Every finding on record at Crest View Lutheran Home

Based on interview and document review, the facility failed to ensure a physician-ordered ultrasound was obtained, and the results were communicated to the provider timely for 1 of 1 resident (R2) reviewed for diagnostic testing follow up and provider notification. The delay from the initiation of the ultrasound order on 7/29/26 until the provider received the results resulted in delayed evaluation and treatment of R2's continued left groin pain and swelling. R2 was subsequently transferred to the emergency department (ED), hospitalized , treated with intravenous (IV) antibiotics, and underwent surgical exploration and drainage of a scrotal abscess. Further, the facility failed to clarify discharge orders from the hospital for blood glucose monitoring for 1 of 1 resident (R6) who received insulin.Findings included: R2 R2's quarterly Minimum Data Set (MDS), dated [DATE], identified R2 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). R2's diagnoses included chronic pain (persistent or recurring pain). R2's physician progress note, dated 7/29/26 at 10:59 a.m., indicated R2 was evaluated for left groin pain after nursing staff reported swelling. The physician identified left groin swelling and tenderness and ordered laboratory testing to rule out infection and a Doppler ultrasound of the left groin. R2's progress note, dated 7/31/26 at 3:32 p.m., indicated Trident Care, the diagnostic imaging provider, was contacted regarding the ultrasound and reported a technician would be sent when available. R2's progress note, dated 8/3/26 at 2:34 p.m., indicated the ultrasound was expected to be completed the following day. R2's physician progress note, dated 8/3/26 at 5:06 p.m., indicated R2's left groin swelling had been present since 7/29/26. Examination identified a reducible, non-strangulated left inguinal hernia. R2 continued to have bowel movements. R2's progress note, dated 8/4/26 at 2:13 p.m., indicated Trident Care was contacted regarding the outstanding ultrasound and reported a technician would be sent, with the date to be communicated to the facility. R2's progress note, dated 8/6/26 at 3:09 p.m., indicated the ultrasound had been completed and the results were pending. The ultrasound was completed eight days after it was ordered. R2's ultrasound report, dated 8/6/26 at 2:35 p.m., identified a probable large bowel-containing hernia extending into the scrotum and indicated a computed tomography (CT) scan was warranted for confirmation. R2's ultrasound report indicated the results were faxed to the facility on 8/7/26 at 8:39 p.m. R2's physician progress note, dated 8/7/26 at 10:30 p.m., indicated the ultrasound results had not been received by the physician. R2 continued to report left groin pain. The physician identified a reducible, non-strangulated left inguinal hernia. R2's physician progress note, dated 8/11/26 at 2:26 p.m., indicated the physician had received the ultrasound results, which identified a large bowel-containing scrotal hernia. R2 was sent to the ED for further evaluation. R2's ED note, dated 8/11/26, indicated R2 presented with left groin pain. A CT scan of the abdomen and pelvis identified diffuse scrotal wall edema and a 3.8-centimeter rim-enhancing fluid collection near the left testicle concerning for an abscess. A scrotal ultrasound identified an approximately 4-centimeter fluid collection in the left inferior hemiscrotum suspicious for an abscess and findings consistent with left epididymoorchitis (inflammation of the epididymis and testicle). The ultrasound also identified right epididymitis (inflammation of the epididymis) with a small right hydrocele (fluid collection around the testicle). R2's ED documentation indicated urology was consulted and recommended antibiotic treatment. R2 was started on IV Zosyn, an antibiotic used to treat bacterial infections, and aspirin was held pending surgical evaluation. R2's hospital documentation, dated 8/12/26, indicated R2 was scheduled for exploratory surgery and IV antibiotics were continued. R2's hospital documentation, dated 8/13/26, indicated R2 underwent left scrotal exploration and drainage of a scrotal abscess. R2 remained under the care of the urology team and was documented as doing better without current pain. During an interview on 8/13/26 at 12:25 p.m., licensed practical nurse care coordinator (LPN)-A stated when a provider ordered a diagnostic test, such as an ultrasound, staff contacted Trident to arrange for the test to be completed at the facility. LPN-A stated the test should generally have been completed within one or two days. LPN-A confirmed R2's ultrasound was ordered on 7/29/26 and was not completed until 8/6/26. LPN-A stated Trident had reported being short staffed. LPN-A reviewed the ultrasound report and confirmed the ultrasound was completed on 8/6/26 and faxed to the facility on 8/7/26. LPN-A stated the report recommended a CT scan for confirmation, and she was unable to locate documentation that the nurse practitioner (NP) was notified of the results before 8/11/26, when R2 was sent to the ED. During an interview on 8/13/26 at 1:19 p.m., Trident Care representative (Rep)-A stated Trident received the facility's telephone order for R2's ultrasound on 7/30/26 and ultrasounds were considered scheduled procedures. Rep-A stated Trident's communication log identified attempts to contact the facility on 7/31/26; however, the calls went unanswered and a message could not be left because the facility's voicemail box was full. Rep-A stated additional attempts were made later that afternoon. Rep-A stated Trident made several additional attempts to contact the facility on 8/1/26, but the calls went unanswered and messages could not be left. Rep-A stated the facility contacted Trident on 8/4/26, at which time the ultrasound was scheduled. The ultrasound was completed on 8/6/26, and the results were faxed to the facility on 8/7/26. During an interview on 8/13/26 at 2:14 p.m., the NP stated R2 had groin swelling and she ordered an ultrasound. The NP stated she was frustrated and upset regarding the delay in obtaining the ultrasound. The NP stated she spoke with nursing staff on 8/7/26 regarding R2 and was informed a physician had evaluated R2 and identified a hernia. The NP stated R2 continued to experience pain during visits on 8/3/26 and 8/7/26, although the pain was stabilized. The NP stated facility staff had not updated her regarding the delay in obtaining the ultrasound. The NP stated that after she received the ultrasound results, she sent R2 to the ED for further evaluation. The NP stated if she had received the ultrasound results sooner, she would have sent R2 to the ED sooner. The NP stated the lapse was inappropriate and could have caused harm. During an interview on 8/13/26 at 2:31 p.m., the director of nursing (DON) stated she expected nursing staff to follow up with Trident sooner regarding the delay and document the communication. The DON stated the NP should have been notified and kept informed regarding efforts to obtain the ultrasound. The DON stated the length of time from when the ultrasound was ordered until the NP received the results was not acceptable and the delay could have worsened R2's condition and potentially caused harm. The facility policy, Notification of Changes, dated 11/25, indicated changes in a resident's condition or treatment were to be shared with the resident and/or resident representative, according to their authority, and reported to the attending physician or designee. The policy indicated its objective was to ensure staff made appropriate notification to the physician or delegated non-physician practitioner and the resident and/or resident representative when a change in condition or an accident occurred that could require physician intervention. The policy indicated its intent was to provide appropriate and timely information regarding changes in a resident's condition to the parties responsible for making decisions regarding the resident's care, treatment, and preferences. R6 R6's quarterly Minimum Data Set (MDS) dated [DATE] indicated R6 had severe cognitive impairment and was dependent on staff for activities of daily living (ADLs). R6's diagnoses included vascular dementia, diabetes, atherosclerosis native arteries, and hypertension. R6's Order Summary Report dated 8/13/26, indicated R6 had an order for Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously one time a day for diabetes with a start date of 5/16/2026. Review of R6's electronic medical record (EMR) failed to identify an order to check R6's blood sugar readings to monitor R'6 blood glucose levels to ensure they were meeting blood glucose target levels. Review of R6's progress notes indicated R6 was sent to the hospital on 5/13/26. R6 returned to the facility 5/15/26. Review of R6's discharge orders dated 5/15/26, indicated R6's metformin (oral medication used to treat diabetes) was discontinued. R6 continued on insulin, however, the discharge orders did not identify a blood glucose monitoring order. When interviewed on 8/13/26 at 9:14 a.m. licensed practical nurse (LPN)-A care coordinator stated they were not sure why R6 did not have blood glucose checks. LPN -A reviewed R6's EMR and stated R6 had blood glucose checks twice daily before they were hospitalized . LPN-A stated when R6 was readmitted a call should have been placed to the provider to clarify if blood glucose checks should be done due to R6 received insulin. When interviewed on 8/13/26 at 12:43 p.m. director of nursing (DON) stated R6's orders should have been reviewed when they were readmitted from the hospital. DON stated the expectation was when R6's orders were put into the computer the person that entered the orders should have noted they were on insulin which should have triggered a call to the provider to clarify the orders. DON stated blood glucose checks for a person on insulin was important to ensure the level was not going too low. DON reviewed R6's EMR, verified there was no order to check R6's blood glucose. Facility provided Medication and Treatment Orders policy dated 1/5/26, however, the policy failed to address clarification of orders.

Based on observation, interview, and document review, the facility failed to provide a safe, clean and comfortable environment for 2 of 2 clients (R23, R37) reviewed for environment. Findings include: Findings included: R23's quarterly Minimum Data Set (MDS) dated [DATE] indicated R23 had moderate cognitive impairment and required staff assistance with activities of daily living (ADLs). R23's diagnoses included Alzheimers disease, iron deficiency anemia, protein-calorie malnutrition, hypertension, chronic kidney disease, hypothyroidism, neuromuscular dysfunction of bladder, vitamin D deficiency, glaucoma, insomnia, muscle weakness, cerebrovascular disease, and history of falling. R23's care plan dated 8/7/26 indicated R23 had an actual alteration in safety related to history of falls, impaired cognition, had decreased safety awareness and history of self-transfers. Interventions directed staff to ensure wheelchair and bed brakes were locked during transfers, do not leave R23 alone in her room when in wheelchair, ensure call light was in reach and have night light on in room at night. On 8/12/26 at 8:05 a.m. observed a grey foam fall mat next to R23's bed, there was a reddish-brown stain that measured two feet by two feet on the fall mat, around the edges of the fall mat there were several areas of foam missing. On 8/12/26 at 2:45 p.m. nursing assistant (NA)-A stated she was not sure who was responsible for cleaning the fall mats, NA-A observed the fall mat, stated she was not sure what was on the fall mat. On 8/13/26 at 9:00 a.m. the fall mat continued to have the reddish-brown stain. When interviewed on 8/13/26 at 9:08 a.m. registered nurse (RN)-A stated she was not aware R23's fall mat was dirty and was not aware of who cleaned the fall mats. When interviewed on 8/13/26 at 9:14 a.m. licensed practical nurse (LPN)-A care coordinator observed R23's fall mat, stated she was not sure what was on the floor mat, stated someone should have cleaned or replaced the fall mat for infection control reasons but was not sure who was responsible for cleaning of fall mats. When interviewed on 8/13/26 at 12:43 p.m. director of nursing stated she expected fall mats to be cleaned when a deep clean of the rooms was done and when staff noticed that the mat as dirty for infection control purposes. Facility provided Deep Cleaning Procedures policy undated and Daily Cleaning Procedures policy undated, however, neither policy addressed cleaning of fall mats. R37 On 8/10/26 at 6:43 p.m. R37's air mattress appeared flat and shifted down exposing the top portion of the bedframe. The bed was in a seated position. On 8/11/26 at 11:23 a.m. R37's air mattress continued to be in shifted down and exposing the bedframe. On 8/11/26 at 1:08 p.m. R37 was resting with head of bed elevated to sitting position. Air mattress continued to be shifted down exposing the top portion of the bedframe. On 8/11/26 at 1:15 p.m. nursing assistant (NA)-A stated she had been in R37's room several times, but R37 was not ready yet. R37 was own person and she directed her own cares. NA-A entered room and stated the bedframe had not been exposed earlier in the day. On 8/11/26 at 1:30 p.m. registered nurse (RN)-A stated NA-A had just reported the exposed bedframe to him. His process would be to check the resident to assure safety and call maintenance. RN-A stated the exposed bedframe had not been reported to him prior. On 8/11/26 at 1:35 p.m. R37 stated she'd been having issues with her mattress. It had been fixed a while back and was good for about 2 weeks. However, she'd been having issues the last few days and no staff had attended to the issue. On 8/11/26 at 1:40 p.m. maintenance director stated he had fixed R37's mattress a few weeks back but was not aware of the current issue. On 8/12/26 at 1:18 p.m. Director of Nursing (DON) stated her expectation was staff would report anytime a bedframe was exposed or if a mattress appeared to not be functioning properly. She expected the resident would be assessed for safety, and the mattress would be evaluated and replaced immediately if necessary. A facility policy was requested, however, none provided.

Based on interview and record review, the facility failed to provide timely care conferences for 4 of 4 residents (R4, R5, R17 and R91) reviewed for care planning. Findings included: R4 R4's quarterly Minimum Data Set (MDS), dated /29/26, identified R4 had intact cognition and was independent with activities of daily living (ADLs). R4's diagnoses included chronic obstructive pulmonary disease (COPD, a chronic lung disease that causes difficulty breathing) and coronary artery disease (CAD, narrowing or blockage of the blood vessels that supply the heart). R4's care plan, printed 8/12/26, identified R4 would have an appropriate discharge plan and R4 and/or R4's family would make safe and appropriate decisions regarding discharge. Interventions directed staff to invite R4 and R4's family to care conferences quarterly or as needed and to discuss discharge planning options as needed. R4's electronic health record (EHR) identified the most recent documented care conference was conducted on 2/3/26. The EHR lacked evidence subsequent quarterly care conferences were conducted. R5 R5's significant change MDS, dated [DATE], identified R5 had moderate cognition impairment and required assistance with ADLs. R5's diagnoses included type 2 diabetes mellitus with hyperglycemia (a condition that causes elevated blood sugar levels) and a pressure ulcer of the right heel (an area of skin and underlying tissue damage caused by prolonged pressure). R5's care plan, printed 8/2/26, identified R5 would be content with long-term care placement and R5 and/or R5's family would make safe and appropriate decisions regarding discharge. Interventions directed staff to invite R5 and R5's family to care conferences quarterly or as needed and to discuss discharge planning options as needed. R5's EHR identified the most recent documented care conference was conducted on 2/19/26 in conjunction with R5's re-admission assessment. The EHR lacked evidence subsequent quarterly care conferences were conducted. R17's annual MDS, dated [DATE], identified R17 had intact cognition and required assistance with ADLs. R17's diagnoses included acute and chronic respiratory failure with hypercapnia (a condition in which breathing is impaired and carbon dioxide levels in the blood are elevated), heart failure (a condition in which the heart is unable to pump blood effectively), and hemiplegia (paralysis affecting one side of the body). R17's care plan, printed 8/12/26, lacked evidence care conferences were addressed or that an intervention was developed to invite R17 and/or R17's representative to participate in quarterly care conferences. R17's EHR identified the most recent documented care conference was conducted on 8/19/25. The EHR lacked evidence subsequent care conferences were conducted in November 2025, February 2026, and May 2026. During an interview on 8/12/26 at 3:29 p.m., social worker (SW)-B stated care conferences should have been completed quarterly. SW-B confirmed R4's last care conference was conducted on 2/3/26 and subsequent quarterly care conferences should have been conducted in April 2026 and July 2026. SW-B confirmed R5's last care conference was conducted on 2/19/26 in conjunction with R5's admission assessment, a quarterly care conference should have been conducted in March 2026, and a care conference should have been conducted following R5's significant change in June 2026. SW-B confirmed R17's last care conference was conducted on 8/19/25 and subsequent quarterly care conferences should have been conducted in November 2025, February 2026, and May 2026. SW-B confirmed the identified care conferences for R4, R5, and R17 had not been conducted. R91 R91's quarterly Minimum Data Set (MDS) dated [DATE], indicated R91 was admitted on [DATE], was cognitively intact, and had the following diagnoses: anemia, hypertension (high blood pressure), renal insufficiency, arthritis and depression. R91's care plan dated 7/28/26, indicated a focus on an alteration in psychosocial well-being related to major depressive disorder, and had the following intervention: -facility will invite resident and their family to care conferences quarterly. This intervention was initiated on 1/19/26. R91's most recent Care Conference Summary was completed on 10/16/25. R91's medical record lacked any evidence a care conference had been conducted since 10/16/25. On 8/11/26 at 12:45 p.m., the regional social work consultant (RSW) confirmed a care conference had not been conducted since October of 2025, for R91. RSW stated the social worker was typically responsible for organizing and conducting the care conferences. However, they did not have one on staff for a long time to guide and direct the department. The care conference for R91 and others had fallen behind and not been completed. RSW stated the expectation was for the care conferences to be completed upon admit, annually, quarterly, and with any significant changes. On 8/11/26 at 12:09 p.m., the director of nursing (DON) confirmed R91's care conferences had not been completed for F91 since October 25', and their expectation was for them to be completed upon admit, annually, quarterly and with a significant change, Furthermore the [NAME] stated the importance of completing care conferences to ensure the residents are included and have a say in their care and treatment plans. A care conference policy for the facility was requested, and none were provided.

Based on observation, interview, and document review, the facility failed to ensure residents with medications accessible at the bedside were assessed to determine whether they could safely self-administer medications and were authorized to self-administer medications for 2 of 2 residents (R4 and R17) reviewed for self-administration of medications.Findings included:R4R4's quarterly Minimum Data Set (MDS) assessment, dated 7/29/26, identified R4 had intact cognition and was independent with activities of daily living (ADLs). R4's diagnoses included chronic obstructive pulmonary disease (COPD) (a chronic lung condition that causes difficulty breathing) and coronary artery disease (CAD) (a condition in which the blood vessels that supply the heart become narrowed or blocked).During an observation on 8/10/26 at 2:00 p.m., a Ventolin inhaler (a medication used to open the airways and improve breathing) was observed on R4's over-the-bed table and was accessible to R4.During a subsequent observation on 8/11/26 at 4:13 p.m., the Ventolin inhaler remained on R4's over-the-bed table and accessible to R4.R4's electronic health record (EHR) lacked evidence a self-administration of medications (SAM) assessment had been completed to determine whether R4 could safely self-administer medications. R4's physician orders lacked an order authorizing self-administration of medications, and R4's care plan lacked documentation addressing self-administration of medications.R17R17's annual MDS assessment, dated 8/5/26, identified R17 had intact cognition and required assistance with ADLs. R17's diagnoses included acute and chronic respiratory failure with hypercapnia (a condition in which breathing is impaired and carbon dioxide levels in the blood are elevated), heart failure (a condition in which the heart is unable to pump blood effectively), and hemiplegia (paralysis affecting one side of the body).During an observation on 8/10/26 at 1:50 p.m., three bottles of oral medications, including ibuprofen 200 milligram (mg) tablets (a medication used to relieve pain and inflammation), a stool softener (a medication used to prevent or relieve constipation), and TUMS (an antacid used to relieve heartburn and indigestion), along with a bottle of dry eye relief eye drops, were observed on R17's over-the-bed table and accessible to R17. R17 stated she took the medications whenever she needed them and when she was unable to get ahold of staff, which she stated occurred often.During a subsequent observation on 8/11/26 at 12:11 p.m., the same medications remained on R17's over-the-bed table and accessible to R17.During an observation on 8/12/26 at 7:43 a.m., the same medications remained on R17's over-the-bed table and accessible to R17.R17's EHR identified the most recent SAM assessment had been completed in August 2025 and determined R17 was not able to safely self-administer medications. The EHR lacked evidence a subsequent SAM assessment had been completed. R17's physician orders lacked an order authorizing self-administration of medications, and R17's care plan lacked documentation addressing self-administration of medications.During an interview on 8/12/26 at 8:02 a.m., trained medication aide (TMA)-A stated a nurse assessed residents to determine whether they could safely self-administer medications. TMA-A stated that if a resident was approved to self-administer medications, authorization would be documented in the resident's physician orders. TMA-A reviewed R4's and R17's physician orders and confirmed neither resident had an order authorizing self-administration of medications. TMA-A accompanied the surveyor to both residents' rooms and confirmed the Ventolin inhaler was on R4's over-the-bed table and the oral medications and eye drops were on R17's over-the-bed table.During an interview on 8/12/26 at 8:07 a.m., registered nurse (RN)-D stated residents were required to be assessed to determine whether they could safely self-administer medications. RN-D stated that when a resident was determined capable of safely self-administering medications, a physician's order was obtained and entered into the resident's orders. RN-D accompanied the surveyor to R4's and R17's rooms and confirmed the medications remained on the residents' over-the-bed tables. RN-D stated the medications should not have been left in the residents' rooms and stated she would remove the medications and initiate the process to address self-administration of medications.During an interview on 8/12/26 at 8:15 a.m., the director of nursing (DON) stated that when a resident wished to self-administer medications, an assessment was completed to determine whether the resident could safely do so. If the resident was determined capable of safely self-administering medications, the facility obtained a physician's order and updated the resident's care plan. The DON stated that when staff found medications in a resident's room, staff were expected to speak with the resident, explain the self-administration process, provide education, and remove the medications until an assessment was completed and a physician's order was obtained.During a subsequent interview on 8/12/26 at 8:51 a.m., the DON confirmed R4 did not have a SAM assessment completed. The DON confirmed R17's most recent SAM assessment had been completed in August 2025 and stated SAM assessments should have been completed quarterly to ensure residents remained safe and able to self-administer medications. The DON reviewed R17's August 2025 SAM assessment and confirmed the assessment determined R17 was not able to safely self-administer medications.The facility policy, Self-Administration of Medications, dated 2/24, indicated residents had the right to self-administer medications when the interdisciplinary team (IDT) determined self-administration was clinically appropriate and safe. As part of the comprehensive assessment, the IDT assessed each resident's cognitive and physical abilities to determine whether self-administration was safe and clinically appropriate. When self-administration was determined to be safe and appropriate, the determination was documented in the resident's medical record and care plan and was reassessed periodically based on changes in the resident's medical and/or decision-making status. If the IDT determined a resident could not safely self-administer medications, nursing staff administered the resident's medications. The policy further directed that medications found at the bedside that were not authorized for self-administration were turned over to the nurse in charge for return to the family or responsible party.

Based on observation and interview, the facility failed to maintain separately locked and permanently affixed compartments for storage of controlled medications in the medication room refrigerator for 3 of 3 medication rooms reviewed for medications storage. Further, the facility failed to ensure medications were properly labeled when an unlabeled medication cup containing medications was stored in a medication cart. Findings include: On 8/13/26 at 9:25 a.m., during observation of the medication room on the 1st floor, licensed practical nurse (LPN)-B opened the refrigerator and removed the unaffixed narcotic lock box from the refrigerator. LPN-B stated the box was always locked but currently was not. It had never been affixed to the refrigerator. On 8/13/26 at 9:58 a.m. director of nursing (DON) accompanied writer to all other medication rooms in the building, 3 total, and confirmed the narcotic lock boxes were not affixed to the refrigerators in any of the medication rooms. DON stated their expectation was for the narcotic lock boxes to be locked and affixed to the refrigerator. A policy was a requested for medication storage and none was provided. During observation on 8/13/26 at 8:47 a.m., an unlabeled medication cup containing several unidentified medications was observed in the top right drawer of the medication cart. Licensed practical nurse (LPN)-B identified the medications as belonging to R74 and stated R74 had refused the medications when she attempted to administer them. LPN-B stated she placed the medications in the medication cart drawer and planned to reattempt administration at a later time. R74's medication administration record (MAR), reviewed on 8/13/26 at 9:11 a.m., identified R74's 8:00 a.m. medications for 8/13/26 had been documented as administered. At the time of the review, the medications remained in the unlabeled medication cup in the medication cart. During an interview on 8/13/26 at 9:16 a.m., LPN-B stated when a resident refused medications, she asked the reason for the refusal and reapproached the resident at least three times. LPN-B stated if the resident continued to refuse the medications, the medications were destroyed. LPN-B confirmed R74's medication cup was unlabeled and stated she had not labeled the cup because she was the only nurse who planned to administer R74's medications that morning. LPN-B also confirmed she had documented R74's medications as administered in the MAR even though R74 had not received the medications. LPN-B confirmed the MAR documentation was inaccurate because the medications had not been administered. During an interview on 8/13/26 at 9:30 a.m., the director of nursing (DON) stated she expected nursing staff to discard medications when a resident refused them and document in a progress note that medication administration would be reattempted at a later time. The DON stated medications should not be documented as administered in the MAR until the medications had been administered to the resident. A facility policy related to medication labeling and storage was requested but was not received.

Based on observation, interview, and document review, the facility failed to ensure fluids were readily available and offered between meals for 1 of 1 resident (R5) reviewed for hydration.Findings included:R5's significant change Minimum Data Set (MDS), dated [DATE], identified R5 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). R5's diagnoses included neurogenic bladder (difficulty controlling or emptying the bladder due to a problem with the nerves that control bladder function) and a pressure ulcer of the right heel (an area of skin and underlying tissue damage caused by prolonged pressure). The MDS also identified dehydration/fluid maintenance as a triggered area.R5's care plan, printed 8/13/26, identified R5 was at risk for dehydration related to impaired mobility and required assistance with food and fluids. The care plan identified a goal for R5 to remain free from signs and symptoms of dehydration. Interventions directed staff to encourage and offer adequate fluid intake, monitor R5 for signs and symptoms of dehydration, and report suspected signs or symptoms of dehydration to the physician (MD) or physician assistant (PA).R5's August 2026, medication administration record (MAR) included an order for staff to document the amount of fluid provided every shift and notify the provider of concerns related to fluid intake. The MAR documented the following daily fluid intake:8/1/26: 1,200 milliliters (mL)8/2/26: 920 mL8/3/26: 960 mL8/4/26: 1,150 mL8/5/26: 820 mL8/6/26: 900 mL8/7/26: 1,370 mL8/8/26: 1,460 mL8/9/26: 600 mL8/10/26: 1,200 mL8/11/26: 840 mL8/12/26: 1,050 mLR5's August 2026 MAR also included an order for staff to monitor urinary catheter output every shift. The MAR documented the following daily urinary output:8/1/26: 1,400 mL8/2/26: 1,100 mL8/3/26: 1,475 mL8/4/26: 1,700 mL8/5/26: 1,050 mL8/6/26: 1,450 mL8/7/26: 1,725 mL8/8/26: 750 mL8/9/26: 400 mL8/10/26: 300 mL8/11/26: 1,250 mL8/12/26: 950 mLDuring observation on 8/10/26 at 12:54 p.m., no water pitcher, drinking glass, or other fluids were observed in R5's room.During observation on 8/10/26 at 4:13 p.m., R5 appeared confused and fidgeted with items in her room. No fluids were observed in R5's room. R5 had an indwelling urinary catheter and had recently been diagnosed with a urinary tract infection (UTI).During observation on 8/11/26 at 10:21 a.m., R5 sat in her room and fidgeted with items in her nightstand. No fluids were observed in R5's room.During observation on 8/11/26 at 1:37 p.m., R5 sat in her wheelchair in her room. No fluids were observed in R5's room.During observation on 8/12/26 at 7:34 a.m., no fluids were observed in R5's room.During observation on 8/12/26 at 1:37 p.m., R5 lay in bed with her eyes closed. No fluids were observed in R5's room.During observation on 8/13/26 at 11:27 a.m., R5 sat in her room and fidgeted with items in her nightstand. No fluids were observed in R5's room.During an interview on 8/13/26 at 11:30 a.m., nursing assistant (NA)-C stated residents did not have individual water pitchers in their rooms and staff offered fluids at meals. NA-C stated staff should have offered fluids as needed to residents who were unable to independently request fluids. NA-C confirmed that R5 was unable to request fluids.During an interview on 8/13/26 at 12:25 p.m., licensed practical nurse care coordinator (LPN)-A stated staff were expected to offer residents fluids at meals and between meals.During an interview on 8/13/26 at 2:31 p.m., the director of nursing (DON) stated staff were expected to offer fluids at the beginning of each shift and throughout the shift. The DON stated residents who were unable to independently request fluids should have been offered fluids more frequently than at mealtimes. The DON stated that adequate fluid intake was important to prevent dehydration and UTIs.The facility policy regarding hydration, availability of fluids, and offering fluids between meals was requested but was not received for review.

Based on interview and document review, the facility failed to ensure timely follow-up and completion of necessary wheelchair modifications for 1 of 1 resident (R36) reviewed for rehabilitative services, resulting in a delay in providing R36 with a new wheelchair.Findings included:R36's quarterly Minimum Data Set (MDS), dated [DATE], identified R36 had intact cognition and required assistance with activities of daily living (ADLs). R36's diagnoses included fractures (broken bones that could affect mobility and physical functioning), Parkinson's disease (a progressive neurological condition that could affect movement, balance, and coordination), and malnutrition (inadequate nutrition that could contribute to weakness and decreased physical functioning).R36's Occupational Therapy (OT) note, dated 7/1/26, indicated R36's new high-back reclining wheelchair had arrived at the facility. R36 fit adequately in the wheelchair; however, his bilateral lower extremities did not adequately reach the floor for self-propulsion. The note identified a plan to complete an adjustment to the right wheelchair brake.R36's OT note, dated 7/2/26, indicated the wheelchair modifications remained incomplete due to difficulty adjusting the right wheelchair brake. A work order had been placed requesting assistance from maintenance. R36 sat in the new wheelchair for 20 minutes and reported the wheelchair was comfortable and that he liked the new style. The note indicated R36 continued to use his existing wheelchair until the modifications were completed.R36's OT note, dated 7/13/26, indicated the director of rehabilitation (DOR) remained unable to adjust the wheelchair brake and was awaiting assistance from maintenance.R36's OT note, dated 7/15/26, indicated R36's power of attorney (POA) was shown R36's new high-back reclining wheelchair. The note indicated the wheelchair continued to await maintenance assistance with the brakes before it could be issued to R36.R36's OT note, dated 7/16/26, indicated the director of therapy (DOT) reported the right wheelchair brake was positioned too close to the armrest, which was identified as a barrier to R36's use of the reclining-back wheelchair with the dumped-seat configuration.R36's OT note, dated 7/20/26, indicated R36 tolerated sitting in the new wheelchair during a therapy session. An attempt to adjust the right wheelchair brake was unsuccessful, and the note indicated maintenance assistance continued to be awaited. R36 continued to use his standard facility-issued wheelchair.During an interview on 8/11/26 at 12:29 p.m., R36's POA stated R36 had an appointment scheduled in June 2026; however, therapy did not allow transportation to be arranged because R36 was not safe using his existing wheelchair. The POA stated therapy indicated they would work on obtaining a new wheelchair for R36 and requested approximately two weeks to do so. The POA stated approximately four weeks later, she followed up and was informed the new wheelchair would be available for R36 to use for his appointment on 8/11/26. The POA stated R36 attended the 8/11/26 appointment using his existing wheelchair rather than the new wheelchair. During the appointment, the existing wheelchair broke and required repair with a screwdriver obtained from the clinic before R36 could return to the facility. The POA stated when R36 returned to the facility following the appointment, the new wheelchair was present in his room.During an interview on 8/13/26 at 10:05 a.m., the DOR stated she had worked with R36 since his admission, primarily to address functional transfers and wheelchair safety. The DOR stated R36 was evaluated on 6/24/26 with a goal of obtaining a new wheelchair and acknowledged she was aware R36 had appointments canceled because his existing wheelchair was not safe for transportation. The DOR stated R36's new high-back reclining wheelchair arrived at the facility on 7/1/26 but required modification to the brakes before it could be issued. The DOR stated she requested maintenance assistance with the brake but ultimately adjusted the brake herself on 8/11/26. The DOR stated the wheelchair was issued to R36 on 8/12/26.During an interview on 8/13/26 at 1:53 p.m., licensed practical nurse (LPN)-C stated a resident should receive a new wheelchair within one or two days after it arrived at the facility. After reviewing the timeline for R36's wheelchair, LPN-C stated it was not appropriate for R36 to have waited that length of time to receive the wheelchair.During an interview on 8/13/26 at 2:31 p.m., the director of nursing (DON) stated she expected staff to follow up on the status of a wheelchair when the process exceeded one or two weeks. The DON stated therapy generally evaluated wheelchairs before they were provided to residents; however, she expected the evaluation process to take no more than one or two days. The DON stated it was not appropriate for R36 to have waited approximately one and one-half months to receive the new wheelchair, particularly because the wheelchair had been at the facility since 7/1/26.A facility policy related to rehabilitative services and follow-up for adaptive equipment was requested but was not received.

Based on interview, and document review, the facility failed to protect a resident's right to be free from physical abuse for 1 of 3 residents (R1) reviewed for abuse. This resulted in actual harm when R2 struck R1 in the face resulting in swelling to the eyebrow, nose fracture, and a laceration to the lip that required hospitalization. The facility had implemented actions on 3/16/26 to prevent recurrence prior to the survey; therefore, the citation was issued at past non-compliance (PNC). Findings include: R1's order summary report dated 3/6/26, identified R1's diagnoses included primary hypertension, traumatic subdural hemorrhage with loss of consciousness of unspecified duration and non-Alzheimer's dementia. R1's comprehensive admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment with no behaviors. R1 required substantial/maximal assistance for toileting, and transfers. R1's activities of daily living (ADLs) care plan dated 3/6/26, indicated R1 was categorically vulnerable adult and required substantial/maximal assistance of one with transfers. Associated interventions directed staff to monitor signs of emotional distress or mood and behavior changes. It also directed staff to provide and maintain safe consistent environment as well as supervision as needed. R1's progress note dated 3/15/26 at 9:19 p.m., indicated R2 struck R1 in the face while both residents were in the TV room. The strike caused R1 to fall from her chair. Staff were present and witnessed the event. Based on staff accounts, the incident appeared unprovoked. R2 was placed on 1:1 supervision immediately following the incident. R1 sustained swelling to the eyebrow, a laceration to the lip and was transferred to the hospital for evaluation. R1's emergency department (ED) provider notes dated 3/15/26 identified R1 was transferred to ED for an evaluation of assault and fall. The note further indicated emergency medical services (EMS) reported that R1 had been struck in the head by another resident, causing her to fall forward out of her wheelchair. R1's head computed tomography (CT) scan identified a large left forehead hematoma (a localized collection of clotted blood trapped under the skin) with associated swelling, a lip laceration, and closed fracture of nasal bone. R2's order summary report dated 2/11/26, indicated R2's diagnoses included disorientation, dementia, other symptoms and signs involving appearance and behavior. R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment with no behaviors identified. R2 required no assistance with transfers or ambulation. R2's activities of daily living (ADLs) care plan dated 2/25/26, R2 was independent with transfers and ambulation. R2's ADLs care plan dated 2/25/26 directed staff to monitor for signs of emotional distress or mood and behavior changes including agitation/aggression. R2's care plan did not identify specific agitative or aggressive behaviors or triggers that may cause agitation or aggression. R2's psychiatric visit note assessment dated [DATE] identified R2 had moderate cognitive impairment. The note further recommended that the care team track and monitor behavioral dysregulation to identify triggers and beneficial interventions. The interdisciplinary team (IDT) was advised to review findings and develop a behavior support plan if agitation persists. Meaningful assessment was limited due to R2's agitation during the evaluation. Given concern involved a highly vulnerable peer, emphasis remained on maintaining appropriate supervision, reinforcing boundaries, and ensuring objective monitoring of behaviors. R2's record reviewed between 3/11/26 through 3/15/26 showed no progress notes demonstrating implementation of the psychiatric visit note assessment recommendations. During this period, the record did not reflect monitoring of behavioral dysregulation, identification of triggers, or documentation of interventions attempted. Further no evidence that the interdisciplinary team reviewed, evaluated, or initiated development of a behavior support care plan that would include appropriate supervision, boundaries, and a monitoring system. R2's ED provider note dated 3/15/26 identified R2 was transferred to ED for evaluation related to aggressive behavior. EMS reported R2 had assaulted R1 and a staff member due to frustration with R1. The note further indicated R2 reported R1 had been harassing him and would not leave him alone, so he hit her. Record review of R2's discharge note dated 3/17/26 indicated R2 was discharged to psychiatric hospital because the safety of individuals in the facility was endangered due to R2's clinical or behavioral status. The note further indicated R2 had been involved in two physical altercations with other residents since admission, where R2 was the victim in the first incident and the perpetrator for the second incident involving R1. During an interview on 3/19/26 at 2:46 p.m., a family member (FM)-A stated staff informed her R1 had been sitting in the TV room area with several other residents when R2 sitting behind her suddenly jumped up and punched her in the back. She reported that R1 sustained a broken nose and forehead hematoma. FM-A expressed fear and uncertainty about R1's safety in the facility and added R2 was no longer on the unit. During an interview on 3/18/26 at 3:31 p.m., nursing assistant (NA)-B stated R2 had a history of impulsive aggression. Staff monitored R2 for agitation, would keep a close line of sight of him, and redirect him to his room when needed. NA-B explained she knew when R2 was agitated because he would demonstrate facial expression changes and spoke in Spanish. NA-B reported prior to the incident on 3/15/26, R2 would become agitated and angry when R1 talked loudly to the television or to staff. When this occurred, she would separate R2 from other residents during those episodes. NA-B stated nurses were aware of both R1's and R2's behaviors but she did not know whether this information was documented and was unsure of where staff were supposed to document episodes of behaviors in the medical record. During an interview on 3/19/26 at 12:16 p.m., NA-C stated R2 could be rude and made angry remarks in Spanish to other residents at times but was usually redirectable. R2 often appeared visibly angry and primarily spoke Spanish when agitated, which he believed created a communication barrier when R1 spoke loudly or called out to staff. NA-C reported nurses had been aware of both R1's and R2's behaviors but did not know whether these behaviors were documented in the medical record or reported to the provider. NA-C worked on 3/15/26, earlier in the day shift prior to the altercation R2 had to be redirected to his room after showing escalating agitation. Then later when NA-C was in the TV room, R2 was sitting approximately six feet away sitting in a recliner behind R1. R2 suddenly got up, walked over to R1, and hit her in the face causing R1 to fall from her wheelchair. The incident happened within a fraction of a second in front of staff. After the incident, NA-C remained with R1 until the nurses arrived, helped assess her and ensured R2 was safely supervised. During an interview on 3/18/26 at 2:59 p.m., NA-A explained R2 sometimes became agitated when R1 yelled at the television or called out to staff in a loud voice but never been physically aggressive before this incident. On 3/15/26 prior to the incident, R1 spoke loudly, Can someone turn down the television? R2 had responded Chica (girl in Spanish), at which point NA-A told R2 to calm down that R1's comment was not directed at him. NA-A explained dayshift staff reported R2 was agitated earlier in the morning, but she was not informed of the specific triggers and did not know whether these behaviors were documented in the care plan. NA-A was in the TV room when she observed R2 walk toward R1 and struck her in the face, causing R1 to fall from her chair. NA-A reported staff immediately intervened, separated the residents, and called the nurse. R2 walked to his room while R1 remained on the floor bleeding until the nurses arrived. NA-A reported being unaware of any behavioral support plan in place for R2. During an interview on 3/19/26 at 1:03 p.m., a licensed practical nurse (LPN)-A, the pm supervisor stated she heard an emergency page and immediately responded to the call in the TV room on 3/15/26. LPN-A reported when she arrived, NA-A and NA-B were present, along with several other residents. LPN-A stated NA-A reported that R2 came up behind R1 and struck her on the right side of the face, below the ear, causing R1 to fall forward from her wheelchair. LPN-A explained she instructed staff to keep the residents separated, initiated 1:1 supervision for R2 and directed staff to call the law enforcement while she was contacting the provider. LPN-A asked NA-A and NA-B whether there had been any behavior earlier in the day that might have led to the incident. She reported they told her R2 had been grumbling in Spanish toward R1 on previous shift but there had been no reports of physical aggression. LPN-A stated she was unaware about any behavior reports and had not previously heard of R2 being aggressive. LPN-A reported she was unaware of whether the care team tracked and monitored R2's behavioral dysregulation to identify triggers and beneficial interventions, and she did not know of any behavioral support plan in place for R2. LPN-A explained she did not identify anything that could have prevented the incident and did not observe any warning signs leading up to it. During an interview on 3/19/26 at 2:00 p.m., a registered nurse (RN)-A, the assistant of the director of nursing (ADON) stated she was informed on 3/15/26 that R2 struck R1, causing R1 to fall from her wheelchair to the floor. RN-A explained LPN-A told her R2 had been sitting by the wall in the TV room and R1 was sitting in front of him, approximately six to eight feet away watching television. RN-A explained she instructed staff to call 911, keep the residents separated, and initiated 1:1 supervision for R2. Her immediate focus after the incident was to ensure residents' safety and confirming 1:1 supervision for R2. RN-A expressed concern R2 might not be appropriate for the locked unit due to his pacing, ambulatory, and unpredictability. RN-A reported R2 had a diagnosis of dementia and had been involved in a previous resident to resident altercation, though the facility had concluded he was the victim. RN-A stated R2 sometimes became agitated he spoke in Spanish but was generally redirectable. RN-A reported she was unaware of the ACP recommendation for the care team to track and monitor R2's behavioral dysregulation to identify triggers and beneficial interventions. She also did not know whether the interdisciplinary team (IDT) had been advised to review findings and develop a behavior support plan for R2. RN-A added she expected nurses to ask appropriate questions when behaviors were reported and to document behaviors according to the resident care plan. RN-A did not recall any recent behavior reports brought to the interdisciplinary team (IDT) meeting. RN-A stated staff receive annual abuse-prevention training and were required to report any suspected abuse immediately to a supervisor or nurses. R2's medical record from 3/11/26 through 3/15/26 showed no evidence the facility implemented the ACP recommendations to track and monitor R2's behavioral dysregulation. There was no behavioral support plan developed despite repeated staff observations of agitations. Although staff were aware of R2's known triggers including loud environments and R1's frequent vocalizations; these observations were not documented. During an interview on 3/19/26 at 10:47 a.m., a nurse practitioner (NP)-A stated R2 should not have been placed in the memory care unit because he was ambulatory and wandered into other residents' rooms, which she believed created a safety risk. NP-A reported she referred R2 for an evaluation by Associated Clinic of Psychology (ACP) but had not received the assessment results. NP-A was unaware of any agitation or aggressive behaviors from R2 prior to the incident and expected nurses to notify the provider of any changes in a resident's mood/behavior. NP-A explained when she attempted to talk to R2, he appeared visibly angry, charged up, became loud while speaking in Spanish, and then walked away to his room. Abuse Prohibition/Vulnerable Adult Policy dated 11/25 directed the facility to protect residents against abuse by anyone, including, but not limited to, facility staff, and other residents or self-abuse. The policy required the interdisciplinary care plan team to review residents requiring behavioral interventions during target behavior meetings to develop individual behavior plans. Record reviewed indicated by 3/16/26, staff were interviewed to gather details regarding the circumstances surrounding the incident. No further incidents were reported to the staff. -On 3/15/26 R2 was placed on 1:1 supervision and later discharged to the psychiatric hospital on 3/17/26. -On 3/16/26 the facility had developed and started education for all staff on the abuse policy and procedures as well as strategies for managing aggressive behaviors. -On 3/16/26 the facility began reviewing all residents with behavioral histories to ensure care plan were current to include triggers with appropriate individualized interventions. -On 3/18/26 through 3/19/26 staff were interviewed and were able to articulate appropriate abuse policy and procedures. This deficient practice is being cited at past Non-compliance

Based on observation, interview, and document review, the facility failed to provide care consistent with a resident's needs, and care plan to eliminate/reduce the risk of an accident during a bed bath for 1 of 3 residents (R1). This resulted in actual harm to R1 when staff repositioned her without a drawsheet and with too much force caused R1 to slide out of the bed to the floor. As a result, R1 sustained a fracture to the left femur that required surgical intervention. The facility had implemented actions to prevent reoccurrence prior to the survey on 12/8/25, therefore, the citation was issued at past non-compliance. Findings include: R1's admission record dated 3/20/25, indicated R1's diagnoses included low back pain, chronic congestive heart failure, closed bicondylar fracture of the left femur, generalized weakness, and hospice care. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition and was on hospice. R1 required substantial/maximal assistance to roll left to right and return to laying on back, as well as the ability to transfer to and from a bed to a chair. R1's mobility care plan dated 6/25/25, instructed to use two staff assist for bed mobility. R1's activities of daily living care plan dated 6/25/25, indicated R1 required assistance from two staff with dressing and undressing, and R1 preferred bed bath. R1's activities of daily living care plan dated 3/20/25, indicated R1 had a self-care deficit. A historic intervention initiated 3/20/25 and cancelled on 6/25/25, informed R1 was substantial/maximal assistance- Helper does more than half the effort. Helper lifts or holds trunk or limbs. R1's skin care plan intervention dated 3/21/25, indicated R1 used an air mattress, directed staff to lift (R1) do not slide to prevent shearing (of skin) and move slowly when truing and repositioning in bed. R1's progress note dated 11/12/25 at 7:42 p.m., indicated R1 had a fall out of bed during incontinence care. R1 was noted on the floor next to the wall in a sitting position with left leg slightly flexed and was complaining about severe pain on her back and left hip. The root cause analysis for the fall identified the bed brakes were not on with the corresponding intervention identified as staff were to ensure the bed breaks were on before starting cares. R1's progress note dated 11/13/25 at 3:00 p.m., indicated staff reported while assisting R1 with cares, she slid off bed when staff attempted to move her closer in order to provide cares. The note further indicated R1 was admitted to the hospital with left femur fracture and the facility initiated staff education regarding fall prevention during bed mobility and care observations. R1's hospital discharge summary note dated 11/18/25 at 7:59 p.m., identified R1, who was bedbound, had an accident at the nursing home where R1 slid out of bed when undergoing a sponge bath. Per emergency medical services (EMS), R1 had rolled out of her bed onto her left side and back. X-rays of R1's left femur was noted to be an acute comminuted and displaced fracture through the distal femoral diaphysis with 14.6-centimeter butterfly fragment. R1's hospital orthopedic note from the Discharge summary dated [DATE] at 11:04 a.m., indicated given the nature of the injury as well as her and family's desire for pain control, R1 was taken to the operating to undergo retrograde intramedullary nailing with open reduction of her left periprosthetic femur fracture. R1's progress note dated 11/19/25 at 6:00 p.m., indicated R1 was re-admitted to the facility from the hospital as a result of sliding out of bed and she was total assist for activities of daily living (ADLs). During an interview on 12/9/25 at 11:28 a.m., a family member (FM)-A stated staff informed her R1 slid out of bed, injured her hip, and was sent to the hospital. After requesting and reviewing the incident report, FM-A stated she learned that during incontinence care, staff pulled R1 forcefully toward the edge of the bed. The bed was not locked at the time, which contributed to R1 sliding off the bed. During an interview on 12/9/25 at 12:58p.m., nursing assistant (NA)-A indicated she worked on 11/12/25 when R1 fell out of bed. NA-A explained R1 was a two person assist for a bed bath, and she and NA-B had been responsible for providing care to R1 that evening. NA-A stated she locked the bed brakes on her side of the bed and thought NA-B did the same on her side. NA-A had to leave the room to get a draw sheet, leaving NA-B in R1's room alone. Upon returning to the doorway, she heard a loud noise and saw R1 lying on her back on the floor. NA-A denied being at the bedside with NA-B at the moment R1 fell. During a subsequent interview on 12/10/25, at 10:03 a.m. NA-A further explained R1's draw sheet had been soiled with stool, so it was removed off the bed; leaving R1 on a bare mattress with no sheet. NA-A had to leave the room to get a clean draw sheet. NA-A then reiterated she did not see R1 fall but heard the noise then saw R1 on the floor. During an interview on 12/9/25 at 3:28p.m., NA-B stated she had worked on 11/12/25, it was her first time working on the hallway where R1 resided. NA-A asked her for help providing a bed-bath to R1. R1 required two staff and R1 had been incontinent of stool. NA-B indicated the air mattress had been deflated. We had started changing R1 and she (NA-B) asked NA-A to go get the linen and other supplies needed. NA-B stated she did not touch the bed or R1 until NA-A came back and she moved the bed away from the wall, positioned herself on the opposite side of the bed, and then she locked the bed. They cleaned the front side of R1, NA-B without using a draw sheet and on a bare mattress pushed R1 toward NA-A, dirty linen was removed, and R1 was rolled back. NA-B asked NA-A for the clean sheet, NA-B rolled her back on the bare mattress while she was getting the sheet put on her side (R1 was still naked, there was no draw sheet). Then NA-B, using her hands, pulled R1 too forcefully toward her so that it would allow NA-A to grab the clean bed sheet on the opposite side this motion caused R1, who was undressed slide out of the bed. NA-B stated R1 landed on the floor on her left side. NA-B acknowledged she did not check R1's care plan before providing care and was unsure whether NA-A reviewed it. NA-B stated after the incident she continued with care for 6 or 7 other residents. NA-B stated she should have used a drawsheet when repositioning and rolling residents and emphasized the importance of reviewing the care plan before providing care. During an interview on 12/9/25 at 1:25p.m., NA-C stated on 11/12/25, she was next door when the incident happened. When she entered the room, she found R1 on the floor between the wall and the bed. NA-C stated she moved the bed to clear space and went out to call for help. NA-C stated it appeared R1 fell because the bed had not been locked. NA-C stated R1 was two persons assist for cares. During a subsequent interview on 12/10/25 at 3:20 p.m., NA-C thought both NA-A and NA-B were in the room at the bedside when R1 slid out of the bed. NA-B was on the floor with R1 while NA-A was standing at the bedside watching them on the floor with R1 completely undressed. NA-C stated she moved the bed by grabbing the footboard to clear the space, covered R1 with a white gown and called for help. During an interview on 12/10/25 at 11:37 a.m., a licensed practical nurse (LPN)-A stated when she got to the room after the incident on 11/12/25, NA-B was holding R1 in a seated position, dressed in a white gown. LPN-A stated when she attempted to reposition R1 onto her back, R1 experienced severe back and left hip pain, and requested hospital evaluation. Staff called EMS, and R1was transported to the hospital. LPN-A stated both NA-A and NA-B initially claimed they were present in the room when R1 slid off the bed. However, NA-A later changed her account and at one point denied being present during the fall. LPN-A stated it was unclear if the bed brakes were locked and/or if the draw sheet had been used. R1 was bedbound and dependent on staff for cares. LPN indicated in no way was it safe to leave resident on an empty air mattress. During an interview on 12/10/25 at 12:36p.m., LPN-B (LPN care coordinator) stated when she got in the room, there was no sheet on the bed, R1 was laying on her back on the floor in between the wall and the bed. LPN-B stated NA-A and NA-B initially told her R1 was rolled toward NA-B during bed-bath when she fell on the floor but could not tell her how. LPN-B stated later, NA-A kept changing her story, at one point NA-A said she was not in the room when R1 fell which contradicted NA-Bs story that both of them were at the bed side providing care to R1 when she fell. The NAs could not tell LPN-B what really happened. However, her theory was when NA-A turned R1 toward NA-B she pulled a little hard, but she was not sure. LPN-B reported the inconsistencies of NA-A's statements to the director of nursing (DON). LPN-B stated she expected staff to review the care plan every day when providing care to residents. After the incident, LPN-B stated NA-A and NA-B went back to care for other residents until the end of their shift. During an interview on 12/9/25 at 1:42p.m., the director of nursing (DON) stated the incident was considered isolated and staff received follow-up education on preventing residents from sliding off the bed. The DON indicated when NA-B and NA-A were interviewed and there were inconsistencies in the interviews of the events that caused R1 to fall off the bed; it was unclear if a draw sheet was used and if NA-A was in the room when NA-B pulled the resident too hard causing the fall from bed. R1 was found on the floor, undressed, lying on her left side. The DON stated she expected both staff to be present during bed-bath if a resident was two persons assist. The DON explained after the incident staff were provided with education pertaining to bed mobility, positioning, and using a draw sheet. R1's care plan was also revised for clarity. Resident Protection Program Policy dated July 2025 indicated that residents will be protected from abuse, neglect, and harm while they are residing at the facility. The policy indicated the facility will strive to educate participants in techniques to protect all parties and will provide necessary services to residents to avoid physical harm, pain, mental anguish, or emotional distress. Record reviewed indicated by 11/13/25, staff were interviewed to gather details regarding the circumstances surrounding the incident. No further incidents were reported to the staff. -NA-B was given written warning and education was provided with ongoing monitoring for compliance. -On 11/17/25 the facility had developed and started education for all of their staff on bed mobility and bed bath procedures for dependents residents. -On 12/8/25 through 12/10/25 staff were interviewed and were able to articulate appropriate bed mobility and bed bath procedures. This deficient practice is being cited at past Non-compliance.

Based on observation, interview and document review, the facility failed to consistently perform hand hygiene with change of gloves while performing blood glucose monitoring. Additionally, the facility failed to clean the community glucose monitor after use. This had the potential to affect any of the 14 residents on the memory care unit who may require blood glucose checks, either routine or emergent. Further, the facility failed to ensure soiled personal laundry and linens were bagged (i.e., contained) at the point-of-use and transported in a manner to reduce the risk of cross-contamination and potential infectious spread in 1 of 1 main washrooms (Evergreen and Willow) and 1 of 1 units (Aspen and [NAME]) reviewed. In addition, the facility failed to properly handle and store clean laundry and linens. This had potential to affect all 78 residents within the care center. Findings include: On 6/24/25 at 3:54 p.m., an observation was completed of medication pass on the memory care unit. During this observation, registered nurse (RN)-E was observed as she performed a blood glucose scan (a test to see how residents current blood sugar was). RN-D applied gloves prior to getting the glucometer (machine which tests and reads blood sugars) out of the medication cart. RN-E then removed a test strip from the bottle and placed it into the machine and proceeded to R283's room to check blood sugar. RN-E cleansed R283's finger with alcohol before sticking R283's finger for a blood drop and blood sugar reading was obtained. RN-E returned to the medication cart with gloves on and placed glucometer on the top of the medication cart, placing nothing between the machine and the medication cart. RN-E proceeded to removed and disposed of test strip from the machine. RN-E then returned the blood glucose monitor to the medication cart, and placed it on top of case it had been stored in without cleaning or disinfecting the machine. RN-E removed soiled gloves without performing hand hygiene with alcohol or washing hands with soap and water. On 6/24/25, at 3:56 p.m., RN-E stated R283 required insulin based on glucose reading. RN-E opened cart to retrieve insulin pen, grabbed a clean pair of gloves without performing hand hygiene, and proceeded to go to the computer behind the desk to verify order. RN-E proceeded to R283's room, put on clean gloves, verified with resident need for insulin and administered insulin. Following insulin administration, RN-E returned to medication cart, removed gloves, and again, failed to perform hand hygiene. RN-E then proceeded to document administration of insulin in the computer. RN-E stated she should have performed hand hygiene before applying gloves to obtain blood sugar, when she removed gloves after placing glucometer in the cart, and before she proceeded to obtain insulin or accessed the computer. RN-E stated she should have performed hand hygiene before applying clean gloves and again after insulin was administered and gloves were removed. RN-E stated hand washing was an acceptable alternative to hand hygiene. RN-E stated she had not disinfected the glucometer prior to placing the glucometer into the medication cart as she normally cleaned the glucometer at the end of the shift. RN-E stated R283 is the only diabetic who receives blood sugar checks on the memory care unit. RN-E then went on to say she tried to clean it immediately after having checked blood sugars, however, as the evening meal was here, she needed to get the insulin to R283, as well as proceed to the dining room to assist with service. RN-E stated the glucometer is wiped with disinfectant wipes to clean. RN-E stated if she needed to leave early, she would assure the oncoming staff were aware to clean the glucometer. RN-E stated it was important to clean the glucometer to sanitize it. On 6/26/25, at 1:22 p.m. an interview was completed with the infection control (IC) nurse, who was also the assistant director of nursing (ADON). The IC/ADON stated it was her expectation that each unit had two glucometers on each medication cart and cleaned them before each use. IC/ADON stated they could alternate glucometers for use with two glucometers. IC/ADON stated staff were to use disinfectant wipes, and go by contact time per recommendations of wipes. IC/ADON stated it was important to sanitize the glucometers to kill any bloodborne pathogens or germs on the glucometer. A facility policy, Blood Glucose Monitoring Infection Control, identified as being revised 2023, indicated it was the facility policy that glucometer units were disinfected after use. The policy further states blood glucose meters are to be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. The facility policy, Hand Washing, revised 3/23 identified to prevent the spread of infections, handwashing must be practiced by all individuals in contact with patients and patient's environments. The policy identified that hand washing/hand sanitizing must be done before performing invasive procedures, after removing gloves, after touching anything which might have been contaminated with blood or bodily fluids, and also before and after providing personal cares for a resident. Laundry On 6/26/25 at 10:34 a.m., the campus' main laundry washroom (downstairs) was toured with housekeeper (HSK)-A present. HSK-A explained they were the primary person who completed laundry for the care center. HSK-A stated downstairs laundry room was used to process laundry from the Evergreen and [NAME] units. The soiled linen receiving area was located on one end of the room with the washers and dryers on the opposite end of room however, in the walking path between these areas were a series of mobile, clothing racks with clean clothes hanging. Two clothing racks that contained clean clothing, were up against the wall with one rack being covered and the other one not covered. On the other side of the walking path was a mobile cart that contained clean clothing on hangers draped over the top of the cart uncovered. HSK-A stated soiled clothing are put in the laundry bin by the entrance of the laundry area by staff. HSK-A stated she would apply a gown and gloves and would sort the clothing in the bin area and would then carry the soiled clothing across the room to the washer, soiled laundry would be unbagged. HSK-A stated when clothes were finished in the dryer, she would place them in clean garbage bags until she could sort and hang them. Three clear garbage bags, each full of clean resident clothing, were sitting on the floor. Two boxes of clean, each full of clean folded bedding, were sitting on the floor along the wall. HSK-A verified the items were not bagged when transporting from the dirty area to the washer and expressed they probably should have been prior to transport as she was walking past clean clothing. HSK-A also verified the garbage bags of clean clothing and bedding in boxes were placed on the floor and stated they probably should not be on the floor due to infection control. On 6/26/25 at 10:44 a.m., a tour of the upstairs laundry unit, that processed laundry from the Aspen and [NAME] units, was completed. The soiled utility room was opened with HSK-A present. Inside was a clothing rack on one side which had clean clothing hanging covered with a sheet and on the other side of room consisted of two sets of stackable washers and dryers and a small cupboard that had a sink and counter space. Area between each side was approximately four feet. HSK-A stated she would bring in soiled laundry, in bags, and place bags on the floor in front of washer to sort and would then place the soiled clothing in the washers. HSK-A stated when clothes were finished in the dryer, she would place the clean clothing on the counter next to the sink to sort and hang on the clothing rack. HSK-A stated all mechanical lifts slings were laundered onsite and were stored in a small white laundry basket, that contained holes on both sides of basket, on the floor under the counter and also stored in a box that was placed on the floor in the corner of room. During interview on 6/26/25 at 1:23 p.m., assistant director of nursing (ADON) verified she was the campus' infection preventionist (IP). ADON explained they have educated staff through staff meetings about the need to bag soiled items when collected and verified soiled laundry and linens should be bagged prior to transport. This was important to do as staff could spread infections from one place to another. ADON stated she would expect HSK-A to transport soiled clothing in bags from the soiled area to the washer and went on to state clean clothing, bedding or slings should not be placed or stored on the floors as that was an infection control concern. ADON stated clean clothing should not be placed on the countertop in the upstairs laundry room as that area, especially the sink, was a highly contaminated area, and was also an infection control concern. A facility Infection Control Program policy, undated, identified the facility would establish a facility-wide system for the prevention, identification, investigation and control of infections of residents, staff and visitors that is based upon facility assessment best practices and regulatory compliance for the goal of quality systems for care. Written standards, policies, and procedures for the Infection Prevention and Control program, include a system for linen handling to prevent the spread of infection to include handling, storing, processing, and transporting linens. A facility policy on soiled laundry handling and transportation was requested but was not received.

Based on observation, and interview, the facility failed to maintain the appearance and integrity of the walls in the memory care unit, including the medication room, to provide for a surface which could be cleaned and homelike appearance. The facility failed to maintain furniture which was clean, with intact, washable surfaces in the memory care day room. The facility failed to ensure room blinds were kept in a state of good repair to provide visual privacy in 3 of 4 resident rooms (rooms [ROOM NUMBER]) observed to have blinds in disrepair. The facility failed to ensure shower rooms were kept in good repair in 3 of 4 shower rooms toured during survey. These concerns had potential to affect any resident who used the three shower rooms. Further, the facility failed to fully investigate missing personal items for 1 of 1 resident (R47) with reports of personal items that was reported missing for approximately nine months.Findings include: During observation on 6/24/25, at 8:44 a.m., in the memory care dayroom, it was noted a brown vinyl covered chair with a wooden frame in day room, placed next to the dining room entry way had a split in the materiel in the center of the seat in the center which measured approximately 10 inches in length. This split was noted to be fully through the materiel, open to the inner cushion. In addition to the center of the chair, there was another area on the upper right side of the chair which was approximately one and a half inches in length, with areas branching out on each end of the split, approximately one half inch to one inch on each side.Near the entry of the dayroom, there was a metal box which is locked with a padlock, labeled Timer. This box is noted to be pulled away from the wall, with broken cement noted where it would be affixed to the wall. The blinds on the far corner in the dayroom is noted to have three broken slats in the blinds, which remain in place but do not allow the blinds to fully close. There is an exit in the dayroom. In the memory care dayroom, there is an exit at the far side of the room. On the wall on the lower, left side of the door frame, there is an area approximately four inches in diameter that is lacking paint which exposed the the cement. The paint surrounding the area has bubbled and is lifting away from the cement. On 6/24/25, at 3:56 p.m., during observation in the memory care unit, it was noted R283's closet shelf had been removed, leaving an area of two inches in width around the entire perimeter of the closet where the top layer of the sheet rock was gone, and the plaster was visible. The closet doors had been removed and the closet opening was open. In addition, on the wall next to the bed for R283, it was noted the sheet rock had been damaged through to the plaster in an area which was estimated to be approximately nine inches in width and 18 inches in height. Attempts to discuss with R283 were limited due to language barrier. R283 acknowledged the areas and shrugged her shoulders. On 6/26/25, at 1:56 p.m. during observation of memory care medication storage room with registered nurse (RN)-B, it was noted on the lower wall on the left side of the room next to the floor, the protective vinyl liner had pulled away from the wall, and paper was pulled away from the sheet rock. This left the plaster in the sheet rock exposed, with plaster dust noted on the floor. The area was measured off by RN-B with footsteps and was observed to be approximately three feet long, and approximately one foot in height. In addition to this, there was also an area on the wall to the right side of the room, next to the paper towel dispenser, where the top sheet had peeled away, and brown paper remained. This area was noted to be approximately nine inches high and six inches wide. RN-B stated these areas need to be repaired.On 6/26/25, at 2:03 p.m. a tour was completed with the Environmental Service Director (ESD). ESD stated when staff identified areas of concern, they should fill out forms, and place the forms in the boxes designated for them. ESD stated the department depended on staff to notify them of any need for repairs. ESD stated the maintenance staff were mindful of watching for needed repairs, however, it was a joint effort. ESD stated there were specified boxes they should put them so the department is aware. Upon reviewing R283's room, ESD stated the wall needed to be fixed. ESD stated the shelves were removed from the closets last year due to concerns with sprinkler functioning. ESD stated the shelves were removed, however, the walls were not patched, and they needed to do so. ESD stated the closet doors were removed from the closets in memory care as the residents were pulling the doors off and maintenance could not keep up with replacing them. ESD stated the box which was padlocked shut, that had pulled away from the wall would have to be repaired. ESD stated there were no work orders present for repair of this area. ESD stated the brown chair with the split in the vinyl will need to be disposed of as it can not be cleaned properly.A facility policy was requested for maintaining the environment with routine checks and audits, and process for repairs and replacement of items as needed, however, was not received. Window Blinds On 6/24/25 at 9:07 a.m., room [ROOM NUMBER] was observed on the Evergreen unit. The room had a large window along the far wall which had white colored, plastic blinds which were pulled closed. The lower one quarter of the blind slats were missing which allowed the building and windows next door to be visible while inside the room, despite the blinds being closed. On 6/23/25 3:32 p.m., room [ROOM NUMBER] was observed on the Evergreen unit. The room had a large window along the far wall which had white colored, plastic blinds which were pulled closed. There were several blind slats missing which allowed the building and windows next door to be visible while inside the room, despite the blinds being closed. On 6/24/25 at 9:12 a.m., room [ROOM NUMBER] was observed on the Evergreen unit. The room had a large window along the far wall which had white colored, plastic blinds which were pulled closed. There were several slats missing from the blinds which allowed the building and windows next door to be visible while inside the room, despite the blinds being closed. On 6/26/25 at 10:42 a.m., reviewed maintenance/housekeeping work order forms from 8/14/24 through 6/25/25, no work order forms regarding rooms [ROOM NUMBER] window blinds were found. When interviewed on 6/26/25 at 12:31 p.m., nursing assistant (NA)-A stated maintenance request slips needed to be filled out when anything was broken. NA-A stated there was a lot of blinds that were broken, this was a privacy concern. When interviewed on 6/26/25 at 12:38 p.m., registered nurse (RN)-D stated maintenance forms for broken blinds or anything that needed to be repaired or replaced was to be filled out right away. Broken blinds created a privacy concern. When interviewed on 6/26/25 at 12:40 p.m., care coordinator (CC)-A stated there was a lot of broken window blinds in the building which created a privacy concern for the residents especially during cares. Shower rooms On 6/23/25 at 12:51 p.m., the shower room on Evergreen unit was observed, there was an electric heater on the wall. The grate covering the heating element had red/brown substance with a red/brown substance along the bottom edge of the casing. There was green and white tiles in the first half of the room where the toilet and sink were located, along the three walls there was a thick black substance where the floor and wall met. In the shower stall the tile where the wall and floor met there was thick black substance around the perimeter of the shower stall with a brown substance extended up the wall tiles about one and half inches. On the half wall, separating the toilet are from the shower stall, there was one tile on the lower portion of the wall missing which exposed the bare wall underneath to water. On the floor between the half wall and the outer wall there was a long brown tile, there was a black and brown substance extending from the brown tile into the shower stall about one and a half inches. On 6/23/25 at 3:05 p.m., Shower room E-2 was observed. The toilet was noted to have a black ring at the level of the water. Where the silver colored flush system connects to the toilet had a slimy black substance around the edge. On the tile surrounding the toilet, was a thick dark brown substance that extended from the toilet about one and half inches across the tile. At the edge of the shower stall there were four tiles missing from the bottom edge, which exposed the bare wall underneath to water. There were four tiles inside the shower stall that were cracked. Around the perimeter of the shower stall there was a black substance where the tiles of the wall met the tiles of the floor. On the floor surface extending from the wall under the shower head into the shower about 4 inches was a slimy orange/yellow substance. The light fixture above the sink contained a reddish/brown substance on all metal surfaces of the fixture. On 6/24/25 at 2:15 p.m., memory care shower room was observed. The toilet was noted to have a black ring at the level of the water. On the wall to the right of shower head the lower eight tiles were cracked. On the wall across from the opening into the shower stall there were five cracked tiles. On the floor from where it meets the wall there was a brownish orange substance extended about six inches across the floor and about four inches up the wall. Across from the shower stall opening, about twelve inches up the wall, was a brown substance smeared across four tiles. On 6/26/25 at 10:22 a.m., the brown substance smeared on the wall in memory care shower room continued to be on the wall. When interviewed on 6/26/25 at 12:25 p.m., trained medication aid (TMA)-A stated housekeeping cleaned the shower rooms daily, they were also sprayed with disinfectant after each use for cleanliness and infection control. When interviewed on 6/26/25 at 12:31 p.m., nursing assistant (NA)-A stated housekeeping cleaned the shower rooms, nursing assistants did not clean the shower rooms. When interviewed on 6/26/25 at 12:38 p.m., registered nurse (RN)-D stated shower rooms were cleaned daily by housekeeping, The showers should be sprayed with disinfectant after every use by the nursing assistants. When interviewed on 6/26/25 at 12:40 p.m., care coordinator (CC)-A stated she was not sure how often the shower rooms had been cleaned, she had wondered about the black stuff in the shower and was not sure if that was stains or mold. On 6/26/25 at 2:03 p.m., a tour was completed with the Environmental Service Director (ESD). Upon reviewing shower rooms ESD stated shower rooms were cleaned daily. ESD verified there were tiles that needed to be replaced, ESD had tried several chemicals on the mold. ESD verified there were many rooms with broken blinds which needed to be replaced, room audits were completed monthly. Facility policy Clean Living Environment dated 1/2024 indicated broken blinds would be repaired or replaced by maintenance and would be audited on a rotating basis. In addition the policy indicated overbed tables, door knobs, night stand, dresser and bed rail surfaces would be cleaned by housekeeping; floors, under beds and bathrooms would be wet-mopped; mirrors, sinks, toilets and walls would be cleaned and disinfected to avoid the spread of disease. However, the policy did not address shower rooms. R47 R47's quarterly Minimum Data Set (MDS) dated [DATE], identified R47 had intact cognition and required assistance with all activities of daily living (ADL)'s. R47's diagnoses included alcoholic cirrhosis of liver without ascites (severe, irreversible liver disease caused by long-term, excessive alcohol consumption), hypertension (high blood pressure), renal failure (occurs when the kidneys lose their ability to adequately filter waste and excess fluids from the blood), hepatic encephalopathy (brain dysfunction that can occur in people with severe liver disease) and fibromyalgia (chronic disorder characterized by wide-spread musculoskeletal pain, fatigue, sleep disturbances, and cognitive difficulties). During review on 6/26/25, Missing Items Log indicated 8/29/24 - resident is missing Cologne with large cosmetic spray, six [6] pairs of leggings, 12 pairs of small socks, new jar of coconut oil, four [4] bras, two [2] pairs of diamond earrings and a double garbage bag of other personal items - unknown if items were found. During interview on 6/24/25 at 3:43 p.m., R47 stated she had multiple different items that had gone missing such as a wallet, jewelry, socks, bras, leggings, perfume and a bag with a lot of miscellaneous items in it that were sitting on her bed. R47 stated she informed multiple staff of missing items and had not heard anything regarding the missing items. R47 stated the items had been missing for approximately nine months and had not been found yet. During interview on 6/25/25 at 12:46 p.m., registered nurse (RN)-F stated R47 reported missing items to several staff throughout the last several months. RN-F stated when an item is reported missing, she would go and look for the missing item, would tell the supervisor and complete a missing items form. During interview on 6/26/25 at 4:07 p.m., licensed practical nurse care coordinator (LPN)-A stated when a missing item was reported, room and laundry are searched. If item was unable to be located a missing items report was completed and given to the receptionist who would make copies for each department. LPN-A stated she was not aware if R47's items were located or not. During interview on 6/26/25 at 4:22 p.m., social worker (SW)-A stated if an item was reported as missing a missing item form should be completed. The missing items would be discussed at our morning meeting; a room search would be completed and most recently SW-A started to email the laundry person to see if they have found the missing item. During interview on 6/26/25 at 4:29 p.m., social services assistant (SS)-B stated she had been responsible for the missing items reports for approximately the past year and was not aware that she had to track the missing items, follow-up and resolutions. SS-B stated she was not aware if R47's items were located. The facility Missing Items policy, undated, identified it was the policy of Crest View Lutheran Home to assist the resident in retaining and using personal possessions that space and safety permit. If an item(s) becomes missing, a thorough investigation will be conducted in attempt to recover the missing item(s). We will make every attempt to assure that possessions are not lost, misplaced or stolen. 1. Residents and families/resident representative are strongly encouraged to keep cash in the Resident Trust Account, in their personal bank account, or at home with the resident until needed. Personal items that are of value (i.e. family heirlooms, jewelry, etc.) are not recommended.2. When a resident/resident representative report a missing item, representative and/or the staff person who identifies missing item will complete a Priority Report for the missing items. 3. All Missing Items form will be turned into the Reception Desk in order for copies to be made, and for appropriate parties to receive the report.4. If there has been identified deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent immediately report to the nursing supervisor. The Nursing Supervisor will notify the Administrator, or designee. 5. Cash and/or items of a higher value (exceeding $20) will be reported to the business office and residents will be encouraged to make a police report to the local police department. The Administrator or designee will be immediately notified of missing items and if theft or misappropriation is determined or alleged, a report to the Office of Health Facility Complaints (OHFC) will be made.6. A copy of the report should be routed to the respective staff listed on the form.7. The Director of Social Services or the designee will work with the resident, and others, to investigate the missing item. The form will be updated with notes from the investigation.8. The Director of Social Services or designee will follow-up with the resident and the resident representative by day 14 of initial Priority Report was made. If the item is found, the word FOUND will be written on the form with date and routed back to those who received the initial report. Some items may be replaced, or refunds may be given if staff error led to the items becoming missing.9. A log of missing items will be kept on the Share Drive, along with investigative notes and updates. 10. Missing items will be discussed between an interdisciplinary team at standing morning meetings on Monday-Friday to discuss updates and investigative findings.Crest View Lutheran Home is not liable for replacement or replacement cost of all lost items.

Based on observation, interview and record review, the facility failed to provide a homelike environment for dining, assuring food was offered to residents and assistance was received as needed in a timely manner. This had the potential to affect all 18 residents served in the memory care dining room. Findings include: R5's quarterly Minimum Data Set (MDS) of 5/8/25, indicated R5 had impaired cognition and was dependent on staff for eating. R9's quarterly MDS of 5/19/25, indicated R9 had impaired cognition, and although R9 required set up for meals, R9 was identified as able to complete eating once set up. R21's annual MDS of 4/30/25, indicated R21 had impaired cognition and required set up for meals. Resident was noted to complete the activity. R25's quarterly MDS of 5/13/25, indicated R25 had impaired cognition and required moderate assist with eating. R36's quarterly MDS of 3/28/25, indicated R36 had impaired cognition and required maximal assistance with eating. R41's annual MDS of 3/21/25, indicated R41 had impaired cognition, and required set up for meals. Resident was noted to complete the activity. R42's annual MDS of 3/31/25, indicated R42 had impaired cognition and required supervision or touching assistance with eating, however, when provided with verbal cues, or touching/steadying assistance, as R42 was able to participate in eating. R48's quarterly MDS assessment of 6/2/25, indicated R48 had impaired cognition and required supervision or touching assistance with eating. R48 required set up for meals, however, with supervision or hands on assist, R48 was able to participate in eating. R72's quarterly MDS dated [DATE] identified R72 had impaired cognition and was dependent of staff for assistance with activities of daily living (ADL's), including eating.R74's significant change assessment MDS of 3/4/25, indicated R74 had impaired cognition and required set up for meals. Resident was noted to complete the activity. R283's admission MDS of 6/3/25, indicated R283 had impaired cognition and required set up for meals. Resident was noted to complete the activity. R284's admission MDS of 6/10/25, indicated R284 had impaired cognition and required supervision or touching assistance with eating. This identified R42 required verbal cues, or touching/steadying assistance while eating. On 6/23/25 at 11:20 a.m., it was noted the dining room in memory care was currently serving noon meal. Nursing assistant (NA)-C was the only staff member in the dining room. Covered plates were placed in front of R5, R48, and R72 without assistance provided to remove the domes from the plates, set up for eating, or being given assistance to eat. The remainder of the residents in the dining room had received assistance to remove the domes from the plates, and the plates were set up in front of them. It was noted at that time, the following domed plates were placed for residents who were not in the dining room, which included R41, R74, R283, and R284. On 6/23/25 at 11:26 a.m., R5 and R25 were observed to have their plates uncovered, and in front of them, however, had been offered no assistance or prompts. On 6/23/25 at 11:29 a.m., R283 arrived in dining room and plate was uncovered. R283 was offered a beverage and was set up for her meal. R283 proceeded to eat independently. All other domed/covered plates remain in place for R41, R74, and R284.On 6/23/25 at 11:31 a.m., registered nurse (RN)-G arrived in the dining room. At that time, the cover was removed from the plate placed in front of R48 (18 minutes from the time first observed) however, RN-G did not provide assistance immediately. At 11:33 a.m. NA-C directed RN-G to provide assistance to R48 to eat. RN-G noted there was no silverware in place and left to get silverware. RN-G returned at 11:37 a.m. (four minutes after going to get silverware, six minutes after plate was prepped, and 26 minutes after plate was observed to be served in front of resident). RN-G was observed seated next to R48, who was sitting with her eyes closed, not eating. On 6/23/25 at 11:34 a.m., NA-C was observed as she aided R72. At 11:35 a.m., NA-C provided verbal prompts across the room to have R25 start eating. This was eight minutes after plate had been observed to have been set up. NA-C did not go to R25, or provide any additional prompts. At 11:40 a.m., without further prompts, R25 started to take some bites on her own. On 6/23/25 11:38 a.m., NA-J entered to speak with RN-G, and then stayed to assist R48 when RN-G left the dining room. On 6/23/25 at 11:40 a.m., NA-C provided verbal prompts, from the table where she was seated, to R42 to eat her lunch. On 6/23/25 at 11:41 a.m., stated to R72 that she had completed her meal. On 6/23/25 at 11:42 a.m., NA-C sat down next to R36, who was seated across from R21. NA-C provided hands on assist to R36 to eat her meal. This was 21 minutes after plate was initially set up. R21 was provided with verbal cues to eat her meal. On 6/23/25 at 11:47 a.m., R9 called out Am I supposed to starve? R9's plate was noted in front of her, however, she received no assistance or prompts. On 6/23/25 at 11:47 a.m., NA-K entered the dining room, however, did not offer assistance to any residents.On 6/23/25 at 11:49 a.m., it was also noted at this time, the following trays remained at the table without residents present: R41, R74, and R284. On 6/23/25 at 11:52 a.m., NA-K offered R25 assistance with her meal. On 6/23/25 at 11:52 a.m., R74 was sought out from the day room and was guided to the dining room. This was 32 minutes after domed plate was placed at her spot in the dining. R74 was set up for dining. R41 and R284 had not yet been assisted or guided to the dining room for noon meal. On 6/23/25 at 11:56 a.m., NA-K continued to provide R25 assistance with her meal. On 6/23/25 at 12:02 p.m., NA-J stated he was unsure where R41 was, however, R284 was in bed. NA-J stated they would put the plates in the refrigerator and heat the meal up later when R284 wished to eat.On 6/23/25 at 12:08 p.m., NA-C stated we are done with lunch. The trays for R41 and R284 remained in place on the tables. On 6/26/25 at 1:41 p.m., NA-C stated overall the dining room services went well. NA-C stated at times it is more difficult if the pool staff are there as they don't know what the residents need. NA-C stated the staff went around and assisted the residents who needed help. They managed with the staff they had, adding sometimes the nurses came to help. NA-C stated they reached out to nurses for assistance if help was needed. On 6/26/25 at 2:00 p.m., registered nurse (RN)-B stated staff began to serve trays on their arrival. RN-B stated he was available to help in the dining room if asked. If the dining room was in need of assistance, the staff were to communicate this to him, and he would go and assistance. RN-B stated the problem was there were three staff, there are four if he was included. RN-B stated Maybe we rearrange the sitting so staff could assist if needed. At least they feed two. RN-B stated some times it was disruptive to a resident if others were seated at the same table. RN-B stated it was of concern if assistance was disrupted when staff left the dining room to assist others, and left the residents without assistance. RN-B stated it was also a concern if the food was placed in front of the residents, and assistance was needed but not provided. On 6/26/25 at 2:22 p.m., NA-D stated the dining room was very busy. NA-D stated when she just sat down with one resident, others were not being helped. NA-D stated that was why she moved between the residents and provided assistance as needed. NA-D stated all nursing assistants needed to move between the residents as well to provide assistance as needed. The facility policy, Assistance with Feeding, revised 11/18, identified the facility policy was to ensure that any resident who needed assistance with feeding received the help in a safe and dignified way. The policy directed staff when they provided assistance during feeding (dining), staff were to be engaged, enthusiastic, and communicable with residents to promote a dignified and enjoyable experience. The facility policy, Activities of Daily Living (ADL), last revised 11/23, identified resident's unable to carry out ADL's independently would receive the services necessary to maintain good nutrition. The policy directed staff that assistance with resident nutrition included dining (both meals and snacks). The facility policy, Food-Serving of, revised 4/24 indicated the purpose of the service [of food] was to serve well balanced, attractive meals to residents, and was to provide adequate nutrition for the well-being of residents. The policy directed the staff to make resident comfortable, assist the resident willingly if she/he required help, and staff were directed to not rush the resident. The staff were directed to make sure that hot foods are hot, and cold foods are cold.

Based on observation, interview and document review, the facility failed to assure medications were properly labeled with the correct dose for 1 of 1 resident, (R20), who received a liquid medication during observation of medication administration. The facility also failed to assure over the counter (OTC) medications were dated when opened in 2 of 3 medication carts reviewed. The facility also failed to consistently date, and/or remove inhalers which were beyond the dates of recommended use, in 1 of 3 medication carts. In addition, the facility failed to remove vaccines which had either an illegible label, or lacked a label, in 2 of 2 medication rooms reviewed. Findings include: Labeling Error: During observation of medication pass on 6/25/25 at 12:17 p.m., trained medication aide, (TMA)-A, was observed as he set up medications for R20. TMA drew Haldol medication up to the 1 (one) mg (milligram) marker on the medication dropper twice. TMA-A stated R20 received 2 (two) mg twice daily, as directed on the medication administration record (MAR), with a dose of 3 (three) mg at bedtime. Upon review of the label on the medication bottle, it identified the dosage of Haldol was 2 mg per ml (milliliters). The medication label on the bottle directed staff to give 1.5 ml (3 mg) by mouth twice daily, and 1 ml (2 mg) by mouth at bedtime. Upon noting the discrepancy between label and amount prepared, TMA was stopped to seek clarification. On 6/25/25, at 12:26 p.m. clinical coordinator (CC)-A was consulted and stated she would follow up on this and seek clarification of orders. It was also noted there was a new bottle of Haldol in the drawer, dispensed by the pharmacy on 6/9/25, which reflected the same instructions as were reflected on the current bottle. TMA-A stated typically, when there was a change of orders, there was a sticker applied to the label which identified Direction change. See MAR [medication administration record]. TMA-A stated subsequent medications dispensed would then have the correct label from the pharmacy. The current medication had no sticker applied to the label to indicate a change in orders. TMA-A stated he was unsure if anyone had called the pharmacy to clarify. On 6/25/25 at 12:37 p.m., CC-A stated upon review of orders for Haldol, it was noted the orders listed on the MAR were correct. CC-A stated R20's medical record identified the dose of Haldol was decreased to 2 mg in the morning and was increased to 3 mg at bedtime on April 25, 2024. CC-A stated when a new order was received, it was faxed to the pharmacy. If there were remaining medication left, a direction change sticker would be applied to the medication for continued use. Subsequent refills would bear the correct instructions. CC-A stated when a discrepancy was noted during med pass, upon clarification of the order, a sticker should be applied to the medication. CC-A stated either the new order for R20's Haldol was not faxed, or the pharmacy had not followed through. CC-A stated follow through was important to assure the correct dosage of medication was given. CC-A stated this discrepancy should have been noted previously, as this had occurred greater than one year ago. TMA-A stated when he noted a discrepancy, he asked the nurse to check into this. If the label was not correct, he or the nurse would put a direction change sticker on it. The nurse would notify the pharmacy. TMA-A stated I should have caught this. It shouldn't have been that long. TMA-A stated when there were discrepancies, the resident could have been given the wrong dose. Medication Room Observation/Storage/Unlabeled Vaccines: On 6/26/25 at 1:56 p.m., an observation was completed with registered nurse (RN)-B in the memory care unit. The refrigerator was inspected and was noted to contain an plastic bag with an illegible name noted on the label, the date dispensed was illegible, with vials of Arexvy (a vaccine for the RSV-respiratory syncytial virus) in it. RN-B stated he was unsure of who this person was, and stated the vaccine would not be used and should have been removed. On 6/26/25 at 2:39 p.m., the clinical coordinator (CC)-A stated this was an RSV dose for R500, who had been discharged in 4/7/25. R500 was scheduled to receive the RSV vaccine on 4/11/25. CC-A stated R500 was no longer a resident and this vaccine should have been removed from the refrigerator. On 6/26/25 at 3:10 p.m., upon review of the medication refrigerator on the transitional care unit (TCU), it was noted there was one unlabeled vaccine package of RSV vaccine. RN-D stated she was unsure as to who this belonged to and stated it should not have been in the refrigerator. On 6/26/25 at 3:46 p.m., CC-A stated the unlabeled dose of RSV should have been removed from the medication refrigerator and destroyed. Dating of medications: On 6/26/25 at 3:16 p.m., the medication cart on TCU was reviewed in the presence of registered nurse (RN)-A. During this review, the following over the counter (OTC) medications were opened but not dated:- Daily Vitamins, one bottle which contained 100 tablets, had at least 50 tablets left as estimated by registered nurse (RN)-A.- Banophen (diphenhydramine) 25 mg (milligram-a unit of measurement) one bottle which contained 100 tablets as estimated by RN-A as having approximately 75 or greater remaining.- Ibuprofen 200 mg one bottle, which contained 100 tablets, as estimated by RN-A as having approximately 80 tablets or greater remaining.- Acetaminophen 325 mg, one bottle which contained 1000 tablets was estimated by RN-A as having approximately 800 tablets remaining. The following inhalers were noted to lack indication as to when they were opened or lacked the date as to when they were to be disposed of per the directions on the label from the manufacturer.R37: Trelegy Ellipta, opened 4/19/25, was noted to have instructions on the manufacturer label to dispose of after six weeks. This was nine weeks and five days after being opened. RN-A stated this was no longer OK to use. R37 was noted to have a second inhaler Anora Ellipta which had been opened 12/20/24. This was greater than six months since opened. RN-A stated this was outdated and should not be used. R39 was noted to have an Ellipta inhaler with eight doses remaining which was undated. RN-A stated the medications which had passed the expiration date established should not be used as they may not be as effective. On 6/26/25 at 3:16 p.m., upon review of the medication cart with TMA-B on the long-term care unit, the following OTC medications were observed to be opened however, lacked a date to indicate when it was opened: Acetaminophen 325 mg, one bottle with 1000 tablets originally dispensed, contained greater than 50% of the bottle as estimated by TMA-B. Acetaminophen 500 mg, one bottle with 1000 tabs dispensed contained greater than 50% of the bottle (approximately 500 or more tablets) as estimated by TMA-B. When asked why an open date was important, TMA-B declined comment. On 6/26/25 at 3:46 p.m., CC-A stated all the OTC medications should have been dated the day they were opened. CC-A stated if the bottles had not been dated, the bottles were to be removed when identified and destroyed. CC-A stated it was important to date the bottles to assure they were not being used beyond the allowed date. CC-A stated the allowed date was not always the same as the manufacturer's expiration date. CC-A stated the staff were to be aware of this with the use of the reference sheet in each med cart, which identified the time frame the medications can be used once opened. CC-A stated all inhalers were to be dated to ensure the inhaler was not used beyond the recommended date of manufacturers. CC-A stated use beyond the could affect the efficacy of the medication. The facility policy, Medication Administration, revised 3/23, identified the medication was to be administered to residents as prescribed by the physician. The policy lacked indication as to how staff was to proceed if there was a discrepancy in the medication label, and the directions on the medication administration record. The facility policy, titled Medication Record, revised 11/24 identified As a physician changes/discontinues a medication, the licensed nurse enters the change on the Medication Record. The policy lacked direction to staff as to what was to be done with current supply of medication if there was a change of dosing. Upon review of both policies, it was noted they lacked direction to staff as to the process for dating of over the counter medications when opened, as well as a process for dating of inhalers and eye drops to indicate date opened, and last date of use allowed. The facility policy, Omnicare Medication Storage Guidance, dated 2024, indicated the above listed inhalers may be used for a period of six weeks only, as recommended by the manufacturer, and may not be used after that date.

During observation and interview, the facility failed to ensure hand rails were securely attached to the wall. This had the potential to affect all residents, staff, and visitors who had access to the handrails.Findings include: During observation on 6/25/25 at 5:53 p.m., handrail between rooms [ROOM NUMBERS] was loose, the handrail was not attached to the second bracket from room [ROOM NUMBER]. The handrail between rooms [ROOM NUMBERS] was loose. The handrail outside of the dining room by the men's restroom was observed to be loose. On 6/26/25 at 2:03 p.m., a tour was completed with the Environmental Service Director (ESD). ESD stated when staff identified areas of concern, there were forms to be filled out and placed into designated boxes. ESD stated the department depended on staff to notify them of needed repairs. ESD stated the maintenance staff were mindful of watching for needed repairs, however, this was a joint effort.On 6/26/25 at 10:42 a.m., reviewed maintenance/housekeeping work order forms from 8/14/24 through 6/25/25, no work order forms regarding handrails was found. A facility policy and/or procedure on handrails was requested, however, none was provided.

Based on observation, interview and document review, the facility failed to ensure the kitchen was kept clean, sanitary and in good repair which had the potential to affect all residents, staff and visitors who received meals from the kitchen.Findings include:During observation of the kitchen and interview on 6/25/25 at 12:18 p.m., dietary director (DD) noted the floor next to the dishwasher had six tiles with corners missing, the grout between four additional tiles was also missing. On the surface where there had been tile and grout there was a green substance on the subfloor. DD stated, yep, there's missing chunks, missing grout and green stuff. DD then stated, watch this, grabbed dish sprayer, soaked down the floor filled the areas where there as missing tile chunks and grout with water stating, see it doesn't look like that anymore, we mop twice a day so it won't look like that later. DD stated this was a cleaning concern and was potential for bacteria to grow. During observation on 6/26/25 at 7:23 a.m., the floor in dishwashing area continued to have missing tile chunks, missing grout and green substance it area where tile and grout had once been. On 6/26/25 at 10:42 a.m., reviewed maintenance/housekeeping work order forms from 8/14/24 through 6/25/25, no work order forms regarding kitchen floor tiles was found. A facility policy and/or procedure on kitchen cleaning and maintenance was requested, however, none was provided.

Based on observation, interview and document review the facility failed to appropriately store nutritional supplements in two of two medication rooms reviewed during medication room storage observation. This had the potential to impact all residents who routinely received, or may received nutritional supplements on those units. In addition, the facility failed to ensure the ice machine was in good repair. This had the potential to affect residents, staff and visitors who obtained ice from the kitchen. Findings include: On 6/26/25 at 1:56 p.m., an observation was completed with registered nurse (RN)-B in the memory care unit medication room. The following boxes of nutritional supplements were being stored on the floor: An open box of Breeze (a nutritional supplement) with 5 boxes of supplement remaining. One case of 24 boxes of Boost nutritional supplements which were unopened. There were two boxes of Ensure Plus which contained 24 boxes of nutritional supplement when unopened. There was one unopened box, and an additional box of 20 containers. RN-B stated the supplements were placed there when they were delivered to the unit. RN-B identified an open space in the cupboard below the sink where the supplements could be stored. RN-B stated he was unaware items could not be kept on the floor for storage. On 6/26/25 at 2:39 p.m., the clinical coordinator (CC)-A stated nutritional supplements were currently being kept on the floor of the transitional care unit (TCU) medication room. CC-A was unaware nutritional supplements were also on the floor of the medication room in the memory care unit. CC-A stated nutritional supplements had also been stored in the dining room of the TCU, however, the supplements needed to be kept in a locked cupboard as some residents would take them from the refrigerator. CC-A stated the cupboard lock was broken, so now all supplements were stored in the medication room on the floor. CC-A stated she was unaware items could not be stored on the floor. On 6/26/25 at 3:10 p.m., upon review of the TCU medication unit, it was noted there were nutritional supplements currently being stored on the floor. RN-D stated the count of the boxes of nutritional supplements were as follows: Ensure Plus, 24 count per case, seven full cases. Boost Nutritional Supplement, 24 count per case, two full cases. Breeze Nutritional Supplement, one case of 24 count per case.RN-D stated this was where the supplements were normally kept. RN-D noted there was space on the metal storage shelves in the medication room if some items were moved to make room for the supplements. RN-D stated she was unaware nutritional supplements could not be stored on the floor. A facility policy was requested for storage of nutritional supplements, however, none was received. Ice MachineOn 6/23/25 at 11:18 a.m., during initial kitchen tour observed ice machine, there were two areas measuring one inch by one inch missing black plastic of the surface of the door. In these areas there was firm, yellow insulation with about a quarter of an inch area that was worn down. The left side area had a brown, yellow substance on the firm yellow insulation along the broken edge of the plastic. On 6/25/25 at 11:47 a.m., dietary director (DD) stated she had never noticed there was worn area on the ice machine door. DD stated the worn areas on the door was not able to be appropriately cleaned or disinfected. this was a concern for infection control and particles could get into the ice. Environmental service director (ESD) entered the kitchen, DD showed ESD ice machine door who directed DD to call the repair person as anything he had would not be appropriate to repair the door. On 6/26/25 at 10:42 a.m., reviewed maintenance/housekeeping work order forms from 8/14/24 through 6/25/25, no work order forms regarding the ice machine door was found. Facility policy for ice machine maintenance was requested and was not received.

Based on observation, interview and document review the facility failed to ensure a comprehensive care plan was developed and implemented to include post-traumatic stress disorder (PTSD) triggers and interventions for 1 of 1 resident (R47) who had a diagnosis of PTSD.Findings include:R47's quarterly Minimum Data Set (MDS) dated [DATE], identified R47 had intact cognition and required assistance with all activities of daily living (ADLs). R47's diagnoses included alcoholic cirrhosis of liver without ascites (severe, irreversible liver disease caused by long-term, excessive alcohol consumption), renal failure (occurs when the kidneys lose their ability to adequately filter waste and excess fluids from the blood), hepatic encephalopathy (brain dysfunction that can occur in people with severe liver disease), and fibromyalgia (chronic disorder characterized by wide-spread musculoskeletal pain, fatigue, sleep disturbances, and cognitive difficulties). During review of R47's electronic health record (EHR), initial visit notes from Associated Clinic of Psychology (ACP), dated 3/17/22, indicated R47 had the following diagnoses: Posttraumatic Stress Disorder and Adjustment disorders with mixed disturbance of emotions and conduct. Visit note indicated R47 had a longstanding history of abuse and had experienced complex trauma since childhood; expressed a general mistrust of people in authority and anxiousness about dependency on others for cares; and reported re-experiencing of trauma and mistrust towards those she sees in authority and has anxiousness about dependency on others. Visit note indicated staff could utilize memory care approaches of making eye contact, explain step-by-step cares, move slowly, and ask questions with some coping tools: socializing, exercise, faith, thought reframing, and musicDuring review of R47's EHR, follow up visit note from ACP, dated 4/2/25, indicated R47 had the following diagnoses: Posttraumatic Stress Disorder and Adjustment disorders with mixed disturbance of emotions and conduct. R47's care plan failed to indicate PTSD triggers and interventions. During interview on 6/26/25 at 2:26 p.m., nursing assistant (NA)-H stated she was not aware of R47's history of PTSD and was not aware of triggers. NA-H stated R47 frequently gets upset with staff and was not sure the reason behind it. NA-H stated it would be important to know if a resident had certain triggers so if they exhibit behaviors we know how to respond. NA-H stated if resident had a history of trauma, it would be on resident's care plan.During interview on 6/26/25 at 3:36 p.m., registered nurse (RN)-F stated she was not aware of R47's history of trauma. RN-F stated R47 had a lot of anxiety and did not like being at the facility. RN-F was not aware of any triggers and confirmed there was no plan of care for PTSD for R47. During interview on 6/26/25 at 4:07 p.m., licensed practical nurse clinical coordinator (LPN)-A stated she was not aware of R47's history of trauma. LPN-A stated if a resident had a diagnosis of PTSD, it would be included on the resident's individualized care plan with any interventions that are in place for resident. During interview on 6/26/25 at 4:39 p.m., social worker (SS)-A stated trauma assessments are completed by herself or the social services assistant. Triggers and interventions would be added to the resident's care plan as it was very important for all staff to know as it could lead to worsened mental health or suicidal ideation. SS-A confirmed trauma assessment was not completed or included in R47's care plan. During interview on 6/26/25 at 5:38 p.m., assistant director of nursing (ADON) stated if a resident had a diagnosis of PTSD, it would be included on the care plan. ADON stated social services would complete the trauma assessment and add information related to PTSD on the resident's care plan. ADON stated R47's care plan should have included behavior monitoring, PTSD/trauma triggers, how staff would avoid those triggers and interventions to be used if R47 was triggered. ADON confirmed R47's care plan did not include PTSD diagnosis, triggers or coping strategies and should be included in care plan. ADON stated it would be important for staff to know the resident's back story and triggers so they can provide the resident with the best possible care. The facility Trauma Informed Care policy, undated, indicated Crestview was dedicated to ensuring that all residents receive appropriate person-centered care as it related to their personal circumstances, including those with a history of trauma or Post-Traumatic Stress Disorder (PTSD).1. Residents undergo a Trauma-Informed Care Assessment upon admission and at least annually or as necessary. Care plans are developed as part of the assessment process. Assessments may consider military service, history of violence or abuse, displacement, medical trauma, or other events that may have contributed to PTSD.2. Staff are trained upon hire and at least annually in regard to trauma and person-centered care, including information about managing behaviors and de-escalation techniques.3. Interactions with residents are conducted in a calm, respectful manner to promote trust. Staff are instructed to explain procedures before initiating care, offer choices and autonomy whenever possible, and avoid sudden movements or yelling.

Based on interview and document review, the facility failed to notify the Ombudsman of transfers and discharge for 1 of 3 residents (R43) reviewed for hospitalizations. Findings include:R43's annual MDS dated [DATE], identified R43 had moderate cognitive impairment and required assistance with all activities of daily living (ADLs). R43's diagnoses included atrial fibrillation (a common type of irregular heartbeat that originates in the heart's upper chambers (atria)), heart failure (a condition where the heart can't pump enough blood to meet the body's needs), hypertension (high blood pressure), cerebrovascular accident (occurs when blood flow to the brain is interrupted, causing brain cells to die due to lack of oxygen and nutrients), depression, attention-deficit hyperactivity disorder (ADHD) (a neurodevelopmental condition that affects brain function and behavior, primarily in the areas of attention, hyperactivity, and impulsivity) and aortic aneurysm and dissection (An aortic aneurysm is a bulge or ballooning of the aortic wall, while an aortic dissection is a tear in the aorta's inner lining, allowing blood to flow between the layers).R43's medical record identified the following MDS assessments:1) 12/3/24 discharge with return anticipated, with a 12/12/24 entry tracking record2) 1/12/25 discharge with return anticipated, with a 1/22/25 entry tracking recordR43's hospital Discharge summary, dated [DATE], indicated R43 was hospitalized with acute metabolic encephalopathy (a sudden and widespread disturbance in brain function caused by metabolic problems) and acute on chronic hypoxemic hypercapnic respiratory failure (a person with a pre-existing chronic respiratory condition experiences a sudden worsening of their condition, leading to both low blood oxygen (hypoxemia) and high blood carbon dioxide (hypercapnia) levels).R43's hospital Discharge summary, dated [DATE], indicated R43 was hospitalized with acute on chronic hypoxemic hypercapnic respiratory failure.Review of the notices to the ombudsman that the facility provided identified:1) Monthly notice for December 2024 discharges - R43 was not listed2) Monthly notice for January 2025 discharges - R43 was not listed There were no other notices to the ombudsman provided by the end of the survey. During interview on 6/26/25 at 4:29 p.m., social service assistant (SS)-B stated she notified the Ombudsman monthly of all transfers and discharges via fax. SS-B confirmed R43's hospitalizations on 12/3/24 and 1/12/25 were missed and were not reported to the Ombudsman. SS-B stated it was important for the Ombudsman to be made aware of all transfers/discharges so additional support could be offered if applicable. A policy was requested but was not received.

Based on observation, interview and document review, the facility failed to ensure parameter mattress (a type of mattress cover or encasement designed to create a gentle barrier around the edge of the bed, preventing falls) was not used in a manner to restrain resident while in bed for 1 of 1 resident (R4) reviewed for restraints.Findings include:R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had moderate cognitive impairment and required assistance with all activities of daily living (ADLs). R4's diagnoses included chronic obstructive pulmonary disease (COPD) (a progressive lung disease that makes it hard to breathe), non-Alzheimer's dementia, hemiplegia (a condition characterized by paralysis on one side of the body), anxiety disorder, depression and insomnia. MDS did not indicate R4 utilized physical restraints. R4's care plan reviewed 6/26/25, identified R4 had a potential alteration in safety and falls related to right hemiplegia, assisted with transfers and psychotropic medication use. Staff were directed to assist R4 with ADLs per his need and per request and had a parameter mattress in place. R4's care plan did not identify the use of pillows to prevent R4 from crawling out of bed. During review of R4's electronic health record (EHR), Physical Device assessment completed on 4/25/25 indicated R4 utilized grab bars that were on bed and a Broda wheelchair. Physical device assessment did not identify the parameter mattress was assessed or utilized by R4. During observation on 6/23/25 at 11:18 a.m., R4 was lying on his back in the middle of his bed with his blankets covering to his chest on a parameter mattress. On R4's right and left side, a pillow was placed that ran along R4's body from his shoulders to his hips. R4's bed was in low position.During observation on 6/24/25 at 3:39 p.m., R4 was lying on his back in the middle of his bed with his blankets covering to his chest on a parameter mattress. On R4's right and left side, a pillow was placed that ran along R4's body from his shoulders to his hips. R4's bed was in low position.During observation on 6/25/25 at 12:06 p.m., R4 was lying on his back in the middle of his bed with his blankets covering to his chest on a parameter mattress. On R4's right and left side, a pillow was placed that ran along R4's body from his shoulders to his hips. R4's bed was in low position.During observation on 6/26/25 at 7:24 a.m., R4 was lying on his back in the middle of his bed with his blankets covering to his chest on a parameter mattress. On R4's right and left side, a pillow was placed that ran along R4's body from his shoulders to his hips. R4's bed was in low position.During interview on 6/25/25 at 12:45 p.m., nursing assistant (NA)-G stated R4 preferred to stay in bed. NA-G confirmed R4 had a parameter mattress, and pillows were placed on both sides of his upper body. NA-G stated R4 was not able to reposition himself and was not able to get out of bed by himself for approximately the past year. During interview on 6/26/25 at 2:26 p.m., NA-H confirmed R4 had a parameter mattress, and pillows were placed on both sides of his upper body. NA-H stated R4 was not able to get out of bed by himself and has never tried to get out of bed by himself for some time. During interview on 6/26/25 at 3:46 p.m., registered nurse (RN)-F stated R4 did not like to get up and that he needed assistance to get out of bed. RN-F stated R4 has not attempted to get out of bed for approximately the past year. RN-F stated R4 was a fall risk. RN-F confirmed R4 had a parameter mattress, and pillows were placed on both sides of his upper body. RN-F stated nursing completes the physical device assessment and stated the parameter mattress/pillows should have been assessed and indicated on the assessment as it could be considered a restraint. RN-F stated she was not sure why R4 still had the parameter mattress in place or why staff were utilizing pillows. During interview on 6/26/25 at 4:14 p.m., licensed practical nurse clinical coordinator (LPN)-A stated parameter mattress needed to be assessed in the physical device assessment that were completed by the nurses on the floor. LPN-A stated the mattress/pillows could be considered a restraint if resident was not able to get out of bed. LPN-A stated R4 was a fall risk and could roll himself out of the bed. During interview on 6/26/25 at 5:40 p.m., assistant director of nursing (ADON) stated parameter mattresses were assessed through the physical device assessment. ADON stated parameter mattresses help resident identify the edge of the bed. The mattress could be considered a restraint when it was used to prevent the resident from getting out of bed or if resident was immobile. ADON confirmed parameter mattress was not assessed or mentioned on the physical device assessment and should have been. The facility Physical Devices policy, dated 3/2023, indicated Crest View Lutheran Homes would assist residents in remaining as independent and safe as possible when transferring or repositioning. 1. The unit nurse or designee will complete the physical device assessment on admission, re-admission, signification change of condition and annually.2. The unit nurse or designee will request physical devices based on the assessments. 3. The unit nurse or designee is responsible for updating the care plan.4. If a resident is reassessed at any point and is found to not need the physical device(s), the assessment and care plan will be updated by the unit nurse or designee and the physical device(s) will be removed. 5. Risk and benefits reviewed with resident or representative and signed. 6. Education is provided, along with A Guide to bed Safety.

Based on observation and interview, the facility failed to ensure resident rights were maintained for 2 of 4 residents (R15 and R43) reviewed for dignity. Findings Include: R15R15's annual Minimum Data Set (MDS) dated [DATE], identified R15 had moderate cognitive impairment and required assistance with all activities of daily living (ADLs). R15's diagnoses included progressive neurological conditions (a disease that causes the nervous system to gradually deteriorate over time), multiple sclerosis (a chronic, often disabling disease that attacks the central nervous system, specially the brain and spinal cord), renal failure (a condition where the kidneys lose their ability to effectively filter waste and excess fluid from the blood), depression, retention of urine, presence of urogenital implants, and hydronephrosis (a condition where one or both kidneys swell due to a backup of urine, often caused by a blockage or obstruction in the urinary tract). MDS also indicated R15 had an indwelling external catheter. During observation on 6/23/25 at 2:53 p.m., R15's urinary catheter leg drainage bag, which was approximately three-quarters full of yellow colored liquid, was showing out the bottom of R15's pant leg and was resting on top of R15's right foot. Drainage bag was visible to all residents and staff present in the dining room. During observation on 6/25/25 at 11:54 a.m., R15 was coming back from the dining room. R15's urinary catheter leg drainage bag, which was approximately one-half full of yellow colored liquid, was showing out the bottom of R15's pant leg and was resting on top of R15's left foot. Drainage bag was visible to all residents and staff that walked past.During observation on 6/26/25 at 11:23 a.m., R15 was seated in the dining room with the urinary catheter leg drainage bag, which was approximately one-half full of yellow colored liquid, was showing out the bottom of R15's pant leg and was resting on top of R15's left foot. Drainage bag was visible to all residents and staff that walked past.During interview on 6/26/25 at 7:28 a.m., R15 stated she was not happy about people being able to see her catheter drainage bag. R15 stated, there is really nothing I can do about it. During interview on 6/26/25 at 2:21 p.m., nursing assistant (NA)-H stated she noticed R15's catheter drainage bag does tend to slide down her leg onto foot. NA-H stated there was nothing she needed to do regarding the catheter drainage bag other than emptying. During interview on 6/26/25 at 3:46 p.m., registered nurse (RN)-F stated R15 had a urinary catheter and NA's should ensure it was covered when R15 was outside her room. RN-F stated she noticed R15's catheter does tend to slide down her leg if not secured onto R15's calf. During interview on 6/26/25 at 4:16 p.m., licensed practical nurse (LPN)-A stated she would expect the urinary catheter drainage bag to be secured on R15's upper calve under her pants. LPN-A stated it should be covered and not visible as it was a dignity concern.During interview on 6/26/25 at 5:44 p.m., assistant director of nursing (ADON) stated she would expect staff to place urinary catheter drainage bag so it was not visible as it could be a dignity concern for the resident.R43R43's annual MDS dated [DATE], identified R43 had moderate cognitive impairment and required assistance with all ADLs. R43's diagnoses included atrial fibrillation (a common type of irregular heartbeat that originates in the heart's upper chambers (atria)), heart failure (a condition where the heart can't pump enough blood to meet the body's needs), cerebrovascular accident (occurs when blood flow to the brain is interrupted, causing brain cells to die due to lack of oxygen and nutrients) and depression. During observation on 6/24/25 at 4:18 p.m., R43 was seated in the dining room with his JP (Jackson Pratt) drainage bag (type of surgical drain used to remove fluids from a surgical site), which was approximately one-half full of greenish-brown liquid, was placed on top of R43's clothing on his right and was visible to all residents and staff present in the dining room. Staff did not attempt to assist R43 with covering bag nor did they ask.During observation on 6/26/25 at 11:03 a.m., R43 was seated in the dining room with his JP drainage bag, which was approximately three-quarters full of greenish-brown liquid, was placed on top of R43's clothing on his right and was visible to all residents and staff that walked past. Staff did not attempt to assist R43 with covering bag nor did they ask.During interview on 6/26/25 at 11:05 a.m., R43 stated staff did not normally cover the drainage bag. R43 stated he felt, embarrassed, that everyone can see the drainage bag.During interview on 6/26/25 at 2:27 p.m., NA-H stated R43's drainage bag was normally placed on top of R43's right thigh. NA-H stated there was nothing that she needed to do regarding the JP drain. NA-H confirmed bag probably should not be visible to others and should have something placed over it.During interview on 6/26/25 at 3:46 p.m., RN-F stated R43 had a JP drain that NA's should assist with covering when outside his room. RN-F stated she had never seen R43 mess with or move the drainage bag. During interview on 6/26/25 at 4:16 p.m., LPN-A stated she had never seen R43 mess with or move the drainage bag. LPN-A stated she would expect the drainage bag to be tucked into pants or placed under his shirt. LPN-A stated it should be covered and not visible as it was a dignity concern.During interview on 6/26/25 at 5:44 p.m., ADON stated she would expect staff to place drainage bag so it was not visible as it could be a dignity concern for the resident.The facility Quality of Life - Dignity policy, last reviewed 4/2024, indicated Crest View Senior Communities to care for each resident in a manner that promotes and enhances quality of life, dignity respect and individuality. Staff will promote dignity and assist residents as needed by keeping urinary catheter bag covered and providing residents dignity with all other cares.

Based on observation, interview, and document review, the facility failed to provide medically related social services of clothing and shoes for 1 of 1 resident (R1) reviewed for clothing. This resulted in harm when R2 displayed a lack of engagement in social activities and diminished level of participation in social interactions because she felt unable to leave her room due to a lack of proper and adequate clothing and shoes. Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 admitted to the facility on [DATE] and had diagnoses including anxiety disorder, depression, alcohol dependence, and acquired absence of left leg below knee. R1 understood others and was able to make herself understood, had mild cognitive impairment, and utilized a wheelchair and limb prosthesis. The MDS identified, it was somewhat important to R1 to choose what clothes to wear, to do her favorite activities, and to go outside to get fresh air when the weather is good. R1's social isolation score was 2, indicating she sometimes felt lonely or isolated from those around her. R1's quarterly MDS dated [DATE], indicated R1 was 48 inches (four feet) tall and weighed 90 pounds. R1's social isolation score was 2, indicating she sometimes felt lonely or isolated from those around her. R1's Social History and Social Service assessment dated [DATE], indicated R2 was historically overall self sufficient and able to manage on her own. R2's physical and functional status was has a left prosthesis at a very young age and right foot is deformed, walked with crutches and has a w/c [wheelchair]. Barriers to discharge were safe to return, needing to get a new wheelchair. The assessment did not identify that R2 lacked clothing and shoes. R1's PHQ-9 Long-Term Care assessment (a diagnostic assessment tool for depression) dated 6/3/24, identified R1 felt down, depressed, or hopeless on two to six days of the 14 day assessment period. R1's life enrichment progress note dated 6/4/24, noted R1 was alert and oriented times three. life enrichment aide (LEA)-A noted R1 had a wheelchair, walker, and she is an amputee, and does have a prosthetic device, but states she has no shoes for her foot. Life enrichment will continue to monitor her progress for the next 90 days. R1's electronic health record (EHR) contained a physician order dated 6/4/24, for R1 to be evaluated and treated by a psychology clinic. R1's progress note dated 6/12/24, indicated a care conference was conducted with R1, therapy staff, nurse supervisor, and a social worker. The note identified R1 had limited finances but did not include any information regarding R1's previously stated need for shoes identified in progress note dated 6/4/24. R1's progress note dated 6/20/24, indicated social services spoke with the manager of the apartment where R1 resided prior to admission who would hold R1's apartment and belongings for thirty days before cleaning it out. Social work was to follow up with resident and speak about vacating the apartment. R1's psychology provider note dated 6/26/24, indicated R1's mood was depressed and anxious. The note included a Clinician's Rating of Severity, a scale to assess the importance of symptoms with regard to clinical need, regulatory systems, and risk management. The severity of R1's symptoms was rated five out of nine on a scale of one to nine (with one indicating little and nine indicating high severity). The note included, she [R1] reports boredom and states that she continues to have loneliness. R1's progress note by the MDS coordinator dated 6/26/24, indicated the writer spoke with R1 about a medical insurance appeals letter and R1 stated would like to start using her prosthesis (with build in shoe), however has a concern about not having a shoe available for the right foot to perform ambulation. Writer notified SS [social services], will notify the rest of the team via email. R1's PHQ-9 Long-Term Care assessment dated [DATE], identified R1 felt down, depressed, or hopeless on two to six days of the 14 day assessment period. R1's record did not specify and/or further assess which symptom (felt down, depressed, or hopeless) R1 had nor potential causes that made R1 feel down, depressed, or hopeless. R1's life enrichment progress note dated 8/30/24, indicated R1 had not attended activities with life enrichment but had accepted one to one visits and there are no concerns at this time. R1's monthly activities attendance calendars dated July through October 2024, noted completion of 11 total one-to-one visits between 6/1/24 and 10/28/24 as follows: - One one-to-one visit in June - Zero one-to-one visits in July - Four one-to-one visits in August - Three one-to-one visits in September - Three one-to-one visits in October R1's psychology provider note dated 9/4/24, indicated R1's mood was depressed and anxious with a Clinician's Rating of Severity symptom severity level of six out of nine. The note included, Time spent in session discussing interventions that she can do to improve her energy level and quality of life. Clinician provided supportive feedback and encouraged her to continue to spend time out of her room as this might be of benefit to her mood. R1's progress note by social services designee (SSD)-A dated 9/5/24, indicated a care conference was conducted with R1, nurse manager, and social worker. The note included resident reported, she doesn't have cloths [sic, clothes]. SW [social work] will look in laundry for donation clothes. R1's PHQ-9 Long-Term Care assessment dated [DATE], identified R1 felt down, depressed, or hopeless on two to six days of the 14 day assessment period. R1's record did not specify and/or further assess which symptom (felt down, depressed, or hopeless) R1 had nor potential causes that made R1 feel down, depressed, or hopeless. R1's psychology provider note dated 9/11/24, indicated R1's mood was depressed and anxious with a Clinician's Rating of Severity symptom severity level of six out of nine. The note included, [R1] states that she continues to have difficulty with a variety of mood concerns with a treatment recommendation/plan to continue current psychological treatment plan and interventions in place. R1's psychology provider note dated 10/2/24, indicated R1's mood was depressed and anxious with a Clinician's Rating of Severity symptom severity level of five out of nine. The note included [R1] states that she continues to feel a decline. She notes confusion, not able to recall things, and a loss of energy . She notes that she thinks that she is sleeping too much during the day. The treatment recommendation/plan was to continue current psychological treatment plan and interventions in place. R1's psychology provider note dated 10/16/24, indicated R1's mood was depressed and anxious with a Clinician's Rating of Severity symptom severity level of six out of nine. The note included, She [R1] reports her mood is 'okay,' and reports her sleep continues to be 'okay' at night. Her energy level presents as low today . She stated her belief is that she is 'getting worse' . Clinician provided supportive feedback and encouraged her to continue to spend time out of her room as this might be of benefit to her mood. The treatment recommendation/plan was to continue current psychological treatment plan and interventions in place. R1's progress notes reviewed between R1's admitted through 10/16/24 did not include identification of any further follow-up regarding her expressed concerns of lack of shoes and clothing. Additionally, even though the psychology provider noted on 6/26/24 identified R1 was lonely and bored, on 9/4/24 encouraged R1 to spend time out of her room, on 9/11/24 noted R1 had difficulty with a variety of mood concerns, on 10/2/24 indicated worsening mood symptoms noting R1 continued to feel a decline, had confusion, loss of energy, and sleeping too much. On 10/16/24 psychology note indicated worsening mood symptoms noting R1 believed she was getting worse. R1's record did include a comprehensive assessment that identified potential reasons why R1 was not coming out of her room and the psychosocial impact. Further it was not evident the facility addressed the psychology providers recommendation to encourage R1 to spend time out of her room. Refer to F679 for additional information. Vulnerable Adult Maltreatment Report dated 10/25/24, indicated the unidentified anonymous reporter (AR) visited R1 the week of 10/13/24. The reporter noted R1 stated she could not go to the dining room because she did not have any clothes and reported she did not have socks, shoes, or slacks. R1 had one to two shirts and typically wore hospital gowns. During an interview on 10/28/24 at 1:23 p.m., AR stated she had visited R1 and R1 indicated she didn't think she could go anywhere because she didn't have appropriate clothing. The AR stated R1 had two shirts the facility had given her, but didn't have socks, slacks, or shoes, and had a coat but it lacked a lining. The AR reported when she visited R1 she was wearing one of the shirts, an oversized button-up shirt over a hospital gown. AR stated the shirt was the same length on R1 as the hospital gown because R1 is super tiny, she is short and on R1 a large shirt would be like a dress. During an observation on 10/28/24 at 11:31 a.m., nursing assistant (NA)-A brought lunch to R1 in her room. R1 was sitting in bed wearing an oversized button-up shirt over a hospital gown with a yellow gripper sock on her right foot. R1 requested beverages from NA-A and provided her with a list, but NA-A did not ask R1 if she wanted to eat outside of her room or encourage her to come out. R1 made an expression of her interest in socializing and speaking with other people stating, It is my job to make a person giggle, but if they laugh that's even [NAME]. During an interview on 10/28/24 at 4:23 p.m., R1 was eating in bed in her room wearing an oversized button-up shirt over a hospital gown with a yellow gripper sock on her right foot. R1 stated she had no clothes and had no clothes because her landlord had thrown them away. She stated she was eating in her room because I can't think of any way of me getting out because I don't have a lot of clothes. I have nothing proper to wear in the lunchroom. R1 indicated the facility had donated some clothes to her, but they did not fit because she was short. R1 stated I would like to try eating in the dining room. During an observation on 10/29/24 at 12:16 p.m., R1 was eating in bed in her room wearing an oversized button-up shirt over a hospital gown with a yellow gripper sock on her right foot. During an interview on 10/29/24 at 12:38 p.m., licensed practical nurse (LPN)-A stated R1 did not go to activities and did not go to the dining room, she always said no, and this was also what staff had reported to her. LPN-A noted she wished all residents would eat in the dining room as it provided more socializing. LPN-A noted she had only seen R1 outside of her room in her wheelchair one time, for physical therapy. During an interview on 10/29/24 at 12:51 p.m., nursing assistant (NA)-A stated she assisted R1 with cares and would clean R1 up and change her hospital gown in the morning. NA-A noted R1 ate meals in her room. During an interview on 10/29/24 at 1:31 p.m., NA-C stated R1 never wanted to come out of her room. NA-C reported she had tried to come to R1 and say 'let's go somewhere together' to get her to come out of her room but when asked if she wants to come out R1 says I have no clothes. NA-C stated two or three weeks ago staff had told the director of nursing (DON) R1 needed clothes when the DON had asked staff if anybody needed clothes to be given out, discussed R1 and DON told the aides everybody should have clothes. NA-C reiterated that R1 never wants to come out and she just wants to stay in her room. During an observation and interview on 10/29/24 at 3:09 p.m., R1 was observed in her bed in her room wearing an oversized button-up shirt over a hospital gown and a yellow gripper sock on her right foot. R1 stated she had some clothing that the facility provided from lost and found, but it was very little, and she did not have any of her own clothing at the facility. R1 stated she had a yellow gripper foot cover, but did not have socks, shoes, or a bra and classified the hospital gown she was wearing as a night gown. R1 noted she needed shoes to be able to use her prosthetic because she needed a shoe for her right foot for balance, a shoe gives me stability and not having shoes has impacted my mobility. R1 indicated the facility had provided her with two shirts, one sweatshirt, and one pair of pants but the pants did not fit appropriately. R1 stated not having clothes makes me not want to go out It is keeping me from wanting to get up and get out . if I looked proper I would love to go out, but I don't want to go out in this, and I don't even know if they allow it. If I were dressed properly, I would enjoy getting out and about. I don't feel my attire is proper. R1 made an expression of hopelessness, stating she felt like she was missing out on things, but had learned to accept whatever there is. R1 recalled mentioning needing clothes to one or two staff members but did not recall who. R1 re-iterated that if I had clothing I was comfortable in, I think I would ask to go to the dining room and ask to go to activities. She believed someone from laundry brought the donated clothes to her room and had noticed clothes in her shared closet but was not sure who they belonged to because no one had spoken to her about them. R1 did not indicate she had any other winter weather clothing apart from one unlined coat. R1 stated she didn't know if she had a social worker, so did not know if they had discussed shoes or clothes with her. R1 showed the surveyor her clean folded clothing which she kept in a plastic bag at the foot of her bed along with other personal belongings. They included one additional button-up shirt, a sweatshirt, and a pair of pants that she indicated was not the correct size. During an interview on 10/29/24 at 3:29 p.m. with the director of social services (DSS) and SSD-A, SSD-A confirmed she wrote a progress note about R1 dated 9/5/24 regarding a care conference. SSD-A stated it was brought up to her that R1 needed clothes, she believed it was nursing staff who informed her, and she went to the laundry department who gave her some donated clothes from the lost and found. SSD-A stated R1 had arrived at the facility without clothing of her own and when she spoke to R1, R1 stated she had no clothing. SSD-A stated, they just gave her basic clothes for now, whatever they can find in the laundry and noted R1 did not have family to call for assistance and R1 was her own responsible party. SSD-A stated laundry provided her with some shirts and pants but she doesn't walk, she's amputated like her foot, so she doesn't need shoes. SSD-A was unable to articulate how she assessed what R1's specific needs were regarding clothing and shoes apart from I just asked her what she needed . I told her 'Oh, will shirts and pants be okay,' she said 'Yes,' so that's how I knew. During an interview on 10/29/24 at 3:29 p.m. with the DSS and SSD-A, the DSS stated if someone needed clothes you could offer a short-term fix like getting things from laundry, but long term we need to ask about finances and if a resident had money to get clothes or had family to assist with getting clothes. The DSS noted social services staff needed to ask R1 what specifically she needs and get her what she needs as soon as we can and find a long-term fix because donated clothes from laundry is a temporary fix, we need to find a long term fix. It is not okay for somebody to not have shoes. The DSS stated R1 should also have a hat, gloves, and a scarf for winter wear. The DSS noted residents needed clothing that meets their needs to feel comfortable, covered, and safe and this could affect mental health . it could affect your socialization, you're not comfortable. The DSS further stated not having adequate comfortable clothing could cause psychosocial harm and it is kind of degrading . like if I was in their shoes I wouldn't like to be walking in a hospital gown . and we don't even know her preferences. The DSS noted sometimes should have followed up and asked if she got the things she needed and if there was anything else she needed. The DSS confirmed R1's progress note dated 6/4/24 from life enrichment identified concerns about have a shoe available for her right foot to perform ambulation and a progress note dated 9/5/24 identified R1 didn't have clothes. The DSS was not sure what had happened after these concerns were noted. The DSS confirmed clothing, including shoes, socks, and bras were a basic need and one pair of pants was not sufficient as dirty clothes could be gone for days while processed by laundry. The DSS confirmed clothing and shoes are a medically related social service and is in our scope, because we help people get the services and things they need to be successful. The DSS confirmed clothing and shoes are important for attaining and maintaining mental and psychosocial health and sometimes your appearance can make you feel a certain type of way. The DSS identified a lack of clothing and shoes could affect a resident by not participating in therapy, self-isolating, I think we would see it across the board affect almost every aspect of their life . I don't know [R1] very well but if she feels like she can't leave her room because of it and she feels uncomfortable, that actually is a problem and is harmful . if I was in her shoes I would not want to be out. During an interview on 10/30/24 at 8:28 a.m., life enrichment aide (LEA)-B stated R1 had not participated in activities and a couple of the times that I talked to her she said it's because she doesn't have any clothes . as far as I know it seemed she wasn't comfortable going to activities in one of the nursing gowns. LEA-B noted being around others in the nursing gown she [R1] didn't feel comfortable. LEA-B stated she gotten R1's clothing sizes and left a note in the mailbox for laundry to find some clothes for her when she became aware of the concern but was not sure when that had occurred. LEA-B confirmed she had continued to see R1 wearing hospital gowns since then and didn't follow up further when she was still wearing them. During an interview on 10/30/24 at 9:32 a.m., R1 noted she loved to crochet and do crafts, but no one had ever offered to do crafts with her in her room. R1 noted she would like to play cards, but no one had ever offered to play games with her in her room and I play solitaire in bed by myself. She stated she may have said no when staff had invited her to attend group activities because she didn't have proper clothing. During an interview on 10/30/24 at 10:02 a.m., trained medication aide (TMA)-A stated R1 always stayed in her room, and she had only seen R1 outside of her room once when someone came to have a meeting with her. TMA-A was not aware of why R1 did not want to come out. During an interview on 10/30/24 at 10:12 a.m., LPN-A stated R1 preferred to stay in her room and would say 'nope' if asked to attend an activity or come to the dining room. LPN-A stated R1 was not very social and I told her you know you should talk to more people, people need to communicate . I would want to be around people. During an interview on 10/30/24 at 11:45 a.m., DON stated R1 doesn't come out of her room a whole lot and I was told she just isn't a very social person. The DON stated she was now aware it was noted in June that R1 had concerns about clothing and shoes, but staff had not told her at the time. The DON stated, adequate clothing and shoes is a basic need and the facility is responsible for meeting that need. The DON identified potential impacts of a lack of adequate clothing and shoes as an impact on dignity, not feeling so good about themselves, psychosocial impact and noted that for a resident with diagnoses of anxiety and depression the potential impact could be higher. The DON confirmed R1 had diagnoses of anxiety and depression. The DON stated if she did not have adequate clothing and shoes I wouldn't feel good about it, I would not be very happy if it was a family member of mine and noted a resident would not feel good about themselves . it may make them feel isolated if that was the reason why they didn't want to come out of their room was because of their clothing. The DON noted isolation could progressively lead to further anxiety and depression. The DON stated if R1 doesn't have shoes to wear her prosthetic and come out of her room it definitely would affect her mood, isolation and it affects her mobility. During an interview on 10/30/24 at 12:41 p.m., R1's primary care provider, nurse practitioner (NP)-A, stated she had never seen R1 outside of her room and assumed she did not eat in the dining room or attend activities. NP-A stated clothing and shoes are basic needs, and she recalled that R1 didn't have any belongings because R1 had mentioned that all her belongings were removed from her apartment. NP-A stated she thought she always saw R1 dressed in a hospital gown. NP-A stated, If the reason someone won't leave their room is because they don't have clothing, if she has stated I'm uncomfortable to leave my room because I don't have these things, I would say it is a priority to have those things. It would have an impact. NP-A noted it could have a negative psychosocial impact, possible increased depression, anxiety, dissatisfaction, it would impair self-esteem . not leave a room for meals or activities could even have a negative cognitive impact in a way because of the lack of stimulation. NP-A noted it could have caused harm and impacted well-being if R1 didn't have clothes and shoes and wasn't comfortable leaving her room because of that. NP-A stated she would feel restricted in the activities she participated in if she did not have adequate and comfortable clothing and stated I don't think the average person would be comfortable attending group activities or dining communally in a hospital gown . I wouldn't be. NP-A noted she was not previously aware of this concern. During a return phone call interview on 11/7/24 at 9:50 a.m., R1's psychology provider, licensed independent clinical social worker (LICSW)-A, confirmed she had been treating R1 over the course of her admission to the facility. LICSW-A stated R1's mood was kind of hit or miss and confirmed she presented as depressed and anxious. LICSW-A noted R1 was having a hard time adjusting to the facility and displayed symptoms including loneliness, boredom, increased confusion, decreased energy, and sleeping too much. LICSW-A noted R1's Clinician's Rating of Severity scores were a scale based on what staff and R1 told her and the clinician's impression. LICSW-A identified R1's scores ranging from five to seven as reflective of R1 not totally doing well. LICSW-A noted R1 was not able to self-soothe effectively and relied on staff to anticipate her needs. LICSW-A identified R1's treatment plan and interventions to include attending activities, talking to others and not bottling feelings up, reaching out to others, and taking medications as prescribed. LICSW-A stated she encouraged R1 to spend time outside of her room, her being around people, and not being alone and recommended this because if she is feeling loneliness or boredom having people around her and eating meals in the dining room, those kind of things might help her. LICSW-A stated the impact on R1 of being isolated and in her room would be a continued decline, more experiencing and expressing being lonely. Her roommate leaves to do things so then she is in her room alone. LICSW-A noted prior to R1's admission to the facility, she lived in a big apartment complex and a lot of people would sit outside or in the common areas and I think she used to do that. LICSW-A believed R1 used to socialize and drink alcohol and believed she missed doing this, though noted R1 was no longer drinking which was a good thing. LICSW-A noted R1 got along well with her roommate and talked to her, and R1 said she wanted to do activities. LICSW-A thought R1 was declining activities when asked by staff because she was usually tired and her energy was low. LICSW-A was unaware of R1's concerns regarding a lack of clothing and shoes and indicated R1 was always in her room when LICSW-A arrived. LICSW-A stated she thought social services staff should get R1 clothing and shoes, and noted the facility needed to work on this. LICWS-A stated if R1 felt she did not have adequate and proper clothing the impact would be R1 continuing to be symptomatic. LICSW-A noted if R1 said she lacked adequate and proper clothing to leave her room it could be harmful to her psychosocial well-being. LICSW-A stated R1 isolating, not socializing, and remaining in her room was harmful. Facility policy titled Quality of Life - Dignity and Privacy dated 12/19, included Procedures: 1.) Resident will be treated with dignity and respect at all times. a. Being 'treated with dignity' means the resident will be assisted in maintain and enhancing their self-esteem and self-worth . 3.) Residents will be assisted in attending the activities of their choice, including activities outside of the facility. Facility job description for Director of Social Services, undated, included Position Summary: . Developing care plans to meet the psychosocial well-being and needs of residents and to enable residents to achieve their optimal level of independence . Responsibilities and duties: . 3.) Provides support services for new residents and their families to facilitate initial adjustment to [facility]. Provide ongoing counseling and problem solving services to residents and family members . 5.) Assess resident's social, psychological, and emotional status and develops a plan of care that meets the residents' needs . 9.) Serves as an advocate for residents, interpreting and upholding the Minnesota [NAME] of Rights and the Vulnerable Adult Act.

Based on interview, and record review, the facility failed to ensure a do-not-resuscitate (DNR) order was accurately reflected throughout the medical record for 1 of 26 residents (R81) reviewed for advanced directives. This resulted in an immediate jeopardy (IJ) for R81 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when the facility obtained a physician's order for R81 to have a full code status even though the physician order for life sustaining treatment (POLST) indicated do not resuscitate (DNR). The IJ was identified on [DATE]. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 3:15 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of D-isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R81's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition. R81's MDS dated [DATE], indicated the following diagnoses: alcohol dependence, alcoholic cirrhosis of the liver, and depression. R81's clinical profile in the electronic medical record (EMR) indicated R81 was her own representative. R81's care plan dated [DATE] indicated full code status. R81's hospital discharge summary dated [DATE], indicated a code status of DNR was confirmed while in the hospital. R81's physician orders in the EMR dated [DATE], indicated R81 was a full code. R81's POLST in the paper chart dated [DATE], indicated do not attempt resuscitation/DNR allow natural death and was signed by R81 and the nurse practitioner (NP). A care conference summary note dated [DATE], indicated R81 and the nursing supervisor were present at the care conference, but nursing was unable to review R81's code status due to R81 not being able to stay awake. R81's nursing progress notes were reviewed from [DATE], through [DATE], and lacked additional documentation the code status was reviewed. During review of the EMR on [DATE], at 1:26 p.m. R81's face sheet indicated full code status and under the miscellaneous tab, a document named POLST not valid, was the POLST dated [DATE], which indicated DNR. During interview on [DATE], at 10:42 a.m. registered nurse (RN)-B stated he would check for the code status of a resident on the profile in the EMR and on the paper chart under the advanced directives tab. RN-B reviewed R81's paper chart which indicated a POLST dated and signed on [DATE], by R81 and the NP. The POLST indicated R81 did not want to be resuscitated. Further, at 11:07 a.m. RN-B stated if there was a discrepancy, he would need to ask the supervisor, and would start CPR in an emergent situation. During interview on [DATE], at 10:50 a.m. R81 was sitting up in bed and alert. R81 stated, let me die if her heart stopped. During interview on [DATE], at 11:04 a.m. RN-D stated if there was a discrepancy on a resident's code status, and the resident was alert and oriented, she would ask the resident if they wanted full treatment, otherwise she would contact the family and the physician and added they could not have both full code and DNR status. RN-D further stated if a resident did not have a pulse, she would check the code status on the face sheet and added the code status which was also located in the hard chart. During interview on [DATE], at 11:05 a.m. RN-E stated if a resident did not have a pulse, she would check the code status in the EMR and then in the hard chart, and if there was a discrepancy, would start CPR and then clarify the code status. During interview on [DATE], at 11:05 a.m. licensed practical nurse (LPN)-E stated if a resident did not have a pulse, he would look for the code status in the care plan behind the door, or in the EMR on the banner. He also stated there was a yellow POLST in the chart, and if there was a discrepancy, he would first administer CPR and sort the rest out later. During an interview on [DATE], at 11:23 a.m. the director of nursing (DON) stated staff went to profile or miscellaneous in point click care to find code status. When the POLST and orders don't match, residents were considered full code. DON verified R81's profile indicated full code. Staff were expected to check the paper chart to confirm. DON stated when the POLST was identified as not valid, it indicated social services had an updated POLST form. The DON stated R81's POLST had recently been updated. However, the record lacked an updated POLST. When there was a discrepancy, she would expect the staff to administer CPR. During interview and record review on [DATE], at 11:38 a.m. the DON stated facility staff were concerned R81 may not have been coherent when the NP reviewed the POLST with R81 on [DATE], so a note was sent to the NP per the patient portal (an electronic communication) on [DATE]. DON provided a copy of the patient portal note sent to the nurse practitioner [DATE]. The note indicated facility staff requested R81's POLST be reviewed a second time with the NP and R81 remain a full code until the POLST was reviewed a second time. The NP replied on [DATE], at 7:24 a.m. that R81 was coherent when the POLST was reviewed on [DATE]. A policy, Cardiopulmonary Resuscitation dated ,d+[DATE], indicated if an individual resident, visitor, or staff is found unresponsive and without a pulse, a licensed staff person who is certified in CPR shall initiate CPR unless it is known that a do not resuscitate order that specifically prohibits CPR exists for that individual. Under the procedure If there was no response, no pulse and no respirations, the code status was checked under the advanced directives tab in the front of the chart. The IJ was removed on [DATE], at 2:45 p.m. when the facility implemented a removal plan which was verified by interview and document review. -On [DATE], reviewed the POLST and code status with R81. -On [DATE], the updated POLST with DNR status was signed by the NP and R81. R81's physician orders, code status, POLST, and care plan were updated with the DNR status. -On [DATE], audits were completed for all residents to ensure physician orders, code status, POLST, and care plan had no discrepancies. -On [DATE] and [DATE], the facility CPR and POLST policies/procedures were reviewed and updated. -On [DATE] and [DATE], education for all professional nursing staff on the CPR and POLST policies/procedures and talking to the resident when there's a question regarding code status was conducted. Professional nursing staff not educated would receive the education prior to the next shift worked.

Based on observation, interview and document review, the facility failed to provide interventions to prevent elopements for 1 of 3 residents (R4) reviewed for elopement. This resulted in an immediate jeopardy for R4, who eloped from the facility. The immediate jeopardy (IJ) began on [DATE], when R4 eloped from the facility and was found by local law enforcement 0.6 miles from the facility. The WanderGuard did not alert staff that R4 left the facility unsupervised as the device was not working. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 10:15 a.m. The IJ was removed on [DATE] at 3:30 p.m. but non-compliance remained at the lower scope of a D, isolated, no actual harm, with potential for more than minimal harm. Findings include: On [DATE], a progress note indicated local law enforcement (LE) found R4 approximately 0.6 miles from the facility with feces on him. LE alerted the facility, and the campus administrator picked up R4 and brought him back to the facility. R4's Diagnosis List printed [DATE], indicated R4's diagnoses included [CONDITION(S)] and history of falling. R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had a moderate cognitive impairment, and exhibited behaviors of fluctuating attention and disorganized thinking. R4's care plan dated [DATE], indicated R4 was an elopement risk because of his poor safety awareness. The care plan indicated R4 should have a WanderGuard (a monitoring system to alert the facility if a resident tried to leave) placed under his wheelchair seat. In addition, the care plan directed staff to check the WanderGuard and its functionality every shift. On [DATE], at 12:58 a.m. a progress note indicated another resident's family member called the facility and reported there was a resident wheeling himself down the street. The note also indicated R4 had poor decision-making skills. R4's Provider Order dated [DATE], ordered 15-minute checks for R4 because he was an elopement risk. On [DATE], at 1:09 p.m. a progress note indicated R4 was spotted heading down the hill and staff brought him back to the facility. R4's Treatment Administration Record (TAR) dated [DATE], indicated 15-minute checks began on the evening of [DATE], and were discontinued on the evening of [DATE] (72 hours later). On [DATE], R4's interdisciplinary team (IDT) note indicated the facility replaced R4's current WanderGuard with a new WanderGuard. R4's Provider Order dated [DATE], indicated R4 should have a WanderGuard for safety, with check of placement and function every shift. R4's provider progress note written by nurse practitioner (NP)-A dated [DATE], indicated R4 was cognitively intact but showed poor decision skills and poor safety awareness. The note indicated the provider ordered neurocognitive testing and psychotherapy. On [DATE], a facility report to the state agency (SA) indicated local law enforcement went to the facility to report R4 was alone and seen approximately 0.6 miles from the facility, and had been incontinent of bowel. The campus administrator went to the location and brought R4 back to the facility. R4's Provider Order dated [DATE], indicated R4 should have 15-minute checks on all shifts. On [DATE], at 2:45 p.m. NP-A was interviewed and stated she wrote an order for a WanderGuard for R4 on [DATE], along with 15-minute checks. NP-A stated she wanted a WanderGuard on both R4's person and his wheelchair. NP-A stated she also ordered a neurocognitive testing because R4 had poor safety awareness. NP-A stated the facility had not made an appointment for the neurocognitive testing. On [DATE], at 3:47 p.m. trained medication aide (TMA)-B stated R1 had a WanderGuard on his wheelchair but she was not aware he eloped during her shift. On [DATE], at 9:54 a.m. TMA-A stated he was not aware R4 had eloped; he could not remember if a WanderGuard was on R1's wheelchair. On [DATE], at 1:34 p.m. licensed practical nurse (LPN)-D stated was unaware R1 had eloped during her shift. On [DATE], at 4:22 p.m. licensed practical nurse (LPN)-C was interviewed and stated she was working [DATE], when R4 eloped. LPN-C stated she thought R1's WanderGuard was still on his wheelchair, but she was not sure. LPN-C stated no one knew he was gone until LE contacted the facility. On [DATE], at 4:27 p.m. LPN-D was observed moving R4 through the front doors accompanied by the receptionist. LPN-B stated they were checking to see if R4's WanderGuard was working. The receptionist stated, It's not working. R1's WanderGuard did not alarm as R4 passed through the doors. LPN-B stated she would contact maintenance to determine why the WanderGuard was not working. On [DATE], a progress note indicated a new WanderGuard was placed on R1's wheelchair and activated. On [DATE], at 9:08 a.m. the campus administrator was interviewed. The campus administrator stated she was checking mail around 2:30 p.m. on [DATE], and saw the police officer at the reception desk. The campus administrator stated the officer told her R1 was at 42nd and [NAME] street. The campus administrator stated she got a blanket and walked to get R1. The campus administrator stated she pushed R1 in his wheelchair back to the facility. The campus administrator stated R1 was wearing a hat, jacket, and gloves over his shirt and pants; he had on shoes and socks. The campus administrator stated R1's WanderGuard was still on his wheelchair, but it was expired so she gave LPN-A a new WanderGuard to replace it. The campus administrator stated she did not verify this was done, and acknowledged it was not recorded in their log. The campus administrator stated R4's WanderGuard was expired, it was placed on [DATE], and was only good for 90 days. The campus administrator stated the WanderGuard should have been replaced on [DATE], therefore, it was expired when R4 eloped on [DATE]. The campus administrator stated the WanderGuard log had not been updated since August of 2021. The facility's Elopement and Wandering Policy and Procedure dated [DATE], directed residents who were assessed for elopement risk would have a WanderGuard placed on their wrist, and if the WanderGuard was found to be not working staff should immediately notify the administrator, DON, and Director of Environmental Services. The policy lacked direction of the process for placing, activating, testing, and monitoring the WanderGuard for function. The immediate jeopardy that began on [DATE], was removed on [DATE], at 3:30 p.m. when the facility successfully implemented a removal plan which included: elopement assessments were conducted on all residents with WanderGuards, all current WanderGuards with replaced with new WanderGuards and their activation was verified, the Elopement policy was reviewed and revised, and staff was educated on how to activate the WanderGuard, monitoring and verifying WanderGuard placement, and elopement precautions. This was verified on [DATE], with staff interviews verifying the education, the WanderGuards were verified in working order, and the Elopement policy was reviewed.

Based on interview and document review, the facility failed to ensure residents were free from sexual abuse for 1 of 3 residents (R1) reviewed for sexual abuse allegations. R1's family member (FM)-B engaged in sexual touching with R1. This resulted in an immediate jeopardy for R1, when FM-B sexually abused her. The immediate jeopardy (IJ) began on [DATE], when staff observed FM-B kissing and cuddling R1 in the dining room. Later in the day, another staff observed FM-B touching R1's genitals over clothing in her room. R1 was not able to give consent for sexual contact due to advanced dementia The administrator and assistant director of nursing (ADON) were notified of the IJ on [DATE], at 6:20 p.m. The IJ was removed on [DATE], at 1:25 p.m. but non-compliance remained at the lower scope of a D, isolated, no actual harm, with potential for more than minimal harm. Findings include: R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had severely impaired cognition, and sometimes understood others. R1's Care Area Assessment (CAA) dated [DATE], indicated R1 had a decreased ability to make herself understood and exhibited confusion, disorientation, and forgetfulness. The CAA also indicated R1 had dementia. R1's care plan (CP) dated [DATE], indicated R1 was a vulnerable adult with interventions of involving the Ombudsman and psychological services as needed. The CP indicated the door to her room should be left open when R1 had visitors. On [DATE], a progress note indicated R1 was disoriented and confused upon arrival to the facility. The note also indicated R1 could not make her needs known. On [DATE], R1's admitting nurse practitioner (NP) progress note indicated R1 was admitted after being hospitalized for a fractured orbital bone and closed head injury following a fall. The note indicated R1 was very agitated, and exhibited signs of acute [CONDITION(S)] and dementia. On [DATE], a progress note indicated R1 was moved to the Memory Care Unit (locked unit) because of behaviors toward other residents. On [DATE], at 4:21 p.m. a progress note indicated a nursing assistant (NA) observed R1 and family member (FM)-B kissing in the dining room, and touching each other's genitals over clothing in R1's room. On [DATE], at 6:29 p.m. a progress note indicated local law enforcement (LE) was called, and were informed of the allegations of sexual abuse. On [DATE], at 11:46 a.m. a progress note indicated LE provided the facility with direction to not allow FM-B back into the building while the investigation was ongoing. On [DATE], at 4:00 p.m. a progress note indicated the administrator notified FM-B he could not come into the facility until an investigation was completed. The note also indicated FM-B stated his relationship with R1 was not conventional. On [DATE], at 8:48 a.m. a progress note indicated the facility contacted the Ombudsman, and the Ombudsman recommended the care plan be updated to indicate a conference should be held with FM-B before he visited again, and any inappropriate situations should be reported to FM-A. On [DATE], at 1:43 p.m. a progress note indicated social worker (SW)-A, the assistant director of nursing (ADON), the administrator, and FM-B met via phone to establish visitation parameters. These parameters were to have the bedroom door open during visits, FM-B would stay off the bed, staff would report any suspicious behaviors to FM-A, and any suspicious behavior would be reported immediately. On [DATE], at 3:30 p.m. a progress note indicated R1 mistakenly referred to FM-B as her (deceased ) husband. On ,d+[DATE];/21, at 9:41 a.ma an email was received from the Ombudsman. The Ombudsman indicated she had no iformation regarding the incident, and had no information regading the resident. On [DATE], at 2:22 p.m. a progress note indicated R1 was sad her boyfriend (FM-B) left, and she had a good visit with him. On [DATE], at 4:08 p.m. a progress note indicated LE informed the administrator there was still an open investigation. The note indicated the administrator contacted FM-B law enforcement was still investigating, and he could not visit the facility. On [DATE], at 11:06 a.m. FM-A was interviewed. FM-A stated FM-B was R1's son-in-law, and had been married to R1's daughter. FM-A stated when R1's husband died , and FM-B's wife died , R1 and FM-B became roommates. FM-A stated their relationship was platonic and because they were Italian, they would hug and kiss. FM-A described the kissing as a peck on the cheek or a peek on the lip, and stated there were no lingering kisses on the lips. FM-A stated R1's mental decline began two years ago, and had progressed where she could not use the television remote, the phone, or other household items she usually used. On [DATE], at 1:06 p.m. licensed practical nurse (LPN)-B was interviewed. LPN-B stated on [DATE], the life enrichment aide (LEA)-A had come to her and told her FM-B was kissing R1 on the lips in the dining room. LPN-B stated she went into the dining room, and observed FM-B sitting with his legs spread open, with R1's wheelchair between his legs. LPN-A stated R1 was facing FM-B. LPN-B stated she immediately reported this to her supervisor LPN-A. LPN-B stated after lunch, FM-B took R1 back to her room. LPN-B stated a short time later, nursing assistant (NA)-A told her FM-B was laying on R1's bed. NA-A reported to her R1 was in the wheelchair next to the bed. LPN-A stated NA-A reported FM-B was touching R1 between the thighs, and R1 was touching FM-A between the thighs. LPN-B stated she reported this immediately to LPN-A, but received no direction from LPN-A on what to do. LPN-B stated she went into R1's room and FM-B was sitting on the bed. LPN-B stated R1 was far away from the bed. FM-B then left. On [DATE], at 1:31 p.m. LPN-A was interviewed. LPN-A stated when LPN-B notified her of R1 and FM-B kissing in the dining room, she had been aware because LEA-A had told her. LPN-B stated she observed FM-B and R1 sitting close together in the dining room, but did not have time to do anything about it because she was busy with an admission. LPN-A stated later that day, NA-A had notified her FM-B was lying on bed R1's bed, and FM-B and R1 were touching each other's genitals over clothing. LPN-A stated she then notified the assistant director of nursing (ADON) and the administrator, but she did not inform them of the kissing in the dining room earlier. LPN-B stated she interviewed R1 who informed her FM-B was like my boyfriend and when he kissed her, she said, I like it when he did that. LPN-A stated R1 had dementia. LPN-A stated FM-B was allowed back in the facility today after a care conference yesterday. On [DATE], at 1:56 p.m. NA-A was interviewed and stated right before lunch, LEA-A told her about FM-B and R1 kissing in the dining room, and she had instructed her to notify LPN-B. NA-A stated after lunch, around 12:30 p.m. she entered R1's room and observed FM-B on the bed and R1 in the wheelchair next to the bed. NA-A stated both were rubbing each other's genitals. NA-A stated she told FM-B he could not lay on R1's bed, and then she reported this to LPN-B. NA-A stated after about thirty minutes, FM-B left. NA-A stated FM-B had been back in the facility visiting R1 this morning. On [DATE], at 2:11 p.m. NA-B was interviewed and stated R1 kisses everyone. NA-B stated R1 would grab other male residents and kiss them because she thought they were her husband. NA-B described R1 as very confused and very blind, and stated she could not see very well. On [DATE], at 2:19 p.m. the administrator and the ADON were interviewed. The administrator stated the Ombudsman told them to let FM-B visit again. The administrator stated FM-B had admitted to non-sexual kissing of R1, and to lying on R1's bed, but denied any touching of each other's genitals over clothing. The ADON stated she was not aware of the nature of FM-B and R1's relationship, but FM-B told them it was not a romantic relationship. The administrator stated when they told FM-B he could come back in the building, he had to keep R1's door open, he could not be on the bed, and no inappropriate touch, FM-B responded, Now I know. On [DATE], at 3:11 p.m. LEA-A was interviewed and stated on [DATE], around 10:00 a.m. there was a group activity in the dining room. LEA-A stated she observed FM-B enter the dining room and sit down beside R1 who was seated at a table. LEA-A stated FM-B positioned R1's wheelchair between his legs really close with her facing him, and he began repeatedly kissing R1 on the lips. LEA-A stated this was not a peck on the lips, and it went on for several seconds LEA-A stated the two were rubbing each other's shoulders and backs. LEA-A stated she felt very uncomfortable, especially knowing FM-B was R1's son-in-law and did not think it was appropriate so she reported it to LPN-B. On [DATE], at 6:51 p.m. FM-B was interviewed. FM-B stated he did not do anything wrong with R1 because they were from an Italian family and very affectionate, they hugged and kissed. FM-B denied any lingering kissing or touching of genitals over the clothing. FM-B stated staff did not understand how much they loved each other and cared for each other. FM-B also stated he had not seen R1 for a few days so he was being extra snuggly and nice to her that night. FM-B stated they snuggled and kissed in her room. FM-B acknowledged R1 had dementia and stated, Hell, I don't know if she knows it's me or thinks I'm her [deceased ] husband. FM-B stated R1 had [CONDITION(S)] and was legally blind. FM-B stated he thought people were misinterpreting their relationship because they had not seen them together before she was admitted to the facility and they just did not understand. On [DATE], at 6:57 p.m. law enforcement detective (LED)-A was interviewed and stated he instructed the facility to keep FM-B out of the facility until LE had completed their investigation. On [DATE], at approximately 3:30 p.m. the administrator was interviewed. The administrator stated they let FM-B back into the facility to visit R1 because he had denied any inappropriate contact. The administrator stated she had not followed LE's recommendations to keep FM-B out of the facility, because she thought their investigation was closed. On [DATE], at 2:00 p.m. R1 was interviewed and stated she was tired and wanted to take a nap. A bag of McDonald's fast food was on the bedside table. R1 stated her husband brought it and she missed him. R1 stated her husband was family member (FM)-B. R1 stated FM-B usually visited every day but he doesn't hear. The facility's Resident Protection Plan dated [DATE], indicated sexual abuse was defined as non-consensual sexual contact of any type with a resident. The Plan lacked indication of how consent was obtained or established. The Plan also directed investigations of allegations of abuse would begin immediately, and a root cause investigation and analysis would be completed. The Plan directed while the investigation was being completed, alleged perpetrators who were visitors would have visitation restricted, and any allegations of suspected sexual abuse would be reported immediately to law enforcement. The immediate jeopardy that began on [DATE], was removed on [DATE], at 1:25 p.m. when the facility successfully implemented a removal plan which included: a thorough investigation of the incident was completed, the Resident Protection Plan was reviewed and revised, and staff were educated on the Resident Protection Plan. R1 had a Protection Plan put into place, and staff was educated on the Protection Plan. Other residents were interviewed and had no concerns with FM-A. This was verified on [DATE], with staff interviews verifying the education, and review of the Resident Protection Plan and R1's Protection Plan.

Based on interview and document review, the facility failed to provide medically related social services prior to discharge for 1 of 1 resident (R10). This resulted in an immediate jeopardy (IJ) for R10 when she was discharged home alone, upon request of her family member (FM)-A without appropriate discharge plans in place to a potentially unsafe environment. The immediate jeopardy began on 10/22/21, when R10 was discharged from the facility without appropriate nursing services and interventions in place prior to discharge. R10 required 24/7 supervision due to her mental illness and assistance with Activities of Daily Living (ADL). The administrator was notified of the immediate jeopardy on 11/4/21, at 3:50 p.m. The immediate jeopardy was removed on 11/5/21, at 3:45 p.m. but noncompliance remained at the lower scope and severity level of a D, no actual harm with potential for more than minimal harm. Findings include: R10's 10/17/21, admission Minimum Data Set (MDS) identified she was admitted to the facility from a local hospital with diagnoses of [CONDITION(S)] disorder of the [CONDITION(S)] type (mental illness causing hallucinations and delusions), anxiety disorder, depression, high blood pressure, [CONDITION(S)], and [CONDITION(S)]. R10 was cognitively intact although she was noted to have disorganized thinking and difficulty focusing. R10 required extensive assistance of 1 staff for bed mobility, toileting, and was able to walk, transfer and perform personal hygiene with supervision. R22 required limited assistance of 1 staff for dressing. R10's Care Area Assessment (CAA) identified R10 had a impaired balance during transitions and maintaining a sitting balance. R10 had noted [CONDITION(S)], dementia, behavioral symptoms, falls, and [CONDITION(S)] drug use. R10's 9/30/21 through 10/6/21, local hospital records identified R10's History and Physical (H&P) noted R10 was admitted with paranoia [CONDITION(S)]. She was brought to the hospital via ambulance (EMS) from home for potential decompensated [CONDITION(S)] and increased paranoia. Upon admission she appeared delusional, paranoid, was anxious, restless, and was showing erratic behavior, showed confusion, and had impaired judgement. R10 would give repetitive sentences and questions, hallucinated, was exhibiting name calling and verbal insults. She was diagnosed with paranoia and [CONDITION(S)]. R10 had concerns of someone placed a bomb in her kitchen while her floor was being redone. Her social history identified she lived at home alone and required a 4 wheeled walker for mobility. She required standby assist of 1 staff. A psychologolical (psych) consult identified her liver function testing was high, although it was unclear if she had been drinking lately. The psychiatric consultant prescribed [MEDICATION(S)] (benzodiazepine) for potential alcohol withdrawal and [CONDITION(S)] activity. R10 was previously hospitalized from 8/8/21 to 8/30/21, for management of seizures, auditory hallucinations, and suicidal ideation. Discharge instructions identified physical therapy (PT) recommended 24-hour supervision upon discharge and was a fall risk, required a rolling walker, standby assistance, and required supervision for all mobility. R10's after visit summary discharge instructions identified R10 required skilled care and occupational therapy. R10's 10/22/21, care plan identified she was at risk for elopment related to poor safety awareness evidenced by aimless wandering and disorientation, at times. R10 had a WanderGuard placed on her left lower leg due to an elopment attempt 10/13/21. R10 required assistance with ADLs related to weakness. She required stand by assist with ambulation and use of her 4 wheeled walker and dressing. She required extensive staff assistance of 1 with bed mobility and transfers. R10 was at risk for falls related to psychoactive medication use, being unsteady and unaware of her safety needs. R10's 10/21/21, Medication Administration Record (MAR) indicated R10 took [MEDICATION(S)] (antidepressant and sedative medication), [MEDICATION(S)] (anti-psychotic), [MEDICATION(S)] (anti-[CONDITION(S)] medication), [MEDICATION(S)] (anti-[CONDITION(S)] medication), [MEDICATION(S)] (anti-[CONDITION(S)] medication), [MEDICATION(S)] (used for Alzheimer's and [CONDITION(S)]), and [MEDICATION(S)] (anti-psychotic). R10's October 2021, Order Summary report indicated R10 had an order for WanderGuard and required a memory care/locked unit. R10's progress notes identified on: 1) 10/10/21 at 4:57 p.m., staff noted R10 arrived at the facility from the local hospital via EMS. She required transfer of 1 assist by staff. Staff documented she had slight forgetfulness. 2) 10/11/21 at 2:18 p.m., the social worker (SW) met with R10 in her room. R10 wanted to transfer to another nursing home. She reported she had called them herself, but they had no openings. She stated before her hospitalization she had a nurse at home who regulated her medication machine. She reported she was in the hospital related to seizures, but documentation showed she had not indicated her mental illness was a factor to the SW. R10 transfers with assist of 1 staff with her walker to the bathroom as needed and used a wheelchair propelled by staff for all other ambulation. R10's FM-A was her immediate contact person for emergencies. 3) 10/14/21 at 10:44 p.m., R10 set off the front door alarm after going outside. R10 was found by nursing sitting in the passenger seat of a car of a delivery person (unknown to R10). R10's WanderGuard alerted staff she left the facility. R10 was confused at times and forgetful. 4) 10/15/21, R10 was moved to another room after her elopment as a safety precaution. FM-A was called and a message left, but no return call from FM-A was received. 5) 10/17/21 at 10:33 a.m., R10 used a phone at the nurse's station to call 911 because she wanted to go home. 6) 10/18/21 at 4:47 p.m., staff documented R10's elopment was reviewed. She had a WanderGuard alarm on and it had sounded, and staff checked the front area of the building. R10 was placed in memory care to prevent further elopements. R10 was noted to have exit seeking behaviors and wanted to return home. 7) 10/21/21 at 12:36 p.m., the SW documented she spoke with FM-A. FM-A wanted R10 discharged as soon as possible. R10 was to discharge the next day. FM-A was to contact R10's independent living skills (ILS) worker and nurse to restart her services. The social worker noted PT and OT was requested by the resident. The SW would ensure this request was on the discharge order for the physician to sign. No further documentation was made identifying the SW was following facility policy by ensuring R10 was appropriate for discharge, where she was discharging to, or if she had the appropriate services and home atmosphere conducive to her safety. 8) 10/22/21 at 1:34, p.m., the discharge summary progress note identified R10 was discharged to home escorted by FM-A. No further documentation was made in R10's progress notes. Interview on 11/2/21 at 2:45 p.m. with R10's mental health care coordinator (MHCC) identified R10 was not a good historian related to her dementia. During a hallucination, she and had once took a hammer to her medication dispensing device. The MHCC stated she had spoken to another family member of R10 (FM-B) prior to R10 being discharged . FM-B was concerned if R10 remined in the facility her trust fund would be eaten up. The MHCC was not made aware of R10's sudden discharge by the facility until after R22 was home. The MHCC was concerned R10 did not have the appropriate supervision needed for someone with memory issues and mental health diagnoses to be discharged to home and required skilled nursing home care. R10's occupational therapy (OT) notes from 10/10/21 to 10/22/21, identified staff had performed a SLUMS test (The Saint Louis University Mental Status Examination: a brief (7 minute) clinician-administered method of screening for Alzheimer's other types of dementia or mild neurocognitive impairment ). R10 scored 12/30, indicating R10 had dementia and recommended R10 have 24-hour supervision upon discharge. R10 was noted to live in an apartment/condo by herself and reported she received help for groceries, managing medication, and scheduling (appointments). R10's bathroom was reported to be equipped with a shower chair and grab bars. OT staff remarked they were unsure of the validity of this [home situation]. FM-A was reported to help as needed. Interview on 11/2/21 at 4:00 p.m., with R10's nurse practitioner (NP)-A identified R10 was admitted to the facility and had attempted elopement from the facility by exiting out the front door and entering the car of male delivery driver's car. R10 had not known this driver. NP-A was concerned as she was not involved with R10's discharge planning process or the interdisciplinary team meetings. NP-A received discharge orders from the social worker who advised her to sign them. NP-A was hesitant as she had not performed an evaluation herself to determine if R10 was appropriate for discharge, but acknowledged she felt pressured by the facility to do so. NP-A stated R10 had known cognitive impairment and with her mental health diagnoses, she required supportive services in place prior to discharge, to include at a minimum home care with 24-hour supervision to reduce the risk of injury and provide appropriate care. NP-A assumed the facility had facilitated the appropriate cares and services be in place prior to R10's discharge and was upset to learn this had not occurred. R10's 10/29/21, PT noted indicated R10's end of care was 10/22/21. PT discharge plans and instruction included R10 return home with home health nursing services and a home exercise program. Interview on 11/3/21 at 9:56 a.m. with the medical director (MD) identified the facility needed to follow the discharge planning process, policy, and procedure and ensure all cares and services were in place prior to discharging a resident to ensure their safety and ability to live alone. Interview on 11/3/21, at 9:57 a.m. the social worker (SW)-A identified R10's daughter initiated a quick discharge. SW-A indicated R10 did attempted to elope while residing in the facility with an unknown male whom she did not know. SW-A agreed R10 required 24-hour supervision and required placement in memory care with a WanderGuard. SW-A did not contact any outside home care agencies, case managers, care coordinator, primary physician, or ILS workers upon R10's discharge. SW-A took FM-A's word she would take care of R10 discharge needs. SW-A agreed there was no discharge planning done at IDT. SW-A agreed it was the facilities responsibility to ensure cares and services were in place prior to discharge. Follow up interview on 11/4/21 at 9:25 a.m. with SW-A stated her only conversation with FM-A was when FM-A became upset R10 was moved down to memory care unit. SW-A stated did not feel the facility was a right fit for R10 who required more assistance with her memory issues and mental health. R10 had a hard time following conversations and would go on tangents. SW-A did not contact any outside home care agencies, case managers, care coordinator, primary physician, or independent living skills (ILS) workers because FM-A stated she would take care of it. She stated now realized that should have had a red flag as R10 had chronic mental health illness and dementia and should have ensure needed services were in place. SW-A was unsure why the recommendations from OT and PT were not ordered. SW-A stated if she would have done a little more research and contacted the other services, she would have had a clear picture of R10's actual needs. SW-A stated she would have filed a Vulnerable Adult report if had known FM-A was not with living with or providing supervision to R10, 24 hours per day. SW agreed she failed to ensure safe and appropriate discharge occurred. Interview on 11/3/21 at 11:23, with R10's ILS supervisor stated R10 had an ILS worker who only came to her home twice a week for 2 hours at a time. R10 had a mental health case manager but that staff only provided services via phone. The ILS supervisor stated she did not feel R10 was safe to be home alone and required advanced care such as a nursing home with 24-hour supervision. The ILS supervisor further stated the previous home care agency nurse refused services to R10 because the agency felt R10 was a liability as they determined she was not safe at home. Later interview on 11/4/21 at 9:07 a.m., the ILS supervisor stated neither the ILS worker (ILS-A) or herself filed a vulnerable adult report because the previous home care nursing agency filed 3 prior to her hospitalization and was awaiting determinations from those reports. Interview on 11/3/21 at 1:45 p.m., with physical therapist assistant (PTA)-A identified therapy recommended have 24-hour supervision based on her cognitive testing with a SLUM score of 12/30 indicating dementia upon discharge. Recommendations for 24-hour supervision was based on the visits therapy had with R10 while in the facility as they questioned her safety to be able to be at home alone. Interview on 11/3/21 at 2:00 p.m., with ILS-A identified R10 required additional support with garbage, laundry, supervision .Maybe a companion-type person. R10 does not have a nurse or other therapies provided in her home at the present time. ILS-A felt R10 was not safe on her own at this time due to significant memory issues and her history of wandering and decreased physical mobility. Interview on 11/3/21 at 4:00 p.m. with mental health case manager (MHCM)-A identified her visits were over the phone and completed monthly. She reviewed medications and check in on R10's mental health. There was no current mental health therapist caring for R10. MHCM-A stated R10's mental health has been up and down with 2 recent hospitalization s as R10 had been more manic within the past few months. MHCM-A stated R10 had not seen a psychiatrist since she was hospitalized . During her conversations with R10 she would stop mid-sentence, was confused, and not clear of what happening in the moment. Interview on 11/4/21 at 8:54 a.m., with R10's primary care physician (MD)-B identified he last saw R10 prior to her admission to the facility. Based on R10's medical history, hospitalization , and exit-seeking behavior, in his expert medical opinion, R10 was not safe to be home alone and required 24-hour supervision and care. R10 should not have been discharged to home from the facility. Interview on 11/4/21 at 1:30 p.m., with the Community Access for Disability Inclusion (CADI)-A case manager stated she was not notified of R10's discharge and was not contacted by the facility regarding the discharge prior to it occurring to assist with appropriate arrangements. CADI-A stated she does not feel the resident was currently safe to be home alone. CADI-A stated FM-A was never actively involved in R10's care and does not want to help with medication set up or administration. Interview on 11/5/21 at 1:00 p.m., with the director of nursing (DON) identified R10's discharge was discussed at the interdisciplinary (IDT) meeting on 10/21/21, the day before she was discharged , but information regarding R10's needed care was not brought forth. FM-A pushed facility staff to do a quick discharge. The DON stated FM-A eluded she would plan and organize services for R10. R10 had been transferred to memory care after R10 had eloped out the front door and got in a car of an unknown delivery driver. R10 moderate cognitive impairment and had difficulty holding a conversation. The DON was unaware of recommendations from the OT for R10 to have 24-hour supervision. The DON knew R10 had prior mental health services before her admission, but unsure of what kind of services she required. The DON's expectation was for the R10's physician to be contacted with requests for discharge so the MD could decide what care and services would potentially be needed and if the discharge was appropriate. The DON agreed the facility was responsible to ensure services were in place and policies and procedures followed to ensure the safety and care of a resident. Interview on 11/5/21 at 3:56 p.m., with the administrator identified she felt the facility failed to provide a safe discharge for R10 because the discharge was quick and the team did not pull together and ensure R10 had services in place before discharge. The administrator felt R10 did not have enough documentation of her needs and agreed there was little to no involvement of R10's physician. The administrator stated communication needs to be improved between therapy, nursing, physicians, social services, and the administrator. Discharge planning should begin upon admission. The SW was to coordinate discharge plans. The administrator agreed it would beneficial if therapy and the physician were included in the IDT meetings. Review of the August 2019, Discharge Policies and Procedures identified it was the responsibility of the SW to coordinate discharge planning and to coordinate community services necessary for a residents upon discharge. The IJ which began on 11/4/21 was removed on 11/5/21, at 3:45 p.m. when it could be verified through interview and document review, the facility reviewed and revised policies and procedures, reviewed other resident's medical records for accuracy, and educated staff to those changes.

Based on observation, interview, and document review, the facility failed to provide adequate supervision and interventions to ensure safe smoking practices for 1 of 8 residents (R74) who currently smoked in the facility, and for the safe consumption of hot beverages for 1 of 1 residents (R74) who sustained a burn from handling a hot beverage. The facility's failure to provide supervision and a safe environment to prevent potential burns from unsafe smoking practices and hot beverages constituted an immediate jeopardy for R74. In addition to the resident in immediate jeopardy, the facility failed to ensure safety interventions were in place to minimize the risk of a burn injury for 1 of 1 residents (R158) who was observed digging in ashtrays for lit cigarettes, and for 1 of 1 residents (R16) observed whose electrical power strip was being used in an unsafe fashion. The administrator, director of nursing (DON) and chief executive officer (CEO) were notified of the immediate jeopardy for R74 on 4/26/12 at 4:12 p.m.. The immediate jeopardy was removed on 5/01/12 at 1:25 p.m. but non-compliance remained at the scope and severity of no actual harm with the potential for no more than minimal harm at a pattern.. Findings include: R74 was observed with multiple cigarette burn holes on his pants and jacket during a tour of the facility on 4/23/12. The facility did not identify this or other safety concerns related to the resident independently smoking unsupervised. R74 had [DIAGNOSES REDACTED]. The most current minimum data set ((MDS) dated [DATE], indicated R74 had no memory impairments and was cognitively intact. The MDS also indicated R74 needs assist with transfers, dressing, set up assist with eating and that he uses a wheelchair for mobility. The current plan of care updated 2/13/12, indicated R74 was independent with smoking. When interviewed on 4/25/12 at 7:17 a.m., nursing assistant (NA)-F, stated over the past winter she noticed cigarette burn holes on R74's gray tee shirt. NA-F also stated she noticed a cigarette burn hole in his winter jacket. On 4/25/12 at 8:08 a.m.., housekeeper-A stated she noticed cigarette burn holes on R74's pants and but not on his tee-shirts. She indicated she thought the cigarette burns occurred over the recent winter. With R74's permission, housekeeper-A and surveyor observed R74 clothing during this time. R74 had 10 pairs of athletic pants in his closet, some made of partial cotton and others were made of 100% polyester. The following was observed for 7 of 10 pair of pants: 1st pair- Dark blue cotton pants with 2 cigarette burn holes on the right leg approximately 1/4" to 1/2" in size. 2nd pair- Dark blue pants with 2 cigarette burn holes on the right knee. 3rd pair- Pants made of 100% polyester, 5 cigarette burn holes on the upper thigh area. 4th pair- Black pants 100% polyester, cigarette burn hole on the right stomach area of pants. 5th pair- Blue pants, 5 cigarette burn holes on the front and the back of the upper thigh area. 6th pair- Pants with multiple cigarette burn holes on front thigh area. 7th pair- Gray cotton pants with an approximate 1 inch cigarette burn on the right side of his pants in the thigh area. The remaining 3 pairs of pants had no cigarette burn holes. During observation of R74 on 4/25/12 at 8:20 a.m. R74's coat had 3 cigarette burn holes on the right chest area of his coat. R74 stated he would let his cigarette rest on his coat while lit, and stated "I know I shouldn't do that". R74 stated he never burned his skin from smoking and the holes in his clothes were from cigarette ashes that dropped onto his pants. Record review identified a facility form titled "Smoking Evaluation" dated 1/10/12, and updated again on 2/7/12, described R74 as alert and noted the facility smoking policy was reviewed with him. It went on to say R74 "...follows the smoking policy, can safely utilize lighter/matches and lit smoking material, the resident has been offered a smoking apron and refuses". The document noted R74 demonstrates safe smoking practices with other residents. The plan indicated "resident smokes independently, cognition intact (issues with compliance in other areas but has always followed smoking regulation)". On 4/25/12 at 8:54 a.m., licensed practical nurse (LPN)-C was interviewed and stated she completed R74's smoking assessment on 2/7/12, after he moved to the Aspen unit and they offered him a smoking apron, however he refused and they felt he was safe to smoke independently without the use of the apron. LPN-C stated she was not aware of any cigarette burn holes on his clothing and if R74 had cigarette burn holes on his clothes, she would not consider that resident safe to smoke independently. On 4/25/12 at 7:17 a.m., R74 was observed lighting his cigarette on the patio located outside the window of the main dinning room . Both of his hands were shaky while he was lit the cigarette. The meal service assistant-H was present, and stated "he shakes all time". On 4/25/12 at 7:19 a.m., nurse supervisor-A stated she completed a smoking assessment on 1/10/12, and felt he was able to smoke independently. She stated he was on the Evergreen unit when she completed this assessment and she could see him smoke, and felt he was safe. She stated when she conducts the assessment, she looks at the clothing the resident has on at the time, and she was not aware he had any cigarette burn holes on his clothing. On 4/25/12 at 7:21 a.m., R74 was observed outside smoking on the patio with a 1/2 inch long ash at the end of his cigarette. He extended his right arm and flicked the ash onto the patio floor. Licensed practical nurse- K (also the facility wound nurse) was interviewed at this time and verified R74 has not received any cigarette burns on his skin. On 4/25/12 at 7:22 a.m., the director of nursing (DON) was interviewed and stated R74 smoked independently and she was aware of the surveyor findings of cigarette burn holes on his clothes. She stated "we offered him a smoking apron and he refused to wear it." The DON stated she had not discussed the risks and benefits of refusing the apron with R74. On 4/25/12, at 7:24 a.m., R74 stated the facility had offered him an apron about a year and a half ago. He stated he was not informed of the risks and benefits of not wearing one until last night, when a staff person told him he "could burn up" if he did not wear it. On 4/27/12 at 12:00 p.m., NA-H stated R74 "has so many (cigarette burn holes in his clothing) it is difficult to know when he gets new cigarette burn holes". On 4/27/12 at 12:22 p.m., a family member (FM)-A was interviewed via phone and stated he was aware of the number of cigarette burn holes in R74's clothing. FM-A stated he purchased seven new pair of pants in February 2012 (2 months ago), which now have new cigarette burn holes. FM-A stated R74 used to live with a family, and they found cigarette burn holes on his clothing too, at times he would fall asleep while smoking. FM-A verified R74's hands were also shaky when R74 smokes his cigarettes. The facility smoking policy updated 1/2012, was reviewed. The policy noted the following: residents or family members that smoke must provide their own smoking materials, Crest View employees may not give residents smoking materials or buy smoking materials for them, residents may be assisted to designated smoking areas and must dispose of smoking materials appropriately. Residents smoking policy will be reviewed with all new residents upon admission, residents smoking materials may be held by nursing staff and given to residents according to resident compliance and/or resident's ability to smoke appropriately, a smoking apron is available adjacent to the smoking area, a smoking evaluation is completed on admission for those residents who wish to smoke. The evaluation will be reviewed quarterly and as necessary for any changes. Although the facility staff were aware of R74's hand tremors and the multiple burn holes on his clothing from cigarette ashes, they continued to allow R74 to smoke independently without supervision and failed to assess and implement additional interventions to ensure R74 remained safe while smoking. R74 also sustained a burn from hot liquids. The facility failed to assess R74's ability to safely handle hot liquids and to provide supervision and interventions to prevent further burns from hot liquids.. A facility document titled "Resident Skin Changes Report" (incident report) dated 1/5/12, noted R74 had a 8.0 cm X by 2.0 (centimeter) intact blister intact on his left inner thigh. The incident report noted R74 stated he spilled hot cocoa on himself. The interventions included a tegaderm skin protectant was to be used over the burn. The incident report indicated the Interdisciplinary Team (IDT) interventions and notes indicated the injury was "self inflicted". There were no other interventions identified to prevent R74 from additional burns with hot liquids. The current plan of care updated 2/28/12, indicated R74 had a burn to his left inner thigh which healed on 2/28/12. The care plan lacked interventions related to handling hot liquids, even though R74 sustained a burn from spilling hot liquids on himself. Document review of the IDT notes dated 1/6/12 noted "reviewed hot chocolate spill of 1/5/12, resident self inflicted injury". On 4/25/12 at 3:33 p.m., the DON was interviewed and stated they did not put any interventions in place after R74's burn from the hot liquid. She stated he was independent with his food and fluids and did not feel they needed to add any interventions. At 12:41 p.m., Cook-A was interviewed and stated she was not aware that R74 had received a burn from his hot cocoa, and he did not use a cup with a lid to prevent potential burns. She stated there were no residents that have burned themselves, and if a resident needed a lid to contain hot liquids, they had them available. On 4/25/12 at 7:17 a.m., R74 was observed lighting his cigarette on the patio located outside the window of the main dinning room . Both of his hands were shaky while he was lit the cigarette. The meal service assistant-H was present, and stated "he shakes all time". Although the facility staff were aware of R74's hand tremors and that he had received a burn on his skin from a hot beverage, the facility failed to assess R74's ability to safely handle hot beverage or implement any interventions to ensure R74 remained safe while consuming hot beverages. The facility initiated an IJ removal plan which included implementing the use of smoking aprons for residents who smoked and were at risk of dropping cigarettes/ashes, revision of the facility smoking policy, training all staff about new smoking policy, and reassessment of R74's ability to smoke and /handle hot beverages safely and safety interventions implemented for R74. Direct care and licensed nursing staff were interviewed on 4/29/12 at 1:00 p.m., and on 5/01/12 between 11:05 a.m. and 11:36 a.m., and were able to explain their responsibility of the facility smoking policy and the interventions in place for R74. R74 was also provided with a covered lid beverage container to prevent further burns. Audits were being conducted of safety intervention implementation. The immediacy was removed at 5/01/12 at 1:25 p.m., and non-compliance remained at the scope and severity level of no actual harm with a potential for no more than minimal harm at a pattern. R158 had behaviors of digging into used ashtrays for lit cigarette butts and struck out at other residents who were smoking in an attempt to take a cigarette from those residents. R158's behavior placed her at risk of being burned, injuring other residents or being injured by other residents. The facility failed to have interventions, including supervision when out on the smoking patio, in place to prevent potential accident hazards for R158 and other residents. R158's had [DIAGNOSES REDACTED]. R158's quarterly minimum data set ((MDS) dated [DATE] indicated she had moderate cognitive impairment, had no behavioral issues and was independent with most ADL's (activities of daily living). R158 was observed at 1:18 p.m. on 4/29/12 coming out to the facilities outdoor resident smoking patio. As soon as she opened the door leading out onto the outside patio 3 other residents R168, R174 and R44 who were out smoking started to yell at R158. "You get away from here, you get out." "Get out of here." Over and over, R158 did not react to the other residents yelling at her and dug into the used ashtray in an attempt to find a lit cigarette, but no lit cigarettes were found. She then walked over to R168 and tried to grab an unlit cigarette and lighter from R168's hand. R158 did not speak and had a flat facial affect, while she was attempting to get the cigarette from R168 hand. R168 pulled her hand away and yelled at R158 to "get out of here." R158 raised her right hand and swung at R168's face. R168 pulled away without being hit by R168. R158 started aimlessly wandering around the smoking patio. Nursing assistant (NA)-A came out to the patio and stated "good everyone has on their smoking aprons." NA-A was informed by the surveyor that R158 swung at R168 and missed when R158 tried to take her cigarette. NA-A stated she would report the incident to the nurse and escorted R158 back into the building. At 1:29 p.m. R158 again came out to the smoking patio again, and the same 3 residents, R168, R174 and R44, began to yell at R158 telling her to "get out." R158 remained with a flat facial affect and did not speak, she tried to get into an ash can which contained used cigarette that measured 4.5 inches across the top, and 4 inches tall. R158 stuck her entire hand into this ash can and pulled out a lit cigarette and preceded to smoke it. NA-A again came out to the patio and escorted R158 inside when she finished the cigarette. After R158 was escorted into the building by NA-A. R168 stated "Thank you for telling them (R158's name) tried to hit me, she does it all the time, she is always trying to take our cigarettes and if you won't give her one, she will hit you. I didn't think anyone would believe me, but now I have witnesses." R174, R44 and R158 all verified that R158 comes to the smoking area multiple times a day digs into the used ash can for a lit cigarette and also try's to take their cigarettes. R158's "safety risk assessment" dated 9/16/11 indicated "aggressive, physically abusive, agitation, aggression, withdrawn, pacing." There was no plan identified as to how staff should intervene, and to help reduce or eliminate these behaviors displayed by R158. A psychology note for R158 dated 5/23/11 indicated under "risk to others: Moderately capable of physical/emotional aggression," and "anger/irritability: frequent, perhaps even constant," and "further assessment/monitoring warranted." R158's follow up psychology note dated 6/6/11 indicated "She continues to exhibit continuous behaviors, particularly around smoking privileges, verbally demanding, aggressive, heightened by confusion, impaired insight and judgement." A submitted Office of Health Facility Complaints (OHFC) form dated 6/21/11 indicated R158 had called a resident a bastard and slapped him in the face when he wouldn't give R158 a cigarette. The facility investigation report indicated the residents were separated and "encouraged not to redirect other residents or call names." An "interdisciplinary team review" noted "depakote (an antisiezure drug often used for behavior manifestation) increased and labs ordered." A facility incident report dated 6/24/11 indicated R158 had asked for a cigarette from another resident and R158 struck her in the arm. The "interdisciplinary team review" indicated "will continue to look for other placement." A facility resident incident report dated 8/19/11 indicated R158 hit another residents shoulder when she came to get a cigarette. An "interdisciplinary team review" dated 8/23/11 indicated "will continue to redirect as needed." A submitted OHFC form dated 8/19/11 indicated R158 had "punched" another resident in the shoulder twice as he had refused to give R158 a cigarette. A "interdisciplinary team review dated 6/27/12 indicated "encourage to keep her distance." An intervention was listed as "(resident name) was told to stay away...staff continue to observe (name) so she doesn't bother others." Another psychology note for R158 dated 8/29/11 indicted "...ongoing issue related to her tobacco use, she receives 1 cigarette every 2 hours (what she can afford) but spends the rest of the time asking anyone and everyone for a cigarette and also digging old cig butts out of the trash/ash trays." The suggestion was made for a secured unit. The psychologist did not identify any interventions, or recommendations the facility could implement to decrease or eliminate these behaviors from occurring even though the psychologist was aware of these concerns. R158's "behavior/intervention monthly flow records" for January 2012, February 2012 and March 2012 included monitoring for "delusional statements, restlessness, withdrawn from activities, continuous pacing, uncooperative, agitation and insomnia" only. The facility did not address R158 behaviors of digging into the ash cans that contained used cigarette butts trying to find a lit cigarette, attempting to hit and grab other residents cigarettes if she was unable to find any in the used cigarette can. R158's plan of care dated 2/24/12 included "Actual alteration in mood and/or psychosocial well-being r/t (related to): and the following items are checked: "depression, anxiety/panic disorder, adjusting to new environment, dementia with behaviors, OCD (obsessive compulsive disorder), delusions, and flat affect." Approaches included check list items such as "psychology consult if indicated, administer medications as ordered and validate feelings." A hand written notation was added, "allow to independently smoke one cigarette every 2 hours. Nursing staff to distribute cigs. She does go out and smoke cigarette butts of others between her own cigarettes despite continuous redirection." R158's plan of care did not address any safety issues with R158 placing her hand into an ash can to get out used lit cigarettes, nor did it address R158 attempting to obtain cigarettes from others, including striking others, and did not direct staff on how to provide supervision and how to handle these behaviors and safety issues. During interview with the facilities director of nursing (DON) at 2:00 p.m. on 4/29/12, she acknowledged R158's plan of care did not include any interventions to keep R158 safe from being burned by digging into the ash can for lit cigarettes, did not include information on how to prevent R158 from being yelled at by her peers and did not address how staff should handle R158's aggressive behaviors toward her peers. Even though psychology and nursing staff identified R158 looked for extra cigarettes continuously, including digging into ash cans for lit cigarettes, attempting to get them from others, striking others at times, they failed to address this behavior for R158. This placed R158 at risk for burns, being yelled at by her peers, hitting others or being hit due to her behavior. R16 had medical equipment plugged into a power strip creating a potential accident hazard. During observation at 9:42 a.m. on 4/24/12, R16 had a nebulizer machine (a machine that delivers medication by aerosol) plugged into a power strip. The power strip was draped over the top of the dresser, then draped partially over the back of a reclining chair plugged into the wall behind the dresser. During interview with registered nurse (RN)-E at 2:10 p.m. on 4/27/12, she stated she was not aware that medical equipment should not be plugged into power strips. She unplugged the nebulizer and found a wall outlet for it. During interview with the facilities director of nursing (DON) at 12:30 p.m. on 5/1/12, she stated medical equipment should not be plugged into power strips. A policy was requested, but not provided.

Based on observation, interview, record review, and policy review the facility failed to ensure residents were free from abusive behaviors exhibited by 3 of 3 residents (R98, R160, R29) reviewed for abuse. The lack of identification, investigation, resident protection, and immediate reporting constituted an immediate jeopardy situation for R98, R160, and R29. The failure to ensure residents were free from abuse/neglect had the potential to affect 34 residents who resided on the Evergreen unit. The administrator and the Director of Nursing (DON) were notified at 4:12 p.m. on 4/26/12 of the immediate jeopardy. The immediacy was removed at 1:25 p.m. on 5/1/12, and the scope and severity was reduced to no actual harm with a potential for no more than minimal harm at a pattern. Findings Include: R98 displayed aggressive and physically abusive behaviors towards other residents. The facility did not identify and assess these behaviors to determine what interventions could be implemented to protect other vulnerable residents from potential abuse. R98 had [DIAGNOSES REDACTED]. R98's quarterly minimum data set ((MDS) dated [DATE], indicated the resident had moderate cognitive impairment, was independent in walking around the facility, and had a history of [REDACTED]. A review of R98's progress notes indicated the following: 6/29/11- "Complaints today that resident has been being angry and mean towards dinner. Observed resident at dinner telling another resident to "be quiet or else." 8/31/11- "Resident got into fight with another resident during dinner tonight. Resident made a point of staring at the other resident all throughout dinner until the other resident got angry. Neither resident would move when asked." 9/4/11- "Receptionist reported to the nurse supervisor that she saw resident attempting to tip (unknown) residents wheelchair by lifting residents wheelchair. No injuries or fall noted. Reported resident- stated "Nothing happened." 10/14/11- R98 and R160 "were engaged in an unwitnessed physical altercation in which R160 sustained some abrasions on his right cheek. Resident (R160) called police but charges were not filed." 12/17/11- "Staff heard noise and went to the scene. Staff saw resident holding onto the shirt of R29, according to him R29 said that he was going to kick him and that annoyed him. No injury noted." 3/2/12- "Upset at 1700 (5:00 p.m.) over another (unknown) resident cutting up tiny pieces of napkins and wipes onto dining table. Perpetrator was apparently even coughing up napkins and tossing them out everyone's side of the table. Author investigated and found evidence of that. However, at intervention time, R98 apparently stood up and author heard another staff screaming help! Help! Stop! Stop! and R98 was ready to strike (unknown) resident with a rolled up sheet of paper- and possibly more. Author sprang up and restrained R98 from strike and calmly requested him to sit down." 4/20/12- R98 pushed R160 "to ground. landed on right side; resident R98 denied doing this and then walked away." A review of R98 incident reports and investigations of these incidents indicated the following: An incident report dated 5/13/11 indicated R98 collided with R29. They both began swearing at each other. R29 hit R98 on the arm, and R98 swung his walker in mid air at R29, and R98 and R29 were separated. The incident was reported to the state agency. The report sent to the state agency indicated R98 and R29 collided into each other but neither resident made contact with the other. The incident report dated 9/4/11, indicated the receptionist reported to the nurse that she saw R98 attempting to tip R3739's wheelchair by lifting the residents wheelchair. The immediate intervention was to give the resident space and to tell writer if he has any concerns. An attached statement from the receptionist working that evening indicated, "I was working Sunday night at the reception desk and I heard some shouting and swearing between two residents. As I was looking to see what was going on I witnessed R98 was shoving his walker against R3739' wheelchair trying to push him over. I told them to stop it and paged the nurse for assistance and she took over the situation." This was submitted to the state agency and the investigative report indicated the receptionist heard yelling and noted R98 was shaking R3739' wheelchair. The report lacked evidence of interventions put into place at that time. An incident report dated 10/14/11, indicated R98 and R160 had a physical altercation. The receptionist reported that R98 punched R160 on the cheek. R160 called the police but chose not to press charges. The immediate intervention was both residents were separated and staff was advised that both residents are not together in the same area. However, there was no indication on how to keep them apart or how this would be communicated to staff. This report was submitted to the state. The investigative report indicated staff were told to keep the residents apart, however, it was unclear how and when this was communicated to staff. R98 was referred for a psychiatric consult at that time. An incident report dated 12/17/11, indicated R98 was found holding R29's shirt. R29 said he was going to kick him and that annoyed him. The immediate action put into place was staff to make sure both residents were not in close contact. However, there was no indication this was communicated to staff and how they were going to monitor the residents. This incident was not investigated or submitted to the state agency. An incident report dated 4/20/12, indicated a resident to resident altercation between R98 and R160. R98 pushed R160 twice until R160 fell over and landed on his right side. R160 complained of right hip pain and was sent for an X-ray which showed a right femur fracture and was admitted to the hospital. The investigative report indicated R160 had a history of [REDACTED]. The report also stated R98 keeps to himself but has issues when someone else gets into his personal space. Although the facility was aware R98 and R160 had previous physical altercations and R98 "had issues when someone gets into his personal space" there were no interventions implemented to keep R98 and R29 separated. The facility had not identified interventions to reduce R98 explosive behavior if someone was in his personal space. A review of R98's psychology dated reports indicated the following: On 11/21/11, R98 had significant defects in insight and had long standing problems with anger management. The notes also indicated "He has been prone to anger issues much of his life, and seem to regard confrontation and aggression as socially acceptable." His risk to others was moderate and seemed physically capable of harming others when agitated. The treatment plan and recommendations were, "He presents with a longstanding mentality where aggression is a viable option, and he is not one to concede. Thus his potential for further altercation with staff and other residents is significant. His cognitive deficits, impaired judgement, etc only adds to this risk potential..." On 12/5/11, R98 had "ongoing aggressive behavior/ verbalization continue reportedly." Treatment plan was "Will remain available to follow resident to facilitate adjustment process, assist with reducing frequency and intensity of volatile behaviors... staff are advised to follow protocol around provision of care to dementia patients (ex approach from front, use names) state your objective, assess mood, if irritable, re-approach, etc." These recommendations were not added to the plan of care. On 12/19/11, R98 was identified as having "anger management issues." R98 was identified as having medium risk and was "capable of growing verbally and physically aggressive quickly." The treatment plan was "Staff are advised to follow safety protocol closely with (R98) with his risk of verbal and physical aggression (ex- keep a safe distance, reading agitation, approach him from the front, make eye contact, use names, and announce what you are there to do). Keep him at a safe distance from other residents when agitated." The treatment plan was not included on the plan of care. On 1/16/12, R98 had an "irritable presentation" although at this time the psychologist indicated R98 risk was low as R98 "has lessened somewhat in terms of risk towards others." No new recommendations were identified at this time. There were no further psychology notes identified in the record. R98's plan of care dated 2/13/12, indicated the resident had behavioral symptoms of altercations with other residents. The approach's consisted of a checklist including observe for changes in cognitive status, assess for medical reason that may contribute to changes in mentation, inform resident of daily routine, validate feelings of frustration, remind and re-orientate as needed throughout the day, use simple communication, allow for choices throughout the day, encourage fluid intake, and psychology consult. Another focus area of the plan of care included physical aggression with the risk level of altercations with other residents as "low" risk. The approach's included those listed above, as well as 1 to 1's with social worker for support and validation, and remove resident to room or private area for persistent and/ or inappropriate behaviors. Although the facility identified R98 had a history of [REDACTED]. Also, there was no indication the facility was aware of or had implemented the specific behavioral intervention recommendations the psychologist made. These recommendations had not be included on the plan of care. R98 was observed at 6:05 a.m. on 4/25/12 sitting in the main dayroom/chapel area reading a newspaper. There were no staff in the immediate area and staff were unable to visualize R98 sitting against the wall near the front door. When interviewed at 6:10 a.m. on 4/25/12 registered nurse (RN)- D stated R98 gets up very early in the morning around 4:00 a.m., and sits out in the main dayroom/ chapel to read his paper. She stated she was not aware of any resident to resident altercations involving R98 and there were no behaviors they needed to be monitoring for R98. When interviewed at 6:20 a.m. on 4/25/12, licensed practical nurse (LPN)- F stated R98 likes to get up very early in the morning. He knew R98 and R160 had previous incidents, and they just tried to keep them apart. He was unaware of any particular behaviors they were to be monitoring for R98. When interviewed at 6:35 a.m. on 4/25/12, trained medication aide (TMA)-A stated he had never seen R98 "cross" with any other residents, but the staff makes sure "no other residents are in his way." When interviewed at 6:50 p.m. on 4/25/12 LPN-E stated she didn't know anything about R98 having any resident to resident altercations with anyone. She did not know of any behaviors staff needed to monitor for R98. When interviewed at 7:15 a.m. on 4/25/12 NA-E stated she was not aware R98 had any previous behaviors and was never instructed to watch him for any behavior or interaction with other residents. When interviewed at 7:25 a.m. on 4/25/12 LPN-G stated she was not aware of any behavior monitoring the staff needed to do with R98. When interviewed at 7:26 a.m. on 4/25/12 TMA-B stated she had heard in the past that R98 and R160 "don't get along" but was not aware of any special monitoring the staff needed to do. When interviewed at 7:30 a.m. on 4/25/12, LPN-H stated R98 is "pretty quiet" so she was very surprised when she heard about him pushing R160. She was not aware R98 had any behaviors. When interviewed on 4/25/12 at 8:15 a.m., the social service director (SSD) stated she did not know much about R98 as had only been at the facility since 2/13/12. She was not aware R98 had previous altercations with residents and stated the information was not passed on to her when the other social workers left the facility. SSD stated if she had known about R98's previous altercations with other residents she would have ensured interventions were in place to protect R98 and other residents. She stated she had not met with R98 for one on one interventions, but she had met with R160 and he was not a "bully- he's no R98." She stated after the altercation between R98 and R160 on 4/20/12, she called the psychologist to meet with R98. The SSD had not put any new interventions into place for R98 and did not get any recommendations from the psychologist on how to protect other vulnerable adults. The SSD stated she would call the psychologist to get the dictation from that visit and check if he had new recommendations for R98. The facility provided the psychology note which was faxed to the facility on [DATE] at 12:42 p.m. It was dated by the psychologist on 4/23/12, and the treatment plan and recommendations were as follows: "Preventive measures/ safety planning in light of this recent incident should involve staff awareness of risk factors, particularly other parties attempting to engage with (R98) in ways that do not agree with him. That (R98) is often sitting in view of staff, should be something that can be diverted by staff before escalating." When interviewed at 9:55 a.m. on 4/25/12, meal service assistant (MSA)-Z stated R98 and R160 had been angry with each other for "a while." She stated several months ago in the dining room R98 and R160 were hitting each other and were moved to separate tables. She was unsure if this was reported. She stated she was working the day of the 4/20/12 incident and R98 was sitting in the main dayroom and R160 came walking in. When she saw they were both in the same room, she said "Oh boy." She stated R98 gets angry but if you don't say anything to him he is fine. MSA-Z stated she told the receptionist to watch out for "those two" and walked away. "It seemed like there may have been a problem" when she left. When interviewed at 11:15 a.m. on 4/25/12, the director of nursing (DON) stated R98 was pleasant and sits in the main dayroom almost all the time. She stated R98 "needs his space" and will yell if anyone gets into his space. She stated she knew that R98 and R160 had issues with each other in the past. The DON stated staff does keep an eye on R98, however, she did state the main dayroom was not staffed nor was it visible to staff at all angles in order to observe any altercations with other resident. She verified R98's plan of care did not include specific interventions to prevent further resident to resident altercations. When interviewed on 4/25/12 at 2:00 p.m., the administrator stated R98 is mobile and the facility can't "put up walls to keep him out of public places." She stated R98 can be "provoked" by others; otherwise he keeps to himself. R98 had multiple incidents of abusive behavior towards other residents from 6-29-11 through 4/20/12 which included: verbal abuse, threatening to kick a resident, raising his hands to strike at a resident, caused an abrasion on R160 cheek, attempting to tip a resident out of a wheelchair, and pushing a resident down to the ground resulting in a [MEDICAL CONDITION]. The facility lacked interventions to protect other residents from R98's behaviors, or protect R98 from potential retaliation from other residents. R160 was not protected from resident to resident abuse although the facility was aware of a history of altercations between R98 and R160. The facility failed to ensure other residents were protected from R160's behaviors, and ensure R160 was free from resident retaliation related to his behaviors. R160 had [DIAGNOSES REDACTED]. R160 quarterly MDS dated [DATE] identified the resident had moderate cognitive impairment, was independent walking around the facility, and had verbal behaviors towards others such as threatening, screaming, or cursing at others 1-3 days in the prior 7 day assessment period. Review of R160's integrated progress notes identified the following: 10-/4/11, "Residents (R98 and R160) were engaged in an unwitnessed physical altercation in which R160 sustained some abrasions on his right cheek. R160 called police but charges were deferred at this time." 3/9/12, "Resident has been overheard by staff and other residents make inappropriate comments to other residents such as 'maybe you should go get your nipples pierced!" 3/21/12, "Resident in Linden station dining room at 1530 and noted to be yelling at (unknown) resident who is confused and yells out frequently. Resident yelling at resident saying to shut up and being argumentative." 4/20/12, "Resident (R98) pushed (R160) to ground, resident fell on right side, (R160) complained of hip pain." The integrated progress note dated 4/20/12, identified R160's X-ray returned showing a right femur fracture and was admitted into the hospital on 4-20-12. The integrated progress note dated 4/23/12 , identified as a follow up from the incident on 4/20/12, noted "This resident (R160) has had a few other altercations with resident (R98) in the past. This resident has had a habit of seeking out (R98) and repeatedly saying things like "go back to bed...this resident will follow (R98). He has a learning disability and routinely repeats himself when speaking to others." A resident incident report from 10/14/11, noted R160 stated (R98) "struck him on the cheek for no reason. He was by the bird cage and resident (R98) suddenly got up and punched him with a closed fist." The analysis and interventions indicated, "Isolated incidence involving another resident...Both residents were separated and urged to avoid contact. Staff advised to ensure that both residents are not together in the same area." Although the incident report directed staff to assure residents are not in the same area, there was no indication of how this would be communicated to staff and how to assure they are kept separate. The one psychology note provided by the facility dated 10/31/11, noted R160 was referred for a psychological evaluation "out of concern about boundaries and some presentation of irritability with another resident... his only concern was a male resident that got in his business and hit him. Apparently, this is the altercation that people were concerned about. He gave me the name of the resident and said that he has done everything in his power to stay away from him." The recommendations on the psychology note included: "... I suspect his intellectual functioning is rather low and, therefore, abstract concepts may be difficult for him to understand. Keeping things in simple sentences and in a concrete manner is advised... ." R160's plan of care dated 4/3/12, identified the resident with [MEDICAL CONDITION], anxiety, personality disorder, [MEDICAL CONDITION], and had a history of [REDACTED]., and psychology consult if needed. R160's plan of care lacked monitoring R160's behaviors regarding resident to resident altercations, did not include ensuring R160 and R98 were not in the same area, and did not address the psychology recommendations. R160's safety risk assessment dated [DATE], lacked the identification of any other behaviors. Although there was an area on the safety risk assessment to identify behaviors, this area was left blank. When interviewed on 4/25/12 at 6:20 a.m., LPN-F stated R160 and R98 had a previous incident but staff didn't have any particular direction on the residents behaviors, the staff just tried to "keep them apart." When interviewed on 4/25/12 at 6:35 a.m., TMA-A stated he had never seen R160 have any problems with residents. He stated staff had no particular behavior interventions to do with R160. When interviewed on 4/25/12 at 7:25 a.m., LPN-C stated she knew of a "couple times" R160 and R98 had gotten into altercations. She stated she had not heard of anything special they were suppose to monitor for; she just knew R160 and R98 "did not like each other." When interviewed on 4/25/12 at 7:26 a.m., TMA-B stated she knew R98 and R160 did not like each other but didn't know of any monitoring or special instructions staff had regarding R160. When interviewed on 4/25/12 at 8:40 a.m., the social service director (SSD) stated R160 is "a busy body" and can be "annoying to people." She stated R160 was never "malicious, he just gets in people's faces." She stated she was not aware of any previous altercations between R160 and R98 as she just started in February and this information was not passed onto her. SSD stated, "It would have been nice to know; they have a real system problem here." When interviewed on 4/25/12 at 9:55 a.m., with MSA-Z she stated R160 and R98 had a history with each other and did not like each other. She stated she tried to keep them separate in the dining area because they had gotten into a physical alteration in the past. MSA-Z stated she tried to keep an eye on R98 and R160 when they were near each other so there was not an altercation. When interviewed on 4/25/12 at 11:15 a.m., the DON stated R160 had "several" altercations with R98 in the past. She stated R160 will "seek people out" to "get to them" and R160 can be "intrusive." Although the facility was aware R160 had these behaviors, the DON verified none of these were identified on the plan of care or assessed to ensure R160 and other residents safety. R160 was still hospitalized at the time of the exit conference on 5/2/12. R160 had incidents of behaviors towards other residents from 10/4/11 to 4/20/12 which included: intrusiveness, antagonistic behaviors, verbal abuse, repeated physical altercations with R98 and yelling at confused residents. The facility lacked interventions to protect other residents from R160's behaviors, or protect R160 from potential retaliation from other residents. R29 was identified with aggressive behaviors towards others and the facility lacked interventions to protect other residents from the behaviors, or protect the resident from potential retaliation from other residents. R29 had [DIAGNOSES REDACTED]. The annual minimum data set assessment ( (MDS) dated [DATE], noted R29's cognition was intact and he had verbal and physical behaviors towards others that significantly disrupted care or living environment. It noted he was not ambulatory, but used a wheelchair and was independent with locomotion on and off the unit. The care area assessment (CAA) completed on 6/22/11 indicated R29 required redirection and reassurance due to inappropriate behaviors. It noted he had a potential behavioral problem that would be addressed in the plan of care to minimize risks and a referral to the house psychologist was warranted. The CAA identified his behavioral disturbances had a pattern and offensive or defensive in nature. It noted R29 would get upset when he needed to be toileted, or when he wanted to be waited on for meals and medication passes. The CAA noted he liked to follow a routine and became aggressive when a routine was not followed. The quarterly MDS dated [DATE], indicated the resident's cognition was still intact and he continued to demonstrate verbal and physical behaviors towards others such as: hitting, kicking, pushing, grabbing, threatening, screaming and cursing. The MDS also noted he had other behaviors not directed toward others. R29 was independent in his wheelchair on and off of his living unit and did not have any impairment with his range of motion. A copy of the resident's current plan of care was provided by the facility on 4/25/12. The care plan identified R29 had a history of [REDACTED]. The care plan included a goal to "not harm self or others" and offered various interventions such as: encourage to express feelings, refer to psychologist, compliment on good mood and behavior, anticipate needs, and use the "behavioral contract". The care plan lacked information to include his history of aggressive acts towards other residents, addressing the aggression towards only staff. When interviewed on 4/27/12 at 12:00 p.m., licensed practical nurse (LPN) -D and R29's nurse practitioner stated R29 once had a behavioral contract, but neither of them could locate it in the chart or elsewhere. Review of the nursing assistant care sheet dated 4/25/12, noted the resident may be verbally and physically abusive, and directed staff to report all behaviors to the nurse immediately and assist with needs as soon as possible to decrease agitation. The facility incident reports identified the following occurrences: On 5/20/11 at 2:00 p.m., staff observed R29 put his right forearm across R22's neck. The physician and family were notified. An analysis as to the cause of the occurrence was noted by a check mark for "behavior". The review by the interdisciplinary team (IDT) on 5/23/11, noted they encouraged R22 not to make comments to R29 about his behavior. On 12/17/11 at 7:00 p.m., R29 staff heard a noise and observed a R98 holding on to R29's shirt. R98 stated that R29 had threatened to kick him. The physician and family were notified. The section to identify an analysis of the cause was left blank. The IDT reviewed it on 12/19/121, and noted R29's [MEDICAL CONDITION] medications were changed just before the incident, and that both residents blamed each other. On 2/3/12 at 10:35 p.m., R29 wheeled up behind R16 who was sitting in a wheelchair. R29 began to make a high pitched yell and reached out and squeezed R16's right shoulder near the neck. R29 stated "Yeah I touched her, she was in my way". The nurse practitioner and family were notified. The analysis of occurrence was noted by a check marks for "behavior" and "medications". The incident report noted his [MEDICAL CONDITION] medications had recently been decreased. The incident was reviewed by the IDT on 2/6/12, and they noted they would have the nurse practitioner review the decrease in medications. On 3/12/12 at 4:00 p.m., R29 punched R3829 in the back of the head. R29 stated " she did not move out of my way" when asked what happened. The family and nurse practitioner were notified. An analysis as to the cause of the occurrence was noted with a check mark for "behavior". The incident was reviewed by IDT on 3/13/12, and the comments section noted " ask nurse practitioner to check labs". On 3/30/12 at 2:00 p.m., R29 pinched R3913 on his right shoulder. He stated the resident was in his way and he wanted to get through. The nurse practitioner and family were notified. The analysis of the occurrence was identified by a check mark for "behavior". The IDT reviewed the incident on 4/2/12, and noted the nurse practitioner would be updated for suggestions. In addition to the incident reports, the following incidents were noted in the facility Integrated Progress Notes (IPN): On 9/7/11- R29 was verbally aggressive and yelling at his roommate to get out of his room. On 2/23/12, R29 was passing out clothing protectors. He was observed with a raised hand going towards R3913. R29 stated R3913 "did not seem appreciative". The facility pastor intervened and there was no physical contact. When reviewed, the psychology progress notes (PPN) indicated the resident had been receiving services since at least 4/18/11. The notes included the following information: 5/16/12- Altercation with another resident a few days ago. Recommendation: position him facing away from a crowd of people, and place in a position that allows easy access to leave and go back to his room. 6/13/11- Recurrent altercation with a female resident. Verbally aggressive towards staff. Reward appropriate behaviors and choices. 7/25/11- Episodes of screaming or calling have reduced in intensity and frequency. Highly impulsive and lacks insight into his impulsivity. Try again to get a behavior program going. The PPN's dated 8/22/11,10/3/11,11/28/12, 12/12/11 and 2/6/12 identified R29 seemed to be doing better because of living on another unit and staff were anticipating and meeting his needs. The PPN dated 3/19/12 indicated R29's obsessive thinking continued, but lacked notation of the resident's aggressions on 2/3/12 when he squeezed a resident's shoulder/neck area, and on 3/12/12 when he punched a resident in the back of the head. The Care Conference Summary note for the time period of 1/3/12 to 4/24/12 lacked any mention of the resident's aggressive behaviors during that time period. The note indicated R29 attended the conference, and the staff talked to him about not making threats to the staff while he waited for their help. The note did not indicate there had been any discussion about his aggression to fell ow residents, and the development of a plan to discourage the behaviors that may put others at risk. When interviewed on 4/26/12 at 11:50 p.m., Resident 116, whom the facility identified as cognitively intact, stated a few weeks ago she witnessed R29 being attacked by R98. She stated R98 was in the face of R29 and had a hold of his arm, and the staff had to break it up. When interviewed on 4/29/12 at 1:24 p.m., RN-E stated R29 had a history of [REDACTED]. R29 was observed lying in his bed watching television. When interviewed, he stated he was feeling find and relaxing. On 4/27/12 at 9:23 a.m., trained medication aide (TMA)-A was interviewed and stated R29 had been aggressive in the past toward other residents, but had not been recently. He stated he had a definite routine, and would become disturbed if he could not follow it. On 4/27/12 at 11:55 a.m., R29 was observed lying on his bed and watching television. At 12:00 p.m., R29's nurse practitioner stated the R29's problem was impulse control, not psychoses. She stated he had been aggressive in the past, less so recently. She had been adjusting his medications to decrease his behaviors and he was much better. On 4/30 at 2:30 p.m., R29 was observed seated at a table with 4 other residents playing card bingo. He waved at the surveyor. At 5:45 p.m., R29 was observed seated outside of R157's room, calmly visiting with her. When interviewed on 5/1/12 at 9:39 a.m., the facility social worker stated R29 was on the psychology case load. She verified that his existing care plan did not contain the warning signs to look for and interventions to implement for his aggressive behaviors towards other residents. She stated R29 was impulsive, impatient, and was cognitively intact. When interviewed on 5/1/12 at 8:15 a.m., the director of nursing stated the R29 had been far more aggressive in the past, but most recently he was better. She stated he did have some incidents of aggression towards others in the prior month, and verified there were several residents in the facility that could not defend themselves if R29 became aggressive. She verified that the care plan lacked specific information about his aggression such as his triggers and his warning signs. She stated R29 had a history of [REDACTED]. R29 had multiple incidents of abusive behavior towards other residents from 5-20-11 through 3-30-12 which included: of verbal abuse, having his arm across R22's neck, threatening behavior, pinching, and "punching" R3829 in the head. The facility lacked interventions to protect other residents from these behaviors, or protect R29 from potential retaliation from other residents. The facility initiated an IJ removal plan which included a comprehensive assessment of all three residents (R98, R160, R29) and their behaviors, updating individual care plans to include specific interventions, trained staff on the recognition of re