Every finding on record at Garrison Mem Hosp NSG Fac

Based on record review, review of facility policy, and resident and staff interview, the facility failed to ensure residents remain free from abuse for 7 of 7 sampled residents (Resident #1, #2, #3, #4, #5, #6 and #7) who were subjected to physical/verbal abuse by other residents. Failure to prevent resident-to-resident physical abuse resulted in altercations involving hitting, slapping, and scratching and placed all residents at risk for serious injury, pain, mental anguish, and emotional distress. During the on-site facility reported incident investigation survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed beginning on 05/24/26 when documentation identified Resident #1 placed her hands around Resident #7's neck. *06/29/26 at 5:00 p.m. the survey team notified the administrator and director of nursing (DON) of the IJ, provided the IJ template, and requested a plan of removal for the IJ. *06/30/26 at 4:45 p.m. the SSA received the removal plan and accepted the plan. The removal plan contained the following interventions for Resident #1: *One-to-one caregiver at all times. *Staff monitor and documented behavior every 15 minutes on Checks for Resident Safety documentation sheet.*The nurse manager will review behavior documentation every eight hours to determine the need to continue one-to-one caregiver.*Defined criteria and assessment time frames for removing one-to-one caregiver. *Education provided to all staff working on 06/30/26 and all on-coming staff. *Educated all staff with in-person training on reporting resident safety events, workplace violence events, one-to-one caregiver, documentation of behaviors, and criteria and assessment time frames for discontinuing one-to-one caregiver. *07/01/26 at 3:25 p.m., the survey team verified the implementation of the removal plan and the IJ removal. The deficient practice remained at an E scope and severity following the removal of the IJ. Findings include: Review of the facility policy titled Mandatory Reporting of Abuse, Neglect, Exploitation, Mistreatment, Misappropriation Prevention or Acts of Violence occurred on 07/01/26. This policy, dated November 2023, stated, . In response to allegations of abuse . or mistreatment, the facility must: . Ensure that all alleged violations involving abuse . or mistreatment . are reported immediately . Abuse against patients/residents can be initiated by various people within the facility. The facility supports and protects . residents . from harm during an investigation of alleged abuse. Patient/resident protection actions include immediately removing the patient/resident from contact with the alleged abuser during the investigation process . measures are taken to provide a safe, secure environment for the patient . Physical Abuse may include but not limited to hitting, kicking, slapping . Mistreatment means inappropriate treatment . of a resident . -Review of Resident #1's medical record occurred on June 29 - July 1, 2026 and identified a diagnosis of vascular dementia. A quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition. The current care plan stated, . I have impaired decision making related to dementia. I'm not able to make safe decisions and this puts me at risk for injury. Resident #1's care plan failed to address wandering, rummaging, behaviors towards others, and individualized interventions for the behaviors. Review of Resident #1's nurses notes identified the following:*05/24/26 at 4:14 p.m. RN [registered nurse] received complaint from another resident [Resident #7] at nurses' station regarding [Resident #1]. Resident entered his room and told him he would not get dinner if certain things were not finished. Resident concerned [Resident #1] will position herself behind him triggering a PTSD [post-traumatic stress disorder] attack endangering both of them. Resident stated [Resident #1] has previously grabbed him around the neck.*05/27/26 at 9:27 p.m. resident [sic] entered day room and walked by another resident that has a hx [history] of combativeness, [Resident #1] said something to that resident [Resident #2] and they grabbed [Resident #1] by the arm, [Resident #1] then hit that resident [Resident #2] in the head.*06/01/26 at 8:00 p.m. upon entering the room this resident [Resident #1] is witnessed rummaging through her roommates [sic] [Resident #3] belongings by her roommates [sic] bed . it is also noticed that this resident [Resident #1] has spots of blood on right forearm, writer asked the roommate if she scratched her and her roommate stated that 'she hit me so you bet I scratched her.' .*06/04/26 at 6:12 p.m. witnessed resident hitting male resident [Resident #5] on his arms as she attempted to shut the patio door. Male resident struck her back. male resident has intact red discoloration on right upper arm.*06/12/26 at 11:15 a.m. [Resident #1] then went to the dining room. She walked up to another resident [Resident #6] and hit her in the left wrist and told resident '[profanity] you get out.'*06/24/26 at 4:00 p.m. At 1500 [3:00 p.m.] Aide . saw . the resident [Resident #1] . slapped current resident [Resident #4] on the arm.-Review of Resident #2's medical record occurred on June 29 - July 1, 2026 and identified a diagnosis of dementia. An annual MDS, dated [DATE], identified severely impaired cognition. The current care plan stated, . has newly diagnosed Dementia. Avoid over-stimulation (e.g., noise, [NAME], other physically aggressive residents). A nurse's note, dated 05/27/26 at 9:36 p.m., stated, [Resident #2] was in the day room when another resident [Resident #1] walked by [Resident #2] and he grabbed this resident by the arm, she then hit him in the head . -Review of Resident #3's medical record occurred on June 29-July 1, 2026 and included diagnoses of multiple sclerosis and generalized anxiety disorder. A quarterly MDS, dated [DATE], identified intact cognition. A nurse's note, dated 06/01/26 at 8:00 p.m., stated, . [Resident #3] was hollering because her room mate [sic] [Resident #1] was by her bed and rummaging through her belongings. This resident stated that her roommate hit her so she scratched her deep enough to draw blood in several spots. During an interview on 06/29/26 at 11:41 a.m. Resident #3 confirmed the incident with Resident #1 on 06/01/26. She stated the facility moved her to a different room the next day, she doesn't feel safe when [Resident #1] is around, and Resident #1 continued to come into her room and take my bible. -Review of Resident #4's medical record occurred on June 29 - July 1, 2026, and included a diagnosis of Alzheimer's disease. A quarterly MDS, dated [DATE], identified intact cognition. A nurse's note, dated 06/24/26 at 4:03 p.m., stated, . Aide . entered room . and saw . the resident [Resident #1] . slapped current resident [Resident #4] on the arm. -Review of Resident #5's medical record occurred on June 29 - July 1, 2026, and included a diagnosis of unspecified mental disorder. A quarterly MDS, dated [DATE], identified intact cognition. A nurse's note, dated 06/04/26 at 9:44 a.m., stated, Resident outside on patio after dinner when a female resident walked out on patio and attempted to shut the door. [Resident #5] told the resident [Resident #1] attempting to shut door not to do so. Female resident responded by hitting resident on bilateral upper arms multiple times. Resident responded in kind striking the female resident on upper arms. The care plan failed to address Resident #5's physical behaviors toward other residents or individualized interventions to address them. -Review of Resident #6's medical record occurred on June 29 - July 1, 2026 and included a diagnosis of dementia. A quarterly MDS, dated [DATE], identified severely impaired cognition. The current care plan stated, . have mental health disorders putting me at risk to make unsafe decisions and this puts me at risk for injury. The medical record lacked documentation of the altercation with Resident #1 on 06/12/26. -Review of Resident #7's medical record occurred on June 29 - July 1, 2026 and included a diagnosis of post-traumatic stress disorder. A quarterly MDS, dated [DATE], identified intact cognition. The current care plan stated, . Resident may have outbursts and or swing out at staff is [sic] frightened related to Post-traumatic stress disorder . Staff will not come up behind me with [sic] talking loudly this may cause to hit out. The medical record lacked documentation of Resident #7's report of an altercation with Resident #1 on 05/24/26. During an interview on 07/01/26 at 9:50 a.m., a nurse (#4) confirmed the altercation between Resident #1 and Resident #6 on 06/12/26. During an interview on 06/29/26 at 5:20 p.m., Resident #7 stated, [Resident #1] came up behind me and grabbed me by the neck. He motioned how Resident #1 placed her hands around his neck. He also stated, I have PTSD. She wanders into my room. He stated he was afraid of what might happen if his PTSD is triggered and he was unsure what he would do if triggered. During an interview of 07/01/26 at 2:05 p.m., a nurse (#6) confirmed Resident #7 did make the complaint documented in Resident #1's medical record and the nurse was unsure when Resident #1 placed her hands around his neck. During an interview on 06/29/26 at 5:10 p.m., an administrative nurse (#1) confirmed the resident-to-resident altercations between Residents #1, #2, #3, #4, #5, #6, and #7. She also confirmed the facility failed to update Resident #1's and Resident #5's care plans related to behaviors and include individualized interventions. The administrative nurse (#1) agreed the facility failed to implement interventions to address Resident #1's behaviors. The facility failed to effectively manage Resident 31's behaviors which resulted in repeated episodes of resident-to-resident abuse.

Based on observation, record review, review of facility policy, and staff interviews, the staff failed to provide appropriate supervision for 1 of 1 sampled resident (Resident #1) who wandered. Failure to provide adequate staff supervision resulted in Resident #1 accessing unsafe areas, hazardous items, and urinating/defecating in common areas and other residents' rooms and placed Resident #1 and all residents at risk of accidents, falls, and/or injuries. During the on-site facility reported incident investigation survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed beginning on 05/02/26 when documentation showed the facility failed to provide adequate supervision for Resident #1 which resulted in access to unsafe areas and hazardous items (scissors, cords, and bags), and environmental hazards related to urinating/defecating in common areas and other resident rooms. *06/29/26 at 5:00 p.m. the survey team notified the administrator and director of nursing (DON) of the IJ, provided the IJ template, and requested a plan of removal for the IJ. *06/30/26 at 4:45 p.m. the SSA received the removal plan and accepted the plan. The removal plan contained the following interventions: *Locks placed and utilized on the doors of the clean linen closet, storage closet at the end of the west hallway, storage closet for the clean nursing/resident supply room, and closet/storage area by the dining room, staff break room, storage room with the ice machine, bath house, and beauty shop.*Utilized the lock on the shower room door.*Verified all doors closed and locked hourly and documented on the Door Lock Log.*One-to-one caregiver assigned to Resident #1 and the resident's behaviors monitored and documented every 15 minutes on Checks for Resident Safety documentation sheet. *The nurse manager will review behavior documentation every eight hours to determine the need to continue one-to-one caregiver.*Defined criteria and assessment time frames for removing one-to-one caregiver.*Education provided to all staff working on 06/30/26 and all on-coming staff. *Educated all staff with in-person training on locking, verifying and documenting all doors are closed and locked, reporting resident safety events and workplace violence events by entering them into the facility event reporting system, one-to-one caregiver, documentation of behaviors, and criteria and assessment time frames for discontinuing one-to-one caregiver. *07/01/26 at 3:25 p.m., the survey team verified the implementation of the removal plan and the IJ removal. The deficient practice remained at an E scope and severity following the removal of the IJ. Findings include: Review of the IRIS [Incident Reporting Information System] Event Reporting Tipsheet [sic] occurred on 07/01/26. This undated tip sheet stated, . An event report is simply a documented record of someone's perception of an unintended or unexpected incident. select the appropriate event type.The Behavioral event type is used to report a patient's behavior . What happens after an event is submitted? Email notification is sent to the director and manager/supervisor of the department to be notified for review . Each of these events is individually reported on at Leadership Huddle each morning. Review of the facility policy titled 1:1 Resident Supervision occurred 07/01/26. This undated policy stated, . The purpose of this policy is to outline the specific criteria, assessment process, and implementation standards for dedicated one-to-one (1:1) care and supervision for residents . ensures resident safety, provides appropriate management for behavioral symptoms . Triggers for initiation include: . Wandering/Elopement Risk: Unsafe wandering patterns that cannot be redirected by standard facility environmental safety measures.Care Planning . The Interdisciplinary Team (IDT) is responsible for updating the resident's care plan to include individualized, meaningful activities and interventions tailored to the resident's strengths . Review of Resident #1's medical record occurred on June 29 - July 1, 2026, and identified a diagnosis of vascular dementia. A quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition. The current care plan, last reviewed by facility staff on 04/09/26, stated, . I have impaired decision making related to dementia. I'm not able to make safe decisions and this puts me at risk for injury. at risk for falls due to history of falls/dementia overestimates [sic] ability . Increased staff supervision with intensity based on resident need. Provide individualized toileting interventions based on needs/patterns . Provide one on one as needed . When frustration/fear is present evaluate for possible cause - (pain, toileting, hunger, thirst) . Transfers independently . Resident is continent of bowel and bladder. Monitor for needing help with toileting. ambulates independently . I will receive necessary setup, cueing, support and assistance level for activities of daily living . Resident #1's care plan failed to address wandering, rummaging, urinating/defecating in inappropriate places, behaviors towards others, and individualized interventions for the behaviors. Review of Resident #1's nurses notes identified the following:*05/02/26 at 8:53 a.m., . angry exhibiting verbal and physical aggression to staff related to cares. Resident exit seeking. began entering any room on unit not locked/closed. found in resident common bathroom with assistive device/[NAME] steady [sit-to-stand lift] placed underneath her feet. became verbally combative refusing assistance from RN [registered nurse] who removed assistive device from resident. found attempting to enter housekeeping closet/locked. entered storage closet attempting to get a rolling stool. combative and did not comprehend when reminded she had fallen from a stool the day before. got back in storage closet removing a broom which was taken away from her and area locked up. attempting to leave building via lobby elevator.*05/08/26 at 2:02 p.m., . continues to exhibit combative behaviors and resents nursing staff redirecting her from entering resident rooms/exhibiting unsafe behaviors. became very upset . this PM [afternoon] as resident presented with a plastic garbage bag of unknown origin over her head/around her neck.*05/09/26 at 2:09 p.m., . continues to exhibit verbally aggressive behaviors and appears to resent nursing staff when redirected out of other resident rooms/storage rooms which occured [sic] this shift. exhibited exit seeking behaviors . found in another resident's room with her pants down squatting and peeing on the floor.*05/19/26 at 6:22 p.m., . sporadically agitated/aggressive throughout day with increase in activity/confusion PM. attempted to/entered resident rooms/storage closets. in activity room going through kitchen drawers and pocketing silverware. attempted to elope from facility via elevator .*05/23/26 at 1:02 p.m., . attempting to urinate in dayroom and multiple resident rooms. found in facility supply room pocketing medical supplies . urinated in the dining room at her table spot. found in kitchenette urinating and getting into paper towels etc.*05/24/26 at 10:22 a.m., . resident pulled her pants down in the middle of the hallway in front of the elevator and food cart and urinated on the floor while residents/staff were leaving dining room. Resident then attempted to defecate in the garbage can next to the food cart. opened south exit door this PM in an elopement attempt. appears to know south exit door code partially and continuously pushed at door until it opened. entered third floor elevator in elopement attempt . continued to attempt to elope by all exits remainder of afternoon. entered nurses station office and attempted to urinate in waste basket.*05/24/26 at 6:28 p.m., . found in another resident room defecating on floor/pants pulled down . resident picked her feces up from off the ground and attempted to hit CNA [certified nurse aide] with it. exited the other resident's room and entered activity room. attempted to enter facility storage area/other resident rooms touching doors/door knobs with soiled hands.*05/25/26 at 2:05 p.m., . attempted to elope in elevator X2 [two times]. wandered hallway exhibiting extreme aggression attempting to elope through exit doors multiple times. found a glass vase/filled it with water and took it out on the patio to drink out of it. entering other resident rooms/found squatting in clean linen/brief closet.*05/28/26 at 10:03 a.m., . wondering [sic] into Staff break room .*05/29/26 at 5:54 p.m., . continues to attempt to elope via exit doors . found naked in hallway after lunch with wet pants discarded near her. found in storage closet with electric cords around her person reorganizing the closet per resident statement. not all facility storage areas have locks/keys. continues to sit in wheeled chairs behind nurses [sic] station. The stop barrier removed by resident.*05/30/26 at 6:31 a.m., . urinated next to a male resident in the hallway. seen bending down to her hands and knees and trying to clean the urine off the floor with her hands and also stepping in it with her bare feet as she had also removed her socks and shoes. found after this incident with a bag of popcorn that someone had thrown in the trash. found bending over and placing popcorn between all her toes as well as eating some of it.*05/30/26 at 5:51 p.m., . continues to enter resident rooms/kitchenette. found in dirty utility room this shift.*06/01/26 at 8:00 p.m., . had to be continually redirected out of others [sic] rooms or rooms that have supplies and the kitchenette.*06/03/26 at 4:11 a.m., . woke up and wandered down to the kitchenette, opened the door to the fridge and pulled her pants down, squatted and urinated and defecated on the floor in front of the fridge.*06/04/26 at 3:55 p.m., . continues to urinate/defecate in other resident restrooms/trash cans.*06/04/26 at 6:08 p.m., . found for second time this shift in same male resident's room. urinated/defecated on the resident's floor.*06/05/26 at 5:31 p.m., . caught urinating in trash can in day room.*06/06/26 at 5:25 p.m., . resident . removed her pants and urinated on the floor in the activity room.*06/07/26 at 6:20 p.m., . Continually wandering into other resident rooms and closets. had BM [bowel movement] in a trash can in another residents [sic] room. found taking items from other residents [sic] rooms and keeping items in her pockets. attempted to elope through locked unit doors. continues to wander at this time.*06/08/26 at 2:06 p.m., . urinated in dayroom prior to breakfast/refusing to allow nursing staff to provide cares. continues to wander in and out of resident rooms/taking resident belongings and toileting. found in a male resident's room prior to breakfast taking his candy. attempted to assist resident away from the candy and out of room at which point resident grabbed a pair of scissors in the male resident's room. resident defecated in activity room/grabbed paper towels to clean it up off a chair and floor.*06/10/26 at 6:36 p.m., Resident cut off her wanderguard [sic] in the dining room with a butter knife.*06/11/26 at 6:05 p.m., . found walking down hallway holding a fluorescent light bulb. attempted to retrieve the light bulb resident retreated to hallway bathroom and locked the door.*06/12/26 at 11:15 a.m., . took pants off and urinated in activity room. Resident in wheelchair sitting in hallway, patient began pushing resident down hallway. When staff tried to redirect her she became verbally aggressive . Patient attempted to hit resident in wheelchair but was unsuccessful.*06/13/26 at 3:46 p.m., . found and prevented from sitting in a chair with wheels she had taken from an undetermined area/moved it to the hallway and was attempting to seat [sic] in it.*06/13/26 at 8:00 p.m., . went into another residents [sic] bathroom and used the toilet, had a bowel movement on the floor . proceeded to dig in the linens .*06/14/26 at 12:50 p.m., . ate 2 [two] puzzle pieces in activity room this shift. continues to get into kitchenette/supply closets etc .*06/17/26 at 10:27 p.m., . found in activity room with pants down squatting in front of the heater peeing on the floor, she then grabbed a glove got down on her hands and knees and tried to wipe it up with a glove and veggie straws.*06/20/26 at 11:19 a.m., . Call light in other patient's bathroom noted when call light was checked patient was seen in bathroom with feces spread throughout bathroom and toilet. had BM on her clothes. Toilet was noted to be clogged by a large number of wipes, paper towels, toilet paper. found in public restroom with other items, toilet was clogged again in the public bathroom.*06/22/26 at 2:51 p.m., . resident was calm and stood at nurses [sic] station and voided on the floor.*06/23/26 at 9:35 a.m., . trying to put chair into kitchen food cart then observed coming out of another residents [sic] room and urine noted on floor and bed in that room.*06/26/26 at 2:24 a.m., . All staff assisting multiple residents when this resident was found in another residents [sic] room.found that she had urinated on the other residents [sic] bed while resident was in it. During an interview on 07/01/26 at 2:05 p.m., a nurse (#6) stated the electric cords documented on 05/29/26 as around her person were around Resident #1's neck. During an interview on 06/29/26 at 5:10 p.m., an administrative nurse (#1) confirmed she expected staff to close and lock doors if they have locks. She stated the facility placed a retractable mesh gate across the kitchenette, but moved it to Resident #4's door to prevent Resident #1 from entering after an altercation between the residents on 06/24/26. The administrative nurse (#1) also agreed Resident #1's behavior posed a risk to all residents, her care plan failed to identify her behaviors or individualized interventions to address the behaviors, and the facility failed to implement interventions to address Resident #1's behaviors and the safety risk posed to all residents.

Based on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to provide appropriate dementia care and services for 1 of 1 sampled resident (Resident #1) with a diagnosis of dementia. Failure to develop and implement interventions to address Resident #1's dementia care needs resulted in the resident's inability to achieve her highest level of functioning as well as other residents resident in the facility. Findings include:Review of the facility policy titled Assessment and Plan of Care occurred on 07/01/26. This policy, dated September 2022, stated, . The comprehensive resident assessment . and plan of care will be developed to maintain or improve each resident's mental, psychosocial and physical well-being. The purpose of the assessment is to provide quality care to the residents as determined by their individual needs. Realizing that each . resident has multiple and changing needs . the care plan take [sic] into account all the physical, psychological, and social characteristics of the resident . The complete health care plan . serves as the guide for effective care, it should be an ongoing reflection of the resident . the health care plan is reviewed by staffing meetings on a timely basis and updated to reflect current problems, goals, and approaches. Procedure: . Social Services will:. Establish related social service goals and approaches . Updating the Care Plan . The care plan . must be maintained and updated on a timely basis . The resident's care . plan will be updated and reviewed at least every 30 days or as indicated by the resident's medical condition.Review of the facility policy titled 1:1 Resident Supervision occurred 07/01/26. This undated policy stated, . The purpose of this policy is to outline the specific criteria, assessment process, and implementation standards for dedicated one-to-one (1:1) care and supervision for residents, particularly those with advanced dementia. ensures resident safety, provides appropriate management for behavioral symptoms . Triggers for initiation include: . Severe Behavioral Symptoms: Frequent aggressive, agitated, or catastrophic reactions that pose an imminent risk to the resident or others. Wandering/Elopement Risk: Unsafe wandering patterns that cannot be redirected by standard facility environmental safety measures. Upon identification of a trigger, the Charge Nurse or Director of Nursing (DON) must conduct an immediate, person-centered assessment. This assessment aims to identify root causes of the behavior, such as pain, hunger, or overstimulation, ensuring that the facility has sufficient information to provide effective care. Care Planning . The Interdisciplinary Team (IDT) is responsible for updating the resident's care plan to include individualized, meaningful activities and interventions tailored to the resident's strengths . Review of Resident #1's medical record occurred on June 29 - July 1, 2026, and identified a diagnosis of vascular dementia. Current physician's orders included Rexulti (an antipsychotic) 2 milligrams (mg) daily, started on 06/24/26, no indication for use documented. The current care plan stated, . Category: ADLs [activities of daily living] Functional Status . I have impaired decision making related to dementia. I'm not able to make safe decisions and this puts me at risk for injury. Category: Falls . at risk for falls due to history of falls/dementia overestimates [sic] ability . Increased staff supervision with intensity based on resident need. Provide individualized toileting interventions based on needs/patterns . start date: 02/12/26 . Category: Cognitive Loss/Dementia Impaired cognition RT [related to] dementia . Adhere to structure of daily programs. Allow resident choices as able . Allow time to respond/complete tasks . Provide cues and reminders for activity schedule . Provide special environmental stimuli - alert to activity schedule. Provide one on one as needed . When frustration/fear is present evaluate for possible cause - (pain, toileting, hunger, thirst) . start date 02/12/26 . Category: ADLs Functional Status . Self Care Deficit RT dementia . Resident is continent of bowel and bladder. Monitor for needing help with toileting. start date 02/12/26 . Category: Activities Is independently capable of pursuing her own self directed activity. May need reminders of Group Program times. Family will provide her with Bismarck Tribune newspaper. Has radio in room to listen to music and news . Invite to all Group Programs allowing her to choose which ones she will attend . Remind her of Church Service in the Chapel the first Sunday of the month . Walks the hallways for exercise . Watches TV [television], has her favorite programs she watches . When weather is nice staff can offer to go for walk with her outdoors . When weather is nice, she will sit outdoors on the patio . Works on Word Finds & [and] Crossword Puzzle Books . start date 02/16/26 . Review of Resident #1's nurses' notes, dated 05/01/26-06/26/26, identified the following:*05/01/26 at 5:38 a.m., . went to sit in chair in dayroom after using the restroom, residents [sic] hands and shirt were covered in BM [bowel movement], staff approached resident to get her to go take a shower. resident [sic] became upset and wandered into another residents room and woke him up while trying to avoid staff.*05/01/26 at 8:02 p.m., . ambulating in corridors naked refusing to [sic] redirection.*05/02/26 at 8:53 a.m., . exit seeking. began entering any room on unit not locked/closed. found in resident common bathroom with assistive device/[NAME] steady [sit-to-stand lift] placed underneath her feet . Resident found attempting to enter housekeeping closet/locked. entered storage closet attempting to get a rolling stool . got back in storage closet removing a broom . exit seeking . attempting to leave building via lobby elevator.*05/02/26 at 5:39 p.m., . has been wondering [sic] from room to room and taking other patient's property. took first dose of ordered seroquel [an antipsychotic] .*05/03/26 at 6:26 a.m., . agitated . stripped in common area and was resistant to redirection .*05/04/26 at 5:42 a.m., . irritable, resistant to redirection, entering other Resident's [sic] rooms and rifling through their belongings .*05/05/26 at 1:39 p.m., . witnessed coming out of the kitchenette with pants halfway pulled down found to have urinated in the drawer . wandering in and out of other resident rooms . redirected to dayroom. Provider on call notified of resident's combativeness, bizarre behavior, and restlessness. Provider ordered . lorazepam [an antianxiety medication] prn [as needed] q 6 hrs [every six hours] . Family notified and agreeable with orders.*05/05/26 at 5:25 p.m., . verbally and physically aggressive with staff. wandering from room to room and actively exit seeking. became verbally aggressive with another resident. Called on call provider and TO [telephone order] received to administer 1mg IM [intramuscular] ativan [an antianxiety medication].*05/05/26 at 5:25 p.m., . wandering around unit, going in and out of resident rooms, redirection not effective. threatening other residents, and upsetting other residents. witnessed going through cupboards and drawers in the activity room and other residents belongs [sic] - redirection out of rooms not effective . becomes combative. attempting to exit seek- pushing code on wall to exit. Provider on call notified, provider ordered IM ativan. (Provider ordered labs and imaging with no new orders noted).*05/06/26 at 10:12 a.m., . seen by rounding provider for behaviors, provider ordered increase to seroquel from 12.5 to 25 mg BID [two times a day].*05/08/26 at 2:20 p.m., . very upset with RN [registered nurse] this PM [afternoon] as resident presented with a plastic garbage bag of unknown origin over her head/around her neck.*05/09/26 at 2:09 p.m., . redirected out of other resident rooms/storage rooms which occured [sic] this shift. exhibited exit seeking behaviors PM. found in another resident's room with her pants downsquatting and peeing on the floor.*05/09/26 at 5:30 p.m., . hostile and entering other resident rooms with increased frequency.*05/10/26 at 5:14 p.m., . continues to enter other resident rooms and staff only areas of floor. found in facility kitchenette attempting to lower pants to toilet on floor. entered another resident room and did not comprehend she could not urinate on the floor.*05/14/26 at 6:18 p.m., . received new MD [medical doctor] order for Rexulti 0.5 mg daily pending insurance approval. If approved resident Seroquel order will be titrated down to 25 mg BID for 7 days followed by Seroquel to decrease to 25 mg daily for 7 days followed by DC [discontinuation] of Seroquel.*05/18/26 at 10:41 a.m., . Rexulti order has been approved by insurance/Rexulti 0.5 mg to begin 052026 [05/20/26] with seroquel titration beginning on this date. Seroquel DC on 060326 [06/03/26].*05/19/26 at 6:22 p.m., . sporadically agitated/aggressive throughout day with increase in activity/confusion PM. attempted to/entered resident rooms/storage closets. in activity room going through kitchen drawers and pocketing silverware. attempted to elope from facility via elevator .*05/23/26 at 1:02 p.m., . verbally combative/aggressive . attempting to urinate in dayroom and multiple resident rooms. found in facility supply room pocketing medical supplies . retrieved supplies from resident. resident agitation/anxiety increased. spent afternoon wandering hallway and entering rooms that were not hers. urinated in the dining room at her table spot. found in kitchenette urinating and getting into paper towels etc .*05/24/26 at 10:22 a.m., . pulled her pants down in the middle of the hallway in front of the elevator and food cart and urinated on the floor while residents/staff were leaving dining room. then attempted to defecate in the garbage can next to the food cart. opened south exit door . appears to know south exit door code partially and continuously pushed at door until it opened. entered third floor elevator . continued to attempt to elope by all exits remainder of afternoon. entered nurses station office and attempted to urinate in waste basket. Redirection to patio/food unsuccessful. entering other resident rooms/attempting to get into facility refrigerator becoming visibly angry when redirected.*05/24/26 at 4:14 p.m., . received complaint from another resident at nurses' station regarding [Resident #1]. Resident entered his room and told him he would not get dinner if certain things were not finished. Resident concerned [Resident #1] will position herself behind him triggering a PTSD [post-traumatic stress disorder] attack endangering both of them. Resident stated [Resident #1] has previously grabbed him around the neck.*05/24/26 at 6:28 p.m., . found in another resident room defecating on floor/pants pulled down . resident picked her feces up from off the ground and attempted to hit CNA [certified nurse aide] with it. exited the other resident's room and entered activity room. attempted to enter facility storage area/other resident rooms touching doors/door knobs with soiled hands. administered PRN ativan 0.5 mg. received additional 1X [one time] MD order for 0.5 mg oral ativan/1845 [6:45 pm.].*05/25/26 at 2:05 p.m., . resident wandering in patient rooms/exhibiting verbal aggression. attempted to elope in elevator X2 [two times]. prevented from pulling her pants all the way down in front of her brother. wandered hallway exhibiting extreme aggression attempting to elope through exit doors multiple times. found a glass vase/filled it with water and took it out on the patio to drink out of it. entering other resident rooms/found squatting in clean linen/brief closet.*05/27/26 at 9:27 p.m., . entered day room and walked by another resident that has a hx [history] of combativeness, [Resident #1] said something to that resident and they grabbed [Resident #1] by the arm, [Resident #1] then hit that resident in the head.*05/29/26 at 5:54 p.m., . confusion unchanged. continues to wander in other resident rooms/takes other resident belongings/eats other resident food. agitation grows during episodes of incontinence. remains incontinent. attempts to use facility/other resident chairs/WC [wheelchairs] as toilets. believes facility is her work place. Successful redirection occurs when resident is open to chores/working. redirections semi effective. continues to attempt to elope via exit doors. found naked in hallway after lunch with wet pants discarded near her. found in storage closet with electric cords around her person reorganizing the closet per resident statement. not all facility storage areas have locks/keys. continues to sit in wheeled chairs behind nurses station. The stop barrier removed by resident.*05/30/26 at 6:31 p.m., . into other residents rooms this shift. taking their belongings and attempting to rearrange their rooms or take side tables into the hallway. urinated next to a male resident in the hallway. found after this incident with a bag of popcorn that someone had thrown in the trash. found bending over and placing popcorn between all her toes as well as eating some of it. combative when popcorn was taken from her.*05/30/26 at 5:51 p.m., . continues to enter resident rooms/kitchenette. found in dirty utility room this shift.*05/31/26 at 3:18 p.m., . continues entering other resident rooms/using other resident bathrooms.*06/01/26 at 8:00 p.m., . witnessed rummaging through her roommates belongings by her roommates bed with no pants or brief on . it is also noticed that this resident has spots of blood on right forearm, writer asked the roommate if she scratched her and her roommate stated that 'she hit me so you bet I scratched her'. had to be continually redirected out of others rooms or rooms that have supplies and the kitchenette.*06/03/26 at 4:11 a.m., . woke up and wandered down to the kitchenette, opened the door to the fridge and pulled her pants down, squatted and urinated and defecated on the floor in front of the fridge.*06/04/26 at 3:55 p.m., . wandered into the room of two residents/sat in one of the residents arm chairs and began going through her personal belongings. The two residents of the room called for assistance from nursing staff. Resident frightened/anxious/potential consequences of someone getting hurt. continues to urinate/defecate in other resident restrooms/trash cans. taking food from numerous resident trays/eating it in dining room at meal time.*06/04/26 at 6:08 p.m., . found for second time this shift in same male resident's room. Room had been cleansed after prior urination episode. urinated/defecated on the resident's floor. wandering hallways.*06/04/26 at 6:12 p.m., . witnessed resident hitting a male resident on his arms as she attempted to shut the patio door. Male resident struck her back.*06/05/26 ay 6:14 p.m., . found in male resident room with a shirt/no underwear/pants sitting naked on his bed trying to get dressed/toilet. The resident of the room used call light and was visibly anxious.*06/06/26 at 5:25 p.m., . observed stripping off her clothes in the activity room. Staff was attempting to assist when resident became combative. removed her pants and urinated on the floor in the activity room.*06/07/26 at 6:20 p.m., . agitated this shift. Continually wandering into other resident rooms and closets. had BM in a trash can in another residents room. Family on unit and witnessed behaviors. found taking items from other residents rooms and keeping items in her pockets. attempted to elope through locked unit doors. continues to wander at this time.*06/08/26 at 2:06 p.m., . urinated in dayroom prior to breakfast/refusing to allow nursing staff to provide cares. continues to wander in and out of resident rooms/taking resident belongings and toileting. found in a male resident's room prior to breakfast taking his candy. staff attempted to assist resident away from the candy and out of room at which point resident grabbed a pair of scissors in the male resident's room. staff backed away and waited for her to leave room/drop scissors which did occur. Resident received PRN Ativan . resident defecated in activity room/grabbed paper towels to clean it up off a chair and floor.*06/10/26 at 6:36 p.m., Resident cut off her wanderguard [sic] in the dining room with a butter knife. Wander guard was replaced and secured .*06/11/26 at 6:05 p.m., . became agitated . arguing with other residents. unable to redirect . found walking down hallway holding a fluorescent light bulb. attempted to retrieve the light bulb resident retreated to hallway bathroom and locked the door.*06/12/26 at 11:15 a.m., . have made attempts to redirect patient from other resident rooms. has . taken important items from other resident. During breakfast patient took pants off and urinated in activity room. wondering [sic] and aggressive . Resident in wheelchair sitting in hallway, patient began pushing resident down hallway. staff tried to redirect . became verbally aggressive . attempted to hit resident in wheelchair but was unsuccessful. went to the dining room. walked up to another resident and hit her in the left wrist on her watch and told resident '[profanity] you get out'.*06/13/26 at 8:00 p.m., . went into another residents [sic] bathroom and used the toilet, had a bowel movement on the floor, had gotten it all over herself . wandered down the hall with no bottoms and and bm smeared down leg and on feet into the dining room and proceeded to dig in the linens . while another resident and his family were in the dining room playing cards and visiting. PRN ativan was given.*06/13/26 at 10:29 p.m., . tries to sit and rest, looks exhausted, states she is tired but continues to get up and wander aimlessly. has [sic] been redirected to rest with a blanket, given a snack and drink. addressed [sic] toileting. no [sic] needs identified.*06/14/26 at 12:50 p.m., . wandering hallways/entering resident rooms and taking their belongings/wearing and soiling their clothing/shoes. Other residents in facility expressing concern/removing and hiding their personal items in their rooms/not going to eat in dining room in order to watch over their belongings. refused activity redirection/folding towels. ate 2 [two] puzzle pieces in activity room this shift. frightened male resident this AM entering his room and taking his belongings. received PRN 0.5 mg lorazepam this AM. told a visitor in the hallway to get the [profanity] out of here . continues to get into kitchenette/supply closets etc.:*06/17/26 at 10:27 p.m., . found in activity room with pants down squatting in front of the heater peeing on the floor, she then grabbed a glove got down on her hands and knees and tried to wipe it up with a glove and veggie straws.*06/18/26 1:33 p.m., . wandering hallways/entering residents [sic] rooms. Exit seeking this afternoon. Multiple intervention initiated and unsuccessful. PRN Ativan 1 mg given and is effective.*06/19/26 at 6:11 p.m., . PRN lorazepam decreased anger but behaviors continue. stripped naked and wandered hallway after her dinner resistive to cares/verbal aggression.*06/20/26 ay 11:19 a.m., . continued wandering hallways. Call light in other patient's bathroom noted when call light was checked patient was seen in bathroom with feces spread throughout bathroom and toilet. attempting to clean area and had BM on her clothes. left bathroom and continued wondering [sic] in other patient room. redirected from other patient room and wondered [sic] down to her room gathering many belongings from other patients. Attempted to give patient PRN ativan patient slapped ativan out of hands onto the ground yelling profanities at staff. TO received to administer 1 mg IM ativan. 1 mg IM ativan administered . continues to refuse allow staff to change patient's clothing as they are soiled with BM.*06/21/26 at 10:14 p.m., . is going into all bathrooms and turning on water and undressing to 'clean up'. became aggressive when attempting to remove her. Found in multiple rooms lying on other residents [sic] beds while they were occupied. Many residents unhappy with this behavior. PRN Ativan given. Many redirection tactics attempted before Ativan was given.*06/23/26 at 9:35 a.m., . anxious and ativan prn given . trying to put chair into kitchen food cart then observed coming out of another residents [sic] room and urine noted on floor and bed in that room.*06/24/26 at 2:18 p.m., . [nurse practitioner] recert [recertification visit] on resident. Orders A1C [glycated hemoglobin,] [a lab test to check blood sugars over time] and TSH [thyroid stimulating hormone] [a lab test to monitor thyroid gland function] and increase rexulti to 2mg daily.*06/24/26 at 4:00 p.m., At 1500 [3:00 p.m.] Aide . saw . the resident [Resident #1] . slapped current resident [Resident #4] on the arm.*06/25/26 at 1:33 p.m., . has sitter in place. very anxious . Roaming and attempting to enter various rooms. Multiple interventions attempted and unsuccessful. PRN Ativan given and effective.*06/26/26 at 2:24 a.m., All staff assisting multiple residents when this resident was found in another residents room. When assisting her out of room it was found that she had urinated on the other residents bed while resident was in it. Review of Resident #1's medication administration records, dated May 1 - June 29, 2026, identified the following:*05/05/26 Ativan (lorazepam) (an antianxiety medication) 0.5 mg oral tablet four times a day as needed for vascular dementia. Renewed every 14 days. Administered 11 times in May and 30 times in June. (discontinued 06/29/26). *05/05/26 lorazepam 1 mg injection one time for agitation, physical and verbal aggression, wandering, exit seeking, vascular dementia.*05/24/26 and 06/12/26 lorazepam 0.5 mg oral tablet one time for verbal and physical aggression with staff, vascular dementia.*05/02/26 quetiapine (Seroquel) (an antipsychotic) 25 mg one half oral tablet three times a day (no indication for use or diagnosis) (discontinued 05/06/26).*05/06/26 quetiapine (Seroquel) 25 mg oral tablet three times a day for vascular dementia, titration of dose for discontinuation began 05/21/26, completed 06/03/26.*05/21/26 Rexulti 0.5 mg oral tablet one time a day (no indication for use or diagnosis), increased to 1 mg daily on 06/10/26, increased to 2 mg daily on 06/24/26. Review of Resident #1's provider progress notes, dated 05/14/26 - 06/24/26, identified the following:*05/14/26 - nurse practitioner note - . seen on rounds today, 5/14/2026, for dementia with secondary associated behaviors. Per nursing staff and third-floor nursing home staff the patient is increasingly combative both verbally and physically. currently taking quetiapine 25 mg 3 times daily and it does not seem to adequately be controlling the patient's dementia related behaviors. Plan: . Start Rexulti 0.5 mg daily. We may adjust dose after 7 days if necessary just ask a provider's input. Titrate off of Seroquel by going down to 25 mg twice daily x 7 [times seven] days. Then decrease further by 25 mg daily x 7 days then stop medication.*06/10/26 - nurse practitioner note - . evaluated on rounds today, 6/10/2026, for dementia with behavior disturbance. Patient was tolerating Seroquel 3 [three] times daily but due to . regulations patient was transition [sic] to Rexulti. Patient is currently on Rexulti 0.5 mg daily and still having significant behavior disturbance. Plan: . Increase Rexulti dose to 1 mg daily and reassess in 1 week. (The medical record lacked documentation of reassessment in one week).*06/24/26 - nurse practitioner note - . examined on rounds today . for increasing behaviors. Per nursing staff the patient will frequently eat food and drink from other residents [sic] plates during mealtime. She is also frequently digging through the garbage and disrobing. Patient was assessed disrobing by this writer while she was in the dining room. Patient is currently taking Rexulti 1 mg daily. She also has as needed lorazepam 1 mg 4 times a day as needed.Plan: . Increase Rexulti to 2 mg daily. Observation of Resident #1 on 06/29/26 showed the following:*11:45 a.m., The resident stood by south hallway doors attempted to open the doors. A CNA (#2) attempted to redirect the resident. The resident became agitated.*11:53 a.m., The resident wandered into Resident #3's room. The CNA (#3) entered the room to answer the call light and redirected Resident #1 from the room into the hallway. Resident #1 hit out at the CNA. The CNA propelled Resident #3 from the room and closed the door. Resident #1 again attempted to enter the room, the CNA redirected the resident and Resident #1 hit out at the CNA, then sat down on a chair in the hallway.*12:03 p.m., The resident stood at an unattended maintenance cart which had a battery operated drill on top of it. The resident ambulated into room [ROOM NUMBER], a nurse (#10) redirected the resident into the hallway. The resident ambulated to the dining room, sat at her table, and ate her noon meal. *12:51 p.m., The resident wandered in the hallway and dining room accompanied by a CNA (#9) who provided 1:1 supervision. The resident attempted to wander into Resident #4's room, which had a mesh gate across the doorway. The CNA (#9) attempted to redirect the resident away from the door, the resident became agitated, and another CNA (#3) assisted to redirect the resident to the activity room for bingo. The CNA (#9) sat with the resident in the activity room. During an interview on 06/29/26 at 11:41 a.m. Resident #3 stated she doesn't feel safe when [Resident #1] is around, and Resident #1 continued to come into her room and take my bible. During an interview on 06/29/26 at 5:20 p.m., Resident #7 stated, [Resident #1] came up behind me and grabbed me by the neck. He motioned how Resident #1 placed her hands around his neck. He also stated, I have PTSD. She wanders into my room. He stated he was afraid of what might happen if his PTSD is triggered and he was unsure what he would do if triggered. During an interview on 07/01/26 at 2:05 p.m., a nurse (#6) stated the electric cords documented on 05/29/26 as around her person were around Resident #1's neck and her Seroquel was stopped because the resident did not have a psychiatric consult. She confirmed the facility did have telemedicine psychiatric services available. During interviews on 06/29/26 at 12:18 p.m. and 5:10 p.m., and the morning of 07/07/26, an administrative nurse (#1) stated Resident #1 had declined cognitively and her behaviors had escalated. She stated the facility's social worker designee assigned to the nursing home lives in Nebraska and is unaware if a licensed social worker visted the facility. She agreed Resident #1's behavior posed a risk to all residents, Resident #1's care plan failed to identify her behaviors or individualized interventions to address the behaviors, and the facility failed to implement interventions to address Resident #1's behaviors and the safety risk posed to all residents. The facility failed to assess and monitor patterns and trends of behaviors in an effort to minimize these behaviors, recognize unmet needs, or prevent situations/triggers which may lead to behaviors or physical aggression toward staff and other residents. The facility failed to develop an effective behavior management program, consistently implement purposeful and meaningful activities in an attempt to manage the behaviors exhibited by Resident #1, evaluate the behavior management program on an on-going basis, and modify interventions as needed. The facility failed to ensure Resident #1 did not infringe upon the rights of others while still allowing her to achieve her highest level of well-being. These failures resulted in physical contact between Resident #1 and other residents and many residents experiencing fear, anxiety, frustration, and anger related to Resident #1's wandering and physically aggressive behaviors. Refer to F600, F689, and F745

Based on staff interviews, the facility failed to have a designated staff member trained in the assessment of residents' psychosocial needs and in the provision of services to meet those needs and failed to have on-site quarterly consultation from a qualified social worker. Failure to have a designated staff member and failure to have on-site consultation from a qualified social worker has the potential for residents to experience unrecognized changes in their mental and psychosocial health.Findings include: During an interview the morning of 07/07/26, an administrative nurse (#1) stated the facility does not have a social work designee, but they have a social worker in Nebraska who is assigned to the nursing home. The administrative nurse stated she is unaware if a licensed social worker visited the facility. A phone interview with another administrative nurse (#7) on 07/07/26 at 12:41 p.m. confirmed the facility does not currently have a social work designee and that a social worker in Nebraska is available, by phone, as needed. Refer to F744

Based on review of the current Facility Assessment and staff interview, the facility failed to review and update the facility assessment annually. Failure to review and update the assessment annually may result in the facility's inability to provide the resources necessary to care for the residents. Findings include: Review of the current Facility Assessment showed a review date of 12/03/24. During an interview on 07/07/26 at 3:15 p.m., an administrative staff member (#8) confirmed staff failed to review or update the Facility Assessment since 12/03/24.

Based on record review, review of facility policy, resident representative interview, and staff interview, the facility failed to notify the resident's physician and/or resident representative for 6 of 6 sampled residents (Resident #1, #2, #3, #4, #5, and #6) involved in resident-to-resident altercations. Failure to notify the physician and/or the resident representative of the altercations does not allow the physician or the representative to make informed decisions regarding medical care. Findings include: Review of the facility policy titled Notification of Changes occurred on 07/01/26. This policy, dated May 2026, stated, . The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring such notification include: . A change of room or roommate assignment . Additional considerations: a. Competent individuals: a. The facility must still contact the resident's physician and notify resident's representative . Review of the facility policy titled Mandatory Reporting of Abuse, Neglect, Exploitation, Mistreatment, Misappropriation Prevention or Acts of Violence occurred on 07/01/26. This policy, dated November 2023, stated, . Physical Abuse may include but not limited to hitting, kicking, slapping . Procedure: Notify patient/resident provider . Notify patient/resident representative . -Review of Resident #1's medical record occurred on June 29 - July 1, 2026, and identified a diagnosis of vascular dementia. A quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition. Review of Resident #1's nurses notes identified the following:*05/27/26 at 9:27 p.m. entered day room and walked by another resident that has a hx [history] of combativeness, [Resident #1] said something to that resident [Resident #2] and they grabbed [Resident #1] by the arm, [Resident #1] then hit that resident [Resident #2] in the head.*06/01/26 at 8:00 p.m. upon [sic] entering the room this resident is witnessed rummaging through her roommates [Resident #3] belongings by her roommates bed . it is also noticed that this resident [Resident #1] has spots of blood on right forearm, writer asked the roommate if she scratched her and her roommate stated that 'she hit me so you bet I scratched her'.*06/04/26 at 6:12 p.m. witnessed resident hitting a male resident [Resident #5] on his arms as she attempted to shut the patio door. Male resident struck her back. attempting to assess but resident paranoid/aggressive. male resident has intact red discoloration on right upper arm.*06/12/26 at 11:15 a.m. Patient [Resident #1] then went to the dining room. walked up to another resident [Resident #6] and hit her in the left wrist .*06/24/26 at 4:00 p.m. At 1500 [3:00 p.m.] Aide . saw . the resident [Resident #1] . slapped current resident [Resident #4] on the arm. The medical record lacked documentation the facility notified Resident #1's provider and/or representative of the altercations with Residents #2, #3, #4, #5, and #6. During an interview on 06/20/26 at 12:26 p.m., Resident #1's representative stated that the facility failed to notify her of the altercations between Resident #1 and Residents #2, #3, #5 and #6, but did notify her for the altercation with Resident #4. She further stated after the incident with Resident #3, the facility moved Resident #3 to a different room and gave Resident #1 a different roommate and failed to notify her of the change. -Review of Resident #2's medical record occurred on June 29 - July 1, 2026, and identified a diagnosis of dementia. An annual MDS, dated [DATE], identified severely impaired cognition. A nurse's note, dated 05/27/26 at 9:36 p.m., stated, resident [sic] [Resident #2] was in the day room when another resident [Resident #1] walked by [Resident #2] and he grabbed this resident by the arm, she then hit him in the head . The medical record lacked documentation the facility notified Resident #2's provider and/or representative of the altercation with Resident #1. -Review of Resident #3's medical record occurred on June 29 - July 1, 2026, and included diagnoses of multiple sclerosis and generalized anxiety disorder. A quarterly MDS, dated [DATE], identified intact cognition. A nurse's note, dated 06/01/26 at 8:00 p.m., stated, . this resident [Resident #3] was hollering because her room mate [sic] [Resident #1] was by her bed and rummaging through her belongings. This resident stated that her roommate hit her so she scratched her deep enough to draw blood in several spots. The medical record lacked documentation the facililty notified Resident #3's provider of the altercation with Resident #1. -Review of Resident #4's medical record occurred on June 29 - July 1, 2026, and included a diagnosis of Alzheimer's disease and a court appointed guardian. A quarterly MDS, dated [DATE], identified intact cognition. A nurse's note, dated 06/24/26 at 4:03 p.m., stated, . Aide . entered room . and saw . the resident [Resident #1] . slapped current resident [Resident #4] on the arm. The medical record lacked documentation the facility notified Resident #4's provider and guardian of the altercation with Resident #1. -Review of Resident #5's medical record occurred on June 29 - July 1, 2026, and included a diagnosis of unspecified mental disorder. A quarterly MDS, dated [DATE], identified intact cognition. A nurse's note, dated 06/04/26 at 9:44 a.m., stated, Resident outside on patio after dinner when a female resident walked out on patio and attempted to shut the door. Resident [Resident #5] told the resident [Resident #1] attempting to shut door not to do so. Female resident responded by hitting resident on bilateral upper arms multiple times. Resident responded in kind striking the female resident on upper arms. The medical record lacked documentation the facility notified Resident #5's provider and representative of the altercation with Resident #1. -Review of Resident #6's medical record occurred on June 29 - July 1, 2026, and included a diagnosis of dementia. A quarterly MDS, dated [DATE], identified severely impaired cognition. The medical record lacked documentation of the altercation with Resident #1, and notification to Resident #6's provider and representative of the altercation. During an interview on 07/01/26 at 9:50 a.m., a nurse (#4) confirmed the altercation between Resident #1 and Resident #6 on 06/12/26 and stated she did not notify Resident #6's provider as no injury and not sure if she notified Resident #6's representative. During an interview on 06/29/26 at 5:10 p.m., an administrative nurse (#1) stated she expected staff to notify resident providers and representatives of all altercations and changes in condition.

Based on record review, review of facility policy, and staff interview, the facility failed to report incidents of potential abuse to officials including the State Survey Agency (SSA) for 4 of 4 sampled residents (Resident #1, #2, #6 and #7) reviewed for resident-to-resident altercations. Failure to report incidents of potential physical abuse to the State agency placed all residents at risk of abuse, mental and emotional distress, and/or physical injury. Findings include: Review of the facility policy titled Mandatory Reporting of Abuse, Neglect, Exploitation, Mistreatment, Misappropriation Prevention or Acts of Violence occurred on 07/01/26. This policy, dated November 2023, stated, . It is the legal responsibility of every . employee to report in a timely manner any reasonable suspicion of abuse or . acts of violence . In response to allegations of abuse . or mistreatment, the facility must: . Ensure that all alleged violations involving abuse . or mistreatment . are reported immediately to the administrator of the facility and to other officials (including to the State survey and certification agency .) . Physical Abuse may include but not limited to hitting, kicking, slapping . Mistreatment means inappropriate treatment . of a resident . -Review of Resident #1's medical record occurred on June 29 - July 1, 2026 and identified a diagnosis of vascular dementia. A quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition. Review of Resident #1's nurses notes identified the following:*05/24/26 at 4:14 p.m. received complaint from another resident [Resident #7] at nurses' station regarding [Resident #1]. Resident entered his room and told him he would not get dinner if certain things were not finished. Resident concerned [Resident #1] will position herself behind him triggering a PTSD [post-traumatic stress disorder] attack endangering both of them. Resident stated [Resident #1] has previously grabbed him around the neck.*05/27/26 at 9:27 p.m. resident [sic] entered day room and walked by another resident that has a hx [history] of combativeness, [Resident #1] said something to that resident [Resident #2] and they grabbed [Resident #1] by the arm, [Resident #1] then hit that resident [Resident #2] in the head.*06/12/26 at 11:15 a.m. [Resident #1] then went to the dining room. She walked up to another resident [Resident #6] and hit her in the left wrist and told resident '[profanity] you get out.' -Review of Resident #2's medical record occurred on June 29 - July 1, 2026 and identified a diagnosis of dementia. An annual MDS, dated [DATE], identified severely impaired cognition. A nurse's note, dated 05/27/26 at 9:36 p.m., stated, [Resident #2] was in the day room when another resident [Resident #1] walked by [Resident #2] and he grabbed this resident by the arm, she then hit him in the head . -Review of Resident #6's medical record occurred on June 29 - July 1, 2026 and included a diagnosis of dementia. A quarterly MDS, dated [DATE], identified severely impaired cognition. The medical record lacked documentation of the altercation with Resident #1 on 06/12/26. -Review of Resident #7's medical record occurred on June 29-July 1, 2026 and included a diagnosis of post traumatic stress disorder. A quarterly MDS, dated [DATE], identified intact cognition. The medical record lacked documentation of Resident #7's report of an altercation with Resident #1 on 05/24/26. During an interview on 07/01/26 at 9:50 a.m., a nurse (#4) confirmed the altercation between Resident #1 and Resident #6 on 06/12/26. During an interview of 07/01/26 at 2:05 p.m., a nurse (#6) confirmed Resident #7 made the complaint documented in Resident #1's medical record, and the nurse was unsure when Resident #1 placed her hands around his neck. During an interview on 06/29/26 at 5:10 p.m., an administrative nurse (#1) confirmed the facility failed to report the incidents between Resident #1 and Residents #2, #6, and #7 to the SSA.

Based on record review, review of facility policy, and staff interview, the facility failed to investigate incidents of alleged violations of potential abuse for 4 of 4 sampled residents (Resident #1, #2, #6 and #7) reviewed for resident-to-resident altercations. Failure to investigate resident to resident altercations for potential abuse placed all residents at risk of abuse, mental and emotional distress, and/or physical injury. Findings include: Review of the facility policy titled Mandatory Reporting of Abuse, Neglect, Exploitation, Mistreatment, Misappropriation Prevention or Acts of Violence occurred on 07/01/26. This policy, dated November 2023, stated, . It is the legal responsibility of every . employee to report in a timely manner any reasonable suspicion of abuse or . acts of violence . In response to allegations of abuse . or mistreatment, the facility must: . Ensure that all alleged violations involving abuse . or mistreatment . are reported immediately to the administrator of the facility and to other officials (including to the State survey and certification agency .) . Have evidence that all alleged violations are thoroughly investigated . prevent further potential abuse . or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator . and to other officials in accordance with state law (including the State survey and certification agency) within 5 working days of the incident . -Review of Resident #1's medical record occurred on June 29 - July 1, 2026, and identified a diagnosis of vascular dementia. A quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition. Review of Resident #1's nurses notes identified the following:*05/24/26 at 4:14 p.m. received complaint from another resident [Resident #7] at nurses' station regarding [Resident #1]. Resident entered his room and told him he would not get dinner if certain things were not finished. Resident concerned [Resident #1] will position herself behind him triggering a PTSD [post-traumatic stress disorder] attack . Resident stated [Resident #1] has previously grabbed him around the neck.*05/27/26 at 9:27 p.m. resident [sic] entered day room and walked by another resident that has a hx [history] of combativeness, [Resident #1] said something to that resident [Resident #2] and they grabbed [Resident #1] by the arm, [Resident #1] then hit that resident [Resident #2] in the head.*06/12/26 at 11:15 a.m. [Resident #1] then went to the dining room. She walked up to another resident [Resident #6] and hit her in the left wrist and told resident '[profanity] you get out.' -Review of Resident #2's medical record occurred on June 29 - July 1, 2026, and identified a diagnosis of dementia. An annual MDS, dated [DATE], identified severely impaired cognition. A nurse's note, dated 05/27/26 at 9:36 p.m., stated, resident [sic] [Resident #2] was in the day room when another resident [Resident #1] walked by [Resident #2] and he grabbed this resident by the arm, she then hit him in the head . -Review of Resident #6's medical record occurred on June 29 - July 1, 2026, and included a diagnosis of dementia. A quarterly MDS, dated [DATE], identified severely impaired cognition. The medical record lacked documentation of the altercation with Resident #1. -Review of Resident #7's medical record occurred on June 29-July 1, 2026, and included a diagnosis of post-traumatic stress disorder. A quarterly MDS, dated [DATE], identified intact cognition. The medical record lacked documentation of Resident #7's report of an altercation with Resident #1 on 05/24/26. During an interview on 07/01/26 at 9:50 a.m., a nurse (#4) confirmed the altercation between Resident #1 and Resident #6 on 06/12/26. During an interview of 07/01/26 at 2:05 p.m., a nurse (#6) confirmed Resident #7 made the complaint documented in Resident #1's medical record and the nurse was unsure when Resident #1 placed her hands around Resident #7's neck. During an interview on 06/29/26 at 5:10 p.m., an administrative nurse (#1) confirmed staff failed to report the altercations between Resident #1 and Residents #2, #6, and #7 to administration, and the facility failed to investigate the altercations.

Based on record review, the facility failed to ensure a physician completed the initial comprehensive in-person visit within 30 days of the resident's admission and complete an in-person visit at least once every 60 days thereafter for 2 of 7 sampled residents (Resident #1 and #6). Failure to ensure residents receive the required physician visits may result in a delay of treatment and negative outcomes for the residents.Findings include: -Review of Resident #1's medical record occurred on 07/07/26 and identified an admission date of 02/09/26. The record showed a nurse practitioner completed the initial comprehensive in-person visit on 02/11/26 and monthly in-person visits through June 2026. The record identified the first in-person visit by a physician occurred on 07/01/26 (almost five months after the resident's admission). -Review of Resident #6's medical record occurred on 07/07/26 and identified an admission date of 01/22/26. The record showed a nurse practitioner completed the initial comprehensive in-person visit on 01/28/26 and monthly in-person visits through March 2026. The record identified the first in-person visit by a physician occurred on 04/11/26 (almost three months after the resident's admission). The facility failed to ensure the physician completed the initial comprehensive in-person visit and the required in-person visit every 60 days.

Based on observation and review of nurse staffing records, the facility failed to ensure staff posted accurate nurse staffing information on 47 of 47 days (May 23 - July 7, 2026) reviewed. Failure to ensure current facility census and nurse staffing information is updated daily and accurate at the beginning of each shift infringes on residents' and visitors' rights to access /review staffing patterns of the facility. Findings include: Observation on the afternoon of 07/07/26 showed nursing staff information, dated May 23 - July 7, 2026, located on a clipboard on the wall across from the nurses' station. Review of the staffing information showed all 47 days failed to identify actual hours worked by direct care staff for all shifts and failed to identify the facility census on nine of 47 days.

Based on record review and staff interview the facility failed to fully inform the resident or resident representative regarding treatment with psychotropic medications for 5 of 5 sampled residents (#2, #4, #5, #9, and #16) reviewed for unnecessary medications. Failure to fully inform the resident or the resident's representative of the risks, benefits, alternatives and obtain consent for psychotropic medications does not allow the right to choose treatment options. Findings include: - Review of Resident #2's medical record occurred on all days of survey. Physician's orders included Buspirone (antianxiety), Duloxetine (antidepressant), Lorazepam (antianxiety), Mirtazapine (antidepressant), and Risperidone (antipsychotic). The medical record lacked documentation the facility informed the resident and/or their representatives of treatment risks, benefits, options, or obtain their consent to the treatment prescribed. - Review of Resident #4's medical record occurred on all days of survey. Physician's orders included Citalopram (antidepressant) and Quetiapine (antipsychotic). The medical record lacked documentation the facility informed the resident and/or their representatives of treatment risks, benefits, options, or obtain their consent to the treatment prescribed. - Review of Resident #5's medical record occurred on all days of survey. Physician's orders included Quetiapine (antipsychotic) and Lorazepam (antianxiety). The medical record lacked documentation the facility informed the resident and/or their representatives of treatment risks, benefits, options, or obtain their consent to the treatment prescribed. - Review of Resident #9's medical record occurred on all days of survey. Physician's orders included Lorazepam (antianxiety) and Bupropion (antidepressant). The medical record lacked documentation the facility informed the resident and/or their representatives of treatment risks, benefits, options, or obtain their consent to the treatment prescribed. - Review of Resident #16's medical record occurred on all days of survey. Physician's orders included Seroquel (antipsychotic), and Memantine (psychotropic). The medical record lacked documentation the facility informed the resident and/or their representatives of treatment risks, benefits, options, or obtained their consent to the treatment prescribed. During an interview on 04/08/26 at 12:15 p.m., an administrative staff member (#1) confirmed the facility failed to fully inform the resident and/or their representatives of psychotropic medication treatment for Residents #2, #4, #5, #9, and #16.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the resident's current status for 6 of 12 sampled residents (Resident #2, #3, #4, #8, #16, and #21). Failure to update care plans limited staffs' ability to communicate needs and ensure continuity of care for each resident.Findings include: Review of the facility policy titled Care Conference and Resident Centered Care Plan occurred on 04/08/26. This undated policy stated, . A comprehensive resident-centered care plan will be developed and implemented for each resident, consistent with their resident rights, that include measurable goals and timeframes to meet the resident's medical, nursing, mental and psychosocial needs, and will contain the following: Services to be furnished to the resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being . Care plans will then be reviewed a minimum of quarterly, as the resident/representative requests, or as needed. Care plans will be reviewed by the team at regularly scheduled care conferences . Care plans must be kept current . - Review of Resident #2's medical record occurred on all days of survey. Physician's orders identified Oxycodone (opioid pain medication) and Risperidone (antipsychotic medication). Resident #2's care plan failed to identify problems and interventions for the use of opioid and antipsychotic medications. -Review of Resident #3's medical record occurred on all days of survey. Physician's orders identified Spironolactone (diuretic), Furosemide (diuretic), Tramadol (opioid pain medication) as needed, and Xarelto (anticoagulant). Resident #3's care plan failed to identify problems and interventions for the use of diuretic and opioid pain medication and goals or interventions for anticoagulation therapy. - Review of Resident #4's medical record occurred on all days of survey. Physician's orders identified Hydrochlorothiazide (diuretic medication) and Xarelto (anticoagulant-blood thinner). Observation on 04/07/26 at 8:48 a.m., showed Resident #4 in the hallway holding a roll of toilet paper in her hand and speaking Spanish to an unidentified housekeeping staff member. The staff member responded, I don't speak Spanish. During an interview on 04/07/26 at 11:50 a.m. an administrative staff member stated, There are translating ear buds at the nurse's station for staff and resident to use. Resident #4's care plan failed to identify problems and interventions for the use of diuretic and anticoagulant medication and translation devices for resident communication. -Review of Resident #8's medical record occurred on all days of survey and identified an indwelling urinary catheter. Resident #8's care plan failed to identify problems, goals, and interventions related to indwelling urinary catheter. -Review of Resident #16's medical record occurred on all days of survey. Physician's orders identified Lasix (diuretic), and Tramadol (opioid pain medication). Resident #16's care plan failed to identify problems and interventions for the use of diuretic and opioid pain medication. - Review of Resident #21's medical record occurred on all days of survey. Physician's orders identified Lasix (diuretic) and Seroquel (antipsychotic medication). The progress notes identified the resident has fallen from his chair. Observation on 04/06/26 at 2:29 p.m. showed Resident #21 asleep at a dining room table. A nursing staff member (#10) indicated he had been there since noon lunch and stated He has a recliner in his room and he won't sit in it. He is ambulatory and he goes back to his table. They had tried a recliner in the corner by his table, but he did not sit in that either. Resident #21's care plan failed to identify problems and interventions for the use of diuretic and antipsychotic medications and the resident's preference for spending most of the day at the dining room table.

Based on observation, review of the dishwasher temperature and chemical concentration logs, review of the manufacturers' guidelines, and vendor and staff interview, the facility failed to ensure the low temperature dishwasher provided adequate heat and sanitization for dishes and utensils washed in 1 of 1 kitchen (main kitchen). Failure to ensure the appropriate wash temperature for the dishwash cycle may result in inadequate cleaning and sanitation of dishware. Findings include:Review of manufacturer specifications for Energy Series 'Green' Machine American Dish Service, Edwardsville, Kansas identified Water Temperature - 120 degrees [Fahrenheit] F.Product specifications for Ultra San Liquid Sanitizer, Ecolab, 2023 Ecolab USA, stated, For Sanitizing Tableware in low-temperature warewashing machines, inject Ultra San into the final rinse water at concentration of 100 ppm available chlorine. Do not exceed 200 ppm .Observation in the main kitchen on 04/08/26 at 8:15 a.m. showed a low temperature chemical sanitizing dishwasher in use. A dietary aide checked the temperature of the wash cycle and obtained a measurement of 99 degrees Fahrenheit (F) stating, It doesn't always get to 120 degrees until later in the morning because they [other departments] are giving baths and doing laundry and using up the hot water. When asked if management or maintenance are aware of the low measurement, a dietary supervisor (#7) stated, Yes, administration and maintenance are aware, but we haven't heard anything. They have been working on the boilers. When asked if anyone had looked at the dishwasher, she said, No Review of the dishwasher temperature and chlorine level logs from March 20 through April 6, 2026, showed the temperature of the dishwasher water failed to reach 120 degrees F per manufacturers guidelines. The chlorine log identified the level at 100-200 parts per million (ppm) on those days.During an interview the morning of 04/08/26, an administrative staff member (#6) stated maintenance was aware of the dishwasher concerns.During a telephone interview on 04/08/2026 at 12:34 p.m., a dishwasher Service Representative (#8) confirmed a low temperature sanitizer is, Always known to require a minimum wash temp [temperature] of 120 degrees. A facility can turn up the water heater or attach a booster heater. But again, from a sanitizing standpoint the Ultra San will complete the sanitization process. The facility failed to address and correct the inadequate dishwasher temperature for 18 days.

Based on observation, record review, professional reference review, and staff interview, the facility failed to obtain an order for oxygen for 1 of 1 sampled resident (Resident #12) observed with oxygen. Failure to obtain a physician's order for oxygen use may result in complications and compromise the residents' respiratory status.Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 1292, stated, . Oxygen Therapy . The medical administration of supplemental oxygen is considered to be a process similar to that of administering medications and requires similar nursing actions. Oxygen therapy is prescribed by the healthcare provider, who orders the concentration, method of delivery, and depending on the method, liter flow per minute .Review of Resident #12's medical record occurred on April 7-8, 2026, and identified the resident returned to the facility the afternoon of 04/06/26 following an acute hospital stay for pneumonia and exacerbation (flare up) of congestive heart failure. Observation on April 7-8, 2026 showed Resident #12 wearing oxygen via a nasal cannula at 2 liters per minute. The physician's orders failed to include an order for oxygen.During an interview on 04/08/2026 at 4:40 p.m., an administrative staff member (#1) confirmed Resident #12 did not have an order for oxygen.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician of a change in condition for 1 of 1 sampled resident (Resident #2) reviewed for a fall with injury. Failure to notify the physician of the fall, potential fracture, and pain prevented the physician from altering the treatment and care for the resident. Findings include:Review of the facility policy titled Fall Protocol occurred on April 7, 2026. This policy dated June 2023 stated, . Post-Fall Management . Immediately perform and document complete head-to-toe assessment. including assessment for possible injuries. Notification. 1. Notify the LP [Licensed Practitioner] immediately at the time of the fall; provide the following: . b. Injury or complaint of pain . d. Obtain order for medical interventions/diagnostic procedures . 3. Patient's representative, as appropriate. Review of Resident #2's medical record occurred on all days of survey. Diagnoses included a right femur fracture. The current care plan stated, . Resident is at risk for falls due to cognitive loss . A progress note, dated 02/03/2026 at 8:15 a.m., stated, . At 0130 [1:30 a.m.] . nurse heard injured resident yelling. Bathroom door was shut. Resident was found on the floor on her back at 0135 [1:35 a.m.] . had no s/s [signs or symptoms] of head injury, all limbs palpated, and resident voiced increased pain in her right leg above her knee. resident was hoyer [mechanical lift] lifted to her bed. Large blanket in her room was rolled up and placed under her knee to help immobilize and stabilize her leg. Nurse contacted ER [emergency room] . and asked for provider on calls number. Noc [night] nurse gave ER staff nurse sit rep [situation report]. ER nurse stated to residents noc nurse that if it didn't appear to be emergent at the time to give tylenol [pain medication] and ice extremity, and to wait to call provider and obtain x-rays at 0800 [8:00 a.m.] this morning. Prn [as needed] tylenol was given around 0200 [2:00 a.m.] . providing non-pharmacological care using conversation to try to keep her mind off the pain. Resident complained of pain at first on her outer right hip and upper right leg. ice pack was applied . Throughout the night she [Resident #2] would say pain was one place and not in others, and other times would say pain was present in areas where she said she didn't have pain prior. Provider on call and family notified of resident condition. X-rays taken around 0815 [8:15 a.m.], and resident transported to the ER at 0900 [9:00 a.m.] .A progress note dated 02/03/26 at 9:38 a.m. stated, . Pain reported by resident to R [right] leg. Leg is swollen and slightly rotated. Femur fracture reported to RN [registered nurse] per [provider name].During an interview on 04/8/26 at 12:15 p.m., an administrative nurse (#1) confirmed staff failed to notify the physician about Resident #2's potential fracture.

Based on record review and staff interview, the facility failed to ensure residents remained free of chemical restraints for 1 of 5 residents (Resident #2) reviewed for unnecessary medications. Failure to document an assessment and appropriate diagnosis for the use of an antipsychotic medication does not allow the resident to attain and/or maintain his/her highest level of practicable well-being.Findings include:Review of the facility policy titled Antipsychotic Drugs occurred on 04/08/26. This policy, dated September 2022 stated, . Based on a comprehensive assessment of a resident, the facility must ensure that: A. Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. Review of Resident #2's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, dementia, and anxiety. Medications included Risperidone (antipsychotic medication).Resident #2's admission Minimum Data Set (MDS), dated [DATE], identified no behaviors and the use of antipsychotic medication. A quarterly MDS, dated [DATE], identified physical behaviors and the use of antipsychotic medication.During an interview on the afternoon of 04/08/26, an administrative nurse (#1) confirmed the facility received an order for the antipsychotic medication after a psychiatric consultation however the order lacked a diagnosis or progress note from the physician.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 of 1 sampled resident (Resident #5) observed to self-administer medications (SAM). Failure to assist/observe residents who are not SAM take their medications may result in adverse health consequences.Findings include:Review of the facility policy Self-Administration of Medication occurred on 04/08/26. This policy, dated January 2024, stated, . Drugs can be left at the bedside and self-administered by the resident only if ordered by the physician. nursing will assess resident/patient for appropriateness of self-administering, this form will be kept in the MAR [medication administration record] . Observation on 04/06/26 at 5:00 p.m. showed Resident #5 seated in the dining room and a medication cup containing several pills on the meal tray in front of the resident. The nurse (#2) administered medications to other residents in the dining room. Resident #5 picked up the medication cup and consumed the pills. When asked if Resident #5 is capable to self-administer medications, the nurse (#2) stated, Yes, I believe so. Review of #5's medical record occurred on all days of survey. The record lacked a physician order for SAM and the care plan identified the following, . I am unable to self-administer my own medications due to dementia history of CVA [cerebrovascular accident] (stroke) . The nurse (#2) failed to assist/observe Resident #5 with her medications.

Based on record review and staff interview, the facility failed to ensure appropriate care and services for 1 of 1 sampled resident (Resident #8) with an indwelling urinary catheter. Failure to obtain a physician's order for an indwelling catheter and catheter cares may result in urinary tract infections (UTIs), discomfort, skin issues, and sepsis.Findings include: Review of Resident #8's medical record occurred on all days of survey and identified an indwelling urinary catheter since admission on [DATE]. The physician's orders failed to include an order for an indwelling urinary catheter or how often to replace the catheter. The record showed facility staff changed the catheter 01/18/26, 15 weeks after admission. Review of Resident #8's progress note, dated 01/18/26 at 5:19 p.m., stated . resident reported severe pain to his catheter insertion site. Urine in tubing noted to be puss [sic] like with some blood noted. Catheter was irrigated with approx [sic] 40 cc [cubic centimeter a unit of measure] of normal saline. Small clot noted to tubing post irrigation, minimal urine return. Resident reported minimal relief post irrigation . Old foley removed. insertion of new 16 fr [French] foley catheter. Approx 30 ml [milliliters] of cloudy yellow urine returned. Site secured. Resident reported relief from pain. During an interview on 04/08/26 at 4:07 p.m., an administrative staff member (#1) confirmed Resident #8's physician's orders failed to include an indwelling foley catheter and how often to change the catheter.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 6 sampled residents (Resident #5, #6, and #8) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), personal protective equipment (PPE), hand hygiene, and surface disinfection has the potential to spread infection throughout the facility. Findings include: Review of the facility policy Enhanced Barrier Precautions occurred on 04/08/26. This policy, revised March 2026, stated, . Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing .Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting . Wound care: any skin opening requiring a dressing . All residents with any of the following: Infection or colonization with an MDRO [multidrug-resistant organisms] . Review of the untitled facility policy regarding hand hygiene occurred on 04/08/26. This policy, dated 04/2023, stated, . team members should use an alcohol-based hand rub for routinely decontaminating hands in these situations: . Before and after donning clean or sterile gloves. Review of the facility policy titled Urinary catheter: Indwelling (Foley) Catheter Care occurred on 04/08/26. This policy, dated 04/07/26, stated, . Emptying Urine Drainage Bag. Clean hands and put on gloves. - Review of Resident #6's medical record occurred on all days of survey identified a history of a MDRO. Observation on 04/06/26 at 3:20 p.m. showed an EBP sign, and PPE supplies on Resident #6's door. A certified nurse aide (CNA) (#5) wearing gloves, assisted the resident with a brief change, adjusted the top sheet, and placed the overbed table next to the bed. The CNA failed to apply a gown prior to completing high contact cares. - Review of Resident #5's medical record occurred on all days of survey. Diagnoses included a non-pressure chronic ulcer of left lower leg. Observation on 04/07/26 showed an EBP sign and PPE on Resident #5's door. * At 9:59 a.m. two CNAs (#3 and #4) applied gloves, entered the room, and assisted the resident to the bathroom. The CNAs removed their gloves, completed hand hygiene and exited the room. The CNAs failed to apply a gown prior to completing high contact cares. * At 10:02 a.m. Resident #5 activated the call light. Two CNAs (#3 and #4) applied gloves, entered the resident's room and bathroom, assisted the resident with toileting hygiene, a brief change, and transferred the resident back into the wheelchair. The CNAs failed to apply gowns prior to completing high contact cares. During an interview 04/08/26 at 2:40 p.m., an administrative nurse (#9) confirmed she expected staff to wear the required PPE when performing high contact resident care tasks. - Observation on 04/08/26 at 10:15 a.m. showed a CNA (#3) apply PPE without performing hand hygiene. As the CNA emptied Resident #8's urine collection bag into a graduated cylinder, urine dripped onto a paper towel underneath the cylinder and soaked through to the floor. The CNA (#3) failed to perform hand hygiene before applying PPE and failed to disinfect the floor where urine dripped. During an interview on 04/08/26 at 10:49 p.m., an administrative nurse (#9) confirmed she expected staff to perform hand hygiene before applying PPE and to disinfect the floor after a urine spill.

Based on record review, review of facility policies, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 4 of 12 sampled residents (Residents #1, #4, #5, and #7). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Interdisciplinary Care Plan and Care Plan Meeting occurred on 02/26/25. This policy, dated December 2023, stated, . C. Develop a care plan based upon information from the Interdisciplinary Team. Review of the facility policy titled Care Conference and Resident Centered Care Plan occurred on 02/26/25. This policy, dated June 1985, stated, . 2. The care plan will include . b) Physician orders . c) Dietary orders . 3. The . care plan will be . b. Developed by an interdisciplinary team, that includes . i. the attending physician . iv. dietary staff member . c. Reviewed and revised . by each member . 5. A comprehensive resident-centered care plan will be developed and implemented for . a) Services . furnished to the resident to attain or maintain their highest practicable . well-being . 8. Care plans will . be reviewed . as needed. - Review of Resident #1's medical record occurred on all days of survey. Current physician's orders included verify monthly weight on the first Wednesday of the month. Review of Resident #1's current care plan stated, . Admission Care Assist Task: 06/07/23-Monthly weight once a day on 1st Wed [Wednesday] of the month . Resident has kidney disease and neuropathy, related to diabetes mellitus . 10/22/2020-Monitor weight weekly . The facility failed to remove contradicting orders from Resident #1's care plan. - Review of Resident #4's medical record occurred on all days of survey. Current physician's orders included restorative nursing ambulation program with a platform walker and assistance of 2 with a wheelchair to follow 3-5 days a week. Review of Resident #4's current care plan stated, . 02/06/25 Restorative Nursing Ambulation Program-Ambulation with platform [NAME] with assist of 2 with wheelchair to follow 3-5 days a week . ADLs [activities of daily living] 01/27/2021 Ambulate with assist of one and front wheeled walker, 1x/d [one time per day], 3-5x's/week, [three to five times a week] . The facility failed to remove contradicting orders from Resident #4's care plan. - Review of Resident #5's medical record occurred on all days of survey. Current physician's orders included verify monthly weight completed once a day on the 1st Tuesday of the month. Review of Resident #5's current care plan stated, . Admission Care Assist Task 05/02/2023 Monthly weight-Once A Day on 1st Tue [Tuesday] of the Month . 04/21/2017 Vital signs and weight weekly and PRN [as needed] . The facility failed to remove contradicting orders from Resident #5's care plan. - Review of Resident #7's medical record occurred on all days of survey. Current physician's order included monthly weights on the first of the month, and a diet order for a diabetic/regular consistency, low potassium diet. Resident #7's current care plan failed to identify orders for monthly weights and type of diet. During an interview on 02/25/25 at 4:45 p.m., an administrative nurse (#2) agreed staff failed to update the residents' care plans.

Based on observation, medical record review, review of facility policy, and staff interview, the facility failed to provide assistive devices necessary to prevent accidents for 3 of 4 sampled residents (Resident #1, #3, and #5) observed during a gait belt transfer and failed to consistently implement fall prevention measures for 1 of 5 sampled residents (Resident #3) identified with a chair alarm. Failure to implement the chair alarm and use gait belts appropriately placed the residents at risk for falls and injuries. Findings include: Review of the facility policy titled "Use of Gait Belt" occurred on 10/11/12. This policy, revised June 2008, stated, ". . . 3. Always use a GAIT BELT. This will allow the caregiver to properly support the patient if required. GAIT BELTS must be used with all patients needing assistance. . . ." - Review of Resident #1's medical record occurred on 10/11/12. [DIAGNOSES REDACTED]. Resident #1's current care plan stated, ". . . I don't want to fall, as I have fallen before. . . . Approaches . . . Use moderate assist of 1 (with) pivot transfer to B.R. (bathroom) using grap (sic) bars. . . ." The care plan failed to address the use of a gait belt as per facility policy. Observation on 10/11/12 at 9:45 a.m. showed a certified nurse aide (CNA) (#1) transferred Resident #1 from the toilet to her wheelchair without using a gait belt. The CNA instead grasped the back of Resident #1's pants to lift and guide the resident to her wheelchair. - Review of Resident #3's medical record occurred on 10/11/12. [DIAGNOSES REDACTED]. Resident #3's current care plan stated, ". . . I am concerned that I might take a fall as I am [AGE] years old (and) sometimes I get up by myself when I know I shouldn't and I also take many medications. . . . Approaches . . . Assist me with my bed mobility and transfers . . . Use pivot technique for Bed to Chair transfers . . . I have problems (with) my memory (and) (with) reasoning . . . Bed (and) chair alarms used . . ." The care plan failed to address the use of a gait belt as per facility policy. Observation on 10/11/12 at 9:55 a.m. showed Resident #3 in the lounge area, asleep in a recliner without a chair alarm in place. A CNA (#2) assisted the resident to sit up in the recliner and applied a gait belt around the resident's waist. The CNA positioned the wheelchair on the resident's left side, assisted her to stand, and pivoted her to the right. Observation showed Resident #3's feet became crossed at the ankles, and she did not fully bear weight. During the transfer, the gait belt slipped upward under the resident's axilla. Upon transferring Resident #3 to her wheelchair, the CNA then assisted the resident to the bathroom, once again using a pivot transfer from the wheelchair to the toilet and from the toilet to the wheelchair. The gait belt remained loose, rested across Resident #3's chest, and slid upward into her axilla during the transfers. The CNA failed to readjust and tighten the gait belt at any time. Observations throughout the morning of 10/11/12 showed Resident #3 seated in her wheelchair or in a recliner without a chair alarm in place. The chair alarm was attached to the resident's bed in her room. - Review of Resident #5's medical record occurred on 10/11/12. [DIAGNOSES REDACTED]. Resident #5's current care plan stated, ". . . may transfer standing turning technique with grab bars or walker as tolerated with moderate assist of one . . ." The care plan failed to address the use of a gait belt as per facility policy. On 10/11/12 at 10:30 a.m., a CNA (#1) assisted Resident #5 to transfer from her wheelchair to the toilet, and from the toilet to her wheelchair. During both transfers, observation showed the gait belt was loose and slid up across the resident's shoulder blades. The CNA failed to readjust and tighten the loose gait belt. During an interview on 10/11/12 at 4:20 p.m., a nursing staff member (#3) stated she expected staff to readjust and tighten gait belts if they become loose during resident transfers, and staff should ensure Resident #3's chair alarm is in place when she is in her wheelchair or the recliner.

Based on observation, review of facility policy and procedure, record review, information submitted by the complainant, confidential staff interview, resident interview, and staff interview, the facility failed to provide adequate supervision and assistive devices to enhance/promote safety and prevent accidents for 3 of 4 sampled residents (Resident #1, #5, #6) identified with falls. Failure to use appropriate transfer aids resulted in Resident #6 experiencing pain during the transfer. Failure to provide supervision during toileting of dependent residents, use appropriate transfer aids, and consistently implement fall prevention measures may result in avoidable falls and/or injuries for all residents. Findings include: Review of the facility policy titled "Abuse Prohibition Program / Grievance" occurred on 08/28/12. This policy, revised May 2011, stated, "It is the policy of (facility name) to maintain the environment free of abuse and neglect. . . . Training of Employees . . . VII. Reporting . . . 2. The reporter of the incident completes the Incident Form. . . ." Written information submitted by the complainant identified concerns that staff failed to consistently implement fall prevention measures, such as bed and chair alarms. - Observation during the initial tour on 08/27/12 at 10:40 a.m. showed Resident #6 seated in a wheelchair with a clip alarm and a pad alarm in place. Observations throughout the survey showed these two alarms in place. Review of Resident #6's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition, delusions, physical and verbal behaviors, and extensive assistance from two or more staff for transfers and toilet use. The current care plan stated, ". . . I am forgetful (and) need help with my cares . . . Approaches . . . DO NOT leave W/C (wheelchair) in room. Use EZ stand (a mechanical sit-to-stand lift) for ALL transfers . . . I don't want to fall, as I have fallen before . . . Approaches . . . Clip alarm on @ all times . . . DO NOT leave W/C in B.R. (bathroom) when resident toileting . . ." A previous care plan, dated 08/09/11, also stated, "Do Not leave W/C in B.R. when resident on toilet." During an interview on 08/28/12 at 1:05 p.m., a nursing staff member (#7) stated she was unsure as to when the facility implemented the pad alarm to Resident #6's wheelchair, but that it had been "over six months at least. Alarms aren't new to her." During a confidential interview, a certified nursing assistant (CNA) expressed concerns related to a lack of staff. She stated, "Sometimes I leave people alone in the bathroom that I know I shouldn't. But another light goes off and I have to go help that person (resident). There just aren't enough people (staff) to get all the work done." Medical record review identified Resident #6 experienced the following falls: * Facility Event Report, dated 06/06/12 at 8:30 p.m.: ". . . Resident found sitting on floor by CNA - Resident states 'I got down on my knees to look under my bed for a card that dropped (and) then sat down on the floor.' . . ." The report failed to identify if alarms were in place at the time of the fall. * Physical Therapy (PT) Progress Note, dated 06/08/12: ". . . Notification of fall slip received. Patient fell on [DATE] (sic) at 2030 hours (8:30 p.m.). . . . Call light was within reach. Wheelchair was locked. Patient's bed alarm and chair alarm were placed properly. . . . We will continue to work on maintaining the clip alarm, but we do have to pin it to her bra in the back because she will take it off otherwise. So, we do continue to encourage staff to maintain that policy. . . ." * Facility Event Report, dated 06/13/12 at 7:45 p.m.: ". . . Resident's alarms sounding off - CNA found Res (resident) sitting on floor in BR - Res states 'I tried to stand up (and) sit in the W/C (and) missed it.' . . ." * PT Progress Note, dated 06/15/12: ". . . Notification of fall slip received. Patient fell at 19:45 hours (7:45 p.m.) on 06/13/12. Resident's alarms were sounding and CNA found resident sitting on the floor in the bathroom. Resident indicated to CNA that she was just trying to get in the chair after toileting. . . . At this point patient was trying to transfer herself from toilet to wheelchair. We have indicated to nursing staff that patient's wheelchair should not be left in front in (sic) her in the bathroom as she does try to get herself into the chair if she sees it. . . . We'll recommend that nursing staff remove wheelchair from toilet during toileting, if at all possible to stick around or near when resident is toileting. . . ." * Facility Event Report, dated 07/09/12 at 12:40 p.m.: ". . . Resident found on floor in BR by nurses station. Was attempting to transfer self back to W/C from toilet. Alarm was not on. . . ." The report failed to identify if the pad alarm was in place, how the resident got into the bathroom, and reason the clip alarm was not in place. * PT Progress Note, dated 07/12/12: ". . . Notification of fall slip received. Patient fell on [DATE] at 1240 hours (12:40 p.m.). Resident was found on the floor in the bathroom by the nurses' station. She was attempting to transfer herself back to the wheelchair. Alarm was not on. . . . We do have a pin that we use and we have to have that fastened to her bra or patient will take off her alarm. Unfortunately, patient has been sneaking into the bathroom herself . . . and she did transfer herself to the toilet, but was unable to get herself back to the wheelchair. Apparently, patient did take the clip alarm off at this point. . . ." Because inconsistencies exist between the Facility Event Report and PT Progress Note, it is unclear as to the exact circumstances of Resident #6's fall. Both documents also fail to indicate if the pad alarm was in place at the time of the fall. * Facility Event Report, dated 07/31/12 at 3:45 p.m.: ". . . Took self to bathroom, slid onto butt when getting off - alarms were on. . . ." * A nurses' note, dated 07/31/12 at 3:45 p.m.: ". . . Found on floor in bathroom - states attempted to sit in W/C (after) vdg (voiding) on toilet 'and it just rolled away.' . . ." * PT Progress note, dated 08/03/12: ". . . Notification of fall slip received. Patient fell on [DATE] at 15:45 hours (3:45 p.m.). Apparently patient took self to the bathroom, alarm was not on correctly. Patient indicated to staff that she was trying to get up and sit in her wheelchair, but it rolled away from her. . . . We do have an order that patient not have the wheelchair in the bathroom with her, but when she takes herself to the bathroom we are unable to carry that out. . . . It should be noted that she's had more and more difficulty over the past few days with standing and turning is almost impossible. Because of that I have initiated the use of EZ stand for all transfers. . . . Also recommend patient continue to use a baby pin with the clip alarm. . . ." Because inconsistencies exist between the Event Report (which stated the alarms were on) and the PT Progress Note (which stated the alarm was not on correctly), it is unclear as to the exact circumstances of Resident #6's fall. Both documents also fail to indicate if the pad alarm was in place at the time of the fall. Observations throughout the survey showed Resident #6's clip alarm pinned to the back of her shirt and not to her bra as recommended by PT. Observation on 08/27/12 at 4:38 p.m. showed a CNA (#9) assisted Resident #6 to the bathroom using an EZ stand lift. The CNA stated the resident "recently had a fall so she has a sore leg," and the staff now use an EZ stand lift. Observation on 08/28/12 at 9:19 a.m. showed Resident #6 inside a bathroom near the nurses' station. Observation showed the resident remained unattended in the bathroom, and staff failed to check on/assist the resident until 10:01 a.m. At 9:53 a.m., Resident #6 shouted from inside the bathroom, "Can somebody come here and help me?" At 9:55 a.m., the resident again shouted, "Help me! Please!" At 10:01 a.m., a CNA (#8) entered the bathroom to assist Resident #6 with personal cares. The resident was incontinent of stool, and observation showed stool on the toilet, the resident's legs, and the resident's clothing. The resident was attempting to clean herself using toilet paper. Another CNA (#10) entered the bathroom to assist Resident #6. A CNA (#10) applied a gait belt to Resident #6's waist and assisted her to stand by standing in front of the resident and using both hands to grasp the gait belt while the other CNA (#8) performed perineal cares. Resident #6 stated, "I can't stand on this leg no more. Gotta sit down. It hurts!" The CNA (#10) then assisted Resident #6 to sit on the toilet. The CNAs assisted Resident #6 to stand again, and the CNA (#8) resumed perineal cares. The resident stated, "I can't stand here very long! It hurts my legs!" The CNAs assisted Resident #6 to sit on the toilet and allowed the resident to rest. Then the CNAs assisted Resident #6 to stand for a third time. While one CNA (#10) grasped the gait belt with both hands, the other CNA (#8) finished perineal care. Resident #6 stated, "I can't take this anymore! It hurts!" The CNA (#8) stated, "Almost done." The CNA (#8) then placed a new brief on Resident #6, and the CNAs assisted her to sit in her wheelchair. During an interview on 08/28/12 at 10:23 a.m., a CNA (#8) stated she was unsure who took Resident #6 to the bathroom and that another nursing staff member (#7) told the CNA the resident took herself. The CNA also stated, "I didn't even know she was in there until (staff #7) told me just now." During an interview on 08/28/12 at 1:05 p.m., a nursing staff member (#7) stated Resident #6 took herself into the bathroom, and she (staff member #7) placed the resident's clip alarm and moved her wheelchair into the hallway. She then told the CNAs Resident #6 was in the bathroom. During an interview on the morning of 08/30/12, two supervisory nursing staff members (#1 and #2) agreed it was unsafe to leave Resident #6 in the bathroom unattended. The staff member (#2) confirmed staff were expected to transfer Resident #6 with an EZ stand lift. The staff failed to transfer Resident #6 appropriately, which caused her pain and jeopardized her safety. Staff also failed to thoroughly investigate/document the circumstances of Resident #6's falls, ensure the consistent implementation of all fall prevention measures (pinning the clip alarm to her bra, verifying the pad alarm was in place, removing the wheelchair from the bathroom), and provide adequate supervision to help prevent future falls. - Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current MDS, dated [DATE], identified the resident is understood and understands others, intact cognition, and extensive assistance from two or more people for transfers and toilet use. The current care plan stated, ". . . 07/18/12 Initiate use of clip alarm in bed/chair at all times . . ." Observation during initial tour, on 08/27/12 at 10:40 a.m., showed Resident #1 asleep in bed with a clip alarm pinned to the back of her shirt between her shoulder blades. Physician's orders identified the following: *07/18/12: "Initiate use of clip alarm in bed/chair at all times. Initiate assist (with) all transfers to and from bed, chair, or toilet . . ." *07/30/12: "Reminder for use of clip alarm at all times bed or chair . . ." *08/27/12: "Pt. (patient) should have clip or pad alarm on in bed or chair at all times. . . ." Facility Event Reports identified the following falls: *07/12/12 at 9:20 a.m.: ". . . Resident put call light on, discovered sitting on buttocks (with) back resting against dresser, states she was dressing @ time of fall . . ." *07/17/12 at 10:00 a.m.: ". . . Resident toileted self (and) had taken bathrobe off (and) was attempting to reach attends that were on the shelf . . . Clip alarm added by PT . . ." *07/27/12 at 10:20 p.m.: ". . . Resident lying on floor on right side, semi fetal position. Stated she bent over to pick something up, became dizzy and slid off bed. Denies injury. Clip alarm was not on. . . ." The report failed to identify a reason the clip alarm was not in place. *07/29/12 at 7:30 p.m.: ". . . Bathroom alarm sounding (and) resident found sitting upright on floor in front of toilet. States stood (without) assist (assistance) from toilet (and) attempted to retrieve item from shelf . . ." *08/12/12 at 7:15 p.m.: ". . . Staff heard resident crying, discovered res. face down (and) lying on (left) side, resident states she 'was reaching for something on floor (and) lost balance,' had taken self to BR, undressed self . . . also took off personal alarm. . . ." *08/14/12 at 6:15 p.m.: ". . . Took alarm off per self (and) attempted to transfer from W/C to toilet (without) staff assist. fell to floor in bathroom . . ." *08/20/12 at 3:30 a.m.: ". . . Resident found kneeling at side of bed, stated she rolled out of the bed . . ." The report does not identify if the bed alarm was in place at the time of the fall. During an interview on 08/27/12 at 4:48 p.m., Resident #1 stated she had to wear the clip alarm because "I was a bad girl. I forgot to call for help a couple times." The resident also stated she does not remove the clip alarm, and she is unable to unhook the alarm herself. Observations throughout the afternoon on 08/28/12 showed Resident #1 resting in bed without her clip alarm in place. The alarm remained attached to the back of her wheelchair, and staff failed to apply it as per physician order. During an interview on the morning of 08/30/12, two supervisory nursing staff members (#1 and #2) verified Resident #1 is supposed to have a clip alarm on when she is in bed. - Written information submitted by the complainant identified staff left Resident #5 unattended in the bathroom during the night of 08/07/12 and Resident #5 fell to the floor. Review of Resident #5's medical record occurred on August 27-30, 2012. A nursing note, dated 08/07/12 at 5:00 a.m., identified the following: "Resident toileted, appears to have attempted to stand per self slid to floor, found sitting beside toilet, holding on to grab bar, denies pain, no apparent injury." A physician's order, dated 08/08/12, stated "use E-Z stand for toileting - may use pivot technique chair to bed transfers only." Written information submitted by the complainant also identified, on 08/10/12, facility staff utilizing a stand lift left Resident #5 in the bathroom for three hours and Resident #5 was discovered when her roommate returned from an outing. Resident #5's nursing notes failed to include any documentation on 08/10/12 regarding staff leaving the resident in the bathroom unattended for an extended period of time. During an interview on 08/28/12 at 1:10 p.m., a nursing staff member (#6) stated she reported the incident to her supervisor and to administrative nursing staff. This staff member (#6) assessed Resident #5, identified no injuries, and stated she failed to document the incident in Resident #5's medical record or complete an incident report. The nursing staff member (#6) received information later that evening that a CNA (#12) utilized the stand lift to transfer Resident #5 to the bathroom at approximately 1:00 p.m. on 08/10/12 and "forgot her." Resident #5's medical record identified [DIAGNOSES REDACTED]. The current quarterly MDS, dated [DATE], identified short and long term memory problems, and extensive assistance of one staff for transfers and toilet use. The current care plan, last reviewed 06/12/12, stated the problem/concern, "I am concerned that I might take a fall . . . Goals - I don't want to fall, help me make safe transfers . . . Approaches . . . Assist me with my . . . transfers . . . Use the stand for my transfers . . ." The care plan failed to address the need to not leave Resident #5 unsupervised in the bathroom after the incidents on 08/07/12 and 08/10/12.