Every finding on record at Eagle Ridge Post Acute

Based on observations, record review and interviews, the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions in the main kitchen.Specifically, the facility failed to ensure staff followed appropriate hand hygiene practices during the meal service.Findings include:I. Professional referenceAccording to the Colorado Retail Food Regulations (3/16/24), retrieved on 6/23/26, Food employees shall clean their hands and exposed portions of their arms immediately as specified under S 2-301.12 before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (Chapter 2-301.14)II. Facility policy and procedureThe Kitchen Sanitation policy, revised November 2022, was provided by regional clinical resource #1 on 6/16/26 at 12:43 p.m. The food service area is maintained in a clean and sanitary manner. Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. Drying food preparation equipment and utensils with a towel or cloth may increase risks for cross contamination. The Hand Hygiene policy, dated 2025, provided by regional clinical resource #1 on 6/16/26 at 12:43 p.m. The policy read in pertinent part, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.According to the policy, hand hygiene should be conducted before and after eating and between resident contacts. III. Observations 1. Kitchen meal serviceDuring a continuous observation of the lunch meal service in the kitchen on 6/15/26, beginning at 11:16 p.m. and ending at 12:34 p.m., the following was observed:At 11:30 a.m. cook #1 began plating residents' meals and placing the plates on the meal trays. At 11:35 a.m. certified nurse aide (CNA) #8 touched her glasses on her face and then continued to place the wipe packets and tickets on the trays that were sent out with the resident meals.-CNA #8 did not wash her hands after touching her glasses. At 11:48 a.m. cook #1 touched the side of her right cheek with her right hand and continued to plate resident meals. -Cook #1 did not wash her hands after touching her face.At 11:53 a.m. the interim dietary supervisor placed a glove on her right hand. She retrieved a large container of cheese from the walk-in refrigerator, touching the door handle with her gloved hand. She used the same gloved hand to scoop the shredded cheese into a sample place cup. She placed a lid over the cup of cheese and set the cup on a resident's meal tray. The interim dietary director returned the large container of cheese to the refrigerator, removed the glove and washed her hands. -The interim dietary supervisor did not perform hand hygiene prior to donning the glove. She did not change gloves and perform hand hygiene after touching the refrigerator handle and before preparing the cup of shredded cheese.At 12:16 p.m. the interim dietary supervisor dropped a resident's diet ticket on the floor. The interim dietary supervisor picked up the ticket from the floor and placed the diet ticket on the counter with the other tickets and washed her hands. At 12:18 p.m. CNA #8 rolled residents' utensils in napkins on top of diet tickets set on the counter. The diet tickets and the rolled napkins were placed on resident meal trays and placed in the meal cart. 2. Resident rooms and dining rooms deliveryDuring a continuous observation of lunch on 6/10/26, beginning at 12:05 p.m. and ending at 12:35 p.m., following was observed:The resident meal cart arrived in the east hall. A sign on the cart reminded staff to offer all residents hand hygiene when delivering trays. Five residents were served their meals in the small east dining room. The residents were not served hand hygiene before their meals. At 12:05 p.m. approximately eight room trays were delivered on the east hallway by three different staff members. A hand sanitizer packet or wipes were on each of the trays. The food plates were delivered to the residents room and trays were stacked on a cart in the hallway. The hand sanitizer packets or wipes left were unopened and thrown away. During a continuous observation of lunch on 6/15/26, beginning at 11:58 p.m. and ending at 12:43 p.m., hand hygiene was inconsistent.Room trays were delivered on the east hallway by four different staff members. A hand sanitizer packet or wipes were on each of the trays. The food plates were delivered to the residents room, the trays were stacked on a cart in the hallway. The hand sanitizer packets or wipes left were unopened and thrown away. Another staff member offered the hand sanitizer packet to four residents in the dining room on the east hallway. The residents used them to complete hand hygiene.-However, the facility failed to offer and encourage the hand hygiene to residents in their room during meal time.At 12:36 p.m. the meal cart was delivered to the west hall. At 12:37 p.m. CNA #6 opened the door of the cart and pulled a tray out for a resident in the small dining room in the west hall. CNA #6 did not perform hand hygiene before retrieving and setting up the resident's meal. At 12:40 p.m. CNA #6 removed a room tray from the cart and delivered the tray to room [ROOM NUMBER]. CNA #6 exited the resident's room. CNA #6 did not perform hand hygiene before or after delivering the room tray. At 12:40 p.m CNA #7 retrieved a meal from the cart and delivered it to room [ROOM NUMBER]. CNA #7 did not perform hand hygiene before or after the room tray was delivered to the resident. At 12:43 p.m. a staff member enters room [ROOM NUMBER]. The unidentified staff member did not use hand hygiene before collecting and serving the room tray to the resident. During a continuous observation of breakfast on 6/16/26, beginning at 8:45 a.m. and ending at 10:20 a.m., five residents ate in the small dining room in [NAME] hall. The residents were not offered hand hygiene prior to being served their breakfast. Three of the five residents were observed to eat hand held items on a cinnamon roll and/or bacon. V. Staff interviewsDietary aide #1 was interviewed on 6/16/26 at 11:05 a.m. Dietary aide #1 said hand hygiene should be conducted when changing tasks, when entering the kitchen, after touching any handles or anything other items away from the stream table or steam line. She said staff must wash their hands before returning to the steam table. The interim dietary supervisor said hand hygiene should be conducted before touching food, before and after changing gloves, when returning to the steam line and after touching the face or anything else that was potentially contaminated. She said she noticed CNA #8 touched her glasses and did not wash her hands. She said she reminded her to make sure to frequently perform hand hygiene and anytime she touches anything on her body. The interim dietary supervisor said she told the dietary staff not to use gloves plating food. She said she rather have them use tongs to avoid the risk of not properly using gloves with food. She said she should not have picked up the diet cards from the floor and placed them on the counter and the meals because the tickets on the floor contaminated the other clean surfaces they touched. The interim dietary supervisor said staff should sanitize their hands before they retrieve each meal tray. She said residents should have their hands cleaned before meals. She said the dietary staff placed a hand wipe on each tray to make sure residents performed hand hygiene before they ate. She said staff should have been providing the hand wipes to each of the residents. Regional clinical resource #1 was interviewed on 6/16/26 at 11:50 a.m. Regional clinical resource #1 said the staff should have encouraged and assisted residents with their hand hygiene by opening up each of the hand wipe packets and offering them to each resident. Regional clinical resource #1 staff should perform hand hygiene between passing resident meal trays or touching anything that could cause potential cross-contamination.CNA #5 was interviewed on 6/16/26 at 3:17 p.m. CNA #5 said it was important for staff to provide hand hygiene before residents eat, especially for residents who used their hands or for finger related foods. He said hand wipes were provided on the trays and staff would help the residents use them. CNA #5 said staff should perform hand hygiene after they pass each tray to a resident's room.

Based on record review and interviews, the facility failed to ensure prompt action was taken upon the filing of grievances of a group. Specifically, the facility failed to ensure resident complaints regarding call light times were acted upon timely.Findings include:I. Facility policy and procedureThe Grievances/Complaints, Filing policy, revised April 2017, was provided by regional clinical resource #1 on 6/16/26 at 4:21 p.m. It read in pertinent part, Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. II. Resident interviews Resident #60's representative was interviewed on 6/10/26 at 10:49 a.m. Resident #60's representative said she had multiple concerns while Resident #60 was staying at the facility; including an incident on 5/9/26 when Resident #60 waited 52 minutes for assistance. Resident #60's representative said there was another time Resident #60 waited for assistance with incontinence care for approximately 45 minutes. Resident #60's representative reported she attempted to discuss multiple concerns in person during a care conference with the nursing home administrator (NHA). Resident #60's representative said she thought her, the facility, the hospice were on the same page, but the issues did not improve after the care conference. Resident #60's representative said she attempted to report her concerns again on 5/19/26, but the NHA never met with her. Resident #60's representative felt the NHA was unprofessional when attempting to discuss her concerns.-A request was made for Resident #60's grievance forms. However, the NHA said they did not have any documented grievance forms.Resident #3 was interviewed on 6/10/26 at 11:26 a.m. She said she had to wait for at least two hours for care at night a few months ago. Resident #55 was interviewed on 6/11/26 at 11:34 a.m. Resident #55 said he frequently had to wait over an hour for assistance between the hours of 6:00 p.m. and 11:00 p.m. He said he usually tried to ask for assistance before 6:00 p.m., so he did not have to wait too long. He said he was concerned that if he had an emergency with low blood sugar, they would not come to help him in time. He said that had not happened to him yet but just in case, he kept a banana and orange juice near him at bedside.Resident #27 was interviewed on 6/16/26 at 3:09 p.m She said during the monthly resident council meetings, the residents voiced their concerns. She said call light times were frequently over 30 minutes. She said there had been multiple times where she had to wait an extended period before anyone came to help. Resident #27 said the call light wait times had gotten better in the last six weeks, but could improve more. She said it would help if certified nursing aides (CNA)'s communicated with the residents when they were waiting for their call lights to be answered. II. Resident group meetingThe resident group interview was conducted with four residents (#18, #26, #35 and #63) who were identified as alert and oriented per facility and assessment on 6/15/26 at 9:30 a.m. Resident #18 said he attended the resident council meeting regularly. He said the resident council and the facility had a standing agenda to address call light times even if it was not an issue at that time. He said the residents had an ongoing concern with the call lights for approximately six months. He said the facility always asked about call light times to address issues that might have come up. Resident #18 said there had been turnover within the nursing staff. He said he felt the facility was short staffed at night. He said the facility was struggling getting certified nursing aides (CNA) hired. III. Resident council minutesThe resident council meeting minutes, dated 4/6/26 at 2:00 p.m. documented a concern about night shift call light wait times. The meeting minutes documented the facility implemented night shift scheduling changes were underway to help stabilize staffing and better support resident care needs. Call light audits remain ongoing, and staff education continues to ensure resident needs were being met.-However, the resident's continued to voice concern with long call light times (see resident interviews above). IV. Grievance formsA grievance form related to long call light wait times completed by Resident #3, dated 4/6/26, was provided by the NHA on 6/10/26 at 11:32 a.m. The grievance form documented Resident #3 reported waiting approximately two hours for assistance before bed on 3/28/26 and 3/29/26. The grievance was signed by Resident #3 as resolved on 4/17/26.-The grievance was not resolved for 11 days after the grievance was first filed.A grievance form related to long call light wait times for Resident #27, dated 4/6/26, was provided by NHA on 6/10/26 at 11:32 a.m. The form documented the resident had to wait an hour for her call light to be answered on 3/4/26 The form documented on 4/24/26, both certified nurses aides (CNA) that worked that shift no longer work for the facility and ongoing education was provided to staff regarding call light wait times. -However, the facility failed to address the resident's call light concern for over 18 days.V. Call light timesAn audit of call light response times throughout the facility from 6/1/26 through 6/15/26 was provided by regional clinical resource #1 on 6/15/26 at 3:33 p.m. Review of the call light response log from 6/1/26 through 6/15/26 revealed the following call light response times:The call light was activated and not answered for 15 to 20 minutes, 109 timesThe call light was activated and not answered for 20 to 30 minutes, 93 times.The call light was activated and not answered for 30 to 40 minutes, 35 times.The call light was activated and not answered for 40 to 50 minutes, 15 times.The call light was activated and not answered for 50 minutes, or longer six times.VI. Staff interviewsCNA #8 was interviewed on 6/16/26 at 12:41 p.m. CNA #8 said she had worked at the facility for two years. CNA #8 said she heard residents complain about long call light wait times earlier in the year, but she heard less complaints over the last month or two. CNA #8 said long waits would happen sporadically when staff was busy, but the facility had increased the number of full time CNAs, and it seemed to help. CNA #8 said if she heard a resident complaint and the resident wanted to complete a grievance, she would contact the social services director (SSD) to complete the grievance form with the resident. CNA #8 said she would also tell the NHA of potential grievances. CNA #8 said she remembered education during a staff meeting regarding the goal of a seven minute average response time for call lights. CNA #8 said answering the call light in a timely fashion helped prevent accidents, recognize emergencies and was good customer service. Registered nurse (RN) #3 was interviewed on 6/16/26 at 12:52 p.m. RN #3 said sometimes residents' lights will be on for long periods of time because one resident will need the help of multiple staff. RN #3 said sometimes a CNA will let her know about a resident complaining of a long call light wait time, or a resident will tell her directly. RN #3 said she will first speak with the resident and try to resolve the concern immediately. RN #3 said if that was not possible, she would assist the resident with completing a grievance form and provide it to the SSD. RN #3 said the facility had recently hired more CNAs, and doing so helped with call light response times. The SSD was interviewed on 6/16/26 at 3:50 p.m. The SSD said she kept track of all grievances filed by residents in the facility. The SSD said she would help resolve most of the grievances, but the grievances related to call light wait times were completed by the NHA, since she was able to review the call light response time log, and the SSD did not. The SSD said she remembered completing the initial part of each grievance for Resident #3 and Resident #27. The SSD said she completed Resident #3's grievance in her room and Resident #27's grievance after Resident #27 mentioned her concern during the April 2026 resident council meeting. The SSD said once she finished writing down the initial complaint, she gave the grievances to the NHA for her to review. The SSD said she thought the NHA reviewed the call light logs and followed up with the residents in a timely manner, but the only date she could confirm when the grievance was reviewed with the resident was next to the signatures on the form. The SSD said she would have wanted more information included with the grievance investigation. The SSD said the investigation portion of the grievance should have included the results of the call light response time review to confirm the complaint. The SSD said the education provided in the following staff meeting was included with the grievance, but the information with the grievance did not show who received the education.The NHA and regional clinical resource #1 were interviewed together on 6/16/26 at 4:18 p.m. The NHA said the facility recently completed their own internal review this spring. The NHA said they identified problems with the process of resolving grievances in a complete and timely manner. Regional clinical resource #1 said the facility policy was to have a grievance from a resident resolved within five days. The NHA said she remember when she received the grievances from the SSD, she spoke with Resident #3 and with Resident #27 shortly after, but she did not remember the day and it was not documented in the grievance investigation. The NHA said call light response times were previously an issue at the facility for 6 months, and it was something they discussed during every resident council. The NHA said they did not change the number of staff assigned to each unit, but part of the improvement in call light response times had been hiring more full time staff and letting go of agency staff. The NHA said she did not remember when she reviewed the call light response times in relation to the grievances filed by Resident #3 and Resident #27, but she reviewed them monthly on average.The NHA said she became concerned with a long call light wait time when the response time was longer than 20 minutes. The NHA said when she reviewed them, she noticed increased call light wait times during shift change and in the evening. The NHA said the call light response time did not necessarily mean the resident did not receive assistance until the time the light was turned off. The NHA said staff were trained to leave the light on if they need additional assistance. The NHA said the education provided related to the grievances included education to answer all call lights within 10 minutes, with an average response less than seven minutes.

Based on observations and interviews, the facility failed to provide a safe, sanitary and comfortable homelike environment for 11 out of 68 rooms.Specifically, the facility failed to ensure resident room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] were clean and in good repair.Findings include:I. Facility policy and procedureThe Safe and Homelike Environment policy, revised February 2021, was provided by regional clinical resource #1 on 6/16/26 at 12:40 p.m. It read in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. II. ObservationsObservations on 6/10/26 at 9:45 a.m. revealed resident room [ROOM NUMBER] had sticky floors. -On 6/16/26 at 8:30 a.m. resident room [ROOM NUMBER]'s floor was sticky. On 6/11/26, observations were completed from 2:50 p.m. to 3:06 p.m. throughout the facility, and the following was observed:The vertical blinds in the window in resident room [ROOM NUMBER] were pulled shut and were missing a slat. The window faced the street and did not allow for privacy when pulled closed. The vertical blinds in the window in resident room [ROOM NUMBER] were pulled shut and were missing a slat. The window faced the street and did not allow for privacy when pulled closed. The horizontal valance at the top of the window was sagging and was separated from the wall. The floor was dry but was sticky.The vertical blinds in the window in resident room [ROOM NUMBER] were pulled shut and were missing multiple slats. The vertical slats were different lengths and did not extend the full length of the window. The window faced the courtyard and did not provide privacy when they were pulled closed.The vertical blinds in the window in resident room [ROOM NUMBER] were pulled shut and were missing a slat. The window faced the courtyard and did not provide privacy when they were pulled closed.The vertical blinds in the window in resident room [ROOM NUMBER] were pulled shut and were missing a slat. The window faced the courtyard and did not provide privacy when they were pulled closed.The vertical blinds in the window in resident room [ROOM NUMBER] were pulled shut and were missing a slat. The window faced the street and did not provide privacy when they were pulled closed.The vertical blinds in the window in Resident room [ROOM NUMBER] were pulled shut and were missing a slat. The window faced the street and did not provide privacy when they were pulled closed.The vertical blinds in the window in resident room [ROOM NUMBER] were pulled shut and were missing a slat. The window faced the street and did not provide privacy when they were pulled closed.Resident room [ROOM NUMBER] had a horizontal [NAME] at the top of the window that was sagging downward in the middle and in despair.On 6/15/26 at 1:53 p.m. The vertical blinds in the window in resident room [ROOM NUMBER] were pulled shut but were missing three slats. On 6/16/26 at 8:30 a.m. the floor in resident room [ROOM NUMBER] was observed a second time and it was still sticky.III. Resident interview and observationThe resident who resided in room [ROOM NUMBER] was interviewed on 6/16/26 at 3:09 p.m. The resident said the housekeepers had gotten better about cleaning recently, but she bought my own mop to make sure her room was clean to the standard that she wanted it. The resident who resided in room [ROOM NUMBER] was interviewed on 6/15/26 at 1:07 p.m. The resident requested his blinds to be completely closed and said the light coming in was too bright. -However, observations of the vertical blinds in the window were already pulled shut but the blinds were missing a slat, allowing the light to shine into the room. IV. Record review The resident council grievance form, dated 6/1/26, documented the floors in the hallway were not being cleaned, resulting in the resident cleaning the floors. According to the grievance, new staff had been hired and were being trained on proper cleaning which would add more staff to help. The June 2026 resident council minutes documented the floors were sticky and they needed to be cleaned regularly. The resident council grievance form, submitted to the facility on 6/1/26, documented the cleaning supply vendor recalibrated the dispensers after finding that the floor cleaning chemicals were a little high. According to the grievance, the sticky floors had improved but the staff would continue to check the floors over the next few days. V. Staff interviewsThe maintenance director and the housekeeper lead were interviewed on 6/16/26 at 2:55 p.m. The maintenance director said it was a continuous effort to replace the broken slates on the vertical in resident rooms. He said the staff submitted work orders to him. He said he replaced the slates in a resident room at least weekly. He said the slates frequently broke, so they were going to switch to a fabric blind. He said the nursing home administrator (NHA) would be ordering fabric blinds to replace the old vertical blinds. He said the replacement of old blinds with fabric blinds would cut down on his labor and make the residents' rooms more comfortable. He said it was important for residents to have blinds in good repair to provide privacy, a sun filter and a homelike environment. The maintenance director said he provided oversight of the housekeepers, but the housekeeper lead worked with staff on cleanliness. The housekeeping lead said she recently was promoted to the housekeeper lead and was currently taking courses on infection control. She said she instructs the housekeeping staff to focus on cleanliness of all surface areas including high touch surfaces in resident rooms to help maintain residents' health and prevention of potential cross-contamination. She said the floors were cleaned on a regular basis because they could have remnants of urine or feces on them and attach dirt. The maintenance director said sticky floors have been an ongoing concern and could pose a risk to hazards such as falls and slips. He said the facility had identified the sticky floors in the facility prior to the survey. He said the floor cleaning solution was premixed from a disperser. He said the supply vendor recently readjusted the solution levels which has helped improve the sticky floors. He said the staff would continue to monitor floor cleanliness. The housekeeper lead said she would continue to do a walk through in each room to make sure the rooms were cleaned by housekeeping and the floors were not sticky. The NHA and the regional clinical resource #1 were interviewed together on 6/16/26 at 3:40 p.m. The NHA said the facility would be getting new floors by the end of the year, which would help improve the overall condition of the floors. The NHA said she would be ordering the same fabric blinds as in the dining room ,but could not purchase them all at one time because of the cost. She said she would start to order new blinds for the rooms with broken slates and faced the street. The NHA said blinds in good condition maintain the temperature of the room, give options on how much sun and light they want in the room, provide privacy, and help create a homelike environment. The NHA said she would have the maintenance assistant conduct an audit of rooms that need the blinds replaced. Regional clinical resource #1 said the facility would replace the broken blind immediately with temporary blinds until the new blinds were installed.

Based on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible in four of seven storage rooms and the main entrance.Specifically, the facility failed to ensure:-Four of seven storage rooms in the facility, which contained chemicals, were kept locked; and, -Ensure the entry of the facility was maintained in a manner that remained as free of accident hazards as possible.Findings include:I. Facility policy and procedureThe Environmental Services Safety Procedures, undated, was provided by the Regional Director of Clinical Services on 6/16/26 at 1:32 p.m. It read in pertinent part, Staff will ensure equipment ( cords, ladders, or chemicals) is properly stored and not left unattended in areas that are accessible to residents. When not in use, equipment will be stored in a locking closet, cabinet or storage area for safety.II. Unsafe Chemical StorageA. Professional reference The safety data sheet (SDS) for HDQ Neutral, dated 11/16/17, documented in pertinent part, Harmful if swallowed. Harmful if inhaled. May cause severe skin burns and serious eye damage. May cause an allergic skin reaction. If ingested, do not induce vomiting. Immediately call the poison center or physician. The SDS for Square One, dated 9/30/19, documented in pertinent part, Causes severe skin burns and serious eye damage may be corrosive to metals. Do not breathe mist, vapors, or sprays. Wash hands in any exposed skin thoroughly after handling. If in eyes rinse cautiously with water for several minutes immediately call Poison Control Center or physician. Corrosive. Harmful contact may not cause immediate pain. Harmful if absorbed through skin. Keep Out Of Reach of Children.The SDS for Damp Mop, dated 6/1/10, documented in pertinent part, Causes mild eye irritation. May cause skin irritation. May be harmful if swallowed. Avoid contact with eyes, skin or clothing. Do not swallow. If ingested, drink one to two glasses of water to dilute the product.The SDS for Upper Limit, dated 12/23/14, documented in pertinent part, Acute health hazard. May cause skin irritation. May cause eye irritation. May be harmful if swallowed. Inhalation of vapors or mists may cause respiratory irritation. Keep Out Of Reach of Children. Ingestion: rinse mouth. Do not induce vomiting. The SDS for Tough on Grease, dated 7/27/15, documented in pertinent part, Causes skin irritation, causes eye irritation. May be harmful if swallowed. Inhalation of vapors or mists may cause respiratory irritation. Keep Out Of Reach of children.The SDS for Sparchlor, dated 4/5/21, documented in pertinent part, Causes severe skin burns and serious eye damage may be corrosive to metals. Do not breathe mist, vapors, or sprays. Wash hands and any exposed skin thoroughly after handling. If in eyes rinse cautiously with water for several minutes, immediately call the Poison Control Center or physician.The SDS for Oxiver TB, dated 3/14/18, documented in pertinent part, Eyes: rinse with plenty of water. If irritation occurs and persists, get medical attention. Ingestion: rinse mouth with water.The SDS for Diffense, dated 9/6/19, documented in pertinent part, May be harmful if swallowed. May cause skin irritation. Inhalation of vapors or mist may cause respiratory irritation. Keep Out Of Reach of Children. Rinse mouth. Do NOT induce vomiting. The SDS for Clean on the go Biorenewables Glass Cleaner, dated 1/24/23, documented in pertinent part, Hazard statement: causes eye irritation. May be harmful if swallowed. May cause skin irritation. Inhalation of vapors or mist may cause respiratory irritation. Keep out of reach of children. If inhaled, remove the victim to fresh air, and keep at rest in a position comfortable for breathing. Call a poison control physician if you feel unwell. The SDS for Super Sani-cloth, dated 6/3/20, documented in pertinent part, Causes serious eye irritation. May cause drowsiness or dizziness. Flammable liquid and vapor. Avoid breathing dust/fume/gas/mist/vapors/spray. Wash face, hands and any exposed skin thoroughly after handling. If exposed or concerned: Get medical advice/attention. The SDS for clean on the go NABC concentrate, dated 7/31/15, documented in pertinent part, Acute health hazard, causes skin irritation, causes serious eye damage, if in eyes rinse cautiously with water for several minutes, immediately call a poison control center or physician, and if on skin or hair wash with plenty of soap and water. Corrosive, harmful if swallowed, inhalation of vapors or mist may cause respiratory irritation. keep out of reach of children. Eye contact may cause permanent damage.The SDS for BNC-15, dated 9/5/15, documented in pertinent part, Harmful if swallowed. Causes severe skin burns and serious eye damage. Corrosive. Inhalation of vapors or mist may cause respiratory irritation. Keep out of reach of children. Ingestion: Rinse mouth. Do NOT induce vomiting. Never give anything by mouth to an unconscious person. Immediately call a poise center or physician.The SDS for Sani -T-10, dated 6/8/09, documented in pertinent part, Causes irreversible eye damage, and skin burns. Harmful if swallowed or absorbed through the skin. Ingestion: Call a poison control center or doctor immediately for treatment advice. Have the person sip a glass of water if able to swallow. Do not induce vomiting unless told to do so by a poison control center or doctor. III. ObservationsOn 6/10/26 at 9:20 a.m. the clean utility room was unlocked. There was a touch keypad on the door, but it had been disengaged. There were two tubs of Super Sani-Cloth Sanitizing germicidal disposable wipes on the lowest shelf in the room. The label on the containers had a warning that included Caution: Keep Out of Reach of Children and Hazards to humans and domestic animals. Warning: Causes substantial but temporary eye damage. Do not get in your eyes or on clothing. There were no staff present in the hallway or within line of sight of the room.On 6/10/26 at 9:21 a.m. the dirty utility room on the west hall was unlocked. The door was slightly ajar and there was a touch keypad on the door, but it had been disengaged. There were no staff present in the hallway or within line of sight of the room. The room was inspected and the following items were observed:-Four, one quart bottles of Oxivir Tb;-One 32 ounce (oz) bottle of Clean on the Go Glass Cleaner 18; and,-One 32 ounce bottle of Diffense Multipurpose, Broad Spectrum Cleaner Disinfectant with BleachOn 6/10/26 at 9:26 a.m. certified nurse aide (CNA) #3 entered the dirty utility room on the west hall. She did not have to enter a code to open the door. She said in order to get the door to latch closed, it had to be pushed really hard and it was normally ajar. On 6/11/26 at 9:46 a.m. the dirty utility room on the center hall was open and unlocked. The dirty utility room was located between the center hallway nurses' station and the director of the nursing's (DON)office. The following items were found on a rack in the back of the closet:-One gallon bottle of HDQ Neutral;-Two, one gallon bottles of Square One;-Two, one gallon bottles of Damp Mop;-Three, one gallon bottles of Upper Limit;-Two, one gallon bottles of Tough on Grease; and,-One five gallon bucket of Sparchlor.On 6/11/26 at 10:05 a.m. the west hall dirty utility closet, located by the west hall nurses' station and the west hall dining room was unlocked and open. The following items were present:-Three, one liter spray bottles of Oxivir Tb Sanitizer.-One, one liter spray bottle of Diffense; -One, one liter spray bottle of Clean on the Go Biorenewables glass cleaner; and, -Three unlabeled bottles with illegible hand writing.On 6/11/26 at 10:13 a.m. the clean utility room on the west hall located directly across from the dirty utility room was opened and unlocked. The following item was found:-One container of Super Sani-cloth, Germicidal wipes;On 6/11/25 at 10:25 a.m. the east utility closet was observed with the maintenance director . He said he was not aware the door was not locking and would work to get this fixed. The following items were found in the utility room: -One, two liters bottle without a cap of NABC concentrate;-One, two liter bottles without caps of BNC-15;-One, two liter bottle of glass cleaner; and,-One, two liter bottles of Sani -T-10.B. Record reviewThe work orders for the doors were provided on 6/11/26 by the maintenance director at 12:00 p.m. The only order in place for utility rooms in the facility was created on 6/11/26 at 10:10 a.m by the nursing home administrator (NHA) (during the survey). An audit was provided by regional clinical resource #1 on 6/11/26 at 1:15 p.m. It revealed there were 11 residents with a brief interview for mental status (BIMS) of seven or less, which indicated they were severely cognitively impaired and had an identified potential to wander throughout the facility.C. Staff interviews CNA #9 was interviewed on 6/11/26 at 10:07 a.m. CNA #9 CNA #9 said the west dirty utility room was unlocked. She said she typically did not work the west hallway, but the utility room was unlocked and did not latch. CNA #9 said she tried to lock the door herself, but was able to open it without entering the code. CNA #9 said she also worked in the center hallway. She said the utility closet on the center hallway was routinely unlocked. She said the staff were lazy and kept it unlocked for convenience. The maintenance assistant was interviewed on 6/11/26 at 10:13 a.m. The maintenance assistant said the utility closet on the west hallway closed too slowly, which caused it not to latch. He said he received a work order on 6/11/26 (during the survey) to fix this and was working on it at that time.The maintenance director was interviewed on 6/11/26 at 10:15 a.m He said the NHA put in a work order that day to have the doors fixed as it was not latching. He said generally staff were to put in work orders for general maintenance issues using their electronic medical record with the Tels system.The maintenance director said the utility rooms needed to be locked for safety. He said he could only fix the issues if he was notified. He said he was not aware that the utility closet on the west hallway was not locking.The maintenance director said they would work on fixing the doors to make sure staff could not unlock the doors and disengage them for convenience. He said he had fixed the door on the west hall previously and would do this with the other doors. He said he would also have increased reporting and increased checks on the doors himself through the month.CNA #4 was interviewed on 6/11/26 at 10:29 a.m. She said she worked in the east hall full time. She said the door was always ajar and the keypad lock did not latch or lock. She said it had been like that for months and she did not report it to anyone because she did not know it was a problem. III. Outside environment failuresA. ObservationsOn 6/16/26 at 12:50 p.m. the awning covering the doorway leading into the main entrance was rusted through on the bottom of the left post when facing the building. There was a three inch gap between the metal and the ground, with rusted, jagged corners exposed. 6/16/26 at 12:55 p.m. the flashing in the yard in front of the facility that separated the grass and the rock in the landscaping was sticking up approximately one foot in the air and was not secured in the ground. The flashing was made of metal and had sharp edges. The flashing was not level with the rocks or grass and was observed near a resident bench in a common area.B.Staff interviews and observationsA tour of the facility was completed with the maintenance director, the NHA and regional clinical resource #2 on 6/16/26 at 4:00 p.m. The maintenance director said they started getting quotes two months ago for the awning to have the metal post replaced as they recognized this was a safety hazard. The maintenance director said the flashing appeared to have been hit by the lawn [NAME] and the landscaping around the facility was a shared responsibility between the landscaping company and the facility. The maintenance director said he would fix this to prevent falls by residents if they utilized the benches in the front of the facility.

Based on observations and interviews, the facility failed to maintain proper storage of medications for two of three medication storage rooms and two of three medication carts.Specifically, the facility failed to:-Maintain medication storage refrigerator temperatures; and, -Ensure medications were stored and labeled correctly in the medication carts.Findings include:I. Facility policy and procedureThe Storage of Medication Requiring Refrigeration policy, not dated, received from the regional clinical resource #1 on 6/16/26 at 12:43 p.m. It read in pertinent part, It is the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature controls. The facility must provide safe and effective storage of all drugs and biologicals in a locked storage area under proper temperature controls with limited access by authorized personnel consistent with state or federal requirements and professional standards of practice. The facility will ensure that all drugs and biologicals used will be labeled in accordance withprofessional standards, including expiration dates and with appropriate accessory and precautionary instructions. The facility will ensure that all medications and biologicals will be stored at proper temperatures and other appropriate environmental controls according to manufacturer's recommendations to preserve their integrity. Refrigerated refers to temperature maintained between 36 - 46 degrees Fahrenheit (F). In a cool place means refrigerated, unless the medication's label states otherwise. Temperature to be monitored daily to ensure proper temperature control and documented on the temperature log with date, time, and signature of the person performing the check clearly written. A separate temperature log will be kept for each refrigerator, if applicable. Historical temperature logs should be kept in a central location. Staff should observe proper storage and labeling requirements for all medications and vaccines during the performance of their daily tasks and should demonstrate safety in regard to the medication's integrity, such duties should be limited to, report improper refrigerator storage temperatures, below 36 degrees F, or above 46 degrees F. Do not administer medication exposed to the above temperature extremes. Remove any expired medications from active stock and discard medication according to facility policy. Only use medication maintained at proper temperatures for administration.II. Observations and staff interviewsOn 6/11/26 at 11:46 a.m. the 200 hallway medication cart was observed with the RN #2. There were five over the counter nasal spray medications in the drawer. Two of the nasal sprays did not have secured caps to cover them. All five nasal sprays were not stored in their original container. Three of the five nasal sprays had no open date on them. The other two nasal sprays were opened in 2025. In another drawer of the medication cart there was a lispro insulin medication pen that was labeled with the opened date using a black pen. The date was rubbed off and made the date unreadable.In another drawer of the medication cart there was a Lantus insulin pens that was not labeled. -The nasal spray medications and the insulin medication pens were not labeled correctly and the nasal sprays were not stored properly to prevent contamination. RN #2 was interviewed during the observations and she said she did not know the correct way to label the medications. She said she knew who the unreadable insulin pen belonged to because she had worked there and knew. She said insulin pens were delivered to the facility and labeled but when a new pen was needed they took the pen out of the original packaging which was in the medication refrigerator. On 6/11/26 at 4:48 p.m. the 100 hallway medication cart was observed with the RN #3. There were five over the counter nasal spray medications laying in the drawer. One of the five nasal sprays did not have a secured cap. Two of the nasal sprays were discontinued according to RN #3 and she removed them from the cart. Another nasal spray had no label and no date, which was removed by RN #3. In another drawer there were two Lantus medication insulin pens labeled with a black marker with resident names. -RN #3 was interviewed during the observations and said the medications were supposed to labeled with an open date before she placed the medication in the medication cart. On 6/11/26 at 5:02 p.m. the 100 hallway medication storage room was observed with registered nurse (RN) #3. There was a vial of purified protein derivative (PPD) which was a skin test used to screen for tuberculosis (TB) exposure. The PPD vial had 10 doses (one millimeter) ml with a standard dose of 0.1 ml per person to test staff and residents. -The PPD vial had approximately one dose left and was not labeled with an open date. On 6/11/26 at 5:12 p.m. the 200 hallway medication storage room was observed with RN #3. There was a vial of PPD that was not labeled with an open date and there was approximately one dose left in the vial.The June 2026 medication refrigerator temperature log was hung on the outside of the refrigerator 100 hallway medication storage room. It revealed the temperature was to be documented twice daily. Two of the temperature readings read 30 degrees, four of the readings were 32 degrees, three readings were 34 degrees, six readings were 35 degrees and six readings were 36 degrees. The current medication refrigerator temperature reading was 37 degrees. -There was no documentation indicating the temperature was addressed.The June 2026 medication refrigerator temperature log was hung on the outside of the refrigerator in the 200 hallway medication storage room revealed the temperature was to be documented twice daily. Six of the temperature readings were 37 degree F.-There was no documentation indicating the temperature was addressed. III. Record review The April 2026 (4/1/26 to 4/15/26) vaccine storage refrigerator temperature log for the 100 hallway was provided by regional clinical resource #1 on 6/16/26 at 6:18 p.m. It revealed the temperatures was to be documented twice a day. Three of the temperature readings read 34 degrees, one of the temperature readings read 35 degrees and six readings were 36 degrees. Two days out of 15 days were not documented with any temperatures. -There was no documentation indicating the temperature was addressed. The May 2026 (5/16/26 to 5/31/26) vaccine storage temperature log for the 100 hallway was provided by regional clinical resource #1 on 6/16/26 at 6:18 p.m. It revealed the temperature was to be documented twice a day. Three of the temperature readings read 34 degrees, one of the temperature readings read 35 degrees and six readings were 36 degrees. Six days out of 15 days were not documented with any temperatures. -There was no documentation indicating the temperature was addressed. The vaccine storage temperature log for the 100 hallway medication storage room for 4/16/26 to 4/31/26 and 5/1/26 to 5/15/26 were not provided.The May 2026 (5/1/26 to 5/15/26) of the vaccine storage temperature log for the center (200 hallway) medication storage room, was provided by the regional clinical resource #1 on 6/16/26 at 6:18 p.m. It revealed the temperatures were documented eight days out of 15 days and no documentation for the other seven days without temperatures. The vaccine storage temperature log for the 200 hallway medication storage room for 4/1/26 to 4/31/26 and 5/16/26 to 5/31/26 were not provided.IV. Additional staff interviews RN #4 was interviewed on 6/15/26 at 8:19 a.m. She said she did not know specifically what date to use (expired date or open date) for each medication and she thought it was the open date. She said some of the residents' names were hard to read and the label rubbed off over time. Regional clinical resource #1 was interviewed on 6/15/26 at 11:27 a.m. She said the facility started one-on-one education today (6/15/26) with the nurses regarding the temperatures of the medication refrigerators and labeling medications. She said they identified the concerns and started the plan of correction today (6/15/26). She said the medications in the 100 hallway medication refrigerator were thrown away and anew one was reordered by the pharmacy to ensure efficiency. RN #1 was interviewed on 6/16/26 at 9:25 a.m. She said the temperature for the medication refrigerator were checked two times a day. She said if the temperature was out of range the director of nursing was notified. She said the director of nursing was doing some education today on temperature logs. She said the nasal caps were hard to keep on the nozzle but when she noticed one uncapped she threw it away. She labeled the open medication with a black marker and wrote the residents name on the nasal spray. The ADON was interviewed on 6/16/26 at 10:43 a.m. She said the process to store medications was to keep the original container or box with the residents full name and the date the medication was opened. She said the caps for the nasal spray should be secured on the spray nozzle to prevent contamination and she said any medication not labeled correctly should be thrown away. She said the insulin pens were labeled with the resident's name and placed into the medication refrigerator and when used the open date was written on the pen itself with a black marker. She said she knew the temperature log was not completed correctly and the facility was working on getting this fixed. V. Facility follow-upThe NHA provided documentation of an inservice sign in sheet for medication storage and temperatures along with labeling of drugs and biological education on 6/16/26 at 4:29 The education was dated 6/12/26, 6/15/26 and 6/17/26 (during the survey).Regional clinical resource #1 provided the plan of correction (POC) and action plan for medication refrigerator temperatures and medication labeling for review on 6/16/26 at 6:18 p.m

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive and at an appetizing temperature. Specifically, the facility failed to ensure residents were served warm food that was appetizing in taste.Findings include:I. Facility policy and procedure The Food Preparation Guidelines, dated 2026, was provided by regional clinical resource #1 on 6/16/26 at 12:43 p.m. The policy read in part, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include; Providing meals that are varied in color and texture; using spices or herbs to season food in accordance with recipes; serving hot foods/drinks hot and cold foods/drinks cold; addressing resident complaints about foods/drinks;honoring resident preferences, as possible, regarding foods and drinks.II. Resident observations and interviewsResident #47 was interviewed on 6/10/26 at 9:23 a.m. Resident #47 said the food did not taste good and felt the facility should do a better job at preparing the food. Resident #5 was interviewed on 6/10/26 at 9:54 a.m. He said he did not like the food at the facility. He said food was repetitive and it was not served to him hot. He said staff had to reheat his food for almost every meal. Resident #12 was interviewed on 6/10/26 at approximately 10:30 a.m. He said the portions were [NAME] and the quality of the food was poor, especially the meat. Resident #3 was interviewed on 6/10/26 at 11:26 a.m. She said the food tasted bad. She said it was bland in taste and needed more seasoning. On 6/10/25 at 12:13 p.m. Resident #14 ate a portion of his meal and then pushed his plate away from him. He said he was not going to eat the chicken on his plate because it smelled bad. Resident #37 was interviewed on 6/10/26 at 2:15 p.m. She said she frequently complained to staff about the food. She said the food was not seasoned correctly, the potatoes were not very good and the zucchini was never cooked rightResident #39 was interviewed on 6/10/26 at 2:18 p.m. Resident #39 said the food at the facility did not taste good and the quality of meals could be better. He said the food tasted institutional. He said he said the food was terrible and he did not eat the majority of my food this morning (6/10/26). He said he did not like the way the chicken was prepared. He said the food was worse on the weekends so he usually just ordered the soup. Resident #58 was interviewed on 6/10/26 at 3:00 p.m. He said sometimes the food tasted good, sometimes the food was bad. He said the lunch today (6/10/26), was not good. Resident #66 was interviewed on 6/10/26 at 4:04 p.m. Resident #66 said the food at the facility was terrible. She said the kitchen often had new staff and she never knew what the food was going to taste like from meal to meal. She said complaining about the food in the resident council was a waste of time. Resident #12 was interviewed again on 6/11/26 at 2:34 p.m. Resident #12 said he was waiting to have his lunch tray taken out of his room. He said he did not eat his ham because it was served to him cold and it was a 1/2 inch slab of meat. He pointed to the two pieces of ham and picked up one of the ham slices, showing the thickness. Resident #5 was interviewed again on 06/15/2026 at 12:26 PM and said he was waiting for the rest of his food to arrive, he received a baked potato and a bun with stew. He said the stew was not good and he ordered a hamburger. Observations right after the interview revealed he received the hamburger.Resident #3 was interviewed again on 6/15/26 at 12:32 p.m. She said she did not like the lunch meal served to her today. She said it did not look or taste good so she was offered another option. Resident #59 was interviewed on 6/15/26 at 12:40 p.m. He said the stew served to him for lunch today (6/15/26) was terrible and he would not eat it. Resident #29 was interviewed on 6/15/26 at 1:13 p.m. Resident #29 said the food was not good at the facility. He said the food was not served hot and it did not taste or smell good. Resident #56 was observed on 6/16/26 at 9:09 a.m. in the [NAME] dining room. She was served her breakfast, tasted it and said it was cold. At 9:12 a.m., Resident #56 asked a certified nurse aide (CNA) to warm up her meal for her. The CNA placed plated food into the microwave at the resident's request. III. Resident group interviewFour residents (#18, #26, # #35 and 63) who were identified ast interviewable by the facility and assessment were interviewed on 6/15/26 at 9:30 a.m. Resident #63 and Resident #26 had concerns with the facility meals. Resident #63 said that the food was hit or miss. Resident #63 said sometimes the food was great, and sometimes it was not. Resident #26 said he recently requested pizza. Resident #26 it was served to him two hours later and it was burnt. He said the quality of food had gone down in the last couple of years. He said he was a picky eater, but he wished the food was better. He said better food would make his life better. IV. Test trayOn 6/15/26 at 12:45 p.m. the lunch test tray was evaluated by four surveyors immediately after the last room tray was delivered. At 12:46 p.m. the temperature and taste of the tray, consisting of vegetable beef stew, a baked potato and a roll was evaluated by four surveyors. The following was observed:Each of the food items was placed all on one plate and covered. -The internal temperature of the potato registered at 108.5 degrees Fahrenheit (F) and felt lukewarm. -The beef stew tasted bland. It was watery and oily. II. Record reviewThe April 2026, May 2026 and June 2026 resident council minutes and associated grievances were provided by the nursing home administrator (NHA) on 6/10/26 at 11:37 a.m.The April 2026 resident council minutes documented new cooks were recently hired. The April 2026 resident council minutes did not document palatability related concerns however an attached resident council grievance forms, dated 4/6/26, documented the cold food and juice coming from the nurses station were served to residents too warm. The grievance form documented the staff would check the refrigerator temperature over the next few days. A second resident council grievance form, dated 4/6/26, documented the cream of wheat cereal was lumpy and not cooked correctly. According to the grievance form, the NHA spoke to the cook about food consistency and cooking procedures.V. Staff interviewsThe interim dietary supervisor was interviewed on 6/16/26 at 11:10 a.m. She said she was not aware of any reported food concerns. She said she was just helping out for a few days before the new dietary director started. She said the cooks should always taste the food before it was served to the residents to make sure it was palatable. The nursing home administrator (NHA) was interviewed on 6/16/26 at 3:32 p.m. She said the facility was aware of food palatability concerns. She said a new dietary manager was starting on 6/23/26. She said she hoped the new manager would help improve the food palatability concerns.

Based on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on two of three units. Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene when cleaning resident rooms; -Ensure indwelling urinary catheters were not touching the floor; and, -Ensure a resident's recliner was free from bowel and bladder stains. Findings include: I. Hand hygiene failures A. Facility policy and procedure The Hand Hygiene policy, undated, was received from regional clinical resource #1 on 6/16/26 at 12:43 p.m. It read in pertinent part, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. B. Observations On 6/16/26 at 8:48 a.m. housekeeper (HK) #1 was cleaning resident room [ROOM NUMBER]. She donned (put on) gloves and sprayed disinfectant on a cleaned rag. She wiped down high touch areas, the door knobs and the bedside table and the resident's call light. She doffed (took off) the gloves and donned new gloves, without performing hand hygiene. She sprayed the sink and the toilet with a disinfectant solution. She took the toilet brush, dipped the brush in a cleaning solution from a green bucket brought into the room and cleaned the inside of the toilet bowl. She emptied the trash, and used the same gloved hand with a clean dry rag to wipe down the hand rails next to the toilet, bathroom door knobs, the sink and sink handles. She walked out the room, put the green bucket back on the housekeeping cart and threw away the trash. She doffed and donned gloves, without performing hand hygiene and went back into the bathroom with another dry rag and wiped down the outside of the toilet, the rim, the toilet riser and the bottom of the toilet near the floor. She used another rag to clean the mirror. She doffed gloves, swept and mopped the resident's room. -HK #1 failed to perform hand hygiene in between donning and doffing gloves. C. Staff interviews The Housekeeping lead was interviewed on 6/15/25 at 3:12 p.m. The housekeeping lead said hand hygiene was completed after glove use. She was new to the role and would be completing education with the housekeepers for cleaning procedures. The assistant director of nursing (ADON) was interviewed on 6/16/26 at 10:43 a.m. The ADON said she was the infection preventionist at the facility. She said hand hygiene should be performed when changing gloves. She said there was a language barrier with a housekeeper and she would complete some further education with her for infection control purposes for HK #1 D. Facility follow-up The nursing home administrator (NHA) provided documentation of glove use education on 6/16/26 at 4:29 p.m. The education was provided on 6/10/26 and 6/15/26 (during the survey). The education read in pertinent part, Gloves should be removed after resident care and before touching common environmental surfaces. Hand hygiene should be performed after removing gloves. Wear gloves when exposure was anticipated (blood, body fluids, mucous membranes, non-intact skin,and contaminated equipment). Remove gloves promptly after the task and before moving through common areas to prevent cross-contamination. Perform hand hygiene after glove removal. II. Catheter failures A. Facility policy and procedure The Catheter Care policy, revised September 2014, was received from regional clinical resource #1 on 6/16/26 at 12:43 p.m. It read in pertinent part, The purpose of this procedure is to prevent catheter-associated urinary tract infections.Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Use standard precautions when handling or manipulating the drainage system. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. Do not clean the periurethral area with antiseptics to prevent catheter-associated UTIs while the catheter is in place. Routine hygiene (cleansing of the meatal surface during daily bathing or showering) is appropriate. Be sure the catheter tubing and drainage bag are kept off the floor. B. Resident interview Resident #44 was interviewed on 6/11/26 at 11:25 a.m. She said she had a history of urinary tract infections (UTIs). C. Observations and staff interviews On 6/15/26 at 1:53 p.m. Resident #44's indwelling catheter bag was hooked to her walker but the catheter tubing was not clipped to her walker. The catheter tubing was laying on the floor in the resident's room. On 6/15/26 at approximately 6:00 p.m. Resident #44 stood in the hallway with her walker. A portion of her catheter tubing touched the floor. On 6/16/26 at 8:37 a.m. a portion of Resident #44's catheter tubing was touching the floor as she stood in her room doorway. At 11:33 p.m. Resident #44 walked into the dining room using her walker. A portion of the catheter tubing surface dragged across the floor as she walked. On 6/16/26 at 11:35 a.m. certified nurse assistant (CNA) #7 observed Resident #44's catheter tubing touching the floor she stood in the dining room talking to another staff member. CNA #7 said the catheter tubing should not touch the floor because the floor could contaminate the catheter. On 6/16/26 at approximately 12:50 p.m. regional clinical resource #1 observed Resident #44 in the dining room. The resident's catheter tubing continued to touch the floor. Regional clinical resource #1 said the resident tubing should be off the floor surface to decrease the risk of potential contamination. She said would offer catheter clips to raise the tubing so it did not touch the floor. C. Staff interviews Regional clinical resource #1 was interviewed again on 6/16/26 at 1:12 p.m. The regional clinical resource #1 said Resident #44 refused to have clips attached to her catheter. She said the facility was working with the therapy department to add tennis balls at the feet of the walker and raise up the catheter bag on the walker to help prevent the tubing from dragging on the floor. The NHA was interviewed on 6/16/26 at 3:40 p.m. She said Resident #44 sometimes had incontinent episodes that resulted in a mess of her chair but she would not let the staff clean it up when she was in her room. She said Resident #44 consistently left her room for lunch and dinner each day. She said her care plan was updated today (6/16/26) to direct staff to clean up any soiled areas in her room when she was out of her room. She said another reclining chair was on order that was easier to clean. CNA) #1 was interviewed on 6/16/2026 at 9:54 a.m. CNA #1 said Resident #44 indwelling catheter often touched the floor. She said the resident refused to have anyone assist her. She said maybe she needed shorter tubing. She said the nurse assisted with catheter care. D. Facility follow-up The 6/16/26 staff in-service and participation sheet was provided by regional clinical resource #1 on 6/16/26 at 1:35 p.m. The in-service and participation sheet identified a combination of 17 nurses, CNAs and housekeepers, were educated on resident furniture cleaning, use of incontinence barriers and catheter tubing management to prevent infection spread; reduce environmental contamination; and, protect resident dignity. III. Sanitation failures A. Observations and staff interviews On 6/15/26 at 1:53 p.m. revealed Resident #44 stood up from her recliner chair and the chair had dried feces on the seat. RN #1 said she was aware of the chair being soiled, but said the resident refused to have it cleaned. The resident sat back down in the recliner chair after wound care to her bottom was completed. At approximately 11:30 a.m. a dried liquid brown substance was observed covering 30% of the sitting portion of Resident #44's reclining chair. The room had an odor of a bowel movement. RN #1 was interviewed on 6/16/26 at 12:37 p.m. RN #1 said she saw feces on Resident #44's reclining chair during wound care on 6/15/26. She said it was not uncommon for Resident #44 to have an incontinence episode that would result in her chair becoming soiled, but would often not let staff clean it up. She said she told the CNA's about the soiled chair on 6/15/26 but she was not sure what was done about it. On 6/16/26 at approximately 12:45 p.m. Regional clinical resource #1 opened the door to Resident #44's room and said her room smelled bad. She observed the soiled surface of the resident's reclining chair. She said she believed the soiled surface of the chair had dried fecal matter on it from the looks and smell of it. The regional clinical resource #1 said she would have the chair cleaned right away and encourage the resident to sit on an incontinence surface protector (chucks) when she sat in the recliner. She said Resident #44 said the resident often refused staff to clean her room. She said she would provide education to the resident and the staff. She said she would contact the resident's family for suggestions to help maintain cleanliness of the resident's chair and possibly have the chair replaced. Regional clinical resource #1 said the Resident #44's reclining chair was now cleaned but a stain remained on its surface. The regional clinical resource #1 said the chair was quickly cleaned when the resident was out of her room. She said the facility would purchase a reclining chair with a washable surface in hopes for the resident to exchange the old chair with a new clean chair.

Based on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity for two (#19 and #49) of three residents reviewed for respect and dignity out of 45 sample residents. Specifically, the facility failed to ensure Resident #19 and Resident #49 were treated with respect and dignity during meals.Findings include:I. Facility policy and procedureThe Dignity policy, revised February 2021, was provided by regional clinical resource #1 on 6/16/26 at 12:40 p.m. The policy read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. When assisting with care, residents are supported in exercising their rights. For example, residents are: groomed as they wish to be groomed; encouraged to attend the activities of their choice, including religious, political, civic, recreational, or social activities; encouraged to dress in clothing that they prefer; allowed to choose when to sleep, eat and conduct activities of daily living; and, provided with a dignified dining experience.II. ObservationsOn 6/16/26 at 1:00 p.m. Resident #19 and Resident #49 were in the small dining room in the [NAME] hall. Certified nurse aide (CNA) #6 stood on the right side of Resident #19. CNA #6 provided Resident #19 several bites of his food while standing beside Resident #19. Licenced practical nurse (LPN) #1 stood on the left side of Resident #49 provided him with a bite of food while standing next to him. At 1:01 p.m. CNA #7 traded places LPN #1. LPN #1 pulled a dining chair out and placed it on the right side of Resident #49. CNA #8 did not sit down next to Resident #49. CNA #7 continue to stand next to Resident #49 and provide him several more bites of food. During a continuous observation of breakfast on 6/16/26, beginning at 8:45 a.m. and ending at 10:20 a.m., the following was observed:At 9:07 a.m. the meal cart arrived in the small dining room in the west hall. At 9:11 a.m. Resident #19 was served his breakfast.At 9:26 a.m. registered nurse (RN) #3 stood next to Resident #19 as she provided him with two bites of scrambled eggs . At 9:39 a.m. CNA #8 placed a clothing protector on Resident #19. CNA #8 did not ask him if she could put a clothing protector on him or explain what she was doing prior to placing the clothing protector on. At 9:45 a.m. Resident #19 began pulling on his clothing protector attempting to remove it. At 10:03 a.m. Resident #19's cinnamon roll was on the floor and his scrambled eggs were on the floor and the table around him. The resident ate the scrambled eggs off the table with his fingers. There was no staff in the dining room to supervise or assist the resident.At 10:16 a.m. RN #3 offered Resident #19 a drink of his water as she stood over the resident. III. Resident #19A. Resident status Resident #19, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physicians orders (CPO), diagnoses included neurocognitive disorder with Lewy's bodies, dysphagia (swallowing impairment), macular degeneration (vision impairment), dementia and other diseases classified elsewhere, moderate, with anxiety, and Parkinson's diseaseThe 6/3/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a BIMS score of two out of 15. The MDS assessment documented the resident required partial to substantial staff assistance with his activities of daily living (ADLs). According to the assessment, Resident #19 needed supervision or touching assistance with eating. B. Record reviewThe ADL care plan, initiated 3/5/26, documented Resident #19 was at risk for an ADL decline and required staff assistance and anticipation of a cognitive decline due to his disease process and Lewy bodies dementia. According to the care plan, the resident would have his needs anticipated and met by staff. The care plan intervention, initiated 3/5/26, documented the resident could use utensils independently and directed staff to assist in the set up and clean up of his meals. IV. Resident #49A. Resident status Resident #49, age greater than 65, was admitted on [DATE]. According to the June 2026 CPO, diagnoses included unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Alzheimer's disease and generalized muscle weakness. The 3/31/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of one out of 15. The MDS assessment documented the resident required substantial to total dependance on staff assistance with his ADLs. According to the assessment, Resident #49 needed supervision or touching assistance with eating. B. Record reviewThe ADL care plan, initiated 12/21/25, documented Resident #49 had an ADL decline and required staff assistance related to impaired mobility, Alzheimer's disease, dementia and muscle weakness. The care plan intervention, revised 12/23/25, directed staff to provide Resident #49 supervision/touching assist with meals when using utensils. The intervention documented Resident #49 need one-to-one staff presence while Resident #49 ate his meals.V. Staff interviewsCNA #5 was interviewed on 6/16/26 at 3:17 p.m. CNA #5 said he sometimes helped with dinner meals when he worked the night shift. He said Resident #19 needed to set up his meals and supervision. He said Resident #19 would often eat with his fingers unless staff prompted him to use his silverware. CNA #5 said residents; the dining experience should feel like home. He said staff should sit next to the resident like a friend, interacting with them at eye level. He said staff should not stand or hover over the residents. He said staff should sit down next to Resident #19 and other residents when they were assisted by staff at meals. RN #3 was interviewed on 6/16/25 at 3:20 p.m. RN #3 said Resident #19 needed assistance at meals varied and lately, he has needed more help. She said staff would have to place the utensils in his hand for him to eat or sometimes needed staff to provide total assistance by placing the food in his mouth for him. RN #3 said Resident #49 required total assistance at meals. RN #3 said staff should sit down with residents who required assistance. She said standing to feed or help them drink from a cup while standing was a dignity concern. She said the residents could feel like they are being punished and made to eat. She said staff should sit next to the resident at their eye level so they could see who was assisting them and see the utensils/food and drink coming towards them. The NHA and regional clinical resource #1 was interviewed together on 6/16/26 at 5:22 p.m. The NHA said residents should be provided with dignity at all times including at meals. Regional clinical resource #1 said the staff should offer residents choices of food and drink. The NHA said staff should ask the residents for permission to place a clothing protector on the resident. regional clinical resource #1 said staff should sit down next to the resident to provide the resident their meal. She said staff should also offer the resident the opportunity to feed themselves by handing them a utensil and cueing them if the resident had the ability. The NHA said residents eating with their hands non-finger foods and not prompted or assisted to use a utensil, could be a dignity concern but she would need to review the resident's care plan. The NHA said the facility could look into adaptive dining equipment such as built up silverware. The NHA said staff should not stand while providing meal assistance and the staff would receive additional training to address the concerns.

Based on observations, record review and interviews the facility failed to ensure the self-administration of medications was clinically appropriate for one (#5) of one resident reviewed for self-administration of medications out of 45 sample residents. Specifically, the facility failed to ensure an assessment was completed in order to determine if the self-administration of medications was clinically appropriate for Resident #5.Findings include:I. Facility policy and procedure The Self-Administration of Medication policy, revised February 2021, was received from regional clinical resource #1 on [DATE] at 12:43 p.m. The policy read in pertinent part, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation, comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: the medication is appropriate for self-administration. The resident is able to read and understand medication labels. The resident can follow directions and tell time to know when to take the medication. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff. The resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication and the resident is able to safely and securely store the medication. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. The IDT evaluates options which allow residents to safely participate in the medication administration process if they wish to do so. Residents who are identified as being able to self-administer medications are asked whether they wish to do so. For self-administering residents, the nursing staff determines who is responsible (the resident or the nursing staff) for documenting that medications are taken. If the resident is able and willing to take responsibility for documenting self-administration ofmedications, the resident is instructed on how to complete a record indicating the administration of the medication. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. The facility reorders self-administered medications in the same manner as other medications. The nursing staff routinely checks self-administered medications and removes expired, discontinued, or recalled medications. Nursing staff reviews the self-administered medication record for each nursing shift, and transfers pertinent information to the medication administration record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered.II. Resident #5A. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), respiratory failure, asthma and anxiety disorder. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required set up and clean up assistance with activities of daily living (ADL). B. Observations On [DATE] at 9:39 a.m. a container of Flonase medication (an inhalant nasal spray) and a container of nasal spray medication (an inhalant nasal spray) was on the window sill next to Resident #5's bed. On [DATE] at 9:46 a.m. a container of Flonase medication and a container of nasal spray medication was observed on Resident #5's window sill next to the bed. On [DATE] at 8:42 a.m. a container of Flonase medication and a container of nasal spray medication was observed on Resident #5's window sill next to the bed. C. Resident interviewResident #5 was interviewed on [DATE] at 9:39 a.m. Resident #5 said he kept the nasal spray medications at his bedside and used these when needed. He said when he felt anxious he was able to use them throughout the day. He said the doctor told him the medications were fine to leave with him. He said he felt better about taking these medications on his own, because it took too long for the nurse to bring it to him when he needed it. D. Record reviewThe altered respiratory status care plan, revised [DATE], revealed the resident had difficulty breathing related to COPD. Pertinent interventions included administering the medication and puffers as ordered, monitoring the resident for medication effectiveness and side effects, elevating the resident's head of bed slightly to assist with difficulty breathing, monitoring for signs and symptoms of respiratory distress and report to the medical director as needed.-However, the care plan failed to indicate Resident #5 was able to self-administer medication of Flonase and nasal spray. Review of Resident #5's [DATE] CPO revealed the following physician's orders:Flonase allergy relief suspension medication. Two sprays in each nostril every 24 hours as needed for congestion. Unsupervised self- administration and was ok to leave at bedside, ordered on [DATE]Nasal spray nasal solution medication. Two sprays in both nostrils four times a day for allergies, unsupervised self-administration, ordered on [DATE]. -However, review of Resident #5's electronic medical record (EMR) did not reveal an assessment was completed for the self-administration of the Flonase or nasal spray.III. Staff interviews Registered nurse (RN) #1 was interviewed on [DATE] at 9:25 a.m. She said residents should not leave any medications at their bedside. She said if a resident wanted to self administer an inhaler or nasal spray, a physician's order was needed. She said education was completed by the physician prior to the resident being able to self administer medications, so the resident knew how to take the medications safely. She said a consent was supposed to be signed too. Regional clinical resource #2 and the assistant director of nursing (ADON) were interviewed together on [DATE] at 10:43 a.m. Regional clinical resource #2 said medications were allowed in the residents' room. Regional clinical resource #2 said an assessment was completed to ensure the resident was safe to administer medications and a physician's order was obtained to self-administer. Regional clinical resource #2 said they tried to discourage medications at bedside for safety reasons, but some residents were more independent. She said after an assessment was completed a lock box was provided to the resident to store the medications safely. The ADON said there was not an assessment completed for Resident #5, but one would be completed today ([DATE] - during the survey). The ADON said the facility would purchase a lock box to keep the medication at bedside. The ADON and regional clinical resource #2 said they were unsure how often the resident used the Flonase or nasal spray medications, which were currently at Resident #5's bedside. The ADON said they trusted that the resident would take the medications per physician's orders.

Based on observations, record review and interviews, the facility failed to provide written notification of room changes and roommate changes for two (#46 and #76) of two residents reviewed for notifications out of 45 sample residents.Specifically, the facility failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #46 and # 56 and/or the resident's representatives.Findings include:I. Facility policy and procedureThe Change of Room or Roommate policy, undated, was provided by regional clinical resource #1 on 6/16/26 at approximately 12:43 p.m. The policy read in pertinent part, It is the policy of this facility to conduct changes to room and/or roommate assignments when considered necessary and/or when requested by the resident or resident representative. The facility reserves the right to make resident room changes or roommate assignments when found to be necessary by the facility or when requested by the resident. Reasons for a change in room or roommate could include, but are not limited to incompatibility of residents in a shared room, medical conditions which prohibit certain room sharing (infection control for isolation), provision of a more accommodating environment to help the resident reach his/her rehab goals; or a request by the resident. The notice of a change in room or roommate will be provided in writing, in a language and manner the resident and representative understands and will include the reason(s) why the move or change is required.II. Resident #46 A. Resident statusResident #46, age [AGE], was admitted to the facility on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included Alzheimer's disease, unspecified dementia moderate with other behavioral disturbances, depression and diabetes. The 5/10/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. She required supervision or touching assistance for toileting and dressing and partial moderate assistance for showers with activities of daily living (ADL). She had no wandering behaviors. B. Resident #46's representatives interviewResident #46's representative was interviewed on 6/11/26 at 12:25 p.m. She said she was notified by the facility that Resident #46 would be moved to another room. She said this happened a few times because Resident #46 kept going through the roommates' belongings. She said she was not offered a choice where Resident #46 was going to live until this last move to have a private room. She said she was not provided a written copy of the changes. C. Record Review The notice of room change notification form, dated 3/19/25, revealed a verbal okay was obtained from the resident's representatives to move Resident #46's room due roommate incompatibility. The form documented consent was given verbally and was signed by the social services director (SSD).-However, there was no documentation in Resident #46's EMR to indicate the facility provided the resident or the resident's representative with written notification of the room change.The notice of room change notification form, dated 6/4/25, revealed a verbal okay was obtained from the resident's representatives reporting Resident #46 would be getting a roommate on 6/4/26. The form documented consent was given verbally and was signed by the SSD.-However, there was no documentation in Resident #46's EMR to indicate the facility provided the resident or the resident's representative with written notification of the room changeThe notice of room change notification form, dated 6/17/25, revealed a verbal okay was obtained from the resident's representative to move Resident #46 from her room [ROOM NUMBER]B to room [ROOM NUMBER]A for bed management. The form documented consent was given verbally and was signed by the SSD.-However, there was no documentation in Resident #46's EMR to indicate the facility provided the resident or the resident's representative with written notification of the room changeIII. Resident #76 A. Resident statusResident #76, age [AGE], was admitted to the facility on [DATE]. According to the June 2026 CPO, diagnoses included vascular dementia with agitation, generalized anxiety and depression. The 6/16/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. She required supervision with AD.B. Observation and interview On 6/10/26 at 1:00 p.m Resident #76 arrived at the facility as a new admission. She was in a wheelchair and staff oriented her to her room and her roommate. On 6/16/26 at 9:45 a.m. Resident #76 was interviewed and said she moved into a new room when she came back from the hospital. She said she was not sure why they moved her, she said she had a roommate when she first moved here but now she had her own room. C. Record reviewThe notice of room change notification form, dated 6/11/26, revealed a verbal okay was obtained from the resident's representatives to move Resident #76 from her room for bed management. The form documented consent was given verbally and was signed by the SSD.-However, there was no documentation in Resident #76's EMR to indicate the facility provided the resident or the resident's representative with written notification of the room changeIV. Staff interviews Registered nurse (RN) #1 was interviewed on 6/16/26 at 9:25 a.m. She said residents occasionally moved rooms. She said usually it was when residents did not get along and for safety concerns. RN #1 said some of the residents with cognitive impairments went through their roomates belongings. She said Resident #76 was moved over the weekend due to an incident with her roommate. She said the management team was notified and the social service director. She was not sure who decided what room to move the resident to. The SSD and regional clinical resource #2 were interviewed on 6/16/26 at 11:26 a.m. SSD said room moves were discussed in the interdisciplinary disciplinary team (IDT) morning meeting. The SSD said she called the residents representative to notify them of the room change. The SSD said in certain circumstances residents had to be moved right away for safety concerns to avoid resident altercations. The SSD said she notified the representatives as soon as possible. Regional clinical resource #2 said families did get a copy of the room change notification. The SSD said when families did sign the room change notice form, it was uploaded into the residents chart. The SSD said Resident #46 had several room changes and roommates because Resident #46 went through the roommates' personal items and the roommates were upset. The SSD said Resident #46 was moved to a private room. The SSD said Resident #76 moved into a private room because she was upset the roommate went through her things. The nursing home administrator (NHA) was interviewed on 6/16/26 at 2:56 p.m. She said room change notifications were discussed in the IDT meetings. She said the residents and their representatives were given at least a three day notice. The NHA said generally residents requested to be moved to another room due to roommates not getting along, and some residents moved to be closer to the nurse station for safety. The NHA said the residents and their representatives were not always notified of the room or roommate changes.

Based on record review and interviews, the facility failed to ensure one (#14) of three sample residents received notification of changes in eligibility for Medicare covered services, what the resident's financial responsibility may be and their appeal rights out of 45 sample residents. Specifically, the facility failed to provide written notification of the costs Resident #14 would incur when his Medicare benefits ended.Findings include: I. Facility policy and procedureThe Advance Beneficiary Notices policy, undated, was provided by the Regional clinical resource #1 (RCR) on 6/15/26 at 5:36 p.m. It read in pertinent part, The facility shall inform Medicare beneficiaries of his or her potential liability for payment. A liability notice shall be issued to Medicare beneficiaries upon admission or during a resident's stay, before the facility provides: The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form.For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice.II. Resident #14A. Resident statusResident #14, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes, chronic kidney disease, dementia, and pain in the right hip. According to the 5/8/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. B. Record reviewA review of Resident #14's electronic medical record (EMR) did not reveal documentation indicating the facility provided the resident or his representative with an Advanced Beneficiary Notice (ABN) that indicated the costs the resident would incur when the medicare services ended (see interview below). III. Staff interviewsRegional clinical resource #1 was interviewed on 6/15/16 at 5:36 p.m. Regional clinical resource #1 said they did not have documentation of advanced beneficiary notifications (ABN) for Resident #14. She said it appeared the facility issued a Notice of Medicare Non-Coverage. Regional clinical resource #1 said an ABN was not completed for Resident #14.Regional clinical resource #1 said Resident #14 chose to discharge from medicare services. Regional clinical resource #1 discharged himself from therapy and had 33 days left of Medicare Part A and he remained in the facility. She said she expects staff to complete ABN's when a resident was discharged from Medicare services as having the most current and accurate information was helpful for the residents to make decisions. -However, review of the EMR did not reveal any documentation regarding the resident's end to Medicare services. Regional clinical resource #1 said she was working on the plan of correction and had already completed staff education regarding the requirements for ABN's on 6/15/26.

Based on record review and interviews the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received necessary services to maintain proper meal assistance for two (#21 and #19) of two residents reviewed for ADLs out of 45 sample residents.Specifically, the facility failed to ensure Resident #21 and Resident #19 received meal assistance. Findings include: I. Facility policy and procedure The ADLs policy and procedure, revised March 2018, was received from regional clinical resource #2 on 6/16/26 at 12:43 p.m. It read in pertinent part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care); mobility (transfer and ambulation, including walking); elimination (toileting); dining (meals and snacks); and communication (speech, language, and any functional communication systems). Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS (minimum data set). Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated and revised as appropriate. II. Resident #21 A. Resident status Resident #21, age [AGE], was admitted to the facility on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included Parkinson's disease, Alzheimer's disease, acute embolism of left lower extremity and depression. The 5/13/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. The resident required supervision or touching assistance with helper provides verbal cues and or touching steadying and or contact guard assistance as the resident completes activity with eating. The resident required substantial or maximal assistance for oral and personal hygiene, showers and dressing. The resident was dependent on staff for transfers and toileting. -However, observations and interviews revealed the resident needed more than set-up assistance with meals (see below). B. Observations During a continuous observation on 6/10/26 from 12:05 p.m. to 2:11 p.m. revealed Resident #21 sat in the 300 hallway dining area. She was sitting in her wheelchair at the table and had a plate of mashed potatoes, spinach, chopped meat and a bowl of dessert. She also had a glass of juice and a supplemental drink next to her. The resident moved the food around the plate using her right hand and took a few bites. An unidentified certified nurse aide (CNA) walked by the table a few times, looked at the resident and the plate of food but did not offer to assist or provide her with the meal. At 1:08 p.m. an unidentified CNA picked up the resident's plate and said it looks like you were not hungry. The resident had not touched the mashed potatoes, spinach or chopped meat. The unidentified CNA left the supplemental drink and the bowl of dessert with the resident. At 2:11 p.m. an unidentified CNA asked Resident #21 if she was ready to go lay down in her room and assisted the resident into her room. The supplement drink and the dessert remained on the table. The dessert and supplement drink remained untouched. -The staff did not provide cueing or meal assistance during the meal, despite the resident only taking a few bites of the mashed potatoes and dessert. During a continuous observation on 6/11/26 beginning at 9:09 a.m. and ending at 9:45 a.m., the following was observed: At 9:09 a.m. Resident #21 was lying in her bed with the head of her bed elevated 30 degrees, asleep. Her eyes were closed and the bedside table was over her. There was a scooped plate of eggs, a bowl of oatmeal and a glass of juice on the table. At 9:45 a.m. the resident was awake and had the bedside table and the food in front of her. The nurse went into the residents room and said I will get you a supplement drink, the nurse left the room and came back with the drink. She took the plate away from the resident and left the supplement drink on the bedside table next to her. -However, Resident #21's plate was observed with the eggs and the bowl of oatmeal when the nurse carried the plate out of the resident's room. The resident did not attempt to pick up the utensil or drink during observations and no assistance was offered to the resident. On 6/11/26 at 2:02 p.m. Resident #21 was sitting in her wheelchair in her room. There was a full plate of food in front of her on the bedside table. On 6/15/26 at 9:29 a.m. Resident #21 was laying in her bed with the bedside table over her. She had a plate of food on top of there and the resident was asleep. Her eyes were closed. At 9:42 a.m. an unidentified CNA went into the resident's room and asked her if she needed help. She offered the resident juice which she took when the CNA held the glass and assisted her with the straw to drink. The CNA did not assist her to take any bites of food. She told the resident she would be back to check on her later and left the room. -However, Resident #21 did not attempt to pick up the utensil to feed herself during the observation. During a continuous observation on 6/16/26 beginning at 8:42 a.m. and ending at 9:20 a.m., the following was observed: At 8:42 a.m. Resident #21 was awake in her bed. The bedside table was over her with a scooped plate of food which consisted of eggs, chopped up meat, a bowl of oatmeal and water on the table. She was attempting to eat the food using her right hand. The resident was able to take a few bites unassisted. At 8:48 a.m. an unidentified CNA checked on the resident, but did not offer the resident assistance or queuing with the meal. At 9:21 a.m. an unidentified CNA went into the resident's room and asked the resident if she wanted anymore and if she was done. The resident did not respond. The unidentified CNA took the plate away. -However, Resident #21's plate had eggs, chopped meat and a bowl of oatmeal when the unidentified CNA carried the plate out of the resident's room. C. Observations and Resident #21's representatives interview On 9/15/26 at 12:45 p.m. Resident #21's representative was providing the resident with meal assistance. The representative said he assisted the resident with eating her meals, because she had a hard time using her right hand. He said when he assisted her with eating she was able to consume all of her food. He said he brought in extra cookies for her because she loved sweets. He said he was on vacation last week and was unable to be at the facility. He said the usual time he visited the resident was at meal time in order to assist her. On 9/16/26 at 12:20 p.m. Resident #21's representative was assisting the resident with her meal. She consumed 100% of the meal with assistance. D. Record review The ADL mobility care plan, revised 12/21/25, documented the resident had an ADL mobility decline and required assistance related to the cognitive impairment related to Parkinsons and Alzheimer's disease. Pertinent interventions included providing set-up assistance for eating, monitoring for changes or decline in ADLs and notifying the physician or changes. The nutritional risk care plan, revised on 5/14/26, documented the resident was at risk for malnutrition. The care plan documented the resident was on a soft and bite sized diet and did not like meat. Pertinent interventions included providing the resident a scoop plate at meals, providing set-up assistance at meals, encouraging oral intake, offering meal alternatives and snacks, offering fortified foods and providing supplements as ordered. The nutritional risk assessment dated [DATE], documented the resident had a significant change. The resident was alert and required assistance with meals. The resident had chewing and swallowing problems when she fed herself. E. Staff interviews CNA #1 was interviewed on 6/15/26 at 9:54 a.m. She said residents had the choice to eat in their room or go to the dining room. She said if a resident needed assistance with their meal, they would go to the dining room. CNA #1 said the staff encouraged Resident #21 to eat on her own and provided quing during meals. She said the resident's family came in during meal times to help her. She said Resident #21 did not eat much breakfast in general. Registered nurse (RN) #1 was interviewed on 6/16/26 at 9:25 a.m. She said the residents who needed assistance with meals ate in the dining room. She said Resident #21 did eat on her own and needed some assistance at times, she said the family came in during meal time to assist. The registered dietitian (RD) was interviewed on 6/16/26 at 10:12 a.m. She said she completed nutrition assessments quarterly, annually and when there was a change of condition.She updated the care plan and talked about the changes in the interdisciplinary team meeting (IDT). She said Resident #21's care plan documented the interventions to assist the resident for meals as needed. She said the resident's representative often came to the facility to help the resident with meals. She said she was notified by the IDT team, the nurse on the unit and or CNAs when the resident had changes or needed more assistance. She was not aware the resident needed more help . III. Resident #19 A. Resident status Resident #19, age greater than 65, was admitted on [DATE]. According to the June 2026 CPO, diagnoses included neurocognitive disorder with Lewy's bodies, dysphagia (swallowing impairment), macular degeneration (vision impairment), dementia and other diseases classified elsewhere, moderate, with anxiety, and Parkinson's disease The 6/3/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of two out of 15. The MDS assessment documented the resident required partial to substantial staff assistance with his ADLs. According to the assessment, Resident #19 needed supervision or touching assistance with eating. B. Observations During a continuous observation of breakfast on 6/16/26, beginning at 8:45 a.m. and ending at 10:20 a.m., the following was observed: At 9:07 a.m. the meal cart arrived in the small dining room. At 9:11 a.m. Resident #19 was served a breakfast of bacon strips, cinnamon roll, hot cereal and scrambled eggs. At 9:23 a.m. CNA #8 saw that Resident #8 had not eaten his breakfast. She asked him if he was hungry and offered him yogurt. The resident did not respond to her question. Between 9:11 a.m. and 9:23 a.m. Resident #19 was not offered assistance with his meal or encouraged to eat. He had not taken any bites of his food independently. At 9:26 a.m. registered nurse (RN) #3 stood next to Resident # 19 as she fed him two bites of scrambled eggs. Resident #19 proceeded to pick up his cinnamon roll and bacon and eat them independently. At 9:39 a.m. CNA #8 placed a clothing protector on Resident #19. CNA #8 did not ask him if she could put a clothing protector on him or explain what she was doing prior to placing the clothing protector on. At 9:45 a.m. Resident #19 began pulling on his clothing protector attempting to remove it. At 10:03 a.m. Resident #19's remnants of the cinnamon roll was on the floor and his scrambled eggs were on the floor and the table around him from him partially feeding himself. The resident ate the scrambled eggs off the table with his fingers. There was no staff in the dining room to supervise or assist the resident. At 10:06 a.m. Resident #19 remained at the table and closed his eyes with a small amount of food left on his plate. Pieces of his breakfast remained on the table and floor. At 10:10 a.m. the staff were observed answering call lights and passing out medications as Resident #19 and another resident sat at the dining table alone. At 10:12 a.m. RN #3 cleaned off the table in from of Resident #19. She spoke to him and offered him a fidget sensory device. Resident #19 acknowledged RN #3 and closed his eyes. At 10:16 a.m. RN #3 offered Resident #19 a drink of his water as she stood over the resident. Between 9:19 a.m. and 10:15 a.m. the resident was not asked if he was thirsty or was offered a drink from his cup. He did not drink from his cup independently. C. Record review The ADL care plan, initiated 3/5/26, documented Resident #19 was at risk for an ADL decline and required staff assistance and anticipation of a cognitive decline due to his disease process and Lewy bodies dementia. According to the care plan, the resident would have his needs anticipated and met by staff. The care plan intervention, initiated 3/5/26, documented the resident could use utensils independently and directed staff to assist in the set up and clean up of his meals. The nutrition care plan, revised 6/8/26, documented Resident #19 had a regular diet but potential for altered nutrition and/or hydration status related to cognitive deficits, diagnosis of dysphagia. Interventions, initiated 3/5/26, directed staff to evaluate the need for assistance with eating and drinking as needed. The cognitive impairment care plan, revised 5/29/26, documented Resident #19 had cognitive loss related to altered cognitive performance with a BIMS score of two (severely impaired) and Lewy Body dementia. Interventions, dated 3/5/26, directed staff to anticipate needs and meet promptly. The 30 day eating task log documented from 5/18/26 to 6/16/26, Resident #19 required supervision or touching assistance during 15 meals out of 83 meal opportunities throughout the 30 day period. The 5/22/26 nutritional risk review assessment indicated Resident #19 required set assistance for meals but his level of assistance varied. The assessment identified Resident #19 fed himself and needed assistance with feeding. According the assessment, the RD recommended staff to assist Resident #19 with meals as needed. D. Staff interviews CNA #5 was interviewed on 6/16/26 at 3:17 p.m. CNA #5 said he sometimes helped with dinner meals when he worked the night shift. He said Resident #19 needed set up assistant with his meals and supervision. He said Resident #19 would often eat with his fingers unless staff prompted him to use his silverware. RN #3 was interviewed on 6/16/25 at 3:20 p.m. RN #3 said Resident #19 needed assistance at meals varied. She said his health was deteriorating. She said sometimes he just needed to supervise him and offer him cues to eat. She said lately he needed more help. She said staff had to place the utensils in his hand for him to eat or sometimes needed staff to provide total assistance by placing the food in his mouth for him. She said staff should staff with residents who required assistance. The NHA and regional clinical resource #1 was interviewed together on 6/16/26 at 5:07 p.m. The NHA said residents who had swallowing concerns and/or need assistance feeding themselves should eat in the dining rooms for increased supervision and cueing if needed. The NHA said Resident #19's health was declining and he was receiving hospice services. She said as he continued to decline, he needed increasingly more staff assistance. Regional clinical resource #1 said they would work with the therapy department to conduct an audit of residents, identifying the current meal assistance needs. Regional clinical resource #1 said the goal was for staff to be able to identify what the resident's level of assistance is at the moment and adapt. The NHA said the facility will provide education to the staff. Regional clinical resource #1 said the training should help staff know their residents' needs and be able to recognize changes from meal to meal and adapt as the residents' needs increase.

Based on observation, record review and interviews, the facility failed to ensure one resident (#3) of three sample residents, was free from significant medication errors out of 13 sample residents.Resident #3 was admitted to the facility on [DATE] with a diagnosis of type 1 diabetes mellitus with a history of experiencing low blood glucose levels. Resident #3 had a physician's order to receive 29 units of Lantus (insulin glargine - long acting insulin) injected subcutaneously each day at bedtime. The resident had another physician's order for Humalog insulin (lispro - short acting insulin) 100 units per milliliters (ml) injected daily at 6:00 a.m., 11:00 a.m. and 4:00 p.m. On 10/22/25 at 7:33 p.m. registered nurse (RN) #1 administered 29 units of Humalog (quick acting insulin) instead of the scheduled Lantus (long acting insulin), which caused the resident's blood glucose to drop. When RN #1 realized the error, he administered the correct insulin in addition to the insulin he administered in error and then instructed the resident to monitor her own blood glucose levels and let him know the results. RN #1 failed to assess the resident's immediate and changing vital signs, so it was unknown how quickly the resident's blood glucose levels dropped and for how long the resident's blood glucose level remained at a dangerous life threatening level. Additionally, RN #1 waited approximately four and a half hours before sending the resident to the emergency room despite the director of nursing (DON) instructing him to send the resident to the hospital at that time per facility protocol. As a result of the facility's failure to ensure Resident #3 received the correct type and amount of diabetic medication at the right time Resident #3 experienced a life threatening hypoglycemic state where her blood glucose dropped to 42 milligrams per deciliter (mg/dL) for an undetermined amount of time. Emergency medical services (EMS) had to administer life saving oral glucose to the resident and take her to the hospital for close monitoring. Specifically, the facility failed to ensure Resident #3 was administered her insulin per physician's orders. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/2/26 to 2/4/26, resulting in the deficiency being cited as past noncompliance with a correction date of 10/24/25.I. Situation of serious harmThe facility failed to ensure Resident #3 received the correct type and amount of insulin, resulting in the administration of an excessive amount of insulin. The facility failed to directly monitor the resident's condition, including blood glucose measurements, heart rate and blood pressure following the significant medication error that was likely to cause the resident significant bodily harm. In addition, the facility failed to seek timely emergency medical service to ensure the resident's health and safety. II. Facility's plan of correction The corrective action plan implemented by the facility in response to Resident #3's serious medication error on 10/22/25 was provided by the nursing home administrator (NHA) on 2/3/26. The facility's plan of correction revealed the following: Identification of others - The facility took the following actions to prevent an adverse outcome from reoccurring. All applicable facility policies and procedures were reviewed and revised by the DON and the medical director (MD) The facility reviewed all residents on diabetic medications to ensure correct orders and accurate care plans (completion date 10/24/25).Systemic changes - the DON or designee re-educated licensed nurses on facility policies and procedures regarding diabetic management and administration of diabetic medications. All nurses were educated prior to working their next shift. A complete medication review was conducted and all residents on insulin were prescribed glucagon for response to hypoglycemic events (completion date 10/24/25).Monitoring - the DON or designee will complete weekly chart audits on all residents receiving insulin medication to ensure accurate administration and no residents were experiencing an untreated hypoglycemic condition. This was to occur for three consecutive months.The administrator implemented a QAPI/PIP (quality assurance and performance improvement/performance improvement project) as a means to gather and process information from the audits. Findings will be reported at the monthly quality assurance meeting until satisfactorily resolved. III. Professional reference According to the American Diabetes Association (ADA), December 2025, retrieved on 2/17/26 from https://diabetes.org/living-with-diabetes/hyoglycemia-low-blood-glucose/severe Severe hypoglycemia occurs when a person's blood sugar drops dangerously low. The person may become confused, pass out (lose consciousness), or treatments for low blood glucose are not working. People who are at risk for severe hypoglycemia: people on blood glucose-reducing medications (insulin, sulfonylureas, or meglitinides), people with a history of severe hypoglycemia.Signs and symptoms of severe hypoglycemia include: An altered mental state; fainting or losing consciousness; incredibly weak and unable to help yourself; seizure; and coma. If left untreated for too long, severe hypoglycemia can lead to brain or organ damage or even death.IV. Facility policy and procedure The Administering Medications policy and procedure, revised 2020, was provided by the NHA on 2/3/26 1:28 p.m. It read in pertinent part,: Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication initials the resident's medication administration record (MAR) on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:a. the date and time the medication was administered;b. the dosage;c. the route of administration;d. the injection site (if applicable);e. any complaints or symptoms for which the drug was administered;f. any results achieved and when those results were observed; andg. the signature and title of the person administering the drug.The Management of Hypoglycemia policy, revised 2020, was provided by the NHA on 2/3/26 at 1:28 p.m. It read in pertinent part, Purpose: to provide guidelines for managing hypoglycemia secondary to insulin therapy or therapy with oral hypoglycemic agents in the diabetic resident. Classification of hypoglycemia: Level 1 hypoglycemia: blood glucose less than 70 milligrams (mg) per deciliter (dL) but less than 54 mg/dL; Level 2 hypoglycemia: blood glucose is less than54 mg/dL; and Level 3 hypoglycemia: altered mental and/or physical status requiring assistance for treatment of hypoglycemia. For Level 2 hypoglycemia (less than54 mg/dL): a. Administer glucagon (intranasal, intramuscular, or as provided); b. Notify the provider immediately; c. Remain with the resident; d. Place resident in a comfortable and safe place (bed or chair); e. Monitor vital signs; andf. Recheck blood glucose in 15 minutes.V. Resident #3A. Resident statusResident #3, age less than 65, was admitted on [DATE], discharged to the hospital on [DATE], readmitted to the facility on [DATE] and discharged to the community on 1/7/26.According to the January 2026 computerized physician's orders (CPO), diagnosis included diabetes mellitus and traumatic brain injury. The 12/17/25 minimum data set (MDS ) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15.B. Resident interviewResident #3 was interviewed on 2/3/26 at 2:30 p.m. via the telephone. Resident #3 said RN #1 administered her insulin injection, pain and sleeping medication and left her room She said RN #1 returned later and told her he had made an error and gave her the incorrect insulin medication. Resident #3 said after telling her about the medication error RN #1 gave her a blood glucose monitor and the supplies to monitor her own blood glucose every 20 minutes. Resident #3 said RN #1 waited to call EMS until he heard back from the on-call doctor when he should have called EMS right away. C. Facility investigation The facility investigation documented on 10/23/25 RN #1 administered the wrong type of insulin to Resident #3, which caused the resident's blood sugar level to drop. When RN #1 realized he administered the wrong type of insulin, he then tried to correct the error by administering the insulin he was supposed to have administered in the first place. Resident #3's MAR documented that the resident was supposed to receive 29 units of Lantus insulin. RN #1 drew up and administered 29 units of Humalog lispro insulin, instead of the long acting insulin. RN #1 recognized the medication and dosing error quickly and tried to correct the medication error by administering the Lantus long acting insulin on top of the administration of the quick acting insulin. -RN #1 made a decision to administer additional diabetic medication designed to further lower a person's blood glucose without consulting with the resident's physician. After the medications error occured RN #1 notified the DON and made a call to the physicians on call service. -The DON instructed RN #1 to prepare the resident and send her out to the emergency room; however, The investigation documented RN #1 failed to assess the resident health status and vital signs. There was no documented record of the resident blood glucose over time and no record of the resident vital signs including her heart rate, blood pressure or cognitive status. Instead RN #1 gave Resident #3 her blood glucose monitor and told the resident to test her own blood glucose and report any problems. The investigation documented upon consulting with the DON, RN #1 failed to follow the DON's instruction to send the Resident #1 to the emergency room for immediate assessment and treatment. RN #1 waited approximately four and a half hours before calling for EMS transport to send the resident to the emergency room. Resident #3 was transferred to the hospital for medical monitoring at approximately 12:00 a.m. -RN #1 failed to follow medication administration standards or physician orders and failed to follow facility protocol for treating a resident in a hypoglycemic state. The investigation documented, the facility conducted record reviews, and interviews. Education was provided to nursing staff on insulin administration. Medication carts were re-organized to separate the different types of insulin medications. Management also created an audit tool to monitor compliance and an audit was performed on all residents with diabetic medications to ensure accuracy and reflection in the resident care plan. Management identified gaps with RN#1 communication about the medication error, and the importance of the nurse monitoring blood sugar levels and seeking timely medical follow up. RN #1 was separated from employment at the facility. D. Record review Nursing note, dated 10/22/25 at 7:43 p.m., documented when the nurse (RN #1) finished administering the resident's evening medications, this nurse discovered that the resident's lispro insulin was on top of the medication cart. The note documented Resident #3 had received 29 units of Humalog lispro instead of 29 units of Lantus. This nurse immediately informed the resident of the error. The resident checked her own blood sugar, so she was given supplies and instructed to check her blood sugar every 29 minutes and report back to this nurse. The note documented she was also encouraged to start eating sugar rich foods. This nurse notified DON and called the on-call physician. The note documented RN #1 was to continue to monitor the resident. Nursing note, dated 10/22/25 at 8:49 p.m., documented Resident #3's blood sugar had varied from 60 mg/dL to 120 mg/dL. The note documented the nurse had not heard back from the on-call physician. The note documented RN #1 decided that if there was no return call from the on -call physician and the resident's blood sugar drops below 55 mg/dL, the resident would be sent to the emergency room.Nursing note, dated 10/22/25 at 10:53 p.m., documented Resident #3's blood sugar dropped to 54 mg/dL. The note documented the nurse had not heard from the on-call physician. The note documented RN #1 called non-emergent ambulance for transport to the emergency room. The note documented Resident #3 was so far asymptomatic.Nursing note, dated 10/22/25 at 11:58 p.m., documented RN #1 received a return call from the on-call physician. The physician gave the order to send Resident #3 to the emergency room. Hospital emergency room treatment note, dated 10/23/25, documented Resident #3 was admitted to the emergency room at 12:11 a.m. and was closely monitored for about five hours with every hour blood glucose checks. Resident #3 was diagnosed with hypoglycemia. The emergency room attempted to discharge the resident, however the resident's blood glucose was not able to be stabilized so the resident was admitted to the hospital for recurrent hypoglycemia. While in the hospital the resident's diabetic condition was monitored closely and her diabetic medications were adjusted for diabetes management. Review of the October 2025 CPO revealed the following physician's orders:Lantus solution 100 units per ml (insulin glargine) inject 13 units subcutaneously one time a day at 6:00 a.m. for diabetes, start date 10/1/25.Lantus solution 100 units per ml (insulin glargine) inject 29 units subcutaneously at bedtime for diabetes mellitus, start dated 10/1/25.Humalog (lispro insulin) solution, injection 100 units per ml per sliding scale: if the blood glucose is 150 - 200, give one unit; if 201 - 250 give two units; if 251 - 300 give three units; if 301 - 350 give four units; if 351 - 400 give five units, inject at 6:00 a.m., 11:00 a.m. and 4:00 p.m., before meals for diabetes; start date 10/19/23. The MAR documented the resident blood glucose results on 10/22/25 were documented as follows: -At 6:00 a.m. the resident's blood glucose was recorded as 120, no sliding scale lispro administered; -At 11:00 a.m., the resident's blood glucose was documented as 90 no, sliding scale lispro administered. -At 4:00 p.m., the resident's blood glucose was recorded as 201, two units of Humalog lispro insulin was administered per the sliding scale order; -At 7:33 p.m., the resident blood glucose result was not documented. RN #1 administered the incorrect type of insulin to the resident; -At 9:00 p.m. the resident's blood glucose was documented as 120.-Per the nursing note 10/22/25 at 10:53 p.m. the resident's blood glucose had dropped to 54 mg/dl. VI. Staff interviews The DON, the regional nurse consultant, the assistant director of nursing (ADON) and the NHA were interviewed together on 2/3/26 at 2:26 p.m. The DON said Resident #3 was administered the incorrect insulin by RN #1 on 10/22/25. The DON said she expected RN #1 would follow the facility emergency protocols for a mediation error and hypoglycemia and should have sent the resident to the emergency room for assessment and treatment right away. She said the nurse did not have to wait for the on-call physician to call back although the on-call physician.The DON said RN #1 did not call her back to report he did not send the resident immediately to the hospital and had not been in contact with the resident's physician's on call. The DON said she did not call RN #1 back that evening to check in on the resident status, as she expected the RN #1 to follow facility emergency procedures and protocol. The DON said that this occurrence resulted in a review with the leadership team. The DON said the team reviewed the diabetes protocol and emergency protocols with the facility medical director (MD) and made changes to the facility policy and procedure to ensure compliance with facility expectations and to safeguard the residents health. The DON said all nursing staff were educated on diabetes medication and diabetic management. The DON said RN #1 was placed on immediate suspension and later separated from the facility. RN #2 was interviewed on 2/3/26 at 5:21 p.m. RN #2 said she checked the physician's order before administering the medication to ensure the correct type and dose of insulin was administered. RN #2 said the facility now kept the long acting and quick acting insulin in separate compartments in the medication cart to help decrease medication errors. The medical director (MD) was interviewed 2/4/26 at 4:30 p.m. The MD said she had been the MD at the facility since April 2025. She said she was in the facility at least weekly and her staff nurse practitioner (NP) was in the facility two to three times weekly. She and the NP provide routine rounds at the facility and will also investigate a situation on the same day as needed. The MD said she was not notified about the insulin medication error to Resident #3 at the time the error occurred. She said she only learned of the error when she was asked to assess Resident #3 on 10/25/25; at the time the resident was admitted to the facility from her hospital stay related to the over dosing of insulin by RN #1.The MD said if she had been notified of the insulin related medication error at the time it occurred she would have asked the nurse to complete a full assessment of the resident's status including all vital signs, blood glucose, and other symptoms. Then she would have provided instruction for the nurse to have the resident transferred to the hospital, at the appropriate time. The MD said Resident #3 had a history of low blood sugars.The MD said in this situation, given the excessive amount of the incorrect insulin provided, the resident could be at cardiac risks as well as long term neurologic risks. The MD said that the facility staff can call her directly, if necessary. The MD said the on-call physician service can also call her directly if needed. She said she followed up with the on-call physicians if needed. The MD said the on-call physician services have reported to her that the facility did not always pick up the call when the on-call physician returns the facility's call. The MD said she completed a policy and protocol review with the facility staff after medication error occurred to Resident #3 which resulted in providing routine glucagon protocols for residents with diabetes and improved monitoring of hypoglycemic symptoms.

Based on record review and interviews, the facility failed to provide, implement and maintain an effective training program for new and existing staff. Specifically the facility failed to provide:-All staff the required annual abuse identification, abuse prevention and abuse reporting training, for 75 out of 83 staff; -All staff dementia management training, for 39 out of 83 staff;-All staff resident rights training, for 31 out of 83 staff; -All staff quality assurance and performance improvement (QAPI) training, for 30 out of 83 staff;-All direct care staff effective communication training, for 49 out of 49 staff; -All staff infection control training, for 20 out of 83 staff members; -All staff compliance and ethics training, for 16 out of 83 staff; and, - All direct care staff behavioral health training, for 13 out of 49 staff. Findings include:I. Facility policy and procedureThe In-Service Training policy, revised April 2021, was provided by the nursing home administrator (NHA) on 2/4/26 at 1:28 p.m. The policy read in pertinent part, All staff must participate in initial orientation and annual in-service training. Required training topics included effective communication, resident rights, preventing abuse,facility QAPI program, infection prevention, behavioral health, and compliance and ethics. II. Staff training recordsOn 2/4/26 a request was made for the facility's staff training records for all active staff members. The records revealed the facility failed to meet the minimum training requirements.The records revealed 39 staff members did not complete the facility's dementia training. No other documentation was provided such as in service training.The records revealed 31 staff did not complete the safeguarding resident rights training. The facility did provide an in service training document, however no sign in sheet was provided.The records revealed 30 staff did not complete QAPI training. The facility provided an in-service training document, as well as a sign in sheet containing all of the staff who had completed this requirement. The records revealed no direct care staff members completed the effective communication training. A copy of the training itself was provided, however no documentation of it being used was able to be provided.The records revealed 20 staff members did not complete infection prevention training requirements. 36 were documented to have completed the online version of the training and 27 were found to have completed the in service training. In-service training was provided and sufficiently covered the topic area.The records revealed 16 staff members did not complete compliance and ethics rights training. Although all staff members were listed on this online training, many did not have a completion date listed. A copy of the training itself was provided, however no documentation of it being used was provided.The records revealed 13 staff members had also not completed the required online behavior training. No other documentation was provided such as in service training.II. Staff interviewsThe NHA and the assistant director of nursing (ADON) were interviewed on 2/4/26 at 10:42 a.m. The NHA said most training was done during the onboarding process. She said about 91 percent of the trainings had been completed and all of the abuse and dementia care trainings were finished. The NHA said they often had lunch and learns for their less tech savvy staff. The NHA said this information was not documented.-However, record review revealed the training had not been completed (see record review above).The NHA, the regional nurse consultant, director of nursing (DON) and the ADON were interviewed on 2/4/26 at 5:39 p.m. The NHA said there were some staffing barriers in getting staff to complete all required trainings. The NHA said this included some staff being part time and lack of time for training when the facility needed staff on the floor to provide care to the residents.The NHA said they were planning on scheduling dedicated training time for those behind on completing required training sessions. The NHA said she felt like the training they pulled was incorrect and thought more staff completed training, however she was not able to locate additional records to prove exactly what staff were trained on and who attended. The NHA said going forward facility leadership planned to complete a log for training to keep on track, as well as scheduling sessions for staff to work on training. The NHA said leadership planned to start this process now and be up to date with all required and needed training components by 6/1/26. The NHA said in the meantime she planned to prioritize the most important training for completion.The regional nurse consultant said the facility's current training plan was not effective to make sure all staff were sufficiently trained as required and she was recommending the facility use the industry approved training platform to ensure compliance.

Based on record review and interviews, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property and resident abuse prevention.Specifically the facility failed to provide 75 of 83 staff members annual training on abuse identification, prevention, reporting and evidence gathering. Findings include:I. Facility policy and procedureThe Abuse policy, revised April 2021, was provided by the nursing home administrator (NHA) on 2/4/26 at 1:28 p.m. The policy read in pertinent part, The facility's resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support abuse prevention, identification and response. This included Provid[ing] staff orientation and training programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. II. Staff training recordsA request was made for the facility's current training records for annual abuse and dementia training on 2/4/26. The records provided failed to demonstrate that facility staff were provided with a thorough abuse training that included abuse identification of all types of abuse; steps and measures to prevent abuse and neglect by staff to resident and techniques to prevent resident to resident altercation; requirements for timely reporting of abuse reporting; and methods of gathering evidence for a thorough and complete investigation.-The records revealed that 75 of 83 total facility staff were not provided annual abuse training as required since 2024. III. Staff interviewsThe NHA and assistant director of nursing (ADON) were interviewed on 2/4/26 at 10:42 a.m. The NHA said most training was done during the onboarding process. She said all staff had been provided abuse and dementia care trainings and they were finished providing each training.-However, record review revealed 75 out of 83 staff members had not received annual abuse training. The NHA said the last time the facility provided an extensive training on abuse prevention was in 2024.

Based on interviews and record review, the facility failed to serve food that accommodates resident allergies, intolerances, and preferences for one (#1) of five residents reviewed out of five sample residents.Specifically, the facility failed to ensure Resident #1 was not served food the resident was allergic to, causing an allergic reaction to Resident #1 which required hospitalization for anaphylactic shock (a severe, potentially life-threatening allergic reaction that can cause a range of symptoms affecting multiple body systems, including skin, respiratory, and cardiovascular).Resident #1 was admitted on [DATE] for long term care with diagnoses of unspecified lack of expected physiological development in childhood, cognitive communication deficit, muscle weakness, lack of coordination and history of anaphylaxis (severe allergic reaction). On 9/24/25 Resident #1 was served tilapia for lunch. Shortly after consuming the fish, Resident #1 developed itching and was having difficulties breathing. Resident #1 was transported to the hospital and was admitted to the intensive care unit (ICU) and treated for anaphylactic shock. Findings include:Record review, observations and interviews confirmed the facility corrected the deficient practice related to Resident #1 being served food with a known allergen prior to the onsite investigation on 10/9/25 to 10/13/25. The deficiency was cited as past non-compliance with a correction date of 10/5/25.I. Incident on 9/24/25The nursing home administrator (NHA) provided the facility investigation on 10/9/25 at 1:10 p.m. It revealed in pertinent part,The investigation summary documented that on 9/24/25 at approximately 12:30 p.m. Resident #1 was served a meal containing fish. The facility monitored the resident's vital signs and provided supplemental oxygen. The facility contacted emergency medical services (EMS) and the resident required hospitalization. [NAME] (CK) #1 was interviewed and admitted they did not check the diet ticket prior to sending the meal. Certified nurse aide (CNA) #1 was interviewed and admitted she did not check the diet order ticket prior to serving the resident. The investigation documented the staff members were suspended at the start of the investigation and then terminated.The investigation revealed CK #1 received a written warning and corrective education on 9/12/25 after serving a different resident a dessert with a known allergen. The investigation documented the facility completed immediate education of current staff within hours of the event. The investigation documented the facility completed an audit of all residents' allergies. In addition, the facility created new signage and education for floor staff to prevent recurrence.II. Facility plan of correctionA. Immediate action to correct the deficient practice for Resident #1The progress note, dated 9/24/25 at 9:25 p.m., revealed the interdisciplinary team (IDT) held an emergency meeting to review Resident #1's change in condition. The progress note revealed education was provided to the nursing and dietary staff on 9/24/25.The facility provided documentation of staff education completed after the incident which included the following:A document titled Food Allergies: Check the ticket inservice, documented an in-person education was provided by the NHA on 9/24/25. The document included five dietary aides, two cooks, 13 CNAs, one licensed practical nurse (LPN) and four registered nurse (RN) signatures. The documentation included education of a five point ticket check for staff to perform prior to serving any food. These five checks included: the resident name and second identification (picture or room number), diet order, texture, liquids and allergies/special notes. The documentation included education that if the tray did not match all five checks, staff were required to perform a stop protocol. The stop protocol directed staff to S-seperate the tray, T-tell nursing and dietary staff immediately, O-observe and ensure the resident did not eat anything from the incorrect tray, P-proof: document the near miss per facility policy.A document titled Food Allergens inservice, documented an in-person education was provided by the NHA on 9/24/25. The document included five dietary aides, two cooks, 13 CNAs, four RNs signatures and one LPN signature. The document included education on major food allergens, how allergens were listed on product labels, signs of an allergic reaction and how to respond at the onset of food allergy symptoms. A document titled ASAP (as soon as possible) dietary meeting inservice, documented an in-person education was provided by the director of nursing (DON) on 9/26/25. The document included five dietary aides, two cooks and one RN signature. The document included education of CMS (Centers for Medicare and Medicaid) standards for dietary standards in long term care and food handling safety including education of cross contamination.B. Identification of other residentsStarting on 9/29/25 through 10/1/25, the facility completed an audit of all residents' food allergies, preferences, and intolerances. One additional resident was identified with a previously undocumented allergy to fish and shellfish. The resident reported the allergy to the facility on 9/29/25 and the facility updated the resident's electronic medical record (EMR) the same day. The allergy was not listed in the resident's referral to the facility. The facility completed a quality care network (a program that provided cross reference documentation between facilities) audit and found the resident allergy in documentation from another facility on 4/14/22, two years prior to the resident's admission to the facility. C. Systematic changesThe facility implemented a new process on the week of 10/5/25 to highlight allergies on meal tickets to clearly identify allergens for staff delivering meal trays. A new magnet was created to hang on the doorway of residents with a food allergy. The purpose of the magnet was to remind staff of a resident's food allergies. The magnet included pictures of high risk food allergens including fish, peanuts and dairy products. The magnet was implemented the week of 10/5/25.On 10/9/25 at 11:50 a.m. paper education was in place on the counter next to the kitchen door and near the meal pick up window. The paper education included a picture of the food allergy magnet and a signature sheet dated for the week of 10/5/25. Instructions below the picture instructed staff to look for the food allergy magnet in the residents' room door way and double check the diet ticket and the food when serving residents.D. MonitoringThe facility provided documents of ongoing dietary ticket audits, beginning 10/4/25, completed by the dietary director. The documentation revealed audits of dietary staff checking to ensure allergens were highlighted on tickets and tickets were checked with each order to ensure food on the tray was correct to the five areas identified in the inservice education: the correct resident, diet order, texture, liquid and allergies/special instructions.Interviews and record review during the investigation revealed corrective actions to identify the resident and other residents who had the potential to be affected by the deficient practice, systematic changes to prevent its recurrence and monitoring to ensure sustained corrections were in place.IIII. Facility policy and procedureThe Food Allergies and Intolerances policy, initiated 2001, was provided by the NHA on 10/9/25 at 1:39 p.m. It revealed in pertinent part, Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s). Severe food allergies are noted on the face of the chart (in the form of a sticker or permanent marking indicating Severe Food Allergy: (name of food) and communicated in writing directly to the dietitian and the director of food and nutrition services. Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat. The attending physician will be notified of the resident's food allergies and orders for emergency medications (epinephrine, antihistamines) and emergency interventions will be documented.IV. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE]. According to the October2025 computerized physician orders (CPO), diagnoses included unspecified lack of expected physiological development in childhood, cognitive communication deficit, muscle weakness, lack of coordination and history of anaphylaxis.The 9/29/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #1 required set up or clean up assistance with eating, oral hygiene and dressing. Resident #1 required supervision or cues with toileting and personal hygiene. Resident #1 was dependent on staff for bathing. The MDS assessment revealed the resident had allergies to sulfa antibiotics, thiazide-type diuretics and fish.B. Resident interviewResident #1 was interviewed on 10/9/25 at 11:05 a.m. Resident #1 said he was not aware he was served fish until after he ate it. Resident #1 said he remembered he began to itch, then he began to have difficulty breathing and became scared. Resident #1 said he had not been served fish since his return to the facility on 9/29/25.C. Record reviewThe change in condition note, dated 9/24/25 at 4:38 p.m., revealed Resident #1 had an altered level of consciousness, difficulty breathing and difficulty swallowing. Vital signs documented at the time of assessment included blood pressure of 131/117 millimeters of mercury (mmHg), pulse of 80 beats per minute (bpm), respiratory rate of 21 breaths per minute and pulse oximetry reading of 80% on 2 liters per minute (LPM) of supplemental oxygen. The progress note, dated 9/24/25 at 9:25 p.m., revealed Resident #1 inadvertently ate fish for lunch. The progress note documented the DON was alerted of the change in condition and immediately contacted the medical director and EMS. The progress note documented the IDT met after the resident was taken to a local hospital by EMS. The progress note documented the DON, the NHA and the social services director (SSD) provided immediate education to staff regarding allergies and diet orders.The emergency room physician note, dated 9/24/25 at 6:11 p.m., revealed Resident #1 presented to the emergency room in anaphylactic shock due to consuming tilapia. The physician considered alternate diagnoses such as angioedema (acute swelling beneath the skin, often affecting the face, lips, tongue, hands, or feet) but this was less consistent with the abrupt onset and exposure to a known allergen. The physician documented this potentially could have been due to a different allergic trigger, though would not change management at that time. In addition to the epinephrine (medication used to treat anaphylactic shock), diphenhydramine (medication used to treat allergies) and steroids initiated by EMS, the physician continued epinephrine administration via an epinephrine infusion at 0.1 microgram (mcg)/kilogram/minute and gave an additional albuterol nebulizer treatment due to wheezing on exam.The intensive care unit (ICU) physician note, dated 9/26/25, revealed Resident #1 was admitted to the local area hospital's ICU after presenting to the emergency room with anaphylaxis after being fed fish at his care facility. The physician documented Resident #1 had facial swelling including eyelids and mouth, the feeling like his throat was swelling, stridor (high pitched noisy breathing) or dyspnea (shortness of breath), lightheadedness and wheezing. The physician documented Resident #1 had a high probability of sudden, clinically significant deterioration, which required the highest level of physician preparedness to intervene urgently. The physician documented they managed and supervised life or organ supporting interventions that required frequent physician assessment.The progress note, dated 9/29/25 at 5:50 p.m., revealed Resident #1 returned to the facility from the local area hospital. The progress note documented Resident #1 was back at baseline health condition, denied pain and was glad to be back at the facility.V. Staff interviewsThe DON and the NHA were interviewed together on 10/9/25 at 1:10 p.m. The DON said on the day of Resident #1's allergic reaction (9/24/25), he did not show signs of allergic reaction immediately, but rather started reporting signs of a reaction approximately three hours after eating. The NHA said during the investigation after the event, the facility found that Resident #1's diet was recently changed to minced and moist. The NHA said the resident might not have recognized the food as fish due to the diet change. The DON said when she was alerted of Resident #1's facial and tongue swelling, she grabbed the epinephrine (epi) pen (medication used to treat allergic reactions) from the emergency kit while another staff member called EMS and another staff member obtained vital signs. The DON said Resident #1 had an oxygen saturation of 78% to 79%, but was still able to speak. She said she increased the supplemental oxygen for Resident #1 and his oxygen saturation improved. The DON said she did not administer the epi-pen because Resident #1's blood pressure was stable, his oxygen improved and the ambulance arrived within six minutes after calling them. The DON said she saw EMS start an intravenous (IV) line on the resident and moved him from a nasal cannula to a mask, but to her knowledge, EMS did not administer an epi-pen either. The NHA said the facility began their investigation of the events the same day (9/24/25). The NHA said during the investigation, the facility found the cook had a previous written warning about attempting to serve another resident a desert with an allergen. The NHA said the resident did not eat the dessert, but because of the previous warnings and education, the facility terminated the cook and CNA #1 after the investigation. The NHA said since the event, the facility had completed an audit of allergies for all residents in the facility, process changes were implemented to have dietary staff highlight the allergies for all meal tickets to indicate residents with allergies and to have magnets made for the doorways of all residents with food allergies. The NHA said the facility also provided education about the changes as well as education about food allergies to all staff. The DON said another process change was implemented in the kitchen and now the dietary aides read the card and stated out loud to the cook what the precautions were, including food allergies. The DON said the cook then read the card back to confirm. The NHA said the facility additionally completed observations of staff in the kitchen and when delivering food to resident's rooms to ensure the process was implemented effectively.

III. Failed to ensure Resident #2's representative was notified when the resident was sent to a cardiology appointment and started on an anticoagulant medication A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included type 2 diabetes mellitus without complications, other specified diabetes mellitus with diabetic neuropathy, presence of cardiac pacemaker, dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and unspecified atrial fibrillation. The 4/23/25 MDS assessment identified Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #2 used a walker for mobility and was independent with most of his activities of living (ADL). B. Resident interview Resident #2 was interviewed on 6/30/25 at 4:40 p.m. Resident #2 said he was placed on a blood thinner medication after he went to his cardiology appointment. He said he let his representative know of the medication changes. He said his representative did not know about the appointment and medication changes until he told her about them. C. Resident representative interview Resident #2's former representative was interviewed on 7/1/25 at 2:13 p.m. The former representative said while she was the resident's representative, she was not informed of medication changes and medical appointments by the facility. She said the facility started Resident #2 started on a blood thinner medication and he had a cardiology appointment. She said the facility never notified her about the cardiology appointments or the medication changes. She said she did not find out about the medication change and appointment until later in May 2025 when Resident #2 told her about them. D. Record review A 12/2/24 cardiologist encounter note identified Resident #2 had a cardiology appointment on 12/2/24. The 12/2/24 facility nursing note identified Resident #2 returned from the cardiology appointment. -Review of Resident #2's EMR did not reveal documentation to indicate that resident #2's representative had been notified of the 12/2/24 cardiology appointment. A 3/17/25 cardiologist encounter note identified Resident #2 had a cardiology appointment on 3/17/25. The encounter note indicated that Resident #2 would be started on Eliquis (anticoagulant/ blood thinner medication) 5 milligrams (mg) twice a day. The 3/17/25 order note identified Resident #2 returned to the facility from his cardiology appointment on 3/17/25 with a new medication order. Review of Resident #2's July 2025 CPO revealed a physician's order for Apixaban (Eliquis) 5 mg twice a day for unspecified atrial fibrillation, ordered 3/17/25. -Review of Resident #2's EMR did not reveal that Resident #2's representative was notified of the 3/17/25 appointment or the medication change. E. Staff education A 7/1/25 staff in-service training (conducted during the survey) with an attached staff participation log was provided by the NHA on 7/1/25 at 11:40 a.m. The education read, Long-term care, the standard of care for documenting conversations with residents and families involves timely, accurate, and objective charting that reflects relevance and supports quality of care, communication, and regulatory compliance. According to the training, documentation should occur immediately after a conversation was had with the resident's representative or before the end of the shift in which the event occurred. The staff participation log documented 15 staff members attended the 7/1/25 documentation training service. F. Staff interviews The NHA was interviewed on 7/1/25 at 2:29 p.m. The NHA said residents' representatives should be contacted when there was a change in condition, such as a medication change, or when a resident had a medical appointment scheduled. The NHA said Resident #2 had a cardiology appointment in December 2024 and again in March 2025. The NHA said Resident #2's EMR did not indicate Resident #2's representative was notified of the medication change or of his appointments. The NHA said the facility had multiple changes in managerial staff in recent months and there was no standardized process to notify residents' representatives and where to document the notifications. She said the facility nursing staff was educated today (7/1/25) regarding the documentation and notification process. The NHA said the director of nursing (DON) would provide oversight to ensure residents' representatives were appropriately notified and the staff documented the notification in the residents' EMRs. The DON was interviewed on 7/1/25 at 5:16 p.m. The DON said she was new to the facility but she or a designated staff member would be responsible for notifying a resident's representative when there was a change of condition for the resident. The DON said the resident's representative would be called on the phone unless the representative identified another form of communication. She said if the representative was not available to take the call, she would leave a message and make sure to call them back again if they did not return the call. The DON said communication with residents' representatives and families was very important. The DON said good communication ensured residents' safety, an accurate care plan and made sure everyone was on the same page. Based on record review and interviews, the facility failed to make immediate notification to the resident representative when the resident had a significant change in condition requiring a need to alter treatment, initiate a resident's transfer or discharge from the facility or when the resident was involved in an accident with an injury for two (#8 and #2) of four residents out of eight sample residents. Specifically, the facility failed to: -Ensure Resident #8's representative was notified when the resident reported pain to her right hip and had difficulty bearing weight on her right leg on 6/24/25 or when the resident was transferred later that same day from an outpatient physician's office visit to the hospital for Xrays of her right leg; and, -Ensure Resident #2's representative was notified when the resident was sent to a cardiology appointment and started on an anticoagulant medication (a blood thinning medication used to reduce the risk of heart attacks, strokes and blood clots). Findings include: I. Facility policy and procedure The Change in Condition of Status policy, revised January 2021, was provided by the nursing home administrator (NHA) on 7/1/25 at 5:10 p.m. It read in pertinent part, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (changes in level of care, billing/payments, resident rights). A significant change of condition is a major decline or improvement in the resident's status that: -will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; -impacts more than one area of the resident's health status; -requires interdisciplinary review and/or revision to the care plan; and, -ultimately is based on the judgment of the clinical staff and the guidelines outlined in the resident assessment instrument. II. Failed to ensure Resident #8's representative was notified when the resident reported pain to her right hip and had difficulty bearing weight on her right leg on 6/24/25 or when the resident was transferred later that same day from an outpatient physician's office visit to the hospital for Xrays of her right leg A. Resident status Resident #8, age greater than 65, was admitted on [DATE] and discharged to the hospital on 6/24/25. According to the computerized physician orders (CPO), diagnoses included legal blindness, history of falls and muscle weakness. The 6/19/25 minimum data set (MDS) assessment was not completed. The 6/19/25 admission summary documented Resident #8 was alert and oriented to person, place, time and situation. B. Resident representative interview Resident #8's representative was interviewed on 7/1/25 at 3:11 p.m. The representative said Resident #8 was still in the hospital. He said to his knowledge, Resident #8 planned to return to the facility soon. He said he remembered the facility calling him when Resident #8 first fell on 6/21/25, but the facility did not tell him Resident #8 was reporting hip pain and difficulty walking occurring on 6/24/25. The representative said he did not find out about the resident's change in mobility until Resident #8 was at an outpatient physician's appointment on 6/24/25 at 3:45 p.m. He said the physician's office called to tell him they wanted to send Resident #8 to the hospital for Xrays. He said he did not receive an update from the facility about Resident #8 being sent to the hospital until approximately 9:00 p.m. on 6/24/25, after he had already visited Resident #8 at the hospital. C. Record review The progress note, dated 6/24/25 at 5:28 a.m., documented Resident #8 reported pain to her right hip and difficulty bearing weight on her right leg. Registered nurse (RN) #2 documented she would have the day shift nurse conduct an additional assessment of Resident #8 and the day shift nurse would make the appropriate phone calls. -However there was no further documentation of a change in condition assessment for Resident #8 or documentation or documentation to indicate the facility notified the resident's representative of the resident's change in condition. The progress note, dated 6/24/25 at 4:32 p.m., documented the outpatient physician's office contacted the facility to notify the facility that Resident #8 was sent to the hospital from the physician's office for Xrays. The note documented that the outpatient office contacted the resident's representative to inform him of the situation. -However, there was no documentation in the resident's electronic medical record (EMR) to indicate the facility had followed up with the resident's representative to ensure he was aware that the resident had been transferred to the hospital from the physician's office. D. Staff interviews The NHA was interviewed on 7/1/25 at 4:30 p.m. The NHA said the facility was notified by the outpatient physician's office (on 6/24/25) that Resident #8 was being sent to the hospital for Xrays. She said the facility assisted with the resident's transport to the hospital. She said she did not have any documentation that indicated the facility notified Resident #8's representative to inform him that the resident was being admitted to the hospital. She said she recently recognized that the facility could improve the documentation regarding communication with residents' families/representatives. E. Facility follow-up On 7/2/25 at 11:46 a.m. the NHA sent an email communication which documented she had spoken with the nurse caring for Resident #8 on the evening of 6/24/25 and the unit nurse told her she had spoken to Resident #8's representative in the evening (on 6/24/25). The NHA documented in the email that the unit nurse told her she did not document notifying the resident's representative because she thought he already knew. The NHA provided an updated late entry progress note which documented the notification to the resident's representative on 6/24/25 at 8:01 p.m. -However, the resident's representative was not notified by the facility at the time the resident was initially sent to the hospital from the physician's office, at least four hours prior to the progress note documentation on 6/24/25.

Based on observations, record review and interviews, the facility failed to ensure one (#4) of three residents reviewed for abuse out of eight sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #4 from verbal abuse and physical abuse by Resident #5. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised September 2022, was provided by the nursing home administrator (NHA) on 7/2/25 at 11:10 p.m. via email. The policy read in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. II. Facility investigations of incidents between Resident #4 and Resident #5 A. Incident of verbal abuse of Resident #4 by Resident #5 on 5/27/25 The facility investigation was provided by the NHA on 6/30/25 at 2:45 p.m. The investigation documented that on 5/27/25 Resident #5 verbally threatened Resident #4. According to the investigation, Resident #5 was interviewed on 5/28/25, a day after the incident occurred. The alleged assailant interview summary documented Resident #5 was very upset and did not want to see Resident #4 in her hall. The interview summary indicated Resident #5 was instructed to use her call light if she thought someone was going to enter her room. Resident #5 agreed to the use of the call light. The investigation identified Resident #4 was interviewed on 5/28/25, a day after the incident occurred. According to the alleged victim summary, Resident #4 was calm and did not remember the incident. The investigation revealed Resident #5 saw Resident #4 in the hallway. Resident #5 made threatening statements towards Resident #4 while following her and told Resident #4 that she should not be in this hall or around Resident #5's room. The investigation documented the residents immediately were separated as Resident #5 continued to make threatening statements to staff that she would kill Resident #4 if she came into her room. Resident #5 was educated on the use of threatening and strong language towards other residents. According to the investigation, Resident #5 was reassured that staff was always available to make sure that Resident #4 did not enter Resident #5's room. The investigation documented the residents ' rooms were on different sides of the facility and staff were instructed to re-direct residents who wandered down towards Resident #5's room. The facility substantiated the verbal abuse allegation based on interviews with staff and documentation. B. Incident of physical abuse of Resident #4 by Resident #5 on 5/29/25 The facility investigation was provided by the NHA on 6/30/25 at 2:45 p.m. The investigation documented that on 5/29/25 a staff member witnessed Resident #5 grab and choke Resident #4. The residents were assessed and no injuries were noted. Resident #4 was interviewed on 5/29/25. She could not recall the incident. Resident #5 was interviewed on 5/29/25 after the incident. The alleged assailant interview summary documented Resident #5 said she saw Resident #4 coming down the hall and went after her because she did not want the resident to go into her room. The interview summary identified Resident #5 was worried that someone would enter her room. Resident #5 was offered a stop sign across her room door and reminded to use her call light. The facility substantiated that physical abuse occurred. III. Resident #4 (victim) A. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included dementia, severe with mood disturbance, Alzheimer's disease with late onset, cognitive communication deficit, need for assistance with personal care, weakness and difficulty in walking. The 6/10/25 minimum data set (MDS) assessment identified Resident #4 had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. She required assistance with activities of daily living (ADLs) and used a wheelchair for mobility. The assessment indicated the resident had inattention, disoriented thinking and verbal behavioral symptoms directed towards others. The assessment indicated she did not have wandering behaviors. B. Resident interview and observation On 7/1/25 at 4:35 p.m. Resident #4 was in her room sitting on her bed. The resident wore a wanderguard around her ankle. Resident #4 said everyone was nice to her and she felt safe. C. Record review The elopement care plan, revised 3/7/25, identified Resident #4 wandered related to Alzheimer's/dementia or other cognitive deficit behavior. According to the elopement care plan goal, Resident #4's safety would not be endangered related to her behaviors. Interventions, initiated 10/31/24, directed staff to monitor Resident #4's whereabouts frequently and monitor her environment for hazards which may increase need for supervision. The cognition care plan, initiated 11/8/24 and revised 6/25/25, identified Resident #4's severe cognitive deficit impaired her decision making skills. According to the care plan, Resident #4 would wander in the halls and into other residents ' rooms. Interventions included anticipating Resident #4's needs and promptly meeting those needs (initiated 11/8/24) and providing redirection when she wandered (initiated 6/2/25). -The comprehensive care plan did not identify Resident #4 was at risk for abuse due to her cognition and wandering into other residents ' rooms. Review of Resident #4's electronic medical record (EMR) revealed the following progress notes: The 3/28/25 nursing note identified Resident #4 was slapped by another resident (Resident #5). -However, according to the facility investigation, Resident #4 was the aggressor. The 5/28/25 weekly summary note documented Resident #4 had an incident that involved another resident (Resident #5) during the week. According to the note, staff would continue to monitor her. -There was no further documentation regarding the 5/27/25 verbal abuse incident with Resident #5 documented in Resident #4's EMR. The 6/4/25 weekly summary note documented there were no new skin concerns this week and Resident #4 had an altercation with another resident. According to the note, the nurse would continue to monitor. -There was no further documentation regarding the 5/29/25 physical abuse incident with Resident #5 documented in Resident #4's EMR. The 6/10/25 social services note document Resident #4 was pleasant and showed no signs of distress. IV. Resident #5 (assailant) A. Resident status Resident #5, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis, other symptoms and signs involving cognitive functions and awareness, anxiety disorder, depression, dementia in other diseases classified elsewhere, severe with mood disturbance. The 4/15/25 MDS assessment identified Resident #5 had severe cognitive impairments with a BIMS score of six out of 15. Resident #5 did not use a mobility device and was independent with most of her ADLs. She did not have inattention and disoriented thinking, but she had hallucinations and delusions. The assessment did not identify the resident had physical and verbal behavioral symptoms directed towards others. B. Resident interview and observation Resident #5 was interviewed on 7/1/25 at 4:48 p.m. Resident #5 said she was trying to get over being angry. She said there was a lady that lived at the facility that came into her room and destroyed all her photos of her family. She said she beat up the resident when she saw her. Resident #5 said she was going to go after her again when she saw the resident a couple days ago but God stopped her from doing anything. She said a couple staff members saw the resident near her room and ran down the hall to get the other resident away from her. Resident #5 said she was offered a stop sign but the stop sign did not work to keep the other resident out of her room. She said the other resident came into her room anyway. Resident #5 pointed at a balled up stop sign banner resting on top of a box next to the door. She said she just wanted the other resident to stay away from her. She said the other resident's room was on the other side of the facility. She said she had recently accepted the Lord and knew she could not do anything to the other resident. C. Record review The behavior care plan care plan, initiated 6/2/25 and revised 6/12/25, identified Resident #5 was at risk for psychosocial well-being concerns. According to the care plan, she believed that someone else was messing with her belongings in her room. Interventions included assisting Resident #5 with conflict resolution as needed, observing for tearfulness, increased agitation, and decreased participation in care (initiated 4/24/25) and providing her with a stop sign barrier for her room door to reduce anxiety associated with her beliefs that unwelcome people would enter her room (initiated 6/12/25). -The stop sign barrier was not initiated until two weeks after Resident #5 was involved in two abuse incidents with Resident #4 (see investigations above). The psychosocial-mood care plan, initiated 6/2/25 and revised 6/12/25, identified Resident #5 was at risk for decreased psychosocial well-being and adjustment issues, emotional distress, ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing related to depression and dementia with behaviors/hallucinations/delusions. According to the care plan, Resident #5 believed there was a tiny woman in her room and believed residents would come into her room, touch her belongings and possibly take them. The care plan identified Resident #5 would exhibit behaviors of agitation and verbal aggression. Interventions, initiated on 6/2/25, directed staff to administer medications as ordered and monitor for side effects as indicated, assess coping strategies and respect Resident #5's wishes to the extent possible, encouraging her to voice feelings and frustrations as indicated, and listening attentively, observing ineffective sleeping patterns, tearfulness, increased agitation, and decreased participation in care. The anxiety care plan, initiated 5/13/25, directed staff to monitor/record/document occurrences and targeted behavior symptoms of pacing, wandering, disrobing, inappropriate response to verbal communication, and violence/aggression towards staff/others. -The comprehensive care plan did not identify specific residents that Resident #5 should be kept apart from as identified in the 5/27/25 progress note (see below). -The comprehensive care plan did not identify Resident #5 was at risk for abuse or of abusing others. Review of Resident #5's July 2025 CPO revealed a physician's order to document Resident #5's targeted behaviors of combativeness, harm to self or others, delusions, hallucinations or other behaviors, ordered 5/23/25. The May 2025 medication administration record (MAR) identified Resident #5 had behaviors on 5/25/25 (hallucinations), however, the MAR documented the resident did not have any behaviors on 5/27/25 or 5/29/25, marking No for behaviors. -However, Resident #5 was the assailant in a verbal incident with Resident #4 on 5/27/25 and a physical incident with Resident #4 on 5/29/25 (see investigations above). Review of Resident #5's EMR revealed the following progress notes: The 3/16/25 behavior note identified Resident #4 would not leave Resident #5's room so Resident #5 attempted to physically move Resident #4 out of room. Resident #5 reported to staff that Resident #4 would frequently try to go into her room so she would put a trash can in front of her to try to keep Resident #4 out of her room. The 3/28/25 nursing note documented Resident #5 suffered physical abuse from another resident (Resident #4). Resident #5 said she was attacked in her bedroom. According to the note, Resident #5 had a bruise to her right arm from defending herself. The 3/29/25 summary for providers note identified Resident #5 was moved to another room in another unit after the incident because Resident #4 and Resident #5 shared a bathroom. According to the note, the physical altercation incident should not happen again. The 5/27/25 summary for providers note identified Resident #5 had behavioral symptoms of new or worsened delusions or hallucinations and verbal aggression. According to the note, the recommendations were to keep them apart. The note did not identify who to keep apart or details of the 5/27/25 verbal aggression incident. -There was no further documentation regarding the 5/27/25 verbal abuse incident with Resident #4 documented in Resident #5's EMR. The 5/29/25 nursing progress note documented Resident #5 was involved in a resident to resident altercation. The progress note identified the residents were separated and skin assessments were completed. According to the progress note, there were no injuries and Resident #5 was educated to notify staff prior to physical contact with another resident. The 6/2/25 interdisciplinary (IDT) note documented staff met with Resident #5 to provide active listening and determine the root cause of her increased anxiety and fear of others entering her room. The note indicated Resident #5 was provided education regarding language utilized in hallways and around/towards other residents or staff. According to the note, the resident's feelings were validated and offered alternative options when she had increased anxiety regarding other residents, such as staff notification and allowing staff to intervene. The resident was provided with relaxing and coping strategies. The 6/7/25 weekly summary note documented Resident #5's hallucinations were improving. According to the note, there were decreased reports of her seeing other people in the room. However, the note indicated she continued to talk about another resident coming to her room. The note identified Resident #5 started to barricade her room door with a walker. The resident was told that staff would check on her at times and there was no need to barricade the door. The 6/12/25 IDT note documented Resident #5's room had a stop sign barrier in place as needed to reduce her anxiety surrounding the belief that someone may enter her room unwelcomed. According to the note, the resident's Risperdal (anti-psychotic medication) was increased on 6/9/25 due to hallucinations and delusions that resulted in her restless agitation which sometimes escalated to verbal and physical altercations. V. Staff education An undated staff education posting was provided by the NHA on 7/1/25 at 6:56 p.m. The posting documented the purpose of the education was to educate floor staff on effective, person-centered redirection techniques for residents exhibiting confusion, exit-seeking, agitation, or repetitive behaviors related to dementia or cognitive impairment. The education outlined the key points of person-centered redirection techniques, to include understanding the purpose of redirection; recognizing when redirection was needed; techniques; examples and team approaches. According to the education, staff should utilize resident behavior tracking to identify patterns or triggers and communicate redirection strategies during change of shift reports. The posting indicated consistency between the shifts (on the strategies) were essential (see interview below). VI. Staff interviews The NHA was interviewed on 6/30/25 at 4:32 p.m. The NHA identified herself as the facility's abuse coordinator. She said after an abuse incident or allegation, statements would be gathered, skin assessments would be completed, video cameras would be checked and the appropriate parties would be notified. She said she would try to determine what happened and report the incident to the State Agency. Registered nurse (RN) #1 was interviewed on 7/1/25 at 5:07 p.m. RN #1 identified herself as Resident #5's nurse but she said she had only worked with the resident four times. She said she was told Resident #5 had moved to her current room because there was a problem with another resident. She said she had not had any problems with Resident #5. RN #1 said Resident #5 had been polite to her and she had not seen any signs of aggression towards others. She said Resident #5 spent most of her time in her room. She said she was not told there were certain residents that Resident #5 should avoid having contact with or that she should not be near other than residents who wandered. She said she had not seen wandering residents near Resident #5 or her room. RN #1 said she was not told that Resident #5 needed extra supervision or monitoring. She said the resident spent most of her time in her room. The director of nursing (DON) was interviewed on 7/1/25 at 5:16 p.m. The DON said all reports of abuse went to the NHA. She said the facility was in the process of educating staff that if a resident used words identifying they were fearful or words that were threatening, it could be an indication of abuse and needed to be reported. The DON said she was aware of the altercations between Resident #4 and Resident #5. She said the staff were directed to use frequent purposeful rounding to prevent future altercations between the residents. She said the rounding was not documented. She said staff had been notified that there was a resident (Resident #4) that would wander from the East hall to the [NAME] hall were Resident #5 resided. The DON said staff should watch the whereabouts of both residents. She said the residents should be care planned for their risk of abuse. Certified nurse aide (CNA) #2 was interviewed on 7/1/25 at 5:32 p.m. CNA #2 was identified as a CNA for the East hall. CNA #2 said to prevent resident-to-resident altercations, she would redirect the residents and try to find out what the residents needed or offer a distraction. CNA #2 said she was not aware of any residents who had specific interventions to prevent altercations or what frequent purposeful rounding was. CNA #1 was interviewed on 7/1/25 at 5:39 p.m. CNA #1 was identified as a [NAME] side CNA. She said to help prevent resident to resident altercations, she would try to walk with the resident, get them a drink or snack. She said if the resident recognized a certain person as the source of agitation, she would separate the residents from each other. She said she knew staff had separated Resident #4 and Resident #5 from each other because the residents were supposed to remain as separated as possible. She said if the one resident from the East hall wandered down the other hall, staff would distract and redirect her back to her hall. She said she thought the frequent purposeful rounding was brought up at a staff or nurses meeting, but she was not able to stay in the meeting long enough to hear everything about it. The NHA was interviewed on 7/1/25 at 6:13 p.m. The NHA said Resident #4 and Resident #5 had a history of behaviors with each other. She said Resident #4 and Resident #5 used to share an adjoining bathroom. She said Resident #4 would get confused and would exit out the wrong bathroom door and into Resident #5's room. The NHA said staff put up a stop sign by Resident #5's bathroom door but it would continue to happen. She said staff moved Resident #5 out of the room with the shared bathroom and across the hall, but on 3/28/25, Resident #4 went into Resident #5's room again causing a resident to resident altercation. She said Resident #5 agreed to move to a room on the opposite side of the facility. The NHA said Resident #5 started to perseverate on her photos looking different in April 2025 but nothing changed with the photos and no one was doing anything to them. The NHA said Resident #5 was having delusions and a medication change was made. The NHA said on 5/27/25 the residents started to argue in the common area and Resident #5 threatened to harm Resident #4. The NHA said on 5/29/25, staff reported they witnessed Resident #5 was trying to strangle Resident #4. She said she looked at the video footage but could only identify Resident #4's shirt was grabbed by Resident #5. She said neither resident had injuries as a result of the altercations. The NHA said a stop sign at the door was offered to Resident #5 after the physical altercation but the resident did not use it. The NHA said Resident #5 said she did not need it because God told her not to hurt anyone. The NHA was interviewed again on 7/1/25 at 6:27 p.m. The NHA said she provided staff with a verbal education and posted a sign at the East nurses ' station for staff to read after the 5/29/25 resident to resident altercation between Resident #4 and Resident #5. The NHA said she could not find the education posting at the East nurses ' station but would continue to look for it or provide a copy (see above). The NHA said the facility needed to do a better job of documenting interventions and education. She said there was only a short period of time between the verbal abuse incident and the physical abuse incident between Resident #5 and Resident #4 in May 2025. She said staff should have been educated as soon and preferably right after the 5/27/25 incident or first thing the next morning, to help prevent future incidents. The NHA said there should have been more documented, other than a nurse's note that identified the residents should be kept separated after the 5/27/25 incident. She said there might have been another piece of documentation to keep an eye on the residents but she was not sure.

Based on record review and interviews, the facility failed to ensure one ( #1) of three residents were provided the care and services necessary to ensure a safe discharge from the facility to the community out of eight sample residents. Specifically, the facility failed to: -Allow Resident #1 to return to the facility after an unplanned discharge to the hospital; -Provide documentation made by Resident #1 ' s physician, including the specific resident needs the facility could not meet, the facility ' s efforts to meet those needs and the specific services the receiving facility would provide to meet the needs of the resident which could not be met at the current facility; and, -Reassess Resident #1 for readmission after he was stabilized at the hospital and ready to return to the facility. Findings include: I. Facility policy and procedure The Transfer or Discharge policy, revised March 2025, was provided by the nursing home administrator (NHA) on 7/1/25 at 5:10 p.m. The policy read in pertinent part, If the basis for the transfer or discharge is that the transfer or discharge is necessary for the resident ' s welfare, and the resident ' s needs can not be met in the facility, the resident ' s physician (or provider) documents: the specific resident needs that can not be met; the facility ' s attempt to meet those needs; and, the receiving facility ' s service(s) that are available to meet those needs. In situations where the facility determines the resident ' s clinical or behavioral status endangers the safety or health of individuals in the facility, the documentation regarding the reason for the transfer or discharge is provided by a physician or provider (but not necessarily the resident ' s physician or provider). Upon notice of transfer or discharge, the resident is provided with a statement of his or her right to appeal the transfer or discharge, including: the name, address, email, and telephone number of the entity which receives such requests; information about how to obtain, complete, and submit an appeal form; how to get assistance completing the appeal process; and, the facility bed-hold policy. II. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE] and discharged to the hospital on 6/9/25. According to the June 2025 computerized physician orders (CPO), diagnoses included depression, developmental delay in childhood, suicide attempt, skin graft failure, muscle contractures and larynx stenosis (a condition requiring a permanent tracheostomy). The 3/19/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required assistance with eating, bathing and hygiene. The MDS assessment indicated the resident had behavioral symptoms directed at others, including yelling, threatening, cursing and throwing items. B. Resident #1 ' s representative interview Resident #1 ' s representative was interviewed on 6/30/25 at 11:23 a.m. The representative said another representative received a call from the facility in the evening on 6/9/25 to inform them Resident #1 was transferred to the hospital due to his behaviors. The representative said the hospital told her Resident #1 appeared stable in the emergency room and did not meet inpatient criteria. She said the hospital was willing to provide a courtesy admission because Resident #1 required assistance to maintain his tracheostomy. She said she spoke with the NHA the next day (6/10/25) and the NHA told her Resident #1 was not allowed to return to the facility, because they could no longer meet his needs and his behaviors were a danger to himself and others. She said the facility reiterated to her that Resident #1 was not allowed to return to the facility on 6/12/25 and she was served a notice of discharge on [DATE], 11 days after the transfer occurred. The representative said the hospital told her Resident #1 had mildly disruptive behavior but had been redirectable by staff. She said the facility and the hospital had spoken to her about finding a new facility for Resident #1, but he had not been accepted anywhere and remained at the hospital at the time of the interview. The representative said Resident #1 wanted to return to the facility and the representative said she was not aware Resident #1 was allowed to appeal the discharge or who to contact for assistance with filing the appeal. C. Record review The progress note, dated 6/9/25, documented Resident #1 had escalating behaviors throughout the shift including yelling and cursing at staff, threatening to kill everybody, repeatedly slamming his door and attempting to take apart his tracheostomy device. The charge nurse, the NHA and emergency medical services (EMS) were called. Resident #1 was placed on five-minute checks. The note documented that when EMS arrived to the facility, Resident #1 told EMS he wanted to harm the facility staff and he was assisted to the local area hospital by EMS. The notice of discharge, dated 6/20/25, was provided by the NHA on 7/1/25 at 3:35 p.m. It documented the reason for discharge was Resident #1 ' s welfare could not be met in the facility and the safety or health of individuals in the facility was endangered. It documented the needs that could not be met were Resident #1 ' s multiple attempts to harm himself during his stay and he threatened to harm staff. -However, review of Resident #1 ' s electronic medical record (EMR) did not reveal documentation that a physician agreed to the resident ' s discharge. -The section of the form for the physician ' s signature was blank and there was no physician's order for discharge. -The section of the form that indicated the contact information for the ombudsman's office for assistance if the resident wished to appeal the discharge was blank. -Additionally, the facility documented an address to another facility for Resident #1 to discharge to, however the facility listed on the form denied the resident ' s admission. -Review of Resident #1 ' s EMR did not reveal documentation that the facility reassessed Resident #1 after he was stabilized in the hospital and ready to return to the facility in order to determine if the facility could meet the residents needs. III. Interviews A frequent visitor was interviewed on 6/30/25 at 11:23 a.m. The frequent visitor said the local hospital called her on 6/17/25 and informed her the facility refused to readmit Resident #1. She said she contacted the facility on 6/18/25 because she had not received a notice of discharge for the resident. She said the facility told her the NHA decided Resident #1 was not allowed to come back to the facility. She said she received a notice of discharge from the facility on 6/20/25, but she told the NHA the form was missing the contact information for the local frequent visitor required on discharge and she told the NHA she needed a corrected form. She said she had not received a corrected form at the time of the interview. The hospital case manager was interviewed on 7/1/25 at 12:14 p.m. The hospital case manager said Resident #1 arrived at the hospital with the initial complaint of becoming aggressive with staff after an argument over the resident having a can of soda. She said according to observations from hospital staff, Resident #1 had been redirectable with boundaries and reminders from unit staff. She said at no time since his admission to the hospital had Resident #1 required one-to-one supervision or the use of as needed medication to manage his behaviors. She said he told staff he had friends at the facility and would like to return home. The hospital case manager said she contacted her supervisor when the facility told her Resident #1 was not allowed to return to the facility. She said the regional operations manager from the facility told her Resident #1 had an accepted referral to a sister facility. She said when she contacted the sister facility, she was told the facility had not received referral information for Resident #1. The supervisor of case management for the hospital was interviewed on 7/1/25 at 12:38 p.m. supervisor of case management said she spoke with the regional operations manager for the facility on 6/20/25. She said the regional operations manager told her he reached out to other facilities in their network. She said she heard back from the regional operations manager later and only one facility considered admitting Resident #1, but declined due to his tracheostomy. She said she had not heard anything new from the facility since those referrals fell through. The facility ' s admissions assistant was interviewed on 6/30/25 at 1:52 p.m. The admissions assistant said she usually managed the discharge process for residents at the facility. She said normally if a resident needed to be sent to a hospital, it was a transfer and completed by nursing staff because the expectation was for the resident to return to the facility. She said when she found out Resident #1 was transferred to the hospital and discharged from the facility without notice, she told the NHA she was not comfortable completing the discharge. She said to her knowledge, the NHA completed the discharge process for Resident #1. The NHA was interviewed on 6/30/25 at 3:12 p.m. The NHA said she was called about Resident #1 ' s behavior on 6/9/25 and directed the nursing staff to contact EMS. She said a few days later, the hospital was requesting to send Resident #1 back to the facility. She said she spoke with her regional operations manager and they agreed that Resident #1 was not allowed to return to the facility because the facility could not meet his needs and because Resident #1 was a danger to himself and other residents. She said when the interdisciplinary team (IDT) reviewed his case, the facility did not follow all of the regulations for Resident #1 ' s discharge, but felt the danger Resident #1 posed to other residents and staff outweighed the risk. She said she and the regional operations manager contacted other facilities in their network but the only potential facility fell through. The NHA said the last time she spoke with the case manager from the local hospital was approximately 6/23/25 when the potential facility fell through. She said to her knowledge, Resident #1 remained at the hospital as of the time of the interview.

Based on record review and interviews, the facility failed to ensure that residents requiring treatments and services for mental disorders or psychosocial adjustment difficulties received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well being for one (#1) of three residents reviewed out of eight sample residents. Specifically, the facility failed to provide mental health counseling services for Resident #1. Findings include: I. Facility policy and procedure The Behavioral Health Services policy, revised February 2019, was received from the nursing home administrator (NHA) on 7/1/25 at 5:53 p.m. The policy read in pertinent part, Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care. Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. II. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE] and discharged to the hospital on 6/9/25. According to the June 2025 computerized physician orders (CPO), diagnoses included depression, developmental delay in childhood, suicide attempt, skin graft failure, muscle contractures and larynx stenosis (a condition requiring a permanent tracheostomy). The 3/19/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident had behavioral symptoms directed at others including yelling, threatening, cursing and throwing items. The resident required assistance with eating, bathing and hygiene. B. Record review Review of the behavior care plan, revised 5/20/25, revealed Resident #1 exhibited symptoms of striking out, grabbing others, verbally or physically abusive, rearranging his room and furniture and inappropriate sexual behavior. Interventions included administrating antipsychotic medications, behavior monitoring by staff for changes in behavior, documentation of changes in behavior including frequency and potential triggers and providing a psychiatrist consultation as indicated. The Preadmission Screening and Resident Review (PASRR) Level II notice of determination for mental illness, dated 3/4/24, revealed specialized services were required for Resident #1. Services required included psychiatric case consultation, individual therapy and a neuropsychological assessment to understand his capacity and the assistance he required. The progress note, dated 4/27/25 at 10:53 p.m., revealed Resident #1 slammed his bedroom door and cursed at staff when staff attempted to redirect Resident #1 from giving soda to another resident who was diabetic. The progress note, dated 5/1/25 at 1:37 p.m., revealed Resident #1 yelled at staff when Resident #1 was asked by staff to leave another resident's room while the resident was not in the facility. The progress note, dated 5/2/25 at 8:25 a.m., revealed Resident #1 cursing at the respiratory therapist after the respiratory therapist noted the room was rearranged and asked the resident where he placed the suction machine. The progress note, dated 5/5/25 at 10:42 p.m., documented Resident #1 had sexually inappropriate behavior toward staff The progress note, dated 5/7/25 at 10:26 a.m., documented Resident #1 cursing at staff. -Review of Resident #1's electronic medical record (EMR) did not reveal documentation that indicated the facility set-up psychiatric case consultation or individual therapy despite the resident having increased behaviors. III. Staff interviews The nurse manager (NM) was interviewed on 6/30/25 at 2:54 p.m. The NM said he was the nurse on the unit the day Resident #1 was transferred to the local area hospital and the nurse who called emergency medical services (EMS). He said Resident #1 attempted to take apart and remove his tracheostomy multiple times on 6/9/25. The NM said Resident #1 had previous outbursts, but normally if the resident was asked to stop and given space he would calm down. The NM said on 6/9/25 Resident #1 was unable to be redirected and his behavior endangered himself and other residents. The NM said he did not know if Resident #1 received any individual therapy services, but the team was attempting to adjust his medications and the activities staff were trying to help with the resident's behavior with non-pharmicological interventions like music. The NHA was interviewed on 6/30/25 at 3:12 p.m. The NHA said in March 2025 Resident #1 left for the week to visit family. She said she was contacted and informed the police were called out to the home during the family visit due to a family altercation. She said Resident #1 had increased behavioral symptoms after this visit. She said when reviewing the weeks of documentation prior to Resident #1's discharge, she noted other times Resident #1 attempted to take apart his tracheostomy and that the facility could no longer keep the resident safe. Cross reference F627: failure to complete an appropriate discharge. The social services director (SSD) was interviewed on 6/30/25 at 3:48 p.m. She said she spoke with Resident #1 frequently, often checking in with him daily. She said when Resident #1 returned to the facility in March 2025 he told her his visit with family was not good and he could not go back. She said initially Resident #1 did not have increased behavior the week after the visit, so she thought he was okay. The SSD said Resident #1 did not receive any individual therapy services because the facility did not have a contract with a third party to provide individual therapy sessions until recently. She said it had been a long time since the previous company stopped providing services. She said to her knowledge, Resident #1 had not received individual therapy services since he was admitted to the facility on on 10/19/24 to present. The NHA was interviewed again on 7/1/25 at 6:12 p.m. The NHA said the facility signed a contract with a new mental health provider on 5/27/25. She said she was not sure when the previous contract ended, but it had been a long time. The NHA said the facility used to have a provider that met with the residents in person, but they started showing up less frequently until they no longer came to the facility at all. The NHA said the facility then contacted a telehealth company for remote mental health services but the residents did not like the remote sessions. She said she did not know if any individual mental health services were provided to Resident #1 this spring while his behaviors escalated.

Based on observations, record review and interviews, the facility failed to ensure one (#54) of five residents out of 45 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #54 was admitted to the facility for long term care on 11/10/23 with diagnoses of chronic obstructive pulmonary disease (COPD), diabetes and generalized muscle weakness. The resident was initially weighed on 11/19/23 and weighed 149 pounds (lbs). The resident was admitted to the hospital from 1/2/24 to 1/8/24 for electrolyte imbalances. Upon readmission to the facility the resident weighed 135.2 lbs. On 1/22/24 and 1/29/24 the resident weighed 123.6 lbs. On 2/5/24 the resident weighed 123 lbs. The resident sustained a 26 lbs (17.4%) weight loss in three months and 12.2 lbs (9%) in one month, which was considered severe weight loss. The facility failed to assess the resident and implement nutrition interventions after the resident sustained severe weight loss on 2/5/24. The facility did not weigh the resident after she sustained severe weight loss, despite the registered dietitian (RD) requesting the resident to be weighed. Findings include: I. Facility policy and procedure The nutritional assessment policy, revised October 2017, was provided by the nursing home administrator (NHA) on 6/11/24 at 3:14 p.m. It documented in pertinent part: The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident' s risks for nutritional complications. Such interventions will be developed within the context of the resident' s prognosis and personal preferences II. Resident #54 A. Resident status Resident #54, over the age of 65, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included COPD, diabetes type II and generalized muscle weakness. The 4/9/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required set-up or clean-up assistance with eating. The resident required substantial or maximum assistance with transfers, showers, toileting and personal hygiene. The assessment documented the resident was 64 inches (5 foot, 4 inches) tall. The assessment did not indicate the residents weight. It documented the resident had not had any significant weight loss or weight gain. -However, the resident had sustained a 26 lbs (17.4%) weight loss in three months and 12.2 lbs (9%) in one month, which was considered severe weight loss. B. Resident interview Resident #54 was interviewed on 6/6/24 at 9:41 a.m. Resident #54 said she preferred to eat in her room with her roommate. Resident #54 said she was served scrambled eggs for breakfast several times per week and she did not like them because of how bland they were. Resident #54 said she sent her breakfast back several times each week because of how bland the scrambled eggs were. Resident #54 said she had lost weight because of this. Resident #54 said she skipped several meals throughout the week because she did not like to eat the bland eggs. Resident #54 said she often felt very hungry by lunch time. C. Observations On 6/10/24 at 8:12 a.m., Resident #54 was observed to have a breakfast tray on her bedside table. The breakfast had been consumed except for scrambled eggs that were untouched on the breakfast tray. D. Record review The nutrition care plan, initiated on 11/21/23 and revised on 11/28/23, documented the resident was at a minimal nutritional risk with consistent food intake greater than 50%. The care plan documented the resident would be offered nutrition for comfort and pleasure while the resident was receiving hospice services. The interventions included monitoring the resident' s intake, obtaining weights as ordered, completing an assessment by the RD and monitoring the resident' s skin for signs of breakdown. -However, a review of the resident' s electronic medical record (EMR) did not reveal the resident was receiving hospice services. -A review of the comprehensive care plan did not reveal documentation indicating new interventions were implemented after the resident sustained severed weight loss on 2/5/24. The 11/14/23 dietary pre-screen assessment documented the resident liked fried and poached eggs and spicy foods. The resident was hospitalized on [DATE], and readmitted to the facility on [DATE] for electrolyte imbalances. The December 2023 CPO revealed Resident #54 was to be weighed weekly for four weeks on Friday mornings, initiated on 11/17/23 and discontinued on 12/8/23. The June 2024 CPO revealed the resident had a physician' s order to be weighed weekly for four weeks, every Monday, ordered 1/15/24 and discontinued on 2/6/24. Resident #54' s weights were documented in the EMR as follows: -On 11/19/23, the resident weighed 149 lbs; -On 1/8/24, the resident weighed 135.2 lbs; -On 1/22/24, the resident weighed 123.6 lbs; -On 1/29/24, the resident weighed 123.6 lbs; and, -On 2/5/24, the resident weighed 123 lbs. -The resident lost 12.2 lbs (9%) from 1/8/24 to 2/5/24, in one month, which was considered severe. -The resident lost 26 lbs (17.4%) from 11/19/23 to 2/5/24, in three months, which was considered severe. -No additional physician orders to obtain weight were documented in the resident' s EMR. The facility had not obtained the resident' s weight in more than four months between 2/6/24 and 6/11/24 after this significant weight loss was documented. A review of the certified nurse aide (CNA) task response history (from 5/15/24 to 6/11/24) revealed staff had documented the amount the resident had eaten for 51 out of 81 meal opportunities during the review period. -There were no documented resident refusals for meals. It was documented the resident ate less than 50% of her meals for two of 51 documented meals. The 6/11/24 nutrition progress note documented the resident was last weighed on 2/5/24 when the resident weighed 123 pounds. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 6/10/24 at 8:42 a.m. LPN #1 said he had seen the kitchen serve Resident #54' s scrambled eggs. He said when this occurred he would ask the kitchen for different eggs. LPN #6 was interviewed on 6/12/24 at 10:29 a.m. LPN #6 said there was not a current physician' s order to weigh Resident #54 weekly or monthly. LPN #6 said nursing staff followed the physician' s order for obtaining the resident's weights. She said a nurse could request to weigh a resident if there was a weight concern identified by nursing staff. The RD was interviewed on 6/12/24 at 11:47 a.m. The RD said the facility did not have a current weight for Resident #54. The RD said she was concerned about the facility using different scales from January 2024 to February 2024 to weigh the resident. The RD said she had verbally requested the nursing staff to obtain additional weights. The RD said she did not document when she requested to have the resident reweighed after 2/5/24. The RD said she did not know why the significant weight loss was not identified or followed up on. The RD said new interventions should have been identified when Resident #54 sustained significant weight loss to prevent further weight loss. The director of nursing (DON) was interviewed on 6/12/24 at 1:05 p.m. The DON said Resident #54 experienced significant weight loss and the facility did not identify it. The DON said no new nutrition interventions were implemented to prevent further weight loss after 2/5/24. The DON said no new weights were obtained for Resident #54 after she sustained severe weight loss on 2/5/24. The DON said Resident #54 should have had her significant weight loss identified in her plan of care and more weights should have been obtained after 2/5/24 to monitor the resident' s status. The DON said the facility could have offered a nutritional supplement, such as a Mighty shake (frozen nutritional supplement), to help maintain Resident #54' s weight. The DON said she was not aware of any inaccurate scales in the facility. The DON was interviewed again on 6/12/24 at 4:32 p.m. The DON said the quality assurance and performance improvement (QAPI) committee had identified that the facility had an issue obtaining and documenting weights in the facility within the last few months, but had not implemented a correction plan. The DON said she needed to work with the RD to ensure residents were getting weighed on a regular basis. The DON said she needed to review weight loss interventions in the facility to ensure they were being updated and documented.

Based on observations, record review and interviews, the facility failed to prevent accidents for two (#2 and #4) of five residents reviewed for accident hazards out of six sample residents. The facility failed to ensure Resident #2's minimum data set (MDS) assessment regarding transfer assistance was accurately reflected in her care plan. The facility failed to provide two person transfer assistance for Resident #2, who had [DIAGNOSES REDACTED]. The resident's care plan, a staff directive for care, was not reflective of her current care needs in relation to what level of assistance she required for transfer. Due to the facility failures, Resident #2 sustained a left [MEDICAL CONDITION] when being transferred by certified nurse aide #5 without having the required assistance of two persons. After Resident #2 suffered a fall and fracture, the facility failed to ensure CNA #5 was provided sufficient training related to the necessity of two-person transfers for Resident #2. The only documentation provided was a corrective action plan to CNA #5 for failure to follow the resident's care plan. Additionally, the facility failed to ensure Resident #4's ordered fall precautions were implemented, which included a fall mat, the bed placed in the lowest position and a lipped mattress. These failures resulted in Resident #4 sustaining a fall. The facility failed to ensure Resident #4 was assessed by a registered nurse prior to moving the resident after the fall. A CNA lifted the resident from the floor to the bed prior to the resident's assessment after the fall. Resident #4 did not have thorough and complete neurological checks adequately performed. Findings include: I. Facility policy and procedure The Fall Management policy, revised 9/10/19, was provided by the director of nursing (DON) on 12/16/2020 at 10:40 a.m. The documented purpose of this policy was to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. It documented a plan of care would be implemented based on the resident's assessed needs. It documented individualized care plan interventions would be implemented for those residents found to be at high risk for falls. It documented a fall intervention would be to complete a thorough analysis of the fall, including time of the day, location of the fall and other causative factors. It documented the facility should identify if interventions were in place at the time of the fall, partially by interviewing staff and residents, if able, to identify potential causative factors. It documented education and communication of the implemented interventions should be shared with direct care staff via a verbal report. It documented if a resident experienced a fall with head injury, if the fall was unwitnessed or if the resident self-reported a fall, neurological checks would be initiated. II. Resident #2 A. Resident status Resident #2, age 94, was originally admitted on [DATE] and was readmitted from the hospital following her fracture on 11/5/2020. According to the face sheet, [DIAGNOSES REDACTED]. According to the MDS assessment completed 8/19/2020, the resident had moderate to severe cognitive deficits with a brief interview for mental status (BIMS) cognition score of seven out of 15. It documented the resident required extensive assistance of two or more for physical assistance in transferring. The resident required extensive assistance of two or more for toileting. The resident was not on a current toileting program, but was occasionally incontinent of urine and bowel. This assessment documented Resident #2 displayed physical behaviors directed towards others, such as pinching and biting, as well as verbal behaviors towards others one to three days during the seven-day lookback period. The MDS assessment completed 11/16/2020 documented the resident had fallen in the last month prior to her readmission, had fallen in the last two to six months and sustained a fracture related to a fall in the past six months. Resident #2 had sustained two or more falls with no injury, two or more falls with injury and two or more falls with major injury since the prior MDS assessment dated [DATE]. The MDS assessment completed 11/11/2020 documented the resident had severe cognitive impairment with a BIMS score of five out of 15. The resident was totally dependent on two or more for transfers and required extensive assistance of two or more for toileting. The resident was occasionally incontinent of urine and always incontinent of bowel. B. Resident observations Resident #2 was observed on 12/15/2020 at 9:51 a.m. She was in bed with a fall mat on the floor beside her bed. She had her call light on and said she needed to pee. A housekeeper was observed passing the resident's room several times. Many staff were present near the nurse's station, which was three resident rooms down the hall. The resident's call light was answered at 9:54 a.m. by concierge #1. The concierge said she used to be a certified nurse aide (CNA), but was now a concierge. She said she was going to find a CNA to help toilet the resident. The CNA arrived at 9:58 a.m. and asked the social services director (SSD) to assist her with Resident #2's transfer. The resident was toileted at 9:59 a.m. Resident #2 was observed on 12/15/2020 at 12:16 p.m. She was in bed with the head of the bed raised. The bed was in the low position and the fall mat was on the floor beside the bed. She said she was not hungry and not to worry about lunch for her. Resident #2 was observed on 12/16/2020 at 10:15 a.m. She said she wanted a pillow placed under her head. She said everyone was treating her well at present. Resident #2 was observed on 12/16/2020 at 12:45 p.m. She was propped up in bed, eating her lunch. The fall mat was on the floor next to the bed and the bed was in the low position. C. Record review The care plan dated 8/25/2020 documented the resident was generally continent of urine with the use of a bedpan, but had some instances of incontinence. It documented the resident had daily living self-care performance deficits related to impaired mobility, post [MEDICAL CONDITIONS]/[MEDICAL CONDITION] affecting her non-dominant left side. It documented the resident would receive her cares in pairs for personal/peri cares by two female caregivers. It documented the resident required extensive assistance by one staff to move between surfaces, bed to wheelchair and as necessary. The care plan dated 11/11/2020 documented that after the resident's new left femur fracture, she required a two-person assist for transfers following surgery. It documented the resident fixated on toileting and would request to use a bedpan every 30 minutes at times. It documented the resident required two staff in her room while one staff checked the resident for incontinence and the need for incontinent care or toileting needs. It documented two staff would assist the resident with her toileting needs. It documented the resident only wanted female caregivers. It documented the resident was dependent with a two-person transfer via a Hoyer lift (mechanical lift) for transfers to move between surfaces, bed to wheelchair and as necessary. -The resident's care plans were not reflective of her care needs as documented in the resident's MDS assessments (see above). The note documented by a registered nurse (RN), dated 10/31/2020 at 11:42 p.m., documented staff heard yelling from Resident #2's room and responded at approximately 10:00 p.m. earlier that evening. The staff found Resident #2 on her back, on the floor of her room. It documented a certified nurse aide (CNA) had attempted to transfer the resident to the bedside commode and the CNA said she slipped. It documented CNA #5 stated she kept the resident from hitting her head and assisted the resident to the floor. It documented Resident #2 was initially able to move all extremities while on the floor and was assisted to the bedside commode, then into bed. Resident #2 complained in Spanish that she had left leg pain and was pointing to her left hip and leg. The on-call physician was contacted at approximately 10:15 p.m., who did not wish to transport the resident to the hospital and recommended monitoring the resident and medicating her for pain. Resident #2 refused all pain medications. Three calls were placed to the resident's power of attorney with no response. Resident #2 continued to call out in pain. The on-call physician was re-contacted at approximately 10:30 p.m. and gave the order to transport the resident to the local hospital for evaluation and treatment. The power of attorney did call back, was made aware of the situation and agreed with the plan to transport to the hospital. The resident was transported via 911 at approximately 11:00 p.m. The intercepted fall investigation dated 10/31/2020 at 10:00 p.m. was reviewed. It documented CNA #5 called the registered nurse (RN) who assessed the resident and stated she was attempting to transfer Resident #2 to the bedside commode when the CNA lost her balance and lowered the resident to the floor. She stated the resident did not hit her head. The resident stated she slipped on her urine and it was not the CNA's fault. The resident said her left leg hurt. There was urine on the floor when she was assisted to bed. The resident was assessed on the floor prior to being assisted to the bedside commode, then back into bed. The resident began complaining of left leg pain and inability to move her left leg when she was back in bed. All extremities were moved with no external rotation of the hip deformity of joints noted. The resident refused all oral medications and wanted to go to the hospital. The nurse received orders to transport and was sent to the local hospital via emergent ambulance. A wet floor was not checked as an environmental factor on this investigation. Predisposing physiological factors for the resident's fall included a gait imbalance, being a high risk for falls, being incontinent, having poor safety awareness and impaired memory. There was no documentation in this post fall investigation that Resident #2 was being transferred by only one CNA just prior to her fall. This was contradictory to the extensive assistance of two or more staff indicated in the resident's MDS (see above). The post fall investigation did not address or analyze if delayed call light response time was a contributor to the resident's fall. The interdisciplinary team (IDT) risk management review note dated 11/1/2020 documented an intercepted fall. The root cause was determined to be behaviors, functional decline, poor safety awareness/insight and accuracy of care plan. The treatment required was the resident being transferred to an acute hospital for higher level of care. Interventions to be put into place were documented as not applicable. It only noted the facility would conduct a facility wide audit of MDS versus care plans. The fall risk evaluation dated 11/1/20 documented the fall risk score was 16, which meant Resident #2 was a high fall risk. It documented the resident had periods of confusion, sustained one to two falls in the past 90 days and was wheelchair/bed bound and needed assistance with elimination. It documented the resident had three or more [DIAGNOSES REDACTED]. The note dated 11/5/2020 documented Resident #2 was being readmitted following her hospitalization , her most recent COVID-19 test was negative and the resident was being placed on quarantine with transmission-based precautions for 14 days. The note dated 11/5/2020 at 10:54 p.m. documented the resident had recently returned from the hospital with a surgical repair of a left [MEDICAL CONDITION], had sutures under the dressing that were clean, dry and intact. It documented the resident now required two-person transfer with a Hoyer lift, was using a bedpan instead of the bedside commode and was being repositioned as frequently as needed. It documented the resident was alert and oriented to person and place, was confused, but was able to use her call light. It documented Resident #2 needed two-person assistance for her safety. The note dated 11/6/2020 at 11:11 p.m. documented the resident required two-person assist with all cares for safety and complained of mild pain to her left hip, mostly with movement. The note dated 11/21/2020 at 10:39 p.m. documented the incisions to the resident's left hip and thigh were open to air, well-approximately with steri-strips in place. It documented the staples were removed two nights ago. D. Corrective action for CNA #5 The corrective action form dated 11/3/2020 documented on the evening of 10/31/2020, CNA #5 failed to follow Resident #2's care plan. It documented while the resident's care plan stated the resident was a one-person assist for transfers, she was a two-person or care in pairs for behavioral health care needs. It documented CNA #5 was alone in the room with the resident when the resident fell and suffered a fracture. The corrective action form did not include any additional, specific education provided to CNA #5 related to exactly why Resident #2 required two-person transfers, both before and after the resident's injury. E. Resident representative interview The resident's representative was interviewed on 12/17/2020 at 9:00 a.m. The resident's representative stated there was only one CNA in the room caring for Resident #2 the evening of 10/31/2020 when she sustained her fall and subsequent [MEDICAL CONDITION]. The resident representative stated he did not want CNA #5 to care for Resident #2 anymore. F. Staff interviews The nursing home administrator (NHA) and director of nursing (DON) were interviewed together on 12/15/2020 at 1:19 p.m. They said they reported Resident #2's fall to the State Agency. They said the fall occurred close to 10:00 p.m. on 10/31/2020 and it was right around shift change. They said CNA #5 assisted Resident #2 to the bedside commode and back by herself. They said, during the transfer, Resident #2 thought she had urinated and both Resident #2 and CNA #5 fell . They said CNA #5 made of point of not allowing Resident #2 to hit her head. They said Resident #2 reported no pain immediately after the fall and staff got the resident up off the floor and assisted her back into bed. They said Resident #2 began complaining of pain when in bed, so staff requested transportation to the hospital for x-rays and treatment. The DON said the facility had always done two-person transfers and peri-care due to the resident's history of making allegations about facility staff. She said, however, the resident's care plan documented the resident should be transferred with extensive assistance of one for some reason. The DON was unable to state why the care plan did not document the required assistance of two for transferring due to past behaviors. She said the resident was able to transfer with the assistance of one with a stand-pivot transfer. She said the facility had enough staff working that night to perform a two-person transfer. She said the resident currently was not experiencing any pain related to her [MEDICAL CONDITION], but was fixated on pain and what might hurt her since she sustained the fall. CNA #5 was interviewed on 12/15/2020 at 4:30 p.m. She said, on the evening of 10/31/2020, she answered the call light and proceeded to transfer Resident #2 to the bathroom by herself. She said, at the time of the fall, Resident #2 was a two-person transfer according to her care plan, as there should have been two staff in the room for the transfer and cares because of the resident's history of behaviors. She said she was aware the resident should have been transferred with two staff, did not want to call the nurse to assist her, as she had been transferring the resident by herself numerous times prior to this fall. She said she usually called for a second staff when getting the resident off the commode because the second person would assist by pulling up the resident's pants. She said she stood Resident #5 up, pulled her pants down and sat the resident on the bedside commode. She said upon transferring the resident back to bed, she felt Resident #2's teeth on her arm and, at the same time, tried to balance the resident by spreading her own legs further apart for a wider stance. She said her right leg buckled and lost strength and both she and the resident fell . She said she was able to secure the resident's head to avoid a head injury and the resident did not hit her head during the fall. She said, during the fall, she tried to sit the resident down onto the floor, as both were below the sink area. She said she called for the registered nurse (RN) who was working that shift, who came to assess the resident. Following the assessment, the resident was placed back on the commode. She said Resident #2 was crying and speaking Spanish. She said she tried to clean urine up off the floor, as the resident was incontinent after the fall. She said there was no urine on the floor at the time of the actual fall and the urine was not a contributing factor for the fall.CNA #5 said, following the resident's fall, no additional education was provided to her She said the facility had provided enough information prior and she did not need any additional education. The social services director (SSD) was interviewed on 12/16/2020 at 9:50 a.m. She said she assisted with Resident #2's care on 12/15/2020 by witnessing the transportation aide, who was also trained as a CNA, assisting the resident onto a bed pan. She said she was only a witness and did not assist in the actual transfer. She said prior to the fall, the resident required two staff to transfer the resident; one to perform the actual transfer and the other to assist with clothing and pulling the resident's pants up or down. She said, at times, the resident would need the Sara lift (mechanical lift) when she was unstable prior to the fall. The SSD said at present, the resident was totally dependent for transfers with two staff and a Hoyer lift. The DON was interviewed on 12/16/2020 at 10:15 a.m. She said Resident #2 was still a two-person transfer. She said she did provide corrective action CNA #5 following the fall and provided documentation of the corrective action at this time. In relation to the IDT, risk management review note dated 11/1/2020, the DON said she thought accuracy of care plan was a poorly worded root cause for the fall, as documented by the interim NHA at the time. She said the facility should have documented the root cause of the fall as staff not following the care plan, which was driven by the MDS. She said the facility would be providing further education to all staff about the necessity of two-person transfers for residents and the exact reasons why a two-person transfer was needed with specific residents. The NHA was interviewed on 12/16/2020 at 1:15 p.m. He said any staff walking by a call light should be answering the call light to see what the resident needed. He said any staff should follow their licensed ability in relation to providing resident cares. He said it was his administrative philosophy for all staff to answer call lights, as he himself, was answering call lights and it was only his third week on the job in this facility. He said he was just laying the foundation for the facility's philosophy for resident care. III. Resident #4 A. Facility policy and procedure The Assessing Falls and Their Causes policy and procedure, dated March 2018, was provided by the DON on 12/17/2020 at 10:33 a.m. It revealed after a resident fell , they were to be evaluated for possible injuries to the head, neck, spine, and extremities. VS should be obtained and recorded as soon as it was safe to do so. If there was any evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. If an assessment ruled out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. Observe for delayed complications of a fall for approximately forty-eight hours after an observed or suspected fall, and document the findings in the medical record. B. Resident #4 status Resident #4, age 92, was admitted [DATE]. According to the December 2020 CPO, [DIAGNOSES REDACTED]. The 10/21/2020 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of two out of 15. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene, and had no [MEDICAL CONDITION], behavioral symptoms or rejection of care. He was always incontinent of bowel and bladder and was not on a toileting program. He had one fall without injury since the prior assessment and received scheduled pain medication. C. Record review The care plan, dated 5/20/2020 and revised 12/1/2020, identified the resident was at high risk for falls related to impaired mobility, poor safety awareness, did not always use the call light, and would attempt to transfer himself. He had a history of [REDACTED]. The December 2020 CPO included the following order: High/low bed, lipped mattress, fall mat for safety due to poor safety awareness. The order was started on 6/16/2020. A progress note, dated 11/14/2020, included an incident note that documented the resident was found on his bottom in front of his wheelchair. His call light was within reach, there was adequate lighting in his room, and denied pain. He was placed on neurological (neuro) checks. The Neurological Assessment Flow Sheet, dated 11/14/2020, was started at 12:15 p.m., at the time of his fall, and ended 11/17/2020 at 7:15 a.m. The form revealed the resident was sleeping four times and no neuro checks were completed at those times. An interdisciplinary team (IDT) progress note, dated 11/20/2020, reviewed the fall that occurred on 11/14/2020 and determined the root cause was his dementia, poor safety awareness, generalized weakness, and over independent behavior. His wheelchair cushion was swapped out and no referrals were made. An incident report, dated 11/28/2020 at 5:45 p.m., documented the resident was found down by a CNA and he was lying on the floor in front of his chair in his room. He was laying on his right side with his head resting on his right arm. The resident was lifted off the floor and placed into his bed by the CNA. The resident was unable to give a description of the incident. The resident was lifted off the floor and into the bed by the CNA, who then informed the RN (registered nurse). The RN assessed the resident and found him to be at baseline. No injuries were observed at the time of the incident. The RN who completed the incident report was RN #1 and the CNA was identified as CNA #7. The Neurological Assessment Flow Sheet, dated 11/28/2020, was started at 5:45 p.m. for the above fall, and ended on 12/1/2020 at 10:00 a.m. The form revealed the resident was sleeping five times and no neuro checks were completed at those times. A hand-written note on the form documented, Did not finish. A progress note, dated 11/30/2020 at 12:26 p.m., documented the following: A licensed practical nurse (LPN) was walking by the resident's room and saw him mid self-transfer and fell with no head involvement. The LPN notified the RN on shift, who assessed the resident and no injuries were noted. An IDT progress note, dated 12/1/2020, reviewed the fall that occurred on 11/30/2020 and determined the root cause was from his attempt to ambulate without assistance. No treatment was required and the new intervention put into place was to offer a helmet to increase his safety if he fell . A progress note, dated 12/1/2020, documented the resident had a witnessed fall on 12/1/2020 and he was currently on neurological checks due to the fall two days prior, on 11/28/2020. The resident did not remember falling and he denied any pain or injury. 4. Observations and initial staff interviews On 12/15/2020 at 2:32 p.m., Resident #4 was lying in bed in his room. He was awake and restless, with his hands on his head. His mattress was a flat, not lipped, and there was no fall mat on the floor. On 12/16/2020 at 12:12 p.m., Resident #4 was lying in bed in his room. His mattress was flat, not lipped, and his bed was not in the lowest position. There was no fall mat on the floor and there was no call light within the resident's reach. CNA #6, who was caring for Resident #4, said his mattress was just a regular mattress, and she did not know what a lipped mattress was. She said she did not know what a high/low bed was, or if the resident was on one. She said she was getting ready to take his lunch to him and would check the bed at that time. At 12:40 p.m., CNA #6 said Resident #4's bed was a high/low bed, but it had not been in the lowest position that morning. She confirmed there was no fall mat on the floor or in his room. She said she thought he was able to use his call light purposefully. D. Staff interviews CNA #7 was interviewed on 12/16/2020 at 1:40 p.m. He said Resident #4 fell on [DATE] around shift change, and he found him lying on the floor in his room. He said he was lying on his right side with his head cushioned on his arm as a pillow and appeared pretty relaxed, and was not complaining of pain. He said he informed RN #1 that Resident #4 fell , and said he did not check his vital signs right away because he was waiting for the RN to assess him first. CNA #7 said RN #1 was busy with another resident and he waited with Resident #4 for approximately 20 minutes, then decided to assist the resident back into the wheelchair he had fallen out of. He said Resident #4 kept repeating, Pick me up, so he used his gait belt and assisted the resident up by himself and placed him in bed. CNA #7 said he did not notice any injuries to the resident and he was not complaining of pain. He stated, I know I shouldn't have done that, and (RN #1) was busy, so I did it myself. He said the facility had provided him with education in the past that if a resident fell , they should not be moved until an RN had assessed them. CNA #7 said the resident had fallen out of his wheelchair while he was eating his dinner, and the fall mat was closer to the bed than the chair. He said Resident #4 did not use his call light and would yell out for help instead. He said he did not believe the resident had a lipped mattress and had never fallen out of bed before. RN #1 was interviewed on 12/16/2020 at 4:44 p.m. He said CNA #7 informed him right around shift change on 11/28/2020 that a resident had fallen out of his wheelchair in his room. He said there was confusion as to which resident it was, and he went and assessed another resident who routinely sat on the floor, rather than Resident #4. A while later, CNA #7 told RN #1 that he had put Resident #4 back in bed before he had assessed him. RN #1 said he had to ask CNA #7 what position the resident was found in, and that he was laying on his side with his head resting on his arm, like he had just gotten comfortable. The RN said after he was informed by CNA #7 that Resident #4 had fallen, he went to the resident's room just a couple minutes later after he put him back in bed. RN #1 said an RN needed to assess residents after they had fallen and prior to moving them. RN #1 said neurological checks should be started as soon as possible for a resident who had fallen and hit their head, or had an unwitnessed fall. The DON was interviewed on 12/16/2020 at 1:10 p.m. She said she was out of the facility for personal reasons when the fall occurred and was not aware CNA #7 had moved Resident #4 after he fell before the RN was able to assess him. She explained she had researched the fall and there was another resident on the same hall as Resident #4 who routinely got down on the floor and crawled around, and he was on the floor at the same time Resident #4 had fallen. There was confusion as to which resident had fallen and the RN did not arrive to assess the resident right away. She said she had spoken to CNA #7, and he told her he knew he was supposed to get the nurse to assess residents who had fallen before they were moved, but he did not do that in this case. She said it was her understanding that CNA #7 informed RN #1 about Resident #4's fall after he had already put him back in bed. She said RN #1 completed the assessment after the resident was back in bed. The DON said neuro assessments/checks were completed after a fall that was unwitnessed, or if the resident hit their head, and should be completed for a total of 72 hours after a fall. She said it was the expectation to wake the resident up if they were sleeping in order to conduct the neuro check. She said she and the staff development coordinator routinely reviewed the neuro check documentation to ensure it was complete, but neither of them had checked the neuros completed for the falls on 11/14/2020 and 11/28/2020, and she did not know why that was. The DON said when a resident was found after a fall, the responding staff member should immediately notify the RN to come and assess the resident. She said there was an RN in the facility at all times, even on the night shift. She clarified a resident should not be moved before they were assessed by an RN, because CNAs and LPNs were not qualified to assess residents for injuries. The DON said if a resident had an ordehr for a high/low bed, the bed should be in the lowest possible position when the resident was in the bed. She confirmed Resident #4 had an order for [REDACTED].

Based on observations, interviews and record review, the facility failed to ensure one (#2) of 14 sample residents was kept free from physical abuse. The facility failed to ensure Resident #2 who was admitted with [DIAGNOSES REDACTED]. The facility's failures to effectively understand how to care for and de-escelate Resident #2, Cross-reference F740, when exhibiting targeted behaviors (see record review below), and provide immediate appropriate interventions contributed to Resident #2 being physically abused and held in involuntary seclusion by the nursing home administrator (NHA). Resident #2 was documented to be afraid of the NHA. Cross-reference F740, facility failed to provide behavioral health services for residents who required behavioral health needs. Findings include: I. Facility policy and procedure The Abuse Policy, last reviewed on 11/15/2019, provided by the director of nursing (DON) on 10/13/2020 at 5:30 p.m., documented the facility did not condone resident abuse and would take every precaution possible to prevent resident abuse by anyone. It documented the residents had the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. It documented identification of abuse should be the responsibility of every employee. The abuse policy defined physical abuse, in part, as controlling behavior through corporal punishment. It defined involuntary seclusion, in part, as separating a resident in his/her room against the resident's will. II. Resident #2 A. Resident status Resident #2, age 53, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the minimum data set (MDS) assessment dated [DATE], the resident was cognitively intact for daily decision making with a brief interview for mental status (BIMS) cognition score of 15 out of 15. It documented the resident was depressed/hopeless and had disturbed sleep seven to 11 days during the 14-day lookback period. It documented the resident displayed little interest in things or activities, was lethargic, felt bad about herself and had trouble concentrating 12 to 14 days during the lookback period. It documented the resident displayed physical behaviors directed towards others, displayed behavioral symptoms not directed toward others and wandered one to three days during the seven-day lookback period. It documented the resident received seven days of scheduled antipsychotic, antianxiety and antidepressant medications during the seven-day lookback period. The MDS documented the resident was independent with transfers, ambulation, dressing and personal hygiene. She was independent with set-up for eating. She required supervision of one for bed mobility and toileting. She needed extensive assistance from one for bathing. B. Record review 1. Computerized physician orders [REDACTED].>According to the October 2020 CPO, the resident was prescribed the following: -[MEDICATION NAME] (supplement), 6 mg (milligram) QD (every day) for [MEDICAL CONDITION]. This was ordered on [DATE]; -[MEDICATION NAME] (antianxiety), 10 mg TID (three times per day) for anxiety. This was ordered on [DATE]; -[MEDICATION NAME] (antidepressant), 45 mg QD for depression. This was ordered on [DATE]; and, -[MEDICATION NAME] (antipsychotic), 80 mg QD for [MEDICAL CONDITION]. This was ordered on [DATE]. 2. Initial psychosocial assessment and history The initial psychosocial assessment and history dated 3/6/2020 documented the resident experienced postpartum depression after the birth of a daughter in 2013. It documented the resident developed an addition to alcohol and still attends AA (alcoholics anonymous). It documented the resident was in a serious car accident in her thirties. It documented she had [DIAGNOSES REDACTED] and had [MEDICAL CONDITION] growing in her brain. It documented she used behaviors such as starvation or anorexia for caretaker attention. 3. Pre-admission screen/resident review (PASRR) Resident #2's PASRR, dated 8/20/2020, documented the resident was being reviewed for new or worsening symptoms. It documented the resident's [DIAGNOSES REDACTED]. It documented the resident displayed the following symptoms which had not been reversed by nursing facility staff interventions: delusions, depressed mood, disorganized thinking, excessive feelings of worthlessness/guilt, hallucinations, hopelessness, low self-esteem, weight and appetite disturbance, sleep disturbances, anxiety, unreasonably demanding/entitled, blatant disregard for others, self-injurious behavior, suicidal talk/thought, water intoxication attempts, suicidal remarks with a plan, aggressive/belligerent behavior and physical threats. It documented the resident was readmitted to the facility following a 10-day psychiatric hospitalization and the resident was still having an increase in psychiatric symptoms. It documented the resident had a prior PASRR Level II screen completed earlier at the facility (this Level II was not provided by the facility), which gave the resident a primary mental health [DIAGNOSES REDACTED]. It gave a secondary [DIAGNOSES REDACTED]. It documented the form the facility submitted that date was using different mental health diagnoses. It was explained to the facility's social services director (SSD) that the facility's mental health [DIAGNOSES REDACTED]. A 30-day limited approval was given with the request the facility's IDT team collaborated to either uphold the Level II [DIAGNOSES REDACTED]. The facility was asked to submit an updated PASRR form with requested information and observations of the resident. 4. Psychiatric hospitalization The medical consultation form from the psychiatric hospital dated 8/9/2020 documented Resident #2 was admitted to the hospital on [DATE]. It documented the resident had become increasingly agitated and aggressive towards the nursing facility staff. It documented the resident punched out a window and lacerated her hand. The resident admitted to suicidal ideation and anxiety. It documented the resident wanted to kill herself due to command hallucinations telling her to do so. The resident stated to her mother and caretakers of the past three weeks that she wanted to end her life. The inpatient treatment plan dated 8/11/2020 documented the resident was [MEDICAL CONDITIONS] type and was fixated on various medications and kept wanting more. She was a fall risk, displayed poor ADLs and was choosing to limit her food intake due to anger and wanting more control. It documented the resident was at odds with her current nursing facility and was acting out. One of the resident's inpatient goals was to work on a safety plan and how to get along with her current nursing facility placement and to contact the nursing facility to discuss the case and the resident's behaviors. The subjective information form dated 8/12/2020 documented the resident wanted polypharmacy consistently and that needed to be limited given the resident was consistently fixated on medications and anything she can get for her anxiety. It documented she was restricting her food intake and fluid intake due to anger at her nursing facility over not getting more medications. It documented Resident #2 continued to have chronic [MEDICAL CONDITION] and wanted more medications. It documented the resident continues to describe herself as overwhelmed by anxiety while showing little evidence of anxiety. The resident had shown little participation in the hospital unit activities and had shown no unsafe behaviors. She was anticipated to discharge back to the nursing facility on 8/14/2020. She reported to the hospital staff she did not like where she was living. It documented the resident appeared to be close to baseline functioning. 5. Resident #2's outpatient mental health provider The progress note from Resident #2's mental health provider, dated 10/9/2020, documented the resident stated she'd had an incident on 10/7/2020 and the police had just left after speaking with her. It documented the resident wasn't able/willing to talk about what happened, but was only willing to say I don't remember. The resident declined to offer any feedback about the incident. 6. Behavior monitoring forms The behavior monitoring forms were reviewed from 8/31/2020 through 10/15/2020. They documented Resident #2 displayed behavioral symptoms on 15 out of the 46 days reviewed. She displayed behaviors such as obsessive rituals, pacing and restless/repetitive movements. Facility interventions included redirection, offering food/drinks, engaging the resident in conversation, relaxation techniques and reassurance/validation. The outcomes of these interventions ranged anywhere from unchanged, to partial improvement, to no further behaviors and to new/worsening behaviors emerging. 7. Progress notes The progress notes for Resident #2 were reviewed from 9/1/2020 through 10/15/2020. The following documentation was pertinent to the resident's behaviors: -The psychosocial progress note dated 9/17/2020 documented the resident continued to watch the clock, asking for PRN (as needed) medications around the clock and often asked for her medications long before they were due. The resident was somewhat easier to redirect and did not always appear to be having the symptoms associated with needing those medications. The resident's affect was very flat with rapid-paced ambulation. She had episodes of banging on the nurse's station door and refusing to leave. -On 9/21/2020, the resident was seen taking water from the nurse's cart. The resident soon came up and asked for more water and was given a small glass. The resident proceeded to stand at the nurse's cart and would not listen to the writer when asked to return to her room. The resident said no, she just wanted to stand there. Later that day, around 10:00 p.m., the resident sat on the floor of the nurse's station, self-soothing and saying she was just too nervous and did not want to be alone. One-on-one staff attention was provided and the resident was comforted and reassured. She was told the nurse would bring her medication to her as soon as she left the nurse's station. She resident, complied, sat on a chair in the hallway and took her medications. The resident was calmer after awhile. The resident went to bed and was seen resting and watching television in comfort. The resident said, I am better now. -On 10/2/2020, it documented the resident was stalking staff, refusing to leave the nurse's station after being denied requests for PRN medications that were too soon to administer. The resident asked the writer to kill her. The resident reported feeling anxious and nervous .Resident returned to her room after sitting in the dining room for several minutes, yelling for water. -On 10/4/2020, it documented the resident could have periods of severe anxiety, but no outbursts on this shift. Resident was stable and continued to ask for ice water every hour on the hour and that had become a behavior for her. It documented the resident would refuse to stay in her room (she was on COVID isolation for her recent psychiatric hospitalization ) until the resident received what she wanted. -On 10/6/2020, it documented the resident had a phone call visit from her psychiatrist and seemed upset when the phone call ended. It documented since that call, the resident had looked for any reason to break isolation and asked for every prn medication she could have. When the nurse explained the resident could not have anything at present, Resident #2 became upset and burst her way into the nurse's station and refused to leave. The DON was able to de-escalate the situation and coaxed the resident out of the nurse's station. Five minutes later, the resident was observed getting her own ice water and contaminated the ice cooler kept in the hallway. The resident proceeded to pull the facility fire alarm. -On 10/7/2020 at 5:12 p.m., it documented the resident appeared to be non-compliant with staff and was disruptive. It documented Resident #2 had set off the fire alarm twice that day and had pushed and put her hands on staff during the past two hours. -On 10/7/2020 at 10:35 p.m., it documented the resident remained very restless and anxious that evening. She repeatedly asked to be tucked in, immediately got out of bed and asked to be tucked in again. It documented the resident had required 1:1 supervision most of the evening. -On 10/9/2020, it documented the resident was anxious and disruptive to staff by following them around and into other resident's rooms by following the staff. She was unable to be redirected and the resident would become forceful by pushing and pulling at the staff. -On 10/12/2020, it documented the resident was pleasant and cooperative with staff that evening. It documented that although the resident reported high anxiety that night, the resident felt more comfortable sitting in the west dining room near staff and stated it helped her feel not so alone. The staff assisted the resident with changing her clothes, brushing her hair and provided her with snacks. The resident was polite each time she asked for water, snacks or her PRN medications. It documented she was not demanding or rude nor was she excessive with her requests. It documented the resident's left arm had some mild bruising that was healing, as well as small scratches observed to her left forearm and right cavicular area. -On 10/13/2020, it documented the resident had a fading bruise to her left arm, which the resident said hurt this date. The resident stated she was afraid of a staff member who inflicted the bruise and reassurance was given to the resident. -On 10/13/2020 at 8:55 p.m., it documented the resident had not been aggressive, but was resistant to calming techniques such as deep breathing, turning off the television and closing her eyes. The resident would not go to sleep. -On 10/14/2020, it documented the resident's bruises to left arm appeared to be fading, as evidenced by yellow and greenish colors. The resident reported her arm was painful and rated the pain 3-10. Tylenol was given with good results. The resident told the writer (RN #2) she was afraid of being hurt and when asked who she was afraid of being harmed by, she stated the NHA's name. RN #2 told the resident the NHA was not in the building. The resident then turned and used her rolling walker to ambulate back to her room. 8. Care plan The care plan dated 9/24/2020 documented the resident had multiple psychiatric [DIAGNOSES REDACTED]. The goal was for Resident #2's number of behavioral episodes to be minimized. Interventions included offering and documenting non-pharmacological interventions as needed, which included range of motion, relaxation and breathing techniques, imagery and distraction techniques, re-positioning, offering a snack or drink, redirection to a favorite activity, offer an independent activity with supplies, offer to call a loved one, assist outside, sit with resident as needed, offer shower or a bath, active listening and validation. It documented caregivers should provide an opportunity for positive interactions and attention. It documented the staff should stop and talk with Resident #2 as they were passing by. It documented staff should explain or reinforce to the resident why certain behaviors were inappropriate or unacceptable. It documented that when behaviors occur, staff should approach the resident and speak to them in a calm manner. 9. Resident #2 interview/observation Resident #2 was interviewed in her room on 10/14/2020 at 5:10 p.m. She ambulated with her rolling walker independently. She displayed good eye contact. Her affect was flat to the point of being [MEDICATION NAME]. Her answers to all questions were brief and she appeared hesitant to elaborate further. She said she had lived in the facility since March 2020. She said she felt no one in the facility had treated her in an abusive or neglectful manner and denied fear of anyone. She stated she was fine at the facility, but expressed an interest in moving to another facility near the (name of local city) area. She said she had family and friends in the area, but still wanted to move over to (name of local city). She was polite and appropriate. Following the brief interview, she was observed asking staff appropriate questions. She received the ice she had requested and went back into her room and quietly shut the door. III. Initial facility investigation The (facility name) action plan for identification and reporting abuse was provided by the director of nursing (DON) on 10/13/2020 at 5:30 p.m. The form was dated 10/8/2020 and documented the investigation started on that date. It documented the corporation received a call from the DON regarding a report of involuntary seclusion by the NHA towards a resident. It documented the NHA was immediately suspended after being reported until a thorough investigation was completed. It documented education regarding abuse and the facility abuse policy was conducted to all staff on 10/9/2020, except for seven staff who either worked PRN (as needed) or were on vacation. The investigation timeline documented on 10/8/2020 at 4:15 p.m., the corporate RN notified the corporate SSD and the chief clinical officer (CCO) of the alleged abuse. The VP of operations was also notified of the allegation via telephone. The VP notified the NHA she was being placed on immediate suspension pending investigation and was instructed to leave the facility until further notice. The DON interviewed all employees working the evening of 10/7/2020 and 10/8/2020. Calls were placed to Resident #2's power of attorney, police, local ombudsman, physician and facility medical director. On 10/9/2020 at 9:00 a.m., the facility's security camera footage was reviewed by the DON and a member of the facility's IT department. The visual findings revealed the NHA blocking the doorway to Resident #2's room. The NHA was observed placing her hands on Resident #2 multiple times and was observed pushing the resident back into her room. On 10/9/2020 at 10:30 a.m., the DON shared her findings with the CCO, regional operations direction, corporate RNA and corporate SSD. On 10/9/2020 at 12:30 p.m., a request was made to have Resident #2's mental health provider see the resident at the facility, but the resident refused this visit. The facility SSD was assigned to follow up with Resident #2 daily for two weeks to assess mood and behaviors, then re-assess for ongoing assessments. The facility planned to arrange crisis prevention training for all staff for further education. The plan was to have the abuse coordinator/designee to review the abuse reporting and investigation process monthly in QAPI for three months. IV. Staff interviews The DON was initially interviewed on 10/13/2020 at 1:15 p.m. She said on Wednesday, October 7, 2020, Resident #2 was observed sitting in the nurse's station on west hall. She was asking for PRN Myltanta, which was not scheduled to be administered for another 45 to 60 minutes. She said the resident had many psychiatric [DIAGNOSES REDACTED]. She said when the resident started attention seeking, her behaviors usually exacerbated and sometimes she needed a short inpatient hospitalization for stabilization. She said on 10/7/2020, she was able to redirect Resident #2 and felt the resident was being gamey with her. She said ten or 15 minutes after redirection, the resident pulled the facility's fire alarm. She said the NHA was sitting with the resident at this time. The DON said she removed all others from the vicinity where Resident #2 and the NHA were seated. She said another five or ten minutes passed and Resident #2 pulled the fire alarm again. She said this occurred around 4:00 p.m. She said the NHA left the building for an appointment and the admissions/marketing (AM) director and RN #2 stayed with Resident #2. The DON said she left the facility for home around 4:30 p.m. She said she heard nothing further from the facility the evening of 10/7/2020. She said she came to work on 10/8/2020 at approximately 6:00 a.m. She said she checked in with the nurses going off duty and asked how Resident #2's evening went: she said she really expected a phone call from the staff the evening prior about Resident #2. The staff said the NHA was in the facility with Resident #2 until 10:30 or 11:00 p.m. the evening prior. They said after the NHA left, Resident #2 was still engaged in attention-seeking behaviors and she kept asking to be tucked in until 1:30 a.m. on 10/8/2020. She said she did not ask any further questions at that time and the staff volunteered no further information then. She said later that afternoon, she stopped in the NHA's office and said she heard the NHA had a long night in the facility the prior evening and asked the NHA what happened. She said the NHA laughed and told her she had to hold Resident #2's door shut the evening prior to get the resident to stay in her room. The DON said the NHA told her it was probably a restraint, probably abuse. The DON said it sounded like a restraint to her. The DON said she immediately left the NHA office, went down to the therapy gym and sat there for a few minutes, asking herself if what she just heard was real. She said she called her clinical consultant and told her they needed to talk. The DON shared what she knew, said the consultant told her to wait a second while the consultant contacted the NHA's supervisor in the corporate office. The supervisor called the NHA to suspend the NHA immediately with the expectation that she had to vacate the building around 3:30 or 3:45 p.m. on 10/8/2020. The DON said the NHA texted her to tell her she was suspended, pending a thorough investigation into the abuse allegation. She said, on 10/8/2020, Resident #2 and the other residents of the facility were fine, but the DON was concerned about what the NHA shared with her about possible restraint and abuse. She said she was not concerned about any other residents being potentially abused because the NHA had left the building. She said she contacted the facility's IT department because she did not have access to the facility's video cameras. She said they set up an appointment to view the video first thing the following morning, 10/9/2020. She said she did not know what to expect on the video camera, due to the NHA describing what had occurred in a jesting manner. She said she watched the video first thing on 10/9/2020 and on the video, right before 6:00 p.m. on 10/7/2020, she observed the NHA coming down the west hall and took a chair and placed in right in the middle of Resident #2's doorway with her knees inside the resident's room and blocked the door to prevent Resident #2 from leaving her room. She said at one point, Resident #2 was observed looming over NHA and at another point, she saw Resident #2 and the NHA hugging each other. She said, on a few occasions, Resident #2 was observed getting out of her room and around the NHA and taking off down the hall toward a fire alarm. She said, while interviewing Resident #2 during the facility's abuse investigation, the resident told her if she pulled the fire alarm, the ambulance would come and give her some [MEDICATION NAME] (an anti-anxiety medication) that the resident wished. She said the first time you could witness the NHA chasing the resident, both the resident and NHA went off screen for a second or two before coming back into the picture. She said this was witnessed on the video several times. She said three or four times she could observe the NHA putting her hands on the resident's left wrist/forearm area and pushed the resident down the hall. She said the video did not have an audio component and could not tell what was being said, but the NHA looked angry at times. She said, at one point, the NHA was observed forcefully pushing the resident back into her room. She said she watched the video for about 35 minutes, until she could not watch the video any longer without becoming upset about what she had viewed. She said, We knew enough at that time that abuse had occurred. The DON said Resident #2 had new bruises on one arm. She said the resident stated she did not remember the event, but did acknowledge that it did occur. She said she did not interview the NHA herself; someone from the corporate office conducted that interview. She said facility floor staff contacted the DON over the following weekend about the bruises noted on Resident #2's arm. She said Resident #2 was still on the isolation wing due to being discharged from her last inpatient psychiatric hospitalization . The DON said if Resident #2's behaviors had occurred in certain (name of local city) faciilities, the incident would have been a non-issue because the facility would have addressed Resident #2's behaviors differently. She said the resident had been asking to be transferred to another corporate facility in the (name of local city) area which contained a behavioral unit and the facility was looking into this transfer. She said after she viewed the video the morning of 10/9/2020, she interviewed five or six residents throughout the building, as the NHA had access to the entire building, and no other residents claimed abuse had occurred to them or they were fearful of anyone in the building. She said she interviewed every staff member working in the facility on 10/7/20. She said one night-shift certified nurse aide (CNA) and the night nurse said the NHA did not handle the situation as they would have. She said a second CNA stated she observed the NHA being rough with Resident #2 and did not know what to do because the NHA was the person she was supposed to report these concerns to. The DON said this was the first time the resident tried to set off the fire alarms in the facility. She said the resident usually liked to pace the halls and talk about the auditory hallucinations and voices she heard in her head. She said the resident was not attempting to hurt herself or others. She said behaviors started in the nurse's station around 3:00 p.m. and the resident was redirectable with a soda. The DON said once the resident got to a certain point, she probably just needed to be taken to the hospital again for a psychiatric adjustment. The DON and the chief clinical officer (CCO), via telephone were interviewed together on 10/13/2020 at 2:58 p.m. The CCO said corporate staff started educating all facility staff on abuse reduction and specifically on what to do if the abuser is actually the abuse coordinator, as the NHA was. She CCO said the NHA was immediately placed on suspension once the abuse allegation was learned and the NHA was scheduled to be terminated by her supervisor, via telephone, on 10/14/2020. She said, besides providing the above education for the seven staff who either worked as needed or were on vacation, the corporation planned to add a round of non-violent crisis intervention training to the staff curriculum. CNA #1 was interviewed on 10/13/2020 at 5:06 p.m. She said she worked on 10/7/2020 from 2:00 p.m. to 10:00 p.m. and witnessed two separate incidents that evening between the NHA and Resident #2. She said the first incident was when the resident was trying to get past the NHA, who was seated in a chair in the resident's doorway, blocking the resident from leaving the room. She said the resident was successful in getting by the NHA and the resident headed for the fire alarm by the back door. She said the NHA got up and took off after the resident, stood in front of the resident and grabbed the resident's wrist, while shoving the resident backwards a little bit. She said the NHA was telling the resident she needed to get back in her room, using a forceful voice. She said the second incident involved the NHA sitting in a chair in front of the resident's room. She said the resident opened her door and found the NHA sitting in a chair, facing the door to the room. She said she observed the NHA standing up and forcefully keeping the resident in her room by grabbing the resident's wrist and pushing the resident back into the room. She said she asked the NHA if she needed help and the NHA said she was fine and had it under control. The CNA denied seeing the resident hit or be aggressive with the NHA. The CNA said since the incident occurred on 10/7/2020, the facility provided an inservice on 10/9/2020, consisting of gentle reminders about abuse and said if you could not get ahold of the NHA to report abuse, staff should try to get in touch with the DON instead. CNA #1 said what she witnessed was physical abuse and forceful restraint by the NHA towards a resident. She said Resident #2 did not mention anything during resident cares and displayed no fear of others. CNA #1 said Resident #2 kinda keeps to herself. The CNA said prior abuse training only came up when there were incidents and staff were only given simple reminders about resident rights and the elder justice act. She said staff complete computerized training related to abuse every three to six months. She said the training covered different types of abuse and scenarios. She said, Instead of laying hands on any resident, I would continue to try to intervene with the resident, while looking out for the safety of the resident and others. I would have tried to redirect the resident with fluids or activities instead. I would have asked someone else for help. The licensed practical nurse (LPN) was interviewed on 10/14/2020 at 10:35 a.m. She said, on 10/7/2020 earlier in the afternoon, Resident #2 ramped up after a call with her psychiatrist. She said she and the DON heard the fire alarm going off the first time at approximately 3:45 p.m. or so. She said she did not know when the resident pulled the fire alarm the second time. She said the resident and the NHA were sitting calmly in the main dining room on west hall for some time, then the AM relieved the NHA when the NHA left the building for an appointment. She said it got to the point Resident #2 was going all over the building, looking for fire alarms to pull. She said the staff would just stand in front of the fire alarms and redirect the resident. The LPN said she would ask the resident to give her hugs instead of chasing her, which the resident complied with. She said Resident #2 was redirectable with effort. She said the following day, Resident #2 was laughing, dancing and she was great. She said because of her approach, she was assigned to be the nurse on that floor the following day. She said she did not ask the resident about the incident and Resident #2 did not seem fearful of anyone. She said she heard that the NHA put her hands on Resident #2, but she did not witness this, as she left the building at approximately 5:45 p.m. She said if it had been her, she would have just kept walking with the resident till she calmed. She said she approached the resident with open hands and the resident responded to her with a hug. She said, This was a weird situation .I still can't believe it happened. The AM was interviewed on 10/14/2020 at 11:07 a.m. She said she was working the evening of 10/7/2020 with the LPN and Resident #2's behaviors started escalating around 3:30 or 3:45 p.m. She said the fire alarm went off once and she and other staff began trying to figure out where the fire was. Somebody told her it was just Resident #2 and she called maintenance to shut off the fire alar(TRUNCATED)

Based on record review and interviews, the facility failed to provide behavioral health services potentially affecting 12 residents who required behavioral healthcare needs including one (#2) of four out of 14 sample residents. The facility failed to address ongoing incidents of behaviors for Resident #2, with [DIAGNOSES REDACTED]. Moreover, the resident had behaviors of persistently asking for water, following staff and continually asking for medications. Due to the facility failures to de-escalate behaviors and address these behaviors appropriately, it resulted in abuse perpetrated by the nursing home administrator (NHA) toward Resident #2 which caused her physical and psychosocial harm (cross-reference F600 for freedom from abuse). Furthermore, the facility failed to develop an effective training program for staff in how to respond and take care of residents with behavioral health needs, which impacted a potential of 12 residents that resided in the facility. Findings include: I. Resident census and conditions The Resident Census and Conditions form, provided by the director of nursing (DON) on 10/13/2020 at approximately 10:30 a.m. It documented the facility had 12 of 59 residents who had behavioral healthcare needs. II. Resident #2 A. Resident status Resident #2, age 53, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the minimum data set (MDS) assessment dated [DATE], the resident was cognitively intact for daily decision making with a brief interview for mental status (BIMS) cognition score of 15 out of 15. It documented the resident was depressed/hopeless and had disturbed sleep seven to 11 days during the 14-day lookback period. It documented the resident displayed little interest in things or activities, was lethargic, felt bad about herself and had trouble concentrating 12 to 14 days during the lookback period. It documented the resident displayed physical behaviors directed towards others, displayed behavioral symptoms not directed toward others and wandered one to three days during the seven-day lookback period. It documented the resident received seven days of scheduled antipsychotic, antianxiety and antidepressant medications during the seven-day lookback period. The MDS documented the resident was independent with transfers, ambulation, dressing and personal hygiene. She was independent with set-up for eating. She required supervision from one staff for bed mobility and toileting. She needed extensive assistance from one staff for bathing. B. Record review 1. Computerized physician orders [REDACTED].>According to the October 2020 CPO, the resident was prescribed the following: -[MEDICATION NAME] (supplement), 6 mg QD (every day) for [MEDICAL CONDITION]. This was ordered on [DATE]; -[MEDICATION NAME] (antianxiety), 10 mg TID (three times per day) for anxiety. This was ordered on [DATE]; -[MEDICATION NAME] (antidepressant), 45 mg QD for depression. This was ordered on [DATE]; and, -[MEDICATION NAME] (antipsychotic), 80 mg QD for [MEDICAL CONDITION]. This was ordered on [DATE]. 2. Initial psychosocial assessment and history The initial psychosocial assessment and history dated 3/6/2020 documented the resident experienced postpartum depression after the birth of a daughter in 2013. It documented the resident developed an addition to alcohol and still attended AA (alcoholics anonymous). It documented the resident was in a serious car accident in her thirties. It documented she had [DIAGNOSES REDACTED] and had [MEDICAL CONDITION] growing in her brain. It documented she used behaviors such as starvation or anorexia for caretaker attention. 3. Pre-admission screen/resident review (PASRR) Resident #2's PASRR, dated 8/20/2020, documented the resident was being reviewed for new or worsening symptoms. It documented the resident's [DIAGNOSES REDACTED]. It documented the resident displayed the following symptoms which had not been reversed by nursing facility staff interventions: delusions, depressed mood, disorganized thinking, excessive feelings of worthlessness/guilt, hallucinations, hopelessness, low self-esteem, weight and appetite disturbance, sleep disturbances, anxiety, unreasonably demanding/entitled, blatant disregard for others, self-injurious behavior, suicidal talk/thought, water intoxication attempts, suicidal remarks with a plan, aggressive/belligerent behavior and physical threats. It documented the resident was readmitted to the facility following a 10-day psychiatric hospitalization and the resident was still having an increase in psychiatric symptoms. It documented the resident had a prior PASRR Level II screen completed earlier at the facility (this Level II was not provided by the facility), which gave the resident a primary mental health [DIAGNOSES REDACTED]. It gave a secondary [DIAGNOSES REDACTED]. It documented the form the facility submitted that date was using different mental health [DIAGNOSES REDACTED]. It was explained to the facility's social services director (SSD) that the facility's mental health [DIAGNOSES REDACTED]. A 30-day limited approval was given with the request the facility's IDT team collaborated to either uphold the Level II [DIAGNOSES REDACTED]. The facility was asked to submit an updated PASRR form with requested information and observations of the resident. 4. Psychiatric hospitalization The medical consultation form from the psychiatric hospital dated 8/9/2020 documented Resident #2 was admitted to the hospital on [DATE]. It documented the resident had become increasingly agitated and aggressive towards the nursing facility staff. It documented the resident punched out a window and lacerated her hand. The resident admitted to suicidal ideation and anxiety. It documented the resident wanted to kill herself due to command hallucinations telling her to do so. The resident stated to her mother and caretakers of the past three weeks that she wanted to end her life. The inpatient treatment plan dated 8/11/2020 documented the resident was [MEDICAL CONDITIONS] type and was fixated on various medications and kept wanting more. She was a fall risk, displayed poor ADLs and was choosing to limit her food intake due to anger and wanting more control. It documented the resident was at odds with her current nursing facility and was acting out. One of the resident's inpatient goals was to work on a safety plan and how to get along with her current nursing facility placement and to contact the nursing facility to discuss the case and the resident's behaviors. The subjective information form dated 8/12/2020 documented the resident wanted polypharmacy consistently and that needed to be limited given the resident was consistently fixated on medications and anything she could get for her anxiety. It documented she was restricting her food intake and fluid intake due to anger at her nursing facility over not getting more medications. It documented Resident #2 continued to have chronic [MEDICAL CONDITION] and wanted more medications. It documented the resident continued to describe herself as overwhelmed by anxiety while showing little evidence of anxiety. The resident had shown little participation in the hospital unit activities and had shown no unsafe behaviors. She was anticipated to discharge back to the nursing facility on 8/14/2020. She reported to the hospital staff she did not like where she was living. It documented the resident appeared to be close to baseline functioning. 5. Resident #2's outpatient mental health provider The progress note from Resident #2's mental health provider, dated 10/9/2020, documented the resident stated she had had an incident on 10/7/2020 and the police had just left after speaking with her. It documented the resident wasn't able/willing to talk about what happened, but was only willing to say I don't remember. The resident declined to offer any feedback about the incident. 6. Behavior monitoring forms The behavior monitoring forms were reviewed from 8/31/2020 through 10/15/2020. They documented Resident #2 displayed behavioral symptoms on 15 out of the 46 days reviewed. She displayed behaviors such as obsessive rituals, pacing and restless/repetitive movements. Facility interventions included redirection, offering food/drinks, engaging the resident in conversation, relaxation techniques and reassurance/validation. The outcomes of these interventions ranged anywhere from unchanged, to partial improvement, to no further behaviors and to new/worsening behaviors emerging. 7. Progress notes The progress notes for Resident #2 were reviewed from 9/1/2020 through 10/15/2020. The following documentation was pertinent to the resident's behaviors: -The psychosocial progress note dated 9/17/2020 documented the resident continued to watch the clock, asking for PRN (as needed) medications around the clock and often asked for her medications long before they were due. The resident was somewhat easier to redirect and did not always appear to be having the symptoms associated with needing those medications. The resident's affect was very flat with rapid-paced ambulation. She had episodes of banging on the nurse's station door and refusing to leave. -On 9/21/2020, the resident was seen taking water from the nurse's cart. The resident soon came up and asked for more water and was given a small glass. The resident proceeded to stand at the nurse's cart and would not listen to the writer when asked to return to her room. The resident said no, she just wanted to stand there. Later that day, around 10:00 p.m., the resident sat on the floor of the nurse's station, self-soothing and saying she was just too nervous and did not want to be alone. One-on-one staff attention was provided and the resident was comforted and reassured. She was told the nurse would bring her medication to her as soon as she left the nurse's station. The resident complied, sat on a chair in the hallway and took her medications. The resident was calmer after a bit. The resident went to bed and was seen resting and watching television in comfort. The resident said, I am better now. -On 10/2/2020, it documented the resident was stalking staff, refusing to leave the nurse's station after being denied requests for PRN medications that were too soon to be administered. The resident asked the writer to kill her. The resident reported feeling anxious and nervous .Resident returned to her room after sitting in the dining room for several minutes, yelling for water. -On 10/4/2020, it documented the resident could have periods of severe anxiety, but no outbursts on this shift. Resident was stable and continued to ask for ice water every hour on the hour and that had become a behavior for her. It documented the resident would refuse to stay in her room (she was on COVID isolation for her recent psychiatric hospitalization ) until the resident received what she wanted. -On 10/6/2020, it documented the resident had a phone call visit from her psychiatrist and seemed upset when the phone call ended. It documented since that call, the resident had looked for any reason to break isolation and asked for every PRN medication she could have. When the nurse explained the resident could not have anything at present, Resident #2 became upset and burst her way into the nurse's station and refused to leave. The DON was able to de-escalate the situation and coaxed the resident out of the nurse's station. Five minutes later, the resident was observed getting her own ice water and contaminated the ice cooler kept in the hallway. The resident proceeded to pull the facility fire alarm. -On 10/7/2020 at 5:12 p.m., it documented the resident appeared to be non-compliant with staff and was disruptive. It documented Resident #2 had set off the fire alarm twice that day and had pushed and put her hands on staff during the past two hours. -On 10/7/2020 at 10:35 p.m., it documented the resident remained very restless and anxious that evening. She repeatedly asked to be tucked in, immediately got out of bed and asked to be tucked in again. It documented the resident had required one to one supervision from staff most of the evening. -On 10/9/2020, it documented the resident was anxious and disruptive to staff by following them around and into other resident's rooms by following the staff. She was unable to be redirected and the resident would become forceful by pushing and pulling at the staff. -On 10/12/2020, it documented the resident was pleasant and cooperative with staff that evening. It documented that although the resident reported high anxiety that night, the resident felt more comfortable sitting in the west dining room near staff and stated it helped her feel not so alone. The staff assisted the resident with changing her clothes, brushing her hair and provided her with snacks. The resident was polite each time she asked for water, snacks or her PRN medications. It documented she was not demanding or rude nor was she excessive with her requests. It documented the resident's left arm had some mild bruising that was healing, as well as small scratches observed to her left forearm and right clavicular area. It documented the resident had a hematoma to her left hip and upper thigh area. -On 10/13/2020, it documented the resident had a fading bruise to her left arm, which the resident said hurt this date. The resident stated she was afraid of a staff member who inflicted the bruise and reassurance was given to the resident. -On 10/13/2020 at 8:55 p.m., it documented the resident had not been aggressive, but was resistant to calming techniques such as deep breathing, turning off the television and closing her eyes. The resident would not go to sleep. -On 10/14/2020, it documented the resident's bruises to left arm appeared to be fading, as evidenced by yellow and greenish colors. The resident reported her arm was painful and rated the pain 3/10. Tylenol was given with good results. The resident told the writer (RN #2) she was afraid of being hurt and when asked who she was afraid of being harmed by, she stated the NHA's name. RN #2 told the resident the NHA was not in the building. The resident then turned and used her rolling walker to ambulate back to her room. 8. Care plan The care plan dated 9/24/2020 documented the resident had multiple psychiatric [DIAGNOSES REDACTED]. The goal was for Resident #2's number of behavioral episodes to be minimized. Interventions included offering and documenting non-pharmacological interventions as needed, which included range of motion, relaxation and breathing techniques, imagery and distraction techniques, re-positioning, offering a snack or drink, redirection to a favorite activity, offer an independent activity with supplies, offer to call a loved one, assist outside, sit with resident as needed, offer shower or a bath, active listening and validation. It documented caregivers should provide an opportunity for positive interactions and attention. It documented the staff should stop and talk with Resident #2 as they were passing by. It documented staff should explain or reinforce to the resident why certain behaviors were inappropriate or unacceptable. It documented that when behaviors occur, staff should approach the resident and speak to them in a calm manner. 9. Resident #2 interview and observation Resident #2 was interviewed in her room on 10/14/2020 at 5:10 p.m. She ambulated with her rolling walker independently. She displayed good eye contact. Her affect was flat to the point of being [MEDICATION NAME]. Her answers to all questions were brief and she appeared hesitant to elaborate further. She said she had lived in the facility since March 2020. She said she felt no one in the facility had treated her in an abusive or neglectful manner and denied fear of anyone. She stated she was fine at the facility, but expressed an interest in moving to another facility near the Denver area. She said she had family and friends in the area, but still wanted to move over to Denver. She was polite and appropriate. Following the brief interview, she was observed asking staff appropriate questions. She received the ice she had requested and went back into her room and quietly shut the door. III. Training documentation for behavioral health A review of training information provided by DON on 10/14/2020 6:00 p.m. documented the NHA had held that position since 9/6/16. It documented the NHA had participated in the following trainings in 2020: -Reporting elder and dependent adult abuse on 3/7/2020; -Self-paced abuse and neglect course on 4/5/2020. It should be noted this course was due for completion on 3/31/2020; -Behavioral health and older adults on 5/17/2020; and, -Preventing, recognizing and reporting abuse on 10/3/2020, just four days prior to the occurrence of abuse. The information documented the corporation had provided the facility education about neuro-developmental disorders on 9/3/2020, [MEDICAL CONDITION] on 9/10/2020, mood disorders part 1 on 9/17/2020, mood disorders part 2 on 9/24/2020, mood disorders part 3 on 10/1/2020, trauma and stress-related disorders on 10/8/2020 and dissociative disorders on 10/15/2020. -However, the facility failed to provide attendance sheets to document which staff, if any, participated in the offered training. The facility did provide documentation that some, but not all staff, completed the following training in 2020: Handling aggressive behaviors, behavioral health and older adults, Teepa Snow: challenging behaviors, understanding mental illness: [MEDICAL CONDITION] disorder, understanding mental illness: [MEDICAL CONDITION], understanding mental illness: depression, understanding behaviors: considerations for client rights and communicating with individuals with mental illness. -The documentation did not include the exact content nor duration of the offered training. IV. Staff interviews The DON was initially interviewed on 10/13/2020 at 1:15 p.m. The DON said if Resident #2's behaviors had occurred in a facility other than this facility, such as certain (name of local city) area facilities with experience into behavioral healthcare, the incident would have been a non-issue because the other facility would have addressed Resident #2's behaviors differently. She said the resident had been asking to be transferred to another corporate facility in the (name of local city) area which contained a behavioral unit and the facility was looking into this transfer. She said she interviewed every staff member working in the facility on 10/7/2020. She said one night-shift certified nurse aide (CNA) and the night nurse said the NHA did not handle the situation as they would have. She said a second CNA stated she observed the NHA being rough with Resident #2 and did not know what to do because the NHA was the person she was supposed to report the concerns to. She said the resident was not attempting to hurt herself or others. She said behaviors started at the nurse's station around 3:00 p.m. and the resident was redirectable with a soda. The DON said once the resident got to a certain point and was no longer redirectable with interventions such as being provided a beverage, she probably just needed to be taken to the hospital again for a psychiatric adjustment. The DON and the chief clinical officer (CCO) were interviewed together via telephone on 10/13/2020 at 2:58 p.m. The CCO said corporate staff started educating all facility staff on abuse following the incident with Resident #2 on 10/7/2020 and concentrated on specifically what to do if the abuser was actually the abuse coordinator, as the NHA was. She said the facility still needed to provide this education to seven staff who either worked as needed or were on vacation. She said the corporation planned to add a round of non-violent crisis intervention training to the staff curriculum. CNA #1 was interviewed on 10/13/2020 at 5:06 p.m. The CNA said since the incident occurred on 10/7/2020, the facility provided an in-service on 10/9/2020, consisting of gentle reminders about abuse and read the NHA could not be reached, staff should try to get in touch with the DON instead. The CNA said the prior abuse training only came up on rare occasions when staff were having difficulty with residents ' behaviors. She said staff were only given simple reminders about resident rights and the Elder Justice Act. She said staff complete computerized training related to abuse every three to six months. She said the training covered different types of abuse and scenarios. She said, Instead of laying hands on any resident, I would continue to try to intervene with the resident, while looking out for the safety of the resident and others. I would have tried to redirect the resident with fluids or activities instead. I would have asked someone else for help. The licensed practical nurse (LPN) was interviewed on 10/14/2020 at 10:35 a.m. The LPN said she would ask the resident to give her hugs instead of chasing her, which the resident complied with. She said Resident #2 was redirectable with continued effort provided by the staff. She said the following day, Resident #2 was laughing, dancing and she was great. She said because of her approach, she was assigned to be the nurse on that floor the following day. She said she did not ask the resident about the incident and Resident #2 did not seem fearful of anyone. She said if it had been her, she would have just kept walking with the resident till she calmed down. She said she approached the resident with open hands and the resident responded to her with a hug. She said, This was a weird situation,I still can't believe it happened. The admissions/marketing director (AM) was interviewed on 10/14/2020 at 11:07 a.m. The AM said she never had any psychiatric training and the only knowledge she had was from some of the nurses working in the facility who had prior psychiatric experience. She said she had never been asked to assist with any redirection for Resident #2 prior to 10/7/2020. She said the resident was not violent, but was on a mission. She said the resident would reach around her to get to the fire alarm, but she was able to redirect her without touching the resident. She said the NHA was the one who pushed cares and pairs, which was being trained to not care for the resident alone when acting out. She said the facility did not provide a lot of support for education and working with residents who had chronic mental illness. She said the staff were fearful of Resident #2 due to lack of training. She said no staff really knew how to address Resident #2. She said one of the CNAs told her she did not feel safe caring for the resident by herself. She said staff asked administration for training related to working with chronically mentally ill residents. She said most nurses were successful in redirecting Resident #2 and the resident did not appear to be fearful of anyone in the facility. She said the resident wanted to go to another facility in the Denver area which could meet her psychosocial needs better. CNA #2 was interviewed on 10/14/2020 at 3:45 p.m. He said facility staff have had no formal training with caring for residents with major mental illness. He said some staff were afraid to work with Resident #2. He said the facility had three other residents similar to Resident #2 and he had concerns about working with these residents with no specific training on addressing behaviors of those with behavioral health. He said if any staff had any concerns with any resident's behaviors, the staff had been instructed just not to go into those resident rooms. He said not entering the resident's rooms as instructed he thought was neglect in and of itself. Registered nurse (RN) #2 was interviewed on 10/14/2020 at 5:20 p.m. She said she had not been working in the building from 10/2/2020 through 10/9/2020. She said she had never witnessed any resident abuse or neglect in the building and no residents had brought attention to any concerns they had about abuse. She said if she had known about any abuse concerns, she would have reported the abuse to the NHA or the DON. She said if they were unavailable, she would phone someone in their corporate office. She said she would have called no matter who the abuser was, even if the NHA. She said she had been provided no training into working with residents who had [DIAGNOSES REDACTED]. The DON was interviewed on 10/14/2020 at 6:01 p.m. She said the culture in the facility about resident behaviors was very strange, but did not elaborate. She said the facility's training into residents with chronic mental illness obviously had not been sufficiently provided. CNA #3 was interviewed on 10/14/2020 at 6:40 p.m. She said she could not recall any specific training into chronically mentally ill residents and their behaviors. She said any training related to behaviors in general was done between computerized self-paced courses and nursing meetings that were probably quarterly. She said what she had tried with Resident #2 in the past seemed to have worked which included her staying calm and quiet, not talking to the resident like she was not reasonable or was a child and making a plan with her. She said Resident #2 did not do well if her space was encroached upon. She said after the NHA left that night on 10/7/2020 , around 10:00 or 10:30 p.m., the resident kept wanting the CNAs to tuck her in for attention repeatedly. She said the resident did not try to go to any fire alarm again after the initial attempt on the same day. She said the resident stayed in her room with no problem after approximately 1:30 a.m. She said she had no problem redirecting the resident the next night on 10/8/2020 and Resident #2 was great. CNA #3 said, For me, it's the approach you use, but I don't know what I would have done that evening. I was grateful (the NHA) stayed. I just know when I saw (the NHA) blocking the door, I would have handled it differently. The SSD was interviewed on 10/15/2020 at 9:58 a.m. She said, It's easy to second guess unless you are in that situation. I would have just walked away. The one thing you are taught is you don't lay a hand on a resident. You have to report abuse no matter who does it. I would have gone to (the DON), then use the corporate 800 phone number or call my corporate consultant. CNA #4 was interviewed on 10/15/2020 at 10:07 a.m. She said if she had witnessed any type of abuse, she would have removed the staff member and walked them to administration and to the chain of command to tell them what she witnessed. She said she would definitely get the resident out of that situation. She said it was not okay to lay hands on a resident in the manner she heard the NHA was using. She said she had received training on mental illness outside of the facility, but never from the facility. She said, We haven't touched on mental illness, just dementia. I keep my hands in my pocket because getting in their space can make them more agitated. You don't want to block residents, let them be free and walk with them. Keep a firm, calm tone with them. Stand beside them, not in front of them. If they are swinging, let them swing and just move away. She said her strategy with Resident #2 earlier that day when the resident had been seeking Tylenol was deep breathing and taking a shower. She said she was just killing time with Resident #2 until her fixation about the [MEDICATION NAME] diminished. She said she had been able to redirect the resident until the nurse came down to relieve her. She ended by saying, In this facility, we are not allowed to restrain residents.

Based on interviews and record review, the facility failed to ensure one (#11) of four residents reviewed of 31 sample residents received timely treatment and care in accordance with professional standards of practice and facility policy. For Resident #11, the facility failed to: -Timely respond, assess, communicate and report to the physician the resident's severe acute pain; -Timely acknowledge, and sign off on, and implement physician orders; -Schedule Resident #11's outpatient ultrasound in a timely manner although the resident was experiencing pain; and -Notify the physician of a change in status and the resident's increased pain. These failures resulted in the resident having a delayed transport to the outpatient imaging center, while the resident was experiencing new acute pain at levels of 7-10 on a scale of 0 out of 10. The facility did not call the imaging center to attempt to schedule Resident #11's ultrasound ordered at 9:40 a.m. by the physician until the next day, and the resident experienced pain and discomfort during that delay. The resident was eventually sent to the hospital after the ultrasound, for immediate surgical intervention due to testicular torsion. The resident experienced prolonged, severe pain and required surgery to have a testicle removed. These failures by the facility resulted in the resident having delayed treatment and surgery, as well as prolonged severe pain. Findings include: I. Facility policy and procedure The Changed in Resident Condition policy, revised 11/23/19, provided by the director of nursing (DON) on 2/12/2020 at 15:45 p.m., read a facility must immediately inform the resident; consult with the resident's physician; and if known, notify the residents legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status such as a deterioration in health, mental, or psychosocial status in either life- threatening conditions or clinical. Examples of a clinical condition change include any change in resident from resident's baseline or onset of new concern or incident. II. Resident #11 A. Resident status Resident #11, age 67, was admitted on [DATE]. According to the February 2020 computerized physician orders [REDACTED]. According to the minimum data set (MDS) assessment completed 11/19/2020, the resident was severely impaired cognitively with a brief interview for mental status (BIMS) score of four of 15. The resident complained of occasional mild pain that did not affect ability to sleep or limit the resident's day to day activities. B. Record review 1. Resident care plan Resident #11's care plan, initiated 11/15/19 and revised 11/19/19, focused, I have a potential for pain/discomfort related to impared mobility, [MEDICAL CONDITION] of right lower leg, factitial [MEDICAL CONDITION], and according to my medical durable power of attorney, I have zero pain tolerance. An intervention listed on the care plan read, Notify physician if interventions are unsuccessful or if current complaints are a significant change from resident's past experience of pain. 2. Medication administration record (MAR) The resident's February 2020 MAR showed the resident had received tylenol 650 mg every six hours as needed for pain (unspecified location) on 2/3/2020 for a pain level of 5/10 at 7:33 p.m. The resident also received tylenol the next night at 9:34 p.m. on 2/4/2020 for a pain level of 4/10. The resident did not receive tylenol for the next 5 days according to the MAR. The resident also had an order for [REDACTED]. There was no administration of this medication between 2/1/2020-2/9/2020. Resident #11's MAR showed the resident received the following pain medication administrations: 2/10/2020: Tylenol 650 mg every 6 hours as needed for pain: -6:33 a.m. for a pain level of 9 -12:50 p.m. for a pain level of 8 -7:11 p.m. for a pain level of 7 [MEDICATION NAME] give 25 mg every 6 hours as needed: -10:31 a.m. for a pain level of 9 -7:11 p.m. for a pain level of 7 2/11/2020: Tylenol 650 mg every 6 hours as needed for pain: -8:37 a.m. for a pain level of 10 [MEDICATION NAME] 25 mg every 6 hours as needed for pain -8:36 a.m. for a pain level of 10 Record review revealed Resident #11 was sent to ultrasound after receiving his 2/11/2020 morning pain medication. Record review and interview below show the pain medication was administered for testicle/scrotal pain, which was not documented on the MAR above. 3. Progress notes and ultrasound order A progress note by the medical director (MD) showed she had seen the resident on 2/10/2020 at 8:22 a.m. A handwritten treatment order by the MD on 2/10/2020 at 9:30 a.m. showed the MD ordered: -US (ultrasound) Left testicle - color doppler for a [DIAGNOSES REDACTED].>-Urine Analysis with culture and sensitivity if indicated. The physician's orders [REDACTED].#2 at 12:40 p.m. (three hours and 10 minutes later). 4. Hospital records The resident's hospital admission records dated 2/11/2020 were obtained and reviewed. The emergency department (ED) doctor's exam noted the resident was complaining of pain at a level of seven out of 10 that was worsened with palpation of the left testicle. Symptoms were improved by nothing he was aware of. Resident #11 had significant [MEDICAL CONDITION] and tenderness to palpation with swelling of the left testicle and hemiscrotum. The swelling was so diffuse the physician could not find any way to try and twist or detorse the testicle at that time. The ultrasound was consistent with a left testicular torsion with hydrocele (swelling in the scrotum). The urology/surgical consult history showed the scrotal pain was sharp and consistent that started Sunday evening. The urology physical exam revealed an exquisitely tender left testicle. The urology surgical notes showed the testicle was [MEDICAL CONDITION] and adhered to the surrounding tissue. The urologist noted the ability to free the testicle and spermatic cord using electrocautery and then ligating (closing off) the spermatic cord, and sending the testicle off for pathology (no pathology results). The resident's procedure was completed without complication and with a post procedure [DIAGNOSES REDACTED]. 5. Nursing documentation A nursing note signed by licensed practical nurse (LPN) #2 on 2/10/2020 at 5:12 p.m. showed the resident's left testicle was hurting. The pain was ranging from 6-9 out of 10. The resident was in tears several times that day. Mildly relieved by tylenol, no relief with [MEDICATION NAME]. Cool washcloth did not help. UA (Urine analysis) ordered by physician. Resident was resting in bed, will continue to monitor. There was no documentation the MD was notified of the resident's severe pain and tearfulness. The next progress noted dated 2/11/2020 at 3:20 a.m. by registered nurse (RN) #2 showed the resident did continue with complaints of testicle pain. She visualized the testicles, no redness or swelling was observed. She offered a warm compress which the resident denied. [MEDICATION NAME] and tylenol were administered at night, no further complaints of pain. The writer encouraged the resident to alert staff if the pain worsened or if he was experiencing any swelling, redness, or difficulty urinating. The resident verbalized understanding. There was no documentation the MD was notified On 2/11/2020 at 5:30 a.m. another progress note by RN #2 showed upon awakening that morning. The resident was complaining of severe pain in the testicles. He was then complaining of pain in both testicles. Upon palpation, the testes were noted to be hardened and swollen. They were not warm to touch and the resident was complaining of more pain upon palpation. RN #2 was not able to roll the testes in the fingers, as they were too hard and the resident was complaining of too much pain. She noted tylenol was administered. (The MAR did not reflect tylenol given at 5:30 a.m. on this date) There was no documentation the MD was notified. A weekly nursing documentation assessment completed by NCC #1 on 2/11/2020 at 7:00 a.m., showed the resident was alert and oriented to person, place, time, and situation with good memory recall and speech impediment. His bowel sounds were active, abdomen soft and with complaints of pain to his testicles. The resident required extensive assistance with ADLs at this time and staff assistance with wheelchair mobility due to extreme pain. Under pain management it read, Resident is in extreme pain. Testicles extremely swollen. US scheduled this AM. There was no documentation the MD was notified. 6. Staff interviews RN #2 was interviewed on 2/11/2020 at 6:20 p.m. She said the resident was having testicular pain around 6:00 a.m. and she gave the resident some pain medications around 7:00 a.m. She said around 5:45 a.m. Resident #11's testes were noted to be hard and full, and more sore than before. She said throughout the night, on 2/10-2/11/2020, he was not reporting pain or changes, but that Resident #11 was not always forthcoming. She said she had asked him if the testes were the normal size, but she definitely knew there was a difference in form and pain from when she first started her shift. She said she could see he was physically in pain when he was sitting. She said she was on the fence about sending the resident to the hospital and feared it was testicular torsion from some research she did on her shift. She said because they had the US ordered and some interventions in place she did not call the MD. She said it was nursing judgment at the facility if she needed to send a resident out, but because it was not affecting his speech or breathing she didn't call. She said it was routine at the facility to call the doctor if there was a change in condition. She said Resident #11 was alert and oriented with some intellectual or developmental delays, but he definitely could make his needs known. NCC #1 was interviewed on 2/11/2020 at 6:30 p.m. She said yesterday the MD came in and looked at him as he was complaining of testicular pain, and she ordered an ultrasound, which he had that morning (2/11/2020 next day after order) that showed testicular torsion. She said Resident #11 went to the emergency room from the ultrasound and needed surgery. She said she was told in handoff report earlier that morning with RN #2 the resident was in a lot of pain. She said she called CNA #4, who was also the transport driver and scheduler, and told her that the ultrasound needed to be done that morning of 2/11/2020 (the next day after initial order). She said she had called the MD when the resident went out to the ultrasound, but had not called her prior to that. Resident #11 was interviewed on 2/12/2020 at 9:56 a.m He said the pain had started Sunday night and they came in Monday and looked at it. He said the pain was so god damn bad Monday morning, and the nurse had him pee in a cup. He said Tuesday morning they took him to get it checked out and he ended up at the hospital. He said it was huge and twisted up and had to remove one (testicle). He said during that time he was given pain medication and it helped a little bit but not much and still had pain after the medication. He said he had not had pain issues prior to this and his pain was much better this morning (2/12/19). He said because of the pain he had not slept Sunday or Monday nights, and had slept last night (Tuesday night, post surgery) much better. LPN #2 was interviewed on 2/13/2020 at 10:05 a.m. She had been the nurse caring for Resident #11 on 2/10/2020. She said she was told by the night nurse when she arrived for her shift Resident #11 was not feeling well and was in pain. She said she left to give him some tylenol and the MD was there and let her know. She said there was no swelling or red flags at that time, so the MD ordered a urinalysis and an ultrasound. She said NCC #2 was helping her with getting the ultrasound scheduled. She said she did not call the ultrasound imaging center to schedule the ultrasound because as far as she knew NCC #2 was taking care of that. She said the tylenol helped the resident's pain a little but he was still in pain so she gave him the [MEDICATION NAME], which didn't help nearly as much so she gave the tylenol again. She said the MD told her verbally she was ordering the ultrasound and wrote the treatment order form as well. She said she would have called the imaging center to set up the ultrasound, but NCC #2 was helping her with that. She said the normal routine when a doctor ordered an outpatient test was to enter it in the computer then call the center and set it up, but she was not sure the process NCC #2 used that day. She said she had not spoken to the transport van driver, CNA #4 who scheduled tests as well, because NCC #2 was taking care of all that for her. She said Resident #11 was having pain throughout that day (2/10/2020) and was still having pain when she left at shift change. CNA #4, who also served as the transporter and scheduler, was interviewed on 2/12/2020 at 11:57 a.m. She said for outpatient tests ordered by doctors the nurses put the order in her box, and most of the time they would come to her and tell her if there was an order that needed to be done right away. She said for the most part though, nurses just stick the order in her box and she checks it every three to four hours. She said the order for Resident #11's ultrasound was not given to her until 2:00 p.m. on Monday (2/10/2020), and she asked NCC #1 what else she needed to schedule the ultrasound. She said NCC #1 told her the imaging center required an order with the ICD 10 code diagnosis (billing diagnosis) on it, and NCC #1 had helped her get that by calling the MD's secretary. She said by the time the referral with the ICD 10 code came back, the imaging center was closed and she was heading out the door home, which she said was around 4:30-5:00 p.m. She said in that situation the test would just be done the next day as the order was not a stat order. She said if something needed to be done after hours that would have come from the direction of the nurses, but she said there was no sense of urgency from nursing that it needed to be done right away, and nobody told her the resident was having pain. She said it was a good question and she did not know why the order did not come to her until 2:00 p.m. when it was given at 9:30 a.m. by the MD and signed off by NCC #2 at 12:40 p.m. She said the next morning she wrote stat on the order and sent it over to the imaging center and they left around 8:30 a.m. She said he was premedicated with pain medicine prior to leaving, but she could tell he was hurting and uncomfortable for sure. Record review showed the referral with the ICD 10 code was received back at the facility with a fax stamp of 2:54 p.m. and was confirmed with NCC #2. NCC #2 was interviewed on 2/12/2020 at 11:45 a.m. She said Monday (2/10/2020) the MD saw Resident #11 and ordered the resident to have a urinalysis and ultrasound. She said the resident did not regularly complain of pain, nor had he complained of pain in the groin area before. She said that morning on 2/10/2020 he was not in terrible distress as he was jovial but did grimace with some pain. She said the physician should be notified if a resident was having a change in status or increased or uncontrolled pain for further instruction. She said she and NCC #1 helped out the floor nurse when or if they were behind and put in orders for them. She said there was a stack of orders and she put in the order for Resident #11's ultrasound. She said she gave the order to CNA #4 by putting it in her box, and she had not attempted to call the imaging center herself. She said she saw the fax with the ICD code later sitting in the fax machine by happenstance as she was down on the other nursing unit where the fax came in, and put that in CNA #4's box and left for the day. She said she did not know why there was a delay in putting the order in at 12:40 p.m. when it was ordered originally by the MD at 9:30 a.m. She said it was not reasonable the resident had not received the ultrasound the same day when it was originally ordered at 9:40 a.m. She said if the resident was having continued pain the on-call physician should have been called and maybe the resident sent to the hospital, and if she had been working that night that's what she would have done. She said it was NCC #1 the next day that said the resident needed to be transported ASAP to the ultrasound. The MD was interviewed on 2/13/2020 at 8:28 a.m. She said she was notified the resident was having pain right away by the nurse when she walked on the unit around 8:30 a.m. on Monday. She said she and the nurse had examined the resident together. She said the order for the ultrasound was not stat and expected it to be done in one to two days. She said she told the nurse verbally about the ultrasound and wrote it out on the treatment order form as well. She said she was not notified the resident was having pain and was in tears nor of the increased pain in both testicles and newly identified swelling, and was only notified the next day when he was refusing to go to the ultrasound because he was so uncomfortable. She said she would have expected to be notified of the pain and change in status, and would expect the facility to at least try to have scheduled the ultrasound for the same day. III. Facility failure The MD ordered the ultrasound at 9:30 a.m. for Resident #11's newly reported testicular pain. However, the order was not entered into the computer and signed off by NCC #2 until 12:40 p.m., she did not attempt to call the imaging center to schedule the ultrasound. CNA #4 did not receive the order for the transport until 2:00 p.m., when she identified she needed a different order form and worked with NCC #1 to contact the MD's office to get the proper order form. The fax was sent back to the facility at 2:54 p.m. NCC #2 said she saw the fax and put it in the transporters box at an unknown time, she again did not attempt to call the imaging center to schedule the ultrasound. CNA #4 said she saw the proper referral/order with the ICD 10 code around 4:30 p.m.-5:00 p.m. when she was done for the day and heading out the door, and she had not called to schedule the ultrasound at any time that day. During this time record review and interviews show the resident was experiencing pain to the point he was expressing tears and worsened to the point the next morning his testicles were swollen and hard. Prior to his transport it was documented the resident was in Extreme Pain and his testciles were extremly swollen. The physician was not notified of any changes or pain issues with the resident. V. Director of nursing (DON) interview The DON was interviewed on 2/13/2020 at 12:04 p.m. She said it was the process at the facility the doctors wrote paper treatment orders and they were later transposed into the electronic medical record (EMR). When an order for [REDACTED].#4 so she could arrange the transportation and accommodations. She said the time frame on this depended on if it was a routine order which could take one to three days, but if it were something super pressing they would get it done immediately. She said nurses should call the MD with significant changes, uncontrolled pain, and new or worsening symptoms and the MD was very welcoming about being contacted. She said Resident #11 was not as alert and oriented as he presented, but was able to make his basic needs known. She said he had the testicular situation starting on Monday and going into Tuesday, and as far as she knew, this was new for him. She said after reviewing the chart and with her staff it was her understanding the pain started on Sunday but he had not made anyone aware till Monday. She said they assessed him and the MD ordered some tests. She said his pain had fluctuated on Monday and they were using tylenol, which seemed to bring him more down to baseline. She said overnight they had treated him for pain and as long as he was not sitting compressing his testicles, it was not bothering him. She said in the morning when he sat up he had more pain and it was more urgent and they sent him out for the ultrasound. She said it was correct that the ultrasound order was put in at 9:40 a.m. and he had not gone out for the test until 8:30 a.m. the next day, and the resident was experiencing fluctuating pain during that time. She said they were waiting on the results of the urinalysis, but she did not see an order from the MD to wait for those results. She said the role of the NCC was to support the floor staff, and that day NCC #2 went to help out and put orders in. She said there was an issue with the ICD 10 code order and they had to fax that over to the MD's office, and by the time the shuffling of papers was over the imaging center was not taking patients. She felt as far as she knew it was followed through timely as the order was routine and it was not something urgent and felt it was ok to wait. She said if it was ordered routine in the morning, she would expect the imaging center to be called that day and did not know if they were called that day for Resident #11.

Based on record review and interviews, the facility failed to ensure one (#11) of three sample residents were free from abuse by certified nurse aide (CNA) #3. Specifically, Resident #11, who was at increased risk for staff to resident abuse, was forcibly placed on a bedpan despite being verbally and physically resistant to care. According to nursing progress notes, on 10/19/19 at approximately 7:15 p.m., CNA #3 was overheard by registered nurse (RN) #1 to have said: (Resident #11), stop scratching me, (Resident #11) you know you are not supposed to pinch people. It was also noted RN #1, a male staff member, was standing on the other side of the resident's privacy curtain and he told CNA #3 he would go get a mop. RN #1 left CNA #3 alone with Resident #11 to retrieve a mop during what was labeled an altercation. Given the staff's knowledge of Resident #11's statements that she was abused by CNA #3, the resident's history of behavioral symptoms, and the failure of the facility to implement care planned appropriate behavioral interventions and follow their abuse reporting and investigation policy, a situation of immediate jeopardy was created with the likelihood of an adverse outcome. Cross-reference to F609, failure to report alleged abuse; and F610, failure to thoroughly investigate an abuse allegation and protect residents from further abuse. Finding include: I. Immediate jeopardy [NAME] Findings of immediate jeopardy On 10/19/19 at approximately 7:15 p.m., CNA #3 forcibly grabbed Resident #11's right arm and pushed her on her side to get her on a bed pan. Resident #11 verbally and physically resisted the care when she became aware of a male staff member on the other side of her privacy curtain. At approximately 9:50 p.m. a police officer arrived at the facility to perform a welfare check on Resident #11. RN #1 did not contact the facility administrator or assess the resident's physical or mental status after the police officer left the facility. On 10/20/19 at approximately 10:30 p.m., the facility began an internal abuse investigation surrounding the events of the evening of 10/19/19. CNA #3 worked her assigned hallway which included Resident #11's room, on 10/20/19 and 10/21/19. CNA #3 was not suspended, supervised or formally reassigned until 10/25/19. RN #1 continued to provide care and supervision for Resident #11 through the last shift he worked on 11/2/19. On 10/23/19 at approximately 1:44 p.m., the director of nursing (DON) was notified of a staff interview in which CNA #1 stated Resident #11 said she had been choked by CNA #3 on the night of 10/19/19. CNA #1 said she reported the choking allegation to RN #1 after leaving the resident's room. The failure of the facility to promptly and thoroughly investigate the abuse allegations and take necessary steps to ensure the ongoing safety of Resident #11, created a situation of immediate jeopardy with likelihood of an adverse outcome if the facility's failures were not corrected. On 11/6/19 at 7:00 p.m., the NHA and DON were notified of the facility's failure to ensure the safety of Resident #11 which created a situation of immediate jeopardy. B. Interim plan to ensure resident safety 1. Resident #11 will be provided a 1:1 employee to ensure her safety. 2. Resident #11 will be provided all cares by two employees with line of sight of the resident. 3. 100% of the staff scheduled to work in the building throughout the night of 11/6/2019 until 6am 11/7/2019 have been provided 1:1 re-education by the NHA or DON regarding the facility abuse policies and procedures; reporting abuse allegations; and the different types of abuse. A total of 82% of all current facility staff have also received this education. 15 employees have not received this education due to either being on a leave of absence or not scheduled to work. These employees will be educated by the DON or NHA prior to being allowed to provide resident care. 4. All facility supervisors have attended reporting abuse allegations presented by (local) County. C. Plan to correct the immediate jeopardy situation On 11/7/19, at 4:00 p.m., the NHA submitted a final plan to remove the immediate jeopardy situation. It read as follows: 1. Resident #11 will be provided a 1:1 employee to ensure her safety for a minimum of 48 hours beginning 11/6/2019 at 8:00 p.m. Resident #11 will be visited daily by either the NHA/DON/ Social Worker/ or Manager on Duty to provide her with emotional support, ensure resident is feeling safe, and to ensure she is being treated with dignity. The resident was interviewed by the NHA on 11-6-2019 and expressed that she feels safe in the building and is not fearful of any staff. 2. Beginning 10/25/2019 98% (46/47) of residents with a BIMS greater than 8 were interviewed using the QIS surveyor tool. Only one of the residents interviewed indicated he had been abused several months prior. This was investigated and a late occurrence report was completed. This resident stated he does feel safe in the building. 81 % (l7/210 (stet) of families for residents with a BIMS of eight or less were interviewed using the QIS surveyor tool. No concerns with abuse or dignity were expressed. 3. A minimum of five resident interviews will be conducted daily to ensure they feel safe and staff are treating them with dignity. 4. Resident #11 will be provided all cares by two female employees with line of sight of the resident. 5. 100% of the staff scheduled to work in the building throughout the night of 11/6/2019 until 6am 11/7/2019 have been provided 1: 1 re-education by the NHA or DON regarding the facility abuse policies and procedures; reporting abuse allegations; and the different types of abuse. A total of 82% of all current facility staff have also received this education. 15 employees have not received this education due to either being on a leave of absence or not scheduled to work. These employees will be educated by the DON or NHA prior to being allowed to provide resident care. 6. Employees will be re-trained by 11-30-2019 by a (corporate name) consultant regarding care of dementia residents, managing difficult behaviors, customer service, and care with dignity. 7. The NHA/DON will re-train staff on or before 11/15/2019 regarding quality of life for residents and emotional support for the staff as caregivers. All employees will complete the CMS Hand in Hand Dementia Care program: modules 1 & 5 by (MONTH) 30, 2019. 8. The CNA and RN involved in the incident were reassigned to different care units on or before 11/4/2019 and will not provide care to resident #11. Both employees have been re-educated by the NHA regarding reporting allegations of abuse. Both employees will complete the CMS Hand in Hand Dementia Care program: modules 1-5 by (MONTH) 30, 2019. These two employees will be closely monitored by the DON through a minimum of five resident interviews weekly with residents on the employees' assigned units to ensure the residents feel safe and these employees are treating them with dignity. 9. The employees will be provided information about the facility Employee Assistance Program to access emotional support. The HR Director and/or DON and/or NHA will meet with a minimum of 10 employees monthly to complete Stay Interviews to determine employee needs and to offer emotional support. C. Removal of immediate jeopardy On 11/7/19 at 4:10 p.m., the NHA and DON were notified the facility's plan to remove the immediate jeopardy situation had been accepted based on the initiation of 1:1 supervision of the resident, documented reassignment of CNA #3 and RN #1, line of sight care provision by two female staff members, increased monitoring of staff involved and continued staff education and support. However, deficient practice remained at a G level, actual harm. III. Facility policy and procedures The Abuse policy, revised 5/23/17, provided by the nursing home administrator (NHA) on 10/22/19, revealed the facility shall take every precaution possible to prevent resident abuse by anyone, including staff members. [NAME] Standards of abuse prohibition included: -Employees have a unique position of trust with vulnerable residents; -A safe environment for a resident is a basic and essential duty of the facility; -Identification of abuse shall be the responsibility of everyone; and -The facility shall promote an atmosphere of sharing with residents and staff without the fear of retribution. B. Approaches and interventions designated for abuse prevention protocols included: -Residents at risk for abusive situations were identified with appropriate care plans developed; -Staff was encouraged to talk with supervisors, department heads or the administrator about residents or situations they found difficult to manage, stressful or frustrating; and -Occurrences, patterns and trends that may constitute abuse would be identified and appropriate action would be taken. C. Reporting abuse standards read: All employees of this facility must immediately report any suspected, observed or reported incident of resident neglect, abuse or misappropriation of resident property, whether by staff members, family members or any other persons to the facility Administrator. An employee who has knowledge or reason to believe that a resident has been a victim of abuse is required to immediately report such incident or suspicion to a member of the Administrative staff. IV. Resident status Resident #11, age 93, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 8/9/19 minimum data set assessment (MDS) revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. She required extensive assistance for toileting and transfers. She had not displayed any physical behavioral symptoms directed towards others, or rejected care. She was frequently incontinent of bladder and always continent of bowel. V. Record review 1. The care plan was provided by the NHA on 10/22/19. The following focus areas and interventions were identified: [NAME] A history of physical aggressiveness with care at times. Interventions initiated 7/17/18 and revised 3/11/19 included: 1. Intervene before agitation escalated. 2. Guide the resident away from the source of distress and engage calmly in conversation. 3. If the response was aggressive, staff was to walk away calmly and engage later. An Intervention initiated 8/1/19 and revised 9/3/19 included: 4. Care to be provided in pairs as able. Male staff to be behind privacy curtain and on the other side of the partially opened door to be available for assistance and to monitor behaviors. If the resident wanted the door closed, honor her wishes. B. A history of resistance to ADL care. Interventions initiated and revised on 2/1/18 included: 1. Allow the resident to make decisions about treatments. 2. Encourage as much participation and interaction by the resident as possible during administration of care. 3. If the resident resisted ADL care, reassure her, leave and return in five to 10 minutes and try again. C. A history of verbal aggression towards staff and confabulated stories. Interventions initiated 2/21/18 and revised 12/12/18 included: 1. Assessment and anticipation of toileting needs, comfort level and body position; 2. Assessment of the resident's understanding of the situation; and 3. Resident allowed time to express herself and her feelings about the situation. 4. Give the resident as many choices as possible about care. An Intervention initiated 2/21/18 and revised 8/1/19 included: 5. Analysis of circumstances, triggers and what would de-escalate the situation; The care plan did not specifically address the risk for potential for abuse in a vulnerable resident. 2. Progress notes Nursing notes revealed the following pertinent information: [NAME] Weekly Nursing Documentation (weekly skin) note effective 10/19/19 at 10:29 p.m. and electronically signed on 10/20/19 by RN #1 (a male staff member) revealed: -No new behaviors -Most recent temperature, pulse, respiration, blood pressure and oxygen saturations all dated 10/5/19 at 10:04 p.m. -Warm, dry and intact skin -The narrative note section to document issues not identified in previous sections contained no information. B. Nursing note dated 10/20/19 at 1:10 a.m., signed by RN #1 read in pertinent part: On 10/19/19 at approximately 7:15 p.m. RN #1 accompanied CNA #3 to Resident #11's room to answer the call light. The resident was yelling out and banging her bed with her back scratcher. He noticed the fall mat was not in place and the last person to leave the room was the resident's son. He noticed a spill on the floor and left to get a mop. RN #1 returned and heard CNA #3 and Resident #11 arguing about the resident's need to urinate versus defecate. He documented CNA #3 said, (Resident #11) stop scratching me, you know you are not supposed to pinch people. He wrote the resident said, Go get the other lady, I do not want your help. He documented CNA #3 left the resident on the bedpan and went and got CNA #1 who completed the care provision with no other altercations. RN #1 documented further that the resident's son came to the facility at approximately 8:00 p.m. and inquired what time CNA #3 finished her shift. He wrote that one of Resident #11's daughters called at approximately 9:00 p.m. and spoke with CNA #1 about the incident with her mom. He wrote that a police officer came to the facility at 9:50 p.m. who indicated he was contacted by the resident's daughter. He documented the police officer said the daughter's version of what happened was a little more exaggerated than the resident's statement. C. A nursing note, dated 10/21/19 at 3:53 a.m., signed by RN #1 revealed he answered Resident #11's call light on the evening of 10/20/19 and he notified the resident there would be two male staff members on the Center hallway after 10:00 p.m. and her care may be delayed. On 10/20/19 at approximately 8:30 p.m he returned to the resident's room and one of her daughters was present. He wrote there was some confusion about what he had told the resident about the two male staff members and care provision for the evening. RN #1 further documented, I pointed out to her daughter about how that was a good example of her dementia and short term memory loss (STML). He documented Resident #11's account of how another CNA had been fired for always pushing her against the wall. He wrote, That might have been part of the reason for her termination but not the only reason. RN #1 documented at that point the resident began to recount the incident the night of 10/19/19. He said he decided to reason with her and asked, So who do you think got mad first yesterday? To which the resident immediately responded, That lady that came in here yesterday and started pushing me around. He responded: No you got mad first yesterday because I could hear you from the nurse station banging the bed with your back scratcher and yelling out that you needed to go poo. He wrote the daughter said it did not matter who started it first and her mother had been abused. She pointed out red marks on Resident #11's arm and he said, Oh yeah, I was told that is only lipstick. He wrote that he told the resident and her daughter that the facility did not tolerate abuse, and he left to care for another resident. RN #1 documented he later returned to the resident's room after the resident's daughter left. He wrote, I took the female CNA with me and we went into the room to determine if it was lipstick or red marks from abuse. He said as he wiped the resident's arm she said, You are just trying to wipe it off so they don't see it. He replied, If it is redness or scratching then it will not wipe off. He wrote abuse was mentioned so the CNA called the NHA and she was told to keep the wipes and call the police. VI. Resident interview Resident #11 was interviewed on 10/22/19 at 2:05 p.m. She said during the evening of 10/19/19 she had been physically abused by CNA #3. She said CNA #3 grabbed her forcefully on her right arm and pushed her aggressively toward the wall despite her repeated requests to stop and statements that CNA #3's actions caused her pain. She said there was a male on the other side of the privacy curtain while CNA #3 forcibly put her on the bedpan. She said she was left unattended on the the bedpan when CNA #3 left the room. She said the incident with CNA #3 caused pain in her right arm directly above and below her elbow. She said she did not feel safe with CNA #3 in her room. She said she called several of her children on the evening of 10/19/19 because she was extremely upset. Resident #11 was interviewed a second time on 11/6/19 at 6:46 p.m. She said she had not seen the mean lady who had grabbed her arm and pushed her toward the wall. She said her son told her she was still in the building. She said she mostly felt safe. She said sometimes staff came to check on her and sometimes they did not. VII. Family interview A daughter of Resident #11 was interviewed over the phone on 10/23/19 at 2:40 p.m. She said she visited her mother on 10/20/19 and she was curled up in a ball and unusually soft-spoken. She said her mother seemed like a caged animal and they had broken her spirit. She said during her visit on 10/20/19, registered nurse (RN) #1 came into the resident's room (see RN notes above). She said he was argumentative and contentious. She said she noticed red marks on her mother's right arm. She said she asked about red marks on her mother's arm and RN #1 told her the marks were from lipstick. She said RN #1 said to her mother, (Resident #11), remember who got mad first? She said his words and demeanor agitated her mother and they began to argue like a couple two-year-olds. She said she told RN #1 it did not matter who had started what, and if the marks on Resident #11's arm were from a staff member, it was abuse. She said RN #1 said CNA #3 also had marks on her arm. She said after RN #1 left the room she and her mom were both extremely upset and her mother was afraid of what staff may do to her. She said sometime after she had gone home on the evening of 10/20/19 she received a phone call from a police officer because the facility had started an abuse investigation. She said she texted photographs of the red marks on her mother's arm to the police officer. VIII. Staff interviews The director of nursing (DON) and NHA were interviewed on 10/22/19 at 11:30 a.m. The NHA said she believed the red marks on Resident #11's arm were lipstick. She produced a ziplock bag with several wet wipes with red smears she said were wiped from Resident #11's arm by RN #1 in the late evening of 10/20/19. The NHA said she looked at the resident's arm and did not see any bruises or broken skin. The NHA she did not consider this as possible abuse until the resident's daughter used the word abuse the evening of 10/20/19. She said Resident #11 and her family were the most difficult she had to deal with in her [AGE] years of experience. Licensed practical nurse (LPN) #2 was interviewed on 10/23/19 at 10:03 a.m. She said she accompanied LPN #1 into Resident #11's room on the morning of 10/20/19 because there was some kind of worry about a mark on Resident #11's arm. She said LPN #1 took a washcloth and wiped off some what looked like makeup. She said there was not an abuse investigation that she was aware of at the time. CNA #3 was interviewed over the phone on 10/23/19 at 11:48 a.m. She said on the evening of 10/19/19, Resident #11 became resistant to care when she heard a male caregiver's voice from the opposite side of the privacy curtain. She said the resident tried to hit her when she helped her onto a bedpan. CNA #3 said she herself may have had a little-bitty hematoma that's pretty much gone on her arm. She said she did not have any scratches, bruises or pain related to care she provided for Resident #11. She said she asked to leave work early on the night of 10/19/19 because a family member of the resident asked another employee what time her shift ended, and she took this as a threat. She said she worked her regular schedule from 2:00 p.m. to 10:00 p.m. on 10/20/19 and 10/21/19. She said she had not been suspended or reassigned and entered Resident #11's room on both days after the incident the night of 10/19/19. She said the situation with Resident #11 and her family prior to 10/19/19 was extremely frustrating. RN #1 was interviewed over the phone on 10/23/19 at 12:28 p.m. He said he accompanied CNA #3 to Resident #11's room because the resident was screaming and banging her bed. He said he and CNA #3 entered the room together and he noticed a spill on the floor. He said he retrieved a mop and stayed on the opposite side of the privacy curtain. He said Resident #11 said, Don't push me to CNA #3. He said CNA #3 said, Don't pinch me, don't hit me. He said CNA #3 came out of the room and she looked pretty upset. He said CNA #3 said, I can't deal with this. He said he did not provide any care or perform any assessments for Resident #11 after the incident with CNA #3 on the night of 10/19/19. He said the skin assessment completed 10/19/19 was a weekly skin assessment. RN #1 said a police officer came to the facility to interview Resident #11 at approximately 10:00 p.m. He said he knew the police officer came to the facility because the resident's daughter had called the police. He said one of the resident's daughters called earlier and asked to speak to CNA #1. He said he did not ask CNA #1 why the daughter called because, I did not want to know. I have worked here since (MONTH) and it is the same old broken record, over and over. She is like a four-year old with a temper tantrum and the next day she forgets. RN #1 said he had a discussion with Resident #11 and one of her daughters on the evening of 10/20/19. He said Resident #11 began to tell her daughter about the incident the night of 10/19/19. He said he tried to be rational with the resident and said, Who got angry first? He said the daughter claimed the red marks on the resident's arm were a result of abuse. RN #1 said he told the daughter he heard in report the marks were from lipstick and he argued a little bit with the daughter. He said he finished medication administration to other residents (on 10/20/19) and returned to the room with CNA #3 (the alleged assailant). He said he told CNA #3, Come on, we have to go see this, the daughter is claiming abuse. He said he was accompanied by CNA #3 and he was sure it was her because she was there on Saturday, 10/19/19. He said he wiped off what he believed to be lipstick from the resident's right arm. He said after that CNA #3 called the NHA at approximately 9:30 p.m. CNA #1 was interviewed over the phone on 10/23/19 at 1:08 p.m. She said on the evening of 10/19/19, Resident #11 said CNA #3 choked her. She said she looked at the resident's neck and felt it was a false claim because she did not see any marks on her neck and the resident had a history of [REDACTED]. The DON was interviewed on 10/23/19 at 1:44 p.m. She said any staff member who was told by a resident they had been hurt or mistreated should notify facility administration immediately. CNA #2 was interviewed on 10/23/19 at 3:48 p.m. She said she worked the morning of 10/20/19 and she heard the police were called to the facility for a welfare check on Resident #11 the night of 10/19/19. She said she was not aware of any staff reassignments on 10/20/19 and she thought Resident #11 was a little quiet on Sunday, 10/20/19 but pretty much normal. LPN #1 was interviewed on 10/24/19 at 10:11 a.m. She said she worked the day of 10/20/19. She said she went into Resident #11's room a couple of times to give her medications. She said she noticed what she thought was makeup on the resident's right arm and tried to wipe it off with a baby wipe but it did not come off. She said she asked LPN #2 to come in the room with her and she used a sanitation wipe and the majority of whatever was on her arm came off. She said she asked LPN #2 to accompany her because she was already associated with whatever happened the night before. She said the police had been called the night before because one of Resident #11's daughters called them because there had been a problem with Resident #11 and one of the night CNAs. She said she was told by LPN #2 the NHA or DON had not been called and she said she would call above her head if the police came in when she worked. She said she asked RN #1 why he had not at least texted the NHA, and he said he was not aware that was an option. The NHA and DON were interviewed a second time on 10/24/19 at 11:15 a.m. They said CNA #3 and RN #1 were on scheduled days off and CNA #3 would be reassigned when she returned to work. They said RN #1 would not be reassigned because he was not alleged to have committed abuse and the need for RN coverage. They said their return to work would depend on the findings of the facility abuse investigation which was ongoing. They said CNA #3 would receive additional supervision or monitoring when she returned to work. They said RN #1 would not be assigned to provide the supervision or monitoring for CNA #3. IX. Mental health provider note A licensed clinical social worker (LCSW) note, dated 11/7/19 at 11:30 a.m., was provided by the NHA on 11/7/19 at 1:10 p.m. The note revealed the LCSW was there to see Resident #11 specifically about her allegation of abuse on 10/19/19 and check in with her mental health and emotions related to it. The LCSW wrote Resident #11 appeared to be matter of fact and was able to relay the story of the allegation. She wrote the resident expressed feelings about grief and sadness. She said the resident was tearful about family dynamics and appreciative of the visit from the LCSW. X. Final NHA interviews The NHA was interviewed on 11/7/19 at 9:30 a.m. She said Resident #11 was a mean person and the most difficult she had worked with in [AGE] years. She said RN #1 received a disciplinary written warning related to abuse reporting requirements. She said CNA #3 and CNA #1 received final written disciplinary actions related to abuse reporting requirements. The NHA was interviewed a second time on 11/7/19 at approximately 3:30 p.m. She said the first time she interviewed Resident #11 she said, That lady hurt my arm, and then talked about the pain in her right arm she always had. She said the facility had to take steps to protect staff from this mean and ugly family. She said the family wanted to see the facility go down and they were after a big paycheck. She said she did not feel the abuse allegation was substantiated, but maybe now she would change her mind.

Based on observation, resident and family interview, and record review, the facility failed to provide adequate supervision and safety devices to prevent accidents with injuries for four of 29 sample residents (#7, #45, #51 and #56). -Resident #45 sustained a fractured femur while being transported in her wheelchair by facility staff. After the fracture, the resident experienced additional falls, pressure ulcers which developed as a result of the resident's decreased mobility after the fracture (cross-reference F314), and placement of an indwelling catheter (cross-reference F315). -Resident #51 sustained repeat falls with fractures. Resident #56 also fell . The facility failed to ensure preventative measures were implemented and new interventions considered to keep the residents safe. -Resident #7 experienced injuries due to inadequate staff supervision and assistance during transfers via wheelchair lift into a private van that was inadequately equipped to protect the resident's safety. The findings were: A. Facility Policy and Procedures On 1/9/12 at 9:50 a.m., the Director of Nurses (DON) submitted the facility's policy "Fall Management Policy and Procedure" dated 1/2008, for review. It stated in pertinent part: -Purpose: The purpose of this fall management policy is to modify or eliminate risk factors and thereby reduce the likelihood of future falls. A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. Research has shown that structured fall reduction programs can substantially reduce the rate of falls and related injuries in nursing facilities. Identify risk factors, followed by timely and appropriate interventions, is the key to a successful program . . . -Procedure: 1. A Fall Risk Assessment will be completed . . . 5. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls . . . Please note, interventions are to be re-evaluated after every fall. The following interventions are to be initiated and/or considered: a. A Physical Therapy (PT) evaluation will be completed within at least 48 hours for any resident who experiences an initial fall , , , g. Assess need for a potential room change - move closer to nursing station. . ." B. Residents 1. Resident #45 Resident #45, a [AGE] year-old female, was admitted to the facility on [DATE], transferred to the hospital 9/17/11, and readmitted on [DATE]. [DIAGNOSES REDACTED]. Record Review: a. Resident Status Minimum Data Set (MDS): According to her 10/31/11 MDS, resident #45 had short- and long-term memory problems and was moderately cognitively impaired, with periods of inattention, disorganized thinking, altered consciousness, and an acute change in mental status. She was noted to have no hallucinations or delusions. Behavioral symptoms included verbal abuse, other socially inappropriate behavior not directed at others, and rejection of care. No preferences were noted for customary routine activities, as that section was left blank. -The resident needed extensive assistance with activities of daily living (ADLs) including bed mobility, and was totally dependent for ambulation, toilet use and bathing. She used a wheelchair, had an indwelling catheter, and was continent of bowel. -Her [DIAGNOSES REDACTED]. -She was not on a scheduled pain management program; received as-needed (PRN) pain medication; presence of pain was noted, as occasional and moderate, although the numerical rating was blank. The staff pain assessment was not done. -The resident had two or more falls since the prior assessment, with no injuries. She was 69 inches tall and weighed 173 pounds. -She was noted to have no pressure risk and no pressure ulcers. She was taking antipsychotic, anti-anxiety and antidepressant medications. There was no family or resident participation in the MDS assessment. Care Plan: (1) ADLs The resident's care plan, dated 7/27/11 and revised 11/1/11, identified "alterations in ADL participation related to limited initiative, decreased mobility." Interventions were: - Staff to provide assist of 1 for dressing, grooming, hygiene, toileting & bathing. - Set up meal trays. - Provide assist of 1 for transfers. - Enc indep w/c (independent wheelchair) propulsion, propels w/c w/ (with) feet (this intervention had a line drawn through it with no date or initials). - Provide w/c propulsion if fatigued. - Hoyer lift transfers of 2 (dated and initialed 9/23/11). (2) Falls The care plan regarding "potential for falls" identified "decreased mobility, dementia, fall history, fx (fracture) R distal femur, non weight bearing." Interventions included monitor positioning in bed, Hoyer lift transfer of 2, sensor pad on bed, long leg immobilizer R leg, check frequently & reposition." The care plan, initiated, on 7/27/11, was revised on 9/22/11 and 11/1/11. The resident's undated, acute care plan noted, "No wt on R leg X at least 6 weeks" due to a [DIAGNOSES REDACTED]." b. Failure to ensure resident #45 was safely transported from the dining room to her room, resulting in a fracture Interdisciplinary Progress Notes: Review of interdisciplinary progress notes revealed a 9/17/11 note from a certified nurse aide (CNA) at 8:30 a.m. that read: "I was clearing out the dining room after breakfast when (resident #45) asked for a ride to her room. As I was wheeling her down the hall she lowered her R (right) foot to the ground. Immediately thereafter I stopped pushing the w/c and heard a loud crack. She started yelling 'I broke my leg.' (A nurse) was down the hall close by - called her over to look @ (resident)." The nurse noted, at 11 a.m. on 9/17/11, "Res cont(inued) to yell 'I broke my leg' while we pushed her into her room. Upon assessment of R knee, no inflammation, no bruising, leg leaning medially. Bump protruding in center of patella, res scream when try to align with upper leg. Limited ROM (range of motion) in extension. Res given Tylenol 325 mg (2 tabs) for pain. Half hour later res still in pain, 9/10 on pain scale. Called (physician with physician on call - new order) to transport res to (local) hospital non-emergent ER (emergency room ) for eval @ 0930 (9:30 a.m.) 10:30 (a.m.) EMS (ambulance) arrived to transport res. Family notified waiting to hear from (hospital) regarding res status." - 9/17/11 at 5 p.m. - "Res daughter called, informed this nurse res has R femur fracture and res will not be returning to facility this shift. Stated they are considering applying a cast or surgery." Hospital Documentation: The initial Emergency Department report noted admission time was 10:43 a.m. The chief complaint was "R knee 'popped' after being caught under w/c ... R leg went under wheelchair, pop, screamed." The [DIAGNOSES REDACTED]." A knee immobilizer was applied and the resident was admitted . The detailed emergency report noted, "She is able to weight bear to assist in transfer, but per report does not walk. Apparently the patient's leg dropped in front of the wheelchair and got caught underneath the wheelchair. Per report, a pop was heard, and the patient screamed in pain. She continued to have pain in the right leg and because of this the patient was transferred by EMS to (the hospital) for evaluation. ...She was sleeping comfortably and would only complain of pain with manipulation of her knee ... I spoke with (physician name) of orthopedics. He reviewed the imaging and recommended knee immobilizer and medical evaluation. He will discuss with the patient and family medical versus surgical treatment of [REDACTED]. The 9/17/11 hospital history and physical (H&P) noted the resident was unaccompanied by family or a caregiver; the reason for admission was "femoral fracture/pain control." The H&P read in pertinent part as follows: -"(Resident) was being moved from breakfast to her room via wheelchair when her right foot was caught under a wheelchair. A 'snap' was heard. The patient had immediate pain in her right knee area. She has a history of right knee replacement. She could not bear weight thereafter. She was transferred to (the local hospital) emergency room ... -Review of systems: Not available from this demented patient. The nursing home transferring her said she had been in her usual state of health with mobility limited to pivot transfers. She apparently has had a right knee replacement, although the timing of that is not available to me. - ... Physical examination: Pleasant, vague, and disoriented. This may have been augmented by a 100 mg fentanyl by squad ... She has no calf swelling and a knee immobilizer ordered by (another physician) is in place. She has tenderness in her right distal femur. She has no edema of her lower legs, no ecchymoses ... -Database: Right distal femoral fracture, slightly displaced noted." Investigative Report of 9/17/11 Incident: The facility's incident/accident report, dated 9/17/11 at 8:50 a.m., revealed as follows: - The accident occurred in the hallway. The resident's [DIAGNOSES REDACTED]. The employee name and title were blank on the incident report. Under "describe," the nurse on duty wrote, "Riding in w/c when incident occurred. Res was being moved down the hall in her w/c and she lowered her R foot. Staff stopped pushing the w/c & res yelled 'I broke my leg' after a loud crack was heard." The resident's knee was circled on the body map. Vitals were listed as temp 97.2, pulse 47, respiration 20, blood pressure 145/71. "Potential R knee fx (fracture)" was noted. The physician and family were noted as notified, and the resident sent to (hospital) ER (emergency room ) for eval via non-urgent EMS, on 9/17/11 at 10:30 a.m. An undated, untimed statement written by the CNA, attached to the incident report stated as follows: -"After breakfast I was clearing out the dining room to get all Rs (residents) to their rooms. (Resident #45) yelled out to be pushed back to her room. As I was wheeling her out of the dining room, I reminded her to keep her feet up as she did not have foot rests on her w/c. She instantly raised her feet and I started pushing her down the hall. -As we got to (the resident's room), she set her foot down on the ground. As soon as her foot was touching the floor I stopped pushing the w/c. The w/c did not touch her foot/leg in any way to have gotten 'caughted' in the wheels of the w/c or any other part. I heard a very loud crack the moment she placed her foot on the floor. The nurse was down the hall passing meds as I called out to her. (Another CNA) came out of the room across (the hall) as she heard the noise as well. (Resident #45) stated she 'broke her leg.' The nurse came down the hall, I explained what happened and the nurse took her to her room." An undated, untimed statement from the director of nursing (DON), also attached to the incident report, read as follows: -"I spoke with (the CNA) regarding occurrence with (resident #45). She reported (resident #45) had requested a ride to her room after breakfast. She said she told (the resident) to lift her feet and she propelled her down the room towards her room. She stated she noted (the resident) put her foot on the floor. (The CNA) stopped propelling the w/c as she heard a "crack" sound. She immediately notified the nurse ... She stated there were no other people in the hallway at the time. -(Resident #45) does not use foot pedals as she has been propelling her w/c with her feet. The staff has been encouraging her to propel herself from her room to the dining room and back. Her room is not far from the dining room. The staff encourage her to continue this to maintain her independence." The DON stated in a brief interview the morning of 1/9/12, that the above statements were written the day of or the day after the incident. The DON said she was not on duty the day the incident occurred. c. Failure to timely train staff after 9/17/11 incident Post Fall Review and Staff Training: Upon request, the DON and nurse consultant provided documentation of a nursing inservice agenda. No curriculum or minutes were provided. The inservices were conducted on 10/7, 10/26 and 10/27/11, two to five weeks after the resident's accident. The inservice agenda included the following pertinent items: "In depth investigation/documentation when occurrences happen i.e. falls, fractures, wounds," and "Resident oversight regarding positioning, adaptive equipment, and safety devices (i.e.) foot pedals." A document, dated 10/25/11, and initialed by an occupational therapy assistant, noted a "foot pedal audit performed 10/24/11 and 10/25/11." The audit was conducted more than a month after the resident's accident. Resident #45 was included on the list of residents for "recommended use of foot pedals when up in wheelchair." A "foot pedal log" dated "October 2011" noted that resident #45 needed a regular wheelchair with an elevating foot pedal, and stated the resident "needs to use foot pedals with right leg support." The DON and nurse consultant were interviewed at approximately 9:30 a.m. on 1/9/12. They said they trained staff on being aware of where the resident's feet were when being propelled, providing rest periods, etc. They said they could not recall any other residents during or since that time period that had experienced similar injuries. However, there was no evidence of a post fall interdisciplinary team meeting or review of the resident's accident. Staff training (see above) wasn't done until more than a month later. d. Failure to adequately monitor the resident and ensure her safety equipment was in working order following her fracture, resulting in four additional falls out of bed Following the resident's hospitalization ,[DATE]-[DATE], the facility noted the resident experienced additional falls from her bed as follows: - On 9/30/11 at 7 a.m., the resident was "found this am by the noc (night) nurse sitting on the floor (with) her back against the bed and both legs straight out in front of her. The R's bed alarm alerted the nurse that the R was no longer in bed. Neuro checks were initiated and the Hoyer lift was used to get her back into bed. R had (no complaints of) pain and no apparent injuries." At 10 a.m., the nurse noted the resident's daughter was at her bedside voicing concern regarding the resident's right leg sustaining a new injury. An X-ray was taken and revealed no new fractures or displacements. - On 10/29/11 at approximately 3:35 a.m., "resident was heard yelling 'help me,' upon entering room resident was found lying on her left side next to the bed. Resident denied any pain. ...Bed was in lowest position, call light on bed. Tab alarm in place, did not alarm but worked when tested . ... V/S 195/85, 82, 98.2, 16 reg 02 96% on 2L. Pupils were R 3 and non-reactive to light and L 4 and non-reactive to light. No hx of eye sx in chart. Resident lethargic but arousable. A&OX2. C/o headache when HOB raised. Dr. (name) on call for (PCP) notified by phone at approx 0345. Per (physician) monitor res and send toER on ly if resident becomes difficult to arouse. 0800 B/P pills given per (physician). Raised area noted to R parietal region of skull, no discoloration, small purple discolorations noted to R elbow/forearm. Neuros being completed q15min per P&P. Will continue to monitor." According to the resident's Fall Log, the resident had confusion, was in a low bed with sensor pad "she did not set off alarm ? position in bed didn't activate alarm - sensor pad checked and was functioning." - On 11/13/11 at 10:15 p.m., "found R sitting on floor (with) her back up against side of bed. 'He is behind the bed and he is cold. Get him out. Call (daughter) and have her come get him, call the cops. I think he is dead. Get my car, it's outside.' CNA & this nurse got client back to bed. Neuro checks started. Skin tear to L forearm ... ADON notified, family notified, MD notified." - On 12/19/11 at 5:35 p.m., "pt. slid out of low bed onto floor (without) injury. Fall witnessed by CNA." An OT screen was noted as having been done on 12/20/11 due to "sliding out of bed - (no) therapy indicated." e. Failure to update care plan See care plan above; the facility failed to update the resident's care plan with all the resident's fall precautions, including low bed with fall mat, ensuring her alarm was in working order, and ensuring staff anticipated her needs to prevent further falls. Family Interview: Resident #45's daughter was interviewed at 11:30 a.m. on 1/5/12. She said she visited the resident every other day. Asked about the resident's femur fracture, she said, "They were pushing her in the wheelchair evidently. They don't put foot pedals on and were just telling her to hold her legs up evidently, so her foot went down, her shoe got caught on the carpet and (she) broke her leg. We (resident's daughter and son-in-law) happened to be out of town - they took her right to the hospital. She's tried to get out of bed and fallen down since then because she thinks she's somewhere else - she forgets she can't walk and gets up. I guess she's just slid out of bed." Staff Interviews: The CNA who was involved in the incident with resident #45 on 9/17/11 was interviewed at 10 a.m. on 1/9/12. She said, "We were near (the social worker's) office. She put her foot down and I heard a crack - there'd never been an issue before that - we weren't going fast at all - the moment she put her foot down I stopped the wheelchair. I had told her to put her feet up. It didn't look like she was struggling and she showed no sign of putting her feet down or being tired." - Asked if the resident typically needed foot pedals on her wheelchair, the CNA said she had pushed her down the hall or she helped herself, it was about "50/50 - there were times she'd propel herself. For me it's a matter of habit to remind someone to lift their feet, previous to this." - Asked if she was provided training after this incident, the CNA said, "Yes, they reminded us that residents needed to have foot pedals on before leaving their rooms. That was a policy before, but we'd left them off because (resident #45) self-propelled so often." - Asked if she typically provided care for resident #45, the CNA said she worked on the East wing and did not typically work with resident #45, because she lived on the Central wing. "But staff team up to get everyone out of the dining room," she added. The nurse who was providing care for resident #45 during the incident was not on duty and was not interviewed. A second CNA was interviewed at 10:15 a.m. on 1/9/12. The CNA said she had provided care for the resident before and after the incident, but she had not been working that weekend. - The CNA said, "I don't push people up and down the hall unless the foot pedals are on. There are some residents who refuse them, but they're alert and oriented. My understanding was (resident #45) was supposed to have foot pedals and her foot slipped off the foot pedal. Some of these aides push people too fast, and you can't be fast with these people. I've seen a couple of CNAs push people down the hall too fast, (the CNA involved in the incident) being one of them. Now (the CNA) stays on east." - "(Resident #45) was unable to self propel before her accident - we always had to push her. The only thing she was able to do was stand and pivot and stuff, but now she can't even do that." - Asked about the falls out of bed that the resident had experienced after the femur fracture, the CNA said, "I'm always walking up and down the hall and checking on people. When I heard she slid out of bed, that was in the evening, so that means to me they're not checking on her - they can't be checking on her. You just have to pay attention - don't stand at the nurses' station - walk the halls and check on the residents." The DON was interviewed at 11 a.m. on 1/9/12. When asked, she said there was no policy on use of foot pedals. The nurse who routinely provided care for resident #45 was interviewed at 12:45 p.m. on 1/9/12. -Asked about the resident's falls, she said the resident had experienced a fracture and her leg was in an immobilizer as a result. "She had put her foot down while being wheeled down the hall." -Asked about the resident's falls from bed, she said "her agitation comes on so quickly out of nowhere - her pressure alarm and everything are always there but it just happens so quickly. Sometimes staff will get right to her - no injuries as far as I know. Everything's in normal limits as far as vitals." -Asked about fall prevention, she said the resident had a pressure alarm, fall mat, and frequent checks on her. "She tends to get thirsty so I offer plenty of water." Asked how often she checked on resident #45 for safety, she said, "When she's hollering and I peek in whenever I walk by to make sure she's doing okay - at least every hour that I'm up and down this hall." The DON was interviewed at 3:15 p.m. on 1/9/12. She was asked again if resident #45, given her dementia and fall risk, should have had foot pedals before wheeling down the hall. She said, "She probably should have had foot pedals." Asked if she had identified a trend regarding the resident's falls since her fracture, the DON said she did not recall a trend, but that she would provide a timeline regarding the resident's falls. The Fall Log provided by the DON later that day identified the falls on 9/17, 10/29, 11/13 and 12/19/11, but did not include the fall on 9/30/11 where the resident first slid out of bed a few days after her fracture. Review of the resident's falls revealed they had occurred during mealtimes and on the night shift. During a follow-up interview with the DON and nurse consultant at 11:45 a.m. on 1/10/11, they were asked if management staff monitored to ensure residents were safe during transport up and down the halls. They said they had monitored staff after resident #45's fracture, but probably did not document their monitoring. 2. Resident #51 Resident #51, an [AGE] year-old female, was readmitted to the facility on [DATE]. Resident #51 was admitted to the facility with documented [DIAGNOSES REDACTED]. The resident was originally admitted to the facility on [DATE] after suffering a fall with a fractured pelvis in an assisted living facility. The resident had a fall in the facility on 8/22/11, where she suffered an olecranon (elbow) fracture that required hospitalization and surgical repair on 8/28/11; she returned to the facility on [DATE]. The resident fell again on 11/30/11, and fractured her left distal femur, was hospitalized and was then re-admitted to the facility on [DATE]. According to a significant change MDS, dated [DATE], the resident wore glasses, scored 12 on the BIMS - had moderate impairment in cognitive skills for daily decision-making, required two-person physical assist with bed mobility, transfers and toileting, one-person physical assist with dressing and bathing, used a wheelchair for mobility, suffered from moderate pain, had falls in the last month and had a fracture prior to admission and was 4' 9" tall and weighed 88 pounds. Her admission MDS, dated [DATE], recorded that she only required supervision with all of her activities of daily living and walked with a walker and one-person assist. The resident currently was receiving hospice services. a. Observations - On 1/6/12 at 7:51 a.m., the resident was sitting in her recliner in her room. Her left leg was extended and a full-length brace had been applied. There was a perimeter-defining air mattress on her bed and a fall mat on floor next to her bed. There was a wheelchair adjacent to her bed with safety straps attached. There was no sensor alarm under her as she sat in her recliner. - On 1/9/12 at 10:05 a.m., the resident was sitting in her room in her recliner conversing with a visitor. The sensor alarm had been placed underneath her in the recliner. - On 1/9/12 at 12:15 p.m., the resident was sitting in dining room in her wheelchair. The safety belt was connected but there was no sensor alarm underneath her. b. Record Review The Computerized physician's orders [REDACTED]. According to Mosby's 2011 Nursing Drug Reference, one side-effect common to all of these medications was dizziness that would increase her risks for falls. There was an order dated 12/2/11 for fall mat and on 12/5/11 for a sensor-alarm to be on at all times and wheelchair seat belt at all times. In addition, there was an order dated 12/2/11, that the resident had to be non-weight bearing on her left lower extremity. Resident #51's Fall Risk Assessments were reviewed. The first one was dated 7/5/11 with a score of 12, the second one dated 8/31/11 with a lower score of 8, and the most current one dated 9/7/11, with a score of 16. A total score of 10 or above represented high risk. There was no evidence that she had been reassessed after falling and fracturing her femur on 11/30/11. The Care Plan for falls dated 7/21/11, included the approaches: Assess resident post fall, monitor resident for unsteady gait, unsafe footwear, poor safety awareness, high-low bed, non-slip footwear, sensor alarm, and OT and PT (occupational and physical therapy) evaluation as indicated. -On 10/18/11 the plan was updated to include - "resident non-compliant with tab alarm, will remove and transfer self, unsteady while up." Seat sensor alarm was added to the approaches. -On 11/30/11 after her femur fracture, the plan was updated to include: fall mat by bedside, lipped mattress and self releasing seat belt in wheelchair. On 12/5/11 another Care Plan for fall prevention was developed and included the following interventions: "Resident to wear brace to left leg per doctor's orders, sensor alarm at all times in bed, wheelchair and recliner, call bell in reach, lipped mattress, staff to frequently remind resident to call for assistance, 2-person transfers, give pain meds as ordered - monitor use and effectiveness, position for comfort." c. Resident Failures The facility failed to provide care and services and implement a care plan that included interventions effective to prevent repeated falls. The resident, who had a history of [REDACTED]. A chronology of these falls follows: - 8/22/11 Fall with fracture of right elbow The Interdisciplinary Progress Notes, dated 8/22/11 - 8/28/11, documented the resident fell in her room, swelling was observed and the resident complained of right elbow pain. She was transported to the hospital where an x-ray confirmed a fractured olecranon. She returned from the hospital on [DATE] with her right arm in a cast and sling with a plan to see the orthopedic surgeon on 8/25/11. After the appointment with her surgeon, her Coumadin was discontinued in anticipation of surgery to repair the fracture on 8/28/11. The resident was hospitalized and her fracture was surgically repaired according to the Operative Report with plate and screws. The resident returned to the facility on [DATE]. The Incident/Accident Report dated 8/22/11 indicated that the resident fell in her room during ADLs (activities of daily living) and the resident stated "My slippers are slippery." There was no indication in the report that the resident was wearing non-slip footwear. The Post-Fall Assessment Report dated 8/22/11 indicated that the fall was unwitnessed, the resident was wearing slippers, the call light was in reach and she had been transferred to this room within the last two weeks. There was no evidence that a referral was considered for therapy to evaluate/treat the resident. There was also no documentation that further interventions had been considered or implemented to help prevent resident #51 from falling again. - 9/6/11 (Two weeks later) Another fall with re-injury to right elbow The Interdisciplinary Progress (IDT) Notes dated 9/6/11 - 9/8/11 documented that the resident "fell out of her easy chair." The resident was seen by her orthopedic surgeon on 9/6/11 who ordered an x-ray that reported the impression, "status [REDACTED].) On 9/7/11 the resident complained of left hip pain, and when the pain increased on 9/8/11 an x-ray was taken and reported no hip fracture. On 9/7/11 the resident's physician ordered a "safety eval for tabs alarm and other safety features secondary to impulsivity and patient's poor safety awareness." On 9/8/11 an alarm was placed on the resident. Further review of the IDT Notes and faxes to physician revealed that resident was removing her tab alarm. On 10/17/11, the physician ordered to discontinue the tab alarm and ordered a seat sensor alarm instead. The Incident/Accident Report dated 9/5/11 indicated that the resident "slipped down out of her easy chair and landed on the floor in front of easy chair." There was a section on the form "Additional comments and or steps taken to prevent reoccurrence." It was left blank. There was no indication in the report that the resident's tab alarm was attached to her at the time of the fall or if it was functioning. The Post-Fall Assessment Report dated 9/6/11 indicated that the witnessed fall was in her room, that she had been readmitted to the facility in the last 30 days related to "fractured arm surgery," that no assistive devices or equipment was in use and that PRN (as needed) meds had been given in the last 2 hours. There was a section on the form for an Action Plan; however, it was blank. There was no evidence that a referral was considered for therapy to evaluate/treat the resident. There was also no documentation in the report that the resident's tab alarm was attached to her at the time of the fall or if it was functioning. - 11/30/11 Fall with fracture of distal femur The Interdisciplinary Progress Notes dated 11/29/11 - 11/ 30/11 documented that at 9:15 p.m. on 11/29/11, the resident was "heard calling out for help and states she was reaching into dresser drawer and slid to floor, causing 3 skin tears to outer left elbow, denies any other injuries." At 9:00 a.m., the next morning the resident "complained of left knee pain, left knee noted to be swollen and warm to touch." The physician was notified and an x-ray was ordered. At 11:00 the nurse documented that the results of the x-ray showed "acute un-displaced fracture of the distal femoral metaphysic." The resident was transported to the hospital. The hospital's History and Physical dated 11/30/11 reported the chief complaint as "Fall with left knee pain" and the history of chief complaint as, " . . . [AGE] year-old female who has had multiple medical problems and multiple falls with multiple fractures who presents to the emergency room from her nursing home after having a fall the night prior where she slid from her wheelchair while reaching for a tissue she dropped. She fell and immediately had pain in her left knee. She had swelling increasing overnight and they obtained a portable x-ray at the nursing home today which showed a left distal femur fracture. The plan after consulting with an orthopedic surgeon was, "Due to her decreased mobility and wheelchair bound state at the nursing home and family's desire for minimal intervention as well as her recent post operative myocardial infarction (post-operatively after the surgery to repair her elbow fracture),