered interventions to address Resident #1's new facility-acquired unstageable pressure injury to the coccyx. A review of the resident's skin breakdown care plan was initiated on 10/9/23, four days after the discovery of the resident's pressure area. It read the resident was at risk for skin breakdown related to activity intolerance, Braden Risk score, impaired activities of daily living ability, impaired mobility, incontinence of bowel, incontinence of bladder, and limited range of motion. The interventions included administering medications as ordered, administering treatments as ordered, and providing an air mattress. -The care plan did not identify the resident had actual skin breakdown and did not include any person-centered interventions to prevent skin breakdown and address the resident's current skin breakdown, even though her MDS assessment (see above) documented she required extensive assistance from two people with bed mobility. There were no instructions to staff to reposition the resident. III. Staff interviews The hospice certified nurse aide (HCNA) was interviewed on 10/12/23 at 11:16 a.m. He said the facility staff do not reposition the resident very often. He said they do not use the boots for the resident's heel. He said when he first started caring for Resident #1, her skin was beautiful, but now it was bad. Licensed practical nurse (LPN) #1 was interviewed on 10/12/23 at 11:45 a.m. She said the CNAs and nurses were responsible for repositioning residents every two hours. She said Resident #1 was unable to reposition herself on her own. She said Resident #1 required two people to assist her with repositioning and bed mobility. CNA #2 was interviewed on 10/12/23 at 1:20 p.m. She said she had worked with Resident #1 since she was admitted to the facility. She said she was the CNA who noticed the open area to the resident's coccyx. She said she reported it to the nurse. She said she thought she had reported it a week ago but could not remember the date. She said she remembered she reported the resident had redness to the coccyx, with a small open area. She said she thought it had gotten worse since she reported it. She said Resident #1 had cognitive impairment and was not able to use her call light to call for assistance. She said Resident #1 was unable to reposition herself. She said the resident required the assistance of two people for bed mobility. She said Resident #1 should be repositioned every two hours and she had repositioned her today. The wound nurse (WN) was interviewed on 10/12/23 at 4:38 p.m. She said the newly identified wound for Resident #1 was reported to her on 10/5/23 by the nurse. She said she did not put any documentation in the resident's medical record and did not put a treatment order in place. The regional clinical consultant (RCC) and the director of nursing (DON) were interviewed on 10/12/23 at 3:50 p.m. The RCC said she was unable to find documentation that Resident #1's newly acquired wound had been comprehensively assessed on 10/5/23 when it was identified. She also said she was unable to find documentation that a treatment had been put in place when the wound was identified. She said the resident's medical record documented that a treatment was not put in place until 10/9/23, four days after the wound was identified. The RCC said a full assessment and a treatment should be put in place immediately when a new skin condition was identified. She said the wound physician could change the treatment order when they assessed it, but a treatment should be in place as soon as a new wound was identified. She said the comprehensive care plan should reflect person-centered interventions to address preventative measures and actual skin breakdown.

Based on record review and interviews, the facility failed to ensure one (#3) of two residents reviewed for abuse out of seven sample residents was free from resident-to-resident abuse. Residents #3 and #6, both severely cognitively impaired, were roommates as of 7/18/23, the date of Resident #3's admission to the facility. Resident #6 had a documented history of resident-to-resident physical and verbal aggression toward staff and other residents, including on 7/25/23 with Resident#3 for talking in his sleep. Despite staff knowing Resident #6's history of resident-to-resident altercations, including against Resident #3 on 7/25/23, staff failed to monitor and develop effective interventions to protect Resident #3 from Resident #6's further abuse. On 8/24/23 at 6:45 a.m., Resident #3 was discovered in his bed with blood on the sheets, with lacerations to his right leg, left thigh, and left hand, and bruising around his right eye. Resident #6 said he hit Resident #3 because he was disturbing his sleep. Resident #3 said that he was beaten up. Findings include: I. Facility policy The Abuse, Neglect, Exploitation, or Misappropriation Reporting and Investigating policy, revised September 2022, provided by the director of nursing (DON) on 10/12/23 at 6:00 p.m. read in pertinent part: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The physician and staff will help identify risk factors for abuse within the facility; for example, significant numbers of residents/patients with unmanaged problematic behavior; significant injuries in physically dependent individuals; problematic family relationships; issues related to staff knowledge and skill; or performance that might affect resident care. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The physician will order measures required to address the consequences of an abuse situation, such as psychological evaluation or suturing of a laceration. The physician and staff will address appropriately causes of problematic resident behavior where possible, such as mania, psychosis, and medication side effects. The staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood, and function. The medical director will advise facility management and staff about ways to ensure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately. The physician will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process. II. Resident #3 and #6 According to the weekly summary note completed the evening of 7/18/23, Residents #3 and #6 were roommates as of 7/18/23, Resident #3's admission. A. Resident #3 Resident #3, age 74, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia, deafness, blindness, and type 2 diabetes. According to the 7/25/23 minimum data (MDS) assessment, the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident required extensive assistance with personal hygiene, eating, dressing, toileting, and transferring. According to physician orders, the resident was on daily antipsychotic and antidepressant medications. The resident's comprehensive care plan, revised in August 2023, identified the resident required placement in the secure unit due to his dementia. The care goal documented the resident would be kept safe. Interventions included removing the resident to a calm environment when conflict arose. A review of Resident #3's record revealed he did not have a history of aggressive behaviors. B. Resident #6 Resident #6, age 77, was admitted on [DATE]. According to the August 2023 CPO, diagnoses included severe dementia with psychotic disturbances and type 2 diabetes mellitus. The weekly summary notes dated 7/1/23 identified the resident as independent with bed mobility, transferring, and dressing. A review of physician orders revealed the resident was prescribed daily antipsychotic medications but according to the medication administration record, he often refused them. 1. Information on resident status on admission According to the progress notes dated 6/27/23, the resident was on close monitoring upon admission due to consistently refusing necessary psychiatric medications (such as Haldol and Zyprexa) while in the hospital, elopement risk and behaviors well known to the physician group from his previous residence at a skilled nursing facility which he eloped from. A skilled nursing facility tuck in note dated 6/29/23, identified the resident as not being able to answer most questions due to his cognition and severe expressive aphasia. He was able to move all extremities. It was also noted that if the resident had significant behaviors or psychosis and continued to refuse medications they could consider monthly intramuscular (IM) Invega. 2. Information on resident behaviors and need for frequent 15-minute monitoring after admission and other interventions a. Nurse's notes On 7/3/23, a nurse's note revealed the resident was on monitoring and 15-minute checks for a behavior - going close to another resident and touching them. On 7/4/23, the behavior was identified again in a nurse's note and the resident was redirected. On 7/5/23, the resident remained on 15-minute checks for behaviors. On 7/6/23, a nurse's note documented that Resident #6 was agitated with another resident and was redirected back to his room where he remained. On 7/6/23, a nurse's note documented that Resident #6 was touching another resident on the shoulder. He was redirected effectively. On 7/7/23 and 7/8/23, Resident #6 remained on 15-minute checks for behaviors. On 7/8/23, an alert nurse's note documented the resident became aggressive and combative toward staff when the nurse attempted to provide medication to the resident. On 7/9/23, a nurse's note documented the hospital reported combative behavior towards staff at the hospital which required them to call security to restrain the resident on the stretcher. He continued on 15-minute checks upon return from the hospital. On 7/25/23, a psychiatric follow-up note identified Resident #6 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. Resident #6 remained on 15-minute checks from 7/10/23 through 8/24/24 when he was removed from the memory care unit and placed on one-to-one observations in a private room following an altercation with Resident #3 (see below). b. A psychiatric evaluation dated 7/6/23 documented that staff reported Resident #6 had assaulted staff with no clear antecedent although there was not any other documentation found confirming these behaviors. c. The resident's comprehensive care plan, created on 7/5/23, identified the resident as having the potential to be physically aggressive and a behavior problem of unprovoked aggression toward other residents related to dementia. The care plan was revised on 7/9/23 and documented a care focus for physically aggressive behaviors toward others. The goal of the focus was that Resident #6 would verbalize understanding of the need to control physically aggressive behavior and fewer episodes of unprovoked aggression. Interventions for managing aggressive behaviors included: -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document the behavior. -Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff members when agitated. -If reasonable, discuss (Resident #6's) behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. There were not any changes made to the care plan after the 7/25/23 occurrence. III. Failure to protect Resident #3 from Resident 6's physical abuse. A. In addition to documentation in the nurse's notes above, a review of Resident #6's progress notes revealed the following documentation of aggressive behavior toward other residents: -On 7/8/23, Resident #6 came to the nursing station complaining about abdominal pain. The provider gave the order for Omeprazole 20mg stat but the resident (threw) the medication away, becoming combative and aggressive and wanting to go to the hospital. The resident was also combative at the hospital and had to have security hold him down on the stretcher. -On 7/25/23, Resident #6 screamed very loud and was yelling at his roommate (Resident #3) who was sleep-talking. Resident #6 was moved to another room for safety. At this time, Resident #6 was on one-to-one monitoring. -On 7/28/23, Resident #6 became angry while trying to talk to another resident and poked him in the eye. The victim said, He punched me. The victim's left side cheek had a small cut and was bleeding. The nurse separated the residents. See the resident's care plan above; there was no evidence the care plan was revised after the above incidents. B. Second resident-to-resident altercation 8/24/23 between Resident #3 and Resident #6 Despite knowledge of Resident #6's aggressive behaviors, including toward his roommate, Resident #3, on 7/25/23 (see above), the facility failed to effectively monitor Resident #6 and take steps to protect Resident #3 from Resident #6's abuse. The reported precipitating event for Resident #6's abuse toward Resident #3 on 8/24/23 was similar to that on 7/25/23. Specifically: 1. A progress note in Resident #6's record read that on 8/24/23, Resident #6 was the aggressor in a physical altercation with his roommate, Resident #3. Resident #6 said Resident #3 was being loud and yelling out throughout the night and it disturbed his sleep so he hit him. Resident #6 was moved to a different neighborhood and room in the facility for safety and per protocol. He was started on one-to-one care for safety. Police were notified and they came to the facility to investigate the incident. 2. A review of the incident note at 9:16 a.m. on 8/24/23 revealed that on 8/24/23 at 6:45 a.m., nursing staff was called to the room of Resident #3. It was discovered that Resident #3 had blood-stained bed sheets, lacerations to his right leg, left thigh, and left hand, and bruising to his right eye. Resident #6 confirmed he assaulted Resident #3 because he was disturbing his sleep. Resident #3 confirmed that he was beaten up. The nurse assessed and examined Resident #3 and treated his injuries before sending Resident #3 to the hospital for further evaluation. A nursing assessment of Resident #3's injuries revealed Resident #3's injuries were measured on the right leg at 19 centimeters (cm) long, left thigh at 2.5 cm, and left hand at 2 cm. Resident #6 was placed on one-to-one monitoring (added to his care plan on 8/24/23), sent to the hospital for further evaluation, and did not return to the facility. 3. The facility investigation dated 8/24/23 confirmed that Resident #6 expressed anger towards Resident #3 for disturbing his sleep; Resident #3 presented with several observable signs of injury upon assessment and his bed sheets were stained with blood; Resident #3 said he was beaten up. V. Staff interviews On 10/12/23 at 1:32 p.m., certified nurse aide (CNA) #3 was interviewed. She said that all staff are responsible for separating residents involved in altercations and do their best to prevent altercations when possible. She said they redirect the residents and report the incidents to their supervisor so they could start the investigation. On 10/12/23 at 1:40 p.m., registered nurse (RN) #2 was interviewed. She said she would separate residents, redirect them, and then report the incident to her supervisor when residents were involved in altercations. She was not aware of the investigation process and was not at the facility when the resident-to-resident altercation between Residents #6 and #3 occurred. The director of nursing (DON) and the chief operations officer (COO) were interviewed on 10/12/23 at 4:00 p.m. The DON said there had been multiple occurrences with Resident #6 and he was discharged from the facility due to his behaviors. Neither the DON nor the COO articulated steps that had been taken since the 7/25/23 event to protect his roommate, Resident #3.

Based on observations, record review, and interviews, the facility failed to ensure one (#1) of three out of seven residents with limited range of motion received appropriate treatment and services. Specifically, the facility failed to properly assess the resident's contracture and ensure the comprehensive care plan identified the contracture, and interventions were put into place to prevent the worsening of Resident #1's left elbow and left hand contracture. Although there were no measurements, staff and resident representative interviews revealed the resident's contracture had worsened. Findings include: I. Facility policy and procedure The Resident Mobility and Range of Motion policy and procedure, revised July 2017, was provided by the director of nursing (DON) on 10/18/23 at 8:00 a.m. It revealed, in pertinent part, Residents will not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The resident and representative will be included in determining these goals and objectives. Documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs. II. Resident #1 status Resident #1, age 78, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included cerebral infarction due to thrombosis of the right middle cerebral artery, expressive language disorder, hemiplegia affecting the left non-dominant side, urinary incontinence, dementia without behavioral disturbance, and pain. The 7/14/23 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score of 12 out of 15. She required extensive assistance of two people with bed mobility, dressing, toileting, and personal hygiene, extensive assistance of one person with eating, and total assistance of two people for transfers. It indicated the resident was usually understood in expressing her ideas and wants and usually understood verbal content. A. Resident representative interview The resident representative was interviewed on 10/11/23 at 4:02 p.m. She said Resident #1 had left-sided weakness from a CVA (stroke). She said the resident's left elbow and left hand were contracted. She said she had brought this up when she was first admitted to the facility in June 2023, but the facility still had not put any preventative measures in place. She said her mom's contracture had gotten significantly worse since her admission. She said when she was admitted , the resident's fingers did not curl into the palm of her hand. B. Observations On 10/11/23 at 9:15 a.m. Resident #1 was observed lying in bed, supine, with her arms folded at her chest and covered with a blanket. -At 4:02 p.m. the resident remained in the same position, lying supine with her arms folded at her chest. A neck pillow was placed underneath the resident's left elbow and left wrist. The fingers on the resident's left hand curled in, almost touching the palm of her hand. There were no preventative measures in place to address the resident's contracture. C. Record review The 6/28/23 occupational therapy start of care evaluation documented the occupational therapist (OT) recommended a splint to the left elbow and the left hand contracture. There was no documentation of measurements of the contracture to the resident's left elbow and left hand in the OT evaluation or elsewhere in the resident's record. A review of Resident #1's comprehensive care plan revealed the facility failed to identify the contracture to the resident's left elbow and left hand and measures to prevent the worsening of the contracture. III. Staff interviews The hospice certified nurse aide (HCNA) was interviewed on 10/12/23 at 11:16 a.m. He said when he first started caring for the resident her contracture was not as bad. He said her fingers did not curl in towards her palm. He said he was the one who put the neck pillow in place for the left elbow and left hand (see observations above). CNA #2 was interviewed on 10/12/23 at 1:20 p.m. She said she had worked with Resident #1 since she was admitted to the facility. She said when the resident was first admitted , she had range of motion in the left arm and was able to move her fingers. -She said the contracture to the resident's left elbow and left hand had gotten significantly worse. She said the resident no longer had range of motion in her left arm and fingers on the left hand curled inward toward her palm. -She said the resident did not have a splint in place for the left elbow or left hand. She said the facility did not have any preventative measures in place for the resident's contractures. The regional clinical consultant (RCC) and the director of nursing (DON) were interviewed on 10/12/23 at 3:50 p.m. The RCC said contractures should be measured upon a resident's admission to the facility or upon the development of the contracture. She said the contracture should be identified in the comprehensive care plan with preventative measures put in place to prevent the worsening. The RCC said she was unable to find documentation that Resident #1's contracture had been measured upon her admission to the facility. She confirmed the contracture had not been identified in the comprehensive care plan and preventative measures had not been put into place.

Based on record review, observations, and interviews, the facility failed to create an environment that protected eight of 21 residents reviewed (#20, #32, #42, #12, #33, #45, #37 and #55) from abuse. RESIDENT TO RESIDENT SEXUAL ABUSE Resident #20, with moderate cognitive loss, exhibited inappropriate sexual behavior toward three residents (#42, #12, and #32), all of whom were severely cognitively impaired. Resident #42 was touched inappropriately on her breast on 7/14/22, Resident #12 was touched inappropriately on her breast on 8/29/22, and Resident #32 was touched inappropriately on her breast on 9/26/22, during the survey. While the facility provided immediate interventions to ensure resident safety after the incidents on 7/14/22 and 8/29/22, the immediate interventions (15 minute checks x 72 hours) were not sustained, and the interventions staff reported they had been given (to keep Resident #20 away from female residents, keep him on 15 minute checks if he was alone and on one on one (1:1) supervision if he was in common areas), were not consistently implemented to prevent further sexual abuse. On 9/26/22, Resident #20 sat at a table in the common area without any staff present, waved Resident #32 to the table, and began to massage her breast, stopping when he realized he was being observed. The facility's failure to develop and implement effective interventions to prevent cognitively impaired residents from being repeatedly subjected to inappropriate sexual behavior by Resident #20 created the potential for serious harm if the situation was not immediately corrected. RESIDENT TO RESIDENT PHYSICAL ABUSE Record review, observations and interview revealed the facility failed to take sufficient steps to protect Resident #45 and Resident #37 from physical abuse by Resident #33 and Resident #55, respectively. Cross-reference F744; treatment/services for dementia care. Findings include: RESIDENT TO RESIDENT SEXUAL ABUSE I. Immediate jeopardy A. Findings of immediate jeopardy Resident #20, with moderate cognitive loss, exhibited inappropriate sexual behavior toward three residents (#42, #12, and #32), all of whom were severely cognitively impaired. Resident #42 was touched inappropriately on her breast on 7/14/22, Resident #12 was touched inappropriately on her breast on 8/29/22, and Resident #32 was touched inappropriately on her breast on 9/26/22, during the survey. The facility's failure to develop and implement effective interventions to prevent cognitively impaired residents from being repeatedly subjected to inappropriate sexual behavior by Resident #20 created the potential for serious harm if the situation was not immediately corrected. On 9/27/22 at 4:00 p.m. the facility's director of clinical operations (DCO) was notified that the facility's failure created an immediate jeopardy situation. B. Facility plan to remove immediate jeopardy On 9/27/22 at 5:42 p.m., the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: Immediate Action: Upon notification of potential sexual abuse perpetrated by Resident #20, a one to one was immediately initiated on 9/26/22. Resident #20 remained on a 1:1 until the resident was discharged from the community at 12:03 pm on 9/27/22. Non-interviewable resident observations to be completed on all residents residing in the secure neighborhood daily for a period of 72 hours to ensure no adverse effects or behavioral changes have been identified. Interviews to be completed on 9/28/22 for all residents who were in attendance at the group activity where the incident occurred, since they would be the only ones affected by the alleged perpetrator. Observations will be documented on Non-Interviewable Resident Observation forms for each individual resident. If any behavioral changes are noted DON/NHA/SSD (director of nursing, nursing home administrator, social services director) to be notified immediately upon discovery for review and recommendations. During the period from 9/27/22 to 9/28/22, all staff were provided education on abuse reporting, response, and ongoing behaviors. Education to include any updated revisions / interventions as well as reporting allegations to the NHA immediately. Education to include documenting behaviors appropriately. When indicated, resident specific education will be provided to staff on interventions. Behaviors to be documented in electronic medical records via POC (point of care) tasks and Risk Management incident reports. All staff members on shift on 9/27/22 were provided immediate education related to abuse reporting guidelines and policy and abuse investigation process. All staff members to be educated by Staff Development Coordinator or Charge Nurse on duty prior to the start of their next shift until such time as 100% compliance is achieved. Beginning 9/28/22, observations to be completed by NHA/Designee at least three times weekly to ensure interventions in place for behavioral residents are followed. Systemic Changes: Education on abuse reporting, response, and ongoing behaviors will be provided and will include proper interventions as well as reporting allegations to the NHA immediately. This education will be continued with all staff members prior to the start of the next shift until all staff have been educated. Residents are reviewed prior to admission for previously identified behaviors to ensure that interventions are in place upon admission. The Capacity for Consent is completed on residents for whom a need is identified i.e. expressing a desire to pursue an intimate relationship with a consenting peer. Routine behavior monitoring to continue with all residents to ensure newly identified behaviors are addressed. Behaviors documented in Point Click Care to be reviewed during daily meetings (Monday through Friday) by IDT (interdisciplinary team) managers including NHA, DON, ADON (Assistant DON), and SSD. NHA or designee to ensure any needed revisions to the behavioral plan of care are put into place following a root cause analysis to ensure person centered interventions are trialed. Staffing is reviewed daily to ensure appropriate staffing in place to meet needs to include behavior management. Care plan to be updated at this time. An immediate complete facility audit of care plans to ensure care plans identify residents with high risk behaviors have appropriate interventions in place. Care plans to be reviewed as needed and quarterly with the routine care conference. The facility will continue to initiate an investigation for allegations of abuse. All investigations will be reviewed upon completion by Corporate Consultant to ensure complete and accurate investigation is completed and appropriate follow up/interventions are put into place. The NHA will be responsible to report allegations of abuse to the proper authorities. Monitoring: Behavior monitoring will continue to be completed on each shift for each resident utilizing POC tasks. Additional behaviors may be documented in risk management and progress notes. Behavior monitoring for behaviors directed at others are triggered to the PCC dashboard for the management team and will be reviewed daily. The facility will track abuse allegations on the abuse log as they occur to identify any trends in residents involved in allegations. C. Removal of immediate jeopardy On 9/28/22 at 4:51 p.m. the NHA was notified that based on review of the facility plan, the immediate jeopardy situation had been abated. However, deficient practice remained at an E level, the potential for more than minimal harm at a pattern. II. Facility abuse policy A. On 9/26/22 at 11:19 a.m. the NHA provided the Abuse Policy developed 9/26/13, revised 10/28/2020. It read in pertinent part; -Definitions: Sexual abuse is a non-consensual sexual contact of any type with a resident. Willful is when the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. -Prevention of abuse, neglect or misappropriation of personal possessions: Residents at risk for abusive situations are identified and appropriate care plans are developed -Abuse by other residents If a resident experiences a behavior change resulting in aggression towards other residents, the facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. -If abuse happens: Separate the assistant from the victim. Isolate the assailant to protect others. Assess and treat the victim. Notify the Administrator on duty. B. Review of the facility policy revealed it addressed categories of abuse but did not address actions to take or interventions to keep residents safe. III. Failure to create an environment that protected Residents #42, #12, and #32 from sexual abuse by Resident #20. A. Resident #20 and Resident #42 1. Resident # 20 - facility knowledge of potentially sexually abusive behavior Resident #20, age 63, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was residing in the secure memory care unit. The 9/27/22 minimum data set (MDS) assessment documented the resident had moderately impaired cognition with the brief interview for mental status score (BIMS) of 12 out of 15. He required supervision with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The resident was independent in ambulation without an assistive device. The resident did not display any behaviors of wandering. A comprehensive care plan, initiated on 9/21/21, identified under trauma informed care, that Resident #20 had problematic behaviors related to history of violence, drug and alcohol use. Resident had the potential to be physically, sexually and verbally aggressive with women and would rub them inappropriately on the legs and chest. Interventions were behavior monitoring, using kind language to remove resident from the situation, reinforce with resident that behavior was inappropriate and divert resident's attention. Continuous observations on 9/26/22 from 12:03 p.m. to 1:30 p.m. showed while drinks were being served in common area on secure unit, Resident #20 attempted to engage the dietary supervisor (DS), asking her if she goes out at night and if she was married. The DS did not engage. Resident #20 was interviewed on 9/26/22 at 4:15 p.m. The resident was able to recall that he had been in the hospital prior to his admission and the reason why he was in the hospital. He stated he had been in the facility for 20 months (correct time frame was 22 months). He was able to provide accurate information regarding his history and his family members. He was also able to recall having eaten fried chicken that the staff had ordered for him for lunch earlier and to count the amount of money he had in his pocket correctly. 2. Resident #42 - facility knowledge of behavior that placed the resident at risk for abuse Resident #42, age 71, was admitted on [DATE]. According to the September 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was residing in the secure memory care unit. The 8/11/22 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of zero out of 15. The resident required extensive assistance with dressing, eating, toileting, and personal hygiene. The resident was independent in ambulation without an assistant device. She had behaviors of continuous inattention and disorganized thinking. The resident's care plan, initiated on 2/11/20 and revised on 2/24/21, documented the resident had behavior challenges related to severe cognitive impairments. She often walked out of her room without clothing, only in an adult undergarment. Interventions were to utilize clothing or blanket to cover the resident and attempt to redirect back to room to dress. The resident had communication deficits and was nonverbal. Continuous observations of the resident on 9/26/22 from 12:03 p.m. to 1:30 p.m. revealed the resident walked independently throughout the unit and talked in nonsensical sentences. 3. Incident 7/14/22 A nursing progress note dated 7/14/22 stated Resident #20 was observed touching a female resident (#42) inappropriately but stopped when asked to do so. The resident denied touching the other resident and was started on 15 minute checks for 72 hours. The facility's alleged sexual abuse incident report dated 7/14/22 documented that Resident #42 had been walking down the hall in only her disposable brief. Resident #20 had walked up behind her and touched her breast. Staff separated the residents and placed the residents on 15 minute checks. Witness statement dated 7/15/22 from activities associate (AA #2) stated that when Resident #20 was observed grabbing the breast of Resident #42, he was told not to do that. He then proceeded to do it once more, then went to his room. 4. Failures in facility response to protect Resident #42, as well as other residents, from potential sexual abuse by Resident #20. a. Review of Resident #20's record revealed the facility failed to take sufficient steps to prevent further sexual abuse by the resident and failed to protect Resident #42 from further abuse. Record review revealed the facility implemented one on one (1:1) supervision and 15 minute checks after the incident but these interventions were not sustained beyond 72 hours. Review of Resident #20's care plan revealed the trauma-informed care plan was revised 7/29/22; however, the revision was that staff would provide reassurance that the resident's needs would be met, and establish a time frame of when they will be met. There was no reference to the resident's behavior on 7/14/22 and no plan to increase supervision of the resident. Review of Resident #20's progress notes revealed physician notes dated 7/18/22, but the note did not mention the resident's recent sexually inapporprate behaviors. It was not until 8/15/22, a month after the incident with Resident #42, that a physician note documented the facility had requested the resident be seen due to sexual assault of another resident, and the resident was placed on [MEDICATION(S)], an antidepressant, 50 mg once a day for sexual dysfunction not due to substance or known physiological condition. Review of the resident's medication and treatment records (MAR and TAR) revealed no orders for behavior monitoring following the 7/14/22 incident. Certified nurse aide (CNA) tasks pulled on 9/28/22 at 11:59 a.m. showed behavior monitoring for behaviors directed at staff, behaviors directed at others and behaviors not directed at others every shift. Behavior tracking was not specific to monitoring for hyper sexual behaviors or other behaviors identified on Resident #20's care plan (physically, sexually and verbally aggressive with women, rubbing them inappropriately on the legs and chest). Review of the resident's progress notes revealed no social service notes after 7/14/22 regarding the resident's inappropriate sexual behavior. b. Review of Resident #42's record revealed the facility failed to take sufficient steps to protect her from further sexual abuse. Review of Resident #42's care plan did not identify the incident on 7/14/22 and, contrary to facility policy (see above; to identify residents at risk for abusive situations and develop appropriate interventions), failed to reveal the plan was reviewed and revised to address the resident's risk for abuse, given her known behavior of walking out of her room without clothing and the resulting incident on 7/14/22. Review of progress notes revealed no social service progress notes in the resident's record regarding the 7/14/22 incident, the resident's psychosocial well-being, or notice to the resident's family regarding the incident. Review of the resident's MAR and TAR revealed no orders for behavior monitoring. CNA tasks pulled on 9/28/22 at 11:59 a.m. showed behavior monitoring for behaviors directed at staff, behaviors directed at others and behaviors not directed at others every shift. There were no specific behaviors indicated to monitor. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Review of the resident census showed Resident #20 resided in a room directly across the hall from Resident #42 until 7/27/22. There was no documentation that Resident #20 had a 1:1 or increased supervision 7/14/22 through 7/27/22. B. Resident #20 and Resident #12 1. Resident #20 - see above - facility knowledge of potentially sexually abusive behavior 2. Resident #12 - facility knowledge of resident safety risk due to severe cognitive impairment Resident #12, age 93, was admitted on [DATE]. According to the September 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided on the unsecure long term care unit. The 7/11/22 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of zero out of 15. She required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The resident required a wheelchair for ambulation. She had behaviors of continuous inattention and disorganized thinking. The resident's comprehensive care plan, initiated on 6/25/20 and revised on 2/11/21, revealed the resident had communication deficits related to cognitive decline. 2. Incident 8/29/22 An incident report on 8/29/22, documented Resident #20 was witnessed in activities by activity assistant (AA) #2 with his hand on the chest above the breast of Resident #12. When facility camera footage was reviewed, it showed Resident #20 had his hand on top of the breasts of Resident #12 earlier in the activity. Residents were separated and put on 15 minute checks for 72 hours. 3. Failures in facility response to protect Resident #12, as well as other residents, from potential sexual abuse by Resident #20. a. Review of Resident #20's record revealed the facility failed to take sufficient steps to prevent further sexual abuse by the resident and failed to protect Resident #12 from further abuse. Documentation provided by the Director of Clinical Operations (DCO) on 9/30/22 after survey exit revealed the resident was put on a therapeutic work program after the incident 8/29/22 to offer distraction and redirection. However, no details regarding the program - its frequency, timing, and location were provided. Likewise, there was no documentation to show it was monitored and effective in distracting and redirecting the resident. Record review revealed the resident's [MEDICATION(S)] was increased 9/12/22 to 100 mg daily due to the resident having been physically, sexually, and verbally aggressive with women/other residents. However, there was no documentation the medication was being monitored for effectiveness, even though the physician note 9/12/22 read to monitor behaviors. Indeed, no orders for behavior monitoring were found in the resident's MAR and TAR. CNA tasks pulled on 9/28/22 at 11:59 a.m. showed behavior monitoring for behaviors directed at staff, behaviors directed at others and behaviors not directed at others every shift. There were no specific behaviors indicated to monitor. Review of Resident #20's care plan revealed it was not reviewed and revised by the interdisciplinary team following this second incident of inappropriate behavior by Resident #20, to consider new interventions as current interventions had been ineffective in preventing a second incident. There was no plan to increase the resident's supervision beyond 15 minute checks for 72 hours. Social services met with the resident 8/30/22 to discuss community discharge with the resident's family and referrals were sent at that time to other secure units. However, there were no notes regarding the 8/29/22 incident or plans on how to prevent further abusive incidents. b. Record review revealed the facility failed to take steps to address Resident #12's potential needs following the 8/29/22 incident. There were no social services progress notes in the resident's medical record after 8/1/22; there were no progress notes regarding the incident or resident's psychosocial wellbeing. Further, there was not a progress note that the resident's family was notified of the incident. There were no orders for behavior monitoring found on the resident's MAR and TAR. CNA tasks pulled on 9/28/22 at 11:59 a.m. showed behavior monitoring for behaviors directed at staff, behaviors directed at others and behaviors not directed at others every shift. There were no specific behaviors indicated to monitor. Review of the resident's care plan revealed no reference to the 8/29/22 incident and the resident's risk for sexual abuse. No revisions were made to protect the resident. C. Resident #20 and Resident #32 1. Resident #20 - see above - facility knowledge of potentially sexually abusive behavior 2. Resident #32 - facility knowledge of resident safety risk due to severe cognitive decline, wandering and history of altercations with other residents Resident #32, age 62, was admitted on [DATE]. According to the September 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was residing in a secure memory care unit. The 9/20/22 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of five out of 15. She required supervision with bed mobility, transfers, eating, and toileting. Requiring limited assistance with dressing and personal hygiene. The resident was independent in ambulation without an assistant device. She had behaviors of continuous inattention and disorganized thinking. The resident's comprehensive care plan initiated on 2/28/22 and revised on 7/12/22, identified the resident had behaviors of wandering into other residents' rooms when looking for a restroom and interventions were to establish behavior monitoring, anticipate and meet resident's needs. The resident had communication deficits related to cognitive decline. Notes in interventions under the behavior care plan documented resident had prior altercations with other residents 3/25/22, 6/10/22, and 7/7/22 but details of the altercations were not documented and there were no notes that the resident was at risk for abuse due to history of alterations. Social services progress notes dated 6/9/22 through 9/25/22 do not address or mention any history of altercations. There are no social service progress notes prior to 6/9/22 in the resident's medical record. Record review revealed no orders for behavior monitoring were found in the resident's MAR and TAR. CNA tasks pulled on 9/28/22 at 11:59 a.m. showed behavior monitoring for behaviors directed at staff, behaviors directed at others and behaviors not directed at others every shift. There were no specific behaviors indicated to monitor. Continuous observations on 9/26/22 from 12:03 p.m. to 1:30 p.m. and again from 2:00 p.m. to 2:40 p.m. revealed Resident #32 walked independently throughout the unit going in and out of other residents' rooms without purpose. Staff were sometimes around but did not redirect the resident. Resident #32 was interviewed on 9/26/22 at 4:25 p.m. The resident could not recall what she had eaten for lunch that day, could not name Resident #20, or provide information regarding her own family members. She was unable to engage in two way conversation and was unable to recall recent events of the day. 3. Incident 9/26/22 On 9/26/22 at 2:40 p.m. Resident #32 was observed walking near the common area in the secure unit. Resident #20 had come in from the attached patio and sat at a table in the common area. No staff were present. Resident #20 had a box of food from an outside restaurant he had ordered and he waved Resident #32 over. Resident #32 came over to look inside the box and Resident #20 began to massage her wrist and arm. He then moved upward to her breast and massaged that briefly before realizing he was being observed. He then stopped and Resident #32 walked away. Facility staff were immediately notified at 2:46 p.m. and Resident #20 was taken to his room. The director of nursing (DON) arrived at 2:58 p.m. and advised the nurse to put Resident #20 on 15 minute checks. At 2:59 p.m., a nurse from the other side of the building arrived and began to provide 1:1 supervision of Resident #20. At 3:23 p.m. the social services director (SSD) arrived and spoke with Resident #20 in his room briefly. The SSD left the resident's room at 3:26 p.m. On 9/27/22 at 10:37 a.m. the NHA provided CNA POC documentation for 6/27/22-9/27/22. The only behavior documented during this time frame was on 9/26/22. Behavior directed towards another resident of grabbing was documented with intervention of 1:1 supervision and removed resident from the situation. However, the behavior of grabbing did not specify it was sexual in nature. IV. Staff interviews revealed the interventions to protect female residents from Resident #20's sexually inappropriate behavior (keep him away from female residents, keep the resident on 15 minute checks if he was alone and on 1: 1 supervision if he was in common areas) were difficult to implement and not always implemented. Licensed practical nurse (LPN) #1 was interviewed on 9/26/22 at 3:32 p.m. She said the interventions the staff had been provided by administration to manage Resident #20's behavior had been to keep him away from female residents. She said that this is very challenging with residents on the secure unit as they wander into each other's rooms and wander all over the unit. Said that there were no other interventions provided. LPN #1 was interviewed again on 9/27/22 at 10:45 a.m. She stated that Resident #20's inappropriate touching behavior had only recently just started in the last year. The administration had instructed them to keep him away from female residents. Prior to the incident on 9/26/22, the staff were to keep the resident on 15 minute checks if he was alone and on 1: 1 supervision if he was in common areas. If they do not have the available staff on the unit to provide a 1:1, then they would request staff from the other unit in the facility. And if they do not have available staff, they would contact an agency to provide staff for a 1:1 sitter. Certified nurse aide (CNA) #2 was interviewed on 9/27/22 at 11:03 a.m. She stated that the staff on the unit were to keep Resident #20 away from female residents but that was difficult. The staff could not keep female residents from walking near him but the staff did talk to him about not touching the female residents. She said that Resident #20 understands what the staff are telling him not to do. The only instruction provided for interventions from administration was to keep him away from female residents but the staff are unable to provide 1:1 or keep residents away from him. The activities director (AD) was interviewed on 9/27/22 at 11:10 a.m. Said that she had worked at the facility since March of this year and there have been two other incidents with Resident #20 touching other residents inappropriately. After the second incident, she tried to ensure Resident #20 was the last resident to arrive at activities and the last to leave so he is not alone with the other residents. However, see above; the AD's intervention was not documented on the resident's care plan. The AD stated the resident is able to comprehend what he is doing and she has had concerns about him in the secure unit because his dementia had not progressed as much as the other residents. The SSD was interviewed on 9/27/22 at 11:21 a.m. She said she discussed the incident on 9/26/22 with Resident #20. He told her that Resident #32 had been walking and fell into his hand and that was how he ended up touching her breast. The SSD stated he then corrected himself and admitted that he had grabbed her breast. The SSD said the resident understood what consent was and acknowledged that he had not received consent from Resident #32 to touch her sexually. When SSD interviewed Resident #32, she could not recall anything that had happened. V. Administration and physician interviews The NHA was interviewed on 9/28/22 at 9:30 a.m. She stated that Resident #20 had been on a waitlist for an all-male secure unit and was now going to be transferring there by 11:00 a.m. today. She revealed the resident had been on the waitlist for this facility since July and now the NHA had received some support from corporate to move him sooner. Resident #20's primary care physician (PCP#1) was interviewed on 9/28/22 at 2:03 p.m. She said she had only known the resident for six months and she had focused on stabilizing his diabetes and insulin since she had begun treating him. She said the facility had asked her to put the resident on medication for his sexual behaviors; however, she did not discuss his sexually inappropriate behaviors further. VI. Staff education and training On 9/27/22 at 2:30 p.m. the NHA provided facility online course completion summary for 1/1/22 thorough 9/27/22 on behavioral health in older adults: preventing, recognizing, and reporting abuse. However, the NHA did not provide subject matter or training instruction for the course. On 9/27/22 at 5:48 p.m. the NHA provided in-service training to staff on abuse and the Elder Justice Act dated 7/25/22. Training included abuse reporting and what to do if abuse occurs. All staff in all departments were required to take this course. On 9/28/22, the NHA provided the sign in sheet for the 7/25/22 in-service given to the staff on reporting of incidents, resident abuse, and the Elder Justice Act. On 9/27/22 at 5:48 p.m. the NHA provided a print out of the online course for behavior tracking and behavior interventions. On 9/28/22 the NHA provided the all staff in-service given to the staff on 8/29/22 after the incident of involving Residents #20 and #12. Summary of topic stated: Staff, please closely monitor Resident #20 (name) and when observed getting close to a female resident, kindly redirect him away from them. He also needs to be separated from female residents when participating in any activities. However, see above; staff reported this intervention was difficult to implement and was not implemented on 9/26/22 when Resident #20 was in a common area, near and then touching Resident #32. VII. Facility follow up after survey exit On 9/30/22 at 4:21 p.m. the DCO provided the following information, often set forth in the findings above, regarding actions taken by the facility. -Facility contacted to law enforcement to make reports of sexual assaults on 7/14/22 and 8/29/22. Law enforcement and the district attorney elected to not press charges due to not meeting statute requirements. Adult protective services also did not open a case. Facility contacted law enforcement after the 9/26/22 incident and due to the victim denying assault occurred and did not show psychosocial distress, law enforcement did not pursue. -After 7/14/22, facility moved Resident #20's room away from the victim's room once another room became available on 7/27/22. -Primary care physician completed onsite assessment of Resident #20 on 7/18/22. Physician added medication for hypersexual behavior 8/15/22. Medication was increased 9/10/22. -Trauma informed care plan put into place 7/26/22 with interventions. -Care conference meeting was held with family 8/8/22 to discuss discharg[TRUNCATED]

Based on observations, record review and interviews, the facility failed to ensure that one (#64) of 31 sample residents who entered the facility without limited range of motion (ROM), did not experience a reduction or loss in ROM. Specifically, the facility failed to: - provide treatment and services in a timely manner to implement interventions and prevent decline in bilateral lower extremities ROM, - provide an assisted device (appliances/splint) for the resident who developed contractures to prevent further decline, - comprehensively assess range of motion (ROM) limitations, and - address the resident's contractures in the Interdisciplinary Care Plan. These failures attributed to resident #64's decline and resulting in the development of contractures in less than 5 months. The findings include: A. Professional References - Physical Medicine and Rehabilitation Principles and Practice, Fourth Edition by Lippincott, Williams and Wilkins, Chapter 68, Immobility and Inactivity: Physiological and Functional Changes by Eugene M. Halar and Kathleen R. Bell, in pertinent part: ". . . Persons who are chronically sick, aged, or disabled are particularly susceptible to the adverse effects of immobility. . . Three main types of effects from immobilization are found in the musculoskeletal system: [MEDICAL CONDITION] and weakness, joint contracture, and immobilization [MEDICAL CONDITION]. . . . Stretching to maintain optimal resting length of the muscle belly as well as viscoelastic properties are important factors in the maintenance of normal muscle function." - Medical-Legal Aspects of Long-Term Care by Jeffrey M. Levine, MD, pages 10 and 58, in pertinent part: "Rehabilitation, another vital component of nursing home care, is the process of delivering the assistance that would help maintain the highest possible level of physical function. The basic principles of rehabilitation include treating the primary disability, preventing secondary disability, enhancing residual function, setting realistic goals, emphasizing functional independence and altering the resident's surroundings to maximize function. Rehabilitation therapy can help in preventing complications of immobility. . . .The individualized care plan consists of a list of specific problems to be addressed. At minimum, the list should include problems identified on the MDS screening assessment. . . . When the care plan is implemented in accordance with standards of good clinical practice, it becomes a powerful, practical approach to providing for the quality of care and quality of life needs of an individual resident." B. Resident Failures Resident #64, [AGE] years old, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's admission assessment, dated 9/4/12, documented the resident required supervision with bed mobility and eating, and extensive assistance with transfers, dressing, toilet use, and personal hygiene. She was using her wheelchair independently within the facility. She had no limitations in ROM. The quarterly assessment, dated 11/26/12, documented the resident did not have limitations in ROM. However, the most recent minimum data set (MDS), significant change assessment, dated 1/8/13, (five months after admission), revealed the resident required extensive assistance with bed mobility and eating, and was totally dependent on staff with transfers, dressing, toilet use, personal hygiene and locomotion (wheelchair). The assessment documented the resident had limited range of motion in a lower extremity on one side. A physical therapy (PT) assessment, dated 12/8/12, did not include documentation, referring to the care plan, for any interventions to prevent contractures for this resident. In addition, there was no nursing documentation addressing contracture prevention. According to the 2/2013 Medication Administration Record, [REDACTED]. 1. Record Review The History and Physical, dated 8/3/12 and during her hospitalization prior to the admission to the facility, revealed she was living independently at an assisted living facility where she fell and sustained a left hip contusion. It also documented, "Radiology here, states no fx (fracture), but has UTI (urinary tract infection), and felt to be possibly overmedicated." Approximately two weeks after admission, on 9/12/12, the resident fell at the facility. A portable right knee x-ray, dated 9/12/12, documented, "no fracture or dislocation present." The PT progress note/assessment, dated 9/17/12, documented, "able to walk (with) hand hold assistance," and referred the resident to the restorative program for ambulation. The facility did not provide records (requested 2/12/13) of ambulation/transfers or lower extremities exercises with resident. The PT did not document any limitations in ROM, however, documentation, dated 9/17/12, revealed the resident complained of knee pain and she considerably declined with all functional activities after the fall on 9/12/12. The next PT note, dated 10/4/12, documented the resident was able to perform lower extremity active ROM exercises without pain, however, right leg discomfort was present. The resident stood three times for 15 seconds each time. The PT also documented, "Talked (with) NP (nurse practitioner) regarding pt's status - will try few more visits to work on (increasing) ROM LE (lower extremities), (decrease) pain, standing ex's (exercises)." The PT documented 45 minutes of treatment time. The next PT treatment/discharge notification/Restorative Nursing Referral, dated 10/12/12, documented, "Pt had a change in functional mobility after her fall - pt c/o (complained) pain/discomfort (R) (right) LE (with) ROM - X-Ray neg(ative). Pt does not c/o pain with sit (to) stand. Please practice sit to stand in (parallel) bars to facilitate transfers." The PT did not document restorative aide training, did not specify how many times per treatment/day/week the resident should practice sit to stand and did not recommend additional modalities/exercises to improve the resident's functional status. The PT visit/evaluation, dated 12/8/12, less than three months after the fall, documented, "contracture (right) hip." The evaluation revealed the resident was able to perform stand pivot transfer with one person assistance and tolerated gentle movement to increase lower extremity ROM. On 1/19/13, the PT documented the resident's right leg was crossed under her left leg and the treatment was limited to wheelchair positioning. On 1/31/13, the PT discharge note revealed the resident's right leg was in external rotation and the right knee with 30 degrees flexion contracture was documented. The resident did not allow any movement due to pain. The PT did not document restorative nursing training nor recommended lower extremity ROM exercise, splints, or alternate modalities to improve the resident's ROM and prevent further decline. The was no evidence of additional communication/documentation between PT, the physician and nursing found in resident's records. The facility did not provide documentation (requested on 2/12/13) to show restorative nursing interventions were implemented to prevent the resident's contractures. 2. Observations On 2/11/13 at 4:07 p.m., the resident was observed in the activities room, sitting in her wheelchair. Both legs were observed in adduction, with the left leg crossed over the right. On 2/13/13 at 1:16 p.m., the resident was observed in the dining room, sitting in her wheelchair with her legs crossed and both knees flexed. The assistant director of nursing (ADON) and the restorative aide (RA) participated in the observation. The RA approached the resident and asked her if she could move her legs out to the side and extend her knees. The resident initiated the motion however, was not able to continue. The RA was trying to help the resident to move her legs; however, the resident did not allow any assistance. The resident did not verbalized any comments. 3. Interviews On 2/13/13 at 11:40 a.m., the director of nursing (DON) stated she was unaware PT had not recommended restorative nursing for preventative measure to prevent leg contractures. On 2/13/13 at 1:21 p.m., the RA stated the resident had severe contractures in her hips and knees. She added that PT did not provide training with restorative or nursing staff to address the resident's contractures or implement interventions other than wheelchair positioning. On 2/13/13 at 5:20 p.m., the PT stated in a telephone interview, she did not include restorative nursing training in her treatment plan for the resident. The PT said they had not provided modalities ordered on the 12/8/12 physician's orders [REDACTED]." The PT also stated she had not included lower extremity ROM on the Restorative Referral form (dated 1/31/13) because the resident was resistant to move her legs. She said PT had not considered different approaches to decrease the resident's contractures. She stated she had not assessed factors affecting ROM, and she had not communicated with nursing staff to schedule any pain medication prior to the PT treatment.

Based on record review, staff interviews, and observations, the facility failed to provide adequate supervision to prevent accidents in an environment that was as free of accident hazards as possible for three out of six sample residents (#1, #2, and #3). Specifically: -The facility failed to ensure that resident #1 had personal safety devices implemented and functioning properly to prevent injury related to falls. Resident #1 was known by the facility to be a high fall risk. The facility failed to ensure the resident's bed alarm was appropriately placed on the resident to prevent the resident from getting up without staff knowledge, falling, and sustaining injuries (fractures). -The facility failed to ensure that resident #2 was adequately supervised during meals to prevent choking/aspiration of food. The resident was admitted to the emergency room 20 hours later, where she was intubated related to a piece of hot dog being lodged in her throat. -The facility failed to ensure swallowing precautions and adequate fall prevention measures were implemented for resident #3. The findings include: 1. Sample resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Status on Admission - known fall risks The initial nursing assessment completed on [DATE] documented: -The resident needed extensive, one-person assistance with mobility/ambulation as well as with dressing/grooming/ADLs (activities of daily living). The resident needed extensive two-person assistance with transfers. -The resident also needed extensive assistance with toileting. It documented the resident as being totally incontinent of bladder and occasionally incontinent of bowel. The resident was scored as a seven out of 21 under the Bowel and Bladder Evaluation section. This signified that the resident was a candidate for a toileting schedule (prompting and voiding). -Under the Sensory/Perception/Mental Status section, the resident was documented as having adequate vision, impaired hearing, adequate communication, she was oriented to her self, she was conscious, and her cognition was moderately impaired. -The resident denied any pain during her initial nursing assessment. The manner that was documented for expressing pain was, "Verbal." The fall Risk Evaluation had eight items out of 34 checked. Per the assessment, "Any factor checked is considered a potential risk for falls." The items that were checked on the assessment were: Decline in functional status; Incontinence; Unsteady gait; Impaired Hearing; Poor Safety Awareness; Decline in Cognitive Status; Diuretics - Lasix 20 mg (three tabs in AM & two tabs at noon); Psychotropic Meds - Zyprexa 5 mg po q HS (every night). The undated Resident Profile form recorded that the resident needed transfer and mobility assistance, was a high risk for falls, and used a wheelchair. It recorded that the resident was to receive assistance with transfers, ambulation, and wheelchair use. It was recorded under the "Other" section of the form that the resident was able to use the call light. The notes recorded that the resident had a bed alarm and a fall mat. The [DATE] hospice nursing visit assessment recorded that the resident was alert and had no signs or symptoms (s/s) of pain noted. The resident was recorded as being oriented to herself, forgetful, and agitated. The resident was recorded as being weak with assistive devices needed including a walker and a wheelchair. Her ADLs were recorded as needing maximum assistance. The hospice CNA visit documentation note, written on [DATE], recorded that the safety measures in place during the visit were: a call light. The resident's assistive mobility devices were wheelchair and walker. The certified nurse aide (CNA) activities of daily living (ADL) tracking sheets documented that on [DATE] between 6:00 a.m. to 2:00 p.m. and again from 2:00 p.m. to 10:00 p.m., that the resident needed extensive assistance for bed mobility and she received one-person physical assistance. For transfers, it was documented that the resident needed extensive assistance and she received one-person physical assistance. For walking in her room/corridor it was documented that the activity did not occur. For locomotion on and off the unit, it was documented that the resident was independent. For toilet use, it was documented the resident needed extensive assistance and she received one-person physical assistance. For personal hygiene, it was documented that the resident needed extensive assistance and she received one-person physical assistance. b. Fall Risk/Interventions The [DATE] computerized physician's orders [REDACTED]. The [DIAGNOSES REDACTED]. There was also an order [REDACTED]. Review of the Treatment Administration Record (TAR) revealed the above order for the "Bed alarm to bed. Check functioning Q shift. Diagnosis: [REDACTED]. The [DATE], 11:00 a.m. nurses note documented, "New order for bedside mat & bed alarm R/T (related to) decreased safety awareness and increased fall risk S/P (status [REDACTED]. The 21 day acute fall care plan, written on [DATE], recorded that the resident was a fall/safety risk. The interventions in the care plan were as follows: -Assess for contributors: BPs (blood pressure) standing/sitting, pain, need to void, meds, gait -Encourage to use call light -PT (Physical Therapy) Ref (referral) -Instruct on safety measures -Adaptive device The 21 day acute fall care plan for fracture/fractured hip, written on [DATE], recorded that the resident was S/P hx fx (history of fractures). The interventions in the care plan were as follows: -Positioning -Pain c. Fall [DATE] with injuries (1) Fall The [DATE], 10:45 p.m. nurses' note documented, "Writer heard resident shout, "Help me, help me." Writer immediately went to resident's room. Upon assessment resident was found with an opened skin (tear) measuring about 2 cm (by) 1 cm to her (left) elbow. When asked what happened, resident said she wanted to use the bathroom and fell . ROM (Range of motion) to all extremities WNL (within normal limits). Neuro(logical) checks initiated. Opened area cleansed with NS (normal saline), TAO (triple antibiotic ointment), and gauze applied and covered with steri-strips. Family and MD notified. VS (vital signs) at time of fall were ,[DATE] (blood pressure) - 97.8 (temperature), 72 (heart rate), 18 (breaths per minute) - 94% (pulse oximeter). Will continue to monitor." The [DATE], 4:30 p.m. nurse's note documented, "Late entry of [DATE]. This nurse was called to nurses' station by the charge nurse on the phone that this resident has just fall(en). Went right away to room, found this resident sitting in the wheelchair beside her bed with the nurse assisting this resident with the skin tear she had obtained to her (L) elbow with the CNA doing her V/S at that time. This nurse asked the charge nurse what happened, he stated he found her on the floor. This nurse saw the skin tear to her (L) elbow requested (asked) the charge nurse if he need(ed) help dressing it, he stated he is ok. This nurse ask(ed) the resident what happened, she stated, "I fell on the floor." She was touching her head, I did assess her head, no open area or any bruise was noted at this time. This resident attempted to stand up at that time, but she was requested by the nurse to wait until the dressing has been applied to her (L) elbow, this nurse left the room and went back to the other unit. At about 10 minutes, I came back again to check on this resident, found resident still in the wheelchair, CNA doing her V/S. I ask(ed) the charge nurse if she is ok, the nurse say (said) that she is ok. This nurse left, gave report to the night nurse (RN - registered nurse), tell (told) her that this resident fall (fell )." The [DATE], 11:45 a.m. nurse's note documented, "Late entry for [DATE]. Writer constantly checked on resident q 2 hours and found resident sleeping." The Unusual Occurrence Report completed on [DATE] documented that the fall occurred at 10:25 p.m. -The resident's mental status at the time of the fall was alert and oriented to self only. The resident was using her wheelchair for mobility. It documented that medication was not an applicable reason that the resident had fallen. Restraints/Safety Devices were also not applicable. -The occurrence report documented that the resident needed first aid only, she was not taken to the MD office, nor was she taken to or admitted to the hospital following the fall. There was no witness to the fall. -The report documented that the resident was found in her room, on the floor, with a skin tear to her left elbow. The resident's blood pressure was ,[DATE], her pulse was 72, her respiration was 18, her temperature was 97.8, the residents' pupils were equal and reactive to light and accommodation, her pulse ox was 93%, and the finger (stick) blood sugar was 101. The resident's orthostatic vital signs were as follows: Lying - HR (heart rate) 70, BP ,[DATE]; Sitting - HR 68, BP ,[DATE]; Standing - HR 72, BP ,[DATE]. -It was documented that the resident's family was notified at 10:45 p.m. and the physician was notified at 10:50 p.m. -The description of what happened was documented as, "Writer heard resident shout "Help me, help me." Writer immediately went to resident's room and saw resident lying on her (L) side on the floor near her bathroom. Upon assessment resident was found with an opened skin (tear) measuring about 2 cm X 1 cm to her (L) elbow. When asked what happened, resident said she wanted to use the bathroom and fell . ROM to all extremities WNL. Neuro checks initiated. Open area cleansed with NS, TAO and gauze applied and covered with steri-strips. Family and MD notified. (2) Injuries A [DATE] physician's telephone order (TO) documented, "Cleanse skin tear to (L) (left) elbow with wound cleaner. Apply steri-strips. Cleanse q (every) day. Notify MD (medical doctor) of changes. D/C (discontinue) when healed." The [DATE], 6:30 a.m. nurse's note documented, "This nurse assessed resident post fall (R) leg is longer than (L) (and) externally rotated. Called the hospice. Received orders for STAT (R) hip x-ray. Resident cries out with movement to lower extremity. Tylenol 650 mg po (by mouth) for pain. (Mobile x-ray company) called for STAT x-ray." On the Medication Administration Record (MAR), there was a note on [DATE] at 6:40 a.m., that the resident received one tablet of Tylenol 325 mg related to her hip pain being eight out of ten. There were no other records of [DATE] or [DATE] of the resident receiving any more pain medication. A second [DATE] TO documented, "STAT (immediate) X-RAY (R) (right) hip R/T (related to) fall." The [DATE] 8:00 a.m. nurses note documented, "Paramedics transported resident to the hospital ER at 8:00 a.m." Review of the discharge summary report from the hospital, dated [DATE], documented that the resident was admitted to the hospital after a fall at her nursing home facility. "The fall resulted in an acute left acetabular fracture and also a right sided pelvic fracture." Review of the resident's Certificate of Death, dated [DATE], documented that the resident passed away on [DATE] at 6:20 a.m. The manner of death was ruled an accident. The immediate cause of death was "Complications of hip fractures." The interval between the onset of the problem and the death was documented as days. The injury was described as occurring when the resident "fell sustaining bilateral hip fractures." (3) Fall follow-up The facility's Post Fall Evaluation, completed on [DATE] by an RN, recorded that the resident fell on [DATE] at 10:25 p.m. It was recorded that the "Resident said she wanted to use the bathroom and fell when going to the bathroom." -Balance/gait/weakness, incontinence/toileting, and cognition/safety awareness were all marked as possible contributing factors to the fall. The other potential contributing factors to the fall were documented as, "Resident incontinent of B&B (bowel and bladder) but will occasionally ask for help to the bathroom. Uses wheelchair for mobility, has unsteady gait, (and) generalized weakness. Call light was within reach. Resident on continuous O2 (oxygen) therapy." -Labs had been ordered for the resident on [DATE], and the resident had three abnormal values. Originally it was documented that there were no x-rays ordered. The answer was later changed to "Sent out to the hospital ER." The recommended corrective actions documented were: -Bed Alarm (pressure alarm), implemented on [DATE] -Encourage fluids, implemented on [DATE] -Q2 hours toileting schedule, implemented on [DATE] d. Failure to ensure safety devices were in place to prevent fall [DATE] Review of the TAR revealed there were nursing initials for having checked to the make sure that the bed alarm was functioning and the bedside mat was in place, two times a day (7:00 a.m. and 7:00 p.m.) starting on [DATE] until [DATE]. However, review of facility post-fall interviews revealed the resident's bed alarm was not attached and sounding the evening the resident fell . Specifically: -On [DATE], the director of nursing (DON) met with the licensed practical nurse to speak with him regarding the resident's fall. The LPN told the DON, "I heard help me, help me down the hallway; I entered her room and found her on the floor trying to get up.. ." The LPN did not report that the resident's alarm was sounding. -On [DATE] at 5:00 p.m., the DON spoke with the CNA who assisted the LPN with the resident after her fall. The CNA stated, "I was in another resident's room and I heard (the) call light. I then went down to the room to see what was happening. I saw the LPN with the resident." The CNA did not report that the resident's alarm was sounding. Staff interviews on [DATE] confirmed the resident's alarm was not activated on [DATE]. Specifically: -On [DATE] at 5:46 p.m., in an interview with the LPN who was on staff the night of the fall he stated, "I assessed the resident. She was shouting, "Help me, help me!" and I went into the room to help her. She was trying to get up and asked me to help her get up. . ." The LPN did not report that the resident's alarm was sounding. -On [DATE] at 10:45 a.m., during an interview with the CNA that was on staff the night of the fall, she stated, "I did not witness anything because I was with another resident when the resident fell . I heard the call light beeping and went to see what happened. When I went into the resident's room, the resident was already in her wheelchair.. ." The CNA did not report the resident's alarm was sounding. -On [DATE] at 12:16 p.m., in an interview with the DON, the DON stated that the night of the fall, there was no alarm sounding when the resident fell . She stated that the staff was made aware of the fall by the resident yelling out, "Help me, help me!" The resident was supposed to have a bed alarm on her bed and she did. The DON stated that although the bed alarm was on the bed, it had not been attached to the resident when she had gotten up to go to the bathroom. She stated that sometimes the resident detached the alarm on her own. 2. Sample resident #2, age 74, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of schizophrenia, dementia, Parkinson's disease, seizure disorder, type two diabetes mellitus, hypertension, chronic obstructive pulmonary disorder (COPD) with asthma, orofacial dyskinesia, goiter, vitamin D deficiency, depression, chronic bronchitis, muscle weakness, and anxiety. The [DATE] significant change MDS assessment documented the resident was able to make herself understood and understand others. She had memory problems and moderately impaired decision-making skills. The resident experienced hallucinations and delusions but did not exhibit any behavioral symptoms. She required extensive assistance by one staff member with eating. The resident had voiced complaints of pain or difficulty with swallowing and received a mechanically altered diet. Record Review: A [DATE] care plan documented the resident was "at risk for choking and aspiration (related to) her (diagnosis) of dysphasia. She need to have no choking episodes." The approaches included: provide a mechanical soft diet with thin liquids; observe for decrease breath sounds, increased temperature, congestion, and wet vocal quality; and cut hot dogs length wise when she requests hot dogs. The [DATE] to [DATE] computerized physician orders [REDACTED]. A [DATE] physician's telephone order (TO) documented the resident's diet was upgraded to regular texture. The resident's care plan and CPOs (see above) had not been updated to reflect the change to regular texture. There was no evidence in the medical record the resident had been educated regarding the risks of consuming a regular diet with swallowing problems and a [DIAGNOSES REDACTED]. A [DATE] dental progress note documented the resident was missing her lower dentures. A [DATE] social services note documented a claim was submitted for new lower dentures, but had not yet been approved. There was no evidence in the medical record the facility considered or solicited the resident's/family's input regarding downgrading the diet texture until the resident had new dentures. review of the resident's medical record revealed [REDACTED]. A [DATE], 8:00 a.m. nurse's note documented the resident experienced shortness of breath and her lungs were "wet (with) crackles." The resident's nurse practitioner was called and an order was received for a STAT (immediate) chest x-ray. The resident's pulse oximetry reading was 93% on three liters of oxygen and she received a Duoneb treatment. A [DATE], 8:55 a.m. nurse's note documented the resident was transported to the hospital via ambulance. A [DATE], 1:15 p.m. nurse's note documented the resident had a hot dog for lunch on [DATE] and drank fluids and only ate bites at dinner on [DATE]. A [DATE] hospital note documented the resident was brought via ambulance due to respiratory distress. The resident was intubated and sedated. She "reportedly did not eat dinner last night and during the day today, [DATE], she developed progressive respiratory distress ...She was bagged on route ...Under direct visualization, a hot dog was identified in her airway. This was removed, and the patient was intubated." The emergency room report documented the resident, after examination of the airway, was found with a "fairly large piece of unchewed hot dog, some other pieces of food fragments are found and grabbed from just about the cords." Staff Interview: On [DATE] at 1:55 p.m., the speech therapist (ST) stated she had not worked with the resident to address her dysphagia prior to her hospitalization on [DATE]. The ST stated on [DATE] at lunch, she was in the dining room working with another resident when she heard resident #2 "gasping for breath." The ST stated the resident had been eating independently in the dining room and was not being supervised. On [DATE] at 2:20 p.m., LPN #1 stated she was the nurse on duty during lunch on [DATE]. She stated, however, she had not done any charting on the resident until [DATE] and she had not assessed the resident prior to [DATE] at 8:00 a.m. The LPN confirmed the resident was not monitored through the lunch meal where she was served a hot dog and was not monitored throughout [DATE] and early morning [DATE] for further breathing problems or signs and symptoms of aspiration. On [DATE] at 1:18 p.m., the dietary manager (DM) stated he was unaware the resident's dentures were missing, and had not looked at downgrading her diet texture to accommodate the missing teeth before the resident's hospitalization on [DATE]. At 1:30 p.m., the DM stated the resident disliked mechanical soft texture, so he had requested the resident's diet be upgraded to regular texture. The DM stated he had not provided education to the resident regarding the risks of consuming a regular diet with a [DIAGNOSES REDACTED]. On [DATE] at 3:20 p.m., the director of nursing (DON) stated she was on vacation on [DATE] and [DATE], but was told that LPN #2 had assessed the resident in the dining room after lunch on [DATE] and provided a nebulizer treatment. On [DATE] at 3:30 p.m., the DON stated she investigated the incident because she was "concerned" the resident had a piece of hot dog in her throat for almost 20 hours and the resident could have died overnight. She stated she was unable to locate any of the documentation regarding this incident, and she did not remember what the investigation concluded. She stated the intervention on the care plan (see above) to cut hot dogs in half length-wise was not added until the resident's re-admission on [DATE], though the intervention had not been dated as such. On [DATE] at 11:35 a.m., the emergency room physician who treated the resident on [DATE] stated the resident had a large, over one-inch long piece of hot dog in her throat. He stated the hot dog was "plump" and was not cut in half length-wise. The physician stated the hot dog had no bite marks in it, and the resident had no dentures in her mouth, which concerned him. He stated the hot dog was lodged deep in the resident's throat and he used a forceps to remove it. 3. Sample resident #3, age 92, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of dementia with delirium, pneumonia, hypertension, and healing fracture of the hip. The [DATE] quarterly minimum data set (MDS) assessment documented: -The resident was rarely/never able to understand others and sometimes able to make herself understood. She had short-term memory problems and severely impaired decision-making skills. The resident exhibited inattention and disorganized thinking at times. She did not exhibit any behavioral symptoms. -The resident required extensive assistance by one staff member with bed mobility, transfers, eating, and toilet use. She used a wheelchair as her primary mode of locomotion. The resident had a history of [REDACTED]. -The resident expressed complaints of difficulty or pain with swallowing and received a mechanically altered diet. a. Failure to Implement Swallowing Precautions Record Review: The [DATE] ST discharge summary documented the resident required cues to alternate solids with liquids, required consistent cues to remain attentive to eating and redirection to continue chewing, and required supervision to use safe swallow strategies. The discharge recommendations section documented, "To facilitate safety and carryover of skilled techniques, and based upon the patient's current abilities/level of functioning, the patient should utilize the following during oral intake: alternate solids with liquids to reduce stasis, encourage small bites and drinks, maintain attention to meals and task at hand, reduce environmental distractions." The [DATE] care conference summary documented, "Pocketing food-watch for it! Cues." A [DATE] nurse's note written at 3:00 p.m. documented the resident was noted by the family to have pocketed food from lunch time in her mouth. The food was removed. The resident currently received a mechanical soft diet texture, but would be trialed on a pureed texture at dinner. A [DATE], 6:00 p.m. nurse's note documented the resident did well with a pureed diet and the diet order would be changed. A [DATE] physician's telephone order (TO) documented an order to change the resident's diet to pureed texture and provide a speech therapy (ST) screen. A [DATE] physician's progress note documented the resident was "pocketing food." The [DATE] care plan addressing the resident's weight loss, updated [DATE], documented approaches to provide a pureed diet and "pockets food." Cross-reference F279: Comprehensive Care Plan - review of the resident's medical record revealed [REDACTED]. pocketing. Observations: Lunch was observed in the dining room on [DATE] from 12:00 p.m. to 1:20 p.m.: -At 12:16 p.m., the resident began eating small bites of food independently. Though CNA #1 was seated next to the resident assisting her tablemate to eat, the CNA did not encourage the resident to alternate solids with liquids. -At 12:25 p.m., CNA #1 told the resident to, "Take a big bite!" and loaded a large spoonful of food for the resident. -At 12:40 p.m., the resident had eaten all of her mashed potatoes. She had not consumed any beverages. -At 1:18 p.m., the resident was wheeled out of the dining room by a CNA and into the activity room. The resident's mouth was not checked for pocketed food after the meal. Lunch was observed on [DATE] from 12:00 p.m. to 12:50 p.m.: -At 12:12 p.m., the resident began eating independently. She ate approximately five small bites of meat without drinking any liquids. Though CNA #1 was seated at the resident's table assisting her tablemate to eat, CNA #1 did not encourage the resident to alternate solids with liquids. -At 12:15 p.m., the resident began playing with her napkin and paper items on her table. Though CNA #1 was at the resident's table, he did not redirect her to the task at hand. -At 12:35 p.m., CNA #2 approached the resident and fed her most of the sweet potatoes. The CNA did not offer the resident her beverages in between bites of the sweet potatoes. -At 12:48 p.m., the resident was wheeled out of the dining room by CNA #2 and taken to the activity room. Her mouth was not checked for pocketed food. Staff Interviews: On [DATE] at 1:55 p.m., the speech therapist (ST) stated the previous ST had worked with this resident, but she had not, so she did not know whether staff had been educated on her discharge recommendations/swallow precautions. -The ST stated she would expect any swallow precautions to be included in the care plan. The ST stated when a resident had swallowing problems and pocketed food, she would recommend the staff encourage the resident to alternate solids with liquids by providing verbal cues to drink or handing a beverage to the resident after each bite. -The ST stated she would also recommend the staff check the resident's oral cavity after each meal for any pocketed food and provide oral care after each meal. The ST stated she would recommend supervision and cuing for the resident and assistance if needed. On [DATE] at 12:46 p.m., CNA #2 stated the resident had no swallowing problems, and the staff did not observe any swallowing precautions for her. On [DATE] at 12:47 p.m., CNA #1 stated the resident used to pocket food, so the staff should check her mouth frequently and encourage her to swallow between every bite. b. Failure to Implement Adequate Fall Interventions (1) History of Falls Record Review: A [DATE] nurse's note documented the resident was found sitting on the floor inside the bathroom. The [DATE] unusual occurrence report documented the resident was found on the floor in her bathroom and did not know how the fall happened. The corresponding post fall evaluation documented the contributing factors were dementia and weight loss. The facility team concluded the resident had crawled from her bed to the bathroom as the bed alarm was sounding but was muffled by a pillow. The recommended corrective actions included providing hipsters and a tab alarm to the wheelchair. There were no recommended interventions to address falls from the bed. A [DATE] nurse's note documented the resident's wheelchair alarm sounded and she was found on the floor. The [DATE] unusual occurrence report documented the resident was found on the floor in another resident's room. She had fallen out of her wheelchair and her wheelchair alarm was sounding. The recommended corrective actions included providing blood sugar and neurological checks. There were no new interventions to prevent falls. A [DATE] nurse's note documented the resident was found sitting on the floor by the bathroom. The [DATE] unusual occurrence report documented the resident was found on the floor by another resident's bathroom. The corrective actions included changed the tab alarm to a pressure alarm on the wheelchair. A [DATE] nurse's note documented the resident was found lying on the floor in the reception area. Her wheelchair alarm was in place. The [DATE] unusual occurrence report documented the resident was found on the floor and her pressure alarm was sounding. The corrective actions included: providing blood pressure, neurological, and blood sugar checks; "hipsters in place;" and "chair alarm in place." There were no new fall prevention measures documented. A [DATE] nurse's note documented the resident was found lying on her side on the floor. The [DATE] unusual occurrence report documented the resident had fallen from her wheelchair. Her wheelchair alarm had sounded. The corrective actions included: "PT (physical therapy) to screen for proper cushion." A [DATE] nurse's note documented the resident was found lying on the floor in a resident room. Her wheelchair alarm was sounding. The [DATE] unusual occurrence report documented the resident was found lying on the floor. Her wheelchair alarm was sounding. The corrective actions included a PT screen for dropping the back of the wheelchair seat. A [DATE] hospice PT note documented the resident was evaluated for wheelchair positioning to decrease falls. The wheelchair seat was lowered in the back to create a dropped seat. The resident was also provided with a ,[DATE] gel/foam contour cushion. (2) Current Fall Risk/Interventions Record Review: The [DATE] nursing data collection tool documented the resident was at high risk for falls related to intermittent confusion, three or more falls in the past six months, chair-bound status, use of a wheelchair, and predisposing diseases. The corresponding fall interventions checklist documented the following precautions were in place: call light in reach, room arranged for safety, familiar items in the room, adequate lighting, wheelchair out of sight while resident in bed, low bed and fall mat, bed and chair alarms, line of sight of staff, and therapy evaluation. The [DATE] care plan addressing the resident's fall risk, updated [DATE], documented the approaches: provide a wheelchair for mobility, provide a pressure alarm to the wheelchair and bed, provide hipsters, ensure the call light is within reach, provide a fall mat, and provide items to keep the resident busy. The intervention to provide a therapy screen for proper wheelchair cushioning was added on [DATE] and the intervention "pommel cushion (and) drop seat to (wheelchair)" was added on [DATE]. A [DATE] physician's progress note documented the resident had multiple falls with only minor injuries. A [DATE] nurse's note documented the resident's wheelchair alarm had sounded in the main dining room and the resident was found sitting on the floor. The [DATE] unusual occurrence report documented the resident was found on the floor with her wheelchair alarm sounding. The recommended corrective actions included: "PT eval(uation) for pommel cushion." review of the resident's medical record revealed [REDACTED]. (3) S