Every finding on record at Caring Acres Nursing and Rehab Center

Based on clinical record review, observations, staff and family interviews and facility policy review the facility failed to ensure 1 of 1 resident (Resident #7) reviewed had updated enteral flush orders. The facility also failed to ensure 1 of 3 residents (Resident #7) reviewed had accurate bowel records, document when a PRN was given and the outcome of the PRN, and staff failed to utilize additional PRN interventions when Resident #7 did not have a bowel movement from 8/2/2026 AM shift until 8/14/2026 at AM shift. This resulted in the resident going to the emergency room (ER) and admitted to the hospital with a diagnosis of a severe 9mm impaction without surgical intervention. The facility also failed to ensure 1 of 3 resident (#10) reviewed for ostomy treatment, had the order placed on the MAR or TAR to be completed by staff. The facility reported a census of 33 residents. Findings include: 1. According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 7/4/2026, Resident #7 had a Brief Interview of Mental Status (BIMS) score of 10. A BIMS score of 10 suggested mild cognitive impairment. Resident #7 had impairments to her bilateral lower extremities, was frequently incontinent of urine and always incontinent of stool, and constipation was not present during the assessment. The MDS documented she required substantial/maximal assistance with mobility, toilet transfers and partial/moderate assistance with chair/bed to chair transfers. Resident #7 had a feeding tube upon admission and while a resident in the facility. The MDS listed the following diagnoses for Resident#7: non traumatic subacute subdural hemorrhage, cancer, urinary tract infection (UTI) (last 30 days), stroke, non-Alzheimer's dementia, seizure disorder, insomnia, and metabolic encephalopathy.A Care Plan Focus Area with an initiated date of 6/30/2026 documented Resident #7 had Activities of Daily Living (ADLs) self-care performance deficit related to dementia and impaired balance. The Care Plan documented Resident #7 required the assistance of one staff with toilet transfers and toileting hygiene. A second Care Plan Focus Area with an initiated date of 7/8/2026 documented Resident #7 required tube feedings related to swallowing problem. The Care Plan documented she was dependent with water flushes to feeding tube. The Care Plan encouraged staff to see physician's orders for current feeding orders. The following Progress Notes were documented for Resident #7:-on 8/4/2026 at 1:40 PM daily skilled nurse's note: gastrointestinal concerns: none, bowel sounds are normal, has normal bowel movements, is continent of bowel, and is not on a toileting program for bowel incontinence,-on 8/5/2026 at 4:01 AM daily skilled nurse's note: gastrointestinal concerns: none, bowel sounds are normal, has normal bowel movements, is continent of bowel, and is not on a toileting program for bowel incontinence,-on 8/5/2026 at 3:03 PM daily skilled nurse's note: gastrointestinal concerns: none, bowel sounds are normal, has normal bowel movements, is incontinent of bowel, and is not on a toileting program for bowel incontinence,-on 8/5/2026 at 5:46 PM milk of magnesia oral suspension, 30 milliliters (mL) was given for constipation. At 7:54 PM milk of magnesia as needed (PRN) administration was effective, -on 8/6/2026 at 1:19 AM daily skilled nurse's note: gastrointestinal concerns: none, bowel sounds are normal, has normal bowel movements, is incontinent of bowel, and is not on a toileting program for bowel incontinence,-on 8/7/2026 at 6:36 PM daily skilled nurse's note: gastrointestinal concerns: none, bowel sounds are normal, has normal bowel movements, is continent of bowel, and is not on a toileting program for bowel incontinence,-on 8/9/2026 at 12:57 PM daily skilled nurse's note: gastrointestinal concerns: none, bowel sounds are normal, has normal bowel movements, is continent of bowel, and is not on a toileting program for bowel incontinence,-on 8/10/2026 at 11:28 AM daily skilled nurse's note: gastrointestinal concerns: none, bowel sounds are normal, has normal bowel movements, is continent of bowel, and is not on a toileting program for bowel incontinence,-on 8/10/2026 at 8:01 PM daily skilled nurse's note: gastrointestinal concerns: none, bowel sounds are normal, has normal bowel movements, is continent of bowel, and is not on a toileting program for bowel incontinence,-on 8/11/2026 at 10:09 PM daily skilled nurse's note: gastrointestinal concerns: none, bowel sounds are normal, has normal bowel movements, is continent of bowel, and is not on a toileting program for bowel incontinence,-on 8/12/2026 at 10:40 AM daily skilled nurse's note: gastrointestinal concerns: none, bowel sounds are normal, has normal bowel movements, is continent of bowel, and is not on a toileting program for bowel incontinence,-on 8/13/2026 at 5:12 AM daily skilled nurse's note: gastrointestinal concerns: poor appetite, swallowing difficulties. Bowel sounds are normal, has normal bowel movements, is continent of bowel, and is not on a toileting program for bowel incontinence,-on 8/14/2026 at 3:01 PM Resident #7 complained of nausea without vomiting but has no order for Zofran (anti-nausea). The on-call provider was called and obtained a new order for Zofran 4 milligrams (mg) every 6 hours as needed (PRN) for nausea/vomiting. Her Electronic Health Record (EHR) updated and a fax was sent to the pharmacy,-on 8/14/2026 at 3:22 PM Resident #7's sister reported that the resident has not had a bowel movement for over seven days and was given MiraLAX last night with only smearing noted today. Resident #7 complained of stomach pain; abdominal assessment completed with no noted abnormalities. Resident #7 reported feeling the urge to go but unable to go and reported feeling nauseous without vomiting. A PRN of Zofran was given per physician's orders. Her vital signs were stable, noted to be sweaty and clammy. Resident #7 was given milk of magnesia (laxative) at this time. Resident #7 had an order for a suppository but the facility had none in stock. An order was placed to pharmacy, awaiting delivery. Resident #7 continued to be monitored closely at this time,-on 8/14/2026 at 3:24 PM milk of magnesia given for constipation,-on 8/14/2026 at 6:55 PM milk of magnesia was effective,-on 8/14/2026 at 7:04 PM daily skilled nurse's note: gastrointestinal concerns: nausea and poor appetite. Resident #7 had complained of constipation today with abdominal pain. Reports of Zofran PRN was given and MiraLAX was given last night but was ineffective, Resident #7 reported feeling better at this time. Resident #7 offered to go to the emergency room (ER) for evaluation but reported feeling better after her bowel movement this evening,-on 8/14/2026 at 9:40 PM daily skilled nurse's note: gastrointestinal concerns: nausea. Bowel sounds are normal, has normal bowel movements, is continent of bowel, and is not on a toileting program for bowel incontinence,-on 8/15/2026 at 12:31 PM resident continued to complaint of stomach pain to lower abdomen. Resident #7 asked for milk of magnesia related to constipation. A Certified Nursing Assistant (CNA) reported resident had four large bowel movements last night. Resident and her sister confirm she had bowel movement. Resident #7 still reported discomfort with poor appetite, noted to be incontinent of loose stool. Resident's gait observed to be unsteady, appeared to be lethargic and weak. The resident was offered to go to the hospital but she refused. After speaking with her and explaining the importance, resident accepted. The on-call provider was called and obtained an order to sent her to the ER for evaluation and treatment,-on 8/15/2026 at 9:33 PM the ER called and stated that Resident #7 was sedated due to severe impaction and will be admitted ,-on 8/17/2026 at 4:28 PM Resident #7 returned to the facility via ambulance. Report from the hospital nurse indicated Resident #7 was admitted to the hospital for a 9-millimeter (MM) fecal impaction and did not need surgical intervention due to the use of enemas to help clear her out. They are sending the follow medication orders: macrobid (antibiotic) 100mg for 4 days, potassium 20 milliequivalent (meq) daily, senna (laxative) daily and MiraLAX daily. Resident did have a bowel movement today, able to answer questions, denied having pain. Review of Resident #7's August 2026 Medication Administration Record (MAR) revealed she had the following orders:-bisacodyl laxative rectal suppository 10mg, insert 1 suppository rectally every 24 hours as needed (PRN) for constipation. This order had a start date of 6/30/2026 and was not signed out as being given between 8/1/2026 through 8/18/2026,-milk of magnesia 30mL by mouth every 24 hours PRN for constipation. This order had a start date of 7/1/2026 and was signed out as being given on 8/5/2026 at 5:46 PM and 8/14/2026 at 3:24 PM with both administrations being effective,-miraLAX give 17 grams (gm) by mouth every 24 hours PRN for constipation. This order had a start date of 6/30/2026 and was not signed out as being given between 8/1/2026 and 8/17/2026,-zofran 4mg give one tablet by mouth every 6 hours PRN for nausea and vomiting. The order had a start date of 8/14/2026 and was signed out as being given on 8/14/2026 at 3:24 PM and 9:20 PM with effective results. Review of Resident #7's bowel movement record, it documented she had a bowel movement on 8/2/2026 at 5:59 AM (incontinent, no size or consistency documented) with no bowel movement documented until 8/14/2026 at 9:38 AM (medium, soft bowel movement). Record review revealed an After Visit Summary report dated 8/15/2026-8/17/2026 documented she was brought to the hospital for nausea, vomiting, abdominal pain and constipation. Complaints of abdominal pain for several days. She was given bowel medications with small results. Within the Physical Exam portion listed an abdominal subcategory with the following documented: there is distention, abdomen is soft, no mass, abdominal tenderness, with guarding, no rebound. In the genitourinary subcategory a comment was documented: swollen anus and rectal issue. An abdominal CT (computed tomography scan) with contrast of Resident #7's abdomen/pelvis was completed for constipation, abdominal pain and to rule out small bowel obstruction. The CT report listed the following findings: there is a very large volume of stool in the rectum. The rectum is distended up to 8.3cm. There is mild rectal wall thickening and surrounding fat stranding, consistent with stercoral colitis (severe fecal impaction). The general surgeon did not advise treatment with fecal disimpaction in the ER due to the swollen rectal issue and high incidence of perforation. A colorectal physician from another hospital advised strong laxatives and enemas for treatment. She was admitted to the hospital for disimpaction and it was largely mildly successful because her stool was so soft had a difficult time trying to disimpact. She was given two soapsuds enemas while she was asleep. Staff from anesthesia came to sedate her so they could have more success. Record review revealed a facsimile, dated 7/10/2026, to Resident's #7 provider with the following request: we had originally asked for flush orders for resident after feedings with g-tube. Can we have orders for 60cc warm water flushes every shift as resident is eating more oral intake and we want to maintain the tube. The physician agreed, signed and dated on 7/10/2026. The order was noted by two Registered Nurses (RNs). Review of Resident #7's July and August (through 8/18) 2026 MAR revealed the following orders:-Enteral Feed Order: flush peg/g-tube/j-tube with 60mL of warm water after each feeding with a start date of 7/2/2026. Flushes were scheduled to be completed at 9:00 AM, 1:00 PM, 5:00 PM, and 8:00 PM.-Enteral Feed Order: every morning and at bedtime flush peg/g-tube, j-tube with 60mL of warm water every shift, with a start date of 7/10/2026 at 8:00 PM. Flushes were scheduled to be completed at 8:00 AM and 8:00 PM.On 8/18/2026 at 12:48 PM Resident #7 laid in bed asking about the hospital. Her sister was in the room and stated she had returned from the hospital yesterday. The resident's sister stated she knew the resident did not have a bowel movement for some time. When she was here Resident #7 would want to go to the bathroom to have a bowel movement but nothing would happen once she got to the bathroom. Resident #7's stated she was constipated and was here when they gave her MiraLAX. It had become so bad that two days before Resident #7 went to the hospital she was having crampy pains; Resident #7 would bend over and draw her knees up. She began grunting and groining in pain. Resident #7's sister stated prior to this she had had issues with constipation and diarrhea but not as serious as this episode.On 8/19/2026 at 2:34 AM Staff T Agency Licensed Practical Nurse (LPN) stated when completing a daily skilled not she completes a head-to-toe assessment, obtains vitals and documents the reason for their stay. When asked how she completes the bowel section of the note she indicated she would listen to bowel sounds and look to see when their last bowel movement was. If anything is abnormal, she will see what is going on, get orders, and get ahold of the provider. She stated they should run a bowel list every morning, at least that's how it is at other places. Every facility has their own bowel protocol to prevent residents from being day 5 or 7 without a bowel movement. On 8/20/2026 at 9:33 AM the Medical Director stated each facility is different when it came to having standing orders for residents that may have constipation issues. He could not specifically recall this facility's standing orders but normally will include MOM and MiraLAX. When the Medical Director was made aware that Resident #7 did not have a documented bowel movement from the morning of 8/2/2026 until the morning of 8/14/2026, he stated that's quite a while. When asked if he was notified of this he stated he was notified prior to her going to the hospital but could not recall when. When he looked at his documentation, he indicated on 8/14/2026 he gave orders for Zofran PRN but nothing before the 14th about bowel issues. He added any notification was about diet and weight changes. When asked how often staff should be looking at resident's bowel record, he thought daily they should be checked. Everyone's bowel record should be looked at daily. When asked if interventions had been implemented could her hospitalization for a severe impaction have been avoided, he stated usually would have enemas for a standing order that could have helped or tried it. If her not having a bowel movement would have noticed earlier interventions could have helped. On 8/20/2026 at 10:44 AM Staff K agency Registered Nurse (RN) stated when completing a daily skilled note she will obtain a full set of vitals, complete assessments of the lungs, heart and gastrointestinal areas. She will go in and look to see why the resident on skilled services. She will basically complete a head-to-toe assessment. When she completes the gastrointestinal section, she will assess the abdomen look at it, listen to each quadrant, listen for bowel sounds, press to see if there is any pain or tenderness. She will then review the bowel record and if she sees the resident is day 3-4 without a bowel movement, she will let the CMA know so they can administer MOM or MiraLAX. She would do a suppository if needed since only nurses can do those. Staff K stated she will review the bowel record that will include how many days a resident has not had a bowel movement. When she worked at the facility, they did not provide bowel sheets. When asked what it meant when the assessment stated normal bowel movement, she stated that resident has bowel movements regularly.On 8/20/2026 at 11:53 AM Staff L Agency RN stated when completing a daily skilled note, she will obtain vitals and usually complete a head-to-toe assessment. When completing the gastrointestinal portion she will listen to bowel sounds, palpate the abdomen, assess for tenderness. Staff L stated to review bowel records she could check the plan of care part of the record to see what is documented they can also ask direct care staff or talk with the residents. When she cared for Resident #7 the sister had mentioned the previous night shift nurse had given her MiraLAX and it was not effective. She offered milk of magnesia, 30mL and was able to have a bowel movement and she wanted more milk of magnesia but the CNAs told Staff L she had 3 large bowel movements the night before. When Staff L checked the documentation to verify this, it was not documented. Resident #7 still complained of abdominal pain even after having loose stools. Staff L had assisted Resident #7 with incontinent cares once or twice because she refused to allow the CNAs to do it. At one time she took her to the bathroom and she was incontinent all over her bed and still went in the toilet. As she walked her back to bed, it was hard for Resident #7 to do. Staff L stated she ended up sending her to the hospital that day to be evaluated. Staff L stated no one told her Resident #7 had not had a bowel movement from the morning of 8/2/2026 until the morning of 8/14/2026, just the sister on the day they sent her to the hospital. When asked if this was the case what should have been done, staff L stated could have started with a PRN of MiraLAX then milk of magnesia. If no results then could do a suppository. She remembered she went to get a suppository but the facility did not have any in house. She came in the next day and asked the overnight nurse if the resident received a suppository, they told her no because she had a bowel movement. When asked if Resident #7 had pain the day she was sent to the hospital, Staff L stated she would lean down and looked like she was in a lot of pain. When she would ask her, the resident would say yes then say no but Staff L felt like the resident was in pain. On 8/20/2026 at 12:40 PM Staff M RN stated when completing a daily skilled note, she completes a head-to-toe assessment and add any comments to the note. When completed the gastrointestinal section, she will listen to the resident's abdomen, assess for pain, see when the last time they had a bowel movement, are they eating good. When asked how do staff know if a resident is day 2 or day 3 without a bowel movement, she stated she thought they printed of a record list. If a resident is on the bowel movement list of not having a bowel movement she will give the resident a PRN, but if they are not on the list, she will not give them anything. She will ask the resident about their bowel movements too if she needs to. When asked if the facility had standing orders if a resident has not had a bowel movement, she stated she was not sure but would guess they would use prune juice, milk of magnesia and enemas. That is usually what she would see at other facilities. Staff M stated if the resident did not have a documented bowel movement from the morning of 8/2/2026 until the morning of 8/14/2026 she would verify to see if that is true. Sometimes the CNAs do not document the bowel movements. If the resident in question is alert, she would ask them as well. If it's true the resident has not had a bowel movement for that long, she would complete an assessment: listen to bowel sounds, talk to resident, then call the doctor to see what they would want us to do. On 8/20/2026 at 12:47 PM Staff N LPN stated as far as she knew the overnight staff were to run bowel movement records but she will do them too if needed. Usually, you look at the bowel record and let the next shift know of residents being day 3 or more without a BM. When asked if the facility had standing orders for residents that did not have a bowel movement, she stated she believed it included prune juice, milk of magnesia, and suppositories. Reviewed her notes about Resident #7 with her and she stated she was not familiar with Resident #7 so she would talk with staff. She does recall that one day shift nurse gave her MiraLAX at the sister's request. She could not recall if the resident had success with the MiraLAX. Staff N stated it was either the same shift, or the next day but the resident got up and went to the bathroom by herself; staff found her in the bathroom. On 8/25/2026 at 9:58 AM Staff O RN stated when she completes a skilled charting note she following the form that pops up and she will usually do a full head-to-toe assessment. Staff O stated the overnight nurses will usually do the bowel record report. When completing the gastrointestinal portion she will talk to the resident, listen to bowel sounds, and ask the last time the resident had a bowel movement. If the resident is not able to say, she will look in their chart. When asked if the facility had standing orders for residents that may be experiencing constipation, she stated she was not sure but she would start with the least invasive intervention then work her way up. If the facility did not have orders, she would contact the provider for orders. When Staff O was told staff documented Resident #7 did not have a bowel movement from the morning of 8/2026 until the morning of 8/14/2026 she stated she would communicate with the aides that they have to do their charting and if the resident did have a bowel movement for that long to let someone know. The last time she took care of Resident #7, she was hard to communicate with and had to speak with the resident's sister. When she assessed her, she remembered she had bowel sounds. 2. Review of Resident #10's census tab revealed he was admitted to the facility on [DATE].The Care Plan Focus Area with an initiation date of 8/19/2026 documented Resident #10 had a colostomy related to malignant neoplasm of rectum. The Care Plan directed staff to monitor skin around stoma for irritation and open areas. Review of Resident #10's order tab revealed the following order: change ostomy bag on bath days and PRN, at bedtime every Monday and Thursday with a start date of 8/11/2026.Review of Resident #10's August 2026 MAR and TAR revealed it lacked an order to change his ostomy bag on bath days and PRN, at bedtime every Monday and Thursday. On 8/25/2026 at 1:16 PM the Director of Nursing (DON) stated when staff complete daily skilled notes, they are to complete a head-to-assessment. Once they are at the gastrointestinal section staff should listen to bowel sounds, ask the resident when their last bowel movement was, assess their feeding tube (if applicable) for residual and ask how the resident is feeling. When asked who runs bowel records to be reviewed, she stated the night nurses are supposed to do that. The report should be for the previous 3 days so they can intervene. The DON stated the medical director just signed off on standing orders for constipation concerns. On day one there are no interventions, interventions would include senna or docusate sodium, milk of magnesia, suppositories or an enema. The DON was informed that Resident #7 did not have a documented bowel movement from the morning of 8/2/2026 until the morning of 8/14/2026 and only had one PRN signed out on 8/5/2026. She acknowledged staff should have contacted the physician to ask for interventions: x-ray to rule out constipation, edemas until cleared up, and a bowel assessment should have been documented. When she was informed a nurse wanted to administer a suppository but was not able to find any in the facility, she stated we should have had them in the refrigerator. The DON stated Resident #7's flush orders should be once a shift, so BID. When she was made aware the BID and TID orders were still active, she stated she would get rid of the TID flush. The DON acknowledged she must have missed that. The DON stated Resident #10's ostomy order should be on the administration record to be carried out, she indicated she would get that on there. On 8/26/2026 at 9:40 AM the Assistant Director of Nursing (ADON) stated the DON updated Resident #10's order so his ostomy order is on the administration record to be changed every 3 days and PRN. The ADON reviewed Resident #7's bowel record and saw she did not have a bowel movement record from them morning of 8/2/2026 until the morning of 8/14/2026. She stated they needed to do audits to make sure the documentation is getting done along and ensure the bowel movement records are getting done as well. The ADON was informed some staff indicated the overnight staff are agency and the reports are not getting printing. She acknowledged they do have agency staff working the overnight shift that do not print the reports. The ADON stated if a resident has not had a bowel movement for 3 days staff need to give a suppository. The ADON was notified when staff went to obtain a suppository for Resident #7, they were unable to find them and had to order more to be delivered to the facility. The ADON shook her head and stated they are located in the refrigerator in the medication room. She stated Resident #7 does eat now, so she has intake and would have output. Staff should have reached out to the doctor to direction and orders. The facility provided a document titled Care and Treatment of Feeding Tubes with an implementation date of 8/20/2026 and revision date of 8/25/2026. The document included the following policy: it is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.Policy Explanation and Compliance Guidelines: 1.Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush.7. Direction for staff on how to provide the following care will be provided:e. Frequency of and volume used for flushing, including flushing for medication administration, and what to do when a prescriber's order does not specify.The facility provided a document titled Constipation and Bowel Management Policy with an effective date of 8/25/2026. PURPOSE The purpose of this policy is to establish a consistent, resident-centered process for the prevention, identification, assessment, treatment, monitoring, and documentation of constipation and other bowel-management concerns. The facility will provide bowel-management services consistent with the resident's comprehensive assessment, medical conditions, medications, preferences, usual bowel pattern, physician/authorized practitioner orders, professional standards of practice, and comprehensive person-centered care plan. The facility will take reasonable measures to prevent constipation, fecal impaction, bowel obstruction, avoidable complications, and unnecessary hospitalizations while maintaining resident dignity, privacy, comfort, and independence. III. POLICY It is the policy of the facility that: 1. Every resident will have an individualized bowel-management assessment. 2. Each resident's normal or usual bowel pattern will be identified whenever reasonably possible. 3. Nursing staff will monitor bowel function according to the resident's care plan and clinical needs. 4. Constipation will not be managed solely by waiting for a predetermined number of days without a bowel movement. 5. Changes from the resident's usual bowel pattern will be assessed promptly. 6. Preventive interventions will be implemented when clinically appropriate. 7. Bowel medications will be administered only pursuant to valid orders, facility approved protocols, or applicable emergency/standing orders. 8. Residents will not receive unnecessary laxatives, enemas, suppositories, or other bowel interventions. 9. Residents will be assessed for possible fecal impaction or other acute gastrointestinal conditions when clinically indicated. 10. Significant findings and changes in condition will be promptly communicated to the physician/authorized practitioner. 11. The resident and/or resident representative will be involved in bowel-management decisions to the extent permitted by law and consistent with resident rights. 12. Bowel-management interventions will be incorporated into the resident's care plan when indicated. 13. All bowel-management interventions and outcomes will be documented in the clinical record.IV. DEFINITIONS Constipation For purposes of this policy, constipation may include one or more of the following: Fewer bowel movements than is usual for the individual resident. Abdominal discomfort or bloating associated with decreased bowel function. A clinically significant change in the resident's established bowel pattern. A resident does not need to meet a universal number-of-days-without-a-bowel-movement threshold before nursing staff assess the resident.V. RESPONSIBILITIESC. Registered Nurse/Licensed Practical Nurse Nursing staff will: Assess bowel status. Review the resident's bowel history and current orders. Identify changes from baseline. Implement ordered interventions. Monitor response to treatment. Notify the physician/authorized practitioner of significant findings. Document assessments, interventions, notifications, and outcomes. Initiate further assessment when an intervention is unsuccessful. D. Certified Nursing Assistant/Direct Care Staff Direct-care staff will: Observe and report bowel movements and changes in elimination. Record bowel movements accurately according to facility procedure. Report abdominal pain, distention, nausea, vomiting, diarrhea, blood in stool, excessive straining, or other concerning symptoms to the nurse. Provide toileting assistance according to the care plan. Maintain resident privacy and dignity. Never independently administer medications or bowel treatments outside their authorized scope. VII. ROUTINE BOWEL MONITORING Bowel movements will be monitored and documented according to facility procedure and the resident's care plan. Documentation should include, when applicable: Date and time. Occurrence of bowel movement. Stool characteristics/consistency when clinically relevant. Amount when clinically indicated. Continence/incontinence. Assistance provided. Toileting or bowel-training interventions. Bowel medications administered. Resident response. Abnormal findings. A resident's absence of a bowel movement will be compared with the resident's established pattern rather than relying solely on a facility-wide numerical threshold. XI. RED FLAGS REQUIRING IMMEDIATE MEDICAL EVALUATION The nurse will immediately evaluate the resident and contact the physician/authorized practitioner or emergency medical services as clinically appropriate for signs or symptoms that may indicate bowel obstruction, perforation, severe impaction, gastrointestinal bleeding, acute abdomen, or another medical emergency. Examples include: Severe or rapidly worsening abdominal pain. Significant abdominal distention. Rigid or markedly tender abdomen. Persistent or repeated vomiting. Vomiting associated with abdominal distention or inability to pass stool/gas. Significant gastrointestinal bleeding. Black/tarry stool when not otherwise explained. Signs of shock or hemodynamic instability. Severe weakness or acute change in condition. Altered mental status associated with acute gastrointestinal symptoms. Suspected bowel obstruction. Suspected perforation. Suspected severe fecal impaction with systemic symptoms. Any condition in which the nurse determines the resident requires urgent medical evaluation.XIII. PRN BOWEL MEDICATIONS PRN bowel medications will be administered according to the medication order or facility protocol. Before administering a PRN bowel medication, nursing staff will: 1. Review the resident's bowel record. 2. Determine when the last bowel movement occurred. 3. Assess for current signs and symptoms. 4. Determine whether the resident's symptoms are consistent with the PRN order. 5. Assess for contraindications or symptoms requiring provider notification. 6. Administer the medication as ordered. 7. Document the intervention. 8. Monitor and document the resident's response. PRN bowel medications will not be administered automatically without consideration of the resident's current clinical status. Repeated PRN use without an effective or sustainable bowel-management plan will be reported to the provider and reviewed for possible modification of the resident's bowel regimen. XV. PHYSICIAN/AUTHORIZED PRACTITIONER NOTIFICATION The physician/authorized practitio[TRUNCATED]

Based on observations, record review, resident council notes review, staff and resident interviews and facility policy review the facility failed to ensure residents were in an environment where staff spoke without the use of curse words. The facility also failed to ensure residents had a choice to not allow a staff member's dog in the facility. The facility reported a census of 33 residents.Findings include:On 8/19/2026 at 12:32 PM observed Resident #8 to be 192 feet away from the front entrance of the building, unsupervised. After staff was alerted and attended to the resident, the surveyor notified the Administrator. She was walking through the east dining room and once she was informed of Resident #8 being outside unattended at the side of the building, she said f*ck I just let him outside. Observed 13 residents inside the dining room. On 8/18/2026 at 10:06 AM Staff E CNA stated the Administrator will bring in her dog, has a diaper on because it was pooping and peeing in the facility. She has noticed the dog in the dining room during meals and she knows there are residents that do not like that: Resident #12 and #17.On 8/19/2026 at 10:43 AM the Activities Director stated she hosts the resident council meetings. Residents have voiced they do not like the Administrator's dog in the building. The Activities Director stated she let the Administrator know that and she told her the residents can go to her about it. The Activities Director stated it was addressed in resident council. The Administrator's dog is pooping in the facility and present in the dining room during meals. Residents will feed it their food when it's in the dining room. Staff would put it in the Administrator's office but then she would let it back out.The facility provided a document titled Brief Interview of Mental Status (BIMS) score. The document listed Resident #15 had a BIMS score of 14. A BIMS score of 14 suggested no cognitive impairment.On 8/20/2026 at 1:13 PM Resident #15 stated the Administrator does not need to have her dog here. She stated some residents do not like dogs and the Administrator knew this.On 8/25/2026 at 1:16 PM the Director of Nursing (DON) was informed of the Administrator cussing in front of residents, she stated she would not allow that to happen. She has denied hearing of residents not liking the Administrator's dog in the facility. She stated there has been complaints brought to her about people saying they do not want the dog here but no one specifically has come to her with that information. She felt the residents have the choice whether or not they want the dog in the facility.On 8/26/2026 at 11:18 AM the Administrator was informed of her saying f*ck in the dining room with staff present, when informed of Resident #8 being outside [NAME] of the facility's front patio without staff knowledge or supervision. She put her head down and said she was so sorry. When asked if this was acceptable language in front of residents, she stated oh no, it is not common language and it was not intentional. She denied hearing of residents that do not like having her dog in the facility. She added they may do a vote on it during resident council. She stated she felt there were more residents that want her dog here than not. She also stated it sounds like staff members are upset about her dog being at the facility. Review of the Resident Council Notes revealed during the 6/30/2026 meeting residents have found dog poop on the floor. During the 7/28/2026 meeting residents stated the Administrator's dog was still in the facility.The facility provided a document titled: Promoting/Maintaining Resident Dignity with an implantation date of 8/20/2026 and revision date of 8/25/2026. The document included the following policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.Compliance Guidelines:1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.The facility provided a document titled Resident Rights with an implementation date of 3/31/2026. The document included the following policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing.

Based on facility document review, observations, resident council notes review, staff, family and resident interviews and facility policy review the facility failed to ensure they provided a safe and sanitary environment for their residents. The facility reported a census of 33 residents. Findings include:Review of the Resident Council Notes revealed during the 6/30/2026 meeting residents have found dog poop on the floor. During the 7/28/2026 meeting residents stated housekeeping is not always here, it's ok but it's not good either and the Administrator's dog was still in the facility.Observations on 8/12/2026 at 10:18 AM revealed the following:-water stains throughout the carpeted areas on the 100, 200 and 300 halls,-room [ROOM NUMBER] did not have a transition strip between the room's tiled flooring and the carpeted hallway,-between room [ROOM NUMBER] and the 300-hall shower room, the carpet flooring heavily water stained with white build up at the floorboard,-room [ROOM NUMBER] did not have a transition strip between the room's tiled flooring and the carpet hallway,-entering the dining room from the 300 hall, no transition strip between the two different flooring textures,-outside room [ROOM NUMBER] a ceiling tile has 3 large circular rust-colored stains; one area is darker then the other two with spots of black in the center.On 8/18/2026 at 12:59 PM in Resident #7's bathroom a ceiling tile had a large brown stain, the light cover in the bathroom had various debris in the cover. The outer toilet bowel had brown substance on it and on the toilet seat. Around the toilet where it's caulked to the floor, there are numerous brown spots around the toilet. Between the heater cover and heater was a round cracker, sugar packet wrapper, various debris.On 8/19/2026 at 9:00 AM the 100-hall had a musty smell present.On 8/19/2026 at 10:36 AM in the 300-hall shower room observed observed the following:A bulky, brown substance on top of the heater cover, with brown stains around the substance,Brown ring at the water level in the toilet,White caulking where the wall tile met the flooring was cracked, had chunks missing with light brown areas,The tiled wall that provides privacy as one enters the shower room, the tile that met the floor is cracked, chunks missing, chunks of caulking missing leaving rigid edges,The light fixture light cover contained debris, the vents on each side of the light covered in fuzzy debris,A second vent cover covered in fuzzy debris,A call light box with the metal hanging from the box with electrical wires exposed,The caulking around the toilet on the floor is light to dark brown with chipped pieces,Where the ceiling meets the wall to the left of the sink, the material is cracked open,The doorframe on the right side is marred, towards the floor the doorframe had disconnected from the wall leaving a gap. At the base of the doorframe where it met the floor board and carpet, area has light brown and white stains on it,The carpet outside of the 300-hall shower room appeared to be wet, dark in color. [NAME] build up at various spots in this location with white build up where the carpet meets the baseboard.On 8/19/2026 at 1:45 PM observed the following:-in room [ROOM NUMBER]'s bathroom, floor had 12 small squared tiles missing to the front left of the toilet, inside the toilet bowel the water is various shades of brown as well as the toilet seat,-two ceiling tiles by the closet, had brown stains on them, two ceiling tiles by the light also had brown stains on them.On 8/25/2026 at 10:42 AM observed the carpet outside of the 300-hall shower room to be wet. While walking across the wet carpet, water seeped up and around the surveyor shoes. There were no caution wet signs present or any warning for ambulatory residents that may pass by. At 11:15 AM the brown substance to the right of the toilet remained on the heater cover in the 300-hall shower room.On 8/25/2026 at 12:04 the following was observed:-in room [ROOM NUMBER]: the sink drain had a dark brown ring around it, dead bugs and debris on bathroom floor and the toilet bowl was a light brown color as well as the toilet seat,-in room [ROOM NUMBER]'s bathroom was a commode with a collection pale that contained various brown stains,-at the bottom room [ROOM NUMBER]'s toilet bowl was dark brown stains,-in room [ROOM NUMBER]'s bathroom a sponge on a plastic stick on the floor, the toilet bowl has light brown staining and a brown circular stain at the water level, the floor to the right of the toilet is missing 36 squared tiles,-in room [ROOM NUMBER]'s bathroom a grey bed pan laid on the floor with brown stains on it, at the base of the toilet where the screws anchor the toilet to the floor on both sides, was various brown stains,-the toilet in room [ROOM NUMBER] had brown stains at the bottom of the toilet bowl.On 8/12/2026 at 11:50 AM Staff A Certified Nursing Assistant (CNA) stated Staff P Housekeeper needs to step up as a housekeeper. She was unsure what Staff P does other than sitting around. On 8/12/2026 at 12:06 PM Staff B Registered Nurse (RN) stated the shower room on the 300-hall has issues with the drain which leads to water in the hallway. If you look at the carpet you can see where it's wet and dry, with a mildew smell. When they asked the Administrator about it, she told them they will get new carpet once they hit a certain census. On 8/12/2026 at 1:45 PM Staff D RN laughed when asked to talk about the cleanliness of the building. She stated the last day she worked, they pulled out a resident's bed to change it and there was dried poop along the top of the heater, trash cans were covered in poop. The bath house on the 300 hall leaks, the carpet gets wet and its rancid. The bath house on the 200 hall has a horrible smell too. She has noticed poop on the siderails and walls. On 8/13/2026 at 3:59 PM Staff Q CNA stated the facility needs some work, there are a lot of stains on the walls that have been there for a while and some dirty toilets. They have one resident that refuses to use her toilet because it's so dirty. Staff Q also stated the bath house smell like sewage and the bath house on the 300-hall should be shut down, you can see water stains on the floor and the water seeps to the basement too.On 8/13/2026 at 5:25 PM Staff C CNA stated she will clean if she needs too while working. She has noticed some deep stain in the toilets.On 8/18/2026 at 10:06 AM Staff E CNA stated housekeeping can be hit and miss, depends on who is working. She stated there are some rooms that are not getting cleaned all the time, there are stink bugs everywhere. When Staff P Housekeeper works, she just sits around on her phone all the time. Staff E stated the bath houses on halls 200 and 300 have odors. The bath house on the 300 hall leaks and floods after showers.On 8/19/2026 at 11:10 AM Staff G CNA/Certified Medication Aide (CMA) laughed when asked her opinion of the overall cleanliness of the facility. She stated it needs a lot of work. She added they have hired more people to help with cleaning and working on fixing the place so that's a plus. Staff G stated the carpet needs replaced where the 300-hall shower leaks out in to the hallway. Because of the leaking shower on the 300-hall it leaves an odor. On 8/19/2026 at 11:20 AM Staff H CNA/CMA stated when Staff I Housekeeper is working, he will mop and dust the resident's room; the rooms get cleaned. She added when Staff P works, she will sit out a wet floor sign but the floor is dry and still dirty. When she does mop, she uses the same dirty water throughout the day. Staff I will use mop pads and switches them out frequently. It's been known that the more residents they admit the more things can get repaired/replaced in the facility. For example, if they get their census to 41 residents they can get new flooring.On 8/19/2026 at 11:56 AM Staff I Housekeeper stated Staff P would mop rooms and never change the water. He denied seeing her deep clean resident rooms. There are stains on the carpet and has been told once their census hit 41 residents they will get new carpet. They have shampooed the carpet but with the shower constantly leaking on the 300-hall it would not do any good until they get that shower fixed. He stated the Administrator's dog poops on the floor, has not seen it pee on the floor because it has a diaper on. On 8/20/2026 at 1:13 PM Resident #16 stated the Administrator does not need to have her dog here. When asked to elaborate, Resident #16 stated her dog poops on the floor and they made the Administrator clean it up. Her dog will go in the dining room while they are eating, the dog will go all over the place. They put a diaper on it but it still poops. When asked if staff come in to clean her room, she stated she will wipe things down herself. She added when they do clean they hardly scrub and do not move furniture to clean under or behind it. Resident #16 stated the facility could be cleaner; the shower room on the 300-hall leaks all over, she did not feel like the dining room floors get cleaned properly either.On 8/20/2026 at 11:53 AM Staff L Agency RN was asked about the cleanliness of the building and she stated it could be better. The carpet is pretty dirty and stained all the time. She added she was not sure they can do anything but wished they could do better.On 8/20/2026 at 12:47 PM Staff N LPN stated she has noticed odors by the 300-hall shower room because it leaks out into the hall carpet.On 8/25/2026 at 1:16 PM the Director of Nursing (DON) stated the Administrator does bring her dog in the facility and has known it to poop and pee in the building. The dog does go in the dining room during meal times as well. The Administrator does try to redirect it along with other staff members. The dog does wear a diaper to stop it from peeing but it will still poop. The DON stated she has cleaned up the messes and they have let the Administrator know she needs to clean up after her dog. When asked what the plan was for the carpet in the facility, she stated the previous maintenance worker had cleaned it a couple times. She added once they get their census to 41 residents they will get new flooring. When asked why it takes an increase in the census to get new flooring, she stated its budget driven, gives them a goal to work towards and encourages everyone to be invested in helping the building. The DON was asked about the wet carpet outside of the 300-hall bath house, she stated the shower leaks. They are working on getting a new bath house on the 100-hall then will fix the 300-hall bath house next. When asked how often resident's bathroom should be cleaned, she stated daily but was unsure of housekeeping's schedule. Their housekeeping supervisor right now is the dietary manager. The DON was made aware of the concerns about Staff P. She stated they have provided education to her and are following her. The DON was shown a picture of the missing floor tile in Resident #13's bathroom. She stated he is independent and that missing tile is a tripping/fall hazard for everyone. On 8/26/2026 at 9:40 AM the Assistant Director of Nursing (ADON) stated the 300-hall shower has leaked for years and it was not getting fixed. They do have plans to get it fixed. They thought if staff faced the shower head away from the wall it would not leak out into the hall.On 8/26/2026 at 11:18 AM the Administrator was asked what her overall opinion of the cleanliness of the facility, she stated it needs attention and she has to get the right people in the right positions to work on things. She indicated resident's bathrooms should be cleaned daily and currently working on implementing deep cleaning schedules with the newer and older staff members. She stated the call light in the 300-hall bath house has been fixed since the DON was notified of it. She added residents are not left in that room alone, staff are always with them. She assured the missing floor tiles in Resident #13's bathroom will be replaced today. She stated corporate has brought in a team to remodel the old beautician's room, on the 100-hall, in to a bath house, then they can work on the 300-hall bath house remodel. They have to have a shower available, that's why the new one on the 100-hall is being completed first. Then they will work on getting new flooring. Previously if the carpet squares were ruined, they will be pulled and replaced but did not fix the problem. They had a roofing company out here to look at the roof because of the leak stains on the ceiling tiles. They were able to fix some issues with the blower system. But once they looked at the new roof, they found some of the lines are not completely sealed. They will get that roofing company out to get those addressed. The previous Maintenance Director removed some ceiling tiles but had not followed through; he was not keeping up with things. The maintenance staff that started yesterday and had done more than the previous staff member. The Administrator was informed of concerns about Staff P spending more time on her phone than cleaning, she stated she knew she was on work restrictions. She added they have hired a few new housekeepers and a new Maintenance Director that will start next week. He has long-term care experience so he will have the other new maintenance staff member learn about long-term care expectations. She stated she does not play around, if they identify issues she wants to fix it, she has a commitment to fix all the things. She knows they need new showers, flooring and a transportation bus. They have goals: once their census is 30, they get new showers, which is happening now. Once they reach 41 residents, they will get new floors. The facility provided a document titled Resident Environmental Quality with an implementation date of 8/20/2026 and revision date of 8/25/2026. The document included the following policy: This facility is designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff, and the public.General Guidelines:1. Preventive maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment.11. Preventive maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment.12. All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue.The facility provided a document titled Routine Bathroom Cleaning Policy without implementation or revision dates. The document's policy included: It is the policy of this facility to establish policies, procedures and guidelines to provide a clean and sanitary environment for residents, staff and visitors in order to prevent cross contamination and transmission of healthcare associated infection (HAI).Policy Explanation and Compliance Guidelines:Procedure:1. Working from clean areas to dirty areas:a. Remove soiled linen from floor, wipe up any spills and remove waste.b. Clean door handle, frame and light switch.c. Clean wall attachments (if applicable).d. Clean inside and outside the sink, sink faucets and mirror. Wipe plumbing under the sink. Apply disinfectant to interior of sink and allow sufficient contact time with disinfectant according to manufacturer's recommendation. Rinse sink and dry fixtures.e. Clean all dispensers and frames.f. Clean call bell and cord.g. Clean support railings, ledges and shelves.h. Clean shower/tub faucets, walls and railing, scrubbing as required to remove soap scum. Inspect grout for mold, apply disinfectant to interior surfaces of shower/tub, including soap dish, faucets and shower head. Allow sufficient contact time for disinfectant according to manufacturer's recommendations. Rinse and wipe dry. Inspect shower curtain and replaced as required.i. Clean entire toilet including handle and underside of flush rim. Apply disinfectant and allow sufficient contact time according to manufacturer's recommendations. 4. Report areas of mold, cracked, leaking or damaged items in need of repair.The facility provided a document titled Companion Animal Visits with an implementation date of 8/1/2026 and revision date of 8/20/2026. The documented included the following policy: it is the policy of this facility to provide a home-like environment and enhance our residents' quality of life by allowing companion animal visits. Policy Explanation and Compliance Guidelines:1. Companion animals, which include animals visiting the facility as part of an activities program, must meet the following criteria in order to enter the facility:a. The animal must be well-behaved and well-trained. If the animal demonstrates that he or she is not well-behaved or well-trained, the animal handler/owner will be asked to remove the animal from the facility.3. All visits must be supervised by persons who know the animal and their behavior.4. Gloves will be used for clean-up of animal urine or feces from environmental surfaces. a. Absorbent materials used in the cleaning process will be placed in leak-resistant plastic bags and discarded. b. The area should then be cleaned according to standard cleaning and disinfecting procedures.

Based on observations, clinical record review, resident and staff interviews, and facility policy review the facility failed to accurately complete elopement risk assessments for 4 of 13 residents reviewed (Resident #4, 6, 11, and 18). The facility reported a census of 33 residents. Findings include:1. Record review revealed a Brief Interview of Mental Status (BIMS) score assessment completed on 5/28/2026. The assessment documented Resident #4 had a BIMS score of 12. A BIMS score of 12 suggested moderate cognitive impairment. The Care Plan Focus Area with an initiation date of 5/23/2025 documented Resident #4 was independent with transfers.Review of Resident #4's assessment tab revealed the following Elopement Assessment was completed on 5/28/2026: is the resident cognitively impaired and independently mobile (with or without device), no was selected as an answer to that question.Continuous observations throughout the survey revealed Resident #4 ambulated throughout the facility independently with no assistance devices.2. Record review revealed a BIMS score assessment completed on 7/9/2026. The assessment documented Resident #6 had a BIMS score of 7. A BIMS score of 7 suggested severe cognitive impairment.Review of Resident #6's assessment tab revealed the following Elopement Assessment was completed on 7/8/2026: is the resident cognitively impaired and independently mobile (with or without device), no was selected as an answer to that question.Continuous observations throughout the survey revealed Resident #6 was mobile throughout the facility independently with the use of a wheelchair.3. Record review revealed a BIMS score assessment completed on 7/28/2026. The assessment documented Resident #11 had a BIMS score of 6. A BIMS score of 6 suggested severe cognitive impairment.The Care Plan Focus Area with an initiation date of 8/13/2026 documented Resident #11 was independent/no set-up or physical help needed for locomotion on and off the unit.Review of Resident #11's assessment tab revealed the following Elopement Assessment was completed on 7/27/2026: is the resident cognitively impaired and independently mobile (with or without device), no was selected as an answer to that question.Continuous observations throughout the survey revealed Resident #11 mobile throughout the facility independently with the use of a wheelchair.4. Record review revealed a BIMS score assessment completed on 7/27/2026. The assessment documented Resident #18 had a BIMS score of 10. A BIMS score of 10 suggested moderately cognitive impairment.The Care Plan Focus Area with an initiation date of 4/22/2026 documented Resident #18 was independent with all transfers.Review of Resident #18's assessment tab revealed the following Elopement Assessment was completed on 4/20/2026: is the resident cognitively impaired and independently mobile (with or without device), no was selected as an answer to that question.Continuous observations throughout the survey revealed Resident #18 mobile throughout the facility independently with the use of a wheelchair.On 8/25/2026 at 1:16 PM the Director of Nursing (DON) was asked what it meant if a resident was cognitively impaired. She stated the resident does not always make safe, appropriate decisions for care or needs. They determine this after completing a BIMS assessment on admission, quarterly, with reported changes. A BIMS under 12 would indicate a resident was cognitive impaired. The DON was asked what it meant if a resident was independently mobile with or without assistance devices, she stated the resident could walk independently. The DON stated the Assistant Director of Nursing (ADON) completes the elopement risk assessments on admission then annually or if the resident has an elopement.On 8/26/2026 at 9:40 AM the ADON was asked what it meant if a resident was cognitively impaired. She stated if the resident's safety awareness is decreased, probably not make accurate and informed decisions. When asked how does the facility determine if a resident is cognitively impaired, she stated currently they use the BIMS assessments unless they do an assessment for early detection of dementia. The ADON as asked what it meant if a resident was independently mobile with or without assistive devices. She stated in all fairness she understood the elopement assessment differently when they were filled out. She thought it meant the resident was independently mobile with just ambulation, not with assistive devices. The have activated a new elopement assessment to start using as the one they currently were using was not a good assessment.On 8/26/2026 at 11:18 AM the Administrator stated she could not give a definition of what it meant if a resident was cognitively impaired because it's an interdisciplinary team (IDT) process. They would look at how well the resident tracks money, organize their thoughts. The definition needs to be defined based on each situation. If a resident has a BIMS under 10, they are cognitively impaired but can be based on other assessment questions as well. A resident that is independently mobile with or without assistive devices means that resident is able to propel or walk independently. She stated the elopement assessments they use are part of the old regimen and working on getting new ones in place for their facility. They have a good IDT that are learning about resident rights and doing the least restrictive measures they can do. The facility provided a document titled Elopements and Wandering Residents with an implementation date of 8/7/2026 and revision date of 8/20/2026. The document included the following policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person- centered plan of care addressing the unique factors contributing to wandering or elopement risk.Policy Explanation and Compliance Guidelines:3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wanderinga. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team.

Based on observations, clinical record review, resident and staff interviews and facility policy review the facility failed to provide proper supervision while residents were outside unsupervised and unattended. This resulted in Resident #1 and #8 leaving the facility's patio without staff's knowledge. Staff also failed to ensure Resident #14's bathroom tile was safe to ambulate on. The facility also failed to ensure residents did not know the door code used to exit the building. Residents were observed entering the code and leaving the front entrance without staff's knowledge. The facility also failed to ensure residents were free of environmental hazards when the carpet outside the 300-hall shower room became saturated in water. Staff failed to alert residents of the area being wet and to proceed with caution. The facility reported a census of 33 residents.Findings include:1. According to an admission Minimum Data Set (MDS) assessment tool with a reference date of [DATE] documented Resident #1 was admitted to the facility on [DATE]. The MDS documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score suggested no cognitive impairment. A Progress Note dated [DATE] at 10:36 AM documented on [DATE] Resident #1 left the facility to go to a nearby lake, unattended and without staff's knowledge. His electric scooter's battery died and a community member alerted facility staff of the resident's electric scooter being dead and the resident needing assistance back to the facility.On [DATE] at 10:42 AM Resident #1 stated when he went to the lake, on his way back his electric scooter died. He ditched the scooter and crawled back to the facility. Resident #1 stated he did not let staff know he was leaving and he forgot to sign out. Resident #1 stated he now has to sign out and make sure his phone is with him before leaving the facility. On [DATE] at 11:50 AM Staff A Certified Nursing Assistant (CNA) stated the Administrator is letting the residents go outside whenever they want and one example of that is when Resident #1 went down to the lake without staff knowing or being with him. The Administrator also wants to get rid of the door code to the main entrance and have automatic doors. On [DATE] at 12:06 PM Staff B Registered Nurse (RN) stated she walked through the dining room and noticed someone outside with a headlamp on. It was dark because he has the lamp part on. It was someone riding their bicycle down by the lake. The bicyclist encountered a gentleman with a stalled-out scooter and asked him to come get help. Staff were able to locate Resident #1 and brought him back to the facility without injuries. No one was aware he was out of the building or even off the property at that time. Staff B stated that Resident #1 did not let anyone know that he had left. At that time, residents were able to go outside whenever they wanted, which is super unsafe. The Administrator gave the residents the access codes to go in and out. Staff B stated the Administrator said this is their home and it's their right. Staff B stated in her opinion no resident is completely independent because they live in the facility and require some sort of supervision. When asked how do staff know which residents are elopement risks and would not follow someone out the door, she stated great question. On [DATE] at 10:07 AM the Director of Nursing (DON) stated on the day he left the property Resident #1 had received his scooter back after occupation therapy (OT) completed his safety evaluation. These evaluations are completed annually and the residents must follow the rules, use the device as intended, staff can intervene when at risk to the resident or peers. Resident #1 went off the property without letting anyone know beforehand. His scooter had died but they were able to get him and his chair back to the facility. The DON talked to him the next day and had him sign the safety wheelchair policy. The resident has to sign the safety wheelchair policy or scooter policy which is what it was labeled in his record. The DON stated they were aware of his safety issues with his scooter at his previous facility. The DON stated Resident #1 had a BIMS of 15, was his own responsibly party and would able to do go off property once staff were notified especially at night. On [DATE] at 1:22 PM the Administrator stated on the day he left the property OT had approved him to be in his scooter. He did not sign out prior to leaving because what he told her was, she had not walked him through that process yet. She acknowledged they had not discussed with him the need to sign out prior to leaving the property. She stated Resident #1 does like to have his freedom with his scooter. Since then, they talked about the process, they had him sign out to go on the porch for three days, then if he wants to leave the porch he needed to sign out. She added Resident #1's choices are sound and he did not meet the threshold for being cognitively declined. On [DATE] at 11:30 AM the surveyor was assisted out the front door by the Administrator. She stated she would be the only to help because she is the only one that knows the code. The surveyor asked if she was sure of that, she replied she knew because she heard residents had the code so she changed it again. She added residents were re-educated on needing supervision when outside. On [DATE] at 3:59 PM Staff Q CNA stated when they heard of Resident #1 needing assistance it was dark. Someone from the community came to the facility to let them know a man in a wheelchair had stalled out by the park and needed help getting back to the facility. One of the CNAs got in their car to go look for him. After 45 minutes she called the CNA thinking maybe to look more by the golf course, so she went outside and he was sitting on the sidewalk to the East of the building just past the dumpsters. It was dark when she found him on the sidewalk. At that time, residents could let themselves out of the facility to smoke because they had the code. But since this incident the residents are not to have the code to go outside, they need to ask staff to let them outside. On [DATE] at 5:25 PM Staff C CNA stated she was not aware Resident #1 had left the building. She stated residents knew the door code and could leave when they wanted. Even after the code was changed, residents still learned it and would share it with each other so they could go out when they wanted. 2. Review of Resident #8's MDS assessment tab on [DATE] at 1:39 PM revealed an entry MDS dated [DATE]. On [DATE] at 12:32 PM Resident #1 alerted the State Surveyor that he was not the resident that had left the building this time. Resident #1 then went to the [NAME] side of the facility's patio where Resident #8 was located roughly 192 feet away from the facility's patio, unattended. Facility staff was made aware of the situation and they escorted the resident back to the facility. A Progress Note dated [DATE] at 12:47 PM documented Resident #8 had asked to go outside and the Administer let the staff know it was fine. The Administrator was alerted by staff that he was outside self-propelling on the sidewalk on the [NAME] side of the building. On [DATE] at 12:32 PM Resident #1 stated he was not the one the left the building this time. When asked to elaborate he stated some guy is on the side of the building and has been there for 10 minutes now. Resident #1 stated he was outside then someone let the other resident outside on the patio. That resident then went down the sidewalk to the side of the building. Resident #1 took the surveyor to the [NAME] side of the front patio and Resident #8 was on the side walk. Resident #8 was in his wheelchair with no foot pedals on, on the side walk, facing north. Staff F Certified Nursing Assistant (CNA) who was seen through the front windows, waved for her to come outside. She went to assist Resident #8 back to the facility. Staff H CNA/Certified Medication Aide (CMA) came outside and was made aware of Resident #8 was found on the [NAME] side of the building without staff present. Staff H stated he had only been in the facility for about a week, week and a half and was not a smoker. Once inside the Administrator was made aware of Resident #8 found without staff present off of the patio area. She stated she had just let him outside. Resident #8 was found 192 feet from the facility's patio on a side walk. To get where he was found, there was a slight hill to go down with broken patches on concrete right off the patio. On [DATE] at 1:27 PM Staff F CNA stated when she arrived to where Resident #8 was, he stated he was sitting down there, enjoying the view. When she asked him if he was aware he was not supposed to be down there without staff, Resident #8 told Staff F he was not. Staff F stated let me rephrase that, she let Resident #8 know he could not be that far from the building unless staff are with you, we have to be able to see you. Resident #8 said ok. He did not want to go back to the facility but agreed to be up the hill and on the patio where staff could see him. Staff F stated the Administrator said it was ok to let him outside, she said he goes out every day to sit on the patio area. If residents go out on the patio, they will check on them every 20-40 minutes. When asked about Resident #8's cognition, she stated he is a little confused but for the most part he knows what he doing. When asked how much time passed from letting Resident #8 outside until she was alerted, he was on the [NAME] side of the building, she stated 2-3 minutes.On [DATE] at 2:34 AM Staff T Agency Licensed Practical Nurse (LPN) stated it is alarming that these residents are getting outside and leaving the property without staff's knowledge. 3. Review of Resident #13's record revealed he was admitted to the facility on [DATE]. Review of Resident #13's Baseline Care Plan revealed he was independent for toilet transfers and walking. On [DATE] at 1:45 PM observed Resident #13's bathroom floor had 12 small squared tiles missing to the front left of the toilet, leaving the floor unlevel.4. On [DATE] at 10:21 AM three visitors entered the facility through the main entrance. A resident went to the main entrance in his wheelchair and asked the visitors to hold the door for him. The resident then went outside. On the window to the right of the main entrance door a typed note stated: Please Make Sure No Residents Are Following You Out the Doors and Are Not with You. Thank You.On [DATE] at 2:07 PM Staff E CNA stated residents used to go outside on their own so the Administrator changed the code. Some residents have figured out the code to get out and the Administrator knows this but has not changed it yet. On [DATE] at 3:00 PM Resident #17 was outside smoking with his peers, no staff present. When asked how he was able to get outside, he stated he knew the code to exit the building. Resident #17 stated he watched staff when they put the code in. He added a bath aide does not cover up the key pad when they put the code in so he saw it. Resident #17 stated he's very observant but does not allow people outside that are not supposed to be outside.On [DATE] at 4:00 PM observed Resident #19 enter the code at the main entrance key pad then walked outside by herself. The surveyor notified the Administrator right away and she stated Resident #19 will never not know that code.5. On [DATE] at 10:42 AM observed the carpet outside of the 300-hall shower room to be wet. While walking across the wet carpet, water seeped up and around the surveyor's shoes. There were no caution wet signs presents or any warning for ambulatory residents that may pass by. On [DATE] at 1:16 PM the Director of Nursing (DON) was asked what staff are to do if the carpet outside of the 300-hall bath house is wet, she stated staff would need to put a wet floor sign out in that area. On [DATE] at 2:57 PM the facility provided a list of residents that were independently ambulatory. This list included 8 residents; 7 residents were independently ambulatory without assistive devices. On [DATE] at 11:18 AM the Administrator stated Resident #8 was safe to be outside by himself based on his BIMS score at that time. There were no reports of elopements and he was cognitive of what he is doing. The Administrator was informed of the water seeping over the surveyor's shoes while walking by the bath house on the 300-hall without caution signs. She stated they have three carpet extractors, there was no excuse why they could not have extracted the water.The facility provided a document titled Resident Outdoor Supervision Policy with a revision date of [DATE]. The purpose of this policy is to establish a safe, consistent, resident-centered process for residents who wish to access outdoor areas of the facility. The facility recognizes that access to outdoor areas, fresh air, sunshine, recreation, smoking areas, gardening, socialization, and community activities can contribute to residents' quality of life, independence, dignity, and overall well-being. The facility shall provide supervision based upon each resident's individual assessed needs and identified risks, while avoiding unnecessary restrictions on resident rights.V. INITIAL ASSESSMENT Each resident shall be assessed for outdoor safety needs upon admission and whenever clinically indicated. The assessment shall consider, as applicable: Mobility; Transfer ability; Gait and balance; Use of wheelchair, walker, cane, or other equipment; Ability to navigate outdoor surfaces; Vision; Hearing; Cognition; BIMS results; Orientation; Safety awareness; History of wandering; History of elopement; Ability to seek assistance; Ability to use the call system or other communication method; Medical conditions; Ability to safely use outdoor furniture and equipment; Ability to recognize environmental hazards; Current care-plan interventions; Resident preferences; Guardianship or court restrictions, if applicable. The facility provided a document titled Resident Environmental Quality with an implementation date of [DATE] and revision date of [DATE]. The document included the following policy: This facility is designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff, and the public.General Guidelines: 1. Preventive maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment.11. Preventive maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. 12. All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue. The facility provided a document titled Resident Independent Community Leave and Sign-Out Policy with a revision date of [DATE]. I.PURPOSE:The purpose of this policy is to establish a consistent, resident-centered process for determining whether a skilled nursing facility resident may leave the facility and community independently without an escort, while protecting the resident's rights to dignity, self-determination, community participation, and freedom of movement. The facility will balance the resident's right to make choices and participate in community activities with the facility's responsibility to provide reasonable protection from avoidable harm. This policy is intended to comply with applicable federal Centers for Medicare & Medicaid Services (CMS) requirements, including 42 CFR S483.10, and applicable State of Iowa nursing facility requirements, including Iowa Administrative Code 481-58.47(6), which provides that residents shall be permitted to leave the facility and environs at reasonable times unless there are justifiable reasons established in writing by the attending physician, qualified intellectual disabilities professional, or facility administrator for refusing permission.II.POLICY Caring Acres Nursing and Rehab recognizes that residents retain their rights as citizens and residents of the United States and have the right to self-determination, including participation in activities and interaction with the community. The facility will not automatically restrict a resident from leaving the facility solely because of: Age; Diagnosis; Disability; Use of a wheelchair or other assistive device; A cognitive diagnosis; Dementia diagnosis; A particular BIMS score; Medicare or Medicaid status; Skilled nursing status; or The resident's need for assistance with other activities of daily living. Any restriction on a resident's ability to leave independently must be based upon the resident's individual circumstances, applicable legal authority, and documented health or safety considerations. II.IMPORTANT COGNITIVE AND LEGAL CAPACITY REQUIREMENTThe Brief Interview for Mental Status (BIMS) is a cognitive screening assessment and shall not be used as the sole determination of a resident's legal capacity, competency, or right to leave the facility. A BIMS score does not, by itself: 1. Establish that a resident is legally incompetent; 2. Establish that a resident is legally competent; 3. Create a guardianship; 4. Terminate or modify a guardianship; 5. Override a court order; 6. Authorize the facility to detain a resident; or 7. Automatically authorize or prohibit independent community leave. The facility shall consider the BIMS as one component of the resident's overall assessment and care planning process. The resident's legal status, including any valid guardianship, conservatorship, court order, commitment order, or other legally enforceable restriction, shall be reviewed before independent community leave is authorized.V. INITIAL ASSESSMENT FOR INDEPENDENT COMMUNITY LEAVE Before a resident is approved for unsupervised community leave, the interdisciplinary team shall evaluate the resident's ability to safely leave and return to the facility. The assessment should consider, at a minimum: 1. Current BIMS score and cognitive assessment findings; 2. Ability to understand the purpose of leaving the facility; 3. Ability to communicate where the resident intends to go; 4. Ability to understand how to return to the facility; 5. Ability to recognize and respond appropriately to safety hazards; 6. Orientation to person, place, and situation; 7. Judgment and decision-making abilities; 8. Physical mobility and functional status; 9. Ability to safely use mobility equipment; 10. Ability to safely navigate streets, parking lots, sidewalks, buildings, and other community environments; 11. Elopement assessment results; 12. Ability to use a telephone or other communication device when necessary; 13. Ability to obtain assistance in an emergency; 14. Vision and hearing; 15. Recent changes in condition; 16. Current physician orders; 17. Existing care-plan interventions; 18. Guardianship or court-order status; and 19. Any other individualized factor affecting the resident's ability to safely leave and return. VI. BIMS GUIDANCE BIMS results shall be considered as follows: BIMS 13-15: A higher BIMS score may support consideration for independent community leave but does not automatically establish approval. The interdisciplinary team shall still consider judgment, functional ability, safety awareness, legal status, history, and current condition. BIMS 8-12: A moderate cognitive impairment score shall prompt additional individualized assessment before independent community leave is authorized. The team shall determine whether the resident demonstrates sufficient functional understanding and safety awareness for the requested activity. BIMS 0-7: A low BIMS score shall prompt an enhanced clinical and safety assessment. A low BIMS score alone shall not automatically prohibit community leave. However, independent leave generally should not be authorized unless the interdisciplinary team can document why the resident nevertheless demonstrates the ability to safely leave and return and there is no legal restriction preventing such leave.APPROVED FOR INDEPENDENT COMMUNITY LEAVE The approval shall be documented in the medical record and communicated to appropriate nursing and interdisciplinary staff. The resident shall be educated regarding: Sign-out/sign-in procedures; Expected return time; Emergency contact procedures; How to contact the facility; Medication considerations; Safe transportation; Weather-related safety; Need to notify the facility of changes in plans; What to do if the resident becomes lost or unable to return; Risks associated with leaving without needed medical equipment or assistance; and The distinction between authorized leave and an unexpected absence/elopement. XI. SIGN-OUT PROCEDURE Before leaving the facility independently, the resident shall complete the facility's community leave sign-out process. The sign-out record shall include, at minimum: Resident name; Date; Time leaving; Destination or general destination; Resident signature or staff documentation if the resident requires assistance with the form; Time returned to the facility. The facility should avoid collecting unnecessary information that would unreasonably interfere with the resident's privacy or right to community access. XII. RETURN TO FACILITY Upon return, staff shall document the resident's return time.If the resident returns with a change in condition, injury, illness, altered mental status, suspected substance use, medication concern, or other significant concern, nursing staff shall complete an appropriate assessment and notify the provider as clinically indicated. If the resident does not return within the expected timeframe, staff shall follow the facility's missing resident/elopement response procedure. An overdue resident shall not automatically be classified as an elopement if the circumstances indicate that the resident knowingly exercised the right to leave but is delayed. The facility provided a documented titled Wet Floor Sign and Floor Hazard Safety Policy with an effective date of [DATE]. The document's purpose was to prevent resident, staff and visitor slips, trips and falls by promptly identifying, warning of controlling, and correctly wet or slippery floor hazards.PROCEDURE Identify & Protect Any employee discovering a wet, slippery, or otherwise hazardous floor must take immediate action. Protect residents and others from entering the affected area. Place a highly visible CAUTION - WET FLOOR sign before or immediately when cleaning begins. Use additional signs, barriers, or traffic diversion when necessary. Correct the Hazard Promptly clean spills, remove excess water, and dry the floor. Address water leaks, damaged flooring, drainage problems, or recurring hazards through Maintenance. Do not knowingly leave a hazardous floor unattended. Sign Placement Place signs where they are clearly visible before a person enters the affected area.Signs must be upright, stable, clean, and legible.5. High-Risk Areas Extra precautions will be used in resident rooms, bathrooms, dining areas, therapy areas, entrances/exits, hallways, ramps, stairs, and other high-traffic areas. Residents requiring assistance will be redirected or assisted according to their care plan when a hazard exists.STAFF RESPONSIBILITY Every employee is responsible for environmental safety. Employees must not walk past an identified hazard assuming someone else will address it. Employees should protect, warn, correct/report, and follow up until the hazard is resolved.

Based on observations, resident council notes review, staff and resident interviews, and facility policy review the facility failed to answer resident's call lights in a timely manner; within 15 minutes. The facility reported a census of 33 residents. Findings include:Observations on 8/18/2026 at 2:30 PM revealed rooms [ROOM NUMBERS] had a white light activated above their door frames. At 2:46 PM, 16 minutes had passed, room [ROOM NUMBER]'s call light was answered and shut off. At 2:47 PM, 17 minutes had passed, room [ROOM NUMBER]'s call light was answered and shut off. Observations on 8/19/2026 at 9:20 AM room [ROOM NUMBER]'s had a white light activated above the door frame. At 9:40 AM, 20 minutes had passed, room [ROOM NUMBER]'s call light was answered and shut off. Review of the Resident Council Note revealed during the 6/30/2026 meeting residents stated on the weekends and nights they wait longer to have their call lights answered. On 8/18/2026 at 9:34 AM Staff F Certified Nursing Assistant (CNA) stated getting call lights answered timely is dependent on how many staff they have on that shift. She added for the most part they get them answered within 15 minutes. Staff F stated yesterday she was alone on the floor while one CNA was on break and the other CNA was doing tests. The nurse on duty did help but not all call lights were answered within 15 minutes. On 8/18/2026 at 10:06 AM Staff E CNA stating answering call lights timely was dependent on how many staff are working and if they are in with other residents. She stated it may take up to 12 minutes to answer them but maybe longer. She added some nurses will help answer them others will not. On 8/18/2026 at 12:34 PM Resident #2 stated call lights are never answered timely. He added it can take up to a half hour or longer and had to wait over an hour during the day. Resident #2 had a clock on his wall, carried a cell phone, and a clock on his television. He said his concern is the wait time when he uses his call light. He has to wait a long time and it seems he has to wait long periods of time for everything and it happens frequently. On 8/18/2026 at 12:48 PM Resident #7's sister stated she comes to visit every day and stays all day with her sister. She stated they have waited for 35 minutes after activating Resident #7's call light, for someone to come in to help them. She indicated she timed it on her phone. She added Resident #7 has had accidents while waiting for someone to answer her call light both urine and stool. On 8/19/2026 at 10:43 AM the Activities Director stated she hosts the resident council meetings. Residents talked about call lights take longer to answer on the weekends and it also depends on who is working. On 8/19/2026 at 11:10 AM Staff G CNA/Certified Medication Aide (CMA) stated answering call lights timely depends on the staffing situation. They can be answered within 15 minutes if they are adequately staffed. They do try their best, especially with a lot of new residents coming in, in a short time. She feels like the facility is trying to adjust staffing with the increase in census.On 8/19/2026 at 11:20 AM Staff H CNA/CMA stated call lights get answered timely but that depends on their staffing numbers. If they are fully staffed call lights are not on long but if they are understaffed it can take a while. She added it's not intentional but when understaffed it could take up to 30 minutes in the mornings to get to call lights because they are getting everyone up for the day. She stated there were some call lights on for a while this morning, there were only two on the floor and they could not get to them. On 8/20/2026 at 9:55 AM during an interview with Resident #13 stated he very seldom used his call light. If he does it's at night when he needs to have a bowel movement. Resident #13 stated last night he turned his call light on to go to the bathroom. He did not see any staff come in to assist him, so he took himself to the bathroom. Resident #13 stated he did not fall. On 8/25/2026 at 1:16 PM the Director of Nursing (DON) stated call lights should be answered within 10 minutes. She stated some days are better than others. The DON indicated she was not sure if they can run call light reports but they do complete audits when they need to, she denied documenting the audits and keeping track of the information obtained. On 8/26/2026 at 9:40 AM the Assistant Director of Nursing (ADON) stated call lights should be answered within 15 minutes. They do not have the ability to run call light reports but they do audits. They have plans on working on things it's just a matter of being able to have time to do them. She felt once the adjustment period is over from new company taking over, staffing and resident numbers increasing, things will fall in to place. The ADON indicated adjustment is the worst part, once things smooth out, they can start implementing changes. On 8/26/2026 at 11:18 AM the Administrator stated call lights are answered depending on what order they are in when staff are answering. Staff are trying to be good about letting residents know when they will be next for assistance. She will help when she can and if it's an immediate request she will help because she is a nurse and she can do those things. The facility provided a documented titled Call Lights: Accessibility and Timely Response with a copyright of 2026, no dates of implementation or revised listed. The document included the following policy: the purpose of this policy is to assure the facility is adequately equipped with a call light at reach resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines:10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. The facility provided a document titled: Promoting/Maintaining Resident Dignity with an implantation date of 8/20/2026 and revision date of 8/25/2026. The document included the following policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.Compliance Guidelines:6. Respond to requests for assistance in a timely manner.

Based on observations, resident council note review, staff and resident interviews and review of the facility's job description, the facility's administration failed to effectively and efficiently maintain administrative responsibilities to ensure provision of ethical, high quality health care services. The facility reported a census of 33 residents. Findings include:Review of the Resident Council Notes revealed during the 6/30/2026 meeting residents have found dog poop on the floor. During the 7/28/2026 meeting residents stated the Administrator's dog was still in the facility.On 8/12/2026 at 9:13 AM Staff E Certified Nursing Assistant (CNA) stated when the new Administrator took over, they took away the need to supervise all residents smoking and the designated smoke times for residents. The residents that do not need supervision can go outside to smoke as they please. On 8/12/2026 at 11:50 AM Staff A CNA stated the Administrator is letting the residents go outside whenever they want and one example of that is when Resident #1 went down to the lake without staff knowing or being with him. The Administrator also wants to get rid of the door code to the main entrance and have automatic doors. The Administrator has gone to pick up residents and brought them to the facility in her personal car from other facilities. Staff A added the Administrator has become the Power of Attorney (POA) for some residents as well and does not understand how that is right. She will allow residents to stay in her office while staff are in there talking about other residents in front of them. On 8/12/2026 at 12:06 PM Staff B Registered Nurse (RN) stated she walked through the dining room and noticed someone outside with a headlamp on. It was dark because he has the lamp part on. It was someone riding their bicycle down by the lake when he encountered a gentleman with a stalled-out scooter and asked him to come get help. Staff were able to locate Resident #1 and brought him back to the facility without injuries. At that time, residents were able to go outside whenever they wanted, which is super unsafe. The Administrator gave the residents the access codes to go in and out. The Administrator told staff this is their home and it's their right. There was no way to know when residents are going in and out of the building. Staff B stated in her opinion no resident is completely independent because they live in the facility and require some sort of supervision. Staff A told the Administrator her worst fear is Resident #1 could have drowned or got ran over. Staff A stated the Administrator joked about it but it was not a joke because Staff A was responsible for him. The Administrator is not looking out for the safety of the residents and staff at the facility. Staff A stated the Administrator has brought in a lot of residents from her previous facility and is the POA for some of them. Staff A stated the shower room on the 300-hall has issues with the drain which leads to water in the hallway. If you look at the carpet you can see where it's wet and dry, with a mildew smell. When they asked the Administrator about it, she told them they will get new carpet once they hit a certain census. Staff A stated the Administrator would also bring her dog in the facility. It would poop and pee in the facility and being the dining room during meals. On 8/12/2026 at 1:45 PM Staff D RN stated when she first started at the facility a handful of residents would go outside to smoke at the designated times with staff present. Since the Administrator started, she has done away with requiring supervision when residents go out to smoke which was about 7-8 residents with maybe 2 residents needing supervision. There were times that those supervised residents would follow the others outside and bum cigarettes off of others without staff present. During a follow up interview on 8/13/2026 at 9:12 AM Staff D stated the Administrator is the POA for residents from the facility she used to work for, that's concerning to her. Staff D stated one day she was sitting at the nurse's station when the Administrator and some other woman had a confused resident with them. In front of everyone that was up at the nurse's station the Administrator told the staff member to sign here and here so they don't have control over your money. She had her phone on speaker phone with his bank and they were discussing his bank account and this paperwork so his family would not have access to his money. She said this was Resident #6, he is very confused. Staff D stated there were 5-6 other residents around while they talked about his bank account numbers, social security number and POA. Staff D stated she looked at the Administrator and the other staff members and said it was not appropriate to talk about this right here in front of everyone. Staff D stated the POA stuff is just [NAME] to her and not appropriate to have those conversations, let alone have someone who is confused sign that paperwork. She also stated the Administrator constantly has residents in her office while doing other resident stuff; they just sit in there and hang out while she is talking about other residents. Staff D stated the Administrator will bring her dog to the facility and not watch it. It will pee and poop in the dining room and on resident's wheelchair. She does not watch the dog, just lets him run. It has pooped in resident's rooms. Staff have to tell her she needs to go clean it up. On 8/13/2026 at 10:07 AM the Director of Nursing (DON) stated if a resident is independent, they can go outside to smoke when they want to. They have three residents that require supervision while smoking. The DON stated on the day Resident #1 left the property he had received his scooter back after occupation therapy (OT) completed his safety evaluation. These evaluations are completed annually and the residents must follow the rules, use the device as intended, staff can intervene when at risk to the resident or peers. Resident #1 went off the property without letting anyone know beforehand. His scooter had died but they were able to get him and his chair back to the facility. The DON talked to him the next day and had him sign the safety wheelchair policy. The resident has to sign the safety wheelchair policy or scooter policy which is what it was labeled in his record. The DON stated they were aware of his safety issues with his scooter at his previous facility. The DON stated Resident #1 had a BIMS of 15, was his own responsibly party and would be able to go off property once staff were notified especially at night.On 8/13/2026 at 10:21 AM three visitors entered the facility through the main entrance. A resident went to the main entrance in his wheelchair and asked the visitors to hold the door for him. The resident then went outside. On the window to the right of the main entrance door a typed note stated: Please Make Sure No Residents Are Following You Out the Doors and Are Not with You. Thank YouOn 8/13/2026 at 1:22 PM the Administrator stated they are using the compliance store to make new policies since the new company has taken over the building. They are making individualized polices as they go. At the time Resident #1 left the property a lot of residents had the code to get out the front door. She had taken care of Resident #1 at his previous facility and was aware of him leaving the property and the need for staff to get him because his scooter battery would die. The Administrator stated the residents were aware of the door code before she started at the facility about 2 months ago. She added they had three cognitively intact males that would watch as the code was put in and remember it. She would have to change the code. She changed the code recently and did believe residents had it, but some will ask to go outside now. She stated she would like to get to the point where they could suspend the door code during day time hours so these residents have more independence. She felt the residents she currently has in the building were only there for medication management. They are getting more residents from a facility that is probably getting their license pulled. On 8/14/2026 at 11:30 AM the surveyor was assisted out the front door by the Administrator. She stated she would be the only one to help because she is the only one that knows the code. The surveyor asked if she was sure of that, she replied she knew because she heard residents had the code so she changed it again. She added residents were re-educated on needing supervision when outside.On 8/13/2026 at 2:07 PM Staff F CNA stated residents used to go outside on their own so the Administrator changed the code. Some residents have figured out the code to get out and the Administrator knows this but has not changed it yet. On 8/13/2026 at 3:00 PM Resident #17 was outside smoking with his peers, no staff present. When asked how he was about to get outside, he stated he knew the code to exit the building. Resident #17 stated he watched staff when they put the code in. He added a bath aide does not cover up the key pad when they put the code in so he saw it. Resident #17 stated he's very observant but does not allow people outside that are not supposed to be outside.On 8/13/2026 at 5:25 PM Staff C CNA stated she was not aware Resident #1 had left the building. She stated residents knew the door code and could leave when they wanted. Even after the code was changed, residents still learned it and would share it with each other so they could go out when they wanted.On 8/18/2026 at 10:06 AM Staff E CNA stated the Administrator does not plan well with admitting new residents. Staff will not know about a new resident coming in until they arrived at the facility during lunchtime as they were in the middle of assisting residents with their meal. The Administrator can help but she won't. No one communicates about the new admissions especially when they are coming to the facility, which leads to poor planning for when they arrive. The Administrator will bring in her dog, has a diaper on because it was pooping and peeing in the facility. She has noticed it in the dining room during meals and she knows there are residents that do not like that: Resident #12 and #17. The Administrator has to keep changing the front door code because residents figure it out. She just changed it Friday and since then has changed it again but residents already know the code. On 8/19/2026 at 10:43 AM the Activities Director stated she hosts the resident council meetings. She stated the main topic has been the new residents do not mix well. Residents have stated the new residents got to pick their rooms, know the code to get outside without staff and the Administrator allows residents to be in her office when other residents talk to her. Residents feel like there is a lot of favoritism with the residents coming from the facility the Administrator used to work at. Residents have voiced they do not like the Administrator's dog in the building. The Activities Director stated she let the Administrator know that and she told her the residents can go to her about it. The Activities Director stated it was addressed in resident council. The Administrator's dog is pooping in the facility and present in the dining room during meals. Residents will feed it their food when it's in the dining room. Staff would put it in the Administrator's office but then she would let it back out.On 8/19/2026 at 11:20 AM Staff H CNA/ Certified Medication Aide (CMA) stated there is favoritism from the Administrator with the new residents coming in. She will allow residents to sit in her office all day. Staff H understands they need residents but a lot of the residents she has brought in are trouble makers. These residents are going to cause problems. One resident has tried to steal phones off the medication carts, another resident thinks he can come and go as he please, some residents will not turn in their smoking materials even though they are supposed to. If they try to lock up their smoking materials, they will say we are stealing their items. The front door code changes so much because residents figure it out. The Administrator wants to replace the front door with an automatic door, without needing a code to get outside. This could create problems if a resident gets mad and decides they do not want be here anymore. Staff H stated she does not mind the Administrator's dog but it free roams the building; he will pee and poop on the floor. This is the residents' home and she does not feel they should have a dog that pees and poops in the building. At meal times, the Administrator will let him roam around on the floor and in the dining room. Staff would put the dog in the Administrator's office during meal times but then she would open the door and let him back out. The Administrator did put a diaper on her dog, but he still poops. Staff H stated the new smoking rules need to be gone. When she first started residents that smoked would go outside at set times. Now, they can go outside whenever they want if they are independent and do not require supervision. She has brought up to the Administrator that staff are being stopped every 2 seconds to get out the resident's smoking materials and let out during resident cares. They have 2-3 residents coming up all the time, multiple ties to go outside. They need to go back to scheduled smoking times, there needs to be more structure but the Administrator stated they are not changing it. This new way is taking the time away from other residents that need cares or tasks completed for them; especially the residents that require more cares.On 8/19/2026 at 11:56 AM Staff I Housekeeper stated there are stains on the carpet and he has been told once their census hit 41 residents, they will get new carpet. They have shampooed the carpet but with the shower constantly leaking on the 300-hall it would not do any good until they get that shower fixed. He stated the Administrator's dog poops on the floor, has not seen it pee on the floor because it has a diaper on. Staff I stated his biggest concern is the Administrator wants to get rid of the locked door feature on the main entrance door. She keeps changing the code but residents watch and will learn it to let themselves outside. On 8/19/2026 at 12:32 PM Resident #1 stated he was not the one the left the building this time. When asked to elaborate he stated some guy is on the side of the building and has been there for 10 minutes now. Resident #1 stated he was outside then someone let the other resident outside on the patio. That resident then went down the sidewalk to the side of the building. Resident #1 took the surveyor to the [NAME] side of the front patio and Resident #8 was on the side walk. Resident #8 was in his wheelchair with no foot pedals on, on the side walk, facing north. Staff F Certified Nursing Assistant (CAN) who was seen through the front windows, waved for her to come outside. She went to assist Resident #8 back to the facility. Staff H CNA/Certified Medication Aide (CMA) came outside and was made aware of Resident #8 was found on the [NAME] side of the building without staff present. Staff H stated he had only been in the facility for about a week, week and a half and was not a smoker. Once inside the Administrator was made aware of Resident #8 found without staff present off of the patio area. She stated she had just let him outside. Resident #8 was found 192 feet from the facility's patio on a side walk. To get where he was found, there was a slight hill to go down with broken patches on concrete right off the patio.On 8/19/2026 at 12:32 PM observed Resident #8 to be 192 feet away from the front entrance of the building, unsupervised. After staff was alerted and attended to the resident, the surveyor notified the Administrator. She was walking through the east dining room and once she was informed of Resident #8 being outside unattended at the side of the building, she said f*ck I just let him outside. Observed 13 residents inside the dining room. On 8/19/2026 at 2:34 AM Staff T Agency Licensed Practical Nurse (LPN) stated it is alarming that these residents are getting outside and leaving the property without staff's knowledge.On 8/19/2026 at 4:00 PM observed Resident #19 enter the code to the main entrance key pad then walked outside by herself. The surveyor notified the Administrator right away and she stated Resident #19 will never not know that code.On 8/20/2026 at 1:13 PM Resident #15 stated the Administrator does not need to have her dog here. She stated some residents do not like dogs and the Administrator knew this.On 8/25/2026 at 10:42 AM observed the carpet outside of the 300-hall shower room to be wet. While walking across the wet carpet, water seeped up and around the surveyor's shoes. There were no caution wet signs presents or any warning for ambulatory residents that may pass by.On 8/25/2026 at 1:16 PM the Director of Nursing (DON) stated the Administrator does bring her dog in the facility and has known it to poop and pee in the building. The dog does go in the dining room during meal times as well. The Administrator does try to redirect it along with other staff members. The dog does wear a diaper to stop it from peeing but it will still poop. The DON stated she has cleaned up the messes and they have let the Administrator know she needs to clean up after her dog.On 8/25/2026 at 2:57 PM the facility provided a list of residents that were independently ambulatory. This list included 8 residents; 7 residents were independently ambulatory without assistive devices.On 8/26/2026 at 11:18 AM the Administrator was asked what her overall opinion of the cleanliness of the facility, she stated it needs attention and she has to get the right people in the right positions to work on things. She indicated resident's bathrooms should be cleaned daily and currently working on implementing deep cleaning schedules with the newer and older staff members. She stated the call light in the 300-hall bath house has been fixed since the DON was notified of it. She added residents are not left in that room alone, staff are always with them. She assured the missing floor tiles in Resident #13's bathroom will be replaced today. She stated corporate has brought in a team to remodel the old beautician's room, on the 100-hall, in to a bath house, then they can work on the 300-hall bath house remodel. They have to have a shower available, that's why the new one on the 100-hall is being completed first. Then they will work on getting new flooring. Previously if the carpet squares were ruined, they will be pulled and replaced but did not fix the problem. They had a roofing company out here to look at the roof because of the leak stains on the ceiling tiles. They were able to fix some issues with the blower system. But once they looked at the new roof, they found some of the lines are not completely sealed. They will get that roofing company out to get those addressed. The previous Maintenance Director removed some ceiling tiles but had not followed through; he was not keeping up with things. The maintenance staff that started yesterday and had done more than the previous staff member. The Administrator was informed of concerns about Staff P spending more time on her phone than cleaning, she stated she knew she was on work restrictions. She added the have hired a few new housekeepers and a new Maintenance Director that will start next week. He has long-term care experience so he will have the other new maintenance staff member learn about long-term care expectations. She stated she does not play around, if they identify issues she wants to fix it, she has a commitment to fix all the things. She knows they need new showers, flooring and a transportation bus. They have goals: once their census is 30, they get new showers, which is happening now. Once they reach 41 residents, they will get new floors. The Administrator was informed of her saying f*ck in the dining room with staff present, when informed of Resident #8 being outside [NAME] of the facility's front patio without staff knowledge or supervision. She put her head down and said so sorry. When asked if this was acceptable language in front of residents, she stated oh no, it is not common language and it was not intentional. She denied hearing of residents that do not like having her dog in the facility. She added they may do a vote on it during resident council. She stated she felt there were more residents that what her dog her than not. She also stated it sounds like staff members are upset about her dog being at the facility. They have a good IDT that are learning about resident rights and doing the least restrictive measures they can do. The Administrator stated she has heard talk about her picking favorites with residents, she said her priority is getting residents in the facility and making them comfortable. She added she takes concerns very seriously and wants the residents comfortable. The Administrator stated Resident #8 was safe to be outside by himself based on his BIMS score at that time. There were no reports of elopements and he was cognitive of what he is doing. The Administrator was informed of the water seeping over the surveyor's shoes while walking by the bath house on the 300-hall without caution signs. She stated they have three carpet extractors, there was no excuse why they could not have extracted the water. She added this was one of the reason's the previous Maintenance Director was let go, he was aware of issues that needed to be addressed in the facility but they did not get done.The facility provided a document titled Administrator-Job Description. The position purpose: leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents.Major Duties and Responsibilities:Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations.Plans, develops, organizes, implements, evaluates, and directs the facility's programs and activities in accordance with guidelines issued by the governing body.Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. Establishes an ongoing system to monitor these key indicators such as the Quality Assurance and Performance Improvement process throughout the facility. Evaluates key performance indicator outcomes with department heads to determine the need for action from leadership and/or management such as re-education or revisions related to the facility's outcomes, regulatory compliance and/or customer satisfaction.Develops and implements processes and systems in conjunction with the Business Office Manager that maintain the fiscal health of the facility. Develops and executes a census and occupancy management strategy that results in improved census and improved fiscal health for the facility. Serves as the facility representative and spokesperson to the public as well as in the professional [NAME]. In so doing, must periodically successfully deliver a confident, concise, message on a variety of topics that is understood by a wide range of persons with diverse backgrounds and levels of education.Leads and coordinates daily, weekly, bi-monthly or monthly management team meetings to discuss priorities and develop solutions with facility leaders such as census, collections, clinical health, survey readiness, customer service satisfaction, activity participation, etc. Develops and maintains positive relationships with residents, employees, and family members through scheduled, deliberate positive interactions with them using face to face, phone, or other means of communication. Evaluates work performance of department heads and maintains accountability across all departments in concert with Human Resources for expected performance outcomes in each respective department. Facilitates, serves, attends or participates in various committees of the facility as necessary. Knows and understands general nursing practices and procedures, OBRA regulations, Code of Federal Regulations, Appendix PP State Operations Manual, reimbursement processes, Life Safety Code regulations, applicable labor relations laws, and all other regulatory entities that may apply.Understands, continues to learn, and teaches others about new CMS program initiatives such as value based purchasing programs like SNF-VBP, SNF-QRP, Quality Measures, Nursing Home Compare, Payroll Based Journal reporting, etc. Ensures delivery of compassionate quality care and services across an interdisciplinary team approach as evidenced by adequate, and competent facility staff, employee turnover, general cleanliness, physical plant condition, and optimal resident functioning-physically and psychosocially. Identifies and collaborates with members of the interdisciplinary team, physicians, consultants, and community agencies to identify opportunities for enhanced services to the residents and/or resolve issues.Recruits talented, qualified individuals in conjunction with Human Resources to fill department head positions as a key factor in building and maintaining a strong and capable team.Performs rounds to observe residents and ensure overall needs are being met. Knows residents by name and sight. Practices management by walking around. Makes himself/herself available to employees at all levels by practicing an open door policy. Knows employees across all departments, all shifts by name and makes himself/herself available periodically on a routine, scheduled basis across all three shifts to gain informal employee feedback.Conducts periodic observations of in-service education to ensure staff members delivering the education are competent with the knowledge and skill set required to accomplish employee learning.Promotes teamwork, mutual respect, and effective communication. Promotes positivity and active daily problem solving. Leads budget development with department heads bi-annually. Leads, in conjunction with the Business Office Manager, weekly or bi-monthly budget compliance meetings to ensure financial goals are met. Reviews and interprets monthly financial statements and provides relevant information to the governing board.Makes written and oral reports/recommendations to the governing board concerning the operation of the facility.Leads, guides and directs facility readiness related to health inspection surveys, Occupational Safety and Health Administration (OSHA) surveys, and any other regulatory entity or requirement. Ensures follow up is completed with any mock survey issues identified in preparation for health surveys, OSHA surveys, and any other regulatory requirement. Ensures the facility's plan of correction response to any regulatory, inspection survey is completed, adequate, implemented and timely. Communicates directly with residents, medical and nursing staff, family members, department heads and members of the interdisciplinary team to coordinate care and services. Responds and resolves complaints and concerns when necessary.Manages and minimizes facility risk through a team approach to achieve desired outcomes in customer service, key performance indicators, employee retention and other areas as identified.Coordinates and cooperates with the facility's liability insurance carrier and legal representative in the unfortunate event of litigation involving the facility. Reads and stays informed regarding regulatory, business practices and other changes influencing facility outcomes; thereby, facilitating continued success for all. Engages as a change agent for the facility when necessary. Ensures resident incidents and concerns that rise to a reportable event such as alleged abuse, neglect, mistreatment, misappropriation, etc. are reported to the correct entity within the stated regulatory requirement. Promotes and encourages an environment of trust among all employees related to the overarching goal of resident safety and abuse prevention.Promotes safe work practices, safety rules, and accident prevention procedures to prevent employee injury and illness.Delegates administrative authority, responsibility, and accountability to other staff personnel as necessary.Additional Tasks:Treats all residents with dignity and respect. Promotes and protects all residents' rights.Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines.Follows appropriate safety and hygiene measures at all times to protect residents and themselves.Maintains confidentiality of protected health information, including verbal, written, and electronic communications.Reports noncompliance with policies, procedures, regulations, or breaches in confidentiality to appropriate personnel. Reports any retaliation or discrimination to HR or compliance officer.Reports any allegations of abuse, neglect, misappropriation of property, exploitation, or mistreatment of residents to appropriate regulatory entities. Protects residents from abuse, and cooperates with all investigations. Reports any occupational exposures to blood, body fluids, infectious materials, and/or hazardous chemicals in accordance with facility policy. Participates in all life safety and emergency drills and trainings. Fulfills responsibilities as assigned during implementation or activation of the facility's emergency plan.Reports work-related injuries and illnesses immediately to designated staff member.Follows established infection control policies and procedures.As a condition of employment, completes all assigned training and skills competency.

Based on observations, record review, facility policy review, resident, family and staff interviews, the facility failed to ensure infection prevention was practiced during meal times by allowing a staff member's dog to be present in the dining room. The facility also failed to ensure infection prevention practices were followed by allowing a staff member's dog to pee and poop in the facility. The facility also failed to ensure 1 of 1 resident (Resident #7) reviewed had clean feeding tube equipment. The facility reported a census of 33 residents.Findings include:According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 7/4/2026, Resident #7 had a Brief Interview of Mental Status (BIMS) score of 10. A BIMS score of 10 suggested mild cognitive impairment. Resident #7 had impairments to her bilateral lower extremities, was frequently incontinent of urine and always incontinent of stool, and constipation was not present during the assessment. The MDS documented she required substantial/maximal assistance with mobility, toilet transfers and partial/moderate assistance with chair/bed to chair transfers. Resident #7 had a feeding tube upon admission and while a resident in the facility. The MDS listed the following diagnoses for Resident#7: non traumatic subacute subdural hemorrhage, cancer, urinary tract infection (UTI) (last 30 days), stroke, non-Alzheimer's dementia, seizure disorder, insomnia, and metabolic encephalopathy.A Care Plan Focus Area with an initiated date of 7/8/2026 documented Resident #7 required tube feedings related to swallowing problem. The Care Plan documented she was dependent with water flushes to feeding tube. The Care Plan encouraged staff to see physician's orders for current feeding orders.On 8/18/2026 at 12:48 PM in Resident #7 room, observed two clear graduates on her bathroom counter; both dated 8/5/2026. One graduate had dirty written on it and the second graduate had rinse only on it. The second graduate with rinse only written on it had water in it with a dead fly floating in it. On 8/19/2026 at 12:15 PM the two graduates dated 8/5/2026 remained on Resident #7's bathroom counter, the one with rinse only continued to have water in it with a dead fly floating in it. On 8/20/2026 at 8:56 AM the two graduates remained on the resident's bathroom counter, the one with rinse only continued to have water in it with a dead fly floating in it. On 8/25/2026 at 9:30 AM the two graduates remained on the resident's bathroom counter the one with rinse only continued to have water in it with a dead fly floating in it. A third graduate was on her bathroom counter dated 8/20/2026 and a syringe dated 8/20/2026. On 8/19/2026 at 2:34 AM Staff T Agency Licensed Practical Nurse (LPN) stated the graduates should be changed out every 24 hours. When asked if the canisters dated 8/5/2026 with a dead fly in it should be changed out, she stated that is gross and should be changed out. On 8/20/2026 at 11:53 AM Staff L Agency RN stated the graduates are usually changed out every 24 hours. On 8/20/2026 at 12:40 PM Staff M RN stated graduates should be replaced probably daily or every week, she's not familiar with this. On 8/20/2026 at 12:47 PM Staff N LPN stated the graduates should be replaced every 24 hours. She believed that was the standard. On 8/25/2026 at 9:58 AM Staff O RN stated if a resident needs a graduate for treatments they should be changed out every shift or every 24 hours. Review of the Resident Council Notes revealed during the 6/30/2026 meeting residents stated a dog goes to the dining room at lunch, have found dog poop on the floor. During the 7/28/2026 meeting residents stated the Administrator's dog was still in the facility.On 8/12/2026 at 12:06 PM Staff B Registered Nurse (RN) Staff A stated the Administrator would also bring her dog in the facility. It would poop and pee in the facility and be in the dining room during meals.On 8/13/2026 at 9:12 AM Staff D RN stated the Administrator will bring her dog to the facility and not watch it. It will pee and poop in the dining room and on resident's wheelchair. She does not watch the dog, just lets him run. It has pooped in resident's rooms. Staff have to tell her she needs to go clean it up.On 8/13/2026 at 5:25 PM Staff C CNA stated the Administrator's dog has peed and pooped in the facility. She has since put a diaper on it when she brings it in to eliminate it from peeing in the building. On 8/18/2026 at 10:06 AM Staff E CNA stated the Administrator will bring in her dog, has a diaper on because it was pooping and peeing in the facility. She has noticed it in the dining room during meals and she knows there are residents that do not like that: Resident #12 and #17.On 8/18/2026 at 10:37 AM Staff R Agency CNA stated a dog does come to the facility and has noticed it peeing in the dining room. Since then, a diaper has been placed on the dog. On 8/18/2026 at 12:34 PM Resident #2 stated there has been a dog in the building that will go in to the dining room during meals.On 8/18/2026 at 12:48 AM Resident #7's sister stated when she was by the nurse's station there was dog poop on the floor. At first, she thought it was a joke because it looked like that plastic poop. The dog does wear a diaper now.On 8/19/2026 at 10:43 AM the Activities Director stated residents have voiced they do not like the Administrator's dog in the building. The Activities Director stated she let the Administrator know that and she told her the residents can go to her about it. The Activities Director stated it was addressed in resident council. The Administrator's dog is pooping in the facility and present in the dining room during meals. Residents will feed it their food when it's in the dining room. Staff would put it in the Administrator's office but then she would let it back out.On 8/19/2026 at 11:10 AM Staff G CNA/Certified Medication Aide (CMA) smiled and laughed when asked if there is a dog that comes in, pees and poops on the floor in the facility. When asked if the dog goes in the dining room Staff G laughed again. When asked if the dog is present in the dining room during meals, she stated she was not sure. Staff G stated the dog does wear a diaper now but it only stops him from peeing, not pooping. On 8/19/2026 at 11:20 AM Staff H CNA/CMA stated she does not mind the Administrator's dog but it free roams the building; he will pee and poop on the floor. This is the residents' home and she does not feel they should have a dog that pees and poops in the building. At meal times, the Administrator will let him roam around on the floor and in the dining room. Staff would put the dog in the Administrator's office during meal times but then she would open the door and let him back out. The Administrator did put a diaper on her dog, but he still poops.On 8/19/2026 at 11:56 AM Staff I Housekeeper stated Staff P would mop rooms and never change the water. He stated the Administrator's dog poops on the floor, has not seen it pee on the floor because it has a diaper on.On 8/20/2026 at 1:13 PM Resident #16 stated the Administrator does not need to have her dog here. When asked to elaborate, Resident #16 stated her dog poops on the floor and they made the Administrator clean it up. Her dog will go in the dining room while they are eating, the dog will go all over the place. Resident #16 stated some residents do not like dogs and the Administrator knew this. They put a diaper on it but it still poops. On 8/20/2026 at 12:40 PM Staff M RN stated she has heard of a dog in the building that will poop and pee in the facility. She has not witnessed this. On 8/20/2026 at 1:27 PM Resident #18 stated the Administrator's dog would sometimes be in in the dining room during meal times. On 8/25/2026 at 1:16 PM the Director of Nursing (DON) stated the Administrator does bring her dog in the facility and has known it to poop and pee in the building. The dog does go in the dining room during meal times as well. The Administrator does try to redirect it along with other staff members. The dog does wear a diaper to stop it from peeing but it will still poop. The DON stated she has cleaned up the messes and they have let the Administrator know she needs to clean up after her dog. The DON stated the graduates in Resident #7's bathroom should be changed out every 24 hours.On 8/26/2026 at 9:40 AM the Assistant Director of Nursing (ADON) stated she was not sure on the policy on when the graduates needed to be changed but it sounds like its unnecessary supplies in her room. On 8/26/2026 at 11:18 AM the Administrator stated she would put her dog in her office during meal times. There policy says they are not allowed in food prep areas but she can't get to her office without going through the dining rooms. Her office is between the two dining rooms, so you have to walk through one of them to get there. She added out of the 50 days she has brought her dog in the facility it maybe had accidents in the facility 3 times. When that happened, she attended to it immediately and cleaned it up per their policy. The facility provided a document titled Standard Precautions Infection Control with a copyright of 2026, no dates of implementation or revised listed. The document included the following policy: All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors. The facility provided a document titled Companion Animal Visits with an implementation date of 8/1/2026 and revision date of 8/20/2026. The documented included the following policy: it is the policy of this facility to provide a home-like environment and enhance our residents' quality of life by allowing companion animal visits. Policy Explanation and Compliance Guidelines: 1. Companion animals, which include animals visiting the facility as part of an activities program, must meet the following criteria in order to enter the facility: a. The animal must be well-behaved and well-trained. If the animal demonstrates that he or she is not well-behaved or well-trained, the animal handler/owner will be asked to remove the animal from the facility.3. All visits must be supervised by persons who know the animal and their behavior.4. Gloves will be used for clean-up of animal urine or feces from environmental surfaces. a. Absorbent materials used in the cleaning process will be placed in leak-resistant plastic bags and discarded. b. The area should then be cleaned according to standard cleaning and disinfecting procedures.5. Animals are not allowed into: a. Protective environments (positive pressure rooms designed to protect high-risk immunocompromised residents from airborne pathogens) b. Food preparation kitchens/areas c. Laundry areas d. Any storage area used for clean/sterile supplies e. Medication preparation areas The facility provided a document titled Care and Treatment of Feeding Tubes with an implementation date of 8/20/2026 and revision date of 8/25/2026. The document included the following policy: it is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.Policy Explanation and Compliance Guidelines:7. Direction for staff on how to provide the following care will be provided:d. Use of infection control precautions and related techniques to minimize the risk of contamination to include changing disposable equipment via manufacturer's guidelines.

Based on observations, clinical record review, facility policy review, resident, family and staff interviews the facility failed to ensure it was free of household flies/insects which resulted in 2 of 3 residents (Resident #2 and #7) reviewed with bug bites. The facility reported a census of 33 residents. Findings include:1.According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 7/22/2026. The MDS assessment tool documented Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS listed the following diagnoses: pressure ulcer of left buttock stage 4, neurogenic bladder, paraplegia, traumatic brain injury (TBI), anxiety, bipolar disorder, post-traumatic stress disorder (PTSD), sleep apnea, neurogenic bowel, pressure ulcer of right buttock stage 3, psychoactive substance abuse, and colostomy status.On 8/18/2026 at 12:34 PM Resident #2 stated there are a lot of flies in the facility and has found weird bugs on the floor. Resident #2 stated he had bug bites recently they burned and itched. When asked where he was in the facility when he got them, he stated in his room in the early morning hours; about 3:00 AM. Resident #2 stated there was a guy in the facility yesterday to spray for bugs.2.According to the admission MDS assessment tool with a reference date of 7/4/2026, Resident #7 had a BIMS score of 10. A BIMS score of 10 suggested mild cognitive impairment. Resident #7 had impairments to her bilateral lower extremities, was frequently incontinent of urine and always incontinent of stool, and constipation was not present during the assessment. The MDS documented she required substantial/maximal assistance with mobility, toilet transfers and partial/moderate assistance with chair/bed to chair transfers. Resident #7 had a feeding tube upon admission and while a resident in the facility. The MDS listed the following diagnoses for Resident#7: non traumatic subacute subdural hemorrhage, cancer, urinary tract infection (UTI) (last 30 days), stroke, non-Alzheimer's dementia, seizure disorder, insomnia, and metabolic encephalopathy.Record review revealed the following progress note was documented on 8/11/2026 at 11:30 AM: this nurse was called into the resident's room this morning and notified she had some skin issues. Upon assessment, Resident #7 noted to have multiple raise areas to her left arm that appeared like bug bites. A call was placed to the on-call provider and received an order for Benadryl cream four times a day for three days as needed (PRN). On 8/18/2026 at 12:48 PM in Resident #7 had two clear graduates on her bathroom counter; both dated 8/5/2026. One graduate had dirty written on it and the second graduate had rinse only on it. The second graduate with rinse only written on it had water in it with a dead fly floating in it. At 2:14 PM observed a flying insect trap plugged in to Resident #7's outlet to the left of her bed. Removed the trap from the outlet, observed various dead inspect on the sticky part of the trap: flies, mosquitos, gnats, houseflies, etc. On 8/19/2026 at 12:15 PM the two graduates dated 8/5/2026 remained on Resident #7's bathroom counter, the one with rinse only continued to have water in it with a dead fly floating in it. On 8/20/2026 at 8:56 AM the two graduates remained on the resident's bathroom counter, the one with rinse only continued to have water in it with a dead fly floating in it. On 8/25/2026 at 9:30 AM the two graduates remained on the resident's bathroom counter the one with rinse only continued to have water in it with a dead fly floating in it. Also observed a fly ribbon trap hanging from Resident #7's ceiling corner behind her recliner by the window. On 8/12/2026 at 12:06 PM Staff B Registered Nurse (RN) stated the facility has a lot of flies with the increased number of people going in and out of the building throughout the day. On 8/12/2026 at 1:45 PM Staff D RN stated there are tons and tons of flies in the building. One time she went to give a resident her medications. This resident had previously had stroke so could not tell but she had flies on her mouth. On 8/13/2026 at 10:42 PM Resident #1 stated they do have flies in the building and he is getting bit. On 8/13/2026 at 3:00 PM Resident #19 stated flies do come in but he has a flyswatter to kill them with. On 8/13/2026 at 5:25 PM Staff C Certified Nursing Assistant (CNA) stated there are a lot of flies. They keep flyswatters around to use. She has noticed some flies hanging around resident's mouths or close by their mouths. Staff C stated she would shoo them away. On 8/18/2026 at 9:34 AM Staff F CNA stated the flies is the building is not too bad, there are some but not a bunch. There are room where they like to hang out in. The front door is constantly open though, that does not help. On 8/18/2026 at 10:06 AM Staff E CNA stated she has noticed cockroaches and a lot of flies in the building. They had someone at the building yesterday to spray. On 8/18/2026 at 12:48 PM Resident #7's sister stated while the resident was lying in bed when she noticed the resident had five bug bites on her left arm and one on her right arm. When she let the facility know, they asked if the resident had a screen on her window or if she had been outside. Resident #7's sister stated she had not been outside since 7/4/2026 when she had family visiting. The window in the resident's room did not have a screen on at that time and at the time of the interview. The facility ordered Benadryl and itch cream for the bug bites. On 8/19/2026 at 9:22 AM Staff S Physical Therapist Assistant (PTA) stated they do have a lot of flies in the building but the front door is opened a lot and left opened at times. She has seen the flies in the building.On 8/19/2026 at 10:43 AM the Activities Director stated the facility does have bugs and flies. She added she felt like the front door opens a lot and lets them. She also felt like it may be an issue for residents that have food in their rooms. She has noticed flies in the dining room but that it's by the front door that is opened a lot. On 8/19/2026 at 11:20 AM Staff H CNA/CMA stated the flies it the building are horrible, especially when it gets hot in the building. She added some rooms attract more than others. On 8/20/2026 at 11:53 AM Staff L Agency RN stated the Assistant Director of Nursing ADON called her to Resident #7's room and showed her the bug bites on her arm. She could not say for certain they were bug bites but they were raised areas. Did not think they looked like bed bug bites. Resident #7 stated they were itchy, so she received an order for Benadryl cream PRN. She would see flies in the building, a lot of them. On 8/20/2026 at 12:47 PM Staff N LPN stated she did not see bug bites on Resident #7, but the resident's sister said she was itching and asked for her cream. On 8/25/2026 at 9:58 AM Staff O RN stated they do have flies in the building but they also have residents that like their windows open. Some resident's windows do not have screens. On 8/25/2026 at 1:16 PM the Director of Nursing (DON) stated the flies will sneak in through the front door. She also stated they just sprayed for bugs last Monday. The DON indicated she was unaware of the fly traps in Resident #7's room. She stated Resident #2 and #7 received the bug bites after they sprayed for bugs. On 8/26/2026 at 1:40 PM Resident #5 stated she does not want to cause issues but the facility has a lot of flies, including her room. On 8/26/2026 at 9:40 AM the ADON was asked about flies in the facility, she stated screens need to be put back on the windows to resident's rooms. The flies are bad this year especially with where the facility is located by the park and there are a lot of trees. This may be why the flies are bad this year. The flies inside have increased since the residents are outside smoking more, the front door is opening and closing more frequently. She was not sure how often the guy comes to spray for bugs but knew he was just here recently. On 8/26/2026 at 11:18 AM the Administrator stated Resident #7's family brought in the fly strips but they should be looking at them too. If they are full, they need to be taken down and only use them when they need them; if there are no flies then they should be taken down. Flies and mosquitos are here, she gets them at home too. When she heard about the residents with bug bites, she wanted to make sure they did not get them while outside because she did not think it was an inside issue and she knows it's not bed bugs. They have had the pest control company come out to spray down all the windows and rooms of those that allowed them in their rooms. The facility provided a document titled Pest Control Program with an implemented date of 8/20/2026 and revision date of 8/25/2026. The document included the following policy: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.Policy Explanation and Compliance Guidelines:Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis.3. Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated.4. Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations.

Based on clinical record review, staff interviews and facility policy review the facility failed to ensure 2 of 3 residents (Resident #1 and #9) had baseline cares plans completed within 48 hours of the admission to the facility. The facility reported a census of 33 residents. Findings include: 1. Review of Resident #1's record revealed a census tab that had a documented admission date of 7/29/2026.Record review for Resident #1 revealed the following Baseline Care Plan was signed off as completed on 7/29/2026. The Baseline Care Plan documented the following: resident was a new admit to the facility, from another facility on 7/29/2026. He was admitted to the facility for long-term stay with type 2 diabetes mellitus without complications, see diagnoses sheet attached. Resident #1 speaks English and his primary reason(s) for admission include: medication administration, 24 hours a day 7 days a week supervision, and unsafe to live independently. He will need to be acclimated to his new environment and may be at risk for falls related to bilateral below the knee amputations. The Baseline Care Plan documented he was on high-risk medications and needed to be observed for adverse effects. The Baseline Care Plan documented the following other interventions: administer medications, treatments, and other services in accordance with physician orders; check vital signs per protocol; offer diet as ordered; provide specialized rehabilitation services as ordered; provide medically-related social services as ordered/indicated; provide care and services in accordance with PASRR recommendations, if applicable; anticipate and meet needs per physical/non-verbal indicators or discomfort/distress and follow up as indicated; provide/assist with Activities of Daily Living (ADLS) as indicated.The Baseline Care Plan failed to include information necessary to properly care for Resident #1 immediately upon his admission, resident-specific health and safety concerns to prevent injury, and assistances of ADLS. 2. Review of Resident #9's record revealed a census tab that had a documented admission date of 8/3/2026.Record review revealed Resident #9's record lacked a Baseline Care Plan.On 8/25/2026 at 1:16 PM the Director of Nursing (DON) stated a baseline care plan should be completed within 48 hours of admission. They should include generally what they see when they are up and moving, how they ambulate, therapy needs, if they have glasses or hearing aids. They can have quick notes about bowel and bladder continence, bath days and if they prefer a bath or shower. The baseline care plans are usually completed by the Assistant Director of Nursing (ADON) or the staff member admitted the resident to the facility. She stated the baseline care plans should be completed by the charge nurse completing the admission as they gather information for their admission assessments. She stated with more agency staff working, this does not always get done. On 8/26/2026 at 9:40 AM the ADON was asked what a resident's care plan should include, she stated their advanced directives, basic activities of daily living (ADL) stuff, and communication. Those are the things they try to make sure are on there.On 8/26/2026 at 11:18 AM the Administrator stated they do summary notes in the communication tab of the facility's Electronic Health Record (EHR) with instructions from their baseline care plan. They also have a Clinical Communications board in the EHR that instruct nurses and CNAs about the resident.The facility provided a document titled Baseline Care Plan with an implementation date of 8/20/2026 and a revision date of 8/25/2026. The documented included the following policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.Policy Explanation and Compliance Guidelines:1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission, whether paper version or PCC assessment.b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders.ii. Physician orders.iii. Dietary orders.iv. Therapy services.v. Social services.vi. PASARR recommendation, if applicable.2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable.a. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives.b. Interventions shall be initiated that address the resident's current needs including:i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk.ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living.iii. Any special needs such as for IV therapy, dialysis, or wound care.c. Once established, goals and interventions shall be documented in the designated format.3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed.

Based on clinical record review, resident and staff interviews, the facility failed to complete a comprehensive care plan for 1 of 3 residents (Resident #1) after they were admitted to the facility. The facility reported a census of 33 residents. Findings include:According to an admission Minimum Data Set (MDS) assessment tool with a reference date of [DATE] documented Resident #1 was admitted to the facility on [DATE]. The MDS documented he used tobacco. Record review revealed a document file titled Resident #1 referral. Within this document included a care plan from the resident's previous facility. This care plan documented he was a smoker as well as he had a behavior problem as evidenced by signing in/out of facility leaving on his scooter to the gas station. His battery had died while traveling to the gas station and staff and/or strangers had to retrieve him several times. On [DATE] he was issued a behavioral contract related to leaving the facility in his scooter and having staff and/or strangers bring him back to the facility. Resident #1 had been approved to drive a power wheelchair and has signed and agreed to the safety recommendations set forth by the facility. On [DATE] Resident #1 and the Long-Term Care Ombudsman were notified of three documented violations of his contact and provided a copy of the contract with violation dates. Per his contract, his power wheelchair has been revoked until his next annual assessment.Review of Resident #1's Care Plan on [DATE] revealed it lacked documentation of him being a smoker. The Care Plan also lacked previous behaviors with going to the gas stations with an uncharged scooter, use of a behavioral contract and him violating this contract, resulting in his scooter being revoked.On [DATE] at 1:16 PM the Director of Nursing (DON) stated a comprehensive care plan should include the same things as a baseline care plan but more in-depth to include medications, specific behaviors for the resident. These are completed by the Assistant Director of Nursing (ADON) but she will help with putting in orders and skin notes. When asked if Resident #1's comprehensive care plan should include his history of leaving his previous facility after signing out, she acknowledged it should be. She added they talked about it and discussed his history; the Administrator was more familiar with his history. When asked if the care plan should include that he was a smoker, she indicated he should have been on there.On [DATE] at 9:40 AM the ADON stated a comprehensive care plan should pretty much include everything specific to the resident's activities of daily living (ADLs), communication, behaviors. She added they working on getting individual behaviors, black box medication warnings on the care plans. She acknowledged she is still learning the ropes of care plans and getting them where they need to be. Herself and the interdisciplinary team (IDT) work together to complete the comprehensive care plans. The ADON was informed Resident #1's care plan did not include his history of leaving his previous facility on his scooter and it dying while he was out. It also did not include he was a smoker. The ADON indicated they were told before not to have a resident's history of behaviors on their care plans. She stated she was not sure how they missed him being a smoker on his care plan. She indicated when they changed their smoking policy all residents needed new smoking assessments and their care plans were updated.

Based on clinical record reviews, observations, resident and staff interviews, and facility policy review the facility failed to ensure 2 of 3 residents (Resident #1 and #8) care plans were updated timely after they both left the facility unannounced and unattended. The facility reported a census of 33 residents. Findings include:1. According to an admission Minimum Data Set (MDS) assessment tool with a reference date of [DATE] documented Resident #1 was admitted to the facility on [DATE]. The MDS documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score suggested no cognitive impairment. A Progress Note dated [DATE] at 10:36 AM documented on [DATE] Resident #1 left the facility to go to a nearby lake, unattended and without staff's knowledge. His electric scooter's battery died and a community member alerted facility staff of the resident's electric scooter being dead and the resident needing assistance back to the facility.Review of Resident #1's Care Plan on [DATE] at 9:49 AM revealed the following documented Care Plan Focus Areas:The Care Plan Focus Area with an initiated date of [DATE] documented Resident #1 wished to leave the community for short periods of time. The Care Plan documented he went to a nearby lake without staff knowing and without signing out. Resident #1 understands the importance of appropriately signing out as evidenced based on verbal understanding. Resident #1 is not to leave the facility without signing out or notifying facility staff. If he wished to leave the community, he will sign out appropriately. A second Care Plan Focus Area with an initiated date of [DATE] documented Resident #1 independently left the facility property on [DATE] without signing out, resulting in a stalled scooter and resident crawling back toward the facility. Resident #1 was unaware of sign-out expectations and did not take his cell phone. The Care Plan documented he was cognitively intact but demonstrates risk-taking behavior. The Care Plan directed staff to: educate Resident #1 on the facility sign-out process; re-orient as needed, review and reinforce motorized scooter safety policy with Resident #1 and obtain signed acknowledgement, set on-property boundary (mailbox area) due to lack of sidewalks, ensure resident understands and agrees, encourage resident to carry his cell phone at all times when outdoors, occupational therapy to continue scooter safety training and assess safe use, staff to monitor resident's outdoor activity and provide reminders as needed, document any refusals unsafe behaviors or deviations from safety plan. A third Care Plan Focus Area with an initiated date of [DATE] documented Resident #1 was approved to drive a power wheelchair and has signed and agreed to the safety recommendations set forth by the facility. The Care Plan documented per agreement Resident #1 has agreed to: complete an initial therapy safety evaluation-previously completed. Any changes in condition affecting physical, cognitive, visual, and or behavioral function requires an additional therapy safety evaluation. Safety evaluation to be completed annually. Resident #1 must follow the facility traffic rules, operate at safe speeds, yield to pedestrians and use the wheelchair only as intended. Staff will immediately intervene when unsafe operation places any person at risk. 2. Review of Resident #8's MDS assessment tab on [DATE] at 1:39 PM revealed an entry MDS dated [DATE]. On [DATE] at 12:32 PM Resident #1 alerted the State Surveyor he was not the resident that had left the build this time. Resident #1 then went to the [NAME] side of the facility's patio where Resident #8 was located roughly 192 feet away from the facility's patio, unattended. Facility staff was made aware of the situation and they escorted the resident back to the facility. A Progress Note dated [DATE] at 12:47 PM documented he had asked to go outside and the Administer let the staff know it was fine. The Administrator was alerted by staff that he was outside self-propelling on the sidewalk on the [NAME] side of the building. Resident #8's Care Plan was reviewed on [DATE] at 9:25 AM. The Care Plan lacked revision after the resident was found 192 feet away from the facility's patio, unattended.The facility provided a document titled Care Plan Revision Upon Status Change with an implementation date of [DATE] and revision date of [DATE]. The document included the following policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.On [DATE] at 1:16 PM the Director of Nursing (DON) stated when Resident #1 left the building on Thursday his care plan should have been updated the next day. They did not view Resident #8's incident as an elopement. They talked about it in the morning meeting and staff about it afterwards.On [DATE] at 9:40 AM the Assistant Director of Nursing (ADON) stated she thought Resident #8's recent event about him leaving the patio unattended and without staff's knowledge was on his care plan. She stated she would get that updated and it should have been updated within 24 hours of the incident. She added she would need to look at the policy but it should be timely not a week later.Policy Explanation and Compliance Guidelines:1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.2. Procedure for reviewing and revising the care plan when a resident experiences a status change:a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable.b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options.c. The care plan will be updated with new or modified interventions.d. Staff involved in the care of the resident will report resident response to new or modified interventions.e. Care plans will be modified as needed by the MDS Coordinator or other designated staff member.f. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care.

Based on clinical record review and staff interviews the facility failed to sign out 1 of 3 resident's (Resident #2) wound treatments as completed. The facility reported a census of 33 residents. Findings include:According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 7/22/2026. The MDS assessment tool documented Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. Resident #2 was at risk for developing a pressure ulcer/pressure injury with the following interventions in place: pressure reducing device for chair, bed, turning/repositioning program, nutrition or hydration intervention to manage skin problems, and surgical wound care. The MDS listed the following diagnoses: pressure ulcer of left buttock stage 4, neurogenic bladder, paraplegia, traumatic brain injury (TBI), anxiety, bipolar disorder, post-traumatic stress disorder (PTSD), sleep apnea, neurogenic bowel, pressure ulcer of right buttock stage 3, psychoactive substance abuse, and colostomy status.The Care Plan Focus Area with a revision date of 6/23/2026 documented Resident #2 had a history of and currently had a stage 4 pressure ulcer to his left buttocks. The Care Plan directed staff to administer treatments as ordered and monitor for effectiveness. Review of Resident #2's June 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the follow orders were not signed out as being completed on 6/16/2026:Cleanse area around ostomy with hibiclens and dry well, apply stoma paste over, apply ostomy appliance as directed, repeat 2 times weekly with bathing and as needed (PRN),Left ischium: place kerlix between thighs and scrotum. Replace two times a day (BID) and PRN for saturation and soiling,Review of Resident #2's July 2026 MAR and TAR revealed the following orders were not signed out as being completed:left 2nd toe dorsal: cleanse wound with wound cleanser, swab with betadine, cover with gauze secure with tape and change daily one time a day for wound treatment. This order was not signed out as being completed on 7/13/2026, 7/14/2026, and 7/16/2026,wound care to left ischial incision wound: wash with saline, rinse well and pat dry. Apply skin prep to the peri-wound and anywhere adhesive may lie and allow to dry. Cover with hydrofera blue to wound bed. Cover with bordered gauze, secure with tape, every day shift. This order was not signed out as being completed on 7/17/2026,left ischium: place kerlix between thighs and scrotum. Replace BID and PRN for saturating, soiling. The order was not signed out as being completed on 7/7/2026 at 7:00 PM, 7/10/2026 at 7:00 PM, 7/13/2026 at 8:00 AM, 7/14/2026 at 8:00 AM, 7/16/2026 at 8:00 AM, and 7/22/2026 at 7:00 PM,toe incision site: cleanse with saline, apply house zinc barrier to entire area, repeat BID and PRN. The order was not signed out as being completed on 7/22/2026 at 8:00 PM.On 8/25/2026 at 1:16 PM the Director of Nursing (DON) stated if an order is not signed out, that means it was not done.

Based on observations, clinical record review, resident and staff interviews and facility policy review the facility failed to ensure 1 of 3 residents (Resident #1) had a smoking assessment completed upon admission. The facility also failed to ensure 2 of 3 residents (Resident #2 and #12) reviewed had their smoking materials secured with nursing staff. The facility reported a census of 33 residents. Findings include:1. According to an admission Minimum Data Set (MDS) assessment tool with a reference date of 8/5/2026 documented Resident #1 was admitted to the facility on [DATE]. The MDS documented he used tobacco.On 8/12/2026 at 4:00 PM observed Resident #1 outside smoking with his peers. Record review revealed Resident #1's record lacked a smoking assessment. 2. According to the Quarterly MDS assessment tool with a reference date of 7/22/2026. The MDS assessment tool documented Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15.A Care Plan Focus Area with an initiation date of 4/11/2025 documented Resident #2 was a smoker. The Care Plan documented his smoking materials are kept secured by staff. The following Progress Note documented on 6/13/2026 at 5:26 PM: Resident #2 was found in his room vaping when staff entered to administer his late evening medication. The resident was asked if he understood that the facility is a non-smoking facility and was reminded that vaping, smoking cigarettes, or using similar products is not permitted inside resident rooms. Staff explained that these restrictions are in place due to safety concerns, including the presence and use of oxygen tanks and oxygen related equipment within the facility. Resident was educated regarding the potential risk associated with smoking or vaping while taking narcotic medications and other prescribed medications. Resident was informed of facility expectations regarding compliance with safety policies. Will continue to monitor, reinforce facility policies, providing ongoing education, and document any continued noncompliance as indicated. On 8/18/2026 at 12:34 PM observed Resident #2 with his hand up to his mouth, noted a small black box in his hand. 3. According to an Annual MDS assessment tool with a reference date of 6/4/2026 documented Resident #12 had a BIMS score of 15. A BIMS score of 15 suggested intact cognition. The MDS documented he used tobacco at the time assessment w6as completed. A Care Plan Focus Area with an initiation date of 6/7/2025 documented Resident #12 was a smoker. The Care Plan documented his smoking materials are kept secured by staff.On 8/18/2026 at 9:34 AM Staff F Certified Nursing Assistant (CNA) stated that resident's cigarettes, lighters a vapes are to be locked up in a box when not outside smoking. On 8/19/2026 at 11:20 AM Staff H CNA/Certified Medication Aide (CMA) stated the new smoking rules need to be gone. When she first started residents that smoked would go outside at set times. Now, they can go outside whenever they want if they are independent and do not require supervision. She has brought up to the Administrator that staff are being stopped every 2 seconds to get out the resident's smoking materials and let out during resident cares. They have 2-3 residents coming up all the time, multiple times to go outside. They need to go back to scheduled smoking times, there needs to be more structure but the Administrator stated they are not changing it. This new way is taking the time away from other residents that need cares or tasks completed for them; especially the residents that require more cares. On 8/20/2026 at 9:55 AM during an interview with Resident #12 stated they do not get enough cigarettes. He then went to his dresser and obtained a full pack of cigarettes and one pack that had two cigarettes. He placed one behind his ear, then put his index finger to his lips and stated they are not supposed to know because he is not supposed to keep them in his room. Resident #12 added some staff let him keep them in his room, other staff do not.On 8/25/2026 at 1:16 PM the Director of Nursing (DON) said no when asked if residents could have their smoking materials in their rooms. She knew Resident #2 has a vape but when she asks him about it, he denies having it in his room. She stated Resident #12 used to work here; he knows the rules. The DON acknowledged smoking assessments are to be completed upon admission, annually or unless there is a change in condition with the resident. On 8/26/2026 at 11:18 AM the Administrator was asked if residents can have smoking materials in their rooms she stated they need to follow their search and seize personal property policy. The smoking materials should be locked up by staff members. If a resident is non-complaint with this, they will complete a compliant sweep and lock up the items. She is looking at getting outdoor lock boxes to go outside that would require a key to get in it. The facility provided a document titled: Resident Smoking and Tobacco Use Policy with an effective date of 7/1/2026. The policy documented the following purpose: The purpose of this policy is to provide a safe environment that supports each resident's right to make informed choices regarding smoking while protecting the health and safety of all residents, staff, visitors, and the facility. This policy complies with all applicable Centers for Medicare & Medicaid Services (CMS), state regulations, and fire safety requirements. The policy included: Residents have the right to smoke or use tobacco products unless prohibited by physician order or otherwise limited due to safety concerns identified through an interdisciplinary Smoking Safety Assessment. Smoking is permitted only in the facility's designated outdoor smoking area. Smoking is prohibited inside the facility, resident rooms, entrances, exits, or any other location prohibited by federal, state, or local regulations. All residents who wish to smoke shall complete a Smoking Safety Assessment prior to receiving smoking privileges.Smoking Safety Assessment The interdisciplinary team shall complete a Smoking Safety Assessment that includes, at minimum, an evaluation of the resident's: Cognitive status Ability to safely light and extinguish smoking materials Judgment and decision-making abilities Mobility and ability to safely access the designated smoking area Vision Hand dexterity Oxygen use Medical conditions affecting smoking safety History of unsafe smoking behaviors Compliance with facility smoking rules Following the assessment, residents will be classified as either an Independent Smoker or a Supervised Smoker.Independent Smokers Residents determined by the interdisciplinary team to safely smoke independently may: Retrieve their cigarettes, cigars, vape devices, lighter, matches, or other approved smoking materials from the secured storage area located at the nurses' station. Access their smoking materials at any time during the day. Smoke independently in the designated outdoor smoking area. Return all smoking materials to the nurses' station immediately after each smoking session for secured storage. Smoking materials shall not be kept in resident rooms unless specifically authorized by the interdisciplinary team. Storage of Smoking Materials The facility shall maintain a secured storage area for smoking materials at the nurses' station. Items maintained in secured storage may include: Cigarettes Cigars Vape devices Tobacco products Smoking materials shall be returned to secured storage immediately following each smoking session. Residents shall not possess smoking materials outside of the designated smoking area unless specifically authorized by the interdisciplinary team.Residents shall not possess smoking materials outside of the designated smoking area unless specifically authorized by the interdisciplinary team. Smoking Safety Reassessments Smoking Safety Assessments shall be completed: Upon admission, if the resident wishes to smoke. Prior to granting smoking privileges. Staff Responsibilities Facility staff shall: Maintain secure storage of resident smoking materials. Verify each resident's smoking status before releasing smoking materials. Ensure smoking materials are returned to secured storage after each smoking session. Resident Responsibilities Residents participating in the smoking program are expected to: Follow all facility smoking rules. Return smoking materials immediately after each smoking session.

Based on observations, staff interviews, family interviews, document review and policy review the facility failed to follow and prepare food according to the facility's menu, which was reviewed by the dietitian. The facility reported a census of 22 residents.Findings include:1. The Minimum Date Set (MDS) 3/8/26 documented Resident #3 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. On 6/3/26 at 2:05 PM Resident #3's family member stated she did not believe they were getting delivery trucks for food and the staff had to go grocery shopping. The family member explained the kitchen staff put together whatever meals they can. States there's no actual menu and they have to put food together daily. 2. The MDS dated [DATE] documented Resident #9 had a BIMS score of 15 indicating no cognitive impairment. On 6/4/26 at 10:07 AM Resident #9 stated he heard the food truck would not deliver food because the facility owed them money. Resident #9 explained the last couple of days the kitchen had been throwing things together and were not writing it on the board because they didn't know what they were having until the day of. Observation on 6/1/26 at 11:45 AM of residents eating ham and bean soup, corn bread, corn and jello with fruit for lunch.Observation on 6/2/26 at 11:53 AM revealed residents eating stuffed green peppers, mashed potatoes, mixed vegetables with lima beans and cookies for lunch.On 6/3/26 an observation of residents eating corn dogs, sweet potato puffs, green beans, and blueberry crisp for lunch. On review of the facility provided document titled, Menu dated 6/3/26, listed the weekly meal schedule as follows: Monday-country fried steak, mashed potatoes, cream gravy, honey-buttered carrots, bread/margarine, and a banana berry cup; Tuesday-summer citrus chicken, seasoned orzo, country trio vegetables, and lemon lime cake; Wednesday-[NAME] sandwich, sweet potato puffs, green beans, and blueberry crisp; and Thursday-meatloaf, potato casserole, seasonal vegetable, bread/margarine, and a pudding sundae.On 6/2/26 at 12:45 PM Staff D, [NAME] stated she cooked all the meals the last two days. Staff D expressed they did not have any of the food for any of the meals listed on this week's menu. Staff D explained she went to the freezer, pulled what they had available and made it. Staff D stated they just got a dietician at the beginning of this week on Monday. She explained they did not get their truck last week and had alternate meals that were made from what the facility still had available last week as well. Staff D expressed the meals were not reviewed by a dietitian last week or this week. Staff D further explained the food delivery company provides the menu for four weeks at a time. Staff D stated the residents have asked what was for dinner because they do not always have the evening meal on the board. Staff D stated sometimes there are complaints about not having enough for seconds. Staff D stated it was a surprise they did not get the food supply for last week. On 6/2/26 at 1:44 PM Staff E, Dietary Manager (DM) stated the facility lacked a weekly menu. Staff E expressed she was worried if she had enough food for the residents. She explained the food delivery company suspended service on 4/29/26 due to an unpaid balance. Staff E stated the CEO flew in and bought food from the grocery store one time. Staff E explained she had also bought food with her own money for the residents. Staff E stated the Administrator would go to the grocery store during this time but that she did not buy enough food. Staff E stated that the facility failed to make required prepayments to the food delivery company, resulting in a missed delivery the previous week. Staff E stated after today she did not think there was going to be much unless the food delivery was made this week. Staff E reported the facility lacked a dietitian to review daily menus since April and she prepared meals based on available inventory without planning. Staff E noted that residents frequently inquired about the daily menu because she could not provide information in advance.On 6/2/26 at 2:25 PM the Director of Nursing (DON) stated that the kitchen is expected to follow the weekly menu provided by the food delivery company. She explained that due to outstanding debts incurred by previous owners, the food delivery company requires the facility to prepay for all food orders. To address supply shortages caused by these payment constraints, the DON reported that staff must occasionally purchase groceries from external sources. She noted that while the facility has been prepaying for recent deliveries, they are actively seeking a new food provider.On 6/2/26 at 3:37 PM the Administrator stated the facility currently has a food delivery company they are working with though the facility is required to pay for the delivery before the company will deliver the food. She stated the food delivery company is who she believed generated the menus for the facility. The Administrator stated the dietitian for the facility started Monday 6/1/26. The Administrator confirmed there are times that staff has to go to the grocery store for food items needed that herself and the CEO of the facility has also had to go grocery shopping. The Administrator explained that the reason the food delivery company had not been making deliveries was because of a past due balance. She expressed her concerns with the menus not being followed and her expectations would be for them to follow the menu provided by the food delivery company. The Administrator explained her frustration with the current food delivery company's request of the facility to pay the balance in advance before the delivery would be made. She stated she is currently trying to find another food delivery company to work with. On 6/4/26 at 8:30 AM Staff F, Account Manager for the Food Delivery Service stated that an outstanding balance originated under previous ownership who currently owned the facility. He explained that after legal review, it was determined the facility owed the outstanding balance because they hired the management team but remained the same owners of the facility. Staff F explained this debt accumulated to approximately $14,000, prompting the supplier to cease shipments and threaten the removal of facility equipment, such as dishwashers and coffee machines. Staff F stated that the facility missed three to four deliveries, including the previous week. Currently, the facility has paid the balance in full; however, they are required to prepay for all future food orders.Observation on 6/3/26 revealed food truck delivery had been completed at the facility with food required for the future week.On 6/4/26 at 2:00 PM the Administrator revealed the facility lacked a formal policy for following menus reviewed by a Dietitian.

Based on the record review, resident family interview, staff interview and policy review the facility failed to provide ready access to personal funds managed by the facility. The facility provided a document with 14 of 22 residents with resident trust funds at the facility. The facility reported a census of 22 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment.On 6/3/26 at 10:52 AM Resident #2 stated she could only get money if the Administrator was at the building. 2. The MDS dated [DATE] documented Resident #5 had a BIMS of 15 indicating no cognitive impairment.On 6/4/26 at 9:52 AM Resident #5 stated she did not know how much she had in her account at the facility currently. Resident #5 said she would like to buy things at the facility like pop if she had money. Resident #5 stated she did not know if she had money or who to get the money from. 3. The MDS dated [DATE] documented Resident #6 had a BIMS of 15 indicating no cognitive impairment. On 6/4/26 at 9:38 AM Resident #6 stated he did keep money in the resident trust at the facility. Resident #6 stated the facility goes shopping twice a month and got him whatever he needed. Resident #6 said it did bother him because he did not know how much was in his resident trust because he used the money to buy cigarettes. Resident #6 said he was not sure if he could get money on the weekends or in the evening. 4. The MDS dated [DATE] documented Resident #7 had a BIMS of 5 indicating severe cognitive impairment. On 6/4/26 at 10:41 AM Resident #7's family member explained Resident #7 could only get the money when the Administrator was at the facility. On 6/1/26 at 11:57 AM the Administrator stated she covered the business office manager position at the facility. The Administrator stated she was the staff that took care of resident funds with the help of the Chief Financial Officer (CFO). The Administrator stated she does have residents that want money from the trust. The Administrator stated Resident #8 frequently asked for money from the trust. The Administrator stated they keep petty cash at the facility for the residents in a lock box in the administrators office. The Administrator stated she was the only staff member that had access to the lock box. The Administrator stated there is a cash bag in the nurse medication cart in the narcotics drawer. The Administrator explained she does not know how much money was in there. The Administrator stated the nurses were aware the money was in the narcotics drawer and there was a log. The Administrator stated she was not sure if the nurses were oriented on the money available for the residents. The Administrator stated she would have to talk to the Director of Nursing (DON). The Administrator stated she had not heard any resident voice any concerns about getting money when they wanted it. On 6/1/26 at 12:26 PM Staff H, Licensed Practical Nurse (LPN) stated the residents are supposed to have money in the narcotics drawer. Staff H opened the narcotics drawer in the medication cart. Staff H stated there was no money available in the drawer for the residents. Staff H stated there were 2 residents with wallets in the drawer but the money in one wallet was money but it was that resident's money. An observation on 6/1/26 at 12:30 PM revealed Resident #8's wallet with a social security card and identification card on the inside of the wallet. A second wallet with Resident #7's identification card (ID) on the outside with her social security card on the inside with $18.00.On 6/3/26 at 2:50 PM Staff B, Certified Nurse Assistant (CNA) stated had worked at the facility for about 2 months. Staff B explained she has heard residents request money from the resident trust and be told they could not have it. Staff B said she has heard residents complain about not being able to get money from their funds. On 6/2/26 at 8:44 AM Staff I, Previous Business Office Manager (BOM) stated Resident #6 and Resident #8 requested money from the resident trust frequently. Staff I stated the residents had requested money and they were unable to get it. Staff I stated she was unable to withdraw the money because she balanced the funds. Staff I stated the Administrator also could not withdraw funds. Staff I stated there used to be money on the medication cart for the residents with a previous administration that was stopped. Staff I stated there was an Administrator that brought money in for the medication cart. Staff I stated the money on the medication cart was not put in place before she was terminated. On 6/1/26 at 12:32 PM the Administrator asked if Staff H knew where the money for the residents to use was in the narcotics drawer. The Administrator explained Staff H stated no there was no money in the narcotic drawer for the residents to use only 2 resident wallets. The Administrator asked Staff H if there was any other money in the whole medication cart and she said no. The Administrator stated there are only 2 resident wallets with their ID and Social Security card present. The Administrator acknowledged after looking through the medication cart there was no money available for residents when she was not at the facility. On 6/4/26 at 2:07 PM the Administrator stated she had recognized that funds were not available to the residents 24 hours a day but now there is a cash box in the narcotics drawer in the medication cart. The Administrator acknowledged they had noticed there was a way to improve that process as well. The Administrator said there was an education on the cash box being available for all the nurses. Review of an undated facility provided policy titled, Resident Trust Fund Policy documented withdrawals may be requested by the resident or authorized representative during normal business office hours. After hours withdrawal requests should be done through nursing staff.

Based on the record review, resident family interview, staff interview and policy the facility failed to provide an individual financial record to the resident and/or power of attorney (POA) in the form of quarterly statements and upon request. The facility provided a document with 14 of 22 residents with resident trust funds at the facility. The facility reported a census of 22 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment.On 6/3/26 at 10:52 AM Resident #2 stated the facility had not given her a quarterly statement on her resident trust account to let her know how much money she had in the trust. 2. The MDS dated [DATE] documented Resident #5 had a BIMS of 15 indicating no cognitive impairment.On 6/4/26 at 9:52 AM Resident #5 stated she had not been given a statement reflecting the amount she had in her resident trust account in a while. Resident #5 explained it had been longer than 4 or 5 months since she had received the statement. Resident #5 said she could only remember getting one statement in the last 2 years. Resident #5 said she would like to buy things at the facility like pop if she had money. 3. The MDS dated [DATE] documented Resident #6 had a BIMS of 15 indicating no cognitive impairment. On 6/4/26 at 9:38 AM Resident #6 stated he did keep money in the resident trust at the facility. Resident #6 stated the facility goes shopping twice a month and got him whatever he needed. Resident #6 stated the facility staff told him yesterday how much he had in the resident trust. Resident #6 explained it had been more than 3 months since the facility had delivered a statement with the amount in the resident trust. Resident #6 stated the facility told him they did not know how much he had in his resident trust since the new company took over in March. Resident #6 explained that since the new company took over they had not been able to tell him until yesterday how much he had in his resident trust. Resident #6 said it did bother him because he did not know how much was in his resident trust because he used the money to buy cigarettes. 4. The MDS dated [DATE] documented Resident #7 had a BIMS of 5 indicating severe cognitive impairment. On 6/4/26 at 10:41 AM Resident #7's family member stated Resident #7 did have money in the resident trust for her. Resident #7's family member stated he did not receive a statement with the amount of money in the resident trust.On 6/1/26 at 11:57 AM the Administrator stated she covered the business office manager position at the facility. The Administrator stated she was the staff that took care of resident funds with the help of the Chief Financial Officer (CFO). The Administrator stated the CFO was Staff G, CFO. The Administrator stated a statement was sent quarterly to the residents and the facility used a local bank. The Administrator stated she was not sure if she was in charge of sending out the statement quarterly. The Administrator called Staff G and put her on speaker phone at that time. The Administrator stated she does have residents that want money from the trust. The Administrator stated Resident #8 frequently asked for money from the trust. The Administrator stated they keep petty cash at the facility for the residents in a lock box in the administrators office. The Administrator stated she was the only staff member that had access to the lock box. The Administrator stated there is a cash bag in the nurse medication cart in the narcotics drawer. The Administrator explained she does not know how much money was in there. The Administrator stated the nurses were aware the money was in the narcotics drawer and there was a log. The Administrator stated she was not sure if the nurses were oriented on the money available for the residents. The Administrator stated she would have to talk to the Director of Nursing (DON). The Administrator stated the resident trust is managed in the Electronic Health Records (EHR) system and that was how the statements are generated. The Administrator stated if Staff G had a new process then she needed to tell her about the process. The Administrator stated she was not familiar with the previous process for resident trust statements either. The Administrator stated that residents had asked for money and how much was in their account. The Administrator stated she told the residents she did not know it was all in the EHR system until this weekend. The Administrator stated she was trying to figure out how to know how much money the residents had and one of the residents was worried about being over resources. The Administrator explained that the resident asked if the facility had been deducting money from the trust and he was comfortable with that. The Administrator stated that resident was Resident #6. The Administrator stated she had not heard any resident voice any concerns about getting money when they wanted it. On 6/1/26 at 12:00 PM Staff G stated she did get everything up to date in the system since she came on in April for the resident trust. Staff G stated there was an external billing company and the Business Office Manager (BOM) was let go prior to her coming on. Staff G stated the residents should be getting quarterly statements that were facility generated. Staff G stated she truly did not know what the previous system was in place. Staff G stated the previous BOM was let go in the middle of March around the 15th. Staff G stated statements were generated March 31st and since she was not at the facility then she did not know how they were distributed. Staff G stated it would be a new process for this quarter for statement delivery and would be given out by whoever the Administrator decided at the facility. Staff G stated she was not familiar with the previous process for resident trust statements either. On 6/4/26 at 2:07 PM the Administrator stated she could not determine that the resident received the trust statement on March 31st of this year for the residents that had a trust with the facility. The Administrator stated she ensured the residents understood what having a trust with the facility meant yesterday. The Administrator stated she expected the statements were handed out quarterly and could not have occurred last time it should have. Review of an undated facility provided policy titled, Resident Trust Fund Policy documented residents or authorized representatives may request an accounting of trust fund activity at any time during normal business hours. The facility shall provide a written statement of resident trust fund activity at least quarterly.

Based on observations, staff interviews, resident interviews, resident family interviews, Electronic Record review (EHR), and policy review the facility failed to provide a clean and homelike environment when the floors in all areas of the buildings that had carpets had large stains. The facility also had an area of the wall in a resident's room that had black furry areas and flaking debris near a pipe with areas of the wall missing. The facility reported a census of 22 residents. Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #9 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 6/4/26 at 10:07 AM Resident #9 stated the hallways have large stains. Resident #9 stated he frequently had his family over and would like the facility to look better. Resident #9 explained his brother came to the facility frequently and would like the building to be in better care. Resident #9 stated the doorway strip between his room and the hallway was coming up off the floor. Resident #9 explained the strip prevented the hoyer from being able to be pushed into his room so they tore the strip up. Resident #9 stated when the strip was coming up it was not difficult for him to get in was just a giant bump to get into his room and an eye sore.Observation on 6/3/26 at 11:55 AM in room [ROOM NUMBER] revealed a large area in the closet with dry, cracked and flaking debris. This area was also missing a large area of the wall with depth and texture of gray material missing from the inside of the wall. The same closet in room [ROOM NUMBER] had a soft ball size area of black fuzzy discoloration with a slightly larger area of spotted raised black fussy discoloration in an area to the left inside the same closet. This closet also had both closet doors propped on top of each other lying on the side of the doors stacked.Observations on 6/3/26 from 12:00 PM through 12:10 PM revealed several large stains on all hallways, in front of the nurses station and on all carpets at the facility. Several stains and discoloration on the carpet larger than 2 or 3 feet. Observations also revealed several doorway termination plates missing between the hallway carpet and resident's room flooring.On 6/2/26 at 8:44 AM Staff I, Previous Business Office Manager (BOM) stated there were missing areas of the wall in room [ROOM NUMBER] and the mold was growing in the closet. On 6/3/26 at 2:50 PM Staff B, Certified Nursing Assistant (CNA) stated had worked at the facility for about 2 months. Staff B stated family and residents complain all the time about the stains on the carpets at the facility. On 6/3/26 at 3:19 PM Staff J, Maintenance Director stated has worked at the facility for 3 weeks. Staff J stated there was a plan to pull all the carpet in the facility. Staff J stated the facility had not obtained prices yet. Staff J stated had not seen any black fuzzy areas or water damage in any resident rooms at the facility. Staff J acknowledged there were several resident doorways missing the termination plate because of wheelchairs pulling them up. Staff J explained he still needed to get the order together but repairs required time and money. Staff J explained the areas in the closet in room [ROOM NUMBER] were a concern to him because that was mildew. Staff J stated in room [ROOM NUMBER] the doors laying down and not being hung was completely unacceptable. Staff J explained he had just seen all of that today and the closet doors would be hung back up by tomorrow. Staff J stated the area on the wall in the closet in room [ROOM NUMBER] needed to be repaired but he needed to repair the shower next door to the room first. Staff J explained that the damage to the wall in the closet was from the shower leaking next door. Staff J stated the black fuzzy areas on the wall were mildew not mold. On 6/4/26 at 12:45 PM Staff A, Registered Nurse stated she had noticed the carpets at the facility. Staff A explained there were several stains on the carpets.On 6/3/26 at 3:39 PM the Administrator stated the company just hired a director of business development last week and had talked to the CEO about it. The Administrator stated staff had brought the issue with the wall and closet in 302 to her attention. The Administrator stated she had asked housekeeping to fix the issue. The Administrator stated the closet doors laying on the ground in front of the closet was unacceptable and embarrassing. The director of business development had discussed carpet repairs but had not developed a plan to repair.On 6/4/26 at 2:00 PM the Administrator stated she did not have a policy for a clean, comfortable and homelike environment or maintenance of the facility.

Based on observations, staff interviews, family interviews and Electronic Health Record review (EHR) the facility failed to ensure the safekeeping and confidentiality of sensitive resident records including the resident's Social Security card and Driver's License identification card for 2 of 2 residents (Resident #7 and #8). The facility reported a census of 22 residents. Findings include:1.The Minimum Data Set (MDS) dated [DATE] documented Resident #7 had a Brief Interview for Mental Status (BIMS) of 5 that indicated severe cognitive impairment.On 6/4/26 at 10:41 AM Resident #7's family stated he felt Resident #7's wallet should be locked up. Stated he does not know where the social security card or her ID is but would want that in a safe area so it did not come up missing. 2. The MDS dated [DATE] documented Resident #8 had a BIMs score of 15 that indicated no cognitive impairment.Observation on 6/1/26 at 12:26 PM revealed Staff H, Licensed Practical Nurse (LPN) opened the narcotic medication drawer on medication cart revealing Resident #7 and Resident #8's wallet with social security cards, insurance cards and drivers license identification cards present in each wallet. Observation on 6/1/26 at 12:32 PM of the Administrator revealed her removing the 2 wallets from the narcotic box on the medication cart and taking the wallets to her office. On 6/1/26 at 12:32 PM the Administrator stated none of the residents social security cards should be kept in the narcotic drawer on the medication cart.On 6/4/26 at 2:07 PM the Administrator revealed she did not think the wallet with Resident #7's and Resident #8's information was appropriately placed when in the narcotics medication drawer. The Administrator stated she notified Resident #7 and Resident #8 that their wallets were in the safe in her office. The Administrator explained the information was being protected as much as the narcotics were. The Administrator said she could not think of a reason the nurse would need access to the social security cards information. On 6/4/26 at 2:00 PM the Administrator revealed the facility lacked a formal policy on protection and safekeeping of confidential and sensitive resident records.

Based on Electronic Health Record (EHR) review, observations, staff interviews, and policy review the facility failed to provide appropriate incontinence care when a resident was not taken to the toilet every 2 hours to prevent stool incontinence to 1 of 3 residents reviewed (Resident #3). The facility reported a census of 22 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. The MDS documented Resident #3 was dependent (staff completed all of the effort or assistance of 2 or more is required) for toilet hygiene. The MDS further documented Resident #3 was always incontinent of bowel.Review of Resident #3's EHR titled Care plan documented an intervention initiated on 10/10/19 that Resident #3 was to be toileted every 2 hours to prevent stool incontinence. Observation on 6/3/26 at 9:59 AM of Resident #3's toilet routine revealed Staff A, Registered Nurse (RN), Staff C, Certified Nurse Assistant (CNA) and Staff B, CNA brought Resident #3 to her bedroom, transferred Resident #3 to bed, removed Resident #3's brief, completed personal cares, applied a new brief, covered Resident #3 up with a sheet and covered Resident #3 up with a blanket. Staff did not offer to take Resident #3 to the toilet.On 6/3/26 at 10:05 AM Staff B stated she had help with Resident #3 getting up that morning. Staff B stated Resident #3 was at the dining room table at 7:30 AM to eat breakfast that morning. Observation on 6/3/26 at 1:29 PM of Resident #3's toilet routine revealed Staff A, Registered Nurse (RN), Staff C, Certified Nurse Assistant (CNA) and Staff B, CNA brought Resident #3 to her bedroom, transferred Resident #3 to bed, removed Resident #3's brief, completed personal cares, applied a new brief, covered Resident #3 up with a sheet and covered Resident #3 up with a blanket. Staff did not offer to take Resident #3 to the toilet.On 6/3/26 at 2:05 PM Resident #3's family member stated will leave her sitting there until lunch, they are not repositioning her every couple hours. Resident #3's family member said staff were not checking Resident #3 to see if she was incontinent. Resident #3's family member explained she expected the staff to perform 2 hours check and change and/or toilet Resident #3 every 2 hours. Resident #3's family members stated she had expressed these concerns to multiple Director of Nursing (DON)'s and requested this be performed. On 6/3/26 at 2:50 PM Staff B explained she knew how to toilet and transfer the residents because it is in their care plan and if there was a change would lean on the co-worker for any changes. Staff B stated Resident #3 has a toilet but it was a shared bathroom. Staff B explained she was told Resident #3 was incontinent. Staff B stated she has not ever toileted Resident #3 on the toilet. Staff B said she had never seen anybody toilet Resident #3 on the toilet. On 6/4/26 at 12:45 PM Staff A, Registered Nurse (RN) stated the residents should be toileted after meals. Staff A explained that residents who can not take themselves to the bathroom should be checked, provided care or taken to the toilet every 2 hours because that was the expectation. On 6/4/26 at 11:58 AM the Director of Nursing (DON) stated Resident #3's care plan indicated she should be offered the toilet or the bed pan every 2 hours because she will be incontinent and that would lead to skin breakdown. The DON stated she expected Resident #3 would have been toileted every 2 hours not any longer. Review of an undated policy provided by the facility titled, Helping a Resident with Toileting Needs documented it was the practice of the facility to assist residents with toileting needs in order to maintain the resident's dignity as well as proper hygiene.

Based on clinical record review, facility investigative file review, employee file review, staff interview and facility policy review the facility failed to provide proper assessments and interventions after 2 of 3 residents (Resident #1 and #4) had a change in condition. Resident #1 experienced a change in condition on May 18, 2025 during the day and on the evening shifts. The nurse that worked failed to assess the resident after staff reported concerns to him. The resident developed a fever at approximately 7:00 PM and staff applied a cold rag to his head. A PRN medication was not given to assist with lowering his fever nor was the physician notified until the resident's vital signs significantly changed at approximately 3:00 AM and was sent to the hospital. The resident was admitted to the hospital and expired 5 hours later. Resident #4 had an unwitnessed fall and complained of left hip pain. Staff failed to call the provider to obtain a PRN order for pain or an order to be evaluated. The resident was sent to the hospital 12 hours later and found to have a left hip fracture. The facility reported a census for 24 residents. Findings include: 1. According to the annual Minimum Data Set (MDS) assessment tool with a reference date of 3/7/2025 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented he was frequently incontinent of urine and bowel. The MDS indicated he required partial/moderate assistance with toileting hygiene and transfers. The following diagnoses were listed for Resident #1: Parkinson's Disease, coronary artery disease and diabetes mellitus. The Care Plan focus area with an initiation date of 2/4/2025 documented Resident #1 had Activities of Daily Living (ADLs) preference deficit related to activity intolerance. The Care Plan indicated Resident #1 required the assistance of one staff to move between surfaces for every transfer. Review of Resident #1's meal intake revealed the following: a) On 5/16/2025 he ate 76-100% of his breakfast and lunch and 26-50% of his dinner. b) On 5/17/2025 he ate 76-100% of his breakfast and lunch and 51-75% of his dinner. c) On 5/18/2025 he ate 76-100% of his breakfast and lunch and refused his dinner. Review of Resident #1's bowel movement record revealed the following: a) On 5/16/2025 he had no bowel movement documented at 12:41 AM and 10:20 AM, was continent of a small formed bowel movement at 8:57 PM. b) On 5/17/2025 he had no bowel movement documented at 1:39 AM, 12:40 PM, and 11:28 PM and was incontinent at 9:59 PM (no other information documented about the bowel movement was noted). c) On 5/18/2025 he had no bowel movement documented at 1:09 PM and was incontinent of a large soft bowel movement at 9:59 PM. d) On 5/19/2025 at 1:11 AM he was incontinent of a large soft bowel movement. Record review revealed Staff D Licensed Practical Nurse (LPN) documented the following Progress Notes: a) On 5/19/2025 at 3:08 AM change in condition: abnormal vital signs, fever, nausea/vomiting, shortness of breath. Resident #1's vital signs were: at 3:09 AM his blood pressure was 116/56 and his pulse was 124, at 3:11 AM his fever was 101.1 and his oxygen saturation was 75% oxygen via nasal cannula was applied. b) On 5/19/2025 at 4:13 AM Resident #1 had audible rhonchi throughout lung fields. Noted emesis to resident's left side of bed, oxygen saturation was 75% on room air, initiated oxygen supplement via nasal cannula a 4 liters (L). Resident was lethargic, skin clammy, unable to verbalize needs. Resident's wife was notified of his status, called the on-call physician and given orders to transport to the emergency room (ER). The Progress Notes for Resident #1 lacked any documentation on 5/18/25. Record review revealed Staff D documented the following change in condition evaluation on 5/19/2025 at 3:08 AM: a) The change in condition, symptoms or signs I am calling about are: abnormal vitals, fever, nausea/vomiting, shortness of breath, that started on the morning of 5/19/2025. b) Vital signs documented as: on 5/19/2025 at 3:09 AM blood pressure was 116/56 with a pulse of 124 and apical heart rate of 121. On 5/19/2025 at 3:11 AM respiratory rate of 28, a temperature of 101.1 and oxygen saturation of 75%, applied supplemental oxygen via nasal cannula c) Additional information as required: signs of aspiration d) Altered mental status with a sudden change in level of consciousness or responsiveness, swallowing difficulties, associated with new onset or progressive aspiration, audible rhonchi noted, resident having difficulty coughing. e) Respiratory assessment was relevant to the change in condition being reported due to the resident experiencing shortness of breath, with an abrupt onset of shortness of breath, fever. f) A cardiovascular assessment was relevant to the change in condition being reported due to the resident experiencing a resting pulse greater than 100 or less than 50. g) An abdominal assessment was relevant to the change in condition being reported due to the resident experiencing nausea and/or vomiting associated with intermittent recurrent nausea and vomiting. h) Things that make the condition or symptom worse are oxygen saturations not improving. i) Other relevant information: visible emesis noted near resident on bedsheet. j) Summarize your observations, evaluation and recommendations: resident likely aspirated. k) Primary care physician was notified on 5/19/2025 at 3:20 AM with recommendations to send to the ER. l) Resident #1's representative (wife) was notified on 5/19/2025 at 3:24 AM. The family provided Resident #1 death certificate that documented a date/time of death of 5/19/2025 at 8:03 PM with an immediate cause of death listed as sepsis due to or as a consequence of aspiration pneumonia. Review of Resident #1 May 2025 Medication Administration Record (MAR) revealed the following as needed (PRN) orders): a) acetaminophen oral tablet 325 milligrams (mg), give 2 tablets by mouth every 4 hours PRN for pain/fever, with a start date of 4/26/2025. The order was not signed out as being given in the month of May, b) milk of magnesia give 30 milliliters (mL) every 24 hours, PRN for constipation with a start dated of 5/1/2025 and end date of 5/22/2025. The order was not signed out as being given while it was an active order, c) gentle laxative rectal suppository 10 mg, insert 1 suppository rectally every 24 hours PRN for constipation with a start date of 5/1/2025. The order was not signed out as being given in the month of May. On 6/12/2025 at 12:29 PM Staff H Certified Nursing Assistant (CNA) stated she took care of Resident #1 on May 17th and 18th during her 6:00 AM-2:00 PM shift. He was fine on Saturday, a normal day for him. The 18th she came in to work and he would always have a bowel movement in the morning and after lunch or right before they laid him down for the day. During her shift on the 18th he did not have a bowel movement during her shift that day. It was not normal for him to not have a bowel movement. Staff H stated Resident #1 did not vomit during her shift but he looked like he wanted to. When asked about any confusion, she stated Resident #1 stated he seemed like he forgot to eat. He would take a spoon of food and put it by his eye or ears, which was not like him. His appetite was not great that day; he did not snack like usually would. She offered him a jell-o cup but he did not eat it at all. Resident #1 was really not himself. As CNA's we look out for our residents, we notice the changes. She was catching the changes but the nurse was not paying attention to her as the resident's caregiver and that was frustrating. She told Staff I Registered Nurse (RN) that he needed to go check on him because he was not right and his color was off. Staff H stated Staff I would not go in the resident's room after he said he would. She would find him outside or doing other things instead. She would confront Staff I about going in to check on Resident #1 and he would tell her yea I will be there in a minute. Staff H added this irritated her. When the 2:00 PM-10:00 PM CNA's came on for this shift, she told them to have the night nurse check in on the resident. She was not sure what was going on, but something was going on with him. When asked which staff member she told this to, she stated Staff F CNA. On 6/12/2025 at 2:07 PM Staff A CNA stated she took care of Resident #1 on May 17th and 18th during her 6:00 AM-2:00 PM shift. Resident #1 seemed fine on Saturday, nothing out of the ordinary. Staff A stated on Sunday after she laid him in bed after lunch, he sounded wheezy. She told the nurse about this and was told to keep an eye on it. The resident did not mention anything about not feeling well. She could not remember which nurse she told about the resident being wheezy. On 6/12/2025 at 2:19 PM Staff F CNA stated he worked 2:00 PM-10:00 PM on the weekend of May 17th and 18th. He took care of Resident #1 on Sunday (May 18th) and when he went to check on him later in the evening, he immediately noticed a foul smell. When he checked the resident, he had soiled himself. Resident #1 had a large bowel movement. When asked to describe the smell he stated it smelled like a rotten brush pile (rotten grass smell), it was somewhere in between soft and pudding consistency. It was a deep dark brown color, it had a green mucous cover. He told Staff D and assumed he went in to look at the resident. When asked if the resident ran a fever over the weekend, he stated he remembered feeling the resident's forehead and it was really hot. Staff F could not recall which day it was. He did remember telling Staff D, in which he went in and confirmed he had a fever. Staff F stated the resident did not eat dinner on Sunday. On 6/12/2025 at 3:12 PM Staff I stated he worked with Resident #1 on May 16th, 17th and 18th during his 6:00 PM-6:00 AM shift. He added that was a bad weekend, different residents had a lot of behaviors. Staff told him Resident #1 was in bed all day, early Saturday morning he got him up with a snack and on Sunday he aspirated. When asked how he knew that he stated when he went to assess him he noted rhonchi lung sounds. When he looked in his mouth he did not see anything; no emesis, loose food. He did note a little bit of emesis on his bed. Staff I denied that Resident #1 had a foul smelling bowel movement that weekend. When asked if Resident #1 had a fever, Staff I stated he thought at one point he did. He then stated when he assessed the resident he was having some difficulty breathing while he had abnormal lung sounds and did have a fever. He denied hearing Resident #1 cough or any cognitive changes during the weekend. He noted Resident #1's oxygen saturations to be low so he applied supplemental oxygen, increased respirations and blood pressure. Staff I denied being informed of the resident complaining of being cold and tired. He stated there was nothing reported to him during the nurse to nurse report at shift change. He denied family reporting concerns about Resident #1 being lethargic or not himself. On 6/13/2025 at 9:10 AM Staff I stated he worked with Resident #1 on May 17th and 18th during his 6:00 AM-6:00 PM shift. Staff I stated when he was leaving the facility on the 18th, Resident #1 was fine. He caught him in the hall from the dining room after dinner. Staff I denied staff reporting concerns to him about Resident #1 over the weekend. When he was informed of the concerns Staff H had about Resident #1, he denied being notified by Staff H. Staff I stated he assisted the resident to the bathroom on Saturday and he was weak while standing. Staff I stated he was a little confused with taking his pills on the 17th and 18th, he needed more assistance in taking them. When asked if there was anything out of the ordinary for Resident #1 he stated there was nothing out of the norm for him. He did appear more tired on the 18th but he was up that day. At 9:44 AM Staff I stated he gave Resident #1 his PRN milk of magnesia later in the shift but could not remember which date it was and whether or not he charted it. He also stated he was unsure if the medication was effective or not because it was later in the day; the 17th or 18th, he could not recall. On 6/13/2025 at 12:50 PM the Director of Nursing (DON) stated she had no reports about his health prior to him going to the hospital. When she came in to the facility on the 16th she saw him and he had the biggest smile on his face. She told him he looked nice and he smiled so big. She indicated he had reoccurring urinary tract infections (UTI) but knew of no other major health issues since she started in March. He had recently had a UTI and finished his antibiotic on the 9th. He was in the process of seeing infectious disease for his UTI's. She indicated the only thing staff should have done that weekend, was to contact her when they sent Resident #1 out to the hospital. During a follow up interview on 6/18/2025 at 1:00 PM, the DON was informed of the information obtained from staff interviews from the weekend of May 16th, 17th and 18th. She indicated she did not know a lot of that information. When asked what should have been done, she stated staff should have reached out to her to get more direction on what to do but at the same time they should have used their nursing knowledge. If he had a fever at 7:00 PM the nurse should have reached out to his provider, give Tylenol, and not waited. When asked what the CNA's should do if they feel like the nurses are not responding to their requests, she stated they can also call her if the charge nurse is not being helpful. On 6/17/2025 at 12:39 PM Staff J CNA stated she took care of Resident #1 during her 2:00 PM-10:00 PM shift on May 17th and 18th. She was working with Staff F, he was new to the facility. As she was changing the resident something was wrong with him but when she asked if he was ok, he said yes but something was off. She told Staff D that something was off. He told Staff J Resident #1 had a fever of 101. When asked what day this was she stated Sunday the 18th about 7:00 PM. Staff J told her he placed a cold rag on his head. Staff J was unsure if he gave the resident a PRN to help with his fever or did any other interventions. When she looked back in on Resident #1 he did have a rag on his forehead. When asked if the resident had a bowel movement that day, she stated yes and Staff F had assisted the resident with getting cleaned up. She noted the bowel movement to be large, green and mushy. She added this was a lot for him and that kind of bothered her. He did not get out of bed for them that weekend, but he did report being cold at one point so she got him a blanket. He already had three blankets so she thought that was odd. He also seemed more tired on Sunday, refused his dinners that weekend and stayed in bed all weekend on their evening shift which was not normal for him. The resident's wife did visit on the 16th during her shift. When Staff J went in to the resident's room to speak with him and he woke up. The wife stated that was the first time he had woken up since she had been there to visit him that day. When asked if he had vomited during her shift, she stated she heard he had. She noticed some green stuff around his mouth but thought he had ate something because he liked to snack throughout the day, so she cleaned his mouth up. No concerns about Resident #1 were reported during shift report with the day shift staff. She felt Staff D could have done more than just put a cold rag on the resident's head when he noted he had a fever. On 6/17/2025 at 12:55 PM Staff B CNA stated she only worked with Resident #1 on the 10:00 PM-6:00 AM shift before he went out. When she got report from the prior shift they reported to her he was not doing very well and she could tell. He had some chest congestion and it was a little worse than normal. Later in the shift Staff D took the crash cart to Resident #1's room and put supplemental oxygen on him and later sent him to the hospital. When asked how long between the oxygen being applied and the resident being sent to the hospital, she stated it was about an hour or so. When asked if Resident #1 had a fever during her shift, she stated she believed so because she remembered seeing a rag on his forehead. When asked if the resident had a bowel movement during her shift she stated she remembered someone had a bowel movement that was a weird color but not sure if it was Resident #1 or not. He was breathing heavily which was not normal for him. She told Staff D about her findings and questioned if the resident was transitioning even though he was not on hospice. She could not recall if Staff D said anything when she informed him of her concerns. 2. According to the quarterly MDS assessment tool with a reference date of 4/16/2025, Resident #4 had a Brief Interview of Mental Status BIMS score of 6. A BIMS score of 6 suggested mild cognitive impairment. The MDS documented she was independent with mobility but required supervision or touching assistance to walk 10 feet, 50 feet with two turns, and 150 feet. Resident #4 was always continent of urine and frequently incontinent of bowel. The following diagnoses were listed for Resident #4: dementia, anxiety, depression, bipolar, post-traumatic stress disorder (PTSD), atrial fibrillation, irritability and anger, and cognitive communication deficit. The Care Plan focus area with an initiation date of 1/8/2025 documented Resident #4 was low risk for falls related to confusion. Staff were encouraged to anticipate and meet the resident's needs, ensure she is wearing the appropriate foot wear and her call light is within reach, encourage her to use it for assistance as needed. She needs prompt response to all requests for assistance. Record review revealed the following Progress Note: a) On 5/18/2025 at 9:21 PM nursing staff alerted the nurse to resident's room where Resident #4 was observed to be lying on the floor with two pairs of pants around her ankles. Her head was pointed to the head of the bed and her feet were pointed toward the exit door in her room. The resident stated she was trying to roll over and get a drink of water and fell out of bed. Note was documented by Staff D. b) On 5/19/2025 at 8:41 AM staff went in to resident's room approximately 30 minutes ago to assist resident with cares. Resident #4 was screaming out in pain with the slightest touch or when staff slide resident in her bed. She was holding her left hip but extending and bending her leg to ease the pain. Resident #4's medical provider was called in regards to her pain. Note was documented by Staff H LPN. c) On 5/19/2025 at 9:53 AM the ambulance arrived to the facility after this nurse called for orders to have resident sent to the hospital for evaluation and treatment. Resident alert and talking with ambulance staff with nonsensical talk about moving her sister this weekend. Resident pleasantly confused and yells out in pain during transfer from bed to gurney. No bruising noted to left hip or leg, no other skin concerns noted at this time. d) On 5/19/2025 at 12:00 PM received a telephone call from the hospital. Resident has a left femur sub capital fracture with mild angulation. Record review revealed the follow facsimile (fax): a) was sent to Resident #4's medical provider dated 5/18/2025 labeled as a routine fax. Staff D documented on the fax: resident observed on the floor in her room. Resident stated I rolled off the bed. She complained of mild discomfort to her left hip. No bruising or obvious injuries noted, she is able to flex left leg and bear weight. Will continue to monitor. The fax had a printed date of 5/18/2025 at 9:45 PM. The medical provider returned the fax on 5/20/2025 at 4:55 PM with no new orders, b) was sent to Resident #4's medical provider dated 5/19/2025. Staff M documented on the fax: ok to send to the ER for evaluation and treatment due to previous fall and uncontrolled pain to left hip/leg. The medical provider returned the fax on 5/20/2025 at 4:55 PM with ok for above. Review of Resident #4's MAR revealed it did not contain a PRN medication for pain until after she returned from the hospital on 5/23/2025. The facility provided the following staff statements: a) Staff F Certified Nursing Assistant (CNA) wrote: on the night of 5/18/2025 I was walking down hall one and as I passed Resident #4's room (around 9:00 PM-9:15 PM) I heard a crash. When I opened the door, I found Resident #4 on the floor. Upon seeing her on the floor, I leaned out the door to call for Staff D Licensed Practical Nurse (LPN), and he activated the call light. Staff D came in about 2 minutes later. We then noticed she had on two pairs of pants. Then Staff D started asking the resident if she can straighten her leg out and she said no, from my hip to my knee hurts really bad. We got her vital signs, Staff D told me to grab her under the arm and assisted the resident back to her bed. After Resident #4 was in bed, I told Staff D that when I found her in her room, the back of her head was across the supporter bar of her overbed table. I mentioned there was a bruise forming on the outside of her left thigh. Again, Staff D asked her to straighten her leg and Resident #4 said she would be fine and just wanted to go back to sleep. We put her quilt on over her, told her to use her call light, and left her to sleep. b) An email statement was provided to the facility by Staff D. The following statement was made: while on my shift on 5/18/2025 at approximately 8:50 PM, I was documenting when I heard the male CNA scream my name from hall 1. As I made my way down there, another resident passed by and said there was a resident on the floor. I observed the resident sitting on the floor next to her bed. I went to grab the equipment needed to take vitals. I was asking her questions regarding her pain and if she could move her leg. As she sat on her bed, after being transferred from the floor, I again asked her to see if she could flex her leg, which she could. Review of Staff D's employee file revealed a document dated 5/22/25 and titled: Notice of Employment Termination. The document indicated the termination of his employment, this decision follows internal review and documentation of multiple serious concerns related to your performance and conduct, including: -improper handling of a resident fall, including transferring a resident in a manner inconsistent with facility protocols, -failure to arrange timely medical evaluation and failure to notify the DON and Administrator. On 6/12/2025 at 2:19 PM Staff F stated one night he found Resident #4 on the floor in her room around 9:00 PM-9:45 PM as he walked down her hall, he heard a crash come from her room. When he opened the door, he saw Resident #4 on the floor, her neck rested on the foot base of her over bed table and her feet were towards the door. She had two pairs of pants on that were down around her ankles and a t-shirt on. When he asked her, what happened she stated she was reaching for her water and fell. Staff F yelled for Staff D, he walked in 2-3 minutes later. Resident #4 would scream in pain when she would move that leg. Staff D told him to grab under her arm and they both lifted her back to bed. During a follow up interview on 6/18/2025 at 11:43 AM Staff F stated D was trying to get Resident #4 to put her leg down because it was in a position as if she was sitting in a chair, but she was sitting on the floor. When he asked her to lay it down, she kept saying I can't I can't, it hurts. Staff D told Resident #4 if you are not able to put your leg down, you will have to go to the hospital. Staff D added if you go to the hospital you probably will not come back. Staff F stated it was obvious something was wrong with Resident #1 because when they transferred her from the floor to the bed she winced and yelled out in pain. He later learned they should have used a mechanical lift to assist Resident #1 from the floor to her bed. They should not have lifted her off the floor by putting their arms under Resident #1's arms and lifted her back to bed. Staff F stated he noticed what looked like a blood blister starting to form on the left, it was in the shape of a L. It looked like her blood vessels had broken and blood was pooling. When asked where this was located he stated her upper leg where her leg meets her hip, on the outer part of her leg. He reported this to Staff D but he blew it off. On 6/18/2025 at 1:00 PM the DON was asked to elaborate on the following statement found on Staff D's termination paperwork: 1. Improper handling of resident fall, including transferring a resident in manner that is inconsistent with facility protocols. She stated if a resident falls staff are to transfer them with a Hoyer (full body lift) and he did not do that. Him and Staff F lifted her up and put her on the bed. 2. Failure to arrange timely medical evaluation and failure to notify the DON and Admin. She stated Resident #4 was complaining about pain, did not provide any pain interventions and ended up having a broken hip. The DON was informed of Resident #4 not having a PRN at time, she stated he should have called to get an order. An interview with Staff D was not able to be conducted, he was deceased at the time of the survey. The facility provided a document titled Significant Condition Change and Notification with approved date of 12/2024. The purpose of the document is to ensure that the resident's family and/or representative and medical provider are notified of changes such as: -an accident or incident with or without injury that has the potential for needed medical intervention, -a significant change in the resident's physical, mental or psychosocial status such as: a) sudden onset of shortness of breath b) onset of a temperature of 101 degrees higher with or with symptoms c) significant chant in/or unstable vital signs d) emesis/diarrhea e) mobility changes f) change in level of consciousness such as lethargy, sudden lack of responsiveness When any of the above situations exits, the licensed nurse will contact the resident's representative and their medical practitioners. Prior to calling the medical practitioner the nurse will complete the SBAR (subject, background, assessment, recommendation) assessment. Calls will be made to the resident's representative until they are reached. The medical provider will be contacted immediately for any emergencies regardless of the time of day. If the medical provider cannot immediately be reached in any emergency, the medical director will be called. If that medical provider is cannot be reached, the DON of the charge nurse can make arrangements for transportation to the emergency department. All significant changes will be recorded in the resident record. Charting will include an assessment of the resident's current status as it related to the change in condition.

Based on clinical record review, facility record review, staff and resident interviews, and facility policy reviews the facility failed to ensure 1 of 3 residents (Resident #1) was free from abuse and psychological harm. Resident #1 reported to staff that Staff A CNA had provided peri-cares in a rough manner, had called her names and used curse words in front of her. The facility suspended Staff A while they completed their investigation and allowed her to come back to work as long as she did not provide cares to Resident #1. Staff reported when Staff A would come to work, Resident #1's demeanor would change: she would become guarded, shaky, stay by other staff member's side, tear up, was fearful for her safety. Resident #1 reported it made her mad because this is her home and she should not feel this way about a staff member in her home. The facility reported a census of 26 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/30/24 at 5:00 PM. The IJ began on 7/23/24, the day Resident #1 reported her concerns. The facility removed the Immediate Jeopardy on 7/31/24 through the following actions: -Staff A, the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were suspended on 7/30/24. -On 7/30/24 the facility began additional re-education for all employees relating to abuse, neglect, and exploitation. All employees currently working will be educated immediately. All other employees will be educated prior to their next scheduled shift. -When new team members begin employment, they will receive Dependent Adult Abuse Prevention and Reporting training as part of their initial onboarding. All other employees will receive Dependent Adult Abuse Prevention training annually, and with any allegation or investigation regarding abuse. -The facility has interviewed all alert residents related to abuse. -The Administrator will interview five random residents about abuse weekly for the next 12 weeks. -The Administrator will interview five random staff members per week for 12 weeks to verify knowledge related to abuse and reporting policies. -The resident impacted had a head to toe assessment completed, no evidence of any injuries noted. -The facility initiated head to toe skin assessments for all residents. Skin assessments will be completed by the end of the day on 8/2/24. -The resident impacted by the event had a post trauma assessment initiated on 7/31/24. -The resident will be on every shift charting for 72 hours. This documentation will be reviewed by the Administrator during morning clinical review, the day following. The scope lowered from J to G at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: According to the Admission Minimum Data Set (MDS) assessment tool with a reference date of 6/24/24, documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairments. Resident #1 had an admitted [DATE]. The MDS documented she did not display any physical, verbal, or other behavioral symptoms during the review period. The MDS documented she was frequently incontinent of urine and was always incontinent of bowel. The MDS listed the following diagnoses for Resident #1: acute cystitis with hematuria, anemia, neurogenic bladder, multidrug resistant organism, septicemia, urinary tract infection (UTI), cerebral palsy, anxiety, depression, psychotic disorder (other than schizophrenia), post-traumatic stress disorder (PTSD), borderline personality disorder, and mild intellectual disabilities. The Care Plan focus area with an initiation date of 6/19/24 documented Resident #1 had activities of daily living (ADL) performance deficit related to cerebral palsy and musculoskeletal impairment. The Care Plan focus area with an initiation date of 6/24/24 documented she has the potential to have manipulative behaviors at times. Staff are encouraged to explain all procedures to Resident #1 before starting and allow the resident to adjust to changes. Review of the facility's grievances revealed the following grievance was filed on Resident #1's behalf: a) Resident stated when staff entered room, she got upset stated I've been waiting for two hours to go to bed. Resident #1 stated Staff A said we have 20 something residents, please be considerate. Resident stated she continued to be agitated then stated Staff A said I'm not doing this, then walked out. The form was signed and dated by the SSD on 7/23/24. The following progress note was documented on 7/24/24 at 5:37 PM by Staff C Licensed Practical Nurse (LPN): this nurse spoke with resident and spent much of the afternoon discussing her feelings about an incident that occurred last night. Resident #1 was visibly upset and had asked this nurse to go with her to talk to the Administrator. Staff C and Administrator told resident that she was heard and that the matter will be looked into. Resident #1 told this nurse that she felt safe at this time and that she did not want a certain person to take care of her. Staff C reassured resident that other staff could meet her needs and she would not have to have cares provided by the person who made her feel uncomfortable. She was informed a bit later by Staff C that there is an investigation and it has been turned in. Resident #1 thanked this nurse for giving her support and reassured that she could come to Staff C at any time and she could tell her anything that was bothering her. They all want her to feel safe. Review of Resident #1's clinical record revealed the following Encounter Psych Progress Note, with a visit date of 7/25/24. Current Symptoms/History of Present Illness: The resident is seen today as a follow-up medication assessment. The resident reports that she is doing well. She has been a bit down due to a situation that happened with staff. She tells the provider she wishes she was in her own apartment. She stated there have been situations around her care which turned into an investigation. She is flat and guarded. She was hesitant to talk but later opened up. She reported doing well beside that. Mental Status Exam: the resident's speech was normal, sharing conversation with normal laryngeal efforts. Appropriate mood and affect were seen on exam. Thought processes were logical, relevant, and thoughts were completed normally. Thought content was normal with no psychotic or suicidal thoughts. The resident's judgement was realistic with normal insight into present condition. Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Language skills included the ability to correctly name objects. Fund of knowledge included normal awareness of current and past events. The facility investigation included the following statements: a) Staff A Certified Nursing Assistant (CNA) wrote: she was working 2:00 PM-10:00 PM on 7/23/24. She had just finished the nurse's orders of passing snacks, ice water, doing rounds, and hourly check-ups on certain residents. She went to assist another resident when a CNA told her that the resident they need to lay down was upset. When Staff A arrived to the resident's room she said: hello, I heard that you were upset and I was wondering if there was anything I could do? Immediately the resident started screaming and yelling, I am not f***ing upset (said that two times), you guys waited forever to come lay me down. Staff A explained the resident, I am sorry, myself and the other CNA just got done with nurse's orders and both of us are getting tired, so we understand. After transporting the resident to bed, Staff A went to assist the CNA with rolling the resident. As soon as Resident #1 saw Staff A was touching her, she started yelling and scream don't f***ing touch me (was said about five times) with the occasional word bitch thrown in. After Staff A ensured the other CNA was at a good stopping point, Staff A told that staff member I can't handle this shit. Staff A then walked over to the other side of the room and grabbed a pillow for the resident's head, then stood around the other CNA, staying there to make sure she did not need any other assistance other than touching the resident. b) Staff B CNA wrote the following statement: on 7/23/24 Staff A and I went to assist Resident #1 to bed. At the time we went in, she was very upset and was yelling at the fact that she did ask two hours prior to be put in bed. Staff B and her were busy doing baths, passing snack cart out and putting other residents to bed. Resident #1 yelled I asked you two f***ing hours ago. Staff A replied with I'm not putting up with your shit tonight. Resident #1 then replied with I am not dealing with your attitude either. Resident #1 was screaming while being put in bed due to her being in pain. After being put in bed, Resident #1 looked at Staff A and said you are not f***ing touching me. Staff B told Resident #1 she had to help roll her to get the sling out from under her. Resident #1 rolled her eyes. Due to the resident screaming while being put in bed, Staff B did ask Resident if she was ok. Resident #1 replied, it didn't matter. Resident #1 was assured she did care if she was ok. Resident #1 did not say anything after that, so Staff B walked out. Staff B told the nurse and she said she would go talk to Resident #1 about it. The ADON (nurse on duty that night) did talk to her and Staff A about the next time letting Resident #1 calm down then reproach her. She signed and dated her statement on 7/25/24. c) The ADON wrote the following statement: on the night of 7/23/24 at 9:30 PM she was passing medications down hall 2 when Staff B came to her and stated Resident #1 was upset, she was screaming at staff when entering her room about how long she had been waiting for staff to put her to bed. Staff A and Staff B apologized for the delay and that they were with other residents and doing the best they could. Resident #1 continued screaming at both CNA's telling them how much bullshit it was and that they were terrible. Staff B then stated Staff A made the comment, I can't deal with this right now. Resident #1 then began screaming at Staff A, don't f***ing touch me, don't f***ing touch me, don't f***ing touch me. Staff B she let Resident #1 know Staff A would not be doing her cares, that Staff B would but still needed Staff A's assistance to roll the resident so Staff B could provide cares. Resident #1 then stated why does that matter, no one cares. Staff B reassured her that they indeed do care. The ADON finished her medications a few minutes later and returned to the nurse's station when the Social Service Director (SSD) informed her that Resident #1 made a grievance that she waited two hours to put to bed and that Staff A was rude to her. The SSD stated she had just talked with Resident #1 and had not had a chance to write it up yet. The ADON questioned Staff A and she stated, Resident #1 was screaming at us for taking so long. She tried to explain why and they couldn't really help it but were trying the best they could. Resident #1 continued to scream at them, saying how awful they were. When they got her into bed, Resident #1 started screaming don't f***ing touch me like five times and Staff A said ok Staff B told Resident #1 that she needed her help rolling her to do cares. The ADON asked why the resident was yelling at Staff A not to touch her. Staff A stated because she was mad and does not like me, never has, she is like that with staff she does not like when she is upset. The ADON asked if she stated that she wasn't or can't going to deal with this right now and she indicated she had not made that statement. After question Staff A, the ADON went to speak with Resident #1. Upon entering the resident's room it was noted that resident was not in distress and was in a calm mood. The ADON stated that she had heard the resident was upset and asked what had happened. Resident #1 stated she was upset because she waited two hours to be laid down and told the staff it was bullshit. She added she should not have to wait that long, then Staff A told her she can't deal with this. Resident #1 indicated she did not like people talking like that to her. The ADON stated she understood and that she would speak with Staff A about the way she spoke to Resident #1 and they apologized. The ADON also took accountability for the staff taking so long to lay her down as she tasked them with passing snacks, fresh ice water, and the baths for the evening to ensure all duties were completed in a timely manner. Resident #1 stated that she understood stuff like that happens sometimes. The ADON then reiterated that this did not excuse Resident #1's comment and that it will be addressed. Resident #1 thanked the ADON, stated no when asked if there was anything else she would like to talk about or needed. Resident #1 still seemed to be in a calm, pleasant mood. After the conversation with Resident #1, the ADON went to the nurse's station and realized a resident needed a neuro check completed and went to find another resident on the floor. This nurse instructed Staff A to complete her charting and take out the trash before leaving as it was already 10:00 PM. Staff A was educated on importance of professionalism and instructed that in situations that are overwhelming, she needs to ensure resident safety then leave the room, go to the charge nurse and allow the charge nurse to intervene. d) The Administrator's statement indicated Staff C entered his office shortly before 3:00 PM on 7/24/24. She stated that she had heard from Staff D CNA had reported a concern to her and that Resident #1 wanted to talk with him. Resident #1 requested Staff C to be with her. Resident #1 came in and said she was very upset with Staff A and the way she's been treatment her. Resident #1 stated Staff A was rude to her but did not want to say what Staff A had said to her. She indicated she reported the incident to the ADON and the SSD. We continued talking but she did not feel comfortable saying anymore. She was assured that is was absolutely fine bringing her concerns to him and that he really wanted to help. The Administrator told her that he wanted her to be happy here because it's her home. Resident #1 asked if Staff A could not be present in her room or provide her care, he agreed. Resident #1 left the room and Staff C returned after and told him that Resident #1 said Staff A said she was not putting up with her shit tonight and that Staff B heard it too. e) On 7/26/24 the Director or Nursing statement indicated herself and Staff E charge nurse entered Resident #1's room and obtained her consent to speak with her about her report of alleged verbal abuse that occurred on 7/23/24 during the evening shift. Resident #1 stated Staff A was mad at her because the ADON made her pass snacks and waters before putting people to bed. She had asked Staff A if she could go to bed and she copped an attitude with her. Resident #1 stated it was really, really bad and she was so vulgar and mean. Resident #1 stated I don't want to tell you want she said. The DON explained the importance of knowing the details. Resident #1 stated Staff A called her a white trash bitch, trailer trash, a f***ing imbecile, told her she never should have been born and she should be dead by now. Resident #1 denied that the statement I am not putting up with your shit tonight was made by any employees to her. Resident #1 was calm and in a pleasant mood prior to the DON and Staff E leaving her room. The DON called Staff B to confirm if any of the above statements were witnessed or heard while her and Staff A were providing cares to Resident #1. Staff B denied hearing any of those and stated the worst thing she heard was Staff A say shit. f) The SSD statement indicated she entered Resident #1's room to do assessments with her. Resident was lying in bed. Once the first assessment was completed, Resident #1 stated she was rude. When asked who was rude, she stated Staff A. When they came in, Resident #1 was upset because she waited two hours to be put to bed. Resident #1 stated Staff A told her there's 20 something other residents and to be considerate. She then stated that Staff A said more but did not state what else was said. Resident #1 stated Staff A said I'm not doing this and walked out of the room. The SSD stated she would write up a grievance and that they would talk to Staff A. Resident #1 thanked her and they finished the assessments. When the SSD left the room, Resident #1 was smiling and appeared content. The facility investigative file included the following summary: a) Resident #1 is a [AGE] year-old cognitively impaired female who was admitted to the facility on [DATE] with a primary diagnosis of acute cystitis without hematuria and spastic diplegic cerebral palsy. b) At 3:00 PM on 7/24/24, Resident #1 reported to the Administer that Staff A had been verbally abusive to her at approximately 9:30 PM on 7/23/24. She could not verbalize the actual statements that Staff A had made to her at that time. When asked if anyone else was present or aware, she stated that Staff B witnessed the incident and that she had reported it to the ADON and SSD the night prior. The DON was immediately notified, and the Administrator initiated an abuse investigation. c) Investigation Findings: 1) On 7/24/24 at approximately 2:00 PM during care, Resident #1 told Staff D that Staff A had yelled at her the night before and that she told her to shut up. She also stated that Resident #1 had reported this to the ADON and the SSD. Staff D immediately reported this to Staff C charge nurse. 2) Staff C followed up with Resident #1 after she finished her talk therapy, at approximately 2:45 PM. Resident #1 told Staff C that Staff A had cursed at her. According to Resident #1's statement to her, Staff A had told her they did not have time for her shit. At that time, she brought Resident #1 to the Administrator, initiating the abuse investigation. Resident #1's initial statement to the Administrator was that Staff A had been verbally abusive to her. When asked what she had said, Resident #1 stated she could not repeat it. She stated it was too terrible for her to report. She also stated that she told Staff A to not touch her after she assisted her to bed. Resident #1 repeated that she no longer felt comfortable with Staff A providing her care. Resident #1 stated she reported her concerns to the ADON and the SSD and Staff B had witnessed all their interactions that night. 3) Staff B stated that Resident #1 was upset and yelling at both staff as they entered her room. They had a hectic night and she had to wait longer than she wanted to be assisted to bed. Staff B confirmed that Staff A told Resident #1 that she wasn't putting up with her shit tonight. She reported this to her charge nurse, ADON that night. 4) The ADON stated that Staff B did inform her of the incident but that Staff A had said she could not deal with this right now to the resident. Staff B stated to her that Resident #1 was upset throughout her cares, but they had tried to reassure her. The ADON followed up with Resident #1 and found her to be calm and not in distress. The ADON let her know that if Staff A had been rude to her that that was not acceptable and that she would follow up with Staff A to address the incident. Resident #1 had no further concerns at that time and stated stuff like that happens sometimes. At no time was Resident #1 upset or voicing concerns about verbal abuse. 5)The SSD stated that the evening of 7/23/24, Resident #1 had brought concerns that Staff A had been rude. When she asked what had happened, Resident #1 told her she had to wait two hours to be put to bed and that Staff A had told her that she needed to be more considerate of the other residents. She also stated that Staff A had said, I am not doing this and walked out of the room. The SSD told her she would fill out a grievance form for her and the team would follow up with Staff A. Resident #1 voiced no other concerns at that time and SSD left her smiling and content. 6)Staff A stated that prior to her entering the room, Staff B had told her the resident was upset. She stated that she entered the room and politely offered to help her. Resident #1 began to yell at them, but she allowed them to assist her to bed. Once in bed, Resident #1 told Staff A that she was not going to f***ing touch her. Staff A only provided support to Staff B as she provided direct care. She left the bedside once Resident #1 was in a safe position and said, I can't handle this shit. Staff A stated she was not directing this at Resident #1 but to her coworker. She denied yelling at Resident #1 and stayed in the room until Staff B completed cares, then left. 7)The Administrator and SSD attempted to follow up with Resident #1 on multiple occasions but were unsuccessful. Resident #1 did not want to speak about the incident or Staff A anymore. 8)On 7/26/24 the DON was able to follow up with Resident #1. At this time she denied that Staff A had told her that she would not put up with her shit or could not put up with this shit. Instead, she now stated Resident #1 called me a white trash bitch, trailer trash, a f***ing imbecile and that she never should have been born and should be dead by now. Resident #1 stated that was what Staff A said on 7/23/24 and Staff B was present. Staff A and Staff B were both asked if any of that was said and they both denied that it was. 9)The Interdisciplinary Team (IDT) reviewed the findings of the investigation. The incident involving Staff A and Resident #1 was the result of frustrations on both party's parts and not intended to be harmful. Review of Staff A's July 2024 timecard, revealed she worked on 7/23/24 from 6:00 PM-10:30 PM. On 7/30/24 at 2:18 PM Resident #1 stated she turned Staff A in because she has been very abusive to a lot of people at the facility, herself included. She works the evening shift, 2:00 PM-10:00 PM, is only 16 and the daughter of the ADON. The ADON will cover Staff A's butt and a lot of her family works here too so they will also cover up for her. She gets special treatment because of that. Resident #1 stated from her stand-point Staff A is very verbally abusive. When asked what has happened, she indicated Staff A has called her a whore, bitch and white trash. She has called her these things to her face. Staff A has also told Resident #1, she is not allowed to have feelings or emotions. Staff A has told her she is not allowed to get her in trouble or say anything. When asked how this made her feel, Resident #1 it pisses her off when Staff A acts like this. This is supposed to be her home, she's not supposed to feel this way about anyone that works here. When Resident #1 does peri-care she does it very hard. She's never been told of any injuries but is sore after Staff A cares for her. She has asked her to please not care for her. Staff A's response to that was I don't f***ing care, I'll f***ing do it anyway's. Last week, while Staff A and Staff B were assisting her to bed, Staff B told the resident I am not dealing with your shit. Resident #1 indicated she has talked with the Administrator, the ADON, DON and SSD about her concerns. All staff tell her when she reports concerns is, they will talk with her. Staff A is back to working at the facility but she is not allowed to care for Resident #1. Resident #1 reported feeling uncomfortable around her presence, does not want her looking at her. On 7/30/24 at 12:36 PM Staff H CNA stated Resident #1 has told her that Staff A has yelled rudely at her, but Staff H has not witnessed this. Resident #1 has also reported Staff A is rough with her while doing cares. The resident reported Staff A wipes roughly. When they go in to complete cares, Resident #1 will say ow, I am sore down there because Staff A had cared for her the previous night. They have told Staff E, Staff C, the Administrator, ADON and DON. They tell staff they will speak with those that are higher up and make sure Resident #1 is ok. When Resident #1 told her what was going, that's when it was suggested Resident #1 call State about this. On 7/30/24 at 1:16 PM Staff I CNA stated Resident #1 had reported to her that Staff A do not treat her well. Staff A does not listen to what Resident #1 wants or what she has to say. Resident #1 has reported to her Staff A has called her not nice things like: she was white trash but that was all Staff I could remember. Resident #1 reported to her that Staff A will not ask to wipe her, she just does it, she is not careful while wiping Resident #1 and is rough. Staff I has heard Resident #1 reporting soreness to her peri-area in the mornings but has not seen any marks. After Resident #1 talked with her she reported these concerns to Staff C and Staff E and they indicated it would be reported to the ADON and DON. When asked how Resident #1 is doing since Staff A returned back to work, she stated the resident is scared and stressed. Staff A is not allowed to take care of Resident #1 since this was reported. On 7/30/24 at 1:32 PM Staff C LPN stated when Resident #1 first admitted to the facility, it took her a bit to get comfortable with staff. Resident #1 was never mean but she did click with a few staff members right away. Resident #1 would come to Staff C for support until she got used to other staff members. Resident #1 would not want Staff A to do her peri-cares and recently had heard Resident #1 turned in concerns about Staff A. Resident #1 reported to her she felt management was not hearing her, like things were not changing and they were not listening to her. Staff C states specially she came in to work on a Wednesday and stated the night before (Tuesday) she asked Staff A to not wipe her and Staff A said, I don't give a f***, she did it anyway's. When Staff A first went in the resident's room, Resident #1 stated the staff member stated I am not putting up with her shit tonight. Staff C continued to talk with Resident #1 to give her support and comfort. Resident #1 went to talk therapy then was ready to talk with the Administrator about what she told Staff C. The resident stated when she spoke with the ADON she told her she would have a talk with Staff A about her attitude from that night. Staff A was suspended and when she returned she was not allowed to take care of Resident #1. When Staff A is in the facility, Resident #1's whole demeanor changes. The first shift staff members will stay until 7-7:30 PM to assist staff with her cares since Staff A is not allowed to care for her. On 7/30/24 at 1:51 PM Staff G stated Resident #1 told her last week that Staff A said to her she wished she never came here. Resident #1 reported last week while Staff A and Staff were assisting with getting the resident ready for bed, Staff A's tone was aggressive. Resident #1 told Staff A no and Staff A said, I don't f***ing care and helped anyway. The resident complained that Staff A was very rough with cares. When Staff G would care for the resident the day after Staff A did, she did not notice any marks but would complain of her peri-area being irritated and sore. When Staff G would work with Staff A she stated she was awful; very defiant with anything that was asked of her, she is very loud and sarcastic. Her mom is the ADON and she would even cuss at her while residents were present. Staff A has always been that way, but it has progressively gotten worse. The ADON would tell Staff A to knock her attitude off, watch your language but Staff A would just roll her eyes and walk away. Staff G denies ever hearing inappropriate comments made to Resident #1 by Staff A, she just knew Resident #1 did not want her taking care of her. When asked how Resident #1 acts now that Staff A is back to work, she stated other CNA's have reported that Resident #1 would not leave their sight while Staff A worked. She would park herself up front with other staff when she was usually out and about throughout the facility. Now Resident #1 is fixated on being with staff when Staff A is working. Staff G stated the resident used to sit in her room to listen to music, but she has not done that the last few days. The day shift staff stay over in to the evening shift to assist with Resident #1's cares when Staff A is working. This has upset Resident #1 because she does not feel like staff are listening to her and does not like going to bed before 7:00 PM just because Staff A is working. Resident #1 reported to Staff G that she feels like she has no choices or rights at this point. She mentioned this has been reported to a lot of people but nothing is being done. That's why she contacted outside entities. On 7/30/24 at 2:41 PM Staff D stated after Resident #1 voiced concerns, she reported it. On Wednesday 7/24/24 she had given the resident a bath. During her bath, the resident was bawling, Staff D indicated she had to hold back her own tears. Resident #1 asked Staff A to not do peri-cares and she did them anyway's. The resident reported Staff A will go in to help her but works very fast and does not respect what Resident #1 says. Staff A told her to shut the f*** up and that she did not care about her bullshit. When asked if any other residents voiced concerns about Staff A, she stated while assisting Resident #4 she wanted her feet moved. Staff A told her to shut the f*** up and I don't care about your bullshit. Staff D looked at Staff A and said she had crossed the line and it was not funny nor was it a joke. Staff A stated it's fine, I gave her a good bath and shaved her legs. Staff A spends a lot of time on her phone. When residents try to talk with her she will not pay attention. She will yell at nurses and her mom, who is the ADON. Will tell her to shut up in front of residents while in the dining room. The DON is aware of their concerns, she has told her about them. When they try to report concerns to the ADON, she gets mad at staff. Staff D stated Resident #1 will walk in to the building in a bad mood, then she is disrespectful with residents. These residents would be happier without her here because she is so disgusting and horrible to the residents. On 7/30/24 at 2:59 PM Staff B stated she worked the night of the alleged incident. Resident #1 reported she was ready for bed. Staff B informed her she will need to get help, Staff A was doing a bath at that time. Resident #1 then stated, I told you two f***ing hours ago I wanted to go to bed. Staff A stated I am not dealing with your shit. Resident #1 stated and I am not dealing with your f***ing attitude. Once they got her to bed, Staff B asked if she was ok and Resident #1 stated it does not f***ing matter. She then looked at Staff A and said you are not f***ing touching me. Staff B indicated Resident #1 did not need her brief changed. Once they left the room, Staff B told the ADON what had happened. The ADON told her she would talk to her. She works with Staff A and there are times she thinks she is joking but she's not. Staff B stated she did not think the comment she made to Resident #1 had meaning behind it. She was having a tough day that day. On 7/30/24 at 3:21 PM Staff F CNA stated Resident #1 came to her, Staff G CNA and Staff D scared of Staff A because she had been physically and verbally abusive to her. Resident #1 stated Staff A called her a bitch and wished she was never born. She had told Staff A not do care on her and Staff A said I don't f***ing care and did them anyway's. Staff E denies observing this but stated Staff A can be really nasty to residents, really mean. If they are assisting Resident #4, the resident will ask for something and Staff A would say I don't care, it's not my problem. Her mom is the ADON and she will tell her to shut the f*** up in front of residents. When asked if residents had voiced concerns about Staff A she stated Staff D had turned her in for incidents with her and Resident #4. When asked how Resident #1 has been since this alleged incident she stated she is very scared. If Staff A comes in to the building you can see she is scared and said to be fearful of her safety. This has been brought to management's attention and Staff A is not allowed to work with Resident #1. Herself and Resident #1 are worried about retaliation

Based on clinical record review, facility investigative file review, resident and staff interviews, and facility policy review the facility failed to report 1 of 3 resident's (Resident #1) allegation of abuse to the appropriate staff members to ensure timely reporting to the State Agency. On 7/23/24 at roughly 8:30 PM Staff A and Staff B had assisted Resident #1 with getting ready for bed. Resident #1 told staff she was upset and yelling that she had asked two hours prior to be put to bed. Staff explained to her they were assisting others with baths, passing the snack cart out and assisting others to bed. Resident #1 yelled I asked you two f***ing hours ago. Staff A replied with I am not putting up with your shit tonight. Resident #1 replied I am not dealing with your attitude either. Staff B reported this to the Assistant Director of Nursing (ADON) (Staff A's mother) and she indicated she would go talk to Resident #1. After speaking with Staff A and Resident #1, the ADON continued with her duties: neuro checks on a resident and found that another resident had fallen on the floor. On 7/24/24 at 3:00 PM Staff C Licensed Practical Nurse (LPN) went to the Administrator's office with Resident #1 to talk about the concerns that was reported to her by Staff D CNA. The facility then reported the allegation to the State Agency (SA) on 7/24/24 at 5:13 PM. The facility reported a census of 26 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/30/24 at 5:00 PM. The IJ began on 7/23/24, the day Resident #1 reported her concerns. The facility removed the Immediate Jeopardy on 7/31/24 through the following actions: -Staff A, the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were suspended on 7/30/24. -On 7/30/24 the facility began additional re-education for all employees relating to abuse, neglect, and exploitation as well as reporting requirements. The facility originally began reeducation on 7/24/24 following the initial report All employees currently working will be educated immediately. All other employees will be educated prior to their next scheduled shift. -When new team members begin employment, they will receive Dependent Adult Abuse Prevention and Reporting training as part of their initial onboarding. All other employees will receive Dependent Adult Abuse Prevention training annually, and with any allegation or investigation regarding abuse. -The facility has interviewed all alert residents related to abuse. -The Administrator will interview five random residents about abuse weekly for the next 12 weeks. -The Administrator will interview five random staff members per week for 12 weeks to verify knowledge related to abuse and reporting policies. -Regional Director of Clinical Services had reviewed documentation of current residents, retrospectively back to 12:00 AM on 7/19/24 with no findings of abuse evident. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: According to the Admission Minimum Data Set (MDS) assessment tool with a reference date of 6/24/24, documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairments. Resident #1 had an admitted [DATE]. The MDS documented she did not display any physical, verbal, or other behavioral symptoms during the review period. The MDS documented she was frequently incontinent of urine and was always incontinent of bowel. The MDS listed the following diagnoses for Resident #1: acute cystitis with hematuria, anemia, neurogenic bladder, multidrug resistant organism, septicemia, urinary tract infection (UTI), cerebral palsy, anxiety, depression, psychotic disorder (other than schizophrenia), post-traumatic stress disorder (PTSD), borderline personality disorder, and mild intellectual disabilities. The Care Plan focus area with an initiation date of 6/19/24 documented Resident #1 had activities of daily living (ADL) performance deficit related to cerebral palsy and musculoskeletal impairment. The Care Plan focus area with an initiation date of 6/24/24 documented she has the potential to have manipulative behaviors at times. Staff are encouraged to explain all procedures to Resident #1 before starting and allow the resident to adjust to changes. Review of the facility's grievances revealed the following grievance was filed on Resident #1's behalf: a) Resident stated when staff entered room, she got upset stated I've been waiting for two hours to go to bed. Resident #1 stated Staff A said we have 20 something residents, please be considerate. Resident stated she continued to be agitated then stated Staff A said I'm not doing this, then walked out. The form was signed and dated by the SSD on 7/23/24. The following Progress Note was documented on 7/24/24 at 5:37 PM by Staff C Licensed Practical Nurse (LPN): this nurse spoke with resident and spent much of the afternoon discussing her feelings about an incident that occurred last night. Resident #1 was visibly upset and had asked this nurse to go with her to talk to the Administrator. Staff C and Administrator told resident that she was heard and that the matter will be looked into. Resident #1 told this nurse that she felt safe at this time and that she did not want a certain person to take care of her. Staff C reassured resident that other staff could meet her needs and she would not have to have cares provided by the person who made her feel uncomfortable. She was informed a bit later by Staff C that there is an investigation and it has been turned in. Resident #1 thanked this nurse for giving her support and reassured that she could come to Staff C at any time and she could tell her anything that was bothering her. They all want her to feel safe. The facility investigation included the following statements: a) Staff A Certified Nursing Assistant (CNA) wrote: she was working 2:00 PM-10:00 PM on 7/23/24. She had just finished the nurse's orders of passing snacks, ice water, doing rounds, and hourly check-ups on certain residents. She went to assist another resident when a CNA told her that the resident they need to lay down was upset. When Staff A arrived to the resident's room she said: hello, I heard that you were upset and I was wondering if there was anything I could do? Immediately the resident started screaming and yelling, I am not f***ing upset (said that two times), you guys waited forever to come lay me down. Staff A explained the resident, I am sorry, myself and the other CNA just got done with nurse's orders and both of us are getting tired, so we understand. After transporting the resident to bed, Staff A went to assist the CNA with rolling the resident. As soon as Resident #1 saw Staff A was touching her, she started yelling and scream don't f***ing touch me (was said about five times) with the occasional word bitch thrown in. After Staff A ensured the other CNA was at a good stopping point, Staff A told that staff member I can't handle this shit. Staff A then walked over to the other side of the room and grabbed a pillow for the resident's head, then stood around the other CNA, staying there to make sure she did not need any other assistance other than touching the resident. b) Staff B CNA wrote the following statement: on 7/23/24 Staff A and I went to assist Resident #1 to bed. At the time we went in, she was very upset and was yelling at the fact that she did ask two hours prior to be put in bed. Staff B and her were busy doing baths, passing snack cart out and putting other residents to bed. Resident #1 yelled I asked you two f***ing hours ago. Staff A replied with I'm not putting up with your shit tonight. Resident #1 then replied with I am not dealing with your attitude either. Resident #1 was screaming while being put in bed due to her being in pain. After being put in bed, Resident #1 looked at Staff A and said you are not f***ing touching me. Staff B told Resident #1 she had to help roll her to get the sling out from under her. Resident #1 rolled her eyes. Due to the resident screaming while being put in bed, Staff B did ask Resident if she was ok. Resident #1 replied, it didn't matter. Resident #1 was assured she did care if she was ok. Resident #1 did not say anything after that, so Staff B walked out. Staff B told the nurse and she said she would go talk to Resident #1 about it. The ADON (nurse on duty that night) did talk to her and Staff A about the next time letting Resident #1 calm down then reproach her. She signed and dated her statement on 7/25/24. c) The ADON wrote the following statement: on the night of 7/23/24 at 9:30 PM she was passing medications down hall 2 when Staff B came to her and stated Resident #1 was upset, she was screaming at staff when entering her room about how long she had been waiting for staff to put her to bed. Staff A and Staff B apologized for the delay and that they were with other residents and doing the best they could. Resident #1 continued screaming at both CNA's telling them how much bullshit it was and that they were terrible. Staff B then stated Staff A made the comment, I can't deal with this right now. Resident #1 then began screaming at Staff A, don't f***ing touch me, don't f***ing touch me, don't f***ing touch me. Staff B she let Resident #1 know Staff A would not be doing her cares, that Staff B would but still needed Staff A's assistance to roll the resident so Staff B could provide cares. Resident #1 then stated why does that matter, no one cares. Staff B reassured her that they indeed do care. The ADON finished her medications a few minutes later and returned to the nurse's station when the Social Service Director (SSD) informed her that Resident #1 made a grievance that she waited two hours to put to bed and that Staff A was rude to her. The SSD stated she had just talked with Resident #1 and had not had a chance to write it up yet. The ADON questioned Staff A and she stated, Resident #1 was screaming at us for taking so long. She tried to explain why and they couldn't really help it but were trying the best they could. Resident #1 continued to scream at them, saying how awful they were. When they got her into bed, Resident #1 started screaming don't f***ing touch me like five times and Staff A said ok Staff B told Resident #1 that she needed her help rolling her to do cares. The ADON asked why the resident was yelling at Staff A not to touch her. Staff A stated because she was mad and does not like me, never has, she is like that with staff she does not like when she is upset. The ADON asked if she stated that she wasn't or can't going to deal with this right now and she indicated she had not made that statement. After question Staff A, the ADON went to speak with Resident #1. Upon entering the resident's room it was noted that resident was not in distress and was in a calm mood. The ADON stated that she had heard the resident was upset and asked what had happened. Resident #1 stated she was upset because she waited two hours to be laid down and told the staff it was bullshit. She added she should not have to wait that long, then Staff A told her she can't deal with this. Resident #1 indicated she did not like people talking like that to her. The ADON stated she understood and that she would speak with Staff A about the way she spoke to Resident #1 and they apologized. The ADON also took accountability for the staff taking so long to lay her down as she tasked them with passing snacks, fresh ice water, and the baths for the evening to ensure all duties were completed in a timely manner. Resident #1 stated that she understood stuff like that happens sometimes. The ADON then reiterated that this did not excuse Resident #1's comment and that it will be addressed. Resident #1 thanked the ADON, stated no when asked if there was anything else she would like to talk about or needed. Resident #1 still seemed to be in a calm, pleasant mood. After the conversation with Resident #1, the ADON went to the nurse's station and realized a resident needed a neuro check completed and went to find another resident on the floor. This nurse instructed Staff A to complete her charting and take out the trash before leaving as it was already 10:00 PM. Staff A was educated on importance of professionalism and instructed that in situations that are overwhelming, she needs to ensure resident safety then leave the room, go to the charge nurse and allow the charge nurse to intervene. d) The Administrator's statement indicated Staff C entered his office shortly before 3:00 PM on 7/24/24. She stated that she had heard from Staff D CNA had reported a concern to her and that Resident #1 wanted to talk with him. Resident #1 requested Staff C to be with her. Resident #1 came in and said she was very upset with Staff A and the way she's been treatment her. Resident #1 stated Staff A was rude to her but did not want to say what Staff A had said to her. She indicated she reported the incident to the ADON and the SSD. We continued talking but she did not feel comfortable saying anymore. She was assured that is was absolutely find bringing her concerns to him and that he really wanted to help. The Administrator told her that he wanted her to be happy here because it's her home. Resident #1 asked if Staff A could not be present in her room or provide her care, he agreed. Resident #1 left the room and Staff C returned after and told him that Resident #1 said Staff A said she was not putting up with her shit tonight and that Staff B heard it too. e) The SSD statement indicated she entered Resident #1's room to do assessments with her. Resident was lying in bed. Once the first assessment was completed, Resident #1 stated she was rude. When asked who was rude, she stated Staff A. When they came in, Resident #1 was upset because she waited two hours to be put to bed. Resident #1 stated Staff A told her there's 20 something other residents and to be considerate. She then stated that Staff A said more but did not state what else was said. Resident #1 stated Staff A said I'm not doing this and walked out of the room. The SSD stated she would write up a grievance and that they would talk to Staff A. Resident #1 thanked her and they finished the assessments. When the SSD left the room, Resident #1 was smiling and appeared content. The facility investigative file included the following summary: a) Resident #1 is a [AGE] year-old cognitively impaired female who was admitted to the facility on [DATE] with a primary diagnosis of acute cystitis without hematuria and spastic diplegic cerebral palsy. b) At 3:00 PM on 7/24/24, Resident #1 reported to the Administer that Staff A had been verbally abusive to her at approximately 9:30 PM on 7/23/24. She could not verbalize the actual statements that Staff A had made to her at that time. When asked if anyone else was present or aware, she stated that Staff B witnessed the incident and that she had reported it to the ADON and SSD the night prior. The DON was immediately notified, and the Administrator initiated an abuse investigation. c) Investigation Findings: 1) On 7/24/24 at approximately 2:00 PM during care, Resident #1 told Staff D that Staff A had yelled at her the night before and that she told her to shut up. She also stated that Resident #1 had reported this to the ADON and the SSD. Staff D immediately reported this to Staff C charge nurse. 2) Staff C followed up with Resident #1 after she finished her talk therapy, at approximately 2:45 PM. Resident #1 told Staff C that Staff A had cursed at her. According to Resident #1's statement to her, Staff A had told her they did not have time for her shit. At that time, she brought Resident #1 to the Administrator, initiating the abuse investigation. Resident #1's initial statement to the Administrator was that Staff A had been verbally abusive to her. When asked what she had said, Resident #1 stated she could not repeat it. She stated it was too terrible for her to report. She also stated that she told Staff A to not touch her after she assisted her to bed. Resident #1 repeated that she no longer felt comfortable with Staff A providing her care. Resident #1 stated she reported her concerns to the ADON and the SSD and Staff B had witnessed all their interactions that night. 3) Staff B stated that Resident #1 was upset and yelling at both staff as they entered her room. They had a hectic night and she had to wait longer than she wanted to be assisted to bed. Staff B confirmed that Staff A told Resident #1 that she wasn't putting up with her shit tonight. She reported this to her charge nurse, ADON that night. 4) The ADON stated that Staff B did inform her of the incident but that Staff A had said she could not deal with this right now to the resident. Staff B stated to her that Resident #1 was upset throughout her cares, but they had tried to reassure her. The ADON followed up with Resident #1 and found her to be calm and not in distress. The ADON let her know that if Staff A had been rude to her that that was not acceptable and that she would follow up with Staff A to address the incident. Resident #1 had no further concerns at that time and stated stuff like that happens sometimes. At no time was Resident #1 upset or voicing concerns about verbal abuse. 5)The SSD stated that the evening of 7/23/24, Resident #1 had brought concerns that Staff A had been rude. When she asked what had happened, Resident #1 told her she had to wait two hours to be put to bed and that Staff A had told her that she needed to be more considerate of the other residents. She also stated that Staff A had said, I am not doing this and walked out of the room. The SSD told her she would fill out a grievance form for her and the team would follow up with Staff A. Resident #1 voiced no other concerns at that time and SSD left her smiling and content. On 7/30/24 at 2:18 PM Resident #1 stated she turned Staff A in because she has been very abusive to a lot of people at the facility, herself included. She works the evening shift, 2:00 PM-10:00 PM, is only 16 and the daughter of the ADON. The ADON will cover Staff A's butt and a lot of her family works here too so they will also cover up for her. She gets special treatment because of that. Resident #1 stated from her stand-point Resident #1 is very verbally abusive. When asked what has happened, she indicated Staff A has called her a whore, bitch and white trash. She has called her these things to her face. Staff A has also told Resident #1 is not allowed to have feelings or emotions. Staff A has told her she is not allowed to get her in trouble or say anything. When asked how this made her feel, Resident #1 said it pisses her off when Staff A acts like this. This is supposed to be her home, she's not supposed to feel this way about anyone that works here. When Resident #1 does peri-care she does it very hard. She's never been told of any injuries but is sore after Staff A cares for her. She has asked her to please not care for her. Staff A's response to that was I don't f***ing care, I'll f***ing do it anyway's. Last week, while Staff A and Staff B were assisting her to bed, Staff B told the resident I am not dealing with your shit. Resident #1 indicated she has talked with the Administrator, the ADON, DON and SSD about her concerns. All staff tell her when she reports concerns is, they will talk with her. Staff A is back to working at the facility but she is not allowed to care for Resident #1. Resident #1 reported feeling uncomfortable around her presence, does not want her looking at her. On 7/30/24 at 3:34 PM the ADON stated she was passing medications on hall 2 when Staff B came to her and said just a heads up, Resident #1 is not in a good mood. She was upset because they took so long to get her to bed. Resident #1 was screaming at them and Staff A made a comment that upset her further. When asked what comment it was, she stated I don't know, something along the lines of I can't deal with this shit right now. Resident #1 screamed back at her don't f***ing touch me, don't touch me. Once she was done with her medication pass, she spoke to Staff A. She reported Resident #1 was yelling at them, saying this place was awful, literally screaming in their faces how long she had been waiting. Resident #1 was yelling at Staff A to not touch her. Staff A was asked if she made the comment can't deal with this shit, she could not remember if she cussed. The ADON told her you can't talk like that to residents, if you get frustrated you can't talk like that. The ADON stated it sounds like it was a slip of the tongue kind of thing. She told Staff A to take the trash out and finish charting. The ADON went in to speak with Resident #1. She indicated she was upset because she waiting forever to get to bed. Staff A told Resident #1 she can't deal with this shit right now and Resident #1 told Staff A to not touch her. The ADON explained to the resident what Staff A said was not ok and it would be handled. The ADON explained she told the staff members to get snacks passed and baths done before getting residents to bed. Resident #1 voiced understanding, was fine and did not want to talk about anything else. When asked who she reported this alleged incident to, she stated to be honest she intended to let the DON know but when she got to the nurse's station two other residents needed her attention. She had one resident that had fallen and one that was crawling in and out of bed. She indicated she was notified of the allegation on 7/23/24 roughly at 9:30-9:40 PM. The DON found out about the allegation the next morning but not from her, from someone else. When asked what she should have done with the information that Staff B shared with her, she acknowledged she should have contacted the DON right away. On 7/30/24 at 2:59 PM Staff B stated she worked the night of the alleged incident. Resident #1 reported she was ready for bed. Staff B informed her she will need to get help, Staff A was doing a bath at that time. Resident #1 then stated, I told you two f***ing hours ago I wanted to go to bed. Staff A stated I am not dealing with your shit. Resident #1 stated and I am not dealing with your f***ing attitude. Once they got her to bed, Staff B asked if she was ok and Resident #1 stated it does not f***ing matter. She then looked at Staff A and said you are not f***ing touching me. Staff B indicated Resident #1 did not need her brief changed. Once they left the room, Staff B told the ADON what had happened. The ADON told her she would talk to her. She works with Staff A and there are times she thinks she is joking but she's not. Staff B stated she did not think the comment she made to Resident #1 had meaning behind it. She was having a tough day that day. On 7/31/24 at 2:54 PM the SSD stated when Staff A and B exited Resident #1's room, she went in to her room to complete assessments for her MDS. Resident #1 told the SSD that her and Staff A got in to it. When asked what happened, the resident told her, Staff A and Staff B came in and she was upset. The resident indicated she yelled because she had to wait to be put to bed. Staff A told her to please be considerate of the 20 other residents in the facility. The resident reported more words were exchanged. Staff A said I am not doing this tonight and left the room. The SSD stated she filled out a grievance on it as she did not think it was abuse. She informed Resident #1 that she would fill out a grievance and let the ADON know. The SSD denied that Resident #1 reported Staff A had cursed that day. On 7/31/24 at 12:51 PM the DON stated she was made aware of the alleged incident on 7/24/23, it had taken place on the evening shift of 7/23/24. Staff C had reported to her that Resident #1 was in the Administrators office informing him of the events that took place on 7/23/24. On 8/2/24 at 2:39 PM the Administrator stated a CNA had reported that Resident #1 complained about Staff A being rude to her the night before. After Resident #1 completed talk therapy, she came to his office and talked with her. She was very nervous and could not give a lot of information at that time. She indicated Staff A was rude, very upset by it and did not want her taking care of her anymore. After they spoke with Resident #1 she reported Staff A was not going to put up with her shit. This cued him to start looking in to this. The DON was not aware of this and the only thing they knew of was a grievance on Resident #1's behalf. The SSD completed the grievance and said it was filed the night before but it did not have, not putting up with her shit, on the form. They had confirmed that Staff A had used very inappropriate language. Staff A denied saying this but to her co-worker out of frustration because the nurse was riding them hard that night. The next day Resident #1's story changed when she spoke with the DON and Staff E. She had denied Staff A had said she was not going to put up with her shit but added new allegations of verbal stuff. Resident #1 stated Staff A told her she wished she was, not born. The Administrator stated in his mind at this point, he was convinced something had happened. Whatever happened was inappropriate and not intended to be abusive. What happened was affecting Resident #1 so they educated Staff A and gave her a final warning before returning back to work. When asked if the ADON should have reported this on 7/23/24 he stated in retrospect, she should have dug more in to what had happened. He stated no matter what, if someone has a concern, he should be contacted directly. The facility provided a document titled F609, Reporting of Abuse Allegations. All suspected violations and all substantiated incidents of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, abuse, including injuries of unknown source, and misappropriation of resident property. Should a suspected violation or a reasonable suspicion or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse, or suspected crimes, or suspected evidence of humiliating or demeaning photographs or recordings) be reported, the facility Administrator, or his/her designee in their absence.

Based on clinical record review, family interviews, resident interviews, staff interviews and facility policy review the facility failed to provide sufficiency of staff (including both quantity and competency of staff) to care for the behavioral health of 5 of 5 residents reviewed (Resident #3, #4, #5, #6, and #10). The State Agency (SA) informed the facility on 7/27/23 at 2:00 PM of the Immediate Jeopardy (IJ) that began as of 1/24/23 at 2:42 PM. The Facility Staff removed the Immediate Jeopardy on 7/28/23 through the following actions: a. On 7/18/23 order received to increase monitoring of behaviors for Resident #5. b. On 7/18/23 Resident #5 assessed by Primary Care Physician. c. On 7/28/23 obtained an order pharmacy medication review for Resident #5. d. Resident #5 has 1 on 1 supervision. e. Residents #3 and #4 placed on different halls and will be monitored twice weekly by direct care staff to observe any kind of distress or changes in behaviors. f. Resident #6 seen by psych and screened for depression, anxiety, PTSD (Post Traumatic Stress Syndrome), and personality disorder on 7/24/23 with no significant findings per physician. g. On 7/28/23 a stop sign picture was placed on Resident #10's door. h. On 7/28/23 facility conducted an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting. It was determined that direct care staff were not appropriately competent and did not exhibit the skills to provide nursing and related services to assure resident safety and and attain their highest practicable physical, mental, and psychosocial well being. i. On 7/18/23 all residents with a BIMS (Brief Interview of Mental Status) of 13 or higher were interviewed for any distress with intervention put in place for the 1 resident with distress. All residents with a BIMS of 12 and below were assessed 7/18/23 for signs and symptoms of distress, crying, agitation, verbal or physical aggression with none noted. j. On 7/28/23 Regional Director re-educated the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Social Worker on the policy for Behavioral Health Service for F740, F741, F742, F743, and F949. Also included in re-education was the Critical Element Pathways for Dementia and CMS (Centers for Medicare and Medicaid) Powerpoint for Nursing Homes which includes 483.40 Behavioral Health Services overview of F740, F741, F742, F743, F744, and F755. k. On 7/28/23 education was provided to current direct care staff on the policies related to F740, F741, F742, F743, and F949. This includes the staff competencies for residents living with behavioral health needs such as care of cognitively impaired residents, mental health and social services needs, knowledge of behavioral health care and services and demonstrate attempts to access professional behavioral health resources and take reasonable steps to seek alternative sources for services not covered by Medicare or Medicaid. Remaining direct care staff and agency staff not available will not be permitted to take an assignment until education is completed. l. Upon hire and annually all direct care staff will receive education on F741 that includes competencies and skill sets to provide nursing services to assure resident safety and to provide the highest practicable physical, mental, and psychosocial well-being of each resident. Competency is established by observing the staff's ability to use this knowledge thorough the demonstration of skill and implementation of specific, person-centered interventions identified in the care plan to meet resident's behavioral health needs. Additionally, competency involves staff's ability to communicate and interact with residents in a way that promotes psychosocial and emotional well-being, as well as meaningful engagements. m. Administrator and DON will monitor and audit all direct care staff through observation twice weekly to ensure competency of skill sets for 3 months and report findings to QAPI monthly for 3 months or until a period of compliance is achieved. The scope lowered from a K to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #3 revealed the resident had short term and long term memory problems, had severely impaired cognitive skills for daily decision making, and had inattention and disorganized thinking behavior present that fluctuates. The resident had diagnoses of anxiety, intellectual disabilities, and down's syndrome. The Care Plan for Resident #3 dated 11/16/22 documented the resident has a behavior problem of attention seeking and making false allegations related to mental disabilities. The care plan directed staff as follows: 1. Anticipate and meet the resident's needs. 2. If reasonable, discuss the resident's behavior. Explain/reinforce why the behavior is inappropriate and/or unacceptable. The Care Plan for Resident #3 dated 1/5/23 documented the resident is a wanderer and wanders aimlessly at times significantly intruding on the privacy of others or activities. The care plan directed staff as follows: 1. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation. Resident prefers: Coloring, IPad, Puzzles, cartoons. 2. Monitor for fatigue and weight loss. 3. Wander alert: wander-guard bracelet placed. The Care Plan for the resident dated 3/31/23 documented the resident has the potential to be physically aggressive related to mental illness. The Care Plan directed staff as follows: 1. Triggers for physical aggression are others touching her walker. Behavior is de-escalated by re-direction. 2. When the resident becomes agitated: intervene before agitation escalates; guide her from source of distress; engage calmly in conversation; if response is aggression, staff to walk away and approach later. The Progress Notes for the resident documented the following: On 1/14/23 at 5:33 PM Physician notified via fax regarding resident behaviors. Staff observed her licking her wall. Staff have not been able to keep her out of other resident rooms or to use her walker. Observed crawling down the hall. On 1/14/23 at 10:53 PM resident wandering facility and being silly dancing in the hall way at bedtime. Resident easily redirected with staff. Resident went to bed around 10:00 PM. On 1/15/23 at 3:41 PM resident wandering facility without walker. Easily redirected most of the time. On 1/16/23 at 10:10 PM update returned in regards to licking her wall-not being able to keep her out of others rooms, her not using FWW (4 wheeled walker), keeps half crawling down the hallway. Get psychiatric evaluation put on calendar for tomorrow. On 1/16/23 at 11:48 PM resident started on increased dose of risperadol. Continues to have multiple behaviors of being in other resident rooms, walking without walker, and standing in the middle of doorways. On 1/17/23 at 10:10 PM resident continues to have increased wandering in facility and into other resident rooms. On 3/16/23 at 10:08 AM reported to Social Worker (SW) another resident walked by this resident. The other resident put a hand on the resident's walker trying to get around her when Resident #3 slapped the other resident's hand and began yelling. Staff intervened and separated but later Resident #3 attempted to run her walker into the same resident. On 3/26/23 at 3:29 PM resident stood in doorway of hall 2 when a male resident attempted to go down the hall. Resident #3 stood in place, stuck her tongue out and started yelling at him. He asked her to move and she refused. Staff intervened and informed her she needed to move to allow others to go by. Resident #3 started crying and stated the male resident hit her. No physical contact observed between the two residents. On 3/27/23 at 6:02 PM resident grabbed a male resident's walker when he was coming into the facility and yelled at him that it was her walker. Staff intervened and separated the two. On 3/27/23 at 11:15 AM SW unable to complete BIMS and mood assessment. Resident recently displaying more behaviors of being verbally and physically aggressive. On 3/28/23 at 10:16 AM SW and Activity Director discussed increased behaviors and need for activities the resident would be interested in. Discussed with family. On 4/9/23 at 2:50 PM resident seeking male resident and asking him to marry her. Resident found sitting on male resident lap kissing him in the family room. On 4/11/23 at 1:54 PM resident required much one on one at meals due to wanted to leave and do other activities. Staff had to redirect resident to table and remind to eat. The Care Plan for Resident #3 lacked any interventions for sexual behaviors. The Plan of Care Note on 6/9/23 at 12:22 PM documented attendees: ADON, Activity Director, CDM (Certified Dietary Manager) resident's sister, SSD. Resident's discharge plan is to remain long term at this time. Advanced directives is a DNR (Do Not Resuscitate) . At this time there is not acute medical conditions main diagnoses: General anxiety, and down syndrome. At this time resident has no skin conditions of concern. Resident weight has remained the same in the last month. Resident does wander from table to table even after multiple attempts of re-direction. Resident is not able to complete a BIMS assessment due to being cognitively impaired. Resident is incontinent of bladder most of the time. At this time resident is not doing therapy. Resident is independent but does need queuing and redirection. resident wanders but is usually pretty good about staying out of other resident's rooms. Resident attends most activities. Family concerns sister (POA) suggests we increase resident's Remeron and decrease Risperdal as she believes it will help with this resident's appetite. In an interview on 7/26/23 at 12:33PM, the resident's sister reported that it was hard for the resident to verbally express herself due to her diagnosis of down's syndrome. The sister stated the resident acted out sexually after she had COVID-19. Staff reported she hid in a male resident's room, Resident #4, and told staff that she was horny. The resident was moved to a different room and had her medication changed. The sister reported she has not been informed by the facility of any additional incidents involving inappropriate sexual behavior. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed a Brief Interview of Mental Status (BIMS) score of 4 out of 15 which indicated severely impaired cognition. The MDS documented a diagnoses to include amnesia. The Care Plan for Resident #4 revised on 2/6/23 documented the resident has a behavior problem (having multiple episodes) related to unrealistic expectations. The Care Plan directed staff as follows: -Anticipate and meet the resident needs. -Caregivers to provide opportunity for positive interaction, attention, stop and interact as passes by. -Monitor behavior episodes and attempt to determine underlying cause. The Care Plan dated 6/9/23 documented the resident has the potential to be verbally aggressive related to the aging process/confusion. The Care Plan directed staff as follows: -Assess and anticipate resident needs. -Give the resident as many choices as possible about care and activities. The Care Plan lacked any indication of sexual behaviors. The Progress Note for Resident #4 documented the following: On 1/24/23 at 12:12 PM the Director of Nursing (DON) went to a female resident room to inform her that it was lunch time. Upon entering the room, Resident #4 was leaning over female residents bed, groping the females breasts and kissing her intimately. The DON informed the resident to leave her room and asked the female resident if she was okay and if she had consented to that encounter. The female did nod her head yes. The DON went to residents room and educated him on the importance of consent and explained that some people may not be able to make proper decisions for themselves. Fax sent to Primary Care Provider (PCP) to update. Residents daughter also notified of encounter. On 1/30/23 at 9:12 PM resident continues on increase dose of Namenda with no signs and symptoms of any adverse reactions noted, multiple behaviors noted tonight- found trying to get resident from room [ROOM NUMBER] (Resident #5) to let him go up under her shirt-this nurse separated them-yelling about taking his pill-why does he have to take them-yelling about blanket-staff went immediately downstairs to get it stood shouting and stomping at nurse's station until she got back up stairs with it. On 3/23/23 at 2:42 PM Care Plan Meeting: attended ADON, SSD (Social Services Director), Activity Director, resident's daughter, resident. Discussed residents care, wt at 139, daughter please resident is starting to gain some. resident c/o (complained of) staff telling resident not to sit too close to female residents staff discussed resident inappropriately touching other residents at times. No other concerns at this time. Plan is for resident to remain in facility contrary to residents belief, daughter is unable to provide the care he needs. Family has no concerns at this time. On 4/9/23 at 2:48 PM resident touching a female resident thigh and rubbing her shoulders and kissed her. On 4/16/23 6:19 PM resident sitting on couch in lounge -seen trying to get his hands up under [NAME] another resident shirt-residents separated, and he went to his room -yelling about it being cold in here. In an interview on 7/26/23 at 11:18 AM, the resident's daughter reported that the resident was accused of touching a female resident, and the resident had always been lovey in behavior. She stated the facility hadn't informed her of anything that has happened between this resident and other residents since the new company took over in 11/22. In an interview on 7/27/23 at 1:16 PM Resident #12 reported that she had observed the resident touch Resident #3's breast and genitals. Resident #12 has observed the resident take his penis out of his slacks and Resident #3 touched the resident's penis. Resident #12 reported that she saw this before the resident had COVID in 4/23. In an interview on 7/26/23 at 2:31 PM, Staff A, CNA, reported that the resident's nickname among staff was Captain [NAME] Pants, and that he can get inappropriate with staff. The aide stated staff remind him to behave. The aide stated he hasn't been an issue since before the beginning of May but before that he was touchy feely. He would sit on the couch and grope female residents. He never would go past first base. He would touch them outside of their clothes and touch breasts outside of clothes. She stated she remembered him with Resident #3 touching her at times and staff separated them and redirected them. In an interview on 7/26/23 at 2:16 PM, the DON reported that she talked to previous Administrator about the incident on 1/24/23 and directed the incident didn't need to be reported to the SA and that she didn't know they had to be reported. 3. The MDS dated [DATE] for Resident #5 revealed the resident had short term and long term memory problems, had severely impaired cognitive skills for daily decision making, and had inattention and disorganized thinking behavior present that fluctuates. The MDS documented diagnoses to include non-traumatic brain dysfunction, Alzheimer's disease, and schizophrenia. The Care Plan revised on 7/20/23 for Resident #5 documented the resident is at risk for wandering and elopement related to impaired safety awareness. The Care Plan directed staff as follows: 1. Ensure a safe distance from other residents who have a tendency to become agitated with her actions. 2. Follow facility elopement policy and procedures. 3. Identify pattern of wandering: purposeful, aimless or escapist; looking for something; or need more exercise? 4. Monitor location with one on one supervision at all times. Document wandering behaviors and attempted diversion interventions. The Care Plan revised on 7/31/23 for Resident #5 documented the resident has a behavior problem of sitting on the floor and going into other resident's rooms related to cognitive impairment. The Care Plan directed staff as follows: 1. Anticipate and meet the resident's needs. 2. Caregivers to provide opportunities for positive interaction, attention, and to stop and interact as passes by. 3. Psyche referral as needed for behavior and medication management. The Care Plan lacked any indication of sexual behavior. The Progress notes for the resident documented wandering in the facility and/or wandering into resident's rooms on the following: 1. 1/30/23 2. 2/1/23 3. 2/12/23 4. 2/19/23 5. 3/30/23 6. 4/9/23 7. 4/17/23 8. 4/19/23 9. 7/23/23 The Progress Notes for the resident documented the following: On 6/10/23 at 3:46 PM multiple residents approached nurse to express concern d/t (due to) resident being in their rooms while they were not. Resident had multiple different candy items that she was hiding and eating which were not hers. Resident also walked by medication cart and stole applesauce in the middle of medication pass. Resident educated but ineffective as resident continued with behavior throughout the whole shift. On 7/17/23 at 10:29 PM CNA paged nurse to resident's room. CNA reported to this nurse that she had walked in on resident and another resident during an inappropriate act. CNA had already started to separate residents and this nurse took the other resident out of the room and delegated cna to stay with Resident #5 until nurse could get back and perform assessment. Male resident escorted to nurses station and this nurse went back to resident's room. Skin assessment completed along with psycho-social eval completed. resident stated to this nurse when asked if she was okay with what happened and she stated she didn't mind it. Skin assessment revealed no skin breaks, marks or vaginal bleeding. Resident stated that she was not injured or hurt. Resident was not showing any obvious signs of being upset or distressed, not crying or agitated. She was not verbally or physically aggressive. Half hour checks completed by staff on resident to ensure safety. Resident found to be wandering a few times and redirected back to her room. Contacted Administrator, DON and ADON immediately after incident at approx 10:21 PM after separating the residents. On 7/18/23 at 9:39 AM DON and ADON spoke with resident's brother at 9:32 AM. DON updated brother on incident between resident and a male resident. Brother stated that he wanted facility to do what they think is right and make sure his sister is okay. Brother aware and gave consent for resident to be seen at local hospital for evaluation per orders from the resident's physician that were received at 9:39 AM. The ED (Emergency Department) Provider Note for Resident #5 signed by a physician on 7/18/23 at 11:32 AM revealed: -Per staff report, another resident went into patient's room, took off his clothes, and laid on top of her. SANE (Sexual ASSUALT Nurse Examiner) nurse reports patient denied sexual intercourse. She states patient told him to stop, then CNA walked by room. CNA reports telling other resident to leave room. Per CNA report, he left patient's room and was sent to a different hallway. Patient has no complaints at this time. -Description of Assault: Patient was in her room, male said he wanted to do sex patient said, get outta here. He took his and her clothes off. She stated this occurred at another facility. Asked to clarify and then said In my room. Patient was asked multiple times and in different ways if there was penile penetration, patient denies each time. (vaginally, orally, anally). Staff CNA at nursing home walked in and found male on top of the patient. She stated that male was undressed and patient undressed waist down. CNA told male to leave room and get dressed. Male got up, left, dressed, and was escorted to a different hallway in facility. Nursing Home Facility called and reported incident to the SA and called law enforcement to report. -Activities Following the Assault: Patient account: I told him get off, get off. Some people walked in and said get outta there. He dressed up and got outta the room. Patient was brought to ED for assessment. Interviewed by SANE RNs and law enforcement. Brother called and consent was obtained for external exam done and to defer the internal exam. -Assessment of General Appearance Note Full body skin assessment performed with unremarkable findings. Adult brief observed to be clean and free from bloody/bodily fluids. In an interview on 7/26/23 at 12:25 PM, Resident #11 reported that Resident #5 came into her room several times and was combative. The resident yelled down the hall for someone to get the resident out of her room. When she tried to corral her towards the door, the resident came at her in a threatening way. Resident #11 did not see her be sexually inappropriate but she felt she could be. Resident #11 stated she told whoever was in charge that she couldn't sit with her because she made her uncomfortable. She stated the resident would come into her room and sit on the sofa and look at her and it was creepy and made her uncomfortable. In undated, untitled documents the following residents reported they did not feel safe because Resident #5 wandered into their rooms: 1. Resident #13 2. Resident #10 3. Resident #11 In an interview on 7/26/23 at 1:17 PM, the resident's brother reported that he was not informed of the 1/24/23 incident or any other incidents of inappropriate sexual behavior or the resident's issues wandering. He stated he was informed by the facility of the incident of sexual abuse that occurred 7/17/23. In an interview on 7/26/23 at 2:16 PM, the DON reported that the residents involved in the incident she charted on 1/24/23 were Residents #4 and #5. She stated she knew the residents were confused and that their families did not give approval for them to have sexual behavior at the facility. She stated she reported the incident to the facility Administrator who advised her that the incident did not need to be investigated. The Progress Note for Resident #5 lacked documentation of any incident on 1/24/23 of a sexual interaction with a male resident. The Progress Note is in the clinical record for Resident #4. 4. The MDS dated [DATE] for Resident #6 revealed a BIMS score of 12 out of 15 which indicated moderately impaired cognition. The MDS revealed the resident had diagnoses of history of malignant neoplasm of bronchus and lung (lung cancer), and malignant neoplasm of supraglottis (throat cancer). The Progress Notes for Resident #6 documented the following: On 7/17/23 at 10:30 PM aide (CNA) called nurses station to have nurse come to room [ROOM NUMBER] (Resident #5's room) at 10:18 PM. Upon entering room found Resident #6 siting in his wheelchair. CNA reported inappropriate sexual incident between the residents. Nurse delegated one CNA to stay with female resident in room and nurse took Resident #6 back to nurses station. Completed assessment with no injury noted and contacted the DON, ADON and Administrator. Moved resident to 115 consented to move and put on half hourly checks. No signs of psycho-social distress, he was not crying, agitated or verbally or physically aggressive. Res was compliant and cooperative with staff and followed directions without incident. Staff continued half hour checks on resident throughout remainder of shift and report given to day nurse on incident. On 7/19/23 at 1:12 AM resident has been 1:1 with staff -out to main lounge with staff to watch TV and just be out of his room. Head down-moving slow tonight-Stated he was told he could have company today and the sheriff came. Nothing more said. On 7/19/23 at 7:59 AM resident refused breakfast this morning after resident stated he doesn't feel like getting out of bed. administrator asked resident if he was feeling ok resident stated no he is feeling depressed. SW will follow up with any new concerns. On 7/21/23 at 10:48 AM SW spoke with this resident today. SW counseled resident on inappropriate behaviors. Resident stated to this social worker that he is very sorry he knows what he did was wrong and that if he could take it back, he would in a heartbeat and won't ever do it again. In an interview on 7/25/23 at 4:19 PM, the resident reported he was walking the hall the evening of 7/17/23 when Resident #5 stopped him and told that she loved him and that she wanted to try him. The resident reported that he hadn't had sex in five to six years and thought he would try to even though he has erectile dysfunction. He stated he was unable to penetrate Resident #5's vagina. A CNA found them trying to have sex and he was moved to his current room. Reported he has had staff with him a lot and that they needed to stop with the increased supervision because he didn't like it. The resident reported that if he knew what would happen, he never would have took Resident #5 up on her offer. 5. The MDS dated [DATE] for Resident #10 revealed a BIMS score of 15 out of 15 which indicated intact cognition. The resident had diagnoses of non-traumatic brain dysfunction, Parkinson's disease and cerebrovascular accident (CVA), TIA (Transient Ischemic Attack), or stroke. In an undated, untitled document, the resident reported he did not feel safe at the facility because Resident #5 came into his room often at night and that she comes and goes into his room whenever she feels like it. In an interview on 7/27/23 at 10:59 AM, the resident reported that Residents #3 and #5 wander into his room during the night, this interferes with his ability to sleep, and he is scared of what they might do to him while he's sleeping. He stated he told management who said they would talk to the two residents, but the wandering continued. The Progress Note for the resident on 7/27/23 at 12:15 PM revealed: Physician seen resident today on rounds, resident stated concerns of not sleeping well lately, New order for Melatonin 5mg PO (oral) HS (every bedtime) PRN (as needed). Added to MAR (Medication Administration Record), resident aware POA (Power of Attorney) called, voice mail left. The MAR for July 2023 revealed an order dated 7/27/23 for Melatonin oral tablet, 5 milligrams (mg) every HS as needed for trouble with sleep. The Behavior Health Services policy dated 7/23 revealed: 1. Residents of our community will receive necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and care plan. 2. Highest practicable physical, mental, and psychosocial well-being : The highest possible level of functioning and well-being, limited by the individual's recognized pathology and normal aging process. Highest practicable is determined through comprehensive resident assessment and by recognizing and competently and thoroughly addressing the physical, mental or psychosocial needs of the individual. 3. Identify the population of the following residents in the facility assessment. Those with with Mental disorders; Psychosocial disorders, or Substance use disorders (SUD), and those with a history of trauma and/or post traumatic stress disorder (PTSD). 4. Assess the resident upon admission, and at least quarterly and with change in condition, utilizing the available PASARR (Preadmission Screening and Resident Review), the MDS and other assessments available, for needed behavioral services that include: Necessary care and services that are person centered to reflect the resident's goals for care, while maximizing their dignity, autonomy, privacy, socialization, independence, choice and safety. 5. Review the assessment, diagnoses and treatment ordered by qualified behavioral health professionals, such as physicians including psychiatrists or neurologists and resulting evidenced based interventions. 6. Assess residents with mental or psychosocial adjustment difficulty, or have a history of trauma and/or PTSD for necessary care and services, appropriate person-centered care plan and individualized treatment to meet their needs. 7. Interview the resident or representative for history and prior level of functioning. 8. Interview and evaluate the resident or representative for stressors or triggers and address on care plan. Evaluate the frequency, urgency, intensity, duration, and impact of the resident's expressions or indications of distress as well as the location, surrounding or situation in which they occurred. 9. Review physician orders for use of medications for behavioral issues and consultations to behavioral health services. 10. Convene an IDT and create a person centered plan of care to support # 1, 2, 3 and 4 above. 1. Apply a person centered approach to care which includes knowledge of each individuals' daily routine, lifelong patterns, lifestyles, interests, preferences, and choices. 12. Revise the plan of care at least quarterly and with change in condition. 13. Interact and communicate with residents in a manner that promotes mental and psychosocial well-being. 14. Provide meaningful activities, including those that address the resident's customary routines, interests and preferences, which promote engagement and positive meaningful relationships between residents, staff, families and other resident in the community. Note, residents living with mental health and SUD's may require different activities based upon their assessment. 15. Provide and atmosphere and environment that is conducive to mental and psychosocial well-being. 16. Utilize non-pharmacological interventions for behaviors prior to initiating pharmacological interventions, for example: Adequate hydration and nutrition; Exercise and pain relief; Individualized sleep and dining routines including schedules for use of the bathroom; Dietary interventions such as increasing fiber to prevent and reduce constipation; Adjusting the environment to be more individually preferred and homelike (soft lights, preventing glare; unobstructed pathways, eliminating overhead paging); Consistent staff; Individualized and meaningful activities based upon lifelong interests or activity patterns; Music, art, massage, or aromatherapy, reminiscing, electronics, computers, essential oils; Providing activities out of doors in sunshine and fresh air; Activities that support the resident's spiritual needs; Meditation, yoga and associated physical activity; Activities that decrease stress and increase awareness of actual surroundings, for example verbal reassurance, Access to therapies, such as psychotherapy, behavior modification, cognitive behavioral therapy; problem solving therapy; Providing de-escalating and coping skills; and Assisting to find programs to assist with substance abuse counseling 17. Assess through the admissions and MDS process upon admission, quarterly and with condition change for individualized behavioral health needs and address the following common disorders: Depression, Anxiety and Anxiety Disorders, Schizophrenia; Bi-Polar Disorders; Substance Abuse Disorders, and PTSD. 18. Provide competency based education for the direct care staff as outlined in the facility assessment, MDS Data, resident assessments, individual plans of care and needs of residents as a whole for those with a history of trauma and/or post-traumatic stress disorder. Include education at a minimum on specific mental disorders, psychosocial disorders, PTSD or substance abuse disorders (as determined by the community need). 19. Provide competency based education and implement procedures on the use of non-pharmacological interventions listed above. 20. Provide competency based education for non-direct care staff, whom may assist residents with behavioral health needs, based upon the facility population and need. 21. Document the resident's assessment of behavioral health [NAME] [TRUNCATED]

Based on clinical record review, family interview, resident interview, staff interview and facility policy review the facility failed to protect residents from alleged sexual abuse for 3 of 5 residents reviewed (Resident #4, #5, and #6). The State Agency (SA) informed the facility of the Immediate Jeopardy (IJ) on 7/27/23 at 2:00 PM that began as of 1/24/23 at 2:42 PM. The Facility Staff removed the immediacy on 7/28/23 through the following actions: a. On 7/18/23 Regional Director of Operations (RDO), Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Social Worker ad-hoc meeting to discuss potential root cause of occurrence. During the meeting a root cause analysis was performed regarding probable nonconsensual sexual activity between resident to resident and to identify areas of opportunity. Root cause analyis performed and determined to be related to poor decision making on Resident #6 behalf and inability for him to know that this resident had mental incapability. b. On 7/18/23 the following actions occurred: the families of Resident #5 and #6 were notified of the incident, Ombudsman notified, police notified, hospice for Resident #6 notified, incident was reported to state agency, Medical Director ordered Resident #5 to go to Emergency Department for evaluation and treatment with the order completed as directed, and Resident #5 had psychiatric evaluation. c. On 7/27/23 Administrator called state agency to report the incident that occurred on 1/24/23. Administrator initiated ANE (Elder Abuse and Exploitation) training to include behavior training and non-pharmacological interventions. RCA (Root Cause Analysis) was completed on 7/28/23. Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held 7/28/23. d. As of 7/21/23 Resident #5 remains on 1:1. e. On 7/18/23 all residents with a BIMS (Brief Interview of Mental Status) of 13 or higher were interviewed for any distress with intervention put in place for the 1 resident with distress. Resident #10 stated that he did not like her coming into his room and no further complaints have been voiced. All residents with a BIMS of 12 and below were assessed for signs and symptoms of distress, crying, agitation, verbal or physical aggression with none noted. f. On 7/28/23 Regional Director re-educated the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Social Worker on abuse, resident rights, Elder Justice Act, The National Consumer Voice for Quality Long Term Care Sexual Abuse in Nursing Homes. g. Beginning 7/18/23 staff was re-educated on abuse, resident rights, Elder Justice Act, The National Consumer Voice for Quality Long Term Care Sexual Abuse in Nursing Homes. All staff including agency have completed the required Allegations of Compliance in-services. Employees will not be able to accept a work assignment until the in-services are completed. New hires and employees on LOA (Leave of Absence) will not be placed on the schedule until the in-services are completed. h. Beginning on 7/18/23, in addition, Licensed Nurses and Interdisciplinary Team (IDT) will be educated on monitoring the effectiveness of interventions as they related to inappropriate sexual behavior for 5 days after an alleged incident. IDT will monitor by discussing at morning meeting. Licensed Nurses will document effectiveness of interventions on MAR (Medication Administration Record) for 5 days each shift. i. DON/designee will audit MARs each shift for 5 days after interventions are in place. Monitoring will continue for 8 weeks, then monthly for 3 months. LNHA (Licensed Nursing Home Administrator) will report findings in QAPI meetings monthly for 3 moths or until a period of compliance is achieved. j. LNHA will submit all reports of alleged abuse weekly to RDO to review to ensure the process meets regulatory guidelines. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed a Brief Interview of Mental Status (BIMS) score of 4 out of 15 which indicated severely impaired cognition. The MDS documented a diagnoses to include amnesia. The Care Plan for Resident #4 revised on 2/6/23 documented the resident has a behavior problem (having multiple episodes) related to unrealistic expectations. The Care Plan directed staff as follows: -Anticipate and meet the resident needs. -Caregivers to provide opportunity for positive interaction, attention, stop and interact as passes by. -Monitor behavior episodes and attempt to determine underlying cause. The Care Plan dated 6/9/23 documented the resident has the potential to be verbally aggressive related to the aging process/confusion. The Care Plan directed staff as follows: -Assess and anticipate resident needs. -Give the resident as many choices as possible about care and activities. The Care Plan lacked any indication of sexual behaviors. The Progress Note for Resident #4 documented the following: On 1/24/23 at 12:12 PM the Director of Nursing (DON) went to a female resident room to inform her that it was lunch time. Upon entering the room, Resident #4 was leaning over female residents bed, groping the females breasts and kissing her intimately. The DON informed the resident to leave her room and asked the female resident if she was okay and if she had consented to that encounter. The female did nod her head yes. The DON went to residents room and educated him on the importance of consent and explained that some people may not be able to make proper decisions for themselves. Fax sent to Primary Care Provider (PCP) to update. Residents daughter also notified of encounter. In an interview on 7/26/23 at 11:18 AM, the resident's daughter reported that the resident was accused of touching a female resident, the resident has always been lovey in behavior. She stated the facility hasn't informed her that anything has happened between this resident and other residents since the new company took over in 11/22. In an interview on 7/26/23 at 2:31 PM, Staff A, CNA, reported that the resident's nickname among staff was Captain [NAME] Pants, because he can get inappropriate with staff. She stated the staff remind him to behave and he hasn't been an issue since before the beginning of May. She added before that he was touchy feely. She stated he would sit on the couch and grope female residents but he never would go past first base. She stated he would touch them outside of their clothes and would touch their breasts outside of their clothes. The aide stated she remembered him with Resident #3 touching her at times. She stated they separated them and redirected them. In an interview on 7/26/23 at 2:16 PM, the DON when she observed the 2 residents involved in the sexually inappropriate behavior on 1/24/23, she knew the residents were confused, and they were easily separated and redirected. The DON reported that the 2 residents were not able to consent to sexual activity and that their families did not give consent for the residents to engage in sexual activity. The DON reported that she talked to previous Administrator about the incident on 1/24/23. 2. The MDS dated [DATE] for Resident #5 revealed the resident had short term and long term memory problems, had severely impaired cognitive skills for daily decision making, and had inattention and disorganized thinking behavior present that fluctuates. The MDS documented diagnoses to include non-traumatic brain dysfunction, Alzheimer's disease, and schizophrenia. The Care Plan revised on 7/20/23 for Resident #5 documented the resident is at risk for wandering and elopement related to impaired safety awareness. The Care Plan directed staff as follows: -Ensure a safe distance from other residents who have a tendency to become agitated with her actions. -Follow facility elopement policy and procedures. -Identify pattern of wandering: purposeful, aimless or escapist; looking for something; or need more exercise? -Monitor location with one on one supervision at all times. Document wandering behaviors and attempted diversion interventions. The Care Plan revised on 7/31/23 for Resident #5 documented the resident has a behavior problem of sitting on the floor and going into other resident's rooms related to cognitive impairment. The Care Plan directed staff as follows: -Anticipate and meet the resident's needs. -Caregivers to provide opportunities for positive interaction, attention, and to stop and interact as passes by. -Psyche referral as needed for behavior and medication management. The Care Plan lacked any indication of sexual behavior. The Progress Notes for the resident documented the following: On 7/17/23 at 10:29 PM CNA paged nurse to resident's room. CNA reported to this nurse that she had walked in on resident and another resident during an inappropriate act. CNA had already started to separate residents and this nurse took the other resident out of the room and delegated cna to stay with Resident #5 until nurse could get back and perform assessment. Male resident escorted to nurses station and this nurse went back to resident's room. Skin assessment completed along with psycho-social eval completed. resident stated to this nurse when asked if she was okay with what happened and she stated she didn't mind it. Skin assessment revealed no skin breaks, marks or vaginal bleeding. Resident stated that she was not injured or hurt. Resident was not showing any obvious signs of being upset or distressed, not crying or agitated. She was not verbally or physically aggressive. Half hour checks completed by staff on resident to ensure safety. Resident found to be wandering a few times and redirected back to her room. Contacted Administrator, DON and ADON immediately after incident at approx 10:21 PM after separating the residents. On 7/18/23 at 9:39 AM DON and ADON spoke with resident's brother at 9:32 AM. DON updated brother on incident between resident and a male resident. Brother stated that he wanted facility to do what they think is right and make sure his sister is okay. Brother aware and gave consent for resident to be seen at local hospital for evaluation per orders from the resident's physician that were received at 9:39 AM. The ED (Emergency Department) Provider Note for the resident signed by a physician on 7/18/23 at 11:32 AM documented the following: -Per staff report, another resident went into patient's room, took off his clothes, and laid on top of her. SANE (Sexual Assualt Nurse Examiner) nurse reports patient denied sexual intercourse. She stated patient told him to stop, then CNA walked by room. CNA reports telling other resident to leave room. Per CNA report, he left patient's room and was sent to a different hallway. Patient has no complaints at this time. -Description of Assault: Patient was in her room, male stated he wanted to do sex, patient stated, get outta here. He took his and her clothes off. She stated this occurred at another facility. Asked to clarify and then she stated it happened in her room. Patient was asked multiple times and in different ways if there was penile penatration, patient denies each time. (vaginally, orally, anally). Staff CNA at the nursing home walked in and found male on top of the patient. She stated that male was undressed and patient undressed waist down. CNA told male to leave room and get dressed. Male got up, left, dressed, and was escorted to a different hallway in facility. Nursing Home Facility called and reported incident to SA and called law enforcement to report. -Activities Following the Assault: Patient account: I told him get off, get off. Some people walked in and said get outta there. He dressed up and got outta the room. Patient was brought to ED for assessment. Interviewed by SANE RNs and law enforcement. Brother called and consent was obtained for external exam done and to defer the internal exam. -Assessment of General Appearance Note Full body skin assessment performed with unremarkable findings. Adult brief observed to be clean and free from bloody/bodily fluids. In an interview on 7/26/23 at 12:25 PM, Resident #11 reported that Resident #5 came into her room several times and was combative. Resident #11 yelled down the hall for someone to get the resident out of her room. When she tried to corral her towards the door, Resident #5 came at her in a threatening way. Resident #11 did not see her be sexually inappropriate but stated she felt she could be. She stated the way Resident #5 looked at her made her uncomfortable. She stated she told whoever was in charge that she couldn't sit with her because she made her uncomfortable. She stated Resident #5 came into her room and sat on the sofa and the way she looked at her made her uncomfortable. She stated the resident invited her to her room too. In an interview on 7/26/23 at 1:17 PM, the resident's brother reported that he was not informed of the incident on 1/24/23 of a sexual interaction with another male resident or any other incidents of inappropriate sexual behavior. He was only informed by the facility of the incident of sexual abuse that occurred 7/17/23. In an interview on 7/26/23 at 2:16 PM, the DON stated when she observed Resident #4 and Resident #5 involved in the sexually inappropriate behavior on 1/24/23, she knew the residents were confused, and they were easily separated and redirected. The DON reported that the two residents were not able to consent to sexual activity and that their families did not give consent for the residents to engage in sexual activity. The DON reported that she talked to previous Administrator about the incident on 1/24/23. 3. The MDS dated [DATE] for Resident #6 revealed a BIMS score of 12 out of 15 which indicated moderately impaired cognition. The MDS revealed the resident had diagnoses of history of malignant neoplasm of bronchus and lung (lung cancer), and malignant neoplasm of supraglottis (throat cancer). The Progress Notes for Resident #6 documented the following: On 7/17/23 at 10:30 PM aide (CNA) called nurses station to have nurse come to room [ROOM NUMBER] (Resident #5's room) at 10:18 PM. Upon entering room found Resident #6 siting in his wheelchair. CNA reported inappropriate sexual incident between the residents. Nurse delegated one CNA to stay with female resident in room and nurse took Resident #6 back to nurses station. Completed assessment with no injury noted and contacted the DON, ADON and Administrator. Moved resident to 115 consented to move and put on half hourly checks. No signs of psycho-social distress, he was not crying, agitated or verbally or physically aggressive. Res was compliant and cooperative with staff and followed directions without incident. Staff continued half hour checks on resident throughout remainder of shift and report given to day nurse on incident. On 7/19/23 at 1:12 AM resident has been 1:1 with staff -out to main lounge with staff to watch TV and just be out of his room. Head down-moving slow tonight-Stated he was told he could have company today and the sheriff came. Nothing more said. On 7/19/23 at 7:59 AM resident refused breakfast this morning after resident stated he doesn't feel like getting out of bed. administrator asked resident if he was feeling ok resident stated no he is feeling depressed. SW will follow up with any new concerns. On 7/21/23 at 10:48 AM SW spoke with this resident today. SW counseled resident on inappropriate behaviors. Resident stated to this social worker that he is very sorry he knows what he did was wrong and that if he could take it back, he would in a heartbeat and won't ever do it again. In an interview on 7/25/23 at 4:19 PM, the resident reported he was walking the hall the evening of 7/17/23 when Resident #5 stopped him and told him that she loved him and that she wanted to try him. The resident reported that he hadn't had sex in five to six years and thought he would try to even though he has erectile dysfunction. He stated he was unable to penetrate Resident #5's vagina. A CNA found them trying to have sex and he was moved to his current room. Reported he has had staff with him a lot and that they needed to stop with the increased supervision because he didn't like it. The resident reported that if he knew what would happen, he never would have took Resident #5 up on her offer. The Physician Progress Notes on 7/17/23 at 10:18 PM revealed a witness statement signed by Staff B, CNA, that documented the following: I was passing my waters when I walked into Resident #5's room and saw Resident #6 on top of Resident #5/inside the resident. Resident #6 had zero clothes on, Resident #5 was only undressed from the waist down. When opening the door Resident #6 was mid-thrust when both residents turned to look at me (Staff B). While in shock, I very calmly asked Resident #6 to please get off of her. I then proceeded to pull out my phone to call the nurse and tell her to get down to Resident #5's room. The nurse and another staff member got to the room in about 10 seconds; which was how long it took Resident #6 to follow directions and get dressed. Resident #6 then followed the nurse to the nurse's station, the staff member stayed with Resident #5, and I continued to pass waters. In an interview on 8/2/23 at 5:04 PM, Staff B reported that while she was passing waters, she got to Resident #5's room and saw Resident #6 in mid thrust while he was lying on top of Resident #5. She called the nurse and while she waited for the nurse to arrive, Resident #6 got dressed. During the night, Resident #5 started wandering, looking for Resident #6's room, when she saw that Resident #6 was not in his room, she wandered the facility trying to find Resident #6. Resident #5 wandered a lot for her normal behavior. The Abuse Prevention Program dated 7/23 revealed: 1. Reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 2. Residents will protected from further abuse, neglect, exploitation or mistreatment while the investigation is in process. 3. Should an incident or suspected incident of resident abuse, mistreatment, misappropriation, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 4. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; g. Interview the resident's roommate, family members, and visitors, as able or as appropriate to the situation; h. Review all events leading up to the alleged incident. 5. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 8. The results of the investigation will be recorded on approved documentation forms. 9. The investigator will give a copy of the completed documentation to the Administrator. 10. The Administrator will inform the resident and his/her representative (sponsor) of the results of the investigation and corrective action taken. 11. The Administrator will report all alleged and final abuse investigations to the state agency per state guidelines. 12. Should the abuse rise to the level of a crime, follow reporting guidelines in Reporting Abuse to State Agencies and Other Entities/Individuals 13. Inquiries concerning abuse reporting and investigation should be referred to the Administrator or to the Director of Nursing Services.

Based on clinical record review, family interview, resident interview, staff interview and facility policy review the facility failed to protect residents from alleged sexual abuse for 2 of 5 residents reviewed (Resident #4 and #5). The State Agency (SA) informed the facility on 7/27/23 at 2:00 PM of the Immediate Jeopardy (IJ) that began as of 1/24/23 at 2:42 PM. The Facility Staff removed the immediacy on 7/28/23 through the following actions: a. Root Cause Analysis was completed 7/28/23. Root Cause findings: Administrator did not report the incident to the appropriate agency within 2 hours. b. On 7/28/23 Regional Director re-educated the Director of Nursing (DON), Assistant Director of Nursing ADON), and Social Worker on abuse, resident rights, Elder Justice Act, The National Consumer Voice for Quality Long Term Care Sexual Abuse in Nursing Homes, and abuse reporting guidelines and investigations. c. LNHA (Licensed Nursing [NAME] Administrator), DON (Director of Nursing) and/or designee will monitor 24/72 hour report 5 times per week for any allegations of abuse. Evidence of monitor reports will be kept in a binder. Any negative findings will be reported to QAPI (Quality Assurance and Performance Improvement) weekly for 8 weeks, then monthly for 3 months. NHA (Nursing Home Administrator) will report findings in QAPI monthly for 3 months or until a period of compliance is achieved. d. LNHA or DON will monitor and audit all reports of alleged abuse and missing residents are investigated thoroughly. RDO/designee will review alleged abuse and elopement investigations after completion by NHA per occurrence. RDO/designee will monitor weekly for 8 weeks, then monthly for 3 months. NHA will report findings in QAPI weekly for 8 then monthly for 3 months. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed a Brief Interview of Mental Status (BIMS) score of 4 out of 15 which indicated severely impaired cognition. The MDS documented a diagnoses to include amnesia. The Care Plan for Resident #4 revised on 2/6/23 documented the resident has a behavior problem (having multiple episodes) related to unrealistic expectations. The Care Plan directed staff as follows: -Anticipate and meet the resident needs. -Caregivers to provide opportunity for positive interaction, attention, stop and interact as passes by. -Monitor behavior episodes and attempt to determine underlying cause. The Care Plan dated 6/9/23 documented the resident has the potential to be verbally aggressive related to the aging process/confusion. The Care Plan directed staff as follows: -Assess and anticipate resident needs. -Give the resident as many choices as possible about care and activities. The Care Plan lacked any indication of sexual behaviors. The Progress Note for Resident #4 documented the following: On 1/24/23 at 12:12 PM the Director of Nursing (DON) went to a female resident room to inform her that it was lunch time. Upon entering the room, Resident #4 was leaning over female residents bed, groping the females breasts and kissing her intimately. The DON informed the resident to leave her room and asked the female resident if she was okay and if she had consented to that encounter. The female did nod her head yes. The DON went to residents room and educated him on the importance of consent and explained that some people may not be able to make proper decisions for themselves. Fax sent to Primary Care Provider (PCP) to update. Residents daughter also notified of encounter. On 1/30/23 at 9:12 PM the resident continues on increase dose of Namenda with no signs and symptoms of any adverse reactions noted, multiple behaviors noted tonight- found trying to get resident from room [ROOM NUMBER] (Resident #5) to let him go up under her shirt-this nurse separated them-yelling about taking his pill-why does he have to take them-yelling about blanket-staff went immediately downstairs to get it stood shouting and stomping at nurse's station until she got back up stairs with it. On 3/23/23 at 2:42 PM Care Plan Meeting: attended ADON, SSD (Social Services Director), Activity Director, resident's daughter , resident. Discussed residents care, wt at 139, daughter please resident is starting to gain some. resident c/o (complained of) staff telling resident not to sit too close to female residents staff discussed resident inappropriately touching other residents at times. No other concerns at this time. Plan is for resident to remain in facility contrary to residents belief, daughter is unable to provide the care he needs. Family has no concerns at this time. On 4/9/23 at 2:48 PM resident touching a female resident thigh and rubbing her shoulders and kissed her. On 4/16/23 6:19 PM resident sitting on couch in lounge, seen trying to get his hands up underneath another resident shirt. Residents separated, and he went to his room, yelling about it being cold in here. In an interview on 7/26/23 at 11:18 AM, the resident's daughter reported that the resident was accused of touching a female resident, the resident has always been lovey in behavior. She stated the facility hasn't informed her that anything has happened between this resident and other residents since the new company took over in 11/22. In an interview on 7/27/23 at 1:16 PM Resident #12 reported that she has observed the resident touch Resident #3's breast and genitals. Resident #12 has observed the resident take his penis out of his slacks and Resident #3 touched the resident's penis. Resident #12 reported that she saw this before the resident had COVID in 4/23. In an interview on 7/26/23 at 2:31 PM, Staff A, CNA, reported that the resident's nickname among staff was Captain [NAME] Pants, and he can get inappropriate with staff. She stated staff remind him to behave. She stated he hasn't had any issues since before the beginning of May but before that he was touchy feely. He would sit on the couch and grope female residents. She stated he never would go past first base, he would touch them outside of their clothes including their breasts. She stated she remembered him with Resident #3 touching her at times. She stated staff separated them and redirected them. In an interview on 7/26/23 at 2:16 PM, the DON reported that the other resident involved in the 1/24/23 incident was Resident #5. She stated she talked to the previous Administrator about the incident on 1/24/23 and was informed the incident didn't need to be reported to the SA. She stated she didn't know they had to be reported. 2. The MDS dated [DATE] for Resident #5 revealed the resident had short term and long term memory problems, had severely impaired cognitive skills for daily decision making, and had inattention and disorganized thinking behavior present that fluctuates. The MDS documented diagnoses to include non-traumatic brain dysfunction, Alzheimer's disease, and schizophrenia. The Care Plan revised on 7/20/23 for Resident #5 documented the resident is at risk for wandering and elopement related to impaired safety awareness. The Care Plan directed staff as follows: 1. Ensure a safe distance from other residents who have a tendency to become agitated with her actions. 2. Follow facility elopement policy and procedures. 3. Identify pattern of wandering: purposeful, aimless or escapist; looking for something; or need more exercise? 4. Monitor location with one on one supervision at all times. Document wandering behaviors and attempted diversion interventions. The Care Plan revised on 7/31/23 for Resident #5 documented the resident has a behavior problem of sitting on the floor and going into other resident's rooms related to cognitive impairment. The Care Plan directed staff as follows: 1. Anticipate and meet the resident's needs. 2. Caregivers to provide opportunities for positive interaction, attention, and to stop and interact as passes by. 3. Psyche referral as needed for behavior and medication management. The Care Plan lacked any indication of sexual behavior. The Progress Notes for the resident documented the following: On 6/10/23 at 3:46 PM multiple residents approached nurse to express concern d/t (due to) resident being in their rooms while they were not. Resident had multiple different candy items that she was hiding and eating which were not hers. Resident also walked by medication cart and stole applesauce in the middle of medication pass. Resident educated but ineffective as resident continued with behavior throughout the whole shift. On 7/17/23 at 10:29 PM CNA paged nurse to resident's room. CNA reported to this nurse that she had walked in on resident and another resident during an inappropriate act. CNA had already started to separate residents and this nurse took the other resident out of the room and delegated cna to stay with Resident #5 until nurse could get back and perform assessment. Male resident escorted to nurses station and this nurse went back to resident's room. Skin assessment completed along with psycho-social eval completed. resident stated to this nurse when asked if she was okay with what happened and she stated she didn't mind it. Skin assessment revealed no skin breaks, marks or vaginal bleeding. Resident stated that she was not injured or hurt. Resident was not showing any obvious signs of being upset or distressed, not crying or agitated. She was not verbally or physically aggressive. Half hour checks completed by staff on resident to ensure safety. Resident found to be wandering a few times and redirected back to her room. Contacted Administrator, DON and ADON immediately after incident at approx 10:21 PM after separating the residents. On 7/18/23 at 9:39 AM DON and ADON spoke with resident's brother at 9:32 AM. DON updated brother on incident between resident and a male resident. Brother stated that he wanted facility to do what they think is right and make sure his sister is okay. Brother aware and gave consent for resident to be seen at local hospital for evaluation per orders from the resident's physician that were received at 9:39 AM. The ED (Emergency Department) Provider Note for Resident #5 signed by a physician on 7/18/23 at 11:32 AM revealed: -Per staff report, another resident went into patient's room, took off his clothes, and laid on top of her. SANE (Sexual ASSUALT Nurse Examiner) nurse reports patient denied sexual intercourse. She states patient told him to stop, then CNA walked by room. CNA reports telling other resident to leave room. Per CNA report, he left patient's room and was sent to a different hallway. Patient has no complaints at this time. -Description of Assault: Patient was in her room, male said he wanted to do sex patient said, get outta here. He took his and her clothes off. She stated this occurred at another facility. Asked to clarify and then said In my room. Patient was asked multiple times and in different ways if there was penile penetration, patient denies each time. (vaginally, orally, anally). Staff CNA at nursing home walked in and found male on top of the patient. She stated that male was undressed and patient undressed waist down. CNA told male to leave room and get dressed. Male got up, left, dressed, and was escorted to a different hallway in facility. Nursing Home Facility called and reported incident to the SA and called law enforcement to report. -Activities Following the Assault: Patient account: I told him get off, get off. Some people walked in and said get outta there. He dressed up and got outta the room. Patient was brought to ED for assessment. Interviewed by SANE RNs and law enforcement. Brother called and consent was obtained for external exam done and to defer the internal exam. -Assessment of General Appearance Note Full body skin assessment performed with unremarkable findings. Adult brief observed to be clean and free from bloody/bodily fluids. In an interview on 7/26/23 at 12:25 PM, Resident #11 reported that Resident #5 came into her room several times and was combative. The resident yelled down the hall for someone to get the resident out of her room. When she tried to corral her towards the door, the resident came at her in a threatening way. Resident #11 did not see her be sexually inappropriate but she felt she could be. Resident #11 stated she told whoever was in charge that she couldn't sit with her because she made her uncomfortable. She stated the resident would come into her room and sit on the sofa and look at her and it was creepy and made her uncomfortable. In an interview on 7/26/23 at 1:17 PM, the resident's brother reported that he was not informed of the 1/24/23 incident or any other incidents of inappropriate sexual behavior or the resident's issues wandering. He stated he was informed by the facility of the incident of sexual abuse that occurred 7/17/23. In an interview on 7/26/23 at 2:16 PM, the DON reported that the residents involved in the incident she charted on 1/24/23 were Residents #4 and #5. She stated she knew the residents were confused and that their families did not give approval for them to have sexual behavior at the facility. She stated she reported the incident to the facility Administrator who advised her that the incident did not need to be investigated. The Progress Note for Resident #5 lacked documentation of any incident on 1/24/23 of a sexual interaction with a male resident. The Progress Note is in the clinical record for Resident #4. The facility policy Compliance with Reporting Allegations of Abuse/Neglect/Exploitation with revision date of 7/23 revealed: 1. The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. 2. New employees will be educated by the department manager, or designee, on issues related to abuse prohibition practices and abuse reporting requirements during initial orientation. Annual education and training will be provided to all existing employees. Front line supervisors will provide education as situations arise. 3. The facility will identify events, occurrences, patterns and trends that may constitute: sexual Abuse, the non-consensual sexual contact of any type with a resident. 4. Alleged violation: A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property 5. Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedure for reporting/response as described below. 6. Protection: The facility will protect residents from harm during an investigation. 7. The Licensed Nurse will: a. Respond to the needs of the resident and protect him/her from further incident. b. Remove the accused employee from resident care areas. c. Notify the Administrator or designee. d. Notify the attending physician, resident's family/legal representative, and Medical Director. e. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. f. Document actions taken in the medical record. g. Complete an incident report is indicated. h. Revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

Based on observation, clinical record review, facility policy review, and staff interview, the facility failed to provide care consistent with professional standards of practice, to prevent pressure ulcers and provide necessary treatment and services to promote healing of a pressure ulcer for 1 of 1 resident reviewed (Resident #1). The facility reported a census of 32 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Findings Included: Resident #1's Minimum Data Set (MDS) dated [DATE] listed an admitted [DATE]. The MDS identified a Brief Interview of Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. The MDS included diagnoses of medically complex conditions of peripheral vascular disease, diabetes mellitus, psychosis and above the knee amputee of the right and left leg. The MDS indicated Resident #1 required extensive assistance of two plus persons for bed mobility, total dependency for transfers and used a wheelchair for a mobile device. The MDS documented the resident did not have any unhealed pressure ulcers/injuries on admission. The Baseline Care Plan dated 3/3/23 identified Resident #1 presented to the facility with skin integrity issues. The care plan also documented the resident required two plus persons for bed mobility, transfers and used a wheelchair for mobility. The care plan lacked documentation of the specified skin integrity issue and interventions to prevent a pressure ulcer. The Skin Observation Tool dated 3/3/23 identified Resident #1 did not present with a buttock wound upon admission to the facility. The Task List Report for Resident #1 initiated on 3/3/23 documented the Certified Nurse's Aides (CNA ' s) as assigned to observe skin every shift. The Braden Scale Assessment for Predicting Pressure Sore Risk for Resident #1 dated 3/3/23 and 3/10 indicated moderate risk for pressure ulcers. The Braden Scale Assessment for Predicting Pressure Sore Risk for Resident #1 dated 3/11/23 indicated high risk for pressure ulcers. The Progress Notes for Resident #1 documented the following: On 3/3/23 at 10:24 PM redness noted to buttocks, incontinent of bowel, cannot tell when she has to go, and uses a bed pan. On 3/6/23 at 11:31 AM the Registered Dietician initial assessment documented the only skin issues as a scabbed area to her left wrist and bruising to her right antecubital area. On 3/12/23 at 9:51 AM staff identified multiple small opened skin areas on the left and right buttock, and a large open area on the right buttock that measured 3 centimeters (CM) by 2.5 CM and had a small amount of green drainage. Areas cleaned and a foam dressing applied. The Progress Notes lacked any other documentation of skin assessments or open areas prior to 3/12/23. On 3/20/23 at 2:01 PM resident's buttocks continue to worsen. Daughter informed staff the resident has a sensitivity to all dressings. Area left open to air and fax to provider. On 3/20/23 at 5:10 PM orders received to discharge home. Review of the clinical record revealed staff failed to assess and intervene related to skin breakdown of the buttock area prior to the formation of the pressure ulcer that measured 3 CM by 2.5 CM when first documented on 3/12/23. The Treatment Administration Record showed Resident #1 received a foam border dressing to the buttock on 3/12/23. The Fax (facsimile) Cover Sheet dated 3/12/23 for Resident #1 signed by a physician included an order to continue with foam dressing changes to the wound on the buttock. The order lacked a dressing change frequency, interventions or further skin care services. Review of the chart failed to show nursing requests or clarifications orders for 3/12/23. The Skilled Charting dated 3/13/23 for Resident #1 documented staff identified a pressure wound to the left buttock. The documentation lacked any measurements or characteristics and documented a dressing change not required. The Treatment Administration Record showed Resident #1 received a foam border dressing to the buttock on 3/18/23. The Weekly Skin assessment dated [DATE] documented the presence of a wound to the left buttock but lacked measurements or any other characteristics. The Weekly Skin assessment dated [DATE] documented the left buttock appears that the area is getting bigger where the bandage is covering the wound. The assessment lacked measurements or any other characteristics. Review of the clinical record revealed the facility failed to implement interventions after the discovery of the buttock pressure ulcer. The Pressure Injury Prevention Guidelines dated July 2023 identified the policy is to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence- based interventions for all residents who are assessed at risk or who have a pressure injury. Policy Explanation and Compliance Guidelines identify individualized interventions that will address specific factors identified in the resident's risk assessment, skin assessment and any pressure injury assessment. Interventions will be implemented in accordance with the physician's orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. Interventions will be documented in the care plan and communicated to all relevant staff. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include. In an interview on 07/27/23 at 2:44 PM, the Director of Nursing (DON), reported Resident #1 assessed to be a low risk for developing a pressure ulcer on admission. When asked how the resident developed the buttock wound, the DON stated, it was caused by moisture, unavoidable. When reminded that Resident #1's urinary catheter prevented moisture, and pointed out Resident #1's limited mobility and cognitive ability, the DON stated, she could see that. The DON reported staff should have called for clarification regarding frequency of wound care. When attempting to further discuss concerns the DON stated, the facility shouldn't have accepted her as an admit because there was a lot going on and she was gone around that time due to personal reasons. She stated things slipped through the cracks.

Based on observation, clinical record and facility policy review, and staff and resident interviews, the facility failed to provide adequate nursing supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for falls (Resident #26). The facility also failed to store a resident's smoking materials in a secured location for 1 of 2 residents reviewed who smoke (Resident #13). Resident #26's fall risk assessment and care plan identified the resident as at risk for falls due to a history of repeated falls and noncompliance. Resident #26 sustained his 5th fall in a two month period on 11/12/22 in his room where he hit his head and sustained a laceration to his right hand. The fall required a transfer to the emergency room and a hospital admission for a temporal epidural hematoma, sutures for the right hand laceration, and right temporal (head area) bone fracture. The facility reported a census of 34 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 10/3/22, Resident #26 exhibited moderately impaired decision-making abilities, signs and symptoms of delirium, inattention that fluctuates, and continuous disorganized thinking. The MDS identified Resident #26 required assist of one staff for transfers, toilet use, and ambulation (walking) using a walker, and included diagnoses of anemia, heart failure, hypertension, renal disease, dementia, edema, and hypothyroidism. Resident #26's Fall Risk Evaluations documented a total score of 45 points or above indicated a high risk for falls. Further review of the resident's Fall Risk Evaluations revealed the following results on the following dates: - The resident scored 65 points on 1/24/22 and 2/11/22. - The resident scored 80 points on 4/4/22, 7/4/22, and 10/3/22. - The resident scored 90 points on 1/2/23. The Care Plan revised on 01/03/23 documented Resident #26 fell related to poor balance and included the following information: a. Required assist of one for toilet use (09/08/22) Initiated 01/09/23 b. Bathroom door removed and replaced with a curtain (11/12/22) Initiated 12/7/22 c. Continue interventions on the at-risk plan (2/24/22) d. Educated resident and wife to use call light for assistance (9/27/22) Initiated 1/9/23 e. Gripper strips placed in front of the recliner (1/2/23) Initiated 01/09/23 f. Initiate neuro-checks per protocol (09/08/22) Initiated 01/09/23 g. Re-education provided to the resident's wife to use call light for assistance rather than asking her husband to help her (10/31/22) Initiated 01/09/23 h. Resident encouraged daily to use call light for bathroom help (3/31/22) Initiated 4/14/22 i. Sent to ED. Assist x 2 for transfers, walking, and toilet use upon return (12/28/22) Initiated 1/9/23 j. Sent to ED. Personal Safety Alarm applied to the recliner when the resident returned. (12/8/22) Initiated 12/14/22 k. Sign placed on walker. Please use our walker with you at all times (2/21/22) l. Tape shut batter door and place toward back of chair out of resident reach (1/9/23) An Incident Report (IR) dated 9/8/22 at 9:35 a.m. identified an unwitnessed fall in Resident #26's room. Staff found Resident #26 lay on his back on the floor and the resident reported he fell backwards. The IR lacked information regarding any safety measures the facility used prior to the incident. The post-fall assessment also lacked information regarding the appliance or devices the resident used for walking, any medications ingested prior to the fall, previous nursing measures taken to prevent falls, and information regarding whether or not the resident's cognitive status had changed recently. Resident #26's Progress Notes revealed the following entries: - On 09/08/22 at 9:44 a.m., Resident #26 lay on his back beside his recliner, head resting on his trash can, and a bump on the back of his head. - On 09/8/22 at 11:01 a.m., Resident #26 transferred to the emergency room for an evaluation because (the resident fell and) he was on a blood thinner. - On 09/08/22 at 2:39 p.m., Resident #26 returned to the facility with no new orders. The note lacked information related to an interventions the facility implemented after the fall occurred. An IR dated 9/8/22 at 6:05 p.m. documented as staff entered the resident's room, they witnessed Resident #26 tipped backwards and fell against the stool and table by the wall next to the doorway. The form revealed the resident had not used a walker at the time of the fall and directed staff provide assist of 1 with bathroom help as a new intervention. Review of Resident #26's progress notes revealed no documentation regarding the 09/08/22 incident at 6:05 p.m. and no care plan update to reflect the change in assistance with toilet use. An IR dated 9/27/22 at 9:50 a.m. identified staff found Resident #26 on his buttocks in front of the door and sweater only on halfway; his wife reported she was helping him with his sweater. The IR documented a new intervention: Resident #26 and his wife educated to call for assistance and remind Resident #26 to sit before donning a shirt or sweater. A progress note dated 09/27/22 at 6:05 p.m., documented Resident #26 hit his head during the fall with new order received to send Resident #26 to the emergency room (ER) for evaluation and treatment. A progress note dated 9/27/22 at 10:35 p.m. revealed ER paperwork returned for Resident #26 which contained a new order that directed staff to make an appointment with a Primary Care Physician to discuss chronic changes to the resident's neck. An MDS dated [DATE] identified Resident #26 scored 7 points on the BIMS test, which meant the resident experienced moderately impaired decision-making skills. An IR dated 10/31/22 at 8:15 p.m., identified staff found Resident #26 on his back with his head toward his recliner, feet pointing at the doorway, and walker out of his reach next to the recliner. The form documented Resident #26 reported he had hit his head, but then he denied it. The IR revealed Resident #26 was helping wife and trying to sit in the recliner, and contained a new intervention that directed re-educate the resident's wife to use the call light to summon assistance. A progress note dated 10/31/22 at 8:49 p.m. revealed the facility received orders to send Resident #26 to the ER for evaluation and treatment. A progress noted dated 10/31/22 at 11:51 p.m. documented Resident #26 returned to the facility from ER with orders for Tylenol 650 mg (milligrams) every 6 hours as needed. The progress notes indicated Resident #26's CT scan of the head and x-rays of the sacrum and coccyx revealed no findings. An MDS dated [DATE], identified Resident #26 demonstrated moderately impaired decision-making skills with long and short and long term memory problems. During an interview on 1/9/23 at 10 a.m., the Director of Nursing (DON) stated she expected staff not to use education or reminders as a fall intervention for a resident with a cognitively impaired resident, because it was ineffective. An IR dated 11/12/22 at 5:10 a.m. revealed Resident #26 fell in his room and hit his head during the fall while on an anticoagulant (blood thinner). The IR documented Resident #26 received a right elbow abrasion and a laceration to the right hand - staff called 911 and Resident #26 was transported to the emergency room for an evaluation. The IR documented the facility removed the bathroom door and replaced it with a curtain. A progress noted dated 11/12/2022 at 8:20 a.m. revealed facility notified by emergency room staff that Resident #26 admitted to the hospital due to a possible brain bleed and skull fracture. A hospital discharge summary dated 11/18/22 revealed Resident #26 admitted to the hospital on 11/12/22 and discharged back to the facility on [DATE]. The discharge summary documented Resident #26 diagnoses during the hospitalization included fall from ground level, temporal epidural hematoma, laceration to right hand that required sutures, and right temporal bone fracture. A progress note from 11/18/22 at 3:11 p.m. revealed Resident #26 returned to the facility from the hospital and staff educated the resident on the call light and needing to use the call light for assistance with going to the bathroom. The progress note showed staff applied a chair alarm to Resident #26's chair for safety. An outside Neurosurgery Consultation dated 11/29/22, documented the provider saw Resident #26 for a 2 week right temporal epidural hematoma follow up. The report identified Resident #26 had the continued appearance of right anterior temporal epidural hematoma with mild mass-effect, and a very subtle increase in size. The note revealed Resident #26 still has an acute component to the hemorrhage. An IR dated 12/8/22 at 3:40 p.m. identified staff found Resident #26 on the floor outside the bathroom and against the wall on his right side with his right arm twisted underneath him. Resident #26 reported he hit his head on the floor. Staff observed bruising to the right side of the top of the head from his forehead to the back of his head, two abrasions on his right hand, and a skin tear to the left thumb. Staff received orders to send Resident #26 to ER. The IR revealed staff would replace the bathroom door with a curtain and add a Position Safety Alarm (PSA) to Resident #26's recliner. The same interventions were listed on the 11/12/22 and 11/18/22 IR's. The facility failed to implement additional/new fall interventions after the fall on 12/8/22. A progress note on 12/8/22 at 9:43 PM, documented Resident #26 returned from the ER with diagnoses of small fracture to the tip of the middle finger of the right hand, a small abrasion to the right temple area, and cellulitis of the legs, with an additional order to start an antibiotic. The progress note documented Resident #26 as noncompliant with his call light. An IR dated 12/28/22 at 7:30 p.m. documented staff found Resident #26 on the floor by the bathroom door - call light not activated and chair alarm not sounding. Resident #26 reported he had hit his head. Staff observed Resident #26 was covered in loose bowel movement, had a hematoma to the back of his head, with his lips blue and exhibiting some wheezing. The facility sent the resident to the ER for evaluation and treatment. A progress note dated 12/28/22 at 11:05 p.m. revealed Resident #26 returned to the facility from ER with a diagnosis of Influenza A and had received Tamiflu (antiviral medication) in the ER. A progress note dated 12/28/22 at 11:45 p.m. revealed staff found Resident #26 on the floor against the wall by the bathroom with a blood smear on the wall, a small laceration to the back, right side of the resident's head, a skin tear to the right elbow, and large, L-shaped laceration to the right lower extremity. The progress noted revealed blood shot out of the resident's right leg, so staff applied pressure to the area and called 911. A progress note dated 12/29/22 at 1:07 AM, documented Resident #26 returned from the ER where they treated his injuries. The progress note directed staff to apply a bed alarm and assist him with ambulation. Review of Resident #26's care plan revealed staff did not add the bed alarm to the care plan as an intervention. During an interview on 1/9/23 at 10:00 a.m., the DON verified the care plan lacked any mention of the bed alarm, but explained that staff utilized the chair alarm as a bed alarm. An IR dated 1/2/23 at 12:08 p.m. revealed staff found Resident #26 on his back in front of the recliner. Staff noted blood came from back of the resident's head and applied pressure. The IR directed staff to apply gripper strips in front of the recliner as a new fall intervention. Closer review of resident's clinical record revealed no documentation of the incident on 1/2/23 and no follow up fall assessments after Resident #26 fell on [DATE]. Review of Resident #23's care plan revised on 1/9/23 revealed an update that directed staff to apply a PSA to the chair and bed when the resident occupied them, tape the battery door of the PSA closed, and place it toward the back of the chair out of his reach. The facility policy titled Accident and Supervision dated 11/1/22 stated the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: a. Identifying hazards and risks b. Evaluating and analyzing hazards and risks c. Implementing interventions to reduce hazards and risks d. Monitoring for effectiveness and modifying interventions when necessary The facility policy title Accident and Supervision dated 2022 stated each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy stated that high risk protocols include providing additional interventions as directed by the resident's assessment, including but not limited to: a. Assistive devices b. Increased frequency of rounds c. Sitter, if indicated d. Medication review e. Low bed f. Alternate call system access g. Scheduled ambulation or toilet use assistance h. Family/caregiver or resident education i. Therapy services referral The policy directed staff to evaluate each resident's risk factors and environmental hazards when developing the comprehensive care plan, monitor each intervention for effectiveness, and revise the care plan as needed. The policy directed when a resident experiences a fall, staff will assess the resident, complete a post-fall assessment and an incident report, notify physician and family, review the resident's care plan and update it as indicated, document all assessments and actions, and obtain witness statement in case of injury. 42132 2. The MDS assessment for Resident #13 dated 12/26/22, identified a BIMS score of 15, which indicated the resident displayed no problems with cognitive impairment. The MDS documented diagnosis that included: hypertension, diabetes, bipolar, and fibromyalgia. Resident #13's Care Plan revised on 2/12/22, failed to identify a focus area &/or interventions related to smoking. Observation on 1/3/23 at 10:58 AM, revealed Resident #13 outside the main entrance on the front porch and dressed properly for the weather. The resident smoked independently while on a cellular phone, without a smoking apron or facility staff present. On 1/3/23 at 2:12 PM, Resident #13 reported he went outside the facility independently to smoke without supervision, assistance from the facility staff, or a smoking apron. Observed a lighter on the tray table beside Resident #13 in his room. Staff F Licensed Practical Nurse (LPN) entered the resident's room to provide a medication per the resident request. Staff F proceeded to clean off the tray table, empty cups, & lids. Staff F did not acknowledge the lighter on the tray table. Resident #13 stated he kept his lighter and cigarettes in his room, that if the facility did not trust him, they would not allow him to keep the lighter in his room. On 1/4/23 at 9:20 AM, Resident #13 outside the front entrance of the facility independently smoking with a fell ow resident. On 1/4/23 at 9:28 AM, Resident #13 returned inside the facility and proceeded to his room without stopping to give the lighter to the facility staff. On 1/5/23 at 4:25 PM, Resident #13 stayed in the hallway outside his room waiting for facility staff. His lighter lay on the tray table inside the door of his room. The Facility Smoking Policy/Consent for Resident #30, signed by the resident on 7/19/22 and initialed by him on 9/8/22, directed: 1. Smoking materials such as cigarettes and lighters would be kept at the nurse's station or by the facility staff 2. Residents were not permitted to have smoking materials in their possession. The Smoking Safety Screen for Resident #13 dated 12/12/22, identified: 1. The resident did not need the facility to store light and cigarettes 2. The resident had the ability to enter/exit the smoking area & smoke without supervision. On 1/5/23 at 2:25 PM, the Director of Nursing reported she hoped the nursing staff in would maintain all residents' smoking materials in a locked cupboard. The DON said although the residents were not supposed to have their lighters, allowed some of the residents to keep their lighters and cigarettes in their rooms, while other residents were required to leave their smoking materials with the facility nurses. The DON stated 2 residents had their smoking materials in their rooms, but one resident used a lock box. The DON stated it was not appropriate for the residents to keep their smoking materials in their rooms. The DON reviewed the Resident Smoking facility and said bullet #13 directed residents were only allowed to smoke if the resident could independently make their way outside the facility and smoke independently as well. The DON added if a resident required supervision with smoking or staff assist to light the cigarette, the resident was not allowed to smoke.

Based on observations, clinical record review, facility record review, hospital record review, staff interviews, physician interviews and hospital staff interviews the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and also failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing for 3 of 3 residents reviewed (#1, 2 and 3). The facility did not demonstrate the pressure ulcer deterioration was unavoidable due to failure to provide weekly comprehensive skin assessments, care plan interventions, pressure relief, turning and repositioning. The facility reported a census of 30 residents. Findings Include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1.According to the admission Minimum Data Set (MDS) assessment tool dated [DATE] Resident #1 admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) test, which indicated the resident was moderately impaired for cognition. The MDS also documented he required extensive assist of 2 staff for bed mobility, transfers, dressing, hygiene and toileting and was totally dependent on 2 staff for a bath. The MDS documented Resident #1 did not have any pressure ulcers but was at risk for developing pressure ulcers. The Baseline Care Plan dated [DATE] documented Resident #1's skin was intact with no interventions listed for pressure ulcers or skin. The Care Plan dated [DATE] documented Resident #1 was at risk for pressure ulcers related to immobility. It documented the resident required a skin inspection weekly to observe for redness, open areas, scratches, cuts, and bruises. The care plan lacked any interventions for pressure relief devices until [DATE] and lacked any updated interventions after skin impairment found. The admission nursing assessment dated [DATE] documented Resident #1 had pink intact skin. The Braden Scale for Predicting Pressure Sore Risk dated [DATE] scored Resident #1 at a moderate risk for developing pressure ulcers. The Progress Notes for Resident #1 included: On [DATE] at 5:44 PM staff documented that, he admitted to the facility, had 2+ [CONDITION(S)] to his feet, a bunion to his left outer foot and left sided weakness. On [DATE] at 9:43 AM, staff documented the resident up in his electric wheelchair, alert and oriented times three, friendly and cooperative. On [DATE] at 7:30 PM staff documented, the resident had moderate non-pitting [CONDITION(S)] to his bilateral lower extremities. The resident requested the nurse to look at his left foot. Callous on bunion left foot is red, 2 small scabs left great toe 0.2cm each. The physician and family were notified. On [DATE] at 5:30 AM staff, documented area to left inner buttock superficial shearing 2cmx1cm also noted area right inner buttocks superficial skin loss shear area 1cmx0.2cm. Areas cleansed and treatment applied. Physician notified via fax and family notified. (Skin assessment done on [DATE] for these areas only) On [DATE] at 10:00 PM, staff documented an area to his left elbow measured 0.5cm circular abrasion. Treatment applied and physician and family notified. On [DATE] at 2:23 PM staff documented that, a fax from the physician was received with new orders for his left foot and left elbow. TAR updated and family notified. On [DATE] at 10:57 AM, staff documented no new skin areas noted. On [DATE] at 9:00 PM staff documented the resident was having increased confusion and not knowing where his wife is. Physician was updated. On [DATE] at 9:27 PM staff documented the resident was dozing off and on with increased lethargy, not able to feed self or propel self in his wheelchair. On [DATE] at 10:24 PM staff documented abrasions to left, elbow dry and scabbed. Scab left great toe healed. Callous bunion left foot now sunken in. Physician updated via fax. On [DATE] at 5:45 AM, staff documented area right inner buttock healing and smaller but area to left inner buttock much worse and larger now measuring 10cmx4cm with green malodorous exudate. Physician notified via fax. (Skin assessment done on [DATE] for these areas only) On [DATE] at 1:09 PM, staff documented resident complaining of pain on his bottom. Only eating 25 percent of his meals. Treatment to bottom done. Physician updated with new orders for wound nurse consult. On [DATE] at 9:14 PM staff, documented resident confused and in bed all shift. On [DATE] at 11:32 AM staff documented resident sent to the hospital for evaluation due to lungs congested and oxygen saturation 78 percent. The Non-Pressure Skin Condition Report for the left foot callous documented: On [DATE] as a reddened callous on the bunion of his left foot. On [DATE], area continuous, has had for a while. On [DATE], callous remains dry is now sunken in with no exudate, [CONDITION(S)] or increased warmth. The Non-Pressure Skin Condition Report for the left inner buttock documented: On [DATE], area presents as superficial shear 2cm by 1cm with light serous drainage and no odor. On [DATE], area much worse and larger with green malodorous exudate 10cm by 4cm with 2mm depth. On [DATE] coccyx is open with maceration noted throughout area pink in color, resident complaining of pain to area. Darkened and white center and maceration of surrounding tissue. On [DATE], area to center of coccyx is now open with slough and odor. Area continues to be painful. The clinical record lacked documentation of a comprehensive skin assessment for the week of [DATE] for the left foot and left inner buttock. The ADL Lookback Report dated [DATE] to [DATE] revealed Resident #1 had not been turned every 2 hours. The facility policy Wound Definitions dated [DATE] documented to measure pressure ulcers upon identification and then weekly and to measure shearing upon identification and then weekly. The facility policy Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Purpose: To ensure a resident who enters the facility without a pressure ulcer does not develop a pressure ulcer unless the clinical condition demonstrates it was unavoidable. To ensure a resident who has a pressure ulcer receives the necessary treatment and services to promote healing, prevent infection and prevent additional pressure ulcers. 2. Elements: Pathway to pressure ulcer prevention and treatment. Pathway to pressure ulcer treatment. Braden scale. Weekly skin assessment for high risk and other skin problems. Weekly pressure ulcer assessment. 3. Procedure: Complete a Braden scale upon admission and then with every comprehensive and quarterly MDS assessment. Follow the steps as outlined in the Pathway to Pressure Ulcer Prevention and Treatment. Document on the Care Plan outcomes and assessments. Review findings with resident, family and staff. The Emergency Department Encounter dated [DATE] documented Resident #1 presented with 3 unstageable pressure ulcers to his sacrum, lateral left great toe and right heel due to slough and/or eschar and/or deep tissue injury. The resident presented complaining of sacral ulcer pain. The resident was started on antibiotics for [CONDITION(S)]. During an interview on [DATE] at 11:50 AM with the Social Worker at the hospital, she stated Resident #1 passed away at the hospital this morning. He was not swallowing, was NPO, the wife decided she did not want to do TPN long term so he was started on comfort cares. She added that the wounds were about the same from when he came into the ER (emergency room ) on [DATE] but were not improving. She stated the resident was septic when he came in and they were doing vitals every 15 minutes. He had pressure wounds to his bottom, left foot and both heels. He did improve from the [CONDITION(S)] but due to not being able to swallow, he continued to decline until he died this morning. During an interview on [DATE] at 1:15 PM with Staff A she stated she did not complete any wound care to Resident #1 the last weekend she worked [DATE] and [DATE]. She stated she signed them off and then ran out of time so she asked the next nurse Staff C coming on to do the treatments. She stated that on [DATE] when she worked, she was training a new RN Staff B and she had her go with an aide and change the dressing to Resident #1's bottom. She added that any new skin issues are relayed to the ADON and she is to follow up on them. During an interview on [DATE] at 1:50 PM with Staff B she stated she saw the wound to his bottom only once during rounds at 5:00 AM on Sunday [DATE]. She stated that she did not provide the care she only held him over while Staff C provided the care. She added that Staff C commented on how it was much worse so Staff C was going to fax the doctor. During an interview on [DATE] at 2:15 PM with Staff LB, she stated she provided the care to Resident #1's buttock wound the morning of [DATE]. She stated she notified the physician because it was much worse than when she had seen it earlier in the week. During an interview on [DATE] at 3:15 PM with Staff D, he stated he had completed all the ordered treatments to Resident #1's wounds on ,d+[DATE] and [DATE] but did not do a full assessment with measurements. He could not recall any open areas or treatments to Resident #1's heels. He stated that the ADON does all the weekly skin assessments. During an interview on [DATE] at 3:25 PM with the Assistant Director of Nursing (ADON), she stated all residents in the building are on the same pressure reducing mattresses the facility buys from [MEDICATION(S)]. She added that the facility has not used any air mattresses on any residents in the last ,d+[DATE] months if ever. During an interview on [DATE] at 11:10 AM with the ADON, she stated the skin records in Resident #1's paper chart copied for the surveyor was all that he had. She stated that he had a Stage 3 pressure ulcer on his buttock sacral area when he discharged to the hospital on [DATE], that she had just been made aware of the deterioration of that wound and that was the only pressure area she was aware of. She stated that she was not aware of any pressure areas on his heels. She added that when a skin assessment is done it is documented on the Skin Condition Report. During an interview on [DATE] at 11:33 AM with the physician for Resident #1 he stated that he was involved with reporting the complaint to DIA. He stated that when Resident #1 was brought into the hospital on [DATE] the wounds he had were quite extensive and that he had developed them while at the facility within 2 weeks. He added that Resident #1 did not admit to the facility with any skin issues on [DATE]. He stated that after about a week the facility notified him that Resident #1 had a wound on his bottom but they did not report any deterioration of the wound until 3 days before hospitalization . He stated that he had been notified of some scab areas on his left foot but had never been notified of any areas on the heels. The physician stated that these areas could have all been avoided if the facility had been turning Resident #1 and if they would have provided more pressure relief devices then what they were using. He stated Resident #1 was admitted to theER on [DATE] with [CONDITION(S)] but the cultures of the wounds and lungs never grew anything. He added that Resident #1 passed away on [DATE] from aspiration pneumonia but that the wounds were a complicating factor. During an interview with the ADON on [DATE] at 2:35 PM she stated she updates care plans within 1 to 2 days of being told about changes and that she would typically update the care plan with any new or changing wounds or pressure ulcers. She added that she was gone during the time the wounds got worse for Resident #1 but the charge nurses are to update the care plans but don't do it. 2. According to the quarterly Minimum Data Set (MDS) assessment tool dated [DATE] Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident was severely impaired for cognitive skills. The MDS also documented she required extensive assist of 2 staff for bed mobility, transfers, ambulation, dressing, hygiene and toileting. The MDS documented Resident #2 did not have any pressure ulcers but was at risk for developing pressure ulcers. The Care Plan dated [DATE] documented Resident #2 was at risk for pressure ulcers related to immobility. It documented the resident required a pressure reduction mattress on her bed but lacked documentation of an updated intervention until [DATE]. The Braden Scale for Predicting Pressure Sore Risk dated [DATE] scored Resident #2 at risk for developing pressure ulcers. The Non-Pressure Skin Condition Reports for Resident #2 documented: On [DATE] she had two areas to her left lower buttocks 1) measuring 1cm by 0.5cm and 2) measuring 1.25cm by 0.75cm. The physician was faxed for a treatment. On [DATE], the area was assessed as one area measuring 4.5cm by 3cm with a green center and very painful to the resident. The physician was faxed for a new treatment. On [DATE], the area was reassessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked comprehensive skin assessments for the weeks ,d+[DATE] and [DATE]. On [DATE], the area was reassessed measuring 1.5cm by 3cm. On [DATE], the area was reassessed measuring 1.5cm by 2.5cm with 1mm depth, wound bed closing and no pain. The clinical record lacked comprehensive skin assessments for the weeks of ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. On [DATE], the area was reassessed as a Stage II measuring 1.5cm by 1cm with 1mm depth. On [DATE], the area was reassessed as healing and measuring 1cm by 1cm. During observation of cares on [DATE] at 1:30 PM, observed nurse Staff E, aide Staff F and aide Staff G enter Resident #2's room. All three staff washed their hands and donned gowns and gloves. The resident verbalized understanding when they told her they needed to do a treatment to her bottom. The aides repositioned the resident onto her side and held her while the nurse completed the cares. The resident's brief was dry. Observed an open area to resident's left hip buttock area. Observed walnut size white circular area with a red open center. The nurse did not measure it but she verbally noted the red open center to be about 2x1cm. Staff E completed the treatment per orders, removed her gloves and washed her hands. The aides completed the cares with the resident. 3. According to the quarterly Minimum Data Set (MDS) assessment tool dated [DATE] Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident was severely impaired for cognitive skills. The MDS also documented he required extensive assist of 2 staff for bed mobility, transfers, ambulation, dressing, hygiene, toileting and total dependence for bathing. The MDS documented Resident #3 did not have any pressure ulcers but was at risk for developing pressure ulcers. The Care Plan dated [DATE] documented Resident #3 was at risk for pressure ulcers related to immobility. It documented the resident required a pressure reduction mattress on his bed and in his wheelchair. The Braden Scale for Predicting Pressure Sore Risk dated [DATE] scored Resident #3 at risk for developing pressure ulcers. The Non-Pressure Skin Condition Reports for Resident #3 documented: On [DATE] and [DATE], he had an open abrasion on his right inner thigh measuring 3.0cm by 2.0cm On [DATE], he had no open areas. The clinical record lacked comprehensive skin assessments for the week of [DATE] and [DATE]. On [DATE], he had an open area on his right upper inner buttock measuring 0.5cm On 2//,d+[DATE] it documented the area was improving and to continue to the treatment. No measurements or description found. During an interview with the ADON on [DATE] at 1:15 PM, she stated Resident #3 did not have any open wounds or pressure areas. The situation detailed above resulted in Immediate Jeopardy (IJ) for the facility. The facility was notified of the Immediate Jeopardy on [DATE]. The facility removed the IJ situation on[DATE]. The scope and severity of the deficiency was lowered from a J to a D. The facility removed the IJ by implementing the following measures: LPN completed head to toe skin assessment on all residents in the facility [DATE]. Contacted all Nursing employee's and educated them on skin protocols and pressure areas [DATE] Posted to Facility Wide Bulletin education with skin assessments and reporting issues to Charge Nurses immediately. Posted Pressure Ulcers in the nursing enclave and at the nurse's station for further education to our Staff. Nurses have been re-educated on utilizing the Skin Condition Reports and Pathway to Pressure Ulcer Prevention and Treatment. The Quality Assurance daily tool includes Skin Issues identified on the form and will be addressed during the morning QA meetings with the QA team. Added on the admin. team calendar a task reminder to prompt skin review weekly. Admin. Nurse shall audit skin sheets weekly for accuracy and completion of weekly skin assessments, skin condition reports and report any negative findings to the Admin. Team for further address. All steps implemented on [DATE]

Based on observations, interviews, and record reviews, the facility failed to adequately monitor medication-related laboratory values in order to ensure residents were free from unnecessary medications for 2 of 2 residents reviewed (Residents #11 and #135). On 6/10/19, Resident #11's physician ordered staff to initiate [MEDICATION NAME] (an anticoagulant or blood thinner) 5 mg daily and then recheck an international normalized ratio (INR, blood test) in two days. An INR is used to monitor how well the blood-thinning medication (anticoagulant) [MEDICATION NAME] ([MEDICATION NAME]) is working to prevent blood clots. The higher the number, the longer it takes the blood to clot, which increases the risk of bleeding. Staff administered the first dose of [MEDICATION NAME] on 6/11/19. On 6/13/19, the resident reported she had a loose stool that contained blood. On 6/20/19, the resident reported she continued to have small blood clots at times when she urinated. On 6/25/19, staff noted the resident had two bruises: one on the right clavicle (collar bone) and one on the left foot arch. The facility failed to successfully obtain an INR laboratory (lab) test until 6/27/19. At that time, the results revealed a critical INR of 12.24 (lab reference range of 0.88-1.16). A subsequent lab result dated 6/28/19 showed an INR result of 3.06. Due to the facility's inability to obtain an INR as ordered in a timely manner, the resident's risk/signs of increased bleeding, and a significantly elevated INR value of 12.24, the facility's actions caused the resident's health and safety to be in Immediate Jeopardy. The facility reported a census of 36 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool, Resident #11 had [DIAGNOSES REDACTED]. The MDS documented a Brief Interview for Mental Status (BIMS) score of 15, which meant the resident demonstrated intact cognition. A fax received on 5/3/19 contained a physician order [REDACTED]. A nurses' noted dated 5/6/19 revealed facility staff sent a fax to the resident's physician to report the resident complained of seeing blood in her urine. The nurses' noted dated 5/10/19 documented the resident complained of blood from the perineal area (the area between the anus and the posterior part of the external genitalia) along with cramping at times. A fax dated 5/10/19 directed staff to hold the Eliquis for 2 days and schedule a pelvic ultrasound due to complaints of bleeding from the perineal area with cramping. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. Staff initials from 5/10/19 on day shift until 5/31/19 were circled to indicate the medication was held or not given. The (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Staff initials from 6/5/19 on day shift until 6/7/19 were circled. A nurse's note dated 6/5/19 documented the resident reported blood clots in her urine. A fax dated 6/5/19 documented an order to hold Eliquis for the second time and have the resident see Urology. A nurse's note dated 6/5/19 showed staff scheduled the resident an appointment with the Urologist. A fax to the physician dated 6/9/19 reported the bleeding had improved when staff held Eliquis. The nurse also documented the resident reported a history of [MEDICATION NAME] use and asked if the provider wanted to start [MEDICATION NAME]. On 6/10/19, staff received an order to discontinue Eliquis and to start [MEDICATION NAME] 5 milligrams (mg) daily, then recheck an international normalized ratio (INR) in two days. The MAR indicated [REDACTED]. A nurse's note dated 6/11/19 documented no complaints of polyuria or urgency with no skin rashes, bruises, or irritation noted. A nurses' note dated 6/13/19 documented the resident reported she had a loose stool that contained blood and mucus. A nurse's note dated 6/13/19 revealed staff sent a fax to notify the provider regarding the resident's loose stools that contained blood and mucus. The note showed the physician returned the fax with an order for [REDACTED]. A lab result dated 6/19/19 informed staff the normalized curve delta too low, maintenance overdue, or failed measured result with regard to the INR and no lab result provided. Record review revealed the resident's medical chart lacked documentation regarding a follow-up with the lab or the physician. The nurse's note dated 6/20/19 showed the resident reported she continued to have small blood clots at times when she urinated. A fax dated 6/25/19 documented the resident on [MEDICATION NAME] with the last INR drawn on 6/19/19. The fax also notified the provider the resident had two bruises: one on the right clavicle and one on the left foot arch, with no known injuries that would cause the bruises. The return fax from the provider and noted on 6/25/19 directed staff to redraw the INR. The lab result dated 6/25/19 indicated the lab canceled the test because the staff person that drew the blood overfilled the blue tube. The chart lacked documentation regarding follow-up of the lab result. The lab result dated 6/27/19 at 8:38 a.m. showed a critical INR of 12.24. At 9:45 a.m., the result revealed a critical INR of 12.23. The lab dated 6/28/19 showed an INR of 3.06. The physician sent a lab result to the facility that staff noted on 6/29/19. The physician directed staff to check the INR on Monday (6/30/19). The physician also requested the resident's [MEDICATION NAME] dose. The chart lacked documentation of follow-up to the physician. The (MONTH) 2019 MAR indicated [REDACTED]. An observation on 6/30/19 at 10:50 a.m. showed a large bruise to the resident's chest and left antecubital area (inner elbow). During an interview on 6/30/19 at 10:50 a.m., the resident stated she wasn't aware of how (the bruises) got there. In an interview on 7/1/19 at 1:25 p.m., the Director of Nursing (DON) reported staff had previously scheduled a cystoscopy procedure (a hollow tube equipped with a lens-cystoscope-inserted into the urethra and advanced into the bladder) for the resident on 6/27/19 as ordered by one of her specialist physicians. Because the resident's INR had been critical that day at 12.24, the resident had not been able to have the cystoscopy as scheduled. After the critical INR result of 12.24, the hospital gave the resident one pill of Vitamin K and rechecked an INR the next day. The INR dated 6/28/19 was 3.06. The DON reported she did not believe any staff had drawn an IDR on 6/13/19 as a nurse had quit between those two days, so she thought the lab draw had been missed. During a follow-up interview on 7/1/19 at 3:08 p.m. the DON reported that since the Resident #11's elevated INR incident occurred, she set up a lab book to record lab orders to make sure they were completed and drawn as scheduled. 2. The MDS for Resident #135 showed [DIAGNOSES REDACTED]. The resident's MAR indicated [REDACTED]. The resident's admission orders [REDACTED]. The first lab result collected on 6/28/19 documented in the resident's chart was 1.59. The physician noted the resident had been on [MEDICATION NAME] 3 mg daily (as [MEDICATION NAME] for deep vein thrombus ([MEDICAL CONDITION])) following surgery. The physician instructed staff to increase the resident's [MEDICATION NAME] dose to 6 mg once on 6/28/19. Then, start [MEDICATION NAME] 4 mg every Saturday, Monday, Wednesday and 3 mg on Sundays, Tuesdays, Thursday, and Fridays and draw an INR on 7/3/19. The resident's baseline care plan dated 6/20/19 lacked documentation related to the use of anticoagulant. During an interview on 7/1/19 at 4:30 p.m., the Administrator and the facility owner reported the facility's registered nurses were capable of drawing blood and taking the blood to the hospital or clinic if the lab person was unable to come to the facility and obtain the blood sample. The Administrator commented the facility had recently had difficulties getting lab results back from the lab. The facility abated the Immediate Jeopardy on 7/1/19 when they updated the Anti-Coagulation Therapy policy and educated pertinent staff regarding the policy updates and changes. The policy labeled Anti-Coagulation Therapy (Nur-1305) with a revision date of 7/1/19 revealed the policy's purpose was to ensure anticoagulation therapy was safely and effectively administered. The policy directed the physician must be notified of the results of the INR before staff administer the next dose of [MEDICATION NAME]. Also: a. If the INR results were within the physician's orders [REDACTED]. b. If the INR results were outside of the physician's orders [REDACTED]. An order must be obtained for the next INR to be drawn. c. If the lab has not been received by the time the next dose of [MEDICATION NAME] was due to the facility must make every effort to obtain the information. If it was still unavailable by the next dose administration the physician must be notified to inform him or her that the lab results are not available so further instructions could be obtained. d. If the facility was unable to verbally communicate results to the physician and an alternate physician was not available prior to the next dosing of [MEDICATION NAME] the DON needs to be notified and good sound clinical judgment should be made to determine to administer or hold the next dose of [MEDICATION NAME]. The policy continued to direct staff to observe for signs of any bruising or bleeding (nasal, skin, and blood in feces, urine or vomit) and notify the physician.

Based on record review and staff interviews, the facility failed to provide adequate nursing supervision to ensure against hazards from falls and failed to provide adequate interventions to keep the resident safe which resulted in Resident #1 having a fractured scapula. The sample consisted of 4 residents and the facility identified a census of 33 residents. Resident #1 experienced multiple falls and the facility staff would find the resident on the floor near the resident ' s bed. Resident #1 required additional interventions/supervision in order to be safe. Findings include: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 2/9/15 which identified the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident had a BIMS (brief interview for mental status) score of 5. A score of 5 identified the resident with a severe cognitive impairment. The resident required the assistance of one staff member with bed mobility, transfers and toilet use. The MDS identified the resident with impaired range of motion of the lower extremities and had limb prosthesis. Review of the Fall Risk assessment dated [DATE] identified the resident with a score of 13. A total score of 10 or above represented the resident to be at a high risk for falls. The Care Plan dated 12/4/14 identified a problem for the potential of falls regarding an amputation. The interventions included and directed staff to: a. Floor mat beside bed, grip strip in front of bed, pressure alarm to wheel chair only (not dated). b. On 4/11/15 Fall: continue with current care plan. c. On 4/13/15 the intervention directed staff to continue with the care plan and provide education to the resident for the need to utilize the call light and to ask and wait for assistance (resident is severely cognitively impaired). d. On 4/18/15 the intervention reflected the resident would have a low to ground bed with no rails up to prevent injury. e. On 4/18/15 the intervention directed the Restorative Aid to monitor the resident for leaving the dining room. f. If resident falls attempt to determine cause for fall and take steps to prevent fall from happening again (no date). Review of the Incident Reports identified the following falls and interventions: a. On 1/17/15 at 3:15 PM the staff found the resident lying on the right side between the wheelchair and the bed. The resident stated he/she could not find the call light although it had been near his/her arm. The alarms were not sounding and the resident stated he/she turned it off. Staff added an intervention to not place the wheel- chair close and place the resident's prosthetic device in the closet when not in use. b. On 2/22/15 at 5:30 PM the alarms sounded and the staff noted the resident lying on the floor beside the bed. The resident stated he/she threw self on the floor. The staff performed 15 minute checks due to suicidal ideation. c. On 3/8/15 at 3:30 PM, the alarm sounded and staff found the resident lying on the floor on the left side beside the bed. Stated had to go to the bathroom. The planned intervention documented on the post assessment form directed staff to orient the resident to surroundings, encourage and teach use of the call light (severely impaired cognitively), keep call light within reach at all times, place items within resident ' s reach, room free from clutter and well lit, monitor frequently by staff, decrease environmental stimuli, chair alarm and bed alarm. The post assessment determined a pattern of falls getting up unassisted and going to the bathroom. d. On 3/12/15 at 3:00 PM, the alarm sounded and staff found the resident found lying on the floor next to the bed with head resting on the bottom of the over bed table. The intervention directed staff to send the resident to the emergency room for an evaluation. Suicide precautions put into place. The Post Fall Assessment determined interventions to prevent further falls did not change from the 3/8/15 fall, except for staff to instruct the resident about the use of assistive devices and encourage use of the devices and offer snacks and fluids. The Nurse ' s Notes on 3/14/15, a late entry for 3/12/15 at 5:00 p.m. reflected when the staff entered the resident ' s room, observation revealed the resident on the floor with head on the night stand. The resident stated he/she had hit head. The nurse documented no noted injury at this time but resident very upset and wanted up off the floor. e. On 4/11/15 at 6:50 PM, the CNA (Certified Nursing Assistant) transferred the resident from the bed to wheel- chair. The resident could not stand on their prosthesis and the CNA lowered the resident to the floor. The intervention directed staff to continue with the Care Plan. (No new interventions were added). The nurse sent a fax (facsimile transmittal) document to the physician and informed of the incident. The facility received orders to monitor the resident. f. On 4/13/15 at 6:00 PM, the Resident #1 transferred self to the bed and fell . Staff found the resident lying with head right side to the bed. The intervention directed staff to educate the resident to utilize the call light and ask for assistance. The nurse sent a fax to the physician. The resident voiced complaints of left shoulder pain and no redness noted. The physician ordered the facility to observe the resident. A nurse sent a fax to the physician and the physician ordered the resident be observed. g. On 4/13/15 at 9:00 PM, the resident turned over in bed and the bed moved. The resident fell between the bed and the wall. The intervention documented none and to continue to Care Plan and monitor for discomfort. h. On 4/17/15 at 1:30 PM the resident yelled and staff found the resident wedged between the bed and the wall. Bed in low, locked position and the fall mat in place. The staff lifted the resident with the Hoyer lift (mechanical lift) and sent the resident to the emergency department for an evaluation. Review of the Diagnostic Imaging Report dated 4/17/15 revealed a comminuted fracture of the left scapula with mildly depressed intra-articular fracture of the superior glenoid (fibrocartilaginous rim attached around the margin of the glenoid cavity in the shoulder blade). Fracture lines also extend into proximal coracoid (part of scapula bone), scapular body and the acromion process (part of scapula bone). The Nurse's Notes dated 4/17/15 at 7:10 p.m. identified the resident returned to the facility via ambulance. The note reflected the resident wore a sling for comfort and healing. The resident wore a Fentanyl (narcotic analgesic patch) 25 milligrams and the physician ordered it to be changed every 72 hours and Tylenol 650 milligrams every 4 hours as needed for break through pain. Review of the March 2015 Medication Administration Record revealed the resident received no medications for pain relief. During an interview on 4/29/15 at 3:00 p.m., Staff A, RN (Registered Nurse) stated the resident was found on the floor on 4/13/15. The resident stated he/she rolled over and fell out of bed. The resident's head had been at the foot of the bed and the bed was locked. The bed had been in a lower position but not to the floor at the time. The resident complained of shoulder pain, but Staff A noted no bruising. During an interview on 4/30/15 at 10:15 AM, Staff B (Registered Nurse) stated the resident yelled for help after the fall of 4/17/15. The staff found the resident facing the wall and the upper body on the bed and the lower body off of the bed. The bed had been high enough only to lock and had been in a locked position. The resident complained of significant left arm pain. On 4/30/15 at 10:40 AM, the DON (Director of Nursing) was interviewed and stated the facility had not put fall interventions on the care plan. On 4/30/15 at 11:05 A.M. the Administrator was interviewed and stated the facility implemented the low bed intervention after the fall on 4/13/15.

Based on observation, record review, staff and resident interviews and review of facility gait belt policy, the facility failed to use equipment in order to prevent accidents during a transfer for 1 of 4 residents reviewed (Resident #1). Resident #1 was transferred to the toilet by the Certified Nursing Assistant. Resident #1 wore an arm sling with a waist belt. During the transfer, the resident began to fall and the staff person held onto the sling waist belt. The staff person had not applied a gait belt around the resident's waist for safety. The resident fell on to the bathroom floor which resulted in a fractured hip, surgery, repair of the fracture and post- operative pain. The facility reported a census of 38 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 03/04/13. The assessment indicated Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) and had no cognitive impairment. Resident #1 required extensive assistance of 1 person with transfers. The MDS identified Resident #1 ' s [DIAGNOSES REDACTED]. A Care Area Assessment (CAA) dated 09/24/12 documented Resident #1 came into the facility due to increased falling at home and family not able to take care of him/her as much as needed. Resident #1 had a stroke many years ago causing left sided weakness, gait instability, and inability to use his/her left arm. A Fall Risk assessment dated [DATE] documented Resident #1 with a score of 12 and a score of 10 or above represented high risk for potential falls. A Pain assessment dated [DATE] documented Resident #1 experienced mild pain occasionally that did not limit his/her day to day activity, or make it hard for him/her to sleep at night. Pain occurred when Resident #1 walked, stood or transferred. The facility Incident Reports identified the resident experienced the following falls: On 10/30/12 at 1:30 a.m. a CNA ambulated Resident #1 from the bed to the bathroom. Resident #1 turned (left) to the toilet when his/her left foot (affected side of body) rolled over and he/she went down (fell ) on both knees. The gait belt and quad cane were in place. On 04/09/13 at 12:40 p.m. Resident #1 fell forward out of the wheelchair. On 04/20/13 at 8:25 p.m. Resident #1 turned real fast, the bed moved, and staff lowered the resident to the floor with the use of the gait belt. No injury noted. A Care Plan dated 09/12/12 identified Resident #1 with falls related to left sided weakness. The approaches included: a. Assist of 1 or 2 with all transfers. The care plan identified the need for assistance with activities of daily living (ADL's). The approaches directed staff to: a. Assist of 1 to 2 with transfers. b. Able to transfer self with walker and cane, assist with mobility as needed changed to needs assist. c. Refused to remove arm sling at any time. d. Wants to remain as independent as possible and does not like to ask for help. Remind to use the call light when needs transferring. The care plan identified incontinence and the approaches directed staff to: a. Toilets frequently at night. Assist with transferring on and off the toilet as needed. The current Care Plan (with a met goal on 05/23/13) reflected Resident #1 needed assist with ADL's related to left side weakness. The approaches included the assistance of 2 with transfers and Hoyer (mechanical) lift. Non weight bearing on the left lower extremity. The Nurse's Notes dated 05/07/13 at 4:30 a.m. documented at 3:30 a.m. the nurse was called to Resident #1's room, where she observed Resident #1 on the floor. The Certified Nursing Assistant (CNA) transferred Resident #1 and the resident fell forward onto the floor. The resident voiced some hip pain. Tylenol (analgesic) given. At 3:30 p.m. a clarification entry documented the nurse entered Resident #1's room at 3:30 a.m. Resident #1 laid on left side in the bathroom. Resident #1 stated that hurt all over, but could not pinpoint pain. Staff took vital signs and assessed Resident #1's legs. Resident transferred with the mechanical lift to the toilet and then to bed. Staff assessed Resident #1's legs/hips again. Two small indentations were noted on Resident #1's bilateral knees from the floor tile. At 4:30 a.m. Resident #1 slept. At 8:15 a.m. Resident #1 rested in bed. The resident did not want to get up, didn ' t think he/she could stand up. Staff explained to Resident #1 that he/she should have an x-ray. Resident #1 stated would not go for an x-ray. At 8:35 a.m. Resident #1 agreed to an x-ray. The hospital telephoned and Resident #1 transferred to another hospital. An Incident Report dated 05/07/13 at 4:30 a.m. documented the treatment or new intervention was to assess resident's readiness to transfer before the transfer and to utilize the facilities policy equipment, not resident's personal transfer equipment. The Post Fall Assessment documented Resident #1 demonstrated gait instability and had no gait belt on. A hospital Emergency Department Physician Documentation report dated 05/07/13 documented Resident #1 known with left hemiparesis following a stroke in 1994, presented to the emergency room with left hip pain after a fall at his/her nursing home. Resident #1 stated staff assisted him/her to the commode and he/she fell in the process. According to the resident, staff did not use a gait belt. A Diagnostic Imaging Report dated 05/07/13 documented Resident #1 had a moderately displaced subtrochanteric (hip area) fracture of the left femur. An operative report dated 05/08/13 documented Resident #1 underwent open reduction and internal fixation (ORIF) of a left subtrochanteric femur (hip) fracture. The procedure included attempts at closed reduction, and then converted to open reduction. A hospital Discharge Note with a discharge date of [DATE] documented Resident #1 underwent left ORIF on 05/08/13. Resident #1 had hypotension after surgery resulting in transfer to the intensive care unit. The physician attributed the hypotension to post op (post-operative) blood/volume loss. The hypotension resolved with fluid and blood transfusion. The hospital course also included post op (operative) blood loss associated anemia, requiring 3 units of packed red blood cells. A Pain assessment dated [DATE] documented Resident #1 experienced pain of the left hip, joint, incision and fracture. The pain occurred almost constantly and limited Resident #1's day to day activity, and made it hard (difficult) for Resident #1 to sleep at night. Resident #1 described the pain as throbbing, and it occurred or increased when he/she walked, sat, stood, toileted, bathed, transferred, received care, therapy and repositioning. A Physical Therapy Plan of Care dated 05/16/13 documented Resident #1 was referred after suffering a left hip fracture on 05/07/13 due to falling in the bathroom. Resident #1 complained of left hip pain, weakness, and decreased functional mobility. Therapy was necessary for strengthening, gait training, balance and pain management. Without therapy, Resident #1 at a risk for falls and increased burden of care. Resident #1's prior level of assistance for bed mobility, gait and transfers required moderate assist (25 to 75% assist) and he/she currently depended on staff for same. A typed statement dated 05/07/13 and signed by Staff E CNA revealed Staff E entered Resident #1's room at approximately 3:30 a.m. to answer the call light. Resident #1 requested to use the bathroom. Staff E placed shoes on Resident #1's feet and assisted him/her to a dangling position at the side of the bed. Resident #1 had the arm sling present with a waist band belt. Staff E placed Resident #1 into a wheelchair and took the resident to the bathroom door, locked the wheelchair in place, and told Resident #1 to wait a minute. Staff E returned and assisted Resident #1 by using the waist sling to a standing position. She had a hold of Resident #1's waist belt and Resident #1 had a hold of the quad cane with his/her right hand when he/she stood up. When Resident #1 attempted to turn left to the toilet, the resident ' s right foot slid forward and he/she lost his/her balance. Resident #1 fell in a twisting motion onto his/her left side. Staff E continued to have a hold on the waist belt but could not to stop the fall. Staff E indicated she worked with Resident #1 since his/her admission the previous year without any problems with transfers. During an interview on 05/23/13 at 10:32 a.m. Staff E Certified Nursing Assistant (CNA) stated she normally put the gait belt on Resident #1, but thought it acceptable to use the immobilizer belt which was already around Resident #1's waist. During the transfer Resident #1's foot slid and he/she fell . Staff E could not stop the fall. Staff E stated she knows now she made a mistake and felt terrible about what happened. Staff E stated she should have used the gait belt. During an interview on 05/23/13 at 10:06 a.m. Staff G Registered Nurse (RN) stated she trained another nurse the night Resident #1 fell . The other nurse told Staff G Resident #1 fell . Resident #1 laid on the floor in the bathroom on his/her left side. Resident #1 stated he/she was going to the bathroom and fell forward. Resident #1 had the immobilizer on, but no gait belt. Staff E told her she used the immobilizer belt. Staff G stated technically it was not a gait belt, but she didn't think they said they couldn't use it. Staff G thought other staff used it as a gait belt. During an interview on 05/23/13 at 9:06 a.m. noted Resident #1's arm immobilizer belt. Resident #1 stated he/she wore it during the transfer when he/she fell . The immobilizer belt had Velcro to fasten it and appeared worn. Resident #1 said he/she didn't know exactly how he/she fell , but he/she knew he/she didn't have a gait belt on. Resident #1 said it was not safe without it; he/she was too big. Resident #1 said all the young girls used the gait belt, they knew better. Resident #1 said the bed moved 1 time and the staff eased him/her down with the gait belt. Resident #1 did not know if staff had a hold of anything when he/she fell and fractured his/her leg. Resident #1 said he/she would never let anyone transfer him/her without the gait belt again. During an observation on 05/23/13 at 3:15 p.m. 2 staff transferred Resident #1 from the bed to the wheelchair with the mechanical lift. During an interview on 05/23/13 at 10:19 a.m. Staff F CNA stated she never used the immobilizer belt as a gait belt. She always put a gait belt on Resident #1. The resident needed a gait belt due to instability. During an interview on 05/23/13 at 11:26 a.m. Staff C CNA stated when she assisted Resident #1 prior to his/her fall and she always used a gait belt due to the resident ' s instability. She did not think it acceptable to use the immobilizer belt like a gait belt. During an interview on 05/23/123 at 2:02 p.m. Staff B CNA stated she always used a gait belt when transferring Resident #1, even if he/she had the immobilizer belt on. Resident #1 was unsteady on his/her feet. During an interview on 05/23/13 at 2:05 p.m. Staff D CNA stated she used a gait belt when transferring Resident #1 because she felt uncomfortable not using one. She did not use the immobilizer belt because it did not provide good support. She didn't think it safe to transfer Resident #1 without a gait belt. On 05/23/13 at 2:08 p.m. Staff A, Certified Nursing Assistant (CNA) was interviewed and stated she always used a gait belt when she transferred Resident #1, because it would not be safe without it. She used a gait belt even if Resident #1 had the immobilizer belt on. During an interview on 05/23/13 at 10:20 a.m. the Physical Therapy Assistant (PTA) stated the sling immobilizer Resident #1 wore would not be acceptable to use as a gait belt. On 05/23/13 at 11:35 a.m. the Certified Occupational Therapy Assistant (COTA) was interviewed and stated she did an in-service in September (2012) on safe lifting, including using a gait belt with all transfers. The COTA stated the immobilizer sling Resident #1 used would not be considered safe to use as a gait belt. She stated the belt was old, stretched out and fastened with Velcro. When the COTA looked at the date of the in-service compared to Resident #1's admitted , Resident #1 resided in the facility at that time, but it probably did not get brought up that the immobilizer sling could not be used as a gait belt. On 05/23/13 at 10:00 a.m. the Director of Nursing (DON) stated the facility policy directed the use of a gait belt unless contraindicated. She had an in-service regarding transfers and started doing random audits for gait belt use after Resident #1's incident. She had no documentation of audits prior to that but she would randomly watch transfers. The DON stated everyone she talked to said they knew to use a gait belt and not the immobilizer belt when transferring Resident #1. She thought Staff E worked at the facility long enough to know to use the gait belt. She thought this was an isolated incident. At 12:10 p.m. the DON stated Staff E received disciplinary action regarding the incident. The DON stated Staff E had no other disciplinary action. An Employee Performance Expectation Disciplinary Action form dated 05/07/13 documented Staff E received a written warning and 3 days suspension. The form indicated Staff E violated safe transfers and predetermination of resident expected behavior. The details listed utilization of waist band belt and position of self during transfer, assisting resident to the toilet. A Caretracker document dated 05/07/13 documented a must read to all nursing staff: to use only gait belts the facility owned for a transferring belt. Do not use waist slings or any other transferring devices. A Quality Assessment and Assurance Action Plan dated 05/13/13 identified the concern of education to use facility issued gait belt with all transfers. The approaches included: a. All staff educated by Caretracker system to use only facility issued gait belts for transfers. b. Random audits of staff to assure gait belts in place and used with transfers. c. Staff reeducation at monthly all staff meetings for 3 months on gait belt use. The facility policy, Gait Belts, indicated the purpose to ensure the proper use of a gait belt, and to ensure the safety of the resident during transfer and ambulation. The procedure included in hand writing staff would use a facility designated gait belt instead of resident's private gait belt. Staff E reeducated on gait belt use and policy by the DON and Administrator 05/07/13.