Every finding on record at Complete Care at Dawnview LLC

Based on observation and staff interviews, the facility failed to ensure food was distributed and served accordance with professionalstandards for food safety. This was a random opportunity for discovery and had the potential to affect a limited number of residents.Resident Identifiers: #31 and #34. Facility Census 61. Findings included Dining Room Observations:a) Serving Tray Sanitization between residents:On 04/13/26 at 12:25PM, It was observed that serving trays were being used to serve the residents.Trash was being put on the trays, dumped in the trash and then re-used without sanitizing before serving the next resident.b) Hand Hygiene During dining room Observation on 04/13/2026 12:15PM, Resident Aide(RA), #93 was observed serving and assisting resident # 31 and #39 at the same table, she removed and was spreading butter on corn bread and removing the brownies from the baggie with her bare hands for Residents #31 and #39. Staff Interviews:RA Interview:During an Interview with RA Employee #93 on 04/13/26 at 12:20PM, she acknowledged she should not have handled the residents food without wearing gloves. Assistant Director Of Nursing(ADON) Interview:During an interview with the ADON on 04/13/26 at 12:35PM, she acknowledged the trays had not been sanitized between each resident and that Employee #93 had not been wearing gloves while handling the resident's food and stated she should have known better .

Based on record review and staff interview, the facility failed to ensure Level 1 pre-screening of a new residents for serious Mental Illness/Intellectual Disability (MD/ID) or a related condition prior to admission to the facility. This failed practice was true for four (4) out of 22 residents reviewed in the Long-Term Care Survey Process. Resident Identifiers: #1, #7, #30 and #45. Facility Census: 61. Findings included: a) Resident #7 During a record review on 04/13/26 at 3:25 PM, it was discovered that a Major Depressive Disorder diagnosis had not been captured on Resident #7's PASARR. There were no other PASARRs on file for this resident. The Director of Social Services, on 04/14/2026 at 3:00 PM, verified the resident's initial PASARR failed to capture the Major Depressive Disorder diagnosis and that a new PASARR had not been completed. b) Resident #1 During a record review on 04/13/26 at 3:36 PM, it was discovered that a Bipolar II diagnosis had not been captured on Resident #1's initial Pre-admission Screening and Record Review (PASARR). There were no other PASARRs on file for this resident. The Director of Social Services, on 04/15/26 at 9:25 AM, verified the resident's initial PASARR failed to capture the Bipolar II diagnosis and that a new PASARR had not been completed. c) Resident #30: During a record review on 04/13/26 at 3:00 PM, it was discovered that a Major Depressive Disorder diagnosis had not been captured on Resident #30's Pre-admission Screening and Record Review (PASARR). There were no other PASARRs on file for this resident. The Director of Social Services, on 04/14/2026 at 3:36 PM, verified the resident's initial PASARR failed to capture the Major Depressive Disorder diagnosis and that a new PASARR had not been completed. c) Resident #45: During a record review on 04/14/26 at 1:50 PM, it was discovered that a Post Traumatic Stress Disorder(PTSD) had not been captured on Resident #45s initial PASARR. There were no other PASARRs on file for this resident. The Director of Social Services, on 04/15/26 at 9:25 AM, verified the resident's initial PASARR failed to capture the PTSD diagnosis and that a new PASARR had not been completed.

Based on observation, record review, and staff interview the facility failed to provide dietary staff with proper food handlers certification. This deficient practice involved [NAME] #20. Facility census: 61.Findings include:On 4/15/26 at 10:36 AM, during a telephone interview the Mineral County Health Department confirmed that dietary staff in a long-term care facility must have a valid food handler's certification. Health Department staff stated, It is like a driver's license, once it expires, it is expired.After reviewing staff certifications, the surveyor found that [NAME] #20 did not have a valid food handlers certification. The food handler's certification expired on March 6, 2026. [NAME] #20 did not renew her food handler's certification until April 14, 2026. Healthcare Services Group, INC. job descriptions state that employees must maintain a current food handler's certification as required by state/county law.Cook #20 was on the work schedule on the following dates:3/8, 3/10, 3/11, 3/12, 3/15, 3/17, 3/18, 3/19, 3/21, 3/22, 3/24, 3/25, 3/26, 3/29, 3/31, 4/1, 4/2, 4/5, 4/7, 4/8, and 4/12On 4/15/26 at 10:45 AM an interview with the Administrator verified that [NAME] #20 did not hold a valid food handler's certification. [NAME] #20 also did not have a ServSafe certification.

Based on observation and staff interview the facility failed to ensure the the most recent state inspection results were easily accessible to residents and others without having to ask. This was a random opportunity for discovery and had the potential to affect more than a limited amount of residents. Facility census: 61.Findings included:During a facility entry on 04/13/2026 at 12:47 PM, observation revealed that the most recent state inspection results were stored in a wall-mounted box but were obscured by a folder labeled concerns. Consequently, the results were not clearly visible to residents or visitors without inquiry. In a follow-up interview on 04/14/2026 at 12:25 PM, the Director of Nursing acknowledged that the survey results box lacked a proper label and that the state inspection results could not be located without assistance. She stated that the facility would correct this issue.

Based on Observations and staff interviews, the facility failed to maintain a safe and accident hazard free environment for the residents. Multiple residents had items/clutter both around and underneath their beds, making both normal movement and resident care dangerous. This was discovered during the normal Long Term Survey Process and has the ability to affect more than a limited number of residents. Resident identifiers #33, #52, #36, #38, #45 and #3. Census: 61.Findings include:During a facility walk through on 4/13/26 the following were accident hazards that were observed in residents rooms:a) Resident #33Books, papers, and boxes on the floor around the bed created a trip and fall hazard for both Resident #33 and staff while providing care.b) Resident #52Multiple personal items created a tight path for movement in the room. This is a trip/accident hazard for the resident and anyone providing care.c) Resident # 36Boxes under the bed made it impossible to lower it fully for safe exit and transfer.d) Resident # 38Boxes under bed and around the sides created a small walking path for resident and caregivers. These are trip and fall hazards and are difficult to clean.e) Resident # 45Boxes and items stored under the bed prevented Resident #45 from safely lowering the bed to proper height for transitioning in and out.f) Resident # 3Boxes surrounded the bed and lined the wall in front of the heating / cooling unit creating a trip and fall hazard and blocking the air/heating control.Interview with Director of Nursing (DON) on 04/13/2026 at approximately 12:20 PM confirmed items on the floor (boxes, papers and other personal items around the resident's bed). They are care-planned for hoarding behaviors, but I agree their things should be on this floor.Secondary followup on [DATE] 3:49 PM with the DON, they went around to each room, removed all items from under and around the beds and placed them in more appropriate storage areas. I agree the items under the beds were an issue.

Based on observation and staff interview, the facility failed to provide a clean, comfortable, and homelike environment for residents in Rooms #100, #102, and #205.This was a random opportunity for discovery that had the potential to affect a limited number of residents. Facility census: 61. Findings included:a) Resident room [ROOM NUMBER]:Upon survey entrance on 04/13/25 at 11:30AM, it was observed the following issues in Room and bathroom:- The left wall inside the resident room had black scuff marks approximately 3 feet long near the bathroom door.- The right side wall had unfinished drywall patching around the light switch.- The left side of the bathroom wall had rough, painted-over, unfinished drywall patching.-back wall above the sink peeling paint above the sink and loose caulking around the sink and counter- Stained tile on the floor around the wall and under the sink. b) Resident room [ROOM NUMBER]: Upon survey entrance on 04/13/26 at 11:35AM, it was observed the following issues in the bathroom:- Unfinished drywall under the light on the back wall above the sink. - Loose caulking around the sink and counter.- stains on the floor under the sink and down the right side wall - cracked bathroom caulking around the sink- loose and hanging Baseboard trim on the back wall under the windowc) Resident room [ROOM NUMBER]: During a Resident interview in room [ROOM NUMBER] on 04/14/26 at 11:30AM, it was observed the following issues in the room and bathroom:- Long black scuff marks on the left side wall near the bathroom door.- Unfinished drywall marks on the wall to the right of the bathroom door.- Cracked and loose caulking around the sink.- Loose and hanging baseboard trim on the back wall under the window.During a walkthrough with the Administrator and the Environmental Manager, on 04/15/26 at 9:35 AM, the manager acknowledged the observed issues in resident room numbers #100, #102, and #205 and stated she would send a list to maintenance for repairs.

Based on observation, record review, and staff interview the facility failed to report verbal grievances from resident Council meetings. This affected Residents #68, #3, #13, and #54. Facility census: 61.Findings included:Review of the facility policy titled Resident and Family Grievances policy, dated 4/5/23 revealed: Grievances may be voiced in the following forums: a) Verbal complaint to a staff member or Grievance Official.After interviews with Residents #68, #3, #13, and #54 it was revealed that the issue of Resident #8's loud television disrupting other residents had been raised in Resident Council meetings. A record review found no reported grievances regarding this matter.Review of Resident Council meeting minutes dated October 22, 2025 and November 19, 2025, confirmed the discussion about Resident #8's loud television.An interview with the Administrator on 4/15/26 at 9:58 AM verified that the concerns were discussed in Resident Council but were not advanced to the formal grievance process.

Based on record review and staff interview, the facility failed to ensure MDS Discharge assessments were completed and submitted in a timely fashion. This was a random opportunity for discovery. Resident Identifier: #46. Facility Census: 61. Findings included: a) Resident #46Review of the electronic medical record revealed that Resident #46 had been discharged from the facility on 08/21/24. The electronic record did not reflect that a Minimum Data Set (MDS) Discharge assessment had been completed and submitted. During an interview on 04/14/26 at 2:07 PM, the MDS Coordinator confirmed the MDS Discharge assessment had not been completed and submitted for Resident #46. The MDS Coordinator stated she would immediately address that oversight.

Based on observation and staff interviews the facility failed to ensure the nurse staffing post form, with the required census information listed, was easily accessible to residents. This was a random opportunity for discovery and could affect a number of residents. Facility Census: 61. Findings included: Upon facility entrance on 04/13/2026 at 11:00 AM, we observed the post staffing form located between the outer entrance door and the lobby door. This placement made it inaccessible to residents and the form lacked the required census information and nursing staff hours worked. During an interview with the Director of Nursing (DON) on 04/15/2026 at 12:48 PM she acknowledged that the post did not list the required census information and was not easily accessible to residents. She also stated that another form was located in the hall but it did not list the required census information.

Based on observation, record review and staff interview, the facility failed to provide a safe, clean, homelike environment regarding the storage of unclean wheelchairs. This was a random opportunity for discovery. Resident Identifiers: #17, #35, #56, #47, #37, #57 and #2. Facility Census: 59. Findings Include: a) Storage of wheelchairs On 11/04/24 at 10:30 AM, a foul odor was noticed by the Surveyors at the end of the 100-hall next to the conference room. Upon further examination, the foul odor was lingering around the wheelchairs and wheelchair cushions were noted with debris and a dried substance. The wheelchairs without cushions were noted with a foul odor and debris on the seats. Most of the wheelchairs observed had the residents' names located on the handles of the wheelchairs. On 11/05/24 at 10:15 AM, the wheel chairs were observed at the end of 100 hall next to conference room. The foul odor and debris were again observed by the Surveyors. On 11/05/24 at 10:25 AM, the Director of Nursing (DON) was asked to come to the end of the 100 halls where the wheelchairs were located. The DON was asked, do you smell a foul odor and see the debris on the wheelchair cushions and the seats of the wheelchairs? The DON agreed there was a foul odor and debris were on the wheelchair cushions and seats of the wheelchairs. The DON stated, there is a schedule for the staff on midnights to clean the wheel chairs. The DON returned with a blank schedule with room numbers and days of the week each wheelchair should be cleaned. The DON then had a staff member bring disinfectant wipes to clean the wheelchairs. The following residents had wheelchairs located in this area: --Resident #17 --Resident #35 --Resident #56 --Resident #47 --Resident #37 --Resident #57 --Resident #2 There were additional wheelchairs located in this area without names located on the handles. No further information was provided during the survey process.

Based on record review and staff interview, the facility failed to revise the care plan regarding a diagnosis of anemia, actual multiple falls with injuries, indicate the diagnosis of dehydration and the administration of intravenous fluids (IVFs), and the discontinuation of an anticoagulant for Resident #28 and Resident #18's transfer to hospice services. This was true for two (2) of 21 residents reviewed during the survey process. Resident Identifiers: #28 and #18. Facility Census: 59. Findings included: a) Resident #28 On 11/05/24 at 8:45 AM, a record review was completed for Resident #28. The review found the resident had multiple falls with actual injuries noted, laboratory results indicating elevated liver functions indicating dehydration as well as low hemocrit and hemoglobin, and the discontinuation of an anticoagulant due to the resident having multiple falls. The care plan was reviewed regarding the noted change of conditions which were found the resident record. The care did not have an indication of actual falls with injuries, abnormal laboratory results indicating dehydration or anemia, receiving IVFs and the discontinuation of an anticoagulant (Eliquis). On 11/05/24 at 10:15 AM, the DON was notified the care plan did not indicate any of the change of conditions. The DON confirmed the care plan should have been updated with the change of conditions for Resident #28. No further information was obtained during the survey process. 51553 b) Resident #18 Findings confirmed on 11/05/2024 by the Director of Nursing for Resident #18 included: Hospice services were ordered for Resident #18 on 10/28/2024. The Director of Nursing acknowledged there was no current care plan for hospice services and stated, that's odd. Findings were confirmed 11/06/24 10:10 AM by the Director of Nursing for Resident #19 included: The resident's care plan stated the patient had a long term use of insulin. The resident's insulin was discontinued on 9/18/2024. The State Surveyor reviewed the care plan with insulin documented and matrix with the Director of Nursing. The Director of Nursing stated, I don't think it's his most recent care plan. On 11/06/24 10:26 AM, the Director of Nursing stated she was looking at the wrong care plan. The Director of Nursing confirmed the care plan stated the resident has long term use of insulin. The Director of Nursing reported she talked with the care plan nurse. The Director of Nursing stated, I changed it to 'history of' on a new care plan.

Based on observation and staff interview, the facility failed to provide an accident and hazard free environment as possible by having a treatment cart which would not lock properly on three occasions. These were random opportunities for discovery. Facility Census: 59. Findings Include: a) Treatment Cart On 11/04/24 at 11:40 AM, a treatment cart was observed unlocked behind the nurses' station which was unsecured and residents are able to ambulate in this area. On 11/04/24 at 11:43 AM, the Director of Nursing (DON) was notified of the treatment cart being unlocked and accessible to the residents. The DON stated, the lock is not working .I'll call Maintanence. At this time, the treatment cart was left in the same area behind the nurses' station. On 11/04/24 at 3:15 PM, the treatment cart was observed unlocked behind the nurses' station. At this time, observations of the unlocked treatment cart continued until 3:30 PM. No staff were observed near the unlocked treatment cart during this time. The Administrator was notified and stated, We have contacted the pharmacy and they are coming to check it. The Administrator advised the DON to move the treatment cart and lock it in the medication room. At this time, an inventory of the items in the unlocked treatment cart was completed. The following items were noted: --Microkill Germicidal Alcohol Wipes (one container) --Sani cloth with bleach (one container) --Antifungal Powder (six bottles) --Zinc Oxide (three tubes) --Ammonium Lactate 12% (two tubes) --Mupirocin 2% ointment (one tube) --Sodium Sulfaceamide 10% (one tube) --Ketoconazole Shampoo (one bottle) --Flucinolone Acetonide Cream 0.01% (one tube) --Pluragel (two tubes) --Therahoney (six small tubes) --Iodosorb Cadexomer Iodine Gel (one tube) --Hydrocortisone (one tube) --Hemorrhoid Ointment (two tubes) --Antiseptic skin cleanser (one bottle) --Hydrogel (two tubes) --Moisturize cream (one jar) --Silicone Cream (one tube) --Antifungal Cream (one tube) --A & D ointment (one tube) --Bisacodyl suppositories (1 box) --Wound cleanser (five bottles) --Providone Iodine wipes (1 box) --Alcohol wipes (1 box) --Fresh Odor Eliminator (one bottle) --Chlorhexidine Gluconate 4% --Sure prep (1 box) --Suture removal trays (four) which includes scissors --Scissors (two) --Disposable razors (four) --Nail clippers (five) --Silver Sulfadiazine cream (one jar) --Triamcinolone acetate cream (one jar) On 11/04/24 at 3:45 PM, the Administrator was asked for a list of wanderers. The Administrator provided a list of 13 wanderers; and, four (4) residents listed on the wanderers list were noted to be wandering in the hallway near the nurses' station. Two (2) residents approached the Surveyors during the time the inventory was being completed. The two (2) residents were redirected by staff. No further information was obtained during the survey process.

Based on observation, record review and staff interview, the facility failed to store and label food in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 59. Findings included: a) A bag of elbow macaroni was found open with no dates. A bag of loose tea bags was opened with no dates. One tea bag was found loose and lying out of the bag. On 11/05/25 the Nutrition Pantry was investigated and the findings confirmed by the CDM at 9:07am included: A can of ground roast coffee with a best by date of 02/29/24 was found. No open date was found on the can. The can was rusty and dirty on the bottom. The CDM reported it was, not stocked from the kitchen. CDM to follow up with the administrator. Findings confirmed by the Certified Dietary Manager (CDM) on 11/04/24 during the kitchen investigation initiated at 10:35 am included.

Based on record review and staff interview, the facility failed upon admission to identify a mental diagnosis for Resident #36 and related diagnoses of dementia and PTSD for Resident #42 on the PASARR. This was true for two (2) of three (3) resident's reviewed under the area of PASARR. Resident identifiers: #42 and #36. Facility Census: 59 Findings included: a) Resident #42 Findings were confirmed by the Social Worker and the Admission's Director on 11/06/24 12:55 PM for Resident #42 included: 1) Diagnoses for PTSD and Dementia were not indicated on the initial PASARR. Diagnosis of dementia from the hospital H&P dated 5/11/22 listed PMH: Dementia 11/2021. 2) The State Surveyor interviewed the Social Worker concerning PASARR for Resident #42 .The Social Worker reported she does not have access to the attached order summary since they had changed companies. The Social Worker stated there was no access to Genesis to attach the diagnosis list. The Social Worker stated, We will have to redo all the summaries. The Social Worker stated, I don't redo them when they get there. (from the hospital) on every resident initially. The Admission's Director stated, Now we know and we will do better. No further information was provided. 3) Record Review indicated a diagnosis of dementia from the hospital H&P dated 5/11/22 listed PMH: Dementia 11/2021. The resident's Physician Determination of Capacity was signed and dated 5/17/22- The patient lacks capacity with a diagnosis of Alzheimer's Disease. 45173 b) Resident #36 On 11/04/24 at 12:54 PM, a record review was completed for Resident #36. The review found the original Preadmission Screening and Resident Review (PASARR) dated 03/04/22 had only dementia listed. The review, also, found the resident had a diagnosis of paranoid schizophrenia. On 11/05/24 at 2:34 PM, the Admissions Director #97 stated, We are trying to get the most recent PASARR from his recent hospitalization in July, 2024. On 11/06/24 at 3:37 PM, the Admissions Director #97 stated, I have called the hospital multiple times and I haven't received the pages that list the diagnoses .I have the signature page from when the physician signed it on 07/22/24 .that's all they have sent. On 11/06/24 at 4:00 PM, the Admissions Director #97 confirmed the initial PASARR dated 03/04/22 did not list the diagnosis of paranoid schizophrenia. No further information was obtained during the survey process.

Based on record review and staff interview, the facility failed to maintain an accurate and complete record regarding transfer dates for Resident #28 and #36. This was true for two (2) of two (2) residents reviewed under the care area of hospitalization s. Resident identifiers: #28 and #36. Facility census: 59. Findings include: a) Resident #28 On 11/05/24 at 10:10 AM, a record review was completed for Resident #28. The review found the resident had been sent to an acute care facility on 08/11/24. However, the transfer form was dated 06/29/24. On 11/05/24 at 11:30 AM, the Director of Nursing (DON) was notified. The DON confirmed the transfer date was incorrect in the medical record. b) Resident #36 On 11/05/24 at 11:00 AM, a record review was completed for Resident #36. The review found the resident had been sent to an acute care facility on 10/04/24. However, the date on the transfer form was 09/04/24. The review, also, found the resident had been sent to an acute care facility on 10/27/24. However, the date on the transfer form was 10/04/24. On 11/05/24 at 11:30 AM, the Director of Nursing (DON) was notified. The DON confirmed the transfer dates were incorrect in the medical record.

Based on record review and staff interview, the facility failed to follow the proper procedures to appoint a healthcare surrogate for Resident # 35. This was true for one (1) of four (4) residents reviewed for advance directives during the survey process. Resident Identifier: 35. Facility census: 59. Findings include: A) Resident #35 At approximately 2:30 PM on [DATE], a review of Resident #35's electronic health record was reviewed. During this review, it was noted the resident had a Physician Orders for Scope of Treatment (POST) form on file, signed by someone that was not named as her healthcare surrogate. Resident #35 was admitted to the facility on [DATE] after a hospital stay. During her hospital stay, the hospital determined Resident #35 did not have capacity to make decisions on her own due to an Acute Cerebrovascular Accident, resulting in confusion and disorientation. The duration of incapacity was determined to be long term. Due to Resident #35 demonstrating incapacity to make informed choices, the hospital completed a checklist for healthcare surrogate (HCS) selection. Resident #35's husband was determined to be the best choice and he agreed to become the HCS. This was completed on [DATE]. Resident #35 was admitted to the facility on [DATE] and was deemed incapacitated by the facility's physician, on this day, due to Multiple Infarct Dementia as evidenced by inability to understand or make medical decisions and being disoriented to person, place and time. On [DATE], Resident #35's husband signed a POST form indicating the resident was to be a full code. Resident #35 was to receive CPR, full medical interventions, feeding tubes, and IV fluids for a trial period of no longer than seven (7) days. Resident #35's husband was admitted to the facility on [DATE]. On [DATE], Resident #35's husband signed paperwork to make a family friend his Power of Attorney (POA). That same day, Resident #35, witnessed by the Secretary, the Director of Nursing (DON), and notarized by the Social Service Director (SSD), signed the same paperwork to make the same family friend her POA. At the time of signing this paperwork, Resident #35 was incapacitated and had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. On [DATE], Resident #35's husband was declared incapacitated. On [DATE], the newly appointment POA filled out a new POST form, indicating Resident #35's code status was now Do Not Resuscitate (DNR) with comfort focused treatments and no artificial means of nutrition. Resident #35's husband passed away at the facility on [DATE]. At approximately 12:00 PM on [DATE], an interview was conducted with the DON and Business Office Manager (BOM) regarding the POA paperwork. During the interview, the DON and BOM both acknowledged Resident #35 did not have capacity when she signed the paperwork to appointment the family friend as her power of attorney. At approximately 1:00 PM on [DATE], the Administrator acknowledged Resident #35 did not have capacity when she signed the paperwork to appointment the family friend as her power of attorney. At approximately 1:10 PM on [DATE], an interview was conducted with the Assistant Director of Nursing (ADON), while she was working a medication cart, about Resident #35's code status. The ADON was asked, if Resident #35 was to code at that moment, how would the facility determine her code status. The ADON pulled up her computer and pointed to the Resident's code status on her chart, which was DNR. At approximately 2:30 PM on [DATE], an interview was conducted with the Administrator. During the interview, the Administrator stated after Resident #35's husband was deemed incapacitated, the facility made the decision to appointment the family friend to be Resident #35's POA. However, the paperwork was completed to appointment the family friend on [DATE], while the husband was not deemed incapacitated [DATE]. The Administrator stated the facility should have gone through an HCS selection process to appoint the family friend as the POA rather than having Resident #35 fill out the paperwork while being incapacitated with a BIMS score of 3.

Based on record review and staff interview, the facility failed to thoroughly investigate allegations of abuse and neglect, by failing to have witness statements signed by witnesses an alleged incident involving Resident #11, and failing to complete witness statements, and notify the police regarding an allegation of misappropriation of funds for Resident #38. This was true for two (2) of four (4) residents reviewed for abuse and neglect during the survey process. Resident identifiers: 11, 38. Facility census: 59 Findings include: A) Resident #11 At approximately 3:30 PM on 11/05/2024, a review was conducted of a facility reported incident concerning Resident #11 on 10/07/2024. During the review, it was noted the administrator of the facility had conducted interviews with four (4) employees regarding the incident. These interviews were typed and signed only by the administrator, with no indication of employee acknowledgement. At approximately 1:00 PM on 11/06/2024 an interview was conducted with the administrator. During the interview, the administrator stated these interviews were conducted over the phone this was the standard way she conducts interviews, and does not usually have the employees interviewed, sign the statements. 50551 b) Resident #38 -Resident Interview: On 11/04/24 at 4:07 PM an interview was conducted with Resident #38 who reported that he had $100 missing from his lock box in his room. He reported that he wears the key around his neck and the only time he takes it off is when he is in the shower. He stated that he reported this incident to staff on 09/05/24. -Review of records: On 11/05/24 at 3:00 PM, a review of the initial reportable, investigation and five-day-follow-up dated for 09/05/24 revealed the following: Resident #38 reported on 09/05/24 to the Social Worker that he had $100 in his lockbox. He reported that the money was in a brown envelope. He does not recall the last time he saw the money. The resident's sister was interviewed by the Social Worker and reported that Resident #38 had money in his lock box. She stated a few months ago she gave him $100 that was wrapped in a piece of white notebook paper and placed in his lockbox. She was uncertain of the last time she saw the money in the lockbox. There were 15 (fifteen) staff interviews/questionnaires on pre-typed forms that were filled in with handwritten answers, 13 (thirteen) of these had no name documented as to the person conducting interview/nor signature of said person. There was 1 (one) form with no date/time of interview. All 15 (fifteen) forms were not signed by the people who had been interviewed. The five-day follow-up revealed that the incident was reported to Adult Protective Services and the Ombudsman. The facility did not verify the incident due to the following: There is no evidence to show any staff member stole his money. He keeps it locked in a lock box with the key around his neck. He has not noticed his lock box out of place or tampered with. Staff who work with resident have not seen or heard of any suspicious activity in his room. Resident and his sister reminded that cash should not be kept in the room. Resident account could be established where he would have access to money as needed. -Staff Interview: On 11/06/24 at 1:25 PM, during an interview the facility administrator revealed she completed the investigation of the incident that occurred on 09/05/24. She stated she only interviewed staff that had recently worked on the resident's hall despite not knowing exactly when the money first came up missing. She acknowledged that these statement interviews were handwritten by her, she had interviewed some via telephone and some face to face, they did not contain her name listed as the Person conducting interview, were not signed by her or by the staff who were interviewed and she stated that she did not know why. She acknowledged that it was unclear as to exactly when Resident #38's money came up missing. She acknowledged that the resident's sister had reported she had given the resident $100 some time ago. Staff interviewed could not recall a time when the resident had it outside of his safe or had spent it. The administrator reported that she assisted the resident in looking through his belongings and did not find the missing money. She could not recall if she had contacted the police but after looking at the five-day-follow-up, she reported that she had not contacted the police in regards to this allegation. She also stated that the money was not replaced by the facility because they did not determine that the facility was at fault. -Review of facility's policy for Abuse, Neglect, Exploitation reveals the following: The facility will report allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Compliance Guidelines: 5. Investigation: a. The facility will investigate all allegations and types of incidents as listed above in accordance with facility procedure for reporting/response as described below. b. The facility will perform an investigation that focuses on whether abuse or neglect occurred and to what extent. Clinical evaluation for any signs of injury, causative factors, and interventions to prevent further injury. Procedure for response and reporting allegations of Abuse/Neglect/Exploitation: When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated: 2. The Administrator or designee will: a. Notify the appropriate agencies as soon as possible but no later than 24 hours after discovery of the incident. b. Initiate and conduct a thorough investigation. Obtain statements related to the incident from victims, individual reporting incident, alleged perpetrator, and any witnesses. d. Notify local law enforcement, Licensing Boards and Registries, and any other agencies as required.

An IJ at F600 was called on 04/03/24 at 1:26 PM . A Plan of Correction (POC) was approved on 04/03/24 at 4:56 PM. The IJ was abated on 04/04/24 at 10:15 AM. Based on record review, observations and staff interviews, the facility failed to protect a defenseless, non communicative resident from sexual abuse and to ensure other residents were protected from sexual abuse. This failed practice had the potential to affect all residents residing in the facility. Resident identifiers: #14 and #20. Facility census: 49. Findings included: Review of the policy and procedure titled Abuse, Neglect and Exploitation dated reviewed/revised 03/22/23 stated that reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specific time frames: immediately, but not later than 2 hours after the allegation is made . In addition Sexual abuse is non-consensual sexual contact of any type with a resident. An unannounced two (2) complaint investigations (#31427, #31733) was conducted with entrance on 04/02/24 at 11:10 AM. The facility was exited on 04/04/24 with reentrance on 04/08/24 and exited on 04/10/24. Findings included: On 03/29/24 at 11:12 AM, a Registered Nurse (RN) #36 made the following general note: Resident was caught with his hand in the shirt of an incapacitated person. Intervention occurred while hand was under the shirt, near the waist line, on the abdomen. Resident was trying to reach further at the time of incident. He continued to try and get near the targeted resident multiple times throughout the day but was unable to. Staff were aware and vigilant in redirected resident to his room and activities. The alleged perpetrator was Resident #20 and the victim was Resident #14. The State Agency did not received an Initial Reporting of Allegations until 04/01/24 at 13:53 (1:53 PM) when the incident was reported to the Nursing Home Administrator (NHA). The reporting was completed for Resident #20 and Resident #14. a) Resident #14 Resident #14 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included Dementia, depression and cognitive communication deficit. A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/05/24 found a Brief Interview for Mental Status (BIMS) of 00. Which indicated a severe loss of cognition. The MDS noted there had been no behaviors noted from the last MDS. b) Resident #20 Resident #20 was admitted on [DATE]. Diagnoses included Dementia, depression and anxiety disorder. A review of the quarterly MDS with an ARD of 03/08/24 found a BIMS of 00 which indicated a severe loss of cognition. The MDS noted there had been no behaviors noted from the last MDS. Resident #20 had no verbal communication. On 04/02/24 a request was made to the Nursing Home Administrator (NHA) for all reportable's from January 2024 through March 2024. There were two (2) residents listed with dates of 01/18/24 and 02/19/24 respectfully. When the NHA was asked if there were any other reportable's, the NHA stated that she had just received an allegation and was being investigated and reported. The sexual abuse occurred on 03/29/24 and was not reported until 04/01/24. This involved an allegation of sexual abuse from resident to resident. On 04/03/24 at 9:40 AM, the NHA produced the reportable regarding the complaint. After further review of employee statements, The NHA found the Registered Nurse (RN) #36 did intervene as well as Nurse Aides (NA's) to remove the perpetrator from the victim. RN #36 failed to notify anyone until 04/01/24. The NHA was not informed of the incident until 04/01/24. The NHA stated that she was aware that the incident needed to be reported within two (2) hours. She had obtained a statement with the RN involved who was on vacation. All but one NA had provided a statement. In addition, the NHA stated that education had been started on 04/01/24 regarding what was sexual abuse for all staff but not sure if this included abuse reporting. The NHA was asked for any evidence when or how the staff monitored Resident #20 after the incident occurred. The General Note Nursing on 03/29/24 at 11:12 AM stated Resident (#20) was caught with his hand in the shirt of an incapacitated person (#14). Intervention occurred while hand was under the shift, near the waist line, on the abdomen. Resident (#20) was trying to reach further at the time of the incident. Resident (#20) was redirected from the resident (#14). He continued to try and get near the targeted resident multiple times throughout the day but was unable too. Staff were aware and vigilant in redirected resident to his room and activities. The following was the phone interview with RN #36 by the NHA on 04/02/24. The interview was as follows: Have you witnessed (resident initials) inappropriately touching residents or attempting to? Give details. Friday, 3/39 - I was at the top of the 100 hall at the med (medication) cart, heard one of the aides say (resident name redacted), stop that. I looked over and saw (female resident name redacted) wheelchair was against the wall near the bathroom and (male resident first name redacted) was in his chair facing her. His hand was under her shirt at the waistline. I came over and removed his hand from her. I told him that was inappropriate, and he could not do that. He laughed. We moved (male residents first name redacted) away from her but he continued to try to go near her. Eventually we took him to the dining room and redirected him by working on a puzzle. If so, what was done to protect the resident? Staff monitored (male resident first name redacted) and eventually had to remove him from the area of where (female first name redacted) sat. No other issues during the shift. What was done to protect other residents? Monitored (male resident first name redacted) whereabouts. No other issues during the shift. Did you report it to the supervisor? No. I documented it and passed it along in report. NA #34 stated that, on 03/29/24 at approximately 1:30 PM, Resident #20 had his arm going up Resident #14 shirt. I took him away from the situation. I told my nurse. I also told all the other aides so they would keep him away from her. Interview by the NHA conducted on 04/03/24. NA's #45 and #7 during an interview on 04/02/24 both stated that they saw Resident #20 putting his hand up the shirt of Resident #14. Both stated they moved them away from each other and into another area. Both reported the incident to their nurse. Resident #20 was placed on 1:1 starting on 04/01/24 at 4:00 PM. On 04/02/24 at 6:18 PM Resident #20 was seen and evaluated by a consulting psych PMHNP-BC and ordered Prozac 10 milligrams every day for mood and inappropriate sexual behavior (ISB). Although an additional recommendation was made to discontinue 1:1 monitoring, the facility made the decision to continue the 1:1. A review of the evidence found staff scheduled to provide 1:1 monitoring since 04/01/24 at 4:00 PM. Random observations of Resident #20 found a staff member with him at all times. Observed sleeping in his room, sitting at the Nurses Station and walking in the hall. F600 Plan of Correction 1. Resident #20 was immediately removed from the area of Resident #14. Resident #20 was monitored and redirected by nursing staff until he was placed on 1:1 observation on 4/1/24. No further contact was made between Resident #20 & Resident #14. Resident #20 was seen by psych provider on 4/2/2024 for supportive visit. Resident #14 was noted to exhibit no signs or symptoms of psychological distress or discomfort and has not had any changes to her normal behavior. 2. All current residents will be interviewed by a member of the department head team by 4/3/24 to determine if they have experienced or have witnessed any sexual abuse by another resident in the facility. All current residents with a BIMS score of 12 or less will be assessed by social work to determine their capacity to consent to sexual activity. The assessments will be completed by 4/3/24. 3. Department Managers were educated by the Regional Clinical Consultant, RN on Non-Consensual Sexual Contact, Abuse, Neglect, Exploitation Policy. Education includes the identification of sexual abuse, stopping and reporting abuse, and the expectation the resident is to remain under direct observation until determined to no longer be a risk to other residents. Nursing Home Administrator, Regional Clinical Consultant and Department Managers will immediately begin education of employees until all current employees have received education. Any employee on LOA or not available to be reached by 4/3/24 will be educated prior to working their next scheduled shift. The NHA will ensure that education has been provided to them prior to beginning their shift. 4. The NHA, DON, or designee will administer quizzes daily until all employees validate understanding of education provided. Findings will be reported by the NHA or DON at the monthly Quality Assurance Performance Improvement (QAPI) Meeting for a period of 3 months to monitor progress towards improvement and recommendations. The following staff members were interviewed regarding the education presented by the facility for abuse reporting and what constitutes sexual abuse between 8:45 AM and 9:58 AM on 04/03/24: Housekeeping #4 NA #34 Med Records/Central Supply #81 RN #69 NA #70 LPN #75 Maintenance Director #84 Maintenance Assistant #94 OTA/DOR #76 Activities Asst. #14 Cook #29 Dietary Aide #30 NA #42

An IJ at F609 was called on 04/03/24 at 1:26 PM . A Plan of Correction (POC) was approved on 04/03/24 at 4:56 PM. The IJ was abated on 04/04/24 at 10:15 AM. Based on record review, reportables review, staff interviews, and policy review, the facility failed to report an allegation of sexual abuse within the required two (2) hour time. Resident identifiers: #14 and #20. Facility census: 49. Findings included: Review of the policy and procedure titled Abuse, Neglect and Exploitation dated reviewed/revised 03/22/23 stated that reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specific time frames: immediately, but not later than 2 hours after the allegation is made . In addition Sexual abuse is non-consensual sexual contact of any type with a resident. An unannounced two (2) complaint investigations (#31427, #31733) was conducted with entrance on 04/02/24 at 11:10 AM. The facility was exited on 04/04/24 with reentrance on 04/08/24 and exited on 04/10/24. On 03/29/24 at 11:12 AM, a Registered Nurse (RN) #36 made the following general note: Resident was caught with his hand in the shirt of an incapacitated person. Intervention occurred while hand was under the shirt, near the waist line, on the abdomen. Resident was trying to reach further at the time of incident. He continued to try and get near the targeted resident multiple times throughout the day but was unable too. Staff were aware and vigilant in redirected resident to his room and activities. The alleged perpetrator was Resident #20 and the victim was Resident #14. On 04/02/24 a request was made to the Nursing Home Administrator (NHA) for all reportable's from January 2024 through March 2024. There were two (2) residents listed with dates of 01/18/24 and 02/19/24 respectfully. When the NHA was asked if there were any other reportable's, the NHA stated that she had just received an allegation and was being investigated and reported. The sexual abuse occurred on 03/29/24 and was not reported until 04/01/24. This involved an allegation of sexual abuse from resident to resident. On 04/03/24 at 9:40 AM, the NHA produced the reportable regarding the complaint. After further review of employee statements, The NHA found the Registered Nurse (RN) #36 did intervene as well as Nurse Aides (NA's) to remove the perpetrator from the victim. RN #36 failed to notify anyone until 04/01/24. The NHA was not informed of the incident until 04/01/24. The NHA stated that she was aware that the incident needed to be reported within two (2) hours. She had obtained a statement with the RN involved who was on vacation. All but one NA had provided a statement. In addition, the NHA stated that education had been started on 04/01/24 regarding what was sexual abuse for all staff but not sure if this included abuse reporting. The NHA was asked for any evidence when or how the staff monitored Resident #20 after the incident occurred. The State Agency did not received an Initial Reporting of Allegations until 04/01/24 at 13:53 (1:53 PM) when the incident was reported to the Nursing Home Administrator (NHA). The reporting was completed for Resident #20 and Resident #14. a) Resident #14 Resident #14 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included Dementia, depression and cognitive communication deficit. A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/05/24 found a Brief Interview for Mental Status (BIMS) of 00. Which indicated a severe loss of cognition. The MDS noted there had been no behaviors noted from the last MDS. b) Resident #20 Resident #20 was admitted on [DATE]. Diagnoses included Dementia, depression and anxiety disorder. A review of the quarterly MDS with an ARD of 03/08/24 found a BIMS of 00 which indicated a severe loss of cognition. The MDS noted there had been no behaviors noted from the last MDS. Resident #20 had no verbal communication. F609 POC 1. Resident to resident incident reported to OHFLAC, Ombudsman, and APS by the facility on Monday, April 1, 2024 at 1500 3:00 PM. 2. No other residents were directly affected by this practice. 3. Department Managers were educated by the Regional Clinical Consultant, RN on Non-Consensual Sexual contact, Abuse, Neglect, Exploitation Policy. Education includes the identification of sexual abuse, stopping and reporting abuse, and the expectations the resident is to remain under direct staff observation until determined to no longer be a risk to other residents. Nursing Home Administrator, Regional Clinical Consultant and Department Heads will immediately begin education of employees until all current employees have received education. Any employees on LOA or not available to be reached by 4/3/24 will be educated prior to working their next scheduled shift. The NHA will ensure that education has been provided to them prior to beginning their shift. 4. The NHA, DON, or designee will administer quizzes daily until all employee validate understanding of education provided. Findings will be reported by the NHA or DON at the monthly Quality Assurance Performance Improvement (QAPI) Meeting for a period of 3 months to monitor progress towards improvement and recommendations.

Based on record review, observations and staff interviews, the facility failed to ensure a resident maintained a continuous oxygen supply. Resident #50 failed to receive oxygen therapy from a portable tank and oxygen concentrator for approximately 20 minutes. This failed practice had the potential to affect all residents receiving oxygen therapy. Resident identifier: #50. Facility census: 49. Findings included: a) Resident #50 Resident #50 was admitted on [DATE]. Diagnoses included Diabetes Mellitus, Congestive Heart Failure, Chronic Obstructive Lung Disease, Hypertension, End Stage Renal Disease, Stage 4, and Respiratory failure. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/23 had a Brief Interview of Mental Status (BIMS) score of 13. This represents the resident is cognitively intact. An addition quarterly MDS with an ARD of 01/19/24 had a BIMS score of 10 which indicated a decline in cognition. Resident #50 is currently in an acute care hospital and returned to the facility on [DATE]. Random observations of Resident #50 on found Resident #50 asleep in her room. Resident #50 had no signs of respiratory distress. Unannounced complaint investigations (#31427 and 31733) were conducted concurrently on 04/02/24 through 04/04/24 and 04/08/24 through 04/10/24. A resident's family member reported that Resident #50 called on 02/18/24 and stated that she was having trouble breathing and the family member called the facility and 911 as well as Resident #50 calling 911. Resident #50 was admitted on [DATE]. Diagnoses included Diabetes Mellitus, Congestive Heart Failure, Chronic Obstructive Lung Disease, Hypertension, End Stage Renal Disease, Stage 4, and Respiratory failure. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/23 had a Brief Interview of Mental Status (BIMS) score of 13. This represents the resident is cognitively intact. An addition quarterly MDS with an ARD of 01/19/24 had a BIMS score of 10 which indicated a decline in cognition. On 02/18/24 Resident #50 was returned to her room by Activities (NA #40) because of an incontinent episode and oxygen tank switched because of running empty. This resident was taken back to Activities but they were ending. NA #40 returned Resident #50 to her room and connected to the oxygen concentrator removed from a portable oxygen tank around 4:00 PM and placed on an oxygen. Resident #50 expressed no distress during dinner. Staff delivered dinner tray to Resident #50 between 5:00 PM-5:15 PM and picked up dinner tray between 5:45 PM-6:00 PM the resident expressed no concerns at this time. At 6:45 PM MPOA received phone calls from the resident stating that she couldn't breathe. MPOA called the facility and reported that the resident needed help. The MPOA called 911 to report Resident #50 couldn't breathe. Concurrently, NA #13 was walking past Resident #50's room and overheard the Resident say calling 911. NA#13 immediately entered the room to see what was happening. She saw the resident was having trouble breathing and ran up the hall to get the Nurse. NA#40 went into the room and saw the oxygen concentrator was off and could not get it turned back on. NA #40 removed the tubing from the oxygen concentrator and plugged into the portable tank and found it was empty. NA #13 came back to the room with the pulse oximeter and turned the concentrator on and had no issue. NA#13 plugged the oxygen tubing back into the concentrator. Resident #50 began to take deep breaths and her oxygen levels returned to baseline. Oxygen levels were in the 90's by 7:03 PM when the ambulance arrived. Resident #50 refused to go to the hospital with the ambulance. The MPOA reported the situation to the NHA on 02/19/24. The resident was interviewed and she stated she didn't know what happened, she was just sitting in her room and suddenly couldn't breathe. She denied touching her oxygen concentrator. Maintenance ran a safety check of the concentrator and found it operating at 96% flow and all safety alarms functioning. Resident #50 was also assessed by the Nurse Fractionate. The NP made the following assessment: On 02/18/24 at 8:07 PM Nursing observations, evaluation, and recommendations are: Resident family called facility and reported to another nurse that her mother was in her room and was having trouble breathing. They also called 911 and had them come and evaluate her. I was not informed at that time of what was going on, aide came down the hall after me, her O2 stat was reading in the 60's at that time. Oxygen was on and functioning properly at that time. Her oxygen was either not hooked up properly to the concentrator/or the tank was empty, her wheelchair was pushed back against the concentrator and her back was up against her oxygen tubing, possibly cutting off her oxygen supply. She was instructed to take several deep breaths. Her oxygen was up to 96% on 4 liters when the ambulance arrived at facility. A close living family member also came to facility. Resident #50 is currently in an acute care hospital and returned to the facility on [DATE]. Random observations of Resident #50 found Resident #50 asleep in her room. Resident #50 had no signs of respiratory distress. Review of pulse oxygen levels on 04/06/24 at 10:01 AM found the following: 04/06/24 at 2:28 AM 97% on room air 04/06/24 at 6:15 AM 97% on room air 04/06/24 at 6:16 AM 97% oxygen via nasal cannula 04/06/24 at 3:12 PM 100% on room air 04/07/24 at 2:57 AM 97% oxygen via nasal cannula 04/07/24 at 9:30 AM 100% oxygen via nasal cannula 04/07/24 at 9:48 AM 100% room air 04/08/24 at 4:41 AM 100% oxygen via mask 04/08/24 at 10:53 AM 96% room air 04/08/24 at 9:031 PM 92% oxygen via nasal cannula 04/09/24 at 3:26 AM 93% on room air 04/09/24 at 12:00 PM 97% oxygen via nasal cannula 04/09/24 at 12:51 PM 98% oxygen via nasal cannula 04/09/24 at 5:00 PM 93% oxygen via nasal cannula 04/09/24 at 6:36 PM 93% oxygen via nasal cannula 04/09/24 at 11:07 PM 95% oxygen via nasal cannula 04/10/24 at 5:01 PM 94% oxygen via nasal cannula 04/10/24 at 5:26 PM 96% oxygen via nasal cannula Physician ordered oxygen at 3L/m via nasal cannula continuously on 0408/24. The following residents were on oxygen therapy with no issues found of respiratory distress or oxygen therapy issues: Resident #1 Oxygen order:4L/minute. Checked on 04/03/24 at 2:24 PM MACHINE TO BE CHECKED ON 6/24. Observed set at 4.0/L. Resident has a trach. This resident discharged on [DATE]. Resident #48 04/03/24 at 2:19 PM 3L/trach mask 02 94%. Observed on 04/04/24 at 9:54 AM. Had trach collar on with O2 via portable tank. Resident #37 On 4/3/24 at 2:24 PM ordered 2L and on 2 liters 2:30 PM. Resident #37 stated that the oxygen was to be on 2L/m and I get to go home. Resident #50 on 04/03/24 at 3:05 PM entered room was not able to determine when the concentrator was serviced. No date that was readable on concentrator. This resident in hospital Returned on 04/06/24 and ordered oxygen at 3L/m continuously. Resident #7 receiving oxygen concentrator via nasal cannula on 04/03/24 at 3:00 PM. The resident is currently asleep. This complaint was substantiated as the facility failed to ensure oxygen was available as ordered and was cited at F695.